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Emergency Medicine 2


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The nasopharyngeal airway can be used in which types of patients?
breathing semiconscious patients and when an oropharyngeal airway is technically challenging
Prolonged use of a bag valve can lead to..?
Distention of the stomach increasing the chance of an aspiration event
What are the steps of successful intubation?
5P's Preparation, preoxygenation, pretreatment, paralysis, and placement
How do you prepare for successful intubation?
IV access, monitors, suction, appropriate sized ET tube, and meds for rapid sequence intubation
What pretreatment may be necessary in small children prior to intubation and why?
Atropine, to blunt the bradycardia induced by succinocholine
What pretreatment prior to intubation may be used in adults with reactive airway disease? What about in adults where there is a concern about increased ICP?
Reactive airway disease - lidocaine 1.5mg/kg
Pancuronium 0.01mg/kg
What sedative agent is used prior to paralysis for intubation?
Etomidate 0.3mg/kg
volar =?
Physical Exam of emergency ortho...?
Palpation for subtle deformities well beyond the area of subjective pain
Neurovascular assessment
Ulnar nerve palsy causes..?
Claw hand
Inability to extend the knee could be caused by paralysis of which nerve?
Femoral nerve
Early treatment of ortho emergencies?
RICE (rest ice compression elevation)
Reduction of long bone deformities
Don't forget to give _____ for open fractures?
In children with trauma to a joint, what is important to consider on imaging?
Comparison to the opposite extremity - difficult to tell the difference between a fracture and an epiphyseal growth plate
Compartment syndrome defined?
When the pressure in a compartment exceeds the arterial perfusion pressure
Most reliable sign of compartment syndrome?
ARDS, neuro involvement, and thrombocytopenia post- closed fractures in leg..?
Fat embolism
If you land directly on your shoulder, and hit hurts to reach across your body, what is the injury?
Acromioclavicular joint separation
when does Acromioclavicular joint separation require surgery?
type iv or higher (when the clavicle is displaced into surrounding areas)
96% of shoulder dislocations are...?
Aneterior shoulder dislocations
how does the patient with an Anterior shoulder dislocation appear?
holding arm in slight abduction and external rotation
What is the most common fracture in Aneterior shoulder dislocations? what nerve should be tested?
Hill-Sachs deformity - fracture of the posterolateral aspect of the humeral head
Test the axillary nerve
Posterior disloactions are caused by...? always associated with...?
fall on outstretched hand, convulsive seizure.
Assoc. with Hill Sachs deformity
Most common mechanism of acute rotator cuff tear? Thisinjury impairs which movement?
Forced abduction.
Impairs arm abduction to 30 degrees
What important structures travel with the humerus?
The deep brachial artery and the radial nerve
Who gets supracondylar fractures? how?
Kids < 15.
Falling backwards on an outstrertched hand
Posterior fat pad sign indicates?
In adults - radial head fracture
In kids - supracondylar fracture
What is fracture of the proximal 1/3 of the ulna with radial head dislocation called?
Monteggia fracture
What is fracture of the distal 1/3 of radius with dislocation of the distal radioulnar joint called?
Causes of carpal tunnel?
RA, hypothyroid, DM, collagen vascular diseases
Phalen's test?
Fully flex the wrists for 60 seconds
Tinel's sign?
Light tapping over the median nerve produces pain or paresthesias
Most common carpal injury..?
High risk of..?
Fracture of the scaphoid. AVN
Smith's fracture?
Like colles, but distal fragment is displaced in the volar direction
neurogenic shock?
state of vasomotor instability resulting from impairment of the descending symp. pathways in the spinal cord, or just a loss of symp. tone
does spinal shock signify permanent spinal cord damage?
often times no
anterior cord syndrome results in loss of which tracts?
spinothalamic and corticospinal tract
Central cord syndrome can be caused by? Affects?
Hyper-extension injuries.
Nerves that cross over at that level
if a penetrating spinal injury is diagnosed, begin treatment with..?
High dose methylprednisolone
if suspecting a c-spine fracture, what xrays should be ordered?
lateral, AP, and odontoid view
C1 burst fracture is called? Caused by...?
Jefferson fracture. Caused by axial loading - someone falls on their head, or something falls on their head
Odontoid fractures are caused by..?
Hangman's fracture?
Fracture of both pedicles of C2 - hyperextension mechanism
Stable or unstable?
atlanto-occipital dislocation
burst fracture of C5 with intact ligaments...
simple wedge fracture
odontoid fracture
flexion teardrop fracture
extension teardrop fracture
atl - unstable
burst c5 - stable
simple wedge - stable
odontoid - unstable
flexion teardrop - unstable
extension teardrop - stable
flexion teardrop fracture is associated with...?
tearing of the posterior complex
bilateral facet dislocation...? stable?
flexion injury
subluxation of the dislocated vertebra
very unstable
Cullen's sign? Gray-Turner's sign?
ecchymosis of the abdomen signifies late retroperitoneal hemorrhage
Gray-Turner's: same, but of the flanks
12% of patients with hyperthyroidism will suffer...?
Pathologic fracture
serious associated injuries are present in up to 95% of patients with a dislocated...?
a pt with a posterior hip dislocation holds the hip how?
flexed, adducted, and internally rotated
most common ortho injury seen in the ED?
knee - in particular, MCL (medial collateral ligament)
50% of patients with ACL injury have a concomitant...?
Meniscal tear
lachman's test?
flex the knee to 30 degrees and pull anteriorly on the tibia
donahue's unhappy triad?
ACL, MCL, and medial meniscus tear
Injury to the ________ occurs in 50% of knee dislocations...
popliteal artery
injury to the tibial nerve causes...?
inability to stand on tiptoes
which ankle fracture warrants a careful radiologic examination? of what specifically?
medial malleolar fracture
proximal shaft of the fibula (Maisoneuve fracture)
10% of calcaneal fractures are associated with...?
lumbar fractures
when do you call for an ortho consult?
compartment syndrome
irreducible fractures
circulatory compromise
open fracture
anything that requires surgery
what is the most frequent complication of orotracheal intubation?
Right main stem bronchus intubation
Patients with COPD, asthma, or CHF that are awake but cannot remain in the supine position may be intubated how...?
Nasotracheal intubation
Most serious complication of nasotracheal intubation?
Intracranial passage of the tube
advance airway adjuncts?
fiberoptic intubation
retrograde intubation
laryngeal mask airway
What is the preferred surgical airway for kids? Adults?
Kids - needle cricothyroidotomy
Adults - surgical cricothyroidotomy
if an airway will be needed for greater than 2-3 days, a surgical cricothyoidotomy should be converted to...?
a tracheostomy
slit lamp exam consists of...?
eval the integrity of the cornea, conjunctiva, and the anterior chamber
fluorescein to light up corneal defects
central retinal artery occlusion occurs in which people?
men in their 60s
fundoscopic exam in central retinal artery occlusion?
pale retina with cherry red fovea
what is amaurosis fugax?
type of TIA - sudden vision loss (Shade over eye), transient, due to carotid-origin embolic shower
classic triad of optic neuritis?
marcus gunn pupil
central vision loss
red vision desaturation
flashing lights, spider webs, or floaters that interfere with vision may be a sign of...? what meds should NOT be given?
retinal detachment
DON'T anticoagulate
painful red eye - most often due to which things?
conjunctivitis, corneal abrasion, or foreign body
which conjunctivitis produces copious DC?
punctate lesions in conjunctivitis?
viral cause
tx of conjunctivitis?
broad spectrum antibx, pain meds
soft contact wearers are especially prone to infection by.?
severe unilateral eye pain, decreased visual acuity and photophobia...?
tx of iritis?
cycloplegic such as homatropine(not a mydratic)
severe unilateral HA, eye pain, N/V assoc with loss of vision....?
narrow angle glaucoma
which drugs decrease aqueous production?
acetazolomide and topical b blockers
which chemicals causes coag necrosis? liquefaction necrosis?
tx of chemical burn...
what's hyphema?
blurred vision after blunt trauma (dull eye pain)... bleeding
basic approach to all tox patients in the ED?
key things on physical exam for tox exposures....?
Vital signs
autonomic signs
motor signs
mental status
describe anticholinergic toxidrome?
"mad as a hatter, dry as a bone, red as a beet, hot as a stove." Also - decreased GI motility, urinary retention, mydriasis.
describe muscarinic toxidrome?
narcotic toxidrome?
resp depression, hypotension, depressed sensorium, miosis
sympathomimetic toxidrome? compare with anticholinergic toxidrome?
very similar except sympathomimetic involves diaphoresis
withdrawal toxidrome?
agitation, hallucination, mydriasis, diarrhea, cramps, lacrimation, tachycardia, insomnia, seizures
major toxic effect of acetaminophen?
metabolite NAPQI causes centrilobular hepatocellular damage
tx of acetaminophen tox...?
4 hour level on rumack-matthew nomogram, activated charcoal, N-acetyl-cysteine (to regenerate glutathione)
methanol tox?
formic acid metabolite - causing a gap acidosis and direct optic nerve toxicity
treatment of ethylene glycol tox?
4MP or EtOH
which drugs can cause anticholinergic syndromes? tx?
antihistamines, antipsychotics, TCAs...
tx - physostigmine
symptoms of calcium channel blocker tox? tx?
brady and hypotension
tx - CaCl2, glucagon, epinephrine, DA
CO tox symptoms
HA, N/V, flu-like syx, CNS dep, tachy, hypotension
tx of CO tox?
100% O2
date rape drug - euphoric and amnestic effects
refractory seizures could be caused by what toxicity?
Organophosphates can cause which toxidrome?
opioid antagonist
standard of care for salicylate poisoning?
activated charcoal
- also consider alkalinization of urine and blood with bicarb
benzo receptor antagonist that can rapidly reverse coma from benzo OD...? what's the problem with this drug/
can lower the sz threshold in pts with TCA OD and induce benzo withdrawal
loxosceles bites can be treated with...?
signs and symptoms of TCA OD?
anticholinergic sx, cardiac dysfunction, intractible szs, and hyperthermia
treatment of TCA tox?
decontamination with MDAC
Sodium bicarb administration
Benzos for sz management
Alpha agonists for hypotension
prerenal failure due to..?
decreased renal perfusion (volume depletion, low CO, abnormal renal hemodynamics)
most common cause of intrinsic renal failure?
longstanding HTN
majority of hospital-assoc episodes of ARF are caused by...?
postrenal failure caused by?
obstructive uropathy
FENA <1 in which condition?
Prerenal failure
Urine Na <20 in which condition?
Prerenal failure
tx of prerenal failure?
volume replacement, d/c offending meds
intrinsic RF treatment?
monitor fluid status,restrict protein, correct eletrolyte abnormalities
dispo for patients with ARF?
what drugs can cause ARF in pts with renal artery stenosis?
ACE inhibitors
#1 cause of death in 1-44 year olds?
Trauma (specificallly, MVCs)
Preparation for a trauma case includes?
History from EMTs
Prep the trauma bay
Airway box
O2 and suction
IVF and supplies
Indications for intubation?
GCS <8
Inadequate breathing
Unable to protect airway
Chin lift is contraindicated if...?
A C-spine injury is suspected
Radial pulse should have a BP of at least...? Femoral?
80 mmHg
what % of ECF is plasma?
which drug is an ineffective pressor in hypovolemic patients?
GCS consists of which 3 categories?
eye opening, verbal response, moto response
most rapid means to lower ICP?
what other method?
volume of blood in an adult?
5 L (7% of ideal body weight)
physiologic response to acute hypovolemia?
In order:
narrowed pulse pressure (increased diastolic press)
slowing of cap refill
decreased systolic pressure
raccon eyes, and battle sign?
late findings in basilar skull fractures
assessment of C-spine in trauma?
posterior midline - any tenderness?
focal neuro deficit?
evidence of intox?
any painful injury that may distract the pt?
quick, non-invasive method of examining the abdomen and pericardium for blood
how to check for pelvic frx?
press down and in on both iliac crests simultaneously
urine myoglobin can be elevated secondary to...?
massive muscle breakdown (rhabdo)
tx of rhabdo?
IVF, sodium bicarb, and mannitol
calculate cerebral perfusion pressure?
Cushing's reflex? sign of?
HTN, brady, hypopnea
sign of increased ICP
in traumatic head injury, what is the target MAP?
intubation considerations for elevated ICP?
intubate early but WITHOUT ketamine
seizure prophy with head bleeds?
how does cardiac tamponade present? findings?
hypotension, muffled heart sounds, JVD, and pulsus paradoxus
electrical alternans on ECG
may present with pulseless electrical activity
which condition can lead to hypotension, absent breath sounds, hyperresonance, distended neck veins, and high airway pressures?
tnesion pneumothorax
hypoxia occurs if an open pneumothorax is greater than?
2/3 trachea diameter
flail chest?
3 or more rib fractures in 2 or more sites with paradoxical motion of chest wall with inspiration
how to demonstrate fluid in the pericardium in tamponade?
echocardiogram, or ED U/S
tx of tension pneumothorax?
angiocath in the 2nd intercostals space in the mid-clavicular line
chest tube if hemo or simple pneumothorax suspected
tx of cardiac tamponade?
subxyphoid pericardiocentesis
splenic injury can cause pain referred to...? eponym?
left shoulder...Kehr's sign
which chief complaints warrant a stat EKG?
chest pain/presure/discomfort
abdominal pain esp in elderly
N/V esp in elderly, diabetics
shortened PR interval suggests?
alternate, abnormal conduction pathway like WPW syndrome
elongated PR interval suggests?
some form of AV block
quick and dirty way of determining the axis of the heart?
leads I and aVF...
both up - normal
aVF down - LAD
I down - RAD
both down - RAD
DDx of U waves?
meds (digoxin, quinidine)
Describe possible characteristics of an unstable cardiac patient?
Ischemic chest pain
tx basics for unstable cardiac patients?
cardioversion (synch or un-synch) per ACLS protocol, then IV meds or other therapy
tx of sinus tachy?
how can you tell there's paroxysmal supraventricular tachy? tx?
abnormal/absent P waves
Tx: unstable --> synch cardioversion
stable --> AV node blockade via adenosis, calcium channel blockers (diltiazem, verapamil), b-blockers, manuevers
tx of a fib?
unstable --> synch cardioversion
stable w/ rapid vent. response --> AV blockade: calcium channel blockers, b blockers, digoxin
pts with pre-excitation syndromes - be careful not to...?
block the AV node by conventional meds
premature ventricular contractions, etiology?
4 H's - hypokalemia, hypomagnesemia, hypoxia, hyperthyroidism
heart disease
what is trigeminy?
every 3rd beat is a PVC
tx of PVCs?
iv lidocaine or amiodarone
iv magnesium sulfate
tx of pulseless v tach?
immediate UNSYCNHED cardioversion
tx for unstable v tach?
synchronized cardioversion, then amiodarone or lidocaine drip
tx for stable v tach?
medical cardioversion with lidocaine, amiodarone, adenosine, or procainamide
etiology of torsades?
ischemic heart disease
hypo-electrolyte states
tx of stable torsades?
electrical overdrive pacing
also consider Mg sulfate
tx of Vfib?
unsynchronized cardioversion, ACLS protocols, and correction of lytes abnormalities
pulseless electrical activity etiology?
Tension pneumo
Cardiac tamponade
H4- hypothermia, hyperkalemia, hypoxia, hypovolemia
Embolism (pulm)
Drug OD
tx of ventricular asystole?
IVF, epinephrine, atropine
Transvenous pacing
for Mobitz II 2nd degree AV block, what tx? What won't work?
transcutaneous or transvenous pacing
Admit for implantable pacemakers
Atropine won't work
tx for 3rd degree AV block?
immediate temporary pacemaker
you should consider a new LBBB to be _______ until proven otherwise?
acute MI
Indications for temporary cardiac pacing?
hemodynamically unstable bradycardia
brady that fails to respond to tx
refractory tachydysrhythmias
early bradyasystolic arrest
how does digoxin cause toxicity?
blockade of the NaKATPase
increased vagal tone and increased AV nodal blockade
EKG signs of WPW?
short PR interval
Delta wave
wide QRS
adult tachycardia
EKG signs of hypokalemia?
more prominent U waves
flattened t waves
EKG signs of hyperkalemia?
hyperacute T waves
wide QRS that eventually blends with the T wave to form a sine wave appearance
ekg signs of hypocalcemia?
prolonged QT
terminal T wave inversion
ekg signs of hypercalcemia?
shortened QT interval
associated symptoms of ACS?
dyspnea, diaphoresis, nausea, lightheadedness, or sense of weakness
define stable angina?
symptoms precipitated by exertion and relieved by rest or nitroglycerin
define unstable angina?
exertional angina of recent onset
angina of worsening character
angina at rest
describe myoglobin as a cardiac marker?
elevated as early as one hour and peaks at 4-12 hours
describe CKMB as a cardiac marker?
rises in 3-4 hours, peaks at 12-24 hours
can be elevated in skeletal muscle injury
describe troponin as a cardiac marker?
rises in 3-6 hours, peaks 12-24 hours
most specific and sensitive
acute MI tx?
beta blockade
in pump failure.. which pressors for hypotension in a volume unresponsive pt...?
sbp 80-100 - dobutamine
sbp 70-80 - dopamine
sbp <70 - levophed
pericarditis - presentation?
pain is worsened by..?
sharp stabbing precordial or retrosternal chest pain...
pain worsened by inspiration or lying flat
assoc symptoms of pericarditis?
low grade fever
test of choice for detection and f/u of pericarditis?
tx for pericarditis
NSAIDs for 1-3 weeks
aortic dissections typically occur in what group?
uncontrolled hypertensive males ages 50-70
physical findings in aortic dissection?
asymmetric pulses with BP differences between extremities
very hypertensive
severe distress
palpable pulsatile mass or tenderness
chest tube required for what size pneumothorax?
Nitro's relief of cardiac vs esophageal pain?
Cardiac w/in 5 minutes, esophageal w/in 10 minutes
life threatening etiologies of abdominal pain...?
ruptured AAA, perforated viscous, intestinal obstruction, ectopic pregnancy, mesenteric ischemia, appendicitis, and MI
INITIAL TEST OF CHOICE FOR BILIARY TRACT DISEASE, AAA, ectopic, or free peritoneal fluid?
Plain films can rule out which abdominal emergencies?
Perforation or obstruction
Colicky pain usually responds to which drugs? Specifically...?
NSAIDs, esp IV Ketorolac
Triad of pain, hypotension, and a pulsatile abdominal mass...?
_______ is virtually 100% sensitive in detecting AAAs?
What is usually the primary inciting factor of appendicitis?
Obstruction of the appendix usually by an appendicolith
CBC in approx 75% of appy pts reveals?
leukocytosis above 10,000
Antibx for appy?
risk factors for cholecystitis?
fat, forty, and female
radiation of pain in acute cholecystitis?
tip of the right scapula
most useful test if suspicious of cholecystitis?
which agents should not be used in acute gastroenteritis?
anti-motility agents (Imodium) because it diminishes diarrheal excretion of organisms
Presentation of patients with acute hepatitis?
Jaundice, dark urine/light stools, hepatomegaly, fatigue, malaise, RUQ pain, N/V, and fever
coagulation should be normalized with FFP in which condition?
presentation of acute mesenteric ischemia?
severe, poorly localized colicky abdominal pain associated with recurrent forceful bowel movements
classic - abdominal pain out of proportion to the minimal physical exam findings
Most useful test to diagnose acute mesenteric ischemia?
Midepigastric abdominal pain usually assoc. with N/V?
Acute pancreatitis
An amylase raised _______ times the upper limit of normal is 98% specific to acute pancreatitis...
All patients with acute pancreatitis should be....
admitted and made NPO
good narcotic choice for pain in acute pancreatitis
Meperidine (better than morphine)
fever, abdominal pain, and rebound tenderness...?
Small bowel obstruction is caused by ________ more than 50% of the time...?
postoperative adhesions
Most significant complications of small bowel obstruction?
Strangulation and bowel infarction
etiology of bronchitis?
viruses (influenza, adenovirus, etc.)
Bordetella pertussis
Virchow's triad of the pathophysiology behind PE?
Vessel wall damage/inflammation
Classic triad of PE presentation?
chest pain
EKG findings in PE?
inverted T3
golden standard for diagnosing PE?
pulmonary angiography
ED treatment of CHF?
intubation or CPAP if no improvement
treatment of COPD in the ED?
ABCs monitoring
albuterol neb
MgSO4 in severe exacerbations
antibiotics (empiric broad spectrum)
ED eval of asthma?
Monitors, O2, pulse ox
Peak expiratory flow rate
CXR - to rule out pneumonia
signs of hyperventilation syndrome?
tachypnea, chest wall tenderness, carpopedal spasm, Chvostek's/Trousseau's sign (hypocalcemia)
this condition likely results from inflammation of CN VII as it courses through the styloid foramen?
Bell's palsy
tx of bell's palsy?
acyclovir AND prednisone
eye patching to prevent keratitis and corneal ulceration
work up of CVA?
STAT head CT - esp if < 3 hrs
standard labs
STAT Accu-check
in hemorrhagic stroke, you want to decrease SBP by no more than _____ to limit hypoperfusion...?
Peripheral vertigo is caused by.?
viral etiology (labyrinthitis)
decaying or "lost" otoliths
peripheral vertigo presentation?
acute onset
intense spinning sensation, N/V
unidirectional nystagmus that can be inhibited by fixation
work-up of peripheral vertigo?
hallpike maneuver
epley manuevers
anti-emetics, anti-cholinergics
most szs in the ED are due to...?
Medical non-compliance in known seizure patients
workup of szs in the ED...
check glucose
head CT
anti-epileptic level
LP if any possibility of intracranial hemorrhage or meningitis
LOC occurs in ____ % of patients with SAH?
75% of SAH is due to...?
ruptured congenital arterial aneurysm
diagnostic test for SAH?
noncontrast head CT
if there is suspicion for SAH and it's not seen on CT, ____ must be performed?
What other condition besides SAH could cause blood in the CSF?
Herpes encephalitis
goal of ICP management is to maintain the cerebral perfusion pressure greater than ______?
A chronic headache that started out mild to moderate in severity and intermittent in nature, described as a deep, aching pain and worsened by coughing, and often maximal upon awakening...?
intracranial tumor / mass
85% of people experiencing malignant hypertension complain of _____?
Temporal arteritis affects women ______ than men, and is uncommon before the age of _____? ESR is usually ____?
Women more than men
ESR 50-100
Jaw claudication is strongly suggestive of...?
temporal arteritis
tx of temporal arteritis?
prednisone 60mg po, arrange a biopsy to confirm diagnosis
Often compression of ______________ can improve the pain of migraine?
the ipsilateral superficial temporal or carotid artery
ergotamine is contraindicated in... ? Should be used w/ caution in ....?
Caution in HTN or CAD

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