Rosh PGY-2 Flashcards
What do you want to avoid cutting in ED thoracotomy?
Phrenic nerve
What approach do you use in ED throacotomy and how can you help distinguish the aorta?
Left anterior-lateral: incision is made along the fifth rib from the sternum to the posterior axillary line
NG tube in the E. You want to cross clamp the aorta to help perfuse the coronaries and the brain
What would you be treating with a ED throacotomy? 5 reasons
1- relieve cardiac tamponade,
2- support cardiac function with open massage
3- aortic cross-clamping
4- internal cardiac defibrillation
5-control cardiac, pulmonary, or great vessel hemorrhage.
What is the indications for ED thoracotomy?
Penetrating: cardiac arrest after initially good vital signs in the field OR SBP <50 after fluids OR ED arrest
Blunt: ED arrest
OR air embolism
Scalp hematoma on the side or back of childs head- you should suspect…
underlying skull fracture
NOT predictive on frontal bone
Tx for flail chest?
Intubation or Non invasive ventilation
Output from CT to go to OR?
> 1,500 mL of blood immediately or > 200 mL/hour for 3 hours
Isolated sternal Fx disposition?
Pain control and DC home
Mortaliy rate is <1%
Most Common finding in basilar skull Fx?
Hemotympanum?
+ FAST, when do you go to the scanner?
when stable
What are the reverisble causes of hemorrhagic shock in trauma?
HemoPTX
Long bone deofrmity
Pelvic bleeding
pericardial tamponade
Where do you put the Chest tube in preggos?
Same spot but 3rd rib and not 4-5th. diaphragm is up 4 cm
Testicualr trauma DDx
hemaotcele hematoma fracture avulsion dislocation into inguinal canal or abomdinal wall trauamtic epipdidymitis scrotal lacs or contusion truamtic torision
Which bad c spine fx has rare neuro deficts?
Hangmans (bilateral pars inter. fx from extension)
Axial load fx?
Jefferson fx, disruption of ant and post ring of C1
5 NEXUS criteria
- Injury
- GCS
- Intoxication
- Neuro deficits
- Midline tender
Hemorrhagic shock criteria HR goes up Pulse pressure narrows RR increases UOP starts to drop slightly BP drops Confused and Lethargic
2 2 2 2 3 4
unilateral facet dislocation dispo
Home and follow up in c collar
MC blunt injury to peds?
to adults
Both spleen
When do you go to IR for pelvic traumatic injury?
Negative fast, positive Pelvic X ray ro exam
If positive FAST its OR
What type of extrmemities do you have in neuro shock?
Warm and Dry
T5 or above, possible bradycardia
S/p Heart transplant Basal Heart rate?
90-110 (loss of vagus nerve!)
acute rejection leads to shock- give pressors
How do you use the PERC
If they are low risk pre test, then go thru the criteria. if you have any 1 + then get a d dimer. if not then no test needed
3 things to do in late decels?
oxygen
bolus
lateral recumebtn positiion
what OD? Hyperpyrexia acidosis gypolcyemia pulm edema/septic picutre hypoK
Aspirin
get uRine Alkoltic w/ bicarb
Give D5W Bicarb + K
Stable V tach- Sync shock or Procainamide?
Procainamide
What is the evolution of STEMI on EKG between these? STEMI Q wave Hypercute T waves J point elevation TWI
Hyperacute Ts- minutes after J point elevation STEMI - flat to convex Q Wave TWI
MC Amiodoarone Side effect
Hypotension (25%) Bradycardia (5%)
class 1 2 3 4 Blocks K and slows AP mechanism of aciton
Deep inverted Ts or Biphasic T=?
Wellens LAD- urgent cath
MC ACS complaint from old ppl?
SOB
weak andd dizzy too
atypicals from Dm2 patient
ETT meds?
Naloxe Atropine !!Vasporessin Epi Lido
Dont give what imed in WPW and why?
BB
Urges accessory pathway usage
compression rate for newborn?
The optimal ratio is 3 compressions to 1 ventilation for a total of 90 compressions per minute and 30 breaths per minute
Trop
earliest?
Peak?
Return to baseline?
3 hours
24-48
5-14 days
Most sensitve and speciifc than others
Vtach Ddx?
Ischemic/Non ischemic cardiomyopathy
CAD
Lytes
Meds
what is a J point?
end of the QRS complex and the beginning of the ST segment. A positive deflection of the J point is termed an Osborn wave and can be seen in hypothermia. Notching of the J point can be seen in benign early repolarization.
why procainamide in VT and WPW?
blocks accessory pathway too
difference on x ray between AICD and pacemaker?
Thick distal leads (big shock) for AICD
Thin for pacemaker
Implant for brugagada, HOCM, HEart failure, Dysthrmias etc
What is pacemaker syndrome (20%) and how do you treat it surgically?
loss of atrioventricular synchrony and the presence of retrograde ventriculoatrial conduction
syncope or near-syncope, heart failure, fatigue, exercise intolerance, dizziness
Get a dual chamber and nto a VVI pacemekaer
First 3 letters of PAcemaker means what?
VVI?
chamber paced ventricle (atrial, dual, none O)
chamber sensed ventricle “”
pacing response inhibited (triggered, dual, none 0)
etoligies for A flutter and Tx
Still BB/CCB/ or electicity
HTN, ischemic, Rheumatic, Cardiomyopathy
Etiologies for A fib
Ischemic valvular heart disease thyrotoxicosis cardiomyopathies myocaridtis
DDx for Sinus Tahc?
Poor HEart function PE Hypovolemia (fluids or hemorrhage) Hypoxia DKA HyperTSH fever drugs withdrawal Pain/anxiety
use mroe adenosine in? less in?
More ceffeine
less carbamazpeine, dipryamdole, heart transplant
tx unstable torsades?
ddx torsades?
shock- it is polymorphic v tach that can turn into v fib
thyroid, drugs, lytes, nutrition, intracranial, congenital, cards problems
high risk syncope needs admit?
abnormal ECG, a history of structural heart disease or heart failure, persistent hypotension, shortness of breath, hematocrit less than 30%, family history of sudden cardiac death, and older age or presence of multiple comorbidities
what to do in torsades if mag doesnt work?
tv PACING (OVER DRIVE PACING 90-120 BPM) which has the effect of reducing the QT interval and preventing a recurrence of torsade. Unstable patients should undergo unsyncronized cardioversion.
3 things seen ekg in wpw
tx?
slurred up
short pr
wide qrs
100 mg procaine
syncope stats
cause of syncope remains unknown in nearly 40% of patients.-vasovagal (21%), followed by cardiac (9.5%), orthostatic (9%), medication related (7%) and neurologic (4%). Patients with vasovagal syncope had no increased risk of death compared to the general population.
DDx for bilateral lower edema
Think oncotic or hydrostatic
Nephrotic syndrome (SLE) Pulm HTN!!! CHF Liver disease Lymph Edema or lymphatic congestion Venous insufficiency Lytes Medications
Blood transfusions. Stable. Itching urticaria. Continue or stop?
Benadryl and continue
Be aware of Iga def
how old can you get NEC
up to 6 months
NRP stuff
Warm dry stimulate- MR SOPA
If apneic or <100 PPV @ 40-60 RR
if still then intubat and THEN CPR 3:1
RSV or flu + but looks good lso get…
UA
which bugs in peds fever in neonte?
e coli amp and GBS = AMP and Gent
no risk factors, a fitting URI fever- what lab do you get and if they are nromal can you send them home to follow up
Bloo Cx
UA
CRP CBC
acrocyanosis lasts for…
up to 48 hours and Os2 sat is normal
Seizure meds for neonatates
phenobarb
lip smacking in kid
worse whens tanding and better when laying down headached with VP shunt
slit shunt syndrome
DX and Tx?
clusters of myoclonic seizures on awakening
hypsarrhythmia EEG
developmental delay.
4-8 months old
Infants will demonstrate brief contractions of the neck, trunk, and extremities lasting five to ten seconds each, occurring in clusters.
INfantile spasms or WEST syndrome
ACTH
prednsione
AEDs
2 month old menignits bugs
Neisseria, strep, H flu
CFTX????? vanc
5-9 yrs old morning headaches, lethargy , ataxia chornic ysmptoms Dx and tx CN 6
meduloblastome— MC
MRI
Surgery and aggressive tx
What do you need to do a needle cric?
12-14 gauge needle
Use the angiocath
3.5 or 3.0 endotrach tube end
a 3 or 5 ml syringe with no plunger
Adapter with 7-0 tube can be attached to the syringe
Age<8
Peds dose anaphylaxis Epi
.01 mg/kg max .3
Difference in epiglottis and bacterial tracheitis
Teach- ins and exp stridor with UTI prodrome. Subglottic narrowing. Staph. 3-8 years
Epi- drooling stridor, thumbprint, dame age group
When can you use adult pads on kids?
Above 10 kg
Kids IO
Pink in kids less Th an 40kg
Distal femur: 2 cm proximal to end of femur in midline
lots of URIs
stridor on expiratoin and in supine
feeding difficutlies
tracheomalacia
goes away by 1
risk facotrs and when to admit in croup
Admit: stridor after rac epi (given to kids with stridor at rest), repepat rac epi doses or stirodr returns
look sout for stridor, AMS, cyanosis, air entry and retractions
amio
lido
epi
doses in acls of rkids
5 mg/kg
1 mg/kg
.01 1:10k
what is your first step for foreign body in airway with hypoxia/resp distress?
Direct Laryngoscopy - with magill forceps (not VL)- and if it is below the cords then mainstem it and push it down
then cric
eye lid lac with fat protrusion needs…
CT and optho- concern for orbtial septum injury with damage to msucle and globe
one abx needed in nec fasc
CLinda for the toxins
recurrent pancreatitis with cholecystitis but no stones or cause found…=?
sphincter of oddi spasm/dusfunction
HIDA > Scinitgripahy >ERCP Oddi testing
Use ROME 4 to help diagnose
What is endopathlamitis
Hypopyn + conjucitvitis from inflammation of post/ant and vitreous part of eye
trauma or inefection
EVALI
bilateral hazy opacties - hemppytsis - not infectious
fibrinous pneumonitis, diffuse alveolar hemorrhage, and eosinophilic or lipoid pneumonia
When to transfer for a burn?
Face/Genitals/Eye/Hands >10% Comorbids!!! Type 3 Inhalational electrical Chemical
- If they are young you can debride and refer
priapism in trauma?
Spinal cord injruy
What is your post sedation doses?
20-30 mcg/kg/min propofol
1 mcg/kg fentanyl or 100 mcg bolus and 100 mcg/hr
Versed 2 mg boluses (Not dialyzable for CKD)
Terrible liver- avoid versed and give ativan (for the metaoblite than can be cleared)
Airway Burn
- Blast less likely to be worse than chronic inhalational fire
- Do a burn a lert if there is airway
- Hoarseness, fullness big physicla exam- more likely to intubate
- you can try albuterol
- think of thier traijectory
- on your own? you may need ot be safe and pull the tirgger if the burn center is a long ways away
- NP scope it!
where do you look when you think rash cleiacs?
elbows- itchy little vesicle - dermaitis herpitiformis
Men UTI stuff
Even 1 WBC in the righ setting is enough
UTI like symptoms gotta think STD
post paetum headache and blurry vision?
Venous thormbosis
Delta sign or trianlge and the posterior part of head CR is white
look for tinnitus and other focal findings (CN, motor, sezireus)
Most sensitive symptom for Cauda equina?
Urinary retention (100 ml) and then urinary incontinence all the regualr stuff plus flaccid parlaysis
Etiologies are most commonly herniated discs, bone fragments, hematomas, epidural abscesses, tumors, or vascular insufficiency.
post paetum headache and blurry vision?
Venous thormbosis
Delta sign or trianlge and the posterior part of head CR is white
What is wellens warning
Biphasic T or deep inverted T
Can be painless at first and trop negative
Prox LAD
can cause sudden cardiac arrest- urgent cath needed
what is De Winters? EKG
AVR: 1/2 mm elevation and then inverted T (looks like wellens)
Precoridal: deep depresison into tall T waves
STEMI - LAD
patient is aysynchronius on the vent- change the setting to ?
2 other things ot do here?
Pressure support
Paralyze/Sedate
What is a segond fracture and why is it improtant?
Lateral avulsion fraction of the knee - possible ACL tear
patient is aysynchronius on the vent- change the setting to
Pressure support
spotnaneous PTX in young helathy kid- when do you put a CT in?
> 20%
Go to vent srttings?
Volume control TV 6 cc/kg FiO2 over 60% at first PEEP 5 Rate 12-16
If hypoxic then creep up Fio2- get ABG and make sure nto too high and abvoe 60 for sure
If still hypoxi then give more PEEP (14 is too high, stay below)
Keep plateau pressures below 35 (parlayze if need be)
What is plateau pressure?
alevoli pressure. there will be a peak and then a plateau this is the resistance int he smal airways
once the alevoli empty then the pressure goes back to baseline
kid comes in with umbilicated papules- tx?
None- moluscum contagiousum
adults get it too
Isopropyl acohol gap stuff an docm plications
Osmol- no anion gap (ketosis without acidosis)
Hemorrhaigc gastritis and tracheobronchitis
epidiymitis tx
> 35 yrs old = Levoflox! or bactrim
<35 yrs old is STD = CFTX and doxy
-posterior lateral and releif with elevation
if anal= its CFTX and levo for enteric bacteria
young fever night sweats weight loss gotta check for...
Lymphadenopathy (non tender)! Hodgkin lymphoma or leukoemias
get CXR for wide mediastinum
200/110 symptomatic tx
go home if good follow up
if not, check BMP
candidiaissi tx
fluconoazole
tick LFTs thrombocytopenia leukopenia Fever sypmtoms
Erlichiosis
how long tx for moderate to severe posion ivy tx
prednisone taper for 3 weeks!
if mild is clamine and benadryl
SCFE tx and complciations
Operative
avbascular nescoriss
Juvenile arthritis stuff
Systemic: rash/Fever/liver/spleen ANA - RF - Tx: Steroids, Tx MTX/Steroids/Nsaids
Oligo: no fever or rash 3 years old female, 1-4 joints, ANA + RF - ESR -
poly: mild ysystmiec, uveitis, 5 joints, ANA + RF + ESR +
all similar tx
MC fx leading to compartment syndorme?
TIbia
foreamrs get it too!
what 3 complications can happen with Massive transfusions?
- Coagulopathy (thats why you give platelts and ffp)
INR >1.5 - give FFP
Plates > 50 - give plates
fibinogen <100 - give cryo - Hypothermia- warm the fludis and patient
- Hypocalcemia
1 unit of reds should raise hgb hct 1/3
pulse ox right at 85% and doesnt get better withO2?
Methemoglobinemia Fe3+
first tests for syph?
RPR or VDRL
then darkfield
ESRD new fistula, what are the complications you need to think of?
Thrombosis of graft- US
bleeding- topical TXA, figure of 8, pressure, gelatin spognes or oturniquet before and after site
Steal syndorme- arterila blood shunted to venous (poor helaing and ischemia
Hypotension right after session- voleume down before
still think sepsis, MI, PE shock
HA, AMS, HTN!, right after dialysis = disequilbirium syndrome High solute removal during dialysis will cause lower osmolality in the blood compared to the brain, resulting in fluid shifting and subsequent cerebral edema… give mannitol (also look at ICH and lytes)
recurrent anpahylaxis, Dx and TX
C1 esterase FFP (contasins C1 inhibtior)
lips toungue (spiekd on the side) but nonpurutis edema
if ACE, supportive care
cryo has no role here
dashboard injruy to knee think
PCL, dislocaiotn
infant macrocephaly, nausea, lehtargy
TUmor
rewarm the body to 35 core first before extremites
that sall
