Rosh Nugz Flashcards
Best 2 ways to see if ROM in preggo?
- Fern
- pH >6.5 Alkaline
*PROM 24-36 weeks consult, electrolysis, steroids
Diverticulitis Symptoms
- Fever
- LLQ pain
- Diarrhea or Constipation
Most common complication of diverticulitis
Phlegmon/abscess
- Admit, Abx, bowel rest, surg consult
Tx diverticulitis w/ obstruction/
NG tube, bowel rest, Abx?
Fistulas wait until acute episode is over
Appendicitis under 5 characteristics
- uncommon
- Non specific/localized pain, N/V
- High risk of perf- rebound tenderness*
- Can look like gastritis
Biggest risk for third trimester painless bleeding?
Dx: Placenta Previa
From: previous C sections
RMSF muscle that gets sore?
calf
What lab tests tell you new MI if htey had one 1 week ago?
- CKMB
or - Trops trending up
Keep E spasm on your ddx!
trouble swallowing with chest pain and resovles
CCB Tx
true allergy to apsirin in MI give…
Clopidgrel (ADP inhibitor)
Aspirin has 23% reduce in 30 day mortality
Dysphagia ddx
Achalasia
Upper GI bleed- how do you decide between dischage home and endoscopy?
Guaic + and tarry stools
Glasgow-Blatchford Bleeding score
if 0=go home oupatient endo
>0= endoscopy in house
Previous dx of diverticulitis and similar presentation, do you get CT?
No
Hx of AAA repair (or syhpylsis, aortitis) and then GI bleed symptoms
Aorticenteric fistula
emergent EGD
Acute management of Varices
ABC (transfusion?)
Octreotide (shunts blood away from splanchnic, somatostatin analog)- Reduced need for transfusion but not mortality
Ceftriaxone (reduces re bleed and complications
What GI pill interferes with clopidgrel?`
PPIs
Non pharm GERD Tx
raise head of bed 30 degrees
weight loss
food avoidance
recent scope
pleuritc pain worse with neck flexion or swallowing
Borhaave
Abx and Surg
battery in stomach - get it or let it pass?
Let it pass if tolerating secretions
sharp and in stomach, go get it or let it pass?
go get it
upper GI series dx what?
ulcer, tumors, hernia, scarring, obsturction
What lab test tells you pancreatitis is biliary?
ALT 3x normal value
What is treatment for alcoholic hepatitis
Supportive care
Glucose, thiamine, hydration, lytes
Suspect Cholecystitis and US is equivocal, why next?
HIDA
Acute chole treatment
NPO
ABx
Fluids
Cholecystectomy within 3 days
How do you know if you should anticoagualte a person in A fib?
HAS BLED score
What medications are contraindicated in WPW?
BB and CCB
- blocks AV node and further exacerbates the re-entreant pathways leading to v fib
how do you test for joint integrity after a large laceration over a joint space like the knee?
Inject 200 cc of saline into joint space away from laceration
+ test if you see fluid coming out of laceration
Young AA kid with stroke like symptoms> 3 things you need to do and what is the cause?
Sickle Cell stroke- not embolic or thrombotic- it is vasooccuslive or sticky
- CT
- baseline labs
- Exchange transfusion of blood to get Hgb above 10 and reduce HgbS under 20%
3 contraindications to nitro
- R inf STEMI- contractility is dependence on diastolic pressure bc RV is low volume pressure pump
- Phosphodiesterase inhibitors like sildenafil
- hypotension
Tx of brochiloitis?
supportive
Oxygen, nasal suction
positive pressure, humidified air thru NC
*day 2-3 is the worst
Reasons to admit bronchiloitis
- less than 3 mo old
- 34 week GA
- RR >70
- Ill appearing
- PO intake down
- Comorbids
loss of sensation area in radial nerve palsy?
snuff box area
last 5 steps of cardianl labor movements
FIEEE
flex, internal rotate, extend, external rotate, expulsion
Puncture wound wihtout going thru a shoe- what abx do you give/
Bactrim 5 days
Cover for staph
dont sew it up
wet wobbly wacky?
NPH
young AA F w/ SOB and new heart block?
think sarcoid
Things to think about in hisotry to see if you need a CT or not?
LOC Vomiting AMS headache mechanism
3 abs to cover for MRSA?
Bactrim
Doxy
Clinda
What lab test or vital sign tells you shock?
None.
-clinical recognition of the presence of inadequate tissue perfusion and oxygenation
5 hard signs of vascula rinjnury after knee dislocation?
- ulsatile bleeding
- bruit
- palpable thrill
- distal ischemia
- expanding hematoma
- look for neuro and pulse difference too
peds partial airway obstruction with normal vital signs> what next?
- keep them still
- Set up DL and needle cric at bedside just in case
- call ENT for them to come remove it
- Back blows are used for chkoing infant less than 1 year old
what 4 things make you think Cavernous sinus thrombosis?
- orbital pain
- Proptosis
- EOM disability
- recent infection/clotting disorder
what hearing difficulty does Bells palsy have?
hyperacusis (sensitivity to certain pitch)
retroauriclar pain
2 causes of posterior shoulder dislocation
Electricity
seizures
inferior shoulder dislocation presents like what with what mechanism?
arm above head and external rotation
swimming pool with arm forward collision
Pull up and lateral to reduce
Ant shoulder dislocation and tx
indentation of deltoid (squared off) and abducted/external rotation
- from fall backwards onto outstretched hand
PR depression on ECG, ST elevation + uremia/recent virus + CP
pericarditis
involuntary contractions of face, torso, extremities ect
on antipshyctoics or anti-emetics
Acute dystonia reactions- mimics stroke!
Give Iv benadryl to cure this
*usually medication related, could be pesudoseizure
Tx of reyes syndrome?
Supportive
-hepatic failure and cerebral edema
Difference in somatization and hypochondriac
Somatization: they believe it is real
Hypochondriac: Symptoms blown out of proportion an doctor shop out of fear
Difference between dermoid cyst and Thyroglossal cyst?
both are midline
Dermoid- 1 under 3 years old and 2 does NOT move with tongue protrusion 3 above hyoid usually
Thyroglossal- under hyoid and DOES move with tongue
Geriatric borke hip now delirious? what next?
Give optiates to treat pain!
check for bladder retention and other causes of delirium
Kanavel criteria
- pain qith passive extension
- tenderness of flexor sheath into the palm
- sausage finger
- held in slight flexion
-local compartment syndrome with sheath
fluids, abx, surgery quickly
5 things to look for on gallbladder US
- sonogrpahic murphys
- pericholecystic fluid
- wall thickening
- stones/ slduge
- CBD dilation
fever, LA, eczema now vesicles and punched out lesions
eczema herpticum - superimposed infection
acyclovir
neurocysitissarcosis tx
- check eyes before tx or vision loss
2. albendazole +/- praziquantel
involuntary contractions of face, torso, extremities ect
on antipshyctoics or anti-emetics
Acute dystonic reactions
Give Iv benadryl to cure this
*usually medication related, could be pesudoseizure
chest pain in peds ddx
- PTX, pneumomediastinum (trauma to chest)
- If it is tension pneumomediastinum incision at suprasternal notch - Pericarditis
- PE
- PNA
- Conginental heart- HOCM, coronary artery abnromalities
thumb dislocation
- NV intact
- digital block
- longitnudianl traction and hyyper extend
- XR and assess for stability
- pslint in extension
What is considered massive hemopytsis and how do you manage it?
- hypotension or impaired gas exchange or
- 100/hr or 500/25 hr
Tx: Mainstem intubate the good lung and have them lie on the bleeding lung in decubtitus to not bleed into the good lung
asthma and albuterol and sats get intially worse- why?
VQ mismatch- aiwarys opened up to non ventilated lungs
Asthma
SE of Mag?
SE of Beta agonist?
Hypotension
Dehydration from increased RR- give them fluids
3 ways why hemoptysis?
erosion into a vessel
coagulaopthy
pulm HTN
why do we do needle before chest tube for tension?
needle gives immediate improvement then put in chest tube
COPD exacerbation tx
Duonebs Abx steroids non invasive vemtialtion -avoid intubations as mortalrity increases
On US does vitreous hemorrhage artifacts move with they eye?
No
Retinal detachement- flashes of light with floaters
Risk factor +, symptoms + for CRAO- what 2 things can you do immediately?
ocular massage and co2 retention breathe into paper bag
Toxic shock syndrome tx?
Fluids
remove foreign body if possible
Clindamycin- blocks exotoxins and kills bacteria
Criteria for acute bronchitis dx?
- Less than 3 weeks
- VS normal
- Absence of Lung disease
- Asbcence of PNA PE findings
Herpes at tip of nose should tell you what?
possible eye involvement
give topical trifluridine/acyclovir
Is there allergic reaction cross reactivity to cephalsporins with PCN allergy?
1-8% Cross reactivity with the beta-lactam ring similiarty structure.
First/second gen cephs are more likely
Cefoxitin and cefazolin
Retrobulbar timeframe to vision loss?
2 hours
retina ischemia when central retinal artery occluded
what tiem point is activated charcoal useful?
1 hour
3 organisms in infant sepsis and Tx?
GBS, Staph, E coli- Amp and Gent or cefotaxime
for both <7 and >7 days presentation
+/- Acyclovir
idniciation for tpa in MI?
if patient will be >90 minutes to balloon time
What does scapula fractures tell you?
- High impact trauma- check skull, lungs etc
2. Check clavicle for scpaular dissocation=emergency surger
low risk appendicitis features
- duration of pain for greater than 48 hour
- previous episodes of similar pain
- lack of migration and right lower quadrant pain
- vomiting before the onset of pain
*obturator sign- keep knee stable and bring the foot out towards you and wall
HHS w/ glucose at 800>seizure— what next?
Fluids!. severe dehyradtion, hyperosmolar, electryltie abnormlaities leads to this
You give heloperidol and then neck and face contractions happens- what next?
Give benadryl or benztropine
-This reaction is caused by disruption in the balance between dopaminergic and cholinergic pathways in the basal ganglia. They tend to occur within 48 hours of administration of a neuroleptic agent. Patients often experience tongue protrusion, acute torticollis, sustained eye deviation (usually upwards) and arching of the back. Laryngospasm is rare but potentially life threatening. Because dystonic reactions occur as a result of cholinergic dominance, they should be treated with anticholinergic agents including benztropine and diphenhydramine. These agents typically reverse symptoms immediately.
Tx of pneumomediastinum?
Supportive care, dont increase pulm pressures, pain management
- alveolar leak
- complications= tension pnuemopericardium , PTX
hemopytsis, hematuria, renal disease?
Goodpastures
3 diagnoses of alveolahrhemorrhage syndromes
- pulmonary capillaritis- inflammaotry (lupus)
- Bland alveolaer hemorrhage- back up from heart, bleeding disorder, no inflammation
- Diffuse alveolar damage- edema + hylaine mebranes of alvoleoli that leads to ARDS
what is pseudohemoptysis?
blood coming from mouth or nose
impending worsening resp failure preceeded by?
AMS lethargy minimal breath sounds acidosis worsenign hypoxia/hypercapnia
Acute asthma exacerbation w/ normal or elevated CO2?
impending respiratory fatigue/failure
COPD vs CHF differences in dx?
- CXR
- BNP
- PE for volume overload
Stable Cervical spine fractures
- Clay shovelers- C6,C7 transverse process
- unilateral facet
- Type 1 (tip) odontoid fracture
Unstable cervical spine fractures
Jefferson bit off a hangmans thumb
- jefferson burst fracture
- bilateral facet (dislocation i think)
- Odontoid 2, 3
- Hangman
- Teardrop
NEXUS criteria
No focal neurologic deficits, normal alertness, no evidence of intoxication, no distracting injuries no posterior midline cervical tenderness.
flail chest tx?
supportive- pain, resp support, do not wrap the chest
Intubate if it is big enough
*negtive insirpaotry pressure causes the segment to move inward
Benzocaine spray used in intubations and procedures can lead to …
methemoglobinemia
pulse ox right at 85%ish and not moving
if mild just oxygen, if above 25% give methylene blue
normal paO2
which topical anestehtic is most cardiottoxic?
bupivicaine
ester or amides more allergenic?
esters > PABA metbaolite
Kid with central cyanosis at 3 weeks. How do you determine if this is cardiac or pulmonary?
Hyperoxia test- need ABG
give 100% oxygen and if paO2 is <150 then cardiac congitnal disease- give prostaglandins- cyanosis wont improve
if it is greater than 150 then pulmonary- cyanosis will improve. Oxygen is able to get into the lungs not shutned away
Target like lesions on plams, soles, body. Causes and Tx?
Erythema multiforme, supportive vs steroids
HSV, medications, pregnency, mlaignancy, X rays
Painless, flashes of light, progressive, curtain like?
Retinal detachment
*between inner neruonal outer pigment layer- Get US!
testicuar pain DDx?
torsion appendage torsion, itis orchitis epididymitis abscess hernia nephrolithiasis gangrene
contraindications to Noninvaisve pressure ventilation?
Altered or obtunded patient, hemodynamic instability inability to tolerate oral secretions recent trauma or injury to the face poor mask fit.
goals of tx for COPD?
- reduce obstruction with albuterol
- increase oxygen [] with supplemental
- reduce inflmmation with steorids
- tx infection
When to intubate in COPD?
altered mental status severe hypoxia hypotension hypercarbia * Altered mental status may suggest worsening hypercarbia as well as an inability to tolerate noninvasive positive pressure ventilation.
SSRI + dextromehtorphan…?
Serotinin syndrome
NMS=antipsychotics, muslce rigidity
MAOI + tyramine= sweaty, hyperthermic, flduhing
Which eye Dx common in sickle cell and which med do you want to avoid?
Hyphema
Acetazolamide- Lowers pH and exacerbates sickling and increases IOP
First line hyphema Rx?
Timolol
Cushings reflex?
HTN
Bradycardia
Bradypnea
hyperventilation wll vaso…
Constrict
dehyrdated old person with neck mass…
supportive parotitis- aggreisve infection
broad spectrum abx
AC joint displaced tx?
Grade 1 2 3 sling and follow up (it can still look pretty displaced and it is still follow up)- 456 get srugery for massive displacement
Which drugs given through an ETT?
Why?
What dose?
What complication to look for after giving it?
NAVEL, naloxone, atropine, vasopressin, epi, lido
no access, in arrest, no IO
2x IV dose
Transient hypoxia from liquid in lungs
complications of malingant otitis externa
brain abscess, CN, mastoiditis, menginitis, sinus thrombosis, osteo
-itching, foul discharge
Which antiviral for flu shold be avoided in COPD/lung patients?
Zanamivir
Oselatmvir- GI
-mantadines: Neuropsyh
how long do you have to prescribe an antivrial?
48 hrs
INH for 6 months if helathy
9 months if pregnant, HIV or 2-11 yrs old
nada
CAP outpatient tx?
inpatient?
macrolide or doxy
Add a 3rd gen ceph or just a flruoquinolone
looks like pulm TB all around an d on CXR but is a drunk bastard?
Lung abscess
unexplained pleural effusion - think what dx?
PE
small pleural effusions need what xray view
lay on side
where to do throacentsis?
2 interspaces below dullness inthe midscapular line
suspect T-E fistula, what next?
Place Ng tube and get x ray to see it coiled
blunt chest injury to sternum- what are you ocncerned for?
Cardiac contusion- dysrhtmias and heart failure can ensure- heart muscle is stunned needs telemetry montoring
subungal hematoma managament
- use electrocautery. If acrylic nail polish use 18 G needle to manually drill
- posterior nail edge disruption is a ocntraindication- need ot remove nail and repair laceration
- just trpehination is enough for most, dontneed ot rpeair lacertion
- repair lac with 6-0 absorbale gut, or glue, cover with nail or other cover and give abx
- check for fracture
RSI a shock patient and they code, why?
intubation and they have their last catecholamine surge and you take it away with paralytics they might code right then
when to pack an abscess?
5 cm or greater
DM2/immunocompromised
pilondial abscess
known malinancy with pericardial effusion and normal VS- tx?
reassurance and f/u
what med can give you epipdidymitis?
amiodarone chemical induced
looks like croup but not better after epi and steroids and looks very sick?
bacterial tracheitis - OR airway management
waht maneurver can you do to reporduce costochondirits?
corwing rooster- both arms up like signlaing for a field goal- then i pull thier elbows bakc and up!
sudden sensorinural hearing loss tx
idiopathic= prednisone for 7-14 days (60 mg)
Sudden sensorineural hearing loss has numerous causes, including idiopathic, infectious, autoimmune disease, neoplasms, cerebrovascular disease, and ototoxic medications.
Could be conductive too
3 electorlytes distubrances to cause prolonged QT?
Low
Ca
Mg
K
bucket/corner metaphyseal fractures in peds…
Abuse- yanking on arms
UMN lesion signs
hyperrelfexia
spastic muscles
Babinski response
Spinal cord lesion*
LMN- hyporeflexia, low muscle tone, negative babinski
Co2 10 Bicarb 10 what pill intox an tx?
ASA- give sodium bicarb
what to use in NMS for muscle rigifity?
Dantrolene or bromocruptine for dopamine agonsit
mainly just stop the offending agent
aferile pedaitric patient 6 yo wit hip pain… Dx and tx
transeint synosvitis- after URi usually- dx of excusion- give steroids (between 3 and 10 yo)
rule out septic arthritis
remeber slipped cap and legg calfe perthes
how to tx a cat bite
- amox-clav
- secondary closure
Clinda/metro + Doxy or bactrim or cefuroxime
no doxy in kids
Peds pt N/V AMS and then
AGMA, HypoCa, Kideny failure
ethylene glycol- give fomepizole
watch out for kidney function
caustic ingestion management
fluids
pain
x ray to see if perf
endoiscopy
tx of oral candidiaisis?
clomtrizole
nystatin oral
refracotr is fluconsazole or Amphortericin B
tx of frost bite
warm, circulating water. gentle rewarming
Pathophys*As the temperature drops below 10°C, cutaneous sensation is compromised. With microvascular vasoconstriction, plasma begins to leak into the interstitial space. Ice crystals begin to form once the temperature approaches 0°C. Once crystals begin forming, intracellular osmolarity rises and cells begin to collapse and die.
- once that cold, hyperkalmiec, acidotic blood return s to system then it is termed core temp after drop
AMA, HTN before 20 weeks, vomtting, blood in vagina 16 week spreggo
mole with trophopblastic disease and possible mets
emergent dialysis in hypercalcemia
> 18
CHF
renal failure
neuro symptoms
vision changes, headache, vomiting, weird neuro symtoms…
venous thrombosis!
aska bout clots and pregnancy
MRV and Heparin
weakness generalized, tired, uncoordinaed movements in an old person, what should you test for and how?
Think early parkinsons- bradykinesia.
- speed, amplitude, and rhythm of skills such as finger tapping and rapid hand movements
- refer to outpatient neurology
How to test for a DVT and what to do if +
3 point US of compressible vein
If non cimopressible- start LMWH and Warfarin outpatient
Clinically suspicious for DVT but negative scan= tx?
Outpatient US for DVT in 1 week
PHOTOPHOBIA + ciliary flush + trauma (or non) + low Visual acuity =?
Iritis - get slit lamp and look for cells
Pain with EOM=… (2)
Optic neuritis
Orbital cellulitis
How to treat a fight bite of the knuckles?
Augmenton
irrigiation
Can close a dog wound if:
The wound is clinically not infected, less than 12 hours old (24 hours for facial wounds)
is not located on the hands or feet
is not a crush injury or a puncture wound
is not heavily contaminated
the patient is not immunocompromised.
How do you treat unstable junctional rhythms?
Like bradycardia- Atropine and then transcutaneous pacing
_ it orignates in AV noe, HIS, or Ventricle. No p waves! Slow and narrow. If fast, narrow no p waves= Accelerated juncitona lrhtynm
How to treat stable and unstable a fib
Stable- Get echo (+/-), anticoagulate, cardiovert
Unstable (150-200J) sync cardiovert
Medical cardiovert- Dilt 15-20 mg bolus over 2 minutes and then go to 5-10 mg/hr. if that fails then give 25 mg in 15 minutes.
* verapamil, metorpolol, procainamide, amio
MAT tx
lytes distrubances/underlying trigger
Mag Sulfate 2 g IV over 1 minute
Abx for cat bite?
Amox- clav
+ x ray
EKG findings for dig toxicity
PVCs most common
and Heart block
-Block Na K atpase- HYPERKALEMIA
- Extra Na in cell leads to more Ca in cell bc of Na/Ca pump= ionotropy
Dont give IV calcium to this! stone heart
MVP pearls
- asymptomatic usually but : CP, palps, SOB
- INcrease Preload=later in systole click
- look for mitral regurg
ranson criteria
Age >55 years, glucose >200, WBC >16,000, AST>250, LDH>350
causes:
1. Steroids
2. Hyperlipiedmia
4-7% mortality for acute pancreatitis
lipase: 4-8 hours of symptom onset and peak at 24 hours. If biliary cause then LFTs/alk phos/bilirubin=biliary >now need an ERCP to reduce mortality!
SBP, give abx before paracentesis?
NO. false negative is very high. Give ceftriaxone (E coli and klebsiella) afterwards unless very sick and risk factors for it
Risks for spetic arthritis
intravenous drug use, rheumatoid arthritis, diabetes mellitus, recent joint surgery, or a prosthetic joint
most common dysrthhmia in kids and tx?
PSVT- Ice to face(15 seconds)/modified valsalva, TOngue dperessor back of mouth>ednosine
poor feeding, tachypnea, and irritability
Sepsis, hypotension depsite fludis and pressors
hypoG, hypoNa, HyperK…
adrenal crisis
Hydrocortisone 100 mg bolus then q6 hour
Drop in crit, back pain, AMS etc.
Can happen in MI, trauma, clots etc!
NEC keys
can occur up to 6 months old
can occur in term babies
vomting and distention- Xray
Huge inverted T waves in anterior leads…
elevated ICP- long QT
Stoke with edema, brain bleed
does subdurals cross suture lines
yes
seconds to minutes peds chest pain on L side of sternum worse with inspiration…
precordial catch
refractory seizure then WGMA… Tx?
B6 pyridoxune 5g IV push slow
INH interferes with GABA and metbaolism of b6
size of PTX to be on just oxygen alone?
20% or less
facial trauma and NG tube you worry about what fracture?
cribiform plate
QT prolonged in clonidine or methadone overdoses?
methadone
viral gastroenteritis with vomtinig and diarrhea, no blood. What are you thinking to see if they shoudl stay or go?
lyte distrubances?
tolerate PO?
playful?
if so then discharge home with reassruance this takes a week
*non bloody, non bilious, watery diarrhea
others at school have it
isolated plateltets are low, normal coags- tx?
ITP >50k observe <50k prednisone < 20 k not bleeding= iv methylpred <20 bleeding= IVIG + steroids -petechia, ecchymosis, mennorhagia, epistaxis
HepSplenmgaly, LA, pallor, bilirubin= leukemia, lymphoma
lymes testing?
ELISA testing with Western Blot and PCR
pericarditis has what else on EKG?
pr depression
Recent A fib and now bradycardia with heartblock, junctional rhythm… Dx and TX?
BB or CCB overdose
recent cancer Dx and chemo 48 hours ago and now N/V AKI, muscle aches, hallucinations
Tumor lysis syndrome- can have seziures, cardiac arrythemia and cardiac arrest
watch out for hyperK, hyperPO4, hypoCa,
give rasburicase/allopurinol and fluids
peritonsillar abscess Tx? fever, trismus, drooling
viral coinfection common?
Needle aspirate>abx>observe 6 hours> imporvement and tolerate PO=CYAAAAA
-Mono
DKA management in adults when the glucose drop sunder 250 switch to…
D5LR
3 main reasons why a stroke could be occurring?
- DVT
- Palps and a fib or ECHO needed
- Endocarditits
deconditioned patient (cancer too) and CT scan shows nothing acute, what is their dispo?
Can they tolerate PO and be safe at home for discahrge
blood transfusion and then fevers chills NV myalgias and hypoTN, now what?
- stop
- fluids (prssors if need be)
- diruetics to maintian UOP and sto renal damage
- hemolysis so send for LDH and hapto to be high and low respectively
at what level calcium (symptomatic or not) do you need to treat for it?
when do you go to dialysis for it?
14-FLUIDS
18
name 5 of the symtpoms from hypercalcemia
atigue, weakness, confusion, hypertension, bradycardia, polyuria, polydipsia, dehydration, nausea, vomiting, constipation, ataxia, and coma
when do you use bisphosphos and clacitonin to hyperclaemia?
you can but it will take a while to work, hydration and fluids is the Tx mainstay
3 ekg changes with hypercalcemia?
Shortening of the QTc interval, PR prolongation, and QRS widening.
upper lobe PNA in a drinker +/- air fluid level? Dx and TX
Klebsiella
Rocpehin and gentamycin (aminoglycoside)
Strep pneumo is lower lobe and lobar consildation
AA w/ hemolytic anemia after new Rx or infection?
G6PD
no NADPH=no glutathione= cant handle oxidative stress and nothing to clean up free radicals
Aspirin, Bactrim, Macrobid etc
what is valentions synrome?
Perforated PUD and pain in lower quadrants bc of paracolic gutter leak
pain can be referred to here lower Quads bc leakage into the area
5 steps in varcieal bleed?
- fluids
- blood/FFP?
- Octreotide
- ceftriaxone
- BB
- SB tube? surgery?
organizsm in Peritonsillar vs retro abscess?
Group A strep- needle aspirate
Strep viridans
what are JONES criteria major and minor?
- evidence of step throat w/ titer or swab
- Joints, cardiac murmur, painless Nodes over bones/tendons,rash sparing the face (erythema marginatium), syndeham chorea
- CRP/ESR, prolonged PR itnerval, arthralgia, fever
3 EKG changes usggestive of STEMI?
ST segment depression
new T wave inversions
hyperacute T waves.
You see a NSTEMI and give aspirin and…
TIcagrelor
shown to be better and reverisbel than ADP inhibtors
Oz sats hovering at 85% - what meds usually do this?
methemoglinemia
topical anesthetics
what bP cut off should a young person be evaluted for HTN immedietaly in ER vs PCP
Diatolic of 115
difference in chalazion vs hordeoulm?
hordelum hurts, bottom eyelid, infectious, acute
chalazion blocked meiboam gland, chronic, top eyelid
what is fluid between the parietal and vsiceral layers in the tunica vaginalis ?
hydrocele
varoceleces are sharp or dull pain?
dull
Pelvic instbaility and negative fast w/ hemo unstable=?
angio embolization
If there is a + fast and pelvic instabilit and hemo unstable=?
ex lap
febrile seizure pearls
- tylenol doesnt prevent reoccurence
- A seizure puts them at increase risk for epilepsy from 1% to 2-3%
- the younger the mor elikley for epilepsy
- antioncvulsatns dont help long term
2 post complications of herpes zoster
- post herp neurlagia
2. bacterial infection
mild and severe treatment of tumor lysis?
- allopurinol, rasburicase IV
2. Hemodilaysis if severe
Tx for unilateral facet dislocation of C5 w/ normal exam?
C collar and follow up outpatient
other facet makes it stable
Tx for HIV oral candidiasis:
- on therapy
- not ontherapy
- clomtrizole/nystatin
- fluconazole
Testicular cancer work up
- US
- down syndrome + large dense and painless
- AFP, LDH, BHcg
DDx: hemotcele, rupture
side effects of physostigmine?
dysrthmias
seizures
anticholonergic treatment?
- benzos
- cooling
- physostigmine
- WBI bc of slowed gastric emptying
how long do tonic cloncis last?
1-2 mins
post ictal for hours
first step if you suspect ectopic?
stable or unstable?
start resuscitiation quickly and if still tachy then surgery
young female with r sided weakness, left sided pain sensation loss and episode of vision loss 1 month ago?>
Think MS! give steroids
young kid with nystagmus, tachy, dialted pupils and AMS?
Dextromethoprhan PCP/opiate ingestion from cough syrup
dog bite tx?
- sutures
- irriagtaion
- abx
- primary vs secondary closure no diff in infection
painless vag bleeding, next best step in 3rd trimester?
US- check for placenta previa! dont do cervical or speculum exam until this is ruled out
Causes for MAT
Criteria for MAT
Tx for MAT
COPD!! /hypoxia
irregular, different p waves, tachycardic
Treat COPD, oxygen & rate control
What is severe sepsis?
Organ disfunction
lactic acidoss
hypotension
barhtolin abscess tx?
ID & catheter drainage ongoing like a tube or Word catheter
opiate withdrawal clinidine dosing?
.1-.3 every hour with a max of 0.7 total in a day
alpha 2 agonist to give hypotension and decrease sympatethci tone
why desmopression in vWF?
stimualtes release of factor 8 by stimualting the release of vWF from endothelial cells
what is the pentad for TTP?
- Fever
- Renal failure
- Neuro complaints
- anemia
- thrombocytopenia
* dont give plateltes it gets worse
DIC labs
High PT PTT
low platelts and fibrinogen
high D dimers and fibrin
lupus blood lab that is chronically low?
plateletes
collagen vascular disease leading to destruction of plateltes
missed dialysis can lead to:
- Heart
- Brain
- Blood
- GI
Uremia
- Pericardititis
- AMS
- plateltet dysfunction and bleeding
- N/V
Blood pearls
COombs tests for what?
retics high or low after parvo infection?
- Ig or complement on RBCs in for autoimmuniehemolytic anemia, coombs negative in aplasitc anemia
- low, aplstic anemia is no hemolysis
When to admit for hyphema?
IOP rx?
contraindicated Rx?
cycoplegics?
mechanical tearing or shearing of the vasculature of the iris or ciliary body. over 33% or 30 IOP Acetazolamide or timolol ASA, ibuprofen atropine/scoplamine
first line for acute otitis media?
amoxicillin 90mg/kg divided into BID or TID for 10 days
Fever, arthrlagies, headache + hypoNa + low platelets
RMSF- no rash can happen especially early!
also petiechiea after BP cuff inflation!
doxy
petiacheal rash in one arm w/ no other explanation?
Rumpele leede phenomena- rupture dermal capillaries with vascular pathology underlying like DM2 or HTN, or HTN emergency!
How do you treat seizures/AMS hypoNa?
HTS 3%: 100 cc over 10 min and then 100 cc over 50 minutes
Hyponatremia labs
Serum Osms Urine Osms Thyroid Cortisol for adrenal insuffiecny calculate FeNa
What do you need to check for after a blood transfusion?
- N/V hemolycitc reaction clincially
2. VOlume overload w/ legs, lungs and AMS
Febrile siezure treatment (3)?
- Observe for hours
- tylenol to drive fever down
- PO challenge them
- education
3 lytes to give you torsades
hypo:
K
Mg
Ca
Dont give Sux to:
- acute renal failure
- neuromuscular disease like multiple sclerosis, amyotrophic lateral sclerosis, and muscular dystrophy.
- spinal cord injuries 1 week to 3months after
- burns 5 days after
Asthma intubations
- cardiac arrest
- Bradypena/resp failure
- respiratory exhaustion (somnolence, eyes closed, subcostal retractions)
- AMS
- before you get there is Heliox, Bipap, Mag and terbutaline
Kanavels criteria
- Suasage finer
- tender along the entire flexor tendon
- Flexed
- pain with passive extnesion
Hypoglceymia pearls
- symptoms start at 50
- Long actign and sulonureas need 24 hour obs
- Catcho,aine surge leads to the sympmtoms when brains dont get their food
What does Alk phos high mean?
What does Alk phos and GGt high mean?
1.liver or cholestatic, if really high chlestatic
2. GGT + Alk = cholestatic
GGT + Alk+ High Conj bilirubin = Obstructive jaundice
Treat these blood transfuions: Stop it +…
- TRALI
- Allergic Hives
- Febrle rxn
- hemolytic reaction
- supportive
- Benadryl, supportive
- Tylenol
- Lots of immediate fluids and some diuretics
Simple 10% w/ stable vitals PTX Tx:
- Non rebreather at 15L
*resrobes 4x faster than observation
resrobes at 2% oer day and admit for obs
NPH Tx?
Large volume off in tap or a VP shunt
Dementia w/ shuffling gait, mood swings, bilateral paesthesia?
B12 deficneicy
difference between herpangina and hand foot mouth dz?
HFM is anterior mouth
herpangina is still coxsackie A but it is posteoir soft palate
what does metronidizole do when alcohol is given?
blocks aldehyde dehydorgenase
fever, 3 day spost partum, lower abd pain?
endometritis + fould smelling lochia
-c section is high risk
5 causes of stridor in kid?
- epiglottitis
- croup
- foreign body
- retroprhagnrala abscess
- tracheitits
* give oxygen and racemic epi to help befor ientubation
how long does balloon time have to be to give altepalse?
2 hours
5 bronchiloitis treatments
- DONT give albuterol or solumedrol
- Fever maanagement/pulse ox/suction/hydration/02 if needed
- Discharge criteria
90% sats
reliable care taker
Day 5 vs day2-3
mild work of breathing
4 wet diapers in 24 hours
5 spots to look for foot and ankle Fx
Posterior edge of medial and lateral malleolus
2) Base of 5th metatarsal
3) Navicular
4) Midfoot (for Lisfranc injury)
5) Proximal fibula (for Maisonneuve fracture)
difference between dancer and jones Fx?
proximal base of 5th is dancer and no surgery and Jones is distal and is surgery
what is a meckles and how do you test for it?
ectopic gastric mucosa caugin gastric acid an dlbeeding and T99 scan
WHat is meralgia paresthetica?
Meralgia paresthetica is the clinical syndrome of pain or dysesthesias, or both in the anterolateral, proximal thigh, due to a compressive neuropathy of the lateral femoral cutaneous nerve. Entrapment of this nerve under the inguinal ligament is common.
- COnfirmed by relfief of pain with lidociane
dfintiiion of status epilipticus
> 5 min seizure or not fully recovered siezure and then gets another one
somatization vs manchuens Vs malingering
lots of symtpoms but no caus
sympathy
external gain
whuich alcohol gives elevated osmool gap without a anion gap?
Isopropyl alcohol
Alcohol dehydo will make it into acetone and is read a s a ketone on the lab. Is is not charged so no acidosis but high OSm
steroid psychosis
3% will commit suicide very severe previously nromal psych histry within 5 days equivalent of 40 mg prednisone
How many WBC is abnromal on UA?
what does nitrite mean?
- 5 WBCs abnromal with no suqames
2. E coli/enterobacter/Klebsiella- convert nitrates to nitrites
How do you know when to give TPA to PE?
Massive PE=dont give fluids to hypotension and give TPA
Hypotension
What 5 things to do you look for in croup patients?
AMS
stridor (@rest= epi, give them 3 hours to return to baseline)
cyanosis
retractions(@rest= epi, give them 3 hours to return to baseline)
air entry
why 3 sided dresseing for open pneumothroax?
to avoid Tension PTX
parkland formula
4 X Kg x % IN NUMBER of full thickness not partial thickness
What increases lithium toxicity?
THiazide diuretics
Symptoms of lithium toxicity include bradycardia, ataxia, tremor, hypothyroidism, eczema, edema, nephrogenic diabetes insipidus, and Ebstein’s anomaly in pregnancy.
Treatment for ITP?
- abive 20 K plateltes observe
- <10k= IVIG and steroids
- 10-20 + bleeding = IViG steroids
- Life threatneing bleeding = give platelts
- Ab directed against plateltes, no bone marrow invovlement
Treatment and considerations for PCP intox?
- Agitation med to give and to avoid
- comlications to look for (3)
- Give benzos, not Haldol (seizures and arythmias)
- Rhabdo (check CK + fluids), Renal failure from CK, Traumatic injuries
- NMDA antagonist
wants attention=? disoder psych
unexplained symtoms=?
Factitious
Somatic symptoms
Disposition for a deep perirecatal abscess?
Admission- if perirectal and supericial can be follow up
if deep and digit rectal exam feels the abscess then admit.
withdraw form whcih med?Tachy, Hypertheermic, rigdity, HTN
Dopamine drugs - NMS!! rigidity is the key here
If no rigidity then clonidine
Difference in preseptal and post septal cellutlitis
preseptal= NO orbital invovlement. No pain with EOM, No visual distrubances, no pupillary defect. Eye looks univolved.
If orbital- then get a CT
What do you need to avoid in any patient with a possibiltiy of HSV in the eye?
topical steorids !
Lid lacs keys
Dont repair:
1. through and throughs
2. Nasolacrimal ducts (use flurosceine) or lid margins
3. ptosis, tarsal plate or levator plapebrae
If <1 mm near margin it hels on its own
*look for corneal abrasian and ruptures here too
spontaneous hyphema in which patients…
sicklers
Phys exam blow out bfractures
entrapment
subQ emphysema
infraorbital paesthesia
LEsion on flurosceine of eye + high speed mechanism of foreign body=…
clincal penetrating injury to eye
It could have sealed up and siedels could be negative. Still give eye patch, antibitoics, anti emietics
Block beta and activate alpha in glaucoma- why?
it block aquehous humor production
BUT! wouldnti this dialte the eye and cuase decreased outflow?
Red looks pink with vision loss +/- pain in eye=?
what disease do you think of?
how to treat?
OPtic neuritis
MS (also sarcoid and syhpilis)
Steorids if MS
otitis externa treatment
make it more acidic- Hydrogen peroxide or acetic acid/hydrocrotisone
tpoical antibitoics
Look out for malgnant otitis externa into the skull
ottiis media complications:
- conducitve hearing loss (Self limited)
- TM perf (SL)
- Labrytinhitis
- cholesteatoma
- facial nerve paralysis - ENT emegrency
- Masotiditis
- Sinus thrombosis
Wax and insect removal form ear?
TM perfs
- insect 2% lidocaine
- wax= mineral oil, hydorgen eroioxde, sodium bicarb
- Heals spontaneously- antibtioics +/-
DDx tinnitis
- Abx, Nsaids, ASA
- Vascualr
- Mechanical
- Menireres
nasal septa hemtoma tx…
Lidocaine withou epi and drain it! dont want septum necrosis
Sinusiitis complications
-phenylephrine 4x per day for 3 days
-meningitis
-thombosis cavernous sinus
- intrcrainal abscess,
robital cellutlites,
osetmyeltiies
how long after you take cialis can you give nitrates in chest pain
best to wait 36 hours!
Tamsulosin is not a contraidinctation (alpha 1 blcoker for BPH)
8 causes of PEA? thinsk H and T
- hypoxia
- Thrombus (PE and MI) may need to give thrombolytics if suspected!!
- Hypothermia
- Acidosis
- Tnesion penumo
- TOx
- hyperK
- hypovolemia
Recent virus or MS or Lupus and then paralyzed from the waist down progressively + sensation loss to a distinct line?
Transverse myelitis
GIve high dose steroids- reoslves over weeks usually
Suspect temproal arteritis what else do you need ot be ocnerned for>?
Aortic dissection, caortid artery, opthalmic artery
give steroids
Suspect GBS- what do you need ot be worried about life threatening
diaphragm invovlement, intubate this patient
need plasmapheresis or IVIG
Difference betwwen anterior, central, hemi cord loss?
anterior = motor/pain gone but DCML good
Central= sensory and motor in upper>Lower
Hemi- ipsi motor and DCML &opposite pain
how to treat mesenteric ischemia?
thombolytivcs
srugery
embolectomy
Acteominophen tox perals
- takes 4 hours to start damage
- minimum requirement is 7.5 grams (150 mg/kg for peds) to do damage
- Induced emesis- not proven to clincially benefit + complicaitons
- Orogaatric laavge if <2 hours old- but complciations arise
- charcoal reserved for spsecifc drugs- carbamazepine, dapsone, phenobarbital, quinine, or theophylline
5 causes of AMS that need emergent therapy?
- Hypoxia
- HTN encephalopathy
- Hypoglycemia
- CNSinfection
- high ICP
What do you give in Valproci acid overdose and why?
- L carnitiine!. ocnsider charcoal and Dialysis too if severe
- it blocks Carbomyl phos synthestase and makes high AMMONIA levels
Drugs to avoid in WPW?
AV node bockers
BB CCB Adensoine Amiodarone
AMS old person Differntial ddx and labs
1. dementia Alzherimers parkinsons with rigidity, pyramidal symptoms NPH- CT big ventricles Vascualr dementia if FND depressed
CT head, CXR, LP
CBC BMP B12 Thyroid ESR UA HIV folate syph
AMS + Bradycardia and HTN=What drugs?
- dex 10 mg
- Mannitol .5-1.0 mg/kg
- hyperventilate
Main difference between central vs periperhal vertigo
- Peripheral is sudden and severe, positional, no FND, w/ N/V/Sweating , hearing loss
- Ill dfined spinning , can be sudden or gradual
DDx peripheral vertigo
- BPPV
- Menieres
- Labryinthitis
- Otototxicity drugs
- Vestibualr neuoniitis- Viral unilateral tinnitus + heairn gloss - No Rx
- Vestibular ganglionitis- Zoster- Ramsay Hunt- Acyclovir
- perilyhym fistula - vertigot with pressure liek flying, diving, coughing
- Labrytihnitis- Sudden vertigo + middle ear fidnings
Mcelinzine and benadryl
Zofran and benzos 2nd line
DDX centeal vertigo
Vertigo:
- BPPV
- Menieres
- Labryinthitis
- Otototxicity drugs
- Vestibualr neuoniitis- Viral unilateral tinnitus + heairn gloss
- Vestibular ganglionitis- Zoster- Ramsay Hunt
- perilyhym fistula - vertigot with pressure liek flying, diving, coughing
- Labrytihnitis- Sudden vertigo + middle ear fidnings
- can also cocur with tumors, bleeds, post concussive
Central:
Cerebellar- HA, Truncal ataxia, ROmberg +, ataxia tandem gait
Lateral meduallry - dyspahgua, dysphonia, facial numbenss, corneal reflex out
Diplopia, dyspahiga, dysartrhia, drop attacks, dizzinies= vertebobasilar
Vertebal artery- truama, chiropracter, Neck pain, vertigo
MS
Vestibualr Migraine
how long can TOdds parlaysis last?
48 hours
pathophys to rheumatic fever?
Cross reacivity of Antibodies to heart, joints skin etc
JONES criteria
Get a head CT when to not to an LP?
papilledema AMS FNDs immunocompromised -to avoid a mass or herniation or ICP high if blunted sulci
IBS
Can be lined with mucuous
Stress induced can be, crhonic pressure, better when poop
HYdration, exercise, fiber
Emergent intervention for a ear infection?
Faical paralysis, needs amyringotomy
Intusseciption Testing
US= 98% and 98%
Air or liquid enema
Tx of herpetic whitlow
COver and NSAIDs 3-4 weeks
give acylovir if immunocomprmised
Tx of rehumatic fever
Pen G
Initial treatment of chrons disease
- Hydration
- Check electrolytes, B12,Iron and rpeleace- also they are ADEK vitmain down as well
- metronidazole and cipro
Diabetic otitis media not getting better with otorhhea…
Malignant otitis externa- broad psecturm Abx (pseudo and staph)+ CT scan
Trismus=measseter invovled
CN invvlement= extenive
Tx of penile fracture
Surgery - repair tunica albuginea and evCUATE HEMAOTMA
risk factor for deathin anaphylaxis?
asthma
Acute new systolic murmur with low oxygen sats- you suspect mitral regurg, what is th ecuases and treatments?
MI!, endocarditis, trauma
All about pulm edema- Nitrates, lasix, oxygen and positive pressure venitlation
acute phenytoin toxicity can be treated with…
Charcoal, GI absorption takes awhile
WHy is there hyperglycemia in CCB overdose?
Calcium mediates inuslin release
Tx of malaria
Quinidine and doxy
Shock index- HR/SBP . Anything great than 0.? is considered shock?
0.7
NPO status, how long do you have to be NPO?
2 hours clears, 4 hours milk, 6 hours solids
NOT based on outcome studies but expert opinion only
DCML pathyway
Coritcospinal
Pain and temp
DCML crosses at brain stem- ipsi loss when spinal cord take out
Corticospinal already crossed above so ipsi loss below
Pain and temp crossed in spinal canal so contra loss
You defib someone do you pause to check fo r apulse directly after?
NO! not intil after the next round of comrpessions
Severe ches tpain in an alcoholic you need ot think of
Borhaave- Give fluids, abx and do X ray or soluble water x ray
Lidocain overdose dose is?
5 mg/kg without
7 mg/kg with
If you use ep becareful in ares iwht poor wound healing because pei decreases it and cuases poor healing
It lasts for up to 60 minutes, comes in seconds
Management of Upper GIB
- Octreotide drip 50mcg bolus, 50 mcg/hr. Somatotatin anaolg to shunt splancnic blood away
- Reduce transfusions not mortality - 1 g Ceftriaxone- reduce rebleed and mortality
- ———- - PPI-no benefits with varcies
- NG tube little useo ther than lowers aspiration risk
- SB tube if unstable
Uncomplicated Diverticuloitits Tx?
1st line & 2nd line
Complicated criteria
- Flagyl and Cipro
- Amox/clav
- sepsis, perforation, uncontrolled pain, high fever, advanced age, significant comorbidities
- fistual or obstruction
Appy pearls
70% have leukocytosis
MOst ocmmonly caused by fecolith or LN enlargement
how to treat pit roseaseca?
Self limited
steorids for itching
Tx of hereditary angioedema?
FFP or c1 esterase inhibnitor rpelacement
GI an dupper resp invovlvemnt
How man cm is conidered small bowel anlargement?
3 on x ray
Type 1 vs Type 2 vWf
1- low levels = give desompressin
2- faulty vWF
Menieres vs vestibular neuritis?
Menieres tinnititus, intermittent vertigo attacks an dheairn gloss
neuritis- one long attack, no hearing issues, after a virla infection
Tylenol overdose shows up within 4 hours:
After 8 hours:
- LFTs and Tylenol level
2. Give 140 mg/kg of NAC
Difference between physiologic, breaskt milk and breaksmilk failure jaunidcie ?
- Physiologic is days after birth bc fetla Hgb breakdown
- > 7 days w/ jaundice but good feeds and weight= guconuryl transferse def. and high unconj. bili
- Low brith weight, low feeds, dehydrated= failure
kernicterus is the brian damage as a result of high bili
Food stuck in your Goose, what do you give?
GLucagon 1 mg slowly
Nitro sublingual can be used
Papin protelytic enzyme but esophigitis
Peds + rash + joint pain + abd pain
HSP, igA vasulitis
get UA for neprhotic syndrome
watch out for GI intussicpetion and perf
DC on +/- Steroids if invivlement of organs is low
Testing for Sypg
primary- Dark field micro
Secondard- RPR
Tertiary - fluroescent treponemal Ab test
Pupils will accomodate but not react to light
time fram for acute graft rejectoin and is it reverisble?
1-12 weeks
Reverisible - fever, pain over the site , failure
Hip pain in MVC- make sure to check for wha thip injury?
Posteori hip dislocation
If cant dorsifle or plantflex and decresaed sensation loss with leg deformity it is surgical emergency for avacualr necrosis
WHat levels VPA and pH will send you to dialysis for VPA overdose?
1300
acute ammonia encpehalopathy
pH <7.1
Coma, shock
give L Carnitine to stop urea cycle and build up of ammonia
Traua with pelvic fracture, & blood at the urethral meatus. What do you do next?
Retrograde urtehrogram,if negative pass a foley
Iburpfren overdoses
USualy asymptomatic and not severe
if over 100mg/kg then in 4 hours they should be symptomatic.
1. Gete Tylenol level
2. watch out for eizure, hypotension, coma, acute renal failure, metabolic acidosis and upper gastrointestinal tract bleeding
5 kawaski criteria and treatment?
4/5 criteria
- Mucous mebranes -even cracked lips
- Cervical LA
- Rash
- palms soles rash
- COnjucitivitis
IVIG and High dose apsirin within 10 days of fever. Coronary aneyrusm complications
WHen do you go and get a bullet in an extremity?
If it is in fragments, near a nerve, vessel, palms/soles ror joint
If unco,plicated, in soft tissue and no infection jsut give pain meds and DC
Tests for poplieal artery injury?
serial physical exams, ankle-brachial indices (ABI), CT angiography, conventional angiography, or duplex ultrasonography
Stab wound to chest, Hypotensive and tachy but has a pulse- pericardiocentesis or throacotmy?
PEricardio
if it doesnt imprvoe then go to thoracotomy
Hepatitis facts
C- lots of carriers, 20% chronic infection rate
B-5 % chronic infection
Clavicle Fx manageent
Sling (not figure 8)and send home with follw up
Vascular injuries are rare, malunion is the most common complication
When should you add steroids to abx for PNA infection?
PJP pneumonia with Hypoxia of 92% sats~ or pao2 of 70= steroids!!!! would help + Bactrim
Inrta cerebral hemorrhage Which Rx(s) is useful 1. Hyperventilate 2. Nicardipiine 3. Manntiol 4. pheyntoin 5. Factor 7A
- No, CPP can lower
- YES!
- Mannitol, varying success
- Pheynotin- seizure snot a bad outcome
- No benefit
fomepizole, HD or ehtanol is antifreeze toxicity?
FOmepizole first
Clincial symptoms and ocntinued acidosis for HD
when do you get alk phos and ggt?
when you ssupect gall bladder disease-cholesstais
Matching- scromboid vs ciguaterA and Tx
GI, Hot/cold, hypoTN, toothlessness feeling, paresthesias, bradycardia
FLushing, redness, metallic/pepper taste
1= Ciguatera- IVF, antiemeitcs, atropine
2= Scromboid- antihistamines
Cocaine chest pain tx and ddx
NItraes, aspirin, possible hydralazine and benzos
Think about PTX< pnumomediastinum and Dissection
Looks like raynauds but has GI symptoms, Hyper K and AKI? Tx and Dx
Scleroderma crisis
Treat hyperK and lytes
THEN give CAPTOPRIL for HTN and renal protection
Give Abx if Diarrhea bc of bacterial overgorwth
High risk of limb ischemia is to what Art line placement?
Brachial artery
HA< sweaty, HTN episodes> testing and tx
Pheo
MEtanpehrines
Phenoxybenzaprine
HYdral and phentolamine in acute crisis
What cna you see on EKG with HOCM?
LVH and DEEP NARROW Qs (inferoir and lateral)
Painting cielings and then a bunch of houlder pain, +neers test, +hawkins test—
Subacromial bursititis- NSAIDs, PT Steroid injections
anyone over 50 years old and fvere and neck pain gets what ABx?
Amp
MVC with tachycardia and sternal tenderness- Tests and complications of possible Dx
Myocardial contusion
EKG trops
watch out for arrythemias
14 yo w/ exertional pre sncope, Arotic murmur worse with quatting needs…
Aortic stenosis, baloon valvuloplasty
perimortem C section pearls
- should be done within 5 minutes of arrest, conitnue CPR
1a. baby needs to have doppler heart tones - Only if the fundus is above the belly button
- From pubic sympgysis to 5 cm below the Xiphphoid
- push bladder out fo the way and then do vertical incision on uterus
- it is htoguht to relive aortocaval pcmpresisonand return blood to heart
- dont do a bedside US, it dealys it
difference in splen ic seuqestation and palastic crisis after a URI?
PArvo!
no reticulocyts are in aplastic
retics will be high in splenic sequestration
Asthma Vent settings and what is plateau pressures?
Low TV (<8ml.kg), Low minute vent (<115 ml.kg), Low RR (permisseve hypercpania is OK to avoid barotrauma), long expiraotry time
Pleateu: end-inspiration pressure when flow is zero, and it correlates to small airway and alveoli pressures.
DRESS syndrome presnetation and tx
MOrbillofrm rash on the body and spares mucous membranes at first
Fever
Internal organ ovlvoement (cna lead ot death)
mailasie, LA, pharyngitis,
IVIG/steroids
Anticonvuslants, Bactrim, Antivirals, dapsone etc
Inorganic mercuray tx? (paint, thermometers)
Organic mercury tx? (pesiticdes, seafood)
Succimer/dimercaprol
NEVER give dimercaprol, give sucimer i think
Chemotherpay, low neutrophils, fever that resolves and VS that look great= DC or admit?
Admit with IV abx. Source of infection only seen in 20% of patients w. neutorpenic fever and infection
achilles tendon rupture splint…
Equinus splint
Posterior mold + stirrups plsint is for tib fibs stability
How many WBC is inflammtory arthritis ?
> 3K but less than 50 K (septic arhtitis)
BB overdose pearls and Tx
Heartblock, Hyper K, HypoG, bronchospasms
- Glucagon and fluids
- Pressor sif need be if bad and LIPID EMULSION IF real bad
- Calcium
- High dose insulin 1 unit/kg?
does clonidine overodse have pinpoint pupils
yes
does metoformin OD usually cause Hypotn and bradycardia?
NO
UV Keratitis tx- think little corneal abrasions
Cyclopegics- atorpine, cyclopentalte
ABx
Optho follow up
1 week ol with bilious vomiting, tx?
Malrotation + volvulus
NG tube, Abx, fluids
upper GI sereis if stable (corskscrew)
Surgery NOW
what is transveres myeltisi
A transverse level of sensory impairment, paraplegia, and sphincter disturbance.
Air embolism treatment
lay supine
100% oxygen
fluids
Ranson crteria for pancreaitits mortlaity
Age 55 WBC 16 GLucose >200 LDH 350 ASt 250
AMS + ataxia + Oculomortor dysfunction
Wernickes- give 100 mg thiamine
anterograde amnseis is korsakoff!
If you suspect mesenteric ischemia w/ nausea, diarrhea, voomiting but pain resolves…
Super high mortality
The nerve has now died, and they are getting close to bowel necrosis. Still need to get CTA abdomen!
Put abx on board and give fluids
use dobutmaine if you need pressors, vessels avoided
Always think about Veni thrombosis or clot in Celic or SMA or IMA! may need heparni!
Abdominal/flank pain + hypotension=
AAA!
Look for risk factors, look for femoral pulses (usually intact and perfusoin distal is uslaly OK)
GIVE fluids, better to maintain BP between 80-100 than possibly disrupt clot formation
asystole- CPR or shock shows best result?
CPR, this is not a shockabel rhythm
if V fib or pulselss vtach hen both have shown good results
epi has not shwon to reduce mortlaity butgets ROSC
Cooling helps with post enuro sypmtoms
Hyperbaric oxygen needs when CO poisoning
7.1 acidosis
25 or 15 if preggo
LOC
end organ ischemia
6 months old, preggo, older than 60, CAD risk factors
Drunk guy satiing in the 80s whiel asleep and 90s when awake- what do you do?
Put Naso airway in
White hazy irregular cornea, photophbia, foreign body sensation= Dx and Tx
Conreal ulceration
Its ifnected, Abx and optho
What length is considered dialted IVC?
2.5 cm and <50% collapse on inspiration
sexaul assault pearls
- Forensic evidence first
- cops only if the ywant it
- offer STD empiric treatment but not necessary to test for it bc postive STD could be used against them if it is positive
Pancreatitis causes and tx
fluids they third space and vomit, pain control
Gall stones Ethanol trauma Steroids Mumps Autoimmune Scropion Hyperlipidemia ERCP Drugs
SDh tx
serial CTs if small, and supportive care
emergent if >5 mm midline shift or FNDs
between dura and subarachnoid
Kid with unstable SVT
Sync cardiovert
if nto try ice bag and then adensoine
Tx of Cynadie posioning after apricots kernels
Hydoxycoablimine (binds cyandie tight) or Nitrites (makes methemogbloin to bind to cyandie)
Look out for for sevfer acidosis
Otitis externa Tx
Mild Acetic acid - avoid!! if you cant see the TM to rule out perf
Moderate - cipro and hydrocotrionse
Severe- Ear is completely cursted over = ““+ear wick
Psueomonas is top offedner
Hepatic encpehalpathy pearl
not proporthional to ammonia level! but it is becasu eliver cant metabolize ammonia an dincresased glutmate in braine
GIVE lactulose
Test of choice for lyme disease?
Bureelia antibody
Approach to BUtt stuff
Thrombosed ext hemorrhois: 48-72 hours= Elliptical incison and removal. If longer then DC with sitz, pain, topical steroids
Perianal abscess- get a CT scan to see the extent of it. Makue sure its not perirectal. If simple then drain. If DM2 or cellutlitis then add Abx to it.
simple febrile seizure is defined as
<15 mintues, no more than 1 in 24 hours, gernealized
menigisumus, complex, on abx, not immunized get an LP
HD for ASA
100 level
AMS
Kidney liver failure
Hyperbaric oxygen needs when CO poisoning
7.1 acidosis
25 or 15 if preggo
LOC
end organ ischemia
Skull fx management
Linear, closed- DC to home i think
Linear, open- Admit obs
open depressed- Admit Abx
HemoTM, battle, raccon, basilar
a fib RVR >48 hours Tx
Dilt 0.25 mg/kg or usually 10-15 mg max 25 bolus to rate control and leave them in A fib target 100 bpm
How much IM versed in a seizure?
10 mg midazolam
2-4 mg IV
How much propofol in a sezirue?
4 mg/kg bolus
1 mg/kg/hr infusion (up to mg/kg/hr)
Mandibular Fx or angioedema of oral cavity, how do you intubate?
Fiberoptic nasally
angioedema from drugs or c1 esterase- give what?
You can give anaphylaxis Rx but it wont help much
C1 or FFP if that is it
Supportive and Airway care is the other- ask them to say EEEEE
Opiod constipation RX
Methylnaltrexone
Abx in TM rupture?
Not if it is suspected to be clean
Lead Posioing Tx?
Abd pain + headaches
<70= Succimer outpatient >70= Dimercaprol + EDTA
Abd pain + GIB + history AAA repair
Aortoenteric fistula- always need outthink about this with syphilis and TB infections or a herald bleed picture!
deep Laceration near knee- what do you need ot make sur eis not involved or else it is surgical emergency?
Joint capsule- inject 150 ml + in joint to see if it comes out the laceration = Abx and surgery
What Induciton agent do you avoid in sepsis?
Etomidate to not suppress the adrenals
Phenylephrine, soft pressures and want quick bump to sustain them
50-100 mcg
Kid bites on a cord and get burn to lateral mouth- DC or admit if they are stable?
DC! delayed bleeding 5-21 days later but can go home without escahromtoy
lead 1: Wide and positive
Leade V1: Negative QRS complex
LBBB
Patella dislocation stuff
get x rays and peronal nerve testing after it
knee imbolizer and f/up ortho
just push on it medially
UTI kids Abx
1st - 4th line
Cefixime
Augmenton
Bactrim
Cipro
best ways to test for MS and what is lhermitte sign?
Flexion of nck and shooting pain down neck/back
Heat temp changes ysmptoms=uthoffs
MRI and LP
What scoring system do you use in a GIB to see if they are high risk?
Glsaco-bltachford to see if they need scope or transfusions
You suspect AKA, what type of acidosis is it and what is their pH?
WGMA- Dehydration, low gluyconeogensis, and high gluconaon/lowinsulin leads to ketones
normal pH bc Alkalosis usually too
Flduids and glucose
tularemia tx?
Streptomycin
How does tyramine cause HTn crisis?
It indirectly Activates catcehomlaines NE. Since it cantbe broken down by MAOIs it does this rapidly
what is double sickening?
Getting betterna dthen worse with sinusitis. Viral>bacterial=give abx
TV pacing nugz
R IJ or L Subclavian is best
Cardiac Pacing
Transcutaneous: 40 to 60 mA to capture
Transvenous: capture at 5 mA then decrease
Electrical capture without a palpable pulse = PEA
Anemia, low platelets, Renal failure, diarrhea
HUS- damages little vessels leading ot shearing RBCs and plaeltes
UA- poreitnuria, RBCs
high haptoglobin, LDH high too.
Hydration an dpaincontorl and transfuions if need be
Clogged G tube steps
- Flush it
- still clogged? replace it and then have them follow up
**within the last 4 weeksplaced? leave it be! immature tract.
Why do we give antiplateltes in ACS?
Plaque thrombosis
Mastitis vs engorement vs abscess Tx
Mstitis is unilateral infection, ocntinue to breastfeed, give Kelfex, usually fevers fatigue
Bilateral = engorement, non breastfeeding, cold compresses
Abscess, pocket, drain
Inferior medial eye abscess looking thing- what do you?
Dacrocystitis- Dont ID it! give Oral clinda
Fat embolism tx?
IVF and O2, nothing else shown to wokr
Sinus Bradycardia DDx
- Vagal tone
- sick Sinus syndromee (SA node disease, fast/slow HR w/ syncope)
- BB
- Hypothyroid
- Hypothermia
- Hypoglycemia
Synthetic function of the liver - INR and ..
albumin to see if you are in ALF
RMSF stuff and tx. hwo do you tx peds?
DOxy and still doxy!
starts outside and spreads in
labs hypoNA, thrombocytopenia, neutropenia, LFTs
Risks for pyloric stneosis
first born male, premature,, erythmycin use
when do you treat methemoglboinemia- what level?
15% symptomatics
30% asymptomatics
Tx third degree Heart block?
Pace them in ED if symtpomatic and get cards for pacemaker placement
HAC tx?
descent, oxygen, steorids
Significant MVC, do you get Abd CT?
Yes, it takes 5-10 rads to damage fetus and CT abd is 2.5-4.5 rads
worse when weeks 2-9 in pregnnayc
umbilicus is blue and infected on newborn, Dx and TX?
Omphalitis of Nec Fasc, Broad specturm
HIV ED testiing
NAAT testing not HIV ab testing if you suspect acute viral illness HIV (more prevlaent than asymtpomatic infection)
PArvo or coxsackie for myocaridtis favorite?
Parvo
unidirectnal nystagmus, central or peripheral?
Peripheral
COntinuous is more central, not episodic
preterm neonate with resp distress, give what if after 1 hr of life?
Caffeine
surfactant if under 1 hour
otitis media + TM perf= abx + consult/f-up/expectant
expectant manegment- heals on its own
HypoK EKG changes
- PR long
- QT long
- ST depressed
- Shallow T
- U wave
Braydcardia and AV block
How much fluid can you take off of a thoracentesis/
Until symptome resolve, you dont need to stop at 1.5L
Which opiod give you mydriasis, Seizures, hallucinations?
Mepiridine
Treatment of E vermicularis?
Albendoazole or mebendizole 1x time dose
3 lower GIB causes?
Diverticular disease, angiodysplasia, and neoplasms
5 things you see with aortic injury on x ray
R mainstem bronchus UP, left is down
Trachea Right, E tothe RIght
Wide mediastinum
What % is cross reactive of cephs to pencillin?
Closer to 1% but techinically 1-10% for first and second gens. Neglgible for 3rd and fourth
Sinusitis, + hemoptysis + Hematuria
Wegners, polyarteritis
Lung + renal bleeding
Goodpasture
Ashtma plus eopsinophils plus sinusitis
Churg strauss
Stridor with crying in croup, do you give rac epi?
No, only when at rest. Give dex
preseptal cellulitis symptoms vs post septal
will not have proptosis, ophthalmoplegia, visual changes, afferent pupillary defect, or decreased visual acuity.
Recent eye surgery with a new hypopyon and loss of vision- Dx and TX
Endopthlamitis- needs and optho right away plus Abx
before peridcardiocentesis what do you give the patient?
Fluid bolus- preload dependent
2 yr old with bloody dirahhea, tachy, febrile, leukocytosis– which abx to give?
Shigellosis- Ceftriaxone
Which spiral fracture is normal on a kiddo?
tibial- rotational fall
Os and fetal tissues in the uterus for miss abortion?
Closed
Still in uterus
Oral hairy leukoplakie is linked to what two viruses? Is is premalginant?
EBV-HIV
NO
Conrerning MI hx, symptoms have resolved, Nomral inital trop but Biphasic T waves…
Wellnes Warning for LAD- Cath urgently
how quckly should endoscopy be performed after a caustic ingestion
12-24 horus but def not after 24 for perforation
dont use charcoal
Dacrocytisi Tx and Bug
Staph
The patient should be placed on topical and oral antibiotics, advised to use warm compresses and given analgesic medications. They should be provided with ophthalmologic referral for outpatient follow-up.
Ptosis, Cant move eye up or medially but pupil reflex is intact—-Dx
Intraneural nutrient artery to CN3- seen in DiBEETS
THe artery is is still giving blood to parasymp peripherally but core is nto working for motor
If Refelx is out then thing bleed, tumor, stroke
Tx of minimamlly dispalced humerus fracutre?
Sling and go home- watch out for Capsulitis and AVN
DONT need to sedate and reduce if minimal
Which GI disease gives you mroe Kidney stones?
Chronhs- mmore oxalata, less Ca and fat absorption
Why is BUN higher in an upper GI bleed?
Bc blood gets absorbed in GI tract and BLOOD urea nitrogen is aborbed
UC treatment
IV fluids, analgesics, 5-aminosalicylates, systemic steroids, and antibiotics if there is concern for infection or perforation.
Toxo Tx
pyrimethamine and sulfadiazine
how do you use CURB 65
COnfusion BUN >19 RR>30 90/60 65
0-1 go home
2+ come in
Aspiration pneumonai with pink frothy sputum in ETT, do you start ABx right away
NO, wait and see after intubation n
Which kidney stones od you admit?
Obsturction and infection (hydro?)
Cant sotp pain or vomiting
One kidney, transplant
Tx of HUS?
Supportive
Dx and TX of Newborn from a gestational DM mother with mild resp distress and murmur?
INterventricular hypertrophy- resolves on its own usually
HOCM mild moderate severe Tx
BB
Alcohol ablatoin
Low EF, sudden cardiadc death risk is ICD placement
Normal TSH, barely low T3 and high T4- which med can cause this?
AMiodarone- wait for a couple months a redraw
Thalessemia pearls
HbBarts or 4 gamma is alpha thal
Beta thelmessemia- is hbF and HbA2 is high
HbSC less evere sickle variant, nromocytic
Kid drinking whole cows milk…. blood disorder
IDA
Elevated Calcicotnin levels in thyroid cancer medullary after thryodiectomy, next move?
Get CT scan for metastic meduallry cancer bc Calcitoni levels are still high
Low OSMs, high Urine SOdum and high urine Osms=Dx?
SIADH- absorba all water and pisss out salt
GIB inpatient vs outpatient socring stuff to look at
Hemoglobin > 13.0 g/dL (men) or > 12.0 g/dL (women); BUN < 18.2 mg/dL; initial systolic blood pressure > 109 mm Hg; HR < 100/min; no melena or syncope at presentation and absence of hepatic disease or heart failure history.
Caustic eye burn- first step and when do you stop
irrigate tiwth 2 liters fluid
then check make sure pH is 7.0-7.2
most common sprained ligmanent
Anteriootalor fibular
Calcaneal fib and posterior talo fib is rare needs a lot of force
Grade 3 is joitn instability
Alc liver failure labs
Macro or microcytic anemia?
GI?
Metabolic?
Macrocytic from folate
Pancreaititrs and PUD
elevated ammonia, estrogen, and progesterone level -
-decreased albumin level. Because the majority of calcium is bound to albumin, a decreased serum calcium will be noted but the free or ionized calcium level is typically normal.
placental abruption, watch out for blood disorder…
DIC
IV epi during arrest 1k or 10k
10k IV
Why mitral ivovlement with ARF?
Ab cross reactivity with the valve tissues- leads topulm HTN leads to RHF
amoutn of pRBC bolus to give a kid
10cc/kg
what does FENA <1 and Urine Na <20 mean with AKI?
Pre renal azotemia or pre renal AKI bc tubes still work to retain Na
ATN from infection, drugs or toxnis would be elevated
sting ray
cold and salt or warm and fresh?
Warm and fresh water
Perilunate vs lunate Dislocation- Tx of perilunates?
Perilunate dislocation is actually capitate dorsal dislocation. Teacup is up. Emergent ortho surgery. check median nerve, avoid AVN
Lunate is dislocated and curve facing down
Blast degrees
primary- shcokwave
secodnayr- fragments
tertiary- propel into obejcts
What do you get after you hae a first positive RPR?
FTA ABS
How to Tx Primary/secondary syph
Late syph
Neruosyph
How to Tx Primary/secondary syph
Late syph
Neruosyph
Kidney stone pain, abd pain, back pain, syncope all should make you thknk
AAA
what level of ANC is considered neutropenic
500
What is HELLP? Tx? Complications?
Labetalol and dleivery
Hepatic hematoma! DICHemolysis, LFTs, emolysis, LFTs,
Low plateltes usually with HTN like preecamlsia
Subclavian Positive and negatvie Central line
Least infection (half as much as internal jugular), PTX
What acronym do you use for ETT Rx?
NAVEL (no V for kids) Naloxone atropine Vaso Epi lidocain
Diaphysis longn brone fracture- NAT or no?
NAT
Symptomatic and _____ hyponatremia
Asymptomatic and ______ hypoantremia get 3% sodium 100 ml over 10 mins and possible a x2 over 50 minutes
120
110
Always think are they low, eu or hypervolemic?
if hypovolemic aim for 0.5 meq an hour
Deeo inverted Ts in v1-v4
ST elevation in V2 and V3 minimal ===
Wellenes or tight stenosis of LAD
Wake up with sudden sensorineural hearing loss> next test?
Brain MRI! most liekly a Viral cause but rule our brainstem strone, pontine angle mass
Air>bone conduction
maybe give sterdois and acylcovir
PAraphimosis vs Phimosis Dx and Tx
Para (paramedics)- urologic emergency- foreksin is stuck up and cant reduce. reduce with frim pressure 5-10 minutes. No uroglogy? Lidociane plus dorsal slit
Phimosis- cant retract foreskin
xtrapyramidal symptoms come about because too Much ____ and not enough ___
Ach
Dopamine
Benztropine block ACH receptors and blocks reuptake of Dopamine
DUKE major
Echo evidence of valve regurg
Blood cx
new murmur
the rest you would think woudl be minor criteria
beefy red ulcer with a painless papule on the dick=
Klebsiella
pulseless torsades, Mg or defib first?
Defib! Mg for a pulse
Suicide risk factors 2 points
Hopelessness/depressio
previos attmept
intent
rational thinking loss
TCA Sodium bicarb stuff
Sodium bicarbonate is the antidote of choice and works via overcoming the sodium channel blockade by providing a sodium load and via inducing an alkalosis to decrease drug binding to sodium channels. Indications for sodium bicarbonate include a QRS duration > 100 ms, ventricular dysrhythmias, and hypotension.
Look for Terminal R wave in in AVR
Skiers thumb management
Lots of stress on the inside of your thumb, like you ginfers didn the splits. And then the UCL ulnar ligmenat is torn and has laxity >35 degress. Thumb spica and urgent surigcal follow up
Tx of low grade moutnaitn sickness?
IVF, acetazolamide and nof urhter ascent progresso n to descent and dex if that doesnt wokr
is infectivity the hgihest in acute infection or AIDS inHIV?
Acut einfection
BIpapa in HF does what?
Decresae afterload and pre load by increased intrahtoac pressure
difference in conus medulalris an cauda equina?
any UMN is conus, very sudden, bilateral, Ankles gone w/ preserved Knees
Mono pearls
Posterior Cerv LA (Ant is strep throat) with exudated in post OP
Almost always rash after pen/amox
splenomgaly dont play sports for 4 weeks after
heterophile Ab test and atypica llymphocuytes
Tx auricalr hematoma- incisr and drainif large, if small needle aspirate and pressure dressing to not let it reaccumulate
nah
muliutple painful ulcers with inguinal LA- what type of organizsm is this?
GN coccobacilli- H Ducreyi
How to treat Cerebal edema in DKA?
Mannitol! begins 6-10 hours after therpay for unknown reason- 90% mortality, usually kids
What 2 co factors do you give inehtlyene glycol and what 2 levels do you get HD?
B6 and B1 to shunt the pathway
Ehtlyene glycol 50
glyciolic acid 8
significant pain with menses young femal tx?
Iburpfoen and Tylenol - dysmenorrhea - prostaglandins mediated
PE massive vs submassive
systolic blood pressure < 90 mm Hg for > 15 minutes, a systolic blood pressure of < 100 mm Hg with a history of hypertension, or a > 40% reduction in baseline systolic blood pressure. Tachy. RV dialtion hypokinesis. Hypoixc and hypoTN think lytics
CHF 3 things ot tx with and HTN
BIpap
IV Nitro
furoesmide
TBI management 2 main things
Hypoxia- intubate
Hypotension - SBP 90
AVNRT tx
Adenosine this is PSVT or valsalva
If it is wide or irregular then think procainamide
garlic odor on poinsing Tx? abd pain, hematuria an jaundicie
Arsenic- urinay alkinalization
traumatic iritis treatment?
Homatotropine
Papilledema and LP
You can do itin IIH but make sure this no mass ocupying lesion and CN abnromalities! it is diagnositic if you have papilledmea
INR <1.5 and platletes 50K are the cut offs
2 meds used in cuhusing syndrome
Cushing disease is pituriaty tumor, syndrome is steroids
- Keotconazole and metyrapone to stop steroigensis or take out hte tumor
what do you do with an accelracted idioventricular rhythm?
Nothing, it is from the ventricles and usally after a reprufion to myocaridum. wide complex and regular, 40-100 beats
What complications for neisseria menigitis can you get?
Ecchymosis and DIC and ganrene of extmeities
Waterson F
How sure can rule out a SAH if you get a CT within 6 vs 24 hours?
100 vs 92%
asymptomatic bacturia complications and 3 tx options
Kelfex, augmenton, Macrobid NOT cipro or bactrim
Uterus is big and porgesterone relaxes smoth muscle so risk of Pyelo is 30%, preterm labor, IUGR, sepsis, UTI, neonatal death
What does posterior MI look like?
Deep ST depression in V1 and V2
Either from Right coroanry or Left circumflex artery
get posterior ekg
What do you give in a MI
Apsirin
Slopidrgrel
heparain
Nitro to vasodialte coraonry arteries (not right sided)
90 minutes from door to balloon time or else thromblytics
120 if transferred
full thikcness lateral wall MI looks like
5 6 lead 1 and AVL STEMI
Subendocardial ischami in ant wall ekg
ST depression in anteriro leads
Same look if it was right sided, 2 3 F
baby had GERD what do you put him on first?
Proetien hydorylsatye AMnio acid formula
if weight loss and esophigitis and ill appearing them do histamine or ppi therpay
liver abscess
CFTX for + and - coverage and metornidazole for anaerobes and E. hisolytica infection
empyema Dx and Tx
GRam stain with bacteria
7.1 pH 50k WBC glucose <60
usualy a parapenumonic effusion
fiberoptic intubations indiations to secure airwway
Clinical findings may include subcutaneous emphysema or crepitus, dysphonia, stridor, hemoptysis, laryngeal tenderness, anterior neck pain with tongue movement, or anterior neck pain with head rotation.
fungal infection Tx of erytehma nodosum, erythema multiforma and rash with lung involvment
FLuconazole, itraconazole for occicodio
Heart block and MI
narrow complex 3rd degree AV block + inferoir wall MI is transeiint and good prognosis
Right bundle, left bundle, posterieor ehmi block have increased rsk of shock, v fib, big infarct size and poor mortality
GI pain, WGMA_ ingestion hypoTN
IRON OD
deferoximine
hydroflurouic acid- what type of gel do you put on it?
Calcium gluconate- if you suspect deep invovlement may need to push it IV bc it binds to those ions
watch out arrythmias
25 RBC on UA follwing a MVC- DC or CT?
DC microscopic without gross heamturia
if gross then CT
cells to look at in acute radiaitonexposure syndrome?
<1500 lymphoytes
Pathophys and complications of HELLP
MIcorangiopathic thrombosis
Patients with HELLP syndrome are at risk for bleeding complications, including disseminated vascular coagulation (DIC), intracranial hemorrhage, placental abruption, and spontaneous hepatic or splenic hemorrhage. Hepatic hemorrhage can progress to hepatic rupture
Most common cuase of SVC syndrome, is it life threatenitng,
Lung cancer
rarely
Drug OD: hallucinate, HTN, Tachy, dilated pupils
Dextromehtorphan
pathophys and TX of TTP
ADAMST13 ab cleaving vWF into smaller thigns to glom up vessels
Plasma exchnage
colitis = Diagnosis name
MEsenteric ishcamia- need abx
impriving hemorrhid >72 hours TX
Sitz bath and steroids
<72 = cut it out
Neck trauma managmeent
Soft signs= CT angio +/- EGD and bronch
HArd= OR
ZOne 1= SC to cricoid
HArd= Non reposnsive shock, no radial pulses, FND, massive hmoptysis
Fevers, quick malar rash- Dx and TX
Erysieplas of superficial dermis- systemic so give IV CFTX if not then give amoxicillin Strep pyo (B)
Mitral stenosis pearls
DSypena on exertion
diasotlic rumble
hoarseness bc L atrium onto recurrent larygeal nerve
What is the cut off ibuprofen OD mg/kg
100 if less than discharge home You would need 28 g or 140 pills in 70 kg person Common:GI and CNS Rare: hypoTN seizure coma
every RBC infusion reaction is supportive care excpet for…
Hemolysis
Diuretics and fludis
RBC transfuons and your patient gets a fever what do you do?
- Stop, could be non hemolytic or hemolytic
- repeat cross match, haptoglobin, LDH, direct antigen test
- Blood cultures
- once hmeoysis is ruled out- restart and give tlyenol. can use leuokcyte recude blood
gamekeeprs thumb injury spot and what do they have toruble doing
Weak pincer grasp bc ulnar colateral lig on medial side . valgus stress
kid huffs keyboard cleaner, passes out- what is happening?
cardiac dysrhytmia bc catecholamine release and senstize myocaridum - give BB
small PTX TX
100% O2 and reshoot xray in 6 hours, DC after
sigmoid volvus Tx
needs flex sig and then opertion to prevent recurrence
Heartblock + a ST depression of a sloped nature=
Digoxin “Dig” that slope
young monagmous prstatitis treatment
E coli
bactirm or flkuoruinoline
unstable angina…
Doesnt have ot be just at rest, it can be new or worsenign anginal pain
sternal fractures
need lateral chest x ray
restrained drivers
low mortality, doesnt alwya smean underying injury
TBI RSI drugs…
Etomidate- ressur eneutral and quick
sux- quick to reassess mental status afterwards
avoid hypoxia and hypoTN
Malraia perals
P. malariae is every third day — vivax, faciparum, ovale is every other day
- recurrence after months of exporusre is vivax or ovale dormant= needs primaquine
what is enoopathlmos?
posterior displacement of the globe - truama
shooting pain when you chew…
Trigeminal neurlagia
what si t called when you get vertigo or joint paint 1 day after you dive and fly?
decomrpession sickenss
Youo stick a chest tube in someone for a PTX and now has an opacity, hypoxic and dyspneic?
Reexpansion pulmonary edema. happens when you turn on suction from a PTX that has usually been there for a few days and repaid expansion of the lung causes fluid shifts. Dont turn on suction right away. Supportive and self limited, PPV if need be
bradycarida with wide QRS- do yu give clacium gluconate or pace them?
Calcum gluconate and try to get K down first
Ectopic preganncy
Repeat if below 1000 in 48 hours
Can be an empty gestastional sac AND a actopic pregnancy it does nto rule it out
Rhogam to Rh neg patients an bleeding
MTX 85-93% medical therpay in early ectopic
Tetanus treamtment
Tetanis Ig Metronidzaole Benzos and ROcuronium! opiods
nerves in spine come out above or below the vertebra?
Below
Esiemnegrner syndrome
L-R shint progresses to R to left shunt! bc overload into the lungs an dpulm HTN
Oxygen wont increase the sats!
WHat to do with an avulsed tooth
60 minutes=rinse and reimplant
>60 minute= soak in citric acid and emergent dental follow up (1% per minute)
kid under 6 years- dont put it back in
differenc betwen grade 2 and grade 1 sprain ankle
grade 2 in decreased ROM but still can wlak on it. Partial tear. immobilize
Grade 1 is full ROM with pain and can walk. microscopic tears
3= no walk, full tear. surgery
treatment of pneumomediastinum?
Supportive if no PTX
periodic paralysis
hyperkalemic, hypokalemic, thyrtoxic types. happens after heavy exercise and high carbs! PAralysis + BMP
give carbonic anydrahes and K sparing siruetics in hypokalemic which is common
ion channel problem. famimlial
when to admit for obs in electircal shock?
> 240 V even if they are asymptomatic - lytes, CK, cardiaac arrtyhmias
when to give tamoflu post 48 hours?
old
copd
ummunocompormised
what other durgs treats herpes keratitis?
trifluridiine
lung cancer, afebrile dullnness to persucssion =
pulmonary effusion
rash, myalagis, travel, rash, fever, headache…
dengue fever
diagnosis of rpecemaplsia to trear
160/110
plus AMS, labs, pulm edema ect
treatment in peds anal fissure
WASH
Warm water, analgesics, st
MC anorectal disorder- if it isnot midline think crohns, orinfectoius
Peritonsillar abscess complication…
internal carotid is 2-3 cm inferior lateral
Drowning mangement
Interventions start with rales in pulm fields- low flow oxygen in the ED- if none then go home
Rales in all field sis high flow oxygen and ICU and if Abnromal BP then conisder intubate and ICU- 3&4 needs hgi flow oxygne
near hanging post complications
neurgenic pulm edema
obsturvive pulm edema
ARDS
flail chest with inadequate oxygenation on NRB- =?
intubate and positive pressure ventilation
if 8 ribs, old, shock, resp fail, comorbids then do this early to reduce mortality
very stressful event, enlarged heart, EKG looks like MI but then cath is negative…
Takotsubo
what is a lizfranc Fx, how do you dx it and tx it?
Tarasal-metatarsal dislocation- cuneifrom and cuboid
keep calc stabel and twist foot. Xray
Nondisplaced= walking boot. Displaced is surgical
Hyperhma stuff
CHeck IOP- eye hsield, rest- f/up
it is a bleeding oiris or ciliary body -
Compartment pressure meausring
When Diastolic - compartment pressure is >30
What is slit venricle syndrome?
VP shunt with intermittent headaches around exercise and stress
Overdrainage and the ventirlces collapse and now obstruct the shunt altogether an dimproves with rest. Needs nuerusurg consults and lay supine/treneldumburg
perforated TM Tx
Discharge and KEep dry
loss of aurerbach plexus…
Aclashia
bulemia metabolci derangements…
HYPO all the way (even hypochloremia)
met alkalosis
fenanyl chest wall rigidity tx
NOT naloxone
needs paralytic
Tx of isopropyl alcohol?
Supportive not fomepizole
TRALI
neutrophils causing enodthelial injruy and vascualr leakege in the lungs
SJS Tx
Burn treatment
including fluid repletion to replace insensible losses, wound care, and prophylactic antibiotics as indicated. Patients with severe oral or airway involvement may require intubation for airway protection as well as transfer to a burn center, depending on the degree of involvement
Mycopalsma can cause this
HF acid treatment
glass etching
White figners directly after— GIve clacium gluconate bc QT and arrtynmais can happen 24 hours later even for 1-5% of surface area
blast injruy apears normal, check_____ to discahrge them
TM
Kid needs Abx and has leukemia, no access- wait or do IO?
IO if can tbe accessed in 1 mintue
Paraphimossi Tx
If ischemic then penile block, and Ab oitnment and dorsal slit
IF non ischemoc soak a sauzein mannitol ro sugar and osmosis to reduce swelling
What INR should you immediaitely reverse it?
Over 4, even if metal valve
K and PCC
ACLS and PEA
Patients not in a “shockable” rhythm should receive high-quality CPR, epinephrine, and a diligent search for potentially correctable causes of arrest should be undertaken. Therefore, because the patient is in cardiac arrest with a rhythm on the monitor but no pulse, chest compressions is the next most appropriate step. Causes include hypothermia, hypoxemia, hypovolemia, hemorrhage, hyperkalemia, hypokalemia, severe acidosis, tension pneumothorax, pericardial tamponade, pulmonary embolism, myocardial infarction, traumatic injury, and toxic ingestion or overdose. Chest compressions should continue with minimal pauses during bag ventilation, definitive airway establishment, or defibrillation (if indicated). Compression depth is 5 to 6 cm (maximum 6 cm), and the compression-to-breath ratio is 30:2 (30 compressions followed by 2 breaths delivered by 100% FiO2 through a bag-valve mask). Once a definitive airway is established, the ventilation rate is 10 breaths per minute or one breath every 6 seconds. Once return of spontaneous circulation (ROSC) is achieved, post-cardiac arrest care may include percutaneous coronary intervention, early goal-directed therapy, targeted temperature management, or aggressive glycemic control.
PLace an NG in Borrhaves?
NO- IVF ABx and surgery
What time period do you give streptokinae in STEMI?
2 hours to PCI
apsirin too nless allerguc
perichornidiritis from a piercing
Pseudomonas coverage plus think staph and strep
cartilage receives its blood supply from the surroungin perichondrium - disrupt htese layres and worse blood flow
is type 1 odontoid fracture stable?
Yes
Ant mid and posterior columns keep this in line. need to knokc out 2 columns for instbaility
Cecal volvulus stuff
it is embryogenic where ileum, cecum and ascedning colon did not adheere to posterior wall. LUQ will shwo the trnasition point
young 30-50
is the teacup up or down in perilunate dislocations
UP
The CAPITATE is what is actually displaced here and the lunate will be up and over the radius
lunate idlsocation is spilled and off the radius
what does mycoarditis look olike on echo
diffuse hypokinesis with multichamber dilation
RCC paraneoplastic syndromes
erythcytosis from erythpoeitnin
PTH, low phosphae
HTN from Renin
Hyperglycmeria from ACTH
bilious emesis and distention in a 1 week old with normal vitals and nromal x ray- youhsould get…
Upper GI series (or abd ultrasound) for midgut volvulus
nursing home variables for PNA
1=33% 2=50% chance of PNA
HR, RR 30, febrile, no wheezing, leukocytosis, crackles, confusion
trach tube wiht resp distrees first move
3 ml NS with suction
stroke and hyperG…
contorl it bc poor neuro outcomes
CRETST=
CREST syndrome are Calcinosis, Raynaud phenomenon, Esophageal dysmotility, Sclerodactyly and Telangiectasias. Most treatment is aimed at symptomatic relief although there is some evidence for the use of methotrexate as an immunosuppressive agent
Rhabdo pearls
CK >5X the upper limits
Get an EKG - renal failure> hypoCa- HyperK-hyperP
How do you treat ermegence reastion from ketamine
benzos
when do you not redcue and go to surgeyr first?
severe pain, is febrile, or has a leukocytosis, then an emergency surgical consultation
Vitals too, Phys exam
Short PR, wide Qrs, upstroke slurred- contradiciated is…
These can be remembered by the mnemonic “ABCD”– adenosine, beta-blockers, calcium channel blockers, and digoxin. Atenolol is a beta blocker and is therefore contraindicated.
AV nodal blockers
lower extremity edema, shortness of breath, hypertension, and microscopic hematuria 1 week after skin infection
VS
URI 2 days later microhematuria
PSGN- weeks plus throat or skin
IgA=URI and then 2 days you get hematuria
HypoNA or SIADH drugs
Carbamazapine/Oxcarb
Anitdepressenats
Antipsychotics
HCTZ and Loops
febirle siezure age range
6 months-5 years
myocarditis
The treatment of myocarditis is supportive and aimed at maintaining cardiac output. This includes management of associated rhythm disturbances and congestive heart failure to hemodynamic support with vasopressors, ventricular assist devices, aortic balloon pumps, and even cardiac transplantation in fulminant cases. Endomyocardial biopsy is the historical “gold standard” for diagnosis of myocarditis, confirming microscopic features of myocardial inflammation and necrosis. However, some studies have questioned the sensitivity and specificity of endomyocardial biopsy, and in the future cardiac MRI may supplant endomyocardial biopsy as the test of choice for myocarditis.
lymes rx
doxycycline.
In pregnant women or children under the age of 8 years, amoxicillin should be substituted.
Patients with neurologic or cardiac manifestations should be admitted and treated with IV ceftriaxone
CNS and AV block is 4 weeks later.
does renal fialure acidosis need bicarb?
yes
Studies have shown that patients with renal failure and metabolic acidosis have a reduced need for dialysis and reduced mortality at 28 days when treated with sodium bicarbonate.
DKA no shown benefit
order of hyperTSH drugs to be given?
Propranolol, PTU, Idodide, Dex
Propylthiouracil is then administered to block synthesis of thyroid hormone and also block peripheral conversion of T4 to T3. Approximately one hour after administration of propylthiouracil, you would then administer potassium iodide to prevent release of stored thyroid hormone. This is done with a one-hour delay to prevent the utilization of the iodide by the hyperactive thyroid to make new thyroid hormone. Dexamethasone is then administered due to concern for adrenal insufficiency in association with severe hyperthyroidism, as well as its ability to decrease peripheral conversion of T4 to T3.
what does high riding prostate mean and the most commone sign for bladder injury is…
Urethreal innjury
gross hematuria
glargien or glimpiride for hypoglycemic events?
Glimpiridie- sulfonurea 24 hours of half life and peak activitiy
glargine is lng acting but never has peak activity
prevention and tx of air embolism in divers
dont hold yor breath
hyperbarics
when to get LP on suspected SAH
if CT negaitve and you stil suspect it
Dx of entomeba hisotlytica?
US and then prtozoan in stool
IV metornidazole- drain only if refractory
Middle lobe bugling fissure on rught?
Pna and bullous myringitis?
Wide mediastinum sick gram positive?
Klebsiella
Mycoplasma pneumo
Anthrax
Eos in urine Plus AKI
AIN
acute renal failure resulting from immune-mediated tubulointerstitial injury. The presence of eosinophiluria in a patient with acute kidney injury suggests acute interstitial nephritis, which is typically an allergic reaction to medications such as penicillins, sulfa-containing antibiotics and diuretics, NSAIDs and proton pump inhibitors. Patients with acute interstitial nephritis may also present with a rash, fever, eosinophilia, and other constitutional symptoms
CATCH 22
DiGeorge Cardiac abnromal face Thymic Cleft platate hypocalcemia 22 chorme
Umbilical prolapse
Trendelmburg or knees and elbowes to c section immedietely or if you cant try tp put it back in the uterue
macule is small and ____
patch is large and ____
flat
Flat
WHat is LBBB on EKG?
Postive and wide in 1
negative QS in V1
RBBB is negative and thenin V1 it is triphasic
Mech action of organopshospahte posions
blocks acethcolinesterase-
2PAM regerneates it
Wach out for brady cardia, bronchsopsms and bronchorrhea - All muscarinic effecgts
nicotninic is fascilautions and paralysis
necrotizing gingivitis Tx
augmenton
oral hygiene rinsies
follow up with dentist for debirdement
A CAT of MUDPILES?
Aspirin
CO CN Caffeine
Acetominophen
Theophyliine
Deep oinverted T waves in Anterior leads
Wellens warning
treatment of radiation protolcitis
Steorid enemas
stool softenres
DC to home
symptomatic seizure of hyponatremia- give ___ml/kg of 3% saline
2-6 ml/kg
needle cric tips
To perform a needle cricothyrotomy a 12 or 14-gauge angiocatheter is inserted into the cricothyroid membrane. If the commercial kit is available, the oxygen delivery tubing with an on/off valve is attached and periodically insufflated for breaths. However, two alternatives exist when the commercial kit is not available. The end of a 3-5 endotracheal tube can be directly attached to the angiocatheter and a subsequent bag valve mask to the endotracheal tube tip. This circuit will have significant resistance although the patient can ultimately be ventilated. An additional option is to attach a 3 mL syringe with the plunger removed to the angiocatheter. The adapter of a 7-0 endotracheal tube can then be attached to the open end of the syringe.
suspected urterhal injury- suprbpuic cath or retro uterhogrm?
Retro urethrogram
alcoholic hepatities
looks like ascending cholangitis a little bit but no stone noted and fatty/cirrhotic liver
Tumor luysis syndomre lytes
K
PO
Uric Acid high
low Ca
Addiosons
Primary low cortisol and aldosterone Hyper K, hypoNa low glucose hypotn and shock Pigmentation
hydrocortiosne
lithium toxicity
HD 5, 4+kidneys or 2.5 and symptomatic (especially siezures)
If low and mild then NS at 2x main rate
button battery in E
button battery in somtach
go get
repeat x ray 48 hours
PUD + Intractable post-prandial vomiting, early satiety =
gastric outlet syndrome
most common pediatric site for foreign body ot get stuck
c6 Cricpharygenal
pacreatitis ddx
BAD SHIT: Biliary, Alcohol, Drugs, Scorpion, Hyperlipidemia, Iatrogenic (ERCP), Trauma
hemorrhagic panreatitis signs
Hemorrhagic: Cullen sign (ecchymosis around umbilicus), Grey Turner (ecchymosis around flanks)
ransons cirteria
16 WBC 55 Age 200 GLucose 250 AST 350 LDH
SBP WBC and PMNs
1000
250
Air or air-fluid level in the gallbladder =
emphysematous cholecystitis (higher risk of perforation 🡪 emergent surgical consult
‘Acalculous: elderly, diabetes, trauma, burns: high risk of perforation and death
Gallstone ileus: stone goes into small bowel with obstruction at ileocecal valve
porcelein gal bladder
increased risk fo cancer
galls otne pacnreatitis needs….
emergent decomrpession
reynolds pentad
fever RUQ jaunidce hypoTN AMS
a fib + abd pain + old= what test?
angiogngraphy for emsneteric ischemia
SBO
1 cause is adhesions
Hernia is #2 cause
Treatment: NG tube, IVF
LBO
1 cause is tumor
X-ray show distended large bowel with no stool in the vault
Treatment: NG tube, IVF
VOlvulus
signmoidopscopy or rectal tube and then surgery to takc it down
cecal volvuslus is striaght to tsrugery i think
hernia
Indirect Inguinal
Most Common
Passage through persistent processus vaginalis deep ingeuinal ring baove/lateral the inferior epigastric
Direct Inguinal
Passage through transversalis fascia and external inguinal canal beoow/medial the epigastric
Femoral
Passage below inguinal ligament (more common in females) and medial to femoral artery
Spigelian
Passage lateral to rectus muscle (difficult to diagnose
Incarcerated = irreducible
Strangulated = irreducible with vascular compromise
Treatment: manual reduction. If strangulated or time of incarceration unknown, do not try to reduce
Crohn’s pt with back pain + limp =
psoas abscess
Extraintestinal manifestation: arthritis, uveitis, sclerosing cholangitis, erythema nodosum
Divertitculitis
May cause urinary symptoms because of irritation of underlying GU structures
Do not miss colon cancer
Outpatient Treatment: Cipro + Flagyl for 7-10 days
Inpatient Treatment: obstruction, peritonitis, immunocompromised, abscess
Abd abscess over ___ cm need drainage
4= percutaneous drianage
Prolapsed non-reducible internal hemorrhid Tx
surgery
anal fissure tx
sitz, stool softener, high fiber
anal abascess stuff
Dull, aching rectal pain, erythema, induration, +/- fever, +/- fluctuance
Rectal exam to rule out intersphincteric abscess
Ischiorectal abscess – lateral
Simple perianal abscess maybe drained in the ED, all others in the OR
Abx not routinely recommended
Think of STDs if they have proctitis
when to remove anal FB
Smooth edged body: remove in the ED (awaiting spontaneous passage can lead to infection and perforation
Signs of perforation: consult surgery
GIB stuff
Platelets:
<50,000 give one per 6 pack of RBC
Liver Failure + GI bleed: octreotide, PPI (reduces rebleeding and transfusion requirement but no mortality benefit), Antibiotics: mortality benefit
diarrhea
Toxogenic diarrhea Abrupt: <24 hours; +/- abd pain No systemic symptoms Invasive diarrhea Slower onset: > 24 hours Fevers, abd pain, blood/mucous/pus in stool (dysentery)
Testing:
Helps to distinguish between invasive vs toxogenic
Usually not done through ER
Stool cultures important for: HIV, food handlers, healthcare workers, C.diff for recent hospitalizations or antibiotic use
O&P – not routinely done but important in men who have sex with men, AIDS, foreign travel
Diarrhea Tx
Dehydration: oral preferred, IV otherwise
Pt’s fed earlier do better
Antidiarrheals:
Loperamide: anti-motility agent, recommended for patient that is afebrile or low grade fever
Bismuth: less effective than Loperamide but can be used with fever and dysentry
Antibiotics: moderate to severe diarrhea with signs of invasive bacterial infection, elderly, immunocompromised
Oral Flagyl and Vancomycin for C.diff
Fluorquinolone: 3-5 days unless proven E.coli 0157:H7
Azithromycin if resistance/allergy suspected
Diarrhe pearls
Symptoms within 6 hrs: preformed toxin (B. cereus)
Symptoms within 6-18 hrs: C. perfringens
Pregnant women eating unpasteurized products: 20 times increase of Listerosis
Shigella can cause seizures in infants
Yersenia – may present like appendicitis
Campylobacter jejuni #1 cause of infectious diarrhea in United States
Amoeba histolytica causes liver abscess
protein c s defieincy
Factor 5 leidein
hypercoagable bc it is unable to stop the cascade
hypercoagable bc it is unable to accept the effects of protein C so cant sotp the cascade
plateltes
Consequences of decreased platelets
<50,000: excess bruising with minor trauma
<30,000: spontaneous petechiae and bruising
<10,000: spontaneous visceral hemorrhage
1 unit considered to raise recipient’s count by 10,000
palpable vs on plapable purura
Non palpable purpura: think low or dysfunctional platelets
Palpable purpura: think angiopathy/vasculitis
low plateltes DDX
Decreased production: Aplastic anemia, malignancy, meylofibrosis, radiation, viral infections, drugs (ethanol, thiazides, estrogens, chemotherapeutics, heparin)
Increased destruction:
ITP/TTP/HUS/DIC/viruses/drugs (heparin)
Splenic sequestration
Enlarged spleen can hold half of blood volume and 90% of platelets
Malaria, rheumatoid arthritis, TB…
Platelet loss
Bleeding, hemodialysis
ITP kids vs adult
transfusion threhsolds
50K bleeding
20 K non bleeding
Kids resovle, adults dont
steorids and IVIG if less than 5
TTP Tx
Steroids, FFPPlex
80% mrtality if untreated
Schixotcytes
DIC
Consumptive coagulopathy
Extrinsic pathway problem
Liberation of tissue activating factor 🡪small fibrin and blood clots deposit in microcirculation 🡪 consume clotting factors and causes hypoxemia🡪fibrinolysis🡪elevated fibrin split products
Etiologies: trauma, sepsis (meningococcemia), transfusion reaction, envenomation, retained products of conception
Labs:
Increased fibrin split products and d-dimer, thrombin time, PTT
Decreased platelets, fibrinogen (may be normal)
TX Treat the underlying cause If primarily bleeding follow the PT (best single test in this setting) PCCs FFP (10-15 mL/kg) Vitamin K Folate If primarily thrombosis consider low dose heparin infusion
1 week after heparin and then drop of platelts by 50%- 3 dos and 2 donts
HIT
- stop heparin 2. reverse warfarin (warfarin necorsis risk) 3. give Ruidn or Agrotroban (direct 2a thrombin inhibuor bc they are high risk of thromobosis)
- Dont give warfarin or 2. plateltes
Direct thrombin inhihibitor and CKD and bleeding
Dialysis need, rneally excreted
Bleeding and on drugs:
Consider tranexamic acid (fibrinolytic inhibitor),
desmopressin (transports VIII and stimulates release of von Willebrand factor
PCC maybe too
Sickle cell
ACS- pulm vasculature from infection, infarction
Oxygen Antibiotics (include a macrolide) Incentive spriometry Pain control Bronchodilator therapy Transfusion (especially if high risk)- for al tyes of crisis if bad enough
Renal, brian, hand and foot, priapism (echange and asiration)
Watch out for splenic sequestration and aplasitc crissis- low theshold for Abx
VwF Tx
Desmopressin
Factor 8 trnsfuion rare
CPP=?
MAP-ICP
Ideal CPP >60
80-15 is great
head trauama:
Elevate head of bed
Maintain adequate oxygenation, ventilation, systemic perfusion
Mannitol 1 g / kg
Hyperventilation (temporizing) to Pco2 of 30-35 mmHg
Emergency decompressive craniotomy
spinal fractures unstable
Jefferson= C burst from axial load
Type 2 and 3 odotoid fractures form flexion (body of dens invovlenmnt)
Hangbmans’ C2 displaced anteriorly bilateral pedicle Fx
Teardrop- flexion or extension but spinal cord injury - frnt of vertbal body is brokena nd pushed the body into th epsinal cord
paralysis and pain below the level, DCML crude tough still intact =
Anteori cord form spinal artery injury
DCML is still intact
most important thing to do in head trauma
avoid hypotension
basilar skull fractures can have a normal..
Head CT
HARD bruit neck signs
HypoTN Art bleed rapid expangin hematoma Deficit neuro Buit
What is SCIWORA
spinal cord injury with out rads evidence
Kids>adults
C sine>TL
Trauma stuff
Chest x ray can lag hours and get worse
Sucking chest wound= 3 sided not Chest tube through it
Tension= needle nto x ray
OR throactomy for hemothroax?
1500
1 for 6 hours
200 for 3 hours
air leak cant get a hole of
THoracotmy inidications
Penetrating trauma and lose vital suddenly
NOT blunt trauma
If you do it, go anteroiro to avoid phrenic nerve
Truauma and then decompensate (RR) 3 weeks later…
CT normal but peritoenal?
Diahrgam injury - CT can miss it
Hollow viscus small bowle injury, CT can miss it
Pancreas easily missed to
MC blunt and penetraitng trauma injury in abdoemn
Spleen
Liver
Old person down with briginid bilteraly iliacs?
Grey turner retorperitonnal bleed
CT shows bladder injnury, what test next and hwich gets surgery ?
Retorgrade cystogram?
Intrapertineoal is surgery, extra just sticka foley in
retrograde urethrogram- urethral injury- dont put a foley
Pelvic injruries
Fall from heigh ti si latreal comrpession and vertical shear
MVC is AP and urethral tears
Sacral fracture can have cauda equina
next step for compression hand injuries?
dont inject into it
hand surgeon iedialtely
compatment pressures
> 20
30 for sure
pulse goes last, pain and paresthsia first
when do you give tetanus Ig?
Unvaccinated + bad injury = Ig!
lidocaine 4mgkg and 7 mg kg epi
Kid brun parkland
Same thing but extra 9 to head
legs are 14 a piece instead of 18
Burns
acid is coagulative burns
3rd degree, 2nd 10% and up, face, hands genitals, inuhaltion, electrical, acid== ALL need burn center!
Peds trauma
MCC of pediatric death > 1 year Follows same ATLS protocol Airway: Large occiput tends to flex neck ETT size : (age/4) + 4 ETT depth: 3 x tube size No cricothyroidotomy if < 8 years old Temporize with Transtracheal jet ventilation: oxygenation but poor ventilation Circulation: pRBC: 10 cc/kg Disability: C-spine fractures less likely than adults SCIWORA: dx by MRI- if still complaining of neuro injury
Preggo trauma
Uterine rupture, baby is usually dead, way worse, no uterine contour, maternal shock
minor fall but no bleeding- placenta abruption - concelaed bleeding
MOre bleeding with preggo pelvic fractures
Blasts
- pressure (lungs, TM, small bowel ) -air filled organs
- debris hitting you
- throws you
- burn injury, anything else
FASTS
needed if unstable, dont go to CT scanner
GO straight to OR if postivr fast
10 hours ago MI symtpoms started, 80 minutes ot next center
Tpa?
Transfer?
Dont transfer?
Transfer- if you can get to the center within the 120 minute hten transfer him
you can give tpa within 12 ours of sympomts, 30 minutes form symptom onset
sudden bilious emeiss ina 4 weeker
- upper gi series?
- NG tube?
- surgery consult?
surgery ocnuslt
the other 2 come after
appy Abx?
Cefotetan or ceofixitn
2nd gen for gram neg and anerboes
keflex is fist gen
Sugungal Hemtoma
trephination
nailremoval
hand surgery
Trephination is indicated for subungual hematomas that are less than 48 hours old, are not spontaneously draining, and are painful
hematoma involves the nail fold or there is a fingertip avulsion that requires subungual sutures for repair, then the entire nail should be removed instead of trephination
large hematoma and tuft fracture DOES NOT need anything more thn trephination
bad fracture or nailbed exporsure is surgery
MTX in abortions
<4cm
stable
no liver disease
not ruptured
cuffend vs uncuffed equations in kids
uncuffed is 4s
cuffed is age/4+3.5
hemoperitoenum reflex?
BRADYCARDIA
camping + low palttes and LFTs high=
ehrichia
give doxy
stupid stuff
dont cause paint in AMS, asthma and eczema hx, CAD and V fib most ocmmon not hyperK
Do kids need abx in asymptomatic bacturia?
no
non HCAP aspiratoin PNA abxx?
Amp and sulbactam
not pip tazo and vanc
hypo ca and hypo mag, why?
malbaosroption, poor diet and pth resistance
GI cocktail?
Viscous lidocaine 2%, 30 mL aluminum hydroxide and 150 mg ranitidine
islated CN3 palsy, pupils reat, check,,…
glucose
bullous pemphigoid
nikolsky negative, old ppl, basement membrane antibodies, oral steorid s
cards syncope
Historical elements indicating cardiac causes of syncope, as opposed to orthostatic or neurocardiogenic episodes, include syncope during exertion, palpitations at the time of syncope, ECG findings of dysrhythmogenesis (e.g., bifascicular block, intraventricular conduction delay, QT interval abnormalities, Brugada pattern findings), and lack of postdrome. Prolonged prodrome and postdrome symptoms are common with vasovagal etiologies, with fatigue and nausea lingering well beyond the event itself, whereas true cardiac etiologies typically have no harbingers or postepisode symptomatology.
NASH Tx?
weight loss thats it
MC liver disease herer
food is stuck when to get enisopcpy?
resp distress
GLucaogon X2 20 min apart and observation if not
painless beefy red ulcer on dick that bleeds easily…
Klebsiella, Donovanosis
Granuloma Inguniale. Klebsiella Ingunale
DOxy or azithro
Lymopgranuloa venereum is Chlamydia
chancroid can have LA too
outpatient DVT meds
LMWH and Warfarin
GOlfer elbow
tennis
little league
radial tunnel synrome
Meidal, pain with resisted flexion
lateral, pain with resised extension
medial elbow pain in kids
compression of posterior interossius nerve
Galezii fx
Radius fx and ulna dislocation
watch out for compartment syndrome
OK sign to test for ant interosseos smedian nerve!!!
Monteggia Fx
Ulna fx radial head dislocation
Ulnar nerve roots for c spine…
C8 - T1
How to repleace K
Each 0.3 meq drop needs about 100 mew replaced
Heart failure comes in with biphasic T waves NOT in v1 or v2
HypoK on diuretics, long QT
St depression with shallo T right into a U wave
possible dig overdose
what is redman syndorme caused by
hustmaine release, not true allergy
first degree heart block tx
supportive
epirudal abscess imag8uine
full spine for skip lesions
What does early R wave tell you
R sight sided problem like RBBB or RI MI
ST depression everywhere make sure to check…
AvR for roximal LAD or left mian one of the two
AICD with v fib, first move
Magnet over it will shock them
and emporary stop to recongize dysrhtmyia
sick sinus syndrome
tachy and brady trading off
needs both pacemaker and for slow and dysrthymics for fast long term
It is usually kn older ppl
atropine is tough to use bc then you get tachy
Match
Deep blue hue with vision changes
blanching with phenylpehinre, one spot focial redness, no vision
slcerititis- neocrtiing vascultitis of slcera- optho and steroids
epislceritits
light in opposite eye makes the opposite eye hurt?
Iritis
You see ciliary flush and hypoyon=
Ant uveitis or iritis
uvea= chorid, iris and cilairy body so need same day optho
DOnt give ____ to Myasthenia gravis
Magnesium
PNA Rigors= Necrotizing PNA= Young person looks good but CXR looks bad= bulllous myrigintis=
strep pneunmo
staph
mycoplasma
mycoplasma
PE X ray findings
PE hmaptons hump: infarct wedge
westermark: not as much blood vessels distal
ITP= Tx TTP= Tx
steroids
PLEX
DDx dyspahgia transfer stage
Transfer- first 2 seconds of swallowng MG, ALS and stroke
Trnasport dysphgia- obstrucive (schzatkis ring vs achlaisa)
button battery for sure***
Button battery to be removed immediately in the E & the nose. If it is in the stomach youc an repeat x ray is asymptomatic.
ID
turtle= slamonella
Ciguatera- hot and cold discpernacy
Peppry fish and histmaine- scromboid
Aids- cryptosporidium
cecal volvus trnaspitoin on x ray in where
LUQ usually
CPP=
ICP=
60
15
TDAP
Clean and no known is TDAP, or clean an dknow is less 10 years tdap
Dirty and no nown is iG and tdap and dirty with known is give TDAP if under5 yers
MG NIF of -20 needs
Intubate and plex
2x sux and half of roc
GB tx?
PLEX IVIG
