Tiny Tips - BoringEM

Causes of descending paralysis

"Got BOMBED" G BS (MF Variant) B otulism O rganophosphate (HEENT exposure) M yasthenia Gravis B rainstem (Pontine infract) E aton Lambert D iphtheria

How do you calculate the size of a PTx in %?

((A + B + C)/3) x 10%

When can the Rumack-Mathew nomogram not be used?

* Time of ingestion cannot be established * >24h after the ingestion * <4h from ingestion * Chronic ingestion * ?Extended release prep

Conditions appropriate for a clinical decision unit

* have evidence for decreased costs / improved or similar outcomes as formal admisison * abdo pain - for imaging or reassessment * chest pain * Asthma - CHF - AFib - Grade I Dehydration * GI Bleed * DVT * Trauma (Blunt or Penetrating Chest or Abdo) * Pyelonephritis - Pneumonia

Infectious causes of bloody diarrhea

- Aeromonas - Salmonella - Shigella - Yersinia - Campylobacter - E Coli with shiga-like toxin (0157:H7) - Entamoeba histolitica

When do the facial sinuses become aerated?

Birth - ethmoid and mastoid antrum 3y - sphenoid and mastoid air cells 6y - frontal 10y - maxillary

Classic cardiac silhouettes

Boot - TofF Egg on string - transposition of the great arteries Snowman - total anomalous pulmonary venous return

Acceptable angulation for Boxer's fracture and metacarpal shaft

Boxer's: 10-20-30-40 rule (D2-5) Shaft: 10 degree in 2-3 and 20 degrees in 4-5

Tube sizes in pediatrics

Broselow tape ETT = (age/4) + 4 (uncuffed - drop 0.5-1 size for a cuffed tube) Chest tube = ETT size x 4 Foley / NG tube = ETT size x 2

Acyanotic heart diseases

CAP VAP C oarctation A S P S V SD A SD P DA

Mechanisms requiring transfer to a trauma center

CDC 2011 Falls -Adults: >20 feet (one story is equal to 10 feet) -Children: >10 feet or two or three times the height of the child High-risk auto crash -Intrusion, including roof: >12 inches occupant site; >18 inches any site -Ejection (partial or complete) from automobile -Death in same passenger compartment -Vehicle telemetry data consistent with a high risk of injury Auto vs. pedestrian/bicyclist -thrown, run over, or with significant (>20 mph) impact Motorcycle crash ->20 mph

Exam findings of serotonin syndrome

CHAARM CNS dysfunction Hyperthermia/Hyperreflexia A utonomic dysfunction (tremor, myoclonus) / A taxia R igidity M yoclonus NOTE: NMS does NOT have myoclonus or hyperreflexia!!!

Hydrocarbon additives that require GI decontamination

CHAMP Camphor - seizures Halogenated HC - dysrhythmias/hepatotoxicity Aromatic HC - bone marrow suppression/cancer Metals (arsenic, murcury & lead) Pesticides - cholinergic crises/seizures/resp depression

San Francisco Syncope Rule

CHESS CHF Hematocrit <30% ECG SOB Systolic BP <90

Causes of hypercalcemia

CHIMPANZEES C a supplementation H yperparathyroidism I atrogenic (Li, thiazines) M ilk-alkali syndrome P aget's A cromegaly, A ddison's N eoplasm Z ollinger-Ellison E xcess Vit A E xcess Vit D S arcoidosis

Neonatal CPR

CPR is indicated if the infant's HR is <60bpm despite 30s of adequate PPV. Chest compression rate is 90/minute Breathing rate is 30/minute (q 3 chest compressions) Epinephrine is used if HR <60bpm after 30s of CPR (dose 0.1-0.3mL/kg of 1:10,000 epi IV)

Pentad of TTP

CRAFTY C NS changes (fluctuating seizures, paresthesias, altered LOC) R enal failure (ARI, hematuria, proteinuria) A nemia (microangiopathic hemolytic with schistocytes) F ever T hrombocytopenia (Plts 10-50)

What is the appropriate imaging study for penetrating flank trauma?

CT-Chest/Abdo/Pelvis with Contrast (triple phase - oral / IV / rectal)

Pediatric cardiac vs respiratory cause of central cyanosis

Cardiac - comfortable breathing, worse with crying, no improvement with O2 Respiratory - uncomfortable breathing, better with crying, improvement with O2

Dive injuries requiring a recompression chamber

-AGE -DCS I and II -Contaminated gases (CO)

Slit lamp findings of blunt trauma to the sclera or lens

-Abrasion - Positive Fluroscein uptake -Scleral laceration -Positive Siedel's -Subconjunctival hematoma -Iridodonesis (iris movement with eye movement - due to lens dislodgement)

Prostatitis: cause, acute vs chronic, treatment

Cause: gram negative KEEPS Acute: usually with cystitis, irritative voiding, fever Chronic: recurrent UTI with same organism Treatment: Cipro x 30d or Septra DS x 30d

Cavernous venous thrombosis: cause, presentation, treatment

Cause: preceded by trauma, bacteremia, or local (facial, dental, sinus, ear) infection Presentation: headache, CN III V IV VI VIII findings (deaf, dizzy, EOM, diplopia, facial movements), periorbital edema, exopthalmos, decreased LOC, death Treatment: antibiotics and anticoagulation

Arsenic (gas, acute, chronic)

-Arsine gas gives hemolysis & ATN -Acute salts give encephalopathy, ARDS, dysrhythmias, N/V/D -chronic salts give sensory neuropathy, Mee's lines, sideroblastic anemia, cancer. >Tx with WBI, BAL (IM), DMSA (PO)

Treatment of box jellyfish sting

-Box jellyfish antivenom -Verapamil IV -Remove nematocysts with razor / credit card after deactivating with vinegar -Analgesia

Things that damage the GI mucosal barrier

-Cigarettes -EtOH -Steroids -H pylori -NSAIDS -Stress / shock

Tetanus prophylaxis

-Clean or dirty wound and immunized (x3 and up to date) - nothing -Clean wound and unimmunized - Td -Dirty wound and unimmunized - Td and TIG

Mechanisms for hypoxic respiratory failure (examples)

-Decreased pO2 (climber at altitude) -Decreased minute ventilation (opioid OD, obesity, GBS, MG, hypoMg/PO4) -Decreased diffusion capacity (COPD) -Shunting (congenital heart disease) -V/Q mismatch (PE, pneumonia, pulm edema)

Factors affecting the rate of heat transfer between objects

-Duration -Transfer Coefficient of objects -Temperature Differential -Heat Capacity -Conductivity of tissues

Patients at LOW risk for suicide

-Few risk factors -Supportive and stable home environment -Contracts to safety -Family/friend available to patient -Follow up appointment planned -No gun in home

Workup for Parvovirus B19 exposure in pregnancy

-Get Parvovirus IgG and IgM levels -If only IgG+ patient is immune; no acute infection -If only IgM+ patient has an acute infection - refer to OBGYN and U/S for ? hydrops -If neither IgG or IgM no acute infection

Bones at high risk of AVN

-Head of femur (Legg-Calve-Perthes syndrome in children generally 4-10yo) -Head of humerus -Scaphoid -Capitate -Lunate (Kienbock's disease) -Patella -Talus -Navicular (Kohler's disease) -Second metatarsal

Causes of DIC

-Infection (bacterial, viral, fungal, especially necrotizing fasciitis) -Cancer (adenocarcinoma, lymphma, leukemia) -Trauma -Shock -Liver disease -Pregnancy (amniotic fluid embolism, HELLP) -ARDS -Transfusion reactions -Crotalid envenomation

Contraindications to cricothyrotomy

-Laryngeal # -< 8 yoa -anterior neck hematoma

DDx for poor R wave progression on an ECG

-Old anterior MI -Lead displacement -LVH -LBBB -LAFB -WPW -Dextrocardia -Tension PTx with mediastinal shift -Congenital heart disease

Contraindications to IO line at a specific site

-Osteoporosis -Osteogenesis imperfecta -Fractured bone -Recent IO site -Needle insertion through areas of cellulitis, infection, burns

Common causes of renal failure in children

-Post-strep GN -HSP -Pyelonephritis -Obstructive Nephropathy (VUR) -Lupus Nephritis -Minimal change disease

Why does EtOH withdrawl occur?

-Regular use decreases glutamate and increases GABA causing increased glutamate receptors and decreased GABA receptors -CNS is hypersensitive to glutamate when EtOH stops

Indications to consult optho for corneal FB

-Removal of rust ring -Large area of visual axis involved -Deeply embedded -Risk of perforation -Multiple FB's

What factors indicate a poor prognosis following drowning / near-drowning?

-Temperature of patient -Age (young) <3 -Duration of submersion > 5 min -Pulse (presence of) -Neurologic status at time of arrival to ED -Bystander CPR delayed > 10 min -Acidosis -Fixed, unreactive pupils -GCS 3

Diagnostic criteria for Idiopathic Intracranial Hypertension

1. Signs/symptoms of ↑ ICP with absence of localizing signs 2. No mass or ↑ ventricles on neuroimaging 3. No suspicion of venous sinus thrombosis on neuroimaging 4. ↑ ICP on opening pressure (> 20 cm H2O) 5. Normal cell count and protein on LP

How does lipid emluslion work?

3 theories: -Lipid sink -Lipids as an energy source -Increased intracellular calcium

Ottawa SAH Rule

A - Age > 40y N - Neck pain/stiffness T - Thunderclap onset L - LOC E - Exertion onset a F - Flexion decreased

Types of lactic acidosis

A - tissue hypoxia B1 - systemic disorders (DM, renal insufficiency, leukemia, sepsis) B2 - substance associated (biguanides, methanol, salicylates, INH) B3 - heritable metabolic disease

APGAR Score

A ppearance (pink, acrocyanosis, cyanosis) P ulse (>100, <100, absent) G rimace (sneeze/cough/pull away, grimace, no response) A ctivity (active, arms/legs flexed, limp) R espirations (good crying, weak cry, absent)

Addictions that can kill in withdrawl

ABBA Alpha blockers (clonidine) Benzo's Barbiturates Alcohol

Approach to CXR

ABCS Airway Breathing (lungs) Cardiac (heart) Skeleton and Soft tissues

Causes of traumatic hemarthrosis of the knee

ACL injury PCL injury Patellar subluxation/dislocation Peripheral meniscal tear Osteochondral fracture Capsular tear

Atopic dermatitis diagnostic criteria

AKA eczema Itchy skin + -flexural involvement -generalized dry skin -H/O asthma or hay fever -Onset of rash before 2yo

Classic stroke neurological findings (AMA, MCA, PCA, Lacunar, Verterbrobasilar, Basilar, Cerebellar)

AMA - contralateral weak/numb legs > hand/face MCA - contralateral weak/numb hands/face > legs PCA - contralateral visual field and light touch Lacunar - pure motor OR sensory Vertebrobasilar - ipsilateral cranial nerve and contralateral weakness Basilar - 'Locked in' syndrome (normal mental status and blinking, can't move voluntary muscles) Cerbellar - dysmetria, dysdiadokinesia, can't walk, N/V

Causes of high output heart failure

AV fistula Pregnancy Cirrhosis Anemia Beriberi Thyrotoxicosis Paget's disease

When can anti-diarrheal medications be given?

AVOID in <2yo and those with fever or dysentery (blood +/- pus or mucous) Consider in patients with severe symptoms along with antibiotics

Bleeding in pregnancy

Abnormal pregnancy -Miscarraige -Molar pregnancy -Ectopic pregnancy Bad for baby -Vasa previa -Placenta previa -Placental abruption Other -Vaginitis -Post-coital -Cervical lesion

Drugs that require quantitative measurement for treatment in overdose

Acetaminophen Ethylene glycol Methanol Digoxin Carbon monoxide Lithium Aspirin Theophylline Valproic acid

Noncontrast CT findings of stroke

Acute (cytotoxic edema) -visualization of the clot/embolism (e.g. hyperdense MCA sign) - immediate -loss of grey-white distinction (e.g. lentiform nucleus and insular ribbon) - 1-3h -Low attenuation of grey matter -Effacement of the sulci Subacute (vasogenic edema) -Wedge shaped area of low attenuation of both gray and white -Mass effect (3-5 days) Chronic (3 weeks - 1 year) -Resorption of infarcted area (looks like CSF) -Volume loss (negative mass effect dilating the ventricles)

Waterhouse Friederichsen syndrome

Adrenal gland hemorrhage secondary to neisseria meningitidis Results in Septic shock DIC Adrenal insufficiency

Red flags in pediatric back pain

Age <4 Fever Weight loss Severe, constant or nocturnal pain Worsening over time History of trauma History of malignancy History of TB Neurologic symptoms

Define AECOPD. What decreases mortality in COPD?

An acute Exacerbation of COPD is characterized by the Antonisen criteria: 1) increased dyspnea, 2) sputum production, or 3) sputum purulence. Generally need 2/3 to treat. Mortality in COPD is decreased by 1) quitting smoking and 2) chronic oxygen therapy

What are the goals / indications of PSA?

Analgesia Anxiolysis Sedation Immobility Amnesia

Zone 3 of the neck and associated injuries

Angle of mandible to skull base Brain Stem (IX-XII) Carotid Jugular Parotid gland Vertebral Artery Spinal Cord Salivary glands

Distinguish vasogenic skin ulcers

Arterial - distal to ankle, shiny, hairless, unswollen skin and thick nails. Less painful when dependent. Venous - proximal to ankle, ++ swelling, weaping. Less painful when elevated. Neurotrophic - sites of repeated trauma that they don't feel. Heels, toes, plantar surface. Not painful. Hypertensive - on lateral malleolus, hemorrhagic bleb becomes an ulcer. Very painful.

Arteriosclerosis obliterans vs Thromboangiitis obliterans

Arteriosclerosis: blue toe syndrome, claudication, ischemic rest pain in an elderly (>50) vasculopath (DM, smoker, HTN, cholesterol). Requires intervention if they have pain at rest. Can have distal ulcers. Thromboangiitis: aka Buerger's disease, get painful erythematous nodules and decreased pulse in peripheral arteries. Only most commonly in male smokers 20-40yo and cure is stopping smoking completely.

Treatment of toxic shock

As for sepsis: fluids, vasopressors, O2, ventilation, steroids, source control Penicillin and clindamycin (stops toxin synthesis) and IVIg (especially for staph TSS)

BV vs Trichomonas vs Candida

BV - pH >4.5, gray-white malodorous discharge, clue cells on wet mount, treat with Flagyl 500 bid x 7d Trichomonas - pH >4.5, yellow-green frothy discharge, trichomonads on wet mount, treat with Flagyl 2g x 1 Candida - pH <4.5, white curds, hyphae on wet mount, treat with Fluconazole 150mg x 1 or clotrimazole 500mg PV tablet

Dive injuries on descent, at depth, on ascent, and require decompression therapy

Descent: IEBT, MEBT, EEBT, Facial barotrauma, barosinusitis Depth: Contaminated gases, Nitrogen narcosis, Oxygen toxicity Ascent: Arterial gas embolism, Pulmonary edema, Barotrauma (alternobaric vertigo, pneumothorax, pneumomediastinum, barodontalgia, GI barotrauma) After surfacing: DSC Decompression therapy: DCS I, DCS II, Arterial gas embolism, contaminated gas (CO)

AXR findings of large bowel obstruction

Distended colon Air-fluid levels Cecal dilation >12cm has increased risk of perforation

Assessment of infectious risk of a dog bite

Dog's Characteristics -immunization status of dog -behavior of dog -endemic area -provoked attack Patient Characteristics -immunization status of patient (incl. tetanus) -medical comorbidities in patient -immunocompromsie in patient -irrigation of wound

Define: Drowning, Immersion syndrome, Diving reflex

Drowning Respiratory impairment from submersion/ immersion in liquid that can cause morbidity and death Immersion syndrome Syncope or cardiac arrest following sudden immersion in water with a more than 5 degree change from core temperature (results in a vagal response +/- vasoconstriction) Diving reflex The immersion of the face in cold water shunts blood to the heart and brain producing apnea and bradycardia and prolonging the duration of submersion tolerated

Encapsulated bacteria

Even SSome Nasty Killers Have Capsular Protection E coli (some strains) S trep pneumoniae S almonella typhi N eisseria meningitidis K lebsiella pneumoniae H aemophilus influenzae C ryptococcus neoformans (yeast) P seudomonas aeruginosa

TORCH infections

Expanded T oxoplasmosis O ther infections (hepatitis B,C, Parvovirus, GBS, Listeria, Candida) R ubella C ytomegalovirus, Coxsackievirus, Chickenpox, Chlamydia (also gonorrhea) H SV2, HIV, HPV Syphilis Classic: Toxoplasmosis, Rubella, CMV, HSV2

Occlusive and nonocclusive arterial injuries

Occlusive -Transection -Thrombosis -Arterial spasm (reversible) Nonocclusive -Intimal flap -Pseudoaneurysm -AVM -Compartment syndrome

Life or limb threatening ortho emergencies

Open fracture Fracture/dislocation with major vascular disruption Major pelvic fracture Hip or knee dislocation Compartment syndrome

Amiodarone side effects

P eripheral neuropathy P hotosensitivity P ulmonary alveolitis P igmentation of skin P eripheral conversion of T4 to T3 inhibited (hypothyroid)

Causes of syncope

P ressure (hypotensive causes) A rrhythmias - Bradyarrhythmias, Tachyarrhythmia's (SVT, NSVT, A.F.), pacemaker malfunctions S eizures S ugar (hypo / hyperglycemia) O utput (cardiac) - AS, PS, MS, IHSS, Cardiomyopathies, Atrial Myxoma, Cardiac Tamponade, Aortic Dissection, MI, CHF O 2 (hypoxia) - PE, Pulm HTN, COPD exacerbation, CO poisoning U nusual causes - Anxiety, Major depressive disorder, Panic disorder, Hyperventilation syndrome, Somatization disorder T ransient Ischemic Attacks & Strokes, CNS dz's

CHF treatment

POND Positive-pressure ventilation Oxygen Nitroglycerine Diuretics

What cancers cause bone mets?

Painful Bones Kill These Suckers Prostate Breast Kidney Thyroid Skin Also Lungs

Risk factors for preeclampsia; Predictors of eclampsia

Person -Adv. Mat. Age -Younger than 20 -New Partner -Low SES -Obesity -Cocaine Pregnancy -Primiparous -Molar preg or mult gestation -IVF PMHx -Hypertension -Hypercholesterol -Previous PIH -Previous GDM -Connective Tissue Disease FHx -Family hx of PIH -Inherited Thrombocytopenia Predictors of eclampsia -elevated WBC, ALT, Creatinine

Primary versus secondary adrenal dysfunciton

Primary is a disease of the gland itself and affects all 3 functions (glucocorticoids, mineralocorticoids, androgens) -See hyperpigmentation, hyperkalemia, hyponatremia, salt craving, and acidosis from the lack of aldosterone / excess ACTH Secondary is a disease of the pituitary and does NOT affect mineralocorticoids (regulated by the RAAS) -Still get hyponatremia, but it is due to increased ADH Both -Hypotension -Depression, delerium, HA, abdominal pain, emesis, hypoglycemia, hyponatremia (differnet reasons), hypercalcemia, fevers, ARF

Dangerous ECG findings on an ECG of a patient with syncope

Prolonged QT WPW Brugada HOCM Ischemia

What is the purpose of risk management?

Purpose -Mitigate harm -Prevent medical error

Causes of ST elevation on ECG

STEMI Printzmetal's LBBB LVH Pericarditis Hyperkalemia Brugada PE Celebral hemorrhage Pacing BER

Common benign pediatric murmurs

Stills - high pitched systolic LLSB musical or vibratory murmur in preschool children Pulmonary flow murmur - LUSB due to hypoplasia of the pulmonary arteries. Resolves 3 to 6 months.

Indications for referral to opthalmology of an eyelid laceration

The 5 L's L id margin L acrimal system L evator or canthal tendons L oss of tissue L eaking of fat

Zone 1 of the neck and associated injuries

Thoracic outlet to inferior cricoid jugular Lung Trachea superior mediastinal vessels Spinal cord Thoracic duct Thyroid Subclavian artery Carotid artery Vertebral artery Esophagus

Peripartum infections that cause maternal or fetal morbidity

Toxoplasmosis Others (syphilis, Hep B, Coxsackievirus, EBV, VZV, HPV) Rubella virus CMV HSV

Type 1 error Type 2 error Alpha Beta

Type 1 error = rejection of a true null hypothesis (a "false positive") - think dude with a + preg test Type 2 error = failure to reject a false null hypothesis (a "false negative") - think pregnant lady with a - preg test Alpha = the probability of a type 1 error Beta = the probability of a type 2 error

Most common fractures in the elderly (UE and LE)

UE -Distal radius (50%) -Proximal humerus (30%) LE -Hip

Neutropenic infections and associated pathogens

Ulcerative oral lesions: Strep viridans, herpes, candida Necrotizing skin lesions: pseudomonas, aeromonas, aspergillus, mucormycosis Black eschar: mucormycosis, aspergillus Abd pain, distension: typhlitis (neutropenic enterocolitis) due to pseudomonas, e coli, clostridium Perineal pain: Gram - bacilli, anaerobes

Treatment of neonatal unconjugated and conjugated bilirubinemia?

Unconjugated -IVF rehydration -IV antibiotics -Exchange transfusion / plasmapheresis -Phototherapy Conjugated -IVF rehydration -IV antibiotics -Exchange transfusion / plasmapheresis -Abdominal ultrasound -Surgical consult -IVIg (if ABO incompatibility)

Define fever of unknown origin and provide DDx

Febrile illness of unknown etiology lasting >14 days Infection - Endocarditis, sinusitis, malaria, RMSF, fungal Collagen-vascular - JRA, SLE, RA, UC, Kawasakis, vasculitis Cancer - Lymphoma, leukemia, Wilms tumor Drug induced - Serum sickness, PTU, TB agents, anticonvulsants, antibiotics, procainamide Miscellaneous - Environmental, Thyrotoxicosis, Familial fevers, Lyme, PE

Urine casts

Hyaline - dehydration, proteinurea, exercise WBC - paranchymal inflammation RBC - glomerulonephritis / vasculitis Fatty - nephrotic syndrome Granular - ATN

Steroid equivalency (hydrocortisone, prednisone, methylprednisolone, dexamethasone)

Hydrocortisone = 1 Prednisone/Prednisolone = 4 Methylprednisolone = 5 Dexamethasone = 25

Treatment of hyponatremia with focal neurologic symptoms, seizure, or coma. Complication of rapid correction.

Hypertonic (3%) saline 100mL over 10m then 100mL over the next hour (approximately 3mL/kg total) After this aim to correct by 0.5mEq/L/h if chronic, 1mEq/L/h is okay if acute Complication: central pontine myelinolysis

Components of the incident command structure

I FLOP I ncident command (overall management) F inance (records on personal/resources, payment to vendors, costs alternatives) L ogistics (provision of facilities, services, materials) O perations (tactical law enforcement, fire, EMS, triage; manages staging areas) P lanning (collection, evaluation and dissemination of operation/resource status; coordinates meetings)

Approach to altered mental status

IS IT MEATS

Explain the hyperoxia test

If a hypoxic child presents and is put on 100% O2 and the sats don't improve, it is likely a cardiac / shunting problem. If it improves to PaO2 >150 or by >10% SpO2 it is likely a pulmonary problem.

Rapid approach to ethical problems

If you have worked out a rule for the issue use it If not, can you buy time and get an ethics consult? If not ask these three questions (if yes, the action is likely to be ethical): Impartiality test, would the practitioner accept this action if they were in the patient's place? Aka the golden rule. Universality test, would it be okay if this action was taken in all similar circumstances? Interpersonal justifiability test, can the practitioner supply good reasons for the action that will satisfy others?

Intoxicated colleague -immediate responsibilities -behavioral characteristics suggesting substance abuse

Immediate responsibilities -Report to CPS -Relieve them from their duties Behavioral characteristics 13. Heavy `wastage`of drugs 14. Inappropriate prescription of large narcotic doses 15. Insistence on personal administration of parenteral narcotics to patients 11. Uncharacteristic deterioration of handwriting and charting 18. Alcohol on breath 1. Personality changes 2. Loss of efficiency and reliability 3. Increased sick time and other time away from work 4. Patient and staff complaints about physician`s changing attitude or behaviour 5. Indecision 6. Increasing personal and professional isolation 7. Physical changes 8. Unpredictable work habits and patterns 9. Moodiness, anxiety, depression, suicidal thoughts or gestures 10. Memory loss 12. Unexpected presence in hospital when off duty 16. Long sleeves when inappropriate 17. Frequent bathroom use 19. Wide mood swings

Complications of ICD and pacemaker placement

Infection of wound Infection of pouch Thrombophlebitics Chronic thrombosis

Causes of monocular diplopia

Iridodialysis Lens dislocation Refractive error Malingering

Causes of hyperacute T waves

Ischemia Hyperkalemia Pericarditis LVH LBBB Benign early repolarization

Causes of anion-gap metabolic acidosis

KULT Ketones Uremia Lactate Toxins

Zones of the hand

Key zones: I - Mallet finger III - Boutonniere deformity V - Fight bite

Predictors of difficult intubation

L ook externally E valuate 3-3-2 M allampati O bstruction / O besity N eck mobility (decreased)

Lab changes in pregnancy

Leukocytosis Relative anemia Low Hematocrit PCO2 down Bicarb down Elevated D-Dimer Increased fibrinogen Low Creatinine

Well's PE Criteria

Likely if 4 or more D VT signs and symptoms A lternative less likely M alignancy P revious P E/DVT H emoptysis I mmobilization hR > 100

Mass casualty triage protocol

Use the START (Simple Triage And Rapid Treatment) Protocol Remember with ABCD

General criteria for low-risk outpatient care

VC SERF Vitals normal Comorbidities (none) Support system in place Emergency care accessible Reliable patient Follow-up arranged

Zone 2 of the neck and associated injuries

Zone II - Angle of mandible to cricoid cartilage Recurrent Laryngeal N. Larynx Pharynx Thyroid cartilage Esophagus Spinal Cord Carotid Jugular Vertebral Vagus nerve Recurrent laryngeal nerve

Presentations that require mandatory reporting

-Child Abuse or Neglect -Long-Term Care and Retirement Homes Sexual Abuse of a Patient -Facility Operators: Duty to Report, Incapacity, Incompetence and Sexual Abuse -Births, Still-births and Deaths -Communicable and Reportable Diseases -Controlled Drugs and Substances -Community Treatment Plans -Gunshot Wounds

Gas in tissues (infectious)

-Clostridia (perfringens, septicum) -Gram negatives (E. coli, Klebsiella, Enterobacter) -Anaerobes (Peptostreptococcus, B. fragilis) -Peptococcus -Group A Streptococcus

Indications for immediate endoscopy of an esophageal foreign body

-Complete obstruction (unable to handle secretions) -Respiratory distress (FB in esophagus can compress trachea) -Sharp objects -Impacted for 24 hours -Coins in the proximal esophagus -Alkaline button batteries -Failure of medical treatment -Coins in children <2yo (relative)

When would it be reasonable to send a physician with an EMS flight crew?

-Complicated, undifferentiated patient -Challenging airway -Obstetrical case -Procedure (chest tube, CVL) -Mass trauma (for help!) -ICU to ICU transfers

Post trauma care in the pregnant patient -Observation -Describe test -How much Rhogam

-Continuous fetal monitoring x 4 hours -Kleihaur Betke test for feto-maternal hemorrhage (if Rh- 50mcg if <12 weeks, 300mcg if <16 weeks; then calculate) -U/S for hemorrhage -NST (best test for abruption - see fetal distress); if >3 contractions in a 1h period observe for 24h; if >12 cxns/h high risk for abruption

Esophageal button battery - mechanisms of injury

-Current from the battery forming a circuit -Release of hydroxide -Pressure necrosis due to esophageal foreign body

Contraindications to CPR

-DNR -Danger to bystander -Irreversible death (Rigor mortis, decomposition, decapitation, transection, decomposition, dependent lividity) In neonates (anencephaly, trisomy 13/18, <400g, <23 weeks, SFH < umbilicus)

Slit lamp findings of penetrating globe injury

-Decreased Anterior Chamber depth -Positive Siedel's -Hyphema -Scleral laceration -Bloody chemosis -Retained implement (FB) -Corneal Laceration -Teardrop pupil -Iris prolapse -iris transillumination defect due to vitreous hemorrhage

Contributors to thte development of GERD and evidence-based ways to get rid of it

-Decreased sphincter tone (anticholinergics, caffeine, benzo's, nicotine, nitrates, peppermint, chocolate, estrogen, progesterone) -Decreased esophageal motility (DM, achalasia, scleroderma) -Increased intraabdominal pressure (pregnancy, obesity) -Decreased gastric emptying (anticholinergic, diabetic gastroparesis, outlet obstruction) Evidence-based treatments: weight loss and bed elevation (also try no eating before bed, stop smoking/etoh, change relevant meds, smaller meals)

Reasons for non-compliance with medications in the elderly

-Dementia -Polypharmacy -Increased side effects -Financial constraints

Medical problems on DDx with interperesonal violence

-Depression, PTSD, suicidal ideation -Headaches -Stress-related illnesses -EtOH / substance abuse -Trauma in pregnancy -Chronic pain -STI/HIV

High altitude pulmonary edema treatment

-Descent -Salbutamol -Oxygen -Nifedepine - decreases pulmonary vasoconstriction -Sildenafil - decreases pulmonary vasoconstruction -Hyperbaric oxygen or CPAP

Addressing the patient leaving AMA

-Determine that they have capacity -Get 'consent' for them to leave AMA - explain risks/benefits/alternatives and ensure that they are not leaving under duress -Ensure they know that they will be welcomed back if they choose to return -Document the encounter and discussion -Have others (nurses) corroborate the information in their notes

3 causes of no detectable etCO2 in cardiac arrest

-Dislodged/misplaced tube -Obstruction of tube (massive PE) or pulmonary edema -Prolonged arrest or downtime -Severe asthma -Large glottic air leak -Equipment failure -Transient decrease expected after administration of epinephrine (vasoconstricts pulmonary blood flow)

What is a molar pregnancy? What are the types? How does it present

-Disordered proliferation of chorionic villi Two types: -Complete hydatidiform mole: absence of fetal tissue -Incomplete hydatidiform mole (much less common): fetal tissue with focal trophoblastic hyperplasia -Can also get choriocarcinoma (responds well to chemo, can metastasize) Presentation -Hyperemesis gravidarum -Crazy high BhCG -Snowstorm U/S

Ankle fractures that require ortho consult

-Displaced medial, lateral, or posterior malleolus -Bimaleolar fractures and equivalent (Deltoid ligament, syndesmosis rupture) -Trimalleolar -Intraarticular with step deformity -Open # -Pilon # -Fracture dislocation -Open fracture -SH III, IV, V

Ultrasound findings in ectopic pregnancy

-Ectopic fetal heart activity -Ectopic fetal pole -Moderate or large cul-de-sac fluid without IUP -Adnexal mass* without IUP -Indeterminate -Empty uterus -Nonspecific fluid collections -Echogenic material -Abnormal sac

Mercury (elemental, inorganic, organic)

-Elemental vapor (ARDS, pneumonitis) or injection (CNS/renal toxicity) or ingestion (nil) -Inorganic ingestion (ATN, gastroenteritis) or chronic (neurasthesia, nephritic syndrome, gingivostomatitis) > BAL (IM) / DMSA (PO) -Organic ingestion/dermal (neurotoxicity, ataxia, tremor, dysarthria) > DMSA (PO) but NOT BAL

Abnormal bloodwork in Kawasaki's disease

-Elevated ESR / CRP -Sterile pyuria -Decreased Hb -Elevated WBC -Plt>450 -Decreased albumin (<30) -Elevated ALT

Side effects of sulpha drugs

-Erythema Nodosum -Erythema Multiforme -SJS -TEN -Hypersensitivity vasculitis -DRESS -Anaphylaxis -Allergic carditis

Measles incubation, symptoms, complications

-Exposure -10 days later get cough, coryza, conjunctivitis, koplik spots and fever -4 days later get rash -Contagious 5 days before the rash and 4 days after -Complications include otitis media, encephalitis, pneumonitis and 20 years later Subacute Sclerosing Panencephalitis

Hemostatic abnormalities in liver failure

-Factor deficiency-2° ↓ protein synthesis -Vitamin K deficiency -2° malabsorption -Thrombocytopenia -↑ Fibrinolysis -↓ Fibrinogen -Anemia

Indications to transfer a patient for primary PCI

-First medical contact to needle time can be <120m -Contraindications to lytic -Presented >12h post onset of CP -Ventricular dysrhythmias -Requires rescue PCI (CP, hemodynamically unstable, persistent STE >50%)

How to perform a retrograde urethrogram

-Flex hip/knee -Displace penis from midline -Shoot KUB -Toomey syringe with water-soluble contrast (60ml) -Infuse over 1 min, KUB during last 10ml

Complications of an IO line

-Fracture -Fat embolism -Pain with infusion -Compartment syndrome -Skin sloughing -Osteomyelitis -Epiphyseal damage

Shaken baby syndrome; imaging studies

-Generally <1yo; can be <3yo -No evidence of impact -SDH and SAH -On fundoscopy see retinal hemorrhages (>75%), papilledema due to increased ICP CT is better for SAH, imaging of intracranial injuries, easier to perform. MRI is better if subacute/chronic, deel cerebral injuries, extraaxial fluid, smaller SDH's

Steps to breech delivery

-Get a C-section instead -Call obstetrics -Monitors -Rule-out prolapsed cord -Open pelvis (knees wide) -Episiotomy -When abdomen is through pull out 10-15cm of cord to try to avoid it getting trapped -Grasp neonate by the pelvis and direct face/abdomen away from the symphysis -Keep the next flexed forward (do not let it extend!! Causes spinal cord injury)

Toxic seizures: effect of glutamate, GABA, benzo's, barb's, EtOH, pyridoxime Treatments for benzo, barb OD

-Glutamate excites; GABA inhibits w Cl channel, Benzo's potentiate GABA (need it!), Barb's and EtOH keep Cl channel open longer (no GABA needed!). GABA is made by Glutamine using Pyridoxime Barb OD: respiratory depression! Intubate and treat with MDAC Benzo OD: flumazenil generally not recommended especially if ictogenic coingestants, seizure disorder, withdrawl, paralyzed

Physiologic changes that affect the pregnant trauma patient

-Gravid uterus compresses IVC (supine hypotension) -Baseline diastasis of pubic symphysis -laxity of pelvic ligaments -Physiologic anemia -Increased blood volume allowing for greater compensation for blood loss but rapid deterioration when reach maximal compensation -increased minute ventilation -Relative hypocarbia -Higher resting HR -Higher resting RR, blood gas with PCO2 30, HCO3 21 -Lower FRC -Abdominal viscera protected by uterus and difficult to examine (abdo exam unreliable)

Sudden sniffing death syndrome

-Happens in HC use. Blocks the delayed rectifier-K channel resulting in long QTc and ventricular arrhythmias. -Upregulation of catecholamine receptors on myocardium and sensitization; sudden surges of catecholamines from adrenaline surge. -Consider avoiding epi in this type of a code. -After resuscitated give benzo's, Mg, beta blockers, overdrive pacing

Indications for operative management of penetrating neck trauma

-Hard signs in zone 2 -Unstable -Transcervical gunshot wound -Platysma violation in zone 2 (relative)

What is required to prove negligence in a malpractice suit?

-Health care provider has a duty of care -That duty of care is breached by breaking the standard of care -The patient is harmed -There is a direct link between the breach and the harm

Differentiating features between heat stroke and heat exhaustion

-Heat stroke has neurological symptoms -Heat stroke has a temperature >40.5 -Heat stroke AST and ALT are much more elevated (in the 10000's) - elevated LFT's are a common lab abnormality in both

Indications for angiography with a pelvic fracture

-Hemodynamic instability with -ive DPL or FAST -Large pelvic hematoma or active contrast extravasation on CT -Large/expanding RP hematoma seen at laparotomy -≥ 4 units blood transfused for pelvic bleeding in 24 h, or ≥ 6 units in 48 h

Common blast injuries

-Hollow viscous -Dismemberment -TM rupture -Air embolism -Pneumothorax -Blast lung

Physical exam findings of aortic dissection

-Hypertension -Pulse Deficit -BP differential between two limbs -Signs of cardiac Tamponade -Stroke like syndrome

Clinical findings of anterior chamber trauma

-Hyphema -Flare -Iridodialysis -Ciliary flush -Sluggish Pupil (cyclitis) -Deep anterior chamber from posterior displacement of iris -Seidel's sign

Causes of hypocalcemia

-Hypoparathyroidism (congenital, maternal, thyroid surgery, radiation) -Tox (chemo, HF, ethylene glycol, furosemide) -Hyperphosphatemia, tumor-lysis syndrome -Malnourished, alcoholism

Causes of amenorrhea

-Hypothalamic - exercise, stress, anorexia, hypothalamic tumor, GnRH deficiency -Pituitary - primary hypopituitarism, Sheehan syndrome, pituitary tumor -Ovarian dysfunction - PCOS, gonadal dysgenesis (Turner's), menopause, radiation/chemo -Endocrine - Hyperprolactinemia, hyper/hypothyroidism, Cushing's, hyperandrogenism (PCOS) -Obstruction - imperforate hymen, cervical stenosis

Indications for CT pre-LP

-Immunocompromised -ALOC (GCS <14) -Seizure in past 7 days -Focal neurologic signs -Papilledema -PMHx of CVA, mass lesion, focal infection, head trauma, CNS Sx Also consider age >60, severe HA/N/V, suspected brain bleed or lesion.

Physiological changes associated with high altitude acclimitization

-Increased HR, BP, and venous tone due to catecholamine release -Increased hemoglobin (due to increased Epo and fluid shift) -Increased 2,3 DPG and right shift of O2 dissociation curve (more O2 for tissues) -Increased minute ventilation (decrease PaCO2 and increased PaO2) -Increased renal excretion of HCO3 Combined these last two are: -Hypoxic ventilatory response (hypoxia induces hyperventilation which blows down PaCO2 causing kidneys to compensate by excreting HCO3)

Mechanisms for arrhythmias

-Increased automaticity (ischemia, electrolytes, drugs) -Reentry (req's 2 conduction pathways with different responsiveness and conduction speed) -Triggered (early afterpolarizations in brady/long QTc; treat by increasing HR vs late afterpolarizations in tachy/increased Ca; treat by slowing HR and decreasing Ca)

Etiology of Pericarditis

-Infectious (Viral - Coxsackie, Echovirus, HIV; Bacterial - Staph, Strep, TB; Fungal - Histoplasmosis; Parasite, Rickettsia) -Postinjury (Trauma, Surgery, Myocardial infarction [Immediate or Dressler's], Radiation) -Metabolic diseases (Uremia, Myxedema) -Systemic diseases (Rheumatoid arthritis, Systemic lupus erythematosus, Sarcoidosis, Scleroderma, Dermatomyositis, Amyloidosis) -Tumors (Leukemia, Lymphoma, Melanoma, Mets) -Medications (Procainamide, Hydralazine) -Aortic dissection

Drugs that cause disulfiram-like reaction with EtOH

-Inhibit aldehyde dehydrogenase leading to buildup of acetaldehyde ABx - metronidazole, nitrofurantoin, sulfonamides, some cephalosporins DM - sulfonylureas (gliclazide)

Steps of critical incident debriefing

-Introduction of intervenor and establishment of guidelines -Invites participants to introduce themselves (while attendance at a debriefing may be mandatory, participation is not) -Details of the event given from individual perspectives -Emotional responses given subjectively with personal reaction and actions -Discussion of symptoms exhibited since the event -Assure participants that any symptoms (if they have any at all) are a normal reaction to an abnormal event and "generally" these symptoms will diminish with time and self-care -Identify individuals who are not coping well -Informal discussion (generally over a beverage and treat) resumption of duty where individuals are returned to their normal tasks -Additional assistance is offered at the conclusion of the process

Causes of RAPD

-Ischemic optic neuropathy (CRAO or CRVO) -Optic neuritis -Optic nerve compression (orbital tumours or dysthyroid eye disease) -Retrobulbar hematoma -Trauma -Asymmetric glaucoma

Anatomic locations commonly involved in traumatic aortic injury

-Isthmus (Ligamentum Arteriosis) -Root (Ascending distal to the Aorta) -Distal descending at the diaphragm

DDx of presumed ankle sprain

-LCL sprain -Peroneal tendon dislocation -Osteochondral talar dome # -Talar post process # -Talar ant process # -Talar lateral process # -Calcaneus ant process # -Midtarsal joint injury -Base 5th MT #

Historical indicators of child abuse

-Magical injuries -Inconsistent story -Inconsistent with childhood development (can't bruise if can't cruise; 3 week-old 'rolling' off of a table) -Unexplained delay in seeking care -History does not explain the injury

Characteristics of malingering

-Medicolegal context of presentation -Discrepency between claimed disability and objective findings -Poor cooperation during exam -Not compliant with treatment -Antisocial personality disorder

Numbness or pain to the outer side of the thigh associated with pregnancy or obesity

-Meralgia paresthetica -Due to compression of the lateral femoral cutaneous nerve of the thigh as it passes the inguinal ligament

Systemic manifestations of hydrofloric acid exposure

-Metabolic Acidosis -Hypocalcemia -Dysrhythmias -Seizures -Tetany

Indications for emergent decompression of a subdural hematoma

-Midline shift >5mm ->1cm thick -GCS decreased by 2 or more since the time of the injury -Fixed dilated pupils -ICP >20mmHg

Toddler's fracture characteristics

-Minimal or no history of trauma -Red flags for NAT are: more transverse fracture with an associated fibular injury -Generally 9m to 3y of age -On physical exam spiral oblique axial load provokes pain (put axial load and twist ankle) -Generally treat with an above knee backslab - sometimes don't need anything.

Diagnostic criteria of Multiple Myeloma

-Monoclonal plasma cells or plasmacytoma in the bone marrow -Monoclonal protein in blood or urine -Organ dysfunction (CRAB criteria) C - HyperCalcemia R - Renal failure A - Anemia B - Bone damage (lesions or osteoporosis)

Characteristics of self-induced knife wounds

-Multiple superficial incisions to trunk/arms/face -Multiple superficial stabs to trunk/arms/face -Parallel incisions on the non-dominant side of the body in close proximety to each other -Sparing of sensitive areas -Linear or curved incisions toward the hand inflicting the wound -Intact clothing covering the wound -Evidence of similar prior wounds

DDx of bulbar neuropathy

-Myasthenia gravis -Lambert-Eaton myasthenic syndrome -ALS -Miller-Fisher variant GBS -Elapidae (coral snake) or Hydraphidae (sea snake) envenomation -Botulism -Lyme disease -Organophosphate poisoning -Congenital syndrome -Penicillamine toxicity

Causes of pediatric GI bleed

-NEC -Ingested Maternal Blood (Cracked Nipple) -Milk Protein Allergy -Reflux esophagitis -Meckel's -Intussuception -Infectious Gastroenteritis -Anal Fissure -IBD -Blood dyscrasia -Child Maltreatment -Polyps -Toxic ingestions

Selected physiologic changes of aging and effects

-Neuro: Altered autonomic/neurotransmitter function leads to orthostatic hypotension and slowing mental function -Skin atrophy: decreased insulation, increased injury, increased infection -Decreased sweat glands: increased hyperthermia -Bone loss: increased fractures -Decreased antibodies and cell mediated immunity: increased infections -Decreased Tv, compliance, resp drive, diffusion capacity: increased CO2, decreased O2 -Decreased hepatic function, blood flow and enzyme function: altered metabolism of drugs -Decreased renal function, total water, vasopressin response: decreased renal elimination, drug excretion -Decreased GI mucosa and HCO3: increased gastric ulcers and perf

Seizure mimics in children

-Newborn jitters -Breath holding spells -Sandifer's syndrome -Syncope -Tics -Dystonia -Sleeping disorders (myoclonus, narcolepsy, night terrors)

Features suggestive of E Coli O157:H7

-Nonbloody diarrhea for 3 days THEN bloody diarrhea -No fever -5 stools/24h -Abdominal tenderness -Pain worsens on defecation -No granylocyte count increase on WBC

Risk factors for Idiopathic Intracranial Hypertension

-Obesity -Lupus -PCOS -Sleep apnea Medications -OCP -Anabolic steroids -Tetracyclines -Vitamin A

Foot injuries requiring ortho consult

-Open # -Fracture-dislocation -Major talar head/neck/body #s -Lisfranc injuries -Most GSWs -Compartment Syndrome

Lyme disease: Organism, Vector, Incubation, Presentation, Diagnosis, Complications, Treatment

-Organism: Borrelia Borgdorferi (spirochete) -Vector: Ixodes Tick -Incubation: Tick must attach long enough (>36 hours) or be engorged -Presentation: 1st stage (days-weeks) erythema migrans & flu-like symptoms/HA; 2nd stage (3-5 weeks) with fluctuating meningoencephalitis/bilat Bells palsy, conduction block/pericarditis, arthritis, keratoconjunctivitis; 3rd stage (>1y) with fatigue syndrome, encephalopathy, radiculopathy, acrodermatitis, and arthritis -Diagnosis: Tick bite, IgM+ from 3-6 weeks, IgG+ >1 month (send both) -Complications: Can get Jarisch-Herxheimer reaction when tx started -Treatment: prophylax within 72h in endemic areas (>20% ticks +) if adult tick on for >36h/engorged - use Doxy 200mg x1; treat with Doxy 200mg BID x 28d (Amoxil in <8/pregnant; Ceftriaxone if meningitis)

Malaria: Organism, Vector, Incubation, Presentation, Complications, Diagnosis, Treatment

-Organism: Plasmodium Falciparum is most dangerous (also Ovale, Vivax, Malariae) -Vector: Female anopheles mosquito -Incubation: 8-28 days -Presentation: Fever in the returning traveler, anemia, constitutional (weak, dizzy, N/V/D, lethargy, myalgia, arthralgia, CP, abd pain, SOB) -Complications: cerebral/seizures, encephalopathy, ARDS, ARI, DIC, anemia, acidosis, hypoglycemia -Diagnosis: Thin and thick peripheral blood smears q8-12h x 3d; also PCR/dark field microscopy; U/S shows splenomegaly/papilledema -Treatment: Chloroquine if sensitive; otherwise quinine & doxycycline

Rocky Mountain Spotted Fever: Organism, Vector, Incubation, Presentation, Diagnosis, Complications, Treatment

-Organism: Rickettsia Rickettsii -Vector: Rocky Mountain Wood Tick -Presentation: Sudden onset fever followed by N/V/abd pain/HA. Gets into vessels and releases tPA & vWF causing microthrombi and vascular permeability. Petechiae develop on wrists/hands then spread inward. Also cardiac (AVB, myocarditis), pulmonary (ARDS), neurologic (meningismis, transient deficits due to microinfarcts), renal (microinfarcts), heme (DIC). -Diagnosis: Serology not positive for 1/52 but req'd for conclusive Dx. Also PCR+ or skin bx at 4-10 days (immunoflorescence +). Probable if clinical criteria; Confirmed with lab. -Complications: Death due to renal failure then ARDS/myocarditis/DIC in 25% if not treated -Treatment: Doxycycline 100mg po bid until asymptomatic x 3d or 7 days. Steroids if severe.

Complications of neuroleptic use and treatment

-Orthostatic hypotension - alpha blockade, give fluids -Acute dystonia - cholinergic, treat with anticholinergic benztropine (cogentin) 1-2mg IV/IM +/- benadryl -Akathisia - motor restlessness, decrease dose or try beta-blocker -Parkinsonism - can be indistinguishable from Parkinson's, tends to resolve over time, decrease dose or start parkinson's meds -Tardive dyskinesia - occurs over years, bad, choreathetoid movements (tongue, grimace, writhing), no known treatments, try switching to atypical or benzo's -NMS

Signs of hypothermia on ECG

-Osborne waves -Shivering artifact -Bradycardia -Prolonged PR, QRS, QTc -Ectopic ventricular beats -Atrial fibrillation -AVB's -VT/VF/Asystole

DDx for non-accidental trauma in children (fractures and bruising)

-Osteogenesis Imperfecta -Rickets -Scurvy -Menkes' Kinky Hair Syndrome -Hypervitaminosis A -Hypoparathyroidism -Congenital Syphilis -Pathologic fractures -Birth fractures -Metaphyseal cupping & spurring (normal variant - bilateral, diaphyseal, smooth) -Periosteal new bone formation (normal variant - especially to the femur) -Cultural practices (Cupping, Coining, Spooning) -Bleeding disorders (hemophilia, vWD, HSP) -Mongolian spots -Hemangioma -'Tattooing' -ITP -HSP -Secondary syphilis

Bronchiolitis treatments

-Oxygen - yes if hypoxic -IVF - yes if dehydrated -Beta agonists - not generally recommended (perhaps 10% responders, atopic people more likely) -Steroids - no -Epinephrine - some bad evidence that it can help prevent hospitalization, but not enough evidence to use it -Epi and steroids together - may be a synergistic response, but more evidence needed. NOT recommended. -Nebulized hypertonic saline - evidence moving towards its use, but it is still not in the guidelines

Treatment of frostbite

-Pain control -Warm the limb in 37-39 degree water (do not allow partial rewarming or refreezing) -Warm the patient with monitors Consider thrombolytics, heparin, tetanus, antibiotics, smoking cessation, debridement

Ottawa Foot Rule

-Pain over the navicular bone -Pain to the base of the 5th metatarsal -Unable to weight bear 4 steps immediately after the injury and in the ED

When can implied consent be assumed

-Patient does not have capacity to express their preferences (CURV) -Immediate action is required (E) -No surrogate decision maker (S)

Requirements for the use of methotrexate in an ectopic pregnancy

-Patient is hemodynamically stable -Tubal mass is <3.5cm -No FHR -No signs of rupture (FF) -BhCG <1200-5000

Reasons to modify the dose of adenosine

-Patient weight (obese, pediatrics), need more or less -Heart transplant (don't use it) -Methylxanthines (theophylline) stimulates receptors, need more -Carbamezapine, needs less -Dipyradamole prevents breakdown, needs less -CVL delivery, need less

When can EMS not transport a patient

-Patient with capacity that refuses -Obvious signs of death -Danger to crew

Treatment of a crush injury in search and rescue

-Patients tend to decompensate 4-6h after being extricated -Circulation reaches crushed limbs releasing toxins systemically causing hypovolemia, hyperkalemia, dysrhythmia -Require aggressive early fluid resuscitation (prior to extrication) and treatment of hyperK/rhabdo while preventing hypothermia

Complications of ocular chemical burns

-Perforation -Scarring -Adhesions of lid to globe (symblepharon) -Glaucoma -Cataracts -Retinal damage

Complications of aortic dissection

-Pericardial Tamponade -Inferior MI -Aortic valve insufficiency -Ischemia -> spinal (Art of Adamkiewcz) -> ischemic stroke -> mesenteric ischemia -> renal ischemia

Potentially live-saving interventions that are part of an ED thoracotomy

-Pericardotomy -Cardiac massage -Cross-clamping of the aorta -Repair cardiac defects -Hemorrhage control with foley or finger -Pulmonary hilar twist (compress or cross-clamp pulmonary hilum)

Seven pulmonary complications of pneumonia

-Pleural effusion / empyema -Pneumothorax -Lung abscess -Bronchopleural fistula -Necrotizing pneumonia -Pneumatocele -Acute respiratory failure

Risk factors for falls in the elderly

-Poor vision -Poor coordination -Position hypotension -Poor hearing -Cachexia

Admission criteria for epistaxis

-Posterior bleed/balloon -Bilateral posterior pack -Hemodynamic instability -Associated facial trauma/ polytrauma -Severe coagulopathy -Significant comorbidity -No follow up/psychosocial concern

Premorbid conditions requiring transfer to a trauma center

-Pregnancy > 20 weeks -Age > 55 and all children -Bleeding disorder -Patient on anticoagulation -End-stage renal disease requiring dialysis -EMS provider judgment

Treatment of unstable (stable) uterine bleeding

-Premarin 25mg IV q4-6h until bleeding stops along with an antiemetic (2.5mg PO bid-qid - follow up with progesterone for normal withdrawal bleeding OR 5-4-3-2-1 regular OCP's/day then 1 pill x 7 days, then 4 day period and restart) -Tranexamic acid 1g IV (1g PO tid-qid while menstrating) -Intrauterine foley to tamponade bleeding -OR - D&C / Hysterectomy

Risk factors for NEC

-Prematurity -Aggressive enteral feeding -Hypoxic insult at birth -Infections

Splint complications

-Pressure necrosis - may occur as early as 2 hours -Tight cast => compartment syndrome >> Univalving = 30% pressure drop >> Bivalving = 60% pressure drop >>Also need to cut cast padding -Abrasions / Cellulitis -Loss of reduction -Thermal Burns → avoid plaster > 10 ply and water > 24°C -DVT/PE: ↑ in lower extremity # -Joint stiffness → Leave joints free when possible and splint in in position of function

Low risk criteria for infants 4-12 weeks with fever

-Previously healthy -Nontoxic appearance -No focal infection -Good social situation -WBC 5-15 <1.5 bands -Normal U/A <5 WBC/hpf -Diarrhea <5 WBC/hpf

High risk for endocarditis

-Prosthetic heart valve -Hx of endocarditis -Unrepaired cyanotic CHD (including palliative shunts, conduits) -Completely repaired CHD with prosthesis during first 6 months post op -Repaired CHD with residual defect (at or near site) of prosthetic valve -Cardiac valvulopathy in a transplanted heart -HCM -MVP with regurgitation -IVDU

Echo findings of tamponade

-RA compression -RV collapse -Hepatic vein dilation -Dilated IVC (no collapse with respiration) -Abnormal TV and MV flow velocities

Physical exam findings of basilar skull fracture

-Racoon Eyes -CSF Otorrhea -CSF Rhinorhea -Hemotympanum -Battle Sign -Acute hearing loss (CN8 injury) -Bilateral CN 7 palsy (looks like 'bilateral bells') -blood in the external auditory canal

Acid-base disturbances in salicylate toxicity; treatment

-Respiratory alkalosis (early) - stimulates respiratory center in medulla -Respiratory acidosis (late) - prolonged high ASA levels depress drive / LOC (preterminal) -Metabolic alkalosis - dehydration, emesis, diaphoresis (contraction alkalosis) -AGMA - early salicylates are a weak acid; late uncoupling of oxidative phosphorylation, increased lactate Treatment: IVF rehydration, K replacement (needed to alkalinize urine), HCO3 to alkalinize urine to trap salicylates, dialysis for AMS, hepatic/respiratory/renal failure, rising salicylate, failure to respond/unable to use (fluid overload) to conservative tx

Indications for intubation and mechanical ventilation?

-Respiratory arrest -Decreased LOC despite maximal therapy -Cardiovascular instability -NIPPV failure or unable to use (exclusion criteria) -Severe dyspnea -Severe tachypnea -Life-threatening hypoxia -Severe acidosis / hypercapnea -Severe illness requiring respiratory support

Definition of acute MI

-Rise and fall of troponin with: ischemic symptoms, Q waves, ST/T changes, coronary artery intervention -Pathological evidence

DDx of the painful hip

-SCFE -Perthes' disease -Bursitis -Tendonitis -Toxic synovitis -Septic arthritis -OA -Arterial insufficiency -AVN femoral head -DVT -Ligament injury (hip, knee) -Occult fracture -Tumour (lymphoma) -Referred pain (spine, knee)

What key feature distinguishes spinal and neurogenic shock?

-SPINAL SHOCK - bulbocavernosus reflex lost; refers to neuro symptoms -NEUROGENIC SHOCK - shock that occurs due to disruption of sympathetic outflow; bradycardic

What is the Ashman phenomenom?

-Seen in supraventricular tachyarrhythmias (generally AFib) -Long R-R interval (has long refractory period) followed by a short R-R interval results in part of the right bundle being refractory -Get a RBBB waveform that looks like a PVC

Indications for IVF in pediatric gastroenteritis

-Shock-Severe dehydration -Deterioration with ORT -Intractable vomiting -Failure to rehydrate with ORT in 8h

Anatomic differences in pediatric patients that change response to trauma

-Small size = more multitrauma -Less protective fat/muscles = more internal organ injuries (liver, spleen, kidneys) -Elastic chest wall = lung injury without # -Open growth plates = different fracture patterns -Large surface area = quicker hypothermia -Faster metabolic rate = quicker desat, hypoglycemia -Better at maintaining BP = tachy as only sign of shock -Bigger head-to-body, thin skull, less myelin = more head injuries -More elastic vertebral column = more SCIWORA -Bigger head = higher fulcrum = C2-3 versus C6 injuries more common

Signs of cholecystitis on ultrasound

-Stones / biliary sludge -Wall thickening (2-4mm) -Distension of GB (>4cm wide or 10cm long) -Pericholecystic fluid -Air in the GB wall (emphysematous or gangrenous cholecystitis) -Murphy's sign (sonographic)

DDx for transaminitis

-Structural: o Inflammatory/ Autoimmune/ Infiltrative: autoimmune hepatitis (PBS, PSC), NASH (? d/t insulin resistance), amyloid o Vascular: Budd-Chiari (thrombosis of hepatic veins or IVC/SVC), portal vein thrombosis, ischemia, CHF o Congen/Degen: neonatal hepatitis -Toxicology: acetaminophen, EtOH, INH, iron, phenytoin, ecstasy (autoimmune hepatitis) -Infection: o Viral: HAV, HBV, HCV, HDV, HGV, EBV, CMV o Protazoan: amoeba o Toxoplasmosis o Associated with bacterial sepsis -Metabolic: Wilson's disease (copper overload), Reye's syndrome, hemochromatosis -Pregnancy: Fatty liver of pregnancy -GI: gallstones, strictures, cholangitis, biliary/pancreatic cancer, annular pancreas (obstructive causes)

Triad of shaken baby syndrome

-Subdural hematoma -Cerebral edema -Retinal hemorrhages

2 additional management considerations in the initial resuscitation of the pregnant trauma patient

-Supine hypotension due to compression of IVC by uterus (lean to the left 30 degrees) -Feto-maternal hemorrhage - do type and Kleihauer-Betke test and treat with WinRho prn

Types of rectal abscess

-Supralevator (high and deep) -Intersphincteric (internal, above pectinate line) -Ischiorectal (lateral; may be able to drain in ED - controversial) -Perianal and Perirectal (only ones we'd drain in ED) Always tx with tetanus; Abx if DM/ immunocompromised/ valvular disease

What are the seronegative spondyloarthropathies?

-They are RF NEGATIVE and HLA B27 POSITIVE . Generally involve the axial skeleton (not extremities) PAIRS - P soriatic arthritis (affects smaller joints, sausage fingers and psoriasis) A nkylising spondylitis (males, back pain, sacroiliitis, bamboo spine) I nflammatory bowel disease R eiters syndrome / reactive arthritis (post GU chlamydia or GI shigella, salmonella, campylobacter, yersinia infection)

Pediatric vs adult bones

-Thicker and more stable periosteum -Faster healing with less immobilization -Better remodeling capability and vascularity -Growth plates weaker than ligaments -More porous and pliable

Stroke mimics

-Todd's Paralysis (postictal) -Hemiplegic migraine -Bell's Palsy -Hypoglycemia/DKA/HONK -MS -Hypertensive encephalopathy -Wernicke's -Central venous sinus thrombosus -ICH - SAH/SDH/EDH -Brain tumor -Conversion disorder -Meningitis/Encephalitis/Abscess

Causes of persistent air leak on a chest tube

-Tracheobronchial transection -Bronchopulmonary fistula -**Incomplete insertion of chest tube** -Leak in the chest tube system

Treatment of arterial air embolism

-Trendelenburg or LLD position -Needle aspiration -Thoracotomy -Aspiration via central line -Compression of source vessel -IVF

What is serum sickness (pathophys, cause, presentation, treatment)?

-Type III hypersensitivity response with immune-complex complement fixation in vessel walls. -Associated with penicillin, sulpha, NSAIDs, Dilantin, Procainamide -Get erythema to fingers/toes, then urticaria, lymphadenopathy, arthralgias, constitutional symptoms 7-21 days after exposure. -Give steroids if severe

Physical exam signs of sexual abuse

-Unexplained vulvar bruising -Hemorrhage -Hymenal or vulvar tears -Loss of hymen out to the margin of the vagina -Signs of STI's (gonorrhea, chlamydia, hsv2, syphilis, trichomonas) Can get HPV, HSV1, Gardnerella vaginosis, Hepatitis B/D and AIDS without assault.

Options for LA in lidocaine allergy

-Use code lidocaine (preservative-free) -Use ester local anesthetic (benzocaine, tetracaine) -Use Benadryl -Test dose pre-use -Use skin glue and/or steri-strips to close wound

Gamma hydroxybutyrate uses, effects, presentation

-Used recreationally, for date rape, and for bodybuilding -Affects dopamine release (inhibits and releases) and binds GABA -Present with decreased LOC, respiratory effort, emesis and mioisis. Rapidly fluctuating LOC and agitation.

DDx for retinal hemorrhages

-Vaginal delivery (resolve in 10-14 days) -Bleeding disorders -AV malformations -Meningitis -Severe accidental head injury

How long are these pediatric rashes congagious for? (varicella, rubella, measles, parvovirus)

-Varicella - 2 days before until lesions are all crusted over -Rubella - 1-2 weeks before they present with rash -Measles - 5 days before and 4 days after -Parvovirus - a week before until the rash starts

Inadequate view of prevertebral soft tissue in children

-View taken on EXpiration -Flexed or neutral (rather than extended) neck

Causes of HSP

-Viruses (EBV, Measles, Mumps, Rubella, Chickenpox, Parvovirus B19) -Bacteria (Shig, Salmonella, Campylobacter, Mycoplasma, GAS) -Drugs (ampicillin, erythromycin, penicillin, quinidine, quinine) -Insect stings

Indications for additional workup of jaundiced infants

-Within 24h of birth -Conjugated -Rapidly rising -No response to phototherapy -Level approaching exchange threshold -Lasts >3 weeks -Toxic appearance

Reasons for treatment failure of an appropriate antibiotic

-Wrong dosage -Wrong duration -Noncompliance -Immunocompromise -Local resistance patterns

Zero order vs First order kinetics

-Zero - constant amount per unit of time (alcohol at low levels, acetaminophen at high levels, salicylates at high levels) -First - constant proportion per unit of time (CO, alcohol at high levels due to Microsomal Ethanol Oxidizing System, acetaminophen at low levels, salicylates at low levels)

Signs of eye pain without a serious origin

-cornea clear -anterior chamber clear -pupils normal in size and reactivity -visual acuity normal or near-normal -extraocular eye movements normal -proptosis absent - eyeball is not tender on palpation

Risk factors for decompression sickness

-dehydration -prolonged dive -inexperienced diver -not using dive tables -multiple dives in a short period -depth of dive -flying after diving -exceeding no-decompression limits -elderly -obesity -cold after diving

Signs of urethral injury. Most reliable in female?

-high riding prostate -blood at the meatus -open pelvic fracture -Scrotal hematoma -Penile Hematoma -perineal hematoma -failure to pass foley x 1 -Fractured penis In female the most reliable sign is inability to pass a Foley catheter

TWhy are children at increased risk from weapons of mass destruction?

-increased RR = increased susceptibility to airborne agents -short = heavy chemicals travel low to the ground increasing exposure -greater surface area to volume ratio and decreased skin thickness = increased proportional absorption -decreased fluid reserves and increased metabolic rate = increased dehydration from V/D and increased toxicity from some exposures (I131)

Characteristics that predispose to violent behavior

-male -hx violence -substance abuse -Poor impulse control or anger control -acute psychosis -Mania -head injury -Dementia -hypoxia -Metabolic disorder

Indications for bicarbonate therapy

-pH <7.1 -HCO3 <12 -Refractory hypotension (to pressors) -TCA toxicity -ASA toxicity -Phenobarb overdose -Ethylene glycol and methanol ingestion Empiric dose is 1 mEq/kg with 1/2 as a bolus and 1/2 over 4 hours

Features suggestive of external eye pain

-pain sensation is usually itching, gritty, scratching, or burning (not a deep-seated ache) -pain is significantly improved by topical anesthetics -eye discharge is common (watery, mucoid or purulent depending on etiology) -photophobia and blepharospasm may be present -visual acuity is usually normal or near-normal (there may be some blurriness) -preauricular lymphadenopathy may be present (e.g. viral or chlamydial conjunctivitis)

False positive free fluid on FAST

-peritoneal dialysis -ascites -physiologic free fluid in female -urine from bladder rupture -Ruptured Ectopic Pregnancy -PID -fluid in bowel or stomach -mesenteric fat -Operator inexperience

Features suggestive of internal eye pain

-severe eye pain (unrelieved by topical anesthetics) -impaired vision -poorly reactive pupils -abnormal slit lamp examination +/- abnormal intra-ocular pressure

Contraindications to LP

-skin or soft tissue infection at puncture site. -Likelihood of brain herniation (mass lesion, papilledema) -INR>1.5 -Plt < 50

Hunt & Hess grading system for SAH

0-5 (prognosis good for 0-1; intermediate 3; poor 4-5) 0 - Unruptured 1 - Asymptomatic / headache 2 - mod-severe headache, nuchal rigidity, nothing focal 3 - decreased LOC, mind focal deficit 4 - stupor, hemiparesis 5 - coma, decerberate

How to remove ticks

1 - "Tweezer" method: Grasp w/ Tweezers close to skin, slow and steady, ensure removal of head; keep for inspection 2 -"Straw Knot" Subtle but constant upward pressure on the string once the tick is "caught" with the knot. 3 - Excisional technique - excise tick with the tissue around it - cut elpitically, close with simple interrupted 4 - Kill with viscus lidocaine a. Grasp with blunt forceps as near to attachment as possible b. Gentle upward traction to remove (no squeezing or jerking)

How does Digoxin work?

1 - Blocks Na/K ATPase leading to increased intracellular Ca++ (increased inotropy, tachyarrhythmias) 2 - Increases vagal tone (anti-arrhythmic, bradyarrhythmias)

Causes of large bowel obstruction

1 - Colorectal cancer 2 - Volvulus 3 - Diverticulitis 4 - Extrinsic compression from mets Also: Abscess, stricture due to chronic ischemia, fecal impaction, IBD, CF, Hirschsprung's, body packers/stuffers, Ogilvie's (pseudo-obstruction)

Contraindications to ED Cardioversion of AFib

1 - Lasted > 48 hours 2 - Rheumatic heart disease 3 - Mechanical valve 4 - History of stroke/TIA

Diagnostic criteria for dementia

1 - Memory impairment AND 2 - One of aphasia, apraxia, agnosia, impairment in executive functioning -Causing significant impairment -NOT due to delerium

ECG changes of pericarditis and how are they different than MI

1 - PR depression and diffuse STE (hours to days) 2 - Normalization of ST segments and flattening of T waves 3 - Deep, symmetrical T wave inversion 4 - ECG reverts to normal (sometimes T waves remain inverted) Different than MI: non-anatomic pattern, concave up, no Q waves, no dynamic worsening

Treatment options in patients with vWD

1 - Tranexamic acid or Aminocaproic acid (plasmin inhibitors - 5g po/iv) 2 - DDAVP (releases vWF and F8 from endothelium - 0.3mcg/kg SC/IV or 1.5mg nasal spray x 2) 3 - Humate-P F8 concentrate (need to ensure it has enough vWF) 4 - Cryoprecipitate (not recommended due to potential for viral transmission)

International Headache Society Migraine Definition (without aura)

1 --> 4 to 72 hours 2 --> At least two of the following: -Aggravation by or causing avoidance of routine physical activity -Moderate or severe pain intensity -Pulsating quality -Unilateral location 3 --> During headache, at least one of the following: -Nausea and/or vomiting -Photophobia and phonophobia 4 --> Not attributed to another disorder 5 --> History of at least five attacks fulfilling above criteria

Mallampati classification

1 -> visible tonsillar pillars, fauces, uvula, soft and hard palate 2 -> visible uvula (except tip), fauces, soft and hard palate 3 -> visible soft and hard palate and base of uvula 4 -> visible hard palate only

Criteria for involuntary admission for mental health reasons

1 Suffering from a mental disorder 2 Likely to harm themselves or others or substantially deteriorate physically or mentally 3 Unsuitable for admission other than as a formal patient (not willing to come voluntarily)

Define futility in medical interventions

1 effective in <1% of identical cases (thorocoromy in blunt trauma and ooha) aka goal futility 2 physiologic, when known anatomic or biochemical abnormalities will not permit interventions (rigor mortis, algor mortis, decapitation) 3 intervention would not achieve the patient's goals for medical therapy in accordance with their values (requires surrogate or records) aka value futility

Pediatric vs adult CPR: 1 rescuer ratio, 2 rescuers ratio, rate, depth, monophasic J, biphasic J, Epi dose, Amiodarone dose

1 rescuer ratio - 30:2 both 2 rescuers ratio - 30:2 adult, 15:2 peds rate - 100 both depth - 2 inches adult, 1/3 of chest AP diameter peds monophasic J - 360J adult, 2 then 4J/kg peds biphasic J - 200J adult, 2 then 4J/kg peds Epi dose - 1mg adult, 0.01mg/kg peds Amiodarone dose - 300mg adults, 5mg/kg peds

IJ central line complications and treatment

1) Air embolism - supportive care, fluids, aspirate air, thoracotomy 2) Dysrhythmia - pull back insulting device (wire, line) 3) Pneumothorax - chest tube, O2, aspiration, Hiemlich valve 4) Arterial puncture with finder needle - with draw 5) Hematoma - pressure 6) Bleeding - pressure 7) Right atrial or ventricular perforation - Cardiac surgery consult

Complications of physical restraints

1) Asphyxia 2) Abrasions 3) Compartment Syndrome 4) Aspiration 5) Death 6) Fracture 7) Skin breakdown

Gastroenteritis bugs that require treatment

1) Culture positive, 2) immunocompromised, and 3) not improving Also: -Shigella dysentariae (even if asymptomatic - public health) -Yersinia (even if asymptomatic - public health) -Salmonella typhi in food handlers, healthcare workers, severe colitis, <3m/o, >50yo -Bacillus anthracis -C difficile -Giardia Lambia -Entamoeba histolytica

Risk factors for TB

1) HIV 2) Close quarters (military, native american, LTC) 3) travel to endemic area 4) homeless 5) IVDU 6) Close contact with patient with TB 7) Occupational exposure 8) Foreign born

DDx for elevated troponin

1) Myocardial Infarction 2) Myocardial contusion 3) Chronic renal insufficiency for Troponin T 4) PE 5) Myocarditis 6) Acute heart failure 7) Perimyocarditis 8) Sepsis, ARDS, end organ strain 9) post-Cardiac procedure (cath, Surg, ablation) 10) Cardiomyopathy (Tako-tsubo) 11) Sympathomimetic drugs (cocaine!) 12) Aortic Dissection 13) Radiation therapy

Steps for accessing a fistula if necessary

1) No tourniquet! 2) Sterile/Clean Prep 3) Firm steady pressure for 10 min after 4) Document thrill before/after 5) continuous infusion to maintain laminar flow and prevent stasis 6) avoid puncturing posterior wall of vessel

Potential treatments of upper GIB

1) Pantoloc 2) Octreotide 3) Ceftriaxone 4) Erythromycin 5) Vitamin K 6) Vasopressin 7) EGD (EsophagoGastroDuodenoscopy) 8) Blakemore 9) Interventional radiology 10) Surgery

Drugs that cause thrombocytopenia

1) Septra 2) Quinine 3) NSAIDS 4) Heparin (unfractionated, LMWH) 5) HCTZ 6) Amiodarone 7) Abciximab (GpII b IIIa inhibitor) 8) Rifampin 9) Ethambutol 10) Dilantin 11) Valproic acid 12) Ethanol

Febrile traveler incubation periods

1-3 weeks -Plasmodium falciparum 6-30d; vivax 8d-3y -Dengue fever 3-14d -Spotted fever ricketsiae 3-21d -Meningococcemia 2-10d -Acute HIV 8-28d -Ebola and other hemorrhagic fevers 2-21d 4-6 weeks -Hepatitis A 15-50d, E 26-42d -Schistosomiasis 4-6 weeks -Amebic liver abscess weeks to months >6 weeks -Hepatitis B 60-150d; C6 6-10 weeks -Tuberculosis weeks-years

Contraindications for fibrinolytic in STEMI and PE

1-Dissection? Stroke 2-Prior ICH? 3-Ischemic stroke in last 3m? Bleed 4-Known vascular lesion? (AVM) 5-Known intracelebral neoplasm? 6-Significant head/facial trauma in last 3m? Can't Clot 7-Active bleeding 8-Bleeding diatheses?

Indications for an ICD

1. Cardiac arrest from VF or VT not caused by a reversible event 2. Spontaneous sustained VT 3. Syncope of undetermined origin with inducable VT or VF 4. Nonsustained VT with coronary artery disease, prior myocardial infarction, left ventricular dysfunction, and inducible VF

Anorexia behavioural characteristics

1. Excessive exercise 2. 'Type A' perfectionist oriented personality 3. Restricting 4. Purging 5. Body dysmophia, fear of gaining weight, lying re: intake 6. Laxative abuse 7. Food- refusal, preoccupation, lying re:intake, denial of hunger 8. Depression 9. Social isolation

HIV prophylaxis - bugs and drugs

1. PCP (Septra) 2. Toxo (Septra) 3. TB (INH) 4. MAC (Azithro) 5. CMV (Gancyclovir)

Differences between the adult and pediatric C-spine

1. a proportionally heavier head 2. higher fulcrum of flexion 3. Less neck muscle mass 4. lax ligaments, allowing for more mobility at C1-C2; 5. incomplete ossification / un-fused physes; 6. horizontally inclined articular facets that facilitate sliding. 7. Anterior wedging of vertebral bodies 8. Pseudosubluxation of C2 on C3 9. Secondary ossificaiton centres may mimic avulsions 10. Variable interspinous distances 11. Widening of the pre-dental space (up to 5mm) 12. Lateral displacement of the masses C1 on C2 13. instability of atlanto-axial joint 14. SCIWORA - due to flexibility of bone

Indications for admission of renal colic

1. infected stone 2. pregnant 3. septic 4. intractable vomiting 5. severe pain 6. urinary extravasation 7. Hypercalcemic crisis 8. Single kidney

Presentation of fat embolism

1.Respiratory distress (earliest and most common manifestation) 2.Neurologic manifestation (confusion, ↓ LOC) 3.Thrombocytopenia 4.Petechial rash 5.Fever, tachycardia, jaundice, retinal changes and renal involvement may occur Fat in urine in 50% within 3 days

Signs of pulmonary edema on CXR

10 classical findings: 1. Cephalization of Vascular markings (marked pulmonary redistribution) 2. Enlarged Heart Shadow - Cardiomegaly 3. Prominent Azygous Vein 4. Bat wing hilum 5. Kerley A lines 6. Kerley B lines 7. Kerley C lines 8. Peribronchial Cuffing 9. Pleural Effusion 10. Interlobar Fissure lines

Congenital Adrenal Hyperplasia abnormalities

21-hydroxylase deficiency Low Na and High K Virulized females, small penis in boys Treat with glucose and hydrocortisone

False negative free fluid on FAST

250-500mL of fluid must be present to be visible on FAST (Sn 60-99%; Sp 80-99%) -small volume -Early in trauma -Adhesions -Timing (not enough preceding time supine) -Operator inexperience

Temperature of hypothermic physiological changes

28 - VF 30 - ACLS meds effective 32 - shivering loss 34 - ataxia and apathy

Types of abuse

3 categories: -Domestic -Institutional -Self Multiple types -Physical -Emotional -Sexual -Neglect -Abandonment -Financial -Factitious disease (Munchausen's by proxy)

Indications for rescue PCI

3 indications CP not resolved Persistent ST elevation Hemodynamically unstable

Surviving sepsis bundles

3h -measure lactate -blood cultures -broad spectrum antibiotics -30ml/kg bolus for lactate >4 or hypotension 6h -vasopressors if map<65 -reassess volume status and perfusion (vitals, cardiopulmonary exam, cap refill, pulse, skin) or get 2 of CVP, ScvO2, cardiac ultrasound, fluid challenge/leg raise -remeasure lactate if elevated

Contraindications to high altitude travel

4 -COPD -Pulmonary hypertension -CHF -Sickle cell Relative contraindications -Pregnancy -Radial keratotomy -Seizure disorder -Previous altitude sickness

Diagnostic criteria for delerium

4 criteria: -Inability to focus/Inattention -Fluctuating course -Cognitive deficit (memory, disorientation, language) or perceptual disturbance not caused by dementia -Evidence that it is caused by a medical condition, ingestion, or withdrawl

What is hypochondriasis? Treatment?

4 key features: -Symptoms are more than the organic disease that is evident -Fear of disease and conviction that one is sick -Preoccupied with their body -Persistent and unsatisfying pursuit of medical care Treatment -Reassurance, legitimize, share diagnostic uncertianty, assure ongoing care, avoid drugs that cause dependency, come up with realistic treatment goals focused on symptom control, arrange single-physician follow-up

The H's and T's

5 H's H ypoxia H ypovolemia H ydrogen ion (acidosis) H ypo / H yper kalemia H ypothermia 5 T's T ension pneumothorax T amponade T oxins T hrombosis (pulmonary) T hrombosis (coronary)

AHA chain of survival

5 links 1 Early recognition of arrest and activation of EMS 2 Early CPR 3 Rapid defibrillation 4 Effective ALS 5 Integrated post arrest care

Indications for neonatal intubation, tube size

6 reasons HR< 60 Meconium aspiration in a flat baby Ineffective or prolonged PPV Congenital diaphragmatic hernia <1000g Delivery of meds Tube size 3.5 if TERM

Weight estimate in children

8 + (age x 2) Up to 8yo

Empiric treatment for meningitis

<1m: Ampicillin (Listeria) & Cefotaxime (Kernicterus) 1-50y or basal skull: Ceftriaxone & Vancomycin >50y: Ampicillin (Listeria), Ceftriaxone, Vancomycin Instrumentation or penetrating trauma: Vancomycin & Ceftazidime

BLS Choking

<1y -Alternate 5 back slaps and 5 chest thrusts until unresponsive 1 to puberty -Abdominal thrusts until unresponsive Puberty to adult -Abdominal thrusts UNLESS pregnant or obese (then chest thrusts) until unresponsive All -If unresponsive with no or agonal breathing begin CPR -Check mouth for FB q breath stop

Management of otitis media

<6 months - antibiotics 6 months to 2y - antibiotics if certain; observe if uncertain 2y - antibiotics if severe; observe if uncertain Observe = reassess in 48-72h

Diagnosis of schizophrenia

>2 of these symptoms for >1 month -Delusions (if delusions bizarre counts as 2) -Hallucinations (if running commentary counts as 2) -Disorganized speech -Disorganized or catatonic behavior -Negative features (avolition, poverty of speech, flat affect) As well as: -Sharp deterioration -Disturbance for >6 months (with prodrome) -Other causes ruled out

Indications for immediate removal of a foreign body in the stomach

>2.5cm wide >5cm long Sharp Toxic (e.g. lead) >3-4 weeks impaction 90% of objects that make it to the stomach make it all the way through. If past the pylorus things can generally be left alone (then require surgery rather than endoscopy). Remove if hasn't moved in 3-4 weeks.

Indications for surgery to remove a foreign body in the small intestines

>99% of these pass without problem -Hasn't moved for >7 days -Hasn't passed in >4 weeks ->1 industrial strength magnet (not a fridge magnet)

FDA classifications of pregnancy risk for drugs

A - controlled studies showing no riskB - animal studies no risk, no controlled human studies C - adverse effects in animals, no human studies D - evidence of risk, use if benefits > harms X - contraindicated in pregnancy

How do you calculate Boehler's angle?

A = Posterior tuberosity B = Apex of posterior facet C = Apex of anterior process

Dialyzable drugs

A BIT SLIMED A rsenic / ANTS (BB's Atenolol / Nadolol / Timolol / Sotalol) B arbiturates I soniazid T heophylline S alicylates L ithium I ctogenic drugs (Valproate, Phenobarb, Carbamezapine) M ethanol E thylene glycol / E thanol D abigitran

Define flail chest and how it causes respiratory compromise

A flail chest has at least 3 continuous ribs, 2 breaks each. This results in paradoxical breathing and inadequate inspiration / expiration. It is also very painful

Erythema nodusum definition, symptoms, treatment

A hypersensitivity vasculitis of the venules of the subcutaneous layers of the skin (inflammatory reaction of dermis and adipose tissue as well). Characterized by painful, subcutaneous nodules that last 3-8 weeks along with fever, malaise, and arthralgias. Treatment: NSAIDS, elevate legs for pain, wear stockings, Potassium iodine (weird!), and steroids (if severe)

Confidence intervals P values vs CI's

A measure of the range of variability around an estimated parameter. Are generally 95%, meaning 19 out of 20 replications of the study will have an estimate of the parameter of interest within the confidence interval. P-values tell you if something is different, CIs illustrate the precision and magnitude of the likely difference.

Hepatitis post-exposure prophylaxis

A: HAIg to unvaccinated close personal contacts, childcare workers/attendees (people who wipe their bum), similar food-borne source in last 2/52 B: HBIg to: -unvaccinated / low titer recipients exposed to source that is HBV sAg + OR high risk -neonates with HBV sAg + mothers C: N/A

Lateral soft tissue x-ray findings of epiglottitis

AAA PBL on TV A ir fluid level A ryepiglottic fold swelling A rytenoid swelling P revertebral tissue swelling B allooning of the hypopharynx L oss of L ordosis T humbprint epiglottis V allecula obliteration

Transfer to a burn center

ABA -Partial thickness burn 10% BSA (2nd degree) -Any 3rd degree burn -Burns to face, hands, feet, genitalia, perinium, joints -Electrical (including lightning)/ Chemical/ Inhalational burn -Pre-existing medical conditions that complicate management -Children at a location that can not care for children -Cocomitent burn and trauma where the burn is the greatest danger -Burn injury in patients requiring social, emotional, rehabilitative intervention

General approach to the intoxicated patient

ABCDDDEF Airway Breathing Circulation Dextrose Decontamination Diagnosis (ECG, VBG, acetaminophen, ASA, osmolality, EtOH) Exposure (features of toxidrome) Elimination (enhance it) Find an antidote

Medical treatment of increased IOP

ABCDPS A lpha 2 agonist (Apraclonidine 1% - decrease production and increase outflow) B eta blocker (Timolol 0.5% - decrease humor production) C holinergic (Pilocarpine 1% - constricts pupil and opens trabecular meshwork) D iuretics (acetazolamide decrease production and increase flow / mannitol - increased drainage) P rostaglandins (Latanoprost - increase outflow) S teroids (Prednisone acetate 1% - decrease inflammation)

Thoracotomy indications and contraindications in thoracic trauma

ABSOLUTE Any - Unresponsive hypotension (BP <70mmHg) Penetrating - arrest with previously witnessed cardiac activity Blunt - Rapid exsanguination from chest tube (>1500ml) RELATIVE Penetrating - arrest WITHOUT previously witnessed cardiac activity Blunt AND penetrating NON-thoracic - arrest with previously witnessed cardiac activity (pre-hospital or in-hospital) CONTRAINDICATIONS -Blunt thoracic injuries with no witnessed cardiac activity -Multiple blunt trauma -Severe head injury

Types of hypersensitivity reactions

ACID I A naphylaxis - IgE-mediated degranulation of mast cells and basophils II C ytotoxic - IgG mediated complex fixation III I mmune complex - IgG or IgM antigen-antibody complex deposition IV D elayed - T cell mediated

Indications for dialysis in renal failure

AEIOU A cidosis / A lkalosis (note: HCO3 can precipitate tetany/convulsions in the setting of hypoCa) E lectrolyte abnormalities (HyperK, HyperMg, HyperCa - MM) I ngestions that are dialyzable O verload of fluid (CHF, pulmonary edema, severe HTN) U remia (pericarditis, N/V, lethargy)

Signs of Delirium (for Confusion Assessment Method, CAM)

AIDA A - cute and fluctuating I - nattention D - eficit cognitively (memory, orientation, language) D - isturbance perceptually Not caused by dementia

What is VATER Syndrome?

AKA VACTERAL Association, these conditions occur together more commonly than would be expected otherwise Vertebral anomolies Anal atresia Cardiac defects Tracheo-esophogeal fistula Esophageal atresia Renal anomolies Limb defects

Define and give a DDx for ALTE. How many kids with ALTE have SIDS?

ALTE is an acute, unexpected change in an infant's breathing (apnea, choking, or gagging), appearance (color change), or behavior (loss of muscle tone) that frightens the observer. Prevalence peaks at 10-12 weeks but can occur in children <1yo. ALTE's not correlated with SIDS! -Neuro - Seizures/Hydrocephalus -Cardiac - Arrhythmia, Congenital heart disease -Respiratory tract infection (Pertussis, RSV) -GI - GERD (Sandifer syndrome) -Metabolic - Hypoglycemia, inborn errors of metabolism, hyponatremia -Sepsis - pneumonia, UTI -Heme - anemia -NAT -Factitious illness -Toxins

Abuse fracture patterns

ANY in a child <1yo Bucket Corner** Diaphysis of humerus, radius, femur, tibia (especially <3yo) Rib** Scapular** Spinous process** Sternum** Skull (stellate)* Vertebral* Digits* Multiple* or Bilateral Different stages of healing*

Down syndrome congenital problems

AO instability Large tongue Increased secretion hypothyroidism Heart disease Tetrology of fallot GI obstruction from pyloric stenosis, duodenal atresia, annular pancreas, Hirschsprungs, imperforate anus

Absolute risk reduction Relative risk reduction NNT / NNH

ARR = Experimental event rate - Control event rate RRR = ARR / Control event rate NNT or NNH = 1/ARR

Distinguishing murmur of AS vs HOCM

AS is more likely to have insufficiency on top of other findings. Valsalva (increased intrathoracic pressure decreases pre and afterload) - HCM louder and AS quieter Squat (increased SVR increases pre and afterload) - HCM quieter and AS louder

Toxic levels: ASA, APAP, Iron, Digoxin, Lithium, Lead, Methanol, Ethylene Glycol, TCA, Theophylline

ASA Dose: 200mg/kg dose Levels (rule of 7's): Therapeutic 0.7-2.1; signs/symptoms >2.8; bicarb >3.5; dialysis chronic >3.5mmoL/L and Acute >7mmol/L APAP Dose: 200mg/kg/24h dose; >150mg/kg/d for 48h; >100mg/kg/d for 72h Level: >1000mmol/L Iron Dose: 20-40mg/kg (mild); 40-60mg/kg (mod); >60mg/kg (severe) Level: >90mmol/L Digoxin Dose: 0.1mg/kg Level: >19mmol/L acute; >12mmol/L chronic Lithium Level: >4mmoL/L acute; >2.5mmoL/L chronic Lead Acute level: >3.4 (IV chelation) Chronic level: >2.2 (PO chelation) Methanol Dose: 0.15mL/kg of 100% Level: >6mmol/L toxic; >15mmol/L HD Ethylene Glycol Dose: 0.2mL/kg of 100% Level: >3mmol/L toxic; >8mmol/L HD TCA Dose: >5mg/kg Theophylline Level: >100mcg/mL acute; >60mcg/mL chronic HD

Vascular complications of IV drug use

AV fistula and pseudoaneurysms (from 'hitting pink') Unilateral hand edema (obliteration of superficial venous circulation) Distal ischemia (severe burning pain distal to injections; possibly FB, talc, precipitate - nothing works to fix it; can need amputation) Infected pseudoaneurysm (infected mass after hitting artery, reason that we assess abcesses for pulsatility)

What is hydrops fetalis, what causes it?

Accumulation of edema or fluid in 2 or more fetal compartments (subcutaneous tissue or scalp, pleural effusion, pericardial effusion, ascites) It is a form of prenatal heart failure that generally stems from anemia due to 1 Rh disease resulting from previous sensitization 2 infection (CMV, parvovirus, syphilis) 3 alpha thalassemia 4 maternal hyperthyroidism or iron deficiency anemia 5 fetal defects, twin transfusion, pSVT

Physical exam findings of iritis

- red eye - ciliary flush - flare - consensual photophobia - acutely - decreased IOP

Causes of congenital stridor

- treacher-collins - pierre-robin - laryngomalacia - tracheomalacia - vascular ring - unilateral or bilateral vocal cord palsy - laryngeal web - down syndrome - hypothyroidism - glycogen storage disease - lingual thyroid - choanal atresia - mediastinal mass - tracheal stenosis

When should an infant not be resuscitated?

-<24 weeks / SFH < umbilicus -<500g birth weight -Anencephaly -Known chromosomal abnormalities incompatible with life (trisomy 13 or 18) -Stop resuscitation at 10m if there has been no HR or respiratory effort

Clinical criteria for massive hemothorax

->1500 mL immediate output blood from chest tube ->200mL/h drainage x 2-4h -Absent breath sounds, dullness to percussion, and shock with or without tracheal deviation

What is conversion disorder?

-A somatoform disorder -Sudden onset of a single symptom not under the patient's control and often associated with la belle indifference -Generally neurological (motor: tremors, paralysis, pseudoseizures, aphonia, ataxia; sensory: anesthesia, blindness, tunnel vision) -Often a psychiatric coping mechanism

TCA OD treatment and treatments that are contraindicated

-AC / MDAC -HCO3 if QRS >100, Terminal RAD >120, Refractory hypotension, Ventricular dysrythmias, Seizures - bolus until improvement or pH >7.5 -Benzo's for seizures -Consider lidocaine for arrhythmias (all others contraindicated) -Cool prn -MgSO4 / overdrive pacing for long QT -Consider lipid emulsion in refractory cases -Physostygmine, flumazenil and most antiarrhythmics are contraindicated

List the hypertensive emergencies and their ideal treatment (goal)

-ACS - nitroglycerine, labetolol (Asymptomatic) -Heart failure - nitroglycerine, furosemide (25% reduction) -Dissection - esmolol & nitroprusside OR labetolol (<140/90) -Ischemic stroke - nicardipine, labetolol (<180/110 for lytic) -Intracerebral hemorrhage - nicardipine, labetolol (25% reduction) -Hypertensive encephalopathy - nicardipine, labetolol (25% reduction) -Kidney injury - fenoldopam, nicardipine (25% reduction) -Preeclampsia - magnesium and labetolol (<160/110 and asymptomatic) -Sympathetic crisis - phentolamine (25% reduction)

DDx for irregular SVT

-AFib -MAT -Atrial flutter/tachy with variable conduction -Parasystole -Extrasystoles

Strong predictors of VT in a rapid wide-complex tachycardia

-AV Dissociation -Fusion beats -Capture beats -QRS >0.16 -R to nadir of S >0.14 -Extreme left axis -Josephson's sign (notching near the nadir of the S wave - a smaller R prime than R) Brugada and Griffith criteria are too unreliable for use and likely cause harm

Reasons abdominal pain is difficult to diagnose in the elderly

-Abdominal musculature decreases - less likely to show rebound or guarding -Omentum is thinner and less likely to contain intra-abdominal process -Increased rate of atherosclerotic disease - decrease in blood flow leading to increased perforation -Dementia - unable to localize pain and difficult historian -May not present with fever or a WBC - immunosenescence -General physiological changes

Complications of esophageal FB's

-Abscess -Tracheo-esophageal fistula -Aorto-enteric fistula -Perforation and mediastinitis / pneumothorax / pneumomediastinum

Emergent presentations of sickle cell disease

-Acute chest crisis -Priapism -Stroke -MI -Splenic sequestration -Infection/sepsis -Aplastic anemia -Pain crisis

Pathophysiology of AKA

-Alcoholics don't eat and use all of their NADH metabolizing EtOH so they can't make glucose -With glucose low insulin isn't produced -Ketones are produced but, without NADH, beta hydroxybutyrate can't be converted to acetoacetate/acetone -BHB gets elevated (~3-6:1 ratio) -Treat with fluid, thiamine, glucose, potassium - as corrected serum ketones will increase (acetoacetate is detected)

Injury patterns requiring transfer to a trauma center

-All penetrating injuries to head, neck, torso and extremities proximal to elbow and knee -Flail chest -Pelvic fractures -Combination of trauma with burn -Two or more proximal bone fractures -Limb paralysis -Amputation proximal to wrist and ankle

4 tributaries to Kiesselbach's plexus, causes of anterior epistaxis

-Anterior ethmoidal artery -Septal branch of superior labial artery -Nasopalatine branch of sphenopalatine artery -Greater palatine artery Causes -Traumatic -Cocaine -Vasculitis -Platelet -FB -Polyp

Biologic agents that have potential as weapons

-Anthrax -Botulism -Brucellosis -Smallpox -Plague (yersinia pestis) -Tularemia -Viral hemorrhagic fevers (Ebola and Marburg) -Q fever -Viral encephalopathy

Anxiety definitions: Anxiety, Panic attack, Agoraphobia, Social phobia, Phobia, OCD, Generalized anxiety, PTSD, acute stress disorder

-Anxiety: a specific unpleasurable state of tension that forewarns the presence of danger (uneasiness stems from the anticipation of some imminent danger, the source of which is unknown or unrecognized) -Panic attack: discrete period of sudden onset of intense apprehension, often associated with feelings of impending doom -Agoraphobia: Anxiety about place or situations from which escape might be difficult (fear of being along in public places). -Panic disorder with agoraphobia: Pts have recurrent unexpected panic attack and become fearful of situations where they might occur -Specific phobia: irrational fear of something that is perceived as dangerous (normal in children) -Social phobia: anxiety d/t social or performance situations -Obsessive-Compulsive Disorder: Obsessions → stress or anxiety which is relieved by a compulsive behaviour -Generalized anxiety disorder: persistent, excessive anxiety or worry for > 6 months -Post-traumatic stress disorder: Heightened arousal and avoidance of stimulus following a significant traumatic exposure -Acute stress disorder: similar to PTSD occurring immediately in the aftermath of an extremely traumatic event

Causes of mesenteric ischemia and risk factors

-Arterial embolism ~50% - mostly SMA (CAD, valvular disease, AF, aneurysms, dissections, coronary angiography) - needs embolectomy -Arterial thrombosis >15% - mostly SMA and have h/o abdominal angina (elderly, PVD, hypertension) - needs revascularization, heparin -Venous thrombosis <15% (same risk factors as DVT/hypercoaguability; Factor V Leiden most common) - needs heparain, thromboplasty -Non-occlusive - 20% (all shock states, cocaine, vasopressors; >50yo) Lactate is highly sensitive CT angiography is most helpful diagnostic test; Angiography is gold standard and early angiography decreases death

What is the NRP pyramid?

-Assess if resuscitation needed, warm, position and clear airway, dry and stimulate -O2 -PPV -Intubation -Chest compressions -Drugs

Sonographic findings of an abnormal TV ultrasound

-BhCG >3000 and no gestational sac -Gestational sac >13mm and no yolk sac ->5mm crown rump length and no fetal heart tones -No fetal heart tones after 10-12 weeks -Gestational sac >25mm and no fetus

Causes of free fluid in the abdomen

-Blood -Urine -Peritoneal dialysis fluid -Ascites > Liver disease - cirrhosis, alcoholic hepatitis, portal vein thrombosis, Budd-Chiari, liver mets (SAAG>11) > Abdominal or ovarian malignancies / carcinomatosis (SAAG<11) > TB peritonitis (SAAG<11) > Pancreatitis (SAAG<11) > Nephrotic syndrome (SAAG<11) > CHF > Hemodialysis

Physical exam findings of central retinal venous occlusion

-Blood and thunder -Disk edema -Dilated tortuous veins -Decreased visual acuity; -RAPD (if ischemic)

Signs of SAH on CT scan

-Blood in the basilar cisterns >> Interpeduncular [anterior to pons just superoposterior of the suprasellar] >> Suprasellar cistern [star sign] >> Prepontine cistern [just inferoposterior suprasellar anterior to the pons] >> Ambient cistern [bottom star legs around the midbrain] >> Sylvian fissue >> Anterior interhemispheric fissure -Isodense basilar cisterns -Hydrocephalus (temporal horns and infundibulum of 3rd ventricle) -Reflux of blood into the 4th ventricle

Tetrology of Fallot cardiac anomolies

-Boot shaped heart (Fall over your own Boots) -Pulmonary hypertension, VSD, RVH, Overriding Aorta -Ductal dependent lesion that crash after PDA closes (2-10 days, treat with PGE1 0.1mcg/kg/m) Tet spells (knees to chest to increase SVR and O2 to decrease PVR)

ECG changes seen in massive head injury

-Bradycardia -Deep T-wave inversion -ST seg Elevation -ST seg depression -QT Prolongation -PR Prolongation -RBBB / incomplete RBBB -Junctional Rhythm, Sinus Dysrhythmias, Sinus Tachy -U wave > 1mm

Types of dystonic reaction and treatment

-Buccolingual (tongue protrusion) -Torticollus (Head deviation) -Oculogyric (upward eye deviation) -Opisthotonus -Laryngospasm Treat with benztropine (cogentin) 1-2mg +/- benadryl 50mg both IM/IV - continue for 48h with q6h po doses

PID requiring admission

-Cannot exclude surgical emergency (e.g. appendicitis) -Pregnancy -Tubo-ovarian abscess -Severe illness with vomiting or high fever -No clinical response to PO meds in 24-48 h -Unable to FU or tolerate outpatient regimen

Drugs that most commonly cause adverse reactions in elderly patients

-Cardiovascular -Diuretics -Non-opioid analgesics -Hypoglycemics -Anticoagulants -Sedatives

Indicators of inadequate blood flow during CPR

-Carotid or femoral pulse not palpable -CPP <15mmHg -EtCO2 <10mmHg -ScvO2 <30% -Art line DBP <20mmHg

Injuries associated with lap belts

-Chance # -Pancreatic Injury -Duodenal Injury -Mesenteric Injury -Bladder injury

Major and minor criteria for Rheumatic Fever. Treatment.

Jones criteria (requires evidence of strep infection + 2 major or 1 major/1 minor) Evidence of strep infection: 1. Elevated ASOT or other streptococcal antibodies 2. Positive throat culture for Group A beta-hemolytic streptococci 3. Positive rapid direct Group A strep carbohydrate antigen test 4. Recent scarlet fever. MAJOR criteria J - oints - polyarthritis of large joints (knees, elbows, wrist, ankles) <3 - carditis (murmurs, effusions, cardiomegaly, CHF) N - Nodules - subcutaneous on extensor surfaces (wrist, elbow, knees, spine) E - Erythema marginatum (painless, non-pruritic) S - Sydenham's Chorea MINOR criteria F - Fever A - Arthralgias C - CRP E - ESR P - PR interval increased Treatment -Penicillin 500mg adults / 250mg peds x 10 days or Benzathine penicillin 1.2million U adult or 600thousand U children IM; long-term prophylactic antibiotics -Aspirin

Bacteria causing UTI's

KEEPPSSS K lebsiella (institutionalized, newborns) E nterococcus (institutionalized) E coli (>80% of UTI's) P roteus (3-11yo) P seudomonas S taphylococcus saprophyticus (can be normal skin flora in perineum) S erratia S almonella

Hemiparesis ipsilateral to a pupil blown secondary to increased ICP

Kernohan's notch syndrome secondary to uncal herniation compressing the contralateral cerebral peduncle. It results in 'false localization'

Key etCO2 readings during CPR Uses in CPR

Key readings: If <10 improve CPR or patient dead If >40 expect ROSC Key uses: -Monitor quality of CPR -Monitor tube placement -Monitor for ROSC during CPR (will see increase >= 40mmHg) -Determine if ROSC unlikely (persistently <10mmHg)

Classification of AMI severity

Killip classes 1 no failure 2 crackles, S3, elevated JVP 3 frank pulmonary edema 4 cardiogenic shock, hypotension, vasoconstriction (oligurea & cyanosis)

Treatment of Tetrology of Fallot

Knee to chest / squat (increased SVR) IVF (increase preload) Anxiolytic (benzo/fentanyl) (decrease RR and PVR) NaHCO3 (correct acidosis - maybe) Phenylephrine (increased SVR) Propranolol (increased preload) 100% O2 (decreased PVR)

LE sensory nerve testing Femoral Saphenous Sciatic Tibial Common peroneal Superficial peroneal Deep peroneal Sural

LE sensory nerve testing Femoral - anterior thigh / knee Saphenous - medial foot Sciatic - N/A Tibial - sole of foot Common peroneal - N/A Superficial peroneal - dorsum of foot Deep peroneal - first web space Sural - lateral foot

List some symptoms of lead poisoning; Treatment

LEADiNG L - Lead lines E - Encephalopathy (Neuro! seizures) A - Anemia with basophilic stippling (Heme!) D - Drop (wrist) i N - Nephro tubular fibrosis; proteinurea; Fanconi syndrome G - G I (Nausea / vomiting / abdo pain / liver damage) Treatment: WBI, Dimercaprol (BAL) and CaNa2-EDTA (with 2nd dose) for acute/symptomatic; PO Succimer (DMSA) and Penicillamine for chronic

Hand muscles innervated by the median nerve

LOAF muscles Lumbricals 1 and 2 Obducens pollicus Abducens pollicus Flexor carpi radialus

Likelihood ratios

LR's use the sensitivity and specificity of the test to determine whether a test result usefully changes the probability that a condition (such as a disease state) exists. + = Sn / (1-Sp) - = (1-Sn) / Sp

How does lactulose correct hepatic encephalopathy? What are other treatments?

Lactulose is converted to lactic acid, acidifying the bowel contents. This converts ammonia (NH3) to ammonium (NH4+) and its positive charge keeps it trapped in the lumen. Remove other sources of protein (e.g. NG for GIB, protein-restricted diet) Clarithromycin or Flagyl (alter gut flora to decrease ammonia production) Acarbose (changes bacterial activity to decrease ammonia)

Large vessel vasculitis

Large vessel: -Takasayu's - pulseless disease, renovascular hypertension -Giant cell - temporal artery headache, amaerosus fugax

Low to high dose trauma imaging

Least CXR Abdo Flat Plate KUB RUG CT Abdo Most

Conditions that require mandatory reporting

Level 1 (immediate call) ABCDeFGHS -Anthrax, Botulism / Bites from suspec animals, Cholera, Diptheria, e, Food poisoning (Shigella, Typhoid fever, E coli with verotoxin), Febrile with travel, Gastroenteritis at institutions, Hepatitis A, Smallpox -Measles, Meningitis (bacterial - neisseria meningitidis, H influenzae) Level 2 (immediate report - vaccine preventable and GI) -Mumps, Rubella, Pertussis -Amebiasis, campylobacter, giardia, listeria, salmonella, trichinossis, tularemia Level 3 (next working day - STI's) -Chancroid, Chlamydia, Gonorrhea, Hepatitis B & C, HIV, Syphilis

What is the feathering cutaneous burn caused by a lightning strike called?

Lictenburg figure

Anterior cord syndrome; causes

Like a car - if it smashes the front the engine won't work (paralysis and pain) but instruments/GPS will (vibration/proprioception) Causes - Dissection and aorta surgery (Artery of Adamkiewicz), hypotension, vasospasm, thrombosis

Distinguish lingual tonsillitis, epiglottitis, peritonsillar abscess, retropharyngeal abscess

Lingual tonsillitis - hot potato voice, pain on tongue depression, scalloped anterior valecula Epiglottitis - hyoid tenderness and muffled (not hoarse) voice, sniffing position Peritonsillar abscess - hot potato voice, drooling, hallitosis, trismus, inferomedially displaced tonsil Parapharyngeal abscess - same as peritonsillar except can have Horner's and oral/nasal/aural bleeding from carotid. Retropharyngeal abscess - supine with head extended, neck pain, meningismus, cri du canard (duck quack voice)

Causes, diagnosis and treatment of SIADH

Lung -Cancer, pneumonia, TB, abscess CNS disorders Head -Infection (meningitis, abscess), mass (subdural, postop, CVA) Drugs -Thiazides, narcotics, oral hypoglycemic agents, barbiturates, neoplastic agents, vasopressin Diagnosis - low Sosm (<280), high Uosm (>100) with no other explanation Treatment - water restriction, treat cause

Indications for lumbar spine x-rays

M alignancy A ge (<18 or >50) F ever I mmunocompromised N euro deficits (progressive) D uration (>4-6 weeks) W eight loss I VDU T rauma

Ring enhancing lesions on Head CT

MAGICAL DR M - Metastatic lesions A - Abscess / Parasite (Neurocysticercosis, Tapeworm) G - GBM I - Infarction C - Contusion A - Acute Disseminated Encephalomyelitis L - Lymphoma D - Demyelinating disease R - Radiation necrosis

Diagnostic criteria of major depressive disorder

MDD classified as 5 or more of these symptoms occurring most days over a 2 week period along with a change in function. MUST have depressed mood or loss of interest/function. SIGECAPS S - leep I - nterest G - uilt E - nergy C - oncentration A - ppetite P - sychomotor slowing S - uicidal ideation Not a mixed episode, due to anxiety, caused by a general medical condition, or consistent with bereavement (<2 months from loss)

Types/causes of diarrhea

MMISO M alabsorption (short gut, CF, IBD, celiac, lactose intolerant) M otility (DM, neuromuscular, scleroderma) I nflammatory - cellular damage causing secretion; can be hemorrhagic (enterohemorrhagic E Coli, Salmonella) or IBD, autoimmune, chemo S ecretory (Toxin-mediated chloride secretion: Enterotoxic E Coli, Shigella, Salmonella, Vibrio, C Diff; does not decrease with fasting) O smotic (altered gut flora from Noro or Rotavirus; ingestion of sorbitol or lactulose; decreases with fasting)

Symptoms (in order) of NMS, medications that cause it, treatment

MR HA altered M ental status (agitated or catatonic) R igidity (lead pipe, tremor)** H yperthermia** A utonomic instability **rigidity and increased temp are necessary for diagnosis** Medications: typical and atypical antipsychotics, lithium, withdrawl from Parkinson's medications, maxeran Treatment: Benzo's, stop neuroleptics, bromocriptine/dantroline/amantidine, cool, ICU, electroconvulsive therapy (Seriously? Seriously??)

Diagnostic criteria for PID

Major -CMT -Adnexal Tenderness -Uterine Tenderness Minor -Oral temp > 38.3 -AbN cervical or vag discharge -WBC on wet mount of prep -Elevated ESR -Elevated CRP -Lab documentation of G+C

Complicated UTI

Male - dysuria usually UTI, if true UTI generally have an anatomic abnormality (prostate hypertraphy) Anatomic abnormality - catheter, stent, stones, neurogenic bladder, PCKD, instrumentation Recurrant UTI - >3/year Nursing home resident Neonate Immunocompromised

For pancreatitis: -Management principles -Local complications -Systemic complications

Management principles 1. Aggressive IV resuscitation, analgesia and antiemetics 2. Initial bowel rest and then early enteral feeding 3. Monitor electrolytes and replace as needed 4. Early Imaging (U/S) to rule out biliary tract source 5. Consider antibiotics 6. Manage complications (local and systemic) 7. Stress ulcer prophylaxis Local complications 1. Pseudocyst 2. Pancreatic necrosis 3. Pancreatic abscess Systemic complications 1. DIC 2. ARDS 3. ARF 4. Hypocalcemia 5. Shock 6. Hyperglycemic

Subluxed tooth: management, complication

Management: -Pain control -Soft diet -Setting and stabilization of the tooth -Dental referral Complication -Osteomyelitis -Loss of tooth -Alveolar fracture

Diagnostic criteria for a manic episode

Manic episodes are characterized by a >2 week period with elevated/irritable mood and >3 of the following GST PAID G randiosity S leep (decreased) T alkative P leasurable activities / P ainful consequences A ctivity I deas (flight of) D istractable Is not mixed, causes marked impairment or requires hospitalization, not due to a general medical condition.

Conditions that can cause a false positive lipase result (not pancreatitis)

Many false positives at standard cutoff. Quite specific at 5x standard level, but down to 60% sensitivity. 2x cutoff is best for maximal sensitivity/specificity. -Cholecystitis -Bowel obstruction -Peritonitis -Duodenal ulcer -DKA -Trauma -Post ERCP -Idiopathic

Theophylline (mechanism of action, presentation in toxicity, cause of death, treatment)

Mechanism: 1) PDE inhibitor - raises cAMP 2) Adenosine antagonism → cardiac effects 3) direct beta- and alpha-adrenergic agonism Presentation: -GI - Nausea/Vomiting -CVS - Tachydysrhythmias -Resp - Tachypnea & resp alkalosis, ALI -CNS - Seizure, anxiety / Agitation -MSK - Rhabdomyolysis -Metabolic - AGMA (lactate), hypoK, hypoMg, hyperglycemia Cause of death: -Arrhythmia in chronic -Status epilepticus in acute Treatment: -MDAC if early -Dialysis or charcoal hemoperfusion

Esophageal narrowings and risk factors for obstruction / dysphagia

Narrowings -Upper esophageal sphincter (cricopharyngeus) -Aortic arch -Left mainstem bronchus -Lower esophageal sphincter Causes of obstruction / dysphagia Poor dentition (they don't chew) Intrinsic -Esophageal carcinoma -Shatzki's ring -Peptic stricture -Esophageal web Extrinsic -Cardiomegaly -Aortic aneurysms or anomylous right subclavian -Goiter -Mediastinal tumor -Enlarged lymph nodes -Zenker's diverticulum Neuromuscular (Neuro - head trauma, brain tumor, CVA, Alzheimer's, Parkinsons, MS, ALS, Myesthenia; Muscular - achalasia, scleroderma) Toxic (Lead or EtOH) Infectious (Bacteria - diptheria, botulism, syphilis, tetany OR Viral - rabies, polio)

Criteria for BV diagnosis

Need 3/4 (Amsel criteria) -Thin, white, homogenous discharge -Clue cells -pH >4.5 -Fishy odor before/after KOH

Post-LP headache

Needle used -Whitacre -Quincke Cause -Big needle -Too much fluid drawn -Traumatic needle -Stylet not replaced -Bevel not longitudinal Treatments -Analgesia -Caffeine -IVF -Blood patch

Nephrotic vs Nephritic syndrome

Nephrotic - HALEH H ypoalbuminea A lbuminurea (>3.5g/d proteinuria) L ipiduria E dema H yperlipidemia (and clotting - produce increased clotting factors) Nephritic - PHAROH P roteinuria (<3.5g/d) H ematuria (micro or macroscopic) A zotemia (increased urea/Cr) R BC casts O liguria (<400mL/d) H ypertension

Classes of chemical warfare agents

Nerve gas (sarin - highly volatile and acts within seconds, tabun, VX - liquid only, requires dermal exposure, manifests up to 18h later) - organophosphate so treat with Atropine to dry secretions and pralidoxime to prevent aging Vesicants (blistering agents - mustard gas gives bullae resembling 2nd degree burns; airway/mucosal injury is dose dependent; decontaminate with 1:10 hypochlorite (bleach); death from secondary infection) Blood agents (cyanide - treat with hydroxycobalamin) Pulmonary agents (phosgene and chlorine - cause choking and inflammation, no treatment except supportive)

illnesses associated with depression

Neuro - parkinson's, CVA, MS, head trauma Life threatening/altering - Cancer, HIV, CAD, MI, ESRD, dialysis Endocrine - hypo/hyperthyroid, Cushings, Addisons, DM Substance abuse

Sequelae of frostbite

Neuropathic -CRPS -Dysesthesia /paresthesia /anesthesia /hypesthesia -Heat/cold sensitivity -Hyperhidrosis -Raynaud's MSK -Atrophy -Compartment syndrome -Rhabdomyolysis -Stricture -Necrosis -Amputation Derm -Edema -Lymphedema -Ulcers Miscellaneous -Afterdrop -Electrolyte abnormalities -ATN -Sepsis

Drugs that can cause methemoglobinemia and its treatment

Nitrates (NTG, nitroprusside) Local anesthetics (eg benzocaine, lidocaine, prilocaine) Dapsone Primaquine Antimalarials (quinine, chloroquine) Paraquat Naphthalene Methylene blue Treatment: Methylene Blue - reduces Fe3+ back to Fe2+

What is needed for a safe discharge plan?

No RISKS R - oaming/wandering I - mminent danger (falls/fire setting) S - uicidal ideation K - inship and relationship (abuse and/or supports) S - afe driving, S ubstance misuse, S elf neglect

ALS Termination of Resuscitation

No defibrillation (AED or manual) No ROSC prehospital Not witnessed by EMS or bystanders No bystander CPR

BLS Termination of Resuscitation

No defibrillation by AED No ROSC prehospital Not witnessed by EMS

Define alcoholism

No good precise definition. Multifactorial chronic disease with various presentations affecting health, function, relationships At least 3/6 of WITHDraw IT (withdrawal / tolerance lumped together to make 6)

Non-compensatory pause vs compensatory pause

Non-compensatory pause: sinus node is reset and beat following the aberrant beat occurs at the same R-R interval as it would have if it came after a regular beat. Compensatory pause: sinus node is NOT reset. One sinus beat is not conducted (meets refractory AVN) and the next is. The next beat comes after exactly 2x the standard R-R interval.

Fundamental bioethical principles

Nonmaleficence, do no harm Autonomy, a patient with capacity's ability to make personal decisions Beneficence, a duty to confer benefit Confidentiality, no revealing health info without consent Distributive justice, fairness in the allocation of resources and obligations Personal integrity, adhering to ones own set of values and morals

DDx of inverted T's

Normal in children / persistent juvenile pattern Intracranial hemorrhage Myocardial infarction BBB Strain in ventricular hypertrophy Hypertrophic cardiomyopathy PE

Causes of urinary retention

Obstructive 1. BPH 2. Stone 3. tumour 4. gross hematuria 5. FB 6. Phimosis 7. Paraphimosis 8. Meatal stenosis CNS 1. Spinal Cord Injury 2. Neurogenic shock 3. Spinal Epidural Hematoma 4. Syringomyelia 5. DM 6. MS Infectious 1. Prostatitis 2. UTI 3. Tabes Dorsalis (Syphillis) 4.Urethritis 5. Balanophthis Medications 1.anticholinergic 2.anti histamines 3.Narcotics 4.TCA (anticholinergic + antihistamine) 5.alpha agonists 6. antipsychotics (Haldol) 7. NSAIDs Other 1. Priapism 2. Penile Fracture 3. Ureteric laceration 4. Lazy bladder syndrome

Causes of hydrocephalus

Obstructive - proximal to arachnoid granulations -Masses (abscess, granuloma, tumor) -Aquaduct stenosis -Congenital (Dandy Walker, Chiari malformations) Non-obstructive - arachnoid granulations -Infection (meningitis, cysticercosis) -Hemorrhage (SAH, IVH, traumatic) -Choroid plexus papilloma Normal pressure hydrocephalus (idiopathic)

On-line vs off-line medical control

Off-line -Protocols (standing orders, practice guidelines, treatment protocols) -Education (initial and ongoing for all provider levels including dispatch; curriculum, evaluation, administration, revision) -Quality improvement (review/observe performance, remediation, develop time standards) -Other (medico-legal, research, debriefing, complaints) Online -Concurrent direction of field team by protocol or consultation -Has medico-legal responsibility for orders -Can be centralized (one site handles all) or decentralized (hospital receiving patient)

Rashes with vesicle / bullae

Old man with BPPV fell into a pool of necrotizing gonorrhea Bullous Pemphigoid / Pemphigus Vulgarus Necrotizing fasciitis (hemmorhagic) Gonorrhea (disseminated)

Dive injuries

On descent -Ear barotrauma (inner, middle, external) -Mask squeeze (facial barotrauma) -Sinus barotrauma At depth -Oxygen toxicity -Contaminated gases -Hypothermia -Nitrogen narcosis On ascent -Alternobaric vertigo -AGE -Pneumothorax/ Pneumomediastinum/ Alveolar hemorrhage -GI barotrauma -Barodontalgia

Toxic DDx for pinpoint pupils

OopC's Organophosphates Opioids Clonidine Phenothiazines (chlorpromazine) PCP GHB

Drugs that naloxone can reverse

Opioids (all) Clonidine Tramadol EtOH Valproic acid

Management options for a pneumothorax Indications for a chest tube Indicators of treatment failure

Options -100% Oxygen -Aspirate and re-xray -Heimlich valve -Chest tube Indications - Bilateral PTX - Traumatic - Hemopneumothorax - PPV - Tension - Large - Transport/HBO - Respiratory symptoms - Failure of conservative treatment Failure - Persistent or expanding PTX - Persistent airleak - Clinical deterioration (worsening SOB) - Recurrence when CT removed

Treatment of PID

Oral: Ceftriaxone 250mg IM then Doxy 100mg / Flagyl 500mg po bid x 14d IV: Cefoxitin 2 q6h IV + Doxycycline 100mg IV q12h

Cholinergic drugs

Organophosphates Carbamates Edrophonium/Tensilon for Myesthenia Gravis Donepizil/Aricept for Parkinsons Urocholine for bladder spasms Physostigmine

Physical exam findings of central retinal artery occlusion; treatment

PE -Cherry red spot -Pale retina -RAPD -Decreased visual acuity Treatment 1. Globe Massage 2. IOP Mgt (Acetozolamide, Mannitol) 3. Anterior Chamber Paracentesis 4. Thrombolytics (tPA) 5. Bag hyperventilation or carbogen (increase PC02)

Treatment of PE, cholecystitis, appendicitis, pyelonephritis in pregnancy

PE -LMWH (Enoxaparin) and admission Chole -Ceftriaxone / Flagyl IV -Gravol / Maxeran / Ondansetron -IVF Appy -Ceftriaxone / Flagyl IV -Gravol / Maxeran / Ondansetron -IVF Pyelo -Ceftriaxone / Ampicillin IV -Gravol / Maxeran / Ondansetron -IVF

Optic neuritis: physical exam, conclusive diagnosis, associated condition, Treatment

PE - see RAPD and red desaturation Conclusive diagnosis - MRI Associated condition - MS Treatment - Solumedrol IV

Asthma severity classifications

PEFR Mild >70% predicted Moderate 40-70% predicted Severe <40% predicted Life threatening <25%

Ingestions that are not absorbed by activated charcoal

PHAILS-O Pesticides Hydrocarbons Acids/Alkalis/Alcohols Iron Lead/Lithium Solvents - Oil of wintergreen

Describe the PICE nomenclature

PICE = Potential Injury Creating Event Assign 3 prefixes: A - static, dynamic (stable vs unknown/escalating number of casualties) B - controlled, disruptive, paralytic (local resources not overwhelmed, overwhelmed requiring augmentation, overwhelmed requiring reconstitution) C - local, regional, national, international Assign a PICE stage based on the projected need for outside aid: 0 - none I - small (on alert) II - moderate (on standby) III - large (on dispatch)

Contraindications to succynilcholine

PMHx -MH (any time) -Pseudocholinesterase deficiency (anytime) Recent PMHx -Burns (>10%, >5 days until healed) -Crush injury (>24h) -Stroke/denervation with paralysis (>5 days to 6 months) -NM disease (>6 months) Current presentation -HyperK (any time) -Cholinergic toxicity

Risk factors for ectopic pregnancy

PMHx - PID, previous ectopic or abortion, tubal surgery, infertility, abnormal anatomy Patient factors - smoker, age Pregnancy factors - has IUD, embryo transfer fertility treatments

PPV and NPV Sensitivity and Specificity Receiver-Operator Curve

PPV - The proportion of people that have a positive test who HAVE the disease NPV - The proportion of people that have a negative test who DO NOT have the disease Sensitivity - The proportion of people who HAVE a disease who have a positive test. Specificity - The proportion of people who do NOT have a disease who have a negative test. ROC - charted with Y = sensitivity and X = 1-specificity; used to determine optimal cutoff value for tests

Pemphigus vulgaris vs bullous pemphigoid

PV -Autoimmune reaction affecting patients 50-60yo generally on penicillamine, captopril or rifampim -Present with oral bullae -> painful ulcers then skin bullae -> painful ulcers -Diagnose with history, + Nikolski sign, + Tzank smear -Treat with high dose prednisone (100-300mg/d), immunosuppresants, plasmapheresis BP -IgG autoimmune reaction of those ~65yo. Less sick than PV. -Present with tense, fluid-filled blisters and a negative Nikolski sign. Mucous membrane involvement is possible but less frequent than PV. -Treat with prednisone and other immunosuppresants for 2-5 years and it generally resolves.

Acute scrotal pain / swelling differential and physical exam features

Pain -Testicular torsion - negative cremasteric reflex -Torsion of the testicular appendage (appendix testis or appendix epididymis) - blue dot sign -Epididymitis - Prehn's sign -Trauma -Orchitis -Testicular tumor WITH hemorrhage (normally tumor is not painful) -Inguinal hernia (if incarcerated/strangulated) Swelling -Varicocele (bag of worms) -Ideopathic scrotal edema -Hydrocele

How can bicarbonate cause a paradoxical intracranial acidosis? Other complications?

Paradoxical CNS acidosis -HCO3 diffuses over the BBB slowly -HCO3 in the plasma is converted by carbonic anhydrase to CO2 which is then blown off to decrease pH -This CO2 can diffuse quickly over the BBB decreasing the CNS pH -With the improved pH the RR is decreased increasing CO2 which again crosses the BBB Other complications -Hypernatremia -Hyperosmolarity -Hypocalcemia -Hypokalemia

Gas laws (Pascal, Boyle, Charles, Dalton, Henry)

Pascal - Pressure on a fluid is transmitted equally throughout Boyle - P1V2 = P2V2 Charles - V1/T1 = V2/T2 Dalton - Pt = P1 + P2 + P3 ... Henry - The amount of gas dissolved in a liquid (solubility) is proportional to the partial pressure of that gas above the liquid

Traumatic iridocyclitis: pathology, presentation

Pathology - blunt injury to globe with inflammation and spasm of the ciliary body and iris (basically traumatic iritis) Presentation - deep eye pain, photophobia, perilimbal conjunctivitis / ciliary flush, cells and flare Treatment - steroids and cycloplegic (and optho)

Pathophysiology of carbon monoxide toxicity Indications for hyperbaric oxygen in carbon monoxide toxicity

Pathophysiology -CO binds to cytochrome 4 of ETC causing cellular asphyxiation -displaces O2 and shifts oxyhemoglobin curve to left -binds to myoglobin causing rhabdomyolysis HBO >25% carboxyHb level >15% carboxyHb level in pregnant or children CVS instability Neurological symptoms

Amniotic fluid embolism: pathophysiology, major causes, presentation

Pathophysiology: release of amniotic fluid into the circulation causing an anaphylactoid reaction Causes: labor, amniocentesis, uterine manipulation (version), placental separation. Can also occur during miscarriage/abortion and spontaneously. Presentation: hypoxemia due to plugging of pulmonary vessels, cardiovascular collapse, non-cardiogenic pulmonary edema, DIC Treatment: aggressive ventilatory and hemodynamic support. Plasma exchange to remove cytokines. Delivery of fetus.

Indications for admission of a fight bite

Patient -Immunocompromised -DM -Unreliable patient Wound -Signs of infection -Open >24 hours -Penetration of joint/tendon sheath -Bone involvement -FB Treatment -Clavulin as an outpatient; Tazocin as an inpatient

Causes of fecal incontinence

Pediatric -Congenital (meningocele, myelomeningocele, spina bifida) -Post-op imperforate anus -Sexual abuse -Neuro (demential, spinal cord injury, autonomic neuropathy from DM, pedental nerve damage from surgery/obstetrics, Hirshsprung's) -Trauma to sphincter -Mass (colorectal cancer, foreign body, hemorrhoids, fecal impaction) -Medical (rectal prolapse, diarrhea, IBD, laxatives)

Causes of priapism

Penile trauma (high flow) Medical conditions -Sickle cell -Leukemia -Spinal cord injury -G6PD deficiency -Thalassemia Medications -ED - papaverine and PGE-1 -Phosphodiesterase inhibitors - sildenafil -Antipsychotics - chlorpromazine, clozapine -Antidepressants - SSRI's - trazodone -HTN - HCTZ -Mood/convulsant - Valproic acid -Recreational - alcohol, cocaine, amphetamines, heroin

Adverse effects of shift work

Peptic ulcer disease Depression Mood swings Drug and alcohol abuse Chronic hypertension Infertility in women Divorce Work related accidents, injuries, and errors

Complications of coughing paroxysms in pertussis

Periorbital edema Subconjunctival hemorrhage Petechiae Epistaxis Hemoptyis Subcutaneous emphysema Pneumothorax Pneumomediastinum Diaphragm rupture Umbilical or Inguinal hernia Rectal prolapse

Exposure prophylaxis (Pertussis, Varicella, Yersinia Pestis, Measles, Hepatitis A, Meningococcus)

Pertussis - macrolide for close contacts Varicella - Varicella Ig if unimmunized and immunocompromised OR pregnant within 72h of exposure; vaccine if unimmunized Yersinia pestis (plague) - ciprofloxacin or doxycycline Measles - Measles Ig within 6 days if not immunized (and pregnant, immunocompromised, <12months) OR MMR within 3 days Hepatitis A - HAIg to unvaccinated close personal contacts, childcare workers/attendees (people who wipe their bum), similar food-borne source in last 2/52 Meningococcus - Ciprofloxacin for adult close contacts, Rifampin for pediatric close contacts

Phases of cold injury / frostbite and treatment

Prefreeze: <10 degrees, loss of sensation, endothelial leak Freeze-thaw: extra-cellular ice crystal formation, extracellular shift of fluid, cells can begin to die Microvascular collapse: intravascular sludging, hyperviscosity, thrombosis, ischemia, necrosis Treatment: rapid warming in 37-39 degree water, do NOT let refreeze or partial thaw; pain control; watch for afterdrop; tetanus; consider abx and splinting; stop smoking; consider thrombolytic or sympathectomy

RTA vs pre-renal failure

Prerenal: normal or hyaline casts, UNa<20, FENa<1%, Uosm>500 ATN: brown or granular casts, UNa>40, FENa>1%, Uosm<500

Ludwig's angina: presentation, bacteria, treatment

Presentation -SIRS -Elevation of the floor of the mouth / tongue -Pain to submental, sublingual, submandibular compartments -Poor / infected dentition Bacteria -Multibacterial: staph, strep, anaerobes, bacteroides Treatment -High dose penicillin + metronidazole -Ceftriaxone + clindamycin

Reye syndrome presentation and cause

Presentation Rash to hands and feet, emesis, transaminitis, fatty liver, cerebral edema, coma, arrest. Cause Unknown. Association with viral syndromes and aspirin. Seems to involve mitochondrial damage.

Diagnosis and treatment of disseminated gonorrhea

Presentation - present with fever, asymmetric migratory tenosynovitis/arthralgias, urethritis, cervicitis and characteristic gun-metal blue rash Diagnosis - Fluorescent-antibody staining of lesions (gram stain and culture are poor), swabs of cervic/urethra, rectum, pharynx (if all 3 swabbed is 75% sensitive, joint tap (50% sensitive), blood cultures (poor), test partner Treatment - Ceftriaxone 2g IV q24h x 3-7 days (until clinical improvement) then Cefixime 400mg po od or Cipro 500 po bid for rest of 7 days. Should probably admit.

Bacterial sinusitis: presentation, causes, complications

Presentation of sinusitis: -Purulent nasal secretions -Purulent posterior pharyngeal secretions -Mucosal erythema -Periorbital edema -Tenderness overlying sinuses -Air-fluid levels on transillumination of the sinuses (60% reproducibility rate for assessing maxillary sinus disease) -Facial erythema Bacterial more likely to have: -Severe presentation -Double sickening -Extra-sinus manifestations -Persisting/worsening after 10 days Causes: -S. pneumoniae -H. influenzae -M. catarhallis Complications: -Venous sinus thrombosis -Lemierre's -Meninigitis/abscess -Orbital cellulitis -Facial cellulitis -Optic Neuritis -Periorbital abscess -Blindness -Proptosis

Post-strep glomerulonephritis: presentation, diagnsosis, treatment

Presentation: hypertension, hematuria, edema, AKI Diagnosis: confirm strep with serology, ASOT, Creatinine, U/A Treatment: treat volume overload (Lasix, Dialysis); hypertension (ACEi, Dialysis), Strep (Penicillin)

Acute mountain sickness / high altitude cerebral edema treatment

Primary -Descent or discontinue ascent Support -Hydration -No smoking -Tylenol / Advil -Oxygen Drugs -Prochlorperazine - stimulates hypoxic ventilatory response -Acetazolamide - prevents periodic breathing at night; helps adapt by excreting HCO3 -Dexamethasone - decreases swelling

Conn's syndrome

Primary hyperaldosteronism from an adrenal adenoma or adrenal hyperplasia. Can also get from an aldosterone producing tumor. Secondary hyperaldosteronism is from a renin-producing tumor or renal artery stenosis. Presentation: hypertension, hypokalemia, and alkalosis. Diagnosis: CT abdomen, serum aldosterone, serum renin. Can also do urine lytes, TTKG Treatment: Spironolactone (aldosterone antagonist) and ACEi

Risk factors for primary and secondary PTx

Primary: -Tall, skinny, male smokers with Marfan's and Mitral valve prolapse at altitude Secondary: -Airway: cystic fibrosis, asthma, COPD -Infectious: TB, PJP, lung abscess, necrotizing -Interstitial: sarcoid, fibrosis, pneumoconioses, tuberous sclerosis -Neoplasm: primary or metastatic -Miscellaneous: endometriosis, pulmonary infarction

Shoulder dystocia: problem, risk factors, diagnosis, treatment

Problem: vertical (rather than oblique) shoulder orientation of fetus (sacropubic) Risk factors: maternal obesity, DM; fetal macrosomia; pregnancy post-date, prolonged 2nd stage Diagnosis: can not deliver either shoulder, turtle sign Treatment: HELPER H elp (obs, anesthesia, neonatal) E pisiotomy (oblique) / E mpty bladder L egs flexed (McRoberts maneuver) P ressure suprapublically to push the anterior shoulder down and to the side E nter vagina (Rubin - post most accessible shoulder toward fetal chest; Woods - rotate 180 degrees Rubin plus spin the opposite hip the other direction) R emove posterior arm (grab hand and sweep arm across the chest and deliver it with the shoulder; can have humerus and brachial plexus injury) Other: -Break the babies clavicle -Symphesotomy

What features distinguish orbital cellulitis from periorbital cellulitis?

Proptosis, opthalmoplegia, and visual changes (look for afferent pupillary defect secondary to increased IOP).

Pros / Cons of BiPAP in respiratory failure

Pros - No sedation required - Less risk of VAP/decreased risk nosocomial infection - Preserves airway reflexes - No blunt airway trauma - In CHF, decreases WOB, ETT, LOS, ICU admission, increases CO - In COPD, decreases ETT, LOS, ICU admission, mortality Cons: - No airway protection - Pressure necrosis - Aerophagia - Claustrophobia - Trauma to eyes (corneal abrasions) - Aspiration

Causes of hyperkalemia

Pseudo - hemolysis, increased platelets, increased WBC's Increased intake - supplements, stored blood Decreased excretion - ARF, tubular defects, hypoaldosteronism Shifts - acidosis, hyperkalemic periodic paralysis, Drugs (beta blockers, digitalis, succynilcholine) Cell injury - rhabdo, tumor lysis, burns, crush, hemolysis

Indications for psychiatric admission

Psychiatric condition that makes the patient: -Significant risk of harm to self or others -Lack of capacity to cooperate with outpatient treatment -Inadequate psychosocial support for safe outpatient treatment -Comorbid condition/complication makes outpatient treatment unsafe (withdrawl, acute psychosis, bizarre behavior)

DDx for diffuse wheeze

Pulmonary -Lower airway o Congenital: CF, Bronchopulmonary dysplasia o Trauma: FB, Aspiration o Infectious: Pneumonia, Bronchiolitis, COPD o Inflammatory: Anaphylaxis o Vascular: PE o Degenerative: Sarcoidosis -Upper airway o Congenital: Vascular ring o Trauma: FB, Caustic ingestion o Infectious: Epiglottitis, Croup, Retropharyngeal abscess o Inflammatory: Anaphylaxis, Angioedema o Neoplastic o Vascular ring Extra-pulmonary -CHF -ARDS

List of ECG changes to look for in the syncope patient

QT BRIDE is Hot She makes your heart race and you feel like passing out - arrhythmias (brady, tachy, AFib, AFlutter, blocks, bifasicular/trifasicular blocks VT...etc) any irregular rate or rhythm QT - long/short QT B - Brugada (1 is a slide, 2 is a saddle) R - Right sided strain (RBBB, s1q3t3, inverted T-waves V1-V4, tachy, Right axis deviation) I - Ischemia D - Delta wave (WPW) E - Epislon wave (ARVD) H - Hypertrophy - HOCM, LVH (AS, DCM)

Predictors of difficult LMA

R estricted mouth opening O bstruction D istored airway anatomy S tiff lungs / Neck

Criteria for the diagnosis of lupus

Require 4/11 ANA is quite sensitive (good rule-out); anti-DS-DNA & anti-Sm are quite specific (good rule-in) -Malar rash -Discoid rash -Oral ulcers -Photosensitivity -Nonerosive polyarthritis -Serositis (pericardial or pleural effusion) -Renal disorder (nephrotic or nephritic) -Neurologic disorder (seizures or psychosis nos) Hematologic disorder (low Hb, WBC, platelets) -Immunologic disorder (anti-dsdna, anti-sm, LAC, anticardiolpin, false + syphilis serology) -Positive ANA

Ductal dependent lesions

Require aorta -> pulm flow-TOF -Tricuspid atresia -Pulmonic atresia -Transposition of the great arteries -Hypoplastic right heart Require pulm -> aorta flow -Coarctation -AS -Hypoplastic left heart

Infections requiring airborne precautions

Respiratory TB Measles SARS Smallpox / Monkey Pox / Varicella (chickenpox and disseminated zoster) +/- Ebola and TB (during aerosolizing procedures)

Limping child

Rheumatic / Inflammatory -JRA - usually polyarticular arthritis -Rheumatic fever - usually polyarticular arthritis -Ankylizing spondylitis -HSP -Gout or pseudogout Congenital / Mechanical -Sickle cell -Limb length discrepancy -Developmental dysplasia -Legg-Calve-Perthes -SCFE -Osgood Schlatter -Femoro-patellar syndrome Trauma -Toddler's fracture -NAT -Hemarthrosis - traumatic or spontaneous Cancer -Osteochondroma -Ewing's sarcoma Infection -Osteomyelitis -Transient (toxic) synovitis - 3 mo-6yrs, usually hip -Reactive arthritis - Strep, Chlamydia, Salmonella, Shigella, Lyme, Yersinia, viruses Referred pain -Appendicitis -Testicular torsion

Stages of acetaminophen toxicity; how it is metabolized

Stages 1 0- 24h - NV, anorexia, diaphoresis & malaise; May be completely asymptomatic 2 24-48h - NV, RUQ and epigastric pain, Transaminitis 3 48-96h - Fulminant hepatic failure - encephalopathy, coma, coagulopathy Hypoglycemia, Metabolic acidosis MODS: Sepsis, renal failure (25% of pts with severe hepatotoxicity), cerebral edema 4 - 4-14d - Liver enzymes return to normal; recovery Mechanisms of metabolism -Glucuronidation 40-60% -Sulfation 20-40% -Direct renal excretion 5% -CYP450 2E1oxidation pathway 5-15% (toxic pathway)

Who gets stool cultures for diarrhea?

Standard Sal, Shig, Camp, Yer, EColi 0157 cultures if: -Bloody diarrhea -LTC patient, healthcare worker, food handler, daycare worker -Severe dehydration, fever, underlying illness Additions -If antibiotics in past 3 months - add C Diff toxin assay -If nausea prominent - add noro / rota / advenovirus test -If shellfish ingestion - add vibrio culture -If >7 days - add ova and parasites

Organisms responsible for endocarditis

Staph aureus (especially in right sided / IVDU) Strep viridans Strep bovis (association with GI malignancies) Enterococcus (add vanco and watch for resistance) HACEK - haemophilus atrophilus, actinobacilus, cardiobacterium hominus, eikenella corrdons, kingella kingae (often chronic IE, hard to culture) Immunocompromised fungal - Candida/Aspirgillus

Gram stain results of bacteria

Staph: Gram+ cocci in singles, doubles, tetrads or clusters Strep: Gram+ paired diplococci (other strep in pairs/chains) Listeria: Gram+ rods single or chains Moraxella caterrhalis: Gram- diplococci Neisseria: Gram- paired diplococci H Flu: Gram- coccobacilli E Coli: Gram- rods Pseudomonas: Gram- rods

Indications for reduction of a distal radius fracture

Step >1mm Radial inclination <15 degrees (normal 22) Volar tilt less than 0 degrees (normal 10-25) Decreased radial height (normal 11mm, loss of 2mm relative to other side is short)

Rashes with a + Nikolsky sign

Stevie got scalded by TEN PV'd nickels Steven-Johnson Syndrome Staph Scalded Skin Syndrome Toxic Epidermal Necrolisis (TEN) Pemphigus vulgaruS (PV) Nikolsky

Shoulder dislocation techniques

Stimson - prone, arm hanging with weight x 20 minutes Traction-countertraction - sheet under arm for countertraction, abducted arm FARES - supine, slow abduction with flexion/extension until 90 degrees then external rotation Milch - supine at 45 degrees, external rotation and abduction to 90/90 then longitudinal traction Scapular manipulation - can be added to traction/countertraction and Stimson, rotate inferior tip medially Cunningham - seated, shoulders adducted, elbow flexed with shoulder on provider shoulder, massage of bicep at mid-humeral level

Disorders that can manifest as anxiety

Substance abuse: sympathomimetics (caffeine, amphetamine, cocaine), hallucinogens (LSD, PCP, Ecstasy, marijuana) Withdrawl: depressants (benzos, barbiturates, EtOH) Cardiac: arrhythmias, mitral valve prolapse Endocrine: hypo/hyperthyroid, hypoglycemia, pheochromocytoma, hyperadrenocortism Resp: asthma, PE Medications: alpha agonists, theophylline, corticosteroids, thyroid hormone

Death trajectories

Sudden death, high function for entire life, accidental deaths Terminal disease, high function then a steep decline, cancer Organ failure, long decline in function with intermittent exacerbations, COPD Frailty, long progressive functional decline with poor function for many years, LTC patients with dementia

Hunter criteria for serotonin syndrome

Taken a serotonergic agent and meet one of the following conditions: -Spontaneous clonus -Tremor AND hyperreflexia -Inducible OR ocular clonus plus: --> Agitation --> Diaphoresis --> Hypertonism AND temperature > 38 °C (100 °F)

Define convergence in a disaster

Tenancy for people to converge on the disaster site

Does the baby need resuscitation?

Term? Breathing or crying? Muscle tone? If yes, no resuscitation needed

List 3 strategies used to decrease injuries

The E's Education - teaching at risk populations how to prevent injury Engineering - design safety into the environment (e.g. highway design) Enforcement - of laws requiring safer behavior (e.g. seatbelts)

Clavicle fracture's requiring orthopedic consultation

The rule of 2's >2 cm displacement 2 or more pieces <2cm from either end of the clavicle >2cm of shortening 2 good 2 be true

Treatment of candidiasis (Thrush, Cutaneous, Vulvovaginal)

Thrush: Adults Nystatin (100,000U/kg) swish and spit 5mL po qid until resolved x 1/52. Infants the same but 'paint the mouth' qid x 7 days. Fluconazole if immunocompromised. Cutaneous: Dry regularly, zinc oxide prn, 1% hydrocortisone prn, Nystatin (100,000U/kg) cream bid-qid OR Clotrimazole 1% qid x 6/52. Can also use Fluconazole 100mg od x 2/52. Vulvovaginal: Clotrimazole intravaginal OTC. Can also use Fluconazole 150mg po x 1.

Treatment of common Tinea (capitis/barbae, kereon, versicolour, unguinum, pedis, other)

Tinea capitis/barbae: Itraconazole 250mg po od x 4/52; Selenium Sulphide shampoo 2x weekly Kerion: As per tinea, plus Keflex 500mg po qid (if infected) and Prednisone 1mg/kg/d x 1/52 Tinea versicolour (Malassezia Furfur): Selenium Suphide shampoo (q monthly for prophylaxis) +/- Fluconazole 400mg po x 1 Tinea unguinum: Penlac (antifungal painted on nail) trial; Ketoconazole 200mg po od x 6 months +/- surgical nail removal Tinea pedis: Clotrimazole 1% bid x 6 weeks Tinea (other areas): Clotrimazole 1% bid x 3 weeks

Causes of simple and closed loop SBO

Top 3: -Adhesions -Hernias -Cancer Intrinsic - congenital, IBD, radiation enteritis, cancer, intussusception, hematoma Extrinsic - hernias, adhesions, volvulus, compressing tumors, abscesses, hematomas Intraluminal - FB, gallstones, bezoar, barium, ascaris

Goals of ED triage

Top priority -To quickly assess (2-3m) all patients as they arrive in the ED -To rapidly identify patients with urgent, life threatening conditions. -To insure the right care at the right time from the right provider -To determine the most appropriate treatment area for patients presenting to the ED. -To reduce morbidity associated with medical conditions through early interventions -To initiate infection control procedures (TB, infectious childhood diseases) Other-To decrease congestion in emergency treatment areas. -To provide ongoing assessment of patients. -To provide information to patients and families about expected care and waiting times -To contribute information that helps to define departmental acuity. -To make a rapid initial assessment of the patients' needs -To identify patient with subtle presentation with potential for serious outcome -To prioritize treatment in accordance with the severity of their medical condition -To reduce delay in treatment and reduce risk of further injury or deterioration

Define TIA; Risk for stroke following TIA

Transient neurological symptoms due to ischemic etiology that 'typically' resolve within 60 minutes of onset. Must result in complete recovery to qualify as TIA. ABCD2 score A ge > 60 B P>140 and/or DBP>90 C linical - Speech (1 point) Unilateral Weakness (2 points) D M D uration 10-60m (1 point) >60m (2 points) 7 day risk score: 0-3 = 1% 4-5 = 6% 6-7 = 12%

Ebola: transmission, incubation, presentation, workup, treatment

Transmission - when infected bodily fluids or contaminated objects come into contact with mucous membranes or non-intact skin Incubation - 2-21 days Presentation - fever, malaise, myalgias, headache, pharyngitis, conjunctivitis, abdominal pain, emesis, diarrhea. Hemorrhage, shock, death 6-16 days from onset. Workup - viral serology, culture and PCR. Thin smears for meningitis (BUT NOT THICK UNTIL EBOLA RULED OUT), rapid antigen malaria assay. Standard septic workup +/- stool culture/ova/parasites, NP swabs, hepatitis/dengue serology. Treatment - supportive. IV hydration. PPE.

Causes of pleural effusion

Transudative -CHF -Nephrotic syndrome -Liver cirrhosis -Myxedema -Malnutrition / hypoalbuminemia -Peritoneal dialysis -SVC obstruction -PE Exudative -Malignancy -Pneumonia -ARDS -Pancreatitis -Rheumatic (RA / SLE) -Esophageal rupture -Uremia -PE

Causes of rhabdomyolysis

Traumatic -Crush -Compartment syndrome -Excessive exertion Non-traumatic (relate to lack of ATP) -Electrolytes (HypoK or HypoP) -Ischemia -Congenital ATP deficiency due to inborn errors of metabolism -Environmental (electrical injury, heat stroke, hypothermia, rattle snake bite) -Endocrine (pheochromocytoma, DKA, HHS, hypo/hyperthermia) -Toxin (SS, NMS, statins, alcohol) -Infections (all types) -Seizures -Rheumatic (polymyositis, dermatomyositis, Sjogren's)

Diarrhea history - key questions

Travel - parasites Antibiotics - c diff Ingestions - food poisoning Well-water - parasites Infectious contacts - virulent bacteria Pets at home - salmonella

Miller Fisher variant of GBS

Triad of ataxia, areflexia and opthalmoplegia of vertical gaze

Eradication treatment for H Pylori

Triple: Clarithromycin 500bid / Amoxicillin 1000bid OR Metronidazole 500bid/ PPI x 10-14d OR Quadruple: Bismuth subsalicylate (pepto-bismol) 525qid / metronidazole 250qid / Tetracycline 500qid / PPI x 10-14d

Distinguish true labor from false labor

True labor -cyclic uterine contractions of increasing frequency, duration, and strength -cervical dilation -bloody show False labor (Braxton-Hicks contractions) -no cervical dilation or effacement -intact membranes -do not escalate in frequency, duration or strength -not sensed by external monitors

Causes of miscarraige

Two main: -Chromosomal anomolies -Uterine malformations (leiomyoma, bifid uterus, uterine scarring, cervical incompetence) Other: -Increased maternal/paternal age -Low pre-pregnancy BMI -History of miscarriage -History of vaginal bleeding -Maternal stress -Increased parity -Autoimmune disease -Endocrine disorders (DM) -Maternal infections -Maternal toxin ingestion (cocaine, EtOH)

West Nile Virus: type of virus, vector, diagnosis, presentation

Type: Flavivirus Vector: Birds (crows/ravens/jays) and Culex mosquitos Diagnosis: WNV IgM in serum or CFS (crossreacts with infection / immunization for Japanese encephalitis virus serocomplex - St. Louis encephalitis; dengue) Presentation: Most often fever, malaise, myalgias, headache, nausea, emesis, rash, lymphadenopathy. Occasionally in the elderly (>70) get weakness -> paralysis; meningitis -> encephalitis; morbidity/mortality. Treatment: supportive. Prevention: mosquito repellents, reducing mosquito numbers

Extra-intestinal manifestations of IBD

ULCERATIVE U rinary stones L iver cirrhosis / sclerosing cholangitis C holelithiasis E rythema nodosum / erythema multiforme / pyoderma gangrenosum R etardation of growth A rthralgias / arthritis / ankylosing spondylitis T hrombophlebitis I atrogenic (steroids) V itamin deficiency E yes (uveitis, episcleritis) Also pulmonary fibrosis

Serious bacterial infections

UTI Bacteremia Meningitis Cellulitis Osteomyelitis Septic arthritis Bacterial gastroenteritis Bacterial pneumonia

UTI treatment length

Uncomplicated lower tract - 3 days with nitrofurantoin, cefixime, cipro, septra Complicated lower tract - 7 days (diabetes, sickle cell, immunocompromised) with cefixime, cipro, septra Pregnancy lower tract - 10 days with cefixime or nitrofurantoin (avoid near term due to hemolytic anemia) or septra (avoid near term due to hemolytic anemia, jaundice, kernicterus) Upper tract - 10-14 days with cefixime or ceftriaxone

DDx neonatal hyperbilirubinemia

Unconjugated -Benign: Physiologic (1st), Breast Feeding (2nd due to dehydration with late milk in 1st week), Breast Milk (due to inhibition of hepatic enzymes in 2-3 weeks) -Hemolysis: ABO, hematoma breakdown, spherocyte, elliptocyte, sickle cell, G6PD, PK -Sepsis: TORCH, UTI -Obstructive: Meconium ileus, Hirschsprung's, Pyloric stenosis, Duodenal atresia -Metabolic/genetic: Hypothyroid, Gilbert, Crigler-Najjer Conjugated -Sepsis: TORCH, UTI, Listeria, TB, Hep B, VZV, HIV, Coxsackie -Obstructive: Biliary atresia, choledochal cyst, bile duct stricture, primary biliary cirrhosis -Metabolic/genetic: Gaucher's, Galactosemia, Nieman-Pick, alpha-1 antitripsin Miscellaneous: drugs, toxins, TPN

When is a diagnostic thoracentesis indicated?

Unexplained pleural effusions Pneumonic and parapneumonic effusions -Pneumonia with a parapneumonic effusion >10mm wide on decubitus films -Loculated pleural effusion -Thickened pleural core Diagnosis of a possible malignancy

Treatment of upper and lower esophageal foreign body

Upper: -Magill forceps / Glidescope -Foley -Bougienage -Endoscopy Lower: -Pop -Glucagon -Maxeran -Nifedipine -SL nitro -Midazolam sedation -Endoscopy

How can we assess for atlanto-occipital dislocation on pediatric c-spine x-rays?

Use power's ratio (should be <1): Basion to anterior cortex of C1 spinous process Opisthion to posterior cortex of dens Also Basion-Dens (BDI) & Basion to dens should be <12mm

Oxygen toxicity symptoms

VENTIAC V ertigo E uphoria N ausea T innitus I mpaired judgement A LOC (Altered LOC) C onvulsions

4 characteristics that determine the toxicity of a hydrocarbon; Effects of toxicity short term and long term

VVSS -Viscosity (lower more toxic) -Volatility (higher more toxic) -Side chains (halogenated more toxic) -Surface tension (lower more toxic) Primary toxicity through aspiration - get bronchospasm, disruption of surfactant, displacement of oxygen, alveolar damage -> V/Q mismatch, hypoxia, alveolar dysfunction, resp failure Also sensitizes myocardium (arrhythmias & sudden sniffing death syndrome - tx w BB), CNS effects (euphoria acutely, dementia and cerebellar dysfunction chronically), RTA, hepatic necrosis, blood cancers

Validity Assessment of validity in a meta-analysis and RCT

Validity - the extent to which a concept, conclusion or measurement is well-founded and corresponds accurately to the real world Meta-analysis -Appropriate question -Comprehensive lit search -High quality, reproducible studies included -Heterogeneity and bias ruled out (Funnel and Forrest plots) RCT -Randomization -Concealed allocation -Blinding -Similar groups -Complete follow-up -Meet recruitment target or stopped early / late -Intention to treat analysis

Causes of varicocele

Venous varicocities of spermatic veins (bag of worms) -Right spermatic vein -> IVC - generally caused by IVC compression or thrombosis -Left spermatic vein -> left renal vein - generally caused by RCC

Psychological signs of child sexual abuse

Very broad definition Regression Acting out Sexualized behavior Disclosure

Risk factors for HIV transmission via sexual intercourse

Victim -Anal > vaginal -Coexisting STD's or genital lesions -Trauma evident -Ejaculate on mucous membranes -Cervical ectopy -Active menstration -Currently pregnant Assailant -Foreskin -Primary infection -Late stage infection -Viral load in genital tract -STI's or genital lesions -Not on HAART -Multiple offenders -Incarcerated, homosexual, bisexual

Risk factors for interpersonal violence

Victim -Demographics (<35yo, female, immigrant, separated or divorced) -Environment (low SES, homeless, previous exposure to violent caretakers) -History (disabled, previous physical or sexual assault) Perpetrator -Demographics (young) -Societal (low income, unemployed, low SES, low academic achievement, criminal behavior) -Psych (low self-esteem, personality disorder, emotional dependence, insecure) -Substance abuse -History (abused as a child, violence in family of origin, history of TBI)

Causes of prerenal failure

Volume depletion (GI losses, diuretics, bleeding, insensible) Volume redistribution (3rd spacing, CHF, cirrhosis) Decreased cardiac output (MI, valve, cardiomyopathy, hypertension meds) Arterial disease (thrombosis, emboli)

CATCH Rule - High Risk Criteria

WIGS W - Worsening Headache I - Irritability G - GCS <15 2 hours after the injury S - Suspected open/depressed skull #

Drugs that cause seizures

WITH LA COPS W ithdrawal / Wellbutrin I NH T heophylline / TCA H ypoglycemic agents L ithium / L ocal anesthetics / L ead A nticholinergics C holinergics / C amphor O rganophosphates P CP S alicylates / Sympathomimetics

Substance dependence

WITHDraw IT W ithdrawal I nterest or Important activities neglected T olerance H arm to physical and psychosocial are known but they continue to use D esire to cut down, control it I ntended time using exceeded T ime spent to acquire it is too much

Kawasaki Disease criteria and treatment

Warm CREAM Warm - fever >5 days >38.5 C - Conjunctival injection (bilateral, non-exudative) R - Rash (primarily on trunk; erythematous, maculopapular, morbilliform - no crusting or vesicles) E - Erythema of palms / soles; Edema of hands / feet; periungal desquamation A - Adenopathy (cervical, >1.5cm, unilateral) M - Mucous membrane changes (lips and oral cavity dry and fissured; erythematous mucousa; strawberry tongue) Coronary artery vasculitis occurs in first 1 or 2 weeks, aneurysms 10 days to 1 month, resolves with increased risk of IHD; also aseptic meningitis, urethritis, thrombosis, cholecystitis Treatment - ASA and IVIg 2mk/kg; watch for Coronary Artery Aneurysm

Conditions that can be treated with plasmapheresis

Weakness syndromes -Guillain-Barré syndrome -Myasthenia gravis -Lambert-Eaton Syndrome Vasculitides -Goodpasture's syndrome -Granulomatosis with polyangiitis -Microscopic polyangiitis -Behcet syndrome Hyperviscosity syndromes -Multiple myeloma -Amyloidosis -Waldenström macroglobulinemia Other -Pemphigus vulgaris -Thrombotic thrombocytopenic purpura -Hemolytic uremic syndrome -Possibly SJS / TEN

ITP: what is it, presentation, acute vs chronic, treatment, when to transfuse

What is it? Autoimmune condition with antiplatelet antibodies Presentation: epistaxis, bleeding from gums, menorrhagia, prolonged bleeding time; most complications if platelets <20 (head bleeds if <5) Acute/Chronic: Acute follows an infection and resolves in <2m; Chronic persists >6 months Cause: most often a preceding infection or idiopathic. Can get from leukemia, heparin, cirrhosis, HIV, Hep C Treatment: Steroids, possibly Azathioprine, IVIg, WinRho (if Rh+ - breaks down RBC's instead of Plt's), splenectomy Transfuse: only give platelets in severe bleeding!

Signs of aortic dissection on CXR

Wide CHAPPLA1N Wide mediastinum (8cm AP, 6cm PA, >25% chest width at aortic knob) C alcium sign H emothorax A ortic knob obscured P aratracheal stripe widened P leural cap L eft mainstem bronchus depressed A ortic window lost 1 st rib fracture N G deviates to the right along with trachea

Kocher criteria to distinguish septic arthritis from transient synovitis

With 0-4 criteria the likelihood is: 2%, 9.5%, 35%, 73%, 93% -Non weight bearing -ESR >40 -WBC >12 -Fever > 38.5 CRP >20 is also predictive

Plexus associated with posterior epistaxis and its tributatries; cause of posterior bleed

Woodruff's plexus, tributaries: -Sphenopalatine artery -Posterior ethmoidal artery Causes: -Anticoagulation -Blood dyscrasia -Rupture of carotid aneurysm -HTN -Ca -Trauma

Needlestick injury: worrysome pathogens, prevalence of transmission

Worrysome pathogens 1) Hep B up to 30% (if HBs & HBe +ve; only 2-5% if only HBs +ve) 2) Hep C up to 3% (1-2%) 3) HIV up to 0.3% percutaneous / 0.09% mucocutaneous Prophylaxis: injection of blood, needlestick from known + patient, sexual assault No prophylaxis: random needlestick or spitting

PE Xray, ECG, echo findings PE predictors of mortality

XRay -Normal -Hampton's hump (wedge shaped opacity) -Westermark's sign (oligemia of distal vasculature) -Pleural effusion ECG -Normal -S1Q3T3 -RBBB -RAD -P-pulmonale -Anterior ST depression / T wave inversion Echo -Normal -Dilated RV -Bowing of septum into LV -McConnell's sign -Dilated IVC Increased mortality -Troponin -BNP -SpO2 <95% on RA -Echo with RV strain / dilation -Shock / hypotension

Diagnostic criteria for strep toxic shock syndrome

You going to the strep SHO? S erology (isolation from a sterile [definite] or nonsterile [non-definite] site) H ypotension (sBP<90 or <5th percentile) O rgan systems (>2/6 involved: Renal, Heme, Liver, Lung, Rash, Soft tissue necrosis)

DDx of the painful red eye

abnormal cornea — e.g. herpes simplex keratitis, corneal ulcer, marginal keratitis, corneal abrasion, -abnormal eyelid — e.g. chalazion/ stye, acute blepharitis, herpes zoster ophthalmicus -diffuse conjunctival injection — e.g. viral conjunctivitis, allergic conjunctivitis, bacterial conjunctivitis, dry eyes, acute glaucoma -ciliary injection/ scleral involvement — e.g. scleritis -anterior chamber involvement — e.g. acute anterior uveitis (iritis), hypopyon, hyphema

DDx of the painless red eye

diffuse — usually this is an eyelid abnormality as most cases of conjunctivitis are painful: e.g. blepharitis, ectropion, trichiasis, entropion, eyelid lesion (e.g. tumour, stye) localised — e.g. pterygium, corneal foreign body, ocular trauma, subconjunctival hemorrhage

Antidotes Acetaminophen Anticholinergics Arsenic, Lead, Mercury Benzo Black Widow Spider Bite Beta Blockers Calcium Channel Blockers Cyanide Digoxin Ethylene Glycol Hydrofluoric acid Iron Isoniazid Lead Methanol Methemoglobin forming agents Opioids Organophosphates, Carbamates Rattlesnake bite Serotonin Syndrome Sulfonulureas TCAs Valproic Acid

Acetaminophen - N-acetylcysteine Anticholinergics - Physostigmines Arsenic, Lead, Mercury - British anti-Lewisite, D-Penicillamine Benzos - Flumazenil Black Widow Spider Bite - Lactrodectus antivenin Beta Blockers - Glucagon, HIE, Lipids Calcium Channel Blockers - Calcium, Glucagon, HIE, Lipids Cyanide - Hydroxycobalamin, Sodium thiosulfate, Sodium nitrate Digoxin - Digibind Ethylene Glycol - Fomepizole, Pyridoxine, Thiamine Hydrofluoric acid - Calcium gluconate paste (make with lubricant), IM, intra-arterial, with Bier block, IV +/- dialysis Iron - Deferoxamine Isoniazid - Pyridoxine Lead - DMSA (succimer), EDTA Methanol - Fomepizole, Folic Acid Methemoglobin forming agents - Methylene blue Opioids - Naloxone Organophosphates, Carbamates - Atropine 2-4mg q5m, Pralidoxime 1g q1h; decontaminate with 5% hypochlorite Rattlesnake bite - CroFab antivenin Serotonin Syndrome - Cyproheptadine Sulfonulureas - Octreotide (inhibits insulin release), Glucagon, Glucose TCAs - Bicarbonate Valproic Acid - L-Carnitine

Liver transplant criteria in acetaminophen-induced and non-acetaminophen-induced fulminant hepatic failure (King's College criteria)

Acetaminophen induced pH <7.3 or lactate >3 after 12h of resuscitation Lactate >3.5 after 4h of resuscitation OR all 3 of: -Cr >300 -INR >6.5 -Grade 3-4 hepatic encephalopathy Non-acetaminophen induced INR >6.5 OR 3/5 of: J aundice >1 week prior to encephalopathy A ge <10 or >40 N on-A non-B hepatitis E tiology: indeterminate or drug reaction B ilirubin >300mmol/L I NR >3.5

List the ways that a patient can be rewarmed from hypothemic states

Active external: -Bair hugger, AV anastomosis, hot water immersion, heating pads, hot water bottles, radiant heat lamp, negative pressure rewarming Active internal -Humidified ventilation, warm IVF, thoracic bladder gastric myocardial or colonic lavage, peritoneal dialysis, ECMO +/- diathermy

Complications of caustic ingestion

Acute Airway burn -> Laryngeal edema Perf'd esophagus -> Mediastinitis Perf'd stomach -> Peritonitis GI bleed Delayed -Esophageal stricture -Pyloric obstruction -Esophageal cancer (1000x)

What is ATN and its diagnostic criteria?

Acute Tubular Necrosis -Death of the tubular epithelium of the kidney -Generally caused by toxins (HHS, rhabdo, hemolysis, aminoglycosides, contrast) and hypoperfusion (shock) -See FENa >1%, Urine Na >40

Classic descriptions: -Acute angle closure glaucoma -Iritis -Scleritis -Orbital cellulitis or cavernous venous sinus thrombosis

Acute angle closure glaucoma -mid-dilated unreactive pupil, steamy cornea, peri-orbital pain , nausea/vomiting and increased intra-ocular pressure Iritis -small irregular pupil, deep-seated eye pain that is worse on eye movement and accomodation, consensual photophobia and positive slit lamp signs of flare and cells Scleritis -deep-seated eye pain that is worse at rest and at night, pain on palpation of the eye and violaceous appearance of the sclera Orbital cellulitis or cavernous venous sinus thrombosis -proptosis, congested chemosis, painful external ophthalmoplegia, and visual loss with a relative afferent pupillary defect

Variola virus (smallpox) - infectious period, quarantine, diagnosis, types, DDx, treatment, prevention

Aerosolized highly infectious virus -Infectious from time of rash to when the scabs fall off (1-2 weeks) -Exposed people must be quarantined x 17 days -Diagnosis - all lesions are the SAME age! Classic look. Febrile prodrome (major criteria) -Types - Major (30% mortality; severe rash/toxicity), minor (1%; minor rash/toxicity), hemorrhagic (>90%; petichial), and malignant (>90%; no pustules; no scabs if patient recovers) -DDx - varicella, monkeypox, HSV -Treatment - cidofovir -Prevention - variola vaccine within 3 days in healthy population; VIG IM also given to high risk people

Age and associated bony malignancies

Age (years) Tumour < 1 - Neuroblastoma 1-10 - Ewing's (tubular bones) 10-30 - Osteosarcoma, Ewing's (flat bones) 30-40 - Primary histiocytic lymphoma, fibrosarcoma, parosteal osteosarcoma, malignant giant cell tumor, lymphoma > 40 - Metastatic carcinoma, multiple myeloma, chondrosarcoma

Anatomic difference in pregnant patients that change response in trauma

Airway - more friable and edematous mucosa, lower esophageal sphincter tone, increased abdominal girth Respiratory - higher RR = greater minute ventilation and lower CO2; higher diaphragm = lower FRC (quicker desat) and req's higher chest tube Cardiac - Increased blood volume, tachycardia, decreased PVR, increased venous congestion/pressures, lots of blood to uterus, aortocaval compression when supine Heme - dilutional and Fe-deficiency anemia; hypercoaguable Abdomen - displaced contents; decreased sensitivity of exam for peritonitis; ALP doubles; decreased GB contractility (increased gallstones; weight gain Nephro - bladder is extrapulvic after 12 weeks; decreased GFR; polyuria and hydropnephrosis due to bladder compression MSK - widened pubic symphesis (4 -> 8mm)

Complications of deep space infections of the posterior pharynx

Airway compromise Mediastinitis Pericarditis Pneumonia Empyema Lemierre's syndrome (jugular vein thrombophlebitis) Horner's (sympathetic chain) Carotid artery erosion or pseudoaneurysm Cavernous sinus thrombosis Mastoiditis Otitis Meningitis Brain abscess

Cervical spine fracture mechanisms

All are flexion, except: Vertical Compression - Burst & Jefferson Extension - C1 neural arch, Hangman, Extension teardrop Flexion-rotation - Unilateral facet, Rotary atlantoaxial

SSSS vs TEN vs SJS - distinguishing features and treatment

All can have Nikolsky's sign but SSSS is through the epidermis and TEN is deeper through the plane of the epidermis/dermis. Generally TEN is >30% and SJS is <10% (10-30 can be either). All can be deadly, SSSS worse in adults (30%) than kids (5%) SJS usually has mucous membrane involvement before rash Treatment of SSSS is cloxacillin / staph antibiotic. SJS and TEN must stop offending agent, fluid resuscitate, infection control (mostly supportive in burn center), and IVIG! Can consider plasmapheresis.

Hip reduction techniques

Allis - patient supine with hip and knee flexed to 90 degrees, get on bed and provide vertical upward traction while someone holds the pelvis to the bed. Works for posterior and anterior-obturator (femoral head seen over obturator foramen). Stimson - patient prone with one leg hanging off of the bed, flex hip and knee to 90 degrees, vertical downward traction while someone holds the pelvis/pushes down on the femoral head. Whistler - patient supine, arm under knee of dislocated hip with arm on opposite knee (both legs flexed at the hip/knee) to use opposite leg as a fulcrum. A modification of this is the Captain Morgan with your leg under the patient's knee instead of your hand.

Schizophrenia negative symptoms

Alogia Affect (flat) Avolition

One pill can kill

Alpha blocker (clonidine) Antihyperglycemic agents (sulfonylureas like gliclazide, glyburide) Beta blockers Barbiturates Calcium channel blockers / Camphor / Chloroquine Digoxin Hypoglycemic agents (sulfonylureas) MAO-I Methadone Methyl salicylate Theophylline TCA Toxic alcohol Iron Lomotil

Congenital heart disease: Obstructive Lesions

Also happen with closure of the duct, but NOT cyanotic. Give them 0.1mcg/kg/m of PGE1 Coarctation of the aorta Hypoplastic left heart syndrome Interrupted aortic arch Aortic stenosis (critical)

Differences in the pediatric versus adult airway

Also note that kids often desat shortly after intubation - be sure to provide PEEP to maintain their smaller than normal FRC

Modified Alverado score, WBC/CRP, U/S and CT for Appy

Alverado score History: -Migration of pain to the RLQ -Anorexia -N or V PE: -T>37.3 -RLQ tender (2 points) -Rebound tenderness, Labs -Leukocytosis (2 points) -Left shift Interpretation: -Treat if >7; Image if 4-7; Unlikely if 4 or less Labs -WBC<10 and CRP<12 have a -LR of 0.09 (very sensitive) but less helpful in peds. U/S -75-95% sensitive, 85-95% specific - operator dependent but 1st choice for kids/women -See non-compressible, thick-walled (>2mm), dilated (>6mm), thickened mesentary, pain with compression, appendicolith CT -95% sensitivity and specificity

STI's and likelihood of pediatric sexual abuse

Always - gonorrhea and syphilis Usually - chlamydia, HSV, trichomonas Possibly - HPV, scabies, pediculosis, BV

Name 3 amide and ester local anesthetics

Amides Bupivicaine, lidocaine, prilocaine Esters Tetracaine, Benzocaine, Cocaine

DDx for sudden visual loss

Anatomic Anterior chamber - hyphema, hypopiom, glaucoma Iris/lens - lens dislocation, iritis Posterior chamber - posterior vitreous detachment or hemorrhage Retina - Retinal detachment, central venous occlusion, central arterial occlusion Neuro-opthalmologic - pre-chiasm (optic neuritis due to ischemia/compression/toxin), chiasmal (tumor), post-chiasm (CVA, tumor, AVM, migraine), visual cortex (CVA)

Uncal herniation (anatomy, pathophysiology, physical exam)

Anatomy - Ipsilateral uncus of the temporal lobe herniates down through the tentorium Pathophysiology - Compresses ipsilateral CN III and cerebral peduncle of midbrain PE - decreased LOC, ipsilateral blown pupil, ipsilateral 'down and out' gaze, contralateral paralysis (opposite in Kernohan's notch syndrome)

Descending transtentorial herniation (anatomy, pathophysiology, physical exam)

Anatomy - expanding lesion in the vertex / frontal / occipital poles or diffuse swelling Pathophysiology - Cerebrum and midbrain pushed down through the tentorium PE - decreased LOC, small but reactive pupils, posturing, sunset eyes (can't move up)

Cerebotonsillar herniation (anatomy, pathophysiology, physical exam)

Anatomy - tonsils herniate through the foramen magnum Pathophysiology - cerebellar or large cerebral mass push brain down compressing the brainstem PE - decreased LOC, flaccid quadriplegia, posturing, respirations cease

Drugs that prolong QT

Antidysrhythmics Ia, Ic, III: procainamide, propafenone, amiodarone Antibiotics: azithromycin, ciprofloxacin Antipsychotics: haloperidol Antiemetics: ondansetron, metoclopramide Anticonvulsants: Antihistamines: Antifungals: Antimalarials: chloroquine Antidepressants: TCA, citalopram Analgesia: Methadone Also, hypoCa, hypoMg, hypoK

What is a teratogen? What characteristics of a drug increase its ability to cross the placenta?

Any chemical, pharmacologic, environmental or mechanical agent that can cause deviant or disruptive development of the conceptus Characteristics that increase crossing the placenta Size (small), ionization (uncharged), protein binding (free drug), pKa (weak organic acids get caught in fetal base-ness), lipid solubility (more soluble)

Pediatic apophyseal injuries

Apophysis is a cartilaginous insertion point for tensions in growing bone Osgoood Schlatter - insertion of the patella into the tibia Severs - insertion of the Achilles into the calcaneus Little leaguer - medial elbow Apophysitis of the hip - ASIS, AIIS, iliac crests or ischial tuberosities

Criteria for Munchausen's by proxy

Apparent illness produced by the parent -Child presents repeatedly -Perpetrator does not acknowledge etiology -Illness disappears when separated

Mental status exam

Appearance Attitude Behavior Mood Affect (appropriateness, lability, eye contact) Orientation (date/time/place) Speech Thought process (disorganized) Thought content (delusions) Perceptions (hallucinations) Cognition (memory, content of thought, preoccupations, coherent speech, ability to reason, insight, judgement) Insight Judgement Suicidal ideation Homicidal ideation Capacity (CURVES)

Ottawa Ankle Rule

Applied to acute ankle injuries with malleolar pain (not hindfoot, forefoot, upper fibula) -Pain to posterior edge of the lateral malleolus from its distal part and 6cm proximal -Pain to the posterior edge of the medial malleolus from its distal part and 6cm proximal -Unable to weight bear 4 steps immediately after the injury and in the ED

PERC Rule

Apply if clinical gestalt = low risk for PE HAD CLOTS H - Hormone (estrogen) use A - Age > 50 D - DVT or PE history (have they HAD CLOTS?) C - Coughing blood L - Leg swelling disparity O - O2 sats < 95% T - Tachycardia (>100bpm) S - Surgery or Trauma (recent)

Definition of ARDS

As per the 2012 Berlin Definition -Respiratory symptoms started or worsened acutely with the last week -PaCO2 / FiO2 ratio 200-300 = mild, 100-200 = moderate, <100 = severe -Bilateral pulmonary infiltrates (CXR or CT) -Not in cardiac failure / no fluid overload

Bleeding reversal agents for Aspirin, Clopidogrel, Ticegralor, Warfarin, UFH, LMWH, Dabigatran, Rivaroxaban, Apixaban, t-PA/lytic

Aspirin: DDAVP for minor, platelets for major Clopidogrel/Ticegralor: DDAVP for minor, platelets for major Warfarin: Depends. Hold if not bleeding. Hold + vit K po if have time. Hold + vit K IV + FFP (15mL/kg or 2-4U) OR PCC 50IU/kg UFH: Protamine sulfate 1mg per 100U LMWH: Protamine sulfate 1mg per 1mg Dabigatran: PCC 50IU/kg, try FEIBA, vitamin K, Tranexamic acid (1g IV), dialysis (only 33% protein bound); send TT (thrombin time to confirm cause) Rivaroxaban/Apixaban: PCC 50IU/kg; try tranexamic acid (1g IV), NO dialysis; send anti-Xa level to confirm cause t-PA/thrombolytic: FFP 2U q6h x 4; Cryoprecipitate x 10U; Tranexamic Acid 1g; Platelets 1 adult; DDAVP 0.3mcg/kg IV; Protamine to reverse any heparin; treat ICP; be prepared to treat seizures

Risk factors for death due to asthma

Asthma history -Intubation/ICU admission for asthma -Hospitalized 2 or more times in past year -To ED 3 or more times in past year -Hospitilization/ED visit in past month ->2 MDI canisters of B-agonist/month -Using or withdrawing from corticosteroids -Difficulty perceiving asthma severity/symptoms Social history -Low socioeconomic status -Psychosocial problems -Illicit drug use (especially cocaine/heroin) Comorbidities -Cardiovascular disease -Chronic lung disease -Psychiatric disease

Pathophysiology of arterial gas embolism following scuba diving

At depth there is an increased solubility of nitrogen which accumulates in the body while the diver is at depth (Henry's law). Upon rapid ascent, the nitrogen comes out of the solution resulting in bubbles which collectively form a gas embolism (Boyle's law)

At risk for an atypical presentation of MI

Aunt Jemima with dementia -Elderly -Diabetic (from all the syrup) -Non-white -Female -Dementia -Hyperlipidemia (from all the sausages) Also: No prior history of MI, history of stroke, /CHF, no family history

Eponym Aviator's Barton's Bennett's Boxer's Chance's Chauffeur's Clay shoveler's Colles' Cotton's Pseudo-Jones Dashboard Dupuytren's Essex-Lopresti Galeazzi's Hangman's Jefferson Jones' Le Fort Lisfranc's Maisonneuve March Monteggia's Nightstick Pilon Rolando's Salter-Harris Segond Stener Smith's Teardrop Tillaux

Aviator's - Vertical # neck of talus with subtalar dislocation Barton's - Intra-articular wrist #-dislocation; dorsal or volar Bennett's - Oblique intra-articular # through base 1st MC Boxer's - # neck of 4th or 5th MC Chance's - Lumbar vertebral # through spinous process, pedicles, and vertebral body Chauffeur's - # radial styloid Clay shoveler's - # tip spinous process C6 or C7 Colles' - # distal radius with dorsal displacement and apex volar angulation Cotton's - Trimalleolar # Pseudo-Jones - # base 5th MT, < 15 mm from proximal end (insertion peroneus brevis) Dashboard - # posterior rim of the acetabulum Dupuytren's - #-dislocation of the ankle Essex-Lopresti - Radial head # with dislocation of DRUJ Galeazzi's - # radial shaft with DRUJ dislocation Hangman's - # pars interarticularis of C2 Jefferson - Burst # C1 Jones' - Transverse # 5th MT base, > 15 mm from proximal end Le Fort - Maxillary # Lisfranc's - #-dislocation of tarsometatarsal joint Maisonneuve - # proximal fibula, disrupted syndesmosis, # medial malleolus March - Stress # of metatarsal Monteggia's - # proximal ulna, dislocation radial head Nightstick - # of ulna, radius or both Pilon - ankle # & distal tibial metaphyseal #, usually w/ intraarticular comminution Rolando's - Comminuted # base of 1st MC Salter-Harris -Epiphyseal # in children Segond - Avulsion of lateral tibia associated with ACL tear Stener - Avulsion ulnar corner base proximal phalange in thumb Smith's - # distal radius with volar displacement (reverse Colles') Teardrop - Wedge-shaped # of anteroinferior portion of vertebral body Tillaux - Avulsion # anterolateral portion of distal tibial epiphysis in adolescents

Etiology of nontraumatic SAH

B CARMEN B lood dyscrasias C avernous angioma A VM R uptured saccular aneurysm M ycotic aneurysm E xtension from intraparenchamyl N eoplasm

Predictors of difficult BVM

B eard O bstructed / O bese / O SA N eck stiffness / N eck mass E xpecting (pregnant) S tridor / S nores

Complications of posterior nasal packing

BAD NOSE B radycardia A sphyxia / Aspiration / Arrest D ysrhythmia N ecrosis of mucosa, palate / Nasorespiratory reflex O titis Media S hock (Toxic Shock) E ustachian tube dysfunction

Erythema nodosum causes

BELTY SLIPS B ehcets E strogen L ofgran's T B Y = V iral (#2) S trep (#1) L ymphoma (NHL) and Leukemia I BD P CN S ulpha

Infectious agents transmitted by blood products and their risks

Bacterial - 1:20,000-50,000 Hep B - 1:153,000 Hep C - 1:2.3 million HIV - 1:7.8 million HTLV CMV WNV Rare Prion dz Rare

Croup vs bacterial tracheitis

Bacterial tracheitis is: -Inspiratory AND expiratory stridor -Does not respond to treatment -Toxic appearance -Hypoxia/Cyanosis -Shaggy trachea on x-ray -Copious secretions following intubation

Equipment required for a neonatal resuscitation

Be prepared for baby WOBLIES W armer / polyethylene bag - all babies O xygen (blended) - for persistent hypoxia B ag and mask - if HR<100, gasping, apnea give 40-60 bpm with PPV L aryngoscope (0 or 1 Miller or Mac) and ETT (3.5) - for meconium suctioning, ineffective/prolonged BVM, chest compressions I ncubator for transport E pinephrine 0.01-0.03mg/kg / 0.1-0.3mL of 1:10,000 1:1,000 = 1mg/mL 1:10,000 = 0.1mg/mL S uction

Benefits and drawbacks of ultrasound in trauma

Benefits -No transfer required -Less resource intensive (Less expsenive) -Available in trauma suite (Bedside) -Easily repeated -No contrast -No radiation -No need for IV Access -Quick -Non-invasive -Sensitive to ~250mL (variable) Drawbacks -Does not visualize parenchyma, retroperitoneum -Poor at identifying hollow viscous -Compromised by subcut air -False negatives - ascites -User-dependent

Associations with Ciguatera toxicity

Big fish (grouper, barracuda) -Anticholinesterase (cholinergic) effects -Gastroenteritis -Hot/cold reversal of sensation or cold allodynia -Teeth feel loose -Brady / resp arrest Treat with antihistamines (treat the itch), atropine, amitryptaline (allodynia), mannitol (controversial)

Painful vs painless genital lesions

BitCH (painful) B ehcet's C hancroid H SV Some Lesions On my Dong S yphilis L GV O ncologic (SCC) D onovanosis

Anticholinergic Toxidrome

Blind as a bat (Mydriasis) Mad as a hatter (Altered mental status) Red as a beet (vasodilation, flushed) Hot as a hare (febrile) Dry as a bone (no secretions/diaphoresis) Bowel and bladder lose their tone Heart runs alone (tachycardia) Atropine, antihistamines, scopalamine, antipsychotics

Approach to CT Head

Blood Can Be Very Bad Blood Cisterns Brain Ventricles Bone

Indications and contraindications for whole bowel irrigation

Body packers Sustained release Charcoal doesn't work High-risk hydrocarbons (CHAMP) -Camphor -Halogenated HC -Aromatic HC -Metals (arsenic, mercury & lead) -Pesticides Contraindicated in bowel obstruction, unable to protect airway, hemodynamically unstable

BLS: trained provider vs untrained provider

Both -AED -911 -Trade Untrained provider -Hands only CPR (2 inches or 1/3 of chest) at 100/m Trained provider -30:2 compressions:breaths if 1 OR 2 providers at 100/m in adults -15:2 compressions:breaths if 2 providers at 100/m in children

Treatment of pediculitis (lice) and scabies

Both -Simultaneously treat the patient, sexual partners, family members, clothing, furniture and homes -Clothes should be washed in hot water and dried in a hot dryer. Other things can be frozen for 5 days. Lice (phthiraptera - pediculosis -Permethrin (Nix) 1% shampoo for 10m on day 1 and 8 while avoiding conditioner for 2 weeks Scabies (sarcoptes scabiei mite) -Permethrin 5% cream applied for 8-14h on day 1 and 8

CPR with advanced airway

Both adults and children -8-10 breaths/m (q 6-8s) with each breath lasting 1s and not synchronized with compressions (don't stop!)

How can VT be distinguished from SVT with aberrancy?

Brugada criteria (note: not good enough to use in real life): 1. Absence of any RS complexes in the chest leads 2. RS duration (measured from beginning of R to deepest part of S wave) greater than 100 msec 3. AV dissociation (often present but overlooked; may be best appreciated in inferior limb leads and V1-2) 4. Specific VT morphologic criteria

Treatment for hyperkalemia

C BIG K Drop C alcium (stablize) B eta agonist / B icarbonate (shift) I nsulin (shift) G lucose K ayexalate (eliminate) D iuretics - Furosemide (eliminate) R enal dialysis (eliminate) o p

Determining capacity

C ommunication U nderstanding R easoning V alues E mergency S urrogate

Things that shift the oxygen-hemoglobin dissociation curve

CADETS turn right and fall down (right shift and decreased oxygen affinity) C - CO2 A - Acid D - 2,3 DPG E - Exercise T - Temperature S - Sickled Hb S NOTE: CO shifts to the left

How can alcoholism be screened for?

CAGE questionnaire C ut down? A nnoyed? G uilty? E ye opener needed? 2/4 require further investigation

Pneumonia definitions: CAP, HAP, VAP

CAP: no hospital or LTC stays for 14 days before presentation HAP: new infection >48h after arrival in care facility VAP: new infection >48h after intubation Healthcare associated: home IV antibiotics, dialysis, wound care, immunocompromised, chemotherapy, nursing/LTC, hospital for 2 days in past 90 days

Components of informed consent

CAPACITY -Capacity assessment (CURVES) DISCLOSURE -Nature of the treatment -Benefits and risks of the treatment -Common/dangerous side effects of the treatment -Alternatives to the treatment (including not having anything done) and their likely outcome VOLUNTARY -Consent given voluntarily and without coercion

Croup score

CARLS! Cyanosis 0 to 5 AE 0 to 2 Retractions 0 to 3 LOC 0 to 5 Stridor 0 to 2

Causes of cavitating lesions

CAVITY C ancer (metastasis) A utoimmune (Wegener's granulomatosis, Rheumatoid Arthritis, Sarcoidosis) V ascular (PE, septic emboli, infarction) I nfection (TB, MRSA, SA, Klebsiella, Fungal) T rauma (pneumatocele) Y outh (congenital things; bronchogenic cyst)

Reportable STI's

CCHAGS -C hancroid (haemophilus ducreyi) -C hlamydia -A IDS/HIV -G onorrhea -S yphilis

Vital signs requiring transfer to a trauma center

CDC 2011 -RR < 10 or RR > 29 -SBP <90 -GCS < 13

Risk stratification for AFib - who needs anticoagulation?

CHADS2 C HF H ypertension A ge > 75 (2 points) D iabetes S troke before (2 points) V ascular disease Age 65-74 Sex (female) 0 = nil; 1 = ASA or anticoagulant (1/3%/y); 2 = anticoagulant (2.2%/y)

Substances that are radioopaque on x-ray

CHIPES C hloral hydrate / C alcium carbonate H eavy metals (Zn, Li, Barium) I ron / I odide P henothiazines / P lay dough E nteric coated S olvents (halogenated)

Intestinal manifestations of IBD

COLITIS C ancer O bstruction L eakage / perf I ron deficiency T oxic megacolon I nanition (wasting) S tricture Also: abscess, fistula

Bacterial causes of diarrhea; antibiotic treatment

CSS Yalk Constantly - So Believe Every Child Vomiting And Pooping C ampylobacter S higella - treat dysenteriae for public health S almonella - treat typhi and all food handlers for public health Y ersinia C lostridium jejuni S taph aureus (toxins) B acillus cereus (toxins) E coli (toxins) C difficile and perfringins (toxins) V ibrio cholera (toxins) and parahemolyticus A eromonas P lesiomonas Toxin-producing generally do not respond to antibiotics Antibiotics for severe infectious diarrhea with no evidence of HUS with cultures pending - children cefixime/azithro x 3-14d; adults cipro x 3-14d

Pneumonia admission decision score

CURB 65 C onfusion U remia (BUN > 7mmol/L) R espiratory rate greater than 30 B lood Pressure < 90/60 65 years of age or more If 2 consider admit; 3 consider ICU

Dermatologic findings in pediatric seizures due to neurocutaneous disorders

Cafe au lait - Neurofibromatosis Ash leave - Tuberous sclerosis Port au Wine Staine - Sturge-Weber

Types of kidney stones and causes

Calcium oxalate 75% - excess calcium (milk alkali syndrome, high dietary intake, antacids, increased PTH). Oxalate increases in radiation enteritis, IBD, and ethylene glycol ingestion. Struvite 15% - infection with urea-splitting organisms (pseudomonas, proteus, klebsiella, staph) Hyperuricemia 10% - gout, tumor lysis syndrome, hematologic malignancies. they are radioluscent. Cysteine 1% - inborn error of metabolism Struvite, urate, and cysteine stones can form staghorn calculi.

Treatment of impetigo

Can be staph or strep Mild - fucidin or mupirocin (2% tid) Moderate/Severe - Keflex or Cloxacillin Bullous (staph only!) - Cloxacillin or erythromycin (if MRSA risks consider clinda or septra)

Angina Classification

Canadian Cardiovascular Society I - No limitation of ordinary activity II - Mild limitation. Symptoms at >1-2 blocks or >1 flight of stairs. III - Moderate limitation. Symptoms at <1-2 blocks or <1 flight of stairs. IV - Severe limitation. Symptoms at rest.

CTAS system -What does CTAS stand for? -How was it derived? -What are the levels and time they need to be seen in? -What is it predictive for?

Canadian Triage and Acuity Scale - derived from ICD diagnoses with modifiers 1 - Resuscitation - immediate assessment 2 - Emergent - 15m 3 - Urgent - 30m 4 - Less urgent - 60m 5 - Non-urgent - 120m CTAS predicts: -Need for consultation -Need for CT -Need for admission -LOS

Stimulant induced chest pain

Cardiac -Endocarditis -Pericarditis -Ischemia/infarction -Stent thrombosis Non cardiac -Pneumothorax -Pneumomediastinum -Pneumopericardium -Aortic dissection -Pulmonary infarction -Infection Foreign body

Drugs that cause drug-induced lupus

Cardiac: procainamide, amiodarone HTN: hydralazine, methyldopa Antimalarial: quinidine Antimicrobial: nitrofurantoin, penicillin, INH, sulfonamides, tetracycline Anticonvulsant: phenytoin Antithyroid: PTU Antipsychotic: lithium, chlorpromazine Gout: allopurinol

Lens dislocation: cause, risk factors, clinical findings, treatment

Cause - Occurs following AP trauma with disruption of the zonule fibers Risk factors- Marfan's, Homocystinuria, Tertiary syphilis Findings - painless, monocular diplopia or blurred vision with iridodonesis, phacodenesis, irregularly shaped lens Treatment - optho

Avalanche: Most common cause of death, prognostic characteristics, treatment

Cause of death 1 Asphyxia 2 Trauma 3 Hypothermia 4 Combination Prognostic -Buried >35m with an obstructed airway -Arrested when extricated -Core temp <32 degrees -K<8 (good prognosis for hospital discharge) Treatment -Consider ECMO if potential for good outcome

Cause and treatment of postpartum hemorrhage

Cause: -Tissue - retained products, accreta (placental villi adhere to myometrium) / increta (enter the myometrium) /percreta (through the myometrium) make more likely -Tone - diagnosis of exclusion -Trauma - perineal tears, vulva/vaginal epithelium trauma, uterine inversion, uterine rupture -Thrombin - vWD, coagulopathy, DIC Treatment Uterine massage Repair lacerations Remove products of conception Oxytocin - run 40U/1L fast; 10U IM Misoprostol (PGE1) - 800-1000mcg PR Hemabate (PGFalpha) - 250mcg IM Pack uterus Foley or bakri balloon in uterus Embolize vessels D&C Hysterectomy

Myasthenia Gravis: Cause, Presentation, Diagnosis, Complications, Treatment

Cause: Antibodies to post-synaptic ACh receptors (take spots & destroy them); set off by BB/ CCB/ Thyroxine/ Steroids/ Surgery/ Trauma/ Infection Presentation: Ptosis, Diplopia, Dysarthria, Dysphagia, Blurred vision with spared pupils, resp failure. Treated patients can present with cholinergic crisis. Diagnosis: Tensilon test, ice to eyes, NIF (<15 intubate)/FVC (<15 intubate); check for anti-AChR antibodies Treatment: Plasma exchange or IVIg (neostigmine and/or thymectomy for chronic); intubate with cisatracurium (Hoffman degradation)

GBS: Cause, Presentation, Diagnosis, Complications, Treatment

Cause: idiopathic, often secondary to Campylobacter, Mycoplasma, CMV or EBV - results in antibodies to nerves Presentation: progressive ascending symmetric weakness and areflexia; Miller-Fischer variant starts centrally (areflexia, ataxia, opthalmoplegia with III/IV/VI affected). Also has autonomic dysfunction (tx brady with atropine; use short acting for hypertension, fluids for hypotension) Diagnosis: CSF elevated protein, normal glucose and WBC Complications: respiratory compromise req'ing intubation if FVC <20ml/kg or NIF <30mL/kg Treatment: IVIg or plasmaphoresis

Thyroid storm: cause, precipitants, and treatment

Cause: increased T3/T4 over a prolonged period of time increases B receptors and sympathetic surge activates them all at once. Precipitants: -Trauma (burns, surgery, thyroid trauma) -Vascular (MI, CVA, PE, CHF) -Toxicologic (Iodine, radiocontrast, hormone ingestion, amiodarone, stopping therapy, ASA, chemo, pseudoephedrine, OP's) -Sepsis -Metabolic: hypo or hyperglycemia -Pregnancy -Psych: mania, emotional crisis Treatment: -Decrease hormone production with PTU 1g po -Decrease release of preformed hormone with Saturated Solution of Potassium Iodide (SSKI) 5 drops 1h after PTU; Li works too -Beta blockade with propranolol 1-2mg IV q15m -Prevent T4->T3 conversion with hydrocortisone 100mg IV -Prevent enterohepatic circulation with cholestyramine -Prevent entry of thyroid hormone into cell with L-Carnitine -Supportive care with cooling, benzos, acetaminophen -Remove thyroid hormones with plasmapheresis, dialysis, plasma exchange -Treat precipitant -Admit to ICU -Thyroid surgery or ablation

Myxedema coma: cause, precipitants, and treatment

Cause: severe longstanding hypothyroidism with a precipitant Precipitants: -Trauma, burns -Vascular: CVA, GIB, MI -Toxicologic: lithium/iodide (decrease release), narcotics, benzo's, barbiturates -Metabolic: hypoglycemia, hyponatremia, hypoxia, DKA, hypercapnea -Cold exposure Treatment -ABC's - note macroglossia/mucosal swelling -IVF - watch Na and glucose (often need to be added) -Thyroid hormone - T4 if old/cardiac hx (T4 300-500ug IV bolus); T3 if young (T3 10-20ug IV bolus). Can also give a bit of each. -Hydrocortisone 100mg IV -Rewarming -Treat precipitant

Botulism cause, types, diagnosis, treatment

Cause: toxin produced by clostridium botulinum; inhibits acetylcholine release Types: infant, food, wound, inhalation Diagnosis: toxin in blood, toxin or bacteria in stool / wound culture, EMG (supportive) Treatment: Source control (if infection), Intubate if FVC<15mL/kg; Trivalent equine antitoxin (adults) or Baby BIG (infants), NG tube (for ileus), treat autonomic dysfunction prn

Chancroid cause and treatment

Caused by Haemophilus ducreyi and presents with painful inguinal ulcerations Treatment with Ceftriaxone 250 IM x 1 or azithromycin 1g x 1 and aspiration of fluctuant nodes (not d&c!)

Lymphogranuloma venereum cause, presentation, diagnosis, treatment

Caused by chlamydia trachomatis Rare in developed nations. Enters skin or mucosa and travels to lymph nodes. Presentation Stage 1: Begins as an ulcer Stage 2 effects: Infected sex organs - inguinal buboes or abcesses Anal sex - proctocolitis Pharyngeal - cervical buboes Buboes are painful! Can necrose. Stage 3 effects: Lymphatic obstruction and edema. Permanent. Diagnosis Serology or direct fluorescent antibody or PCR Treatment Doxycycline 100 bid x 3 weeks and possibly needle aspiration

Acute cerebellar ataxia

Causes 40% off ataxia presentations in children History of recent illness (vzv, coxsackie, echovirus) Features worst at onset, extremities > trunk, wide based gait, recover completely

Diagnosis and causes of SROM

Causes: -UTI -Infection (choriaminoitis, Bacterial vaginosis, GBS) -Trauma -Incompetent Cervix -Cigarette Smoking Diagnosis -Perform sterile speculum exam vaginal exam, pooling in posterior fornix -Nitrazine test (Blue = +) - false pos with semen and urine in vagina -Ferning - false positives with blood (if >10% blood), semen, fingerprints or cervical mucus

Metabolic alkalosis: causes

Causes: hypovolemia, hypokalemia, hypochloremia DDx: -Volume contracted (saline responsive, urine Cl<10): Vomiting, diarrhea, NG suction, diuretics -Normal or expanded volume (saline unresponsive, urine Cl>10): primary hyperaldosteronism (Conn's), secondary hyperaldosteronism (CHF, cirrhosis, nephrotic syndrome, Cushing's, Barter's, Licorice, ectopic ACTH) -Other: milk-alkali syndrome, citrate, nonparathyroid hypercalcemia Treatment -Saline responsive: fluid and acetazolamide -Saline resistant: replace K and spironolactone (aldosterone antagonist)

Otitis externa: bacterial cause, treatment, risk factors

Causes: pseudomonas (!!), staph, gram negatives, fungal Treatment: Ciprofloxacin / ciprodex + clavulin Risk factors: immunocompromise, DM, trauma, AIDS, elderly

Ultraviolet keratitis: causes, presentation, treatment

Causes:-Sun lamps, tanning booths, snow/watter reflection, Welder's arc Presentation -Latent for 6-10h then FB sensation, tearing, photophobia, decreased VA, conjunctival injection, diffuse punctate lesions Treatment -Short acting cycloplegic, antibiotic, oral analgesia, education, follow up with optho

Causes of cyanosis

Central -Decreased sat (altitude, hypoventilation, V/Q mismatch, impaired O2 diffusion, shunt) -Hb abnormality (methemoglobin, sulfhemoglobin, CO) Peripheral -Arterial obstruction, venous obstruction, cold exposure, redistribution

Causes of diabetes insipidis

Central - idiopathic, head trauma, tumor, ICH, infection Nephrogenic - PCKD, renal dysplasia, congenital Systemic - SCD, sarcoidosis, amyloidosis Drugs - amphotericin B, lithium, dilantin, aminoglycosides

Central vertigo vs peripheral vertigo

Central: -Positive HINTS -Insidious onset -No N/V, mild severity -Associated with other neurological symptoms -No auditory symptoms -Nystagmus not fatiguable, vertical or rotatory -No change with head position Peripheral: -Severe -Sudden onset -Associated with Nausea / Vomiting -Normal other neurologic symptoms -Fatiguable Horizontal Nystagmus -Positive Dix-Hallpike

What is assessed on pelvic exam in true labor? How can fontanelles be distinguished?

Cervical dilation, cervical effacement, presenting part, station of presenting part, orientation of presenting part The anterior fontanelle has 4 sutures while the posterior fontanelle has 3. OA is the most common presentation.

What is the code for pacemaker type?

Chamber paced - A, V, D Champer sensed - A, V, D Response to sensing - Inhibit pacing (V or A and V) or Trigger pacing (old) Programming - simple, programmable, rate adaptive, communicating, none Antitachy response - pace or shock or dual

Effect and indications for use of a magnet on a pacemaker

Changes a standard pacemaker to VOO mode and turns off defibrillation in an ICD/pacemaker -Atrial tachycardia with rapid ventricular rate -Runaway pacemaker (re-entry tachycardia) -Bradycardia due to oversensing

Treatment for BB and CCB OD

Charcoal Atropine Calcium Glucagon Catecholamines (Isoproterenol, dopamine for BB; norepi or epi for CCB) Vasopression Insulin (1U/kg then 1U/kg/h) / Glucose (D50 amp then 0.5g/kg/h) Lipid emulsion (1.5cc/kg bolus then 0.25cc/kg/h infusion) Balloon pump ECMO

The triad and tetrad of ascending cholangitis

Charcot's triad: -Fever -Jaundice -RUQ pain Raynaud's pentad: -Charcot's triad plus altered mental status and shock (hypotension/tachycardia)

Types of weapons of mass destruction

Chemical - nerve agents (sarin/vx), mustard gas Biological - anthrax, plague, botulism, tularemia, smallpox, ricin Radiation - simple or dispersal Nuclear - BOOM Explosive - BOOM

Opthalmia neonatorum: definition, causes and timeline

Chemical: day 1 due to erythromycin at birth; do nothing Gonorrhea: Day 2-5, Cefotaxime and topical Chlamydia: Day 5-14, erythromycin po q6h HSV 1,2: Day 2-15, IV acyclovir

Risk factors for child abuse

Child -Premature -Difficult temperament -Developmental delay or chronic medical condition -Social isolation Caregiver -EtOH or substance abuse*** -Abused as a child -Intimate partner violence -Mental illness -Single parent Demographic -Low SES -Ethnic minority

Classes of vWD and treatment

Class I - quantitative defect - DDAVPClass II - qualitative defect - Factor VIII and cryoprecipitate Class III - no vWF - Factor VIII and cryoprecipitate

What is the difference between classic and exertional heatstroke?

Classic is in older people with chronic disease in high temperatures, sweating is absent, rhabdo and ARF are rare, lactate is BAD Exertional is in young people exerting themselves, sweating is common, rhabdo and ARF are common, and lactate is less bad

What is a critical incident? What is critical incident stress? What is the goal of critical incident debriefing?

Critical incident -An unintended event that occurs when health services are provided to an individual and results in a consequence to him or her that: 1 are serious and undesired (death, disability, injury or harm, unplanned admission to hospital or unusual extension of a hospital stay 2 does not result from the individual's underlying health condition or from a risk inherent in providing health services. Critical incident stress A situation which causes a person to experience unusually strong emotional reactions which have the potential to interfere with their ability to function either at the scene or later. Goals of debriefing Allow participants to discuss freely the events and articulate emotions in a safe environment.

Crohn's versus colitis

Crohn's affects mouth to anus / Colitis large colon and rectum only Crohn's commonly found in terminal ileum and colon / Colitis starts at rectum and moves proximally Crohn's is transmural / Colitis is superficial mucosa Crohn's has skip lesions / Colitis is continuous Crohn's gets primary sclerosing cholangitis / Colitis gets colon cancer

Approach to the Alarming Ventilator

D - Disconnect the patient from the ventilator +/- provide gentle pressure to the chest (assess for and treat breath Stacking and Equipment failure) O - Oxygen (100%) and manual ventilation with a bag (check compliance by squeezing the bag: difficult bagging suggests Pneumothorax or Obstructed tube, very easy bagging suggests Dislodged tube or Equipment failure due to a deflated cuff) T - Tube position/function (see if the tube has migrated to assess for Dislodged tube; pass a bougie or suction catheter through to see if the tube is Obstructed) T - Tweak the vent (prevents breath Stacking by decreasing respiratory rate, decreasing tidal volume or decreasing inspiratory time) S - Sonography (assess for pneumothorax, mainstem intubation, plugging)

Diagnosing the cause of an alarming ventilator

D - Dislodged tube O - Obstructed tube (mucous plug, blood, kink) P - Pneumothorax E - Equipment failure (ventilator, tubing, etc) S - Breath Stacking [breath] (Auto-PEEP)

Compare DCS I vs II

DCS I (the bends) affects MSK, skin, lymphatics. Get cutis marmorata, periarticular pain, peau d'orange, DCS II (any other organ system: CNS (spinal or cerebral) Inner ear (staggers - similar to IEBT) Pulmonary (chokes) Fetal

Mucosal edema: DDx and treatment

DDx -Anaphylaxis -Hereditary angioedema -ACE-i induced angioedema Tx -Epi -Benadryl -Steroids -C-1 esterase inhibitor -FFP

Indications for laparotomy in penetrating abdominal trauma

DIE Unstable PIG!! D iaphragmatic injury I mplement in situ E visceration Unstable (especially if FAST / DPL +) P eritoneal signs I ntraperitoneal air G I hemorrhage / G SW to abdomen

Approach to bradycardia

DIE! Drugs (BB, CCB, Dig) Infarction Electrolytes (especially K!)

Signs of retrobulbar hemorrhage and indications for lateral canthotomy

DIP A CONE (DIP is primary indications; A CONE is secondary) D ecreased VA I ncreased IOP (>40) P roptosis A fferent pupillary defect C herry red macula O pthalmoplegia N erve head pallor E ye pain

Well's DVT Criteria

DImPLES and the 3 C's (-2 points if an alternative diagnosis is as likely) - Likely if 2 or more D VT previously I mmobilization (paralysis, plaster) P ain (along deep venous system) L eg swelling (entire leg) P itting edema (to only the affected leg) S urgery (last 3m) C ancer (palliative or treated in past 6m) C alf swelling (>3cm circumference difference C ollateral veins (visible and nonvaricose)

Approach to the alarming ventilator

DOTTS D - Disconnect the patient from the ventilator +/- provide gentle pressure to the chest (assess for and treat breath Stacking and Equipment failure) O - Oxygen (100%) and manual ventilation with a bag (check compliance by squeezing the bag: difficult bagging suggests Pneumothorax or Obstructed tube, very easy bagging suggests Dislodged tube or Equipment failure due to a deflated cuff) T - Tube position/function (see if the tube has migrated to assess for Dislodged tube; pass a bougie or suction catheter through to see if the tube is Obstructed) T - Tweak the vent (prevents breath Stacking by decreasing respiratory rate, decreasing tidal volume or decreasing inspiratory time) S - Sonography (assess for pneumothorax, mainstem intubation, plugging)

Diagnostic criteria for staph toxic shock syndrome

DR FrOH (NO culture needed) D esquamation of the skin (begins during recovery phase after 1-2 weeks; R ash (blanching, macular, erythematous, NOT itchy, fades before desquamation) F ever (>38.9) r O rgan systems (>3/7 involved: CNS, mucous membranes, GI, renal, hepatic, heme, MSK) H ypotension (sBP < 90 or < 5th percentile in children)

Vaccine schedule

DTaP, Hib, pneumococcal, meningococcal by 6m Start influenza and 6m MMR at 1y and 5y HBV and HPV at 12y

Causitive factors for emergency physician stress

DURR diversity, uncertainty, relationship difficulties, resources 1 difficult patient and professional relationships 2 diversity of practice elements 3 diminished resources 4 decisions of uncertainty

Causes of hypernatremia

Decreased H20 intake - altered thirst perception (altered LOC), inability to obtain water Increased H20 less -GI - V/D/suctioning -Renal - tubule defect, osmotic diuresis, diabetes insipidis -Dermal - excessive sweating, burns -Hyperventilation Increased Na intake -Exogenous - Na tablets, bicarb, hypertonic saline, inappropriate formula -Renal - increased reabsorption due to hyperaldosteronism, Cushing's, corticosteroids

Causes of hypocalcemia

Decreased albumin Decreased magnesium PTH insufficiency or resistance Sepsis Fat embolism Vitamin D insufficiency Chelation (PO4, citrate, free fatty acids in pancreatitis, HF poisoning, Tumor Lysis Syndrome)

Causes of hypercapnea

Decreased drive - CNS disease, sedatives, exogenous toxins Neuromuscular diseases Thoracic cage diseases - kyphoscoliosis, obesity Increased dead space - COPD

Reasons Cancer patients are at increased risk of infection

Decreased immune function -Physical barrier breakdown (mucositis, indwelling catheters, cytotoxic effects on GI cells) -Functional asplenia / splenectomy (heme cancers) -Neutropenia (chemo, radiation, bone marrow suppression) -Decreased T and B cell function (disease and chemo) Increased exposure -Invasive procedures -Prophylactic abx decreases normal flora

Causes of hypokalemia

Decreased intake Increased losses -Renal (increased aldosterone, corticosteroids, RTA, licorice) -Gastrointestinal -Dermal Shifts - vomiting, diuretics, hyperventilation, insulin, B2 agonist, hypokalemic periodic paralysis Drugs - PCN, Levodopa, Li, amphoteracin, Dopamine

Anemia differential approach

Decreased production -Lack of stimulation (renal disease, chronic disease) -Unfunctional marrow (infiltrative disease: amyloid, metastasis; marrow disorders: aplastic, myelofibrosis; blood cancers: lymphoma, leukemia; tox: heavy metals, clozapine) -Lack components (B12, Folate, Fe) Increased destruction -Intravascular (mechanical: prosthetics and microangiopathic DIC/TTP; transfusion reaction: ABO, antibodies; defects: G6PD, sickling) -Extravascular (abnormal RBC: spherocytosis, thalassemia)

DDx thrombocytopenia (not drugs)

Decreased production - Marrow infiltrate, Aplastic anemia, Viral (measles), Drugs, Radiation, B12/folate def Destruction - ITP, TTP, HUS, DIC, Viral infection Sequestration - ↑ Spleen, Hypothermia Loss - Hemorrhage, HD, Extracorporeal circulation

How does O2 increase the speed of PTx resolution?

Decreases the partial pressure in the blood and as per Henry's gas law this results in the N2 from the PTx being resorbed more quickly into circulation. It increases resorbtion from 1-2%/d to 4-8%/d

What is the anal fissure triad? Treatment?

Deep ulcer Sentinal pile (hypertrophic edematous skin tag) Enlarged anal papilla Treatment with WASH (warm water, analgesia with nitro/lidocaine/nifedepine, stool softeners, high fiber diet) as per hemorrhoids.

Brown-Sequard Syndrome deficits, causes

Deficits: ipsilateral proprioception / vibration / motor; contralateral pain and temperature Causes: penetrating injury, cord compression

Horner's syndrome: definition, presentation, causes

Definition -Loss of ocular sympathetic innervation due lesion anywhere in cervical sympathetic chain (hypothalamus > brainstem > cervical cord > chest > carotid sheath > cavernous sinus > orbit) Presentation -ptosis, miosis (worse in the dark), anhidrosis- Causes: -CNS: strokes, tumor, headache syndromes, brachial plexus trauma (during delivery) -RESP: lung carcinoma, Pancoast tumor -CVS: carotid dissection -H+N: otitis media, herpes zoster

Paroxysmal nocturnal hemoglobinuria definition, diagnosis, complications

Definition - Stem cell defect with abnormal sensitivity of RBCs, neutrophils and platelets to complement Diagnosis - Get hemosiderinurea, low RBC/Plt/Neutrophils, chronic hemolysis -Luekocyte alkanine phosphatase levels are elevated -Complications: thrombosis of arteries and hepatic vein. Also MUST transfuse with WASHED RBC's or compliment on them will lead to lysis.

Traveler's diarrhea: definition, organisms, investigations

Definition - history of travel and >3 stools/24h +/- fever, abdominal cramps, emesis Organisms -Bacteria 50-80%. Specifically E coli (ETEC), Shigella (Mexico/Africa), Campylobacter (Asia), Salmonella (Europe) -Viruses 0-20%. Specifically Adenovirus, rotavirus. -Protozoa <5%. Giardia, Entamoeba. Investigations - Stool C&S +/- C Diff if: fever, tenesmus, gross blood, planned Abx. Ova and parasites if >10-14 days of symptoms. Treatment - Hydrate. Loperamide if no contraindications. Cipro 500bid x 3d or Azithro 500mg od x 3d but likely not justified unless bloody, severe, and not likely to be E Coli.

Tetanus definition, complications, management

Definition: Acute onset of hypertonia or painful muscular contractions (usually of the muscles of the jaw and neck) and generalized muscle spasms without other apparent medical causes, Complications: Respiratory failure, autonomic dysfunction, MSK spasms (Long bone fractures; tendon rupture; Subluxations, Dislocations (esp TMJ)), rhabdomyolysis Management: -Supportive treatment with intubation, GABA blockade (Benzos, Midaz, Propofol +/- Dantrolene, Magnesium), alpha blockade (phentolamine) -Toxin treatment with Human Tetanus IG 500U (administer AWAY from Td shot) -Infection treatment with debridement, Flagyl 500 mg IV q6h (7.5mg/kg for children)

Hyperemesis gravidarum: definition, onset,

Definition: emesis that causes starvation metabolism with weight loss, dehydration, ketonuria, and ketonemia Onset: 6-20 weeks Pathyphys: unsure, associated with increased B-hCG, molar pregnancy, and multiple gestation Management: fluid rehydration, enteral nutrition, diclectin (doxylamine and B6) up to 8 tabs/d then gravol then zofran/maxeran then methylprednisone

Drug side effects: Delirium, Syncope, GIB, Tinnitus

Delirium -Benzodiazepines (lorazepam, diazepam) -Opioids (morphine, fentanyl) -Hypoglycemics (glyburide, insulin) -CVS (BB, CCB) -Anticholinergics (benadryl) Syncope -Antiarrythmics (IA, IC, II, III, IV) -Antibiotics (quinolones, macrolides) -Antipsychotics (chlorpromazine, haloperidol), --Diuretics via electrolyte disturbance -Antihypertensives (Clonidine, nitrates) -Hypoglycemics (glyburide, insulin) GI bleeding -Anticoagulants (coumadin) -Antidepressants (SSRI) -NSAIDs (toradol) -Steroids Tinnitus -Salicylates -Lithium -Diuretics (Furosemide, Acetazolamide) -Aminoglycosides -Antimalarials (chloroquine, quinine)

Define delusion, hallucination, and disorganized speech

Delusion: Firm, fixed, false belief not in keeping with a person's cultural upbringing that are often religious, somatic, or persecutory. Hallucination: Sensory experience that only exists to the person experiencing it. Disorganized speech: Loosening of associations with shifts between topics. Can be circumstantial, tangential, neologisms, perseveration, or word salad.

Factors linked to preterm labor

Demographic andPsychosocial -Extremes of age -Low SES -Tobacco use -Cocaine abuse -Psychosocial stressors Reproductiveand Gynecologic -Prior preterm delivery -Multiple gestation -Endometrial cavity anomaly -Cervical incompetence -1st trimester bleeding -Placental abruption or previa Infections -UTI -Bacterial vaginosis -Nonuterineinfections

Approach to priapism

Determine low (painful) or high (not painful) flow Treatment of low flow ->4h duration requires treatment -Noninvasive tx - walk up stairs (decrease flow to penis), ice packs, compress -PO treatment - terbutaline 5-10mg PO (beta agonist) -Analgesia with dorsal nerve block -Aspiration of cavernosum -Injection of alpha agonist (phenylephrine) or methylene blue -Sicklers get O2 and hydration as well Treatment of high flow -Angiography, surgical shunt, if painful can do block

Drugs that cause hypoglycemia

Diabetic drugs -Glyburide -Insulin -Metformin -Acarbose -Rosiglitazone HTN / Heart drugs -Beta-blocker overdose (Propranolol) -MAOi -ASA Abuse -Methanol -EtOH

Diagnosis of SBP. Differentiating primary versus secondary bacterial peritonitis

Diagnosis: -PMN >250 cells/mm3 -Positive culture -Ascites fluid pH <7.34 or a gap between blood pH of >0.10 -lactate >25 Primary: -Protein <10 -Prior SBP -Bili >42mmol/L -Platelets <98 -Single bacteria cultured Secondary: -Protein >10 -Glucose <2.8 -LDH > upper limit of normal serum LDH -Multiple types of bacteria cultured

Umbilical cord prolapse: diagnosis and treatment

Diagnosis: see the cord on pelvic, suddenly non-reassuring FHR Treatment: emergency C-section, mother in knee to chest position with head down, fingers elevate presenting part, Foley to install 500-750 cc of fluid into bladder, replace cord above the presenting part

Suspicous pediatric murmurs

Diastolic Louder than 3/6 Murmurs with other sounds Cyanosis or respiratory distress Bounding or weak pulses Abnormal cardiac silhouette or vasculature on cxr

Characteristics of benign early repolarization

Diffuse Temporally stable Highest in V2-5 Concave up QRS notched at J point Concordant T's

Contrast Dilated, Hypertrophic, Restrictive, Takotsubo, Peripartum Cardiomyopathies (cause, treatment)

Dilated: Mostly idiopathic but caused by ethanol, smoking, HTN, pregnancy, infection (myocarditis). Treated with pre and afterload reduction (ACEi, diuretics, PPV) Hypertrophic: Caused by HOCM, AS, CAD, HTN. Treated with afterload reduction (BB). Must maintain preload! Restrictive: Caused by amyloidosis, sarcoidosis, hemochromatosis, scleroderma, radiation, glycoven-storage diseases (Fabry/Gaucher). Treat underlying cause. Optimize preload (fluids). Takotsubo: Caused by ? stress hormones. Treat as MI (indistinguishable from anterior STEMI) then BB and ACEi until recovery. Peripartum: Caused by pregnancy (3 months before delivery to 6 months after). Treat afterload (hydralazine/labetolol until delivery, ACEi/BB after), preload (nitro), and contractility (digoxin) until recovery.

Mechanisms of lightning injury

Direct strike - hit by discharge Contact - touching an object that was hit by lightning Sideflash - charge from a nearby object flashes through the air Step voltage - lightning travels through the ground Upward streamer - electrical connection from ground back to the clouds

What are light's criteria?

Distinguishes between exudative and transudative effusion Exudative have at least one of: Pleural fluid >2/3 of upper level of normal serum LDH Pleural LDH/serum LDH >0.6 Pleural protein/serum protein >0.5 Highly sensitive, less specific for exudate

What are the target times for ACS?

Door Data (10m) Decision Drug (lytic 30m, PCI 90m in center)

Heroin: drug complications, IVDU complications, adulterant complications

Drug - Seizure, Coma, Death - Apnea/hypoxia, Non-cardiogenic pulmonary edema - Bradycardia, Hypotension - Hypothermia IVDU - HIV, Hep B, Hep C - Sepsis, Endocarditis - Cellulitis, Abscess - DVT, Thrombophlebitis Adulterant - Botulism - Enterobacter agglomerans (cotton fever) - Agranulocytosis (levamisole) - Sepsis/infection

What is DRESS? Treatment?

Drug Rash with Eosinophilia and Systemic Symptoms Found in anticonvulsant hypersensitivity (carbamezapine, phenytoin, lamotragine, phenobarb). Usually in first 2months of therapy. Can cause MOSF (nephritis, carditis, pneumonitis) as well as tight blisters, morbilliform rash, facial edema. Treatment Withdrawl of the causative drug. Steroids are controversial. Consider NAC.

Things that cause EM, SJS and TEN

Drugs -Antibiotics - Sulpha and PCN's -Anticonvulsant - Phenytoin, Carbamazepine, Barbiturates -Antiinflammatory - ASA, Allopurinol, NSAIDS Post vaccination (polio, measles, smallpox, tetanus, diptheria) Lymphoma

Definition of DKA

Due to a lack of insulin and increase in glucagon leading to hyperglycemia, osmotic diuresis, and ketoacidosis. Glucose >13.9mmol/L (peds <11) pH <7.3 HCO3 <18 (peds <15) Serum or urine ketones

Criteria for diagnosing Endocarditis

Duke's criteria () BE FIVER (+ if 2 major, 1 major 2 minor, 5 minor) B - Blood cultures (2 positive with typical pathogens) E - Echo lesions (vegetation, perivalve abscess, prosthetic valve dehisence, new regurgitation) F - Fever (>38) I - Immunologic (Roth, Osler, rheumatoid factor) V - Vascular (Janeway, septic emboli, conjunctival hemorrhage) E - eccentric blood culture (single positive culture unless organism does not cause IE) and echo (consistent with IE but do not meet criteria) R - risk factors (IVDU, prosthetic valve)

ECG findings of lithium toxicity; drugs that cause lithium toxicity

ECG findings -QT prolongation -Sinus Bradycardia -T-wave inversion or flattening -ST depression -U wave -SA block -First degree AV block Drugs that cause lithium toxicity -ACE inhibitor - Ramipril -ARB - Valsartan -NSAID - Naproxen -Diuretics - Lasix, thiazides

Injury and associated nerve damage: -Elbow fracture -Shoulder dislocation -Sacral fracture -Acetabular fracture -Hip dislocation -Knee dislocation -Lat tib plateau fracture

Elbow fracture - Median or ulnar Shoulder dislocation - Axillary Sacral fracture - Cauda equina Acetabular fracture - Sciatic Hip dislocation - Femoral Knee dislocation - Popliteal Lat tib plateau fracture - Peroneal

Arterial embolism vs thrombosis

Embolism -Source of emboli -Sharp demarcation (no collaterals) Thrombosis -History of claudication -Contralateral findings of partial occlusion -Diffuse atherosclerosis (lots of collaterals)

DDx for somatoform disorder

Endocrine (hyperparathyroid, thyroid disorders, Addison's, insulinoma, panhypuitarism) Toxicology (botulism, CO, heavy metal toxicity) Neuro (MS, myesthenia gravis, GBS) Other (porphyria, Lupus, Wilson's disease, Uremia)

NRP algorithm - indications for entering and 6 steps

Enter algorithm if problem with Term / Tone / Breathing 1 - Warm, position airway, dry, stimulate x 30s 2 - If SpO2 not at target - supplemental O2 prn 3 - If HR<100, gasping, apnea, O2 not rising - Assist breathing with PPV x 30s 4 - If HR<60 - ETI and Chest compressions (rate of 90; 3:1 compression:breath ratio) 6 - If HR still <60 - Epinephrine, consider hypovolemia or PTx

Mixing push-dose epinephrine and phenylephrine

Epinephrine 1mg / vial 1mcg/mL in 1L 10mcg/mL in 100mL 100mcg/mL in 10mL Phenylephrine 10mg / mL 100mcg/mL in 100mL 40mcg/mL in 250mL

Doses of inotropes / vasopressors (epi, norepi, dopamine, dobutamine, phenylephrine)

Epinephrine - 0.05-0.5mcg/kg/m Norepinephrine - 0.05-0.5mcg/kg/m (5-20mcg/m push) Dopamine - 5-20mcg/kg/m Dobutamine - 5-20mcg/kg/m Phenylephrine - 5-20mcg/m push

High risk HIV exposures

Exposures 1. Percutaneous needles (deep injuries, blood on device, venipuncture) 2. Mucous membrane 3. Sexual contact Contact (Triple therapy PEP) 1. Patient has symptomatic HIV 2. AIDS 3. Acute seroconversion 4. High viral load

Breakdown DDx of red eye

Extra-orbital (e.g. orbital cellulitis, cavernous sinus thrombosis, carotid-cavernous fistula, cluster headache) External eye (e.g. eye lid and conjunctival disease) Internal eye (e.g. iritis, glaucoma)

Causes of occult irritability in children

FAT SHIC F racture A buse T esticular torsion S urgical abdomen (hernia) H air tourniquet I mproper feeding C orneal abrasion / C olic Also: diaper rash, anal fissure

Plants and animals containing cardiac glycosides

FLOWeRY BF Foxglove Lily of the valley white Oleander Weed of milk Red squill Yellow oleander Bofo toad Firefly

Soft signs of arterial injury in neck trauma

FOAHHDDS F ocal neuro deficit O ropharnygeal blood A irleak from chest tube Hemoptysis / Hematemesis H ematoma (non-expansive) D ysphagia / Dysphonia D yspnea Subcutaneous Air (or mediastinal Air)

Compare factitious disorder, Munchausen's Syndrome, Munchausen's syndrome by proxy, Malingering,

Factitious disorder: symptoms and signs produced or feigned in the absence of external benefit to take on the sick role, IS a mental disorder, unmarried educated women <40yo with healthcare background. Munchausen's: a form of factitious disorder, wide variety of illnesses with intent of gaining hospital admission, hospital shoppers, believe they are very important, initially praise care -> become disruptive -> rage and AMA Munchausen's by proxy: a form of factitious disorder where illness produced/feigned in a child. Persistent presentations with symptoms that stop when perperator is removed. Parents work in healthcare. Notify protective services and consult psych for mother. Malingering: Malingerers ARE motivated by external incentives! Not a mental disorder. Assume somatization unless otherwise proven. Often medicolegal context, discrepancy between findings and disability, poor cooperation, antisocial behavior. Don't want to get better; gaming the system.

Factors contained in FFP

Factors 2, 5, 7, 8, 9, 10, 11, 12, 13

What are the common pacemaker malfunctions?

Failure to capture - lead displacement or break, block or battery Oversensing - sensing T waves or extracardiac stimulus Undersensing - poor lead connection or break, small amplitude, poor contact Inappropriate rate - battery, response to atrial dysrhytmias

Causes of false BhCG test

False positive -Post-menopausal (usually <10) -Abortion (x 60 days) -BhCG secreting tumor (hydratiform mole) -Exogenous source (e.g. to induce ovulation) -Incomplete abortion, abortion with 2nd fetus, abortion with heterotopic ectopic False negative -Dilute urine early in gestation

etCO2 for tube placement -False positives -False negatives

False positives -Carbonated beverage in stomach (should wash out after 6 BVMs) -Recent BVM ventilation -Administration of bicarb (first 5-10 min after administration) Possible False Negatives - Prolonged arrest - Equipment failure (cuff leak, expired) - Complete obstruction at level trachea or both bronchi - Severe asthma - Massive PE

Clinical features and complications of heat stroke

Features -Temperature >40.5 -CNS dysfunction (delirium / coma) -High output CHF -Centrilobular necrosis in liver (AST / ALT >10,000) -Elevated lactate Complications -Rhabdomyolysis -ATN -Coagulopathy / DIC -Hypocalcemia and Hyponatremia

Diagnosis and management of oncologic emergencies: febrile neutropenia, SVC syndrome, Tumor lysis syndrome, Hyperviscosity syndrome, Hypercalcemia

Febrile neutropenia: Oral Temp >38.3 (x1) or 38.0 (x1h) with ANC<1 or expected <0.5 (biggest drop 5-10 days post chemo). NO rectal temps. Treat with Tazocin x 14d if stable + vanco/gent if not stable. SVC syndrome: Present with periorbital edema, plethora, facial swelling, arm swelling, dyspnea. Diagnose with CT. Treat with radiation/chemo or stent (stent best). Tumor lysis syndrome: See hyperkalemia, hyperphosphatemia, hyperuricemia, hypocalcemia. Treat with IVF +/- urinary alkalinization if acidic +/- dialysis. Can also try rasburicase with consultations. Allopurinol can prevent but not treat. Hyperviscosity syndrome: Lab can't run tests. Happens with MM, Waldenstrom's Macroglobulinemia, Leukemia. Present with CNS/vision changes. Treat with exchange transfusion, plasma/leukopheresis. Hypercalcemia: Due to mets or parthyroid-like hormone. Treat with hydration, furosemide, bisphosphonates, calcitonin.

LE motor nerve testing Femoral Saphenous Sciatic Tibial Common peroneal Superficial peroneal Deep peroneal Sural

Femoral - Knee extension Saphenous - N/A Sciatic - Knee flexion Tibial - Foot plantar flexion Common peroneal - N/A Superficial peroneal - Foot eversion Deep peroneal - Dorsiflexion of foot / toe extension Sural - N/A

Criteria to call a febrile seizure simple

Fever >38.5 6 months to 6 years 1 episode in 24 hours / per illness Duration <15 minutes Generalized No neurological history

Kanavel signs of flexor tenosynovitis

Fingers held in slight flexion Fusiform (symmetrical) swelling Pain to palpation of flexor tendon Pain on passive extension

Fixed vs Rotary transport

Fixed advantages -Can travel greater than 300 km -Can fly faster Faster -Pressurized -Less noise -More space for crew and equipment -Less affected by turbulence -Instrument flight rules / fly in worse weather Rotary advantages -Can fly directly to scene -Can reach scenes that ground/fixed wing can not -Can fly directly back to hospital

Features of drug seeking behavior

Frequent -Multiple visits for the same complaint -Changes appearance or alias between visits Focus -Unbearable pain -Focused on getting pain medicine not determining the underlying problem -Allergic to narcotic alternatives -Requesting specific medication Stories -GP unavailable -Lost prescription -Presents with common unverifiable conditions (toothache, renal colic, abdominal pain) -Creative complaints / explanations

Causes of ICD malfunction

Frequent shocks -Shocking SVT -Oversensing T waves -Having frequent VF/VT (hypoK, hypoMg, Ischemia, drug-induced) Inadequate shocks (dizzy/syncope) -Undersensing VT -Shocks not strong enough -Inadequate backup pacing for brady Cardiac arrest -Likely VF did not respond to defibrillation -May have not detected VF (change parameters)

Aquatic skin infections: fresh, salt, hot tub, tropical

Fresh - aeromonas hydrophilia (cipro) Salt - vibrio velnificans (cipro) Hot tub - pseudomonas (cipro) Aquarium - mycobacterium marinum (TB meds - RIPE)

Toxins with characteristic odors: Freshly cut hay - Garlic - Bitter almonds - Rotten eggs - Pears - Glue - Fruity - Wintergreen -

Freshly cut hay - phosgene Garlic - arsenic, organophosphates Bitter almonds - cyanide Rotten eggs - H2S Pears - chloral hydrate Glue - toluene, solvents Fruity - EtOH, acetone, isopropyl alcohol Wintergreen - methyl salicylate

Non freezing injuries

Frostnip - superficial injury, no tissue death, resolves with warming Chilblains - repetitive dry cold, cold 'sores' to face and hands (erythema, pruritis, edema), can ulcerate, more likely in Raynaud's & APLS, can tx with nifedipine Trench foot - prolonged wet cold >0 degrees. Wet socks. Rubor when dependent, pallor when elevated (vasomotor paralysis). Painful. Can get bullae.

Organic versus functional blindness

Functional -Can't write own name -Difficulty with finger apposition -Optokinetic reflex intact

Grades of caustic esophageal injury by endoscopy, contraindications to endoscopy

Grade 1 (1°): edema and hyperemia Grade 2 (2°): 2a = noncircumferential 2b = near-circumferential superficical ulcers, friability, white membrane, hemorrhage Grade 3 (3°): transmural involvement with deep injury, necrotic mucosa, perforation Increased grade = increased stricture Contraindications - perforation! Do scope at 12-24h to optimize avoidance of this in significant ingestions. Can do earlier in ? ingestions. Surgery for perf!

Grades and treatment of hepatic encephalopathy

Grades I - Depression, irritability, disordered sleep, mild cognitive dysfunction II - Lethargy, disorientation, asterixis III - Somnolence, disorientation, confused speech IV - Coma Treatment -Stop all sedatives / CNS depressants -Correct hypokalemia (allows ammonia to be excreted renally) -Remove GI protein (treat bleed, decrease protein intake, treat constipation) -Give lactulose 30mL qid (becomes lactic acid and traps NH4+ and decreases transport time) -Flagyl or Clarithromycin to kill NH3 producing gut flora -Acarbose to decrease NH3 production -MARS

Bacillus anthracis (Anthrax) - transmission, types, treatment

Gram + spore forming bacilli Transmission - inhalational (high mortality), cutaneous, oropharyngeal, gastrointestinal Inhalation - flu like symptoms (fever, cough) over 2-10 days then abrupt deterioration (sepsis, shock, hemorrhagic mediastinitis, dyspnea, stridor); diagnose with CT chest (cultures are late); 50% die with treatment; no human-to-human spread Cutaneous - spores into open wound; after 1-5 days get a papule, vesicle, black eschar; need to prevent dissemination; can culture or do serology GI - rare; eating contaminated meat; nausea, vomiting, fever, lymphadenitis, acute abdomen; 50% die Oropharyngeal - sore throat and neck swelling; dysphagia and respiratory distress Treatment - cipro OR doxy PO if cutaneous and non-toxic; if toxic cipro/docy + 2 of rifampin/clindamycin/impipenem IV x 60 days along with Vaccine

Yersinia pestis (plague) - types. ddx for buboes, treatment, prophylaxis

Gram - bacilli Can be pneumonic (infectious! from inhalation), bubonic (buboes!! from flea bite), or septic (release of endotoxin; bubonic can become septic in 50% and septic can become pneumonic) DDx for buboes - tularemia (francisella), cat scratch disease (bartonella), staph/strep Treatment - IV cipro and doxy alternative; streptomycin iv preferred Prophylaxis - PO cipro or doxy

DDx for hematuria (>5RBC / hpf)

Hematological/Cardiac -Sickle cell (infarcts) -Coagulopathy -Endocarditis Renal -Glomerular - primary glomerulonephritis (post-strep) or secondary glomerulonephritis (HUS, TTP, Lupus nephritis, HSP, Beurger's disease, Wegener's, Goodpastures, microscopic polyangitis) -Nonglomerular - trauma, pyelonephritis, AIN, RCC, infarct, AVM, Polycystic Kidneys, Exercise Postrenal -Ureter - stone, TCC -Bladder - trauma, TCC, cystitis -Prostate - prostatitis, BPH, prostate cancer -Urethra - Foley, urethritis False -Myoglobin -Menstration -Traumatic cath -Drugs (rifampin, nitrofurantoin, chloroquine/hydroxychloroquine) -Feeds (beets, berries, food coloring)

AIDS-defining illnesses

Heme -CD4<200 Malignancies -Kaposi's Sarcoma -Lymphoma -Cervical cancer (invasive) Neuro -HIV-associated encephalopathy -Progressive multifocal leukoencephalopathy -Toxoplasmosis of brain Fungal infection -Candida (esophageal or pulmonary) -Histoplasmosis -Cryptococcus -Coccidiomycosis Protozoa infection -PJP pneumonia -Isosporiasis -Toxoplasma gondii -Cryptosporidium Viral -HSV (persistent, pneumonia, esophagitis) -CMV (except spleen/liver/lymphatics) Bacterial infection -Tuberculosis -Mycobacterium avium complex -Salmonella sepsis -Recurrent bacterial infections

Complications of fractures

Hemorrhage Vascular injury Nerve injury Compartment syndrome Volkmann's ischemic contracture Avascular necrosis RSD Fat embolism syndrome Fracture blisters

Rashes with petechiae / purpura

Henoch the Tick gave Meningitis to DICk the purple drug addict Ricketsia (RMSF) Meningococcemia DIC (purpural fulminans) Endocarditis

Hepatitis serology

Hep A -For acute infection send HAV IgM -For chronic infection send HAV IgG Hep B -For acute infection send HBV sAg and HBV cAb IgM -For chronic infection send HBV cAb IgG -For vaccine immunity send HBV sAb Hep C -HCV Ab

Indications for a pacemaker

High level block (2nd or 3rd degree): -And symptomatic brady -And asystole >3s (AFib pauses >5s) -Following AV ablation -With neuromuscular disease -Intermittently block and bi or trifascicular block -With exercise

HEART score

History - slight 0/ moderate 1 / high 2 ECG - normal 0 / nonspecific 1 / ST depression 2 Age - <45 0 / 45-65 1 / >65 Risk factors - none 0 / 1-2 1 / >2 2 Troponin - < limit 0 / 1-3x limit 1 / >3x limit 2

Hordeolum, chalazion, dacrocystitis, blepharitis

Hordeolum (stye): acute localized swelling of an eyelid due to obstruction of the glands of Zeis; tx with warm compresses x15m q4-6h Chalazion: focal inflammatory lesion due to obstruction of meibomian gland (can result from hordeolum); tx by optho with excision/steroid injection Dacrocystitis: inflammation of medial lacrimal sac; can progress to periorbital cellulitis; tx with clavulin and compresses Dacroadenitis: inflammation of the lateral lacrimal gland (lateral 1/3 of upper lid); can progress to orbital cellulitis; tx with clavulin and compresses Blepharitis: matted red eyelid margins, FB sensation, burning; tx with clean with shampoo bid, warm compresses, artificial tears

Antibiotics for bites

Human - Eikenella Corridens - give Clavulin (Clindamycin + [Septra OR Levo] if allergic); resistant to 1st gen cephalosporins Cat - Pasturella multicoda - give Clavulin (Septra or Levofloxacin if allergic); resistant to Clindamycin/1st gen cephalosporins Dog - Polymicrobial (staph, strep, anaerobe) and Capnocytophagia Canimorsus - give Clavulin (admit with 3rd gen cephalosporin if elderly, asplenic, immunocompromised)

Phases of transplant rejection

Hyperacute - periop or immediate postop, relates to ABO or other antibody mismatch, get organ failure and SIRS Acute - first months after transplant, host vs graft disease, mild systemic symptoms and minimal pain, dysfunction of organ Chronic - gradual deterioration due to inflammation over years

Categories of hypertension in pregnancy

Hypertension in pregnancy: >140/90 Preeclampsia: A disorder of pregnancy characterized by hypertension and new/worse proteinuria, adverse conditions during pregnancy that is thought to be due to endothelial dysfunction Types of hypertension in pregnancy Chronic hypertension: dx'd before 20 weeks Gestational hypertension: dx'd after 20 weeks and no proteinuria Pre-eclampsia with chronic hypertension: proteinuria (>300mg/24h) and BP >160/110 in a patient with known hypertension Pre-eclampsia: proteinuria (>300mg/24h) and BP >140/90

Thyroid diseases

Hyperthyroid -Graves (TSH receptor antibodies) -Toxic multinodular goiter (multiple overactive and big areas, can cause SVC syndrome) -Toxic adenoma -Acute thyroiditis (gland is tender) --> Autoimmune (Hashimoto's antibody to thyroid peroxidase; Postpartum; Sporadic) --> Infectious (De Quervian's viral; suppurative bacterial) --> Drug induced (amiodarone, iodine, interferon, lithium) -Pituitary adenoma -Gestational trophoblastic / germ cell tumors (create TSH-like hormone) Hypothyroid -Hypothalamic and pituitary underactivity (tumors, Sheehan's, amyloidosis, sarcoidosis, radiation) -Late thyroiditis (as per above) -Iatrogenic (thyroidectomy, ablation, lithium, iodine, amiodarone) -Congenital (causes cretinism)

Grades of acromioclavicular joint separation

I - AC ligament sprain II - AC ligament rupture; CC ligaments sprained but intact. Joint space widened and slight ↑ displacement of clavicle III - Complete rupture of AC and CC ligaments, muscle attachments. Joint space widened and CC distance ↑ IV - Similar to III, but clavicle → posterior into trapezius V - Similar to III, but clavicle → upwards even more VI - Similar to III, but clavicle → inferiorly

Types of myocardial infarction

I - ischemia due to a primary coronary event (plaque rupture or dissection) II - supply-demand ischemia III - sudden cardiac death with symptoms of MI IV - MI with coronary instrumentation V - MI with CABG

Distinguish Le Fort I, II, III

I - through maxilla; maxilla moves forward when pulled II - through nasal bridge, orbits, lacrimal bones, maxilla; nose and maxilla move forward when pulled III - nasal bridge through orbits (ethmoid, maxilla, orbital walls) and zygomatic arches; face moves forward when pulled

Causes of pancreatitis

I GET SMASHED I diopathic G allstones E thanol T umors (pancreas, ampula, choledochal) S corpion stings M icro - Bacterial (Mycoplasma, Camylobacter, TB), Viral (Mumps, Coxsackie, Rubella, Varicella, CMV, hepatitis, EBV), Parasites (ascaris, echinococcus) A utoimmune (SLE, PAN, Crohn's) S urgery / trauma H yperlipidemia / H ypercalcemia (hyperparathyroid) E mboli / ischemia D rugs / toxins (ethanol, azathioprine, lasix, HCTZ, estrogens, valproic acid, tegetrol, APAP, ASA, sulfonamides)

Classification of tibial spine fractures

I Incomplete avulsion without displacement II Incomplete avulsion with minimal displacement IIIA Complete avulsion with displacement IIIB Complete avulsion with displacement and rotation

Organic versus functional psychosis

I give MADFOCS about this M emory deficits (organic - recent; functional remote) A ctivity (organic - psychomotor retardation, tremor and ataxia; functional - repetitive activity, rocking, posturing) D istortions (organic - visual; functional - auditory) F eelings (organic - emotional lability, functional - flat) O rientation (organic - disoriented; functional - oriented) C ognition (organic - islands of lucidity, can occasionally focus; functional - continuous scattered thoughts, unable to focus) S ome other things (organic - age>40, sudden onset, abnormal exam, abnormal vitals, aphasia, decreased LOC; functional - age<40, gradual onset, normal PE, normal vitals, normal LOC)

Causes of non-cardiogenic pulmonary edema

IS NOT THE HEART I nhaled Toxins (Ammonia, Chlorine, Phosgene, Nitrous oxide) S IRS / Sepsis / Septic Shock N eurogenic (seizure, strangulation, trauma, SAH) O verdose (Heroin, methadone, cocaine) T hyrotoxicosis T rauma H eat (Smoke! Remember to also consider carbon monoxide!) E lectrocution H igh altitude pulmonary edema E mbolism (clot, air, amniotic fluid, fat), E clampsia A SA toxicity (also opiates, TCA, amiodarone) R eperfusion or Re-expansion pulmonary edema (or Rocky Mountain Spotted Fever*) T ransfusion

Structured handover

ISBAR Identity Situation Background Assessment Recommendation

Intention to treat analysis Per protocol analysis

ITT - patients are analyzed in the initial groups that they are assigned to (regardless of whether they cross over) PP - patients are analyzed based on the treatment they received; crossovers and loss to follow-up are excluded

Causes of esophageal perforation

Iatrogenic - operations / scopes Boerhaave's - intraesophageal pressure increased Trauma - penetrating, blunt (rare), caustic ingestion Foreign body Barrett's esophagus Zollinger-Ellison syndrome Tumor - extrinsic or intrinsic Aortic aneurysm

Diagnostic algorithm for PE in pregnancy

If leg symptoms -> compression U/S (treat if pos) If no leg symptoms or U/S neg -> CXR If CXR clear -> V/Q scan If V/Q inconclusive -> CTPE If CXR abnormal -> CTPE If CTPE neg -> stop

Diagnostic criteria for giant cell arteritis

If you have 2 treat and get biopsy, if you have 3 just treat. 1 - >50yo 2 - new onset localized headache 3 - ESR >50 4 - abnormal biopsy with mononuclear infiltration or granulomatous inflammation Also presents with visual changes, palpable temporal artery, jaw claudication, headache

Transfusion complications (immediate, delayed, massive)

Immediate -Acute hemolytic reaction -Febrile non-hemolytic reaction -Anaphylactic reaction -Urticarial -TACO -TRALI Delayed -Delayed hemolytic -GVHD -Infectious transmission (bacterial, Hep B/C, HIV, Syphilis, Malaria) Massive -Citrate toxicity (hypoCa) -HyperK -Hypothermia -Dilutional coagulopathy

Transfusion reactions (immune, non-immune)

Immune -Febrile non-hemolytic 1:300 -Hemolytic (ABO incompatability) 1:40,000 -Delayed hemolytic -Anaphylactic 1:40,000 -Urticarial 1:100 -TRALI 1:40,000 -Transfusion-related immunomodulation (TRIM) - immunocompromised following -Post-transfusion purpura Non-immune -Citrate toxicity (hypoCa) -HyperK -Hyperthermia -Dilutional coagulopathy -TACO 1:700 -Transfusion of pathogens (Hep B 1/50,000; Hep C 1/2,000,000; HIV 1/2,000,000; bacterial 1/20,000)

Causes of sideroblastic anemia

Impaired production of porphoryn; leads to anemia and excess Fe in RBC's (Fe ring in sideroblasts) -Toxins: Lead, Alcohol & INH -Premalignant condition in elderly (often get AML) -Malignancy -RA -Pyridoxime deficiency

Historical indicators of elder abuse

Implausible mechanism of injury Inconsistent history between patient and caregiver Delay to presentation Unexplained injuries Elder being called 'accident prone' Past history of frequent injuries Noncompliance with meds, appointments, directions Caregiver does not know patient's history/meds Caregiver answers all questions Caregiver/patient reluctant to give answers Strained patient/caregiver interactions Poor living situation

Infections associated with decreased cell mediated immunity

Important in transplant and HIV Bacteria - Listeria, Legionella, Nocardia, TB Viruses - CMV, HSV, VZV, EBV Fungi - Coccidiomycoses, Blastomycoses, Histoplasma, Cryptococcus Parasites - Toxoplasma, Strongyloides

Sgarbossa Criteria

In setting of LBBB, the criteria for calling AMI is >3 points: >1mm concordant STE (OR 25, 5 points) >1mm STD in v1, v2, v3 (OR 6, 3 points) >5mm discordant STE (OR 4.3, 2 points) Also look at ST (baseline to T) / S (top of S to baseline) ratio <-0.25

Drugs that can cause serotonin syndrome

Increased 5HT can occur through a number of different mechanisms: * ↑ 5HT release: ecstasy, mirtazepine * ↓ 5HT reuptake: SSRIs (citalopram), some narcotics (meperidine, dextromethorphan, tramadol, methadone), trazodone, venlafaxine, cocaine * ↓ 5HT breakdown: MAOI (selegine), clonazepam Also lithium

Causes of compartment syndrome

Increased content: -Bleeding (Vascular injury, Coagulation disorder, Anticoagulant use) -↑ Capillary filtration (Reperfusion post-ischemia, Trauma, Intensive muscle use, Burns, Intra-arterial injection, Orthopedic surgery, Snakebite) -↑ Capillary pressure (Intensive muscle use, Venous obstruction) ↓ Compartment Volume - Closure of fascial defect - Excessive limb traction - Tight cast, dressing, splint - Lying on limb Miscellaneous -Infiltrated infusion -Pressure transfusion -Leaky dialysis cannula -Muscle hypertrophy -Popliteal cyst

Cyanotic heart disease

Increased lung markings 1-Truncus arteriosis 2-Transposition of the great arteries 5-Total anomalous venous return Decreased lung markings 3-Tricuspid atresia / pulmonary atresia 4-Tetrology of Fallot

Mumps incubation, presentation, complications, treatment

Incubation - 18 days (and lasts 7-10) Presentation - fever, myalgias, malaise, parotid swelling, orchitis, meningitis Complications -Orchitis, Meningitis, GBS, Transverse myelitis, Deafness, Pancreatitis, Mastitis, Oophoritis, Myocarditis, Arthritis Treatment -IVIg if meningitis/pancreatitis

Pertussis incubation, phases, prevention, treatment, complications

Incubation: 1-3 weeks Phases: -Catarrhal (1-2 weeks) - rhinorrhea, fever, malaise. Infective. -Paroxysmal (2-4 weeks) - staccato cough (40-50x/d) worse at night/cold. Whoop on inspiration between coughs, Emesis after cough. Infective. -Convalescent (months) - residual coughing Prevention - immunization and boosters Treatment - Azithromycin x 3-5days to prevent spread within 3 weeks of onset (6 weeks for pregnant, <1y). Not infective after 5 days. Complications - pneumonia, encephalopathy, earache, seizures. 1.6% fatality rate in infants <1y.

Indications and dosing of DigiFab

Indications -Levels of Dig (19nmol/L acute, 12nmol/L chronic) or K (>5mmol/L) -Rhythms (ventricular or hemodynamically unstable brady) -Ingestion of 10mg or >0.1mg/kg (child), cardiac glycoside with dysrhythmia, co-ingestion of cardiotoxic drug Dosing -Empiric - Acute 10 vials; Chronic 5 vials; Arrest 20 vials; Plant 10-20 vials -Amount: Amount ingested (mg) x 0.8 (bioavailability) / 0.5 (vials needed / mg) -Steady state Note that digifab WRECKS the levels! (Bound is counted the same as unbound)

Indications and contraindications for pupillary dilation Dilating agents

Indications -Need for better fundoscopic exam -Prevention of synechiae (iritis) -Decreased pain (iritis - relax ciliary muscles) Contraindications -Need to monitor pupils -Shallow anterior chamber Parasympatholytic cycloplegics (shortest to longest) -Tropicamide 1% (4h) -Cyclopentolate 1% (6-25h) -Homatropine, scopolamine, atropine Sympathomimetics -Phenylephrine 2.5% (3h) -Cocaine 5% (2h)

Indications and Contraindications to tocolysis

Indications -Preterm premature labour with -High risk for safe transport Contraindications -Chorioamino -Acute vaginal bleed -Fetal demise -Eclampsia -Sepsis -DIC

Indications for dialysis in tumor lysis syndrome and risk factors

Indications for dialysis -Phosphate >3.2 -Potassium >6 -Uric acid >590 -Creatinine >880 -Volume overload -Symptomatic hypocalcemia Risk factors -LDH > 1500 -Advanced disease -Preexisting renal dysfunction -Acidic or concentrated urine -Preexisting volume depletion -Youth

Indications for reimplantation of amputation; contraindications to reimplantation; relative contraindications to reimplantation

Indications of replant -Multiple Digits -Single digit between PIP & DIP (insertion of tendons between there) -Thumb -Wrist/forearm -Sharp amputation proximal to elbow -All pediatric amputations Absolute contraindications to reimplantation -Crush injury -Unstable patient Relative contraindications -Severe multilevel -Self inflicted -Extremes of age -Serious comorbidity -Proximal to PIP

Atropine in pediatrics: indications, mechanism and complications

Indications: 1. Post-intubation bradycardia 2. Symptomatic Bradycardia secondary to vagal tone 3. Neonatal intubation - as prophylaxis 4. Cholinergic toxidrome Mechanism - decreases vagal tone speeding sinus/atrial and AV conduction. Onset is 1-2m and it lasts 2-4m. Complications - can get a paradoxical bradycardia in low (<0.1mg) doses

DDx for pediatric fever

Infection (bacterial, viral, fungal, parasite) Inflammation -vasculitis like Kawasaki -IBD -collagen vascular like SLE and JRA Neoplastic -leukemia -lymphoma -wilms tumor -neuroblastoma Toxicologic -ASA, sympathomimetic, anticholenergic, SS, NMS, MS Environmental (heat stroke) Congenital -CAH

Complications of long-term DM

Infection (immunocompromised secondary to decreased neutrophil and lymphocyte activity) Diabetic foot Insulin allergy (must go desensitization or change type) Cutaneous manifestations (diabetic dermopathy, dermal hypersensitivity at injection sites as well as hypo or hypertrophy, acanthosis nigrans, necrobiosis lipoidica diabeticoricum, xanthoma diabeticorum) Macrovascular complications (CAD, CVD, PVD) Microvascular complications (Nephropathy, Retinopathy, Neuropathy)

DDx for dysuria in peds

Infection: UTI, pinworm, vaginitis (gardneralla, trichomonas, candida, STI), balanitis, pinworm Trauma: self-induced, sexual abuse, straddle injury Irritation: bubble bath, soaps, douches, foreign body Other: labial adhesions, renal stones

Unilateral CNVII palsy

Infectious -Lyme -Bell's Palsy -Ramsay-Hunt -Viral (VZV, HIV) -Otitis Media / Externa / Mastoiditis Trauma -Middle Ear Barotrauma -Facial laceration Brain -Schwannoma -MS -Brainstem lesion or mass (aneurysm) Weird -Diabetic Neuropathy -Sarcoidosis

Back pain red flags

Infectious - fever, IVDU Fracture - history of trauma Cancer - weight loss, history of cancer Cauda equina - urinary retention, fecal incontinence, saddle anesthesia, distal weakness Nocturnal pain

Causes of cerbral venous thrombosis

Infectious-Sinusitis -OM -Facial cellulitis -Systemic infections Noninfectious -Injury to cerebral venous system (Trauma, Surgery, Tumour) -Dehydration -Hypercoagulability

Causes of sudden hearing loss

Infectious: -Mumps -Measles -Influenza -HSV -Herpes zoster -CMV -Mono -Syphilis Drugs (ototoxic) - Aminoglycosides - Gent, Amikacin - Loop diuretics - Lasix - ASA - Indomethacin - Chemotherapeutic agents (Cisplatin, Methotrexate) - Quinine Vascular (sludging) -Macroglobulinemia -Sickle cell disease -Leukemia -Polycythemia -Fat emboli -Hypercoagulable Conductive: - Cerumen - Foreign Body - OM - OE - Barotrauma - Trauma - Neoplasm

What is toxic megacolon? What causes it? What's the treatment?

Inflammation of the smooth muscles of the colon leads to dilation and perforation if untreated. Patients look toxic and have dilated colon on AXR (>6cm). Often due to infection (C Diff gets po vanco or po/iv flagyl; other gets ceftriaxone/flagyl), IBD (gets tazo and steroids), antimotility agents (anticholinergic or opioid - stop them). May need OR.

DDx of neck masses

Inflammatory -Adenitis (Bacterial, Viral, Fungal) -Cat-scratch disease -Tularemia -Local skin infection -Sialoadenitis -Thyroiditis -TB Congenital -Branchial cleft cyst -Thyroglossal duct cyst -Dermoid cyst Neoplastic -Benign -Malignant (Sarcoma, Salivary gland, Thyroid, Lymphoma) Metastasis (1° ENT cancer, Lung, Esophageal)

How is volume of distribution calculated?

Ingestion (mg) / Concentration (mg/L) = Distribution (L) Distribution (L) / Patient weight (kg) = Vd (L/kg) Very low (<1) = dialyzable High = not dialyzable

Radiographic findings of Legg-Calve-Perthes disease

Initially - small head, wide joint space, subchondral crescent sign, irregular physis Fragmentation - fragmented epiphysis with lucencies and densities Reossification - return to normal density with irregular shape Healed - residual deformity

Diabetic drugs: name, mechanism

Insulin - opens GLUT channels so cells can use glucose Glyburide - stimulates insulin release Metformin - sensitizes cells to insulin +/- decreases intestinal absorption Acarbose - prevents glucose absorption from intestines Rosiglitazone - sensitizes cells to insulin

x-ray signs of posterior shoulder dislocation

Internal rotation Lightbulb / Drumstick sign Loss of overlap of humeral head on glenoid Increased distance between glenoid and head of humerus Trough sign (reverse Hill-Sachs lesion)

Causes of post-renal failure

Intrarenal / ureteral - stone, malignancy, oxalate crystals, sloughed papilla Bladder - stone, clot, BPH, cancer, neurogenic bladder Urethra - phimosis, stricture

Causes of hemolytic anemia (low haptoglobin, high LDH)

Intrinsic: -Enzymes (Pyruvate Kinase or G6PD) -Membrane (Spherocytosis, Elliptocytosis, PNH) -Heme (Thallasemia, Sickle Cell) Extrinsic -Mechanical (Microangiopathic - DIC/TTP/HUS/Vasculitis/Preeclampsia) -Other (valves, march) -Immunologic --> Alloimmune (ABO IgM intravasc / Rh IgG extravasc) --> Autoimmune (Reticular neoplasms [CML, CLL, lymphoma, myeloma], Inflammatory (SLE/RA/PAN/UC), Drugs (quinine, quinidine, methyldopa, PCN/cephalosporins, sulfa), Infectious (CMV/EBV/Mycoplasma/Coxsackie/Hepatitis), Thyroid, Environmental (hyperthermia, brown recluse bites, freshwater drowning, burns, snakes, malaria) Abnormal sequestration (hypersplenism)

Types of radiation exposure

Irradiation - no need to decontaminate / threat to staff Internal contamination - isolate patient, secretions, body fluid, staff External contamination - decontaminate by removing clothes, soap and water, PPE until cleared Additional management - involve radiation safety officer, appropriate decontamination PREhospital, triage based on condition not exposure, in nuclear fallout give everyone potassium iodide

Definition and classification of COPD

Irreversible, progressive airway destruction secondary to an abnormal inflammatory response. Chronic bronchitis: productive cough for >3 months in the past 2 years; high pCO2 Emphysema: destruction of the lung parenchyma due to imbalance of elastase/antielastase from inflammation; low pCO2 (breath a lot to maintain pO2) 4 classes in the Gold Classification - all have FEV1/FVC < 70% I Mild FEV1>80%; no symptoms II Moderate FEV1<80%; AECOPD and SOBOE III Severe FEV1 <50%; affects QoL IV Very Severe FEV1 <30%; R heart failure

Describe the motor deficit in central cord syndrome, causes

It is MUDdy! Motor > sensory Upper > lower Distal > proximal Causes - hyperextension injury of neck, elderly with spinal stenosis

MRSA risk factors

J ail S ports H omeless / H ealthcare I VDU R esidence C rowded

Unstable C-Spine Fractures

Jefferson Bit Off A Hangman's Tit And Pinky J efferson fracture (burst fracture of C1 seen on odontoid view) B ilateral Facet Joint Dislocation (look for a step on the lateral, FLEXion mechanism) O dontoid 2 or 3 (odontoid view neck or body fracture) A tlanto-occipital / A xial dissociation (head detached with wide spinous process separation) H angman's fracture (see break around the spinolaminar line at C2. HyperEXTENSION) T eardrop (break of anteroinferior part of the spinal body, most often HyperFLEXion) A ny fracture-dislocation P osterior neural arch of C1

Delirium vs Dementia vs Psychosis (vitals, onset, course, hallucinations, orientation, delusions, speech, movements, psychomotor)

vitals - delirium ABnormal, dementia normal, psychosis usually normal onset - delirium acute, dementia slow/insidious, psychosis acute course - delirium fluctuates, dementia slowly progresses, psychosis stable hallucinations - delirium visual & auditory, dementia, dementia no, psychosis auditory orientation - delirium no, dementia maybe, psychosis usually delusions - delirium transient, dementia yes, psychosis yes speech - delirium incoherent, dementia normal, psychosis usually coherent movements - delirium asterixis/tremor, dementia apraxia/intention tremor, psychosis absent psychomotor - delirium variable, dementia variable / agitated, psychosis variable agitation

How does iodide bolus affect thyroid hormone production?

2 possible effects: Wolff-Chaikoff effect: excess iodide inhibits ion trapping, thyroglobin iodination, and blocks the release of thyroid hormone Jod-Basedow effect: in patients with Graves or multinodular goiter who are iodine deficient it can induce hyperthyroidism

Congenital vs Adult Torsades

Congenital: precipitated by tachycardia, catacholamine excess, and delayed afterpolarization, treat with beta blockers, associated with Romano-Ward syndrome (LQT1 K channel and LQT3 Na channel) and Jervall & Lange Nielson (LQT1 K channel) syndrome Adult: precipitated by bradycardia, early afterpolarization, treat with beta agonists, associated with drugs

Contrast heat cramps, heat edema, heat syncope, prickly heat

Cramps - due to fluid replacement with hyptonic fluids Edema - vasodilation causes pooling which leads to swelling Syncope - vasodilation and dehydration lead to decreased CO and fainting Prickly heat - obstruct the sweat pores, staph infection, vesicular rash - treat with chlorhexidine cream

X-ray signs of intussusception

Crescent sign Target sign Abdominal mass (no air in one area - usually RUQ) / No liver edge sign Air fluid levels (SBO) Dilated loops of bowel (SBO) NOTE: In adults (as opposed to children) you do not want to reduce this with enema as it is often caused by cancer and this can result in seeding

Crisis vs psychiatric emergency

Crisis: acute emotional upset arising from situational or developmental problems that results in temporary inability to cope Psychiatric emergency: acute behavioral disturbance related to severe mental or emotional instability or dysfunction requiring medical intervention

Femoral nerve injury

Motor - weak knee extension, can't climb stairs or get up from sitting Sensory - varies, most reliable superomedial to patella Reflex - decreased patellar

Causes of false positive hematuria

Myoglobin Porphyria Bilirubinuria Munchausen's Menstrual blood Meds -Nitrofurantoin -Dilantin -Rifampin -Quinine Foods -Food coloring -Beets -Rhubarb -Berries

Stages of graded assertiveness

OSCE Observation Suggestion Challenge Emergency

List 10 teratogens

Heavy metals/toxins: Lead, CO, Iodine Anticoagulant: Warfarin Antiarrhythmics: Amiodarone, Quinine Anti-inflammatories: NSAIDs, misoprostol Antiepileptics: Phenytoin, VPA, carbamazepine Chemotherapeutics Busulfan, methotrexate, thalidomide Anti-hypertensives: ACEI, ARBs Dermatologic: Retinoic acid derivatives Androgens/Estrogens: OCP, HRT, diethylstilbestrol Antipsychotics: Lithium Drugs of Abuse: EtOH, cocaine Antibiotics: Erythromycin, tetracycline, aminoglycosides

Nicotinic stimulation effects

Monday - mydriasis Tuesday - tachycardia Wednesday - weakness tHursday - hypertension Friday - fasciculations Saturday - seizures And the 3 C's Confusion Convulsions Coma

How do high voltage electrical injuries differ lightning injuries?

More often, high voltage electrical injury causes -Muscle necrosis -Rhabdomyolysis -Compartment syndrome -Kissing burns -Mouth burns But does not cause -Lictenburg figures -Karaunoparalysis

Most common abdo injury in stab wound Most common abdo injury shooting Most common abdo injury blunt trauma

Most common abdo injury in stab wound Liver Most common abdo injury shooting Small bowel Most common abdo injury blunt trauma Spleen

How can we assess for pseudosubluxation on pediatric c-spine x-rays?

Most commonly C2-C3 Look at spinolaminar (Swischuk's) line drawn from anterior cortex of the C1 to C3 spinous process. If the line is >2mm anterior to the anterior cortex of C2 suspect a posterior element fracture.

Rabies carriers and PEP

Most to least common: -Bats, Raccoons, Skunks, Foxes (assume rabid unless none in area or lab neg - give PEP) -Dogs/cats/ferrets (observe x10d if caught; PEP if caught and suspected rabid; consult public health if escaped and not suspected) -Rodents/lagomorphs (no proven transmission - no PEP)

Sciatic nerve injury

Motor - paralysis of hamstring (knee flexion) and all muscles below the knee Sensory - posterior thigh and below the knee Reflex - decreased Achilles tendon

What is Still's disease? Treatment?

Multisystem inflammatory disorder characterized by fever, arthritis, sore throat, myalgias, pericarditis, hepatitis, splenomegaly, and salmon colored rash that occurs ONLY with the fever. Treat with NSAIDs, Steroids, IVIg

Compare NMS, SS and MH problem / treatment

NMS * Lack of dopamine * Rx: Stop drug, Cool, Hydrate, Benzos, Paralyze with Non-depolarizing, Bromocriptine, Amantidine, Dantrolene SS * Too much serotonin * Rx: Stop drug, Cool, Hydrate, Benzos, Paralyze with Non-depolarizing, Cyproheptadine MH * Congenital Ca2+ regulation problem in the sarcoplasmic reticulum * Precipitated by inhaled anesthetics or depolarizing muscle relaxants * Rx: Stop drug, Cool, Hydrate, Dantrolene

Acute angle closure glaucoma - definition

NOBy MICCS Symptoms (2 of) -N /V -O cular pain -B lurring vision with halos Signs (3 of) -M id-dilated nonreactive pupil -I OP greater than 21 mm Hg -C onjunctival injection -C orneal epithelial edema -S hallower anterior chamber

NEXUS Rule

NSAID -No N euro deficits -No S pinal tenderness -No A ltered LOC -No I ntoxication -No D istracting injury

Heart failure classes

NYHA Functional classes for CHF I - Asymptomatic with ordinary physical activity II - Symptomatic with ordinary physical activity III - Symptomatic with less than ordinary physical activity IV - Symptomatic at rest

Structured crisis management

SNAPPS Stop Notify Assessment Plan Priorities Suggestions

Causes of Seizure

STATUS EPILEPsy S - alicylates / S eizure med noncompliance / S trychnine T - ricyclic Antidepressants A - VM / A cute hydrocephalus / A nticholinergics T - rauma / T raumatic bleed (ICH, SDH) U - remia (Renal Failure) S - trychnine / S ugar (low glucose) / S epsis (meningitis) E - lectrolytes (Hyponatremia, Hypocalcemia) P - esticides I - ctogenic foci (e.g. post TBI, post stroke) L - ithium / L idocaine intoxication E - clampsia / E tOH withdrawal Psy - Psy chogenic Non-Epileptic Seizures (formerly known as 'pseudo seizures')

Intubation preparation

STOP I C BARS Suction Tubes Oxygenate Prepare with Preload, Position, Pharmacy (drugs), Post-intubation plan IV's CO2 monitoring Bougie & Blades Alternate airway Rescue airway Surgical airway

DDx for febrile and altered mental status patients

SWEAT Sepsis Withdrawal Endocrine (thyroid) & Environment (heat stroke) Agitated delirium Toxidromes (sympathimetic, anticholinergic, amphetamines, salicylates, SS, NMS, MH, strychnine, hallucinogens)

Describe the SAVE triage system

Secondary assessment of victim endpoint Used to assess patients in order of priority determined by START. Must have >50% chance of survival to devote resources Black unsalvageable Red immediate Yellow brief delay Green no intervention to save life or limb needed

Serotonergic agents Entactogens Dissociative agents

Serotonergic agents: LSD, psilocybin (mushroom); panic attacks, psychosis, flashbacks Entactogens: -Amphetamines, MDMA; hyperthermia, hyponatremia, SIADH -Bath salts; halucinogen and sympathomimetic -Mescaline; like LSD but with N/V Dissociative agents: -PCP, ketamine; seizures, hyperthermia -Dextrometorphan; dissociative, opioid, and serotonergic (SS)

-Severe eye aching -Prominent photophobia -Impaired vision -Cloudy cornea -Corneal opacification -Circumcorneal conjunctival injection -Cloudy anterior chamber -Pain on eyeball palpation -Proptosis -Impaired, or painful, extraocular eye movements -Fever, toxic appearance -Hyperpurulent discharge from an "angry" eye -Prominent nausea and vomiting -Small, irregular, poorly-reactive pupil -Fixed mid-dilated pupil -Increased intra-ocular pressure -History of connective tissue disease, or granulomatous disease

Severe eye aching Iritis, keratitis, acute angle-closure glaucoma, scleritis, orbital cellulitis, cavernous sinus thrombosis (CST) Prominent photophobia Iritis, keratitis Impaired vision Iritis, keratitis, acute angle-closure glaucoma, orbital cellulitis, CST Cloudy cornea Keratitis, acute angle-closure glaucoma Corneal opacification Keratitis - chemical or infectious Circumcorneal conjunctival injection Iritis, keratitis Cloudy anterior chamber Iritis Pain on eyeball palpation Scleritis (+++), orbital cellulitis, CST Proptosis Orbital cellulitis, CST, posterior scleritis Impaired, or painful, extraocular eye movements Orbital cellulitis Fever, toxic appearance Orbital cellulitis (+), CST (++) Hyperpurulent discharge from an "angry" eye Gonococcal conjunctivitis/endophthalmitis Prominent nausea and vomiting Acute angle-closure glaucoma Small, irregular, poorly-reactive pupil Iritis Fixed mid-dilated pupil Acute angle-closure glaucoma Increased intra-ocular pressure Acute angle-closure glaucoma, iritis (secondary complication) History of connective tissue disease, or granulomatous disease Iritis, scleritis

HELLP Syndrome

Severe form of pre-eclampsia Labs H emolysis E levated L iver enzymes L ow P latelets (<100) PE:Jaundice, edema, hypertension, tachycardia, dehydration, tachypnea Treatment -Consider steroids, BP control -> delivery is definitive

Rashes that start on the palms

Sifting Rocks Scabbed Emma's Hands Siphylis RMSF Scabies EM Hand/foot/mouth (Coxsackie) Also Reyes syndrome Serum sickness Kawasaki Endocarditis

Sinus venous thrombosis: signs and organisms

Signs: -Presents with fever and headache -Can have proptosis (opthalmic vein), mydriasis, CN 3,4,6 palsy, Periorbital edema and eye pain -Progress to altered mental status, meningeal signs, seizure, coma Organisms: -Strep, Staph, Moraxella, Hemophlius, Bacteroides, Fungi

Similarities and differences between ethics and law

Similarities -case based -existed since ancient times -change over time -strive for consistency -incorporate societies values -basis for health care policies Differences -laws are formal, adversarial and directive -ethics rely on individual values, can be interpreted by medical professionals and respond to rapidly changing environments

List simple asphyxiants, pulmonary irritants, cellular toxins

Simple asphyxiants: NO, CO2, N2, methane Pulmonary irritants: -Low solubility (Phosgene, NO2 - mucous membranes - upper airway) -Medium solubility (Chlorine) -High solubility (Ammonia, HF, HCl, H2S, SO2 - lower airway); consider nebulized HCO3 Cellular toxins: CN, H2S, CO Thermal injury: smoke inhalation

Simple vs complex skull fracture

Simple: -Linear not crossing suture lines -<2mm of separation Complex: -Linear crossing suture lines ->2mm of separation -Stellate -Comminuted -Depressed -Compound -Diastatic

Sinus tachycardia vs SVT features

Sinus-Has stimulus (dehydration, pain, fever) -P waves -HR variability -Beat to beat variability (irregular R-R) -<220 in infants and <180 in children SVT -No precipitant -No P waves -No HR variability -Beat to beat variability (constant R-R interval) -HR>220 in infants and >180 in children

Factors affecting stone passage

Size (5mm 98% in <4w; 5-7 60%; >7 40%) Shape (spiculated less likely) Location (can be in calyx, UPJ, pelvic brim, UVJ, vesicular orifice) Obstruction (complete pass less than incomplete)

Small vessel vasculitis

Small vessel -Goodpasture's - anti-GBM antibody +, alveolar hemorrhage, glomerulonephritis (RPGN). c-ANCA negative (unlike Wegener's) -Microscopic polyangitis - alveolar hemorrhage, glomerulonephritis, nerve involvement. NOT granulomatous (unlike Wegener's). p-ANCA+ (unlike Goodpasture's) -Wegener's granulomatosis - necrotizing granulomatous with upper resp (sinusitis, otitis, ulcers, tracheal stenosis), lower resp (bilat nodular infiltrates with cavitation), renal (RPGN), can have multiple other sx's, c-ANCA + -Churg-Strauss - asthma attacks, allergic rhinitis, eosinophilia. Constrictive pericarditis. -Behcet's - uveitis (also optic neuritis, iritis), apthous ulcers, genital ulcers. -HSP - IgA mediated hypersensitivity vasculitis mostly in <20yo. Fever, lower extremity palpable purpura, abd pain (occasionally intussusception), glomerulonephritis, arthralgias.

What is somatization? List the somatoform disorders.

Somatization The unconscious experience and communication of psychological distress through physical symptoms. -Somatization disorder -Conversion disorder -Pain disorder -Hypochondriasis

What is somatization disorder?

Somatization disorder -Unexplained physical symptoms beginning before 30yo -At least 4 sites of pain, 2 GI symptoms, 1 reproductive/sexual symptom, 1 neurologic symptom -Not explained by another medical condition -Not intentionally feigned/produced Risk factors -Women, low SES, alcoholism, addictions, poor education, interpersonal problems

Antiarrhythmic types/actions

Some Buggers Kill Cats S odium channel blocker (a block fast, b block inactivated phase, c block both) - procainamide/TCA/cocaine, lidocaine/phenytoin, flecainide/dilantin B eta blocker - propranolol/esmolol K potassium channel blocker - amiodarone/sotalol C alcium channel blocker (slow) - verapamil/diltiazam

SALT mass casualty triage algorithm

Sort (Still 1st, wave 2nd, walk 3rd) Assess (basically sort with START) Lifesaving intervention -Control hemorrhage -Open airway -Chest decompression Treatment/Transport

Syphilis (Stages, Diagnosis, Treatment)

Stages -Primary - painless chancre (papule -> 1cm ulcer) with painless lymphadenopathy -Secondary - 6 weeks to 6 months post-exposure, symmetrical non-pruritic macular/papular rash to palms and soles, can have condyloma lata around genitals, fatigue, lymphadenopathy, exanthem, myalgia, pharyngitis -Latent - Nil -Tertiary - gummas, granulomatous ulcerative lesions on skin, liver, bones, brain; Argyll-Robertson pupil; Tabes Dorsalis; Thoracic aortic aneurysm Treatment -VDRL is positive after primary syphilis. Used for screening (false positives in SLE, thyroiditis, lymphoma, post-vaccine, mycoplasma, mono, hepatitis, measles, malaria, pregnancy) -FTA used for diagnosis (flouresence treponomal antibody test) Treatment -Primary & secondary: Benzathine penicillin 2.4 million U IM; VDRL goes non-reactive after ~12 months -Latent or tertiary: treat weekly x 3 -Watch for Jerisch Herscheimer reaction

Indications for imaging in UTI

1st episode in children (<2yo or male get ultrasound) Atypical presentation Severe symptoms Females with recurrent infections ARF Renal colic with obstruction Sepsis

Immediate management of a pressure gun injury

Cleanse Splint Td Analgesia Antibiotics Examine for compartment syndrome Plastics for admission

Antibiotics effective against MRSA

Clindamycin Septra Doxycycline Vancomycin Linezolid Cefepime Ceftobiprole Daptomycin Tigecycline

Diagnostic criteria of HHS

Glucose >33 Sosm >320 pH >7.3 HCO3 >15

Complications of immobilization

Pneumonia DVT/PE UTI Wound infection Decubitus ulcers Muscle atrophy Stress ulcers

Vent settings for an asthmatic

RR - 6-10 Vt - 5-8mL/kg Minute ventilation - low PEEP - 2.5-10 (match iPEEP) Flow - 100L/m (high) I:E ratio - 1:4-6

Mechanisms of NAC in acetaminophen toxicity

(1) Glutathione precursor (2) Glutathione substitute (3) Enhances sulfation pathway leading to non-toxic metabolites (4) Antioxidant effects and free radical scavenger (5) Enhances hepatic microcirculation

Consideration for deciding to give AC

(1) Toxin can be bound by AC (2) Ingestion <1h generally, sometime <2h or longer (especially if ingestion slows gastric motility) (3) Protecting airway (4) No known antidote (5) No bowel obstruction / ileus (6) Ingested substance / amount likely to be toxic

Techniques for airway management after a failed intubation

- LMA/supraglottic airway - OPA/NPA + BVM - intubating LMA - Cricothyrotomy - Fiberoptic - glidescope, bronch, light wand

What are the NEXUS Criteria?

2 Exam -Neurologic deficit -Midline cervical tenderness 3 Credibility -Normal GCS -Not intoxicated -No distracting injuries NSAID Neuro deficit Spine (C-spine) pain Altered MS Intoxication Distracting injury

The TIMI (NSTEMI) Score

2 or more episodes of angina in past 24h 7 days history of ASA use C AD (known and >50%) A ge > 65 R isk factors (>3) T roponin S T changes Gives 14 day risk of death, MI, or need for revascularization (0-1 = 5%; 6-7 = 40%)

Targeted preductal SpO2 after birth

1m - 60-65% 2m - 65-70% 3m - 70-75% 4m - 75-80% 5m - 80-85% 10n - 85-95%

Internal hemorrhoid classification and treatment

1st degree - sense of fullness, no prolapse, medical management 2nd degree - prolapse during defecation and spontaneously reduce, medical management 3rd degree - prolapse spontaneously and during bowel movement, reduce spontaneously, medical or surgical management 4th degree - permanent prolapse with risk of thrombosis, surgical repair

What are the indications for monitoring/ admission after electrical injury?

Clinical -Cardiac arrest, LOC, hypoxia, chest pain, suspected conductive injury, other injury requiring admission ECG -Abnormal or dysrhythmia has occurred Risk factors -Known CAD -Risk factors for CAD

Clinical and radiographic findings of an orbital fracture

Clinical findings -Enophthalmos -Diplopia -Inability to gaze upward; Pain or Restrictions of EOM -Step deformity palapable -Subcutaneous emphysema -Infraorbital nerve anesthesia Radiographic -Tear drop sign (opacification in the shape of a tear at the bottom of the orbit) -AFL in maxillary sinus -eyebrow sign (lucency in the shape of an eybrow at the top of the orbit)

Globe rupture: clinical findings

Clinical: eye pain, decreased visual acuity, bloody chemosis, 360 degree SC hemorrhage, teardrop pupil, Seidel, deep anterior chamber Treatment: optho consult, tetanus, antibiotics (tazo), antiemetics, CT if FB

PDA - when does it close? PGE1 - indications and complications

Closure -Physiologic at 10-15 hours -Anatomic at 30 days PGE1 indications (start at 0.1mcg/kg/m) -Cyanosis refractory to oxygen -Refractory shock -Refractory cyanosis AND shock Complications -Apnea -Fever -Brady -Seizures -Flushing -Hypotension -Decreased platelet aggregation

Stages of wound healing

Coagulation - hours - 2 days Collagen - days - peaks at 7 days; 60% strength at 4 weeks Contraction - begins at 4 days Epithelialization - new skin; can complete over sutured lacerations within 48 hours

Study types: Cohort Study, Case Report, Meta-analysis, Clinical Decision Rule, Case Control

Cohort study - Choose a group of people with similar characteristics/exposures and then follow them to observe whether they get the disease, compared to a control group/general population. Case Report - The report of a single interesting case in detail. Meta-analysis - Comparing and combining the information from several studies to identify patterns and effects that cannot be seen in multiple single studies. Clinical Decision Rule - A series of attributes (Hx, Px findings) that, when taken together, alter the likelihood of a person having a disease process. Usually derived through a regression analysis of observational data, they must be derived, validated. Case Control - A longitudinal (usually retrospective) study when you identify a bunch of 'cases' and matched controls without an outcome of interest and then try to map back to the 'cause' (exposure, RF) that may have lead to the disease.

Causes of CVL obstruction

Complete -Clots -Precipitant -Mechanical obstruction Withdrawl -Against vessel wall -Vein thrombosis -Fibrin sheath -Ball-valve thrombus Intermittent -Pinching between clavicle and 1st rib

Complications and management of hyphemas

Complications -Traumatic Glaucoma -Synchiae -Staining of cornea -Rebleed -Blindness Management 1) Conservative Mgt - HOB up, metal shield 2) Long acting cycloplegic (homatropine, Atropine) 3) Stop anticoagulants, ASA; avoid NSAIDs 4) Manage IOP (traumatic glaucoma) 5) R/O globe rupture

Complications and non-pharma treatments of rib fractures

Complications: -Pneumothorax -Hemothorax -Pain -Pneumonia Non-pharma treatments: -Incentive spirometry -Coughing / Deep breathing exercises -IPPV -Internal Fixation

Poor predictors of outcome in upper esophageal bleed

Components of the Rockall score Age >60 Heart failure Ischemic heart disease Renal failure Liver failure Metastatic cancer Gastric cancer Vigorous bleeding

How do humans transfer heat?

Conduction - from a warmer to cooler object through direct physical contact Convection - loss to circulating air and water molecules Radiation - transferred by electromagnetic waves Evaporation - conversion of liquid to gas

Conductive vs sensorineural hearing loss

Conductive -Weber: Lateralizes toward affected side (conduction louder to affected side) -Rinne: BC is > AC -Caused by cereneum impaction, perf'd TM, cholesteatoma Sensorineural -Weber: Lateralizes away from affected side (conduction louder to normal side) -Rinne: AC is > BC (or normal) -Caused by acoustic neuroma, meniere's disease

Physiologic changes in the elderly leading to altered pharmacodynamics

GI Decreased motility / absorption Decreased hepatic metabolism / albumin for binding Decreased hepatic blood flow / metabolism MSK Increased adipose and decreased lean body mass / increased Vd Decreased total water / altered Vd GU Decreased GFR / decreased elimination

Causes of intrinsic renal failure

GN (microscopic polyangitis, Goodpasture's, Wegener's, HSP, SLE, postinfectious) Tubular (ATN, nephrotoxins - aminoglycosides, contrast, heme pigment, myeloma chains) Interstitial (AIN, SLE, sarcoid, lymphoma) Vascular (HTN, HUS, TTP, PAN, scleroderma)

Volvulus types, risk factors, x-ray findings

Gastric: hiatal hernia, either between 40 and 50yo or <1yo. Often have diaphragmatic defects, gastric ulcer or cancer, adhesions, paralyzed diaphragm. Can't pass NG tube!! Midgut: abnormal embryonic rotation of the midgut. Twisting results in duodenal obstruction and SMA compression. Bilious emesis and distension with double bubble xray and corkscrew upper GI series. Cecal: pregnancy, 'coffee bean sign' pointing to LUQ, also can have air-fluid levels in the small bowel, paucity of colonic gas. Treatment surgical. Sigmoid: elderly, psych/neuro disease, institutionalized, constipation, high fiber diet, 'coffee bean sign' pointing to RUQ, bird's beak contrast. Treatment endoscopic detorsion or surgery.

Anatomic difference in elderly patients that change response in trauma

General - on medications Cardiac - decreased reserve, can't increase HR Pulmonary - decreased compliance and increased chest wall rigidity, brittle bones Neurologic - brain atrophy increases mobility and shearing of bridging veins (SDH); dura is fused so less EDH Derm - skin is thin and brittle, easier to lacerate and tear, forms ulcers quicker MSK - osteopenia so increased fractures, decreased joint mobility, spinal stenosis

Describe how factors should be replaced in Hemophilia A and B

Generally use F8 & F9 concentrate, respectively. As per Canadian Hemophilia Guidelines Give 0.5IU/kg/% activity needed for F8 repeat q12h prn Give 1IU/kg/% activity needed for F9 repeat q24h prn Minor: epistaxis, hemarthrosis, abrasions, lacerations give 20-30U/kg of 8 or DDAVP for A or 35-50U of 9 for B. Also TXA swish for oral. Major: GIB, neck/sublingual bleeding, RP or intra-abdominal bleed, HI, major trauma, CNS bleed, sx procedure - want >80% - empiric 50U F8 for A or 100U F9 for B

Ultrasound findings in a NORMAL pregnancy

Gestational sac, 5, 1000 Yolk sac, 6, 2500 Fetal pole, 7, 17,000 FHR, 8

Cyanide toxicity and treatment

Get AGMA with a crazy high lactate; MSOF Treatment: hydroxycobalamin to form cyanocobalamin (B12) 5g empirically. Historically used amyl nitrite (if no IV) or sodium nitrite (if IV) to make methemoglobin and then Na thiosulfate to make excretable thiocyanate. ONLY thiosulfate or hydroxycobalamin in fires

Xray findings of SCFE

Get AP and a frog leg lateral (slips posteromedial so easier to see on lateral) Klein's line dies not intersect epiphysis Smaller epiphysis Metaphysis moves laterally and does not overlap the acetabulum Wide physis

Ottawa Knee Rule

Get x-rays if: Age >55 Inability to transfer weight 4 times at time of injury OR in ED Inability to flex to 90 degrees Patellar tenderness Fibular head tenderness

DDx for proteinuria

Glomerular (can be >10g/d) -Nephrotic syndrome, minimal change disease, membranous GN, focal segmental glomerulosclerosis, Post-strep GN, IgA nephropathy Tubular (generally <2g/d) -UTI -AIN -Sickle cell Overflow -Multiple myeloma, Waldenstrom's macroglobulinemia, Amyloidosis Other -Orthostatic proteinuria -Pregnancy -Exertion, stress

Causes of ascending paralysis

Goes BOTTOM VP G BS B uckthorn / B-virus (Herpes Simiae) O rganophosphate (extremity exposure) T ick paralysis T oxic neuropathies (DM, EtOH, B-vitamin deficiencies, Buckthorn) M etabolic (hyperkalemic periodic paralysis) V iral (Rabies, CNS VZV/CMV, West Nile) P olio

DDx for bilateral CNVII palsy

Gosh, bilateral CNVII isn't just B2E2LLS3 GBS (Millar-Fischer variant) Basilar Skull # / Bacterial Meningitis EBV / CMV Ethylene glycol toxicity Lyme Leukemia Sarcoidosis / Syphillis / Sarcoma, Kaposi's

Gout vs Pseudogout (crystals, risks, treatment)

Gout -Negatively birefringent needle urate crystals -Risks: obesity, DM, HTN, diuretics, alcohol, meat, seafood, beer, legumes -Treat: allopurinal (production), probenacid (excretion) chronically; colchicine 1.2/0.6/0.6, NSAIDS, steroids acutely Pseudogout -Positively birefringent rhomboid calcium pyrophosphate crystals -Risks: hyperparathyroid, hypothyroid, hypoMg, hypoPO4, Wilson's, Hemochromatosis -Treat: As for gout except steroids > NSAIDs/Colchicine; also treat underlying cause but does not affect course.

Open fracture classification and management

Gustillo classification system I - <1cm, clean, tx with 1st gen cephalosporin II - >1cm, minimal soft tissue damage, tx with 1st gen cephalosporin IIIa - significant soft tissue damage with adequate coverage, 1st gen cephalosporin and aminoglycoside (gentamicin) IIIb - significant soft tissue damage with INadequate coverage, same tx as IIIa IIIc - open # with vascular injury , same tx as IIIa Add Pen G or Clinda if concern for anaerobes (farm injury) and Cipro if concern for salt water (pseudomonas) Irrigate, cover, splint without reduction UNLESS N-V compromise

HEADSS social history

H ome E ducation A fter school D rugs S exual history S uicidal thoughts/attempts

Causes of non-anion gap metabolic acidosis

H yperalimentation A cetazolamide R TA D iarrhea U reto-enteric fistula P ancreatico-duodenal fistula S aline E ndocrine (hyperparathyroid) A rginine (excess TPN) S pironolactone

Causes of culture negative endocarditis

HACEK H aemophilus aphrophilus A ctinobacillus C ardiobacterium hominus E ikenella corrodens K ingella Kingae

Hard signs of vascular injury

HARD Bruit Hypotension Arterial Bleed Rapidly expanding hematoma Deficit (pulse/neuro) Bruit/thrill

Differential diagnosis for a NAGMA

HARDUPS Hyperalimentation / TPN Acetazolamide RTA Diarrhea Ureteral diversion Pancreas Spironolactone

Risk of bleeding on an anticoagulant

HAS BLED H ypertension A bnormal liver/renal function S troke history B leeding predisposition L abile INR E lderly (>65) D rugs / EtOH usage

Causes of heart failure

HEART Valves FAILED H ypertension E ndocarditis / E nvironment (heat wave A nemia R heumatic heart disease T hyrotoxicosis Valves F ailure to take meds A rrhythmia I nfection / I schemia / I nfarction L ung (COPD, PE, Pneumonia) E ndocrine (Pheochromocytoma / Hyperaldosteronism) D ietary indiscretions (salt / fluid)

List of conditions causing immunocompromise

HIVED ARMS ITCH H IV I VDU V ascular insufficiency E thanol use D M A splenia R F M alnutrition S teroid use I mmunizations lacking T ransplant C ancer H epatic Failure

Effects of typical antipsychotics

HOT DAMN Fever Dopamine receptor blockade Alpha blockade Muscarinic blockade Na/K channel blockade (wide QRS and long QTc)

SIRS

HR > 90 RR < 20 OR PaCO2 <32 T < 36 OR > 38 WBC <4 OR >12 OR >10% bands

HUS vs TTP vs DIC

HUS -Caused by Shiga toxin of O157:H7 -Renal symptoms predominate -Consumptive (elevated DDimer decreased haptoglobin but normal LDH) -Children with bloody diarrhea -Plasmapheresis ineffective TTP -Caused by lack of ADAMTS13 (? autoimmune) not cleaving vWF precursor -Neuro symptoms predominate -Adults -Non-consumptive (normal DDimer/Haptoglobin/fibrinogen but elevated LDH) -Schistocytes -Treat with plasmaphoresis or plasma exchange DIC -Consumptive: low fibrinogin and fibrin levels; high DDimer -Bleeding and clotting at the same time; ultimately bleed when factors gone -Schistocytes, anemia, thrombocytopenia -Caused by multiple underlying disorders

Effect of diseases on clotting: HUS, TTP, DIC, Hemophilia, vWD

HUS - decreased Plt; increased BT TTP - decreased Plt; increased BT DIC - increased INR/PTT/BT; decreased Plt Hemophilia - increased PTT vWD - increased BT

Physiologic effects of long term EtOH abuse

Heart - HTN, CHF, cardiomyopathy, arrhythmias Lung - pneumonia due to aspiration, decreased airway reflexes GI - esophagitis, mallory-weiss/boorhaave's, fatty liver/hepatitis/cirrhosis, pancreatitis, diarrhea, vitamin deficiency CNS - symmetrical polyneuropathy, Wernicke encephalopathy, Korsakoff dementia, cerebellar degeneration ID - immunosuppression, neutropenia Metabolic - insulin resistance, electrolyte abnormalitiies, AKA Heme - anemia, neutropenia, thrombocytopenia due mostly to malnutrition; decreased clotting factors due to liver failure

Risk factors for SIDS

Maternal -Smoking and drug use, Low SES and education, <20yo, black/native, no prenatal care Prenatal -Prematurity, IUGR, low birth weight, multiple births, smoking Postnatal -Smoking, prone sleep, loose bedding, soft surface, cosleeping, warm ambient temperature, infection, cardiac anomolies

Adverse conditions that qualify hypertension in pregnancy as preeclampsia

Maternal symptoms -persistent or new/unusual headache -visual disturbances -persistent abdominal or right upper quadrant pain -severe nausea or vomiting -chest pain or dyspnea) -maternal signs of end-organ dysfunction (eclampsia, severe hypertension, pulmonary edema, or suspected placental abruption) Abnormal maternal laboratory testing -elevated creatinine -elevated AST, ALT or LDH with symptoms -platelet count <100x109/L -serum albumin < 20 g/L Fetal morbidity -oligohydramnios -intrauterine growth restriction -absent or reversed end-diastolic flow in the umbilical artery by Doppler velocimetry -intrauterine fetal death

Describe the Haddon matrix

Matrix to assess and modify factors related to injury HAVE Host Agent Vector/Environment Before, during, and after injury

X-ray signs of mechanical SBO, closed loop obstruction, ileus. Normal measurements of bowel.

Mechanical -Dilated proximal loops and flattened distal loops -Sharply angulated or step-ladder loops of small bowel -Multiple air-fluid levels -'String of pearls' (pockets of gas trapped in the plicae semicircularis when the bowel is full of fluid) Closed-loop -Coffee bean sign (U-shaped bowel loop also seen in sigmoid volvulus) -Pseudotumor sign (fluid filled loop resembling a mass) Ileus -Dilated loops throughout the entire bowel including the colon -Dilation less prominent -Air fluid levels less prominent Bowel measurements: -Small 3cm -Large 6cm -Cecum 9cm

Intra vs Extraperitoneal bladder injury (mechanism, location, treatment, clinical, cystogram)

Mechanism Intra: Blunt Extra: Penetrating Location Intra: Dome Extra: Anterior Treatment Intra: OR Extra: Foley unless bladder neck, rectal, vaginal injury (then OR) Clinical Intra: hematuria, anuria, pain, meatal blood, peritonitis and abdominal distension Extra: hematuria, anuria, pain, meatal blood, pelvic fracture Cystogram Intra: enhances colon and other intraperitoneal structures Extra: remains in pelvis

Digoxin: mechanism, ECG findings, toxic presentation, treatment

Mechanism - 1) increased automaticity due to increased intracellular Ca due to blockage of Na/K ATPase and 2) increased vagal tone causing decreased HR ECG Findings - see U waves with scooped ST and shortened QTc Common: PVC's, AVB with increased ventricular automaticity, atrial tachy and vent brady due to ABV Rare: AF with slow ventricular rate, bidirectional VT NEVER: AF with rapid ventricular response Toxic presentation - Metabolic: Hyperkalemia (accumulates due to all of the blocking of Na/K ATPase - predicts outcome!!) GI: Nausea, vomiting, anorexia CNS: lethargy, confusion, weakness (acute) and headache, delirium, yellow-green halos, snowy vision Treatment - digifab! Lidocaine as antiarrhythmic if necessary (increases AV conduction and decreases automaticity), decrease shock energy and don't TV pace, avoid calcium (stoneheart)

Mechanism and 3 presentations of MAO-I toxicity; treatment

Mechanism - prevents breakdown of NE / Epi Presentations: Overdose - latent for 12-24h, then neuromuscular and cardiovascular excitation, then deplete catecholamines and crash Food/MAO-i interaction - quick onset sympathomimetic crisis with HTN/HA that is short-lived (cheese, meat, fish, wine, beer, sauerkraut) Drug/MAO-i interaction - quick onset sympathomimetic/serotonergic crisis that lasts as long as the drug (serotonin and sympathetic drugs) Treatment - OD (benzo's for agitation, cool, phentolamine for early; IVF and pressors for late), Food (phentolamine), Drug (same as OD with extras if serotonin syndrome)

Rabies mechanism, stages and management

Mechanism: -Travels up nerves at a rate of 8-20mm/d to the brain (Negri bodies) and salivary glands (infect others), causes cytokine storm and serotonin hyperactivity. Stages: I Incubation II Prodrome (1d-1w) III Acute neurological illness - can be furious (80% - hyperactive then lethargic, hydrophobia, salivation, spasms), dumb (20% - limb weakness, fever, looks like GBS), or non-classic (Thailand; brainstem/ motor/ sensory deficits pronounced; seizures) IV Coma (7-10d following acute neuro) V Death (2-3d following coma) Prophylaxis -Scrub and clean wound then rinse with povidone-iodine -If vaccinated give additional doses at 0 and 3 days -If unvaccinated give 20U human RIG near bite (and far from vaccine) then vaccine at 0,3,7,14,28 days Management -Ketamine (inhibits viral replication?)

Medial and lateral epicondylitis

Medial - Pitcher's/Golfer's Elbow -Flex wrist then try to pronate against resistance - pain to medial epicondyle Lateral - Tennis -Extend and supinate wrist then try to flex against resistance - pain to the lateral epicondyle (Cozun test) Both - treat with rest, RICE, PT

PE findings of tension pneumothorax

Mediastinal shift Decreased AE to affected side Tracheal Deviation Subcutaneous emphysema Hypotension JVD

Medical and surgical hemorrhoid treatment

Medical: WASH W arm water A nalgesia (topical nifedipine, lidocaine for external; internal controversial) S tool softeners H igh fiber diet Surgical: sclerotherapy, hemorrhoidectomy, banding

Medium vessel vasculitis

Medium vessel: -Polyarteritis nodosa - mostly CNS/GI necrotizing arteritis, no venous involvement, non-granulomatous, palpable purpura, hypergammaglobulinemia, ANCA negative -Buerger's disease - aka thromboangiitis obliterans, 20-40yo male smokers, painful dark phlebitis migrans nodules -Kawasaki disease - Warm CREAM, pediatrics

At risk or hazardous drinking (men, women, elderly)

Men: 14/week or 4/session Women: 7/week or 3/session Elderly: 7/week or 1/session

Definition and causes of menorrhagia and metrorrhagia

Menorrhagia is prolonged (>7d) or heavy (>80cc) bleeding Metrorrhagia is bleeding at irregular intervals (e.g. between periods Non-structural (COTIPE) C oagulopathy O vulatory dysfunction (ovulation, anovulation, exogenous steroids) I atrogenic (OCP) / I nfectious (endometritis, cervicitis, vaginitis) P regnancy (implantation, ectopic, abortion, molar) E ndometriosis E ndocrine (Cushing's) Structural (PLAMT) P olyps L eiomyoma A denomyosis M alignancy (Endometrial / Cervical / Ovarian cancer) T rauma (sexual abuse, foreign body)

Ethylene Glycol ingestion: metabolism, complications, treatment, stages of toxicity

Metabolism: to Glycoaldehyde -> Glycolate -> Glyoxylate -> Oxalate -> Calcium Oxalate Complications: AGMA (due to glycolic acid and lactate due to cytochrome oxidase dysfunction), hypocalcemia (chelation), crystal nephropathy, CNS punctate hemorrhages and aseptic meningoencephalitis, myonecrosis Treatment: Block with fomepizole, HCO3 to keep ethylene glycol trapped, give Pyrodoxine, Thiamine, Magnesium to aid detoxification; correct hypocalcemia, HD > 8mmol Stages of toxicity: I acute neurologic, II cardiopulmonary, III renal, IV delayed neurological

Methanol ingestion: metabolism, complications, treatment

Metabolism: to formaldehyde then formic acid (detoxified with folate) Complications: putaminal necrosis (in basal ganglia -> parkinsonism), optic neuropathy (blindness), increased free radicals, AGMA (formic acid and lactate due to cytochrome oxidase dysfunction) Treatment: block conversion with fomepizole, HCO3 to keep formic acid trapped in serum; Folate to aid in decontamination, HD (if suspect ingestion, ph<7.3, HCO3<20, OG>10, >15mmol)

DDx of osmolar and anion gap

Methanol Ethylene glycol DKA SKA AKA Lactic acidosis Uremia

Ethylene glycol vs methanol

Methanol gives visual symptoms more often Methanol targets basal ganglia/putamen (EG more diffuse) Ethylene glycol causes hypocalcemia Ethylene glycol causes calcium oxylate crystals

Hyphema grading system

Micro - just anterior chamber RBC's I - <1/3 II - 1/3 - 1/2 III - >1/2 IV - full (eight ball hyphema)

Diagnostic aid for a migraine

Migraine is likely with two or more of the POUND criteria: -P ounding -hO urs lasts (4-72) -U nilateral -N ausea and vomiting -D ebilitating

Hypothermia stages

Mild 34-36 Moderate 30-34 Severe <30

Hemophilia % classifications

Mild 6-49% activity Moderate 1-5% activity Severe <1%

Mimics appendicitis Backpacker's diarrhea Raw/undercooked poultry Associated with GBS Diarrhea and seizures Associated with Reiter's Raw oysters/shellfish Prolonged diarrhea Dysentry without fever Fried rice GI and neuro Cold allodynia / hot/cold reversal Worse after EtOH ingestion Mayo/potato salad Eggs

Mimics appendicitis: campylobacter and yersinia Backpacker's diarrhea: giardia lamblia, campylobacter Raw/undercooked poultry: campylobacter Associated with GBS: campylobacter Diarrhea and seizures: shigella Associated with Reiter's: salmonella Raw oysters/shellfish: vibrio parahemolyticus, plesiomonas Prolonged diarrhea: yersinia, aeromonas, parasite Dysentry without fever: e coli O157:H7 Fried rice: bacillus cereus (toxin mediated) GI and neuro: ciguatera toxin Cold allodynia / hot/cold reversal: ciguatera toxin Worse after EtOH ingestion: ciguatera toxin Mayo/potato salad: staph aureus Eggs: salmonella

Phases of disaster plan

Mitigation - reduce impact of any hazards Preparedness - training exercises, resource catalog Response - assessment of situation and coordination of resources Recovery - debrief and return to normal operations

Indications for active rewarming in hypothermia

Moderate or severe hypothermia No shivering Cardiovascular instability Co-morbidities (DM, trauma, endocrine) Failure to rewarm Toxicologic hypothermia Septic hypothermia Infants and elderly

Extensive ileofemoral DVT: Names and diagnosis

Phlegmasia Cerulia Dolens - swollen, congested, painful, cyanotic leg due to iliofemoral occlusion. Treat with thrombectomy. Phlegmasia Alba Dolens - painful white leg secondary to arterial spasm that results from iliofemoral occlusion. Looks like arterial occlusion. Worse then cerulia. Treat with thrombectomy.

DDx for target lesions

Pityriasis rosea (herald patch with salmon colored central clearing) Tinea corporis (very well defined) Erythema multiforme (dark center, clearing, dark halo) Urticaria (raised, migratory) Erythema marginatum (dark center, clearing, dark halo similar to multiforme but there is only 1 and it is much bigger) Secondary syphilis

Complications of FB's (plastic, glass, metal, organic, iron, copper)

Plastic, glass, metal - inert; don't remove Organic - endopthalmitis; remove Iron - siderous oxidation of ocular tissue leading to visual loss; remove Chalcosis - sterile inflammatory reaction to copper; remove

Drugs MDAC is appropriate for

Please Quit Drinking the AC Dummy Phenobarb Quinine Dapsone Theophylline / TCA (maybe) ASA (concretions) Carbamezapine Digoxin (maybe) / Dilantin (maybe) / Dabigitran Consider more in sustained release formulations

Associations with Scombroid

Poorly refrigerated fish (Tuna, mahi mahi) Histidine in decomposing fish gets broken down into histamine; treat with antihistamine -Rapid flushing to head/face/torso -Gastroenteritis -Metallic taste in mouth

Causes of tall R wave in v1

Posterior MI RBBB RVH WPW type A Children and adolescents Dextrocardia

Define power. How is power used in study design? How is power used in critical appraisal? What affects the power?

Power = 1 - beta; the probability of a type II error. e.g. when studies are underpowered they are likely to be 'falsely negative' and miss a true effect. Study design: To estimate the needed sample size needed to show a treatment effect and reject the null hypothesis. Critical appraisal: To confirm that the study has the required number of study subjects to make the conclusions that the authors are proposing. Affect power: -Level of alpha / significance (power decreases with higher levels of certainty) -Sample size (power increases with the sample) -Treatment effect (larger it is, less power needed)

Definition of stable angina

Predictable Transient (<15m) Reproducible with activity Relieved with rest/nitro

Predictors of organic anxiety disorders

Predictors -Onset after 35yo -Lack of childhood, personal, or family history of anxiety/phobias -Lack of avoidance behavior -Absence of live events that would exacerbate anxiety -Poor response to anxiolyticsiD

Treatment of active TB

RIPE (side effects) x 9 months! R ifampin (orange body fluid) I soniazid (INH injures nerves and hepatocytes) P yrazinomide E thambutol (E=eyes - optic neuritis; can't distinguish red/green)

Infections that predispose to apnea in children

RSV Pertussis Chlamydia trachomatis / pneumoniae

RUQ pain in pregnancy / RUQ pain and jaundice in pregnancy

RUQ pain in pregnancy -Hepatitis -Cholestasis of pregnancy -Choledocholithiasis -Cholecystits -HELLP -Acute Fatty Liver of Pregnancy -Capsular hematoma -Appendicitis RUQ pain and jaundice Cholestasis of Preg Acute Fatty Liver of Pregnancy

Hand sensation testing

Radial nerve - dorsal 1st web space Median nerve - volar tip of D2 Ulnar nerve - volar tip of D5 Axillary nerve - deltoid distribution

Hand motor testing

Radial nerve - wrist extension (get wrist drop) Posterior interosseous branch of the radial nerve - thumb extension (get Monkey hand) Median nerve - thumb opposition to fingers Anterior interosseous branch of the median nerve - OK sign (thumb IP flexion) Ulnar nerve - Froment's paper sign; finger abduction and adduction (get Claw hand) Axillary nerve - Shoulder abduction

Prognostic factors for pancreatitis

Ranson criteria (on admission) - mortality for 1-2 = 1%; 3-4 = 15%; 5 = 50% Non-gallstone / Gallstone A GALL A ge >55yo / >70yo G lucose >11 / >12 A ST >250 / >250 L DH >350 / >400 L eukocytes >16 / >18 BISAP score Urea > 8.92 Impaired mental status >2 SIRS criteria Age >60 Pleural effusion

Indications for hyphema admission

Rebleed Elevated IOP >50% (grade III) Decreased VA Child abuse Noncompliant

Sternbach's criteria for serotonin syndrome

Recent serotonergic med/med increase, no recent neuroleptics, no other cause, and 3 CAN features Cognitive -Agitation, Confusion, Delirium, Hypomania Autonomic instability -Tachy, HTN, shiver, diaphoresis, mydriasis, diarrhea -Neuromuscular activity Fever, ataxia, tremor, hyperreflexia, myoclonus, muscular rigidity

Rome III criteria for IBD

Recurrent abdominal pain/discomfort for at least 3d in the past 3m associated with 2/3 of: -Improvement with defecation -Onset associated with a change in stool frequency -Onset associated with a change in stool appearance

Causes of hypoMg

Redistribution - TPN, refeeding, pancreatitis, DKA correction Extrarenal losses - Vomiting, Hyperemesis Gravidarum, Anorexia, Bulimia, Diarrhea, sweating, burns, fistula, hyperaldosteronism Renal losses - Diuretics (Loop Diuretics, amphoteracin, EtOH), Bartter's, Osmotic Diuresis, DKA Inadequate intake - Malnutrition, Malabsorption, Alcoholism, Critically unwell Toxins - Cisplatin, Hydrofluoric acid

Effects and treatment of cocaine. Who needs admission? Why does it cause MI's?

Releases DA, NE, Epi and 5HT and decreased pre-synaptic reuptake of NE, DA, 5HT -NE: vasoconstriction by stimulating alpha receptors (alpha agonist) -Epi: increases myocardial contractility and heart rate by stimulating B1 receptors (B agonist) Fast Na channel blockade → local anesthesia + ↑ cardiac depolarization (↑ QRS) Similar to TCAs; acts as a class Ia antidysrhtymic (blocks the fast Na channels; binds quickly during phase 0) Vasoconstriction and platelet aggregation d/t ↑ endothelin production and ↓ nitric oxide production Treatment: Benzo's (no haldol due to anticholinergic), Cooling, Phentolamine (1mg prn), IVF, intubate/paralysis prn, ASA/heparin/nitro if ACS Admission: CAD or CAD risk factors, chest pain, cardiogenic shock, elevated cardiac markers, ECG changes, arrhythmias Why does it cause MI's? Vasoconstriction, increased cardiac demand, decreased filling time, increased platelet aggregation

Outline the phases of iron poisoning, a rare complication, and treatment

Remember: Gluconate 13%, Sulphate 20%, Fumarate 30% Fe I GI effects (hemorrhagic GI effects) x 6 hours II Quiscient x 12 hours III Systemic (vasodilatory shock; negative ionotrope, hepatorenal dysfunction with impaired oxidative phosphorylation) IV Liver failure V Resolution (GI scarring, stomach obstruction) Complication: Weirdly facilitates growth of Yersinia enterocolitica - can cause sepsis Treatment: WBI, IVF, Deferoxamine (if GIB, AGMA, shock, AMS, >90umol/L, seen on x-ray; watch for hypotension/ARDS/ATN/Yersinia sepsis)

5 locations of urinary obstruction

Renal calyx UPJ (uretopelvic junction) Pelvic brim UVJ (uretovesicular junction) Vesicular orifice

Causes of hypermagnesemia

Renal failure Increased absorption - hyperparathyroid, hypothyroid, adrenal Mg load - laxatives, enemas, antacids, untreated DKA, tumor lysis, rhabdomyolysis, management of eclampsia

Risk factors, presentation, and treatment of cerebral edema in DKA

Risk factors -New onset diabetes -Children <5yo -Extremely ill on presentation -Treated with HCO3 -Excessive fluid replacement -Rapidly dropping serum osmolality Presentation -HA -Behavioral changes -Incontinence -Seizures -Autonomic (BP and temp) Then coma, respiratory arrest, death Treatment -Mannitol 1-2g/kg over 15m -Decrease IVF and insulin rate -Intubate, hyperventilate, CT head NB - cause is unknown - ? idiogenic osmoles

Pill esophagitis: risk factors and common causes

Risk factors -Old age -Decreased esophageal motility -Extrinsic compression -Increased pill size -Gelatin coated Common causes -Tetracyclines -Antivirals -ASA / NSAIDs -KCl -Quinidine -Bisphosnates

Uterine inversion: risk factors, diagnosis and treatment

Risk factors: -Primip -Oxytocin use -fundal implantation -forceful traction on umbilical cord -MgSO4 use Diagnosis -Severe abdominal pain -Visualization of the uterus at the os or in the introitus Treatment -Do NOT remove the placenta while the uterus is out -Give tocolytics (terbutaline, MgSO4, halogenated anesthetics to relax the uterine ring -Replace uterus -Then start oxytocin

Acute necrotizing ulcerative gingivitis: risk factors, causitive agents, presentation, treatment

Risk factors: immunocompromise, smoking, local trauma, stress/fatigue Presentation: trench mouth, fever, malaise, LA, ulcerating of papillae, gray pseudomembrane, pain, hallitosis Cause: anaerobes (fusobacterium, spirochetes) Management: saline rinses, analgesia, abx (penicillin or erythromycin), dilute hydrogen peroxide rinses, dentistry f/u

Predictors of difficult cric

S urgery H ematoma / H ave infection (abscess) O besity R adiation T rauma / T umor

What is the SAAG? How is it interpreted?

SAAG = serum-ascites albumin gradient (serum albumin - ascites albumin) This replaces the distinction between transudate/exudate SAAG<11 = inflammation or decreased oncotic pressure (Carcinomatosis, TB, Pancreatic or biliary ascites, nephrotic syndrome) SAAG>11 = portal hypertension (Cirrhosis, Alcoholic hepatitis, portal-vein thrombosis, Budd Chiari, liver mets)

Suicidal ideation assessment

SAD PERSONS scale correlates with the decision to admit to psychiatry. Does not predict risk of future suicidality. S ex (male) - 1 A ge <19 or > 45- 1 D epressed diagnosed or features suggestive - 2 P revious serious attempt or psych care - 1 E thanol abuse or street drugs - 1 R ational thought (not) - 2 S eparated, widowed, divorced - 1 O rganized plan or serious attempt - 2 N o social support - 1 S tated future intent - 2 <6 - Outpatient >6 - ED psych evaluation >9 - Psych admission

Layers of the scalp and associated hemorrhage

SCALP Skin Connective Tissue (Caput succedaneum) Aponeurosis galea Loose areolar tissue (Subgaleal hematoma) Periosteum (Cephalohematoma limited by sutures)

Practical approach to the crashing neonate

SCRAMS S epsis C ardiac A buse M etabolic S urgical emergencies

CATCH Rule - Medium Risk Criteria

SDH S - Skull # D - Dangerous mechanism (MVC, fall >3ft or 5 stairs, bike accident without helmet) H - Hematoma (boggy)

Side effects of steroids

SHORT TERM o Insomnia o Mood alterations or Psychosis o GI upset o Increased appetite/weight gain o Fluid retention o Hyperglycemia o Hypokalemia LONG TERM o Hyperglycemia o Osteoporosis o Thin skin, easy bruising, poor wound healing o Rare: HTN, PUD, AVN, Allergic reaction o Adrenal suppression if > 4 courses/year

Define SIDS, apnea, pathological apnea, apnea of infancy, apnea of prematurity, periodic breathing

SIDS: sudden infant death in a child without historical, physical, laboratory, or postmortem findings that explain the death. Peaks at 3-5 months (90% <6 months) Apnea: cessation of air flow (central, obstructive, mixed) Pathologic apnea: apnea lasting >20s with bradycardia, cyanosis, hypotonia Apnea of infancy: pathologic apnea with no identifiable cause Apnea of prematurity: pathologic apnea associated with pre-term delivery (generally resolves by 37 weeks) Periodic breathing: breathing pattern with 3 or more pauses each lasting >3s with 20s of normal breathing surrounding them.

Depression symptoms

SIGECAPS Sleep Interest Guilt Energy Concentration Appetite Psychomotor slowing Suicidal Ideation

Cholinergic Toxidrome

SLUDGE and the killer B's Salivation Lacrimation Urination Defication Gastro upset Emesis Bradycardia, Bronchorrhea, Bronchospasm Also mioisis and lethargy Organophosphates, carbamates, mushrooms

Signs of Lithium toxicity

SNAP MUD S eizures N /V/D A taxia P arkinsonian M yoclonus U MN D elirium/D ecreased LOC Chronic: nephrogenic DI and hypothyroidism and SILENT (syndrome of irriversable lithium effectuated neuro toxicity - cerebellar dysfunction, EPS, dementia) Look for LOW AG

What is Mackler's triad? How can the problem be diagnosed?

Suggests esophageal rupture -Subcutaneous emphysema -Chest pain -Vomiting Diagnose with contrast study. Use gastrograffin if no risk of aspiration (safer but less sensitive test; pneumonitis if aspirated) THEN barium (worse inflammatory response through perforation). Try CT if normal or unsafe to do.

Suppurative and non-suppurative strep complications

Suppurative -Peritonsillar abscess -Retropharyngeal abscess -OM / Mastoiditis -Sinusitis -Cervical adenitis -Osteomyelitis -Meningitis Non suppurative -Rheumatic fever -Scarlet fever -Post-strep glomerulonephritis -Erythema nodosum -Toxic shock syndrome -PANDAS (pediatric autoimmune neuropsychiatric disorder associated with group A streptococcus)

Approach to the striderous child

Supraglottic -Congenital (Micrognathia, Macroglossia, Choanal atresia) -Acquired (Retropharyngeal abscess, Epiglottitis) Glottic -Congenital (Laryngeal web, Vocal cord paralysis, Laryngeomalacia) -Acquired (Laryngeal papilloma) Subglottic -Congenital (Subglottic stenosis, Hemangioma) -Acquired (Croup, Subglottic stenosis) Tracheal -Congenital (Tracheomalacia, Tracheal stenosis, vascular ring) -Acquired (Bacterial tracheitis, Foreign body)

Special tests for the shoulder (Jobe, Drop arm, Neer's, Hawkin's, Painful arc, Lift off, Lift off lag, Yergason's, Speed's)

Supraspinatus Jobe's: 90 degrees abd, 30 degrees anterior to coronal plane, internally rotated/pronated - weakness or pain = supraspinatus involvement. Drop arm test: passive abduction to 90 degrees. If can't be maintained, possible large supraspinatus tear. Supraspinatus/Impingement Neer's: Hand stabilizing scapula, passive flexion to 180 degrees. Pain towards 180 degrees indicates impingement. Hawkin's: imagine a hawk being held on an arm (90-90 flexion at shoulder/elbow) then internally rotate and see if there is pain. Indicates impingement. Subacromial bursitis Painful arc: Abduction with pain from 70-100 degrees indicates subacromial bursitis. Subscapularis Lift off test: assess for tear by putting internally rotated hand on back, holding elbow, and getting patient to lift off. Lift off lag: assess for rupture by doing same but passively lifting off and seeing if patient can maintain. Biceps Yergason's sign: Flex elbow to 90 and have patient try to supinate against resistance. Pain is positive. Speed's test: Extend elbow and supinate forearm. Flex shoulder against resistance. Pain is positive.

PRAM characteristics

Suprasternal indrawing Scalene retractions Wheezing Air entry Oxygen saturation All scored 0-2

Components of surge capacity and critical substrate for hospital operation

Surge capacity: S taff S tuff S tructure (physical location and infrastructure) Hospital operations: 3 S's plus: Communication Transportation Managerial support

How do you assess for pseudosubluxation in the pediatric C-spine?

Swischuk's line (anterior arch of C1-C3 is within 2mm of C2)

RSV prophylaxis recommendations

Synagis Give to: Born at <29 weeks and <12m old at start of RSV season Chronic lung disease Congenital heart disease

TCA mechanisms of action; OD treatment

TCA Thinker 1 - Indirect GABA antagonism (seizures) 2 - Serotonin reuptake inhibition (serotonin syndrome and agitated delirium) 3 - Norepinephrine reuptake inhibition (initial hypertension and agitated delirium) Cardiac 4 - Na channel blockade in phase 0 of cardiac depolarization (wide QRS - associated with Sz & arrhythmia, impaired inotropy) 5 - K efflux blockade prolonging phase 3 of cardiac repolarization (long QT) 6 - Alpha-1 adrenergic blockade causing vasodilation (hypotension) Anti 7 - Anticholinergic (delirium, seizures, sedation, coma, prolonged gastric emptying, anhidrosis) 8 - Antihistamine (sedation) 9 - Antidepressant (this actually results from the Norepi/Serotonin reuptake inhibition, but it balances out the acronym!) Treatment: HCO3 alkalinization to competitively inhibit Na blockade and decrease TCA affinity for Na channel

Principles of TCCC? What are the leading causes of preventable death in tactical trauma? How are the combat zones classified and how does this affect care?

TCCC = Tactical Combat Casualty Care 1- prevent additional casualties 2- accomplish mission 3- save maximum lives 4- minimize morbidity of injured Causes of death -Airway compromise (cric) -Hemorrhage (tourniquets) -Tension PTx (decompress) Zones -Hot - tourniquet (no airway or C-spine management) -Warm - not under direct fire - cric, decompression, IV and hemorrhage control, CPR, analgesia, abx -Cold - evacuation area - standard ATLS treatment

The crashing neonate

THE MISFITS T rauma / abuse H eart disease / H ypothermia / H ypoxia E ndocrine (CAH, hyperthyroid) M etabolic (hypoglycemia, hyponatremia, hypocalcemia) I nborn errors (ammonia) S epsis (most common!) F ormula mishaps I ntestinal catastrophes (volvulus, NEC, diaphragmatic hernia) T oxins (home remedies) S eizures

Appearance assessment of the pediatric assessment triad

TICLS Tone Interactivity Consolability Look/gaze Speech/cry

Niacin deficiency

aka Vitamin B3 and results in Pellagra 4D's: Diarrhea Dermatitis Dementia Death

Thiamine deficiency

aka vitamin B1 Wernicke's Encephalopathy- WACO: ataxia, confusion, opthalmoplegia Korsakoff's Psychosis - irreversible short-term memory loss Beri-beri - high output heart failure secondary to vasodilation and fistula formation

Cobalamin deficiency

aka vitamin B12 Megaloblastic anemia Neurologic changes (paresthesias, ataxia, clonus, memory loss) Psychiatric (depression, psychosis) Folate looks the same except NO neurologic changes and it happens faster.

What effect does warming the blood of a hypothermic patient have on the patient's ABG results? (pH, pO2, PCO2)

pH - lower pO2 - higher pCO2 - higher

CO treatment; hyperbaric indications

t1/2 on room air 4.5h; 100% 1.5h; hyperbaric 30m Indications for hyperbaric oxygen: COHb >25% (anyone), >15% pregnant/child; symptoms (syncope/seizure/AMS/AMI/focal neuro/dysrhythmia); consider in other cases -> Does NOT decrease mortality; may decrease neuro sequelae

x-ray and ultrasound findings of pancreatitis

x-ray -Pleural effusion -Pancreatic calcification -Free air (? due to perf'd something) -Ileus -ARDS Ultrasound -Occasionally can see CBD stone and/or enlarged hepatic duct (suggesting distal obstruction)