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EM Final Study Guide > Pages 11-20 > Flashcards

Pages 11-20 Flashcards

1
Q

Critical decisions and interventions in pneumonia?

A
  1. Appropriate room w/ standard and droplet precautions.
  2. Full set of vital signs w/ pulse ox
  3. Supplemental oxygen for hypoxic patients.
  4. Evaluate mental status and ability to protect airway
  5. If hypotensive: 2 IVs should be established
    - Normal saline or lactated ringers
    - Should hypotension not respond to fluids, pressors
  6. Antibiotics once diagnosis made
    - Early administration improves outcomes
  7. IVF
  8. O2
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2
Q

Diagnostic testing for pneumonia?

A
  1. CXR: may not show early in illness
    - If H/P strongly suggest, absence of infiltrate doesn’t prevent the diagnosis and treatment.
  2. ABG: not needed for most patients
    - Useful when considering intubation
  3. Sputum evaluation: sensitivity is around 50%
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3
Q

What can lateral CXR show in pneumonia?

A

Infiltrate in a retrocardiac location

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4
Q

When are Lobar infiltrates seen?

A

Bacterial infections

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5
Q

When are Interstitial patterns seen?

A

Pneumocystis carinii and Mycoplasma

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6
Q

When are Cavitary lesions seen?

A

TB or fungal infection

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7
Q

When are Pulmonary abscesses seen?

A

Staphylococcus or Klebsiella

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8
Q

Bad prognostic signs for pneumonia in ABG?

A

Respiratory acidosis with elevation of pCO2 worrisome for impending respiratory failure

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9
Q

Sign of good sputum sample in pnuemonia

A

Less than 10 squamous cells per HPF and greater than 25 WBC per HPF

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10
Q

Abx for CAP?

A
  1. Doxycycline
  2. Macrolides
  3. Sulfonamides
  4. Fluoroquinolones
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11
Q

Abx for Aspiration pneumonia?

A
  1. Ampicillin/sulbactam
  2. Piperacillin/tazobactam
  3. Clindamycin + aminoglycoside
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12
Q

Abx for Nosocomial pnuemonia?

A
  1. Antipseudomonal B-Lactam Plus:
    a. Piperacillin/ tazobactam
    b. Imipenem
    c. Meropenem
    d. Cefepime or Ceftazidime
  2. Anti-MRSA agent:
    a. Vancomycin
    b. Linezolid
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13
Q

Abx for pneumonia in kids?

A
  1. Amoxicillin

2. Macrolides

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14
Q

Curb 65 Criteria?

A

One point for each:

  1. Confusion
  2. Urea greater than 19
  3. Respiratory rate over 30
  4. SBP under 90 or DBP under 60
  5. Age over 65
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15
Q

Curb 65 recs?

A

0-1: Treat as an outpatient
2-3: short stay or watch as outpatient
4-5: Hospitalization, maybe ICU

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16
Q

When do asthmatics need rapid tube intubation?

A

Severe respiratory distress AND one of the following:

  1. Albuterol or other therapies do not reverse symptoms
  2. Significant hypoxia even with O2
  3. Too tired to breathe on own
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17
Q

How often do asthmatics need airway management?

A

Acute asthma requires airway management in less than 1% of patients

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18
Q

How is O2 administered in acute asthma?

A

Usually administered w/ aerosolized B2-adrenergic bronchodilator at 6-8 L / min in a nasal cannula (mild exacerbations) or a non-rebreather (severe exacerbations)

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19
Q

Goal of O2 therapy in acute asthma?

A

SpO2 more than 92%

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20
Q

Management severe acute asthma exacerbation that is not improving with aerosolized albuterol?

A

1a. Subcutaneous epinephrine 0.2 mg
or
1b. Terbutaline 0.25 mg
2. Corticosteroids oral or IV: onset 4-6 hours

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21
Q

Negative side effects of epinephrine?

A

B1 and a-effects which can lead to tachycardia or myocardial ischemia

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22
Q

What is the best predictor of result in acute asthma exacerbation?

A

Results at 1 hour after initiation of treatment of PFTs and peak flow

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23
Q

How often can nebulized albuterol be used?

A

Every 20 minutes for up to 3 dose
- Higher doses of a continuous albuterol via a nebulizer is not necessarily more effective than repeated lower doses, but is frequently used in patients with severe exacerbations or when the patient does not respond to the initial 3 doses

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24
Q

What is Ipratropium and when is it used? Best route?

A

Anticholinergic agent used in severe asthma or Beta-blocker induced asthma

  • There is evidence that combining it with a β2-adrenergic agonists may provide additional benefit compared to a β2-adrenergic agonists alone
  • IM faster and more consistent delivery than SC
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25
Q

Can theophylline be used in acute asthma exacerbation?

A

Not recommended in acute asthma

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26
Q

Is there evidence for use of Non-invasive positive pressure ventilation (NPPV) in acute asthma?

A
  • Provides inspiratory assistance as well as PEEP
  • Enhances patient breathing in acute respiratory conditions by providing rest in patients w/ significant work of breathing and early fatigue
  • Use in COPD and CHF patients has been well established
  • Use in acute asthma has been studied and is promising, but needs further evidence
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27
Q

Goal before discharge in acute asthmatic?

A

To obtain more than 70 percent predicted or personal best FEV1 or PEFR

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28
Q

Describe the treatment of COPD exacerbation?

A
  1. Oxygen: to all hypoxic patients w/ suspected COPD
    - Use Venturi mask NC
    - Avoid use of a non-rebreather mask with 15 L/min of oxygen, unless not responding to lower flow rates
    - In patients w/ chronic CO2 retention, may cause respiratory depression w/ the rapid rise in O2 depressing central ventilatory drive
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29
Q

Next step after O2 in COPD exacerbation?

A

1a. Albuterol : bronchodilators provide most rapid response
- Even after multiple doses a response may occur
- No role for long acting B-agonists (salmeterol)
or
1b) Ipratropium bromide: given every 4 hours
- Combination therapy is not superior

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30
Q

Use of steroids in COPD exacerbation? Difference in treatment course from asthma?

A
  • IV steroid such as methylprednisolone or prednisone orally should be started in the ED to help treat inflammatory component
  • Typical regimens are 10-14 days with tapering doses in contrast to 5 day pulse therapy w/ asthma
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31
Q

When to use antibiotics in COPD exacerbation?

A

Used if signs of infection are present AND in patients with moderate to severe exacerbations

32
Q

Next step in COPD if not responding to pharm?

A

NPPV by facemask aids oxygen delivery and decreases work of breathing

  • Start early before acute neurologic deterioration or respiratory depression
  • Respiratory therapist is invaluable in mgmt
33
Q

Ventilator settings in COPD exacerbation?

A
  • TV of 4-5 ml / kg of ideal body weight
  • Initial flow is typically 50-100%
  • Initial mode is typically assist control with a fixed number of ventilations being delivered even if the patient is paralyzed or taking insufficient breaths per minute
34
Q

How to handle elevated peak pressures in COPD intubation?

A

Can become increased due to a stacking phenomenon

- Relieve by disconnecting ET and then start w/ a more prolonged expiratory phase or decreasing minute ventilation

35
Q

When are primary pneumothorax secondary pneumothorax commonly seen?

A
  1. Primary: patients w/ no underlying pulmonary disease - Most common in thin, young males with history of tobacco use
  2. Secondary: patients with underlying pulmonary disease
36
Q

Presentation of pneumothorax?

A
  1. Sudden onset of sharp chest pain, often unilateral
  2. SOB: often increases over time as pneumothorax grows
  3. Cough
  4. Occasionally pain more prominent in back/shoulder
  5. Tachycardia/tachypnea and
  6. Hypoxia
  7. Hypotension
37
Q

Most common procedures to cause a pneumothorax?

A
  1. Central line
  2. Thoracentesis
  3. Pacemaker
  4. Tracheostomy
  5. Biopsy
  6. CPR
  7. PPV
38
Q

Rx tension pneumothorax?

A

Needle decompression in the 2nd intercostal space at midclavicular line

  • If successful, a chest tube should be placed as needle decompression is only temporizing
  • Converts tension pneumothorax to simple pneumothorax
39
Q

Definition of Large pneumothorax and Rx?

A

Greater than 20%

- Chest tube is usually indicated

40
Q

Abx for open fracture?

A

Cefazolin

41
Q

When to use MRI in orthopedic complaint?

A

Objective weakness NOT related to pain, loss of bladder fxn, or suspicion for epidural abscess

42
Q

What is nursemaids elbow and rx?

A

Elbow Held adducted, semiflexed, prone

  • Radial head displaced from annular ligament
  • Hyperpronation reduction works best
43
Q

Risk factors for septic joint?

A
  1. IV drug use
  2. EtOH
  3. DM
  4. Skin infection
  5. HIV
  6. Immunocompromisation
  7. Arthritis
  8. Joint infection or replacement.
44
Q

Diagnosis septic joint?

A

Aspiration:

  • Synovial lactate > 10mmol/L
  • Synovial WBC 50,000
45
Q

Coverage and ABX in septic joint?

A

Cover staff and Neisseria

- Combination of pen / ent or a later-gen cephalosporin

46
Q

Rx scaphoid injury?

A

Thumb spica immobilization

47
Q

Vascular source of scaphoid

A

Radial artery

48
Q

What is NEXUS criteria and what is it used for?

A

To determine if cervical imaging needed in blunt trauma:

1) NO TENDERNESS at posterior midline
2) No focal neuro def
3) Normal level of alertness
4) No intoxication
5) No distracting injury

49
Q

Ottawa Knee rules?

A
  1. Age>55
  2. Pain at patella or head of fibula
  3. Inability to take 4 steps
  4. Inability to flex to 90 degrees
50
Q

Ottawa Ankle rules?

A
  1. Pain at Posterior edge of Med/Lat Malleoli
  2. Base of 5th Metatarsal
  3. Medial aspect of Navicular
    OR
  4. Inability to bear weight for 4 steps
51
Q

Signs and symptoms of compartment syndrome?

A

Pain, paresthesias, pallor, poikilothermia, pulselessness. Can occur anywhere where swelling can occlude blood supply

52
Q

How to cast foot / ankle injury?

A
  1. Immobilize joints above and below
  2. NON-Circumferential allows for swelling
  3. UNDER PADDING→PLASTER→ACE.
  4. Repeat neurovascular exam.
53
Q

When to use SPICA bracing?

A
  1. Scaphoid injuries
  2. Lunate injuries
  3. First metacarpal fractures
  4. Injury to ulnar collateral ligament
  5. De Quervain tenosynovitis
54
Q

How to place thumb SPICA?

A

Distal to IP joint of thumb

  • Proximal along distal 2/3 of radial forearm
  • Position wrist / hand neutral, extend wrist 20 degrees, abduct thumb (wine glass)
55
Q

What is a sugar tong and how to use?

A

Distal ulnar/radius fracture: MCP palmar around elbow to MCP dorsally

56
Q

How to mold elbow?

A

Elbow 90 degrees, wrist and hand neutral, wrist extends to 20 degrees, Abduct thumb

57
Q

Differential of AMS?

A 
"AEIOU TIPS"
Alcohol
Epilepsy/Electrolytes/Encephalopathy
Insulin
Opiates/Oxygen (lack there of)
Uremia
Trauma/Temp
Infections
Poisons/Psychogenic
Shock, Stroke, SAH, Space-Occupying Lesions
58
Q

What is the AVPU scale?

A

A=alert
V=responds to verbal stimuli
P=responds to painful stimuli
U=unresponsive

59
Q

Decreased level of consciousness with cranial nerve findings is what, until proven otherwise?

A

Brainstem lesion

60
Q

What does petechiae with AMS make you think of?

A

Meningococcemia

61
Q

Workup for AMS?

A
  1. Rapid glucose
  2. CMP
  3. ABG or VBG
  4. Thyroid function tests
  5. Ammonia level
  6. Serum cortisol level
62
Q

Rx for hypertensive encephalopathy?

A
  1. Nitroprusside
  2. Labetalol
  3. Lenoldepam
63
Q

Rx metastatic CNS lesions with vasogenic edema?

A

Glucocorticoids

64
Q

Rx Wernicke’s encephalopathy?

A

Thiamine

65
Q

Diagnosis of acute stroke?

A

Often relies solely on H/P as CT images often do not show acute infarct for 6-72 hours after the interruption of flow

66
Q

Inclusion criteria for thrombolytics in acute stroke?

A
  1. Ischemic stroke w/ measurable defect on stroke scale
  2. Time of onset less than 3 hours ago
  3. Over 18 years old
67
Q

Exclusion criteria for thrombolytics in acute stroke?

A
  1. Intracranial hemorrhage on CT
  2. Clinical picture of subarachnoid
  3. Known AVM or aneurysm
  4. Prior intracranial bleed
  5. Active internal bleeding
  6. Plt<10k, PT>15s, INR>1.7, on blood thinners
  7. BP>185/110
  8. Brain surgery in past 3 m
  9. Major surgery within 2 weeks
  10. Pregnant
  11. Post-MI pericarditis
68
Q

BP Mgmt in acute stroke?

A

Patient’s generally autoregulate cerebral perfusion pressure = antihypertensive agents should be withheld unless MAP greater than 120 or systolic greater than 220 - - Patients who receive thrombolytics, blood pressure should be treated if the systolic blood pressure exceeds 180 or the diastolic blood pressure exceeds 105 to reduce the risk of hemorrhage.

69
Q

Use of antiplatelette therapy and stroke?

A
  • Aspirin proven useful in preventing recurrent stroke or stroke after TIA
  • Recommended within 48 hours of onset of symptoms
  • Delayed at least 24 hours if received thrombolytics
70
Q

Presentation of meningitis?

A 
Classic triad: (present in less than 1/2 adult patients)
1. Fever
2. Neck stiffness
3. AMS 
Others:
1. HA
2. Neck pain
3. N/V
71
Q

Meningitis presentation in kids?

A
  1. Lethargy
  2. Irritability
  3. Poor feeding
  4. Rash
  5. Bulging fontanel
  6. Hypothermia
  7. Kernig’s sign: flexing hip and extending knee elicits pain in the back and legs
  8. Brudzinski’s sign: passive neck flexion elicits involuntary hip flexion
72
Q

What is Kernig’s sign?

A

Flexing hip and extending knee elicits pain in the back and legs

73
Q

What is Brudzinski’s sign?

A

Passive neck flexion elicits involuntary hip flexion

74
Q

Diagnosis meningitis?

A

Prompt LP is diagnostic procedure of choice

75
Q

When to do CT before TP in meningitis?

A
  1. AMS
  2. New onset seizures
  3. Immunocompromised
  4. Focal neurologic signs
  5. Papilledema
76
Q

CSF findings suggestive of bacterial meningitis?

A
  1. Positive Gram’s stain w/ identified organism
  2. Glucose less than 40 mg/dL
  3. Ratio of CSF/blood glucose less than 0.40
  4. Protein greater than 200 mg/dL
  5. WBC greater than 1000/mL
  6. Greater than 80% polymorphonuclear neutrophils
  7. Elevated opening pressure of CSF during LP

EM Final Study Guide (29 decks)

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