NBME + SAEM trauma + CaseFiles Emergency Combined Deck

what is the formula for MAP?

((2xdiastolic) + SBP) / 3

Hamburger Sign

(+) if Pt desires to eat-->want to think about other causes of RLQ abdominal pain

AAA classic triad

(1) abdominal pain (2) hypotension (3) syncope (more in thoracic)

Write out GCS and describe each category.

*"4 Eyes, Jackson 5, V6"*

MCC of Post-operative Fever

*"6 W's"* W-*Wind*: Atelectasis, PNA W-*Water*: UTI W-*Wounds*: Wound infxns, abscess W-*Walking*: DVT W-*"Wonder" drugs*: Drug adverse rxn W-*Womb*: Endometriosis **Fevers BEFORE post-op day 3: LESS LIKELY to be due to infection UNLESS Clostridium or B-hemolytic streptococci are involved**

MCC of HCAP and HAP

**GN bacilli** 1. Psuedomonas aeruginosa 2. E.coli 3. Klebsiella pneumo 4. Acinetobacter

What are the 3 main parameters of the Glasgow Coma Scale? When/Why it is used?

*1. Eyes 2. Verbal 3. Motor* Used to assess disability (CNS dysfxn) in a trauma pt

Define ABCDE's of Trauma

*A*-Airway *B*-Breathing *C*-Circulation *D*-Disability *E*-Exposure

Classification of Burns

*Based on depth of tissue destruction* 1. *First-degree*: superficial, epidermis--painful, erythematous, NO blister formation (eg.sunburn) 2. *Second-degree*: epidermis + partial dermis--painful, blister formation 3. *Third-degree*: epidermis, full dermis, and deeper organs--painful, white, charred

How do you stabilize the airway in conscious pt?

*Conscious* --Supplemental O2 via NC or face mask

MCC Aspiration PNA

*Polymicrobial* (typically anaerobes) 1. Peptostreptococcus 2. Bacteroides 3. Fusobacterium

(+) B-hCG (UPT) + SHOCK in F pt...think

*Ruptured* Ectopic pregnancy (until proven otherwise)

How do you estimate the % Body Surface Area (BSA)?

*The "Rule of 9's":* 1. Head and *EACH* Arm: 9% 2. Back and Chest *EACH*: 18% 3. *Each* Leg: 18% 4. Perineum: 1%

How do you stabilize the airway in an unconscious pt?

*Unconscious* --Jaw-thrust maneuver to lift tongue off post. oropharynx --Chin-lift maneuver can be used, but MUST be cautious as to NOT hyperextend neck and move potentially unstable C-spine --Will intubate if GCS <= 8

What two ways can stable patients with AF of greater than 48 hours or unknown duration can be cardioverted in?

- (1) Anticoagulation for 3 to 4 weeks prior to, and following cardioversion - (2) Imaging by TEE and, if no intracardiac thrombus is seen, acute anticoagulation with heparin/LMWH, followed by cardioversion, and anticoagulation for 3 to 4 weeks.

A significant percentage of patients (_____) labeled with a diagnosis of NCCP will have an adverse cardiac event within _____.

- 2-3% - 30 days

Trauma patients who are hypotensive and resuscitated to normal blood pressures are likely to have a greater amount of _____ and increased _____.

- Bleeding - Transfusion requirements

The most common causes of CHF include _____, while the most common causes of an acute exacerbation are _____.

- Coronary artery disease and hypertension - Myocardial ischemia or infarct and noncompliance

PE dx (ecg, xcr)

- Ddimer: rule-in - ECG: sinus tachy! - XCR: normal or atelectasis. Wedge shaped infarcts hampton's hump and westermark's sign- pathopneumonic

_____ confirm the diagnosis of DKA and are enough reason to start fluids. Some providers prefer to wait for a _____ before starting insulin.

- Hyperglycemia, ketosis, and acidosis - Potassium level

_____ is defined as markedly elevated blood pressure in the presence of end-organ damage, whereas _____ is markedly elevated blood pressure without end-organ effects.

- Hypertensive emergency - Hypertensive urgency

Patients with hypertensive emergency should be admitted to a _____, preferably an _____.

- Monitored setting - Intensive care unit

Regular rate tachycardias include several types of supraventricular tachycardias and ventricular tachycardias. As a general rule, _____ arise from above the ventricles, while _____ may be supraventricular or ventricular in origin.

- Narrow-QRS complex tachycardias - Wide-QRS complex ones

What are the noninvasive maneuvers and interventions that may eliminate the need for intubation?

- Nasopharyngeal airways - Chin lift - Suction - BiPAP

Patients are categorized as having septic shock if after adequate volume resuscitation, they have _____.

- Persistent hypotension requiring vasopressors to maintain MAP greater than or equal to 65 mm Hg - Lactate greater than or equal to 2 mmol/L

In the acute setting, the initial management of AF is typically directed toward _____ through the use of _____.

- Ventricular rate control - AV nodal blocking drugs

Bronchiolitis tx

-Supportive care: O2, hydration, nasal suctioning, pulmonary toilet, ventilator -Albuterol, maybe? -Racemic epinephrine - Corticosteroids

SIRS criteria

-Temp: <96.8 or >100.4 - HR: >90 - RR: >20 or PCO2<32 - WBC: <4 or >12 or bands >10%

Occult UTI -agents -rf

-agents: E coli, gnr, enterococcus -RF: age < 12mos, duration of fever 2+days, uncircumsized males

Cocaine-Related Chest pain -cause -tx

-cause: coronary vasospasm - tx: benzodiazapem (NO beta blockers)

Acute Bacterial Meningitis -dx -tx

-dx: lumbar puncture (careful not to herniate) -tx: abx and dexamethasone

Lidocaine with epi. -don't use it? -treatment

-ears, nose, penis and toes -phentolymine

Occlusive Stroke -etiology -dx -tx

-embolus from heart -dx: stat CT (rule out hemorrhage) -tx: tPA within 4hrs

Non-Occlusive acute mesenteric ischemia -etiology -sx -tx

-etiology: "intestinal angina" after eating. -sx: Anorexia in elderly people or critically ill -tx: difficult. vasodilation, anticoagulate

Venous occlusive Acute Mesenteric Ischemia -etiology -sx -tx

-etiology: Starts in venous arcades and progresses to SMV -sx: slower onset than arterial -tx: Heparin, IV thrombolytics, thrombectomy

myxedema coma features

-hypothyroidism -hypothermia -brady, hypotension, low Na, low glucose -facial/extremity edema

Arterial occlusive Acute Mesenteric Ischemia -etiology -sx -dx -tx

-origin of the SMA -sx: pain out of proportion to exam -dx: angiography "thumbprinting" -tx: heparin, glucagon, intraarterial papaverine, laporatomy

orbital cellulitis symptoms

-pain w/eye mvmt -swollen, proptosis, dec EOM, vision changes

Subarachnoid hemorrhage -sx -dx

-sx: worst HA of life -dx: head CT/LP

urine output in a septic patient should be greater than .__ ml/kg/h and abx should be administered within 1 hour of recognition

.5 ml/kg/hr

chad score of 0, 1, 2 --> which do you treat and how?

0 - no treat 1 - Warforin or aspirin 2 -6 warfarin

when is prophylaxis for rabies administered?

0,3,7,14 day

what is the incubation period for tetatnus?

1 - 3 weeks

tx migraine 1. 2.

1 nsaids 2 serotonin agonist (triptans)

after how many weeks does graft vs host present ?

1-2 weeks

Unstable Pts: Hypothermia Tx

1. *Active core* re-warming (eg. NG or bladder lavage, pleural lavage or cardiac bypass) +warm IV fluids and warm air

Mod-to-Severe Hypothermia: Tx

1. *Active* re-warming using heating/electrical blankets, radiant heat, or *warm-water immersion* +warm IV fluids and warm air

Mild Hypothermia: Tx

1. *Passive* re-warming using blankets, warm water +warm IV fluids and warm air

Chest pain immediate goals tx

1. ABC/Stabilization/resuscitation ("Oh MY": IV, O2, monitor, pulse-ox) 2. ECG 3. +/-CXR

To DECREASE risk of Post-operative Fever:

1. ABx: Pre and Post-op 2. Incentive spirometry 3. Foley (short-term) 4. Early Ambulation 5. DVT prophylaxis: anticoag, compression stockings

"Big-Five" life threatening causes of chest pain

1. ACS/MI 2. PE 3. PTX 4. Aortic dissection 5. esophageal rupture

DDx of Family hx of Abdominal pain

1. Acute Intermittent Porphyria 2. Familial Mediterranean Fever

Elderly presentation of PNA

1. Afebrible (or hypothermic) 2. Tachypnea 3. AMS 4. Decline in baseline fxn 5. Sepsis

MCC PNA in Immunocompromised pts

1. Aspergillus 2. CMV 3. TB 4. PCP

MCC of infiltrates in dependent areas of lung (eg. posterior segment of upper lobes; superior segment of lower lobes) on CXR in suspected PNA

1. Aspiration PNA

Mechanisms of PNA

1. Aspiration of pathogens 2. Inhalation of pathogens 3. Hematogenous spread 4. Impaired host defenses (eg. decr mucociliary clearance, immunocompromised) 5. Secondary bac infxn following viral URI

Hypothermia: Labs

1. BMP (Electrolytes) 2. A/B status

Appendicitis: Imaging Studies

1. CT with PO or IV contrast (w/ *findings of periappendiceal stranding OR fluid, enlarged appendix*)--MOST sensitive!!! 2. U/S (w/ *findings of enlarged,NON-compressible appendix*--preferred for children and preg)

Primary EMBU applications

1. Cardiac/IVC/Shock 2. FAST and pneumothorax 3. Aorta 4. Gallbladder and biliary 5. First trimester pregnancy and female pelvis 6. Evaluation for urterolithiasis and acute renal failure 7. Procedural guidance 8. Devaluation for DVT 9. Ultrasound of lungs and pleurae 10. Musculoskeletal and soft tissue evaluation

Types of Shock

1. Cardiogenic 2. Neurogenic 3. Septic 4. Hypovolemic 5. Anaphylactic

MCC of *Atypical Appendicitis* presentation (-->incr risk of misdiagnosis-->incr risk or mortality)

1. Children 2. Elderly 3. Pregnancy 4. Anatomical--Retrocecal appendix

Wound preparation steps

1. Cleansing (saline under pressure 8psi) 2. Debridement is critical 3. Exploration is critical

Hyperthermia: Tx

1. Cool pt (cold water/ice, wet blanket, cold IV fluids) 2. Give Benzo to prevent shivering 3. R/O causes of fever (i.e. infxn, drug rxn)

ABx use in tx of baceterial PNA:

1. Decr mortality 2. Improves pt outcomes

PNA: High-risk Pts

1. Elderly 2. Smokers 3. Pts with an impaired gag reflex 4. HIV

Appendicitis: Tx (Perforation)

1. Give IV *ABx* *UNTIL* pt is afebrile with normalized WBC 2. Wound closure via *delayed primary closure*

Appendicitis: Tx (Abscess)

1. Give IV *Broad-spectrum ABx* 2. Drain (percutaneous) 3. Surgery: elective appendectomy 6-8wks post-ABx tx

PE Signs of Appendicitis

1. Hamburger Sign 2. Psoas Sign 3. Obturator Sign 4. Rovsing's Sign

MC Causes of Acute Appendicitis

1. Hypertrophied lymphoid tissue (MC) 2. Fecalith 3. Foreign body 4. Tumor 5. Parasites 6. Viruses

MCC of patchy infiltrates on CXR in suspected PNA

1. Legionella 2. Mycoplasma 3. Chlamydia

*The Heavenly 7* (Pain Descriptors)

1. Location/Radiation 2. Timing 3. Setting 4. Quality 5. Quantity 6. Alleviating/Aggravating factors 7. Associated s/sx

Appendicitis: Tx (General management)

1. Make NPO 2. IV hydration 3. IV analgesics 4. IV anti-emetics 5. IV ABx (G(-) and anaerobes)

Appendicitis: Tx (Definitive)

1. Open appendectomy --OR-- 2. Laparoscopic appendectomy

RUQ and LUQ spaces

1. Pleural 2. Subphrenic 3. Splenorenal/hepatorenal (morrison's pouch) 4. Inferior pole

What is the first thing you should do in evaluating a TRAUMA pt?

1. Primary Survey: ABCDE

Etiology of widespread cortical dysfunction --> confusion

1. Primary intracranial disease 2. Systemic dz that affect CNS 3. Exogenous toxins 4. Drug withdrawl

Typical clinical s/sx of PNA

1. Productive cough w/*purulent* sputum 2. SOB 3. Pleuritic chest pain *pts at extremes of ages can present atypcially*

Peritoneal Signs

1. Rebound and Guarding 2. Hypotension 3. Fever 4. Elevated WBC

You arrive at a scene/pt presents to ED in which you suspect a *hypothermic pt*, what should be your *first steps*?

1. Safe environment 2. Remove pt from cold environment/exposure (incl. wet clothing) 3. Begin re-warming and thawing (in cases of frostbite)

MCC of multilobar consolidation on CXR in suspected PNA

1. Staph. aureus 2. Psuedomonas 3. H.influenzae

MCC of CAP

1. Step pneumo 2. H. influenzae 3. Legionella 4. Mycoplasma 5. Chlamydia

MCC of focal lobar consolidation on CXR in suspected PNA

1. Strep pneumo 2. Klebsiella

Systemic Inflammatory Response Syndrome (*SIRS*) Criteria

1. Temp 2. HR 3. PaCO2, O2 sat 4. WBC

Frostbite: Tx

1. Thawing using same mild/mod-to-severe hypothermia tx methods +warm IV fluids and warm air 2. IV Narcotic analgesia (to control pain asst'd w/thawing

How do you assess pt's airway?

1. Visualize airway to check for patency, obstruction (secretions, soft tissue, foreign objects--eg. broken teeth)

Lung exam findings of PNA

1. Wheezes 2. Rhonchi 3. Rales 4. Bronchial breath sounds

Wadell triad

1. closed head injury 2. intraabdominal injury 3. mid-shaft femur fracture

Croup tx

1. cool mist/hot shower 2. dexamethasone 3. racemic epinephrine nebulized

tx for a patient in anaphylaxis (with impending respiratory failure): 1 2 3

1. epi 2. intubate 3. steroids

how to conduct a SANE exam what to do first? what else to do? use a _____ lamp for semen colposcopy with _______ blue

1. make sure there are no life threatening injuries 2. get details of the attacker the last menstrual period contraceptive use ? undress on a white sheet and collected the clothes for a legal purposes head to toe exam - search for bruises, lacerations, bite marks, pelvic exam use a wood lamp for semen colposcopy with toluone blue

Anatomic differences of kids

1. more compact organs 2. relatively compact head 3. more elastic ligaments

Location of McBurney's Point

1/3 the distance from ASIS to Umbilicus

dogs cat and ferrets who have bitten a human should be observed for ___ days

10 days

toxic dose of tylenol?

10 g

what are stroke criteria for a hosptial: 10 min 15 min 25 min 45 min

10 min - physical eval 15 min - neuroeval by a specialist 25 min - ct head 45 min - radiologist read

what percent of patients who get blood transfusions get hep c ?

10%

how prevelant is elderly abuse? where does it usually take place and by who?

10% home - by the family

how much should you initially lower blood pressure in patients with hypertensive emergency? (first hour/day) what drugs do you use to do this?

10-15% of the MAP in the first hour / 20-25% the the end fo the first day nicardipine (drip) / labetalol (bolus +drip) / sodium nitroprusside

pit viper bites should be monitored for ___ hours coral snake bites should be monitered for __ hours

12 pit 24 coral

EMT-basic

120+ hours of training. All CFR skills. O2 admin, basic extrication skills. Assist with patient's meds (NTG, MDI)

what is the threshold for pregnancy on a bhcg

1500

GCS: motor response

1=none 2=extension to pain (decerebrate) 3=flexion to pain (decorticate) 4=withdraws to pain 5=localizes pain 6=follows commands

GCS: verbal response

1=none 2=incomprehensible sounds 3=inappropriate words 4=confused 5=oriented

GCS: eye response

1=none 2=pain 3=voice 4=spont

patients 1 month older to 50 yo with meningitis should receive what antibiotics ? patients <1 m old should receive what abx ? patients > 50 should receive what abx?

1m - 50y = Rocephin (2g) , Vanco <1 m = Rocephin + ampicillin >50 = Rocephin, Vanco, Ampicillin

hyperthryoidism treatment for the first trimester vs the second trimester?

1st - PTU 2nd - methimazole

1st and 2nd line medications for hyperemesis in a pregnant women?

1st - pyridoxine b6 2nd - ondansetron

what films must be ordered for a joint that is suspected of being septic?

2 views of the areas above and below the area of concern

dose of B2 agonist for neb for the first hour and follow hours?

2.5/5mg every 20 min / 1st hour 2.5-5 mg every 30 for the remaining hours

what is sepsis

2/4 SIRS criteria source of infection

after how many weeks in hypertension considered preeclampsia?

20 weeks

Emergency Medical Dispatcher

24hrs of training. Provide "pre-arrival instructions" Medical priority dispatch.

Moderate Hypothermia

28-32 C (82.4-89.6) CNS depression, paradoxical undressing, cardiac dysrhythmias develop (sinus brady, afib), Osborn J waves.

tx cholingeric OD? (2 and A)

2PAM and atropine

septic patients should get abx within __ hours of arrival to the ER?

3 hours

how much NS should you give for every mL of blood loss?

3 ml NS for every 1 ml blood loss

3-2-2 rule

3 vertical fingers into the patients own mouth 2 fingers between the floor of the mouth and the thyroid cartilage 2 or less mallampati score

what is the maximum amount of time that bismouth salycilate or antibiotics should be used?

3 weeks

hyponatremia causing seizures tx?

3% saline

aortic aneurysm: CTA + echo every year

3.5-4.5c

Rapid administration of _____ are the cornerstone of ED therapy for patients with sepsis.

30 mL/kg crystalloid fluids and broad-spectrum antibiotics

when does peak bronchoconstriction occur for patients with an asthma attack? when does the late phase attack start? what medications do you give to stop initial asthma attacks/late phase reaction?

30 minutes 4 hours (inflammation, bronchial B2 agonist (early) steroids (late phase)

how often is gas on an xray seen in cases of NSTI?

30%

septic shock is defined as SBP <90 or MAP < 70 after __mL/Kg of NS

30ml/Kg of NS

Mild Hypothermia

32-35C (89.6-95) Shivering, hyper-reflexia, cold diuresis

at what temperture do patients develop bumble, stumbles and tumbles from hypothermia?

34

at what temperature can a hypothermic patient be pronounced dead?

35 degress - regardless of if asystole and fixed pupils are present

___ on waveform capnography indicates adequate compressions

35-40

pneumothorax found on Xray should be treated how?

36-40 french tube thoracostomy (IF pneumo is greater than 20%!)

rewarming an extremity is done a pool of circulating water at a temperature of __-__ degrees?

37-39

>38 or <___ hr > ___ RR > __ or PACO2 < ___ WBC > 12 or < ___ greater than __ = SIRS

38,36 HR >90 RR > 20 or PACO2 < 32 WBC 12, 4 greater than 2 ! = SIRS

ratio for fluids to blood loss

3:1

AAA surgery indication

3cm=aneurysmal 5.5 cm elective surgery recommended

what age group of SCD usually gets splenic sequestration? sudden pallow, abdominal fullness, tachycardia and weakness how quickly can death result?

3m-5y -- a matter of hours can cause death (splenectomy)

*Parkland Formula* for *fluid repletion* in 2nd-degree and 3rd-degree burns:

4 X pt's weight (kg) X %BSA involved *[fluid to be given over 24h]* *First 8h*: Give 50% of calculated amount *Final 16h*: Give remaining 50% of calculated amount

how long after testicular torsion will the testicle be unsalvageable

4-6 hours

how long after a stoke can thrombolytics be given?

4.5 hours

aortic aneurysm: CTA + echo every 6 months

4.5-5.5cm

SAH is most common in what age group

40-60

Boxer's fx

4th or 5th metacarpal. Close fist and look at hand alignment and look for finger malrotation.

suture size for the face? suture size for all other areas of the body?

5-0 face 3-0 all other

MI complication: papillary muscle rupture symptoms

5-10 days after MI hypotensive, mitral valve dys

MI complication: free wall rupture symptoms

5-10 days after MI rapid tamponade, PEA, sudden death

lacy reticular rash on the cheeks

5th disease (parvo b19)

when do alcoholics usually being to show signs of withdrawl? how do yuo treat?

6-48 hours after last drink sieizure subside within 12 hours of onset give benzos to treat

Simple Febrile Seizure a child between 6-__ months a seizureof this type: ____-____ spontaneous convulsion within ___ minutes ____ seizures in 24 hours Complex Febrile Seizure lasting longer than ___ with a _____ period occuring more than ____ in 24 hours

6-60 months tonic-clonic spontaneous cessation within 15 minutes one seizure in 24 hours lasting >15m postical >1 x in 24 hours

how to irrigate a wound?

60 ml syringe w/ a 16-19 guage needle and sterile saline

what should you keep the MAP above in permissive hypotension? who can not get permissive hypotension ?

60-70 TBI patients, cardiac history patients

how much should bchg increase in 48 hours ( in a nonsymptomatic patient)

66% (lack of normal rise indicated abnormal pregnancy)

how many BVM with 100% O2 need to be done to pre ventilate for RSI?

8

at what GCS should you intubate the patient?

8 or less

GCS of ___ or less = intubate a child GCS of ___ or less = intubate in an adult

8 or less intubate

what are the suggested setting for an ET tube? breaths per minute volume (mL/kg, PEEP - yes or no inspiratory to expiratory rate 1:__ inspiratory flow rate of __

8-10 breaths / min volume 6-8 ml/kg no PEEP I:E 1:4 inspirtatory flow rate of 100

EMT-I (intermediate)

80-1000hrs (vary by state). IVs, some medications, advanced airway skills (ET, combi-tube)

what should map be kept near to maintain spinal cord perfusion?

85

bchg 1500 and nothing seen on ultrasound --> what percant chance is there that it is an ectopic pregnancy?

85%

what is the standard door to balloon time for PCI in AMI

90 minutes

drowning in infants < ___ months is suspicious for child abuse

< 6m

normal hr/bp/rr for a child <1, 1-5, 5-10

<1 120 80/40 40 1-5 100 100/60 30 5-10 80 120/80 20

patients must present within ___ hour of ingestion to receive gastric lavage

<1 hour

COPD vs CHF: BNP <100 >500

<100 - BNP >500 - CHF

PCI or thrmobolyticfs if <120 minutes thrombolysis is best within __ hours

<120 --> PCI < 4 hours = thrombolytics

Severe

<28C (82.4) Pulmonary edema, oliguria, loss of reflexes, acidosis, hypotension, coma, ventricular fibrillation, asystole.

hypothermia s defined as a core body temperature < ___ ?

<35

a PaCO2 of greater than what warrants intubation of a pregnant woman? a PaO2 of less than what is an indication that respiratory failure is approaching?

<45 paCo2 <35 PaO2

when can you use methotrexate for ectopic?

<4cm

what kidney stones spont pass?

<4mm

treatment for kidney stones (3)

<6 cm increased fluids, strain urine, give alpha blocker (tamulosin)

bites that are seen within ___ hours can be closed primarily? older than ___ hours should be closed how?

<6 primary secondary

what are blood products indicated? when are platelet transfusions indicated?

<7 <10,000 <20 w/ bleeding <50 w/ severe trauma PTT >17

a wide qrs is great then ___ ms?

>.12 ms

after __cm of cecal dilation perforation risk increases

>10cm

prolonged PR interval is ____

>200msec (5 small boxes)

Define fever in kids

>38C (100.4F) - infant 38.5 (101.3F) -older kids

aortic aneurysm surgery

>5.5cm >1 cm/yr

what characteristics of an abscess classify it as complicated? (complicated abcesses shuld receive abx in addition to I&D)

>5cm, having an area of surrounding cellutlitis, or in an immuncomprised host

who needs radiography of the neck? age, mechanism, movement

>65, traumatic MOA, not able to rotated neck

hyperkalemia is considered severe after what level?

>7

A 22 year old man is punched in the nose during a fight. He presents to the emergency department with obvious nasal bone deformity. Pressure controls the bleeding. Physical exam reveals no maxillary bone or orbital rim tenderness, intact vision and extraocular movement. The oropharynx and mandible are unremarkable. Nasal inspection reveals a swollen, ecchymotic, tender nasal septum. Which of the following is the most appropriate initial step? A. Incision and drainage of the septal hematoma followed by nasal packing B. Needle aspiration of the septal hematoma C. Plastic surgery consult for immediate reduction of nasal fracture D. Facial CT scan to rule out more serious facial fractures E. Outpatient follow-up with an ENT specialist to surgically correct a deviated septum

A

Stanford classification (aortic dissection)

A: involves Ascending aorta (w or w/o descending) 80% of dissections - older pts w/ HTN B descending aorta only - mar fan's, ehler Danlos, pregnancy

AVPU

A= awake V=verbal stimulation response P= painful stimulation U= completely unresponsive

1st step in treating patients with penetrating trauma to the chest abdomem or pelvis?

ABCDE (primary survery)

Evaluation of a trauma patient begins with assessment and stabilization of the _____.

ABCs

2 areas common for berry aneurysms (SAH)

ACA PCA

_____ is a common feature in DKA and is usually idiopathic, especially in younger patients.

Abdominal pain

Gas permeable dressings

Abrasions, burns, road rash, ulcers

Asthma tx

Albuterol (beta 2 agonist) Ipratroprium (anticholinergic agent) Corticosteroids: use in ALL acute attacks Magnesium sulfate Terbutaline/Epinephrine: parenteral beta-agonists

what does AEIOU DIPS stand for and why sis it used?

Alcohol Electrolytes/encephalopathy/endocrine Insulin Opiods/oxygen Urea Drugs Infection Porphyria Shock/stroke/lesions causes of AMS

Confusion

Alteration in higher cerebral functions (memory, awareness, attention). Sx, not a dx

Look for causes of _____ after you have started your initial resuscitation.

Anaphylaxis

Call _____ early if a difficult airway is anticipated.

Anesthesia and/or surgery

Unstable angina (plaque rupture)

Angina that is new in onset occurs at rest or is similar but somewhat "different".

CHA2DS2 VASc Score is used to determine?

Annual Stroke Risk

LGIB dx

Anoscopy: localizes lesion to rectum Colonoscopy: procedure of choice, difficult to perform without bowel prep or if active bleeding Nuclear red blood cell scan Angiography

what is the only condition is which rapid aggressive blood pressure lowering is used? what is the ideal SBP under and HR less than in the treatment of this condition? what medication is ideal for this because of its abiliity to lower heart rate and blood pressure?

Aortic disection BP< 100 HR<60 labetalol/esmolol

Expressive aphasia, stroke (carotid ischemia), pain radiates to back, CXR: widened mediastinum

Aortic dissection clinical picture

Obtundation

Awake but NOT alert. Psychomotor retardation

Stupor

Awaken with stimuli but little motor or verbal activity when aroused.

A blunt trauma patient presents, transported by EMS from a motor vehicle collision, with inability to provide a history, due to alcohol intoxication. He has no signs of trauma on external evaluation, but he is hypotensive. An ED ultrasound is performed at the bedside, and is depicted in the figure. Given the patients' clinical condition and image seen, what is the most likely diagnosis? [image] A. Rupturing abdominal aortic aneurysm B. Free intraabdominal fluid C. Ruptured gallbladder D. Fat embolus from femur fracture

B

During a bar fight, a 42 year old man is stabbed in the left side with an unknown weapon. He presents to the emergency department with dyspnea, pulse of 108, blood pressure of 138/92, and oxygen saturation of 94% on room air. He has absent breath sounds on the left side; you note a small puncture wound in the midaxillary line at the level of the 10th rib. His abdominal exam is normal. Two large-bore IVs are established. What is the appropriate management of this patient? A. Left-sided chest tube, portable chest x-ray, diagnostic peritoneal lavage, and admission B. Left-sided chest tube, portable chest x-ray, and abdominal CT scan C. Endotracheal intubation, portable chest x-ray, exploratory laparotomy in the OR, and admission D. Endotracheal intubation, left-sided chest tube, portable chest x-ray, and admission E. Left-sided chest tube, portable chest x-ray, and admission

B

Using the rule of 9s, what is the approximate burn surface area of a victim who has sustained second-degree burns to the anterior chest and anterior area of both arms? A. 20% B. 25% C. 30% D. 35%

B

_____ is a hormone released by the ventricles in response to stretch. It can be useful as a diagnostic marker for HF.

BNP

_____ is a hormone released by the ventricles in response to stretch. it is a useful measure of HF

BNP

Always anticipate the difficult airway and have _____ immediately available.

Backup airway devices

_____ is a lifesaving intervention for almost all patients with respiratory failure—know how to do it!

Bag-valve-mask ventilation

Anticholinergic drugs

Benadryl diphenhydramine (OTC cold, sleep meds), antiparkinson, anticholinergic meds, benzotropine, Jinsom weeds, atropine tx: neostigmine

in the undifferentiated AMS patient what should be checked immediately?

Blood Sugar

Therapy must be initiated promptly with _____ if blood products are not immediately available.

Blood product administration or with fluids

Definition of *Hypothermia*

Body temp of *<35C/<95F* *+/-* AMS, neuro deficits

Definition of *Hyperthermia*

Body temp of *>40C/<104F*

_____ should always be considered in the differential diagnosis of acute CP, especially if the patient has been vomiting or performing any activity where barotrauma may have been sustained due to valsalva maneuver.

Boerhaave syndrome

Coma causes?

Brainstem dysfx and/or bilateral cortical dz

A 32 year old female is shot with a 38-caliber pistol at close range in the right anterior chest. She presents to the emergency department intoxicated and yelling. Her vitals include a pulse of 92, blood pressure of 134/84, and oxygen saturation of 97%. She has clear breath sounds bilaterally. The entrance wound is just above the right breast and an exit wound is noted in the right axilla. What is the most appropriate management of this patient? A. IV access, endotracheal intubation, CT scan of chest to look for pneumo- or hemothorax, or injuries to the heart or great vessels B. IV access, endotracheal intubation, emergency department thoracotomy to search for cardiac or pulmonary vascular injury C. IV access, endotracheal intubation and simultaneous placement of a right chest tube, bedside ultrasound, portable chest X-ray, and admission to the ICU if stable D. IV access, portable chest X-ray, tube thoracostomy, and exploratory thoracotomy in the OR to search for cardiac or pulmonary vascular injury E. IV access, portable chest X-ray, right chest tube placement if X-ray shows a pneumo- or hemothorax, admission to the ICU for observation

C

Which of the following trauma patients can be managed conservatively without immediate laparotomy in the OR? A. 27 year old man with hemoperitoneum by bedside ultrasound; hypotensive B. 19 year old man with splenic laceration; peritoneal signs on exam C. 24 year old man with liver laceration; hemodynamically stable D. 30 year old man with a gunshot wound to the epigastrium E. All of the above should go to the OR for exploratory laparotomy.

C

A 24 year old woman is playing racquetball and sustains a direct blow from the ball to the right eye. She presents to the emergency department complaining of eye pain and double vision. On exam, her right eye does not track properly with upward gaze. This finding suggests which of the following injuries? A. Zygomatic arch fracture B. Ethmoid fracture C. Inferior orbital wall fracture D. Inferior orbital rim fracture E. Superior orbital rim fracture

C. The patient most likely has an orbital floor fracture with entrapment.

A 46 year old man is brought in by EMS after a motor vehicle collision in which he was an unrestrained driver. Although he has no obvious injury to his head or neck, he complains of chest pain and appears very short of breath. His vital signs are: T 99.2 F, BP 85/57, HR 123, RR 36, SpO2 95% on non-rebreather. The CXR demonstrates a tension pneumothorax. Of the following, which is the most appropriate next step in this man's care? A. Performance of a chest CT scan to further delineate the pathology B. Transfusion of 2 units of O-negative packed red blood cells C. Placement of a needle decompression device, followed by repeat CXR D. Placement of a chest tube followed by a chest xray to determine proper placement

C. This patient needs emergent chest decompression and this is rapidly done by needle thoracostomy. A chest CT may be performed, but only once he is stabilized. A formal chest tube will be placed, but placement may not be rapid enough and he may decompensate in the meantime. Transfusion of blood does nothing to correct the physiology of a tension pneumothorax

what to order for a fever without a source in a 1-3 month infant? empiric abx to give to all *ill* appearing infants less than 3 months old ?

CBC blood cultures urinalysis urine culture cxr lumbar puncture - depending on clinical presentation rocephin

what testing must be done for the ill appearing infant less than 3 months old?

CBC, Blood cultures, urinalysis, and urine culture

Septic workup in kids

CBC, UA, CSF, CXR

Treatment of _____ includes oxygenation, correction of the underlying cause, and relief of symptoms by preload and afterload reduction, diuresis, and possibly inotropic support.

CHF

interstitial edema and kerley b lines - cardiomegaly, upper zone vascular redistribution (cephalization) and pleural effusion

CHF

CHADS stands for?

CHF = 1 HTN - 1 Age >75 - 1 Diabetes - 1 Stroke/TIA - 2

Cardiac markers and sensitivities

CK-MB: Sensitive >90% for MI 5-6 hrs after sx Troponin-I: Sensitive, duration for days Troponin-M: less sensitive, duration for days

what facial nerve exists the stylomastoid foramen

CN 7

Coma etiologies NOT to miss

CNS: hemorrhage, stroke Infx: meningitis, sepsis Metabolic: hypoglycemia, DKA, HHNK

treatment for asystole

CPR epi 1mg every 3-5mn

eval c-spine in an obtunded patient?

CT

imaging for spinal fracture (initial evaluration)

CT

imaging if you suspect AAA or PE?

CT

what imaging may be helpful in identifying injuries to the retroperioneum in a stab wound to the back?

CT

definitive DX of aortic dissection

CT + contrast

imaging for kidney disease?

CT abdomen

what imaging do you have to do to rule out stroke in patients with hypertensive encephalopathy?

CT head w/o contrast

diagnosis for kidney stone

CT w/o contrast

test of choice for patients with suspected PE?

CTA (VQ with renal failure)

pain that is worse at night, unrelieved by rest, unexplained weight loss, mild to moderate spinal tenderness imaging?

Cancer CT

It is critical to _____ lower blood pressure to avoid inducing a hypoperfusion state that leads to cerebral ischemia.

Cautiously

Primary closure

Clean wound

Sympathomimetic drugs

Cocaine, amphetamines, anorectics, otc stimulants, herbal, PCP (nystagmus)

Febrile infant (29-56 days) mgmt

Complete septic workup 28-56d: admission "Low risk" criteria: withhold abx "High risk" criteria: abx

How does pump failure cause shock?

Contractility or HR (ex: acute MI, arrhthymias, late sepsis)

Definitive therapy for _____ of hemorrhage should be arranged as soon as possible.

Control

Heat Stroke

Core temp >40C w/ CNS dysfx in setting of environmental heat load

A 36 year old man is a restrained driver involved in a high speed MVA where his car is struck on the driver's side door with significant intrusion. His physical exam is significant for a large contusion on his left flank. His abdominal exam is benign and rectal exam reveals a normal prostate. A Foley catheter is placed with return of gross hematuria. Which test is indicated to evaluate for the presence of urologic injury? A. CT abdomen / pelvis with IV contrast alone B. CT abdomen / pelvis without contrast C. Ultrasound of the kidneys D. CT abdomen / pelvis with IV and transurethral contrast E. Ultrasound of the bladder

D

What is the most common cause of death in Americans aged 20 to 40 years? A. Cancer B. Drug overdose C. AIDS-related illness D. Trauma E. Pneumonia

D

Cholinergic toxidrome

DUMBELS D: Diarrhea, diaphoresis U: urination M: miosis B: bradycardia, bronchorrhea E: emesis L: lacrimation S: salivation, seizures

How does inadequate volume cause shock?

Decreased preload (ex: hemorrhage, dehydration)

Rovsing's Sign

Deep *palpation of LLQ*-->RLQ pain

Delerium v Dementia

Delerium always has an organic cause.

When to close? Golden hour.

Depends on clinical scenario. 8-12hrs

Drugs that cause heat stroke

Diphenhydramine (Ach) phenothiazines (dopamine blockers) Ethanol Cocaine Ecstasy

Healing by secondary intention

Dirty wound. Least favorable will make a big scar.

The rate of success of cardioversion is closely linked to the _____. Up to 70% of new onset AF will spontaneously convert.

Duration of the AF

Febrile infant (<2yrs) agents

E. coli, Group B strep, listeria monocytogenes, HSV 1, HSV 2

Always order an _____ in a patient with suspected tachyarrhythmia.

ECG

An _____ should be performed immediately in all patients with chest pain concerning for ACS.

ECG

GI bleed diagnostic imaging of choice?

EGD

what diagnostics should be done to overdose patients?

EKG

test for ACS? E (d), C (i), 3 labs

EKG cxr --> pulmonary edema/AAA cbc cmp pt/ptt

EM Basic Eye lecture

EM Basic Eye lecture

EM Basic Seizure lecture

EM Basic Seizure lecture

EMS personnel

EMT-B EMT-I EMT-P

EMT-paramedic

EMT-B training plus 1000+ hrs of training. Clinical rotations in ED, ICU, CCU, labor & delivery and anesthesia. Strict CME requirements. ET intubation, surgical airway, chest decompression, EKG

what diagnostic test will come back elevated for a patient with temporal tenderness and headache

ESR > 50 (usually older than 50 too!)

The airway should be secured _____. It is much easier to extubate a patient without severe laryngeal edema than to intubate a patient with an occluded posterior oropharynx.

Early and often

Early Goal-Directed Therapy (EGDT):

Early antibiotics + resuscitation minimizes mortality in septic shock.

Heat related illness

Edema Tetany malaria rubra syncope cramps exhaustion

Unstable patients with AF or Wolff-Parkinson-White tachyarrhythmia with AF should undergo immediate _____.

Electrical cardioversion

_____ should be given at the first sign of respiratory distress or cardiovascular compromise.

Epinephrine

dT

Every 10 years or booster. Okay in pregnant women

Supracondylar fx

FOOSH (fall on outstretched hand) Gartland 1: non-displaced Gartland 2: displaced but intact Gartland 3: displaced with disruption or ant/post periosteum. Neurovascular compromise/comapartment syndrome

Leading cause of pediatric morbidity

Falls. Most common from 0-14

Aortic Dissection treatment goals

Fluid and BP control (beta blockers, nitroprusside)

what does D stand for in the ABCDE of the primary evaluation ?

GCS

what is the most common cause of NCCP?

GERD

Abdominal pain + N/V, anorexia, changes in bowel habits, melena, hematochezia...think...

GI causes

_____ cannot be used to reliably rule out a cardiac etiology for an episode of CP.

GI cocktail

Abdominal pain + dysuria, pyuria, hematuria, CVA tenderness...think...

GU/Renal causes

When doing contrast studies to locate the site of esophageal perforation, _____ should be used instead of barium to avoid severe mediastinal and intra-pleural inflammatory reactions.

Gastrografin

Abx prophylaxis

Generally not necessary, except cat bites, certain hand injuries, foot punctures

pneumonia that occurs within 30 days of wound care, in a patient living in a nursing home, or hospitalized withing the past 90 days or have been in the hospital for the past 2 days

HCAP

treat status epilepticus?

HD benzodiazepines

CO

HR X SV

What is the FIRST VS you want to stabilize/change in *Hemorrhagic* shock? Why?

HR, because BP begins to decrease ONLY after there has been a blood loss of ~30-40% of total blood volume.

what diseases are cause with AFIB? (think PMH)

HTN and CAD and Hyperthyroidism

CV causes of AMS

HTN, enceophalopathy MI, CHF, PE Hypoxia Hypercarbia

_____ is key for both basic and advanced airway management.

Head position

A trauma patient should be assessed systematically for the source of _____.

Hemorrhage

Laboratory evaluation is not as sensitive as the combination of history, clinical examination, physical examination findings, and vital sign abnormalities for the diagnosis of _____.

Hemorrhagic shock

UGIB high risk (re-bleed, mortality)

Hgb: <11 Shock Tachycardia of >110-120 BPM Age >60 Coagulopathy Co-morbidities such as cancer

Reasons for fevers

Host defense Endogenous pyrogens (IL-1, IL-6): rheumatic disease, Exogenous pyrogens: LPS, cocaine, anti-cholinergics

Metabolic causes of AMS

Hypoglycemia Hepatic encephalopathy Thyroid dyxfx Alcohol withdrawal

_____ in a trauma patient is hemorrhage until proven otherwise.

Hypotension

Permissive hypotension should not be applied in the treatment of _____ because low blood pressures can contribute to secondary brain injuries.

Hypotensive trauma patients who also have moderate or severe traumatic brain injuries

patients with a GI bleed should be admitted to what hospital setting?

ICU

patients with hypertensive emergency should be admitted to what unit?

ICU

where to admit patients with tetanus?

ICU, give Tetatnus IG, and vaccine

the first dose of epinephrine should be administerd how for anaphylaxis?

IM (anterolateral thigh)

tx transient aplastic crisis?

IVIG

Most morbidity in DKA is _____.

Iatrogenic

CT objective

Id of specific organ injury and or free fluid and/or retroperitoneal andmusculoskeletal injury → IR or OR

anaphylaxis is an Ig__ mediated reaction?

IgE

How does inadequate resistance cause shock?

Inappropriate low SVR (ex: SIRS, anaphylaxis, burns, Addisonian crisis)

Each organization and practice facility should identify workable approaches to address the _____ of patients encountered in the emergency department.

Increased critical care medicine needs

Healing timeline

Initial epitheliization: 24-48h Peak collagen synthesis 5-7d Strength of wound: 5% at 2 weeks, 35% at one month

`most common location of a herniated disk?

L4-L5

4-10 year old child with a limp complaining of hip or knee pain?

LCP (avascular necrosis)

treatment for NSTEMI

LMWH anti-platelets

Abdominal Pain

LOCATION, LOCATION, LOCATION!!! + PAIN onset

what is considered the best diagnostic indicator of preload? what is becoming a more popular indicator of preload?

LVEDP central venous catheter (estimates fluid volume)

sick patient coming back from the middle east?

MERS

_____ greets chest pain at the door.

MONA (morphine, oxygen, nitroglycerin, and, most importantly, aspirin)

ideal study for a child suspected of having ostero myelitis?

MRI

imaging for spinal cord infection

MRI

Leading cause of pediatric morality

MVA

tear of the gastroesophageal junction

Mallory Weiss tear

UGIB dx

NG lavage: EXCEPT known esophageal varices, active PUD, Mallory-weiss tears, gastric bypass surgery Endoscopy: 12-24 hours if bleeding stops

Wound lecture pearls

NO absolute golden hour, tap water is as good as NS, do NOT soak in betadine, non-sterile gloves ok, hand wounds less than 2cm> big, bulky dressings as good as sutures

how do you manage small bowel obstruction?

NPO IV fluids NG tube decompression

if esophageal rupture is contained what can be done?

NPO NG Tube BSA and parenteral nutrition

treat boorheaves? NNFBS

NPO NG tube IV resuscitation BSA Urgent Surgical consult

tx musculoskeletal chest pain?

NSAIDS

treatment for pericarditis

NSAIDs + colchicine

skin popping with black tar heroin usually causes this type infection?

NSTI

A single normal ECG cannot be used to make the diagnosis of _____.

Non-cardiac chest pain (NCCP)

kids response to shock

Normal BP w/ early shock. Different baseline HR, BP Greater propensity for spinal cord injury without radiologic abnormality (SCIWORA) More heat loss (sa)

Cryptic Shock

Normotensive + high lactate = profound tissue hypoxia. SBP >90 or MAP >65. Lactate >4.

if there is not time to cross match blood was should be ordered (for men and women) ?

O negative blood in females O positive blood in males

initial treatment for sepsis? (3)

O2 if is sat is < 93 2 Large bore Ivs fluid bolus 30 mL/kg in the absence of CHF/renal failure)

Tdap

Once, 20-65 yo. Pregnant women after 20weeks.

Use an _____ when bagging a patient.

Oral airway

CRITOE

Ossification centers of the elbow: C-capitellum=1yr, R-radial head=3yr, I-internal medial epicondyle=5yr, T-trochlea=7yrs, O-olecranon=9yrs, E-external (lateral) epicondyle=11yrs

STEMI for less than 12 hours --> ?

PCI

common allergies for anaphylaxis? trees nuts, peanuts, bees, and what medcation?

PCN peanuts treenuts bees

tx strep?

PCN x 10 d

Abdominal pain + fever, cough...think...

PNA

Define: Ventilator-Associated PNA (VAP)

PNA that arises 48-72h after intubation. It is a type of hospital-acquired PNA.

Define: Hospital-Acquired PNA (HAP)

PNA that arises within at least 48h after hospital admission. HAP includes: Ventilator-Associated PNA.

Define: Community-Acquired PNA (CAP)

PNA that occurs in a pt living in the general population or community

Define: Healthcare-Associated PNA (HCAP)

PNA that occurs in a pt with substantial healthcare contact (eg. IV Abx, chemotherapy, or wound care w/n the past 30d; nursing home or long-term care facility; hospitliaztion for at least 2d w/n the past 90d; hemodialysis).

what medication should be given to patients with upper gi bleeds?

PPI to prevent rebleeding

rare complication of GABS pharyngitis

PSGN

UGIB causes

PUD, gastric erosions, variceal bleeding, Mallory-weiss tear, esophagitis, duodenitis, aortoenertic fistula, renal disease

Difficult sutures

Palms Shins Joint involvement vermillion border

Psoas Sign

Passive *extension* of the hip-->RLQ pain

Obturator Sign

Passive *internal rotation* of the *flexed* hip-->RLQ pain

One of the most common reasons for hypertensive emergency is _____.

Patient noncompliance with antihypertensive medication

The goals of patient resuscitation are not normalization of vital signs and laboratory parameters but to sufficiently _____.

Perfuse key organs

Opioid toxidrome

Pinpoint pupils, respiratory depression, lethargy to coma, bradycardia, hypothermia, borderline, hypotension

Infection causes of AMS

Pneumonia UTI Sepsis Meningitis

Introduction of a _____ has led to improvements in outcomes in post-cardiac arrest patients.

Post-cardiac arrest consult team

ROM of that occurs earlier than 37 weeks?

Preterm Premature rupture of membranes

bit by a ferral animal and developing symptoms of fever headache, malaise, nausea, emesis, and productive cough, and hydrophobia

RABIES

Bronchiolitis

RSV invades nasopharyngeal epithelium cell-cell transfer to lower airway and cause mucus plugging, and edema sx: grunting, nasal flaring

Supine watersheds

RUQ: 4 spaces LUQ: 4 spaces Subxiphoid:1 Suprapubic:1

blisters on the tip of the ear with focal neurological deficits are an indication of what disease

Ramsey hunt

what is the most common treatment to optomize outcome of drowned patients?

Rapid initiation of resusitation in the prehospital arena

Take time to thoroughly prepare for _____. Poor preparation should never be the reason for a failed airway.

Rapid sequence intubation (RSI)

mcc of transient synovitis?

Recent URI

Definition of *Shock*

Reduction in end-organ perfusion due to impaired tissue oxygenation

Passive external rewarming

Remove wet garments, apply blankets, let them shiver

The ECG will dictate the next step in management; new ST elevation generally requires immediate _____. "Time is myocardium."

Reperfusion therapy

Treatment of atrial fibrillation (AF) begins with a search for any underlying _____ of the arrhythmia.

Reversible causes

what to give for a patient who was sexually assulted with penile penetration without the use of a condom? What testing shuold be done?

Rocephin - 125mg Azithromycin - 1 g Metronidazol - 2 g HBIV emergency contraception HIV prophylaxis STI testing

Abdominal pain + SYNCOPE OR SHOCK in Elderly pt...think

Ruptured AAA (until proven otherwise)

xanthochromic fludid is diagnostic for what cause of headache

SAH

Normotensive Shock

SBP<90, but >40mmHg drop fro baseline. It's not about the pressure it's about the O2 demand

11-15 year old obese boy complaining of hip of knee pain?

SCFE

Def'n of *Sepsis*

SIRS + nidus for infxn w/persistent hypoxemia

overdose of edrophonium or physostigmine

SLUDGE (cholinergic overdose)

st elevation of 2 contiguous leads lbb (new) with a history suggestive of MI st depression in leads v1-v3 with a prominent r wave and upright t-wave

STEMI (PCI)

What predicts intracranial injury risk (should CT)?

Seizures, low CGS, scalp hematomas (parietal/temporal), altered mental status. NOT LOC.

_____ is defined as a life-threatening organ dysfunction due to a dysregulated host response secondary to an infection.

Sepsis

Severe Sepsis:

Sepsis + Organ dysfunction (elevated Cr, INR, altered mental status, elevated lactate, hypotension that responds to fluids)

Def'n of *Septic Shock*

Sepsis + end-organ damage w/persistent hypoxemia

Patients with _____ should be reassessed by repeat focused examination (including vital signs, cardiopulmonary exam, capillary refill, pulse, and skin findings), central venous pressure monitoring, central venous oxygen saturation assessment, bedside cardiovascular ultrasound, and/or dynamic assessment of fluid responsiveness to passive leg raise or fluid challenge.

Septic shock

EMS curriculum

Set by the Federal Department of Transportation

Delerium

Severe confusion associated with 1. Motor restlessness 2. Transient hallucinations 3. Disorientation 4. Delusions

Septic Shock

Severe sepsis + hypotension. Hypotension does NOT respond to fluid (30cc/kg bolus)

Neurological causes of AMS

Siezure Stroke CNS mass

Febrile child (3+yrs)

Similar to adolescents and adults

Patients in DKA are almost always dehydrated and have significant _____, regardless of their specific laboratory values.

Sodium and potassium deficits

Toddler fx

Spiral or oblique fx through distal 3rd of tibia non-displaced. -Etiology: Often un-witnessed fall or minor trauma. -Sx: Limp. Pain with gentle twisting of LE or heel tap. -Tx: short or long leg cast for 3-4weeks

_____ are all helpful pharmacologic adjuvants for managing the many symptoms of anaphylaxis.

Steroids, antihistamines, and beta agonists

MI (occlusion) or NSTEMI

Sub-sternal chest discomfort > 15 min associated with dyspnea, diaphoresis, light-headedness, palpitations, n/v (12.5% of MIs are clinically silent)

Always have _____ available.

Suction

What other option will you use in the event that a pt cannot be intubated (2ndary to obstruction or upper airway trauma)?

Surgically create an airway via *Cricothyroidotomy*.

If the patient is unstable (as evidenced by hypotension, pulmonary edema, altered mental status, or ischemic chest pain), _____ should be performed immediately. In stable patients, a 12-lead ECG should be obtained, and medical therapy can be initiated.

Synchronized cardioversion

TX for myxedema coma

T4 glucocorticoids antibiotics fluids/electrolyte correction

A 22 year old running back is struck from behind by a 300-pound lineman. The blow occurs below the knee as his foot is firmly planted and two other linemen are holding his upper body. He presents to the emergency department with gross anterior dislocation of the tibia on the femur. His foot is cool and pale, and dorsalis pedis and posterior tibial pulses are not detected by Doppler ultrasound. What is the most appropriate management for this patient? A. Immediate reduction in emergency department under conscious sedation without X-rays B. Open reduction in OR with exploration of popliteal artery C. Immediate orthopedic consultation without attempts to manipulate the knee D. Immediate arteriography to assess for popliteal artery disruption

The answer is A. A knee dislocation frequently injures the popliteal artery, threatening the survival of the limb. Immediate reduction for the dislocation is warranted to attempt to restore flow through the artery, and should be attempted by the ED physician without waiting for orthopedics. Transport to the OR is an unnecessary delay, and while arteriography will be indicated, the most urgent priority is restoring blood flow.

A 76 year old restrained driver is involved in a head-on collision at about 35 mph. He arrives at the emergency department in a cervical collar and on a backboard. His only complaint is neck pain, and he has mild posterior neck tenderness. A CT scan of the neck shows no fracture and only degenerative arthritis. Upon re-evaluation you note the patient has difficulty raising his arms against gravity and there is decreased grip strength bilaterally. The remainder of his neurological exam is normal. What is the most appropriate management for this patient? A. Administration of IV steroids and ordering of cervical MRI B. Reassurance and discharge with NSAIDs given the non-anatomical distribution of weakness C. Immediate neurosurgical decompression D. Flexion and extention radiographs to rule out ligamentous injury E. Discharge home with a hard cervical collar with neurosurgical follow-up

The answer is A. Central cord syndrome results from a hyperextension injury, typically in elderly patients with significant degenerative joint disease. The ligamentum flavum buckles into the cord, resulting in a contusion of the cord's central portion.

A trauma patient resuscitated in the ED, has a post-tube thoracostomy computed tomography (CT) scan as depicted in the figure. What finding is present? [image] A. Persistent pneumothorax B. Aortic rupture leading to a right hemothorax C. Pericardial tamponade

The answer is A. The chest CT shows a chest tube in place on the right, with incomplete reinflation of the lung. The left hemithorax is grossly normal, but there is a large right pulmonary contusion, as well as pneumothorax and small hemothorax on the right. The aorta appears intact (aortic injuries usually leak into the left hemithorax, not the right).

Choose the INCORRECT statement regarding thoracentesis from the anterior approach (needle decompression): A. The recommended insertion site is the second intercostal space, midaxillary line. B. An upright chest X-ray should always be performed following a thoracentesis to confirm the successful relief of a tension pneumothorax and the absence of hemothorax or other complications. C. If a tension pneumothorax is confirmed via needle decompression, then a thoracostomy tube should be placed as soon as possible. D. A 14- to 20-gauge needle is inserted perpendicularly over the superior edge of the rib. E. After the needle is inserted into the pleural space, a rush of air confirms the presence of a tension pneumothorax.

The answer is A. The recommended insertion site for needle decompression of tension pneumothoraces is the second intercostal space along the midclavicular line. If a lateral approach is needed, the recommended insertion site is the fourth or fifth intercostal space in the midaxillary line. The lateral approach poses a greater risk of parenchymal injury. The needle should always be inserted over the superior edge of the rib as the neurovascular bundle runs along the inferior margin (answer B). The remaining answers are all correct statements regarding thoracentesis (answers C, D, E).

The patient in the figure sustained minor blunt trauma to the eye, and has a normal head/orbital computed tomography (CT) scan. Ophthalmological examination is normal, other than the blood as shown in the figure (the blood does not cross the limbus). Of the choices below, which diagnosis is the most likely based upon the figure? [image] A. subconjunctival hemorrhage B. foreign body C. ruptured anterior chamber D. hyphema E. globe rupture

The answer is A. The subconjunctival blood as depicted in this patient, can be expected to resorb without intervention over days to weeks. The figure does not suggest rupture of anterior chamber or hyphema; globe rupture and foreign body are less likely given the normal examination and CT scan.

A 23 year old man is stabbed in the anterior neck with a 3-inch knife during a street fight. At the scene, there is some bleeding, which is controlled with direct pressure. He presents to the emergency department breathing comfortably and in no distress. His pulse is 88, blood pressure 126/76, and oxygen saturation 99% on room air. There is a 1cm laceration 2cm above the right sternoclavicular junction, lateral to the trachea. There is mild oozing and no obvious underlying hematoma. There is no obvious subcutaneous air, and he has clear lung sounds. What is the most appropriate management for this patient? A. Angiography, esophogram, and admission for observation B. Local wound exploration and discharge home after 6-hour observation period C. CT scan of the neck and discharge home after 6 hours of observation D. Immediate operative exploration E. Local wound exploration and discharge home if no significant injury identified

The answer is A. Zone I penetrating neck injuries are located between the sternal notch and the cricoid cartilage. A major concern is injury to non-compressible vascular structures such as common carotid, vertebral, subclavian, aortic arch. Other structures in this area include trachea, esophagus, and lung apices. Physical exam is often unreliable and angiography, esophogram, and observation are warranted.

Following a brawl at a local bar, a gentleman presents with an impressive right-sided periorbital ecchymosis. All of the following physical examination findings would suggest an orbital blowout fracture EXCEPT: A. right-sided epistaxis B. proptosis C. right-sided infraorbital subcutaneous emphysema D. anesthesia of the right infraorbital region E. diplopia with upward gaze

The answer is B. Orbital blowout fractures classically involve the maxillary or ethmoid sinus and consequently often cause either epistaxis (through the connection of the maxillary sinus with the nose) or subcutaneous emphysema (through the entry of air from the sinuses into the subcutaneous tissue). A fracture through the maxillary sinus may extend through the portal by which the second branch of the trigeminal nerve exits, thus causing anesthesia of the ipsilateral infraorbital region. If the inferior rectus muscle gets trapped within the fracture of the inferior orbital wall, patients will be unable to look upward causing diplopia with upward gaze. Orbital blowout fractures are not typified by proptosis. In fact, proptosis in the setting of trauma should prompt physicians to suspect the possibility of a retrobulbar hematoma.

An 82 year old woman with osteoporosis slips and falls onto her right hip. She cannot get up and is brought to the emergency department by ambulance. As you enter the room you notice her right leg is abducted and externally rotated. What type of injury does she most likely have? A. Intertrochanteric femur fracture B. Femoral neck fracture C. Acetabular fracture D. Posterior hip dislocation E. Subtrochanteric femur fracture

The answer is B. Patients with dislocation tend to have internal (not external) rotation.

In differentiating high voltage electrical injury from lightning injury, which of the following is your best discriminator? A. Fractures or dislocations B. Deep burns C. Loss of consciousness D. Cardiac arrest

The answer is B. Patients with high voltage injury commonly present with devastating burns. The burns are most severe at the source and ground contact points. The most common sites of contact with the source include the hands and the skull. The most common areas of ground contact are the heels. Deep burns occur in less than 5% of lightning injuries. Electrical injuries may cause four types of superficial burns or skin changes: linear burns, punctate burns, feathering, or thermal burns. Loss of consciousness, cardiac arrest and orthopedic injuries can be seen in both high voltage electrical injury and lightning injury. Electrolyte abnormalities are not common in either injury.

A right-handed patient sustains a circumferential burn (see figure) to the distal right forearm and hand, which is cool despite warm ambient temperature. Regarding the initial assessment and management of the patient, which of the following is correct? [image] A. As shown in the Figure, the burn represents about 10% of total body surface area B. The involved areas of this 3rd-degree burn would be expected to be mostly insensate C. Prophylactic penicillin should be given to any patient with a significant burn D. Pain medication should be withheld pending obtaining operative consent for emergency burn debridement

The answer is B. The answer is D. 3rd-degree burns are often insensate; withholding pain medication is not necessary; one hand is about 2-3% TBSA, and prophylactic antibiotics are not recommended

A 41 year old man is seen in the emergency department after a street fight where he punched another man in the mouth. He has a small, jagged laceration over the dorsum of the metacarpophalangeal joint of his right hand. The wound is irrigated copiously, tetanus is given, and the wound is left open to heal by secondary intention because of the infection risk. In addition to treating Streptococcus and Staphylococcus species, antibiotics must also treat which other bacterial species? A. Escherichia. coli B. Eikenella corrodens C. Pasteurella multocida D. Actinomyces israelii

The answer is B. There are many species of bacteria in the human mouth, and Eikenella corrodens is an aggressive one, frequently causing infection in the first 24 hours after injury.

Following a motor vehicle collision, in which of the following patients is an emergency department Caesarian section most likely indicated, assuming a fetus at 29-weeks gestation? A. Mother with severe head trauma, blood pressure 170/90; fetal heart tones 120 beats per minute B. Mother pulseless and apneic for 2 minutes' duration and still in arrest; fetal heart tones of 100 beats per minute C. Mother with gunshot wound to abdomen, blood pressure 96/42; fetal heart tones undetectable D. Mother with abdominal pain, blood pressure of 80/40; fetal heart tones 100 beats per minute E. Mother with vaginal bleeding, blood pressure 118/78; fetal heart tones 80 beats per minute

The answer is B. Though emergency C-section after maternal death is a rarely indicated procedure, rapid intervention (within minutes) of maternal demise has resulted in viable births.

Following a motor vehicle crash, a 25 year old man presents complaining of a painful right eye. Visual acuity is 20/200 in the right eye and 20/25 in the left eye. The right eye protrudes from the orbit and the patient has right eye pain with extraocular movement. What is the most likely cause of his symptoms? A. ruptured globe B. retrobulbar hematoma C. chemosis D. hyphema E. orbital blow-out fracture

The answer is B. Traumatic proptosis with impaired extraocular movements is classic for retrobulbar hematoma. Sequelae include optic nerve ischemia and secondary visual impairment. A ruptured globe presents with enophthalmos, not proptosis, as vitreous humor leaks out of the eye. Neither hyphema nor chemosis causes proptosis. Orbital blowout fractures can cause inferior rectus muscle entrapment and secondary pain with impairment of extraocular movement. Yet, they do not present with proptosis - unless complicated by retrobulbar pathology.

A 32 year old man is struck several times in the head with a baseball bat. Upon emergency medical service arrival, he is mildly confused, vomits once, and complains of a severe headache. The emergency medical technicians establish two large-bore IVs. Prior to arrival at the emergency department, he loses consciousness and begins to seize. He is actively seizing when he is brought into the trauma bay. What should be the first step in the management of this patient? A. Administration of mannitol 50 g IV B. Emergency craniotomy C. Rapid sequence intubation using paralytic agent D. Administration of 2 liters NS bolus

The answer is C. The airway should be managed as the first priority in this patient. The other maneuvers may be helpful but are secondary to securing an airway and providing oxygenation/ventilation. Airway comes first!

The major abnormality on the image below is at which level? [image] A. C3/C4 B. C4/C5 C. C5/C6 D. C6/C7

The answer is C. The patient has anterior displacement of C5 on C6.

A patient presents to the ED after a fall with chest pain. A chest xray shows a rib fracture but no pneumothorax, and a chest CT is ordered. What is the most appropriate treatment for a small pneumothorax, detected only on chest CT, in a hemodynamically stable trauma patient? A. Chest tube placement B. Heliox by face mask C. Immediate needle decompression D. 100% oxygen

The answer is D. An occult pneumothorax may resorb with only oxygen administration, not requiring invasive management. Needle decompression is used for tension pneumothorax, and heliox may be used for reactive airway disease to reduce resistance to flow.

You are practicing in a trauma center a receive a call from an outlying facility that they would like to transfer a male patient to you with a spinal cord injury after significant flexion and compression of the vertebral body. What does this injury pattern tell you about the patient's symptoms? [image] Figure used with permission from Hamilton et al, Emergency Medicine: An approach to clinical problem-solving A. The patient likely has symptoms on only one side of the his body B. Patients with anterior cord syndromes have only sensory symptoms C. The patient likely disproportionately greater weakness in the lower extremities (as compared to the upper extremities) D. The patient likely has paralysis and loss of sensation to pain and temperature bilaterally below the lesion

The answer is D. Answer A describes central cord syndrome, typically caused by hyperextension. Answer C describes Brown-Sequard Syndrome, caused by hemisection of the cord. Answer B is anterior cord, often caused by flexion and injury to the anterior spinal artery; patient with this cord syndrome often have more than just sensory symptoms.

A patient falls onto his face, and has a CT scan of the face as shown in the Figure. Which indirect finding suggestive of possible facial fracture is present on the CT? [image] A. Nasal fracture B. Extra-sinus air C. Exopthalmos D. Fluid (blood) in the sinuses

The answer is D. Blood in the sinuses can be a useful indirect indicator of facial fracture.

Which of the following is an accurate statement? A. Bedside ultrasound can image the retroperitoneum. B. Bedside ultrasound is the test of choice for diagnosing solid organ injury. C. Diagnostic peritoneal lavage usually cannot identify the presence of hemoperitoneum. D. Diagnostic peritoneal lavage cannot determine the etiology of hemoperitoneum. E. Bedside ultrasound can reliably determine the etiology of hemoperitoneum.

The answer is D. Diagnostic peritoneal lavage is extremely sensitive for the detection of hemoperitoneum and can lead to many negative laparotomies. Neither bedside ultrasound nor diagnostic peritoneal lavage can identify the source of the hemorrhage though. A trauma ultrasound at the bedside can only identify fluid in the peritoneal cavity, and CT scan is the test of choice for diagnosing solid organ injury.

An 18 year old hockey player is hit in the mouth with a puck, fracturing a maxillary canine tooth. He brings the severed piece of tooth with him. On physical exam, the tooth is fractured halfway between the tip and the gumline. The root of the tooth is still firmly intact. The exposed fracture site has a yellowish tinge without blood. Of the following choices, which is the most appropriate management for this patient? A. Application of calcium hydroxide, placement of aluminum foil, and dental follow-up B. Placement of tooth fragment in saline gauze, outpatient dental follow-up C. No specific treatment required D. Immediate dental consult to avoid abscess formation E. Replace fractured piece and place acrylic splint

The answer is D. Ellis II dental fracture involves enamel and dentin. The fracture site typically has a yellowish tinge. Ellis III dental fractures are characterized by exposure of pinkish pulp and often blood. These fractures require immediate dental consultation to prevent abscess formation.

In which of these patients is emergency department thoracotomy indicated? A. Patient with stab wound to the anterior chest who is dyspneic with an oxygen saturation of 80% and a blood pressure of 168/102 B. All of the above should undergo emergency department thoracotomy. C. Unbelted driver in a high-speed motor vehicle crash who loses his pulse while being extricated, and arrives at the E.D. after a 45-minute transport D. Patient with a gunshot wound to the chest who upon arrival is unconscious and pulseless, with a systolic blood pressure of 60 E. Pedestrian struck with massive pelvic fractures who loses pulses and blood pressure at the scene

The answer is D. Emergency Department thoracotomy is a controversial procedure. When chosen carefully, successful resuscitation can occur. Cardiac arrest due to blunt trauma has a dismal success rate and is generally not considered an indication for ED thoracotomy. Thoracotomy for penetrating chest wounds has the best success rate. An awake patient with a relatively normal blood pressure does not need one performed in the Emergency Department. An unconscious and pulseless patient with a detectable blood pressure has the best chance for survival.

A 46 year old construction worker falls 6 feet off a ladder onto a concrete surface and has sudden and severe low back pain. The pain radiates down his right leg and he develops numbness over the anterior shin and dorsum of the foot. On physical exam he has decreased sensation to pinprick over the dorsum of the right foot (medially) and some weakness in right foot dorsiflexion. At which level is a protruding intervertebral disc most likely? A. L1-L2 B. L2-L3 C. L3-L4 D. L4-L5 E. L5-S1

The answer is D. Sensation of the dorsal aspect of the foot and dorsiflexion of the foot are functions of the L5 nerve root. Herniation of the L4-5 disc would result in compression of L5.

A young male patient presented to the emergency department with a history of single gunshot wound from unknown source and caliber. He was hemodynamically stable and had little pain in the right lower quadrant of the abdomen, which was the site of two wounds about 6 inches apart (see Figure). No other wounds were identified during physical examination. Which of the following statements regarding this case is true? [image] A. The superior-medial wound (at the top right of the Figure) is likely the entrance wound, and the inferior-lateral wound is likely the exit wound, of a single missile B. The two wounds are more likely than not the result of two separate missiles C. If it is suspected that the two wounds are from the same missile, the emergency department physician's documentation should note which wound is the entrance, and which is the exit D. Wound description is essential for the emergency medicine specialist. However, description of a wound as to entrance or exit is best left to forensic examination.

The answer is D. The overall evidence points to a superior-medial to inferior-lateral wound trajectory, with subcutaneous ecchymosis indicating the missile track and the more ragged wound at the inferior-lateral (groin) region most likely an exit wound. However, though wound description is very important for the emergency physician (both as a guide to injury evaluation and also as an early characterization of wounds, before interventions such as wound exploration obscure physical findings), speculation as to whether wounds are entrance or exit wounds are best left off of the E.D. record. Clinicians tend to oversimplify and/or misinterpret physical wound characteristics. Thus, the best course is a meticulous description (or photograph) of the wound, noting items such as tattooing (i.e. of gunpowder) or stellate tissue destruction (which can be due to expansion of gun barrel gases in a contact wound) but leaving interpretation of the physical evidence to forensics experts. The wound characteristics are not consistent with self-inflicted injury, though the ED physician should have a low index of suspicion for psychiatric consultation when there is doubt on this subject.

The patient depicted in the figure presents to the ED just after sustaining a pellet-gun wound to the right eye. What do the arrows most likely indicate? A. iritis B. keratitis C. pterygium D. hyphema E. hypopion

The answer is D. The patient has a fluid level/meniscus in the anterior chamber, that is most likely indicative of hyphema (collection of blood). Hypopion (collection of purulent material) is less likely in this setting, and keratitis (corneal inflammation) and iritis (inflammation of the iris) are not indicated by the arrows. A pterygium is a growth which is visible on the sclera, and which crosses the limbus onto the cornea.

In a patient with a suspected ruptured globe from penetrating trauma to the eye, all of the following should be performed EXCEPT: A. ophthalmology consultation B. visual acuity assessment C. administration of broad spectrum antibiotic therapy D. ascertainment of intraocular pressure via tonometry E. ascertainment of tetanus status

The answer is D. Tonometry should not be performed in patients with suspected ruptured globe, as application of the Tono-Pen pressure to the eye may cause the vitreous humor to exude from the eye, thereby complicating the injury. Tetanus status is important to check, as ocular injuries, like skin injuries, may be a portal for tetanus exposure. Broad-spectrum antibiotic therapy is indicated. Anti-emetic therapy may be helpful in preventing the elevations in intraocular pressure associated with vomiting. Visual acuity assessment is important and ophthalmology consultation is critical.

Which of the following cervical spine fractures is considered stable? A. Jefferson fracture of C1 B. Hangman's fracture of C2 C. Flexion teardrop fracture D. Bilateral facet dislocation E. Transverse process fracture

The answer is E. A transverse process fracture involves only one of the supporting spinal columns (the posterior column) and is therefore stable.

Which of the following patients should undergo abdominal trauma evaluation? A. 22 year old with stab wound to fourth intercostal space on right B. 30 year old with pelvic pain and tenderness after fall C. 25 year old restrained passenger in high-speed MVA; no abdominal complaints D. None of the above E. All of the above

The answer is E. The diaphragm can rise to as high a level as the fourth intercostal space and can be injured by stab wounds at this level. Unsuspected injuries are common in high speed motor vehicle crashes. Pelvic injuries are associated with intra-abdominal injuries and can distract a patient from such an injury. Therefore, all of these patients need an evaluation of their abdomens.

A patient presents with a self-inflicted wound, with resultant loss of vision in the right eye. With regard to the figure, which of the following statements is most likely true? [image] A. Medial canthotomy should be performed immediately. B. If ambulance providers contact medical control about a patient with this injury, they should be directed to replace the globe back into the orbit. C. Life-threatening hemorrhage is a major risk with this injury. D. The patient will probably recover visual function. E. Search for other self-inflicted injuries (or ingestions) is paramount.

The answer is E. The patient is unlikely to recover any visual function, which renders more important parallel efforts to identify (treatable) injuries or ingestions that are less obvious than the ocular avulsion. Lateral (not medial) canthotomy is an emergency procedure that may be indicated in some patients with ocular injury and retrobulbar hematoma (with resultant traction on the optic nerve), but the procedure is unlikely to help this patient. Since manipulation of an injured globe risks further trauma and extrusion of vitreous humor, prehospital recommendations for eye trauma are limited to protection of the injured eye and expedited transport to definitive care. Life-threatening hemorrhage is not a major risk with this type of injury

Which is the most common associated neurological finding with a distal radius fracture? A. Decreased sensation over the hypothenar eminance B. Weakness with flexion at the finger MCP joints C. Wrist drop D. Weakness of finger adduction E. Decreased sensation over the thenar eminance

The answer is E. This finding is due to median nerve injury.

The most sensitive bedside test for nerve injury in a finger after trauma is: A. light touch B. O'Riain wrinkle test C. pain D. temperature sensation E. two-point discrimination

The correct answer is E. Light touch is a good screening test, but two-point discrimination is more sensitive and should be used routinely in evaluating injuries to digits. The O'Riain wrinkle test involves placing the digit in warm water and looking for wrinkling of the digital pulps. Presence of wrinkling indicates the nerve is intact.

Which is not part of the Ottawa ankle rules? A. inability to walk 4 steps at the time of the injury B. inability to walk 4 steps in the emergency department C. tenderness over the lateral malleolus D. tenderness over the medial malleolus E. tenderness over the talus

The correct answer is E. The Ottawa ankle rules are a validated (for adults) set of physical exam findings to determine if an ankle X-ray is needed after an injury. If any of the first 4 answers is present or if there is tenderness over the navicular or base of the 5th metatarsal, an X-ray should be obtained. If the correct answer to all questions is no, then an X-ray is not needed.

Stable patients with AF for less than 48 hours can be cardioverted in the ED without anticoagulation provided they have no prior history of _____. Long-term anticoagulation is based on the CHADs/CHADS-VASc score and risk of bleeding.

Thromboembolism, mitral valve disease, or LV dysfunction

Hypothermia: EKG findings

To monitor for arryhthmias (eg. bradycardia, slow AF)--> *J-wave (Osborn wave)*

Burns: Tx (Prophylactic)

Topical ABx (eg. Silver Sulfadiazine)

Stable angina

Transient, episodic chest discomfort that is predictable and reproducible

Patients with AF have a _____ times higher risk of stroke than the general population. Risk mitigation for stroke begins in the ED with an assessment of CHADS/CHADS-VASc scores and possible initiation of anticoagulation.

Two to three

Non-absorbable sutures

Type: Monofilaments Subtypes: Ethilon (nylon,black) Prolene (polypropylene, blue, springy)

Absorbable

Types: Monofilaments Subtypes: Vicryl Dexon

suspected hyperemesis gravidum --> what tests should be done?

U/S to assess for adnexal masses and define the type of pregnancy

If the provider cannot distinguish between VT and SVT with aberrancy with certainty, the patient should be treated as if _____ is present.

VT

What Rx should you AVOID in *Hypovolemic* shock?

Vasopressors

Anticoagulation with either _____ reduces the risk of thromboembolism.

Warfarin (INR goal of 2-3) or NOAC

Febrile young child (2mos-3yrs) mgmt

Well appearing: urine dip, UCx Ill-appearing non-toxic: CBC, urine dip Toxic appearing: septic work-up, immediate abx

imaging for NSTI? best approach when NSTI is suspected?

XRAY surgical exploration --> dishwater pus

MC isolated organism in refrigereated blood products

Yersinia enterocolitica

what is the most effective form of birth control after rape?

a copper IUD

the presence of stool or air in the rectal vault suggests what? the presence of air and fluid levels in the small intestine with that ansence of stool and air through the colon indicate what?

a partial obstruction

should an abdominal would have local exploration? should a chest wound be explored locally?

abdomen - yes chest (lung) - no -- can cause pneumothorax

what type of pain is common in DKA?

abdominal pain

infants who have and abnormal _____ and temperature greater than 38.5 or are ill appearing have an increased risk of SBI

abnormal cry

what are three risk factors for syncope ? E, H, B

abnormal ekg HH < 30/9 BNP >300

repetivitive visitis falls and coop control of medical conditions in the elderly may be sugns of ?

abuse

core treatment for sepsis? (2)

abx + fluids/pressors

should tubo-ovarian abcesses be treated with I&D or abx?

abx -- ceftriaxone 250 IM + oral doxy for bid for 2 weeks

Urospesis tx

abx and fluid resuscitation, admission (River protocol for goal directed therapy)

patients taking this medication will have more severe anaphylactic reactions during transfusion because of their inability to degrade bradykinin?

ace inhibitors

14 months old comes in seizing with a fever - what is the treatment?

acetominapin and observation

pupillary block of the trabecular network

acute angle glaucoma

tx varicella?

acyclovir

admit or discharge patients with severe nausea, vomiting, fever, or signs of infection

admit

drowning resuscitation that remain symptomatic, or has been inconscious, hypoxic, apneic, or have an abnormal chest x-ray

admit

patient who have seizures and don't return to baeline should be d/c or admitted?

admitted

what age is testicular torsion is more common?

adolescents with rigorus physical activity

side fx of etomidate?

adrenal suppression

waxy casts=

advanced renal disease chronic renal failure

is hypertension greater in caucasians or african americans?

african americans

Asthma

airway hyperresponsiveness --> dead space ventilation. hypercapnea & respiratory acidosis, end-expiratory wheeze

medication for wheezing during anaphylaxis (not epinephrine) what medication will be condinued for days?

albuterol patient will take steroids for the rest of the week

how can you quickly excrete a TCA overdose (causing seizures)?

alkalyze the urine

history for the trauma patient: AMPLE

allergies medications past medical history last meal events leading up to accident

Wound lecture pitfalls

always remember ABC, look for assoc injuries, don't miss high pressure injuries, always assess for foreign body, abx v delayed primary closure for high risk wound and or co-morbid conditions

if diltiazem doesn't work to control rate in AFIB what drug can be used to control rhythm

amiodarone

a small pneumothorax visualized by CT and missed by CXR is referred to as what? should an occult pneumothorax be treated initially or rechecked in 4-6 hours?

an occult pneumothorax

eyelids should be repaired by who?

an oculoplastic surgeon

anaphylaxis reaction can not occur without prior sensititization _____________ reactions can occur without prior sensitization?

anaphylactoid reactions can occur without prior exposure

antidote for eloquiis? antidote for warfarin?

andexanet vit k FFP PCC

aplastic crisis occurs from a transient suppression of erytheropoeieis and it is charachterized by significant anemia accompanied by anemia and a low ________ count and is most

anemia and a lot reticulocyte count

angioedema/urticarial --> ____/___ --> bronchospasm of upper and lower airways

angioedema--> hypotension/bradycardia --> bronchospasms (anaphylaxis)

mad as a hatter (hallucinations) dry as a bone (anyhydrosis) red as a beet (incrased agitation and fever) blind as a bat (mydriasis)

anti-choligerics

anti-muscarinic vs sympathomimetic overdose?

anti-cholinergic --> dry skin sympathomimetic --> wet skin both hypertension

TX for diverticulitis

antibiotics 1st CT + contrast (if no response)

anticholinergic overdose treatment? cholinergic overdose treatment?

anticholinergic --> benzos and physostigmie cholinergic OD --> atropine and pralidoxime

anticholinergics cause this type of pupil (mydriasis/miosis) cholinergics cause this type of pupil (mydriasis/miosis) pinpoint pupils respiratory depression hypertension

anticholinergics cause this type of pupil (*mydriasis*/miosis) cholinergics cause this type of pupil (mydriasis/*miosis*) pinpoint pupils --> opiod overodse respiratory depression --> sedatives hypertension --> sympathomimetics

patient shows up the ER and has afib for >48 hours. what should be done? how long should coagulation continue?

anticoagulate and THEN cardiovert TEE, heparin --> enoxaparin OR Coumadin for a few weeks (either way INR needs to be 2-3 continue anticoagulation for amonth

treat pyelonephritis? supportive care?

antipyretics and urine culture IV hydration, analgesia, antipyretics, anti-biotics, admit

tx priapism?

aspiration of blood from the corpora cavernosa with dilute epinephrine and an early urologic consult

Pneumonia

aspiration or hematogenous spread to lungs of organsism that cause exudative inflamm response, fibrin deposition. Sx: pleuritic chest pain

treat an acute MI: 1 2 3

aspirin oxygen nitrate morphine

who is labetalol contraindicated in?

asthma, COPD, CHF, cocaine/meth

features of ethylene glycol poisoning

ataxia, hallucinations seizures "sweet breath"

as temperature declines bradycardia develops - how can you treat this? what rythems can develop? what waves will appear on an EKG? V4,V5

atropine atrial fib j-wave (osborn wave)

treatment for organophosphate poisoning

atropine pralidoxime

tx eikenlla?

augmentin 2 weeks

best method to avoid e. coli in an area of high occurance?

avoid food and water

what is bacteremia

bacteria in blood (MUST have + cultures)

purulent discharge and bilateral gluing of the eyelids in the morning?

bacterial conjuctivitis

gold standard for diagnosis of strep?

bacterial culture

fever, neck stiffness, and altered mental status --> next diagnostic test? Should antibiotics and steroids be started before this lumbar puncture if a delay is expected (ie ct scan) - which abx?

bacterial meningitis lumbar puncture yes -dexamethasone + rocephin + ampicillin (if you think listeria is present )

outpatient uti abx symptomatic relief for UTI inpatient pyelonephritis abx complicated pyelonephriis abx

bactrum , nitrofuritoin , cipro phenazopyridine (CI in G6PD deficiency) cipro 500, nitrofuritoin rocephin

paralysis except upward gaze (locked in syndrome) -- what artery occlusion?

basilar artery occlusion

what animals commonly carry rabies?

bats

why give bblocker, PTU, and ioddine for thyroid storm?

bblocker - blocks symptoms PTU stops the synthesis of T4 Iodine inhibits the release of stored T4

patient taking bblocker with angioedema give what med? patient taking ace inhibitors with angioedema give what medication ?

bblocker --> iv glucagon ace --> acatibant

what drug is controversial for the treatment for cocaine overdose due to the risk of unopposed alpha adrenergic effect leadin to increased hypertension and coronary vasoconstrition

bblockers

what drug should not be used at the time of pregnancy for hypothyroidism b/c it can cause neonatal bradycardia and hypoglycemia?

bblockers

how can you treat hyperthyroidism in pregnancy?

bblockers (contraindicated in patients with congestive heart failure and asthma)

no pulses present in the extremeties --> what can aid in determining if pulses are present?

bedside doppler

EKG before or after MONA? why

before --> PCI if STEMI

patients with testicular torsion may have this congenital deformity

bell clapper

a patient has a drooping mouth and can't wrinkle their forehead -->

bells palsy (upper and lower paralysis)

what should you do if a patient becomes emergently HTN or hyperthermic and is suspected cocaine/methamphetamine body packing?

benzodiazepines and surgical consult

tx anticholinergic overdose?

benzos

what medication is used to help with alcohol withdrawl? what medicaion can hel pwith tachycardia and hypertension?

benzos bblockers

tx cocaine OD? anxiety --> Depression -->

benzos for anxiety phentolamine for HTN

prevention of travelers diarrhea?

bismuth salycilate (not in an immunocompromised host)

Acute angle glaucoma can result in what permanent deformity?

blindness (dec blood flow to the optic nerve)

Anticholinergic toxidrome

block acetylcholine transmission Mad as a hatter, blind as a bat, red as a beet, hot as a hare, dry as a bone, full as a tick

what should be checked in all patients with ams at bedside?

blood glucose

what symptoms can result from being the victim of rape?

body aches, alterations of appetite and sleeping, a variety of emotional reactions

vomiting, lower CP, subcutaneous emphysema

boerhaaves syndrome

are patient with SCD at increased risk for ischemic or hemorragic stroke? what imaging should be done if this is suspected?

both - CT

persistent pain of the bowel is indicative of what?

bowel ischemia/necrosis

what is a sign of electrical burns that indicates the passage of electricity likely went through the heart

burn on both hands

what object requires emergent removal in an asymptomatic patient?

button battery

what vertebrae level controls the diaphragm? whats the best way to assess for this?

c3,4,5 blood gas (inc. co2)

b2 agonist bind pulmonary receptors, which increases the activity of this enzyme causing a drop in calcium and resulting in smooth muscle relaxation

cAMP

what life saving measure is used for patients with severe hyperkalemia?

calcium glucanate

_______ is effective for magnesium overdose?

calcium gluconate

mc type of renal stone

calcium oxolate

reverse the effects of potassium? shift potassium back into the cells?

calium albuterol, insulin, kayexalate

3 things to do if a patient presents to the ER with a ferrel animal bite?

call animal control give active/passive rabies vaccine admin tetatnus vaccine

CAP pneumonia (rust) HAP pneumonia (green) pneumonia in an alcoholic (kurrant jelly sputum ) tx???

cap - strep pneumonia - azithro HAP/HCAP - psuedomonas - vanco + pip/taz + klebsiella pneumonia

how do you differentiate NSTEMI from UA?

cardiac markers

Active internal rewarming

cardiopulmonary bypass, ECMO, warm pleural and peritoneal irrigation, arteriovenous rewarming, esophageal rewarming tubes, endovascular rewarming

cat bite infection human bite infection? shrapnel infection?

cat - pasturella human - eikenella shrapnel - C. perfringens

dogs caryy what diseas cat bites what disease human bites what disease

cats - pasturella dogs - staph humans - eikenella

saddle anesthesia and urinary retention

cauda equina syndrome

cause of epidiymitis ? systematic illness, pain out of proporthion, erythematous scrotum, crepitus later? transillumination of the scrotum? testicular tenderness with parotitis (mumps)? tx? most common malignancy in young men? what kind? painless swelling of the testicle "blue dot sign" ? tx?

cause of epidiymitis ? chlamydia/gonneria systematic illness, pain out of proporthion, erythematous scrotum, crepitus later? fourniere's gangreen transillumination of the scrotum? hydrocele testicular tenderness with parotitis (mumps)? tx? orchitis, scrotal support most common malignancy in young men? what kind? testicular cancer, seminoma painless swelling of the testicle - testicular cancer "blue dot sign" ? tx? appendageal torsion --> analgesia and scrotal support for 3 days

labs for sepsis c c b l u c e

cbc cmp 2 bc la UA /bhcg cxr ekg

abx for PID? (2)

ceftriaxone 250 IM + oral doxy for bid for 2 weeks

(-) romberg, but ataxic gait

cerebellum problem

mcc of morbidit in DKA?

cerebral edema (brain cells draw water in) -- more common in peds

cervical motion tenderness will be noted postitive by the _______ sign

chandalier sign

features unstable angina

chest pain at rest, minimal exertion normal troponins EKG may/not show changes

features of stable angina

chest pain worse w/exertion normal troponins EKG=normal at rest, ST depression on stress EKG

what is the most important study in a patient with suspected pnuemonia?

chest xr

mc electrical injury of children?

chewing on electrical cord

where is the most common place for a forigh body to lodge in a child or adult?

child: proximal esophagus at the cricopharyngeal narrowing adult: distal esophagus, (stricture malignancy achalasia)

what std increases the risk of ectopic pregenancy?

chlamydia

farm hand with choligeric symptoms

cholinergic od

what empiric antibiotics should be used for acute diarrhea?

ciprofloxacin

know this chart

classification of hemorrhage

tetanus vaccine or TIG ? clean minor wound? all other wounds?

clean minor wound --> tetanus vaccine all other wounds --> tetanus vaccine and TIG

localized bowel tenderness should raise the suspicion for ______ bowel obstruction

closed loop obstruction

Melenemesis

coffee ground emesis, partially digested blood

what is contra in diverticulitis

colonoscopy

most common type of large bowel obstuction (specific cancer) what is the most common site for this?

colorectal carcinoma splenic flexture

tensions pneumothorax should be treated how in the field vs emergency?

community - needle decompression ER - tube thoracostomy

anterior, posterior, or central cord injury? complete motor paralysis greater upper extremity weakness compared to lower loss of vibratory sense and proprioception

complete - anterior central -- upper weaker than lower *p*osterior -- loss of vi*b*ratory sensation and *p*ropriotception

Coma

complete failure of the arousal system with no sponatenous eye opening

absence of bowel sounds and flatus are assocaited with this type of obstruction?

complete obstruction

what is curb65 and how does it related to inpatient/outpatient care?

confusion uremia rr > 30 BP<90 >65 0-1 = outpatient 2 - careful outpatient/inpatient 3-5 inpatient

constant kidney pain is a stone located in the _____ colicky kidney pain is a stone located in the _____ pain is typically not caused by a stone in the renal ___ or ____

constant - stone in the kidney colicky pain is a stone in the ureter no pain - renal pelvis or bladder

tracheal deviation will the ________ to the tension penumothorax

contralateral tension pneumothorax --> needle decompression

DX & TX for orbital cellulitis

contrast CT orbits IV antibiotics

_____ and ___ skin indicates that a child is in hemorragic shock until proven otherwise

cool and mottled skin in a child is a sign of hemorrhage

treat sympathomimetic overdose --> not a medication

cool them !

tx heat stroke? cool the patient to ____ (temp). how? what can shivering be controlled with?

cool to 104 - remove all clothing and cool with mist benzo control shivering

what can you give to septic shock patients who are unresponsive to fluids/pressors?

coriticosteroids

hazy / cloudy stroma

corneal ulcer

gold standard for MI diagnosis?

coronary markers

gold standard to abcess evaluation?

ct

if you suspect esophageal rupture what test should be ordered?

ct

eval a possible cervical spine fracture? (2)

ct or 3 view of the spine

imaging for suspected bowel obstruction

ct scan

what type of ulcer are a late sequelae of lightening strike?

curling ulcers

what should be done after the primary survey (ABCDE) in a stab wound patient? (3 x,l,f)

cxr,, -- hemothorax, pneumothorax labs -- fast -- pericardial and intraperintoneal free fluid

treatment for serotonin syndrome

cyproheptadine

what is usually the first manifestation of vaso-occlusive events in sickle cells patients ?

dactylitis - infant beomces irritable and reuses to walk , or cry when touched or held

treatment for malignant hyperthermia

dantrolene dopamine agonists (bromocriptine)

name the best method for clearing the toxin: dapsone, carbamazepine, phenobartital, quinine, theopphylline lithium, methanol, aspirin phenobarbitol and theophylline asipirin and phenobartbial

dapsone, carbamazepine, phenobartital, quinine, theopphylline --> activated charcoal lithium, methanol, aspirin --> hemodialysis phenobarbitol and theophylline --> charcoal hemoperfusion asipirin and phenobartbial --> urinary alkinazation

most common two types of rape?

date rape and acquaintance rape

alcohol with fluctuating levels of consciousness, cognitive disturbances, profound confusion, and severe sutonomic hyper activity

delirium tremens

Isoniazide increases seizure risk as a result of depleted ____ how do yu treat this?

depleted B6 IV pyridoxine

giving what medication with the first dose of antibiotics has been shown to decrease neurologic sequelae as well as mortality in patients with bacterial meingitis ?

dexamethasone

what are some red flags for NSTI?

diabetic foot uclers and infections of the perineum (leads to fourneirs ganggreen)

hyperglycemia, anion gap acidosis, and ketosis

diabetic ketoacidosis (na - (cl + co2)

what is the ultimate treatment for all ckd patients who have severe hyperkalemia

dialysis

will a patient with a large bowel obstruction typically be constipated of have diarrhea?

diarrhea

drug to convert afib?

diltiazem (CCB - slows av node conduction by blocking calcium channels)

treatment for mercury toxicity

dimercaprol

what is the mc fracture assocaited with a ground level fall with an outstretched hand?

distal radius fracture

physiologic response to submersion to reduce the utilization of oxygen including bradycardia and peripheral vasoconstriction

diving reflex

aphasia is seen with paralysis of which area

dominant hemisphere - brocas

aside from insertion of a copper IUD what medications can be given to prevent concraception ?

double dose of OCP bid x 1 day Progestin 1 dose 1.5 g progestin 2 doses .75 gram Ilipristal acetate 30mg

severe larygospams casuing hypoxia and loss of consciousness

dry drowning

right vs left sided heart failure: dyspnea peripheral edema

dyspnea - left sided peripheral edema - right sided

gram negative rod causing utis

e coli

what areas of the body should not be given lidocaine with epinephrine?

ears, nose, penis, and toes

sick patient coming back from a trip from liberia?

ebola

sick patient coming back from africa?

ebola

imaging to evaluate a pericardial effusion?

echo

26 yo with a abdominal pain, a bhcg of 4700 and a transvaginal ultrasound showing an empty uterus next?

ectopic pregency

what two population are at greater risk for hypothermia - why?

eldery and intoxicated - decreased glycogen stores and altered body response

Fever Unknown Origin (FUO)

elevated temperature but despite investigations by a physician no explanation has been found

mcc of ruptured esophagus?

endoscopy

how to treat anaphylaxis during transfusion

epinephrine, antihistamines, bronchodilators, and corticosteroids

nonpurulent cellulitis restrcicted to the superficial skin layers with a sharply demarceted border what is this called -- what bug causes it?

erysipelas strep pyogens

name an induction agent for RSI name a paralytic for RSI?

etomidate - induction (ketamine, propofol) rocuronium - paralytic (succ choline, vecuronium)

how often should you screen for sexual assault?

every visit

Hyperpyrexia

extreme elevation of body temp ≥ 41.5°C due to high set point

3 parts of GCS

eye response (4) verbal response (5) motor response (6)

features of NSTEMI

features of unstable angina *elevated troponins

patient with a blood transfusion presents with a fever chills and headache without hemodynamic instability

febrile non hemolytic transfusion reaction

________ in a first time transfusion reaction should be treated as an acute hemolytic reaction until proven otherwise

fever

what should the physical exam focus on in patients with suspected tylenol overdose?

fever, RUQ tenderness, and mental status

a clinicians concern for sickle cell crisis should be hieghtened by what?

fever, severe abdominal pain, respiratory or nuerologic sympotoms, joint swelling, priapism, or pain that is not releieved by usualy measures

the presence of what symptoms related to small bowel obstruction should be managed by referral to a surgeon ?

fever, tachycardia, abdominal tenderness, leukocytosis

when to admit a patient with an abcess?

fever/lymphangitis/

Certified First responders

first on scene firefighter, police etc. 45hrs of training. CPR, AED, splint and bleeding control.

when does hyperemesis gradvidarum usually occur?

first trimester

what are the hallmarks of acute angle glaucoma?

fixed, dilated, mid position pupil, with corneal edema (clouding). elevated IOP (normal high is 20)

macule patch papule plaque vessicle bullae nodule pustule petechia pupura wheal

flat flat > 10 mm solid raised solid raised > 5 mm fluid filled fluid filled > 5 mm purulent filling non blanching non blacking > 3 mm edematous transient plaque

mainstay of treatment for acute diarrhea?

fluid and electrolyte replacement

absence of tissue damage upon rewarming? second/third degree skin burns upon rewarming?

frost nip - no permanent damage frost bite - 2/3 degree damage

Cold related illnesses

frostnip pernio-chillblains Kibe (chilblains on heel) Trench foot Surfer's ear Frostbite

superfiscial skin abscess?

furuncles

immunocompromised patients should receive blood that has been 'cleaned' with this procedure?

gamma iradiation

suspected esophageal rupture --> gastrograffin or barium?

gastrograffin

what to do if a patient is bleeding from a snake bite?

give antivenom and blood products

__________ is effective as a CCB overdose?

glucagon

treatment for beta blocker overdose

glucagon, atropine

in any person presenting with asymmetric poly arthritis, tenosynovitis, and pustular skin lesions, this infection should be considered in the differential diagnosis

gonorrhea

1-2 weeks following transfusion symptoms of fever, maculopapular rash, pancytopenia leading to sepsis

graft vs host disease

donor lymphocytes engraft the proliferate in the recipients bone marrow

graft vs host disease

bacterial meningitis: gram positive diplococci --> gram negatice diplocicci --> gram negative coccobacilli --> gram postive rods -->

gram positive diplococci --> strep pneumo gram negatice diplocicci --> neisseria meningiditis gram negative coccobacilli --> heamophulious infleunza gram postive rods --> listeria

a patient with a lactate greater than __ is in sepsis

greater than 4

a mediastinal crunch heard with each heart beat due to the surrounding air

hamman sign - esophageal perf

profuse sweating, thirst, nausea, vomiting, confusion, and headache 100-104 flushed, hot, dry, skin, >40 or 104

heat exhaustion (may have collapsed) Heat stroke (unconsious)

Active external rewarming

heating pads, radiant heat lamps, warm baths

what is the most reliable sign of kidney injury? what test should be done if a patient has hematuria?

hematuria CT scan

hypertension is more common in this type of stroke

hemorrhage

mc cause of death in trauma patients after TBI?

hemorrhagic shock

dark brown urine vs bright red urine?

high stone in the kidney (upper) vs low stone in the ureter

how to assess the severity of asthma disease?

history and physical and peak expiratory flow

what 'lie' will a torsed testicle usually have? tx? what do you need to do before treatment? will surgery need to be done eventually?

horizaontal medial to lateral rotation = significant pain relief if correct (IV pain meds first) --> eventual surgerical fixation

voilentcontraction of respiraty , diaphramgatic, laryngeal, and pharyngeal muscle initiated by consumption of water?

hydrophobia

crush injuries and burns result in an increase in this ion ?

hyperkalemia

side effects of ace inhibitors and spironolactone?

hyperkalemia

side fx of succinyl choline? Hyper (ion) emia)

hyperkalemia

what is complication of advanced CKD? (ion)

hyperkalemia

mortality in sympathomimetic overdose is usually from _______

hyperthermia

serotonin syndrome features

hyperthermia muscle rigidity flushing, diarrhea, seizures

what are some manifestations of alcohol withdrawl? (autonomic symptoms)

hyperthermia, htn, , tachycardia, hyperreflexia

what nerve supplies the tounge

hypoglossal nerve

white cells visible along the lower rim of the anterior chamber

hypopyon

what does HAT stand for (sepsis)

hypotension SBP <100 AMS (GCS <15) Tachypnea >22

hypoglycemia, sepsis, and hypothyroidism are conditions that may coincide with ______

hypothermia

5 H's

hypovolemia hypoxia H+ (acidosis) hypo/hyperkalemia hypothermia

ATN causes

hypovolemia sepsis rhabdo aminoglycosides amphotericin B

for any intentional overdose - levels of what 2 OTCs should be measured?

ibu and acetaminophen

DPL objective

id of abnormal presence of blood, intestinal contents - old school

when should a blood transfusion or exchange be initiated in SCD patients?

if PaO2 <70, or low crit

TIG

if not full immunized and current (within last 10 years)

in all cases of meningitis: opening pressure will be elevated, CSF will be cloudy, cell counts will be increased, and protein will be elevated: if the glucose level is normal --> what is the org? if india ink stain is positive --> what is the org? if acid fast stain is positive --> what is the org? if CSF lactate is elevated --> what is the org?

if the glucose level is normal --> viral if india ink stain is positive --> fungal if acid fast stain is positive --> tiburculosis if CSF lactate is elevated --> bacterial

name three veins which commonly get DVTs?

iliac, femoral, popliteal

what is the most likely cause of death after a lightening strike?

immediate cardiac arrest

what are some red flags for potentially serious or life threatening causes of rash?

immunocompromised, fever, toxic apparance, hypotension, petechia or purpura, diffuse erythema, severe pain, mucosal lesions

uterine cramping, vaginal bleeding, passage of tissue, and an open cervix in a pregnant tissue

incomplete abortion

Minimally conscious state

inconsistent but discernable evidence of consciousness. Altered state. Able to follow commands/purposeful behaviors/simple commands

individual with excess sun exposure have more absorption of ______ becaues of increased production of vitamin D

increased calcium absorption

cramping leading to cervical dilation painless cervical dilation?

inevitable abortion cervical insufficiency

CP with fever and hypoxia --> ?

infection

features of pre-orbital cellulitis

infection of anterior eyelid NO proptosis, vision changes, eye pain

long term effect of PID include?

infertility, risk of ectopic, fitz-hugh-curtic syndrome

what is the initial treatment for hyperkalemia? (how much)

inhaled albuterol 20 mg

what are indications for a tube thoracotomy after tube thoracostomy?

initial output > 1000 or 200 ml/hr for the first 4 hours

Aortic Dissection

intimal tear with entry of blood into the media "dissects" between the intima and adventitia.

this type of violence is common in relationship and should be screened for at every visit?

intimate partner violence

when PCO2 is greater than 40 in a pregnant woman with asthma what should you consider?

intubation

what is the cushing triad

irregular breathing widening pulse pressure brady

if a wound does not penetrate the abdominal fascia how should it be treated?

irrigation and closure

why give sickle cell patient (not crisis!) patients hydroxyurea?

it increases fetal hemoglobin --> decreases the risk of SCC occuring however it can cause immunosuppresion and the patient needs to be monitored

tx hyperemesis in a pregnant women?

iv fluids (NS)

how far should you advance an ET tube?

just beyond the thyroid cartilage (watch it pass through the cords! and listen for breath sounds)

children may have excessive bleeding from the _____ artery as a result of perioral burns?

labial artery

pure motor or sensory deficit

lacunar infarct

gold standard for diagnosing PID?

laparoscopy

how to eval possible diaphragm injury?

laparoscopy

gold standard for ectopic pregnancy what method of abortion is used for a hemodynamically unstable patient

laparoscopy surgery

if vital signs worsen in a child thought to be having a hemorrhage what should be done?

lapartomy

Regional block (amides: lidoaine, bupivicaine)

large areas: when needed to avoid tissue distortion. Areas where infiltration is painful (ex: digital block, plantar surface)

Croup

laryngotracheobronchitis always caused by a virus (paraflu) in pharyngeal epithelium that spread to larynx and produce mucus and edema. Sx: Seal-barking cough, steeple sign on xcr

a left MI will present as volume loading in the ___ a right MI will present as volume loading in the ___

left - lungs right - body

avascular necrosis of the femoral head leading to a childhood limp that is painful

legg calve perth disease

Kraissel's lines

lines of minimal tension. Important for wound contractures

what type of meningitidis is suspected in an older alcoholic or immunocompromised patient?

listeria

suspected cases of any emerging infectious disease should be reported to who?

local health department (will report to the CDC)

how to eval an abdominal would in a stable patient? what is anterior fascia is penetrated?

local wound explroation contact a surgeon

most common presentation of tetanus is what?

lock jaw

Tip of the basilar stroke sx

locked in syndrome

PE risks

long trips, pregnancy/OCP, cancer risks, virchow's triad (venous stasis, hypercoagability, endothelial damage) -- #1 risk factor= prior DVT/PE

Buckle (torus) fx

longitudinal force on kid bones. easier to see on lateral.

classic triad of symptoms for diagnosing PID include (3)

lower abdominal tenderness adnexal tenderness cervical motion tenderness

Anterior infarct sx

lower extremity weakness> upper

suprapubic pain, dysuria, foul smelling urine hematuria, urinary frequency and urgency ill appearing and abnormal vitas signs w/ systemic symptoms (f/n/v)

lower urinary tract upper urinary tract

submaxillary mass with elevation of the tounge and trismus?

ludwigs angina

erythema migrans

lyme burelia burgdorfia doxy

what medication should be given to patient with SCD and acute chest syndrome?

macrolide and rocephin

mc cause CHF? mc cause CHF exacerbation

mc cause CHF - CAD/HTN mc cause chf exacerbation - mi/noncomplaince

mc kidney stone kidney stone occuring with low pH kidney stone occuring from proteus, pseudo, and klebsiella (urease producing)

mc kidney stone - calcium kidney stone occuring with low pH - uric acid kidney stone occuring from proteus, pseudo, and klebsiella (urease producing) - magnesium

what part of the brain controls breathing?

medulla

are kidney stones more common in men or women?

men

petechial rash, nuchal rigidity, failure to fully engage or return to baseline level

meningitis

metabolic symptoms of salicylate toxicity

met acidosis + resp alkalosis

what labs develop from hypothermia?

metabolic acidosis - liver circulation declines and lactic acid increases increased hemocrit - from hemo concentration declined reflexes

what folinic acid antagonist can be used to abort an ectopic pregnancy?

methrotrexate

diarrhea type: mexico - backpackers - (2 - g,c) undercooked chicken (s,s) undercooked hamburger meat - raw seafood - 6 hours of eating a mayo salad - 12 hours after eating food - day care settings?

mexico - e.coli backpackers - (2 - g,c) - giardia, campylobacter undercooked chicken (s,s) salmonella, shigella undercooked hamburger meat - e.coli 0157 raw seafood - vibrio cholera 6 hours of eating a mayo salad - staph aursu 12 hours after eating food - e.coli day care - rotovirus

what is the cardiac box? what should be done immediately if there is an stab wound in the cardiac box?

mid clavicular from the clavicles to the epigastric region FAST scan (100 accurate)

when is it most likely that PID infection will move from the vagina to the uterus?

mid cycle with estrogen is low and the cervical mucus in this -- for this reasons progesterone BC prevent PID mensus is also a possible time for Uterine infection due to loss of the cervical plug

EMS length of training

minimums set by the DOT, but overseen by the states

Opioid drugs

morphine derivatives (hydrocodone, methadone, meperidine, propoxyphene, fentanyl) tx: narcan/naloxone

what is the most dangerous intentional form of child abuse? what is the most common type of child abuse? what is the most common cause of death in elderly patients?

most dangerous -- head most common -- skin and soft tissues most morbid in elderly s/p injury -- MI

___ casts=ATN

muddy brown/granular

what are signs of abuse in the elderly?

multiple falls frequent ER visits weight loss unkempt appearance missing assistive devices feelings of worthlessness

waxing and waning symptoms

multiple sclerosis

drug for tylenol overdose? what else can you give?

n-acetylcysteine activated charcoal

antidote for opiod overdose?

nalaxone

narrow QRS - ____ the ventricles wide QRS - ___ the ventricels

narrow - above the ventricles wide - VTACH

EKG appearance of SVT

narrow QRS no p-waves (buried in QRS)

what are the two most common causes of bacterial meningitis?

neisseria menigiditis strep pneumonia

RBC casts=

nephritic

what vessels are the preffered route for electrical transfer in the human body? n,v,m what structures are less conductive? b,t,f,s

nerves, vessels, muscle bones, tendons, skin, and fat

what infection can result from undercooked pork in latin american countries? calcified cysts in the brain? treatment?

neurocysticercosis (taenia solium) albendazole + lorazepam (for seizures)

what is the best antihypertensive for hypertensive encephalopathy? (crosses the blood brain barrier)

nicardipine

do buccal lacerations <2cm need to be repaired?

no

in gun shot wounds, is it safe to consider that the bullet has taken a straight path?

no

will cardiac markers be elevated in Unstable anglina?

no

will h/h fall immediately in a hemorrhagic patient?

no

can a gi cocktail be used to rule out a cardiac related chest pain? can nitro differentiate between CP and GERD can an EKG rule out cardiac pain

no no no

does afib less than 48 hours require anticoagulation?

no (if patients present in the ER with AF <48 hours --> cardiovert and discharge home)

can an you use an OPA in a conscious patient or with an unconscious patient with a gag reflex?

no - must be unconscious without a gag reflex

can you give actiavated charcoal to patients who are unconscious or cannot protect their airway?

no - risk of aspiration

is emergent removal of body packers suggested?

no - the objects could rupture

patient who can't kind a comfortable postion with flank pain patient with abdominal pain who feels better when supine w/ flexed knees

no comfortable position - kidneys supine w/ flex knees - acute abdomen

mcc of seizure?

non-compliance

variant angina features

non-exertional chest pain transient ST elevations normal troponins

biggest reason for HTN emergency?

noncompliance

treat pericarditis

nsaids

what pain medication should be avoided in patients with renal insufficiency, older patients, and diabetes

nsaids

Critical Life threatening AMS not to miss

o Hypoxia/diffuse cerebral ischemia (CHF, MI, shock) o Systemic process: hypoglycemia o CNS infx o HTN encephalopathy o Elevated ICP

Atypical MI symptoms

old people feel weak inferior wall MI; only with N/V - not chest pain

how should you position a patient who is seizuring? what shuld you do? what should you give? what should you give if the first med doesn't work after two rounds?

one their side suction lorazepam x2 --> phenytoin

respiratory depression and miosis

opiod overdose

mild cases of alcohol withdrawl are treated with ? severe cases of alcohol withdrawl are treated with ?

oral benzos iv benzos and hydration

Cholinergic drugs

organophosphates/carbamate pesticides, carbamate medicinals (donepezil, physotigmine, pyridostigmine), nerve gas agents

tiny fractures of the apophysis of the tibial tubercle rapid growth spurt and repetitive stress (running, jumping, and jogging worsen symptoms) TX/

osgood schlaughter RICE + NSAIDS

intermittent crampy abdominal pain in a female lasting for longer than 24 hours without fever?

ovarian torsion

AAA RF

over 50yo, atherosclerosis, peripheral vascular disease (PVD), first degree relative with AAA

treat CHF exacerbation? (3) O,A,L treat CHF w/ hypotension?

oxygen (NIPPV), ace/nitro, lasix add dobutamine/milrinone and a small fluid bolus

general treatment for sickle cell crisis?

pain management, oxygen (if hypoxic), hydration

subconjunctival hemorrhages should be _______ and not affect ____

painless and not affect vision

sign and symptoms of vascular/neuro injury? 6 ps

painless pallor, poikilothermia, pulseless, parsthesia, paralysis

injury to the buccal branch of CN7 are associated with decrased activity by what gland?

parotid

transient red cell aplasia (a transient cessation of erthropoiesis result in the acute onset of anemia and reticulocytopenia) is most commonly the result what virus?

parvo b19

what is the biggest indicator for chest pain ?

patient age

tx uti in pregnant women

penecillin and cephalosporin

Subxiphoid space

pericardial space

pain associated with this entity is worse when supine and impreoves with erect posture and sitting up -- auscultation of the heart may reveal a rough scratch y sound known as a pericardial friction rub

pericarditis

swilling in the peritonisllar region with uvula deviation , fever, sorethroat, and trismus

peritonsillar abscess

red, scaly, lesions, often on the face, hands or feet

pernio (chilblains)

ways to prevent zika virus?

perthrin treated long sleeve clothing

Shock

physiologic state characterized by inadequate oxygen delivery. Delivery isn't keeping up with demand

treatment for anticholinergic overdose

physostigmine

this type of sepsis is a common cause of death in children with SCD?

pneumococcal sepsis

who should you contact for addition help with an overdose patient comes in the ER?

poison control

confirmation of ROM? (3)

pooling of amneotic fluid in the posterior fornix nitrazine strip with a pH >7 (vaginal pH is usually 4.5-6) amniotic fluid ferning on microscopy

all patients with a dvt at or above the level of the ______ vein should be treated with anticoagulation

popliteal vein

lack of visual recognition is seen with stroke to what artery?

posterior cerebral

treatment for WPW

procainamide

most patients will have acute diarrhea will be self limited, but patients with what symptoms will need abx?

profuse diarrhea, dehydration, fever > 101, bloody diarrhea, >65, severe abdominal pain, >48 hours of diarrhea, immunocompromised

initially shock is compensated, then in the __________ phase arterial pressure falls, causing the blood to sludge. Finally in the irreversible stage of shock all efforts to resuscitate the patient are futile

progressive

what arrythmia can develop in patients who are immursed in cold water

prolonged QT

(+) romberg tests ___

proprioception

tx bells palsy

protect the eye at night (eye pathc) a course of steroids artificial tears

most common site of infect of a joint in a child?

proximal femur

seizures with the loss of continence that are not followed by a posticle period management

pseudoseizure nothing

bat wing sing on xray

pulm edema

dysuria, flank pain, fever, nasua

pyelonephritis

fever, pyuria, and cva tenderness usually indicate ___________ and is caused by _____

pyelonephritis and obstruction

at what point in the intestinal tract will an object pass?

pyloris

The _____ has been developed to rapidly identify patients at increased risk for death secondary to sepsis.

qSOFA score

the HbS gene is autosomal _____

recessive or dominant

first priority of treating patients with acute diarrhea?

rehydration

aside from cyanide toxicity, what side effect is associated with relfex sodium nitroprusside?

relfex tackycardia

tx patient with SJS/TENs?

remove offending allergen and hydration

features of mercury toxicity

renal insuff tremor mental status changes red cheeks/lips muscle weakness

succynil choline is contraindicated in patients with what other co-morbidity (paralytics, hyperkalemia)

renal patients

musculoskeletal chest pain will be _____

reproducible on movement or palpation

what is the hallmark of transfusion related acute lung injury?

respiratory distress with the presence of diffuse bilateral alveolar and interstitial infiltrates on radiographic imaging

how does N-acetylcysteine work?

restores glutathione stores

Hyperthermia

results from uncontrolled temperature regulation (e.g. heat stroke), body temp rises above set point

what will be seen on eye exam for baby with shaken baby syndrome?

retinal hemorrhages

fever, sore throat, stiff neck in a child?

retropharyngeal abcess

Suprapubic space

retrovesicular (P of Douglas)

how do you remove foreign body from peds

rigid bronchoscopy

ill appearing infants less than 3 months old should be admitted to the hospital and receive this antibiotic regaurdless of lab work

rocephin

begins on wrists forearms and ankes and forearms then spreads

rocky mountain spotted fever.

sudden onset of rash after resolution of a high fever

roseola (human herpes virus 6)

pink maculopapular rash on face spreading to the turnk ?

rubella

cough coryza conjuctivitis koplik spots (bluish white papules of a red base of buccal mucosa)

rubeola

nomogram used to find if tylernol ingestion is

rumack matthew nomogram

a complaint of a "gush" of fluid or a persistent leakage of fluid

rupture of membranes

patients with a ruptured TOA present in _____ - this is a surgical emergency

ruptured toa present in shock

throbbing HA s/p lumbar puncture as a result of bending over

s/p lumbar puncture

septal trauma may lead to hematoma formation which can lead to necrosis of the septum causeing this deformity?

saddle nose deformity

Contaminated wounds

saliva, stool, dirt, wood or other organic matter. No visual debris

what does SLUDGE stand for

salivation lacrimation urination defication GI upset Emesis

what are the salter harris classifications?

salter harris

erythematous "sandpaper" rash with increased redness in the folds, strawberry tounge, and confluent petechia in lines (pastia lines)

scarlet fever

in gerenal bites older than ___ hours old are closed by primary or secondary intention?

secondary

synchronus firing of neurons

seizure

does zika stay in semen or blood longer?

semen

red-pink maculopapular rash that begins on trunk and speads to palsm and soles appears 2-3 months after initial chancre

sencodary syphillis

what is severe sepsis

sepsis + end-organ dysfunction (AMS, hypo, inc creatinine, DIC)

what is septic shock

sepsis + hypotension that persists after fluids

abx for : sepsis unclear: 3 sepsis pulmonary: 2 sepsis urinary: 2 line associated: 1

sepsis unclear: pip/tazo + vanco + amikacin sepsis pulmonary: pip/tazo + levofloxacin sepsis urinary: levofloxacin + amikacin line associated: vancomycin

child comes in with a painful limp and no injury --> aspirate and culture --> >50,000 cells/L >90% PMN ?

septic arthritis

EMS scope of practice

set by each state

SALTER-Harris

severity scale based on epiphysis fx S=straight across A=above epiphysis L=low or beLow epiphysis T=Two or Through ER=erasure of growth plate or crush

initial treatment for an asthma attach in a pregnant women?

short acting b2 (followed acting by inhalfed corticosteroids) --> PEFR <80 or a decrease in fetal activity warrent medical treatment

valine substituted for glutatimine at the 6th aminoacid position of the beta chain

sickle cell anemia

atrial rate 100-160 with normal rhythm atrial rate 250 - 350 (saw tooth) dissociated p wave, 100-250 beats per minute

sinus tachy atrial tachy ventricle tachy

painless limp in a child going through a growth spurt

slipped capitelo femoral epiphysis

mc cause of small bowel obstruction mc cause of large bowel obstruction?

small - adhesion large - cancer

Frostbite risk factors

smoking, prolonged hand/arm vibration, chronic dz affecting vasculature

what medication can help narrow a widened QRS complex in overdose?

sodium bicarbonate

Greenstick fx

soft bones in which the bone bends and only partially breaks.

the most common airway obstruction is what?

soft palate/tounge --> chin lift jaw thrust after making sure the airway is clear

sharp, constant, and generally localizing fo one of four quadrant dull, cramping, deep or achin

somatic pain visceral pain

what drug can help facilitate the movement of activated charcoal through the intestine?

sorbitol - give 1x with first dose

rapidly enlarging spleen, a sudden drop in hemoglobin, and potential for shock

splenick sequestration

Dementia

stable course of confusion, slow onset, irreversible, progressive, no impairment of consciousness, alert, normal vitals

mc bug of cellulitis?

staph

mc spinal cord infection?

staph

most common organism for a septic joint

staph

imaging if you suspect cauda equina syndrome?

stat MRI

EMS certification

states with local credentialing

continuous seizure lasting longer than 5 minutes or two or more sequential seizure without a return to baseline

status epilepticus

stones <___cm will usually pass urgent urological consult is needed for stones greater than __ cm., inadequate oral pain control, solitary kidney, complete obstruction

stones < 6 will pass >8 cm urgent urological consult

what to do if you get an acute hemolytic reaction during transfusion? what diagnostic test should be run?

stop transfusion and change to NS to maintain UOP of > 1 mL/Kg/hr run a coombs test (direct antiglobulin test)

age less than 15 fever ansense of cough tonsillar exudate

strep

after the HIB vaccine, most infections in infants 1-3 years old were from?

strep pneumo

bacteria causing specific signs in bacterial meningitis? strep pneumo --> listeria --> neisseria -->

strep pneumo --> seizures listeria --> focal neurological deficits neisseria --> palpable purpura

3 mcc for AOM? DOC for children <2? tx for children >2?

strep pneumo, heamophleuos infl, m. cat Amoxicillin watchful waiting

a patient has a drooping mouth but can wrinkle their forehead -->

stroke

Response to a trial of _____ does not distinguish between coronary artery disease and GERD induced esophageal spasm.

sublingual nitroglycerin

Avulsion fx

sudden traction forces by muscles results in avulsion of apophysis (twisted ankle or ligaments/muscles attached)

what meds can cause SJS?

sulfa, phenytoin, carbamazepine

tx SERS, MERS, Ebole, Zika, ?

supportive (fluids/antipyretics/possible intubation

tx dactylitis?

supportive care, warm compress

an immediate consult for esophageal rupture? who?

surgery

definitive treatment for testicular torsion

surgery

tx ludwigs angina?

surgical I&D

tx peritonsillar abscess

surgical I&D

tx retropharyngeal abscess?

surgical incisision and drainage

although lactate and base deficit are poor indicators of shock, their normalization at 24 hours after resuscitation is a good prognostic indicator of ______.

survivial

when do you do imaging for pyelonepritis?

suspected blockage

bedside glucose and cy scan or the head are the most urgent diagnostiic studies in a suspected ______

suspected stroke

mydriasis, hallucinations / serizures, and diaphoretic skin

sympathomimetics (coke, ecstacy and meth)

synchronized or unsynchronized cardioversion for AFIB?

synchronized

unstable patients with arrhythmia (hypotensions, pulmonary edema, ams, ischemic chest pain) -->

synchronized cardioversion

do hypokalemia, hypocalcemia, and hypomagnesemia cause tachy or brady rythems ?

tachy (as does meth, hyperthyroidism, and cocaine )

Sympathomimetic toxidrome

tachycardia, elevated bp, dilated pupils, hyperactive bowels, diaphoresis

Spontaneous pneumothorax risk factors

tall, young, thin, smoker

target sign - swirl sign -

target sign - intusseption swirl sign - volvulus

SIRS criteria

temp >38C <36 WBC >12 <4 HR>90 RR>20

Fever without source

temp >39, normal physical exam (well appearing, no obvious bacterial illness, petechiae -- occult)

5 T's

tension pneumo tamponade toxins/tablets thrombosis (PE) thrombosis (MI)

any patient with a injury from a metal object should be asked if they have had this vaccination in the past 5 years?

tetanus

devitalized, crushed, or infected tissue should be treated with this immunization if the patient has not had one in the past 5 years?

tetatnus

if a fallopean tube ruptures where will a patient bleed into?

the abdomen

what specific region of the fallopian tubes does the ectopic pregnancy most likely occur in?

the ampulla

what reflex will be absent if testicular torsion is the cause of pain

the cremasteric reflex will be absent

what is the vermillion border?

the junction of the lip and the skin

Occult bacteremia

this is rarely happens anymore because of vaccines (h flu, strep pneumo)

what are some of the clinical implications of AFIB?

thromboembolism and loss of atrial kick

fever, tachycardia, and hyperreflexia

thyroid storm

what 2 drugs can cause hyperkalemia

tmp-smx ACEI/ARB

a deep bite from an animal should be radiogaphed why?

to check for teeth in the wound

why is it important to apply compressive dressings the auricular hematomas after drainage?

to prevent cauliflower ear

nondisplaced fracture of the distal tibia in children who are commonly younger than 2 without a history of a traumatic event ?

toddlers fracture

tx acute angle glaucoma? 1. dec aqueous humor 2. increase drainage

topical bblocker or carbonic anhydrase inhibitor (acetazolamide 500 mg orally/iv) pilocarpine (miotics)

24 year old presents with testicular pain over the past 24 hours (left sided) WBC psent, and increased intratesticular flow on doppler

torsion of the appendix testis

Opioid-like drugs

tramadol, clonidine, imidazolidines

tx splenic sequestration?

transfusion

mcc of acute hip pain in children 3-10 years old?

transient synovitis

foot prolonged exposure to a cold wet environement leading to decreased peripheral circulation

trench foot

while the presence of obstruction in the distal small bowel causes feculant vomiting, obstruction in the large bowel does not cause vomitus b/c of the presence of the ileocecal valve

true

where does varicella start and spread to?

trunk to extremities

complication of PID?

tubo-ovarian abcess

how much fluid for infants with hemorrhage?

two bolus of 20ml/kg (warmed)

tx abcess (s. aures) --> B or C tx erysipelas (S. pyogens) --> P or R tx NSTI (MRSA) --> C and V

tx abcess (s. aures) --> clindamycin tx erysipelas (S. pyogens) --> PCN or recephin tx NSTI (MRSA/c. perfringes) --> Clinda + Vanco

50% of lightening strike patients have rupture of this membrane?

tympanic membrane

anaphylax*I*s is what type of hypersensitivity reaction?

type 1

patient comes in with abdominal pain, vaginal discharge, and fever. On physical exam cervical motion tenderness is present with pain of the right adnexa. what are the next tests that should be done? should this patient be admitted and started on antibiotics?

u/s to R/O abscess gon/chlam assays CBC screen for stds admit and start on antibiotics

imaging if you suspect pregnancy issue?

ultrasound

imaging to be done to evaluate abdominal bleeding in an infant?

ultrasound or CT

always order an ____ (imaging) and perfom arthrocentesis

ultrasound to exam if the joint has an effusion

Aortic Dissection physical exam

unequal decreased or absent peripheral pulses, aortic insufficiency murmur

if a wrist fracture involves dislocation of the radius and ulna should it be fixed with closed manipulation an nerve block OR ORIF?

unstable --> ORIF

how long to continue insulin in a patient with DKA? when to do Dextrose?

until the anion gap has hormalized when the serum glucose is 22-300

activated charcoal is recommended in tylenol overdose up to ___ hours after ingstions

up to 4 hours after ingestion

IM epinephrine is dosed *0.1* mg/kg up to __ doses IV epinephrine is dosed 2-10 micrograms/min ped epinephrine is dose 1 -3 microgram/kg/min

up to three doses

MCA infarct sx

upper extremity> lower extremity; aphasia (left side), right sided hemi-paresis and sensory loss, left hemi anopsia, gaze preference toward the stroke.

asterixis and seizures are a result of this cause of AMS

uremia

tx epiglottitis?

urgent ENT referral

RSV positive infants < 3 months old should at least receive what two test?

urinalysis and urine culture

tx narrow complex tachycardia? tx wide complex tachycardia?

vagal, adenosine/diltiazem amiodarone

papules to vesicles that eventually crust

varicella (chicken pox)

what should you give to a septic patient who is unresponsive for 30ml/kg or whose lactate is greater than 2 on repeat blood work?

vasopressor

gold standard for diagnosis of DVT?

venography

MI complication: w/in first 48hrs

ventricular arrhytmia

dizziness and diplopia are common with this neurologic syndrome

vertbrobasilar syndrome

should you start a patient on potassium in DKA if it is elevated or wait until it falls?

wait until it falls

patients with known IgA definciency should be given pRBC that have been _____ free of plasma proteins

washed

common symptoms of anaphylaxis

watery eyes increased bronchial secretions increased smooth muscle tone causing wheezing incrased capillary permeability hypotension

Frostbite - appearance -dx

waxy, hard, insensate. Blisters containing blood or clear fluid. Don't rub affected areas. -dx: clinical, angiography, technetium99

in severe PE dilation of proximal pulmonary vessels with coppapse of distal vasculature is noted -- this sign is seen a triangular or rounded pleural based infiltrate with its apex pointed to the hilum

westermarks sign hamptons hump

when does shivering stop?

when glycogen stores run out (several hours)

when should warming of a hypothermia patient take place?

when it can be done without interruption

when can you discharge an OD patient?

when they are asymptomatic (may need to be admitted or observed)

opposed to surgery what can be done for body packers?

whole bowel irrigation

what does vtach look like on EKG

wide complex

6 W's of post-op fever

wind=pneumonia/atelectasis water=UTI wound infections/abscess walking=DVT/PE wonder drugs (drug rx) womb-endometritis

emergency contraception is most successful if it is given within the first __ hours

within 72 hours

Delayed primary closure

wound infx concerns

if you suspect foreign body aspiration what imaging should you get?

xray

DX & TX for subungual hematoma

xray 1st trephination to relieve pressure

are rape survivors at increased risk for chronic medical problems?

yes

can alcohol withdrawl patients have seizures (tonic clonic) and hallucinations

yes

can gastrograffin be used to find and esophageal tear?

yes

do abx help patients who have been submersed in grossly contaminated water?

yes

do you do a ct scan with a seizure a recent history of head injury

yes

should patients who recover from heat stroke be admitted to the hospital?

yes

should unnimunized children with febrile seizure get a lumbar puncture?

yes

can rheumatic fever be prevented be prevented by abx for strep throat? can PSGN be prevented by abx for strep throat?

yes no

can zika be transferred vertically during pregnancy to the child? can zika be transferred through sexual intercourse

yes yes

is the sickle cell trait usually asymptomatic ?

yes - except for severe stress (severe dehydration , temperature, or pressure change)

are blood products donated from 1st degree relatives more likely to cause GVHD?

yes -- must irradiate

Acute Bacterial Meningitis bugs

young people: strep pneumo and neisseria meningitis old people: listeria

Foreign body aspiration

younger children into R main-stem bronchus, ball-valve effect sx: classic triad: wheezing, sudden cough, choking, diminished unilateral breath sounds

what to give for post exposure prevention for HIV? this should be administered as long as the patient is seen within ___ hours of exposure?

zidovudin (1 month) <72 hours of exposure

sick patient after a mosquito bite in mexico/central america?

zika virus