Priority Topics Flashcards
ACLS steps for shockable rhythm
Give O2
Attach defib
Vent fib or pulseless ventricular tachycardia
SCREAM
Shock
CPR - 30:2 ratio for 2 min
Rhythm - check q2m and shock if indicated
CONTINUE CPR
Epinephrine q3-5m 1 mg IV/IO OR can give vasopressin in place of 1st or 2nd dose of epi
AM - Antiarrhytmic medication - give Amiodarone, lidocaine or mag sulfate
Shockable rhythms
Ventricullar fibrillation
Pulseless ventricular tachycardia
Pulseless
EMERGENCY
Medications that cross into breast milk
Antimetabolites, chloramphenicol, diazepam, ergots, golds, metronidazole, tetracycline, lithium, cyclophosphamide
Absolute contraindications to breastfeeding
HIV, HTLV type 1 and 2, infant galactosemia
Safest SSRI in pregnancy and breastfeeding
Sertraline
Common issues when breast feeding
Inadequate milk (consider domperidone), breast engorgement (cool compresses, manual expression), nipple pain (clear milk off after feeds, moisturizer, topical steroids), mastitis (treat with cloxacillin or cephalexin), inverted nipples, maternal medication
What is in Pediacel?
Six-in-one needle that protects against pertussis, diphtheria, tetanus, polio, Hib (Haemophilus Influenzae type B) meningitis/epiglottitis
When should children get DTap IPV Hib
2, 4, 6, 18 months
When should influenza vaccine be started in children?
6 months and annually thereafter
Side effect of rotavirus vaccine
Intussusception
Meckle’s diverticulum
Side effects of TdaP IPV vaccine
Possible seizure on same day (rare)
What vaccine causes ORS as a side effect?
Oculo respiratory syndrome
Bilateral red eyes AND cough/wheezing/hoarseness/sore threat/tightness/difficulty breathing/swallowing
Influenza
What vaccine should be avoided in preganancy?
Live - polio, MR, varicella
Oral typhoid
What vaccine should be avoided in preganancy?
Live - polio, MR, varicella
Oral typhoid
Side effect of DTaP
Large swelling can occur with 4-5th dose
Self limiting
Not an allergy sign, future doses remain safe
Side effect of MMR
Rare but thrombocytopenia is possible
Orchitis (mumps)
Parotitis (mumps)
Arthralgia (rubella)
What is hypotonic hyporesponsive episode and what vaccine is it associated with?
Sudden onset of reduced muscle tone, hyporesponsiveness, pallor/cyanosis within 12 hours of immunization
Rag doll reaction
Associated with pertussis vaccine
Not a CI to further doses
What is the only vaccine given at birth?
Hepatitis B
2nd dose given at 2 months
What medical exams should be done on new immigrants to Canada?
- chest xray and report for > 11 yo
- urinalysis > 5 yo
- syphilis serology > 15 yo
- HIV testing > 15 yo or those who have an HIV mother, identified risk or received blood products
- serum creatinine > 15 yo and children with h/o HTN, DM, kidney disease
- psychosocial support
- develop immunization catch up schedule
What immunization should pregnant woman have?
Tdap every pregnancy between 27-32 weeks or earlier if risk of preterm labor
Rubella for all non immune mothers
What should be asked at each well baby visit?
Rourke
Parent and caregiver concerns
Breastfeeding up to 2-3 yo + Vitamin D 400 IU/d
What education and advice should be discussed at 1 week?
Rourke
Car seat, safe sleep position (avoid bed sharing, crib safety, position, room share), firearm safety
What education and advice should be discussed at 1 month?
Rourke
Second hand smoke, supervised tummy time, no OTC cough/cold meds
What education and advice should be discussed at 2 months?
Rourke
Car seat, safe sleep, poisons, firearm safety
What education and advice should be discussed at 4 months?
Rourke
Night walking, healthy sleep habits, parent bonding, postpartum depression, assess home visit need, family healthy active living, screen time, social status (making ends meet, food insecurity)
What education and advice should be discussed at 6 months?
Rourke
Second hand smoke, supervised tummy time, dental cleaning with fluoride, no OTC cough or cold meds
What education and advice should be discussed at 12-13 months?
Rourke
Night walking, parenting, making ends meet, high risk infants needing home visits, family healthy active living, avoiding juice or beverages high in sugar
What education and advice should be discussed at 18 months?
High risk children, making ends meet, active family, second hand smoke
Rourke
What education and advice should be discussed at 2+ years?
Rourke
Avoid juice and high sugar drinks, car seat, bike helmet, discipline, depression, making ends meet, second hand smoke, dental health, no OTC cough/cold meds, health sleep habits
How do you monitor growth according to the Rourke record?
Measure length, weight and head circumference and plot on graph up until 2-3 yo then do height, weight and BMI
When ocular assessments should be done in a child according to the Rourke record?
Red reflex all visits
Start visual acuity at 2 years
Do corneal light reflex from 6 months onward
At what point in the Rourke record should tonsil size and sleep disordered breathing be assessed?
1 year onwards
When can you start introducing solids?
Pediatrics
6 months
Give iron containing foods - iron fortified cereals, meat, tofu, legumes, poultry, fish, whole eggs
Discuss allergenic food - eggs and peanuts
Avoid high sugar food and drink
What is a Broselow tape?
Broselow Tape relates a child’s height as measured by the tape to their weight to provide medical instructions including medication dosages, the size of the equipment that should be used, and the level of energy when using a defibrillator
Neurologic symptoms that are possible after vaccination
Persistent crying, seizure, paraesthesia, paralysis, guillain barre, subacute sclerosing panencephalitis, meningitis
System reactions that can occur after vaccination
Adenopathy, anaphylaxis, allergic reaction, erythema multiforme, rash, hypotonic hyporesponsive episode, arthralgia, severe diarrhea or vomiting
Other reactions that are possible after vaccination
Parotitis, orchitis, thrombocytopenia, narcolepsy, ORS, bell’s palsy, intussusception
Indicators of good CPR
- Push hard >2 inches (5 cm) and fast (100-120/min) and allow complete chest recoil
- Minimize interuptions
- Avoid excessive ventilation
- Rotate compressors every 2 minutes or sooner if tired
- If no airway then 30:2 compression ventilation ratio
- If PETC02 < 10 mmhG attempt to improve the quality
Drug therapy in ACLS
Epinephrine
Amiodarone
Lidocaine
Advanced airway in ACLS
- Endotracheal intubation or supraglottic advanced airway
- Waveform capnography or capnometry to confirm and monitor ET placement
- Once in place give breath nce every 6 seconds (10/min) with continuous chest compressions
How to you confirm ROSC
Return of spontaneous circulation
Pulse and blood pressure
Abrupt sustained increased in Petc02 > 40 mmHg
Spontaneous arterial pressure waves with intra arterial monitoring
Reversible causes cardiac arrest
– Hypovolemia
– Hypoxia
– Hydrogen ion (acidosis)
– Hypo-/hyperkalemia
– Hypothermia
– Tension pneumothorax
– Tamponade, cardiac
– Toxins
– Thrombosis, pulmonary
– Thrombosis, coronary
H’s and T’s of ACLS is a mnemonic used to help recall the major contributing factors to pulseless arrest including PEA, asystole, ventricular fibrillation, and ventricular tachycardia. These H’s and T’s will most commonly be associated with PEA, but they will help direct your search for underlying causes to any of arrhythmias
What are indicators of inappropriate resuscitation?
Asystole, long code times, poor pre code prognosis, living wills, DNR
What are indicators of inapproriate resucitation?
Asystole, long code times, poor pre code prognosis, living wills, DNR
What is important to remember in a code?
RE: family
Speak to the family
Examples of autosomal recessive conditions
cystic fibrosis - deficiency in the chloride channel CFTR
inborn errors of metabolism
PKU, von Gierke’s, Pompe’s, glycogen storage diseases, sphingolipidoses (except Fabry’s), and mucopolysaccharidoses (except Hunter’s)
sickle cell anemia
thalassemias
albinism
ARPKD
hemochromatosis
1/4 of offspring affected when both parents are carriers
Must have 2 defective copies of the gene
Examples of autosomal dominant conditions
von Willebrand disease (most common)
Huntington’s disease
osteogenesis imperfecta
achondroplasia
Marfan syndrome
neurofibromatosis type I
acute intermittent porphyria
Only one copy of the defective gene is required to express the disease phenotype
What medications are used for rate control in atrial flutter?
Beta blocker, diltiazem, verapamil, digoxin
What medications are used for chemical cardioversion in atrial flutter?
Sotalol, amiodarone, type 1 antiarrhythmics
First line treatment for depression in youth
Fluoxetine
Paroxetine is not recommended for youth
Blocks serotonin reuptake. Can cause sexual dysfunction, headache, GI upset, weight loss, tremors, increased QT interval
First line oral medication for HTN in pregnancy
Labetalol, methyldopa, nifedipine, other beta blockers
AVOID ACEi and ARBs, PRAZOSIN OR ATENOLOL
First line treatment for PMS
Exercise, CBT vitamin B6
Can try SSRI (citalopram or escitalopram) continuously or during luteal phase (day 15-28)
Combined hormonal contraception
First line treatment for suspected endometriosis
Combined hormonal contraception ideally continuous or progestin alone (oral, IM, SC)
First line IV antihypertensive in a hypertensive emergency
Labetalol except in CHF
Nitroglycerine - used in coronary ischemia and HF
Hydralazine - used in eclampsia
First line medication in a high risk bite
Amoxicillin + clavulanate (Augmentin)
Alternatves: Doxycycline (in children older than 9) or ceftriaxone
First line pharmaceutical treatment for chronic pelvic pain
- NSAIDs (ibuprofen, ASA< naproxen)
Second line: Opioids - Combined OCPs
- GnRH agonists
- Progestins
First line therapy for generalized neuropathic pain
Gabapentin, pregabalin, TCA, SNRI
First line treatment for post herpetic neuralgia
Lidocaine patch
Capsaicin
Gabapentin, pregabalin
TCA
Anticonvulsant
First line treatment for trigeminal neuralgia
Carbamazepine
Phenytoin
Baclofen
Treatment for giant cell arteritis
Treat promptly with glucocorticoids if suspected
Diagnostic biopsy can be done later
Can lead to blindness if not prompty treated
Signs of endometriosis on laparoscopy
- Mulberry spots: dark blue or brownish-black implants on the uterosacral ligaments, cul-de-sac,
or anywhere in the pelvis - Endometrioma: “chocolate” cysts on the ovaries
- “Powder-burn” lesions on the peritoneal surface
- Early white lesions and clear blebs
- Peritoneal “pockets”
Who should have urgent undelayed antibiotic treatment?
Meningitis, septic shock, febrile neutropenia
Common causes of chest pain
Angina/MI, GERD, anxiety, pulled muscle, costochondritis
Presentation of typical angina
- Substernal pressure (may radiate to neck, jaw, shoulders, left arm)
- Occurs with exertion or stress
- Relieved with rest (5-10 min) or nitro (immediate)
If 2/3 then atypical angina
If 0 or 1/3 then noncardiac pain
Definition of unstable angina
New or rapidly worsening pattern of typical angina that severely limits usual activities or occurs at rest
Chest discomfort or pain caused by poor blood flow and oxygenation of the heart that is unpredictable and can occur at rest.
Signs of aortic dissection
HTN, asymmetric BP in upper extemities (>20 mmHg difference), diastolic murmur, hypotension
Widened mediastinum or pleural effusion on CXR
Contast CT: fast, non invasive, highly senstive
Gold standard for aortic dissection diagnosis
MRI
Howevere sometimes not readily available and can be time consuming
Sudden pleuritic pain (sharp pain that is worse with deep inspiration) with shortness of breath
Tension pneumothorax
Usually unilateral
Look for hyperressonance on percussion and unilateral reduction of breath sounds
Sudden pleuritic pain (sharp pain that is worse with deep inspiration) with shortness of breath ± syncope, tachypnea, tachycardia
Pulmonary embolism
Workup for pulmonary embolism
1 D dimer (if low clinical probability) or go straight to CT pulmonary angiogram
2. CXR - frequently normal
3. VQ scan - sensitive but low specificity
4. ABG - hypoxemia with Aa gradient (no real diagnostic use)
4. VQ scan, contrast chest CT, angiogram to confirm
If highly suspicious go straight to CT angiography to look for fillling
Pulmonary angiography is gold standard for PE but rarely used and contraindicated if renal dysfunction
High risk causes of chest pain
Pericarditis
Acute corony syndrome (MI)
Pneumothorax
Pulmonary embolism
Aneurysm
Aortic dissection
How to screen chest pain patients
Site: ask where the pain is
Onset: clarify when the pain first started and if it came on suddenly or gradually
Character: ask the patient to describe how the pain feels
Radiation: ask if the pain moves anywhere else
Associated symptoms: ask if there are any other associated symptoms
Time course: ask how the pain has changed over time
Exacerbating or relieving factors: ask if anything makes the pain worse or better
Severity: ask how severe the pain is on a scale of 0-10
Explore the patient’s ideas, concerns, and expectations
Summarise the patient’s presenting complaint
Then screen for other body system symptoms, PMHx, drug hx, FMHx, social hx
First line antianginal medications
Beta blockers
Ho to exclude ischmic heart disease in chest pain pts
Coronary angiography
What vaccine should be given before transplants?
- to all transplant patients: DTaP, pneumococcal, infuenza, hepatitis A and B, COVID-19
- in select patients: MMR, varicella, HPV, herpes zoster
Emergent treatment for severe bradycardia
Check for hypoperfusion (LOC, hypotension, severe chest pain)
Try atropine if present
If no resonse then transcutaneous pacing or IV dopamine/epinephrine
Consider hyperkalemia and treat if present
Emergent treatment of asystole or pulseless electrical activity
CPR
Epi IV q3-5m
Consider H’s and T’s
Treatment of PE
- Admit for observation and stratify risk
- In low risk then send home with anticoagulation
- O2 to target > 90% sat
- Anticoagulate ASAP with LMWH or fonaparinux or unfractionated heparin or oral factor Xa inhibitors (rivaroxaban, apixaban, edoxaban) or direct thrombin inhibitors (dabigatran)
- Give IV thromboyltic for massive PPE and no CI
- May need IVC filter
Gold standard to diagnose aortic dissection
MRI
Sensitive and specific but not always readily available and can be time consuming
Gold standard to diagnose Hirschsprung’s
Rectal biopsy
Psychiatric condition that should be included in the differential of fatigue
Depression
First line investigations for fatigue
Urinalysis, CBC with differential, blood glucose, HbA1c, TFT
Electrolytes, lipid panel, syphilis, HIV
Possible: ESR/CRP, U&E, LFT, ferritin, calcium, anti endomysial and anti giladin AB
Important things to remember to ask in the history taking of fatigue
Complete medication list and history
Sleep disturbances
Lifestyle issues
Most definitive test for herpes type 1 and 2
NAAT assay of vesicle fluid or ulcer swab
Can do HSV PCR which is 100% specific but not as sensitive
An edematous external auditory cancl with increased pain when pushing on the tragus or pulling on the pinna
Otitis externa
Erythematous and bulging tympanic membrane
AOM
Erythemarous and fluctuance over the mastoid region
Mastoiditis
Clinical diagnosis not a radiological one
Potentially life threatening complication of AOM that manifests as redness and swelling over the mastoid region immediately posterior to the external ear. If suspected then administer IV AB urgently and refer to otolaryngology for surgical debridement
MCC pediatric ear pain
Otitis media
MC S. pneumoniae, H. influenza, M. catarrhalis, viral
Arises from Eustachian tube obstruction secondary to edema from URTI, allergies or inadequate opening that can lead to negative middle ear pressure causing influx of pathogens from nasopharynx
First line treatment for acute otitis media
High dose amoxicillin
Second line = Augmentin or cephalosporin
Recurrent infections may require myringotomy and tube insertion
MCC hearing loss in children? Adults?
Childen: acute otitis media or otitis media with effusion
Adults: cerumen impaction
MCC hearing loss in children? Adults?
Childen: acute otitis media or otitis media with effusion
Adults: cerumen impaction
MCC hearing loss in children? Adults?
Childen: acute otitis media or otitis media with effusion
Adults: cerumen impaction
MCC hearing loss in children? Adults?
Childen: acute otitis media or otitis media with effusion
Adults: cerumen impaction
Vaccines to give post splenectomy
Ideally 14 days prior to splenectomy or day 14 or on discharge give:
HiB regardless of age or previous immuization history, quadrivalent meningococcal, serogroup b meningococcal, both pneumococcal conjugate and polysaccharide. Hep B indicated for those with repeat transfusions ie: sickle cell or thalassemia
Annual influenza
Boosters every 5 years for bacgerial vaccines
Achalasia vs esophageal stricture
Achalasia - failure of LES smooth muscle to relax
A/W ilness, cancer, Chaga’s, Allgrove’s
25-60 yo
Tx myotomy, pneumatic balloon dilation, Botulinum
Esophageal stricture - physical narrowing of the esophagus
A/W GERD, swallowing corrosive substance, radiation, damage from NG tube
> 40 yo
Tx balloon dilation, stent, surgery to remove some tissue
Both present with difficulty with swallow
Tests to order in acute abdominal pain
ALP, ALT, AST, bilirubin
Lipase, amylase
Urinalysis
Beta HCG
Troponins
Lactate
What are enlarged hard left supraclavicular nodes associated with?
Gastric carcinoma
A hypotensive, tachycardic or febrile patient in the setting of abdominal pain is concerning for?
Ischemic bowel, ruptured AAA, sepsis
Hyperactive bowel sounds are suggestive of?
Mechnical bowel obstruction
SBO signs and treatment
Intermittent, colicky, postprandial pain with recurring cramps q3-10m, vomiting, crescendo descrescendo rushes of high pitched peristalsis sounds and history of previous surgery
Do abdo xray and CT to diagnose and urgent referral to surgery to treat. Can try NG tube decompression.
Signs and treatment of irritable bowel syndrome
Chronic and recurrent abdominal pain and/or altered bowel habits for at least 6 months with at least two of the following:
- Defectation increases or improves pain
- Change in stool frequency
- Change in stool appearance
Treat with diet and lifestyle changes
Clinical signs of pancreatitis
Constant midepigastic pain radiates to left shoulder and back and worsens with laying on back (supine)
Fever, RUQ pain and jaundice
Charcot’s Triad
Describes the symptoms and presentation of cholangitis
Reynol’s pentad = those sx + hypotension and altered mental status
Cholangitis is inflammation of the bile ducts leading to infection of the gallbladder, liver or biliary system. It is a progression of choledocholithiasis.
Extraintestinal manifestations of inflammatory bowel disease
Crohn’s: erythema nodosum (red, painful nodules on the shin bilaterally typically), pyoderma gangrenosum (lower extremity ulcers), perianal skin tags, oral ulcers, arthritis, uveitis and episcleritis, gall stones, fatty liver, osteoporosis
UC: erythema nodosum, pyoderma gangrenosum (less common, more often in Crohn’s), arthritis, uveitis,
Treatment for vaginal candida
Clotrimazole, butoconazole, miconazole, terconazole, fluconazole
Look for hyphae and spores on wet mount
Treatment for bacterial vaginosis
None if non pregnant and asymptomatic unless scheduled for procedure or surgery
Oral: metronidazole (better in preg)
Vaginal: metronidazole, clindamycin, probiotics
Look for CLUE cells (squamous epithelial cells dotted with coccobacilli)
INcreased risk of preterm birth
Treatment for trichomoniasis
Metronidazole
Treat partners too!
Positive whiff test, yellow/green smelly discharge
