EMPA Mid Term 1 of 2 (Combined MEM6210-13 Sets)
What is the ratio of fluids you want to replace for every "amount" of blood and why?
3:1 ratio because only about 30% of fluids that are given stay in the intravascular space since the crystalloid is hypo-oncotic so the gradient is for the fluid to shift to the extravascular space.
CK levels become elevated within ____ hours after coronary artery occlusion, peak between ___ and ___ hours, and return to normal between __ and ___ days.
4 to 8 hours; 12 to 24 hours; 3 to 4 days
If tactile stimulation and blow-by-oxygen are not succesful after 30 seconds in improving the apneic and/or bradycardic (<100/min) newborn, then a BVM should be used with a ventilation rate of ___ to ___ breaths/min.
40-60 breaths/min
What is the lowest, mea, and ped tox dose for diltiazem?
420mg, 2167mg, 5.7mg/kg
What is the minimum volume that ventilation bags should have for ventilating infants and children?
450 mL
STEMI patients who receive fibrinolytics should receive full-dose anticoagulants for a minimum of ___ hours.
48
How does NAC affect mortality in treatment of fulminant hepatic failure?
48% down to 20% in survival decreased cerebral edema 68% down to 40% decreased vassopressor need 80% down to 40%
What is the maximum recommended APAP dose?
4gm adult, 75mg/kg ped
Because of an increased bleeding risk, it is recommended that Clopidogrel be withheld for ______ before CABG, if possible. However, this decision is usually not known, so give it in the ED unless you know they are getting the CABG.
5 days
Prognosis for intact survival of the infant is best if delivery occurs within ____ minutes of maternal arrest.
5 minutes, if not it should still be done, but no case reports of it ever working after 25 minutes.
You should reduce the arterial PCO2 by no more than __ mm Hg per hour?
5 mm Hg or else you could cause basically the symptoms of alkalemia :) cardiac dysrhythmias, seizures, etc...
What is the survival rate of birth of pre-term newborns at: 22 weeks? 23 weeks? 24 weeks?
5%, 25-30%, and >50-60%
Dobutamine
5-20mcg/kg/min Rule: 6 x wtkg to make 100mL. 1mL/h = 1.0mcg/kg/min
Asymptomatic or non-severe (>1.4) hypocalcemia should likely get oral therapy, what is the dose?
500-1000 mg PO TID, depending on the severity
What should all fluids administered contain in salicylate tox?
50g/L of glucose (5%)cy / failure
What is the lowest, mean, and ped tox dose for nifedipine?
50mg, 245mg, 8mg/kg
Which serotonin receptor is believed to be response for SS?
5HT2a
Hip dislocation should be reduced in ___ hours because delays in reduction correspond with higher incidence of a avascular necrosis
6
How long should observation in TCA?
6 hours because of rapid change from asymptomatic to ill
What is the preferred size for a tracheostomy or endotracheal tube used during cricothyroidotomy?
6 mm (never >7 mm in either case)
How long after a transplant do the pathogens go back to normally being caused by bacteria more common of CAP?
6 months
Fibrinolytic Therapy is indicated for patients with STEMI if time to treatment is <___ to ___ hours from symptom onset, and the ECG has ________.
6 to 12 hours; at least 1mm of ST elevation in two or more contiguous leads
What are the ECG changes seen in Hyperkalemia?
6.5-7.5 = prolonged PR interval, Tall peaked T Waves, and short QT interval 7.5-8.0 = flattening of the P wave, QRS widening 10-12 = QRS complex degradation into a sinusoidal pattern
Dosing of Unfractionated Heparin in possible ACS?
60 units/kg IV bolus (max 4000), then 12 units/kg/h (max 1000) infusion
What does a lunate dislocation look like on plain films?
"spilled teacup", middle "C" on lateral dislocated into palm Pathognomonic also is "Piece of Pie" sign on the PA view
How does the cardiotox of sotalol differ from other BB?
(K channel blocker) ventricular dyrhythmias from Long QT PVC, bigeminy, Vtach, vfib, torsades
How do you calculate the bicarb deficit? and correct slowly over time?
(Normal HCO3-patient's HCO3-) x 0.5 x body weight (kg) Infuse half the above amount slowly, then the rest over 6-8 hours.
What are NSAID GI changes?
*dyspepsia, gastritis, gastric/duodenal erosions, * mucosal bleeding, gastric/duo perf *common
What are the reasons you admit a patient with unexplained syncope after initial work-up?
- Abnormal EKG - Suspicion of structural disease, especially a hx of CHF - HCT <30 - SOB - SBP <90 mmHg - Family hx of sudden cardiac death - Advanced Age (no exact age but <45 should be fine)
What is the PERC Rule?
- Age <50 - SPO2 >94% on RA - HR <100 - No prior VTE - No recent surgery/trauma (requiring hospitalization, intubation, or epidural anesthesia in past 4 weeks) - No hemoptysis - No estrogen use - No unilateral leg swelling
What PE patients should be considered for fibrinolytics?
- Cardiac Arrest at any point - Hypotensive and has Massive PE - Severe Respiratory Failure (SPO2 <90 on O2 & increased work of breathing) - Evidence of R Heart Strain on Echo or - Elevated Troponin or - Both
What are some indications for a Central Venous Catheterization?
- Inability to obtain peripheral access - Access to central circulation needed for procedures - Pulmonary Artery Catheter Placement - Transvenous Pacemaker Placement - Urgent Hemodialysis - Measurement of Central Venous Pressure - Sepsis - CHF - Pericardial Effusion - Administration of: Sclerosing medications Vasopressors Concentrated ionic solutions Cytotoxic chemotherapeutic agents
What is the criteria for NPPV in a trauma patient?
- Spontaneous Respirations - Absence of Respiratory Acidemia/hypercarbia - intact mental status - PaO2 of >65 mm Hg - presence of a functioning NG tube - Absence of maxillofacial trauma
What qualifies as health care-associated pneumonia?
- hospitalized for 2 or more days in last 90 days - nursing home/long-term care residents - patients receiving home IV antibiotic therapy - dialysis patients - patients receiving chronic wound care - patients receiving chemotherapy - Immunocompromised patients
Early invasive therapy (i.e. PCI) is recommended for Unstable Angina/NSTEMI patients if:
- recurrent angina/ischemia with or without symptoms of CHF - elevated cardiac troponins - new or presumably new ST-segment depression - high-risk findings on noninvasive stress testing - depressed left ventricular function - hemodynamic instability - sustained vewntricular tachycardia - PCIs within the previous 6 months - prior CABG
What is a normal osmolar gap in healthy individuals
-14 to + 10
Neonates <1wk drugs
-Amp 25mg/kg q8hrs -Cefotaxime 50mg/kg q12hrs
Neonates 1-4wks drugs
-Amp 25mg/kg q8hrs -rocephin 75mg/kg qd or Cefotaxime 50mg/kg q8hrs
CCB OD
-CaCl 10% 0.2-0.25mL/kg IV (ped) 10mL IV adult -glucagon 50-150 mcg/kg IV ped, 3-10mg IV adult Rescue IV lipid emulsion 20%
Cyanide/Hydrogen Sulfide
-Cn Antidote kit Amyl adult only; H2S use only Na nitrite -hydroxocobalamin 70mg/kg IV upto 5gm over 30 min repeat up to 3 times coadmin with Na thiosulfate
Ethylene glycol / methanol
-Ethanol 10% IV 10 mL/kg IV over 30 min then 1.2mL/kg/h IV -Fomepizole (also used for disulfiram-ethanol rxns) 15mg/kg IV then 10mg/kg Q12hrs
What are the criteria for nontoxic ingestions?
-Only one substance -absolutely identified -substance product label must not contain any consumer product safety commission signal words indicating a potential hazard of toxicity. -must be unintentional -an approximate amount must be known -asymptomatic for duration of observation period -easy follow up or responsible parent/guardian must be present
Adults with petechial rash drugs
-Rocephin 2gm q12hrs Or -Cefotaxime 2gms q4-6hrs -consider adding doxy 100mg iv q12hrs for RMSF
Asplenic patients drugs
-rocephin 1 gram qd upto 2gm q12hrs for meningitis
Adults (non neutro) pneumonia drugs
-rocephin 1-2gms q12hrs -azithromycin 500mg day then 250mg daily -Levaquin 750mg or avelox 400mg qd -vanc 15mg/kg q6hrs or 1gm q12hrs
Children (non neutro) >3mos drugs
-rocephin 75-100mg/kg qd Or -Cefotaxime 50mg/ kg q8hrs -consider Vancouver 15mg/kg q8hrs or 1gm q12hrs
Infants 1-3mos drugs
-rocephin 75mg/kg qd Or -Cefotaxime 50mg/kg q8
Adults (non neutro) biliary drugs
-unasyn 3gm q6hrs -zosyn 4.5gms q6hrs -timentin 3.1gms q4hrs
Adults (non neutro) iv drug use drugs
-vanc 15mg/ kg q6hrs or 1gm q12hrs
Neutropenic children and adults drugs
-vanc 15mg/kg q6hrs Plus one of the following: -ceftazidime 2gm q8hrs adult and 50mg/kg q8hrs up to adult dose -cefepime 2gm q8hrs adult and <40kg 50mg/kg q8hrs up to adult dose -imipenem 500mg q8hrs adult, >3mos 15-25mg/kg q6hrs, 1-3mos 25mg/kg q6hrs, 1-4wks 25mg/kg q8hrs, <1wk 25mg/kg q12hrs
Adults (non neutro) unknown source drugs
-vanc 15mg/kg q6hrs or 1gm q12hrs Plus Pick one of the following: -imipenem 500mg q8hrs to 1gm q8hrs -meropenem 1gm q8hrs -doripenem 500mg q8hrs -ertapenem 1gm qd
Epinephrine
0.01-0.03 mg/kg (ET 0.03-0.1mg/kg); Infusion 0.1-1.0 mcg/kg/min Rule: 0.6 x wtkg = mg needed to make 100mL. 1.0mL/h = 0.1mcg/kg/min.
What is the dosing for Atropine in kids?
0.02 mg/kg, then repeat in 5 min. (Minimum dose is 0.1 mg and max dose is 0.5 for child and 1.0 for adolescent)
Should only be used if still trying for IV access, but if used then Endotracheal Epi dosing is?
0.03 to 0.1 mg/kg (0.3 to 1 ml/kg) endotracheal of a 1:10,000 solution. (follow with several PPV's)
Prostaglandin E1
0.05-0.1mcg/kg/min
Whats the dose of naloxone?
0.05mg IV / 0.4mg IV (opiate dep / naive), onset 1-2min, lasts 20-90min. Low slow - minimize withdrawl 2mg Q3min upto 10mg for apnea until reversed
What is the recommended dose of Naloxone for newborns?
0.1 mg/kg (0.4 mg/ml) IV, remember half life of narcan is less than the narcotic, so may need to readminister.
Adenosine
0.1-0.2mg/kg followed by 5cc flush; max 12mg
Isoproterernol
0.1-1.0 mcg/kg/min Rule: 0.6 x wtkg to make 100mL to get 1mL/h = 0.1 mcg/kg/min
A rise in pH of ____ generally causes a ___ decrease in serum K+.
0.10 rise in PH = 0.50 decrease in K+ because the K+ is exchanged into the cell for H+ to help lower the pH back to normal
What is the IV weight based dosing of morphine, Hydromorphone (Dilaudid), Fentanyl?
0.1mg/kg 0.015mg/kg 1.0 mcg/kg
NaHCO3- should only be used in severe acidosis where it precludes or jeopardizes therapy for the underlying disease, if this is the case and it is used then the dosing is?
0.5 mEq/kg, for each mEq/L rise desired in [HCO3-] goal is >8 mEq/L of HCO3- or improvement in shock or dysrythmias
What is the fluid resusc rate when treating sepsis?
0.5L q5-10 min (or 10-20ml/kg q 5-10 min in kids)
Atropine adult (child)
0.5mg up to 3gm (0.02mg/kg; 0.1mg min up to .5-1.0mg)
As a guideline, the PCO2 in patients with significant metabolic alkalosis should rise ____ mm Hg for every ____ mEq in increase in HCO3-. The PCO2 rarely rises above ___ mm Hg in compensation for metabolic alkalosis.
0.7 of PCO2 for every 1 HCO3- 55 mm Hg max compensation usually
A 1 gram decrease in albumin results in a ___ mg/dL decrease in total calcium, with no change in ionized fraction.
0.8
What is the dosing of Sodium Bicarbonate in kids after achieving adequate ventilations?
1 mEq/kg but ENSURE adequate ventilations
What is the dose of Enoxaparin (Lovenox)?
1 mg/kg SC every 12 hours
In respiratory Acidosis, each ___ mm Hg increase in PCO2 results in a ____ mmol increase in H+.
1 to 1
With normal respiratory compensation, PCO2 falls by ___ mm Hg for every ___ mEq/L fall in HCO3-.
1 to 1; 1 PCO2 for 1 HCO3-
With adequate ventilations, you can give sodium bicarbonate as part of the newborn resuscitation at what dosing?
1 to 2 mEq/kg of a 4.2% solution (0.5mEq/ml) which equals 2 to 4 ml/kg
What is the % of people who have an MI and % who have unstable Angina with normal or nonspecific ECGs? Nondiagnostic or evidence of ischemia that is age indeterminate?
1% to 5%; 4% to 23% 4% to 7%; 21% to 48%
What is the protocol for hyperinsulinemia-euglycemia?
1) 50mL 50% glucose in water IV 2) 1U/kg regular insulin bolus 3) 0.5-1.0 U/kg regular insulin infusion along with D10W at 200mL/h (adult) or 5mL/kg/h (ped) 4) monitor serum glucose q20min, titrate glucose to maintain level between 150-300 5) once rates stable x 60minutes decrease glucose monitor to hourly 6)monitor serum K levels and start iv K for <3.5
What is a toxic exposure to APAP?
1) >10gm or 200mg/kg single dose 2) >10gm or 200mg/kg over 24 hours 3) >6gms or 150mg/kg per 24 hr period for at least 2 consecutive days. Empiric values- use judgement although >12gms = 30% chance of 4hr APAP level of >200mg and 6% incidience of hepatotoxicity
What is the treatment of salicylate tox?
1) GI decon: gastric lavage, SDAC, sorbitol (single), whole bowel irrigation (enteric/sustained release 2)fluid and electrolyte replacement: NS and potassium (maintain 4-4.5) 3) ion trapping- alkalinization with bicarb 4) extracorporeal elimination: dialysis, filtration, hemodiafiltration
Describe treatment algorhithm of BB tox?
1) Hypotension -> ECG, U/S, Pulm art cath: QRS >120: bicarb decreased contract: glucagon, norepi, insu-glu, Ca gluconate good pump: IVF decreased SVR: norepi Brady: atropine, glucagon, pacing
What are some other things not in the ASA definition that can denote a difficult pediatric airway?
1) More than two attempts with the same blade 2) Need to change blade or use intubation stylet 3)need for an alternative intubation technique or rescue device.
What is the algorithmic approach to chronic cough?
1) Reduce smoking and D/C ACE/ARB's 2) Treat PND, if gets better work-up 3) Eval and tx for asthma 4) get chest and sinus imaging, if not done 5) eval for GERD 6) Send to specialist for CT of chest and +/- bronchoscopy >95% will get better with this approach
What are the 5 stages of Fe tox (what are the 2 clinically important)
1) abdominal pain, N, vomiting, diarrhea *absence of GI symptoms after 6hrs, excludes sig tox 2) latent 6-24hr - can be false with worsen acidosis or end of mild tox 3) systemic tox- shock metabolic acidosis, coagulopathy (biphasic), hypovolemia, renal failure, cardiomyopathy 4) hepatic stage 2-5 days, transaminase elevates and may progress to failure 5) delayed sequale - 4-6weeks pyloric stenosis, gastric outlet obstruction
What are some precautions that can be taken to minimize the bleeding risks with fibrinolytic therapy?
1) avoid unnecessary needle sticks 2) avoid any arterial punctures 3) limit venous access to compressible sites (including central lines especially to IJ or SC) 4) avoid nasogastic tubes and nasotracheal intubation
What two things separate Dementia from Delirium?
1) clouding of consciousness (reduction of awareness of external environment, may manifest as difficulty sustaining attention) 2) varying degrees of alertness (drowsiness to stupor) also sensory misperception
What are the 4 essential components of an exam for musculoskeletal trauma?
1) inspection 2) Active/Passive ROM 3) Palpation 4) Neurovascular Status
The most common causes of a chronic cough are...in this order?
1) smoking, often with chronic bronchitis 2) upper airway cough syndrome (PND) 3) asthma 4) GERD 5) ACE or ARB medications
What are some general guidelines for interaction with a aggressive or potentially violent patient?
1) stay distant from the patent 2) avoid excessive eye contact 3) maintain a somewhat submissive posture and tone of voice 4) stand where you are not threatening the patient and your exit is not blocked
What are the 3 stages of ethylene glycol toxicity?
1- neurologic at 30minutes to 12 hrs; CNS dep, coma, seizure, similar to ethanol. Can get cerebral edema. 2- cardiopulmonary 12-24hours; tachycardia HTN, tachypnea, CHF, ALI, long QT. **most deaths at this stage 3- renal 24-72hrs; most common is renal failure, may require short term dialysis for weeks but rarely permanent damage.
What is the minimum lethal dose of ethylene glycol?
1-1.5 mL/kg or 1.1-1.7gm/kg
Discuss pralidoxime dose for organophosphate tox.
1-2gm adult 20-40mg/kg up to 1gm in children mixed with NS infused over 5-10min continous infusion often needed reverses muscle weakness best before aging, but recommended in symp even after 24-48hrs
Sodium Bicarb
1-2mEq/kg 4.2% (= 0.5mEq/mL). Dilute in sterile water only not NS.
Discuss delayed organophosphate induced neuropathy.
1-3wks, legcramps, weaknes, paralysis, similar to GBS irreversible neurologic and neurobehavioral sequelae include: neuropsych def and paralysis
Discuss the intermediate syndrome of cholinesterase inhib.
1-4 days later, no evidence of cholinergic excess, occurs in 20%, paralysis of neck flexors, muscles innervated by CN, proximal limb, and respiratory muscles. electromyography may assist in Dx may resolve in 5-18d early aggressive antidote therapy helpful
Nitroprusside
1-8mcg/kg/min
What are the 6 criteria for SIADH (Syndrome of Inappropriate Secretion of Antidiuretic Hormone) and what type of hyponatremia is it?
1. Hypotonic (euvolemic) Hyponatremia 2. elevated urine osmolality (>200 mOsm/kg) 3. Elevated urine Na+ (usually >20 mEq/L) 4. Clinical euvolemia 5. Normal renal, adrenal, cardiac, hepatic, and thyroid function 6. Correctable with water restriction
What are the indications for metabolic blockade with fomeprizole / etoh?
1. documented plasma methanol or ethylene glycol >20mg/dL. 2. If cant get levels above then: a) documented or suspected sig methanol or ethylene glycol ingestion with ethanol level lower than approx. 100mg/dL OR b) Coma or AMS in a pt with unclear history and: 1-unexplained serum osmolar gap >10 or 2- unexplained metabolic acidosis and ethanol level < 100mg/dL IF ethanol is >100mg/dL then blockade already present and can wait for levels UNLESS etoh level might drop below 100mg/dL then treat. Can take DAYS to process due to prolonged halflife.
Lidocaine
1.0-1.5mg/kg bolus or 20-50mcg/kg/min infusion Rule: 60 x wtkg = mg needed to make 100mL to get 1mL/h = 10mcg/kg/min.
Normal range of Magnesium?
1.5-2.5
Each 100 milligram increase in plasma glucose decreases the serum Na+ by ___ to ___ mEq/L.
1.6 to 1.8 decrease in Na+ for every 100 mg increase in glucose
Patients with documented cardiac syncope have a 6-month mortality rate that exceeds ___%, so timely and thorough evaluation is warranted.
10
The initial 12-Lead EKG should be obtained and interpreted within ___ ___ of presentation for patients with symptoms suggestive of myocardial ischemia?
10 minutes
What is the dosing for Calcium parental treatment?
10 ml of 10% CaCL2 IV over 10-20 minutes then infusion with 0.02-0.08 mL/kg/h
The reduction in Na+ when treating hypernatremia should not exceed__ to ___ mEq/L per day.
10 to 15
It is justified, due to likely severe morbidity and/or mortality, to cease resuscitation on on a newborn after _____ min, and certainly after _____ min of Asystole.
10, and 15
What is the dosing of Labetalol IV? oral?
10-20 mg IV over 2 min, then may give 40-80 mg at 10 min intervals, max of 300mg total dose. Infusion rate would be 2 mg/min, titrate to affect, max total dose again is 300mg Peak in 15 min, lasts 2-4 hours Oral=200-400mg PO, repeat every 2-3 hours, onset is 30-120, duration is 6-12 hours.
What is the the dosing for Factor IX in nose bleeds, GI Bleeding, or CNS? Oral mucosa/deep muscle? joints?
100 units/kg; 50 units/kg; 30-40 units kg
1 in _____ likely will develop cancer from 10 mSv worth of radiation (one Chest/Abd/Pel Scan)
1000
What is the recommended intial dose of deferoxamine, and other dosing regimen
1000mg IV at 5mg/kg/hr through second access. May cause hypotension (not absolute contra). Infusion rate can be increased by 15mg/kg/h as tolerated with goal of 360mg/kg or 6gm in the first 24 hours.
In most situations, what initial fluid dose is given for newborn resuscitation?
10ml/kg by slow IV push over 5-10 min
What is the single best test to identify patients with AMI upon ED presentation?
12 Lead EKG
Hand surgeon's should repair all flexor tendon injuries...primary repair should happen in ____ hours, and secondary repair should happen in _____ weeks?
12 hours; 4 weeks
Troponin's reach their peak at ____ hours and remain elevated for ___ days.
12 hours; 7-10 days (Great for delayed presentation)
The lowest PCO2 achievable in spontaneous respiration is about ____ mm Hg.
12 mm Hg of PCO2
How to dispo dig tox patients?
12hr obs with confirmed ingestion, asymp accidental go home symptoms or large get monitored unit Fab = icu call poison control call pysych
If time allows, precut the endotracheal tube proximally at the ____ mark at the ET tube adapter site when intubating newborns.
13 cm mark
What is the normal range of Na+ according to the book?
135-150 <120 = symptoms <113 = likely seizures >158 =symptoms BUT THE RATE OF CHANGE IS QUITE IMPORTANT
How do you calculate the Arterial to Alveolar oxygen gradient? How do you adjust for age? and what is normal in a young, healthy person?
145-PaCO2-PaO2 2.5+0.21 (age in years)(+ or - 11) <10 mmHg is normal
For clinically relevant correction of coagulation factors you need to give ____ mL/kg (or __ units in a 70 kg adult)?
15 mL/kg; or 4 units in a 70 kg adult
What does skin look like in methemoglobenmia? blood?
15% - gray skin 20% - chocolate blood
How much pleural effusion fluid do you need in the hemithorax to see it on upright chest films?
150-200 mL
What is a moderate salicylate toxicity?
150-300mg/dL tachypnea, hyperpyrexia, diaphoresis, ataxia, anxiety
Amiodarone adult (child)
150mg@20-60min (5mg/kg @20-60min; 5-15mcg/kg/min)
What are two ways to calculate pediatric ET tube size based on age?
16+age(yrs), then /4 or age(yrs)/4, then +4,
What % of acute ischemic stroke patients have elevated troponins? what is the relative risk of death in these individuals compared with normal troponins?
17; 3.2
What Aldrete score does someone need at a minimum (or return to baseline) post procedural sedation to be discharged?
18
Medial clavicle epiphysis appears at age ___ and last in the body to close at age _____
18; 22-25
What is the minimum lethal dose of methanol?
1gm/kg or 1.25mL/kg
What is the atropine dose for organophosphate tox?
1mg or more in an adult q5min 0.01-0.04 mg/kg (never <0.1mg) IV in child titrate till bronchosecretions attenuate, not pupil dilations if after initial dose anticholingeric symptms dont appear then this indicative of organophos tox DOES NOT REVERSE MUSCLE WEAKNESS
Bony displacement of >____ between the base of the ____ and ____ is considered an unstable Lisfranc injury.
1mm; 1st and 2nd metatarsal
A person with normal or near normal coronary arteries on cardiac cath has developed significant epicardial stenosis with ___ years of the procedure.
2
What is the dosing for Defibrillating children in pulseless VT or VF?
2 J/kg, then follow with 2 min or 5 cycles of CPR
Where is the Achilles tendon most commonly ruptured due to this also being its weakest area of blood supply?
2 to 6 cm above the calcaneal insertion
Dopamine infusion
2.0-20mcg/kg/min (renal <5; cardiac B1 5-10; pressor A 10-20) Rule: 6 x wtkg to make 100mL. 1mL/h = 1.0mcg/kg/min
With a ___ L reservoir bag with an oxygen flow of ___ lpm you can theoretically deliver 100% oxygen.
2.5 L reservoir bag @ 15 L/min
Initial doses of Albuterol (Neb and MDI) for acute asthma treatment?
2.5-5.0 mg every 20 min for three doses = NEB 4-8 puffs every 20 minutes up to 4 hours = MDI
You should not leave a digital tourniquet on for > ______ minutes?
20
What angulation is okay for thumb metacarpal fracture?
20 degrees
What is the oral dose of Potassium replacement?
20 mEq of K+ every 30-60 minutes until desire result achieved. A cumulative dose of 20 K+ will increase K+ by 0.25 mEq/L
If a child is hypotensive, give fluid boluses of _________ as rapidly as possible, <20 min preferable.
20 mL/kg
If significant blood loss is suspected in a newborn (e.g. - abruptio placenta with large amount of visible blood loss) then what dose of fluid might the newborn need initially?
20 ml/kg slow IV push over 5-10 min
With an average Hb of 15 grams/dL, the O2 capacity of Hb is ____ ml O2/L of whole blood.
200 ml O2/L of whole blood
Angulation of <____degrees in the 4th metacarpal and <_______ degrees in the 5th metacarpal will not result in functional impairment. For 2nd and 3rd metacarpals <____ degrees is acceptable. Splint injury, will have some cosmetic deformity but likely regain full function, level of angulation at time of injury does not correlate with level of cosmetic deformity later on.
20; 40; 15
CaCl (child)
20mg/kg
The osmolar gap can be used to estimate the blood alcohol level in uncomplicated ingestions because osmolarity increases___ mg/dL for every ___ mg/dL of ethanol.
22 and 100
The accepted age of fetal viability varies among institutions, but ___ to ___ weeks is generally considered potentially viable.
22 to 26 weeks
Resuscitation should be attempted in newborns who are ____ weeks gestation or older.
23
When do most SS patients improve?
24 hours
What is the blindness dose of methanol?
24gms or 30mL
What is the initial dosing for Hemophilia A, Factor VIII replacement therapy for all things besides GI Bleeding/CNS? GI Bleeding or CNS?
25 units/kg initial dose 50 units/kg initial dose
Demonstration of new ischemia on ECG increases the risk of AMI from ___ to ___ % and the unstable angina risk from ___ to ____%.
25% to 73% 14% to 43%
Dose of Metoprolol for Possible ACS?
25-50mg PO in first 24 hours
What is the optimal initial depth of tube placement, during nasotracheal intubation, as measured by the nares?
28 cm in Men, 26 cm in Women, because the carina is 32 cm from the nares in the average person.
What is the fluid rate for whole bowel irrigation in Fe tox for adults and kids?
2L/h of ethylene glycol adult or 250-500cc/h ped
What is the chest compression, ventilation cycle according to Tintinalli for newborn resuscitation?
3 chest compressions to 1 ventilation, for total of 90 compressions to 30 breaths/min
After AMI, serum myoglobin levels rise within__ hours of symptoms and are elevated in 80-100% of patients at __ to __ hours; peak at __ to __ hours; and with normal kidney function, return to baseline within ___ hours.
3 hours; 6 to 8 hours; 4 to 9 hours; 24 hours
Metatarsal fracture with _____ displacement or _____ degree of angulation typically require surgical reduction.
3 to 4 mm; >10 degrees
When Na is decreasing by more than 0.5 mEq/L an hour or below 120 and is associated with coma or seizures you give ______ at a dose of ______. But you shouldn't raise the Na+ more than ___ to ____ per hour. Could increase that to ___ to ____ if seizures exist.
3% saline solution @ 25-100 mL/hr, no faster than 0.5-1 rise in Na+ per hour, can raise to 1 to 2 if seizures
Whats the dirty way to acutely block metabolism of toxic alcohols?
3-4 1oz shots of 80 proof liquor in 70kg adult.
What is the normal range of K+?
3.5-5.5 <2.5 = symptoms
In non-emergent blood transfusions the rate of infusion for the first ___ minutes is slow. Why?
30 min; to look for a transfusion reaction
What is the breathing rates during BLS for newborn? Infant? Child? Adult?
30-60/min (1-2 s); 12-20/min (every 3 secs); same; 10-12/min (every 5 secs)
What is the dose of Clopidogrel (Plavix)?
300-600mg PO loading dose
What is the Amiodarone and Lidocaine dosing in VF?
300mg, IV Bolus and 1.5 mg/kg IV initial dose followed by 0.75mg/kg IV for two more doses
WHat is the lowest and mean tox dose for verapamil and ped tox?
720mg, 2708mg, 16mg/kg
What are the author's recommended D-Dimer cut-off during pregnancy?
750 - 1st trimester 1000 - 2nd trimester 1250 - 3rd trimester
Due to the high energy typically required to fracture the scapula there is a high association (_____%) of injuries to the ______, ______, ______, with _______ being the most common.
75; ipsilateral lung thoracic cage shoulder girdle rib fractures
If displacement of both lateral masses (measured as offset from the superior corner of the C2 vertebral body on each side) is >____, when added together, then rupture of the transverse ligament is likely, and the spine is unstable.
7mm
What is the half-life of D-Dimer and how long will it stay elevated after symptomatic PE?
8 hours, 3 days
What is a normal measured Calcium range?
8.5 - 10.5 <6.0 or >14 = serious physiologic effects
Once intubation is performed for a poorly responding meconium birth newborn, you will suction the trachea, and administer 100% O2. Then you will attach a meconium aspirator to the ET Tube and set the wall suction between ___ and ____ mmHg while the ET Tube is slowly withdrawn.
80 to 100 mmHg
Where do most sialoliths form?
80% submandibular (Wharton)
If hypothermia is though to be responsible for the arrest in pediatrics, what tempurature should the body be raised to before terminating efforts?
86 F or 30 C
If a fracture appears overriding on plain film, what must you look at?
90 degree view to eval for overriding fracture
What is a normal Chloride level?
95-105
How much Fe does deferoxamine bind?
9mg Fe per 100mg deferoxamine
Some have suggested that if the pretest probability of ACS is ___% then no further testing is indicated. Others have suggested a threshold of ___%.
< or = 2%; <1%
What is a normal compartment pressure?
<10
What are the indications for Platelet transfusions?
<10,000 & Asymptomatic <15,000 & minor bleeding or coag D/O <20,000 & major bleeding <50,000 & thora/paracentesis, Gen Surg, or massive transfusion <100,000 & neuro or cardiac surgery
At what age do you switch from surgical cricothyroidotomy to needle cricothyroidotomy?
<10-12 yrs of age
What is the upper and lower cutoff points for the BNP being useful?
<100 or <80 is good, not CHF >400 is likely CHF 100-400 = unhelpful
What are the low cutpoint and high cutpoint for BNP?
<100 or >500
In room air, the normal A-a gradient is ___ mm Hg in a healthy 20 year old.
<15 mm Hg A = partial pressure of O2 in Alveoli (PAO2) a= partial pressure of O2 in artery (PaO2)
What is a mild salicylate toxicity?
<150mg/dL tinnitus, hearing loss, dizziness, N/V
What typical toxic levels of TCA
<1mg/kg = safe >2.5mg/kg = some toxicity >10mg/kg = serious life threatening >1gm/kg = generally fatal
Which lid lacs dont need repair?
<1mm at lid edge
What are the 3 levels of paraquat/diquat tox?
<20mg/kg (28diquat) - minimal 20-40- death 5d-wks later from pulm fibrosis with GI corrosion, ARF, pulm injury >40- death within 5 days from multi organ failure, GI, cardiogenic shock
Discuss predicted levels of Fe tox.
<20mg/kg elemental or <300mcg concentra Nontoxic or mild GI 20-60mg/kg elemental or 300-500mcg concent Moderate overall Expect sig GI and poss systemic >60mg/kg or >500mcg conc Moderate to severe sys tox >1000mcg concentration severe sys and increased morbidity
What is the definition of a non-viable fetus?
<22 weeks gestation or <400 grams
Describe stage 1 APAP tox?
<24hrs s/p anorexia, nausea, vomiting, malaise hypokalemia
For Forearm tendon injuries what % of laceration requires no repair, vs simple suture repair, vs specialist repair?
<25% - no repair 25-50% - simple suture repair >50% - specialist repair
What is generally considered a safe adult ingestion of trazodone?
<2gms; unless coingestion
In the first hours after birth, hypoglycemia is defined as _______ in the preterm newborn and _______ in the term infant?
<30-35 mg/dL and <35 to 40 mg/dL
The Combitube is not recommended for patients <___ inches tall.
<48 inches
Narcan
<5 or <20kg = 0.1mg/kg (0.4mg/ml) >5 and >20kg = 0.2mg
The ASA has set the trigger to transfuse blood at a hemoglobin of ___ (hematocrit of ____)?
<6, <18%
Respiratory Failure is characterized by ____PaO2 or ____ SaO2 on RA.
<60 PaO2 or <90% SaO2 on RA
How does time effect APAP therapy with acetylcysteine.
<8hrs post ingetsion = 100% effective >24 hours still decreases risk of hepatotoxity
First-Hospital-Door to first-balloon time for PCI should be ___ minutes?
<90 minutes
The change from baseline AG is really more useful, however an AG of _____ is virtually always abnormal even without comparison values.
> 15 mEq/L
What does of Aspirin should all Unstable Angina/NSTEMI/STEMI patients get? What kind do you not use?
> or = 162mg, preferably 325mg, and don't use the enteric-coated kind since this will delay absorption
What physical exam finding is predictive of a DVT?
> or = 2 cm difference in diameter of the lower leg (10cm below the tibial tubercle) is predictive of a DVT (OR 1.8)
What is the definition of a massive transfusion?
>10 units of blood within the first 24 hours of injury
Blood transfusion is not recommended if the hemoglobin is ___ (hematocrit of ___)?
>10, >30%
If the pleural effusion is significant than what should you be able to see on lateral decubitus films or U/S?
>10mm pleural fluid strip
What is a diagnostic varus or valgus stress test when testing LCL and MCL?
>1cm of laxity with no end point compared with the other knee = complete rupture of MCL or LCL <1cm laxity or firm end point = partial tear none of the above = strain
Care providers should target those who are ___% risk for ACS to undergo further testing.
>2%
What arrest scenarios are associated with a poor outcome?
>20 min of arrest or no response to two doses of epinephrine
What amount of vertebral body compression is considered unstable?
>25% for C3-7, and >50% thoracic and lumbar
What is a severe salicylate toxicity?
>300mg/dL AMS, seizures, ALI, renal failure, arrhythmias, shock
How do you diagnose scapholunate dissociation on a PA wrist film?
>3mm in widening of the scapholunate joint space
How would you ventilate using a needle cric on a kid?
>5 yrs old: High Flow Oxygen tubing attached directly to wall mounted 50 psi oxygen <5 years old: BVM attached to catheter using a 3 mm ET Tube as an adapter
What ulnar fractures are considered unstable?
>50% displacement >10% angulation or involving the proximal third of the ulna
Which patients with ITP needed treated? Kids? How?
>50,000 Platelets = no treatment <50,000 with bleeding or risk factors = treatment <20,000 to 30,000 = treat even without symptoms If BLEEEDING, usually need admitted (Adult or Child)
How long must a cough be present to be "chronic"?
>8 weeks
Arterial oxygenation saturation should be restored to _____ and ventilation controlled to maintain a PaCO2 of ___ to ___ mm Hg when treating shock using the ABCDE tenets.
>93%, and 35-40 mm Hg
When used in low-risk ED populations, myocardial perfusion imaging has been shown to have very high sensitivity and NPVs >______% for myocardial infarction.
>99%
What are some disqualifiers for getting CCTA as an imaging modality? Absolute contraindications?
A Fib or frequent ectopy, or HR not <65 also people with coronary stents or CABG Absolute: IV contrast allergy, pregnancy, and extreme caution is renal disease
Why is careful serial observation crucial in etoh pts?
A depressed mental status that fails to imporve or any deterioration should be considered secondary to other causes and evaluated aggressively.
Any patient with a ventricular rate of >300 beats/min should raise suspicion for ______?
A preexcitation syndrome such as WPW or LGL.
If you got an inferior wall MI what else should you obtain prior to labs, tx, etc...?
A right-sided lead V4 (V4R)
Discuss Fe tox treatment algorithm
A) asymptomatic- calculate ingestion: <20mg/kg observe 6 hours and DC. 20-60mg/kg or unk radiograph and gi decon and get 4 hr post ingestion lab. If greater than 60mg/kg then treat like GI. B) GI- volume resus, check acid-base, get xray, gi decon, antiemetics, check 4hr level. If <500 or unavailable AND asymptomatic with normal acid base then observe 6 hours and DC. If >500, or acidosis/persistent symptoms/symptoms develop then start chelation therapy and treat like systemic. C) systemic-volume resus, acid-base, xray, decon, antiemetics, check Fe level, start chelation and get baseline urine. Continue until clinically stable. Can check urine color but not useful..all about symptoms
What special labs might be of use in Fe tox?
ABG - bc more rapid than serum chems Type and Cross- may need blood
What is the "pop" considered pathognomonic for in regards to a knee injury?
ACL injury, usually pop is followed by swelling a few hours post-injury
What is one diagnosis that must always be considered as a potential cause of the heart failure until excluded?
AMI
What is the most common symptom with TCA overdose?
AMS
Hypoglycemia toxidrome
AMS, diaphoresis, tachycardia, HTN +/- paralysis, slurred speech, bizarre behavior, seizures glucose containing solutions, octreotide
Sertonin toxidrome
AMS, increased muscle tones, hypperreflexia, hyperthermia +/- intermittent whole body tremor cooling, sedation with benzo, supportive, theorectical cyproheptadine
What are the common typical features of the rare fatal NSAID tox?
AMS, metabolic acidosis, shock
Anticholinergic Toxidrome
AMS, mydriasis, dry flushed skin, urinary retention, decreased Bowel sounds, hyperthermia, dry membranes +/- seizures, dysrhythmias, rhabdo, Physostigmine, sedation with benzo, cooling, supportive therapy
Salicylate Toxidrome
AMS, resp alkalosis, met acidosis, tinnius, hypernea, tachycardia, diaphoresis, vomiting +/- low grade fever, ketonuria MDAC, urine alk with potassium repletion, hemodialysis
What are risk factors for rhabdo in cocaine/amphetamine od?
AMS, seizures, dysrhythmias, cardiac arrest, unstable. PTs with initial CK <1000 with normal creatinine are unlikely to get complications
What are the minor diagnostic criteria?
AMS, tachycardia, abnormal BP, diaphoresis, leukocytosis, tachypnea, tremor, elevated CK, incontinence
Who gets admitted wtih antipsychotic OD?
6hr observation for ortho hypoten with ortho vitals. Must be free of AMS, pulse, BP, QTc prolong with 6 hours after ingestion. Any toxicity should be admitted including ECG changes. Consider admit to ICU for MNS monitoring.
Normal two point discrimination is < _______ at the fingertips and is often < _____? Do you need to test the uninjured hand?
6mm; 2mm; Yes
If giving HCO3- in treatment of shock due to acidosis, then you should only correct the pH to_____.
7.25
What level should you check in all OD cases?
APAP
What is the leading cause of acute liver failure in US?
APAP 40% with mortality between 5-80% without NAC And death on days 3-5 to hepatic complications including cerbral edema, hemorrhage, shock, ALI, supsis, multiorgan failure. Survivors develop complete hepatic regeneration without residual impairment.
What do you do if you are trying to clear a foreign body in a child (1 Y to Puberty)?
Abdominal thrusts
Name the absolute and relative contraindications to Fibrinolytic Therapy?
Absolute: active or recent bleeding (<14 days) ischemic stroke in last 2-6 months any prior hemorrhagic stroke intracranial or intraspinal surgery or trauma in last 2 mo intracranial/intraspinal neoplasm, aneurysm, or AV malf known severe bleeding diasthesis current anticoagulant tx Uncontrolled HTN (>185/100) Suspected Aortic dissection or pericarditis Pregnancy Relative: active PUD CPR >10 min hemorrhagic optho conditions puncture of non-compressible vessel in last 10 days advanced age >75 yrs old significant trauma/surgery within past 2 wks-2 months advanced renal or hepatic disease
What is a drug you can use to treat alkalemia?
Acetazolamide
What is the primary metabolite of isopropanol, and what are important features?
Acetone and doesn't appear in serum for 30-60minutes and 3 hrs in urine. It is not toxic to eye kidney cardiac tissues, as compared to metabolites of ethylene glycol and methanol. isopropanol half like 6-7hrs acetone half life 17-27hrs
Most poisons
Activated charcoal 1gm/kg (ped) 50-100gm adult PO
What should you be thinking about if you have pulmonary edema, smaller than expected heart size, and no response to your conventional treatment?
Acute Mitral Regurg, need an emergency bedside echo if unstable
What does a Change in H+/Change in PCO2 ratio of 0.8 mean?
Acute Respiratory Acidosis
Sepsis remains the most common condition associated with acute lung injury and _____.
Acute Respiratory Distress Syndrome (ARDS)
Define Septic Shock?
Acute circulatory failure characterized by persistent hypotension <90 SYS <60 MAP >40 change in BP from baseline Despite fluid resuscitation
What two populations have a known and unknown risk from gadolinium contrast MRI's and should only have it done if necessary and with risks being told to them?
Acute or Chronic Renal Insufficiency - Possible nephrogenic systemic fibrosis Pregant patients - crosses to fetal system with prolonged exposure of unknown risk
What EKG findings might you see for Mitral Regurgitation?
Acute: May see inferior MI Chronic: Left Atrial Enlargement or LVH
What is an accurate rule of thumb for proper tube placement in a newborn?
Add 6 + newborn weight (in kg) (e.g. - A 1 kg newborn should have the tube advanced until the 7cm marking is at the level of the lips)
What drug can you use to treat SVT (HR around 160-200) with regularly, regular rhythm that has WPW, or is pregnant?
Adenosine
How do you pre-oxygenate an adult for RSI?
Administer 100% O2 for 3 minutes via NR mask at 15 lpm according to Tintinalli...
What 3 things are definitely associated with atypical presentation of ACS?
Advanced Age, Female Gender, and Hx of DM
Adults (non neutro) biliary bugs
Aerobic gram negative bacilli, enterococci
Adults (non neutro) urinary (hospital pyelo) bugs
Aerobic gram negative bacilli, enterococci
Neutropenic children and adults bugs
Aerobic gram negative bacilli, especially pseuodmonas, staph au
Describe Central Cord Syndrome?
Affects spinothalamic and corticospinal tracts, so loss of motor and lesser degree pain and temperature. WORSE IN ARMS vs LEGS. Usually can control bowel/bladder. GOOD PROGNOSIS, but likely loss of fine movements to arms/hands, hyperextension injury to old person
Describe stage 4 APAP tox?
After Day 5 Clinical improvement (day 7-8; complete by 1-3 mos) or Deterioration to multi-organ failure and death.
The diagnosis of "possible ACS" is given if:
After HX, PE and ECG no alternative DX is found Elements of presentation could be consistent with ACS ECG has no diagnostic findings First cardiac markers are normal Then If feels there is >2% chance that this is ACS, then the diagnosis of possible ACS is given.
Once in the ED, what treatment should be continued for 24-72 hours in the treatment of rhabdomyolysis?
Aggressive Fluid Rehydration
At what point is chollinesterase permenantly destroyed?
Aging- highly variable from minutes to days
WHat should you do early in management of CCB tox?
Airway management particulary in AMS due to protection from vomiting during GI decon with lavage/SorMDAC/whole bowel and from side effect of glucagon. ALso allows focus to be on treating precipitous cv collapse and not having to perform a crash airwary
Most common causes of Macrocytic Anemia?
Alcohol Abuse, Liver Disease, Hypothyroidism, and B12 and Folate Deficiency
Which TCA pts need admitted?
All symptomatic. May dc (barring other reasons for admit such as psych) if asymp after 6 hrs. Severe to ICU. Cleared 24hrs after symptom free
Which MAOI patients get admited?
All. >1mg/kg -> ICU <1mg/kg accidentaly exposures to floor Always consult medical toxicologist. Minimum 24 obs for asymptomatic patients, with early transport by ACLS providers to ICU. Strict dietary/medication adherence during admission and x 2 weeks.
What is the dosing for Tpa, Enoxaparin or UFH for PE treatment?
Alteplase 100mg infusion over 2 hours Enoxaparin (LMWH) = 1mg/kg SC UFH = 80 units/kg bolus then 18 units/kg/hr with (PTT kept <120)
What is important to remember when performing Central Venous Catheter procedure?
Always maintain a firm grip on the wire - do not let go of the wire for any reason. DO NOT CUT THE WIRE MAINTAIN A GRIP ON THE WIRE AT ALL TIMES
If a patient is unable to learn new information or recall information already learned they have a _____?
Amnestic D/O
Patients with a suspected anaerobic source: abd, biliary, female Gen tract, necrotizing cellulitis, odontogenic, soft tissue bugs
Anaerobic bacteria with gram negative bacilli
What are the four lines in a lateral C-Spine x-ray from anterior to posterior?
Anterior Longitudinal Ligament Line Posterior Longitudinal Ligament Line Spinolaminar Line Spinous Processes Line
What findings on EKG are suggestive of the left anterior descending coronary artery being occluded?
Anterior MI findings which are ST segment elevation in V1-3
How do you treat Aortic Dissection with meds?
Antihypertensives...need negative ionotrope first such as a B-Blocker (metoprolol or esmolol), then if still not around 120 or 130 systolic then add a vasodilator such as nitroprusside.
Intermediate risk patients for ACS who have concerning features (i.e. T wave inversions, known coronary artery disease, and indeterminate cardiac markers) may be given ____ therapy.
Antithrombin (i.e. UFH or Lovenox)
What dysrhythmias can you see in dig tox?
Any, although vent abnormalities more common in chronic than acute tox
What other conditions are included in the "Acute Aortic Syndromes" diagnosis?
Aortic Dissection Intramural Hematoma Aortic Aneurysmal Leakage (i.e. Ruptured AAA) Penetrating Atherosclerotic Ulcer
Syncope in the setting of exertion or a systolic murmur should raise your suspicion for what?
Aortic Stenosis
Generally severity of symptoms is more concerning than the presence of a new murmur, however there is one exception, what is it?
Aortic Stenosis and syncope who appear well at rest
What cardiac abnormality should be excluded as a cause of syncope in the elderly?
Aortic stenosis
What are the patient requirements for you to use an esophageal airway?
Apneic and unconscious
Discuss Rumack-Matthew nomogram.
Applies only to level between 4hr-24hr level after single ingestion originally >200mg but FDA lowered to >150 NOT FOR CHRONIC / RECURRENT / Extended release without clinical correlation: Recurrent recommendation is draw level and assume that total ingested was a single dose at very begining of when APAP therapy started. Extended release rec is to draw one level and then draw repeat 4-6 hours later in those cases that initial is high but not above line. If second level high then NAC. If initial above nomoline then no need, just NAC. >200mg = hepatotoxicity 60% (Defined as ALT >1000), 5% mortality, 1% renal
How does pH affect salicylate?
As acidosis progresses nonionized forms increase allowing great blood brain barrier penetration = higher brain levels at lower pH.
When should charcoal hemoperfusion be used for paraquat?
As soon as possible, and continued 6-8hrs
If you are not sure if bleeding into a joint is occuring, what is one way to help figure it out?
Ask the patient, they are pretty reliable at knowing when bleeding is occuring
What is the first line antiplatelet for patients with possible ACS?
Aspirin
Treatment for MVP in the ED?
Asymptomatic - Nothing Symptomatic - B-Blockers If at big risk for embolization then anticoagulate
How do you disposition NSAID OD patients?
Asymptomatic = dc after 4-6 hours obs. Symptomatic = admission for obs and supportive care. This includes abnormal vitals! All OD get reported to poison control Most have good outcomes as long as initial insult survived
How do you treat NSAID OD pts?
Asymptomatic with history of ingestion = directed physical examination/history with focus on Mental status, GI, renal and include info on: type of NSAID, coingestants, amount of NSAID (<100mg/kg vs >400mg/kg). minimal lab eval GI decon with charcoal, not lavage unless mass quantities in last hour. Fluid/electrolyte replacement Screening ECG for coningestants measure APAP salicylate levels Symptomatic patients with AMS, seizures, shock resp dist, cardiac dysrh, need aggressive resus: definitive airway, fluid/pressors, benzos for seizures, gastric lavage for large dose mefenamic acid or phenylbutazone. ENTERIC Coated = whole bowel lavage with polyethylene glycol.
Systemic Inflammatory Response Syndrome (SIRS) is defined as?
At least two of the four criteria: 1) ABNORMAL TEMP >38.3 C (100.9 F) Adults >38.5 C (101.3 F) Children or <36 C (96.8 F) All 2) TACHYCARDIA (no extrenal stimulus, painful stimuli, long term drug use, etc) >90 HR Adults >2 SDs for age in Children Bradycardia if <1 year old 3) TACHYPNEA >20 breaths per min or PaCO2 <32 mm Hg Children = >2 SDs for age or Vent due to acute process 4) High WBC's >12,000 leukocytes < 4,000 >10% immature bands
When is the osmolar gap at its highest?
At peak of parent alcohol concentration - 30-60minutes after ingestion
What is the first-line drug for treating symptomatic bradycardias in the absence of a treatable cause in kids?
Atropine
What drug is a Class IIa recommendation for symptomatic bradydysrhythmias and what is the dosing?
Atropine @ 0.5mg every 5 min until results or 3 mg reached
What is prudent to do if you suspect dig tox vs ccb?
Avoid calcium (maybe safe?) and treat CCB other ways
What two drugs are considered safe in pregnancy for asthma treatment and should be given just like non-pregnant patients?
B2 Agonists and Corticosteroids
What do you do if you are trying to clear a foreign body in a conscious infant (<1 y/o)?
Back blows and chest thrusts
What are fractures of the volar or dorsal rim of the distal radius called? They involve the articular surface and are often comminuted.
Barton Fractures
How do you correct the QT duration?
Bazett's equation: QTc=QTm/square root of R-R QTm is QT measured in seconds R-R is interval between two R waves in seconds (this equation adjusts the QT to 60 beats per min, since QT is heart rate dependent)
What do DHP CCB due compared to other 2 classes?
Bind selective to vascular smooth muscle with little cardiac action
You are performing CPR in a child that has a FB obstructing his/her airway, what should you NOT do when a cycle is complete?
Blind Finger Sweeps
A calcaneal fracture should be suspected when the ____ angle on the lateral ankle film measures _____.
Boehler; <25 degrees
Where should you check the pulse in an infant (<1 year old)?
Brachial
When should you give atropine for heart rate in organophos tox?
Brady and Tachy. Tachy IS NOT contraindication for atropine use in organophos tox. b/c it may be result of hypoxia from cholinergic syndrome.
What should be the initial setting on a ventilator for kids?
Breath rate of 20-25 breaths/min, with peak inspiratory pressures between 15-20 cm H2O usually gives a tidal volume of 8 to 12 mL/kg. You can add 3-5 of PEEP also.
What syndrome should be considered a potential cause of syncope when the patient has a family history of sudden death?
Brugada Syndrome
Match the following level with the motor function deficit? C5-6, C6-7, C7-8, C8-T1, L1-3, L4-S2, L4-5, L5-S1, S1-2, S2-4?
C5-6 = Arm Abduction C6-7 = Wrist Extension C7-8 = Elbow Extension C8-T1 = Finger abduction T2-7 = Chest Muscles T9-12 = Abd Muscles L1-3 = Hip Flexion L2-4 = Knee Extension L4-5 = Ankle Dorsiflexion L5-S1 = Great Toe Extension S1-2 = Ankle Plantar Flexion S2-4 = Voluntary Rectal Tone/Bladder
What lab should you get for any patient taking clozapine or chlorpromazine, even if therapeutic?
CBC especially if febrile, b/c they have highest incidence of causing agranulocytosis.
How does BB tox differ from ____ that also cause hypotension and bradycardia?
CCB (elevated lactate / hyperglycemia) dig (hyper K / dig level) Class Ic like propafenone (wide complex brady) clonidine (opioid symptoms) organophosphates (muscarinic toxidrome)
What should you avoid in Wide Complex SVT?
CCB, B-Blockers, and Adenosine
What CV drug has accounted for the most deaths?
CCB, also the second most common rx drug death
What is a myocardial imaging modality that is a less painful, more efficient, and safer alternative to traditional angiography?
CCTA (Coronary CT Angiography)
What are the most common causes of pleural effusion?
CHF, pneumonia, cancer
Opioid Toxidrome
CNS Dep; Resp Dep; Miosis +/- hypothermia, bradycardia, ALI Support ventilation +/- naloxone
Where should you focus particular attention on when looking for a source of sepsis?
CNS, Pulmonary system, intra-abdominal structures, urinary tract, skin, and soft tissue
Alkalemia is of particular concern in patient with what disease?
COPD
Describe CPAP verus BiPAP?
CPAP provides a continuous level of positive pressure throughout the respiratory cycle and is analogous to positive end-expiratory pressure in mechanical ventilation BiPAP provides a different level of positive pressure for inspiration than positive pressure for expiration
What imaging modality is more sensitive, more specific, and more expeditious than plain films for evaluating C-Spine injuries?
CT
What is the imaging modality of choice for suspected C-Spine fractures and currently usually the initial imaging choice at trauma centers?
CT
If a distal tibial growth plate fracture in kids (triplane fracture) is suspected, what type of imaging should be done?
CT Scan to help delineate further articular surface damage
What is the imaging procedure of choice for posterior sternoclavicular dislocation?
CT with contrast
What mode of imaging is particularly good for evaluating those portions of the cervical spine that is commonly missed in pediatric trauma patients? What are two commonly missed portions?
CT; occipitoatlantal and cervicothoracic junctions
What is the primary organ system affected by BB TOX?
CV with hallmark of brady and shock
What is Genu VII bells palsy?
CVA masquerading as bells, only difference is pt lacks ability to abduct CNVI palsy
What are the hemodynamic parameters that should be maintained during sepsis treatment?
CVP 8-12 mm Hg MAP >65 mm Hg SVO2 >70%
Calcium Chloride should only be given to kids for symptomatic hyperkalemia, hypocalcemia, or CCB overdose, what is the dose?
Calcium Chloride: 20mg/kg (10% solution), slow push Calcium Gluconate: 60-100 mg/kg (10% solution)
What is special about propxyphene?
Can act as sodium channel blocker leading to AV blocks, seizures, wide QRS. Treat with bicarb for cardiac and narcan for seizures.
What is special about methadone
Can cause cardiac electrical abrnomalities including long QT -> torsades. Monitor and fix electrolyte imbalances Dont worry about QTc <500
What should you worry about in adults >40yo with lateral persistent neck masses lasting >6wks
Cancer = 75% of these
What is found for most sudden cardiac death victims on postmortem examination?
Cardiac Abnormalities
What is the one imaging modality that provides all the cardiac information?
Cardiac MRI, as opposed to working on NPV's, Cardiac MRI can actually delineate between true ACS and not ACS
What should be considered in all older patients with recurrent syncope and negative cardiac evaluations?
Carotid sinus hypersensitivity
What is noncardiogenic pulmonary Edema?
Caused by heroin. Can present upto 24 hours later after OD. Consider in hypoxia pts with rales, tachypnea, despite normal cardiac silhouette on CXR. Treat supplemental O2, vent support with PEEP. *Do not need additional narcan/diuretics/digoxin
Assuming no allergies, what Abx should all open fracture patients get and what can you add for gross contamination?
Cefazolin; add aminoglycoside for gross contamination
What is central cyanosis versus peripheral cyanosis?
Central Cyanosis: blue tongue or buccal mucosa and is due to inadequate pulmonary oxygenation or abnormal Hb Peripheral Cyanosis: blue fingers or extremities, due to vasoconstriction or low blood flow
Using the formula _______ you can determine if the H+ changed appropriately, if not then it is likely a mixed disorder.
Change in H+ = 0.8 (Change in PCO2)
Discuss GI Decon in FE tox.
Charcoal - not helpful will screw up colonscopy Lavage - maybe whole bowel- maybe in children works endoscopy for bezoor gastromoty for BIG ingestion consider radiograph No role for hemodialysis doesn't work
What do you do if you are trying to clear a foreign body in an infant that is unconscious?
Chest compressions
The mere lack of a radial pulse does not indicate ischemia unless accompanied by these signs:....
Child refusing to open hand Pain with passive extension of fingers forearm tenderness
What two types of pneumonia have sore throat as a symptom?
Chlamydophilia and Mycoplasma
What is the only drug with FDA approval for use in intractable hiccups? Dosing?
Chlorpromazine, 25-50 mg IV, repeat in 2-4 hrs if needed 25-50mg PO TID-QID also
What is a common cause of thrombocytopenia that can be determined during the HX (minus meds)?
Chronic Alcohol Abuse, will clear up if abstains for 7 days
What does a Change in H+/Change in PCO2 ratio of 0.33 mean?
Chronic Respiratory Acidosis
What is the one acid-base disorder where there may be complete compensation?
Chronic Respiratory Alkalosis
Mitral regurgitation is most commonly caused by...?
Chronic: MI or ischemia, MVP,LV Dilation, Rheumatic Heart Disease Acute: MI or Infective Endocarditis causes papillary muscle rupture
What are two PE tests/signs for hypocalcemia and describe them?
Chvostek sign = twitch at corner of mouth when facial nerve in front of ear is tapped Trousseau sign= Carpal spasm (extension of phalangeal joints, flexion of MCP and wrist) when BP cuff on upper arm is left above systolic for 3 minutes
What are the ASA Physical Status Classifications?
Class I - Normal, healthy Class II - Mild Systemic Dz Class III - Severe Systemic Dz Class IV - Severe Systemic Dz with constant life threat Class V - Moribund who will die without procedure
What are the Mallampati classes?
Class I: Faucial pillars, soft palate, and uvual are visible Class II: Faucial pillars and soft palate are visible, but the base of the uvula is obscured Class III: only base of uvula is visible (5% failure rate) Class IV: None if these three structures are visible (20 % failure rate)
How do you diagnose MAOI OD?
Clinical soley based on history of ingestion.
What is the preferred antiplatelet agent (Adenosine Diphosphate Receptor Antagonists)?
Clopidegrel (Plavix), works faster and less side effects
Patients with indwelling vascular devices bugs
Coagulation negative staphylococcus
What kind of splint should not be used for carpal or wrist fractures?
Cock-up splints
What is the most serious complication of a supracondylar fracture?
Compartment Syndrome of the Forearm (also known as Volkmann ischemic contracture)
Discuss methanol toxicity and relation to ethanol.
Competes for metabolism with ethanol and coingestions may delay presentation to 12-24 hours. It is only mildly inebriating. Be concerned for visual changes.
Describe the difference between compression vs burst fracture to lower spine? Flexion-Distraction vs Fracture dislocation?
Compression - axial load and flexion, anterior column fails only, stable unless >50% height loss Burst - axial load, anterior and middle column fail, possible fragments into spinal canal, unstable Flexion-Distraction - usually seatbelted kid post MVA with anterior compression fracture, anterior column still intact which prevents subluxation, unstable Fracture dislocation - most injuring, unstable, all three columns fail.
Should whole bowel lavage be used in BB tox?
Consider for SR
How do you disposition ethylene glycol patients?
Consult tox. May DC if: no ethanol, symptom free x 6 hours, no osmolar gap, no metabolic acidosis. If facility doesn't offer dialysis then transfer immediately just in case. Don't forget psych consult before DC
How do you disposition methanol patients?
Consult tox. May DC if: no ethanol, symptom free x 12 hours, no osmolar gap, no metabolic acidosis If facility doesn't offer dialysis then transfer immediately just in case. Don't forget psych consult before DC
What is hypokalemia during the first 24 hours of APAP tox ?
Correlates with high 4hr APAP levels
What is something you do during ET tube intubation that you don't want to do when using an LMA?
Cricoid pressure, it almost always impedes insertion of LMA's.
Which type of fluid (crystalloid vs colloid) is recommended for hypovolemia resusc? Why?
Crystalloid, because studies show no difference and crystalloids are cheaper
What is a lab that you may get when trying to rule in/out PE, but is normally elevated in pregnancy and will not be helpful if trying to rule in/out PE in a pregnant patient?
D-Dimer
Treatment for anterior Sternoclavicular dislocation?
D/C without reduction, little to no impact on function and will usually re-dislocate when you let go
Significant hypoglycemia in a newborn (<25-30 mg/dL) must be treated immediately with __________ (include dosing)?
D10W, 2 ml/kg IV bolus, then start 100ml/kg/24h IV infusion until 30-60 min glucose follow-ups become stable.
Glucose
D10W, 2mL/kg
How do you calculate the MAP? What should you maintain it above?
DBP + (pulse pressure/3) Maintain above 60 mm Hg
How do you dispo organohphos tox?
DC home: minimal after decon and 6-8hours obs Dont give clothes back to pt ICU for significant Death usually in 24hours from resp
How do you dispo CCB tox pt?
DC: asymptomatic regular release after 6 hours or sustained release after 12 hours As a rule all potentially toxic ingestions should be admitted / monitored for 12-24 hours
Describe general treatment for organophosate patients?
DONT WITHOLD PENDING CHOLINESTERSE LEVELS. Protective clothing- prevent secondary healthcare tox airway, intense resp support, decon, prevent absorption, admin antidotes
Describe stabe 2 APAP tox?
Days 2-3 improvement in anorexia, nausea, vomiting BUT gets abdominal pain, hepatic TTP elevated tranaminases/bili, PT( if severe)
Describe stage 3 APAP tox?
Days 3-4 recurrence of anorexia, nausea, vomiting Encephalopathy, anuria, jaundice hepatic failure, metabolic acidosis, coagulopathy, renal failure, pancreatitis
What other treatments should you use organochlorine tox?
Decon pts, gastric lavage, consider cholestyramine in symptomatic exposure to chlordecone
How do you treat pyretherin tox?
Decon, observe, treat underlying effect like asthma = release
In general, for each ___ decrease in pH, serum K+ will increase by approximately ___ mEq/L.
Decrease in 0.10 pH = Increase of 0.5 in K+
Name some considerations that should be thought about when considering intubating a pregnant patient?
Decreased tolerance for hypoxia and apnea Tongue, Mucosa, and Supraglottic edema and friability Difficult mask ventilation (Low FRC, elevated diaphragms, and increased intra-abdominal pressure) Mallampati Class III airway is common Weight Gain and Obesity (increased neck folds, foreshortened necks) Increased risk of aspiration (increased gastric emptying time and decreased lower esophageal sphincter tone)
An elderly patient with no prior psychiatric disorder being evaluated due to new psychiatric problems should raise a high degree of clinical suspicion for ___ ?
Dementia
What is defined as ... a pervasive disturbance of cognitive functioning in several areas, including memory, abstract thinking, judgment, personality, and other higher cortical functions such as language?
Dementia
What is special about buprenorphine?
Depending on person and timing can act as agonist, antagonist, or manage withdraw (or cause)
What drug can you give if the factor level is greater than 5% in Hemophilia A instead of providing replacement therapy? Dosing? Route?
Desmopressin 0.3mg/kg IV over 15 to 30 minutes or Intranasal form single spray in kds >5 years old (150 mcg) spray to each nostril in adults and adolescents (300 mcg)
Insulin / oral hypoglycemics
Dextrose 0.5gm/kg; 1gm/kg (adult) Refractory- octreotide 1mcg/kg sc q6hrs peds 50-100mcg/ SC Q6 adult
What is the definition of a difficult pediatric airway as defined by the ASA?
Difficulty with BVM Ventilation, or tracheal intubation, or both.
If giving calcium in treatment for Hyperkalemia, what medication should you look for in the patient?
Digitalis, because hypercalcemia potentiates the toxic cardiac effects of digitalis, use of calcium in patients taking this should be avoided.
Digoxin and cardioactive steriods
Digoxin Fab 1-2vials peds; 5-10 IV acute adult/ 3-6 IV chronic adult
What medications are typically considered safe with MAOI?
Direct acting sympathomimetics because they do not rely on circulating MAOI for deactivation (albuterol, epi, dopa, norepi, vasopressin, terbutaline, etc). Misc: APAP, antibiotics (except linezolid, furazolidone), barbituates, benzos, CCB, steriods, lidocaine, morphine, nitro, nitropruss, NSAIDS, phentolamine, procainamide
What is a radiographic finding that helps identify femoral neck fracture on AP plain film of hip?
Disruption of Shenton's line (curve using superior edge of foramen obturator and medial edge of femoral metaphysis)
What about wernicke's encephalopathy?
Don't delay glucose admin for hypoglycemia over concern for wernike. Only risk for prolonged glucose admin, but should still do thiamine at some point even if glucose normal.
Which SNRI is more likely to cause N/V/dizzy?
Duloxetine
What is Dyspnea, vs Tachypnea vs Orthopnea vs Trepopnea vs Platypnea s Hypernea?
Dypsnea is subjective difficulty breathing Tachypnea is rapid breathing Orthopnea is dyspnea in recumbent position Trepopnea is dyspnea in a specific type of recumbent position Platypnea is the opposite of othopnea Hyperpnea is hyperventilation is excess of metabolic demand
Infants 1-3mos bugs
E coli, kleb, entero, h flu, strep pneumo, nei menin
What diagnostic studies are useful in undifferentiated shock?
ECG, bedside cardiac u/s
Where should the perimortem c-section be performed in maternal cardiac arrest?
ED, they should not be moved to an operating suite, this only wastes valuable time.
What are the requirements based on the 2007 Consensus guidelines for the diagnosis of MI?
Elevated Troponin and at least one of the following: - ischemic symptoms - new ST and T wave changes - new LBBB - new Q Waves - imaging showing loss of viable myocardium or new regional wall motion abnormality
Experienced obstetricians, anesthesiologists, pediatricians or neonatologists help facilitate the care of pregnant patients in cardiac arrest, but what if they are not available?
Emergency care and procedures should not be delayed. Do what needs to be done, and get a hold of the closest neonatal care center as soon as possible for rapid transport.
Any patient with a cervical spine injury at C5 or above should have what intervention performed?
Endotracheal Intubation
What treatment is required for all meconium deliveries in which the newborn is limp and poorly responsive at birth?
Endotracheal intubation and direct tracheal suction
Adults (non neutro) urinary complicated catheter bugs
Enterobacteriaceae, pseuodmonas, enterococci, rare staph au
If fluids fail to resolve hypotension in a pregnant patient then what pressor is preferred and what is the dosing?
Ephedrine 5 mg IV every 5 minutes until a response is seen
SC doses of Epi and Terbutaline for asthma treatment?
Epi 0.3-0.5 mg every 20 min for three doses SC Terbutaline 0.25 mg every 20 min for three doses SC
What is the continuous infusion rate for Epinephrine, Isoproterenol, Dobutamine, Dopamine, and Lidocaine in kids?
Epi and Iso: 0.1-1.0 mcg/kg/min (0.6 mg/kg, then fill to 100mL) this will give 0.1mcg/kg/min when dripping at 1 mL/hr Dobutamine and Dopamine: 5-20 mcg/kg/min (6mg/kg, then fill to 100ml), this will give 1.0 mcg/kg/min when dripping at 1mL/hr Lidocaine: 20-50 mcg/min/hr (60 mg/kg, then fill to 100ml), this will give 10mcg/kg/min when dripping at 1 mL/hr
What are two other drugs that could be used for symptomatic bradydysrhythmias if cardiac pacing and atropine don't work? and dosing?
Epi or Dopamine @ 2-10 mcg/min IV for Epi and 2-10mcg/kg/min IV for dopamine.
What is the medication treatment for Asystole or HR <60 for >30 seconds despite ventialtions at 100% O2 and chest compressions for newborn resusc (including dosing)?
Epinephrine, 0.01-0.03mg/kg (0.1-0.3 ml/kg) Iv push of a 1:10,000 solution (flush with NS, repeat every 5 min as needed)
What is the vasopressor infusion of choice in children? and why?
Epinephrine, because dopamine requires endogenous norepinephrine which may be low in kids in cardiac arrest
What are the two most common alcohols ingested?
EtOH, isopropanol: typicially don't case metabolic acidosis, but sudden cessation in chronic use can lead to ketoacidosis
Do not attribute which of the toxins as the cause of a significant metabolic acidosis?
Ethanol
What is the preferred induction agent for trauma?
Etomidate
Name 3 induction agents and dosing for pediatric RSI?
Etomidate 0.3 mg/kg Ketamine 1-2 mg/kg Propofol 1-2 mg/kg
List the 3 preferred induction agents, dosing, and reasons for or against?
Etomidate, 0.3 mg/kg, onset < 1 min, duration 10-20 min, Decreases ICP and IOP, BP Neutral, but No analgesia, decreases cortisol, and may cause myoclonic jerking, seizures, and vomiting in awake patients. Propofol, 0.5-1.5 mg/kg, onset 20-40 secs, duration 8-15 min, Antiemetic, Anticonvulsant, decreases ICP, but causes No analgesia and causes apnea and decrease in BP Ketamine, 1-2 mg/kg, onset 1 min, duration 10-20 min, Bronchodilator, Dissociative "amnesia", and ANALGESIA, but causeas increased secretions, BP, and also the emergence phenomenon.
What are some specifics about the induction agents?
Etomidate: may suppress the adrenal axis even in one dose and needs axiolysis and analgesia afterward Ketamine: Is a bronchodilator, preserves respiratory drive, cardiovascular stimulant, asthma drug of choice Propofol: may cause hypotension, requires anxiolysis and analgesia afterwards, may need higher dose in infants
How do you test the radial nerve?
Extend the fingers and wrist, then with thumb in hitch hiking position, resist against further extension
Describe preseptal cellulitis.
Eye is not involved. visual acuity maintained, pupillary reaction maintained, full painless ocular motility
What FEV or PEFR constitutes a severe COPD exacerbation when performing bedside spirometry?
FEV1 of <1.oo L or PEFR of <100 L/min if he is not chronically severely obstructed
How long is Factor VIII and Factor IX good for?
FVIII: 8-12 hours FIX: 16-24 hours
What concern in renal failure with digibind therapy?
Fab-Dig complex renally excreted...decreased in RF, possible rebound tox in 10 days as complex degrades and no dialysis dosnt help bc high molecular weight
What clotting factor is deficient in Hemophilia B? What is the old name for this one?
Factor IX; Christmas Disease (i.e. not as common so it is like Christmas :)
How do you calculate how much factor VIII and IX to give a patient?
Factor VIII: (Desired FVIII - Baseline FVIII)/2 x kg Factor IX: (Desired FIX - Baseline FIX) x kg
What clotting factor is deficient in Hemophilia A? What is the old name for this one?
Factor VIII; classic Hemophilia (i.e. the MOST COMMON)
True or False: Hypoxemia in PE is predictable?
False
True or false GI symptoms like NVD are common in CCB OD?
False
If you have a patient with high risk for catastrophic complications (i.e. someone with a mechanical heart valve) that has been non-compliant and stopped taking their coumadin, you should D/C them with instructions to restart their coumadin. T or F?
False; because there is an increased thrombogenesis for the first 24 to 36 hours when starting coumadin, hence the heparin bridge (should be continued until INR is therapeutic for 2 days)
What radiographic finding on lateral knee films suggest intra-articular fracture?
Fat-fluid level (lipohemarthrosis)
In patients with renal failure or with hemodynamic instabilities, what is likely the opiate of choice?
Fentanyl
Name the Analgesics used in pediatric RSI? and dosing?
Fentanyl: 1-2 mcg/kg (SHORT ACTING, preserves hemodynamic stability) Morphine: 0.1-0.2 mg/kg, LONGER ACTING, may cause a histamine release
What is the dosing of Epinephrine for children in PEA? IV and IO? 1st and 2nd dose?
First Dose: IV: 0.1ml/kg of 1:10,000 (0.01mg/kg) IO: 0.1mL/kg of 1:1,000 (0.1mg/kg) Second Dose: IV or IO: 0.1mL/kg of 1:1,000 (0.1mg/kg) every 3 minutes
Treatment of symptomatic 2nd Degree AV Block (Type I) Wenckebach?
First line: Atropine (0.5 mg IV, repeat every 5 minutes, max of 2 mg IF THAT DOESN'T WORK: Transcutaneous pacing
What Abx should be held as second line due to developing resistance?
Fluoroquinolones "oxacins"
What type of Abx should not be used in MG patients when treating pneumonia?
Fluoroquinolones or Telithromycin
Outpatient treatment for pneumonia in patients with significant comorbidities? What about inpatient but non-ICU patients?
Fluorquinolone (Levo 750mg PO x 5 days or Moxifloxacin 400mg PO x 7-14 days) or Augmentin 2 gms BID plus Z-Pak Inpatient: Same fluoroquinolones and dosing, but given IV or Rocephin 1gm IV plus Azithromycin 500mg IV
Methotrexate (leucovorin only)
Folic acid 1-2mg/kg IV Q4-6hrs
What antithrombin should not be used as monotherapy for PCI?
Fondaparinux, you need to add UFH or bivalirudin prior to PCI
How do you disposition opioid tox patients?
For heroin: d/c home in 1-2 hours IF: independently mobility, SpO2 >92% on RA, RR>10, >50bpm, normal temperature, GCS 15. If not heroin then observer 4 to 6 hours except with buprenorphine, methadone, propoxyphene, tramadol, diphenoxylate/atropine which all require longer observation due to prolong effects
Neonates <1wk bugs
GBS, e coli, klebsiella, enterobacter
What specific treatments for anticholinergic tox?
GI Dcon=charcoal sedation-benzo widcomplex tacy-bicarb cholinesterase inhibition-physostigmine (severe agitation only needing restraints and not responding to benzos, not when conduction abnormalities present).
How do you treat APAP tox?
GI decon, timely use of acetylcysteine, supportive care
The combo of _______ with fibrinolytics is not proven to be superior to fibrinolytics alone or in combo with LMWH and so should not be done in the ED.
GP IIb/IIIa inhibitors
What is a distal radius fracture with dislocation of the radioulnar joint is called?
Galeazzi Fracture-Dislocation (also called a reverse Monteggia)
Neonates 1-4wks bugs
Gbs, e coli, kleb, entero, h flu, s pneumo, staph epi
What are the Ottawa Knee Rules and who do they apply to?
Get an x-ray if there is any of the following: Age >55 y/o TTP at head of fibula isolated tenderness of the patella inability to flex knee to 90 degrees inability to transfer weight to injured leg for four steps immediately following injury or in ED Has been validated for children 2-16 years old also
What are the Pittsburgh Knee Rules?
Get x-rays if: <12 or >50 y/o cannot walk 4 steps immediately following or in ED
If preload is marginal or the patient is hypotensive and they have RV infarction then what do you do?
Give 1-2L of NS, if not resolved then start inotropic support with Dobutamine.
beta blockers
Glucagon 50-150mg/kg ped; 3-10mg adult IV Rescue IV lipid emulsion 20%
Adults (non neutro) unknown source bugs
Gram negative bacilli, staph au, strep, others
What CNS effects do you see in NSAID OD?
HA, nystagmus, diploia, AMS, coma, muscle twitching, seizures (mefenamic acid)
Patients who exhibit acute systemic reactions such as fevers, chills, hypertension, tachycardia, dyspnea, chest pain, or cardiac arrest usually within 30 min of heparin administration should be evaluated for ____ by obtaining an immediate _______.
HIT; platelet count (could be between 20-150, but a drop by 50% from baseline count is considered HIT)
What pneumonia should be considered in elderly and COPD patients?
Haemophilus Influenzae
For what patient is Atropine allowed to be used cautiously, but will likely not work due to lack of vagal stimulation?
Heart Transplant patients.
What medication when combined with Aspirin takes the mortality rate decrease from 23% to 56% and as such the combination should be used in patients with ACS?
Heparin
List at least 6 drugs that can cause Thrombocytopenia?
Heparin Gold Salts Sulfa-containing Abx Quinine or Quinidine Ethanol Aspirin Indomethacin Almost all BP meds (Diuretics, then CCB, then BBlockers) Acyclovir NSAIDs Digoxin Procainamide Penicillins/Cephalosporins Antihistamines Nitroglycerin Plavix Ranitidine and Cimetidine Rifampin etc........
What is a compression fracture to head of humerus from anterior shoulder dislocation? from posterior dislocation? to anterior rim of glenoid from anterior dislocation?
Hill-Sachs lesion Reverse Hill-Sachs lesion Bankart lesion
How do you calculate number of vials or dig fab>
History based: total body load = 0.8 x amount ingested 1 vial contains 38-40mg dig fab = neutralizes 0.5mg of dig Simple combined: number of vials = [serum dig lev (ng/mL) x pts wt (kg)] / 100
Which Opioids are semi-synthetic derivatives?
Hydrocodone, Oxycodone, Hydromorphone, Oxymorphone, Dihydrocodeine, Diacetylmorphine (Heroin)
The most common cause of Hypertonic Hyponatremia (Osmotic Pressure >295)?
Hyperglycemia
What is the most common side effect of Prednisone?
Hyperglycemia
What is something you must think about when using Succinylcholine and name the specifics of this issue?
Hyperkalemia, the serum potassium rises on average 0.5 mEq/L transiently when succinylcholine is given.
What are early systemic signs of infection and septic shock?
Hyperthermia, Hypothermia, Tachycardia, Tachypnea, Wide Pulse Pressure, and Mental Status Changes
If you have Hyopmagnesia, then you likely have what other deficiencies?
Hypokalemia, Hypocalcemia, and Hypophosphatemia
What are the four main categories of shock?
Hypovolemic, Cardiogenic, Obstructive, and Distributive
What makes the diagnosis of Acute Lung Injury turn into ARDS?
Hypoxemia = <200
What is hypoxia vs hypoxemia?
Hypoxia is insufficient delivery of oxygen to the tissues Hypoxemia is abnormally low arterial oxygen tension
Describe the Salter-Harris Fractures I thru V based on what is broken off?
I: The entire epiphysis II: The entire epiphysis plus a portion of metaphysis III: Portion of epiphysis IV: Portion of epiphysis and metaphysis V: Nothing (compressed)
How do you dispo BB tox pts?
ICU = AMS, brady, conduction delay, hypotension Admit = sustained release DC = asympt after 6 hrs with immediate release form
What findings in inferior MI on EKG lend to the Left circumflex coronary artery being occluded?
III is not > II, no depression in I or aVL or elevation in V1 or V4R but the opposite...ST elevation in I,aVL, V5-6 and depression in V1-3
If alkalemia is severe (HCO3- > 45 mmol/L) and s/s are not responsive to therapy then you can consider what drug and what dosing?
IV Hydrochloric acid at 0.1 normal solution (100 mmol/L), infused at 0.1 mmol/kg/h through a central venous catheter Can calculate by body weight using this formula: Dose to correct = Change in [HCO3-] x weight in kg x 0.5
What is the preferred initial treatment in a sympathetic crisis due to cocaine or amphetamine overdose? If BP not resolved after that, what BP med would be good? would be bad?
IV benzo's, repeat as needed. Good- Nitro Bad - B-Blocker (might cause a storm)
IV bupivacaine
IV lipid emulsion 20%
How do you treat asymptomatic dig patients:
IV, monitor, GI decon SDAC 1gm/kg, frequent re-eval, calculate dose of dig fab
How do you treat symptomatic dig patients
IV, monitor, GI decon with MDAC 1gm/kg then 0.5gm/kg Q4-6hrs Brady: atropine / pace / digibind vent dysrh: digibind, MgSO4 2-4gms, lidocaine 1mg/kg, fosphenytoin, cardiovert (last) Cardiac arrest...cpr, digibind5-10 vials if dose unk hyper K, NO CALCIUM, glucose-insulin, bicarb, digibind, kayoexlate, dialysis hypomag, eval renal stat, MgSO4 2-4gm NO GASTRIC lavage = increase vagal stim and asystole
What is the dosing of Adenosine in kids?
IV: 0.1-0.2 mg/kg, followed by 2-5 mL NS bolus Can double and repeat once. MAX single dose is 12 mg.
What is the Epinephrine dose for children in Bradycardia...IV? and ET?
IV: 0.1ml/kg of 1:10,000 (0.01mg/kg) ET: 0.1mL/kg pf 1:1,000 (0.1mg/kg)
What is the dosing for lidocaine in a child? IO?
IV: 1.0-1.5 mg/kg, bolus IO: Double IV dose and dilute with 3-5 mL of NS
What is the dosing of Amiodarone in kids?
IV: 5 mg/kg over 20-60 min, then 5-15 mcg/kg/min infusion (no more than 3 boluses (15mg/kg/d) in one day), only push rapidly if treating VT or VF.
How do you treat hypotension initially in organophos tox?
IVF bolus crystalloids
Who should be admitted for isopropanol?
If asymptomatic after 4-6 hours dc with possible substance abuse / psych consult. If symptomatic admit (resp dep, obtunded).
Why is the position of the fingers when the injury occurred in the hand important?
If flexed when injured, then the cut tendon end may be retracted if examined in neutral position
How do you treat stable SVT (rate >220, usually between 250-350) in children?
If stable you can try vagal maneuvers, Adenosine, and Cardioversion. Adenosine 0.1 mg/kg is the recommended drug for SVT in kids.
What can you supposedly tell from the CVP during shock treatment?
If the CVP does not rise after 250-500 mL's of fluid then it is still compliant and not full. If it rises 5-7 mm Hg then it is no longer that compliant and it is full.
When should a child undergoing RSI be given Atropine?
If they develop symptomatic bradycardia, not as a pretreatment.
How to treat metheglobinemia patiens?
If time recent, charcoal dermal decon as indicated methlene blue reserved for symptomatic patients or for thos asymptomatic pts with levels >25%. get ECG, supportive care consider cimetidine for pts taking dapsone
What are some things requiring immediate hand surgeon consultation? delayed consultation?
Immediate: vascular injury with signs of ischemia or not controlled hemorrhage irreducible dislocations grossly contaminated wounds severe crush injury open fracture compartment syndrome high pressure injection injury hand/finger amputation Delayed: extensor/flexor tendon laceration (if not repaired) flexor digitorum profundus rupture (closed) nerve injury (proximal to mid middle phalanx) closed fractures dislocations ligamentous injuries with instability
What should you do to prevent tube displacement in kids?
Immobilize their heads in a neutral position
When is it safe to rapidly correct hypernatremia without fear of cerebral edema?
In acute hypernatremia The idiogenic osmoles are not filling the brain cells yet, that takes time to occur (a few days)
What are the initial symptoms <4 hours after NSAID OD?
abdominal pain, n/v
What will the patient's leg look like on exam for a femoral neck fracture?
abducted, shortened, and externally rotated
What factors are consistently seen as putting a syncope patient at increased risk?
abnormal EKG on presentation and/or hx of heart disease, particularly structural heart disease especially characterized by a history of CHF.
If you suspect major pelvic or abdominal injury it is probably prudent to get the IV access where?
above the diaphragm
ALthough hemodialysis is not effective for most BB, which might it work for?
acebutolol, atenolol, nadolol, sotalol
What substances might serum level affect therapy?
acetaminophen, salicylate, Li, Dig, valproate, phenytoin, carbamazepine, theophylline, CO, methemoglobin, methanol, ethylene glycol, Fe, paraquat
acetaminophen OD
acetylcysteine 140mg/kg load with 70mg/kg Q4hrs x 17 doses PO
What is the mainstay of APAP tox treatment?
acetylcysteine: in early ingestions <8hrs prevents NAPQI formation in late ingestions >24hrs acts as antioxidant and reduces hepatotox Primary complication is N/V due to rotten egg taste
How does K level differ in acute vs chronic dig tox?
acute = hyper K chronic = normal / hyp K
What is onset of BB tox?
acute IR 1-4hr acute ER unk >6hr?
What is the most common symptoms for mitral regurg?
acute: severe dyspnea, tachycardia, and pulmonary edema chronic: exertional dyspnea
What is the major therapeutic challenge in anticholinergic tox?
adequate control of the agitated individual with sedation to limit other symptoms from hyperthermia, rhabdo, trauma
Pneumothoraces more commonly result from the _____________ than from high pressures in children.
administration of excess tidal volume
Define Procedural sedation?
administration of sedatives and dissociative anesthetics to induce a depressed level of consciousness while maintaining cardiorespiratory function so that a medical procedure can be performed with little or no patient reaction or memory
How do you dispo physostigmine pts?
admit them
What patients may blood or sputum cultures be warranted?
admitted to ICU those with Leukopenia Cavitary Lesions Severe Liver Disease Alcohol Abuse Asplenia Pleural Effusion (moderate level of evidence)
What is the inital dose for methylene blue?
adult 1-2mg/kg of 1% over 15min (slow b/c rapid may induce metheglobinemia) clinical improvement in 20minutes may need repeat dose
What is considered generally nontoxic in bupropion OD?
adult <450gm (notice this is just above the therapeutic dose)
How long should you observe bupropion OD pts?
adults >450mg = 8 hrs UNLESS SR = 24hrs
What is a worriesome anticholinergic tox symptom?
agitation induced hyperthermia due to inability to sweat -> elevated body temp -> multisystem damage including rhabdo
What are the most common bupropion OD symptoms?
agitation, dizziness, tremor, N/V, drowsiness, tachycardia with sinus tachy the most common ECG.
TCA norepi reuptake inhibition
agitation, mydriasis, sweating, tachy, HTN; tx with supportive
The most common causes of Rhabdo in adults are?
alcohol and drugs of abuse medications muscle disease trauma neuroleptic malignant syndrome seizures immobility infection strenuous physical activity heat-related illness
What other medications are contraindicated in TCA oD?
all class Ia/Ic/III antiarrhythmics, CCB, BBs
Child CCB ingestions...
all should be taken seriously as single tab can be lethal.
What does the risk of tox in diphenhydramine correlate with?
amount ingested adult: moderate symptosm >300mg severe >1gm diphenhydramine child: moderate; 7.5mg/kg
TCA seizures are usually brief except with which two?
amoxapine and maprotiline that both can cause SE
What do the delta receptors cause?
analgesia and antidepressant, clinical sig unknown
What do the mu receptors cause?
analgesia, sedation, miosis, respiratory depression, cough suppression, euphoria, and decreased GI motility.
What is the treatment required for a displace (unstable) Lisfranc injury?
anatomic reduction via emergent ortho consult
What reflexes must always be tested when doing a neuro exam for possible spinal injury?
anogenital reflexes, because sacral sparing even with complete sense and motor loss equals incomplete spinal cord injury
What is the most common jaw dislocation?
anterior
What are the most common types of knee dislocations, in order of most common?
anterior (40%) posterior (33%) lateral (18%) medial (4%)
What is the most common major joint dislocation?
anterior glenohumeral dislocation
A prominent medial end of the clavicle that is visible and palpable anterior to the sternum is diagnostic of ____?
anterior sternoclavicular dislocation
The key to maintaining the pediatric oxygen saturation during intubation attempts is _________.
anticipation and the early use of good bag-mask ventilation.
What anticholinergic is the most commonly implicated in OD?
antihistamines like benadryl
What does the term "anticholinergic" generally referr to?
antimuscarinic
What else can you consider in treatment of SS?
antiserotonin- cyproheptadine 4-12mg upto 32mg, only in PO form, if no response after 32mg stop trying. Also concern for subclinical rhabdo in 60% Could also try chlorpromazine (watch for hypoTN / muscle rigidity); or dantrolene (use in malig hypothermia)
Pit vipers (crotalidae)
antivenom FAB 4-6vials over 1hr initial control
Define minimal sedation?
anxiolysis with normal arousal to verbal stimuli
Traditionally what size of ET tube was recommended to be uncuffed?
any tube below 5.5 (although chart shows 5.5 included in uncuffed?) Also recent literature says it is okay as long as cuff pressure can be monitored.
Patients with blunt chest trauma and evidence of mediastinal widening should be evaluated for ___ and ____?
aorta and thoracic spine injuries
Which organophos pts dont get pralidoxime?
asymptomatic or minimally symptomatic carbamate
How do you treat body packers?
asymptomatic, consider whole bowel lavage with miralax. If develop any symptoms consults SURGERY For stuffers consider charcoal as well
How do most NSAID OD pt present?
asymptomatic.
What type of c-spine injuries are EXTREMELY unstable?
atlanto-occipital injuries
What treatment for organopho tox may prevent / abort siezure
atropine (still use benzo though for treat)
Discuss specific CCB tox therapy.
atropine alone....not usually effective Calcium salts...variable response but can improve perfusion and rate pacing often restores rate but minimally improves pressure (indicated in hypotensive with <30BPM) IVF crystalloid to 2L is ok, consider central monitor for more due to increase risk of pulmonary edema
Dislocation of the hip carries the potential for what bad complication?
avascular necrosis of the femoral head
What is the biggest complication concern for a scaphoid fracture?
avascular necrosis of the proximal segment leading to disabling arthritis
What are some discharge intructions that should be given to patients prescribed opioids?
avoid making important decisions, avoid driving, operating heavy machinery, climbing or working from heights, and should include instructions for treatment of constipation
What nerve is most commonly injured with an anterior shoulder dislocation?
axillary nerve (tested by pin prick to deltoid)
Vascular injuries in anterior shoulder dislocations are rare, but when they do occur the tend to involve what nerve and patient population?
axillary nerve, elderly
Why doesnt an equivalent reduction in O2 carrying capacity with anemia isnt the same as methmoglobinemia?
b/c meth shifts disaccociation curve to the left reduces the amount of O2 delivered to tissue at a given PaO2
Which stents are likely to restenose in the short term? which stents usually restenose 9 to 12 months later?
bare metal stents; drug-eluting stents due to Plavix cessation 9-12 months later
How is the decision on which fibrinolytic usually decided?
based on the institution
Why is it important to quickly treat hypovolemia when your going to or currently treating with PPV when treating hemorrhagic shock?
because PPV can cause diminished venous return and thereby; decreased cardiac output in the setting of hypovolemia
Why is close observation of patients with a suspected knee dislocation essential?
because even with normal distal pulses a popliteal artery injury cannot be ruled out
Why is the presence of a new systolic murmur an ominous sign?
because it may signify papillary muscle dysfunction, a flail leaflet of the mitral valve with resultant mitral regurgitation, or a ventricular septal defect
Why should you reserve protamine reversal for the major bleeding complications of UFH therapy?
because there is a 0.2% chance of anaphylaxis with a significant mortality rate
Why is tendon testing against RESISTANCE important for hand injury evaluation?
because up to 90% of a tendon can be lacerated and still have preservation of ROM without resistance
How can administering dual therapy antiplatelets effect down stream therapy?
because you should not undergo a CABG within 5 days of receiving Clopidogrel
Where should you always make sure you insert the central venous catheter when attempting a femoral vein insertion?
below the inguinal ligament above the inguinal ligament can cause severe hidden bleeding into the retroperitoneal space
What is the most common anesthetic associated with methmeglobinemia?
benzocaine
What is the drug of choice for TCA seizures?
benzos
What is the leading cardiovascular medication OD in the US?
beta blockers
What is a rare, but specific ECG finding for dig tox?
bidirectional vtach
What are two airway procedures that you should not do in children <10 years old?
blind nasotracheal intubation and surgical cricothyrotomy Reasons: Adenoids/Tonsils will bleed and cricothyroid membrane is too small
What illness do pyretherins cause?
block Na channel on neuronal cells and increased nicotinic symptoms with norepi release. Cause dermal, pulm, GI, neuro illness allergic hypersensitivity reactions most common
How does sulfhemoglobinemia compare to meth?
blood - green-black; pulse ox tends toward falsely low readings. requires less level to generate same symptoms. Does not respond to methylene blue and is clinicaly INDISTINGUISHABLE treatment generally supportive, but may require PBRC becaue it is permanent
What should be presumed to be the cause of hypotension until proven otherwise?
blood loss
Anyone in shock who shows minimal or modest hemodynamic improvement after 2-3 L of rapid fluids is in need of a ______ _______.
blood transfusion
What injury can occur in Zone III injuries to the extensor tendons of the hand? Describe it?
boutonniere deformity; extension of MCP and DIP, with flexion of PIP
Sacral fractures that involve the central sacral canal can produce _____?
bowel or bladder dysfunction
Carefully perform the neurovascular exam in humeral fracture cases because the _____ and ____ are very close to the coracoid process and can be injured.
brachial plexus and axillary artery
What do open femur fractures require?
broad spectrum Abx, copious irrigation, and further irrigation and debridement in the OR
What do B2 receptors do when agonized?
bronchodilation relaxes visceral smooth muscle (uterus, can cause ileus) Increases skeletal muscle contraction / glycogenolysis stimulates hepatic gluconeogensis/lysis vasodilation
WHat is the common pulm finding in BB tox?
bronchospasm
Which atypical antidepressant is most likely to cause a seizure in OD?
bupropion and this is unassociated with other symptoms so you can have isolated seizures
How would nerve dysfunction due to elevated compartment pressures manifest?
burning or dysesthesias in the sensory distribution of that nerve
How can bystanders who witness a sudden cardiac death event improve a victim's chances for survival significantly?
by alerting the emergency response system promptly
How do you calculate the expected PaO2 when a patient is given Oxygen?
by multiplying the actual delivered percentage by 6.
Describe treatment algorithm for ccb
calcium salts x 3 bolus Epi / norepi 1-5mcg/kg/min glucagon OR insulin/glucose fat emulsion Q5min x 3 atropine / pacing extracorporeal blood pressure support as rescue *realistically may start multiple therapies simultaneously
How do you test opposition of the thumb and how can you tell during this test if median nerve function is lost?
cannot oppose against resistance
What are the possible complications of a radial head fracture?
capitellum, coronoid, and olecranon fractures medial collateral ligament injury medial epicondyle avulsion fx secondary to valgus stress elbow dislocation
What is the hallmark radiographic finding when looking at plain films for a turf toe injury?
capsular avulsion
Any patient with AV blocks and symptoms should have _________ _______ ______ applied in the ED.
cardiac pacing pads
What is the most commonly missed wrist injury?
carpal bone fracture
What is the first step in treating all complications of Peripheral Venous Access?
catheter removal
Discuss the two anticholinergic syndromes.
central-fever and CNS peripheral-tachy, flushed, dry stuff, urinary, ileus
In patients with a modestly elevated INR (3 to 5) and NO clinically evident bleeding what is the treatment?
cessation of warfarin (for 1-2 doses), careful observation, and periodic monitoring
What should you do in an old person with AMS on dig and / or seeing greenish yellow halos?
check a dig level
Which iron formulations are less toxic than expected for a given level?
chelated irons due to steric interference nonionic irons
What structure is likely to be injured in the wrist for a child? old lady?
child: weaker, immature epiphyseal plate or radial metaphysis old lady: distal radial metaphysis, Colles fracture
Who is at the greatest risk from radiation exposure?
children, the younger you are the greater the risk
Whats the preferred calcium salt, route, and dose for CCB?
chloride, 1-3mL through central line may need repeat dosing due to short half life or infusion of2-6gm/hr may need high levels on serial measurements for refractory patients
What are the classes of herbicides?
chlorophenoxy compounds (agent orange) bipyridyls paraquat diquat urea-substituted organophosphates glyphosate
When might urine alk help?
chlorophenoxy herbicides phenobarbital chlopropamide salicylates
WHat do organophophates and carbamates have in common?
cholinesterase inhibitors (cholinergic) most common insecticides associated with systemic illness most commonly used due to lack of persistence in env / tox
Which is worse in kids, acute or chronic salicylism?
chronic and may mimic viral illness with hyperthermia, hyperventilation, AMS, volume depletion, acidosis, severe hypokalemia. Higher mortality. acute usually accidental and well tolerated , but acidosis and academia occur primarily in <4 yo and nearly all <1yo. Older tend to have mixed disorders with resp alkalosis, anion gap acidosis, and alkalemia
What is the definition of shock?
circulatory insufficiency that creates an inbalance between tissue oxygen supply (delivery) and oxygen demand (consumption).
Sinus tach is the most common nontypical SSRI s/e seen in OD, but which SSRI can cause significant widening of QRS/QTc?
citalopram
What is the first step in the evaluation of a patient with a low measured Na+?
clinical evaluation of ECF volume status and measured and calculated plasma osmolalities
What is the most important guide to Fe therapy?
clinical recovery
Up to 10% of initial radiographs fail to find a fracture, so what drives initial treatment for possible scaphoid fracture and what is the treatment?
clinical suspicion; short-arm thumb spica splint
Ventricular Tachycardia cannot be differentiated from SVT with aberrancy on the basis of ____, ____, or ____.
clinical symptoms, blood pressure, or heart rate
How do you treat opioid withdrawl?
clonidine 5mcg/kg PO if BP >90 atarax 50-100mg QID x 5 days antiemetics DONT ADMINISTER METHADONE/NARCAN to dependent persons UNTIL withdrawl symptoms start.
What is the treatment of posterior hip dislocation?
closed reduction using sedation or general anesthesia, if possible, within 6 hours
What is required for definitive id of dyshemoglobenemias?
co-oximetry
Discuss ethylene glycol toxicity.
colorless, odorless, sweet tasting. Not toxic until metabolized like methanol with metabolite being glycolic acid. Most goes through liver 80%. Also causes metabolic acidosis One pathway for glycolic acid is conversion to oxalic acid which can cause hypocalcemia and calcium oxalate crystal deposition causing tissue damage. Also gastric irritant
How does salicylate toxicity affect acid-base?
combination of respiratory alkalosis, metabolic alkalosis (from volume contraction) and metabolic acidosis with anion gap
When perfusion defects are identified, a nuclear cardiologist or radiologist can differentiate reversible ischemia secondary to coronary stenoses from past infarctions by.......?
comparing stress and rest imaging
Tight fitting casts or splints may increase the risk of ____ ______?
compartment syndrome
What other injuries need to be considered when someone is diagnosed with a pilon fracture?
compartment syndrome and lumbar vetebrae fractures (especially L1)
Describe the difference between a complete spinal lesion and incomplete?
complete = no sensory or motor below the level of injury incomplete/partial = some sensory or motor or both at any level below the injury including just anal sensory
The NASCIS trial reported that methylprednisolone infusion resulted in improvement of both motor and sensory function in patients with ______ or _______?
complete or incomplete spinal lesions
What does the loss of ability to extend the elbow likely mean?
complete triceps tendon rupture
How is a patella reduction performed?
conscious sedation, then flexion of hip, extension of knee and slide patella back into place
Distal clavicle fractures are often associated with _____ which may require operative intervention to avoid nonunion.
coracoclavicular ligament
Why is hemodialysis considered the extracorporeal technique of choice in severe and what are the indications?
corrects acid-base and electrolyte abnormalities while rapidly reducing body salicylate burden. respiratory and vent support clinical deterioration or failure of improvement despite intensive support care and alkaline diuresis lack of success in establishing an alkaline urine renal insufficieny / failure severe acid-base disturbance AMS ALI *also consider at levels >100 (not to be used as sole determinant, also in elderly. Continue until level <20. Be wary in those who may not tolerate it CV strain.
What is the narrowest point of the child's trachea?
cricoid ring
What is the most common infectious cause of pediatric upper airway obstruction?
croup
When should you suspect methemoglobinemia?
cyanosis that doesnt improve with sup O2 that are clinically less symptomatic than would be expected otherwise for given o2
When does most post op tonsillectomy bleeding occur?
days 5-10
Iron OD
deferoxamine 15mg/kg/h IV
What is the most common cause of Aortic Stenosis?
degenerative calcification
Patients immobile for a prolonged period due to inability to send for help should be evaluated for ____ and ____?
dehydration and rhabdomyolysis
Brachial plexus eval in severely injured patient: Adduction and internal rotation of the shoulder indicates weakness of the ______ muscles which is a ___ distribution. Elbow extension is due to weakness of _______ which is a ___ distribution. Flexion of digits and wrist is weakness of _______ which is
deltoid and infraspinatus - C5 biceps - C6 the extensors - C7
Sedative-hypnotic Toxidrome
depressed LOC, slurred speech, ataxia +/- stupor/coma, depressed respirations, apnea, bradycardia ventilator support
What are neurologic manifestations of BB tox?
depressed mental status, coma, siezures Likely result from combination of hypoxia, Na channel block, and direct neuronal tox
What are common CNS findings in BB tox?
depresssed mental status, coma, psychosis, seizures
The complication rate of PSA is primarily determined by the interaction of _______ and _______.
depth of sedation AND patient's current medical condition
What is the chelation antidote?
desferoxime
How do you calculate Na+ deficit?
desired plasma Na+ minus actual plasma Na+ x TBW TBW = 60% of total weight
How do you calculate naloxone infusion dose?
determine "wake up dose" and administer 2/3 of that dose per hour by IV infusion. If you do this, should admit to monitored bed
What are some possible complications from perilunate and lunate dislocations?
development of carpal instability patterns that lead to early arthritis delayed union malunion nonunion avascular necrosis median nerve compression from lunate dislocation volarly into the carpal tunnel
There is data that supported the theory that the difference between ____ and ____ is a better determinant of potential irreversible muscle damage than just compartment pressure. What pressure difference does it say predicts need for surgical intervention?
diastolic blood pressure; < or = 30
What are common organophosphates?
diazinon, acephate, malathion, parathion, chlorpyrifos
What should you do with the Sodium Bicarbonate if treating neonates or premature infants?
dilute in a 1:1 ratio with sterile water to help reduce the hyperosmolarity
How does pH affect urinary elimination of salicylate?
directly proportional to urinary flow rate, but logarithmically proportional to urine pH- alk is better
What trapezium fractures require surgery?
displaced fractures >1mm or diastasis >2mm
The poor judgment and disorganization in Schizophrenic patients may lead to _______ and should be remembered when evaluating them.
disregard for medical problems
75% of all hemarthroses are caused by ______?
disruption of the ACL
What is a clue to distal radioulnar joint disruption on a lateral wrist film?
dorsal or volar displacement of the ulna bone which is usually centered and overlapping the radius
What are the 3 Ds of epiglottitis?
drooling, dysphagia, distress
If there is reversible ischemia wall motion on stress echo will be normal during rest, but there will be ___, ___, or ____ during stress.
dyskinesis, hypokinesis, or akinesis
What is the classic triad for Aortic Stenosis?
dyspnea, chest pain, and syncope
Commons symptoms in Acute AR?
dyspnea, with possible tachycardia and hypotension that turns into cardiogenic shock and then death
What type of syncope is usually sudden and without prodromal symptoms?
dysrhythmias
EPS toxidrome
dystonia, torticollis, tremor, muscle rigidity +/- choreoathetosis, hyperreflexia, seizures Benadryl, benztropine, benzos
What is the definitive treatment of high-pressure injection injuries to the hand?
early surgical decompression and debridement (amputation rate is as high as 30%)
Why shouldn't you use atropine in corneal abrasions?
effect lasts up to 2 weeks
What is the "terrible triad" elbow injury?
elbow dislocation with radial head and coronoid fracture
What needs to be done for all perilunate and lunate dislocations?
emergent orthopedic consultation
What are some reasons that a DIP dislocation may be irreducible?
entrapment of an avulsion fracture, the profundus tendon, or volar plate
What are a few things that can assist you in the patient's disposition?
estimating the lethality of the attempt and the likelihood of rescue
You may need to adjust the osmolal gap calculation if there is coingestion of what?
ethanol
How much does 100mg/dL of each alcohol change osmolar concentration?
ethanol 22 isopropanol 17 methanol 31 ethylene glycol 16
This comparison when performing a knee exam should be done during all orthopedic exams, but especially during the palpation and stress testing portions?
examination of the uninjured knee
What should you monitor closely and avoid when ventilating a child?
excessive hyperventilation
What is the most frequent presenting complaint for mitral stenosis?
exertional dyspnea
What exam finding is likely to be abnormal with a transverse patella fracture?
extensor mechanism (straight leg raise against gravity)
Where is the most common site of tendon injury in the hand?
extensor tendons
How do you manage hyperthermia in organochlorine?
external cooling
What are the five factors to help you determine if a patient will be a difficult BVM? How many do you need to qualify?
facial hair, obesity, edentulous patient, advanced age, and snoring.
If you are transferring, imaging, pressure testing compartments, starting lines, etc on a Hemophilia patient you need to do ___ first.
factor replacement therapy
What does the presence of vocal sounds indicate when performing nasotracheal intubation?
failed attempt
What is a hallmark that can be seen during treatment that signifies a significant right to left shunting?
failure of arterial oxygen levels to increase in response to supplemental oxygen
What is the most common cause of a femoral neck fracture?
fall
What should be done as soon as the diagnosis of compartment syndrome is clinical made or as soon as the determination that the tissue pressure is elevated in relation to the diastolic pressure?
fasciotomy
The _______ or ________ venous sites are not recommended for IV access during resuscitation of a pregnant patient with >20 weeks' gestation. Why?
femoral and saphenous, because the uterus pushes on the inferior vena cava which decreases venous return, so medications may not work so well from any infradiaphragmatic site
What are the are the major diagnostic criteria for MNS?
fever, muscle rigidity
What is contraindicated in treating cardiac ischemia in pregnant patients that is not in non-pregnant patients?
fibrinolytic therapy, it is a relative contraindication in pregnancy
What level of CK, in the absence of brain or cardiac injury, is considered by most investigators to be required for the diagnosis of rhabdomyolysis?
fivefold or greater increase above the upper limit of normal
What PE test can you do to help you eval for bicep tendon rupture?
flex elbow with arm abducted and externally rotated to look for midarm "ball" which is the distally retracted biceps muscle
How do you test the median nerve on hand testing?
flex the distal phalanx of the thumb against resistance
How do you reduce an MCP dislocation?
flex the wrist to relax the flexor tendons, then apply pressure to the dorsum of the proximal phalanx in a distal and volar direction
Positive pressure ventilation following intubation in pediatrics will decrease preload, what is something that should be done prior to intubation to help combat this?
fluid bolus 20ml/kg due to likely dehydration, etc
What are the indications for bicarb in TCA OD
fluid refractory hypoTN, conduction abnormalities / dysrhythmias; 1-2meq/kg bolus to urine 7.5-7.55 Don't forget to add K for the hypoK youre causing
What treatment comes next if the newborn remains bradycardic despite BVM followed by intubation, ventilation, and chest compressions?
fluids and medications via IV (ET Epi can be given if no IV access)
How do you treat trazodone hypotension, what about concerning ingestions?
fluids and norepi....don't use B adrenergic or can worsen hypotension Consider SDAC; or gastric lavage (1hr)
benzodiazepines
flumazenil 0.01mg/kg IV ped; 0.2mg IV adult
The recent use of what medications put a patient at increased risk for tendon rupture?
fluoroquinolones and corticosteroids
Which SSRI is the only one with 2 halflives because the active metabolite is equal to parent?
fluoxetine 2-4days and norfluoxetine 7-14days
When are traction splints contraindicated?
for open fractures with grossly contaminated bone ends or when sciatic nerve injury is probable
What causes toxicity with methanol?
formic acid and metabolic acidosis
What is the hangman's fracture?
fracture of both pedicles of C2 allowing the body of C2 to displace anteriorly on C3
What is a Colles fracture and what does it look like on plain films?
fracture of the distal radial metaphysis; dorsiflexion or "dinnerfork" deformity
How do glaucoma patients get chronic salicylate toxicity?
from carbonic anhydrase inhibitors by increasing the volume of distribution allowing tox at therapeutic levels
Which corneal FB should be removed by opth?
full thickness
How do you calculate osmolar gap?
gap = measured - calculated. Calculated = 2x Na + BUN/2.8 + glucose/18 + ethanol/4.6 + isopropanol/6.0 + methanol/3.2 + ethylene glycol/6.2.
What causes benign hiccups?
gastric distension, alcohol intoxication, excess smoking, abrupt change in environmental temps, or psychogenic
What is a striking early feature of isopropanol ingestion?
gastric irritation
Which therapies are not of use in organophosphate posioning?
gastric lavage, charcoal, urinary alk, hemodialysis
What is the first line agent for BB tox?
glucagon, bolus 0.05-0.15 mg/kg (3-10mg in 70kg adult) or infusion of 1-10mg/h NV are common side effects
What ECG finding denotes Sinus Arrythmia when there is normal P waves, P-R Interval, and 1:1 atrioventricular conduction?
greater than 0.12 secs (3 boxes) of variance in the P-P interval.
What is one rare but easily treatable cause of peristent hiccups?
hair touching TM in ear
Hallucinogenic toxidrome
hallucinations, dysphoria, anxiety +/- hyperthermia, mydriasis, nausea, sym symptoms generally supportive
Anyone with decreased pincer function and volar-ulnar tenderness to MCP of thumb = ______ referral. If greater than _____ degrees of radial angulation with lateral stress, then the patient needs _______; this injury is called?
hand surgery; surgical consultation; gamekeeper's thumb or skier's thumb
What does a mitral regurg murmur sound like?
harsh apical systolic murmur starts at S1, ends at S2 S3 and S4 may be heard...RADIATES into the AXILLA
How is sotalol unique?
has K channel blocking activity
What are NSAID CNS changes?
headache, cognitive difficulties, behavioral changes, psychosis, aseptic meningitis
In pulmonary edema patients from salicylate tox what is effective and should be considered in this subset of patients?
hemodialysis
Qualitative tests, such as the urine dipstick, that uses the orthotoluidine reaction cannot differentiate between ____, ____, or _____?
hemoglobin, myoglobin, and RBC's
What is the onset of withdrawl syndrome from opioids?
heroin = 12 hours from last methadone = 30 hours from last
How do you distinguish herpangina from herpetic gingivostomatitis?
herpangina spares buccal mucosa
What does Aortic Regurg murmur sound like?
high pitched blowing diastolic murmur immediately after S2.....or, mid-diastolic rumble (Austin Flint Murmur) in lateral decubitus heard at apex of heart.
What will be seen on a lateral knee film with patellar tendon rupture?
high-riding patella
Which BB are more neurotox?
highly lipophilic like propranolol, betaxolol, nebivolol, and penbutolol
What other areas of the foot should be palpated when examining an ankle injury?
hindfoot and midfoot over the calcaneus, tarsals, and base of the 5th metatarsal
What might help diagnosis cholingeric syndrome from organophosphates
hydrocarbon / garlic Dont use plasma cholinesterase level - no prognostic value
Nitroprusside
hydroxocobalamin 70mg/kg upto 5gm over 30 mins may repeat up to 3 doses in combo with Na thiosulfate.
What Electrolyte effects do you seen in NSAID OD?
hyperK, hypoCa, hypoMg
What else is an important therapy in BB tox?
hyperinsulinemia=euglycemia
What are NSAID Pulm changes?
hypersensitivity pneumonitis, bronchospasm, pulm edema
What is the most common cause of death in Serotonin Syndrome?
hyperthermia
What does crhonic salicylate intoxication look like?
hyperventilation, tremor, papilledema, agitation, paranoia, bizarre behavior, memory deficits, confusion, stupor
What CV effects do you see in NSAID OD?
hypoTN, shock, brady dysrhythmias
What is a worriesome findings in MAOI OD?
hypotension - omninous finding, usually resistant
Describe mild DHP CCB OD.
hypotension and reflex tachy in mild/mod...but can cause complete heart block in high dose like all other ccbs
What are common CV findings in BB tox?
hypotension, bradycardia, conduction delay/block, ventricular dys (sotalol), asystole, decreased contractibility
What is the differential diagnose to CCB in the setting of bradycardia, AV block, hypotension?
hypothermia ACS hyperK cardiac glycoside tox BB tox Ia/Ic antiarrthymics clonidine tox
What should be corrected before propofol administration?
hypovolemia
Why is prompt recognition of SS important in Emed?
iatrogenic worsening may occur due to administering serotonergically active meds like pain killers. How to prevent? Use lexicomp/epocrates.
WHat is the most commonly reported NSAID in OX?
ibuprofen, by far. Patients who develop symptoms usually ingest >100mg/kg and present with abdominal pain nausea, vomiting with in 4 hours. >400mg/kg: severe: coma, apnea, metabolic acidosis.
Which two NSAIDs may be associated with wide AG met acidosis?
ibuprofen, naproxen, due to being weak acids along with their metabolites
What is the goal of ED evaluation for patients presenting with syncope?
identify those at increased risk for both immediate decompensation and future risk of serious morbidity or sudden death
How should you interpret Fe levels in tox?
if measured in 4-6 hours of ingestion correlate with severity of tox BUT low serum Fe levels do not mean absence of tox
What is a major limitation to Head imaging using CT?
imaging of the posterior fossa
If you find a spinal column injury what further evaluation should this prompt you to perform?
imaging of the rest of the spine, 10% have a 2nd injury at another level
What is the treatment for a "one part" proximal humerus fracture?
immobilization (such as sling and swathe), ice, analgesics, and ortho referral
TCA inhib voltage gated Na channels
impaired conduction, wide QRS complex tachy, brugada pattern, ventricular ectopy; tx NaHCO3, hyperventilation, hypertonic saline
What is the treatment in general for respiratory acidosis?
improve alveolar ventilation, so doubling the Ventilations per minute (Vm) will decrease PCO2 by 50%
What separates Effexor from the other SNRIs?
in doses >225mg can cause HTN
What causes digibind failure?
inadequate dosing moribund state before admin, incorrect diagnosis of dig tox
What are the most common reasons for intubation failure?
inadequate equipment preparation and poor patient positioning.
How much will one unit of PRBC's affect the patient's H/H?
increase the HCT by 3% and the HGB by 1 gram/dL Usually start with 2 units for increase of HCT 6%/HGB 2
Hypercapnia is never a result of what?
increased CO2 production
What are hematologic NSAID changes?
increased bleed risk from plate inhibition, bone marrow suppression, aplastic anemia, agranulocytosis, thrombocytopenia, renal cell aplasia, hemolytic anemia
Eight variables are significant independent predictors of pneumonia in nursing home patients, what are they?
increased pulse rate respiratory rate >30/min Temp > or = to 100.4 or 38 C somnolence or decreased alertness presence of acute confusion lung crackles on auscultation absence of wheezes increased leukocyte count
What are cardiac NSAID changes?
increased risk of MI and subsequent SCD
Do the cardiac troponins and CK-MB have dependent or independent predictive value or prediction of adverse events and diagnosis of ACS?
independent
What happens once urine returns from vin rose to normal?
indication to assess patient and potentially stop therapy of desferoxamine if asymptomatic
What does diagnosising a retinal detachment require?
indirect dilated fundoscopic exam by oph in 24hrs
What are some CNS effects of cocaine/amphetamines?
infarcts brain and spinal cord, unilateral / bilateral blindness, crack eye, keratitis, crack dancing (chorea), cocaine washout
Define pericoronitis
inflammation of the operculum, or the gingival tissue overlying the occlusal surface of an erupting tooth
At what rate of K+ replacement is cardiac monitoring recommended?
infusion rates >20 mEq/h
What is the most common exposure to pyretherins?
inhaled from aerosolized forms in public places.
Propofol produces greater peak plasma concentration in elderly, because of this what dosing adjustments should be made when using propofol for PSA in elderly?
initial and subsequent doses should be 50% of the recommended doses for a young healthy adult.
What are risk factors for middle clavicle fracture nonunion?
initial shortening of >2 cm comminuted fracture displaced fracture significant trauma female elderly
Discuss hyperinsu-eugly therapy.
insulin bolus 1U/kg along with 0.5gm/kg glucose infusion of 0.5U/kg/hr along wih Q20-30min glucose checks until euglycemic then Q1-2hrs May require glucose infusion May have hypo K but dont replace unless <2.5 or other source of true K loss
If no response to CCB pt from pressor then what to consider?
insulin/glucose
After intubation, what should efforts focus on with CV in ccb
insuring adequate perfusion, NOT SPECIFIC heart rate...30-40 may be acceptable
How do you treat mitral stenosis?
intermittent diuretics for pulmonary edema treat atrial fibrillation anticoagulation for patients at risks for arterial embolism Refer to cardiology for mechanical intervention (if needed)
Which femoral fractures can have significant blood loss and may require crystalloids or blood transfusion?
intertrochanteric and subtrochanteric fractures
Medial clavicle injuries can be associated with _____ injuries and develop late complications such as arthritis.
intrathoracic injuries
Which Barton fractures require ORIF?
involving >50% of the articular surface or carpal subluxation
What is the role of B Blockers in the treatment of "possible ACS"?
it is unclear
Should you treat BP in vascular lesions, stroke, and bleeds in the head?
it's controversial, maybe <160/100, if hypertensive encephalopathy then yes, but must rule out vascular D/O including stroke first.
What separates isopropanol from ethanol/methanol/ethylene glycol?
its a secondary alcohol (OH on central carbon) and as such gets metabolized to ketone rather than an acid. This results in the hallmark of ketosis with an osmolar gap in toxicity.
Why is a sling in forearm fracture important?
joint above and below the fracture needs to be stabilized, the sling keeps the elbow at rest
Contrast is usually used for Abdominopelvic CT's except when looking for _____.
kidney stones
What is the most common cause of flexor tendon injury?
laceration
What is important to consider when you diagnose a hindfoot fracture?
large axial force to heel is likely the cause and associated injuries should be suspected
What may you see on ECG with Aortic Dissection?
largest portion at 41% showed non-specific ST and T wave changes
Define "acute cough"?
lasting <3 weeks and usually self limited infectious upper respiratory or bronchial infections
What does the murmur of Aortic Stenosis sound like?
late peaking systolic murmur at the 2nd right intercostal space, radiating into carotids and diminished carotid pulse with delayed upstroke AKA PULSUS PARVUS ET TARDUS
What is the radiographic hallmark of a scapulothoracic dissociation?
lateral displacement of the scapula on CXR
The perilunate dislocation on which wrist film? What will it look like?
lateral film; capitate dorsal to lunate, lunate maintains articulation with radius
What is the best plain film view for seeing a dorsal avulsion fracture of the triquetrum?
lateral or an oblique view in partial pronation
What might you find on CXR for mitral stenosis?
left heart border straightening
Which eyelid lacs need ocuplastic repair?
lid margin, 6-8mm of medial canthus, inner lid surface, wounds associated with ptosis, those that involve: tarsal plate / levator palpebrae
Both the spinothalamic tracts and dorsal columns have to be damaged to affect what sensation since it is transmitted through both?
light touch
What happens if you give Nitro to a patient with RV infarction?
likely reduced cardiac output and hypotension
WHat is a last ditch method for lifethreatening cardiotoxic TCA OD?
lipid emulsion 20%, 100mL bolus over 1 minute
What is the presence of blood and glistening fat globules on knee joint aspiration pathognomonic for?
lipohemarthrosis (intra-articular knee fx)
Which two uncommon medications have decreased renal clearance when combined with NSAIDS?
lithium, methotrexate (have had fatalities for this combo)
Many patients with type B lactic acidosis have what type of underlying disease?
liver
What surgical transplant patients are most likely to get bacterial pneumonia in the first 3 months? What organisms predominate?
liver, heart, or lung transplants; Gram-Neg (P. Aeruginosa if ventilated), S. Aureus, Legionella
What is the dose for fomeprizole?
load 15mg/kg over 30min then 10mg/kg q12 hrs.
TCA inhib voltage gated K channels
long QT, torsades, vent ectopy; tx MgSO4, overdrive pacing
Discuss chlorophenoxy tox
look for muscle tox-rhabdo, myotonia, hyperthermia, cardio symptoms hypoTN, tachy pulm symptoms Supportive treatment including urine alk, hemodia (severe), resp support, decon Dispo most over 4-6 hours, most are this. Significant admit
What happens to cardioselectivity of BB in OD?
lose selectivity
Describe Brown-Sequard Syndrome?
loss of ipsilateral motor, vibration, and proprioception and contralateral loss of pain and temperature sensation, usually from penetrating injury, hemisection of cord, or protruding disc etc.. BEST PROGNOSIS
Describe anterior cord syndrome?
loss of motor, pain, and temperature due to damage to anterior portion of the spinal cord involving the spinothalamic tracts and corticospinal tracts. Vibration and Proprioception is maintained. BAD PROGNOSIS, hyperflexion injury
Who is diagnostic stress testing recommended for (in relation to ACS type patients?
low to moderate risk; NOT very low or very high
Describe Cauda Equina Syndrome?
lumbar,sacral, coccyx injury to nerve roots (peripheral nerves, not cord) variable loss to motor, sensation, etc.. Saddle anesthesia, bowel or bladder dysfunction, sciatica, etc.. GOOD PROGNOSIS
What are NSAID derm changes?
maculopapular rashses, TEN, photosensitivity reactions
What is the most common tendon injury in athletes?
mallet finger, usually after blunt trauma
Why do pesticides present as complex syndromes?
marketed under multiple formulations with shared brandnames. inert ingredients in high enough doses can be tox to people
Acute onset of respiratory distress, pulmonary edema, and cardiogenic shock may be associated with? 3 things
mechanical valve failure tearing of the prothesis large clot obstructing the valve or preventing closure
Posterolateral displacement of the supracindylar fracture will likely affect what nerve? especially what branch
median (especially the anterior interosseous nerve)
RPA in an adult is more likely to extend where?
mediastinum; most commonly caused aerobically by Strep viridans/pyogenes and anaerobically by bacteroides / peptostreptococcus
What medications for pain shouldnt you prescribe to MAOI patients for concern over SS?
meperidine, dextromethorphan, tramadol, propoxyphene, flexeril.
Elevated Osmolal gaps are seen in what types of posionings?
methanol and ethylene glycol
What is the adjunct therapy for methanol? ethylene glycol?
methanol: folic acid 1mg/kg up to 50mg Q4-6hrs EG: pyridoxine, thiamine, mag. Mag: 2gms x 1 IV pyr/thia: 100mg IV Q6hrs for 2 days
Oxidizing chemicals (nitrites, benzocaine, sulfonamides)
methylene blue 1-2mg/kg IV
Use of high-dose __________ remains a controversial treatment in acute blunt trauma injury?
methylprednisolone
What is the only way to protect yourself from being misled by referred pain and missing a crucial diagnosis when evaluating musculoskeletal trauma?
meticulous palpation examination
What does the murmur of MVP sound like?
mid systolic click
The most common site of humeral fractures is the _____ third?
middle
Complete rupture of the biceps tendon is most common in who?
middle aged men
How else does treating sotalol tox differ from standard BB?
might need mag, pacing, lidocaine etc
What other organ systems are effected by salicylate?
might see acute lung injury, proterinuria (levels >30) when concentration reaches 40mg/dL hearing loss = 40dB
Discuss urea-substitued herbicides.
minimally tox to humans, may have methmoglobinemia
There are three mechanisms that always get triggered when a person becomes hypoxemic, what are they in order of being triggered?
minute ventilation increase: Tachypnea Pulmoary arterial vasoconstriction to areas increased heart rate: Tachycardia
What is the cornerstone of acute cocaine / amphet toxicity?
monitoring vitals and sedation use benzos, but avoid Haldol etc bc lower seizure threshold and worsen hyperthermia / d sysrhythmias
What GI/hepatic effects do you see in NSAID OD?
more abdominal pain, n/v, hepatic injury, rare pancreatitis
How do you identify injury of the anterior interosseous branch of the median nerve on exam?
motor only; "OK" sign
What are complications of high dose deferoxamine?
mucormycosis, renal insufficiency/failure, pulm tox, sepsis from Y enterocoltica
The decision to provide dual therapy, Aspirin/Plavix should be made in concert with _______.
multidisciplinary, institution-specific treatment algorithms
What are the most prominent and life threatening CCB effects?
myocardial depression and peripheral vasodilation
What is it called when a patient has no s/s of MI, but has a troponin above the 99th percentile of normal?
myocardial necrosis
What type of mycocardial imaging allows the clinician to evaluate regional variations in myocardial blood flow?
myocardial perfusion imaging
Opiods and clonidine
naloxone try and OD on it.... start at 0.01mg IV peds and 0.4-2mg IV
Which 2 NSAIDS increase plasma warfarin levels?
naproxen and phenylbutazone (also decreases elimination)
Which NSAIDS have been associated with pancreatitis in OD?
naproxen, ibuprofen, indocin
The midfoot is divided into two columns, the medial column contains the cuneiforms, the first 3 tarsometarsal joints, and the ____ bone.
navicular
How do you overcome the acute angle of the oral,pharyngeal, and tracheal angles in a child?
neck extension (when no neck trauma) and sometimes a small roll under the shoulders (folded, not rolled)
What is the subglottic, invasive airway of choice in children <10 yrs old?
needle cricothyrotomy
How much and what kind of gastric contents needs to be aspirated in order to get aspiration pneumonitis?
needs to have a pH <2.5 and have volume of .3-.4 mL/kg (i.e. 20-30 mL in adults)
A patient who is warm, peripherally vasodilated, and hypotensive with relative bradycardia may have what?
neurogenic shock
What type of issue noted with a dislocation would make addressing the injury as soon as possible very important?
neurologic or vascular compromise
WHat is the predominant symptom in organochlorine tox (think DDT / lindane)
neurological. Mild: dizzy, ataxia, fatigue, malaise H, irritable, delirium, apprehension, tremulosusness, myoclonus, facial parathesia. FEVER IS COMMON Severe: seizure, coma, resp fail, death. Chronic: deficits in balance, reaction time, verbal recall
An isolated ulna fracture is also called a ____ fracture?
nightstick fracture
If a patient looses consciousness and has persistent neurologic deficits or altered mental status can this be called neurologic syncope?
no
How should Salmeterol be used in asthma treatment?
no more than BID and not for acute attacks only for chronic maintenance
Should you attempt to reverse a suspected chemically caused aniscoria in ED?
no, results not reliable
The presence of _____ hallucinations suggests a medical, not psychiatric, cause of psychosis (such as alcohol withdrawal).
non-auditory
What paralytic should you use?
non-depolarizing due to poss of prolonged para with succh due to needing cholinesterase to remove it
What is a PE findings that helps delineate displaced from non-displaced femoral neck fractures?
non-displaced often come in weight bearing displaced are usually unable to bear weight
What pre-treatment is no longer recommended in RSI?
nondepolarizing neuromuscular blocking agents
What is the most effective pressor for TCA hypoTN?
norepi due to direct competition at a ad sites; start at 1mcg/min titrate to BP upto 30mcg/min
What may be the most effective B agonist in BB tox?
norepinepherine due to increasing rate and BP. Could try isoprotterenol (can cause vasodilation) use 160-200mcg/min
What is the usual dose of dig, what is toxic and what tends to be fatal?
normal 150-200mcg toxic in adult with single 1-2mg ingestion fatalities at 10mg adult, 4mg child
A complete tendon laceration to a dorsal hand extensor tendon proximal to the juncture could result in _____?
normal extensor function
What about calcicum inBB tox?
not routine, consider in refrac shock dose for gluconate: 0.6mL/kg over 5-10min followe by 0.6-1.5mL/kg/hour as infusion CaCl2 has to go through central line and dose is 1/3 gluconate dose check iCa level every 30minutes with goal of 2x normal iCa
What should you be careful not to do when covering gastroschisis with kerlix and plastic wrap?
not to compress the intestine which would cause obstruction of blood flow to the bowel.
What might you find on EKG for mitral stenosis?
notched or biphasic P waves
How to dispo organochlorine pts?
obs for 6hrs admit for signs of sig tox or if hydrocarbon involved (solvent)
What should you always look for in a patient with hypotension?
occult bleeding
Significant pain with weight bearing after normal radiographs should raise suspicion for _____, especially ______ and the best imaging to evaluate this concern is _____.
occult fx femoral neck or acetabulum MRI
What are the risk factors for developing an Achilles Tendon Rupture?
old age, prior quinolone use, and prior steroid injection
How should a patient be counseled to take his pain medication when discharged?
on a regular basis or when the pain begins to return, not wait until its peak
How dangerous is oil of wintergreen?
one mL of 98% methyl salicylate solution contains 1400mg of salicylate. Can get toxic from topicals and 5 to 10 mL lethal for a toddler.
What is a "one part" fracture of the humerus?
one or more fragments is displaced < 1cm and is not angulated >45 degrees
If the PIP joint has evidence of complete ligamentous rupture or the joint is irreducible, then ____ is required.
operative repair
What does corneal clouding following chemical eye injury mean?
oph referral.
What should you evaluate for early in the patient with AMS, hypotension?
opioid, and hypoglycemia because they are easily corrected
WHat are the common insecticides?
organophosphates carbamates organochlorines pyrethrins/pyrethroids neonicotinoids DEET
Even narcotic analgesics have virtually no effect on the pain of movement and manipulation unless combined with what?
other central nervous system - acting agents
What is often "per se" the least important value on diagnosis and management of acid-base disorders?
pH
What are prognostic indicators of mortality from APAP tox?
pH <7.3 despite fluid/hemo resus combo of coag PT >100 and renal fail Cr >3.3 Grade III/IV hepatic encephalopathy. Also APACHE II >15, lactate >3 (after fluid), phosphate >1.2 (on second day)
The most consistent clinical sign for compartment syndrome in the hand is....?
pain
Discuss nicotinic effects with cholinesterase inhibitors
pallor, mydriasis, tachycardia, HTN
What direction is he scaphoid usually pointed on the lateral wrist film and what is the normal angle formed by its' axis with the lunate?
palmar flexed; 30-60 degrees
What makes the diagnosis of compartment syndrome in the hand more difficult than in other locations?
paresthesias may not be associated and extremely subtle motor deficits and assessing response to passive stretch difficulty
What does pain along the course of the tendon during resistance testing suggest, even if strength appears adequate?
partial tendon laceration
A value assigned by a patient on a pain scale is not an absolute value, but rather a reference point based on _____ _______ ________.
past personal experience
Massive steroid therapy has not been found to be effective (in fact can be harmful) in ________ spinal cord injuries?
penetrating
What is a symptom on HX of hiccups that makes the cause likely organic, not psychogenic?
persistence during sleep
The most common sign of ITP is the development of ____? What other symptoms are common?
petechiae is most common; also mild epistaxis, gingival bleeding, and menorrhagia in young women
Which NSAID was associated with worst outcomes in tox and removed from the US Market in the 1970s
phenylbutazone, can still get it for your horse.
What shouldn't you use for TCA seizures?
phenytoin, physostigmine, bicarb
What is the most common cause of aniscoria?
physiologic- diff typically <1mm and react normally
Anticholinergics NOT TCAs
physostigmine 0.02mg/kg IV ped, 0.5-2mg slow IV over 2-5min adult
What is unpredictable and often occurs in previously nonobstructive lesions?
plaque rupture
Posterior sternoclavicular dislocations can have life threatening complications such as _________ and need ortho consult for reduction likely in OR.
pneumothorax compression of great vessels, trachea, esophagus
With fractures of the femoral condyle distal sensation and pulses must be check due to the potential for a _______ artery injury and which sensation area should be tested? and for which nerve?
popliteal artery dorsal web space between toes 1 & 2 deep peroneal nerve
What is important in the history when a penetrating knee injury is suspected?
position of knee when injury occurred
If IV fluids resuscitation is not enough to maintain the MAP at 85-90 for neurogenic shock, then what is the next treatment that can be added?
positive inotropic pressors
What is an acute CNIII palsy with ipsilateral pupillary dilatation?
posterior communicating artery aneurysm until proven otherwise
What constitutes 90% of hip dislocations?
posterior dislocations
What are two radiographic signs of an elbow fracture on plain films due to hemarthrosis?
posterior fat pad and very prominent anterior fat pad "sail sign"
Where is the most common site of oral cancer in the US?
posterolateral aspect of the tongue accounting for 50% of oral cancers in the US
Cholinergics
pralidoxime (2PAM) 20-40mg/kg IV over 5-10min ped; 1-2gms IV over 5-10min adult
What should you use in CCB pts refract to calcium?
pressors...better evidence anyway FIRST LINE for persistent hypotension in CCB oD titrate to sbp>90 may need multiple or phosphodiesterase
Why not prescribe oral anesthetics?
prevent healing and obliterate the noraml corneal protective mechanism
What is the goal of early and vigorous decon in paraquat?
prevent pulm tox. ANY exposure = MEDICAL EMERGENCY, with hospitalization even if asymptomatic Use low FIO2 with NPPV for hypox limit superoxide radical GI lavage KEY even with risk of perf from NG tube maintain intravascular volume to prevent prerenal Immediate GI decon with absorbents like charcoal, diatomaceous fullers earth, bentonite q4hrs
What are common S/E of trazodone?
priapism (most common drug cause-reason for DC and this includes clitoral as well as penile); orthostatic hypotension, drowsiness
What ECG finding in organophosphate tox correlates with severity and mortality in severe tox?
prolonged QTc
What makes Osteomyelitis less likely, even though many times it is unavoidable?
prompt and meticulous treatment
All open and neurovascularly compromised fractures require what?
prompt eval by orthopedic surgeon
Injury to the dorsal column will affect what sensations and what side?
proprioception and vibration, ipsilateral side
heparin
protamine 1mg to 100U UFH over 15 min 0.6mg/kg IV ped empiric 25-50mg IV adult empiric
Discuss organophos decon.
protective clothing dispose of clothing and hazardous waste wash pt with soap water
What should you do first when treating dysrhythmias in children?
provide ventilation and oxygenation, and correct hypoxia, acidosis, and fluid balance since most disrhythmias in kids are secondary to hypoxia not primary cardiac events.
Shoulder dislocations combined with _____ generally require orthopedic consultation and may need operative repair
proximal humerus fractures
What diagnosis in syncope requires all organic causes to be excluded before you can make it?
psychiatric cause of syncope
Describe horners syndrome.
ptosis, miosis, anhydrosis CXR, CT brain/cervical, CTA/MRA head /neck for dissection
What is a well recognized complication of TCA od?
pulmonary edema
INH / Gyromitra esculenta / hydrazine
pyridoxine gm for gm of INH 70mg/kg max 5gm ped; 5gms IV adult
What findings might you see with large dose cocaine toxicity?
quinidine like effects on conduction with wide QRS, negative inotropy, bradycardia, hypotension
What drugs tend to interact with dig, which is most associated with increased hospitalizations in the elderly?
quinidine, procainamide, BB, CCB, amiodarone, aldactone, Indocin, clarithromycin, erythromycin clarithromycin
Posteromedial displacement of a supracondylar fracture of the elbow may involve what nerve?
radial
What is the ED treatment for a scapholunate injury?
radial gutter splint or short arm volar posterior mold
What is the most common nerve injury from a humeral shaft fracture and what does it look like on exam?
radial nerve; wrist drop and loss of sensation to dorsal webspace of thumb
What is the goal when administering oxygen in a COPD exacerbation?
raise the PaO2 above 60 mmHg or SaO2 above 90%
What is the therapeutic goal for BP when treating Aortic Dissection?
ranging from <140 to <110
What is the most common complication in anterior shoulder dislocation?
recurrent dislocation
What is the treatment for displaced supracondylar fractures of the elbow of the extension type?
reduction and emergent ortho consultation
What is a reason radiographs may not show a fracture if imaging is based on pain location alone?
referred pain, need to do thorough examination first. Also first day, images might not show a fracture yet
What are the indications for urgent hemodialysis after methanol or ethylene glycol ingestion?
refractory acidosis <7.25 with AG >30 and/or base deficit less than -15 visual abnormalities (applies only to methanol) renal insufficiency deteriorating vital signs despite aggressive care electrolyte abnormalities rectory to conventional therapy serum methanol or ethylene glycol level of >50mg/dL
Describe reduction of the CMC joints?
regional block; then traction, flexion, and longitudinal pressure
What antiemetics should be used in Fe tox?
reglan, zofran
Metoprolol reduced the risk of ___ and ___ by 5% respectively, however it increased the risk of ____ by 11%, so it should not be given IV, but current guidelines say to give it ___ within ___ hours provided they have none of the following:......basically old, in failure, or shocky VS
reinfarction and VF, cardiogenic shock, PO, 24
What is one thing you can do besides keep limb at level of heart, supplementing oxygen, and supporting blood pressure in a hypotensive patient while surgical correction is being arranged?
remove restrictive casts or dressings
Patients should be seen within 7 days if put in a knee immobilizer due to painful stiffness that develops quickly. What should you encourage patients in a knee immobilizer to do multiple times each day?
remove the immobilizer and perform a few exercises to prevent stiffness and quadriceps weakness
What medical condition should you think about when giving someone LMWH since they are at an increased risk of bleeding complications due to accumulation of the agent?
renal impairment patients since LMWH is cleared by the kidneys
What renal effects do you see in NSAID OD?
renal insufficiency
What should be the first step after a failed intubation attempt?
repositioning
What symptom of opioid tox is most likely able to cause death? treatment?
respiratory depression. BVM, narcan, ET, SDAC 1gm/kg PO (ingestion <1hr), can use MDAC for diphenoxylate-atropine.
What is the treatment for Type I and II acromioclavicular injuries?
rest, ice, analgesics, immobilization, and early ROM exercises (7 to 14 days)
What is a method of intubation that is rarely used anymore?
retrograde tracheal intubation, since it takes forever and we have better options now.
What is a Smith Fracture?
reverse Colles, distal radial fracture with volar angulation instead of dorsal
Slow administration of fentanyl (1-3 mcg/kg over 5 minutes) followed by slow and careful flushing of the IV line can help prevent _________?
rigid chest syndrome
What is a frequent but often missed injury during anterior shoulder dislocation that if still causing pain or weakness 2 to 4 weeks later should prompt an MRI?
rotator cuff tear
What is a complication concern for lunate fracture? What is this complication also called?
same as scaphoid (avascular necrosis of the proximal portion); Kienbock disease
What is the most common carpal bone fractured?
scaphoid
What is the most commonly injured ligament in the wrist?
scapholunate ligament
What are the most common mirtazapine OD symptoms?
sedation, confusion, sinus tach, mild HTN
TCA antag post synap a adrenergic receptors
sedation, miosis, orthostatic, hypotension, reflex tachy; treat with IV fluids and norepi
TCA inhib of serotonin reuptake
sedation, myoclonus, hyperreflexia; tx supportive, maybe cyproheptadine for SeroSyndrome
Which bupropion OD pts get admitted?
seizure, persistent sinus tach, lethargy
What is the key to effective pharmacologic pain management?
selection of an agent appropriate for the intensity of pain, prompt onset of analgesic activity, ease of administration, safety, and efficacy
What does horizontal eye nystagmus indicate in isolated etoh ingestion?
sens of 70-80% for BAC >80; sens 80-90% for BAC >100
What are the two things that make up the foundation of traditional observation unit protocols?
serial cardiac markers followed by objective cardiac testing
What is the most serious SSRI related s/e?
serotonin syndrome
What is the hallmark of the tyramine reaction?
severe occipital or temporal headache usually rapid onset after ingestion of provocative food within 15-90minues. May also be associated with HTN, diaphoresis, mydriasis, neck stiffness, pallor, neuromuscular excitement, palpitations, chest pain
What will be the initial complaint of an awake patient with compartment syndrome?
severe pain possibly difficult to control with narcotic pain meds
Which salicylate patients require intubation?
severe; set vent at hyperventilation to cause resp alkalosis to prevent academia and worsening CNS outcome.
A potentially difficult airway should be anticipated when the following findings or conditions are present:
short neck micrognathia large tongue trismus morbid obesity Hx of difficult intubation anatomic anomalies of the airway and neck
What does a posterior hip dislocation look like on PE?
shortened, internally rotated, and adducted
What should you remember about closed reduction of femoral head fractures in the ED?
should be limited
Which patients shouldnt get CAI for opth conditions?
sickle cell - causes sickling due to drop in pH
How do carbamate and organophosphate tox dif?
similar just shorter acting less penetration to CNS = less symptoms often resolve in 4-8hours: atropine DoC (therapy not needed beyond 12hours) Dont bother with checking level Dont use pralidoxime in isolated carbamate; should use if mixed with organo or insecticide unk usually DC home with f/u, may need 24hr obs
Discuss superwarfarin considerations>
single ingestion may result in marked anticoag for weeks to months. Not detected on normal warfain assays (need reference lab for levels) INR check 24-48hrs after ingestion if using vit k1, repeat INR q4hrs then repeat Q24hr until dose established
WHat is the most common anticholinergic tox rhythm?
sinus tach 120-160s
What is the classic TCA ECG pattern?
sinus tachy, RAD of terminal 40ms, prolonged PR/QRS/QT. Seen frequently but if absent does not eliminate the possibility of toxicity, and lifetreatening complications.
What is the most common findings in antipsychotic OD?
sinus tachy, orthostatic hypotension Long QT on ECG
What is a contraindicated treatment with femoral neck fractures?
skeletal traction, will likely compromise further the blood supply to the femoral head
What treatment is usually adequate for ED management of humeral shaft closed fractures?
sling and swathe
What are NSAID reproductive changes?
slow uterine contract, premature ductus art closure, fetal ICH, necrotizing enterocollitis, oligohydraminos, renal dysfunction
When might the seidel test be negative in corneal lac?
small spontaneously closing
BEIR VII states that there is a linear dose-related relationship to ionizing radiation exposure and ______ that likely has no lower limit.
solid cancers
What is the best lab test for evaluating methanol / ethylene glycol toxicity?
specific alcohol measurements, but if unavailable then evaluate osmolar gap. If alcohol level is <20mg/dL in asymptomatic then likely not toxic If >50mg/dL concern for ocular If >150-200 mg/dL fatality risk increases unfortunately lab testing dependent on time sample drawn with relationship to time of ingestion
What are NSAID hepatic changes?
spectrum of hepatic injury from asymptom transam elevations to fulminant failure
For cervical injuries, what does MRI best assess?
spinal cord, disk, and ligamentous disruption, can also detect soft tissue injury and hematoma
What can complicate determining complete or incomplete spinal injury?
spinal shock, loss of reflexes until spinal shock resolves (false complete injury)
If the patient has loss of pain and temperature sensation to the right side, what spinal tract is injured and what side?
spinothalamic tract, left side
What are the two ascending pathways in the spinal cord?
spinothalamic tracts and the dorsal columns
If a knee is unstable in multiple directions you need to maintain suspicion for what and why?
spontaneously reduced knee dislocation, because they have a high incidence of complications including popliteal artery and peroneal nerve injury
How do you test ulnar nerve integrity?
spread and push the fingers together against resistance
What do B3 receptors do when agonized?
stimulate lipolysis stimulate thermogenesis
What should you do if bleeding develops during UFH therapy, regardless of aPTT?
stop the UFH therapy
What is a nursemaids elbow? how do you fix it?
subluxation of radial head from tugging on pronated extended arm. Fix it with either hyperpronation or supination and flexion
Dont give ____ for organophos.
succhy, BB, ester anesthetics
Which drugs should be mixed with cocaine/amphet
succinylcholine, mivacurium, MAOI
What, in a patient with a chronic behavioral health disorder, or previously "normal" patient should prompt evaluation for an underlying medical or neurologic disorder?
sudden onset of major changes in behavior, mood, or thought
What additional view is useful in detecting non-displaced vertical or marginal fractures to the patella?
sunrise (skyline, axial, or tangential) view
Except in right to left shunt how do you treat all other hypoxemic patients?
supplemental oxygen
Major talus fractures, such as ones involving the head or neck, are ____ and require ____. Why?
surgical emergencies; immediate ortho consult; high risk of avascular necrosis
When might whole bowel irrigation be beneficial?
sustained / delayed release substances Fe / heavy metals lead paint chips Li drugs carried by body stuffers and body packers
If mallet finger is left untreated what deformity could result? Describe it?
swan-neck deformity; extension of PIP and DIP flexed
If a patient develops a hypersensitivity reaction to an opiate, then what is the prudent thing to do given current literature?
switch to a drug from a different opioid class
When would a CXR during pregnancy be recommended?
symptoms of respiratory tract infection and varicella exposure
What are common OD SNRI symptoms?
tachy, HTN, diaphoresis, tremor, mydriasis with sinus tach the most common ECG.
What do you typically see with SSRI + EtOH?
tachycardia, hypotension, lethargy
What is the dose of ethanol?
target 100-150mg/dL. load 800mg/kg (10mL/kg 10%) then maint of ~100mg/kg/h
What is a poor marker of prognosis in SS?
temp >41C (106F)
What is MNS?
tetrad of fever, muscular rigidity (lead pipe / cogwheel), autonomic dysfunction, AMS (including mutism). Usually develops over 1-3 days
What should be assumed when a person presents shortly after PCI with symptoms of ACS?
that they are having abrupt vessel closure, until proven otherwise
What is the definition of PEA?
the presence of an organized rhythm without the presence of a detectable pulse in an individual who is clinically in cardiac arrest.
What is the purpose and use of pain scales?
the quantitate pain severity, used to select and administer the appropriate type of analgesic and reassess the pain response to determine if they need repeat dosing or a stronger medication
What are a few necessary explorations during history taking of a patient who intentionally overdosed on a substance?
their understanding of the agents toxicity and their level of intent
If the pleural effusion patient has dyspnea at rest, then what should be done?
therapeutic thoracentesis with drainage of 1 to 1.5 L of fluid
Why should you not routinely use IV Vitamin K1 for reversal of over-anticoagulated patients from warfarin?
there is a rare, but serious non-dose related risk of anaphylaxis with the IV form
Wernicke syndrome / wet beri-beri
thiamine 5-10mg IV ped; 100mg IV adult
What is the definition of poor response to asthma treatment per Tintinalli and need admitted? Good response? Middle ground?
those with persistent symptoms and FEV or PEF of <40% predicted Good Response = resolution of symptoms and FEV or PEF of >70% predicted Middle ground is inbetween and most can go home, but needs to be individualized for these folks
The distance between the mentum and the hyoid bone should be?
three to four fingerbreadths
What is the most commonly fractured long bone in the body?
tibia
Inability to dorsiflex the toes suggests a _____ nerve injury. Inability to plantar flex the great toe suggests a ____ nerve injury?
tibial nerve; peroneal nerve
What is the goal for ventilations during sepsis treatment?
tidal volume of 6 ml/kg of ideal body weight
What is the first priority of care in an elbow dislocation?
to assess the neurovascular status if structures that are vulnerable: brachial artery & radial/median/ulnar nerves
How do you titrate IV Nitroglycerin?
to blood pressure not symptom control...10% reduction in MAP for normotensive patients and 30% reduction in MAP for hypertensive patients
When knee immobilizers are placed what must the patient be told?
to do ROM exercises daily to avoid contracture and maintain mobility
If there is inadequate respiratory compensation in acidosis then the appropriate treatment is?
to first correct the respiratory problem
After intubation what is a CXR used for?
to identify mainstem bronchus intubation or to locate the ETT Tip, but DOES NOT tell esophagus vs trachea.
Why is immediate ortho consult required for talus dislocation?
to prevent neurovascular compromise
Why should you examine the relation of HCO3- to the AG and the HCO3- to the expected PCO2 compensation in every wide AG acidosis patient?
to see if other (respiratory) acid-base disorders exist
What lab is not helpful regarding iron studies in Fe tox?
total iron binding capacity
Newer methods of CCTA enabled reduction in radiation exposure by 70-80% making it similar in radiation dose to _______ and substantially less than _____.
traditional angiography; SPECT Myocardial Perfusion imaging
A predental space of >3mm on lateral c-spine view implies _______ and >5mm implies ______?
transverse ligament injury; transverse ligament rupture
What is the treatment for acute respiratory alkalosis?
treat the underlying cause FYI - Paperbag breathing doesn't work very well it does raise the PCO2 a little, but also lowers PO2, research shows it is mostly psychological
What should you do if you suspect CCB vs BB?
treat with Ca, b agonists, glucagon, insulin, and pacing.....so the same therapy
When might cardiac pacing be most effective?
treating sotalol caused torsades
How does isopropanol compare to ethanol?
twice as potent and has duration of action 2-4 times longer.
What dose should concern you in chronic users of CCB to cause tox?
twice their regular daily
Although the ideal endotracheal doses for drugs other than epinephrine have not been studied, current recommendations support the use of _____________times the respective IV dose.
two to three
How wide should the mandibular opening be in an adult?
two to three fingerbreadths
What is required for diagnosis of MNS?
typically both major and 2 or more minor with recent history of use (upto 1 mo with depot agent)
The adductor pollicis is innervated by the ______ nerve?
ulnar
What is the ED treatment for a triquetrolunate ligament injury?
ulnar gutter splint or short arm posterior mold
What is the most readily available site for emergency vascular access in the newborn?
umbilical vein
What are poor prognostic factors for salicylate tox?
unconsciousness on presentation, fever, severe acidosis, seizures, dysrhythmias, advanced age. respiratory acidosis is usually a premorbid event
What are the contraindications to NPPV?
uncooperative or obtunded patient inability of the patient to clear airway secretions hemodynamic instability respiratory arrest recent facial or gastroesophageal surgery burns poor mask fit extreme obesity
When do patients with normal HgB concentration typcially develop symptoms with methemoglobinemia?
until levels above >20% IN healthy patients between 20-30% symptoms include anxiety, HA, weakness, lightheadness, tachypnea, sinus tachy levels 50-60% impair O3 delivery to vital tissues = MI, dysrhythmias, AMS (coma), siezures, lactic metabolic acidosis. >70% largely incompatible with life Comorbities that shift curve back to the right, may tolerate higher percentages
How long do you continue EtOH?
until toxic level is <20mg/dL. Check levels every 1-2hrs
How do you treat a s/p tonsillectomy bleed?
upright, NPO, direct pressure with something coated in thrombin/or equivolume epi/1%lido solution ALWAYS CONSULT
WHat are the normal ONS measurements on u/s
upto 5mm adult upto 4.5mm child upto 4.0mm infant obtain measure 3mm posterior to glove b.c contrast greatest at this point, measure both eyes
All would agree that progressive neurologic deterioration is an indication for ______ ______?
urgent surgery
What lab is only good before starting treatment for hyponatremia and as such should be collected in the ED prior to starting treatment?
urine electrolytes
What is one way of maximizing flow rates?
using the largest internal diameter catheter possible
Ankle dislocation without vascular compromise should be reduced by an orthopedic surgeon, what are the signs that require emergent reduction by an ED physician without pre-reduction films?
vascular compromise (dusky foot or absent pulses) or tenting of the skin
90% of scapulothoracic dissociation have _____ injuries, with the ____ and _____ being the most common.
vascular injuries; subclavian and axillary arteries Brachial plexus (often complete) in >90% also
What lab is needed to identify a wide anion gap acidosis?
venous electrolytes (NO ABG NEEDED)
What are indications for dig fab use?
ventricular dysrhythmis, unresponsive hemodynamically unstable brady, hyperK >5.5 with known or suspected dig tox level
If a patient in AF is stable then the first priority is?
ventricular rate control
What is the most potent neg inotrope CCB?
verapamil, also the most death causing CCB due to its equal cardiac depression and vessel dilation
What can of hallucinations should be assumed to have an organic pathology until proven otherwise?
visual hallucinations
What are other imaging modality, such as CCTA, more reliable in than Cardiac MRI?
visualization of the entire coronary tree
How do you treat Fe Tox coagulopathy?
vit K1 and/or FFP
What do kappa receptors cause?
weak analgesia, sedation, miosis, decreased intestinal motility, dysphoria, hallucinations
Ultimately, the decision regarding CPR and its likelihood to benefit the patient; decisions to withhold, limit, or provide resuscitation efforts are to be made by the EM Physician in the context of _______, _______, and _______.
well-accepted research results patient and family wishes professional judgement
When can chest compression be stopped in newborn resuscitation?
when the HR exceeds 60 beats/min
When do you treat a fibular fracture like a stable ankle sprain?
when there is <3mm displacement and no signs of medial ligamentous injury
When should you consider termination of resuscitation efforts in a pediatric?
when there is a high certainty that there will be NO response to further ACLS, no specific marker, just everything taken into account.
What might you see on CXR for aortic dissection?
widened mediastinum or abnormal aortic contour
What is the toxic dose of isopropanol?
with 70%: symptoms at 0.5mL/kg toxic at 1mL/kg (lethal 2-4mL/kg adult) children symptomatic after 3 swallows.
When would you expect to see hepatocyte injury after APAP tox?
within 12hrs
Does activated charcoal work in BB tox?
yes if <2hrs post ingestion or longer for SR
How do you make the clinical diagnosis of acute lung injury?
you need the combination of: Arterial Hypoxemia (PaO2 / fraction of inspired O2 = <300) and Bilateral pulmonary infiltrates on CXR in the absence of Pneumonia or Acute HF
How do you check the pressure of an inflatable splint to see if it is overinflated?
you should be able to dent it with moderate thumb pressure
What are the landmarks to find the scaphoid?
In triangle made up of radial styloid, extensor pollicus longus and brevis
What rates should be consider SVT in an infant? child?
Infant = >220 Child = >180
What can look indistinguishable from a staph or strep cause of soft tissue infection?
Infection from Gram NEG organisms
What findings on EKG are suggestive of right coronary or left circumflex coronary artery involvement?
Inferior MI findings which are ST elevation in II, III, and aVF
In what type of MI or Ischemia should Nitro be used very cautiously in? Why?
Inferior Wall Ischemia/MI because 1/3 of these patients have RV involvement. RV infarction makes the patient volume dependent. Nitrates will get rid of the preload they need.
What is the most common serious viral infection in the elderly?
Influenza
What common illness does dig tox mimic in elderly?
Influenza and gastroenteritis
What is special about diphenoxylate-atropine?
Initially anticholingeric dominant picture followed by opioid picture. Delayed onset, especially in peds by 6-12 hours even in small doses. Under 6yo recommend admission for 24 hour observation. Older need 6 hour ED obs. Should use charcoal in all cases.
What effect does salicylate have on respirations?
Initially increases, but will decrease with severe OD
Discuss one-time warfarin rodenticide ingestions.
Insignificant, rarely cause coagulopathy unless large or repeated exposure over several days. No therapy typically needed for single mouthful SHould get baseline INR and repeat n 12-24 hours If INR >2 with bleeding risk then use vit K1 oral and recheck INR q 4hrs initially then q24 until stable
Discuss pulse oximetry in metheglobinemia.
Interpet carefully, usually falsely elevated. If meth level >30% Spo2 may trend toward constant 80-85%. ABG may also be initially deceptive bc PaO2, a meaurs of dissolved, not bound oxygen is normal.
What are some things that are different or should be considered when performing CPR on a pregnant patient?
Intubate early, Tilt the patient (limit aortocaval compression) Perimortem C-Section should be done within 5 min of maternal arrest if fetus is >20 weeks Consider open chest CPR after 15 minutes of maternal arrest
What can you add to Albuterol, Bitolterol, or Levalbuterol to improve bronchodilation and decrease need for hospitalization?
Ipratropium Bromide
Anemia: MCV Low, RDW High, Ferritin Low =
Iron Deficiency
The most common causes of ventricular tachycardia are?
Ischemic Heart Disease and AMI
What does mechanical ventilation do for the Asthmatic when they are intubated? What does it not do?
It allows them to rest and removes work of breathing, it does NOT relieve the airflow obstruction
What do you need to remember about the hemodynamic response to 2-3 L of fluids?
It can be transient
Why do only men seem to get symptomatic Hemophilia?
It is X-linked
What does CPAP do?
It is a form of NPPV that provides constant positive pressure throughout the respiratory cycle
What about acetylcysteine / charcoal?
It is absorbed by it, but no evidence that it inhibits clinical effectiveness in most circumstances. should seperate by 2 hrs though
What is the CURB-65 rule and how can you use it?
It stands for: Confusion Uremia >7 RR > 30 DBP <60 >65 years old <2 = low mortality rate, may help determine who should be considered for ICU care = or >3 should probably go to ICU
Burst fracture of C1 is called? Cause?
Jefferson Fracture, blow to top of head
What is a metaphyseal-diaphyseal junction fracture of the proximal 5th metatarsal called?
Jones fx
What additional views (etc) could be used to eval femoral head fractures?
Judet views and thin-cut CT scan
Acute dig toxicity correlates best with what?
K level not dig...there is lag between symptoms and dig level if checked <6hrs before peak...can have high dig (before distributes in tissues) with minimal symptoms, be wary
What is the differential diagnosis for Wide Anion Gap Acidosis?
KULT K=Ketones or Ketoacidosis U=Uremia (Renal Failure) L=Lactic Acidosis T=Toxins Toxins = ACE GIFTs A=Aspirin C=Cyanide/CO2 E= Ethanol (ketosis) G=Glycols (Ethylene and Propylene) I=Isoniazid F=Ferrous Iron T=Toulene
What is the number one thing to ensure in a child with a partial airway obstruction?
Keep them as calm as possible in a quiet, comforting environment.
Which induction agent is the agent of choice in a pediatric with asthma?
Ketamine
What induction agent should you not use in the elderly or in potential cardiac ischemia patients during RSI?
Ketamine, due to possible hypertension and tachycardia
What pneumonia looks like Strep, but involves Alcoholics/nursing home residents, has brown "currant jelly" sputum, and is gram negative paired coccobacilli?
Klebsiella Pneumoniae
What is the Mnemonic for drugs you can administer endotracheally?
LEAN (Lidocaine, Epinephrine, Atropine, and Naloxone)
What are some of the reasons it can be difficult to interpret the EKG?
LVH, LBBB, Ventricular Pacing Rhythm Early Repol Pericarditis Hypothermia etc....... see chart in book
What anti-hypertensive medication should be used for preeclampsia/eclampsia? Which one should NOT be used?
Labetalol = good ACE-I = bad
What in the Wide AG Acidotic DDX is not a diagnosis but a syndrome with its own DDX?
Lactic Acidosis
What ligamentous injuries are associated with lateral tibial plateau fractures? medial tibial plateau fractures?
Lateral = ACL and LCL Medial = PCL and MCL
Which plain film view provides the best view of the dorsal angulation and comminution for Colles fractures and what, in general, is considered an unstable fracture?
Lateral view; >20 degrees of angulation intra-articular involvement marked comminution more than 1 cm of shortening
What are the symptoms of left-sided HF versus right-sided HF?
Left Sided HF: dyspnea, fatigue, weakness, cough, paroxysmal nocturnal dyspnea, orthopnea Right-Sided HF: Peripheral Edema, JVD, RUQ Pain, Hepatojugular reflex
What pneumonia has no seasonality (more common in summer) and commonly is complicated by GI symptoms (abd pain, vomiting, and diarrhea)?
Legionella
What findings in Anterior MI on EKG show likely Distal left anterior descending coronary artery occlusion?
Less than 1mm ST depression in II, III, or aVF or ST elevation in II, III, and aVF
What must you ensure you rule out if you diagnose a 1st - 4th proximal metatarsal fx?
Lisfranc Injury
Pain elicited by torsion of the midfoot raises suspicion for what injury?
Lisfranc injury
What in the differential would be a contraindication for using Amiodarone?
Long QT Syndrome, since it prolongs the QT interval :)
What is an important clinical aspect of MAOI OD?
Low ratio of therapeutic to toxic, predisposing to sig drug toxcity with ingestions slightly larger than normal; AND, appearance of toxic symptoms may not develop for 6-12 hours (can be as long as 24hours) after ingestion.
What enzyme limits tyramine entrance to systemic circulation?
MAO-A; loses function after inhibition at >80%; think about the pickled/fermented foods
What part of the history may be the key to diagnosing a fracture or dislocation?
MOI
What is considered the gold standard for definitive diagnosis of a scaphoid fracture?
MRI
What is the appropriate second diagnostic test when ultrasound is not diagnostic in suspected appendicitis in a pregnant patient?
MRI
What is the diagnostic test of choice for describing the anatomy of nerve injury and delineating entities such as herniated disks or spinal cord contusions?
MRI
Which imaging modality has a distinct advantage in evaluation of suspected spinal cord compression whether caused by trauma, infection, or metastatic disease including direct characterization of edema, hematoma, or transection?
MRI
Which imaging modality is the most sensitive for detecting small or nondisplaced fractures or insufficiency fractures from osteopenia: Plain film, CT or MRI?
MRI
If you have a high suspicion for a stress fracture of the femoral neck in a high-risk patient (athlete, etc) then what imaging should be considered?
MRI or bone scan
If a person with pneumonia lives in a nursing home then what pathogen should you cover them for?
MRSA
What do B1 receptors do when agonized?
MYOCARDIAL increases inotropy/chronotropy KIDNEY inc renin release EYE inc aqueous humor production
What is a medial ankle injury, interosseous membrane disruption, and proximal fibula fracture called?
Maisonneuve Fracture (could be as low as 6 cm from distal fibula)
What should be suspected when there is tenderness to palpation of the fibular head or proximal fibula after an ankle injury?
Maisonneuve fracture (fibulotibialis ligament tear)
If there is significant medial malleolus swelling then what injury should be suspected?
Maisonneuve fracture (proximal fibula and fibular shaft)
What is important to remember when considering giving the diagnosis of orthostatic hypotension of benign cause?
Many serious causes of syncope have orthostatic symptoms
What medical issues predispose to aortic syndromes?
Marfan syndrome, Ehlers-Danlos syndrome, Bicuspid Aortic valve, and FMHX of Aortic Dissection
When would you expect to see peak salicylate levels in oD?
May be 18-24hours as they reduce gastric emptying...shorter for oil of wintergreen, as long as 60 hours for significant ingestions of enteric coated.
What is special about gastric lavage of anticholinergic patients?
May use >1hr due to delayed motility
Why shouldn't you acidify urine for amphetamines?
May worsen renal tubular necrosis.
What does EKG or CXR show in Aortic stenosis?
Maybe LVH, LBBB or RBBB, but usually normal.
What is something that could be contributing to the syncope noted in the AMPLE hx?
Medications...B Blockers blunt HR response, diuretics = volume depletion
What is the normal range for RBC, HGB, and HCT...in Men and in Women?
Men: RBC: 4.5-6.0 HGB: 14-17 HCT: 42-52 Women: RBC: 4.0-5.5 HGB: 12-15 HCT: 36-48
The use of _____ with Monoamine Oxidase Inhibitors has been associated with severe adverse reactions, including death from serotonin syndrome.
Meperidine
Name one Phenylpiperidine (Synthetic) Opioid? Name one Anilidopiperidine (Synthetic) Opioid?
Meperidine Fentanyl
What are two conditions where Pulse oximetry will be incorrect? how will it be incorrect?
Methemoglobinemia: will read 80-85% no matter what it really is and will be falsely elevated and not show the response to oxygen Carboxyhemoglobinemia: will read it as normal Hb (oxyhemoglobin) and be falsely elevated and not show a response to oxygen
What is the dosing for metoprolol, esmolol, labetalol, and nitroprusside in Aortic Dissection?
Metoprolol 5mg doses (max of 15mg initial bolus) then 2-5mg/hr infusion Esmolol 0.1-0.5mg/kg IV over 1 min then 0.025 - 0.2mg/kg/min infusion Labetalol 10-20mg IV, then repeat every 10 min at 20-40mg until desired effect (max initial dose of 300mg) Nitroprusside 0.3mcg/kg/min IV infusion
What type of murmur is mitral stenosis? (describe it)
Mid-diastolic rumble, crescendo into S1
Name the Sedatives used in pediatric RSI? and dosing?
Midazolam (Versed): 0.1 mg/kg (SHORT ACTING) Lorazepam (Ativan): 0.1 mg/kg(LONGER ACTING)
How do you monitor minimal sedation patients? Moderate/Deep?
Minimal: frequent LOC checks, vitals Q15min with continuous pulse oximetry Mod/Deep: Continuous LOC and all vitals except BP which is Q5min, and mod=consider ETCO2, deep=recommend ETCO2
How long does MAOI washout take?
Minimum 2 week abstinence period. Typically to avoid SS.
Adults (non neutro) intra abdominal bugs
Mixed aerobic and anaerobic gram negative bacilli
Dissociative sedation is a type of _____ sedation.
Moderate
Fracture of the proximal third of the ulna with radial head dislocation is called a ________ fracture? Missing this diagnosis can lead to _____?
Monteggia Fracture-Dislocation chronic pain, limited ROM, and possible radial head excision as treatment
Describe pre-sedation pain management choices including dose, titration, duration of action?
Morphine, 0.1mg/kg, 0.05mg/kg q3-5 min until controlled, duration = 3 h Fentanyl, 1.5 mcg/kg, 0.75 mcg/kg q2-3 min until controlled, duration = 1 h Hydromorphone, 0.0125 mg/kg, 0.006mg/kg q3-5 min until controlled, duration 3 h
Which Opioids are completely naturally occuring? What is their classification?
Morphine, Codeine; Phenanthrenes
What is the Onset, Peak Effect, and Duration of action of IV Morphine, Dilaudid, and Fentanyl?
Morphine: 1-2 min, 3-5 min, 1-2 h Dilaudid: 3-5 min, 7-10 min, 2-4 h Fentanyl: <1 min, 2-5 min, 30-60 min
Why shouldn't you use NSAIDs and warfarin?
Most NSAIDS don't effect warfarin levels/elimination but platelet inhibition increases risk of bleeding.
How are BB and TCAs similar?
Most exhibit Na channel blocking properties
How do you treat tyramine reactions?
Most resolve without specific treatment over 6 hours, but get ECG for chest pain (rare MI), get head CT for neuro symptoms (rare ICH). Dont use BB for HTN (unopposed alpha)
Cholinergic Toxidrome
Muscarinic effects: SLUDGE Nicotinic effects: muscle fasciulations / weakness +/- bradycardia, miosis/mydriasis, seizures, resp failure, paralysis Airway protection/ventilation, atropine, pralidoxime
What pneumonia commonly has extrapulmonary symptoms, such as, rash, joint pains, bullous myringitis?
Mycoplasma Pneumonia
What is the most common finding in SS?
Myoclonus at 57%- useful because otherwise uncommon finding in other conditions
What are NSAID renal changes?
NA / H2O retention, *hyperK, mild azotemia, *renal failure *common
What should NOT be used in the ED treatment of mild to moderate metabolic acidosis?
NAHCOs (Sodium Bicarbonate) since it will create more CO2 into the cells worsening the acidosis, the increased CO2 may also exceed the ventilation capabilities of the person if the are already at max Vm, and you may get an "overshoot" alkalosis
What is the Mnemonic for the femoral vein location?
NAVEL (Nerve, Artery, Vein, Empty Space, Lymphatics)
What is the Neb and MDI dosing for Ipratropium in asthma treatment?
NEB = 0.5mg every 20 min for three doses MDI= 8 puffs prn every 20 min for three doses
Are ethanol preparations interchangeable?
NO DO NOT ADMINISTER PO PREP VIA IV.
Can antibiotics be substituted for airway management in ludwigs angina?
NO, edema may take up to 1 week to resolve with abx therapy
Na channel blockers/ urine alkanization
Na HCO3 1-2meq/kg IV bolus followed by 2meq/kg/hr infusion
Adults with petechial rash bugs
Nei menin, rickettesia
When should you adminster medications in MAOI patients?
Never, unless absolutely necessary, at the lowest possible dose, and only after checking for interactions. (due to poor availability of data)
What is the compression rate in BLS for newborn versus other ages?
Newborn = 120/min, all other ages 100/min
What is the compression/ventilation rate for newborns? Infants/Children? Adult?
Newborn = 3:1 Infant/Child = 15:2 (30:2 if single rescuer) Adult = 30:2 no matter what
Can you use a normal resting echocardiogram in the ED to exclude ACS?
No
Can you use placement of a patient in the low-risk group to exclude ACS?
No
Does a "normal" AG exclude the presence of increased concentration of Unmeasured Anions (UA's)?
No
Does administration of glucose before thiamine increase the risk of acute Wernicke encephalopathy?
No
If a trauma patient has hypotension can it be presumed to be from neurogenic shock?
No
In the ED, are cardiac risk factors useful as predictors of risk of MI or other ACS?
No
Is identification of specific organism through blood or sputum necessary to direct antibiotic treatment?
No
Is it possible to generalize the extent and quality of pain for a specific patient?
No
Is there a use for Leukotriene modifiers in the ED (i.e. montelukast, zafirlukast, or zileuton)?
No
Does MDAC help in NSAID OD?
No evidence, nor does any dialysis type treatment as NSAIDS are highly protein bound.
Canadian C-Spine Criteria for C-Spine clearance?
No high risk factors: 65 y/o or greater dangerous MOI (fall >3ft, high-speed MVA, rollover, ejection, bicycle or ATV, etc) The presence of paresthesias in extremities Low risk factors allowing for assessment Simple rear end MVA Patient able to sit up in ED Patient ambulatory at any time Delayed onset of neck pain Absence of midline neck tenderness Patient is able to rotate neck 45 degrees right/left
NEXUS Criteria for C-Spine clearance?
No midline cervical tenderness Normal level of alertness and consciousness No evidence of intoxication Absence of focal neurologic deficits Absence of painful distracting injury
What are the dosing limits for K+ replacement?
No more than 40 mEq should be added to each L of fluid Infusion rates should be no greater than 40 mEq/h
Should you use flumazenil in mixed ODs?
No seizure boy!
Should the presence of miosis (constricted pupils) be use as the sole indicator for the use of naloxone?
No this is unreliable because many other toxins can produce small pupils along with mental status depression, and some opioids classically leave pupil size unaltered (e.g. meperidine, propoxyphene).
Should labs be used to make the initial decision of airway support?
No this should be done quickly using s/s of inadequate oxygenation/ventilation
Do CCB's (Calcium Antagonists) reduce mortality rate after AMI?
No, and they may be harmful to some patients with cardiovascular disease
Can you add on an osmolar gap to previous sample?
No, bc the volatile alcohols may have volatized resulting in a "normal" gap. Should be processed at same time as other tests immediately after drawing.
Does normal AG exclude salicylate toxicity?
No, because should raise suspicion of coingestion such as sedative-hypnotic causing suppression of respiratory drive.
Is it wise to use a single salicylate level in moderate to severe toxicity?
No, because will lull in to false security, must account for preparation and time, so serial measurements every 1-2 hrs recommended until stabilized clinical picture or declining levels
According to Tintinalli when it was written was there any good RCT's to support 1:1:1 RBC, FFP,Platelet tranfusions or fresh whole blood?
No, but still!
Should you use anticholinergics to treat tardive dyskinesia?
No, can worsen symptoms. They are used for parkinsonian symptoms / dystonia (diphenhydramine/benzotropine) and should be continued 2 days orally after parenteral therapy dc'd.
should you patch an eye with a corneal ulcer?
No, due to risk of P. aeroginousa which causes rapid ulceration and corneal melting with perforation.
Should you use physostigmine challenge in undifferentiated poss anticholinergic tox?
No, due to risks.
Does disseminated meningococcemia require shock and meningismus?
No, it can present with shock only
Is the tiered approach to pain management preferred?
No, it subject's the patient to more prolonged suffering. It is preferable to select initial analgesics that are appropriate for the pain intensity
Should AMS with adequate arterial BP be attributed to CCB od?
No, look for other cause
Should prophylactic Abx be given for Aspiration Pneumonitis?
No, not until they develop Aspiration PNEUMONIA (usually >48 hours later, no improving, etc)
Should you draw specific NSAID levels, besides APAP / salicylate? nomogram?
No, serum levels don't correlate with symptoms or outcomes. The ibuprofen nomogram is not clinically useful since most hospitals don't draw ibuprofen levels, and tox is usually mild / brief.
Is the use of loop diuretics in the treatment of malignancy-related hypercalcemia recommended?
No, will worsen volume depletion, hypokalemia,hypomagnesia
Can you reliably use BP to determine shock?
No, you can have shock with a normal BP, and no shock with hypotension.
Are G6PD patients at increased risk for methmoglobenemia?
No.
Is there a role for hemodialysis (etc) in dig tox?
No.
Should GI decontamination be use as a punitive measure.
No.
Should you delay bicarb therapy to correct hypokalemia in salicylate tox patients when trying to alkanize urine?
No.
Is malignant neuroleptic syndrome an OD?
No. Usually occurs at onset of therapy or with dosage change.
Should you use epi in organochlorine tox?
No. myocardium is hyperexcitiable to catecholamines
Can serial cardiac markers over time exclude unstable angina? AMI?
No; Yes. AMI has necrosis which is what the markers test, but unstable angina does not involve necrosis only ischemia....so No;Yes.
What are the three leading noninfectious causes of pleural effusion in HIV patients?
Non-hodgkin lymphoma, Kaposi sarcoma, and adenocarcinoma
What is the treatment for ITP for non-life-threatening and life-threatening bleeding?
Non-life-threatening = 60-100mg Prednisone/day with taper after count is normal and maybe IV Immunoglobulin 1 gm/kg/day x 2 days Life-Threatening= Methylprednisolone 30mg/kg/day IV x 3 days IV Immunoglobulin or Anti-D and Platelet Transfusions as needed (hold until first treatment is complete)
What does the EKG and CXR look like for MVP?
Normal
What will the bleeding time be in Hemophilia A or B?
Normal, it is just the aPTT that may be prolonged (intrinsic coagulation cascade)
Should you place emphasis on previous stress tests?
Not at all
Does ACC/AHA guidelines say that ACE Inhibitors should be given within 24 hours PO...IN THE ED?
Not necessarily in the ED...
What is the universally consistent effective treatment for BB tox?
Not one. May need multiple therapies to resuc sick pts.
Is atropine helpful in BB tox?
Not really, but probably wont hurt
Is there use in routine salicylate lab testing?
Not unless the patient suggests they took it, AMS, or signs of toxicity present
How useful is a previous negative cardiac test?
Not very, still need to do work-up
What is dose used in US of acetylcysteine for APAP?
ORAL: 140mg/kg load with 70mg/kg Q4hrs for 17 additional doses - dilute in something. (72hr regimen) IV adult/ped: 150mg/kg in 200m: D5W over 15-60minutes load followed by 50mg/kg in 500mL D5W over 4hrs, followed by 100mg/kg in 1L D5W over 16 hrs. May use only 500m: of 2% solution to treat 33kg child for full 20hr regimen (20hr regimen) monitor for anaphylactoid reaction, only 2% solution through peripheral
Where do most deep neck infections come from?
Odontogenic infections, typically mandibular teeth
What does an APD represent?
Optic nerve defect
1/2 of all TCA ingestions involve what?
Other substances that typically worsen TCA OD symptoms
How do you treat Mitral Regurg (acute and chronic)?
Oxygen, nitrates (i.e. Nitroprusside), diuretics, and intubation if needed. Nitroprusside to reduce afterload. If Hypotensive add Dobutamine. If asymptomatic, then anticoagulate.
What is the initial treatment for Bradycardia in kids?
Oxygenation and ventilation
What are the normals for EKG reading? P Wave? PR Interval? QRS duration? ST segment height? QT duration?
P Wave = 2.5 blocks mm wide / <0.3 mV (3 blocks) tall PR Interval = 3 to 5 mm (0.12-0.20 seconds) QRS duration = 1.5 to 2.5 mm (0.06 to 0.10 seconds) ST segment height = <0.1 mV (1 mm) QT duration = <0.47 seconds if correct for heart rate
What is the most common cause of AIDS related death in pregnant women?
PCP Pneumonia
What is a normal dose of PRBC's? Platelets (single donor)? Platelets (pooled donor)? FFP? Cryo?
PRBC: 2 units or 15 ml/kg Single Plt: 1 unit or 5 ml/kg Pooled Plt: 6 units or 5 ml/kg FFP: 4 units or 15 ml/kg Cryo: 10 units or 1 unit/5 kg
What is the dosage effect of the common doses for PRBC, PLT, FFP, Cryo?
PRBC: HGB by 1, HCT by 3% (2 units = x2) PLT: increases up to 50,000 FFP: raises most coag factors by 20% Cryo: Raises fibrinogen by 75mg/dL
What is the most common dysrhythmia in dig tox?
PVCs
What is the definition or diagnostic criteria for Hypoxemia?What does formal diagnosis require?
PaO2 <60 mm Hg ABG analysis
What are the ventilation goals?
PaO2: 60-90 mm Hg PaCO: 40 mm Hg pH: 7.35-7.45 FIO2 of 40%-60% Inspiratory Peak Pressure <35 cm H2O
Discuss bipyrdyls (para/diquat)
Para= highly tox (add color and emetic) 10-20mL adult / 4-5mL of 20% in child Distribute to organs highest in kidney / lung Can see hypoxia due to pulm fibrosis days later Severely caustic occuring minutes to hours in GI tract Diquat similar just less severe (no additivies) need CXR - mediastinal erosions need upper endo for mucosal evaluation 10hr paraquat level >0.4 = poor prog for survival
Who is at higher / lower risk of getting APAP tox?
Patients with lower glutathione such as alcoholics / AIDS / P450 induced patients. Children are less likey to get hepatoxicity than adults in moderate dose due to increased sulfation.
Describe opioid withdrawl.
Peaks in 3 days. starts with anxiety, yawning, drug craving, crying, drooling, sweating, body aches. Then irritable, tremor, piloerection, mydriasis Then insomnia, muscle spasms, abd pn N/V/D
Patients with peristent symptoms and STEMI should recieve what?
Percutaneous Coronary Intervention (PCI) or fibrinolytic therapy
Which tyramine patients need admited?
Persistent symptoms beyond 6 hours. Otherwise asymptomatic after 4 hours of observation could be released.
Patients with a suspected anaerobic source: abd, biliary, female Gen tract, necrotizing cellulitis, odontogenic, soft tissue drugs
Pick one of the following -Flagyl 15mg/kg load then 7.5mg/kg q8hrs -clindamycin 600-900mg q8hrs adult, for children 10mg/kg q8hrs
Adults ( non neutro) urinary (hospital pyelo) drugs
Pick one of the following: -Levaquin 750mg qd -avelox 400mg qd -zosyn 4.5gms q6hrs -rocephin 1-2gms q12-24hrs -Amp 1-2gms q4-6hrs plus gent 1-1.5mg /kg q8hrs
Adults (non neutro) intra abdominal drugs
Pick one of the following: -imipenem 500mg q6hrs to 1gm q8hrs -meropenem 1gm q8hrs -doripenem 500mg q8hrs -ertapenem 1gm qd -unasyn 3gm q6hrs -zosyn 4.5gms q6hrs
Adults (non neutro) urinary complicated catheter drugs
Pick one of the following: -zosyn 4.5gms q6hrs -imipenem 500mg q8hrs -meropenem 1gm q8hrs -doripenem 500mg q8hrs -Amp 1-2gms q4-6hrs plus gent 1-1.5mg/kg q8hrs
Possible legionella patients drug
Pick one of the following: -azithromycin 500mg then 250mg qd -erithromycin 800mg q6hrs
What are the causes of acute exacerbation of COPD that need to be considered?
Pneumonia Pneumothorax PE Acute Abdomen Asthma CHF Tuberculosis Metabolic Disturbances
What type of ankle dislocation is most common? What is usually the mechanism? What injuries usually are present?
Posterior; Backward force on a plantar flexed foot; tibiofibular ligaments rupture and lateral malleolus fx
Approximately 90% of elbow dislocations are ________?
Posterolateral
What type of fluid should not be given to rhabdomyolysis patients?
Potassium or Lactate containing solutions
What is the in hospital dosing and outpatient dosing for Prednisone and Methylprednisolone for asthma treatment?
Prednisone: Inpatient: 40-80mg PO 1-2 doses/d until reaches 70% of predicted PEF or personal best Outpatient: 40-60 PO 1-2 doses/day for 5-10 days Methylprednisolone: Inpatient: 1 mg/kg every 4-6 hours Outpatient: 150mg depot IM single dose
What patients have a definite contraindication for Succinylcholine?
Preexisting hyperkalemia, myopathies, or myasthenia gravis
How do you treat bupropion od?
Prep to manage seizure with IV access GI decon if <1hr Whole bowel for SR
What patients are at an increased risk of the most serious and fatal complication of IV contrast, idiosyncratic anaphylactoid reaction
Previous reactions Asthmatics Diabetics B-Blocker or Metformin use renal or cardiac failure extremes of age allergies or atopy
What is the most common finding on ECG for hypocalcemia?
Prolonged QT interval (normal T wave, ST segment is prolonged)
If after initial exam and testing you cannot rule out heart cause of newborn cyanosis, then you should consider giving _____ (include dosing)?
Prostoglandin E1 continuous infusion at 0.05 to 0.1 mcg/kg/min (consult pediatric cardiologist for infusion rate)
What can be given and how to reverse the anticoagulant effect of UFH?
Protamine (1mg per 100 units of UFH) IV slowly over 1-3 minutes and never more than 50mg in any 10 min period
What type of pneumonia may arise in prolonged hospitalization patients, recieved broad spectrum Abx of high dose steroids (Immunocompromised)?
Pseudomonas Aeruginosa
In HIV patients what is a very common, but not most common pathogen causing pneumonia?
Psuedomonas Aeruginosa
Sympathomimetic Toxidrome
Psychomotor agitation, mydriasis, diaphoresis, tachycardia, HTN, hyperthermia +/- seizures, rhabdo, MI Cooling, sedation with benzos, hydration
What is the most common "medical" cause of death in pregnant patients?
Pulmonary Embolism (19.6%) then hemnorrhage, pregnancy-induced hypertension, and infection
What are some specific end points to BB tox resus?
QRS<120 EF >50% HR> 60BPM SBP >90 urine out 1-2mL/kg/h adult improved mental status
Describe Q-Wave based criteria for AMI on EKG?
QS deflections in V1-3, maybe 4 = Anteroseptal rS deflection in V1 with Q waves in V2-4 or small R waves in V1-4 = Anterior Q waves in V4-6, I, aVL = Anterolateral Q Waves in I and aVL = Lateral Q Waves in II, III, and aVF = Inferior Q Waves in II, III, aVF, and V5-6 = Inferolateral Initial R waves in V1-2 >0.04s and R/S ratio is greater than or = to 1 =True Posterior Q waves in II, III, aVF and ST elevation in V4R = Right Ventricular infarct
What is one way to remember the top 6 highest likelihood ratio's in AMI for history?
REDVomit R = Radiation to Right Arm, Left Arm, or Both E = Associated with Exertion D = Diaphoretic Vomit = Nausea/Vomiting
What clinical triad has high sensistivity for opioid tox?
RR <12, miosis, circumstantial evidence of opioid use = 92% sens, 76% spec,
What is the method of choice for airway management during trauma?
RSI
What is the preferred method of emergent intubation?
RSI
What is the most common fracture of the elbow?
Radial head fractures
Sensory and Motor test for Radial, Median, and Ulnar Nerves?
Radial: Sensory = dorsum of thumb webspacing Motor: Extension of wrist and fingers against resistance Median: Sensory = 2 point discrimination over tip of index Motor = "OK" sign with thumb and abduction of the thumb (recurrent branch) Ulnar: Sensory = 2 point discrimination over tip of 5th Motor = Abduct index finger against resistance
What historical factor has the highest likelihood ratio of the DX being AMI?
Radiation to Right Arm or Shoulder (4.7)
What is RSI?
Rapid-Sequence Intubation is the administration of induction and neuromuscular blocking agents to facilitate tracheal intubation
What are the only 2 FDA approved MAOI for the treatment of parkinsons?`
Rasagiline, Selegiline: both MAO-B selective
For Respiratory acidosis the ratio to help differentiate what is going on is?
Ratio = Change in H+ / Change upward in PCO2 Ratio <0.33 is metabolic alkalosis Ratio = 0.33 is Chronic respiratory Acidosis Ratio between 0.33 and 0.8 = Chronic respiratory acidosis with an acute respiratory alkalosis or metabolic acidosis, examine the pH Ratio = 0.8 is Acute respiratory acidosis Ratio = Metabolic acidosis
What is a second drug you could use to treat hiccups? dosing?
Reglan, 10mg IV or IM, or 10mg PO TID for 10 days
What is the most common cause of mitral stenosis?
Rheumatic Heart Disease
AvnRT can occur in normal hearts or in association with what conditions?
Rheumatic Heart Disease Acute Pericarditis Acute MI Mitral Valve Prolapse Preexcitation syndromes
What will you see on EKG for Right Sided Valvular Disease?
Right Atrial Enlargement, RVH (righ axis deviation and R Wave in V1 >10mm)
Name the non-depolarizing paralytic agents, dosing, and reasons for/against?
Rocuronium, 1 mg/kg, 1-3 min onset, duration 30-45 min, can cause Tachycardia, Tint says duration makes this second choice after succinylcholine. Vecuronium, 0.08-0.15 mg/kg (or 0.15-0.28 mg/kg high dose protocol), onset 2-4 min, 25-40 min (or 60-120 with high dose protocol), causes prolonged recovery in obese, elderly, or patients with hepatorenal dysfunction Atracurium, 0.4-0.5 mg/kg, onset in 2-3 min, duration is 25-45 min, causes Hypotension and bronchospasm due to histamine release, but is very well suited for ongoing paralysis in patients with renal or hepatic failure.
Pretreatment prior to RSI with _________ is no longer recommended.
Rocuronium, a non-depolarizing neuromuscular blocking agent
Paralytics for pediatric RSI, name them and dosing?
Rocuronium: 1 mg/kg Succinylcholine: 1.0-1.5 mg/kg in >10kg kids 1.5-2.0 mg/kg in <10 kg kids
What are some specifics about the paralytic agents?
Rocuronium: nondepolarizing, longer duration (i.e. 45 minutes ish) Succinylcholine: Shorter acting (i.e. 8 min ish), better intubating conditions at 60 secs, may cause bradycardia in children and HYPERKALEMIA CARDIAC ARREST in children with undiagnosed neuromuscular disease
What pathogens that occur with increased frequency in diabetics (for pneumonias)?
S. Aureus, gram negative, Mucor, and Mycobacterium tuberculosis
Numbness, paresthesias, or "shock-like" sensations in the extremities that develops within 48 hours (especially in children after trauma) is concerning for _______ and must be expeditiously evaluated for evidence of _____ _____ _____?
SCIWORA (Spinal Cord Injury Without Radiographic Abnormality) spinal cord injury
What is the dosing of Nitro...SL, Paste, and IV?
SL = 0.4 mg, up to 3 (1 every 5 minutes) Paste = 1-2 inches IV = 5 mcg/min, increase by 5 every 3-5 min, once at 20mcg/min then increase by 10 mcg/min every 3-5 minutes, max rate of 200mcg/min Onset 2 min, duration is 1 hour, paste may last 3-4 hours if not removed..
Define DUMBELS for muscarinic effects.
SLUDGE + KILLER Bs Defecation Urination Muscle weakness, miosis Bradycardia, bronchospasm, bronchorrhea Emesis Lacrimation Salivation
What findings in inferior MI on EKG lend to the proximal right coronary artery being occluded?
ST elevation in III greater than II, plus ST depression >1mm in I and/or aVL and ST elevation in V1 and/or V4R
What findings in inferior wall MI on EKG will tell you the likely occluded artery is the right coronary artery?
ST elevation in III is > that in II, plus ST depression of >1mm in I and/or aVL
What findings in Anterior MI on EKG show likely proximal left anterior descending coronary artery occlusion?
ST elevation in V1-3 and ST elevation in V1 is >2.5mm or a RBBB with a Q wave, or both or ST depression of >1mm in II, III, or aVF
When should you suspect dig tox?
SVT with AV bloc or junctional escape rhythms
When might hemodialysis help?
Salicylates ethylene glycol Li methanol carbamazepine amanita (mushrooms)
TCA antago of postsynaptic muscarinic receptors
Sedation, coma, agitations, confusion, ataxia, hallucinations, seizure, mydriasis, dry mouth, dry skin, flushed skin, tachy, HTN, hyperthermia, ileus, urine retention, tremor; tx supportively only NOT physostigmine
TCA antago o postsynaptic histamine receptors
Sedation; tx supportively
What is the sensitivity and specificity of SPECT perfusion imaging when compared with traditional coronary angiography?
Sens = 85-90% Spec = 80-90%
What are some indications for Bicarbonate therapy in Metabolic Acidosis treatment?
Severe Hypobicarbonatemia (<4 mEq/L) Severe Acidemia (pH <7.20) with s/s of shock or myocardial irritation no responding to tx Severe Hyperchloremic Acidemia
Since no vital sign or value is diagnostic what is one way to help tell if someone has shock?
Shock index: HR/SBP Normal = 0.5 - 0.7
What is a major difference in timing with regard to amphetamines vs cocaine?
Similar onset (route dependent), but cocaine only lasts upto 2hrs whereas amphetamines up to 12 hours.
Which knee dislocation patients should get arteriography?
Some authors say all patients due to up to 1/3 of patients having a popliteal artery injury
What should the settings be for NPPV?
Spontaneous Mode IPAP set at 8 to 10 EPAP set at 3 to 4 supplemental O2 at 3-5 L/min but adjusted with each change increase EPAP incrementally by 1 to 2 cm H20 ALWAYS KEEP AT RATIO (1:2.5 EPAP/IPAP) If Hypercarbia continues then increase only IPAP at 1 to 3 cm increments
What plain film views do you need to help evaluate for a hamate fracture? What imaging could diagnosis an occult fracture?
Standard plus carpal tunnel view; CT or Bone Scan
What is the Stanford and DeBakey classifications for Aortic Dissections?
Stanford Type A = any involvement of ascending aorta Stanford Type B = only descending aorta DeBakey Type 1 = ascending, arch, and descending DeBakey Type 2 = ascending only DeBakey Type 3 = only the descending
What CXR findings are pretty consistent with Staph Aureus? Klebsiella? Moraxella Catarrhalis?
Staph - Empyema, lung abscess Klebsiella - bulging fissure sign Moraxella - diffuse infiltrates
Adults (non neutro) iv drug bugs
Staph Au
What type of pneumonia is gradual in onset, may present after a viral illness (so better than worse) and has gram-positive cocci in clusters?
Staphylococcus Aureus
If, despite assisted ventilation for 30 seconds, the newborn remains bradycardic with a HR of <60/min, you should?
Start chest compressions
What is the time frame for TCA ECG stuff?
Start in 6 hrs usually last 36-48hrs.QRS >100ms, brugada, terminal RAD >120, warrants bicarb and admission
Transiet quadriparesis, especially in young boys following sports injuries, lasting seconds to minutes, and resolved by 48 hours are called?
Stingers
What is the mnemonic for Hypercalcemia and what does it stand for?
Stones, Bones, Moans, and Groans Stones = Renal Calculi Bones = Osteolysis Moans = Psychiatric Disorders Groans = PUD, Pancreatitis, Constipation
What is the most important step in treating SS?
Stop S medications, supportive and admit ALL
What about the Done nomogram?
Stop it.
What is the most common pathogen causing pneumonia in alcoholics? what are other pathogens that should be considered though?
Strep Pneumo; Klebsiella and Haemophilus
What is the most common cause of penumonia in patients with HIV?
Strep Pnuemo
Adults (non neutro) pneumonia bugs
Strep pneumo, mrsa, gram negative bacilli, legionella
Asplenic patients bugs
Strep pneumo, nei menin, h flu, capnocytophaga
Children (non neutro ) >3mos bugs
Strep pneumo, nei menin, staph au, h flu
What are the most common pathogens causing postinfluenza pneumonia, in order?
Strep. Pneumo, Staph Aureus, and H. Influenzae
What pathogens should Antibiotics be directed at when COPD exacerbation patients have increased sputum volume or purulence noted?
Streptococcus Pneumoniae, Haemophilus Influenzae, and Moraxella catarrhalis
What type of pneumonia presents as sudden onset, fever, rigors, tachycardia, tachypnea, bloody (rusty) sputum production with cough? What does it look like on a gram stain?
Streptococcus Pneumoniae, gram-positive diplococci
What is the most common cause of CAP pneumonia? followed by...?
Streptococcus Pneumoniae, then viruses and atypicals like Mycoplasma, Chlamydophila, and (severe) Legionella
Name the depolarizing paralytic, dosing, and reasons for/against?
Succinylcholine, 1.5 mg/kg, onset 45-60 secs, duration 5-9 min, rapid onset, short duration Complications include: Hyperkalemia in patients with burns, denervation injury, significant crush injuries, and severe infection >5 days old Masseter Spasm Increased intragastric, intraocular, and possibly intracranial pressure Malignant Hyperthermia Bradycardia Prolonged Apnea with pseudocholinesterase deficiency or mysathenia gravis Fasciculations
What is the preferred paralytic for RSI in the ED?
Succinylcholine, according to Tintinalli
If carcinoma, cocaine use, myasthenia gravis, cirrhosis, etc is noted prior to emergent intubation in the ED, what paralytic should be avoided?
Succinylcholine, due to decreased succinylcholine metabolism.
Who is the typical intentional salicylate OD patient and what do they present with?
Suicidal young woman with N, V, tinnitus hearing loss, sweating, hyperventilation at >30mg/dL
What is the treatment for toxic alcohols?
Supportive and block production of toxic metabolites, correct electrolyte / acidosis. No use of gastric lavage or charcoal. In levels >50mg/dL = indication for dialysis. Use bicarb to maintain pH of 7.35-7.45
How do you treat SSRI OD?
Supportive with SDAC with observation for 6 hours unless continued lethargy/tachy then admit; unless serotonin syndrome
How do you treat antipsychotic OD?
Supportive with cardiac monitoring Aggressive fluids for hypoTN, norepi/phenylepherine for refractory For QTc >500ms treat with Mg regardless of Mg level due to risk for torsades For ICD/ vent arrhythmias treat with bicarb, lidocaine 2ndline (dont use amio/quinidine, procainamide, propafenone or any class Ia/Ic/III/IV AR due to cardiotoxicity worsening) Benzos for seizures Consider intubation for resp dep
What is treatment of isopropanol toxicity?
Supportive, no need for fomeprizole / ethanol. No gastric lavage / charcoal. Consider intubation, and type and cross for gastric bleed. If refractory to other treatments hemodialysis removes both isopropanol and acetone consider for >400mg/dL
How do you treat SNRI oD?
Supportive, watch for early seizures and get IV access. Consider SDAC. Consider Whole bowel for SR.
What do you treat mirtazapine OD with?
Supportivive and with SDAC GI decom. Observe for 8 hours and dc. Men metablize faster than women 26hrs in men 37 hrs halflife in women
At the time the latest version of Tintinalli was written was there good evidence that limited fluid resusc or no fluid resusc in certain situations is better?
Supposedly not., according to Tintinalli permissive hypotension is not well supported yet.
How do you treat Aortic Stenosis?
Symptomatic = Admit and replace valve Afib= cardiovert and anticoagulate If discharging then need to avoid vigorous activity
How do you treat unstable SVT (rate >220) in children?
Synchronized Cardioversion (0.5 - 1 J/kg), if not working switch to 2 J/kg and repeat
What is SIRS criteria?What does it progress to?
Systemic Inflammatory Response Syndrome - early stages of shock: Two or more of the following is required for SIRS diagnosis: - Temp >100.4 F (38 C) or <96.8 F(36 C) - HR >90/min - RR >20/min - WBC > 12, <4 or >10% immature bands It progresses to "multi-organ dysfunction syndrome" which is ARDS, myocardial depression, DIC, liver or renal failure.
What are the possible EKG findings in PE?
T wave inversions in V1-4, incomplete RBBB, or S1Q3T3
What are the 4 ECG findings common in therapeutic dig that ARE NOT indications of tox?
T wave schanges like flattening/inversion QT shortening scooped ST with depression increased U wave amplitude
What two foot injuries is CT the preferred imaging modality?
Talus fractures and Lisfranc injuries
When should you suspect septic shock?
Temp >38.3 C (100.9 F) Adult Temp >38.5 C (101.3 F) Children or <36 C (96.8 F) in ALL plus SYS BP <90 (or 2 SDs below normal for kids) plus evidence of inadequate tissue perfusion
Anemia: MCV Low, RDW Normal, RBC Normal/High =
Thalassemia
What is different anatomically about the airway in an infant and young child?
The airway is higher and more anterior in the child's neck than in the adult's.
What is the important limitation to measuring serum ketones?
The chemical reaction (nitroprusside reaction) is only positive for species whose carbonyl moeity has an alpha-methyl group. This may not work for Alcoholic or Diabetic Ketoacidosis which many may be Beta-Hydroxybutyrate.
What is required for direct schiotz tonometry?
The conversion scale to convert the number on the device to IOP.
What has more predictive value for an acute cardiac event: cardiac risk factors for CAD or the presence of symptoms?
The presence of symptoms
Should children receive pre-treatment agents in RSI?
There is an absence of literature to support it
What is the typical MAOI toxidrome?
There isn't one, nor a common progression of symptoms.
What is the MAOI OD antidote?
There isn't one. Support them and don't make them worse. This includes NOT giving them ipecac Treat hypertension cautiously with short acting agents to avoid hypotension: phentalomine 2.5-5mg IV bolus Q10-15min nitroprusside, fenoldopam. Treat hyperthermia with benzos and cooling...antipyretics aren't effective
What do you do for pediatric patients with micrognathia that need airway support?
These patients usually respond to BVM or LMA Airway management.
If a person has intra-abdominal bleeding how might their vitals signs look? why?
They could have bradycardia or lack of tachycardia in 30% of patients who have shock because of increased vagal tone due to the hemoperitoneum
What test should be performed if there is tenderness or a palpable defect to the Achilles tendon?
Thompson test
What is a PE test you can do to help diagnose Achilles Tendon Rupture?
Thompson test; foot will not plantarflex if the tendon is ruptured
List what laboratory studies/results suggest DIC?
Thrombocytopenia Prolonged Prothrombin & Activated Partial Thromboplastin Decreased fibrinogen and antithrombin III increased fibrin monomer, fibrin split products, and D-Dimer levels
What is ED APAP therapy based on?
Time to presentation: 1)<4hr from ingestion: Consider gi decon, send >4h apap level, if get level back <8h then use nomogram. If not get level back <8h then give 1st NAC dose and then plot once level returns. 2) 4-24hours: Same as <4hr period 3) Unknown or >24hr: consider GI decon for unknown, Send APAP / LFTS and give 1st dose NAC. APAP >10mcg/mL or AST/ALT increased continue NAC AND if pH <7.3, PT>100, Cr >3.3, AMS then send to liver transplant unit. If APAP level <10mcg/mL supportive care only.
How do you disposition APAP tox patients?
To the floor for all NAC, unless unstable/SI. If not at risk for toxicity, ED obs for 4-6 hr. Report all apap tox to regional poison control for data purposes. Dont forget psych consult for intentional
What is the mainstay for treatment of Alkalemia?
Treat the underlying cause and supportive care
Oxygen therapy is the mainstay of treatment for cyanosis, what is also important in the treatment of cyanotic newborns?
Treating the underlying cause
True or false, Blowout fracture patients with a normal inital eye exam require exam by oph?
True - need full dilated to look for detach/tears etc
What if you run out of glucagon?
Try phosphodiesterase inhibitor at continuous infusion of mcg/kg/min (dose is drug spec).
What is the formula for the length of tube depth at the lips in kids?
Tube size x 3
List the 3 types of von Willebrand Disease?
Type 1 - Quantity issue (normal but less, maybe 20-50% normal quantity) Type 2 - Quality issue (abnormal and dysfunctional) Type 3 - Severe and Complete (almost no vWF)
How do you treat von Willebrand disease? How does the treatment work for Type 1?
Type 1 = Desmopressin 0.3mg/kg IV or SC every 12 to 24 hours (3-4 doses) 150mcg (one spray to nose) for kids >5 yrs old 300mcg (one spray each nostril) adults/adolescents It causes release of vWF from the endothelial cells, can raise vWF by 3-4 fold, but will become depleted after 3-4 doses Type 2 and 3 - vWF containing concentrate or Cryoprecipitate (10 bags of cryo every 12-24 hours)
Describe the types of AC joint injuries?
Type I - Sprain Type II - AC ligament rupture, but CC ligaments sprained, slight widening of AC joint and slight displacement Type III - All ligaments ruptured and likely 100% dislocation of AC joint Type IV - Type III with posterior displacement in or through trapezius Type V - rupture of all supporting structures (200-300% displacement of coracoclavicular joint) extremely gross abnormality Type VI - inferiorly dislocated
Which Salter-Harris fractures may not be radiographically detected?
Type I and V
The most common type of odontoid fracture is? Which type is stable?
Type II - where odontoid attaches to body of C2; Type I
What types of AC joint injuries are severe and require surgical repair?
Types IV, V, and VI
How long does withdrawl last?
Typically 2 days but mild depression can last 2 weeks, or longer. Be concerned for SI. No evidence antidepressants help.
WHat is the treatment for MNS?
Typically supportive. Consider intubation for reducing temperature, muscle rigidity and for typical airway reasons. Make sure to use nondepolarizing agents like roc. Most fatalities occur from muscle rigidity (from complications including rhabdo, ARF, resp failure, DIC, CV collapse). Sedate with benzo. Dantrolene for severe cases (NOT CONCURRENT WITH CALCIUM = CV Collapse)
What kills amphetamine / cocaine patients?
Typically the result of hyerthermia, dysrhythmias, sezures, hypertension, hemorrhage / infract, encephalopathy.
In patients in whom a CABG is planned which type of Heparin should be used and when?
UFH 12 to 24 hours prior to surgery
What are the first line drugs for clinically stable, monomorphic VT including dosing?
USE THIS ONE FOR AMI, LV DYSFUNCTION, or UNKNOWN CARDIAC STATUS: Amiodarone, 150 mg over 10 min, repeat every 10 minutes (total dose max is 2 grams) OR infusion 0.5mg/min over 18 hours IF NO AMI OR LV DYFUNCTION: Procainamide, 50 mg/min IV, up to 17 mg/kg in non-CHF patients. OR infusion of 2.8mg/kg/hour (in non-renal patients)
The imaging modality of choice for evaluating gallbladder disease, ovarian or testicular disorders, and ectopic versus intrauterine pregnancy is _____.
Ultrasound
How much MAOI can be toxic?
Under the right circumstances, single tablet.
Any spinal injury with neuro deficits or radiographic evidence of injury should be considered ______.
Unstable injury
Was are the "goals" in "goal-directed therapy of septic shock? **Although this is dis-proven now:)
Urine output >0.5mL/kg/h CVP of 8-12 mm Hg MAP 65-90 mm Hg ScvO2 >70% during ED resusc
What can you do to help prevent over hydrating children when giving them fluid boluses?
Use a pediatric microdrip assembly
Which acute ethanol intoxications need admit?
Usually none, dc when clinical sober. Shouldn't let drive home unless near 0, not just legally sober due to liability.
What is a serious presenation of TCA od?
Usually seen at 6 hrs and is coma, cardiac conduction delays, SVTG, hypoTN, resp dep, PVC, Vtach, seizures
How bad is the GI bleeding in acute NSAID OD?
Usually you don't get bleeding with acute.
Where is the internal carotid artery located with regard to PTA?
Usually, laterally and posteriorly to the posterior edge of the tonsil...don't go deeper than 1cm
If there is a language or cross-cultural difference, what pain assessment modality preferred because it is the least affected by these factors?
VAS (Visual Analog Scale)
Most patients with a wide complex tachycardia have ________ and should be approached as if they have_____ until proven otherwise.
VT
Patients with indwelling vascular devices drugs
Vanc 15mg/kg q6hrs to 1gm q12hrs
What type of syncope has a slow, progressive onset with associated prodrome (lightheadedness, maybe sweating/nausea)?
Vasovagal Syncope (AKA reflex-mediated or neurally mediated syncope)
If you have a patient complaining of palpitations that are associated with dizziness, syncope, or presyncope then you should be concerned about what?
Ventricular Tachycardias
Anticoagulant rodenticides
Vit K1 1-5mg/d PO ped; 20mg/d PO adult
Anemia: MCV High, RDW High, = ? What if RDW is normal?
Vitamin B12 or folate deficiency; Alcohol Abuse, Liver Disease, Hypothyroidism
What anticoagulant should not be used in pregnancy?
Warfarin, but LMWH and UFH are safe and do not cross the placenta.
How do you calculate the water deficit in Liters?
Water Deficit (L) = ([measured Na/normal Na]-1) Serum Na rises about 3 to 5 with every Liter of water deficit
What is the most reliable approach for achieving therapeutic effects with UFH and preventing further thrombosis during the acute thromboembolic events?
Weight-based dosing protocol
What are the rare but pathognomic CXR findings for PE?
Westermark Sign - wedge-shaped area of lung oligemia Hampton's Hump - dome shaped opacification in periphery
When is use of Naloxone contraindicated in newborns which otherwise meet criteria for Naloxone administration?
When maternal narcotic addiction is suspected
At what level of maternal PO2 should we be concerned that the fetal PO2 is going to start dropping significantly now too?
When the maternal PO2 drops below 60 mm Hg. This is due to the Fetal Hemoglobin having a greater affinity for oxygen than maternal hemoglobin.
When should you initiate airway management?
Whenever there is a concern about airway patency, oxygenation, or ventilation
Does a puncture wound with extension to the depth of an underlying fracture count as an open fracture?
YES
Does the standard hospital mattress provide adequate spinal support?
YES
Are defects noted by transient changes in regional function noted by stress echocardiography more accurate at detecting ischemia that ECG and patient symptoms?
Yes
Do you have to maintain sedation after paralysis?
Yes, to avoid patient awareness
Who is the prototype patient for cocaine ACS?
Young (33yo) male (7:1 gender preference) cigarette smoker, regular cocaine user presenting 3 hours (2/3rds pts) after use. Caused by increased myocardial O2 demand, coronary artery vasoconstriction, increased atherogenesis, direct myocardial toxicity.
Outpatient treatment for uncomplicated pneumonia patients? 2nd line?
Z-Pak or Clarithromycin 1gm PO x 7 days 2nd line: Doxy 100mg BID x 10-14 days
What are the zones of the extensor tendon injuries to the hand?
Zone I - distal phalanx and DIP Zone II - middle phalanx Zone III - PIP Zone IV - proximal phalanx Zone V - MCP Zone VI - dorsum of the hand Zone VII - wrist Zone VIII - distal forearm
Flexor tendon injuries to hand; describe the 5 zones?
Zone V - proximal to carpal tunnel Zone IV - carpal tunnel Zone III - distal edge of carpal tunnel to proximal edge of flexor sheath Zone II - involves both flexor digitorum profundus and superficialis, common laceration site, usually partial not complete laceration Zone I - from insertion of superficialis tendon to the profundus tendon
What is the formula for calculating the anion gap?
[Na+] - ([HCO3-] + [Cl-]) = AG
IV contrast could decrease the excretion of Metformin and cause an accumulation of Metformin which could cause_______?
a potentially fatal lactic acidosis