Orientation Review Flashcards
1
Q
Narcan
A
Best for pt with pinpoint pupils (not reliable), low RR, stigmata of narcotic use. Give 2mg to adult or child. Not in a helicopter or if intubated. SE vomiting, reports of HTN, pulmonary edema
2
Q
OPENING GAMBIT
A
- O2 2. O2 Sats 3. IV access 4. ECG monitoring 5. 12-lead EKG, +/- portable CXR
3
Q
PINPOINT PUPILS
A
opioid OD, pontine hemorrhage, cholingeric OD, organophsophage
4
Q
narcan dose for ROCLAVAX
A
10mg
5
Q
glucose dose for infant
A
D10 at 10cc/kg
6
Q
glucose dose for child
A
D25 at 4cc/kg
7
Q
glucose dose for adult
A
D50, give 50cc (1amp)=25g
8
Q
5 patients who need thiamine
A
- The cachectic calorie malnourished 2. disheveled alcoholic 3. malabsorption syndromes (short gut, gastric bypass, etc) 4. hyperemesis gravidarum 5. anorexia nervosa
9
Q
Wernicke’s Triad
A
- encephalopathic 2. ataxic 3. lateral rectus palsy/nystagmus
10
Q
Mneumonic for things that narcan can reverse. Name them
A
ROC-LAVA-X reserpine, opiates, clonidine, lomotil, ACEi/ARBs, valproate, aldomet (methyldopa), xanaflex (tizanadine, like soma)
11
Q
Causes of hypoglycemia
A
All hypoglycemics need it Re-ExPLAAAINeD Renal failure: insulinase in kidney. If little blood getting through, insulin not getting metabolized Exogenous insulin or oral hypoglycemics Pituitary insufficiency Liver disease: hepatitis, hepatoma, tylenol OD, etc Adrenal failure; Alcohol ingestion (esp in children); Aspirin toxicity Infection (sepsis UPO in children); Insulinoma Neoplasm: insulinoma, malnutrition, loss stores Drugs: ASA, oral agents, beta-blockers (block sympathetic outflow)
12
Q
Sulfonylurea overdose rx
A
octreotide-suppresses endogenous insulin secretion
13
Q
glucagon side effets
A
bad nausea and vomiting, rebound hypoglycemia
14
Q
How much does 1 amp D50 raise blood glucose?
A
200
15
Q
What if D50 doesn’t raise BGL?
A
think insulin or oral hypoglycemic OD
16
Q
How to make epi drip?
A
1mg epi in 1L of NS → 1mg/cc; piggy back into high flow IV with NS wide open Start at 1cc/min for 1µg/min. If no response @ 1-2 minutes → Increase to 2cc/min or 2µg/min
17
Q
Parkland formula
A
4cc/kg x BSA Burned; 1st ½ in the 1st 8 hours since burn; 2nd ½ in the next 16 hours (this is in addition to maintenance IVF!)
18
Q
Rule of 15
A
[Bicarb + 15] = expected PCO2 = expected last two digits of the pH
19
Q
Delta Gap
A
compare the (gap – 14) to the (bicarb – 24). Should be equal and in opposite direction for a single metabolic disturbance
20
Q
Osmoles and alcohols
A
346: Multiply osmolar gap x 3 for methanol mg %, x4 for ethanol, and x6 for isopropyl alcohol.
21
Q
GAP ACIDOSIS and a RESPIRATORY ALKALOSIS
A
SEPSIS with hyperventilationrule out ASA toxicityrule out Bleeding, and breathing hard due to pain Alcohol withdrawal; a keto-acidosis with tachypnea
22
Q
Anion-gap acidosis differential
A
MUDPILES Methanol Uremia DKA and other ketoacidoses paraldehyde isoniazid, iron lactic acidosis ethylene glycol salicylates
23
Q
Two types lactic acidosis
A
Type A = hypoxic tissue makes lactate (hypoperfusion, Carbon Monoxide, Cyanide, Methemoglobinemia) Type B = impaired lactate clearance (Iron, INH toxicity, Methanol, Salicylates, diabetes, sepsis, liver damage, alcoholism, Metformin, genetic)
24
Q
Non-anion gap acidosis
A
HAARD UPS Hyperventilation—chronic Adrenal insufficiency Acetazolamide Renal Tubular Acidosis Diarrhea Uretero-enteric diversion Pancreatic fistula Saline over-infusion in diarrhea
25
Treatment symptomatic hypoglycemia
1) 1 amp D50 2) Ask about DRUGS (short or long-acting insulin, sulfonylurea) and SUICIDALITY 3. GLUCAGON stimulates glycogenolysis/gluconeogenesis (!! N/V, rebound HYPOglycemia!!) 4. OCTREOTIDE for type-II diabetic or sulfonylurea OD, will suppress native insulin secretion 5. Watch the K+!!
26
Treatment thyrotoxicosis
(1) Dexamethasone (2) Propranolol (3) PTU (4) Oral potassium-iodide
27
Causes of hyperK
1) NOT – hemolyzed sample 2) Renal Failure 3) Acidosis 4) Adrenal insufficiency 5) Cell Breakdown—Rhabdo, Post-Ictal, Tumor Lysis
28
The 5 causes of Sine Wave on EKG and Their Treatments:
1) HyperK → Calcium Choloride 2) TCA overdose → NaBicarb 3) Beta-blocker overdose → glucagon, insulin, calcium 4) CaChannel blocker overdose → calcium, insulin 5) Severe Acidosis → NaBicarb
29
HyperK treatment
1. CaCl 10cc, max at 2 amps. This is for the wide QRS, stabilizes membranes 2. 10U Regular Insulin IV + 2amps D50 3. Albuterol or other Beta-Agonist 4. NaBicarb if acidotic 5. IV Fluids, especially in DKA, rhabdo, tumor lysis, adrenal insufficiency
30
1 U of insulin moves how much glucose into cell?
4g
31
The 5 EKG findings of Hypokalemia:
(1) Flat T (2) U wave (3) LONG QT (4) Non specific ST Wave changes (5) V-tach or Torsades
32
The 5+ causes of HypOKALemia:
(1) Insulin; (2) Alkalosis; (3) Albuterol, beta agonists; (4) Renal—diuretics, hyperaldosteronism; (5) GI—vomiting, diarrhea, fistula, pancreatic/biliary losses; (6) HypOMagnesemia (hypokalemia is a better indicator than the actual Mg level!)
33
When to give hypertonic saline in hyponatremia?
seizure, coma
34
How much hypertonic saline to give in hyponatremia with seizures?
100cc over 10minutes, then drip 100cc over 1 hour
35
Hyponatremia: sodium correction goals
Raise Na by 2-3mEq acutely. (Then, no more than 0.5mEq per hour or 12mEq per day)
36
The 5 causes of DKA
(1) Insulin lack (2) Indiscretion with sugar (3) Infection (4) Ischemia--brain, heart, bowel (5) Infant on board
37
DKA Treatment
The 5 treatments for DKA: 1. Fluid: 1L bolus, then 500cc/hr for 4 hours (too much = CEREBRAL EDEMA!) 2. Insulin: load 0.1 unit/kg IV -then- maintain 0.1 unit/kg/hr IV (subQ when Gap is closed), GIVE HOME DOSE LONG ACTING INSULIN 3. Potassium – If K \> 5.1, recheck in 1 hour. If K
38
When to add glucose in DKA?
-When blood glucose drops to about ~250, SLOW the insulin, ADD DEXTROSE.
39
When to add potassium in DKA treatment?
When K at 4.0
40
Treatment of AKA:
1. Hydrate (NS or D5NS) 2. Provide carbohydrate (sandwich) 3. Replete vitamins and minerals (banana bag) 4. Give K and magnesium (banana bag) 5. Treat underlying cause: pancreatitis, CNS, sepsis, pna, gi bleed, etc.
41
Hypercalcemia
1. NS (125-250cc/hr) to trade saline in, calcium out. 2. Lasix to insure good urine output. 3. Bisphosphonate (on admission).
42
5 causes of Altered Mental Status:
1. Vital Sign Abnormalitieshypoxia, hypercarbia, hypoperfusion, hypertensive encephalopathy, severe fever or hypothermia; 2. Toxic/Metabolic Hypoglycemia, high or low Sodium (not K), Acidosis/Alkalosis, Uremia, Hepatic encephalopathy, any drug or poison 3. Structural brain lesion—mass, bleed, demyelination 4. CNS infection—encephalitis, 5. Psychiatric causes, Dementia
43
Wrenn's seizure distinguishing characteristics
1. Post-Ictal State—confusion, paralysis, sore muscles, fatigue for hours 2. Amnestic during sz—will not recall a “lightheaded” feeling 3. Post-Ictal State—confusion, paralysis, sore muscles, fatigue for hours 4. Fell so hard there was trauma—head or tongue lac, as opposed to slumping or swooning 5. History of true seizure
44
Positive orthostatics
Systolic drop \>20, Diastolic \>5, or HR rises by 20 in 1 minute of standing
45
syncope workup
H&P, orthostatics, vital signs, ECG, CBC (anemia), electrolytes, BGL
46
San Fransisco syncope rules: admit if patient has any of the following
(a) history of CHF; (b) shortness of breath; (c) SBP \< 30
47
3 major categories for syncope causes
(1) Cardiovascular MI; PE; Tamponade; Arrhythmia (bradycardia most common); Aortic Stenosis (chest pain, short of breath, syncope); HOCM (syncope following exertion!!); Hypovolemia; autonomic dysfunction; carotid sinus hypersensitivity (turning head or neck surgery); pulmonary hypertension; \*\*Brugada syndrome (2) Neurologic \*Vertebrobasilar insufficiency/Subclavian Steal ; increased ICP (4) Neurovascular or metabolic Vaso-vagal syncope; Hypoglycemia
48
Vertebrobasilar insuffiency-symptoms?
(5D’s—Drop attack, Dizzy, Dysarthria, Dysphagia, Diplopia)
49
Brugada Syndrome ECG findings
triad of (1) Saddle-shaped ST elevation in V1-3; (2) RBBB; (3) T-wave inversion.
50
Seizures-5 causes
(1) vital sign abnormality—hypoxia, hypoperfusion, HTN emergency, Febrile (2) toxic/metabolic—hypoglycemia, hyponatremia, alcohol withdrawal, (3) structural brain lesion—mass, blood (4) CNS infection—herpes encephalitis (5)underlying seizure disorder, off of meds
51
vital sign abnormalities with seizure
hyperthermia, tachycardia (later bradycardia), hypoxia (and acidosis)
52
5 treatments of status seizures
1. ABC/NGT-turn on side (if not intubated!), protect, give O2, check sats, check GLUCOSE, narcan 2. Benzo-(ativan 1-2mg up to 6-8, IM too) 3. Consider causes with specific antidotes-if pregnant, give Mg 6 grams 4. Keppra 1g load, or phosphenytoin 20mg/kg @100-150mg/min 5. barbiturates (if you can manage airway)
53
Phenytoin vs. fosphenytoin
\*Phenytoin (the original) is slower, can cause hypotension, long QRS and Stevens Johnson’s syndrome \*Phosphenytoin is dosed the same but pushed faster, can cause asystole!
54
Alcoholic having seizure-what other diagnostic test to get?
CT
55
5 causes of seizures that need more than benzos
1. hypoxia-O2 2. hypoglycemia-D50 3. hyponatremia-hypertonic saline 4. ecclampsia-Mg 5. INH toxicity-B6 \*SAH and herpes encephalitis can cause sz refractory to benzos
56
Bell's palsy treatment
prednisone valtrex eye lube, tape shut at night, protect in wind
57
Discriminating HA features that are very worrisome
(1) WHOML, first migraine, sudden onset or syncopeSAH until proven otherwise (2) Coagulopathy— 1. heparin/coumadin/plavix; 2. dialysis (cyclical brain swelling/shrinking); 3. uremic (bad platelets); 4. liver dz (low Factor VII); 5. hemophiliac (3) Cancer or HIV—mass lesion (4)Trauma, even a few weeks ago—old SDH in elderly fall patient; older than 50 (5)Fever, stiff neck, altered mental status, focal neuro complaints/deficits
58
To do LP without head CT:
(1) non-focal exam; (2) normal mental status; (3) normal eyes including DISCs; (4) young and otherwise healthy. This never happens, and meningitis patients need antibiotics in 30 minutes, so… Blood Cx (50% will tell you the bug)Antibiotics (no change in cells, protein, glucose, or even gram stain in 4 hours)CTLP
59
Empiric tx of bacterial meningitis:
(1) Caffeine 250mg IV over 30 min (2) IV fluids (3) Caffeinated soda, 2 liters per day (4)Blood patch
60
The 5 treatments of Migraine:
1. Compazine 10mg (or Reglan, Phenergan, Thorazine, Droperidol—longQT!); 2. Benadryl 25mg 3. DHErgotamine-45 (not in old or pregnant) 4 .Morphine 5. Home on high dose Motrin
61
5 treatments of cluster headache
1. 100% O2 2. Intranasal Lidocaine 4% on soaked gauze; 3. Proparicaine in affected eye 4. Migraine remedies 5. Home on 2 weeks Prednisone 40-60mg with taper
62
Management of TIA/Acute Stroke
ABCs—prevention by keeping NPO N/G/T—check for hypoglycemia Activate Stroke Team Stat head CT Thrombolytics within 3 hours of symptoms
63
Special studies for TIA
(1) Carotid duplex; (2) MRI/MRA; (3) TEE
64
Send ?stroke/?TIA pts home on
Send home on: (1) ASA; (2) Plavix if already on ASA; (3) heparin/coumadin if already on plavix
65
Risk of stroke after TIA
10% within 3 month, half of these occur within first 48 hours
66
10 Red Flags of Back Pain:
1. Extremes of age 2. Female with highrer risk of osteoporosis and fracture 3. Fever 4. Neurologic symptoms, weakness, incontinence Historical: 5. h/o CA or immunosuppression 6. h/o trauma 7. h/o bowel or bladder dysfunction 8. h/o weight loss 9. h/o IVDA 10. h/o steroid or other immunpsuppressing meds
67
Indications for intubation:
Failure to maintain airway—altered LOC, no gag Failure to oxygenate (sats dropping) or ventilate (PCO2 rising) Multisystem instability—severe shock, crashing, physiologic reserve waning Projected Clinical Course—e.g. airway swelling after burn resuscitation Need for transport/definitive tests—combative, harmful to self
68
Problem with ventilator
DOPE; Displacement of tube, Obstruction of tube or airway, Pneumothorax, Equipment failure.
69
Patient on a ventilator goes into PEA
hink PTX or hypotension from high intrathoracic pressure due to breath stacking. Tx = disconnect the vent, allow a few seconds of exhalation (Breath Stacking causing decreased preload, hypotension, arrest), bag, check for PTX.
70
Patient in status asthmaticus is getting better, then goes into PEA
worry about two causes immediately: Hypoxia and Pneumothorax. Tx = Bag ventilate, needle the chest.
71
5 causes of Hypoxia:
1. VQ mismatch (the common lung diseases): PNA, Asthma, COPD, Atalectasis, PE, pulmonary edema, ARDS 2. Shunt: cardiac defect with RL shunt. Will NOT improve with supplemental O2 3. Diffusion defect: interstitial lung disease 4. Hypoventilation: resp depression, CNS injury, peripheral neuromuscular dz, chest wall rigidity 5. Low Fi02: altitude, SCUBA system malfunction \*items 1, 2, and 3 give you a large A-a gradient.
72
Lower limit of PaO2 =
96 – [age/4]
73
A-a Gradient =
PaO2 from blood gas – [150 – (PCO2 from blood gas / 0.8)]
74
3 causes of “Saturation Gap”
1. CO poisoning (headache, nausea, vomiting, abd cramps, in houseboat/trailer/ice-storm, cherry red, perfect SaO2). 270/90/30: Half-life 270 min to resolve on room air, 90 min on 100% O2, and 30 min in hyperbaric O2 chamber 2. Methemoglobinemia (PaO2 of exactly 88%, blue-grey skin, smoke inhalation?) 3. Cyanide poisoning (overdose of nitrates, smoke inhalation?) Perfect SaO2
75
Cyanosis and relationship to Hb
Cyanosis occurs with absolute 3-5 grams deoxy-Hb. (i.e. cyanosis occurs at higher SaO2 if polycythemic, or lower SaO2 if anemic)
76
Anaphylaxis-5 causes
(1) Drugs (2) Contrast (3) Transfusion (4) Food (5) Stings
77
5 treatments for Anaphylaxis
EPI 0.3mg 1:1000 IM for adult, (0.1 for cardiac risk, 0.01/kg for child) Benadryl 25mg IV (as effective as 50mg, with less side effect) H2 blocker of choice Solumedrol 80 or 125mg IV IV Fluids +/- epi drip (= 1cc 1:1000 in 250cc NS piggyback at 15 uDrops per minute)
78
5 causes of Wheezing:
1. Reactive Airways--asthma, COPD, allergies, inhalation pneumonitis. (Clues include hx of the disease, response to nebs, FEV1 or peak flow before and after nebs, road test) 2. CHF--check a BNP; 3. Mass effect--foreign body, tumor, pneumonia, interstitial lung disease; 4. Pneumothorax; 5. Pulmonary embolism—broncho-active molecules released under ischemia, might improve with nebs, don’t be fooled
79
Asthma exacerbation treatment
1. Oxygen 2. Albuterol, nebulized or inhaler with spacer Ipratropium added to one or more of the nebulizers 3. Steroids: Solumedrol 80 or 125mg IV 4. Magnesium: 2 grams IV over 10 minutes, 0.5 grams/hour. Only useful in severe attack, do NOT use if hypotensive or renal failure! 5. Terbutaline, or 6. Epinephrine: 0.3mg 1:1000 subQ x 1; \<\> 7. CPAP or BiPAP: if normal mental status 8. Inubation: if tiring out, decreasing mental status. will only have about 15 seconds before the O2 sat starts to drop
80
Unilateral leg swelling-causes
(1) Cellulitis (2) Trauma (3) DVT (4) ruptured Baker’s cyst (5)lymphatic obstruction by tumor or parasite
81
PNA abx
Inpt CA-rocephin + azithro HACP: add coverage pseudomonas (zosyn), MRSA (van) immunocompromised-consider bactrim and steroids for PCP Tb? be sure to isolte
82
Pneumonia disposition decision
CURB-65 Confusion Uremia RR \>30 BP
83
Low-molecular weight heparin is bad in:
renal failure, obesity; can still see HIT in LMWH
84
7 deadly causes of CP
1. ACS 2. Aortic Dissection 3. Tamponade/effusion/carditis 4. Esophageal rupture/Boerhaaves 5. Pulmonary embolism 6. Pneumothorax 7. Pneumonia
85
7 deadly causes of Shortness of Breath:
1. Upper Airway obstruction-FB, anaphylaxis, vocal cord spasm 2. Reactive airway disease exacerbation 3. PE 4. pulmonary edema/heart failure 5. PTX 6. PNA 7. ACS
86
Aortic dissection rule questions to ask
maximal at onset, tearing or ripping pain into back, migratory
87
Questions to ask possible ACS which make it less likely
Ask sharp? Pleuritic or reproducible? No heart dz? 48 hr of steady pain (“yes” to these three makes ACS 1% likely
88
Aortic dissection workup/treatment
Get both arm BP, CBC, BMP, Coags, Type+Cross, CXR, spiral CT of chest or TEE, esmolol for BP control
89
Tamponade signs
distended neck veins (but clear lungs on CXR), muffled heart sounds, hypotension
90
Nitroglycerin contraindications
Vital signs: SBP100 or \<50 RV or Inferior MI Recent Viagra, Cialis, Levitra Valvulopathy or Cardiomyopathy Bezold-Jarisch reflex hypersensitivity (nausea and vomiting due to vagal tone)
91
Nitro dose in CP
0.4mg sublingual X3
92
beta-blocker contraindications
HR 120 SBP\<120 Acute CHF or low cardiac output ANY heart block Asthma/RAD/COPD
93
Treatment for Cocaine-associated chest pain:
Aspirin Ativan or Valium Nitroglycerin or nitro drip always obtain repeat 12-lead and enzymes consider further anti-platelet/anticoagulation if also high risk for MI
94
5 "MIs" (elevated troponins) that aren't MIs
Demand Ischemia PE Myocarditis CHF Sepsis
95
MI patient with pulmonary edema
NO beta-blocker, give lots nitroglycerin, go to cath lab instead of thrombolytics
96
MI pt with inferior MI/hypotension/shock
no nitroglycerin; add fluid bolus
97
MI management-go
ABCDE O2/IV/Monitor/12-lead/CXR: e.g. Sinus rhythm with ST elevations in I/ aVL /V6 5 vital signs: e.g. 154/92; 90; 22; 97% on 4L NC; 98.0F REPEAT ECG in 10-20 minutes; draw CBC, BMP, Coags, Enzymes Immediate Interventions ASA 325mg PO chewed x 1 if not allergic / PLAVIX 600mg PO if not bleeding \*NTG 0.4mg Sublingual x 3 if no contraindications \*Consider B-blocker for uncontrolled HTN/tachycardia with no contraindications Lovanox 1mg/kg SubQ \*Thrombolytics or PCI-balloon
98
5 treatments of PULMONARY EDEMA
Oxygen Nitroglycerin drip, start at 10mcg, max out Albuterol only if wheezing IV lasix 40mg if CXR evidence of edema CPAP if good BP and mental status
99
5 reversible causes of Cardiac Tamponade.
(1) Trauma (2) Uremia (3) Infection/TB (4) Malignant effusion—breast CA or lymphoma (5) Rheumatic effusion—RA/SLE
100
BP lowering limits in hypertensive emergency
no more than 25% in first hour
101
5 main organs damaged in hypertensive emergency
Brain Eyes Heart Lungs Kidneys
Brain—focal signs or altered mental status
Eye—papilledema, flame hemorrhages
Lungs—flash pulm edema with shortness of breath. Get CXR
Heart—chest paincheck pulses and BP in BOTH arms for right-to-left drop indicative of Aortic Dissection, get EKG
Kidney—microscopic hematuriado a UA on HTN pts.
102
Treatments for hypertensive emergency
Nicardipine drip 4-15mg IV per hour. Becoming the standard
Nitroprusside drip 5ugm IV per min, titrate up 5X5.
Can Increase ICP!
Builds up thiocyanate in renal failure—acts like lidocaine toxicity!
Adverse events reported in ACS!
ACS, CHF, and cocaine intoxication: Nitroglycerin drip 5ugm IV per min., then Lasix
Head trauma/high ICP: Nicardipine
Eclampsia: Labetolol with MgSO4
Aortic Dissection: Esmolol drip, titrate to heart rate of 55
Wt(kg)/2 = Loading dose, then loading dose/10 per minute (80kg, 40mgload,4mg/min)
Alcohol withdrawal or cocaine intoxication: Ativan, goal:drowsy – redose every 2-4mg q 5 min
Heroin withdrawal or rebound HTN: Clonidine
Pheochromocytoma or Autonomic Dysreflexia (the paraplegic who can’t feel anything but has increased sympathetic tone due to fecal or urinary retention): Phentolamine (alpha-blockade), 2nd line – spinal anethesia.
HTN and unrelated complaint: Beta-blocker
-HTN urgency are high renin states with vasoconstriction and fluid depletion, need maintenance fluids.
103
Aortic dissection-esmolol dosing
Give loading dose then maintenance dose, titrate to HR of 55. Loading dose=wt in kg /2 Maint dose=loading dose/10 per minute
104
alcohol withdrawal treatment
Benzos. Give Ativan or Valium. Titrate to effect, not a fixed dose. Fluids/Lytes/Supplements. A Banana Bag
105
banana bag components
ne liter of D5NS at 200cc/hour, containing 1 amp multivitamin, 100mg thiamine, 20-40mEq K, 2grams Mg
106
5 phases of Alcohol Withdrawal:
(1) tremulous/tachycardia/anxious in 6-8 hours (2) Seizures in 24 hours (3) hallucinosis in 24-48 hours (4) Delirium Tremens = acting wild/all vitals elevated/need to be restrained in 3-5 days (5) post-abstinence personality changes
107
Monocular Vision Loss: GO CART MTV
glaucoma optic neurtitis CRAO, CRVO amaurosis fugax retinal detachment retina trauma migraine temporal arteritis vitreous hemorrhage
108
EKG rates to know-300, \>200, \>160, exactly 150,
300—max in human. Rate \> 300 = artifact \>200 is a bypass tract (WPW) \>160 is usually re-entry (AVNRT/AVRT) exactly 150 is A-flutter with 2:1 block
109
Other things not to miss on ECG
hyperK, S1Q3T3 (PE), PR depression (pericarditis), Delta Waves (WPS), flutter waves, increased QT, Brugadda (v1-v2), Q-S Wave (Left ventricular aneurysm)
110
Deadly causes of sinus tachycardia
Hypoxia Shock Pulmonary Embolism Pericarditis/Myocarditis Thyrotoxicosis Pheochromocytoma
111
8 non-ischemic causes of ST elevation
Early Repolarization LVH Bundle Branch Block Pericarditis Hyperkalemia (V1-2) Ventricular Aneurysm (with Deep Q-S waves, don’t give lytics!!) WPW or bypass tract Brugada syndrome
112
5 causes of low voltage
(1) Pericardial effusion (2) Infiltration of amyloid, sarcoid, hemochromatosis, glycogen storage (3) COPD (V1-V3) or PTX (V4-V6) (4) Myxedema coma (Hypothyroidism) (5) obesity/anasarca/edema
113
5 EKG findings in hyperK (in order)
(1) Peaked T (2) Flat P (3) Short PR (4) QRS widens (5) Sine wave
114
5 EKG findings in hypoK (in order)
(1) Flat T (2) U wave (3) LONG QT (4) Non specific ST Wave changes (5) V-tach or Torsades
115
5 causes of long QT
Drugs—Benadryl, anti-psychotics, levofloxacin/moxifloxacin, quinine Hypo’s—K/Mg/Ca Hypo’s—thermia or –thyroid Increased ICP Genetic—Ramano Ward/Jervell-Lange-Neilson
116
5 causes of syncope seen on EKG
Long QT LVH Right Heart Strain WPW Brugadda
117
5 EKG findings that could be PE
Right Axis Deviation RBBB A-fib or A-flutter Unexpected tachycardia S1Q3T3
118
The 5 causes of PVCs and Ventricular Ectopy
Hypoxia; know the O2 sat, consider CO poisoning with false 100% sats Ischemia; get some enzymes and another 12-lead Electrolytes; K, Mg; Look at QT interval! Check the BMP, supplement Sympathetic tone; increased ICP!!, pressors, cocaine, alcohol withdrawal (is Ativan your antiarrhythmic?), Severe pH issue; check an ABG on the ventilated or the sick-as-shit patient
119
Dr Lown and PVCs
Dr. Lown predicts increasing risk of V-fib in pts with ACS based on frequency (\>5/min) and complexity of PVCs
120
Frequent PACs
must consider atrial distension from high end-diastolic pressure Occult heart failure
121
5 heart blocks and their causes
1st degree: Degenerative—B-blocker, CaChannel-blocker, lupus, ARF, Lyme disease 2nd degree I—Post MI! Digoxin, B-blocker, CaChannel-blocker, Lyme disease 2nd degree II—Anterior infarct!bad, try to open the artery and need to pace (will progress) 3rd degree—Ischemia, RCA lesion! sick sinus Left Bundle Branch Block—must rule out MI! Always consider ischemia as cause in pt with heart block
122
The 5 causes of Sine Wave on EKG and Their Treatments:
1) HyperK → Calcium Choloride 2) TCA overdose → NaBicarb 3) Beta-blocker overdose → glucagon, insulin, calcium 4) CaChannel blocker overdose → calcium, insulin 5) Severe Acidosis → NaBicarb If you treat hyperK, you will essentially treat all other causes of SINE WAVE.
123
The 5 treatments for Hyperkalemia
1. CaCl 10cc, max at 2 amps. This is for the wide QRS, stabilizes membranes 2. D50 x 2 amps plus Regular Insulin 10 Units IV (D50 unnecessary if glucose\>250) 3. Albuterol or other Beta-Agonist 4. NaBicarb if acidotic 5. IV Fluids, especially in DKA, rhabdo, tumor lysis, adrenal insufficiency
124
The 5 things that drive K into a cell:
(1) Insulin (2) beta agonist (3) rising pH (4) Sodium (5) Magnesium
125
Rhabdomyolysis Treatment:
1. IV fluids to obtain urine output of 1.5-2 cc/kg/hr or 200cc/hr 2. NaBicarb to alkalinize urine (may use acetazolamide) 3. Mannitol ONCE EUVOLEMIC to increase urine output
126
The 5 causes of DKA (the 5 UNDERLYING I’s)
(1) Insulin lack
(2) Indiscretion with sugar
(3) Infection
(4) Ischemia--brain, heart, bowel
(5) Infant on board
127
The 5 causes of Seizures:
1. vital sign abnormality—hypoxia, hypoperfusion, HTN emergency, Febrile
2. toxic/metabolic—hypoglycemia, hyponatremia, alcohol withdrawal,
3. structural brain lesion—mass, blood
4. CNS infection—herpes encephalitis
5. underlying seizure disorder, off of meds
128
10 Red Flags of Back Pain:
Demographics:
1. Extremes of age
2. Female with hirer risk of osteoporosis and fracture
PE findings:
3. Fever
4. Neurologic symptoms, weakness, incontinence
Historical:
5. h/o CA or immunosuppression
6. h/o trauma
7. h/o bowel or bladder dysfunction
8. h/o weight loss
9. h/o IVDA
10. h/o steroid or other immunpsuppressing meds
129
The 5+ treatments of Asthma Exacerbation
1. Oxygen
2. Albuterol, nebulized or inhaler with spacer
3. Ipratropium added to one or more of the nebulizers
4. Steroids: Solumedrol 80 or 125mg IV
5. Magnesium: 2 grams IV over 10 minutes, 0.5 grams/hour. Only useful in severe attack, do NOT use if hypotensive or renal failure!
6. Terbutaline, or
7. Epinephrine: 0.3mg 1:1000 subQ x 1;
\<>
1. CPAP or BiPAP: if normal mental status
2. Inubation: if tiring out, decreasing mental status. will only have about 15 seconds before the O2 sat starts to drop
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There are no clinical or CXR findings that reliably tell you what bug you’re treating, but:
“XR worse than patient” or bullous myringitis =
“patient worse than XR” might
“multilobe pna with pus pockets”
“rigors and rusty sputum”
There are no clinical or CXR findings that reliably tell you what bug you’re treating, but:
“XR worse than patient” or bullous myringitis = mycoplasm
“patient worse than XR” might = PCP, get HIV test (LDH is worthless)
“multilobe pna with pus pockets” – S. aureus
“rigors and rusty sputum” – S. pneumo
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Treatment of Methanol O/D
ABCs
Consider NGT (glucose, thiamine, banana bag)
Reverse Acidosis (1 amp of bicarb for each 0.1 under 7.35 – 1meq over 5-10m increase 0.1)
Block Metabolism (fomipazole 15 mg/kg then 10mg/kg IV q12h)
Enhance Elimination (HD if sx with levels \>25-50%)
(Ethylene glycol is same treatment except pyridoxine to assist in metabolism)
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Hypothermia: 5 EKG findings:
(1) J/Osborne wave—risk of re-warming arrhythmia
(2) Sinus brady
(3) Slow A-fib
(4) long QT
(5) V-fib that doesn’t respond to drugs or shocks.
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The 5 treatments of Hypothermia:
REWARMING with warm lights, warm blankets, warm IV fluids, warm gut lavage.
Narcan, glucose, thiamine—the malnourished, drugged out, street person passes out in the cold
Antibiotics—elderly get hypothermic in sepsis
Steroids—is this a metabolic catastrophe?
Synthroid—is this myxedema coma?
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Three times to NOT give atropine to bradycardia (3H’s)
Hypothermia, Hypoxia, Head trauma
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5 Hyperthermic syndromes:
(1) Heat stroke
(2) Thyrotoxicosis
(3) neuroleptic malignant syndrome
(4) Serotonin syndrome
(5) malignant hyperthermia
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The 5 treatments of Heat Stroke
Wet and Windy—avoid ice immersion, slow down when reaching 102-103F
Benzos for shivering
IV fluids, but slowly (usually not hypovolemic, but watch for “cold diuresis”)
Support of organ failure in the ICU—Delerium, hepatitis, renal failure, DIC, ARDS
Search for co-morbid illness—the elderly lady with heat stroke by radiation may be immobile, have occult UTI or PNA; the marathon runner with heat stroke by exertion may have carbon monoxide poisoning, hypoglycemia, or dehydration as well
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Digitalis toxicity:
Blocks NaKATPase, increases intracellular calcium. Pt feels sick, sees yellow-green halos, gets confused.
- EKG findings?
- treatment?
- Dig EXCITES AND BLOCKS: Junctional Rhythm, PSVT with block.
- Syndrome includes: PR \>200, Bradycardia, ST depression in V4-V6 in “hockey stick” pattern and most common EKG finding is frequent PVCs.
- Treat with Magnesium and 5 vials of Digibind. Do NOT give calcium.
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Digitalis and potassium
- Acute Digitalis O/D produces Hyperkalemia.
- Hypokalemia leaves you prone to Digitalis Toxicity
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ASA Toxicity: Lab findings and treatment
D5W with 3 amps of Nabicarb, 40meq of K+ at 200cc/hr.
Metabolic Acidosis → Nabicarb (to alkalize urine)
Hypoglycemia → glucose
Hypokalemia → K+
Volume depletion/hypotension → volume
Edema (ARDS, cerebral) → Judicious
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Alkalinization for ASA vs. TCA OD
In ASA, alkalinize URINE (goal \>7.5)
-improves excretion
In TCA, alkalinize SERUM
- increases protein binding, decreases active TVA
- PUSH bicarb if wide QRS
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What things can be dialyzed?
TPALS
Theophylline
Phenobarbitol, potassium
Alcohols (methanol, ethylene glycol)
Lithium
Salicylates
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Sgarboassa Criteria-Read through LBBB to find an infarct
Specific but not sensitive; therefore go to PCI or lytics in any patient with Sgarbossa score of **\>3** or new LBBB
CONcordant ST elevation \> 1mm (5pts)
DIScordant ST elevation \> 5mm (2pt)
ST depression \> 1mm in V1,2,3 (3pts)
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"All waves negative in lead I"
think limb lead reversal (could also be dextrocardia-look at V1-V6)
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“Tall, positive, late R-wave in aVR (where all waves should be negative)”
TCA overdose
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3rd degree AV block may be a sign of occlusion of what artery
RCA (AV node is supplied by RCA 90% of time)
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The 5 types of SVT and their causes and treatments
1. Sinus tachycardia—regular, \<140, true p wave. Look for underlying cause—pain, fever, thyroid, shock, PE, cocaine, anemia (occult blood in stool?)
2. AVRT/AVNRT—regular, \>160. Vagal maneuvers, adenosine, synchronized shock. Adenosine failure usually from the IV being too far from heart or identifying wrong rhythm.
3. A-flutter—regular, 150, flutter wave. Fairly stable. Use diltiazem for rate control.
4. A-fib with RVR—irregular, narrow, fast, no P wave. Goals of treatment are rate control and anti-coagulation. Avoid converting in the ED unless absolutely sure onset \<24-48 hours ago. \*Diltiazem and Lovanox, then refer to cardiology. No difference in mortality between converting or just rate control+anticoag. May admit for TEE to evaluate for mural thrombus.
HTN (most common cause)
Alcohol (most common cause under 45 years old)
Ischemic/CAD (15% post-MI get this)
Sympathomimetics, cocaine, caffeine
Thyrotoxicosis
Embolic—PE
Pericarditis
Rheumatic fever with mitral stenosis
5. Multi-focal Atrial Tachycardia—irregular, P waves vary in morphology. This is a rhythm of chronic hypoxia and COPD. Mortality is 25%. Fairly stable, but if rate is too fast or patient has symptoms—first line therapy is magnesium 2 grams IV over 10 minutes (!! can’t give B-blocker or CaChannel blocker because of COPD). Also get a theophylline level.
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The 7 deadly causes of sore throat:
Peritonsillar abscess—teens already treated for strep throat, bulging tonsil, uvula pushed away
Retropharyngeal abscess—spontaneous in kindergarten age kid
Epiglottitis—now in adults, no stridor or drooling, fat red uvula, pain out of proportion. Directly visualize the epiglottis, get lateral neck soft tissue XR (85% sensitive)
Diptheria—immigrants and old women
Ludwig’s Angina—anaerobes, brawny/tense edema of anterior neck
Vincent’s Angina—ulcerating gingivitis, anaerobic tooth infection, fistulas into great vessels
Lemiere’s syndrome—Septic thrombophlebitis of the internal jugular vein from fistula
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“Centor criteria” for Strep Throat”
(1) Lack of rhinitis or cough
(2) Anterior cervical LAD
(3) Any exudates
(4) Fever, even subjective.
- Score of 0-1 means \<5% chance of strep. No test, no treatment
- Score of 2 means unsure, 5-50% chance of strep. Rapid strep test, treat if positive
- Score of 3-4 means \>50% chance of strep. No test, just treat (reduce duration and prevent transmission)
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Strep throat treatment
Treatment: 1.2 million U of benzathine in butt, 2 days of PO PenVK, 2 days of prednisone, new toothbrush. Tx does not prevent glomerulonephritis or peritonsillar abscess. Number Needed to Treat to prevent rheumatism is 1000.
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Purpura/Petechiae:
1. Infections (RMSF, meningococcemia)
2. Leukemia
3. Low Platlets (ITP/TTP)
4. Vasculitis (HUS, HSP)
5. Bleeding d/o (vW syndrome)
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TTP Signs/Symptoms:
"FAT RN"
Thrombocytopenia (\<20K)
Hemolytic Anemia (hgb \< 10)
mild renal dysfunction
Neurologic Symptoms (HA or AMS)
Fever
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TTP Causes:
Idiopathic
Familial
Drugs (plavix, quinine, ticlodipine, opana)
Post-partum
Infections-HIV
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DDX of Rash involving palms and soles
MRS. TECK
Meningococcemia
Rickettsial/RMSF
Syphilis
Toxic Shock Syndrome
Erythema Multiforme
Coxsackie
Kawasaki
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Rhogam:
\< 12 wks – 50 mcg IM
\>12 wks – 300 mcg IM
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Post-partum Hemorrhage:
Uterine Massage
Oxytocin 40U in 1L, 20cc/min
Methergine IM 0.2 mg
Carboprost (Hemabait) IM 0.25 mg
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STDs
PID Treatment: Ceftriaxone 250mg IM plus Doxycycline 100mg BID x 14 days
Trichomoniasis: Flagyl 2 grams x 1 dose
Chlamydia: Azithromycin 1 gram x 1 dose
Gonorrhea: Ceftriaxone 125mg IM
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SICK YOUNG BABY "THE MISFITS"
Trauma
Heart disease, hypovoluemia
Electrolytes
Metabolic
Inborn errors of metabolism
Sespis
Formula mishap (dilution, overconcentrated)
Intestinal Catastrophe
Seziures, other CNS abnorms.
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HSP "ARENA"
abdominal pain, rash, edema, nephritis, arthritis
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