PEM Sample Q part 2 Flashcards
Boyle’s law
(P1V1 = P2V2)
-volume of gas is inversely proportional to pressure (increased altitude = decreased pressure = increased volume of air) –> PTX will expand with higher altitude and may cause tension physiology
Dalton’s law
partial pressure of a gas mixture is the sum of all the partial pressures of the gases within the mixture
- Increasing altitude = decreased atmospheric pressure = for any given FiO2, you will have a lower PaO2
Lower PaO2 causes increase in ventilation and thus decrease in PaCO2 (higher pH = shifts oxygen dissociation curve to L = increases PaO2)
4 steps to carry-out prior to air transport
- NGT insertion to decompress stomach
- Chest tube placement for even small PTX
- Instill liquid into foley/ETT balloons
- Ensure adequate oxygenation
Advantages of ground transport
- Less expensive
- Not dependent on weather
- Door to door transfer
- Better for shorter distances
- Less noise/vibration/thermal variances etc
Disadvantages of air transport
- Cost
- Size of aircraft limits # of pts, equipment, personnel
- Weather dependent
Management of Necrotizing Fasciitis
- Consult surgery: debridement
IV Abx: Ceftriaxone, Clindamycin, Vancomycin
RF associated with Nec Fasc
- Omphalitis
- Varicella infection
- Immunocompromised state (leukemia, HIV, DM)
- Recent hx of trauma or surgery
- NSAID use
3 precipitating events for thyroid storm
- Trauma
- Infections: pneumonia, URI, enteric infections
- Iodinated contrast studies
- Surgery
Mngmt of Thyroid Storm
- Inhibiting thyroid hormone production: methimazole
- Cardiovascular support: propranolol
- Temperature: cooling measures (tepid washcloths, Tylenol)
Complications of cooling post arrest
- coagulopathy
- bradycardia
- infection
Indications for cooling s/p arrest
Limited data in children - persistent coma s/p out of hospital arrest; use 32-34 degrees
10 ways to rewarm a patient
- Passive - remove wet clothing, warm room, warm blankets, warm IVF, bear hugger
- Active: ECMO, peritoneal lavage, pleural irrigation, bladder irrigation, warmed humidified air through canula
DDx. knee pain in athlete
- Osgood-Schlatter: TTP at tibial tuberosity
- Singed-Larsen syndrome: TTP at inferior pole of patella
- Patellofemoral syndrome
- Osteochondritis dissecans
- SCFE
DDx. leg weakness /paresthesias in gymnast
- Spinal cord tumor
- Spondylolisthesis
- Disc herniation
- Transverse myelitis
- Vertebral osteomyelitis/discitis
Neurologic injury with anterior knee dislocation
Peroneal N –> foot drop
Vascular injury with anterior knee dislocation
popliteal artery
XR findings for hip joint effusion
- asymmetric widening > 1 mm in teardrop distance
Medication Tx. Status epilepticus
- First line = IN/IV/IM Ativan or Midazolam, PR Diazepam
2. Second line: phenobarbital, phenytoin, fosphenytoin
DDx status epilepticus
- Febrile seizure
- Electrolyte changes: hyponatremia, hypoglycemia
- Toxic ingestion: TCA antidepressant
- Cardiac dysrhythmia
- Meningoencephalitis
- Intracranial mass or hemorrhage
3 indications for laparotomy in Blunt Abdominal Trauma
- Hypotension with (+) FAST or w/o other source of bleeding
- Free air or rupture of hemidiaphragm on XR
- Peritonitis
- Multisystem injuries with indication for craniotomy in presence of + DPL or + FAST
Clinical findings in Neurogenic Shock (4)
- Hypotension
- Bradycardia
- Widened pulse pressure
- Flushed/warm periphery
Most likely injured abdominal organs with blunt trauma
spleen > liver > kidney > pancreas
5 factors that affect severity of electrical injury
- Frequency = AC > DC
- Intensity of current = higher voltage is worse
- Duration of contact
- Resistance (wet skin decreases resistance)
- If thrown a distance, associated injuries increase severity
C/I to IO placement
- fracture at site of placement
- overlying skin infection
- bone dysplasia
Complications of IO placement
Complications: - Fracture - Compartment syndrome - Osteomyelitis (if > 24 hours used) - Subcutaneous abscess - Skin necrosis Pain
US measurements in pyloric stenosis
Thickness > 3 mm
Length > 15-17 mm
EKG changes in hyperkalemia
- peaked T waves
- prolonged PR / QRS interval
- Decreased amplitude of p waves
- sine wave pattern
- > 10: v.fib / asystole
Non-medication causes of hyperkalemia (4)
- Tumor lysis syndrome
- Hemolysis
- Trauma / Burns / Crush injuries
- Adrenal insufficiency
- Renal insufficiency
Most emergent ED management of hyperkalemia
IV Calcium Gluconate 10% IV, 60-100 mg/kg, max 2 g
others: insulin/glucose, albuterol, furosemide, kayexalate
RF for sepsis in newborn (5)
- Prolonged ROM
- Maternal infection - chorioamnionitis
- Maternal GBS (+) or Previous sibling with GBS (+) infection
- Birth outside of hospital setting
- Prematurity
Four causes of jaundice (non-hemolytic)
- Gilbert’s syndrome
- Autoimmune hepatitis
- Viral hepatitis
- Cholangitis / cholelithiasis with obstruction
- Acetaminophen overdose
3 clinical features of acute liver failure
- Jaundice / icterus
- Hepatomegaly / splenomegaly
- Encephalopathy
- RUQ pain
- Easy bruising/bleeding (coagulopathy)
Infant with vomiting, FTT, ammonia > 200 - 2 urgent ED management steps
- Begin IVF with dextrose containing solution
- Prepare for hemodialysis
- Obtain labs including CBC, BMP, Liver panel, urine / serum organic acids, blood gas
Associated conditions with SCFE
- Hypothyroidism, GH supplementation, hypogonadism –> check TFTs, GH levels
RF: male, obesity, black
4 xray findings in SCFE
- Steel sign
- Widening of physis
- Decreased height of epiphysis
- Klein’s line - lateral cortical line along femoral neck does not intersect the epiphysis
4 conditions assoc with rectal prolapse
- Constipation
- Cystic fibrosis
- Crohn’s disease / Ulcerative colitis
- Hirschsprung disease
- Intussusception
Causes of PID that are NOT STI
- childbirth
- Miscarriage /abortion
- IUD use
- Pelvic surgery or endometrial biopsy
- appendicitis
Minimum clinical criteria for PID
- Sexually active pt with pelvic / lower abdominal pain with no other cause AND one of CMT, uterine TTP or adnexal TTP
Definitive clinical criteria for PID
- Endometrial biopsy with histopathologic evidence of endometritis
- Laparoscopic abnormalities c/w PID
- US or MRI with thickening fluid filled tubes or tuboovarian complex
CF of salicylate toxicity
- Tachypnea
- Fever
- Tachycardia
- Tinnitus / vertigo
- Nausea /vomiting/diarrhea
AMS
MOA of succinylcholine
binds at nicotinic Ach-R at NMJ, is not broken down by Ach-esterase, thus does not allow motor unit to repolarize
Causes bradycardia by acting on PNS –> Ach-R –> M2 cholinergic R and sinus and AV nodes
C/I to succinylcholine
- hypersensitivity
- History of muscular dystrophy or myopathy
- Family hx or personal hx of malignant hyperthermia
- Hyperkalemia
- Significant trauma or burn (after acute phase)
- Ocular surgery, penetrating eye injuries or close angle glaucoma
- Pseudocholinesterase deficiency
Indications for arthrocentesis
- Concern for septic joint
- Traumatic hemarthrosis to relieve pain
- Joint effusion causing severe pain / limitation of function
- Traumatic hemarthrosis to relieve pain
C/I to arthrocentesis
- overlying skin infection
- Hemophilia
- Presence of fracture near joint site
- Hemophilia
Jefferson fx
burst of C1 –> axial load
Hangman’s fx
fx of pedicle of C2 –> hyperextension
Cervical distraction injury
increase in atlantoaxial distance –> acceleration/deceleration injuries, NAT, difficult delivery
Unstable Cervical Fractures
- Jefferson, C1, axial
- Hangman’s, C2, hyperextension
- Odontoid, type 2/3
- Bilateral facet dislocation
- Teardrop fx: flexion
MOA of Epi in CPR
increased arterial blood pressure and coronary perfusion pressure via alpha-1 adrenergic effects
Secondarily: inotropic (increases cardiac contractility)
LEAN mnemonic for ETT meds
L - lidocaine
E - epinephrine
A - atropine
N - naloxone
4 physical exam findings with rib fracture
- Tenderness on palpation
- Crepitus
- Chest wall deformity
- Ecchymoses of chest wall
- Sx of respiratory insufficiency: tachypnea, retractions, acc mm use
6 underlying thoracic injuries from rib fracture
- Pneumothorax
- Hemothorax
- Pulmonary contusion
- Pulmonary laceration
- Pericardial injury with pericardial tamponade
- Large vessel (subclavian A) laceration or tracheal lac in 1st rib fx
- Spleen / liver / diaphragm laceration
2 mechanisms of acidosis in severe asthma
ineffective ventilation = increased CO2 retained –> respiratory acidosis
- Salbutamol use = lactic acidosis –> metabolic acidosis
Also get lactic acidosis from hypoxia and tissue hypoperfusion
3 meds used to tx methanol ingestion
- Folic acid
- Ethanol
- Fomepizole
- Sodium bicarbonate
- Thiamine / pyridoxine (ethylene glycol)
Medium Risk - CATCH Head injury rule
- Any sign of basilar skull fx
- Large, boggy hematoma of scalp
- Dangerous MOI: MVC, fall from > 3 ft or 5 stairs, fall from bicycle w/ no helmet
High Risk - CATCH Head Injury Rule
- Hx of worsening headache
- GCS < 15 at 2 hours
- Suspected open or depressed skull fracture
- Irritability on examination
Locations for occult blood loss in trauma patients
- Retroperitoneal
- Scalp
- Pelvis
- Long bone fracture
- Chest
Qualities of heart murmur that require further work-up
- Harsh, diastolic murmur
- Grade >3
- Location: not apex or LLSB
- Radiation to back
Non-cardiac causes of heart murmur
- High output states: fever, anemia, hyperthyroidism
- Pulmonary HTN
Pregnancy
- Pulmonary HTN
Topical meds you can use for T&A bleed
- Epinephrine 1:1000 - Oxymetazoline
- TXA (can use topical or IV)
- also give IVF, PRBC, pressors
Mngmt of post T&A bleed
- Suction
- Apply pressure to bleeding site (gauze + vasoconstrictor, use McGill forceps)
- Consider intubation to prevent aspiration
Chance fracture
lumbar fracture (through vertebral body, spinous process and pedicles) from flexion-distraction injury Typically T12-L2
What types of injuries is a Chance fx assoc with? (4)
Associated with intraabdominal injuries
- Pancreas
- Duodenal hematoma
- Mesenteric pedicle injury
- Hollow viscous injury
6 signs/effects of ecstacy or MDMA use
CNS: euphoria, hyperactivity –> panic, psychosis
VS: hyperthermia, HTN, tachycardia
MSK: rhabdomyolysis, bruxism
Ocular: mydriasis –> blurry vision
Metabolic: hyponatremia (increased free water intake)
4 labs to guide massive transfusion protocol (1:1:1)
- CBC (Hb, platelets)
- Coags: PT/INR, PTT, fibrinogen
- Calcium (can get hypocalcemia)
Complications of massive transfusion protocol
- Metabolic alkalosis
- Hypocalcemia
- Hypothermia
- Hyperkalemia
4 steps to instruct parent on how to give epi-pen
- Recognize signs/symptoms of anaphylaxis
- Given in anterolateral thigh
- Take cap off, swiftly insert needle, hold for 10 sec for med to release
- Call 911 or proceed to closest ED immediately
Fever in transplant pt < 1 month post surgery
normal post surgical complications - wound infection or infection present before that was exacerbated by surgery, infection transmitted by allograft
Fever in transplant pt 1-6 mos post op
- latent viral infections (CMV, EBC, HHV6, hepB/hepC)
2. Opportunistic infections: listeria, aspergillus, pneumocystis
Fever in transplant pt > 6 mos post op
community acquired infections (resp viruses), opportunistic infections
Mngmt of FAO
- ABCs
- IVF - bolus with normal saline –> D10 infusion to suppress lipolysis
- Obtain blood work: VBG, glucose, ammonia
- Avoidance of fasting
- Oral carnitine replacement
What are the SIRS criteria?
- Core temp > 38.5 or < 36
- Increased HR > 2 SD or if < 1 yr old bradycardia
- Increased RR or need for mechanical ventilation
- Elevated /reduced WBC with > 10% bands
Signs/symptoms of severe colitis
- Severe abdominal pain / distension
- Bloody stool
- Fever
- Signs of dehydration (tachycardic, low BP, poor perfusion, dry MM)
- Signs of anemia (pale, low BP)
Extraintestinal manifestations of IBD (8)
- Oral: aphthous ulcers
- Eyes: uveitis
- Skin: erythema nodosum
- Joints: arthritis
- Liver: hepatitis, primary sclerosing cholangitis
- Venous thromboembolism
- Kidney stones
- Pancreatitis
- Low bone mineral density / osteoporosis
When do you start and stop deferoxamine?
START –> iron level > 500 mcg/dL, severely symptomatic patients, sig AG met acidosis
STOP –>usually 24 hours, when metabolic acidosis and shock are resolved; prolonged tx risks pulmonary toxicity from deferoxamine
5 stages of iron toxicity
- GI symptoms: 6 hours - NV, pain
- Latent recovery phase: 6-24 hours
- Shock/metabolic acidosis: 6-72 hrs
- Fulminant hepatic failure: 12-96 hrs
- Recovery with GI scarring/obstruction (weeks later)
2 determinants of hydrocarbon toxicity
- High volatility (aspiration)
- Low surface tension (displaces surfactant)
- Low viscosity (aspiration)
What substances does activated charcoal NOT work on?
- Hydrocarbons
- Toxic alcohols
- Metals: iron, lithium
- Pesticides
- Solvents
Admission criteria for omphalitis (4):
- Signs of systemic illness
- Significant cellulitis/abscess
- Age < 2 months
- Tenderness, discharge
Pathogens - omphalitis (5)
- Polymicrobial
- Staph aureus
- GAS
- Gram negative: e.coli, klebsielle, proteus
anaerobes
Four causes of Methemoglobinema (not drug/chemical induced)
- Drinking well water
- Congenital: enzyme deficiency
- Infants < 6 months when exposed to dehydration, illness or topical anesthetics (inadequate enzyme levels)
- G6PD deficiency
What medications can cause methemoglobinemia?
Antibiotics: TMP-SMX, dapsone
Local anesthetics
Metoclopramide
Nitrates
What are some vagal maneuvers to try in SVT? (4)
- Bearing down x 15-20 secs
- Rectal stim w/ thermometer
- Blowing into straw
- Diving reflex: place bag of ice / water over nose and eyes x 35 sec OR in older kid - knees to chest, hold breath and bear down
*Contraindicated: carotid massage, orbital pressure
Medical mngmt of SVT
- adenosine 0.1 mg/kg, second 0.2 mg/kg, max 6 then 12 mg
2. synchronized cardioversion (0.5 to 1 J/kg)
Criteria for dx of sinusitis (3)
- Persistent nasal discharge > 10 days
- Worsening cough, fever or discharge after period of improvement
- Severe onset with fever > 39 sec or purulent nasal dc > 3 day
Electrolyte abnormalities seen in acute renal failure
- Hyperkalemia
- Hyperphosphatemia
- Hyponatremia
- Hypocalcemia
- Metabolic acidosis
2 complications of vaginal lacerations
- Assoc urethral tears
- Urinary retention from severe pain or injury
- Significant bleeding from deep vulvar lacerations
Life threatening complications of heat stroke (8)
- Rhabdomyolysis
- AKI
- Hyponatremic dehydration
- Liver failure –> Coagulopathy
- High output cardiac failure
- Pulmonary edema / 7. ARDS
- Cerebral edema
3 signs of urethral injury
- Blood at urethral meatus
- Bruising of penis or perineum
- High riding prostate
- Urinary retention or inability to urinate
4 injuries associated with crack cocaine use
- Oral mucosal burns
- Laryngeal / airway burns
- Crack lung = interstitial fibrosis, noncardiogenic pulm edema
- Aspiration
Risk of using labetalol in sympathomimetic syndrome?
Labetalol is a BB which would result in unopposed alpha stimulation with increased HTN, cardiac output and cardiac ischemia
Causes of congenital stridor (7)
- Laryngomalacia
- Esophageal web/sling
- Vascular ring/sling
- Subglottic stenosis
- Laryngeal N paralysis or vocal cord paralysis
- Tracheal hemangioma
- GERD
Newborn sepsis (bacteria, abx)
Group B strep, Strep pneumo, E.coli, Listeria
Tx. Ampicillin + Cefotaxime
Infants/children sepsis (bacteria, abx)
Strep pneumo, Neisseria meningitis, H Flu, GBS
Tx. Ceftriaxone, Vanco
Adolescent sepsis (bacteria, abx)
N.mening, s. pneumo
Tx. Ceftriaxone, Vanco
Features of Organic Psychosis (6)
- Rapid onset (days to weeks)
- Disoriented
- Memory loss
- Visual/olfactory/tactile hallucinations
- May have abnormal VS or pathologic autonomic signs
- Fluctuating cognition and attentions
Concern for elevated ICP w/ impending herniation - mngmt?
- HOB at 30 degrees elevated
- Intubation with hyperventilation
- Hyperosmolar therapy: 3% NS or mannitol
- Decrease metabolic demand: ventilation, normothermia, normoglycemia, can allow permission HTN
- Immediate neurosurgical consult
Indications for imaging in penetrating trauma of oropharynx?
- Location: lateral tonsillar pillar
- Continued bleeding
- Large, expanding hematoma
Adenosine - MOA, indication
MOA: slows conduction thru AV node
Indication: SVT
0.1 mg/kg –> 0.2 mg/kg (6 mg –> 12 mg)
Amiodarone - MOA, indication
5 mg/kg
MOA: class III antiarrhythmic, inhibits alpha and beta R, affects Na,K and Ca channels, prolongs AP and refractory period, decreases AV conduction
Indication: VT, refractory pulseless Vfib / VT
Clinical features SVC syndrome
- Plethora
- Facial edema
- JVD
Landmarks for Chest tube placement
5th intercostal space (between 4th and 5th rib), midaxillary line, at level of nipple, insert above lower rib, advance posteriorly in apical direction - Secure with sutures - Apply occlusive dressing - Attach to drainage system (suction) - Check placement on CXR Measure output drainage
Complications of chest tube placement (8)
- Bleeding (injury to vessels)
- Infection
- Laceration of intraabdominal organs
- Subcutaneous emphysema
- Pain
- Reexpansion pulmonary edema
- Intercostal neuralgia/neuritis
What are two measures in the hyperoxia test?
- Measure level of PaO2 while breathing 100% O2
PaO2 < 100 mmHg and failure to increase systemic arterial oxygen saturation implied cardiac etiology (measure preductal - R radial AA)
Signs/symptoms of hypocalcemia (6)
- Muscle cramps (carpopedal spasm)
- Paresthesias (oral, hands/feet)
- Laryngospasm
- Bronchospasm
- Hypotension
- Dysrhythmias
Bones at risk of idiopathic avascular necrosis (5)
Tarsal navicular bone Femoral head and condyles Scaphoid Metatarsal heads Humeral
clinical features of acute liver failure
- jaundice
- scleral icterus
- coagulopathy
- hepatomegaly
- encephalopathy
- Constitutional: NV, fever, fatigue, pain
Risk factors for opioid addiction in teens
- Chronic disease
- History of abuse (physical / sexual)
- Family member with addiction
- Hx of mental health illness
- Low SES/homelessness
Potential causes of jaundice (not hemolytic)
- Medication/toxin induced - tylenol o/d
- Autoimmune hepatitis
- Cholangitis
- Sepsis
- Obstruction: biliary atresia, choledochal cyst, cholelithiasis
- Primary sclerosing cholangitis (IBD)
- Tumors of hepatobiliary system
anion gap formula
Na - (Cl + HCO3), normal < 10
Serum osmolarity formula
2Na + BUN/2.8 + Glucose / 18
fluid deficit formula
% dehydration x weight [ 1 kg = 1 L]
max lidocaine dose (ml) formula
max dose (mg/kg) x wt / 10 x 1 / conc %
