ER Exam 7/12/21

CXR finding indicating thoracic aneurysm?

(enlarged aortic silhouette)and confirm by echocardiography, contrast CT, or MRI

tx of aortic aneurysms

. Pharmacologic control of hypertension is essential, usually including a beta blocker for thoracic aortic aneurysm. 2. Surgical resection for symptoms for large aneurysm Ascending thoracic aortic aneurysms > 5.5 cm Descending thoracic aortic aneurysms > 6.0 cm, or AAA > 5.5 cm) For persistent pain despite BP control, or for evidence of rapid expansion(> 0.5 cm/year) In patients with Marfan's syndrome thoracic aortic aneurysms > 4-5 cm usually warrant repair Less invasive endovascular repair in an option for some patients with descending thoracic or AAAs.

tx of hypertensive emergency

. Tx with IV agents (nitroprusside, nicardipine, labetalol, esmolol)--> start with lowest dose, constant BP monitoring required 2. Subsequent doses and intervals of admin should be adjusted according to the BP response and DOA of the agent 3. Replace with PO antihypertensives at pt becomes asxs and BP improves and wean off parenteral rxs 4. In absence of htn encephalopathy, goal is to lower MAP generally over several hours to prevent precipitous reduction in cerebral, coronary, and renal blood flow to prevent organ ischemia

tx of unstable bradycardia

1st choice is Atropine 0.5mg (max 3mg) If no success, can start Dopamine drip or Epinephrine drip (both are 10mcg/kg in 500cc)--> (Typically, the wider the QRS, the less likely the Atropine will work and the worse the outcome is expected) Always put pacer pads on

Tx of brain abscess

3G ceph + flagyl for polymicrobial + Nsurg. Steroids not routinely recc'd Empiric Abx: 3G cephalosporin (eg ceftriaxone) + metronidazole43 Risk for MRSA (surgery/trauma): add vancomycin Tb, Fungal, Parasitic risk: add specific treatment for that per ID Nsurg consult early (almost all need drainage) Steroids not indicated in all but may help if cerebral edema. I ask neurosurgery their preference.

tx of PMVT and normal baseline QT

: prompt defib in hemodynamically unstable pt BB if BP tolerates→ metoprolol 5 mg IV every 5 min, to a total of 15 mg IV amiodarone may prevent recurrent episode Urgent coronary angio and possible revascularization

what sodium level suggests volume depletion?

<20 mmol/L

tx of cva with ischemic inafrct on ct

ASA

tx of tia

ASA

tx of agitation

Accucheck STAT #1: "noncoercive de-escalation is the intervention of choice" #2: Chemical Sedation: FGA, SGA, BZD, Ketamine B52: #3: Physical restraints for actively violent pts that cannot be subdued by other means and pose clear risk of harm HOB 30 degrees, supine, one arm up and one arm down

tx of septic shock

Antibiotic treatment: Immunocompetent Adult Many acceptable regimens include (1) piperacillin-tazobactam (3.375 g q 4-6 h (2) Imipenemcilastatin(0.5 g q 6 h), ertapenem ( 1 g q 24 h) or meropenem(1 g q 8h) or cefepime ( 2g q 12 h) If the patient is allergic to B-lactam agents, use ciprofloxacin(400 mg q 12 h) or levofloxacin(500 mg-750 mg q 12 h plus clindamycin(600 mg q 8 h) Vancomycin (15 mg/kg q 12 h) should be added to each of the above regimens Removal or drainage of a focal source of infection A. Remove indwelling IV catheters; replace Foley and other drainage catheters; drain local source of infection B. R/O sinusitis in pts with nasal intubation C. Image the chest, abdomen, and/or pelvis to evaluate for abscess Hemodynamic, respiratory, and metabolic support A. Initiate treatment with 1-2 L of NS administered over 1-2 h, keeping the CVP at 8-12 cm H2O, urine output at > 0.5 ml/kg per hour, and mean arterial BP at > 65 mm Hg. Add vasopressor therapy if needed B. If hypotension does not respond to fluid replacement therapy, hydrocortisone(50 mg IV q 6 h) should be given. If clinical improvement results within 24-48 h, most experts would continue hydrocortisone treatment for 5-7 days C. Maintain oxygenation with ventilator support as indicated. Recent studies favor the use of low tidal volumes-typically 6 ml/Kg of ideal body weight-provided the plateau pressure is < 30 cm H2O D. RBC transfusion is recommended when the blood Hgb level decreases to < 7 g/dL with a target level of 9 g/dL General Support Nutritional supplementation should be given to pts with prolonged sepsis(oi.e., that lasting > 2-3 days) with available evidence suggesting an enteral delivery route. Prophylactic heparin should be administered to prevent DVT if no active bleeding or coagulopathy is present Insulin should be used only if it is needed to maintain the blood glucose concentration below ~180 mg/dL

what dx is mostly discovered as asxs pulsatile mass on PE?

Aortic aneurysm

sxs of LMCA

Aphasia, L gaze, R viz field

tx of aortic dissection

B-blocker (esmolol iv drip) Nitroprusside Surgical Consult

tx of htn in pt with cva

BP MUST BE <185/110; goal is sBP "around" 150-165 Labetalol IVP Q10min @ 20mg -> 40mg -> 60mg -> 80mg (max 300mg total) or/then nicardipine gtt ASA, BP management, glycemic control (if not candidate)

sxs of MCA stroke

C/L weakness arm>leg

diagnosis of brain abscess

CT + IV contrast, no LP since lesion increases ICP and can cause iatrogenic herniation if LP is done

SAH diagnosis

CT brain ("may" be enough to r/o if symptom onset <6hr) CTA brain & neck (up for debate*) Watch 0ut for: Anemia -> false neg on CT

preferred method of examining a potential TRA?

CTA (cta has replaced aortograms)

tx of SDH

Conservative: serial CT Surgical: burr drain

tx of hypoglycemia

D5 and/or D10 PO food DC vs admit vs ICU

tx of brady-tachy syndrome

Dual chamber systems(DDI, DDDR, DDIR) may delay or prevent occurrence of AF When AF present, VVI, or VVIR Antiarrhythmic therapy may be indicated to prevent paroxysmal tachyarrhythmia.

On CT you see a football shaped/lentiform hypodense region of the brain. It does not cross suture lines. dx?

EDH

tx of SAH

Early neurosurgery (Clip) or IR (Coil) PO Nimodipine for all aSAH (AHA Level A) BP control (nicardipine gtt DOC; alternatives: labetalol, clevidipine, enalapril. Rarely [never] nitroprusside) Goal sBP <160 "reasonable" (AHA Level C) Comfort measures (avoid NSAID. Some say avoid narcs since in theory could alter neuro exam validity but this is dogmatic/debatable) HOB 30 degrees

if a pts ammonia is high and they have asterixis, what is the dx?

FHF

tx of ICH

Get neurology & neurosurgery on board early Cblr bleed = Nsurg emergency Reverse anticoagulants/coagulopathy Sz ppx w/ AED only if evidence for seizures (levetiracetam), Comfort measures: antiemetics (ondansetron), aggressive analgesia (opiates are ok; but try to preserve exam) BP-lowering meds: nicardipine (also esmolol, labetalolol, clevidipine, enalapril, phentolamine) avoid nitroprusside as it tends to inc ICP

tx of Seizures

Give BZD, BZD, BZD; then intubate when they become apneic; then give more BZD 0-5 mins: ABC's, IV, Monitor, Glucose 5-10 mins: Initiate therapy w/ BZD (Level A) Rampart et al 2012 RCT NEJM: Lorazepam IV is noninferior to Diazepam IM 20-40 mins: 2nd tier drugs Fosphenytoin 20 PE/kg IV (max 1500 PE) Valproic acid 40mg/kg IV (max 3000mg) Levetiracetam 60mg/kg IV (max 4500mg) 40-60 mins: 3rd tier drugs Propofol 1-2mg/kg IV Midazolam 0.2mg/kg IV (max 2mg/kg) Pentobarbital 5mg/kg IV Q5M

tx of hypernatremia

Hypotonic IVF like D5! or 1/2 NS

tx of aortic dissection

ICU Sodium nitroprusside accompanied by beta blocker(e.g., IV metoprolol, labetolol, or esmolol), for target HR 60 beats/min, followed by oral therapy Avoid direct vasodilators(e.g., hydralazine) because they may increase shear stress. If beta blocker contraindicated, consider IV verapamil, or diltiazem - surgical repair not usually indicated unless continued pain or extension of dissection is observed (serial MRI or CT every 6-12 months)

tx of hypermagnesemia

IVF

tx of etoh intox

IVF does NOTHING to hasten etoh metabolism KS/WE: thiamine + folic acid + IVF

tx of hypercalcemia

IVF, Diuretics

tx of DKA and NKHOC

IVF-> Insulin gtt -> D5 ½ ICU

tx of ARF

IVF/dialysis, usually admit

tx of htn with pulmonary edema

If due to circulating catecholamines due to stress-- tx with conventional PE therapy If P caused by HTN causing LV failure→ tx with nitroglycerin or nitroprusside (DOC)

tx of hypertensive encephalopathy

Immediate BP reduction of 20-25%-->nitroprusside 0.3-1.0 mcg/kg/min, NTG, labetolol AVOID >20-25% BP reduction in 30-60 min (too rapid lowering of BP can lead to cerebral hypoperfusion) Replace with PO antihypertensive as patient becomes asymptomatic and BP improves

tx of cardiogenic shock- cardiac tamponade

Immediate volume expansion & pressors to maintain BP Therapeutic Pericardiocentisis

ICP management

Initial Tx: HOB >30 degrees, IVF, mild sedation is good -> NM blockade/coma/intubation (after neuro exam) Medical Tx: mannitol, diuretics, hyperventilation Neurosurgery: ventriculostomy, lobectomy

what is asterixis

Involuntary jerking movements of the hands. due to hepatic encephalopathy

sxs of anterior cerebral artery stroke

LE > UE weakness behavior disturbances Urinary incontinence

what to order to distinguish encephalitis from encephalopathy

LP

tx of myxedema coma (hypothyroid)- high tsh

Levothyroxine + liothyronine, ICU

CT or MRI for a PCA stroke?

MRI! CT sensitivity is awful (7-42%) MRI sensitivity: about 88-92%

tx of hypomagnesemia

Magnesium sulfate IV (severe) Magnesium Oxide PO (mild)

tx of PMVT and long baselines QT (TdP)

Mg++

tx of anaphylaxis

Mild symptoms such as pruritus and urticarial can be controlled by administration of 0.3-0.5 ml of 1:1000(1.0 mg/ml) epinephrine SC or IM with repeated doses as required at 5-to 20-minute intervals for a severe reaction 2. An IV infusion should be initiated for administration of 2.5 ml of 1:10,000 epinephrine solution at 5-to 10 min intervals NOTE: Epinephrine provides both alpha and beta-adrenergic effects**, resulting in vasoconstriction and bronchial smooth muscle relaxation. 3. Volume expanders such as normal saline, and vasopressor agents, e.g., dopamine, if intractable hypotension occurs 4. Antihistamines such as Benadryl 50-100 mg IM or IV 5.. Nebulized albuterol or aminophylline 0.25-0.5 g IV for bronchospasm 3. O2, endotracheal intubation or tracheostomy may be necessary for progressive hypoxemia 4. Glucocorticosteroid(methylprednisolone 0.5-1.0 mg/kg IV) not useful for acute manifestations but may help alleviate later recurrence of hypotension, bronchospasm or urticaria 5. For antigenic material injected into an extremity consider: use of a tourniquet proximal to the site, 0.2 ml of 1:1000 epinephrine into the site, removal without compression of an insect stinger if present PREVENTION: 10% will have a second reaction within 72 hours No way to predict who will get it Observation, or discharge home WITH AN EPIPEN is crucial to remember → Discharge WITH AN EPIPEN, not just a prescription Write a prescription for a second EpiPen Think of a referral to an allergist

should you give your pt low dose ASA when they have uncontrolled htn?

NO- since risk of hemorrhagic stroke increased with uncontrolled htn

tx for hypovolemic hyponatremia

NS (slow and steady, do not rapidly correct or else CPM)

tx of sciatica

NSAID

tx of hemorrhagic cva

Neurosurgery consult NO tPA Sz ppx (levetiracetam) Tight BP control (nicardipine, labetalol). Goal sBP <140-160

tx of htn with angina

Nitroglycerin (doc) May need Nitroprusside

tx of vertigo

PO meclizine, epley, supportive care, dc

tx of AAWD

Phenobarbital: superior neurochemistry, closely matching all of etoh inhib fx BZD: only address GABA Diazepam (T ½ 43h) > lorazepam (T ½ 14-20h) more predictable; peak result in 5min

tx bell's palsy

Prednisone 60mg x7d, Artificial Tears, +/- valacyclovir 1gm TID x7d

tx of thyroid storm (tsh low)

Propanolol + Thionamide + Hydrocortisone + BZD + cooling -> SSKI. ICU

tx of afib

Pt with recent onset AF and hemodynamic instability or angina→ IMMEDIATE SYNCHRONIZED CARDIOVERSION (50-100J) If hemodynamic instability exists Type III agents (sotalol, amiodarone) can be used If pt stable, HR should be controlled with IV diltiazem, digoxin or beta blocker

tx of AAA

Repair Recommended When risk of rupture > risk of surgery; occurs with a AAA > 5.5 cm or if tender For persistent pain despite BP control, or for evidence of rapid expansion 4 cm AAA annual risk of rupture < 5 % 6 cm AAA annual risk of rupture 15 % EVAR approach is now done for more than 75 % of al; AAA repairs in USA→ endovascular grafts bridge intrarenal aorta to both iliac arteries

CT shows crescentic/croissant hypodense area of the brain. it does crosses suture lines. dx?

SDH

what is Super Refractory Status Epilepticus?

SE > 24 hr after meds, or 22% of SE

causes of distributive shock?

Sepsis, toxic OD, anaphylaxis, neurogenic (e.g. spinal cord injury), endocrinologic (addison's dx, myxedema)

tx for hypocalcemia

Severe: Calcium Gluconate (PIV) or Calcium Carbonate (CVC only) Mild: PO Ca++ & Vit D

tx of 3rd degree av block

Stable patients require observation with ECG monitoring until transvenous pacing is performed. Unstable patients require emergent pacing, either transcutaneous or transvenous. Atropine usually not helpful in wide complex block because of intranodal location of lesion.

tx of older pt with ams and pyuria

Stable, elderly, AMS with no s/s of UTI but + bacteriuria and/or pyuria should be observed for resolution of confusion for 24-48 hours without antibiotics

Tx of TRA

TEVAR All pts with TRA's should be initially managed with controlled hypotension to maintain a systolic BP of 100 mm Hg until definitive repair or continued medical therapy is instituted

Tx of vfib

THE ONLY TREATMENT→ IMMEDIATE DEFIB (200-300-360

these cxr findings indicate what dx? Left apical cap Mediastinal widening Obscured aortic knob, Widening of the paravertebral stripe, Downward deviation of the left mainstem bronchus, Rightward deviation of NG tube Opacification of aorta-pulmonary window.

TRA traumatic rupture of the aorta

tx of htn with stroke sxs

Treat when CVA diastolic > 140 persist after 1 hr. Lower BP to ~ 30% MAP Tx: Nitroprusside IV

tx of htn with renal failure

Tx: Furosemide to increase Na excretion Consider Nitroprusside

best screening tool for aortic aneurysms?

US

dx if you see delta waves on an ekg?

WPW syndrome

tx of meralgia paresthetica

Wt loss, stop using belt & tight clothes

what is the dx if a pt has a triad of fever, HA and focal neuro deficits?

abscess

tx of encephalitis

acyclovir for HSV #1. Add 3G ceph + vanc until bacteria r/o'd. No empiric steroids unless anti-NMDA Supportive Care Frequent ABC & consideration for elective intubation Watch for elevated ICP (HOB 30 degrees, consider hypertonic saline/mannitol/diuretics/hyperventilation) Empiric sz ppx w/ AED (valproic acid or phenytoin preferred over levitiracetam). Sz occur in 15% Steroids not routinely recommended empirically ***Empiric ACYCLOVIR for ALL (d/t prevalence of HSV)*** Empiric abx also recommended (until bacterial causes are excluded): cefriaxone + vancomycin +/- ampicillin Anti-NMDA: steroids + IVIG, plasma exchange

tx of SVT

adenosine if ineffective then flecainide or synchronized cardioversion

tx for PMVT due to catecholaminergic polymorphic VT

beta blockers

dx if you see st elevation in leads V1-v3 w/ saddleback pattern?

brugada syndrome

tx of EDH

craniotomy

what type of shock is septic shock?

distributive shock

what is preferred for a shock pt that needs serial measurements of BP?

intrarterial line

tx of PMVT due to brugada syndrome?

isoproterenol

tx of FHF

lactulose and admit

sxs of RMCA

neglect, agnosia, apraxia, R gaze L viz field

what is NCSE?

non-convulsive status epilepticus. Hard to diagnose. Need EEG.

tx asymptomatic bradycardia

observe

sxs of vertebrobasilar/basilar artery

ophthalmoplegia, crossed deficits, V, coma, "locked in"

sxs of lacunar stroke

pure motor/sensor, mixed, ataxic hemiparetic, dysarthric/clumsy

tx of vtach

put defib pads immediately on pt electrocardioversion- refractory pts or those who become unstable if QRS and T wave can be distinguished, emergenct synchronized cardioversion with synchronized shock using either biphasic or monophasic defib IV amiodarone IV procainamide IV liodcaine CCBs or BBs for pts with structurally normal hearts nonsustained vt- no specific tx unless symptomatic- tx underlying mechanism

tx of saturday night arm (radial n)

rehab

tx of carpal tunnel

splint, PT, rest

vasoactive drugs for shock pt

start with NE or D, for persistent hypotension add Phenylephrine or vasopressin

tx of meningitis

steroids -> 3G ceph + vanc for s. pneu #1 and Neisseria.+ ampicillin for Listeria. + acyclovir for HSV.

if you see a thin shell of calcification on the imaging of an ascending thoracic aneurysm, what serologic test should you order?

syphilis

sxs of cerebellar stroke

think DDDD

Tx of cva with normal CT

tpa if less than 4.5 hrs from onset and no CI or else ASA

Mg++ for PMVT?

used for PMVT and long baselines QT (TdP) Mg++ less likely to be effective for PMVT if baseline QT interval normal since likley cause is MI

What rx class are CI in hemorrhagic shock?

vasopressors (since increasing BP would only making hemorrhage worse)

sxs of PCA stroke

vision (field, gaze, CN3) sz

tx of RV MI?

volume infusion

tx for euvolemic hyponatremia

water restriction

tx for hypervolemic hyponatremia

water restriction