Misc EM Topics Flashcards
Define TIA
Transient episode of neuro dysfunction WITHOUT evidence of infarct (return to baseline in less than 24 hrs)
Define stroke
Neuro dysfunction 2/2 cerebral infarct (as evidenced by neuroimaging or signs of permanent injury)
Define penumbra stroke
Ischemic but not infarcted tissue (potentially viable if circulation restored promptly)
Etiology of ischemic stroke
Cerebral artery blockage
Types of ischemic stroke
- Thrombotic (clot forms in brain)
- Embolic (clot forms away from brain and swept through to brain)
Etiology of hemorrhagic stroke
Arterial leakage or rupture 2/2 HTN, AVM, anticoagulants, aneurysm
Types of hemorrhagic stroke
- Intracerebral hemorrhage (vessel within the brain)
- Subarachnoid hemorrhage (vessel on brain surface)
How should onset of stroke be described if unable to determine specifically?
“Last known well”
Diagnostics of stroke
- NIH stroke scale calculation
- HINTS testing (Head Impulse, Nystagmus, Test of Skew)
What is HINTS testing?
To determine if vertigo is peripheral or central (cerebellar)
Which patients will present with abnormal (positive) head impulse testing?
Peripheral vertigo
Which patients will present with unidirectional, horizontal nystagmus?
Peripheral vertigo
Which patients may reveal skew deviation with alternate eye cover testing?
Central vertigo
How will peripheral vertigo patients perform on HINTS testing?
- Head impulse: abnormal (positive)
- Nystagmus: unidirectional, horizontal
- Skew: absent
How will central vertigo patients perform on HINTS testing?
- Head impulse: normal (negative)
- Nystagmus: rotatory, vertical, or direction changing horizontal
- Skew: deviation with alternate eye cover testing
Most ischemic strokes will be evident on head CT within:
6 hours
When is head/neck CTA obtained in stroke evaluation?
If onset was less than 3 hours ago
When is MRI ordered for stroke evaluation?
Confirming diagnosis in TIAs OR if not giving tPA
Treatment of stroke
- If less than 3 hrs onset, give tPA unless contraindicated
- Intra-arterial fibrinolysis
- Mechanical thrombectomy
- Aspirin if out of tPA window
- BP reduction (labetalol, nicardipine)
BP reduction in stroke treatment
- Ischemic: reduce BP if SBP is over 185
- Hemorrhagic: reduce BP if SBP is over 140
How to treat hemorrhagic stroke?
- Reverse anticoagulants
- Hematoma evacuation
- Aneurysm clipping or embolization
What is EMTALA?
- Protects medically indigent pt from being refused care
- Mandates a minimum of “medical screening exam” and treatment if emergent
Why are pediatric patients more susceptible to CT radiation than adults?
Children’s cells proliferate more rapidly
Define priapism
Pathologic erection involving corpora cavernosa but NOT glans or corpus spongiosum
Treatment of priapism
- Urology consult but don’t wait to treat
- Terbutaline SC deltoid, repeat in 30 min prn
- Pseudoephedrine
- Corporal aspiration of blood then injection of phenylephrine (local pressure then compression dressing)
Define phimosis
- Inability to retract foreskin (rarely emergent)
- Generally from poor hygiene leading to infection or scarring
- Treat w/topical steroids, dilation or circumcision
Define paraphimosis
- Inability to reduce retracted foreskin back over glans
- Venous engorgement can lead to gangrene
- Emergency reduction necessary! Manual compression or wrapping distal penis w/phlebotomy tourniquet
Define Fournier gangrene
- Polymicrobial necrotizing fasciitis of perineal, perianal or genital areas
- Infection tracks along fascial planes and may spare deep muscular structures or even overlying skin
Pathophys of Fournier gangrene
- Microorganisms produce enzymes which cause coagulation of local nutrient vessels
- Allows for proliferation of anaerobes which release enzymes responsible for degradation of fascial barriers
Risk factors for Fournier gangrene
- DM
- PVD
- Immunocompromise
- Obesity
- Alcoholism
Treatment of Fournier gangrene
- Management of shock if present
- Emergent surgical consult
- Abx (cipro and clindamycin)
Methods of ring removal
- Ring cutter: can be painful, ring must be bent open
- String technique: painful, may be difficult to pass string under ring
- Tourniquet
Describe tourniquet method of ring removal
- Elevate above heart
- Apply tightly distal to proximal
- Quickly remove after a few min and apply lubrication
- Retract skin proximally with one hand while pulling ring distally
Options for fish hook removal
- Push through (push it)
- String technique (yank it)
- Needle over barb (cover it)
Treatment of plantar puncture wound
- Core out, irrigate, pack x 24 hrs
- Ensure tetanus is UTD
- Consider abx proph (but limited evidence)
Plantar puncture wound infections
- Within first 72 hrs is MC staph/strep (use Keflex)
- After 72 hrs is MC pseudomonas (use Cipro)
Treatment of AV fistula bleeding
- Apply direct, localized pressure
- BP cuff above and below fistula may help
- Very superficial suture followed by pressure bandage (temporary measure, best to consult vascular surgery first)
- Address BP, correct any coagulopathies
Treatment of fistula aneurysm
Emergent vascular consult to avoid rupture
Describe Ottawa knee rules
If 1 or more, x-ray indicated:
- Patella tenderness
- Fibula head tenderness
- Inability to flex 90 degrees
- Inability to bear weight
- Age over 55
Describe Ottawa ankle/foot rules
If 1 or more, x-ray indicated:
- Malleolar, navicular OR base 5th MT pain on palpation
- Inability to bear weight
Describe Salter-Harris
Classification of pediatric fractures
1: through growth plate
2: through growth plate and metaphysis
3: through growth plate and epiphysis
4: through all 3 elements
5: crush injury of growth plate
Prescription writing guidelines
- Use leading zeros (0.1 mg) but not ending zeros (1.0 mg)
- Use correct formulations
- Adjust for renal or hepatic dysfunction
- Verify correct drug when using EMR
Every prescription requires:
- Name and DOB
- Drug name, dosage, frequency
- Duration, quantity, refills
- How to administer
Every order requires:
- Date and time
- Initials or ID stamp
- Drug name
- Dosage
- Route
- Frequency (if more than 1 dose)
Examples of bio-equivalent IV and oral meds?
- Fluoroquinolones
- Azithro, clarithromycin
- Bactrim
- Metronidazole
- Cephalosporins
Amoxicillin and Augmentin uses
- OM
- Sinusitis
- Pneumonia
- Tonsillitis (Pen Vee K 1st line)
- UTI
Adult dosing of amoxicillin
500 mg PO TID OR 875 mg PO BID
Peds dosing of amoxicillin/augmentin
45 mg/kg/day PO (divide into 2-3 doses)
90 mg/kg/day PO (divide into 2-3 doses) for otitis media
Duration of amoxicillin use
7-10 days
5-7 days for high dose otitis media
Uses of cephalexin (keflex)
- Skin infections
- OM
- Tonsillitis
- UTI
- Bronchitis
Adult dosing of cephalexin (keflex)
250-500 mg PO QID
Duration of cephalexin (keflex)
7-10 days
Describe PCN allergy cross-reactivity rate
Approximately 1%
Lower for 3rd-4th generation cephalosporins
Uses of ceftriaxone (rocephin)
- PNA
- Cellulitis
- Meningitis
- Pyelonephritis
- Chlamydia
Adult dosing of ceftriaxone
1 gm QD (IM or IV)
Duration of ceftriaxone
Generally transitioned to PO alternative after few days; single dose for chlamydia
Bactrim uses
- UTI/pyelonephritis
- PCP PNA
- Bronchitis
- MRSA skin
Adult dosing of Bactrim
- 1 DS (double strength) BID
- PCP rx is weight based
Duration of Bactrim
7-10 days
3 days for uncomplicated UTI
Bactrim drug interations
Known to inhibit warfarin clearance (results in high INR)
Uses of Ciprofloxacin
- UTI/pyelonephritis
- Diverticulitis
- Infectious diarrhea
Adult dosing of Ciprofloxacin
250-500 mg BID OR 400 mg IV q12h
Duration of Cipro
- 3 days for UTI
- 5-7 days for diarrhea
- 10-14 days for diverticulitis
Cipro drug interactions
Known to inhibit warfarin clearance
Azithromycin uses
- Bronchitis/PNA
- Sinusitis
- Tonsillitis
- Chancroid/chlamydia
Adult dosing of Azithromycin
- “Z pack” (500 mg day 1, then 250 QD x 4d) for respiratory
- 1 gm PO single dose for chancroid/chlamydia
- IV usually 500 mg QD x 2d then PO transition
Doxycycline uses
- Lyme/Anaplasmosis/RMSF
- PNA/bronchitis
- Cellulitis including MRSA
Adult dosing of Doxy
100 mg PO BID
Duration of Doxy
- 7-10 days
- 21 days for Lyme/tick
Side effect of Doxy?
Photosensitivity
Uses of acetaminophen (tylenol)
Pain, fever
Adult dosing of acetaminophen (tylenol)
325-1000 mg q4-6h prn (325 or 500 mg tablets)
Peds dosing of acetaminophen (tylenol)
15 mg/kg q4h
160 mg/5 mL elixir, 120 mg or 325 mg suppository
Uses of ibuprofen (motrin/advil)
Pain, fever
Adult dosing of ibuprofen (motrin/advil)
400-800 mg q6-8h prn (200 mg tablets)
Peds dosing of ibuprofen (motrin/advil)
10 mg/kg q6h prn
100 mg/5mL elixir
Adult dosing of hydrocodone/tylenol (Vicodin)
1-2 tab q4h prn
5, 7.5, or 10 mg/300 mg; Norco Tylenol is 325 mg
Adult dosing of oxycodone/tylenol (Percocet)
1-2 tab q4h prn
5, 7.5, or 10 mg/325 mg
Adult dosing of morphine sulfate
2-6 mg IV/IM/SQ q 15mins - 4hrs
shorter intervals for IV routes
Adult dosing of hydromorphone (Dilaudid)
0.5 - 2 mg IV/IM/SQ q 30 mins - 4 hrs
Adult dosing of Fentanyl
25-100 mcg IV/IM q 30-60 mins
Describe Fentanyl
Shorter duration than morphine/dilaudid
Less hypotension
Consider Duragesic patch for home pain management
Adult dosing of Ketorolac (Toradol)
30 mg IV or 60 mg IM q6h prn
Describe Ketorolac
- NSAID side effects/contraindications
- Good for renal/gallbladder pains
Describe Tramadol (Ultram)
Non-narcotic, non-NSAID pain med
What is a non-narcotic and non-NSAID pain med?
Tramadol (Ultram)
What is Ultracet?
Tramadol with 325 mg Tylenol
Adult dosing of Tramadol
25-100 mg PO q6h prn
What does “mindful medicine” utilize?
Thorough DDX and bias elimination
Types of bias
- Availability
- Anchoring
- Framing
- Confirmation
- Premature closure
Define availability bias
- Favors the common diagnosis w/o proving its validity
- Providers tend to be influenced by recent events or info
Define anchoring bias
- Prior diagnosis/opinion is favored and misleads provider from correct current diagnosis
- Provider relies on established diagnosis/opinion which impacts subsequent judgments
Define framing bias
- Failure to recognize that the data available does not fit diagnostic presumptions
- Provider connects data in a manner that suggests a diagnosis but all relevant data has not been gathered
Define confirmation bias
- Info is selectively interpreted to confirm a belief
- Provider has a preferential diagnosis and a finding, or lack of specific finding, during the hx/PE/workup used to support that diagnosis
Define premature closure bias
- Rushed diagnostic conclusion
- Provider jumps to a conclusion but fails to see additional relevant info
