MTB 2 CK - Emergency Flashcards
you see a guy pass out in front of you. you shake him and he is unresponsive. what is the first thing you do?
a. start chest compressions
b. feel for pulse
c. look, listen, and feel for breathing
d. call 911
e. precordial thump
d. call 911
ACLS steps:
- check responsiveness
- activate emergency response + get an AED
- circulation (check pulse, start compressions/cpr)
- defibrillate (check for shockable rhythm w AED)
CPR
-how many chest compressions per min?
100
another term for unsynchronized shock?
another term for synchronized shock?
defibrillate
cardiovert
algorithm for Asystole/PEA
pulseless
CPR - Epi - Shock
CPR - Epi - Shock
algorithm for Vfib + pulseless Vtach
Shock - CPR – Shock - CPR - Epi – Shock
or
Shock - CPR - Epi
pt w Vtach has a pulse + is stable
-next step?
IV Amiodarone
or
IV Procainamide, or IV Sotalol
pt w Vtach has a pulse + chest pain
-next step?
cardiovert / Synchronized Shock
signs of hemodynamic instability in Vtach - 4
SOB / CHF
low BP
chest pain
Confusion
torsades is equal to which type of arrhythmia
Vtach
causes of torsades
QT prolongation:
hypoMg, hypoK
drugs: TCA’s. Lithium, Antipsychotics, amiodarone/procainamide
macrolides: azithromycin
when is Gastric Lavage most useful
ingestion
Dangers of gastric lavage
Altered mental status: aspiration
Caustic ingestion: burning of the esophagus and oropharynx
Ipecac Usage
Never in the hospital.
Can be used at home
Cathartics
Not a good answer (sorbitol). Speeding up GI transit time does not eliminate ingestion without absorption
Forced Diuresis Tx
Also not a good answer. Can often lead to pulmonary edema.
pt has acute AMS or unresponsiveness for unknown reason
-best next step?
- Naloxone + Dextrose + Thiamine
2. Intubate
Benzodiazepine overdose
Flumazenil, acute withdrawal can cause seizures so be careful
TX for pt w unknown pill overdose
Charcoal
(superior to lavage and ipecac)
toxins in blood drop fast
charcoal will not work in what overdose?
*Lithium* iron cyanide lead alcohols
what symptoms indicate dialysis?
apnea *HoTN* renal failue liver failure coma
bicarb diuresis is TX for 2 overdoses
aspirin
phenobarbital
Acetaminophen Toxicity & Fatality levels?
-what about in toxicity in alcoholics?
Toxicity: 8-10 g
Fatality: 12-15 g
- 4g
what lab value to watch in acetaminophen toxicity?
PT
What do with toxic levels of acetaminophen
N-acetylcysteine
Overdose of acetaminophen more than 24 hours ago
No therapy possible
AST 2500, ALT 1800
- alcohol or acetaminophen?
acetaminophen
alcohol is 2:1 & more like 300:150
If amount of ingestion is unclear…
Get a drug level
Charcoal and N-acetylcysteine
Charcoal won’t make N-acetylcysteine ineffective. No contraindication.
Most likely dx:
Tinnitus and hyperventilation
Respiratory alkalosis progressing to metabolic acidosis
Rental toxicity and altered mental status
Increased anion gap
Aspirin overdose
Aspirin and lactate production
Interferes with oxidative phosphorylation and results in anaerobic glucose metabolism (producing lactate)
Aspirin multisystem toxicity
Causes ARDS
Interferes with PT production and raises PT time
Metabolic acidosis from lactate
Tx of Aspirin Toxicity
Alkalize Urine
-increase rate of aspirin excretion.
Blood gas in aspirin overdose
Respiratory alkalosis with a decreased CO2 and bicarb level (because of metabolic acidosis rising)
Ex: 7.46, CO2 22, Bicarb 16
pill overdose: confusion & lethargy mydriasis RR 7 HR 115 EKG - wide QRS DX? next step?
TCA overdose
-bicarb
Tricyclic Overdose Suppression of Seizures
Benzodiazepines. So if you reverse benzos with flumazenil and the pt ingestion a lot of TCAs you open them up for seizing.
Best initial test to detect TCA toxicity
EKG will show widening of QRS complex. QT prolongs as well until torsade de pointes.
Sodium bicarbonate in TCA overdose
Bicarbonate protects heart against arrhythmia, has no effect on increased urinary excretion (as in aspirin)
TCA toxicity symptoms leading to death
Seizures and arrythmia
TCA toxicity smptoms
Anticholinergic effects:
Dry mouth
Constipation
Urinary retention
Caustics ingestion (drain cleaner, acids, alkali)
TX?
-next step?
Fluids
-Endoscopy
(Giving the opposite will cause an exothermic reaction and make the perforation/damage worse)
Most common cause of death in fires
CO poisoning
Cause of death in CO poisoining
MI
CO is like anemia in that it removes carrying capacity/functional RBCs
Blood gas in CO poisoining
PO2 is normal because it can’t release. Because oxygen not released to tissues you get lactic/metabolic acidosis.
Ex: 7.35, pCO2 26, HCO3 18
Most accurate test in carbon monoxide toxicity
Level of carboxyhemoglobin
Best initial tx for carbon monoxide toxicity
100% oxygen
hyperbaric oxygen - CNS & cardiac symptoms, metabolic acidosis
Methemoglobinemia
Oxidized hemoglobin that is locked in the ferric state.
Brown and will not carry oxygen
Which drugs can cause methemoglobinemia
Benzocaine and other anesthetics
Nitrites and nitroglycerin
Dapsone
Blood color in CO vs. Methemoglobinemia
CO - abnormally red
Meth - abnormally brown
Dx Test and Tx for Methemoglobinemia
Methemoglobin level
Best initial tx is 100% oxygen
Most effective therapy is methylene blue (decreased half life of methemoglobin)
DX: diarrhea urinary incontinence muscle weakness bradycardia bronchospasm emesis lacrimation salivation sweating seizures
organophosphates
Nerve gas
(prevents breakdown of ACh)
flu-like sxs w/o fever
First step in organophosphate tx
- Atropine
(blocks effects of ACh that is already increased. Dries up respiratory secretion.) - Pralidoxime
(reactivates acetylcholinesterase, which won’t act fast enough in an acute reaction.)
pt w HTN, DM, & systolic dysfunction is admitted for 2 days of NVD. he is dehydrated, and his glucose is 180.
-next best step
digoxin level
have to think that pt is on dig in systolic HF
which electrolyte value leads to digoxin toxicity?
Hypok
incr digoxin binding
Digoxin toxicity leads to what electrolyte abnormality?
-next step?
HyperK
(digoxin has taken up all binding sites)
tx - digoxin Ab’s + bicarb/insulin
Most common presentation for digoxin toxicity
GI problems (N/V/abdominal pain)
Hyperkalemia
Confusion
Visual disturbance such as yellow halos around objects
Rhythm disturbance (bradycardia, atrial tacycardia, AV block, ventricular ectopy)
most Accurate test for digoxin toxicity
Digoxin level!
Best initial test for digoxin toxicity
EKG + potassium level
EKG shows downsloping of the ST segment
Most common arrhythmia in digoxin toxicity
Atrial tachycardia w variable AV block
indication for digibind
CNS sxs
Cardiac sxs
K >5 + sxs
Most likely dx:
Abdominal pain
Renal tube toxicity (ATN)
Anemia
Peripheral neuropathies such as wrist drop
CNS abnormalities such as memory loss and confusion
Consider lead poisoning
Most accurate test for lead poisoning
Lead level
BEst initial diagnostic test for lead poisoning
Increased level of free erythrocyte protoporphyrin
Most accurate test for sideroblastic aenmia
Prussian blue stain, detects increased iron built up in RBC mitochondria
Tx of lead poisoning
Chelating agents. Succimer is he only oral form of lead chelator. Ethylenediaminetetraacetic acid (EDTA) and dimercaprol (BAL) are parenteral agents.
Adverse effects of mercury poisoning
Inhaled mercury vapor - lung toxicity presenting as interstitial fibrosis
Neurological problems - nervous, jittery, twitchy, sometimes hallucinatory
Tx for mercury poisoning
No therapy to reverse pulmonary toxicity
Chelating agents: dimercaprol and succimer can be effective
intoxication + blurry vision?
Methanol
- causes blindness
Similarities with Methanol and Ethylene Glycol
Intoxication Metabolic acidosis INcreased anion gap Osmolar gap Treated wtih fomepizole and dialysis
Sources of Methanol vs. Ethylene Glycol
Methanol - wood alcohol, cleaning solutions, paint thinner
Ethylene glycol - antifreeze
Toxic metabolite in Methanol vs. Ethylene Glycol
Methanol - formic acid/formaldehyde
Ethylene glycol - oxalic acid/oxalate
Presentation of the Methanol vs. Ethylene Glycol
Methanol - ocular toxicity
Ethylene Glycol - renal toxicity
Initial diagnostic abnormality of Methanol vs. Ethylene Glyco.l
Methanol - retinal inflammation
Ethylene glycol - hypocalcemai, envelope shaped oxalate crystals in urine
Osmolar Gap
Increased in methanol and ethylene glycol. Also regular alcohol.
Expected osmolarity:
Serum osm = 2Na + BUN/2.8 + glucose/18
Best intial tx for methanol and ethylene glycol toxicity
Fomepizole -(inhibiting alcohol dehydrogenase prevents production of toxic metabolites) Dialysis - remove toxins
TX of Snake Bites?
Immobilization (decr movement of venom)
Tx - antivenim
Black widow Spider bite
Abdominal pain, muscle pain
Hypocalcemia
Tx. Calcium, antivenin
Brown recluse spider bite
Local skin necrosis, bullae, and blebs
No lab abnormalities
Tx with debridement, steroids, and dapsone
Dog, cat, and human bites
TX?
infections?
Amoxicillin/clavulanate - (Augmentin)
Tetanus vaccination booster if more than 5 years
Dogs and cats: Pasteurella multocida
Humans: Eikenella corrodens
prophylaxis after human bites?
animal bite?
HIV + HBV
tetanus + rabies
Rabbies prophylaxis includes what?
human diploid cell vaccine
+
HR16 passive immunity
Head trauma with LOC management
Head CT first, without contrast.
Subdural and epidural hemotoma
Can only be distinguished with CT.
Epidural related to head fracture
Lucid interval
Second LOC occurring soon after initial.
Epidural + subdural hematoma
Concussion TX?
wait 24 hrs before returning to work
observe for mental status changes
Contusion Tx
Majority no treatment needed, severe may need surgical debridement
Subdural and epidural TX
Large hematoma
Intubation + hyperventilation
Mannitol
Drainage
Hyperventilation in Hemotoma
Decreases pCO2, leading to a constriction of cerebral circulation. This decreases volume and decreases pressure.
Mannitol
Osmotic diuretic that decreases intravascular volume. Limited benefit.
Definition of Intracranial Hemorrhage
Compression of ventricles or sulci
Herniation with abnormal breathing/unilateral dilation of pupil
Worsening mental status or focal findings
Most likely dx and tx: Head trauma No focal finding No lucid interval Normal CT
Concussion
Tx: No specific tx, observe at home for lucid interval or new focal findings
Most likely dx: Head trauma Rarely focal No lucid interval Ecchymoses on CT
Contusion
Tx: No specific treatment; observe in hospital
Most likely dx: Head trauma \+/- focal findings \+/- lucid interval Venous, crescent
Subdural
Tx: Drain large ones
Most likely dx:
+/- focal findings
+/- lucid interval
Arterial, biconvex or lens shaped hematoma
Epidural
Drain large ones
Indications for stress ulcer prophylaxis
Head trauma
Burns
Endotracheal intubation
Coagulopathy (platelets
Best initial therapy for burns
100% oxygen to treat smoke inhalation and carbon monoxide toxicity
Etiology of death in burns
Airway burn or volume loss.
Intubation of Burn Pts Indications
Stridor, Hoarseness, Wheezing
(indicate Laryngeal edema)
Burns inside the nasopharynx or mouth
Volume replacement in burns
Lactate ringers
1/2 required in the first 8 hours
1/4 in second 8 hours
1/4 in third 8 hours
4 mL for each percent of surface area
Surface area percentages of burn victims
Head - 9%
Arms - 9% each
Legs 18% each
Chest or back - 18% each
Each hadn width is one percent of BSA
Most common cause of death several weeks after burn
Infection - give prophylactic topical antibiotics (silver sulfadiazine) NOT IV antibiotics
Most likely dx and tx: Exertion High outside temperatures *Normal body temp* Normal CPK and potassium level
Heat cramps/exhaustion
Tx - oral fluids + electrolytes
Most likely dx and tx: Exertion High outside temperatures *Elevated body temp* Elevated CPK and potassium
Heatstroke
Tx - cool down - (spray w water)
Most likely dx and tx:
Antipsychotic medications
Elevated temperature
Elevated CPK and potassium
Neuroleptic malignant syndrome
Dantrolene or dopamine agonist:
Bromocriptine or cabergoline
Most likely dx and tx:
Anesthetics administered systemically
Elevated temperature
Elevated CPK and potassium
Malignant hyperthermia
Tx: Dantrolene
Most likely DX? Intoxicated person Low body temperature J waves on EKG -*next step?*
Hypothermia
-fingerstick glucose
most common 2ndary cause of hypothermia is hypoglycemia
most common secondary causes of hypothermia? - 3
hypoglycemia
hypoThyroid
sepsis
Best initial test for hypothermia?
MCC of death?
EKG
Cardiac arrhythmia
Management of Drowning
Positive Pressure Ventilation
NO STEROIDS OR ANTIBIOTICS
Specific types of drowning
Salt: acts like CHF - wet, heavy, lungs
Fresh water: causes hemolysis from absorbing hypotonic fluid into the vasculture
Initial management of cardiac arrest
Open airway, head tilt, chin lift, jaw thrust.
GIve rescue breaths if not breathing
Check pulse and start ches tcompressions if pulseless.
When to give precordial thump
Within 10 minutes of witnessed arrest.
Management of pulseless activity
CPR
Asystole tx
After CPR
Epinephrine (or vasopressin)
Will shunt blood to critical areas like heart and brain
Unsynchronized Cardioversion
VF and VTach without pulse
When to give epinephrine during arrest (VF)
Two unsynchronized cardioversions, then epinephrine/vasopressin followed by another electrical shock.
When to give amiodarone/lidocaine (VF)
Given after 2 shocks, epi, schock. Amiodarone first choice.
Managing VTach
Pulseless VT: Same way as VF
Hemodynamically Stable: Amiodarone, lidocaine, procainamide, THEN cardiovert.
VF management
Shock, drug, shock, drug, shock, drug, CPR the whole time
Hemodynamically unstable Vtach
Perform electrical cardioversion several times, followed by medications such as amiodarone, lidocaine, or procainamide.
Hemodynamically unstable definition
chest Pain
Dyspnea
Low BP
Confusion/AMS
VT with a pulse
SYNCHRONIZED CARDIOVERSION
pt is unresponsive, no pulse + sinus bradycardia EKG
DX?
next 2 steps?
Pulseless Electrical Activity (PEA) (heart electrically normal, no motor contraction) 1. CPR 2. *IV Epinephrine* (up to 3 x) -- same as Asystole --
which 2 causes of pulselessness are non-shockable?
Asystole + PEA
Most likely arrhythmia:
Palpitations, dizziness, lightheadedness
Exercise intolerance/dyspnea
Embolic stroke
Atrial
AFib most common arrhythmia in the Untied States
causes of Asystole & PEA
Hypoxia, Hypothermia, Hypovolemia, Hypoglycemia, Hyper/HypoK+
Tamponade, Tension pneumothorax,, Toxins (metabolic acidosis), Thrombosis (PE, ACS)
Tx of hemodynamically unstable atrial arrhythmias
Synchronized cardioversion (prevents deterioration into VT and VF)
pt has Afib & is stable
-next step?
IV *Diltiazem* / Verapamil or IV *Metoprolol / Esmolol* or Digoxin (*EF
Next step fter rate control, in AFib
*Aspirin* (CHADS of 1) or *Warfarin* (CHADS of 2+) or Dabigatran (Pradaxa) or Rivaroxaban (Xarelto)
(ANTICOAGULATE)
what conditions indicate electrical cardioversion in a pt w Afib? - 3
(after rate control & anticoagulation)
1st episode of AFib
worsening sxs
hemodynamically unstable
(RHYTHM)
which drugs can be used for cardioversion?
electrical cardioversion is preferred
Ibutilide, flecainide, procainamide or sotalol - (*CAD* w/ normal EF) or amiodarone, Dofetilide -w (CAD w *EF
Afib for > 2days
-what can you do before discharge?
- TEE*
a. NO CLOT? - IV Heparin + Cardioversion
b. CLOT? - IV Heparin + Return in 3 wks
when to use Heparin in Afib
Current Visible Clot in atrium
Non-anatomical causes of Afib
Alcohol
caffeine
cocaine
transient ischemia.
CHADS2
Aspirin
If it were 2 or higher, warfarin, dabigatran, rivaroxaban
SVT Tx
- valsalva, carotid massage, dive reflex, ice immersion
- Adenosine
BB (metoprolol), CCB (diltiazem) or digoxin if adenosine not effective
Most likely dx:
SVT alternating with ventricular tachycardia
SVT that gets worse after diltiazem or digoxin
Observing the delta wave on the EKG
Wolff-Parkinson-White Syndrome
Preexcitation syndrome with early depolarization of the ventricle
Most accurate test for WPW
Cardiac electrophysiology (EP) studies
Acute therapy of WPW
Procainamide or amiodarone
only if WPW currently presenting
Chronic therapy for WPW
Radiofrequency catheter ablation, curative for WPW.
EP studies tell you where anatomic defect is
contraindicated drugs in WPW
Digoxin and CCB
block normal AV node and promote alternate pathways
arrhythmia in a COPD pt?
TX?
Multifocal Atrial Tachycardia
tx - O2, IV Diltiazem or Verapamil
(avoid BB’s)
pt w HR of 52 is lethargic
-next step?
IV Atropine
2nd line: Transcutaneous pacing, Epi, Dopamine
pt w HR of 19 has normal hx & physical
-next step?
nothing
- only treat symptomatic pt’s*
- fatigue
- HoTN
- LOC
- dizzy
which AV blocks get a pacemaker?
Mobitz II
3rd degree
Third degree AV block Tx
Pacemaker (most effective tx for bradycardia)
First Degree AV Block Tx
Extended PR - can treat sx with atropine
Second degree Type I
Mobitz I or Wenckebach - progressively lengthening that leads to a dropped beat. Commonly a part of normal aging.
Second degree Type II
Mobitz II - just drops a beat with no lengthening (warning). Mobitz II can progress into a third degree AV block. EVERYONE GETS A PACEMAKER
Tx for post MI VTach
Fix ischemia, do an angiography for angioplasty or bypass
Risk of recurrence of VTach factor
Left ventricular function is the most important correlate of the risk of recurrence
Caustic ingestion managament
Check for perforation (CXR or lung sounds). Endoscopy to assess damage. Don’t give charcoal because caustic ingestion causes DAMAGE and you’re not trying to prevent systemic absorption.
TX for BB overdose?
glucagon
TX for CCB overdose?
calcium
mj juice - aka?
joke
propofol
EKG changes in SAH?
diffuse T wave inversions
