Urgent Care Flashcards by Kristie Edmisten

Characteristics of second degree burn - superficial partial thickness

Erythematous, pink, moist, weeping
Blistering
Most painful!
Blanches with pressure

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Characteristics of second degree burn - deep partial thickness

Red, yellow, pale white, dry
Blistering
Not usually painful
Absent capillary refill
May need skin graft

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Characteristics of third degree burn - full thickness

Waxy, white, leathery, dry
Painless
Absent cap refill

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Characteristics of 4th degree burn

Black, charred, eschar, dry
Painless
Absent cap refill
Into underlying muscle, fat, bone

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Risk factors for spontaneous pneumothorax

Family history
Smoking
Males

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Diagnosis of pneumothorax

CXR

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Treatment for small stable spontaneous pneumothorax

Oxygen and observation

If resolved after 6 hours on CXR can go home

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Treatment for large stable spontaneous pneumothorax

Pleural aspiration, possible chest tube

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Treatment for unstable spontaneous pneumothorax

Chest tube

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Acute hypoxemic respiratory failure following a systemic or pulmonary insult without evidence of heart failure

ARDS

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Most severe form of acute lung injury

ARDS

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Three clinical settings that account for 75% of ARDS cases

Sepsis syndrome (MC)
Severe multiple trauma
Aspiration of gastric contents

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Common Risk Factors for ARDS

Sepsis
Aspiration of gastric contents 
Shock infection
Lung contusion
Non-thoracic trauma
Toxic inhalation
Near-drowning
Multiple blood transfusions

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Rapid onset of profound dyspnea that occurs 12-48 hours after initiating event. Labored breathing, tachypnea, frothy pink or red sputum, intercostal retractions, diffuse crackles

ARDs / Respiratory Failure / Arrest

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A quiet chest, agitation or confusion are ominous signs of impending:

Respiratory failure

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Diagnosis of ARDS / acute respiratory failure

CXR - diffuse patchy bilateral infiltrates
Upper lung zone venous engorgement
Marked hypoxemia

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Treatment for ARDS / acute respiratory failure

Identify and treat underlying cause

May require tracheal intubation and positive pressure mechanical ventilation

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Unarousable unresponsiveness in which the subjects lie with eyes closed

Coma / deteriorating mental status

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Characterized by lack of focal physical examination findings - pupils are typically small and reactive, but may be large in severe poisoning as from barbiturates

Toxic metabolic coma

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Cornerstone of coma / deteriorating mental status assessment

Neurologic exam - descriptive, systematic, reference point for serial assessment

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In hypoglycemic patients with a history of alcohol abuse or malnutrition, _________ should be administered before _________

Thiamine

Glucose

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If elevated ICP is suspected in pts, elevated head to ___________ and keep at midline. _________ will help reduce ICP

30 degrees

Mannitol

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Symptom complex associated with severe psychiatric disease with stupor, excitement mutism, posturing

Catatonia

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Allergic reactions / anaphylaxis are _____ mediated

IgE mediated

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DDX for allergic reaction / anaphylaxis

``` Myocardial ischemia Gastroenteritis Asthma Carcinoid Epiglottitis Hereditary angioedema Vasovagal reactions ```

Treatment for allergic reactions / anaphylaxis

``` Control airway Supplemental oxygen Limit further exposure Epinephrine IM for pts in shock IV fluids for hypotension Antihistamines ```

Special consideration for anaphylactic pts with bronchospasms

Albuterol

Non GI Factors for acute abdomen

Cardiorespiratory - cough, chest pain, dyspnea Genitourinary - urgency, dysuria, vaginal discharge Trauma - falls, MVAs

Important medications to ask about with acute abdomen

NSAIDs Antibiotics Steroids

More common causes of abdominal pain in pts > 50 y/o

``` Biliary disease Bowel obstruction Diverticulitis Cancer Hernia ```

Reasons for urgent surgical referral with acute abdomen

1. Systemic signs - tachycardia, hypotension, fever 2. Free air on CXR under diaphragm 3. Free fluid if not ascites

Acute management of acute abdomen

Aggressive fluid resuscitation Analgesics Antiemetics (Zofran) ABX - broad spectrum

Most common cause of third trimester bleeding - premature separation of a normally implanted placenta after the 20th week of gestation but before birth

Abruptio placentae

Any bleeding that occurs after 28 weeks gestation. Complicates approximately 5% of all pregnancies

Third trimester bleeding

Bleeding with abdominal pain and/or uterine tenderness in third trimester is suggestive of

Abruptio placentae

Profuse, painless bleeding in third trimester is suggestive of

Placenta previa

Non obstetric causes of third trimester bleeding

``` Genital tract lesions Infections Intercourse Friable cervix Cervical carcinoma ```

Workup for third trimester bleeding

CBC, PT/PTT UA and cervical cultures to r/o infxn If location of placenta is unknown, perform US to r/o placenta previa Vaginal examination to r/o labor

Fetal Well Being Test

1. Check for fetal heart tones and conduct NST (non stress test) 2. Amniocentesis considered for fetal lung maturity for the assessment of delivery options 3. Administer RhoGAM if Rh- and send a Kleihauer-Betke test to assess for the extent of fetomaternal bleed

Treatment for third trimester bleeding

Delivery for term pts | Bed rest and cautious tocolysis for stable preterm pts

____ and ______ bites have higher rates of infection than dog bites

Cat and human

Bites are usually polymicrobial, but __________ is the single most common isolate

Pasteurella

________ bites are particularly concerning for the possibility of closed-space infections

Hand

__________ prophylaxis indicated for non infected bites of the hand and ___________ required for infected hand bites

Antibiotic prophylaxis | Hospitalization

Cat bites in any location should receive prophylaxis of:

Augmentin 500 mg TID x 5-7 days | If PEN allergic: clindamycin and doxy

All infected bite wounds need to be __________ for direct therapy

Cultured

Important evaluation for all bites: (2)

Rabies | Tetanus

Treatment for scorpion stings

Antivenom

Risk factors for foreign body aspiration

Altered mental status Alcoholism Impaired cough/swallowing reflex Dementia

Foreign body aspirations are more commonly on the:

Right side

Coughing, choking, wheezing, or hemoptysis

Foreign body aspiration

Complications of foreign body aspiration

Aspiration pneumonia | Gastric aspiration may cause ARDS

Diagnosis of foreign body aspiration

1. Bronchoscopy - provides direct visualization and removal | 2. CXR

Most common cause of cardiac failure / arrest

Ischemic heart disease

Most common rhythms of cardiac arrest

Vtach | Vfib

Fracture with right angle to the axis of the bone

Transverse

Fracture where bone has twisted appearance - also called torsion

Spiral

Fracture where fracture line is between horizontal and vertical direction

Oblique

Fracture where bone is splintered or brushed

Comminuted

Displacement of bone from a joint

Dislocation

Imaging of fractures / dislocations

XR - ap and lateral Radionuclide bone scanning - increased uptake at fracture site CT MRI - best for occult hip fracture

Treatment for open fracture

Debride and irrigate in OR ABX - cephalosporins and aminoglycosides Tetanus status Immobilize and fixate to preserve function

There is significant potential for ___________ with fracture of the femur

Hemorrhage

Any less serious loss of congruity or a less than complete dislocation

Subluxation

Most common sites of dislocation

Anterior shoulder Posterior hip Posterior elbow

Treatment of dislocations

Assess neurovascular status - closed reduction | Assess neurovascular post reduction as well

Elevated blood pressure with no apparent acute end organ damage

Hypertensive urgency

Management of hypertensive urgency

Decrease BP by 25% over 24-48 hours using ORAL agents

Drugs used for hypertensive urgencies

Clonidine Captopril Labetalol Nicardipine

Elevated BP and acute end organ damage - usually systolic blood pressure > 180 and/or diastolic BP > 120

Hypertensive emergency

Damage that can occur from hypertensive emergency

Neurological Damage Cardiac Damage Renal Damage Retinal Damage

Management of hypertensive emergency

Decrease BP by no more than 25% within the first hour and an additional 15-20% over the next 23 hours using IV agents

Drugs used for hypertensive emergency

Nicardipine or Clevidipine Labetalol, Esmolol Nitroglycerin Furosemide

95% of pulmonary embolus' arise from:

DVTs in the lower extremities above the knee or pelvis

Most people who die from PE die from:

Subsequent PEs | Not the initial one

Most common signs/symptoms of pulmonary embolus

Dyspnea, tachypnea | Pleuritic chest pain, hemoptysis

Most common predisposing condition for PE

Factor V Leiden

Physical exam with PE

Pulm exam - usually normal, may have rales or a pleural friction rub + Homan's sign

Diagnosis of PE

1. Helical CT scan - best initial test 2. V/Q scan 3. Pulmonary angiography - gold standard 4. Doppler ultrasound - lower extremity DVT

A normal CXR in the setting of hypoxia is highly suspicious for

Avascular markings distal to the area of the embolus on CXR

Westermark's Sign | PE

Wedge-shaped infiltrate (represents infarction) on CXR

Hampton's Hump | PE

S1Q3T3

Most specific for PE

Management of PE

1. Anticoagulation - LMWH 2. Warfarin for at least 3 months (apixaban, dabigatran) 3. IVC filter 4. Thrombectomy/Embolectomy

Prophylaxis of PE

1. Early ambulation in low risk, minor procedures 2. Elastic stockings/SCD/venodyne boots 3. LMWH

Acetaminophen poisoning treatment

Acetylcysteine | Monitor APAP plasma concentration

Aspirin poisoning treatment

Check serum salicylate level Induce emesis Charcoal to bind drug

Harmful substance poisonings treatment

1. Avoid emetics 2. Small amounts of water as diluents 3. May do activated charcoal

General principles of management for substance poisonings

Induced vomiting and/or gastric lavage no longer recommended | Activated charcoal

Orbital cellulitis is usually secondary to:

Sinus infections

Orbital cellulitis most commonly occurs in

Children

Decreased vision, pain with ocular movement, proptosis (bulging eye), eyelid erythema and edema

Orbital cellulitis

Diagnosis of orbital cellulitis

High resolution CT scan | MRI

Management of orbital cellulitis

IV abx - vancomycin, clindamycin, cefotaxime