Miscellaneous

Question 1

Important factors to document prior to procedural sedation

Answer 1

ASA Score:
I A normal healthy patient
II A patient with mild systemic disease
- Current smoker, social alcohol drinker, pregnancy, obesity (30<BMI<40),
III A patient with severe systemic disease
- i.e. Poorly controlled DM or HTN, COPD, morbid obesity (BMI ≥40), active hepatitis, alcohol dependence or abuse, implanted pacemaker, moderate reduction of ejection fraction, ESRD undergoing regularly scheduled dialysis, history (>3 months) of MI, CVA, TIA, or CAD/stents.
IV A patient with severe systemic disease that is a constant threat to life
- EF <40, uncorrected/decompensated heart disease, acquired or congenital.
ASA V
- A moribund patient who is not expected to survive without the operation
ASA VI
- A declared brain-dead patient whose organs are being removed for donor purposes

Pre-procedure fasting (no need to delay - can pre-medicate)
Alcohol use / Drug use
Allergies
BP
Focused cardio-resp exam (non-specific)
AIRWAY ASSESS (Difficult BVM or Intubation)

Question 2

Who should be in the room for procedural sedation

Answer 2

MD + RN + 2nd doc completing procedure

Question 3

Anesthesia Billing

Answer 3

Only if has a 2nd physician
Can use anesthesia codes:
- Premiums:
Overnight, evening weekend and holiday
Extra Units: ASA Score (3,4,5), BMI > 45, Patient in sitting position (>60 degrees)
- Complexity
- Procedure

Question 4

4 Immune mediated reactions

Answer 4

Anaphylaxis - IgE, asthma, atopy
Cytotoxic / Compliment. Autoimmune hemolytic, Graves, Thrombocytopenia, Myesthenia
Immune: RA, membranous nephropathy, Lupus,
Delayed: Sensitized TH1 cells. Contact dermatitis, Hashimotos, Celiac.

Question 5

Allergy Type Mechanisms

Answer 5

Type 1: Immediate
- IgE mediated mast cell degranulation and histamine release

Type 2: Cytotoxic Antibody Reaction
- IgM and IgG mediated.

Type 3: Immune COmplex Mediated
- Antigen / Antibody Complex mediated

Type 4:
- Sensitized TH1 cells results in delayed

Question 6

Rhogam - when to give, how much and why

Answer 6

300 U
In Rh- mothers with bleed or miscarriage
Prevents: hemolytic anemia of the newborn

Question 7

Anaphylaxis def’n

Answer 7

REVIEW NEW DEFINITION

Question 8

Risk Factors for Having Anaphylaxis

Answer 8

Men < 16, Women > 30
Higher SES
Hx of atopy

Question 9

Risk factors for Severe Reation

Answer 9

Extremes of ages
Comorbid disease
On Beta-Blcokers
Drug use

Question 10

Mechanism of epinephrine in anaphylaxis

Answer 10

Mast cell and basophil stabilization (Beta)
Bronchodilation
Vasconstriction
Inotropy and chrontropy

Question 11

Approach to drug rash

Answer 11

Timing
Mucous Membrane Involvement / Distribution
Sick / Not sick
Febrile

Review Drug Rashes / Derm from Dr. Yiu

Question 12

DRESS Syndrome

Answer 12

Onset within: 2-6 weeks
Duration : Several weeks
Features: facial edema, morbilliform, pustules
Mortality: 10%

Question 13

SJS / TENS

Answer 13

Onset within: 2-6 weeks
Duration : 1-3 weeks
Features: Mucosal involvement, sick, Nikulsky, necrosis
Mortality: 5-35%

Question 14

AGEP

Answer 14

Onset within: 48 hours
Duration : < 1 weeks
Features: facial edema, pustules, tensemorbilliform, pustules
Mortality: 5%

Question 15

Erythroderma

Answer 15

REVIEW - See EM Wiki

Question 16

Chronic Urticaria

Question 17

Psychosis Symptoms

Answer 17

Delusions
Hallucinations
Thought Disorders

Question 18

Differential for Psychosis (10 Things) - Emergency Medicine Context

Answer 18

1) Schizophrenia - age, decline over time, duration of symptoms
2) Depression with psychotic features - Elderly and postpartum, lead in of SIGECAPS then psychosis (“end stage depression”), most common is delusion (depressive delusions - illness, guilt, being dead, poverty)
3) Mania - manic symptoms precede psychosis
4) Delusional Disorder - Isolated delusional disorder. Better functioning, no preceding or co-morbid symptoms. Somatic type (bugs, parasites etc), erotomaniac
5) Drug induced psychosis - Most common in sims, most common delusion is formication.
- Once intoxication is over, the psychosis is a psych emergency
- Cocaine up to 5 days
- Methamphetamine up to 2 weeks
- Marijuana 5-7 days
6) Delirium
7) Medical Illness or medication induced psychosis
- Medical Illness / Meds -> Delirium (systemic illness, metabolic) -> Psychosis (isolated w/o delirium neurologic illness)
- If they do not know where they are then they are likely delirious
8) Dementia
9) Brief Reactive Psychosis (Brief psychotic episode) - In context of massive stressors, appears drug induced.
10) Mini/micro psychosis of an unstable personality - Few hours in duration.
- Antipsychotic is psychiatry glue. Use least sedating option and least weight gain

Question 19

Common causes of decompensation in schizophrenia

Answer 19

Medication compliance
Stessors
Drugs and EtOH