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1
Q

Push Dose Epinephrine:
- How to create

A
  • Take 10mL syringe of saline with only 9mL of saline
  • draw 1mL of cardiac epi (1:10,000 | 0.1mg/mL)
  • This creates 10 mcg/mL
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2
Q

Push Dose Epinephrine:

  • Onset
  • Duration
  • Dose
A

Onset: 1 minute
Duration: 5-10 minutes
Dose: 0.5-2mL (5-20mcg) q2-5 minutes

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3
Q

Convulsive Status Epilepticus:
1st Line Treatment

A 
IM Versed (0.2-0.5mg/kg, max 10mg), single dose
IV Ativan (0.1mg/kg, max 4mg), repeat x1
IV Valium (0.15-0.2mg/kg, max 10mg), repeat x1
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4
Q

Convulsive Status Epilepticus:
2nd Line Treatment

A 
IV Fosphenytoin 20mg PE/kg, max 1500 mg PE / dose 
IV Valproate (40mg/kg, max 3000mg) 
IV Keppra (60mg/kg, max 4500mg) 
IV phenobarbital (15mg/kg)
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5
Q

Convulsive Status Epilepticus:
3rd Line Treatment

A

Repeat Second Line treatments
Anesthetic dosing thiopental, versed, pentobarb, propofol

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6
Q

Coronary Vessels to EKG Lead:

  • LAD
  • LCx
  • RCA
A

Coronary Vessels to EKG Lead:

  • LAD –> V1-V4
  • LCx –> V5-V6, I, aVL
  • RCA –> II, III, aVF
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7
Q

Coronary Vessels to EKG Lead:

  • V1-V4
  • V5-V6, I, aVL
  • II, III, aVF
A

Coronary Vessels –> EKG Lead:

  • V1-V4 –> LAD
  • V5-V6, I, aVL –> LCx
  • II, III, aVF –> RCA
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8
Q

Axis: Right on EKG

A

QRS down in I
QRS up in aVF

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9
Q

Axis: Left on EKG

A

QRS up in I
QRS down in aVF

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10
Q

If on AC, what’s the management for epistaxis?

A

If on AC, do RESORBABLE packing for epistaxis as per American Academy of Otolaryngology Jan 2020 guidelines.

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11
Q

New CHF. Cause most likely?

A

Valvular disease.

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12
Q

CHF + Prosthetic heart valve. Cause?

A

Valve thrombosis.

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13
Q

Seizure - physical exam findings that’s most specific.

A

Lateral tongue bite is 100% specific for seizure. But only 25% sensitive. (Using on population with transient LOC / syncope)
Tip of tongue and lips biting are more likely psychogenic than real seizure.

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14
Q

How to differentiate *cardiogenic pulmonary edema* from *noncardiogenic pulmonary edema* (pneumonia, fibrosis, TB, etc.)

A

Cardiogenic pulmonary edema: thin/regular pleural line

Non-cardiogenic pulmonary edema: thickened, irregular pleural line.

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15
Q

Myocardial injury

A

troponin I elevation; acute injury if there’s a rise/fall.

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16
Q

Myocardial infarction

A

acute myocardial injury + mycocardial ischemia signs (symptoms of ischemia, new EKG changes, pathologic Q-waves, imaging abnormality, finding coronary thrombus)

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17
Q

Cardiac necrosis progresses in what direction?

A

sub-endocardial (inside) –> sub-epicardial (outside)

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18
Q

Importance of Type II MI

A
  • higher frequency of women > men
  • higher mortality (short + long term) than Type I MI
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19
Q

(Obvious stuff): 3 reasons for
Type II elevation

A

Inadequate supply
Inc demand
can’t get the supply to the demand

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20
Q

Frequency of ST-elevation in Type II MI

A

3-24%

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21
Q

“Stable” troponin elevation definition

A

<20% variation of troponin values

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22
Q

Recurrent MI

A

Repeat MI AFTER 28 days

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23
Q

Re-infarction MI

A

Repeat MI BEFORE 28 days

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24
Q

Frequency of post-operative cardiac injury

A

35% of patients have elevation of troponin
17% have an elevation and rising pattern suggesting evolving myocardial injury.

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25
Q

Takotsubo’s syndrome: mortality

A

Inpatient mortality is same as STEMI (4-5%; from cardiogenic shock, ventricular rupture, malignant arrhthmias)

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26
Q

% of STEMI that is actually Takotsubo’s syndrome

A

1-2% of suspected STEMI; 90% are post-menopausal women

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27
Q

EKG findings in Takotsubo’s syndrome

A

STE: 44%
STD: <10%
TWI: 12-24 hours after, will develop deep, symmetric TWI and QTc-prolongation

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28
Q

Takotsubo’s resolves in what percent

A

85-90% have complete resolution.

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29
Q

Takotsubo’s vs Acute MI: 2 most important features for differentiation

A

QTC > 500 in acute phase for TTS
and
normalization of LV funciton after 2-4 weeks for TTS

30
Q

Which is more important? Absolute changes in assay or relative changes in measurement

A

absolute changes are the most important.
Use a lower cut-off for women, higher for men.
Don’t use an age-related cutoff

31
Q

This diffuse pattern is suggestive of
Left main disease
or
Multivessel disease

A

STD > 1mm in 6 leads
+/- STE in AVR or V1
Hemodynamic compromise

32
Q

STD > 1mm in 6 leads
+/- STE in AVR or V1
Hemodynamic compromise

A

This diffuse pattern is suggestive of
Left main disease
or
Multivessel disease

33
Q

EKG manifestations suggesting Acute MI (in the absence of LVH/BBB)

A

STE in 2 contiguous leads; >1mm in all leads except V2-V3. (use >2mm in male>40; >2.5mm in male <40; >1.5 in all females)

STD: new horizontal or down-slopping STD > 0.5mm in 2 continguous leads
or
TWI: >1mm in 2 continuous leads with prominent R-wave or R/S ratio > 1

34
Q

Absence of STE in V1-V6
Tall, prominent, symmetric T-waves V1-V6
Upsloping STD > 1 mm V1-V6
STE > 1 mm in aVR
Symmetric, deep (>2 mm) TWI in V3-V4

A

Signs of LAD Occlusion

35
Q

Signs of LAD Occlusion

A

Absence of STE in V1-V6
Tall, prominent, symmetric T-waves V1-V6
Upsloping STD > 1 mm V1-V6
STE > 1 mm in aVR
Symmetric, deep (>2 mm) TWI in V3-V4

36
Q

STE in aVR > 1 mm

A

Anterior (LAD) or inferior STEMI
Sign of increased 30 day mortality in acute MI

37
Q

Isolated STD > 0.5 mm in V1-V3 could be a sign of ____

A

Left circumflex occlusion

38
Q

Left circumflex occlusion could be hinted at on an EKG by ___

A

Isolated STD > 0.5 mm in V1-V3

39
Q

Locations for posterior EKG leads (V7-V9)

A

V7: left posterior axillary line
V8: left mid-scapular line
V9: left paraspina border

40
Q

Cutpoint for STE in posterior leads

A

For V7-V9 use 0.5 mm STE

41
Q

V7-V9 with >0.5 mm STE or
STD > 0.5 mm in V1-V3

A

Left circumflex occlusion or infero-basal ischemia / posterior MI

42
Q

New name for posterior MI

A

Old name for infero-basal MI

43
Q

Old name for infero-basal MI

A

New name for posterior MI

44
Q

Left circumflex occlusion or infero-basal ischemia / posterior MI
EKG findings

A

V7-V9 with >0.5 mm STE or
STD > 0.5 mm in V1-V3

45
Q

EKG changes associated with PRIOR MI

A
  • Any Q-waves in V2-V3 > 0.02s or QS complex V2-V3
  • [Q-wave > 0.03s and >1mm deep] or [QS complex]
    in [Leads I, II, aVL, aVF, V4-V6] OR [in any 2 contiguous leads]
  • R-wave > 0.04s in V1-V2 and R/S>1 with a concordant positive T-wave in absence of conduction defect.
46
Q

QS complex is normal in which lead

A

V1

47
Q

LBBB Criteria

A

QRS duration of > 120 ms
Dominant S wave in V1
Broad monophasic R wave in lateral leads (I, aVL, V5-V6)
Absence of Q waves in lateral leads (I, V5-V6; small Q waves are still allowed in aVL)
Prolonged R wave peak time > 60ms in left precordial leads (V5-6)

48
Q

Appropriate discordance on EKG

A

The ST segments and T waves always go in the *opposite* direction to the main vector of the QRS complex

49
Q

Inappropriate concordance on EKG

A

J-point and ST-segment elevation in positive leads and J-point and ST-segment depression in negative leads

50
Q

Normal Axis = QRS axis between

A

-30° and +90°

51
Q

Left Axis Deviation = QRS axis

A

less than -30

52
Q

Right Axis Deviation = QRS axis

A

greater than +90°

53
Q

Extreme Axis Deviation = QRS axis between

A

-90° and 180° (AKA “Northwest Axis”)

54
Q

Axis: Normal on EKG

A

QRS up in I
QRS up in aVF

55
Q

Axis: extreme axis deviation on EKG

A

QRS down in I
QRS down in aVF

56
Q

ECG Criteria for Left Anterior Fascicular Block (LAFB)

A

Left axis deviation
qR complexes in leads I and aVL
rS complexes in leads II, III, aVF
QRS duration normal or slightly prolonged (80-110 ms)
Prolonged R wave peak time in aVL > 45 ms
Increased QRS voltage in the limb leads

57
Q

Features consistent with sodium-channel blockade

A

Interventricular conduction delay — QRS > 100 ms in lead II

Right axis deviation of the terminal QRS:

  • Terminal R wave height > 3 mm in aVR
  • R/S ratio > 0.7 in aVR

TCA Overdose: Usually sinus tachycardia 2/2 muscarinic (M1) receptor blockade.

58
Q

TTP
Classic Pentad

A

Fever
Thrombocytopenia
Anemia (microangiopathic, hemolytic)
Neurologic findings (confusion, difficulty speakin,g headaches, vomiting, etc)
AKI

59
Q

Hip dislocation
Which nerve damaged?

Loss of sensation in posterior leg and foot
Loss of dorsiflexion or plantarflexion
Loss of deep tendon reflex at ankle

A

Sciatic nerve injury

(occurs in 10% of hip dislocations)

60
Q

Hip dislocation
Which nerve damaged?

Loss of sensation over thigh
Weakness of quadriceps
Loss of DTR at knee

A

Femoral nerve injury

61
Q

Hip dislocation
Which artery is damaged?

Hematoma
Loss of pulses
Pallor

A

Femoral artery injury

62
Q

Kanavel’s criteria

A
  1. Tenderness of flexor tendon
  2. Symmetrical / fusiform swelling of finger
  3. Flexed posture of finger
  4. Pain with passive extension
63
Q

1st line oral medication
Raynaud’s phenomenon

A

nifedipine or amlodipine

(long-acting dihydropyridine CCB)

64
Q

Fox’s sign

A

eccchymosis of upper lateral thigh; inferior to the inguinal ligament

The ecchymosis is parallel with, but distal to the inguinal ligament with a well demarcated upper border defined by attachment of the membranous layer of the superficial fascia (Scarpa’s fascia). Most often occurs in patients with retroperitoneal bleeding, usually due to acute haemorrhagic pancreatitis.

65
Q

Stabler’s sign

A

ecchymosis over the inguinal ligament.

in neonates, think neonatal adrenal hemorrhage

66
Q

Bryant’s sign

A

ecchymosis of the scrotum

Think retroperitoneal bleeding

67
Q

Gold standard to dx

Placental Abruption

A

Tococardiography

68
Q

What is this?

A

Epsilon wave

69
Q

Altered Mental Status (AMS) Etiology

AEIOU TIPS Mnemonic

A

Alcohol, acidosis

Endocrine, epilepsy, electrolytes, encephalopathy

Infection

Opiates, overdose

Uremia

Trauma

Insulin

Poisoning, psychosis, pharmacology

Stroke, seizure, syncope

70
Q
A

EM (6 decks)

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