CCM - RC

"SILVER-TD"mnemonic for petechial rash

"SILVER-TD"mnemonic S. pneumo, meningococcal ITP/TTP/HUS Leukemia Vasculitis (HSP/PAN) Extra bad infection - DIC, TSS, Endocarditis RMSF Typhus/Typhoid Drug reaction (SJS/TEN) w/ thrombocytopenia = ITP, TTP, HUS, RMSF, Typhus, Typhoid fever, Sepsis with DIC w/ out = HSP, IE, drug reaction (SJS/TEN), meningiococcal/penumococcal (unless severe w/ DIC)

Treatment of hypercalcemia

(1) Aggressive hydration (Consider lasix) (2) Bisphosphonates (3) Coritcosteroids for MM/Lymphoma to reduce conversion to activated Vitamin D (4) Hemodialysis for refractory/not telerating fluids

Mechanisms of dysrythmia

(1) Altered Automaticity: • Abnormal - spontaneous phase 4 depolarization in non-pacemaker cell • Enhanced - ↑ depolarization slope in pacemaker cell • Causes: ischemia, electrolyte imbalance, drugs (2) Reentry: abnormal conduction • 3 requirements: 1) 2 paths available for impulse conduction 2) Unequal responsiveness of 2 limbs (one limb refractory) 3) Slowed conduction in one limb (3) Triggered: 2° to afterdepolarizations (early or delayed) o Delayed 2° ↑ Ca (intracellular) in ischemia reperfusion and digoxin toxicity (enhanced by ↑ HR) o Early - classic is TdP (enhanced by ↓ HR)

Disorders arising on ascent

(1) Alternobaric vertigo (2) Barodontalgia (3) GI Barotrauma (4) Pulmonary barotrauma (5) Arterial gas embolism (6) Decompression sickness

Overview of organ transplant related complications

(1) Anatomical (2) Infection (3) Rejection (4) Drug Toxicity

How to break layngospam

(1) Apply pressure at Larsen's notch (posterior to msatoid process) (2) Positive pressure ventilation -> Bag through (3) Deepen sedation (3) Paralyze and intubate

Pathophysiology of smoke inhalation

(1) Asphyixiant (2) Pumlmonary irritant - Thermal burns - Soot (3) Systemic toxicity - Cyanide - Carbon monoxide

Complications of CPR

(1) Aspiration (2) GI Trauma (3) Cardiac trauma (4) Bone trauma (5) Pneumothorax (6) Fat emboli

Pathophysiology of aortic dissection

(1) Atherosclerotic ulcer -> intimal tear (2) Disruption of vasa vasorum -> intramural haematoma (3) De novo intimal tear

Advantages of LMWH heparin over heparin

(1) Better bioavailability (2) More predictable dose-response (3 Longer plasma half-life

Indications for retrograde urethrogram

(1) Blood at urethral meatus (2) Inability to void (3) Perineal hematoma (4) High riding prostate

Surgery in native valve infective endocarditis

(1) CARDIAC FAILURE related to valvular dysfunction - Aortic or mitral IE with severe acute regurgitation or valve obstruction causing refractory pulmonary edema or cardiogenic shock (2) UNCONTROLLED INFECTION - Locally uncontrolled infection (abscess, false aneurysm, enlarging vegetation) - Persisting fever and positive blood cultures >7-10 days - Infection caused by fungi or multiresistant organisms (3) SYSTEMIC EMBOLISM - Aortic or mitral IE with large vegetations (>10 mm) following one or more embolic episodes despite appropriate antibiotic therapy - Aortic or mitral IE with large vegetations (>10 mm) and other predictors of complicated course (heart failure, persistent infection abscess) - Isolated very large vegetations (>15 mm)

Zones of injury in burn

(1) Coagulative necrosis (2) Stasis/Ischemia (3) Hyperemia

2015 - ACLS - High Quality Adult CPR

(1) Compression rate of 100-120/min (2) Compression depth of at least 5 cm (but no more than 6cm) (3) Allow full recoil after each compression (4) Minimize pauses in compressions (no more than 10s) (5) Ventilate adequately (2 breaths after 30 compressions, each breath delivered over 1 second, each causing chest rise)

Mechanisms of heat loss

(1) Conduction: Physical transfer between medium (2) Radiation: Transfer of heat via infared rays - Main mechanism of heat loss (3) Convection: Transfer of heat via movement of air/water vapors along skin (4) Evaporation: Loss of heat by conversion of water to gas - Main method of heat dissipation in hot enviroments (5) Respiration

Procedures for which antibiotics prophylaxis for infective endocarditis is recommended for those with relevant high risk conditions

(1) DENTAL PROCEDURES - manipulation of gingival tissue - periapical region of teeth - perforation of the oral mucosa (2) RESPIRATORY procedures that involve incision of respiratory mucosa (3) GI/GU tract procedures if ongoing infection (4) Procedure involving infected skin/MSK tissue

What are the five hemodynamic goals for AORTIC STENOSIS?

(1) Decrease heart rate (2) Maintain sinus rhythm (3) Increase LV preload [maintain a full ventricle] (4) Increase SVR (5) Maintain PVR

Basic Pathophysiology of any cytopenia

(1) Decreased production (2) Increased destruction (3) Sequesteration/loss

Choosing Wisely Canada - Critical Care

(1) Don't start or continue life supporting interventions unless they are consistent with the patient's values and realistic goals of care (2) Don't prolong mechanical ventilation by over-use of sedatives and bed rest. (3) Don't continue mechanical ventilation without a daily assessment for the patient's ability to breathe spontaneously. (4) Don't order routine chest radiographs for critically ill patients, except to answer a specific clinical question. (5) Don't routinely transfuse red blood cells in hemodynamically stable ICU patients with a hemoglobin concentration greater than 70 g/l (a threshold of 80 g/L may be considered for patients undergoing cardiac or orthopedic surgery and those with active cardiovascular disease).

Which pregnant women should receive magnesium

(1) Eclampsia (2) Severe preeclampsia (3) Non-severe but: - severe hypertension - headaches/visual symptoms - right upper quadrant/epigastric pain - platelet count < 100 000 × 109/L - progressive renal insufficiency - elevated liver enzymes

2013 CDA guideline for Diagnosis of Diabetes

(1) Fasting glucose >7.0 mmol/L (2) HbA1C > 6.5 (adults) (2) 75g OGTT 2hr post or Random glucise > 11.1

Methods of active external rewarming

(1) Forced warm air blankets (2) AV anastamoses rewarming Up to 3 degrees celcius/hour if combined with minimally invasive core rewarming (warmed IV fluids)

HIV Replication and Sites of Antivral Action

(1) Fusion of HIV to CD4 cell facilitated by GP and co-receptor interactions (2) Reverse transcriptase encodes viral DNA from RNA copy (3) Integrase facilitases incorporation of viral DNA in host cell DNA (4) Viral RNA produced by cellular machinery (5) Immature virions are formed and protease cleaves to produce new HIV

Types of tetanus

(1) Generalized - generalize muscle contractions throughout body, autonomic dysfunction (2) Localized - persistent muscle spasm close to site of injury (3) Cephalic - Localized variant to cranial nerves (4) Neonatal - Generalized tetanus of newborn related to umbilical cord infection

Roles of n-Acetylcsteine (NAC) in APAP overdose

(1) Glutathione precursor (2) Glutathione substitute (3) ↑Sulfation route (non-toxic route) (4) Free radical scavenger and antioxidant (5) Alters hepatic microcirculation and oxygen delivery

TTM Protocool

(1) Goal temperature as quickly as possible (w/in 6 hours) (2) Maintain temperature for 24 hours (3) Rewarm to 37 degrees celcius at 0.5 Celcius /hours (4) Strict Maintenance of normothermia until 72 hours post arrest (5) No neuroprognositcation until 108 hours (36 hours after normothermia phase)

Indication for retrograde cystogram

(1) Gross Hematuria (2) Urethral injury (3) Severe pelvic fracture

Methods of active core rewarming

(1) Heated humidified air (1-2.5 degrees celcius/hour) (2) Peritoneal lavage/dialysis (1 -3 degrees celcius/hour) (3) Thoracic lavage (3 degrees celcius/hour) (4) Mediastinal irrigation (5) Endovascular rewarming (6) Extracorporeal rewarming - Venovenous ecmo 2-3 degrees celcius - Hemodialysis: 2-3 degrees celcius - Venous arterial ecmo: 3-4 degrees celcius - Cardiopulmnary bypass 9.5 degrees celcius/hour

Indications for thoracotomy with traumatic hemothorax

(1) INITIAL drainage is more than 1500ml or 20 mL/kg (2) PERSISTENT bleeding greater than 7 mL/kg/hr or 200ml/hr (3) INCREASING hemothorax seen on chest x-ray films. (4) Patient remains HYPOTENSIVE despite adequate blood replacement, and other sites of blood loss have been ruled out. (5) Patient DECOMPENSATES after initial response to resuscitation IPIHD Initial Persistent Increasing Hypotensive Decompensates

Management of abdominal hypertension/abdominal compartment syndrome

(1) Improve abdominal wall compliance - Optimize sedation/analgesia - Neuromuscular blockade - Avoid HOB >30 Degrees (2) Evacuate intra-luminal contents - Orogastric tube - Rectal tube - Pro-kinetic agents (3) Evacuate abdominal contents - Paracentesis - Percutaneous drainage (4) Correct positive fluid balance - Judicious fluids - Diuriesis/dialysis (5) Optimize ventilation and organ support

Mechanisms of high altitude acclimitization

(1) Increased minute ventilation in response to hypoxic ventilatory response (2) Bicarbonate elimination by kidneys (3) Catechoalamines to increase cardiac output (4) Increased EPO -> Increased Hgb (5) Increased 2-3 DPG causing rightward shift of oxygen hemoglobin dissociation curve

Mechanisms of Ischemic Heart Disease with Cocaine

(1) Increased oxygen demand secondary to increased HR/BP/ionotropy (2) Decreased oxygen supply due to coronary vasoconstriction (3) Induction of a procoagulant state -> Platelet effects: prothrombotic, antifibrinolytic (4) Accelerated atherosclerosis and LVH -> CHRONIC

Effect of correcting arterial blood gas values to physiologic temperature of 37 degrees celcius

(1) Increased partial pressure of dissolved gases (2) Decreased pH

MOA of Digoxin

(1) Inhibiti Na/K ATPase leading to increased intracellular sodium and increased extracellular potassium -> Increased intraceullular calclium as calcium/sodium antiporter cannot work -> Ionotropu (2) increase vagal tone, which results in decreased conduction through the SA and AV nodes

Differential Diagnosis Elevated Troponin

(1) Injury related to primary MI (2) Injury related to supply/demand mismatch (3) Direct cardiac injury not related to MI (4) Miscelanous/multifactorial

Risk Categories of PE from JAMA Thrombolysis Meta-Analysis

(1) Low risk (HD stable and no evidence of RV dysfunction) (2) Intermediate risk (HD stable and objective evidence of RV dysfunction) - RV Dysfunction = Biomarkers or echo evidence (3) High Risk (HD unstable and/or SPP <90)

What are the five hemodynamic goals for MITRAL STENOSIS?

(1) Maintain or slightly increase preload (2) Decrease HR (3) Maintain contractility (4) Maintain SVR (5) Decrease/maintain PVR.

What are the five hemodynamic goals of MITRAL REGURGITATION?

(1) Maintain preload (careful not to overload) (2) Increase or maintain HR (3) Decrease SVR (4) Decrease PVR (avoid anything that increases PVR!--you want it all to go forward) (5) Maintain contractility

Areas of Dopamine Blockade and clinical effects

(1) Mesolimbic: psychosis and emotion (2) Nigrostriatal: EPS (movement effects) (3) Mesocortical: Cognition and -ve Sx (4) Substantia nigra/hypothalamus: NMS (5) Tuberoinfundibular: Prolactin

Indications for non-invasive mechanical ventilation in COPD

(1) Mod-severe SOB (2) RR > 25 (3) Mod-severe acidosis (pH <7.35 and pCO2>45)

Summary of disorders involving neuromuscular junction - MG - LE - Tick - Botulism - Organophosphate - Tetanus - Strychnine

(1) Myasthenia gravis - Autoantibodies against post synaptic nicotine receptor lead to receptor destruction and competition for binding site of remaining receptors (2) Lambert-Eaton syndrome - antibodies to the presynaptic voltage-gated calcium channels leading to inadequate actelycholine release (3) Tick paralysis - toxin that inhibits transduction at the neuromuscular junction by blocking influx of sodium ions. This prevents presynaptic terminal axon depolarization and inhibits release of acetylcholine at the nerve terminal (4) Botulism - toxin mediated irreversible disruption in stimulation-induced acetylcholine release by the presynaptic nerve terminal (5) Organophosphates - Inhibit action of acetylcholinesterase (6) Tetanus - toxin travels to the spinal cord where it inhibits the release of glycine, an inhibitory neurotransmitter, from Renshaw cells. As a result, alpha motor neurons become hyperactive, and muscles constantly contrac (7) Strychnine - competitive antagonist of glycine, an important inhibitory neurotransmitter in the spinal cord, brainstem, and higher centers [12]. Strychnine's toxicity is attributed to action at the postsynaptic receptor in the motor neurons of the spinal cord's neural horn

Complications of pancreatitis

(1) Necrosis (2) Infection (3) Pseudocyt (4) Hemorrhage (5) Bowel edema, illeus (6) Third spacing (7) Splanchnic vein thromobosis (8) Pseudoaneurysm (9) Abdominal compartment syndrome (10) Multi-organ failure

Acute Chest Syndrome in sickle cell disease - Diagnosis

(1) New pulmonary infiltrate (2) + Some combination of - fever - chest pain Pulmonary symptoms

Disorders arising at depth

(1) Nitrogen narcosis "rapture of the deep" (2) Oxygen toxicity (3) Contaminated gases This is why deep divers must use hormoxic and hypoxic trimix gases

BP targets in ischemic stroke

(1) No tPA: If > 220/110 then Target 180 - 200 (2) tPA: If >180/105 then Target 155-175

Two characteristic complications of methanol poisoning

(1) Optic Neuropathy (2) Putaminal Necrosis

Mechanisms of pulmonary toxicity with hydrocarbons

(1) Oxygen displacement and hypoxia (2) Bronchospasm (3) Direct pulmonary injury (4) Hemorrhage

7 P's of RSI

(1) Prepare (location, equipment, monitors, IV, personnel) (2) Preoxygenate (3 minutes or 8 VC breaths) (3) Pretreatment (4) Paralyze with induction (5) Position (6) Pass tube with proof (7) Post-intubation management

Passive external rewarming

(1) Prevent further heat loss (2) Promote metabolic spontaneous rewarming 0.5 - 2 degrees celcius/hour

High risk conditions for infective endocarditis necessitating prophylaxis

(1) Prosthetic valve (2) History of IE (3) Cardiac valvulopathy in transplant (4) Repaired CHD with residual defect close to prosthetic (5) Completely repaired CHD with prosthetic for first 6 months (6) Unrepaired cyanotic CHD including palliative shunts

Types of pulmonary barotrauma

(1) SQ Emphysema (2) Pneumomeadiastinum (3) Pneumothorax (4) Alveolar hemorrhage (5) Arterial gas embolism

Predisposing factors for heat illness

(1) Set point malfunction - Hypothalamic hemorrhage (2) Pump malfunction - Cardiac disease - Beta blockers (3) Radiator malfunction - Drugs (anticholinergics) - Skin disease - Occlusive clothing (4) Low coolant levels - Dehydration (5) Damaged conducting system - DM/atherosclerosis (6) Increased heat production - Exercise - Drugs (sympathomimetics) - Fever - Delerium tremens - Thyroid storm - MH/NMS - Seizures

Deep space infections of the neck

(1) Submandibular - sublingual - submaxiallary (2) Peritonsillar (3) Parapharyngeal (4) Retropharyngeal* (5) "Danger" potential space* - midline - skull base to diaphragm (6) Prevertebral space* - midline - skull base to coccyx * = Access to mediastinum

Signs of raised ICP on CT scan

(1) Sulcal effacement (2) Slit like venricles (3) Loss of grey white differentiation (4) Herniation

Treatment groups after radiation exposure

(1) Survival probable: no or mild/brief GI symptoms, lymphocyte count normal; received < 2 Gy -> Outpt (2) Survival possible: GI symptoms last 24-48 h, delayed hematopoietic effects; received 2-10 Gy -> Aggressive supportive care - Blood product transfusion - G-CSF - Antiinfective - TPN - Reverse ioslation - Antiemetics (3) Survival improbably: early fulminant GI symptoms, early CNS symptoms; received > 10 Gy o If isolated, may attempt aggressive resuscitation o In mass casualty situation, analgesia only

Acclimitization to heat

(1) Sweating at low temperature, increased volume, less salt (2) Decreased HR, increased SV, early release adolosterone

Amsel Criteria for BV

(1) Thin, white homogenous discharge (2) Clue cells on microscopy (3) pH >4.5 (4) Whiff test 3 of 4 needed for diagnosis

Berlin definition of ARDS

(1) Timing - onset must be within 1 week of a known clinical insult or new or worsening respiratory symptoms (2) Imaging - Bilateral opacities not fully explained by effusion, lung/lobar collapse, or nodules (3) Origin of edema - Not fully explained by cardiac failure of fluid overload (4) Oxygenation - Minimum PEEP/CPAP of 5 PaO2/FiO2 <300 (mild) PaO2/FiO2 <200 (moderate) PaO2/FiO2 <100 (severe)

Mechanisms of pacemaker mediated tachycardia

(1) Tracking of a native atrial tachyarrhythmia (2) Endless loop tachycardia - via a retrograde av nodal circuit

Recommendations for STEMI seen at non-PCI capable center

(1) Transfer to PCI hospital if anticipated FMC to balloon time <120 minutes with DIDO goal <30 minutes (2) Fibronlysis within 30 minutes of arrival if anticipated FMC to balloon time >120 minutes

Definition of Massive Transfusion

(1) Transfusion of 1 blood volume within 24 hours (2) Transfusion of >50% blood volume within 4 hours (3) Transfusion of 4 units of pRBCs within 1 hour within anticipated ongoing losses

Mechanisms of hypercalcemia of malignancy

(1) Tumor secretion of parathyroid hormone-related protein (PTHrP) (2) Osteolytic metastases with local release of cytokines (3) Tumor production of 1,25 dihydroxyvitamin D (calcitriol) (4) Ectopic tumor secretion of parathyroid hormone (PTH)

Herniation syndromes

(1) Uncinate/transtentorial herniation: uncinate process of the temporal lobe herniates into the anterior part of the opening of the tentorium cerebelli (2) Central Tentorial: symmetrical downward movement of the thalamic region through the opening of the tentorium cerebelli (3) Subfalcine: Displacement of the cingulate gyrus under the falx and across the midline. (4) Transcalvarial: Displacement of brain through a defect in the skull (5) Foraminal/Tonsillar herniation: Downward herniation of the cerebellar tonsils into the foramen magnum

Class I Implantable Cardiac Defibrillator indications

(1) VF/VT cardiac arrest not caused by transient event (2) Spontaneous sustained VT (3) Syncope NYD with VT induced at EPS and meds failed (4) Nonsustained VT with CAD/poor LV/prior MI and VT induced at EPS study not suppressed by medication

Confirmation of ETT Placement

(1) Visual confirmation (2) End tidal CO2 * (3) Auscultation (4) Esophogeal detector device (5) Ultrasound (6) Bronchoscopy (7) Condensation (8) Chest movement (9) Radiography

Chest xray findings of aortic dissection

(1) Wide mediastinum (2) Abnormal aortic contour (3) Calcium sign (4) Deviation of trachea/NGT to right (5) Depression of left main stem broncus (6) loss of AP window (7) Large left pneumothorax (8) left apical cap (9) Widened paratracheal sripe

Chest Xray findings of traumatic aortic rupture

(1) Wide mediastinum (2) Left apical pleural cap (3) Downward displacement of the left bronchus (4) Tracheal deviation to the right (5) Deviation of NG tube to the right (6) Large left hemothorax (7) Abnormal aortic contour (8) Right paratracheal stripe thickening (9) Fracture of the 1st rib (10) Obscured aortic knob (11) Multiple rib fractures (12) Loss of AP window

Classic Tetrad of Neuroleptic malginant syndrome

(1) altered mental status (2) "lead pipe" rigidity (3) hyperthermia (4) autonomic dysfunction.

Definition of neutropenia

(1) an ANC of 500 cells/mm3 or les (2) an ANC expected to decrease to 500 cells/mm3 during the next 48 h.

Methods of botulism diagnosis

(1) botulinum toxin in the patient's blood (2) botulinum toxin or C. botulinum in the gastric contents, stool, or wound of the patient (3) toxin or organisms in the suspected food source.

Normal Functions of Von Willebrand Factor

(1) bridging molecule at sites of vascular injury for platelet adhesion (2) promotes platelet aggregation (3) carrier for factor VIII, increasing the half-life

Causes of immunosupression in diabetic patients

(1) defects in immune function (2) excess substrate for fungal and bacterial growth (3) vascular insufficiency related to microangiopathy and atherosclerosis (4) sensory neuropathy that leads to wound neglect

Most common treatable causes of a dementia

(1) depression (pseudo-dementia) (2) intracranial mass (3) medications/chemical intoxication (4) NPH

Diagnostic criteria of hepatorenal syndrome

(1) diagnosis of cirrhosis and ascites; (2) diagnosis of AKI according to ICA-AKI criteria increase of at least 26 µmol/L and/or ≥ 50% from baseline, within 48 h; (3) no response after 2 consecutive days of diuretic withdrawal and plasma volume expansion with albumin (1 g/kg of body weight); (4) absence of shock; (5) no current or recent use of nephrotoxic drugs (6) no macroscopic signs of structural kidney injury (proteinuria, microhematuira, renal U/S)

Sources of injury with electrical current

(1) direct trauma from the electric current coursing through the body (2) trauma from conversion of electrical energy to thermal energy (3) mechanical effects of the electric current, including violent muscle contractions and falls.

End point of atropine dosing in organophosphate ingestions

(1) drying of respiratory secretions (2) easing of respiration (3) MAP greater than 60 mm Hg.

Physiologic effects of cortisol

(1) facilitates gluconeogenesis (2) lipolysis (3) inhibits insulin secretion (4) anti-inflammatory actions and immune-modulating effects (5) augmenting vascular reactivity to vasoconstrictors (6) retarding bone growth

Classic pentad of Thrombotic Thromboctyopenic purpura

(1) fever (2) hemolytic anemia (3) thrombocytopenia (4) renal impairment (5) neurologic manifestations

Five evidence based techniques for the prevention of central line infections

(1) hand washing (2) using full-barrier precautions during the insertion of central venous catheters (3) cleaning the skin with chlorhexidine (4) avoiding the femoral site if possible (5) removing unnecessary catheters

Diagnosis of DKA

(1) hyperglycemia (glucose>11.1) (2) ketonuria (or +ve serum ketones) (3) academia (pH<7.3), and HCO3<18

Iatrogenic injuries in DKA

(1) hypoK (2) hypoglycemia (3) alkalosis (4) CHF (5) cerebral edema

6 I's of DKA precipitants

(1) insulin (underdose) (2) infection (3) ischemia/infarction (4) intoxication (5) iatrogenic (steroids, thiazides, antipsychotics, surgery), (6) infant/pregnancy

Anatomy of Wall of Vasculature

(1) intima (contains endothelium which prevents exposure to thrombogenic subendothelial tissue) (2) media (concentric, layered smooth muscle cells), (3) adventitia (connective tissue with nerves (important for autonomic control of vessels) and vasa vasorium

Mechanisms of button battery corrosion

(1) leakage of an alkaline electrolyte (2) pressure necrosis (3) generation of an external current that causes electrolysis of tissue fluids and generates hydroxide at the battery's negative pole.

Categories of mesenteric ischemia and risk factors

(1) mesenteric arterial embolus - CAD (post-MI mural thrombus, CHF) - Valvular disease - Arrhythmias (especially atrial fibrillation) - Aortic aneurysm or dissection - Coronary angiography (2) mesenteric arterial thrombosis - Classic risk factors for atherosclerosis - History of other atherosclerotic diseases (3) nonocclusive mesenteric ischemia - Low CO CV disease (CHF, arrhythmia, cardiogenic shock, post CABG) - Hypotension (septic shock) - Drugs (vasopressors, digoxin, ergot alkaloids, cocaine) (4) mesenteric venous thrombosis - Hypercoagulable state (SCD, AT III/protein C/S deficiency, PCV/myeloproliferative disorders, cancer, OCP/estrogen/pregnancy) - Inflammatory (pancreatitis, diverticulitis, appendicitis, cholangitis) - Trauma (operative venous injury, post-splenectomy, blunt abdo trauma) - Miscellaneous (CHF, renal failure, decompression sickness, portal HTN)

Acceptable imaging techniques for ancillary testing in determination of death by neurologic criteria

(1) radionuclide imaging (nuclear medicine testing) (2 4-vessel cerebral angiogram (3) computed tomography (CT) angiography (4) magnetic resonance (MR) angiography

Ventilation strategies in asthma

(1) reduction of the respiratory rate (2) reduction of tidal volume (3) shortening of inspiration by increasing inspiratory flow

Definition of fever in neutropenic patient

(1) single oral temperature of >38.3°C (101°F) (2) temperature of >38.0°C (100.4°F) sustained for >1 hour

Mechanisms of hypokalemia in ASA Toxicity

(1) vomiting (stimulation of medulla) (2) increased renal excretion of Na, HCO3, K in response to respiratory alkalosis (3) salicylate-induced increased permeability of renal tubules (4) intracellular accumulation of Na and H2O (5) inhibition of active transport system secondary to uncoupling of oxidative phosphorylation

Determinants of myocardial oxygen demand

(1)HR (2) afterload (3) contractility (4) wall tension - Ventricular pressure - Radius

Oxygen Content of Arterial Bood

(1.34 x hemoglobin concentration x SaO2) + (0.0031 x PaO2) (Oxygen bound to hemogolobin) + (Dissolved oxygen)

Pathophysiology of autonomic dysreflexia

(A) A strong sensory input into the spinal cord via intact peripheral nerves (B) massive reflex sympathetic surge -> widespread vasoconstriction -> hypertension (C) brain detects hypertensive crisis (D) (i) brain attempts to shut down the sympathetic surge by sending descending inhibitory impulses. These impulses are unable to travel to most sympathetic outflow levels because of the spinal cord injury at T6 or above (ii) Reflex bradycardia

Confusion Assessment Method

(A) Acute onset with fluctuating course (B) Inattention AND Either/or (C) Disorganized thinking (D) Altered LOC

Indications for ICP Monitoring After Traumatic Brain Injury

* ICP should be monitored in all salvageable patients with a TBI (GCS 3-8 after resuscitation) and an abnormal CT scan * ICP monitoring is indicated in patients with severe TBI with a normal CT scan if at least of 2 of the following features: (1) age > 40 years (2) unilateral or bilateral motor posturing (3) SBP < 90 mm Hg.

Hemodynamic Targets in TBI

* SBP at least 100 mm Hg for patients 50 to 69 years * at least 110 mm Hg for patients 15 to 49 or greater than 70 years * Treating ICP of 22 mm Hg or greater is recommended * The recommended target CPP value for survival and favorable outcomes is between 60 and 70 mm Hg

CVP Waveform in Cardiac Tamponade

* The CVP is raised *All CVP waveform components are elevated * a and v waves are tall * x descent is steep * y descent is (usually) absent

Overdampened arterial line

- Air bulbble in tubing - Clot in catheter tip - Incorrect (too elastic) tubing

MOA of Valproic Acid

- Binding of acetyl-COa interfering with fatty acid metabolism and leading to hepatic steatosis/Possibly Reye Sydrome - Can also lead to carnitine depletion => formation or hepatoxic metabolitis and inhibition of urea cycle causing hyperammoniemia

Features of Takosubo cardiomyopathy

- Decreased LV systolic function with regional wall motion abnormalities - Absence of obstructive coronary artery disease - ST elevation - Positive cardiac biomarkers

Complications of Massive Tranfusion

- Dilutional coagulopathy - Thromobocytopenia - Hypothermia - Hypocalcemia - Hypomagnisemia - Hyperkalemia

Advantages of fomepizole over ethanol

- Ease of use - Simple dosing - No direct observation required - No CNS depression - Longer duration - Predictable pharmacokinetics

Ebola Summary Virus Presentation Incubation period Epidemiological risk factors

- Filovirus - nonspecific viral syndrome followed by fulminant septic shock, coagulopathy, and a mortality rate of greater than 50% - Incubation 2 - 21 days (1) contact with blood or other bodily fluids or human remains of a patient known to have or suspected to have Ebola viral disease (2) residence in—or travel to—an area where Ebola viral disease transmission is active (3) direct handling of bats or non-human primates from disease-endemic areas West Africa - Guinea, Sirrea Leone, Liberia

Dengue fever summary Virus Vector Presetnation

- Flavivirus - Aedes mosquito - Febrile viral illness - Positive Rumpel-Leede (tourniquet test) - Muscle aches/joint pain (break bone fever) - Can progress to critical illness, systemic vascular leak, hemorrhage

Indications for Transfer for Angiography After Fibrinolytic Therapy

- Immediate transfer for cardiogenic SHOCK - Urgent transfer for FAILED reperfusion or reocclusion - As part of an EARLY INVASIVE strategy in stable* patients with PCI between 3 and 24 h after successful fibrinolysis

Strategies to enhance solute clearance

- Increase filter lifespan with anticoagulation and predilution - Rationalise planned interruptions to CRRT - Improve vascular access - Increase the blood flow rate - Increase the dose of dialysis Increase the dialysate flow rate Increase the ultrafiltration rate Increase the replacement fluid rate - Use of pre-dilution - Adjust of dialysate to modify concentration gradients - Increasing the surface are of the filter

Potential Etiologies of Pericardits/Myocarditis

- Infections - Autoimmune disease (SLE) - Acute rheumatic fever - Recent MI/cardiac surgery - Malignancy - Radiation therapy to mediatinum - Uremia - Drugs - Prior pericarditis

Multi-Organ Dysfunction

- Organ dysfunction involving (1) respiratory, (2) renal, (3) cardiovascular (4) hepatic, (5) hematologic (6) GI and (7) CNS - defined as a (1) physiologic derangement, (2) clinical support provided, or (3) clinical syndrome comprising several abnormalities - Aggregate severity can be quantified with scores

Whom to suspect hereditary angioedema

- Recurrent episodes of angioedema without urticaria or pruritus or other triggers - Unexplained recurrent episodes of self-limited, colicky, abdominal pain (typically lasting one to three days), especially in patients who also have had cutaneous angioedema. - Unexplained laryngeal edema (even a single episode). - Family history. - Low complement C4 in a patient with angioedema

Calcium disodium EDTA

- Severe lead in combination with BAL

Botulism Management

- Supportive care; Intubation - GI decontamination - Anti-toxin (equine) or BIG (for infant botulism) - Consider ABx only in wound botulism and after anti-toxin to prevent toxin release

Emergency management of bleeding on DOAC

- Surgical Haemorrhage control - Identify anticoagulant name - Establish time of last dose - Calculate the patient's creatinine clearance - Give tranexamic acid 1 g intravenously - Idarcizumab (if available) or else activated prothrombin complex concentrate for dabigatran. - Prothrombin complex concentrate administration for all other DOACs. - If bleeding is continuous and unabated, administer recombinant factor VIIa - If the patient has acute kidney injury and is taking dabigatran, arrange for dialysis

Contraindications to Intra-Aortic Balloon Pump

- aortic regurgitation - aortic dissection - severe aorto-iliac or PVD - aneurysm or other anatomical disease of aorta - prosthetic aortic tree grafts - local sepsis - lack of experience with management - severe coagulopathy - not effective in a setting of a CI of < 1.2 and tachyarrhythmias-

Pathophysiology of botulin toxin

- binds to the presynaptic nerve membrane, becomes internalized, and then inhibits the release of acetylcholine - occurs predominantly at the cholinergic synapses of the cranial nerves, autonomic nerves, and neuromuscular junction - Causes flaccid paralysis and autonomic dysfunction

Mechanism of action of high-dose insulin therapy

- increased glucose and lactate uptake by myocardial cells - improved myocardial function without increased oxygen demand - increased pyruvate dehydrogenase activity, thus hastening myocardial lactate oxidation and clear the cytosol of glycolytic byproducts that can impair calcium handling and cause diastolic dysfunction. - promotes excitation-contraction coupling and contractility

Risk factors for invasive candiasis

- indwelling central venous catheter (CVC) - broad-spectrum antibacterial agents - prolonged ICU stay - recent major surgery - necrotizing pancreatitis - any type of hemodialysis - immunosuppression.

Janeway Lesions

- non-tender, small erythematous lesions on the palms or soles - dermal microabscess - septic emboli from endocarditis

Osler Nodes

- painful, red, raised lesions found on the hands and feet. - causes by immune complex deposition

MRSA infections risk factors

- recent hospitalization - recent outpatient visit - recent nursing home admission - incarcerated - children at daycare - military recruits - sports team - Antibiotics exposure - Chronic illness - IVDU - Low SES - Close contact with MRSA

Hunt and Hess Classification and Prognosis

0 Unruptured aneurysm 1 Asymptomatic or minimal HA/slight nuchal rigidity (30%) 2 Mod-severe HA; nuchal rigidity; no FND except CN palsy (40%) 3 ↓ LOC, confusion, or FND (50%) 4 Stupor; mod-severe hemiparesis (80%) 5 Deep coma; decerebrate posturing; moribund (90%)

Definition of unstable angina

1) REST angina: occurring at rest for at least 20min or angina lasting >20min after resting from activity 2) NEW-onset angina: within last 2 months of at least class II 3) Increasing or PROGRESSIVE angina: previous angina more frequent, longer in duration or ↑ by 1 class (of at least class III)

Characteristics of dialyzable toxins

1) Small Vd<1L/kg (2) low protein-binding (3) small size, (4) water soluble,

Contraindications to beta blockade in ACS

1) signs of HF 2) evidence of low-output state 3) increased risk for cardiogenic shock 4) other contraindications to beta blockade (e.g., PR interval >0.24 second, second- or third-degree heart block without a cardiac pacemaker, active asthma, or reactive airway disease)

Normal ECG effects of digoxin

1. "scooped" ST depression 2. flattened, inverted or biphasic T waves 3. shortened QT interval 4. increased PR (vagal tone) 5. prominent U waves 6. peaking of terminal T wave 7. J point depression

Categorization of caustic injuries on endoscopy and risk for stricture formation

1. 1st degree: edema, hyperemia 2. 2nd degree (30% strictures): ulcers, exudates, friability, hemorrhage a. 75% strictures if circumferential 3. 3rd degree (90% strictures): deep ulcers/necrosis

DDX of hypotension during blood transfusion

1. Acute hemolytic transfusion reaction 2. Bacterial sepsis 3. Severe febrile non-hemolytic transfusion reaction 4. Bradykinin mediated hypotension 5. TRALI 6. Anaphylaxis

Risk factors for HAPE

1. Ascent profile 2. Infection 3. Sedatives 4. Previous HAPE 5. Cold weather 6. Exertion 7. Young (<20) 8. pHTN 9. Left to right shunt 10. Re-entry to altitude

Complications of myocardial infarction

1. Bradyarythmia/AV block 2. Tachyarythmia 3. Cardiogenic shock 4. LV free wall rupture 5. Septal rupture 6. MV/papillary muscle rupture 7. Pericarditis a. Infarct pericarditis b. Dressler's syndrome 8. Ischemic stroke 9. Hemorrhagic stroke following fibrinolysis 10. Hyperglycemia 11. Complications of ACS treatment

Clinical features of beta blocker overdose

1. Bradycardia 2. Hypotension 3. Unconsciousness 4. Respiratory arrest/insufficiency 5. Hypoglycemia (peds) 6. Seizures 7. Bronchospasm 8. VT/VF 9. HyperK 10. Hepatotoxicity/mesenteric ischemia, renal failure

Indications for CMV seronegative products

1. CMV-seronegative pregnant women 2. Intrauterine transfusions 3. CMV-seronegative allogeneic bone marrow transplant recipients

Differential diagnosis of bradycardia and hypotension in trauma patient

1. Cardiac contusion 2. Retroperitoneal bleed -> Vagal tone 3. Bleed with beta blocker on board 4. Neurogenic shock (Dx of exclusion)

Management of ASA overdoses

1. Correct dehydration-U/O 2-3 ml/kg/h, add 5% dextrose 2. Correct hypokalemia, hypoglycemia 3. Alkalinize urine: Aim for urine pH >7.5-8 with a max serum pH 7.45-7.5 4. Hemodialysis

Diagnosis of Neuroleptic malignant syndrome

1. Development of rigidity or temperature with use of neuroleptic (97% and 98%) 2. Two of: CNS - Diaphoresis - dysphagia - tremor - incontinence - change in LOC - mutism AUTONOMIC - tachycardia - HTN LAB - leukocytosis - elevated CK 3: Not cause by another substance or disease

Components of the anatomically difficult airway

1. Difficult intubation 2. Difficult BVM 3. Difficult ventilation with supraglottic device 4. Difficult surgical airway

Six toxic effects of iron

1. Direct GI irritant 2. Direct cardiotoxicity 3. Uncouples OP 4. Free radical production 5. Capillary permeability 6. Interferes with thrombin

Factors that influence extent of caustic injury

1. Duration 2. (Type) Tissue penetration - Acid: Coagulation necrosis - Base: Liquefacation necrosis 3. Volume 4. Viscosity 5. pH/pKa 6. Concentration 7. TAR (titratable acide/alkaline reserve) (amount of neutralizing substance required to bring pH to physiologic) 8. Food in stomach

Five stages of iron toxicity

1. Early GI (0-6h) - vomiting->diarrhea+/-bleeding, pain 2. Remission (apparent recovery) (6-12h) 3. CVS/MOD (12-48h) 4. Hepatic failure - 2-5 days post ingestion 5. Late GI - scaring and possible obstruction (weeks later)

List CDC recommendations for prevention of TB transmission in the ED

1. Early identification + triage (mask + isolation for high-risk) 2. Isolation (negative pressure room) 3. PPE (surgical mask for patient, N95 mask for caregivers) 4. Preventative therapy after exposure - see BOX 5. TB skin testing (q 6 months for ED workers) 6. Consideration of BCG vaccination

Indications for dialysis in lithium toxicity

1. End-organ toxicity (ie. aLOC, CVS, Endo) 2. Inability to eliminate toxin (Renal Failure) 3. Inability to tolerate fluid therapy (CHF) 4, Arbitrary levels (>4.0mEq/L in acute, >2.5mEq/L in Chronic)

Seven major pharmacodynamic effects of TCAs

1. Fast Na channel blockade (deceased conduction) - affects phase 0 depolarization 2. α1 receptor blockade (vasodilation/hypotension/miosis/reflex tachycardia) 3. Biogenic amine (5HT/NE) reuptake inhibition (delirium/seizures/initial HTN) 4. Muscarinic receptor blockade (anticholinergic effects) 5. Histamine receptor blockade (sedation/coma) 6. K efflux channel blockade (prolongs QT - affects phase 3 repolarization) 7. GABA receptor antagonism (CNS excitation/seizures) - bind to picrotoxin site GABAA

Case definition of staph toxic shock syndrome

1. Fever >38.9 2. Diffuse rash 3. Desquamation (at 1-2wks) 4. Hypotension 5. Multisystem involvement, 3 of: a. GI, MSK, MM, Renal, Hepatic, Heme (low plate), CNS 6. Cultures - May be positive for S Aureus - Negative RMSF, Leptospirosis, rubeola

DDX of difficulties with urinary alkalanization in salicylate overdose

1. Hypokalemia (stops H+ diuresis) 2. Hypomagnesemia (stops H+ diuresis) 3. Continued Acid production 4. Pre-alkalinization urine in bag

Streptococcal toxic shock syndrome case definition

1. Hypotension 2. Multi organ involvement - Renal impairment - Coagulopatjhy - ARDS - Liver involvement - Generalized erythmatous rash - Necrotizing soft tissue infection 3. Isolation of Group A Streptococcus

DDX of high pressure alarms on ventilator

1. Inadequate sedation/analgesia - dysynchrony 2. Displaced Tube (right mainstem) 3. Obstruction by secretions of kinking of ETT 4. PTX 5. Acute bronchospasm 6. Decreased compliance (worsening CHF) 7. Overdistention of stomach (peds)

MOA of NaHCO3 in TCA overdose

1. Increases Na gradient -> overwhelms Na channel blockade 2. Reduce acidosis -> reduced binding of TCA to Na receptor 3. Improves acidosis

Phases of Caustic Injury

1. Initial necrosis, vascular thrombosis 2. Superficial layers sloughs off (day 2-5) 3. Granulation tissue forms (1-4 weeks) 4. Stricture forms due to contraction (months)

Components of clinical examination for brain death

1. Loss of consciousness 2. No motor response to pain stimuli 3. No brainstem reflexes (1) Pupillary light reflex (2) Cough reflex (3) Gag reflex (4) Oculocephalic (5) Oculovestibular 4. Apnea

What are the four hemodynamic goals of AORTIC REGURGITATION?

1. Maintain preload 2. Increase HR>/= 80 bpm (the less time you have for the blood to go back across the valve, the less regurgitation you have) 3. Maintain contractility 4. Decrease afterload (rather than a decrease in afterload, don't let it increase—don't "clamp them down").

Causes of elevated osmolar gap

1. MeOH 2. EtOH 3. Ethylene glycol 4. Propylene glycol 5. Isopropyl 6. Mannitol, sorbitol 7. Glycerol 8. Ethyl ether 9. Acetone/acetonitrile Non-toxic causes: DKA/AKA MOF/critical illness/ CRF Hyperlipid/proteinemia

CXR Findings of esophogeal rupture

1. Mediastinal air with or without subcutaneous emphysema 2. Left-sided pleural effusion 3. Pneumothorax 4. Widened mediastinum

Rosen's guidelines for dialysis in toxic alcohol ingestions

1. Metabolic acidosis 2. Electrolyte imbalances 3. Renal compromise 4. Visual symptoms (MeOH) 5. Deterioration in condition

Side effects of succinylcholine

1. Paralysis (fasciculations) 2. Bradycardia (children) 3. Hyperkalemia 4. Increased IOP (possibly) 5. Masseter spasm (children) 6. Malignant hyperthermia

Generally agreed indications for platelet tranfusion

1. Patients with non-immune thrombocytopenia and clinically significant bleeding platelet count < 50 x 109/L. 2. Head trauma or life threatening hemorrhage platelet count <100 x 109/L. 3. Platelet dysfunction from congenital or acquired causes (e.g., cardiopulmonary bypass surgery) and clinically significant bleeding. 4. Immune mediated thrombocytopenia with severely reduced platelet count (<20 x 109/L) and severe bleeding. 5. massive transfusion protocol

Components of the determination on brain death

1. Presence of unresponsive coma 2. Absence of brainstem reflexes 3. Absence of respiratory drive after a CO2 challenge In addition: -cause of coma must be known and must be consistent with permanent cessation of brain function - Conditions that may mimic a brain death must be ruled out.

Acid Base Effects of ASA

1. Resp alkalosis: direct stimulation of medullary resp centre (increases sensitivity of resp center to PCO2) 2. Metabolic acidosis: uncouples oxidative phosphorylation (primary cause of toxicity) 3. Metabolic alkalosis: contraction alkalosis 4. Resp acidosis: ASA induced ALI or resp muscle fatigue → preterminal event

Can't miss diagnosis of headache

1. SAH 2. CO poisoning 3. Temporal arteritis 4. Bacterial meningitis 5. Acute Glaucoma 6. Hypertensive Crisis/PRES 7. Brain abscess 8. Subdural hematoma 9. Shunt failure 10. HACE 11. preeclampsia

Ways to get an arterial gas embolism

1. Surgery (CVS, Obs/Gyn, NSx, Ortho) 2. Vascular access 3. Pulmonary injury (ETT, Diving) 4. Hydrogen peroxide ingestion

Mechanism of action of tetanus toxin

1. Tetanospasmin binds motor endplate and moves up axon 2. Binds inhibitory neurons, preventing release of GABA and glycine (motor excitation and spasms) 3. Binds to preganglionic centers (autonomic dysfunction) 4. Irreversible (new axons must form for recovery)

Risk factors for toxic shock syndrome

1. Use of superabsorbent tampons 2. Postoperative wound infection 3. Post-partum period 4. Nasal packing 5. Bacterial infections 6. Influenza A 7. Varicella 8. DM 9. HIV 10. Chronic cardiac disease 11. COPD

Factors affecting hydrocarbon toxicity

1. Viscosity (low viscosity = increase aspiration potential) 2. Volatility (propensity to form gas; high volatility can displace O2 causing hypoxia) 3. Surface Tension (low surface tension = greater dispersal) 4. Chemical Side Chains

BNP - EFFECT - CUTOFFS

1. sodium excretion 2. vasodilation 3. inhibit renin <100 = no CHF >500 = CHF Dx

Adverse effects of positive pressure ventilation

1. ↑ intra-thoracic pressure causing: - ↓venous return and CO - Air trapping (iPEEP) - Barotrauma - ↑ V/Q ratio 2. Infection 3. Respiratory alkalosis 4. Agitation and ↑ distress 5. ↑ WOB if dysynchrony with vent

Fractional Excretion of sodium

100 x (Na(urine) x Cr(plasma)) / (Na (serum) x Cr(urine)) <1% pre-renal

How much fetal blood transfusion can be treated with a 300 microgram dose of rhogam

15 ml RBC 30ml whole blood For every 0.5ml more of blood an additional 10mcg rhogam is needed

Normal Volume of pericardial fluid

15 to 50ml

Volume central conducting airways

150ml

Cormack-Lehane score

1: Full view of glottis 2: Partial view of glottis 3: Epiglottis only 4: No epiglottis or glottis

ASA Anasthesia Classifcation System

1: Healthy 2: Systemic disease, no functional limitation 3: Systemic disease, marked functional limitation 4: Systemic disease, constant threat to life 5: Moribund

Mallampatti

1: soft palate, uvula, fauces, and pillars visible 2: soft palate, uvula, fauces visible 3. soft palate, base of uvula visible 4: only hard palate visible

Classification of frostbite

1st degree - Erythema and anesthesia 2nd degree - Erythema, edema, and superficial vesicles 3rd degree - Hemorrhagic vesicles 4th degree - Injuries extend into deep tissues

Depth of injury in thermal burns

1st degree: Superficial/epidermal damage (no blistering) 2nd degree: Superficial partial thickness: epidermis and papillary dermis Deep partial thickness: to reticular dermis 3rd degree: Full thickness through dermis 4th degree: Extend to SQ tissue/connective tissue/bone/muscle

Causes of hypercalcemia

1° Hyperparathyroidism Malignancy Medications • Thiazides • Lithium • Estrogens • Vitamin A/D toxicity Granulomatous diseases • Sarcoid • TB • Coccidiomycosis • Histioplasmosis Endocrine disorder • ↑ thyroid • Adrenal insufficiency • Pheochromocytoma • Acromegaly

SIRS criteria

2 or more of: 1. Temp >38 °C or <36 °C 2. RR >20 or PCO2 <32 3. HR >90 4. WBC >12, <4, or >10% bands

Urine Osmolar Gap in NAGMA

2(Na+K) + (Urea + Glucose) In NAGMA should be >150 Less implies deficity in NH4 excretion

SILENT (Syndrome of irreversible lithium-effectuated neurotoxicity)

2/12 after Li cessation, cerebellar damage/dysfunction, vacuolization in brain, EPS, brainstem dysfunction, Dementia. Fever is a poor prognostic sign

Carbon monoxide half life at various O2 concentration

21%: ~5 hours 100% ~ 1 hour HBO: ~ 30 minutes

Threshold for ED treatment of SBP based upon ascitic fluid cell count

250 neutrophil cells/mm3

TPN Calculations

25kcal/kg = Energy Requirements 1g/kg/day = Protein requirements kcal/gram protein = 4 Non-protein calories =2/3 carbohydrate and 1/3 lipid kcal/gram carbohydrate = 3.4 kcal/gram lipid = 10 kcal/ml of propofol = 1.1.

Components of NIH Stroke Scale

3 ORIENTATION (1) LOC (2) Orientation to month/age (3) 2 step command 2 Eye (1) Horizontal gase (2) Visual fields by confrontation 4 Motor (1) Facial palsy (2) Motor arm (3) Motor leg (4) Limb ataxia 2 Sensory (1) Sensory - noxious stimuli (2) Neglect/extinction 2 Language (1) Language comprehension (2) Dysarthria

Surviving Sepsis Campaign Bundles 3 hour 6 hours

3 hour 1) Measure lactate 2) Obtain blood cultures prior to antibiotics 3) Administer broad spectrum antibiotics 4) Administer 30 mL/kg crystalloid for hypotension or lactate 4mmol/L 6 hour 1. Apply vasopressors for ongoing hypotension 2. Re-assess volume status if hypotension persists • Repeat focused exam OR TWO OF THE FOLLOWING: • Measure CVP • Measure ScvO2 • Bedside cardiovascular ultrasound • Dynamic assessment of fluid responsiveness with passive leg raise or fluid challenge 3. Re-measure lactate if initial lactate elevated.

Relationship between fsw and atm

33fsw = 2ATM 66fsw = 3ATM 99fsw = 4 ATM 23mmHg per foot As a result of Boyle's law Fractional changes in volume are greatest near the surface

Class I Pacemaker implantation conditions

3° AV block and 1 of: • Symptomatic ↓ HR • Asystole > 3 sec or escape <40 bpm • Post catheter ablation AV node • Post-operative not expected to resolve • Neuromuscular disease Symptomatic 2° AV block regardless of type/site Bi/trifascicular block with intermittent AVB AMI and 2° or 3° AV block Symptomatic ↓ HR due to sinus node dysfunction Recurrent syncope due to carotid sinus stimulation

High risk period for neutropenia after chemotherapy

5 - 15 days after last dose Nadir is typically day 5 - 10

The D's of a posterior circulation stroke

5 D's Dizziness Dysphagia Dysarthria Diplopia Dystaxia

Serum pH to target in TCA overdose

7.5 - 7.55

Rule of 9's for TBSA

9% for head, arms, 18% for legs and trunk and abdomen, 1% for groin Infants: head and trunk 18%, legs 14%, arms 9%, 1% for groin

Recommended FMC to balloon time if STEMI seen at PCI Capable hospital

90 minutes

CBS Recommednations of prophylactic platelet transfusion

<10 for hospitalized/therapy induced thrombocytopenia <20 for CVC placement <50 LP <50 non-neuraxial surgery Consider CABG with peri-op bleeding

Unsecured cerebral aneurysm blood pressure target

<160mm Hg Systolic

Cortisol levels for diagnosis of adrenal insufficency

<415 is diagnostic, >930 excludes; cosyntropin with <250 change is diagnostic. If critically ill and <930, consider treating empirically, but if can do cosyntropin, look for delta 250 as described

Positive family history of CAD

<55 years old in 1st degree male relative <65 years old in 1st degree female relative

Causes of Acute liver failure

A Acetaminophen, hepatitis A, autoimmune hepatitis, Amanita phalloides (mushroom poisoning), adenovirus B Hepatitis B, Budd-Chiari syndrome C Cryptogenic, hepatitis C, CMV D Hepatitis D, drugs and toxins E Hepatitis E, EBV F Fatty infiltration - acute fatty liver of pregnancy, Reye's syndrome G Genetic - Wilson disease H Hypoperfusion (ischemic hepatitis, SOS, sepsis), HELLP syndrome, HSV, heat stroke, hepatectomy, hemophagocytic lymphohistiocytosis I Infiltration by tumor

Definition of minimally concious state

A state of severely altered consciousness in which minimal but clearly discernible state (MCS) behavioural evidence of self- or environmental awareness is demonstrated MCS is characterised by inconsistent, but reproducible, responses above the level of spontaneous or reflexive behaviour, which indicate some degree of interaction with their surroundings

Definition of vegetative state

A state of wakefulness without awareness in which there is preserved capacity for stimulus-induced arousal, evidenced by sleep-wake cycles and a range of reflexive and spontaneous behaviours

Stanford classification system of Thoracic Aortic Dissection

A: Ascending aortia involved B: Descending aorta only (distal to left subclavian)

Levels of PPE

A: Greatest level of eyes, skin, and mucus membranes Includes SCBA and fully encapsulating chemically protective suit FULLY ENCAPSULATED B: Greatest level of respiratory protection but lesser eye and skin Includes SCBA and chemical resistant clothing suit HOODED SUIT C: Known/quantified respiratory substance where skin and eye exposure unlikely Air purifying respirator and chemical resistant suit AIR PURIFYING RESPIRATOR D: Work uniform for nuisance contamination only CONTEXT SPECIFIC

Contraindications to air medical transport ABSOLUTE RELATIVE

ABSOLUTE Cardiac arrest in progress Unlikely to survive Imminent obstetrical delivery DNR Head injury with increased ICP and pneumocephalus Respiratory failure with persistent hypoxemia on PPV and high FiO2 Decompression sickness RELATIVE Severe hypoxia Trapped gas that cannot be vented 12-24h after scuba diving Active labour Psychosis/dangerous patient SCD Recent casting Severe anemia Occular surgery within 2 weeks

guidelines regarding size of pneumothorax ACCP BTS

ACCP Small: <3cm apex to cupola Large: 3cm or more from apex to cupola BTS Measure lung margin to chest wall at level of hilum Small: <2cm Large: 2cm or more

Medications with mortality benefit in chronic heart failure

ACEi/ARB Beta blocker Aldosterone (Class III/IV)

Causes of primary adrenal insufficency ACUTE CHRONIC

ACUTE Adrenal hemorrhage (meningococcemia, anticoagulation, trauma, pregnancy) anticardiolipin antibody syndrome CHRONIC Autoimmune (Addison's) - isolated or PGA TB and disseminated infections (HIV) Metastatic ca (breast, lung) Infiltrative (hemochromatosis, amyloid) Congenital (eg CAH) Bilateral adrenalectomy Drugs (etomidate, ketoconazole, rifamipicin)

Causes of respiratory acidosis ACUTE CHRONIC

ACUTE Airway disturbances • Obstruction • Aspiration Pulmonary Disease • Pneumonia • Edema Thoracic cage disorders • Pneumothorax • Flail chest ↓ vent 2° NMD • Myasthenia • CNS injury • GBS Drug-induced CNS ↓ CHRONIC Lung Disease • COPD • IPF NMD • Myasthenia • Muscular dystrophy Obestity hypoventilation

Causes of secondary adrenal insufficency ACUTE CHRONIC

ACUTE Pituitary apoplexy (hemorrhage) Postpartum pituitary necrosis (Sheehan's) TBI Relative adrenal insufficiency (sepsis, trauma) Chronic Pituitary tumour (primary or metastatic) Pituitary surgery or irradiation Chronic steroid use with functional deficiency Infiltrative (sarcoid, TB) TBI Postpartum pituitary necrosis (Sheehan's) Empty sella syndrome

Advantages and disadvantages of non-invasive positive pressure ventilation

ADVANTAGES 1. Preserves speech, swallowing, airway reflexes 2. ↓ airway trauma 3. ↓ VAP rate 4. ↓ LOS/ICU 5. Available for patients who decline ETT 6. ↓ intubation (COPD, CHF) 7. ↓ mortality (COPD, possibly CHF) DISADVANTAGES 1.. Same as PPV above (barotrauma) plus 2. Aerophagia 3. Pressure ulcer 4. Trauma to eyes (corneal abrasions) 5. Claustrophobia 6. Aspiration

AHS Hypothermia Classification

AHA Classification of hypothermia severity Mild: 34.1 - 35 Moderate: 30-34 Severe: <30

TIMI SCORE

AMERICA: Age > 65 Markers (increased serum cardiac markers) EKG (ST depression) Risk factors (3 or more CAD risk factors) Ischemia (2 or more anginal events/24 hours) CAD (prior coronary stenosis of 50% or more) Aspirin use within past 7 days

Drug causes of pancreatitis

ANLGESICS Tylenol ASA/salicylates Opiates Indomethacin AEDs VPA Carbamazepine IMMUNOSUPRESSANTS Steroids Cisplatin Azathioprine Cyclosporine GI H2-blockers Octreotide CVS Methyldopa Furosemide Thiazides Clonidine Enalapril Ergotamine Procainamide ABX Metronidazole Erythromycin Nitrofurantoin Tetracycline TMP-SMX INH Rifampin OTHER Accutane Colchicine Estrogens/OCP Organophosphates

Infarct syndromes Anterior Cerebral Middle Cerebral Posterior Cerebral Fisher Lacunar Syndrome

ANTERIOR CEREBRAL ARTERY Apathy, abulia, disinhibition Conjugate eye deviation Contralateral motor/sensory loss leg > arm MIDDLE CEREBRAL ARTERY Aphasia (dominant hemisphere) neglect (nondominant hemisphere) Contralateral motor/sensory loss face/arm > leg POSTERIOR CEREBRAL ARTERY Contralateral homonyous hemianopia Visual agnosia Alexia Agraphia Fisher Lacunar Stroke Sydromes Pure motor stroke Pure sensory stroke Mixed sensoriomotor stroke Ataxic hemiparesis Dysarthria/clumsy hand

Medications associated with Immunethrombocytopenia purpura (ITP)

ANTIBITOICS Ampicillin Cephalexin Gentamicin Penicillin Rifampin Trimethoprim-Sulfamethoxazole Vancomycin CARDIOVASCULAR Acetazolamide Amiodarone Chlorothiazide Digoxin Furosemide Methyldopa Procainamide Quinidine Quinine (tonic water) Spironolactone ANALGESICS Acetaminophen Aspirin Allopurinol Morphine Lidocaine NEUROLOGIC/PSYCHIATRIC Carbamazepine Diazepam Phenytoin Tricyclic antidepressants Valproic acid MISCELANEOUS Heparin Cimetidine Ranitidine

Medications implicated in ITP

ANTIMICROBIALS Ampicillin Cephalexin Gentamicin Penicillin Rifampin Trimethoprim-Sulfamethoxazole Vancomycin Quinidine Quinine (tonic water) ANALGESICS Acetaminophen Aspirin Morphine Lidocaine ANTICONVULSANTS/PSYCHATRIC Carbamazepine Valproic acid Tricyclic antidepressants Diazepam Phenytoin CVS Acetazolamide Amiodarone Chlorothiazide Digoxin Furosemide Spironolactone Procainamide MISCELANEOUS Allopurinol Chlorpheniramine Cimetidine Heparin Methicillin Methyldopa Minoxidil Ranitidine

Causes of Progressive Paralysis ASCENDING DESCENDING OTHER

ASCENDING GBS Tick paralysis DM EtOH Spinal abscess or hematoma Buckthorn Rabies Polio Vit deficiency B1/B6/B12 Heavy Metals VZV/CMV/WNV CNS infections ALS DESCENDING Botulism MG Lambert- Eaton Diphtheria Tick paralysis (if bitten on head) Miller-Fischer syndrome (GBS) Organophosphate poisoning Poison Hemlock/Nicotine Pontine infarction OTHER Paralytic shellfish Tetrodotoxin (Puffer, BR octopus) Neurotoxic shellfish Ciguatoxin (also: Gila monster, Grayanotoxins, Aconitine, Veratrum) Periodic familial periodic paralysis Thyrotoxic periodic paralysis HIV Hypophosphatemia Hypomagnesemia Porphyria Lyme disease Paraneoplastic Coral Snake DCS II (spinal cord syndrome)

Recommended intervention for choking children >1 year of age and adults who have severe obstruction but are concious

Abdominal thrusts If not effective consider chest thrusts (especially pregnant or obese)

Contraindications to hyperbaric therapy

Absolute Untreated tension pneumothorax .;~ Relative Upper respiratory infections Emphysema with C02 retention;~ Asymptomatic air cysts or blebs on the lungs History of thoraic/ear surgery Uncontrolled high fever Pregnancy Claustrophobia (see complications ofHBO)

Summary of Stewart Approach

Acid base status determined by three independent variables (1) PCO2 (2) [ATOT] total plasma concentration of the weak non-volatile acids, inorganic phosphate, serum proteins, and albumin (3) [SID] difference between the sums of concentrations of the strong cations and strong ions

Causes of Vasopressor Refractory Shock

Acidosis Hyper/hypothyroid Anaphylaxis Adrenal insufficency Hypocalcemia Occut bleeding Toxicologic LVOT

Contraindications to systemic anticoagulation

Active bleeding High risk of bleeding (hemophilia, thrombocytopenia) History of GI bleeding Severe hepatic disease Allergy On current anticoagulation Palliative High falls risk

General Summary of Heavy Metal Poisoning

Acute 1. N/V/D 2. ATN 3. Cardiomyopathy 4. Dysrhythmias 5. aLOC 6. Peripheral Neuropathies (wrist drop classic for lead) Chronic 7. CNS Sx more than GI 8. Hematological Sx - Sideroblastic (lead) - Hemolysis also 9. Rashes and colored lines (Mee's Lines)D 10. CRF

Pathophysiology of tick paralysis

Adult tick attaches itself and releases neurotoxin from salivary glands while feeding (Ixobotoxin) o Toxin affects sodium flux across axonal membrane at NMJ oResults in failure to release ACh (ascending paralysis) oRapid reversal when toxin gone

Risk factors for ACEi induced angioedema

African smoking older age female (DM ↓ risk)

Risk factors for pregnancy induced HTN

Age < 20 1st pregnancy Multiple gestation Molar pregnancy ↑ cholesterol Pre-gestational DM Obesity FHx or personal history of GHTN

Additional exclusion criteria for tPA from 3 to 4.5 hours window

Age >80 years Severe stroke (NIHSS>25) Taking an oral anticoagulant regardless of INR History of both DM and prior ischemic stroke

Management of tumor lysis syndrome

Aggressive hydration Allopurinol Rasburicase (recombinant urate oxidase) Dialysis Supportive care for electrolyte abnormalities

Differential Diagnosis of Hemoptysis

Airway Disease Bronchitis (acute or chronic) Bronchiectasis Neoplasm (primary and metastatic) Trauma Foreign body Parenchymal Disease Tuberculosis Pneumonia, lung abscess Vascular Disease Pulmonary embolism Arteriovenous malformation Aortic aneurysm Pulmonary hypertension Vasculitis (Wegener's granulomatosis, systemic lupus erythematosus [SLE], Goodpasture's syndrome) Hematologic Disease Coagulopathy (cirrhosis or warfarin therapy) Disseminated intravascular coagulation Platelet dysfunction Thrombocytopenia Cardiac Disease Congenital heart disease (especially in children) Valvular heart disease (e.g. Mitral stenosis) Endocarditis Miscellaneous Cocaine Postprocedural injury Tracheal-arterial fistula

Causes of secondary pneumothorax

Airway Disease • COPD • Asthma • CF Interstitial Lung Disease • Sarcoidosis • IPF • Tuberous sclerosis • Lymphangiomyomatosis • Pneumoconioses Neoplasms (1° and 2°) Infections • Necrotizing pneumonia/lung abscess • PCP (often bilateral), HIV • TB Miscellaneous • CTD • Pulmonary infarction • Endometriosis/ catamenial PTX

Clinical criteria for anaphylaxis

All definitions require rapid onset (minutes to hours) 1. Involvement of the skin, mucosal tissue, or both AND AT LEAST ONE OF THE FOLLOWING: A) Respiratory compromise B) Reduced blood pressure or associated symptoms of end-organ dysfunction 2. TWO OR MORE of the following after exposure to a likely allergen for that patient A) Involvement of the skin-mucosal tissue B) Respiratory compromise C) Reduced blood pressure or associated symptoms D) Persistent gastrointestinal symptoms 3. Reduced BLOOD PRESSURE after exposure A) Infants and children: low systolic blood pressure (age-specific) or greater than 30% decrease in systolic blood pressure B) Adults: systolic blood pressure of less than 90 mm Hg or greater than 30% decrease from that person's baseline

Contraindications to Non-Invasive Positive Pressure Ventilation

Altered MS Absence of protective airway reflexes Excessive secretions Severe respiratory failure Significant hemodynamic instability Lack of patient co-operation Facial surgery/patient anatomy precluding mask fit Upper airway obstruction

Antibiotics with concentration dependent effects

Aminoglycosides Daptomycin Fluoroquinolones Metronidazole Azithromycin Ketolides

Henry's Law

Amount of gas dissolved in a liquid is proportional to partial pressure of gas at depth So nitrogen comes out solution on ascent

Drugs associated with G-6PD Deficiency Hemolysis

Analgesics and antipyretics- ASA Antimalarials - primaquine, quinine Nitrofurantoin Sulfa drugs - Septra, diamox Miscellaneous fava beans, methylene blue, BAL

DDX of allergic reaction during transfusion

Anaphylaxis Minor Allergic reaction (most commonly urticaria)

Malaria Vector

Anopholes mosquito

Risk factors for AMS/HACE

Ascent profile Infection EtOH/Sedatives Genetics Dehydration Low Residence altitude

Charles Law

At a constant pressure temperature and gas volume are directly related V1/T1 = V2T2 Tank left in sun can increase pressure and explode Pressure decreases as regulator gas cools

Boyle's Law

At a constant temperature pressure is inversely proportional to volume P1V1 = P2V2 So gas filled spaces contract with descent and expand with ascent

Diagnosis of Peritoneal dialysis infection

At least 2 of 3: (1) Signs of peritonitis (2) Effluent cell count with WBCs more than 100/μL (after a 2 hour dwell) with at least 50% neutrophils (3) Positive gram stain/culture

Specific Arrhythmias with digoxin toxicity

Atrial fib with slow, regular ventricular rate (AV dissociation) Nonparoxysmal junctional tachycardia (rate 70-130) Atrial tachycardia with block (atrial rate 150-200) Bidirectional VT

Mannitol Beneficial effects Cautions

BENEFICIAL (1) osmotic gradient to reduce CE (2) Initial volume expander (later diuretic) (3) Free radical scavenger (4) Reduced viscosity to increase CBF CAUTIONS (1) Diuresis -> hypotension (2) Decompress hematoma -> bleed (3) Renal failure

Bedside index for severity in acute pancreatitis (BISAP)

BISAP BUN >8.92 Impaired mental status SIRS Positive Age >60 Pleural effusions present Mortality 22% with score of 5

Airway assessment Mnemonics BVM DL SUPRAGLOTTIC SURGICAL

BVM M Mask seal O Obsesity/obstruction A Age >55yo N No Teeth S snoring/stiff lungs DL L Look externally (clinical gestalt) E Evaluate (3-3-2) 3 Mouth Opening 3 Thyromentaldistance 2 Hyomental distance M Mallampati O Obesity/obstruction N Neck mobility limited SUPRAGLOTTIC R Restricted mouth opening O Obstruction D Disrupted/distorted airway anatomy S Stiff lungs SURGICAL S Surgery M Mass A Anatomical/access problems (obesity, edema( R Radiation T Tumor

DDX of fever during transfusion

Bacterial sepsis/contamination Acute Hemolytic Transfusion Reaction Febrile Non-Hemolytic Transfusion Reaction

Three stroke syndromes that can cause coma

Basilar artery thrombosis Large hemispheric strokes (ie. big MCA territory) Stroke with mass effect (posterior fossa, others)

Management of Tetanus infection

Benzos (antagonize toxin) Dantrolene Magnesium infusion Paralysis Labetalol for sympathetic hyperactivity Pace bradycardia TIG Tetanus toxoid (Vaccine) Clean wound Flagyl to kill any bacteria present

Antibiotics with time dependent effects

Beta-lactams Vancomycin Carbapenems

Deep Tendon Reflexes

Biceps: C5, C6 Brachioradialis: C6 Triceps: C7 Patellar: L4 Achilles Tendon: S1

Examples of incomplete trifascular block

Bifascicular block + 1st degree AV block (most common) Bifascicular block + 2nd degree AV block RBBB + alternating LAFB / LPFB

Signs of basal skull fracture

Blood in ear canal Hemotympanum Rhinorrhea Otorrhea Battle's sign (retroauricular hematoma) Raccoon sign (periorbital ecchymosis) Cranial nerve deficits - Facial paralysis - Decreased auditory acuity - Dizziness - Tinnitus - Nystagmus

Malignancies commonly associated with hypercalcemia

Breast Lung Head and Neck cancers Kidney Multiple myeloma Leukemia

AIDS Defining Conditions

Burkitts Lymphoma Candidiasis of bronchi, trachea, or lungs or esophagus Candidiasis of esophagus† Cervical cancer, invasive§ Coccidioidomycosis, disseminated Cryptococcosis, extrapulmonary Cryptosporidiosis, chronic intestinal Cytomegalovirus disease/retinitis Encephalopathy, HIV related Herpes simplex: disseminiated Histoplasmosis, disseminated or extrapulmonary Isosporiasis, chronic intestinal Kaposi sarcoma† Lymphoma, CNS Mycobacterium avium complex Mycobacterium tuberculosis of any site, pulmonary,†§ disseminated,† or extrapulmonary† Pneumocystis jirovecii pneumonia† Progressive multifocal leukoencephalopathy Salmonella septicemia, recurrent Toxoplasmosis of brain, onset at age >1 month† Wasting syndrome attributed to HIV CD4 <200

CHADS2 Score Stroke Risk

C Congestive heart failure 1 H Hypertension: 1 A Age ≥75 years 1 D Diabetes mellitus 1 S2 Prior Stroke or TIA or Thromboembolism 2 Score and %Annual Stoke risk 0: 1.9 1: 2.8 2: 4.0 3 :5.9 4: 8.5 5: 12.5 6: 18.2

Pathophysiology of hereditary angioedema

C1 Esterase Deficency

Treatment options for hereditary angioedema

C1 inhibitor concentrate (plasma-derived) (Berinert, Berinert P, Cinryze) In United States: Recombinant C1 inhibitor Conestat alfa (Ruconest, Rhucin) Bradykinin B2 receptor antagonist Icatibant (Firazyr) Kallikrein inhibitor Ecallantide (Kalbitor) Plasma

Dermatomal Sensory examination

C2: Occiput C3: Thyroid cartillage C4: Upper shoulder C5: Lateral arm near elbow C6: Thumb C7: Dorsum Middle finger C8: Dorsum pinky finger T1: Medial Arm near eblow T4: Nipple level T10: Umbillicus L1: Femoral puslse L2: Medial thigh L3: Medial leg near knee l4: Medial Malleolus L5: Dorsum of foot S1: Sole of foot

Dermatomal Motor Examination C5 through T1 L2 through S1

C5: Elbow Flexion C6: Wrist extension C7: Elbow extension C8: Finger flexors T1: Finger abduction L2: Hip flexion L3: Knee extension L4: Ankle dorsiflexion L5: Long toe extension S1: Ankle plantar flexion

Differential diagnosis of asthma/wheeze

CARDIAC Valvular heart disease Congestive heart failure LUNG PARENCHYMA COPD exacerbation Pneumonia Allergic bronchopulmonary aspergillosis Löffler's syndrome UPPER AIRWAY ANAPYLAXIS Laryngeal neoplasm Foreign body Vocal cord dysfunction ENDOBRONCHIAL DISEASE Neoplasm Foreign body Bronchial stenosis Carcinoid tumor Allergic or anaphylactic reaction MISCELLANEOUS GERD Noncardiogenic pulmonary edema

Etiologies of stroke in youger patients and associated risk factors

CARDIAC DISEASE Congenital heart disease PFO Arrythmia Myocarditis/cardiomyopathy Endocarditis Rheumatic heart disease HEMATOLOGIC Sickle cell disease Inherited coagulopathy Acquired prothrombotic state - Lupus - Pregnancy - OCPs - Nephrotic syndrome - Malignancy VASCULAR -NON INFLAMMATORY Dissection (aortic, vertebral, carotid) -Fibrmuscular dysplasis - Marfan's - Traumatic Moyamoya - Primary - Secondary (Down's, Neurofibramatosis) -INFLAMMATORY Vasculitis Infectious/post-infectious METABOLIC Inheritbed matbolic disease (Fabry, Menkes) INGESTION Cocaine, amphetamines

Causes of shock

CARDIOGENIC - Impaired contractility - Mechanical complication - Valvular dysfunction - LVOT RHYTHM - Too fast - Too slow - No atrial kick OBSTRUCTIVE - INTRAVASCULAR PE Air embolus Occlusive vascular lesion - EXTRAVASCULAR Abdominal compartment syndrome Tension pneumothorax Cardiac tamponade Pneumomediastinum Caval compression Dynamic hyperinflation HYPOVOLEMIC Hemorrhagic - Trauma - Atraumatic Non-Hemorrhagic DISTRIBUTIVE - Sepsis - Neurogenic - Liver failure - AI - Anaphylaxis - Post bypass vasoplegia ENDOCRINE - Severe acidosis - Thyroid disease - AI - Drugs ? Measurement errors

Test in work-up of hemolytic anemia

CBC with peripheral smear Reticulocyte count Direct antiglobulin (Coombs) test LDH, Bilirubin, and Haptoglobin

Severe manifestations and clinical features of malaria falciparum that increase mortality

CEREBRAL malaria - Decrease LOC - Prostration - Not feeding - Multiple seizures MULTI-ORGAN DYSFUNCTION METABOLIC Hypoglycemia Metabolic acidosis (lactate) Jaundice Severe anemia Acute renal failure ARDS - Respiratory distress - Pulmonary Edema DIC - Spontaneous bleeding -Hemoglobinuria Circulatory collapse Hyperparasitemia (>5%)

Hydrocarbons to decontaminate via NG Lavage

CHAMP 1. Camphor (Sz) 2. Halogenated hydrocarbons (Chloral) (dysrhythmias and hepatotoxicity) 3. Aromatic hydrocarbons (Toluene) (bone marrow suppression/cancer) 4. Containing Heavy Metals (As, Hg, Pb) 5. Containing Pesticides (cholinergic tox

Risk factors requiring further evaluation of hematuria in: CHILDREN ADULTS

CHILDREN Trauma Flank or abdominal pain Hypertension Edema Proteinuria (>2+ on dipstick) Signs of coagulopathy ADULTS Trauma Abdominal pain Age older than 40 years Cigarette smoking Occupational exposure Analgesic abuse Persistent hematuria

Radio-Opaque Toxins

CHIPES Chloral hydrate, calcium Halogenated hydrocarbons, Heavy metals Iron, Iodines Phenothiazines, Potassium, Packets (condoms) Enteric coated preparations Solvents, Salicylate

CLASSICAL VERSUS EXERTIONAL STROKE

CLASSICAL Older, sedentary patients Predisposing risk factors or medications Heat waves Anhidrosis Normoglycemia Mild coagulopathy Mild CK elevation Oliguria Mild acidosis Normocalcemia EXERTIONAL Heathy/Young/Strenuous exertion Sporadic Rhabdomyolysis Renal failure Hypoglycemia Coagulopathy Marked Lactic acidosis Hypocalcemia

Myxedema Coma CLINICAL FEATURES TREATMENT

CLINICAL FEATURES Decreased mental status Hypothermia Bradycardia Hyponatremia Hypoglycemia Hypotension Precipitating illness TREATMENT IV corticosteroids prior to thyroid hormone replacement T4 preferred for elderly/cardiac patient T3 for young and healthy

Thyroid Storm CLINICAL FEATURES MANAGEMENT

CLINICAL FEATURES Hyperthyroid Fever AMS-trouble concentrating all the way to coma Sympathetic Surge Precipitating Event MANAGEMENT (1) Supportive IVF (glucose) cooling paracetamol (2) Beta-Blockade propanolol increments (1mg IV) or esmolol boluses -> infusion (50-100mcg/kg/min) (3) Inhibition of Thyroid Hormone Synthesis Propylthiouracil 1000mg or Methimazole 30mg PO (Maybe PTU Preferred, earlier onset and inhibits peripheral conversion of T4 to T3) (4) Inhibition of Thyroid Hormone Release via Wolf-Chaikoff Effect (1 hour after synthesis block) Saturated solution of potassium iodide (SSKI) 5 gtt by or Lugol's solution 4-8 gtt by mouth (5) Administration of Corticosteroids (inhibit T4 to T3 conversion, treat relative adrenal insufficiency) MISCELANEOUS L-Carnitine (block entry of thyroid hormone into cells), 1 g \ Cholestyramine (blocks enterohepatic recirculation of thyroid hormone), 4 g PO every 6 hr

Indications for ECG monitoring after electrical injuries

CLOAK CASH Cardiac arrest LOC Observed dysrhythmia Abnormal ECG Known cardiac disease/significant risk factor Chest pain Admission for other injuries Suspicious for conductive injury Hypoxia

Components of SOFA

CNS Glasgow Coma Scale CVS MAP/Vasopressor support RESP PaO2/FIO2, mmHg HEME Platelets RENAL Creatinine Urine output LIVER Bilirubin

Risk factors for bleeding with DOACs

CNS Previous ICH Brain metastases Recent intracranial surgery Demographic Elderly Low body weight Comorbidity Elderly Renal failure Cancer Thrombocytopenia Co prescription of antiplatelet Previous GI bleed or hematuira

Complications of RMSF

CNS Seizures Encephalopathy Peripheral Neuropathy Hearing Loss CVS/RESP Myocarditis ARDS METABOLIC/HEME DIC Renal failure DERM Skin Necrosis/Gangrene

Causes of SIADH

CNS Disease Brain tumour, infarction, injury, abscess Meningitis/encephalitis Pulmonary Disease Pneumonia TB Lung abscess Aspergillosis Drugs Vasopressin Diuretics Chlorpropamide Vincristine Thioridazine Cyclophosphamide Antidepressants Antipsychotics Malignancy

Global Oxygen Delivery

CO X CaO2

Causes of LOW Co-oximetry and HIGH Pulse Oximetry Readings

COHb MetHb Radiofrequency interference

Complications of epiglottis

CONTIGOUS SPREAD Retropharyngeal abscess Mediastinitis Meningitis LUNG PTX Empyema Pneumonia SYSTEMIC Sepsis ARDS Necrotizing fascitiis

Activated Charcoal Contraindications Complications

CONTRAINDICATIONS o a/w not protected o antidote o not absorbed, o risk of GI perforation/obstruction, o risk of aspiration. COMPLICATIONS Aspiration/vomit Corneal abrasion SBO/perf Acute appendicitis

NNT for NIPPV - COPD - ACPE

COPD 1 in 8 were helped (preventing death) 1 in 5 were helped (avoiding intubation) CHF 1 in 13 were helped (life saved) 1 in 8 were helped (prevented intubation)

High risk conditions at altitude

COPD CHF Morbid obesity Sleep apnea syndromes Coronary artery disease Sicke cell disease Symptomatic pulmonary hypertension High risk pregnancy Radial keratotomy Seizure disorder

Physiology of Non-Invasive mechanical ventilation in: - COPD - CHF

COPD: ↓ WOB improves V/Q mismatch splints airways open ↓ WOB improves V/Q mismatch ↑ CO, redistributes lung water

PJP Indications for Corticosteroids Indications for IV Septra

CORTICOSTEROIDS A-a>35 PaO2<70 SEPTRA intubated no po intake A-a>45 PaO2<60

Overview of Continuous renal replacement therapy

CRRT Dialysis Dose: ~ 25 cc/min clearance × 60 min × 24 hrs = 36 L clearance/day CRRT Fluid Removal: ~ 1-2 cc/min (50-100 cc/hr or 1.2-2.4 L/d)

Summary of physiological changes during pregnancy

CVS - Increased HR - Decreased MAP - Decreased CVP - Increased cardiac output - Supine hypotension after 20th week HEME - Increased blood volume - Decreased Hematocrit GI - Decreased sphincter tone, decreased motility, and decreased gastric pH = increased aspiration risk - Gravid uterus displaces and protects abdominal organs - Bladder is intrabdominal RESP - Decreased FRC and increased O2 consumption leads to decreased oxygen reserve - Increased RR and decreased paCO2 - Diaphragm higher EXTREMITY - Increased blood loss from LE extremity injuries to pelvic venous compression - Baseline pubic diaphasis

Indications for sodium bicarbonate in TCA overdose

CVS - ↓BP - QRS ≥ 100 msec and symptomatic - Arrhythmia (VT) Seizure (does not tx sz, marker for significant toxicity) Acidosis

Organisms that can cause dysentery

Campylobacter Salmonella Shigella Yersinea E.coli C.diff Vibrio P. shigelloides A. hydrophilia E. histolytica Stongyloides

Complications of Infective Endocarditis

Cardiac - Heart failure - Pervialvular abscess - Pericarditis/pleural effusion Septic embolization - Stroke - Renal infarction - Vertebral osteomyelitis - MSK abscess - Glomerulonephritis Metastatic abscess Mycotic aneurysm

Medications causing lupus

Cardiovascular (high) Procainamide (IA antiarrythmic) Amiodarone (III antiarrythmic) Quinidine Anti-HTN (high) Hydralazine Methyldopa Reserpine Abx (moderate) INH PCN Sulfonamides Streptomycin Tetracycline Nitrofurantoin Anticonvulsants (moderate) Phenytoin (IB antiarrythmic) Ethosuximide Anti-thyroid (low) PTU MMI Psych (low) Chlorpromazine Lithium Miscellaneous (low) Allopurinol Phenylbutazone

Indications for active rewarming

Cardiovascular instability Moderate or severe hypothermia (≤32.2° C) Inadequate rate of rewarming or failure to rewarm Endocrinologic insufficiency Traumatic or toxicologic peripheral vasodilation Secondary hypothermia impairing thermoregulation Infants/eldery

Conn's Syndrome

Cause of primary hyperaldosteronism (75%) - due to aldosterone-producing adrenal adenoma Pathophysiology: - increased aldosterone and decreased renin despite increases in volume - aldosterone -> renal Na retention, K excretion Rx: Spironolactone

Causes of Diabetes Insipidus

Central Head trauma Tumor (craniopharyngioma) ICH CNS infection Granulomatous (TB, sarcoid, Wegener's, histiocytosis) Nephrogenic Congenital renal problem PCKD Renal dysplasia Obstructive uropathy ↑ Ca, ↓ K Systemic SCD Sarcoidosis Amyloidosis Drugs Amphotericin B Phenytoin Lithium Aminoglycosides Demeclocycline Cisplatin Idiopathic

Teratogen Classes

Chemical, pharmaceutical, environmental, or mechanical agent that causes deviant or disruptive development of the conceptus A: Controlled studies show no risk B: No evidence of risk to humans - Animal studies show no risk or are negative C: May endanger fetus - Human studies lacking - Animal studies positive or lacking - Benefit may outweigh harm D: Positive evidence of risk - Benefit may outweigh harm X: Drugs contraindicated in pregnancy based on human or animal studies and benefits not outweighed by harms

Intermediate to low solubility pulmonary irritants

Chloride Hydrogen sulfide Phosgene

Physical exam findings in hypocalcemia Chovstek's sign Trousseau sign

Chovstek's sign tapping facial nerve causes muscle twitch Trousseau sign BP cuff X3 min → carpal spasm

Features that suggest tuberculosis rather than CAP

Chronic symptoms Failing to improve with routine medications Relapse following fluroquinolone administration Relapse following corticosteroid administration Gram stain with weakly positive/negative rods Signs of healed TB on CXR Pneumothorax Pleural effusions

Potential MAOi drug interactions

Classes of MAOi drug interactions Sympathomimetics (Drugs us abuse and pscyhiatric) Methylxanthines Serotonergic agents (SSRIs, TCAs, Lithium)

Causes of large bowel obstruction

Colorectal cancer (> 50%) Volvulus (15%) Diverticular disease (10%) External compression from metastatic disease Stricture (IBD, chronic ischemia) Fecal impaction Adhesions Hernia Pseudo-obstruction (Ogilvie's) Intussussception

Contents of Zones of Neck Common to all 3 Zones (I, II, III)

Common Vascular • Carotid artery • Vertebral artery • Jugular vein Neurological • Spinal cord Zone I Vascular • Subclavian artery • Superior mediastinal vessels Aerodigestive • Esophagus • Lung apices* • Trachea Other • Thyroid* • Thoracic duct* Zone II Aerodigestive • Esophagus • Larynx* • Trachea • Pharynx* Neurological • Vagus nerve • Recurrent laryngeal nerve Zone III Neurological • Cranial nerves IX - XII Other • Salivary/parotid glands

Disorders on descent

Common theme: Trapped air generates negative pressure as can't equalize with increased external pressure on descent (1) Middle ear barotrauma -> TM rupture (2) External ear barotrauma (3) Barosinusitis (4) Facial barotrauma (5) Inner ear barotrauma -> Round window rupture

MOA of Allopurinol

Competitive inhibitor of xanthine oxidase -Typically converts nucleic acid byproducts to uric acid -Prevents synthesis of uric acid but does not affect already formed uric acid

MOA of allopurinol

Competitive inhibitor of xanthine oxidase -Typically converts nucleic acid byproducts to uric acid -Prevents synthesis of uric acid but does not affect already formed uric acid

Concentration versus time dependent killing

Concentration (Cmax/MIC) Can also be AUC/MIC Rule of thumb -> Aim for Cmax ~ ten times MIC Time (Time > MIC) Should exceed MIC for at least 50% of dosing interval

Causes of Transudative pleural effusions

Congestive heart failure Cirrhosis with ascites Nephrotic syndrome Hypoalbuminemia Myxedema Peritoneal dialysis Glomerulonephritis Superior vena cava obstruction

20-30-40 Rule for Guillan Barre syndrome

Consider need for mechanical ventilation if: Forced vital capacity <20ml/kg Maximal inspiratory pressure <30 cm H20 Maximal expiratory pressure <40cm H20

DDX of pulsus paradoxus

Constrictive pericarditis Severe COPD/asthma Restrictive cardiomyopathy PE RV infarction with shock

Post antibiotic effect

Continued bacterial supression even after antibiotics levels fall below MIC More common with antibiotics that have concentration pharmacodynamics

Rumack-Matthew Nomogram - Nomogram 4 hour treatment threshold - Contraindications to use

Contraindications (1) Unable to measure APAP (2) Time of ingestion unknown (3) Time of ingestion > 24 h prior

Correcting serum sodium for hyperglycemia

Corrected sodium = Measured [Na+] + [3/10 × ([Glucose (mmol/L)] − 5)

Products of adrenal gland

Cortex cortisol, aldosterone, and androgens Medulla Catecholamines

Differential diagnosis of ICU acquired weakness

Critical illness polyneuropathy Critical illness myopathy Prolonged neuromuscular blockade Cerebral/brain stem infarct Spinal cord lesion Guillane barre syndrome Myasthenia gravis Eaton lambert syndrome Rhabdyomyolysis

Differential of generalized cerebral dysfunction in HIV patient

Cryptocococcal Meningitis

Features of SJS/TEN

Cutaneous lesions (Nikolsky positive) Mucosal involvement - Oral - Occular - Urogenital Complications: electrolyte imbalance hypovolemic shock with renal failure bacteremia insulin resistance hypercatabolic state multiple organ dysfunction syndrome Pnuemonitis GI complication SJS - skin detachment of <10 percent of BSA TEN - skin detachment of >30 percent of BSA SJS/TEN overlap - skin detachment of 10 to 30 percent

Ventilator Troubleshooting Mnemonics DOPES

D Dislodegement O Obstructed Tube P Pneumothorax E Equipment failure S Stacking of breaths

Potentially Dialyzable toxins

DAVI STUMBLE Dilantin Amanita toxin VPA Isopropyl alcohol Salicylates Theophylline Uremia Methanol BB/Barbiturates (phenobarb) Li Ethylene Beta-Blockers STAN Sotalol Timolol Acebutolol Nadolol

Let go current Definition Amperage - Child - Woman - Man

DEFINITION maximum value of electric current through the body of a person at which that person can release himself or herself AMPERAGE Child: 4 mA Women: 7 mA Man: 9mA

High risk features with GI Bleed

DEMOGRAPHIC Advanced age (older than 60 years) Alcoholism Current smoker COMORBIDITIES • Congestive heart failure • Diabetes • Chronic renal failure • Malignancy • Coronary artery disease History of abdominal aortic aneurysm graft History of peptic ulcer disease Known liver disease, cirrhosis MEDICATION USE • Aspirin • Nonsteroidal anti-inflammatory drugs • Steroids • Anticoagulants (warfarin, heparin) • Chemotherapeutic agents

Host factors predisposing to meningitis

DEMOGRAPHIC Age < 5 or > 60 Male Low SES Crowding African-Canadian Household contact COMORBIDITY Splenectomy SCD Alcoholism/cirrhosis DM Thalassemia major IVDU Endocarditis Immunocompromised Malignancy ANATOMIC Dural defect Recent colonization Contiguous infection (sinusitis) VP shunt

APACHE II Components

DEMOGRAPHICS Age Chronic health problems VITALS Temperature Mean arterial pressure Heart rate Respiratory rate Glasgow Coma Scale score LABS PaO2 or A-a gradient pH or serum HCO3 Sodium Potassium Creatinine Hematocrit White blood cell count

Differential Diagnosis of Stroke

DIMS VN INFECTIOUS Brain abscess Meningitis Encephalitis Cerebral malaria Endocarditis METABOLIC/TOXIC Glucose Sodium Hepatic encephalopathy Ingestion/poisoning Wernicke's encephalopathy Heat stroke STRUCTURAL Tumor Extra-axial bleed VASCULAR Thoracic aortic dissection Cranial/vertebral dissection Cerebral vasculitis Sickle cell crisis NEUROLOGICAL Hemipalegic migraine Todd's paralsysis Non-convulsive status epilepticus Myelopathy Peripheral neuropathy

NOACs Direct Xa Inibitors Thrombin Inhibitor

DIRECT Xa Apixaban Rivaroxaban THROMBIN Dabigatran

Risk factors for NMS

DRUG RELATED Rapid drug loading IV formulations Typical high potency antipsychotics - Loxapine - Haloperidol PATIENT RELATED Dehydration Hx of NMS Preceding psychomotor agitation prior to neuroleptic

Differential diagnosis of a double gap

DRUGS 1. MeOH 2. Ethylene glycol 3. Propylene glycol 4. Acetonitrile CONDITIONS 1. DKA 2. AKA 3. MOF 4. CRF

Causes of Status Epilepticus

DRUGS INGESTION/INTOXICATION Bupropion Camphor Clozapine Cyclosporine Flumazenil Fluoroquinolones Imipenem Isoniazid Lead Lidocaine Lithium Metronidazole Theophylline Tricyclic antidepressants WITHDRAWAL Alcohol Antiepileptic drugs Baclofen Barbiturates Benzodiazepines INFECTIOUS CNS abscess Encephalitis Meningitis METABOLIC Hepatic encephalopathy Hypocalcemia Hypoglycemia or hyperglycemia Hyponatremia Uremia CNS LESIONS Acute hydrocephalus Anoxic or hypoxic insult Arteriovenous malformations Brain metastases Cerebrovascular accident Chronic epilepsy Eclampsia Head trauma Intracerebral hemorrhage Neoplasm Neurosurgery Posterior reversible leukoencephalopathy Remote structural injury

Diving Disorders requiring hyperbaric therapy

Decompression sickness Arterial gas embolism Contaminated gas exposure

Goals of recompression therapy with diving injuries

Decrease Mechanical obstruction of air bubbles Increase Nitrogen washout by ↑ tissue-blood gradient Increase O2 delivery to ischemic tissues

Causes of secondary hypothermia

Decreased Heat Production Endocrinologic failure - Hypopituitarism - Hypothyroidism - Diabetes Insufficient fuel - Hypoglycemia - Malnutrition - Extreme exertion Neuromuscular inefficiency Age extremes Increased Heat Loss Environmental Induced vasodilation - Pharmacologic - Toxicologic Erythrodermas Iatrogenic - Emergency deliveries - Cold infusions - Heatstroke treatment Impaired Thermoregulation Peripheral failure - Neuropathies - Acute spinal cord transection - Diabetes Central failure, neurologic - Central nervous system trauma - Cerebrovascular accident - Hypothalamic dysfunction - Parkinson's disease - Anorexia nervosa - Multiple sclerosis Miscellaneous Associated Clinical States Sepsis Pancreatitis Cardiopulmonary disease Vascular insufficiency Uremia Multisystem trauma Wernicke-Korsakoff syndrome

Causes of Hypomagnesemia

Decreased Intake - Alcohol abuse - Starvation - TPN Redistribution - Hungry bone syndrome - Treatment of DKA - Refeeding - Pancreatitis Drug induced • Aminoglycosides • Amphotericin • B-agonists • Cyclosporine • Diuretics • Theophylline Increased losses - Renal (renal failure, post-obststructive, ATN) - GI (Diarrhea, vomiting, GI Suction, fistula) Other - Pregnancy

Pathophysiology of TTP

Deficient ADASMTS13 protease activity allows accumulation of von Willebrand Factor multimers which lead to formation of platelet plugs/microthrombi

Risk factors for lithium toxicity

Dehydration Na+ Depletion ARF/CRF Thermal Stress Preeclampsia High Li dose Drug Interaction diuretics NSAIDs ACE-I ARB Levaquin flagyl tetracycline SSRIs

CT/MRI Findings of CVST

Dense triangle sign → clot in sinus "Empty delta sign" → filling defect in sinus Absent or decreased flow Cerebral edema Hemorrhage secondary to venous congestion

Risk factors for decompression sickness

Depth of dive/Length of dive Age Obesity Fatigue/exertion Dehydration/fever Cold temp after diving Diving at altitude Flying after diving Presence of PFO Male sex (risk taking) Tobacco/EtOH use

Contrast Induced Nephropathy

Diagnosis: ↑ Cr by 25% in presence of contrast and absence of other causes; typically within 3 days and recovery within 10-14 days Risk Factors: CRI DM MM age > 60 ↓ volume ↑ dose

Etiology of Non Cardiogenic Pulmonary Edema

Direct Injury -Aspiration -Inhalation injuries -Near drowning -Pulmonary contusion -Diffuse pulmonary infection Indirect Injury -Sepsis - Mechanical ventilation -Transfusion related acute lung injury -High altitude pulmonary edema -Neurogenic insults -Pancreatitis -Cardiopulmonary bypass -Severe non-thoracic trauma -Fat emboli -Uremia -Coagulopathies -DIC DRUGS OPIODS Heroin Methadone Morphine CARDIAC Calcium channel blockers Propranolol Acetazolamide Chlorothiazide/Hydrochlorothiazide MISCELANEOUS ASA Methotrexate TCAs Protamine Oxytocin

DDX MAHA

Disseminated Intravascular Coagulation (DIC) Thrombotic Thrombocytopenic Purpura (TTP) Hemolytic Uremic Syndrome (HUS) HELLP syndrome Heparin-Induced Thrombocytopenia (HIT) Paroxysmal nocturnal hemoglobinuria Malignant hypertension Antiphospholipid syndrome Scleroderma Malignancy prosthetic valve

Description of Rash of Rocky mountain spotted fever - Distribution - Apperance

Distribution - Ankles and wrists - Then palms and soles - Followed by centripetal spread Appearance - Initially puritic blanchable macular rash - Progresses to palabple, non blanchable rash/petechiae

NINDS Recommended time intervals

Door to physician 10 min Door to CT completion 25 min Door to CT reading 45 min Door to treatment 60 min Access to neuro expertise 15 min Access to NSx expertise 2 h

Receptors Affected by Antipsychotics

Dopamine Serotonin Alpha 1 Muscarinic cholinergic Histamine Fast sodium channel Potassium channel

Significant Iron Overdoses

Dose 60mg/kg Level 90umol/L (at 4 hours)

Secondary Causes of Dementia

Drug or toxin induced Infectious (intracranial) chronic meningitis, encephalitis, abscess, HIV-1 infection, slow virus infection, neurosyphilis Cerebrovascular disease (multi-infarct dementia) Metabolic or electrolyte disturbance Endocrinopathies Nutritional Intracerebral disorders Head trauma Mass effect (tumor, hematoma, abscess) Hydrocephalus Psychiatric (pseudodementia) Other (e.g., collagen vascular disease, paraneoplastic syndrome)

DDX of Hot and Altered

Drugs - Sympathomimetics - Anticholinergics - ASA - Malignant hyperthemia - Neuroleptic malignant syndrome - Serotonin syndrome Infections - Sepsis - CNS infections - Cerebral malaria - Rabies Metabolic - Thyroid storm - CNS - Seizures - Intracebral hemorrhage

Causes of rhabdomyolysis

Drugs and toxins - Ethanol - Sympathomimetics/hallucinogens - Statins - CO - Biologic toxins (elapids, hymenoptera) - Immunosuppressants (cyclosporine) - Colchicine Infections METABOLIC Metabolic myopathies (congenital, dermato/poly myositis) Electrolyte abnormalities Endocrine (↓ thyroid, ↑ parathyroid, pheochromocytoma) Hypoxia ENVIROMENTAL Trauma and compression Electrical current Exertion Hyperthermia (NMS, MH, classic or exertional heat illness) Hypothermia

Organism associated with HUS - Transmission

E Coli O157:H7 Raw ground beef Water-borne Person-to-person

Manifestations of lyme disease EARLY DISSEMINATED EARLY (3-6 weeks) LATE

EARLY Days to weeks Erythema migrans (target/bullseye lesions) Flu like illness DISSEMINATED EARLY Neurological manifestations - Cranial neuropathy (bilateral CN VII) - Meningioencephalitis - Radiculoneuropathy MSK - Acute inflammatory large joint arthritis Cardiac - Carditis - AV nodal block most common LATE - Peripheral neuropathy - Encephalopathy - Chronic arthritis

pradiloxime (2-PAM) EFFECTS INDICATIONS

EFFECTS 1. Breaks down Organophosphates 2. Breaks down ACh-OP bond 3. Binds free Organophosphate INDICATIONS Arrhythmias CVS instability Respiratory depression/apnea Fasciculations Seizures Use of large amounts of atropine

Digibind dosing EMPIRIC AMOUNT INGESTED STEADY STATE

EMPIRIC Cardiac arrest: 20 vials IV push Acute ingestion: 10 vials over 30 minutes Chronic toxicity: 5 vials over 30 minutes AMOUNT INGESTED Based on dose ingested (1 vial binds 0.5mg digoxin) # vials = amoun (mg) x 0.8(bioavailability) / 0.5 STEADY STATE (1) Based on steady-state level (level obtained 6-8h after ingestion) # vials = serum dig level (ng/mL) x weight (kg) / 100 * - SI unit conversion: take digoxin level (ng/ml) x 1.28 = digoxin level in nmol/L

Management of caustic injuries: - Endoscopy Indications/Contraindications - Emergent OR indications

ENDOSCOPY intentional ingestions unintentional ingestions with Sx Contraindicated After 24 hours Days 2 -14 is highest risk for perforation OR Free air Peritonitis Increasing/severe CP or abdo pain Hypotension

Goldfrank's guidelines for blockade and dialysis in Toxic Alcohols

ETHYLENE GLYCOL BLOCKADE 4 mmol/L DIALYSIS 8 mmol/L METHANOL BLOCKADE 8 mmol/L DIALYSIS 16 mmol/L

Heat exhaustion versus heat stroke

EXHAUSTION Vague malaise, fatigue, headache Core temperature often normal; if elevated, below 40° C Mental function essentially intact; no coma or seizures Tachycardia, orthostatic hypotension, clinical dehydration Other major illness ruled out STROKE Exposure to heat stress, endogenous or exogenous Signs of severe central nervous system dysfunction Core temperature usually above 40.5° C, may be lower Hot skin common, and sweating may persist Marked elevation of hepatic transaminases

Risk factors for TB Infection

EXPOSURE Close contact with known case Foreign born (Asia, Africa, Latin America) Low SES/medically underserviced Resident of LTC facility Occupational exposure IMMUNE COMPOMISE HIV infection Elderly IVDU

Causes of SBO relative to intestinal wall

EXTERNAL to Intestinal Wall Postoperative adhesions Hernias Volvulus Compressing masses (tumors, abscesses, hematomas) INTRINSIC to Intestinal Wall Primary neoplasms Inflammatory (e.g., Crohn's disease, radiation enteritis) Infectious causes (e.g., intestinal tuberculosis) Intussusception Traumatic (intestinal wall hematoma) INTRALUMINAL Bezoars Foreign bodies Gallstones Ascaris infestation

Complications after Traumatic Brain Injury EARLY LATE

Early - Post-traumatic seizures (early <7 days) - Meningitis - Brain abscess - Cranial osteomyelitis - DIC - DVT - Neurogenic pulmonary edema - Arrhythmia - Neurogenic stunned myocardium Late - Chronic traumatic encephalopathy - Acquired epilepsy - Cognitive-behavioral deficits - Heterotrophic ossification - Post-traumatic amnesia

Complications of IVIG

Early Anaphylaxis Flushing URTI TRALI TACO Late Thromboembolic Aseptic meningitis Kidney injury Hyponatremia Hemolyisis Infection (rare)

Complications of rhabdomyolysis EARLY LATE

Early (<24h) electrolyte disturbances hepatic dysfunction compartment syndrome death Late (>24h) ARF DIC compartment syndrome

Causes of secondary Hypertension

Endocrine - Pheochromocytoma - Cushing's syndrome - Hyperaldosteronism - Thyroid disease - Parathyroid disease Pulmonary - Obstructive sleep apnea Renal - Chronic kidney disease - Polycystic kidney disease - Renal artery stenosis Vascular - Coarctation of the aorta Drugs - Oral contraceptives - Herbal: Ephedra, ginseng, ma huang Illicit: Amphetamines, cocaine Psychiatric: Buspirone (Buspar), carbamazepine (Tegretol), clozapine (Clozaril), fluoxetine (Prozac), lithium, TCAs Steroid Sympathomimetic: Decongestants, diet pills

Hemodynamic targets during ACLS

EtCO2 > 20 CPP >20 Arterial diastolic >25

Causes of Hyponatremia

Euvolemic • SIADH (inappropriate ↑ Na in urine) • Psychogenic polydipsia (dilute urine) • Adrenal insufficiency • ↓ thyroid • Renal failure Hypovolemic • Renal losses (diuretics, RTA, Na-wasting) • GI losses (V/D, NG losses, fistulas) • Third-spacing (burns, sepsis, BO, pancreatitis) • Excessive sweating • Addison's Hypervolemic • CHF • Cirrhosis • Nephrotic syndrome

Indications for intubation in asthma

Exhaustion • Decreasing level of consciousness • Signs of respiratory muscle fatigue • Weak breathing efforts • Silent chest • Onset of hypercapnia • Progressive or refractory acidemia (pH < 7.10) • Inability to maintain oxygenation by mask (oxygen saturation < 90%) • Cyanosis • Cardiac instability - Severe hypotension - Severe cardiac dysrhythmia or ischemia

Winter's Rule (Resp compensation for acute metabolic acidosis)

Expected CO2 = (1.5X(HCO3) + 8) +/-2

Androgue and Madias Formula

Expected change in serum sodium with liter of infusate (Infusate sodium concentration - serum sodium concentration)/TBW + 1 TBW = 0.6 X wt for non elderly men TBW = 0.5 X wt for non elderly women/elderly men TBW = 0.45 X wt for elderly women

Swan neck deformity

Extension at PIP and flexion at DIP caused by displacement of lateral bands proximally/dorsally Complication of chronic untreated mallet finger

Risk factors for severe anaphyaxis

Extremes of age - Very young - Elderly Comorbid conditions - Cardiovascular disease - Pulmonary disease Others - Concurrent use of beta-blockers and ACEi - Concurrent use of cognition-impairing drugs - Recent anaphylaxis episode

Light's Criteria for Exudative Effusion

Exudate if one or more of following: (1) Pleural fluid protein/serum protein > 0.5 (2) Pleural fluid LDH/serum LDH > 0.6 (3) Pleural fluid LDH > 2/3 upper limit normal for serum LDH

Causes of inaccurate end tidal CO2 for ETT placement confirmation

FALSE NEGATIVES Following bolus of IV epinephrine Severe airway obstruction (bronchospasm) Massive PE Large glottic air leak Massive PTX Cardiac arrest FALSE POSITIVES Use of IV Bicarbonate (transient effect after administration) Esophageal intubation after carbonated beverage consumption (effect transient) Esophageal intubation after IV epinephrine Contamination by gastric contents

D-Dimer Results CAUSES OF FALSE POSITIVE FALSE NEGATIVE

FALSE POSITIVE Infection (eg, pneumonia, sepsis) CARDIOVASCULAR Acute coronary syndrome Arterial thrombosis Acute cerebrovascular event Atrial fibrillation Disseminated intravascular coagulation Vaso-occlusive sickle cell crisis Vasculitis Superficial phlebitis OTHER Cancer and malignancy Recent surgery Pregnancy Age >70 years Trauma FALSE NEGATIVE Symptoms of PE for >3 days Small PE Use of qualitative latex fixation tests Anticoagulated patients

Constituents of Octaplex

Factors II, VII, IX, X Protein C Protein S Heparin

Kernohan's notch phenomenon

False localizing sign where compression of contralateral cerebral peduncle causes ipsilateral paralysis

Rule of thumb % elemental iron by different formuatlions

Ferrous Gluconate 12% Ferrous sulfate 20% Ferrous fumarate 33%

Symptoms/Complication of corynebacterium diptheriae

Fever Pharyngitis Weakness Dysphagia Diphtheric membrane (from toxin) Peripheral neuropathy ->Palate, then proximal muscles Leads to paralysis Myocarditis (ST changes, AVB, dysrhythmias) Can affect CNS Can affect Kidneys Cutaneous ulcer (cutaneous type) Bull neck (malignant type)

Empiric treatment for febrile neutropenia with PCN allergy

Fluroquinolone Aminoglycoside

Expected anion gap correction for hypoalbumnemia

For every 10 drop in albumin expected anion gap decreases by 2.5

Free water deficit calculation

Free H2O deficit (in L) = TBW X (1-{140/Na}) TBW = 0.6 X wt for non elderly men TBW = 0.5 X wt for non elderly women/elderly men TBW = 0.45 X wt for elderly women

Conditions that can mimic brain death

Fulminant Guillan-Barre Syndrome High Spinal Cord Injury Baclofen Toxicity Organophosphate toxicity Delayed neuromuscular blockade Profound hypothermia

Causes of Pancreatitis

G: gallstones E: ethanol (alcohol) T: trauma S: steroids M: mumps (and other infections) / malignancy A: autoimmune S: scorpion stings/spider bites H: hyperlipidaemia/hypercalcaemia/hyperparathyroidism (metabolic disorders) E: ERCP D: drugs

Causes of elevated lipase

GASTRONINTESTINAL Pancreatitis Cholecystitis Bowel obstruction or infarction Duodenal ulceration Celiac disease OTHER DKA HIV Renal failure

ICH score

GCS Score: 3-4 (2); 5-12 (1) ICH Volume: >30 mL (1) IVH (Intraventricular Blood): Present (1) ICH Location: Infratentorial (1) Age: ≥80 years (1) 30-Day Mortalities for Total ICH Scores 0 = 0% 1 = 13% 2 = 26% 3 = 72% 4 = 97% 5 = 100% 6 = estimated to be 100%; no patients in the study fell into this category

Organisms patients with febrile neutropenia are predisposed to

GRAM NEGATIVE BACILLI Including Psuedomonas GRAM-POSITIVE COCCI including methicillin-resistant strains of S Aureus GRAM-POSITIVE BACILLI FUNGI Candida sp. Aspergillus sp.

Triggers of autonomic dysreflexia

GU Related Bladder distention Urinary tract infection Calculus Cystoscopy/instrumentation GI Related Bowel distention Bowel instrumentation/colonoscopy Appendicitis or other intra-abdominal pathology/trauma Anal fissure OB/GYN Menstruation Pregnancy - Especially labor and delivery Sexual intercourse MISCELANEOUS VTE Pressure ulcers Ingrown toenail Burns or sunburn Blisters Insect bites Contact with hard or sharp objects Temperature fluctuations Constrictive clothing, shoes, or appliances

Definition of preeclampsia

Gestational hypertension with one or more of the following: ● new proteinuria, or ● one or more adverse conditions,* or ● one or more severe complications.* Severe preeclampsia is defined as preeclampsia with one or more severe complications

Overall percentage metabolism of acetaminophen by different routes

Glucoronidation 40-60% Sulfation 20-30% CYP450 oxidation (toxic component) 5-15% Direct renal clearance 5%

When to consider transfusion in SCD

Goal is to maintain HgbS <30% if: -Acute anemia -Acute chest syndrome -Perioperative -Acute Neuro Deficit -Multiorgan Failure

Gustillo Classification system of open fractures - Description - Recommended Antibiotics

Grade I: < than 1 cm, punctured from below Grade II: Laceration 1-5 cm; no extensive soft tissue damage Grade III: Large laceration >5cm, associated contamination or crush I: Ancef II or greater: Add gentamcin Gross contamination: Add Penicillin for clostridium coverage

Complications of AAA repair

Graft infection Aortoenteric fistula Pseudoaneurysm Graft migration Stenosis Thrombosis Structural failure

qSOFA

H (100) A (15) T (22) 2 or more of: Hypotension: SBP less than or equal to 100 mmHg Altered mental status (any GCS less than 15) Tachypnoea: RR greater than or equal to 22 identified patients with suspected infection who are likely to have a prolonged ICU stay or to die in the hospital

Pathophysiology of altitude illness - HAPE - Cerebral Edema

HAPE (1) heterogenous hypoxia-induced pulmonary vasoconstriction. causing capillary leakage (2) Impaired sodium resorption across alveolar interstium MOUNTAIN SICKNESS/CEREBRAL EDEMA Poor hypoxic ventilatory response /periodic breathing during sleepig -> Hypoxia -> Cerebral vasodilitation and altered capillary permeability leading to cerebral edema

Hemodyanmic goals for management of thoracic aortic dissection

HR <60 SBP 100-120

HASBLED Score for bleeding risk with anticoagulation

HTN history (uncontrolled, SBP>160) Abnormal renal (transplant, dialysis, Cr >200) or liver (cirrhosis, AST/ALT/ALP >3X normal, bilirubin >2X normal) Stroke history Bleeding (prior history major bleed, predisposition) Labile INR Elderly (age >65) Drugs (antiplatelet) or EtOH use 0: 1% 1: 3.5% 2: 4% 3*: 6% 4: 9% 5: 9% >5: High risk, rare, unknown

Causes of Low Oxygen Extraction Ratio (high ScVO2)

HYPEROXIA (e.g high FiO2 gas, hyperbaric oxygen or ECMO) DECREASED OXYGEN CONSUMPTION - decreased metabolic rate, e.g. (hypothyroidism, sedatives/ hypnotics, hypothermia) - decreased muscular activity (e.g. sedation/analgesics, muscle paralysis, ventilatory support) - Starvation/hyponutrition - Sepsis due to shunting and histotoxic hypoxia - Histotoxic hypoxia, e.g. cyanide poisoning

HACEK Organisms

Haemophilus aphrophilus Actinobacillus actino/mycetem/comitans Cardiobacterium hominis Eikenella corrodens Kingella kingae

Areas with chloroquine sensitive malaria

Haiti DR Central America Middle East

Contraindicated medications in parkinson's patients

Haloperidol Anti-psychotics Phrocloperazine Metoclopramide

Multi-system lightning injuries

Head and Neck - Traumatic injuries - TM rupture - Occular injuries including cataracts - Dilated unreactive pupils CVS - Asystole > Vfib - Transient ST changes, long QT Skin - Burns - Ferning Extemities - Keraunoparalysis - transient vasospasm CNS - Transient LOC, confusion, amnesia Other - Pulmonary contusion/hemorrhage

Multi-system electrical injuries

Head and neck - Airway/facial burns - Cataract risk CVS - V fib > asystole - Sinus tachycardia, transient ST changes, long QT, PVCs, Afib, BBB Skin - Burn at source and ground contact point Extremities - Muscle injury - Compartment syndrome - Joint injuries CNS - LOC - Seizures - Immediate parasthesia/weakness - Delayed neurological damage (SCI, Transverse myelitis, ALS) Other - organ viscera damage possible - Respiratory arrest/tetany

Budd-Chiari Syndrome

Hepatic vein thrombosis

Reversal of warfarin with significant bleeding

Hold Warfarin Vitamin K 5-10mg IV PCC (or FFP/rFVIIa)

Solute diffusivity flux

How fast a solute moves across a membrane

Beta Blockers in Cardiac Arrest

Huffing Chloral Hydrate VT storm HOCM

Causes of metabolic alkalosis

Hydrogen ion loss - GI Losses - Renal losses: Diuretics, barter, gittelman - Excess mineralcorticoids - Severe hypokalemia Bicarbonate gain - Exogenous administration - Contraction Alkalosis -> Increased Reabsorption

Causes of a NAGMA

Hyperalimentaion (TPN) Acetazolamide RTA Diarrhea Uroenteric fistula Pancreatic fistula Saline resus

CT findings in an acute ischemic stroke

Hyperdense MCA sign Sulcal effacement Loss of the insular ribbon Loss of grey-white matter interface Mass effect Acute hypodensity Blurring of the basal ganglia

Non Malignant Causes of Hypercalcemia

Hyperparathyroidism Hyperthyroidism Renal Insufficency Drugs - Thiazides - Lithium - Calcium carbonate Hypevitaminosis (A & D) Acute AI Immobilization Acromegaly Myxedema Milk-Alkali Syndrome Sarcoidosis Benign Monocolal Gammoapthy Familialy Hypocalciuric Hypercalcemia

Relative Contraindications for Fibrinolysis in acute MI 12 Total 2 Hypertension 3 Neurology 6 Trauma/Bleeding Pregnancy

Hypertension related ● History of chronic, severe, poorly controlled hypertension ● Significant hypertension on presentation (SBP >180 mm Hg or DBP >110 mm Hg) Neurology related ● History of prior ischemic stroke >3 mo ● Dementia ● Known intracranial pathology not covered in absolute contraindications Trauma/Bleeding related ● Traumatic or prolonged (>10 min) CPR ● Major surgery (<3 wk) ● Recent (within 2 to 4 wk) internal bleeding ● Noncompressible vascular punctures ● Active peptic ulcer ● Oral anticoagulant therapy ● Pregnancy

True Hypertensive Emergencies

Hypertensive encephalopathy Dissecting aortic aneurysm Acute left ventricular failure with pulmonary edema Acute myocardial ischemia Eclampsia Acute renal failure Symptomatic microangiopathic hemolytic anemia Intracerebral hemorrhage Non-Secured SAH Acute hypertensive retinopathy Post-operative with concern for hemostasis

Differential diagnosis of anemia causes by decreased RBC production

Hypochromic Microcytic • Iron deficiency • Thalassemia • Sideroblastic anemia • Lead poisoning • Chronic disease (can be normocytic, normochromic) - ca, renal or inflammatory disease Macrocytic • B12 deficiency (megaloblastic) • Folate deficiency (megaloblastic) • Liver disease • Hypothyroid • Hemolysis Normocytic • Bone marrow involvement o Aplastic anemia o Myelofibrosis o Myelophthisic anemia • Chronic disease

Side effects of deferoxamine

Hypotension Renal failure ARDS Yersinia Entercolciata sepsis

Conditions that may be worsened by PEEP

Hypotension (volume depletion, tamponade) RV failure Right and left intracardiac shunts Hyperinflation Asymmetric or focal lung disease Bronchopleural fistula ↑ ICP (but PEEP <12cmH2O well tolerated)

Differential Diagnosis of Prolonged QTc

Hypothermia Hypokalemia (due to u waves) Hypocalcemia Hypomagnesemia Acute coronary syndrome Elevated ICP Sodium channel blocking drugs Congenital Other medications -Macrolide antibiotics -Fluroquionolones -Methadone -Metoclopramide -Ondansetron -Anti-psychotics -Anti-depressants

Complication of SBO

Hypovolemia/shock Metabolic alkalosis Electrolyte derangement Perforation Sepsis Respiratory compromise from distention Aspiration

Causes of respiratory alakalosis

Hypoxia mediated • High altitude • Severe anemia • V/Q mismatch CNS mediated • Psychogenic • CVA • Trauma • ↑ ICP, tumour Pharmacologic • ASA, caffeine, nicotine • Progesterone • Thyroxine • Vasopressors/inotropes Septicemia Pulmonary • Pneumonia • PE • Edema • Mechanical hyperventilation • Atelectasis Hepatic encephalopathy Hyponatremia

Debakey classification system of Thoracic Aortic Dissection

I: Ascending and descending aorta II: Ascending aorta only III: Descending aorta only

NYHA Heart Failure Classes

I: Asymptomatic with ordinary physical activity II: Symptomatic with ordinary physical activity III: Symptomatic with < normal physical activity IV: Symptomatic at rest

Stages of Mycobacterium tuberculosis infection

I: Aveolar macrophage phagocytoses bacilli (if host resistant then destroyed and no infection) II: Bacterial replication, lysis, tubercule formation, and lymphohemotogenous dissemination III: Cell mediated immunity If immunocompetent then granuloma forms and primary infection arresed I immunocompromised the primary progressive TB IV: Reactivation of dormant infection

Types of decompression sickness

I: Musculoskeletal/lymphatic involvement II: Beyond MSK involvement - Spinal cord - Cerebral - Inner ear - Pulmonary

Killip Classes and Mortality

I: No CHF (6%) II: Crackles/JVD (17%) III: ACPE (38%) IV: Cardiogenic shock (67%)

Canadian CV Society Angina Classification

I: No limitation with ordinary physical activity (strenuous activity causes angina) II: Mild limitation (e.g. climbing stairs rapidly) III: Severe limitation (< 2 blocks or 1 flt stairs causes angina) IV: Symptoms with minimal exertion or at rest

Zones of the neck

I: Sternal notch/clavicles to cricoid cartilage II: Cricoid cartilage to angle of mandible III: Angle of mandible to base of skull

Causes of PPH and associated risk factors

I: tone -> Uterine atony (1) overdistention of the uterus (multiple gestations, fetal macrosomia, and polyhydramnios) (2) prolonged labor (3) chorioamnionitis (4) use of tocolytics (5) general anesthesia with halogenated compounds. II: trauma (1) Uncontrolled delivery (2) macrosomia (3) episiotomy (4) nulliparity (5) maternal coagulopathy (6) operative delivery (7) prolonged second stage of labor (8) preeclampsia (9) malpresentation III: tissue -> Retained products multiparity prior cesarean sections placenta previa previous curettage uterine anomalies IV: thrombin -> Coagulopathy placental abruption eclampsia amniotic fluid embolism postpartum infections dilution of clotting factors due to volume resuscitation retained products of conception

Overview of intermittent dialysis - Limiting factor - Clearance - Fluid removal

IHD Dialysis Dose: ~400 cc/min blood×~2/3 cleared×240 min = 60 L clearance/4 hour dialysis session IHD Fluid Removal: ~ 8-16 cc/min (500-1000 cc/hr or 2-4 L/4 hour dialysis session)

Complications of central venous catheterization

IMMEDIATE Bleeding Arterial puncture Arrhythmia Air embolism Thoracic duct injury (with left SC or left IJ approach) Catheter malposition Pneumothorax or hemothorax DELAYED Infection Venous thrombosis, pulmonary emboli Catheter migration Catheter embolization Myocardial perforation Nerve injury

Complications of bacterial meningitis

IMMEDIATE Coma Inability to protect airway Seizures Cerebral edema CVS collapse DIC Resp arrest Dehydration Pericardial effusion SIADH Death DELAYED Seizures Focal paralysis Subdural effusions Hydrocephalus Intellectual deficits Sensorineural hearing loss Ataxia Blindness Bilateral adrenal hemorrhage (Waterhouse-Friderichsen) Peripheral gangrene Death

Risk factors for TB Reactivation

IMMUNESUPRESSION HIV IVDU DM Prolonged corticosteroids Immunosuppressive therapy Hematologic disease ESRD TB RELATED Recent 1° TB infection (<2y) CXR suggests prior untx'd TB MALNUTRITION Chronic malabsorption syndrome Intestinal bypass/gastrectomy Low body wt (< 10% below ideal) MISCELAENOUS Silicosis Head/neck cancer

Causes of High Oxygen Extraction Ratio (low ScVO2)

INADEQUATE OXYGEN DILVERY (OH CRAP; shock) - Oxygen (hypoxic hypoxia) - Hemoglobin (anemia) - Contractility - Rate/ rhythm - Afterload - Preload Shock/ hypoperfusion due to other causes or Increased oxygen consumption (VO2) - fever and inflammatory states (e.g. sepsis, burns, trauma, surgery) - increased metabolic rate (e.g. hyperthyroidism, adrenergic drugs, hyperthermia, burns) - increased muscular activity (e.g. exercise, shivering, seizures, agitation/anxiety/pain, weaning from ventilation/ increased respiratory effort)

Precipitants of decompensated heart failure

INCREASED PRELOAD noncompliance (most common)) Medication noncompliance Dietary excess (Na) REDUCED CONTRACTILITY MI/ischemia Dysrhythmia Acute valvular problem Myocarditis INCREASED AFTERLOAD HTN (cocaine, w/d BP meds pheo) INCREASED DEMAND Anemia PE Pregnancy ↑/↓ thyroid emotional upset extremes of temperature Systemic infection (sepsis, pneumonia) MISC Drugs (ßB, CCB, NSAIDS, glucocorticoids, vasodilators, antidysrhythmics,

Dimercapol/BAL

INDICATION - Indicated for severe lead (levels >70) in conjunction with EDTA Calcium Disodium (but give BAL 4 hours prior) - Arsenic if not tolerating PO/GI Compromise - Inorganic mercury CAUTIONS - Avoid in Elemental and Organic Mercury -> CNS Toxicity - Avoid in G6PD deficiency and peanut allergy

Gastric Lavage Indications Contraindications

INDICATIONS (1) Given time/amount of ingestion a large amount in stomach (2) Highly toxic ingestion/dose (3) No effective antidote or safe method for removal (4) AC not likely to be effective or unavailable CONTRAINDICATIONS o known antidote o unprotected A/W, o AC works o aspiration risk o coagulopathy o GI perforation risk (recent sx) o size of ingested material>tube

Flumazenil INDICATIONS ABSOLUTE CONTRAINDICATIONS RELATIVE CONTRAINDICATIONS

INDICATIONS (1) clear overdose in nonhabituated use (2) reversal of concious sedation ABSOLUTE CONTRAINDICATIONS H HEWS Hypersensitivity to Flumazenil Habtiual benzodiazepine user Eliptogenic co-ingestatnt Withdrawal from sedative/hypnotic Seizure activity/myoclonus RELATIVE CONTRAINDICATIONS PASH Panic attacks Alcoholics Seizure disorder (not on benzos) Head Injury

Intraaortic Balloon Pump INDICATIONS CONTRAINDICATIONS

INDICATIONS Cardiogenic shock Refractory ventricular arrhythmias Acute MR and VSD Cardiomyopathies Catheterization and angioplasty Weaning from bypass CONTRAINDICATION Aortic regurgitation Uncontrolled sepsis Aortic dissection Abdominal aortic aneurysm Chronic end-stage heart disease with no recovery Tachyarrhythmias Aortic stents Severe peripheral vascular disease Major arterial reconstruction surgery

Indications for emergency intervention in SVC syndrome AND Management

INDICATIONS FOR EMERG INTERVENTION Signs of Cebreal Edema Central Airway obstruction MANAGEMENT HOB elevation Glucocorticoids Radiation/Chemotherapy (depending on tumor) Stent placement

DDX of bilateral pulmonary infiltrates in IC patient

INFECTION Viruses -Cytomegalovirus -Respiratory syncytial virus -Influenza, parainfluenza -Adenovirus -Varicella Pneumocystis jiroveci NON-INFECTIOUS Fluid overload and pulmonary edema TRALI Radiation damage Chemotherapy-induced toxicity Bronchiolitis obliterans Pulmonary hemorrhage Progression of disease (lymphangitic spread of carcinoma, leukemic infiltrates)

Causes of cerebral venous sinus thrombosis

INFECTIOUS Sinusitis OM Facial cellulitis Systemic infections NON-INFECTIOUS Injury to cerebral venous system: • Trauma • Surgery • Tumour • Dehydration Hypercoagulability

Indications for Tube Thoractostomy for Pneumothorax

INITIAL SIGNS AND SYMPTOMS Tension Traumatic (except asymptomatic, apical) Moderate to large PTX Symptomatic Associated hemothorax Bilateral PTX regardless of size CLINICAL COURSE Increasing after initial conservative Rx Recurrence after removal of chest tube Patient requires ventilator support Patient requires GA

Chest guidelines - Supertherapeutic INR without bleeding

INR 3-4.5: Hold one dose warfarin INR 4.5-10: Hold one or two doses of warfarin INR >10: Hold warfarin 2.5-5mg of Vitamin K PO

Octaplex dosing for warfarin reversal

INR >5: Dose 3000 IU INR 3-5: 2000 IU INR <3: 1000 IU

Complications of Intra-Aortic Balloon Pump

INSERTION - failure to advance catheter beyond iliofemoral system because of atherosclerotic disease (common) - aortic dissection and arterial perforation - may cause retroperitoneal hemorrhage - malposition - accidental femoral vein cannulation and damage to local structures DURING USE - thrombosis at the insertion site causing limb ischemia - peripheral embolisation and end organ ischaemia (e.g. limb ischaemia with compartment syndrome, gut, kidneys and spine) - incorrect positioning with vascular occlusion (e.g. SCA, renal arteries and other aortic branches) - infection - perforation - balloon rupture (look for presence of blood in the connecting tubing) - gas embolisation - haemolysis and thrombocytopaenia - peripheral neuropathy - timing errors DURING/AFTER REMOVAL - haemorrhage - pseudoaneurysm - AV fistula - entrapment leading to inability to remove

Complications on inflammatory bowel disease INTESTINAL EXTRA-INTESTINAL

INTESTINAL (1) Strictures (2) Fistula (3) Obstruction (4) Abscesses (5) Perforation/peritonitis (6) Infectious colitis (7) Malignancy EXTRA-INTESTINAL (1) Arthritidies - Axial - Peripheral (2) Opthamologic - Epsicleritis - Uveitis (3) Dermatolgic - Erythema nodosum - Pyroderma gangrenosum - Apthous ulcers (4) GU - Calcium oxalate stones - Fistula (5) Hepatic - Pericholangitis - Cholelithiasis - Primary sclerosing cholangitis (6) Hematologic - Anemia - Hypercoagulable state

Classification of hemolytic anemia

INTRINSIC - Extravascular Enzyme defect • PK • G6PD Membrane abnormality • Spherocytosis • Elliptocytosis • Paroxysmal nocturnal hemoglobinuria • Spur cell anemia Hemoglobin abnormality • Hemoglobinopathy • Thalassemia • Unstable hemoglobin • Hemoglobin M EXTRINSIC - Intravascular Immunologic • Alloantibody • Autoantibody Mechanical • Microangiopathic • CV - i.e. prosthetic valve Environmental • Drugs • Toxins (brown recluse, snake venom) • Infections (malaria, Bartonella, Clostridium) • Thermal (severe burns), freshwater drowning, hyperthermia Sequestration

Types of radiation exposures

IRRADIATION ionizing radiation passes through an object, no hazard risk to others (unless exposed to neutrons) CONTAMINATION object coated in radioactive particulate matter ; needs decontamination INCORPORATION Internal contamination; • radioactive material ingested, inhaled, or absorbed through wound

Causes of TTP

Idiopathic—most cases Infection - HIV Pregnancy Malignancy Bone marrow transplantation Drug therapy - Quinine - Oral contraceptive pills - Clopidogrel - Ticlopidine - Trimethoprim - Pegylated interferon - Simvastatin Chemotherapy Pancreatitis Autoimmune - Systemic lupus erythematosus =- Antiphospholipid syndrome

AHA recommendation for resuscitative hysterotomy

If no ROSC by 4 minutes

Indications for washed blood product transfusion

IgA deficient patients with a documented anti-IgA, when RBC from an IgA deficient donor are unavailable, Patients with a history of anaphylactic transfusion reactions of unknown etiology, Recurrent and/or severe febrile or allergic transfusion reactions, if not ameliorated by pre-transfusion medications or responsive to plasma reduced RBC

MOA of herparin induced thrombocytopenia

IgG antibodies that bind to platelet factor 4/heparin complex activating platelets and triggering a pro-coagulant response

Indications for CT prior to LP

Immunocompromised ALOC Seizure FND Papilledema or other signs ↑ ICP History of: • CVA • Mass lesion • Focal infection • Head trauma

Summary of 2015 AHA guidelines for Fibrinolysis for Primary PCI when considering time of symptom onset

In STEMI patients presenting within 2 hours of symptom onset, immediate fibrinolysis rather than PPCI may be consideredwhen the expected delay to PPCI is more than 60 minutes In STEMI patients presenting within 2 to 3 hours after symptom onset, either immediate fibrinolysis or PPCI involving a possible delay of 60 to 120 minutes might be reasonable In STEMI patients presenting within 3 to 12 hours after symptom onset, performance of PPCI involving a possible delay of up to 120 minutes may be considered rather than initial fibrinolysis (Class IIb, LOE C-LD).

Dalton's Law

In a mixed gas the total pressure is equal to the sum of partial pressures of each constituent gas, which each behave as if they occupy the total volume alone Ptotal = P1 + P2 + P3 ... Pn Partial pressure of each component goes up at depth, so for example, you breath higher concentration of nitrogen at depth

Factor IX Dosage

In absence of an inhibitor, each unit of FIX per kilogram of body weight infused will raise the plasma FIX level approximately 1 IU/dl. Dose = Weight (kg) X the desired rise in factor level

Toxic megacolon

In patient with colitis -> development of nonobstructive colonic dilatation plus systemic toxicity

Factor VIII Dosage

In the absence of an inhibitor, each unit of FVIII per kilogram of body weight infused will raise the plasma FVIII level approximately 2 IU/dl Dose = Weight (kg) X the desired rise in factor level X 0.5

Hunter Criteria for Serotonin Syndrome

In the setting of exposure to a known serotonergic agent, serotonin syndrome can be diagnosed by the presence of any of the following: (1) Spontaneous clonus (2) Tremor and hyper-reflexia (3) Inducible clonus and (I)agitation or (II)diaphoresis or (III)Hypertonic with temperature > 38° C (4) Ocular clonus and (I)agitation or (II)diaphoresis or (III)Hypertonic with temperature > 38° C

Therapeutic Hypothermia - Whom to cool - Whom to Exclude

Inclusion - Adult - Comatose - Strongest for OHCA, shockable, presumed cardiac - Can also consider for OHCA and IHCA with any rhythm Exclusion - Improving neurological status and obeying verbal command after ROSC - Known bleeding diasthesis (medication-related, such as warfarin or aspirin does not exclude patient) - Suspected or confirmed acute ICH/CVA - Known disease making 6-month survival unlikely - Core temperature < or equal to 30°C on admission - Time from cardiac arrest > 6 hours - Refractory shock

Delta Ratio

Increase in anion gap (Calculated AG - Normal AG) / Decrease in bicarbonate (24-serum bicarbonate) <0.4 NAGMA 1 -2 Simple AGMA > 2 Superimposed metabolic alkalosis

Risk factors for placenta previa

Increased Maternal age Increased Parity Smoking Prior c-section

Causes of High Output Heart Failure

Increased Preload Renal retention Na/H2O ↑ mineralocorticoids Decreased Afterload AV fistula Pregnancy Cirrhosis Severe anemia Beriberi Thyrotoxicosis Paget's disease Vasodilator medications Tachycardia-induced ↑ beta sympathetic activity

Risk factors for Thoracic Aortic Dissection

Increased aortic wall stress Hypertension (especially uncontrolled) Pheochromocytoma Cocaine/stimulant use Weight lifting/other Valsalva situations Deceleration injury/blunt trauma Aortic coarctation Medical conditions affecting aortic media Genetic disorders/syndromes: Ehler-Danlos, Marfan, Turner bicuspid aortic valve, familial dissections/aneurysms Inflammatory vasculitides: syphilis, granulomatous arteritis, tuberculous, salmonella, Takayasu, giant cell, systemic lupus erythematosus, Behc¸et Iatrogenic wall injury Cardiac/valvular surgery intra-aortic balloon pump use aortic cannulation, cross-clamping sites catheterization Other Male sex Age >50 y Pregnancy Polycystic kidney disease Chronic corticosteroid use or immunocompromised states

Succimer/meso-2,3-dimercaptosuccinic acid

Indication - Lead (levels greater than 45) - Arsenic - Organic and inorganic mercury

Phyostigmine for anticholinergic overdose - Indications - Contraindications - Complications

Indications Severe agitation Seizures Hyperthermia Possible others: Hypertensive crisis Coma Dysrhythmia Contraindications TCA OD QRS > 0.10sec Asthma Complications seizures muscle weakness bradycardia complete AVB bronchoconstriction vomiting and diarrhea

Precipitants of mysathenic crisis

Infection Aspiration Surgery Pregnancy Drugs CVS ß blockers CCB Quinidine Lidocaine Procainamide ANTIBIOTICS Aminoglycosides Tetracyclines Clindamycin Colistin OTHERS Phenytoin NM blockers Corticosteroids Thyroxine

Common precipitants of hepatic encephalopathy

Infection GI Bleeding Dehydration Constipation METABOLIC Hypokalemia Metabolic alkalosis Renal failure Dietary protein overload

Causes of Exudative pleaural effusions

Infections Neoplasms Connective Tissue Disease - Rheumatoid arthritis - Systemic lupus erythematosus Abdominal or Gastrointestinal Disorders Pancreatitis Subphrenic abscess Esophageal rupture Abdominal surgery Miscellaneous Conditions Pulmonary infarction Uremia Drug reactions Postpartum Chylothorax

Pathophysiology of cyanide

Inhibits complex IV (cytochrome A3) in Electron Train Chain leading to ARREST (rather than uncoupling) of aerobic metabolism

Carbon monoxide toxicity

Inhibits oxygen transport Blocks cytochrome IV Induces lipid peroxidation Binds myoglobin in muscle

TB Meds and their side effects Isoniazid Rifampin Pyrazinamide Ethambutol 2nd line Streptomycin Levofloxacin Cycloserine

Isoniazid (hepatotoxicity, neuropathy, Sz in overdose) Rifampin (orange discoloration body fluids) Pyranizamide ( Hepatotoxicity, arthralgias) Ethambutol (retrobulbar neuritis) Streptomycin (nephrotxicity, ototoxicty, teratogenic) INH + RIF + PYR + ETH X 8 weeks INH + RIF X 18 weeks

Adenosine dose adjustments

LARGER Theophylline Caffeine SMALLER Dipyridamole Carbamezepine Heart transplant CVC Access

Things that shift the oxygen hemoglobin dissociation curve

LEFT (less O2 off loading) - MetHb - CO - inc pH - dec 2,3-BPG - dec CO2 - dec temp RIGHT (more O2 offloading) - inc Temp - inc 2,3-BPG - dec pH - increased CO2

Dialysis Indications with Salicylate Overdose

LEVELS >7.2 mmol/L (acute), >3.6 mmol/L (chronic) Rising ASA level ORGAN FAILURE Intubation Severe acid-base disorder Hepatic failure Renal failure ↓ LOC/seizures Pulmonary edema Failure of conservative treatment

indications for WBI

LIMPS BACK Lithium iron metals packer/stuffer sustained bezoar asa ccb valproiK acid

Causes of lyangospasm

LOCAL airway manipulation extubation ENT procedures fluids (e.g. blood, secretions, vomitus) foreign body aspiration reflux near drowning SYSTEMIC ketamine tetanus hypocalcemia strynchnine poisoning vocal cord dysfunction epilepsy (rare) sleep-related laryngospasm psychogenic pseudo-laryngospasm

Differential Diagnosis of Diffuse ST elevation

Large STEMI Pericarditis Myocarditis Ventricular aneurysm Hyperkalemia Coronary vasospams Brugada LVH LBBB Paced rhythm Benign early repolarization Post electrical cardioversion Acute cerebral hemorrhage

Relative resistance of different tissues to electricity

Least Nerves Blood Mucous membranes Muscle Intermediate Dry skin Most Tendon Fat Bone

Risk factors for impaired T-cell immunity and organisms to consider

Leukemia Chemotherapy Immunsupressive medications -Corticosteroids -Immunomodulators -Biologics HIV/AIDS ESRD

Risk factors for imparied humoral/b-cell immunity and organisms to consider

Leukemia Multiple myeloma Alcoholic/cirrhosis Corticosteroids

Suggested indications for hyperbaric oxygen in carbon monoxide poisoning

Level >25% (15% Preg or Child) CNS LOC Sz Coma Confusion Visual Sx Ataxia CVS/RESP Dysrhythmias Inability to oxygenate METABOLIC Metabolic Acidosis

Indications for Intralipid therapy in toxicology

Local anesthetic (bupivacaine, lidocaine) TCA CCB (verapamil) BB (lipophilic) Bupropion Cocaine

Tumors that frequently metastasize to the brain

Lung Breast Melanoma Kidney GI tract

ring enhancing lesions on CT MAGICAL DR

M: mets A: Abscess G: GBM I: Infarct (subactue) C: Contusion A: AIDS L: Lymphoma D: Degeneration (MS) R: Resolving Hematoma

Features of Hemolytic Uremic Syndrome

MAHA Thrombocytopenia Bloody Diarrhea Prominent Renal Failure More common in children

DUKE Criteria for infective endocarditis MAJOR MINOR DIAGNOSIS

MAJOR (1) Positive blood cultures for IE (one of the following): •Typical microorganisms consistent with IE from two separate blood cultures: - Staphylococcus aureus - Viridans streptococci - Streptococcus gallolyticus (formerly S. bovis) - HACEK group - Enterococci (2) Evidence of endocardial involvement (one of the following): Echocardiogram positive for IE: - Vegetation - Abscess - New partial dehiscence of prosthetic valve - New valvular regurgitation MINOR - Fever: Temperature ≥38.0°C - Predisposition: IIVDU or predisposing heart condition - Vascular phenomena: Septic emboli Immunologic phenomena: Glomerulonephritis, Osler nodes, Roth spots, or rheumatoid factor Microbiologic evidence: Positive blood cultures that do not meet major criteria OR serologic evidence of active infection with organism consistent with IE DIAGNOSIS DEFINITE 2 major 1 major + 3 minor 5 minor POSSIBLE 1 major + 1-2 minor 3 minor

Winnipeg Criteria for Antibiotics in COPD

MAJOR -DP2 Need at least 2 of: (1) increased dyspnea (2) increased sputum production (3) increased sputum purulence MINOR Or 1 major and at least 1 of the following: Upper respiratory infection in the past 5 days Fever without other apparent cause Increased wheezing Increased cough Respiratory or heart rate increased 20% above baseline FUCVW Fever URTI (5 days) Cough increase Vitals abnormal Wheezing Increase

PRECIPITANTS OF EM AND SJS/TEN

MC : HSV and mycoplasma Any viral, bacterial, fungal infection Vaccines Drugs SJS / TEN - "SATAN" Septra / Sulfa (MC) Allopurinol Tetracycline Anticonvulsants (Phenytoin, Valproic, Tegretol) NSAIDs / ASA

Precipitants of myxedema coma

MEDICAL Cold exposure Infection/sepsis (especially pneumonia) CHF Trauma/burns CVA GI Bleeding MI ↓ O2, Na, or glucose ↑ CO2, Ca DKA DRUGS Sedative/hypnotics, narcotics neuroleptics, anesthesia Amiodarone, Li, iodides Phenytoin, rifampin Non-compliance, interference with absorption (Fe, Ca, etc)

Precipitants of thyroid storm

MEDICAL Infection/sepsis CVA MI CHF PE Bowel ischemia PSYCHIATRIC Emotional stress Acute manic crisis TRAUMA Thyroid and non-thyroid sx Blunt/penetrating trauma Vigorous palpation of gland Burns PREGNANCY Toxemia Hyperemesis Postpartum ENDOCRINE Hypoglycemia DKA HHNC DRUGS Thyroid hormone ingestion Contrast studies Amiodarone Iodine ingestion Anesthesia induction Drugs (chemo, pseudo -ephedrine, organophosphates, ASA, NSAIDs) Overdiuresis can aggravate or precipitate

Theophylline MOA TOXIC EFFECTS

MOA (1) Endogenous catecholamine release (via alpha 2 blockade) (2) Adenosine antagonism -> decreased histamine -> bronchdilitation TOXIC EFFECTS GI Distress Tachycarrrythmia, hyperadrenergic, MI -> especially beta agonism (may need beta blocker, alpha agonist) Hypokalemia, Hyperglycemia Seizures

Colchicine MOA Phases of Toxicity

MOA Binds to tubulin -> Inhibiting microtubule formation -> Ihibits mitosis in rapidly dividing cells Phases of Toxicity I: (0-24 hours) GI Toxicity Leukocytosis Hypovolemia II: 2 - 7 days Pancytopenia MODS Seizure III: 7 onwards Rebound leukocytosis Alopecia

MRSA Coverage Pseudomonas Coverage Anaerobic Coverage Enterococcus Coverage

MRSA - Vanco - Septra - Clinda - Linezolid - Doxycycline PSEUDOMONAS - Ceftazidime (& 4th gen) - PipTazo - Ciprofloxacin - Meropenem - Aminoglycosides ANAEROBES - Flagyl - Clinda - Tazo - Carbepenems - Levofloxacin ENTEROCOCCUS - Beta-lactams (non PCN, e.g. amp, tazo) - Vancomycin (not VRE) - Cephalosporins - Gentamycin

Risk factors for HIV infection

MSM/bisexuality/heterosexual exposure to person at risk IVDU and other high risk behaviour Blood transfusion prior to 1985 Infected mother (vertical transmission) Occupational exposure High prevalence area

Causes of AGMA

MUDPILESCAT Methanol, metformin Uraemia Diabetic ketoacidosis Propylene glycol, paracetamol Iron, isoniazid Lactate (numerous causes) Ethanol, ethylene glycol Salicylates Cyanide, carbon monoxide Alcoholic ketoacidosis Toluene

Contraindications to succinylcholine

Malignant hyperthermia Neuromuscular disease Rhabdomyolysis Hyperkalemia on EKG Burns, crush, denervation >5 days until healed

Phlegmasia alba dolens

Massive DVT of deep illiofemoral system but with sparing of superifical collaterals Milky white leg but no venous congestions Alba = WHITE

Limits of Safe Serum Sodium Increased Response if overshoot

Max increase in 24 hours -> Probably no more than 8mmol/L If overshoot consider demopressing 2mcg lock and free water

Causes of rapid intravascular RBC Destruction

Mechanical hemolysis from DIC Massive burns Toxins (venoms ie brown recluse, cobra) Infections such as malaria or Clostridium sepsis Severe G6PD with oxidant stress Decompensated SCD (usually viral) ABO incompatibility transfusion reaction Cold agglutinin hemolysis (mono, mycoplasma organisms) Paroxysmal nocturnal hemoglobinuria exacerbated by transfusion Immune complex hemolysis (eg quinidine)

Differential Diagnosis of Elevated Lactate

Medication Related Biguanide (metformin) Antiretrovirals (Zidovudine) Ethanol/methanol/ethylene glycol Salicylates Cyanide Acetaminophen Beta-adrenergics Iron INH Theophylline Caffeine H2S Non-Hypoxic Causes DM Liver failure Kidney failure Thiamine deficiency Inborn errors of metabolism Tumour lysis syndrome Heat stroke Hypoxic Causes Regional hypoperfusion Any shock state Seizure Severe anemia Respiratory failure CO Bowel ischemia Abdominal Compartment Syndrome Compartment Syndrome

Medical conditions which can present as psychosis

Metabolic • ↑ Ca • ↑ CO2 • ↓ glucose • ↓ Na • ↓ O2 Inflammatory • Sarcoidosis • SLE • GCA Organ Failure • Uremia • Hepatic encephalopathy Deficiency States • Niacin • Thiamine • Vitamin B12 • Folate Neurologic • Alzheimer's • CVA • Encephalitis (eg HIV) • Encephalopathies • Epilepsy • Huntington's • MS • Neoplasms • NPH • Parkinson's • Pick's disease • Wilson's disease Endocrine • Addison's • Cushing's • Panhypopituitary • Parathyroid disease • Postpartum • Sydenham's chorea • Thyroid disease

Indications of Methylene blue with methemoglobinemia

Metabolic acidosis Symptomatic Methemoglobin level >25% Contraindications G6PD Deficiency Co-ingestion of serotnergic medications

Adjunctive therapies in toxic alcohol poisoning - Methanol - Ethylene glycol

Methanol Levucorin (metabolized folate) 50mg IV q4H Ethylene glycol Thiamine 100mg IV q6h Pyridoxine 50mg IV q6h Replace Magnesium if deficient

CD4 count thresholds and risk for opportunistic infection

Mild (<200): PJP, TB Moderate (<100): Cyrptococcus, Toxoplasmosis Severe: (<50): MAC, CMV

Azygos vein and relationship to SVC syndrome

More severe if at or below azygos because drainage relies on retrograde flow through azygos to IVC

Etiologies of cirrhosis

Most common causes Alcohol (60 to 70 percent) Biliary obstruction (5 to 10 percent) Primary or secondary biliary cirrhosis Chronic hepatitis B or C (10 percent) Hemochromatosis (5 to 10 percent) NAFLD (10 percent) Less common causes Autoimmune chronic hepatitis Genetic metabolic disease Porphyria Wilson's disease Granulomatous liver disease (e.g., sarcoidosis) Polycystic liver disease Echinococcosis Schistosomiasis Chronic, passive hepatic congestion Veno-occlusive disease

PEA Differential diagnosis by QRS Width NARROW WIDE

NARROW Mechanical/RV problems - Thromboembolism - Tension PTX - Hypovolemia - Tamponade - Mechanical hyperinflation - AMI with myocardial rupture WIDE Metabolic/LV Problems - Hyperkalemia - Sodium channel blocker toxicity - Agonal rhythm - AMI with pump failure

SOG PREECLAMPSIA - SEVERE ADVERSE CONDITIONS

NEURO Eclampsia CVA/TIA Cortical blindness or retinal detachment Decreased LOA (GCS < 13) Posterior reversible encephalopathy syndrome CVS/RESP Uncontrolled/severe HTN (160/110) Markedly decreased saturation (<90%) Significant pulmonary edema Positive ionotropic support Significant myocardial ischemia/depression GI/RENAL AKI (Cr > 150) New indication for IHD Hepatic dysfunction (INR >2) or rupture HEME Platelets <50 OBSTETRIC Abruption

SOGC PREECLAMPSIA - ADVERSE

NEURO Headache Visual symptoms CVS/RESP Chest pain Dyspnea Oxygen saturation < 97% HEME Coagulopathy Lower platelets RENAL/GI Increased creatinine/uric acid Nausea/vomiting Elevated LFTs Low albumin OBSTETRIC Abnormal FHR IUGR Oligiohydroaminosis Absent/reversed end diastolic flow by Doppler us

Antibiotic mechanisms of action - class examples for each - bacterocidal or static

NHIBITION OF CELL WALL SYNTHESIS - Beta-lactams (PCN, cephalosporins, carbapenems) - Vancomycin all bactericidal INHIBITION OF PROTEIN SYNTHESIS - Aminoglycosides (bactericidal) - Clindamycin - Macrolides - Tetracyclines all static INHIBITION OF NUCLEIC ACID SYNTHESIS - Fluoroquinolones - Metronidazole - Rifampin all bactericidal ANTIMETABOLITES - Sulfonamides/ Trimethoprim - nitrofurantoin (static) - Dapsone

Cholinergic Toxidrome Nicotinic Component Muscarinic Component

NICOTINIC • Diaphoresis • Mydriasis • Tachycardia • HTN • Urine retention • Twitching/fasciculations • Cramping • Paralysis (fasciculations 1st) MUSCARINIC SLUDGE + KIller B's Salivation Lacrimation Urination Defectation Emesis Bronchorrea Bradycardia

Differential diagnosis of low and slow NON-TOX TOX

NON-toxicological causes: MI with cardiogenic shock Hyperkalemia Myxedema coma Spinal cord injury Hypothermia TOXICOLOGIC causes: Calcium channel blockers Beta-blockers Digoxin Opiates Alpha-2 antagonists (e.g., clonidine) Sodium channel blockers

Causes of chest pain with stimulants

NONCARDIAC: Pneumothorax Pneumomediastinum Pneumopericardium Aortic dissection Pulmonary infarction Infection FB aspiration CARDIAC: Endocarditis Pericarditis Ischemia (acute/chronic effect) Coronary stent thrombosis

Urinary anion gap in NAGMA

Na + K - Cl UAG <0 (negative) in NAGMA suggests NH4 excretion: - GI loss of HCO3 - Proximal Type II RTA UAG > 0 (positive) Inappropriate lack of acid excretion by kidney - Type I/IV RTA

Synchronized cardioversion recommended energies

Narrow regular: 50-100J Wide regular: 100J Narrow irregular: 120 - 200J

SOAP BRAIN MD

Need at least 4 of 11

Cause of a pericardial effusion

Neoplasm Lung Breast Esophagus Also: Lymphomas GI Primary tumors Scarcomas Pericarditis -radiation -infection idiopathic Connective tissue diseases - SLE - Scleroderma - RA - Rheumatic fever Metabolic disorders - Uremia - Myxedema - Choleserol pericarditis - Bleeding diathesis Cardiac disease - AMI - CHF - Aortic dissection - Coronary aneurysm Drugs - Dilantin - Anticoagulants - Procainamide Traumatic

Absolute Exclusion Criteria 3 hours tPA for CVA - 5 Neurological - 4 Vital signs/imaging - 3 bleeding/coagulopathy

Neurologic (1) Significant head trauma/stroke in last 3 months (2) Symptoms suggest SAH (3) History of previous ICH (4) Intracranial neoplasm, AVM, or aneurysm (5) Recent intracranial or intraspinal surgery Vital Signs/Imaging (1) Elevated BP (systolic >185 mmHg or diastolic >110 mmHg) (2) Blood glucose concentration <50 mg/dL (2.7 mmol/L) (3) CT demonstrates multilobar infarction (hypodensity >1/3 cerebral hemisphere) (4) ICH on non-contrast CT scan Bleeding/coagulopathy related (1) Arterial puncture at noncompressible site in last 7 days (2) Active internal bleeding (3) Acute bleeding diathesis including but not limited to: - Platelet count <100 000/mm³ - Heparin received within 48 hours, resulting in abnormally elevated aPTT greater than the upper limit of normal - Current use of anticoagulant with INR >1.7 or PT >15 seconds - Current use of direct thrombin inhibitors or direct factor Xa inhibitors with elevated sensitive laboratory tests

Absolute Contraindications for Fibrinolysis in Acute MI 10 Total 5 Neurology 3 Bleeding/Trauma 1 Hypertension Streptokinase

Neurology ● Any prior ICH ● Known structural cerebral vascular lesion ● Known malignant intracranial neoplasm ● Ischemic stroke within 3 months (EXCEPT acute ischemic stroke within 4.5 h) ● Intracranial/intraspinal surgery within 2 mo Bleeding/trauma ● Suspected aortic dissection ● Active bleeding or bleeding diathesis ● Significant closed-head or facial trauma within 3 mo Hypertension ● Severe uncontrolled hypertension (unresponsive to emergency therapy) ​ Other ● For streptokinase, prior treatment within the previous 6 mo

Drugs that may precipitate a mysathenic crisis

Neuromuscular blocking agents Antibiotics - Aminoglycosides - Clindamycin - Fluoroquinolones - Vancomycin Cardiovascular drugs - Beta blockers - Procainamide - Quinidine Chloroquine Hydroxychloroquine Phenytoin

Sequale of frostbite

Neuropathic Chronic pain Altered sensation Autonomic dysfunction Raynaud's syndrome Musculoskeletal Atrophy Compartment syndrome Rhabdomyolysis Stricture Osteoarthritis Necrosis Amputation Dermatologic Edema Lymphedema Chronic or recurrent ulcers Miscellaneous Core temperature afterdrop Acute tubular necrosis Electrolyte fluxes Gangrene/Sepsis

Gestational Hypertension

New bp reading of 140/90 or higher Occurs during pregnancy (after 20 weeks) and resolves during postpartum period

When to stop NAC for acetaminophen toxicity

No Aceteminophen detectable No evidence of liver injury

Low risk features for GI Bleed

No Comorbidities Normal vitals Little blood on exam Negative gastric aspiration (if done) Normal Hb Good supports Understands return instructions Immediate access to ER available Follow-up in 24hrs

Drugs and Conditions Associated with Acute Hyponatremia

OPERATIVE Postoperative phase Post-resection of the prostate Colonoscopy preparation DRUG Recent thiazides prescription 3,4-Methyleendioxymethamfetamine (MDMA, XTC) Cyclophosphamide (intravenous) Oxytocin Recently started desmopressin therapy Recently started terlipressin, vasopressin BEHAVIOR Polydipsia Exercise

List common organisms in necrotizing skin infections Type I and Type II necrotizing fasciitis - organisms and hosts What organism is responsible for "gas gangrene"

ORGANISMS - S. Aureus - MRSA - GAS - Bacteroides (anaerobic) - Clostridium perfringes (anaerobic) - "gas gangrene" TYPE I - Polymycrobial - DM / immunocompromised hosts TYPE II - Single agent (MC = GAS) - Any host GAS GANGRENE - Clostridium perfringens

Relative contraindications for tPA at 3 hours in CVA - 3 unique - 3 overlap with MI relative contraindications

OVERLAP (1) Pregnancy (2) Major surgery or serious trauma within previous 14 days (3) Recent gastrointestinal or urinary tract hemorrhage (within previous 21 days) UNIQUE (4) Only minor or rapidly improving stroke sx's (5) Seizure at onset with postictal residual neurological impairments (6) Recent acute myocardial infarction (within previous 3 months)

Overview of SVC syndrome NON-MALIGNANT CAUSES

Obstruction of blood flow through SVC due to compression. thrombosis, or infiltration Most commonly malignancy (Lung CA, Lymphoma, mets, breast) NON-MALIGNANT Goiter Pericardial constriction Primary thrombosis Sclerosing aortitis Mediastinitis Indwelling catheter

When to terminated pre-hospital CPR in pulseless hypothermia victim

Obvious signs of irreversible death Valid DNR order Conditions unsafe for rescuer Avalanche burial ≥35 min, airway packed with snow, and asystole

Triad of Wernicke's Encephalopathy

Oculomotor abnormal mentation truncal ataxia

Disadvantages of nitroprusside test for ketones

Only detects acetoacetate whereas B-Hyrdroxybutyrate is predominant ketone in DKA and AKA (especially)

Bechet's Disease

Oral apthous ulcers along with: genital lesions Cutaneous lesions (nodules, erythroderma, pyroderma) Neurological Occular (uveitis, iritis,) Other rheumatological manifestation

Beta blockers with significant membrane stabilizing effects

PAN Propranolol Acebutolol Nadolol

Alveolar gas equation Simplified to Room Air at Sea Level

PAO2 = FiO2(Patm-PH20) - PaCo2/RER Simplified: PAO2 = 150 - (PaCO2/.8)

Whom to perform an ED Thoracotomy

PENETRATING TRAUMA WITH: Cardiac arrest within 15 minutes (WEST) + signs of life in field SBP < 50 mm Hg after fluid resuscitation BLUNT TRAUMA WITH: Cardiac arrest within 10 minutes SUSPECTED AIR EMBOLISM - Unlikely to be successful if no echo evidence of cardiac motion or effusion based on 2015 Annals of Surgery Prospective Case control study by Inaba

Agents that do no adsorb to activated charcoal

PHAILS Pesticides Hydrocarbons Acid/alkalais/alcohols Iron Lithium/Lead Solvents

Risk factors for placental abruption

PMHX/Pregnancy History Prior abruption Thrombophilia Prior miscarriage ↑ Maternal age ↑ Parity RISK FACTORS RELATED TO CURRENT PREGNANCY HTN/Preeclampsia Smoking Cocaine use Trauma

Approach to renal failure

PRE-RENAL VOLUME DEPLETION GI losses Diuresis Blood losses Insensible losses VOLUME REDISTRIBUTION 3rd spacing (pancreatitis, peritonitis, trauma, burns) CHF Cirrhosis/liver disease Sepsis Anaphylaxis Hypoalbuminemia ↓ CO MI Valve disease CM Anti-HTN meds Nitrates RENAL Vascular, large vessel • Renal artery thrombosis/stenosis • Renal vein thrombosis • Atheroembolic disease Vascular, small/medium vessel • Scleroderma • Malignant HTN • HUS/TTP • HIV-assd microangiopathy Glomerular • SLE • IE • Vasculitis (PAN, Wegener's, HSP) • HIV-assd nephropathy • Essential mixed cryoglobulinemia • Goodpasture's • Post-streptococcal GN • RPGN Tubulointerstitial • Drugs • Toxins (heavy metals, ethylene glycol) • Infections • MM ATN • Ischemia (shock, sepsis, severe prerenal azotemia) • Nephrotoxins (abx, contrast, myoglobinuria, hemoglobinuria) OBSTRUCTIVE Intrarenal and Ureteral • Stone • Sloughed papilla (Sudden deterioration in DM, NSAIDs, SCD) • Malignancy • Retroperitoneal fibrosis • Uric (TLS) or oxalic acid (ethylene glycol) crystals • Sulfa, MTX, acyclovir, indinavir Bladder • Stone • Blood clot • BPH (#1) • Cancer • Neurogenic bladder (#2) Urethra • Phimosis • Stricture

Cooling heat stroke PREFERRED METHODS ADJUNCTS

PREFERRED Evavoprative cooling with large fans and skin wetting Ice water immersion ADJUNCTS Ice packs to axillae and groin Cooling blanket Peritoneal lavage (unproven efficacy in humans) Rectal lavage Gastric lavage Cardiopulmonary bypass

MAOi Toxicity PRESENTATION PHASES

PRESENTATION (1) MAOI OD (2) MAOI food-beverage interaction (3) MAOI drug interaction PHASES I: Asymptomatic/latent - may last up to 24 h II: Neuromuscular and CVS excitation III: CNS depression with CVS collapse IV: Complications of previous phases

CXR in TB PRIMARY POSTPRIMARY OTHER

PRIMARY Pulmonary and hilar or mediastinal nodes POST PRIMARY Upper lung infiltrate +/- cavitation/volume loss OTHER Tuberculoma (nodular lesions from healed primary TB) Ghon focus (calcified scar of previous tuberculoma) Ranke focus (calcified hilar lymph nodes) Miliary TB (multiple 1-3mm nodules) Pleural effusion

Cause of PVCs and Vtach

PRIMARY CARDIAC Ischemic heart disease Valvular disease Acute or previous myocardial infarction or ischemia Cardiomyopathy Myocardial contusion METABOLIC Hypokalemia Hypoxemia Hypomagnesemia Hypercapnia Acidosis Alkalosis DRUGS Digitalis toxicity Class I antidysrhythmic agents Ethanol Methylxanthine toxicity Other drug intoxications (especially cyclic antidepressants) MISCELANEOUS Idiopathic causes† Catecholamine excess*

Pacemaker Coding

PS Remember Pacers (1) Pace (2) Sense (3) Response (4) Programmability

Spurrious Hyponatreamia PSEUDOHYPONATREMIA REDISTRIBUTIVE HYPONATREMIA

PSEUDOHYPONATREMIA falsely low Na if serum high in lipids or protein (therefore relative % of H2O is ↓) REDISTRIBUTIVE HYPONATREMIA extra osmotically active solute in serum draws H2O into intravascular space, diluting Na (i.e. glucose, mannitol)

Complications of: Peritonsillar Abscess Retrophayngeal Abcess

PTA Upper airway obstruction Abscess rupture -> Pneumonia, empyema, pulmonary abscess, sepsis Contigous spread - Parapharyngeal abscess - Retropharyngeal abscess - Ludwig's angina - Mediastinitis - Myocarditis - Carotid artery erosion - Lemierre's syndrome - Meningitis - Cavernous sinus thrombosis - Cerebral abscess RPA As above plus: - Transverse myelitis - Epidural abscess - Atlantoaxial separation

Causes of hypocalcemia

PTH insufficiency • 1° hypoparathyroidism • 2° hypoparathyroidism (H/N sx, metastatic ca, infiltrative diseases, sepsis, pancreatitis, burns, drugs (cimetidine, EtOH, chemo), Vitamin D insufficiency - ↓ Ca, ↓ PO4 • Rickets • Malabsorption • Liver/renal disease • Anticonvulsants (phenytoin) PTH resistance Calcium chelation • ↑ PO4 • Citrate • Free fatty acids (pancreatitis) • Fluoride poisoning Alkalosis (cautious HCO3 correction)

Pulmonary Vascular Resistance

PVR = (MPAP - PAWP) X 80/CO

phlegmasia cerulea dolens

Painful inflamed blue leg with thrombosis of both deep and superficial that can progress to venous gangrene if capillaries thrombose CERULEA = BLUE

Stigmata of chronic liver disease

Palmar erythema Jaundice Fetor hepaticus Spider angioma Caput medausae Ascites Asterixis Gynecomastia

Emphysema

Pathological term for alveolar destruction without visible fibrosis

Malignant hyperthemia Pathophysiology Triggers Features Management

Pathophysiology Genetic defect in raynodine receptor on sarcoplasmic reticulum -> uncontrolled Ca2+ release -> abnormal skeletal muscle contraction Triggers Depolarizing muscle relaxants (sux) Inhaled volatile anasthetics Features rising expired carbon dioxide despite increased MV muscle rigidity rhabdomyolysis hyperthermia tachycardia acidosis hyperkalemia Management Discontinue offending agents Dantrolene Cooling Hyperventilate Supportive measures

Hyperviscoscity Syndrome - Pathophysiology - Presentation

Pathophysiology: Excessive elevations in paraproteins/blood components leading to: (1) Relative HYPOERFUSION caused by sluggish blood flow (2) PROLONGED BLEEDING time caused by circulating proteins that interfe with platelet function Presentation Classic triad: (1) Mucosal/skin bleeding; (2) Visual symptoms; (3) Focal Neuro Deficits stroke CHF ATN Pulm edema

Describe how you perform the bedside ice bag test for MG

Patient with ptosis Measure distance between lids in most severely affected eye Apply ice to eye for 2 min Measure distance again Positive test is improvement of at least 2 mm in ptosis OR tensilon test

Who requires irradiated blood products

Patients at risk of GVHD (for example undergoing bone or stem cell transplants)

Whom to consider for ED thoracotomy according to Rosen's - Penetrating - Blunt

Penetrating - Cardiac arrest at any point with initial signs of life in the field - Systolic bp < 50 mm Hg after resuscitation - Severe shock with signs of tamponade Blunt Cardiac arrest in ER

Operative indications for type B dissection

Persistent pain Uncontrollable HTN Occlusion of major arterial trunk Aortic leakage/rupture Aneurysm development

Phases of cardiac action potential

Phase 4 - electrical diastole; -90 mV Phase 0 - depolarization; fast Na channels Phase 1 - slight repolarization; Na channels close, K efflux Phase 2 - plateau; slow Ca channels influx balanced by K efflux ↑ cytosolic Ca → myofibril contraction Phase 3 - rapid membrane repolarization as slow Ca channels close, K flows down gradient (outside cell) and Na/K ATPase operates to restore membrane potential

Risk factors for frostbite

Physiologic Genetic Core temperature Previous cold injury Acclimatization Dehydration Overexertion Trauma: multisystem, extremity Dermatologic diseases Diaphoresis, hyperhidrosis Hypoxia Mechanical Constricting or wet clothing Tight boots Immobility Psychological Mental status Fear, panic Attitude Peer pressure Fatigue Intense concentration on tasks Hunger, malnutrition Intoxicants Environmental Ambient temperature Humidity Duration of exposure Wind chill factor Cardiovascular Hypotension Atherosclerosis Arteritis Raynaud's syndrome Cold-induced vasodilation Anemia Sickle cell disease Diabetes Vasoconstrictors, vasodilators

Treatment of TTP

Plasmapheresis is most important Glucocorticoids and Rituximab are adjuncts

Type of malaria species

Plasmodium falciparum (Irregular fevers or continuous) P.malariae (72hrs intervals) P.ovale (dormant) [48hr intervals; hypnozite phase] P.vivax (dormant) [48hr intervals; hypnozite phase] P. knowlesi (newer identification; ?24h interval) All are protozoa

Indications for Multi-Dose Activated Charcoal Elimination

Please Quit Drinking The Activated Charcoal Very Dumb Phenobarb Quinine Digoxin, Dilantin Theophylline/TCA, ASA/Atenolol Carbamazepine, Valproic Dapsone

Electricity formulas Power Current

Power = Current (squared) X Resistance X time P = I2Rt Current = Voltage divided by resistance I = V/R

Definition of massive hemoptysis

Practical: volume that is life threatening by virtue of airway obstruction, blood loss, or hypoxia Volume: 100 - 600ml

Corticosteroid substitution

Prednisone 5mg = Dexamethasone 0.75mg (no mineralcortiocid effect) = Hydrocortisone 20mg

Pascal's Law

Pressure transmitted to a liquid is applied equally to all parts of a liquid As depth increases pressure increased and is uniformly applied

Overview of frostbite management

Prethaw Stabilize patient and core temperature Assess Doppler pulses and appearance Protect part - prevent partial thaw and refreeze Rehydrate patient Surgical consultation Rapid rewarming of the affected digits in hot water (39°C) with chlorhexidine and isopropyl alcohol Immersion of affected parts in hot water (39°C) in a hydrotherapy whirlpool daily (starting the day after rewarming) Débridement and aspiration of clear blisters Application of aloe vera protective ointment and porous low-adherent wound dressings Elevation of affected parts Avoidance of tobacco and alcohol Tetanus-diphtheria immunization Oral ibuprofen every 6 hours For grade 3 or higher frostbite: Intravenous infusion of iloprost 2 ng/kg per min, 6 h/d, for 5 days For grade 4 frostbite: After administration of iloprost, concurrent intravenous infusion of alteplase (for one day; weight-based dosage, progressively increased to a maximum total dose of 100 mg) and heparin (for 72 hours; dosage based on weight and prothrombin time)

Risk factors for fatal asthma

Previous serious exacerbations 1. Previous severe exacerbation (intubation or ICU) Evidence of poorly controlled asthma 2. > 2 admissions for asthma in past year 3. > 3 ED visits for asthma in past year 4. Admission or ED visit for asthma in past month 5. > 2 ventolin MDI canisters used/month 6. Current or recent use of systemic steroids Poor symptom perception 7. Difficulty perceiving degree of airflow obstruction Comorbidities 8. Comorbidities (CV disease, chronic lung/psychiatric) 9. Serious psychiatric or psychosocial issues 10. Illicit drugs (inhaled cocaine or heroin)

ECG Changes with lithium toxicity

Prolonged QTc Bradycardia T-wave flattening ST changes

Predisposing factors for infective endocarditis

Prosthetic heart valve Prior IE Congenital cardiac lesion with high pressure gradient -(VSD, TOF, PS) Rheumatic heart disease IVDU Calcific degenerative valve - (MV, AV - most common RF in elderly)

Conditions that increase the duration of action of succinylcholine

Pseudocholinesterase deficiency Organophosphate poisoning

Complications of tuberculosis

Pulmonary PTX Empyema/Effusion Endobroncial spread Airway TB --> Bronchiectasis Hemoptysis (Ramussen's aneurysm!) Primary TB pneumonia Extra-Pulmonary Cervical lymphadentitis (scorfula) Bone and Joint Infections Spinal TB (pott's disease) Thyroid Adrenal Renal TB Milliary/Disseminated TB CNS disorder (menningitis, tubercoluma) GI tract

Differential diagnosis of Dyspnea

Pulmonary Airway obstruction Spontaneous pneumothorax Pleural effusion Pulmonary embolus Asthma Neoplasm Noncardiogenic edema Cor pulmonale Pneumonia Anaphylaxis Aspiration COPD Epiglottitis Cardiac Pulmonary edema Pericarditis Congenital heart disease Myocardial infarction Valvular heart disease Cardiac tamponade Cardiomyopathy Abdominal Mechanical interference Pregnancy Hypotension/Intrabdominal sepsis Ascites Obesity Metabolic or endocrine Toxic ingestion Renal failure Fever DKA Electrolyte abnormalities Thyroid disease Traumatic Tension pneumothorax Simple pneumothorax hemothorax Rib fractures Cardiac tamponade Diaphragmatic rupture Flail chest Hematologic Carbon monoxide poisoning Anemia Acute chest syndrome Neuromuscular CVA, intracranial insult Multiple sclerosis ALS Organophosphate poisoning Guillain-Barré syndrome Polymyositis Tick paralysis Porphyria

Variables that are directly measured using pulmonary artery catheter

Pulmonary artery pressure Central venous pressure Cardiac output Pulmonary artery saturation Mixed venous oxygen saturation Core temperature

Pulmonary Renal Syndrome - with anti-GBM - ANCA Positive - ANCA Negative

Pulmonary-renal syndrome associated with anti-GBM antibodies: Goodpasture's syndrome Pulmonary-renal syndrome in ANCA-positive systemic vasculitis Wegener's granulomatosis (Granulomatosis with polyangitis) Microscopic polyangiitis Churg-Strauss syndrome Pulmonary-renal syndrome in ANCA-negative systemic vasculitis Henoch-Schönlein purpura Mixed cryoglobulinaemia Behçet's disease IgA nephropathy

Benign Cholestatis of pregnancy

Puritis and jaundice for mother Fetus - Prematuity - Stil birth - Distress - Imparied vitamin K absorption leading to coagulopathy and ICH Need OB F/U and Vitamin K supplementation

Simplified Shunt Fraction

Qs/Qt = (1-SaO2)/(1-SVO2)

Shunt Equation

Qs/Qt = (CcO2 - CaO2)/(CcO2 - CvO2)

Echocardiography findings suggestive of cardiac tamponade

RA compression RV diastolic collapse Dilated IVC with lack of inspiratory collapse Abnormal resp variation in tricuspid and mitral flow velocities (doppler)

Pathophysiological Consequences of Chronic Renal Failure

RENAL: Low/no urine output METABOLIC AND ENDOCRINE Associated o Hyperkalaemia o Abnormal Ca++ o Hyperphosphataemia o fluid feeding and protein restriction CVS: Hypertension Atherosclerosis Pericarditis RESPIRATORY Prone to pulmonary oedema NEUROLOGICAL: Dialysis disequilibrium Polyneuropathy and myopathy DERMATOLOGIC: Fragile skin HEMATOLOGICAL: Anaemia Platelet dysfunction GASTROINTESTINAL: Impaired motility Bleeding risk related to gastric ulceration IMMUNE: Increased risk of infection PHARMACOLOGIC: Altered clearance of medications that have predominant renal excretion VASCULAR ACCESS Fistulas used for dialysis may complicate CVC and arterial access

Rash on Palms and Soles RICKS SEEDS

RICKS SEEDS R: RMSF I: IE (Janeway lesions and oslers nodes) C: Coxsackie virus (HFM) K: Keratoderm Blennorrhagia (Reiters) S: Secondary syphilis S: Scabies E: Enterovirus (HFM) E: EM / SJS D: Disseminated gonococcemia S: Small Pox

Rabies Causative Agent Major reservoirs in North America

RNA rhabdovirus of genus Lyssavirus bats, raccoons, skunks, and foxes

TYPES of Renal Tubular Acidosis (RTA) RTA Type II RTA TYPE I RTA Type IV

RTA Type II Defect in proximal bicarbonate absorption Alkaline urine -> Acidotic mild NAGMA Hypokalemia RTA TYPE I Defect in distal acid excretion NAGMA Alkaline Urine Renal stones Hypokalemia RTA Type IV defect in cation-exchange in the distal tubule with reduced secretion of both H+ and K+ NAGMA Acidotic urine Hyperkalemia

MOA of Raburicase

Recombinant xanthine oxidase Catalyzes conversion of uric acid to more soluble allantoin Can quickly decrase serum uric acid levels

MOA of raburicase

Recombinant xanthine oxidase Catalyzes conversion of uric acid to more soluble allantoin Can quickly decrase serum uric acid levels

Indications for early invasive strategy in NSTEMI

Refractory angina Signs or symptoms of HF or new or worsening mitral regurgitation Hemodynamic instability Recurrent angina or ischemia at rest or with low-level activities despite intensive medical therapy Sustained VT or VF

How a pulse oximeter works

Relative absorbance of red and infared wavelengths of light

Pathophysiology of DKA

Relative lack of insulin and glucagon excess (1) ↑glucose → osmotic diuresis → dehydration and loss of Na, K, Mg, PO4 (2) Peripheral cells cannot use glucose → break down proteins → AA → go to liver → used for gluconeogenesis → ↑glucose (3) High levels of glucagon promote ketogenesis -> Long-chain FFAs circulate in the blood → partially oxidized and converted to acetoacetate and beta-hydroxybutyrate by the liver -> THIS IS THE MECHANISM FOR AGMA (4) Altered LOC: hyperosmolality, acidosis, impaired glucose utilization, poor HDs

Complications of Tumor Lysis Syndrome

Renal failure secondary to urate nephrocalcinosis Cardiac Dysrhythmia Neuromuscular symptoms - Cramps - Confusion - Seizures Sudden death

Diagnosis of acute otitis media

Requires all 3 of the following: (1) acute onset (2) signs of middle ear effusion (bulge, limited mobility, A-F level, otorrhea) (3) signs of middle ear inflammation (erythema or otalgia)

Pathophysiology of frostbite

Requires temperature below zero degrees celcius (1) Ice crystal formation (2) microvasculat thrombosis and stasis

Causes of failure to improve with pneumonia

Resistant microorganism Uncovered pathogen Inappropriate by sensitivity Parapneumonic effusion/empyema Nosocomial superinfection Nosocomial pneumonia Extrapulmonary Noninfectious Complication of pneumonia (e.g., BOOP) Misdiagnosis: PE, CHF, vasculitis Drug fever

Underdampened arterial line

Resonant frequency of system approaches natural frequency of artery - Excess tubing length - Tachycardia - Highoutput - Stopcocks

Indications for invasive mechanical ventilation in COPD

Resp arrest ↓ LOC despite maximal therapy CV instability (shock, heart failure) NIPPV failure or exclusion Severe SOB or ↑ RR Life-threatening hypoxia Severe acidosis/↑pCO2 Other: metabolic abNs, sepsis, pneumonia, PE, barotrauma, massive pleural effusion)

Definition of drowning

Respiratory impairment from submersion in water

Rock Mountain Spotted Fever Organism Vector Endemic Areas Management

Rickettsia rickettsii - olbigate intracellular gram negative coccobacillus Causes vasculitis and microinfarcts in diverse end organs Vector - American dog tick (Dermacentor variabilis) - Rocky Mountain wood tick (Dermacentor andersoni) Endemic South East USA Arizona Management 1st line antibiotic (even for pediatrics) Doxycycline 2nd line anitibotic Chloramphenicol

Etiologies of non-traumatic SAH

Ruptured saccular aneurysm (80%) AVM (most common cause in children) Cavernous angioma* Mycotic aneurysm Neoplasm Blood dyscrasias Extension from intraparenchymal haemorrhage

Cardiac Conduction system blood supply SA NODE AV NODE BUNDLES OF HIS

SA NODE 55% RCA 45% Cx AV NODE RCA (90%) BUNDLES OF HIS RBB and LASF supplied by LAD LPIF supplied by RCA or LCA

Rertroperitoneal organs

SADPUCKER Supra-renal glands Aorta/IVC Duodenum (2nd and 3rd) Pancreas (head and body) Ureters Colon (ascending/descending) Kidneys Esophagus Rectum

Arterial pressure index

SBP Injured/SBP Uninjured <0.90 is concerning

Malaria Treatment SEVERE NON-SEVERE

SEVERE Artesunate (IV) NON-SEVERE Malarone Quinine + Doxycycline Choloroquine if known susceptible

Indications for empiric MRSA Coverage in Febrile Neutropenia patients

SICK Hemodynamic instability or other evidence of severe sepsis SITE Pneumonia documented radiographically Positive blood culture for gram-positive Clinically suspected serious catheter-related infection Skin or soft-tissue infection at any site Severe mucositis COLONIZATION Colonization with MRSA, VRE, Penicllin resistant strep

Signs and symptoms suggesting possible fatal asthma attack

SIGNS accessory muscles use Heart rate > 120 Respiratory rate > 25 Difficulty speaking Altered level of consciousness III Quiet chest Diaphoresis Inability to lie in the supine position Peak expiratory flow < 30% of predicted after therapy Oxygen saturation < 90% III Cyanosis III SYMPTOMS Sense of progressive breathlessness or air hunger III Sense of fear or impending doom III Progressive agitation or anxiety

Jarisch-Herxheimer reaction

SIRS like inflammatory response that occurs after 1st dose of antibiotic related to release of spirochette exotoxins

Pulmonary Artery Catheter Waveforms and Pressures

SVC/RA = 0-6 mmHg RV = 25/0 mmHg PA = 15-30/5-15 mmHg PAOP = 2-10 mmHg

Systemic Vascular Resistance

SVR = (MAP-CVP) X 80/CO

Drugs to avoid in thyrotoxicosis

SYMPATHETIC STIMULATION Pseudophedrine Ketamine Ventolin THYROID HORMONE Amiodarone Iodinated contrast material ASA

Findings in Thyrotoxicosis - Symptoms - Physical Exam Findings

SYMPTOMS Constitutional: Weight loss despite hyperphagia fatigue, generalized weakness Hypermetabolic: Heat intolerance excessive perspiration Cardiorespiratory: Heart pounding and racing dyspnea on exertion chest pains Psychiatric: Anxiety restlessness emotional lability confusion Muscular: Tremor Ophthalmologic: Tearing, irritation, wind sensitivity, diplopia, foreign body sensation Thyroid gland: Neck fullness, dysphagia, dysphonia Dermatologic: Flushed feeling, hair loss, pretibial swelling Reproductive: Oligomenorrhea, decreased libido, gynecomastia PHYSICAL EXAM Vital signs: Tachycardia, widened pulse pressure, bounding pulses, fever Cardiac: Hyperdynamic precordium, systolic flow murmur, prominent heart sounds, atrial fibrillation, evidence of heart failure Ophthalmologic: Widened palpebral fissures (stare), lid lag, globe lag, conjunctival injection, periorbital edema, proptosis, limitation of superior gaze Neurologic: Fine tremor, hyperreflexia, proximal muscle weakness Psychiatric: Fidgety, emotionally labile, poor concentration Dermatologic: Warm, moist, smooth skin; fine, brittle hair Neck: Diffuse symmetric thyroid enlargement, sometimes with a bruit and palpable thrill; thyroid with multiple irregular nodules or a prominent single nodule; tracheal deviation, venous prominence with arm elevation (Pemberton's sign)

Clinical Features of Hypothyroidism

SYMPTOMS Paresthesias Fatigue Cold intolerance Weakness Muscle/joint pain Poor concentration Drowsiness Constipation SIGNS Pseudomyotonic reflexes Change in menstrual periods Hypothermia Dry, scaly skin Puffy eyelids Hoarse voice Weight gain Non pitting edema Diastolic HTN Narrow pulse pressure

Indications for thoracic surgery opinion with pneumothorax management

Second ipsilateral pneumothorax. First contralateral pneumothorax. Synchronous bilateral spontaneous pneumothorax. Failure of chest tube to resolve Spontaneous haemothorax Professions at risk (eg, pilots, divers) Pregnancy

Lemierre syndrome

Septic thrombophebitis of the internal jugular vein with anaerobic organisms (Fusobacterium necrophorum) Often complicated by septic embolization

SPICE Organisms

Serratia Providencia Indole-positive Proteus species Citrobacter Enterobacter Other organisms in this class include: Acinetobacter, Cronobacter, Edwardsiella, Hafnia, Morganella, and rarely Pseudomonas Therapuetic options: nitrofurantoin (for cystitis only), trimethoprim-sulfamethoxazole, carbapenems, aminoglycosides and fluoroquinolones

Complications of therapeutic hypothermia

Shivering Arrhythmia Hemodynamic instability Hyperglycemia Cold diuresis Hypokalemia Increased infection risk

ECG findings suggestive of Pulmonary Embolism

Sinus tachycardia S1Q3T3 new RBBB/RAD Anterior (V1-V4) T wave Inversions

Potential ECG findings in TCA overdose

Sinus tachycardia Terminal R in aVR > 3mm R/S ratio in aVR > 0.7 Wide QRS • >100 msec 30% (1/3) seizures • >160 msec 50% (1/2) arrhythmia Brugada-like picture Prolonged QTc STE in right precordial leads (V1-V3)

Encapsulated Organisms

Some nasty killers have some capsule protection" Streptococcus pneumoniae Neisseria meningitidis Klebsiella pnemoniae Haemophilus influenzae Salmonella typhi Cryptococcus neoformans Pseudomanas aeruginosa

Strychnine -Sources - MOA - Complications - Treatment

Sources: rodenticide, adulterant in some drugs MOA: Antagonizes glycine (inhibitory neurotransmitter that binds and opens Cl- channels - like GABA) receptor in the spinal cord Leads to unopposed CNS excitation in the spinal cord (just like TETANUS) -clonus, opsithotonus, 'risus sardonicus' - normal LOC Complications: resp arrest, rhabdo, acidosis Rx: Benzos, NMB, quiet environment

High risk organisms in patients with splenectomy or functional asplenia

Splenectomy or Functional Asplenia BACTERIA Streptococcus pneumoniae Haemophilus influenzae Neisseria meningitidis Capnocytophaga canimorsus Bordetella holmesii PARASITES Babesia sp.

Most commonly injured abdominal organs with: Stab Wounds Gunshot wounds Blunt Abdominal trauma

Stab Wounds Liver Small intestine Gunshot wounds Small intestine Colon Liver Blunt Abdominal trauma Spleen Liver Small Intestine

Stages of ethylene glycol toxicity

Stage 1: Acute neurologic (30 min-12 h) - inebriation similar to EtOH; nystagmus Stage 2: Cardiopulmonary (12-24 h) - HTN, tachy, ARDS, circulatory collapse Stage 3: Renal (24-72 h) - oliguria/anuria, ATN Stage 4: Delayed neurologic (6-12 days) - cranial neuropathy (facial diplegia/deafness)

Ulcer grading

Stage I - Intact skin with signs of impending ulceration, initially presenting blanchable erythema indicating reactive hyperemia Stage II - A partial-thickness loss of skin involving epidermis and dermis Stage III - A full-thickness loss of skin with extension into subcutaneous tissue but not through the underlying fascia Stage IV - A full-thickness tissue loss with extension into muscle, bone, tendon, or joint capsule

Stages of rabies infection

Stages of rabies infection (1) incubation (2) prodrome (3) acute neurologic illness/clinical rabies - Furious/encephalopathic - Dumb - Non-classic (Sensory/motor deficits, brainstem) (4) coma (5) death

Nikolsky sign positive

Staphylococcal Scalded Skin Syndrome Toxic Epidermal Necrolysis Bullous impetigo Pemphigus vulgaris Epidermolysis bullosa Second degree and Third degree burns

Stages of Hepatic Encephalopathy

Subclinical: Subtle decreased in motor/psychomotor functioning I: Impaired attention, irritability, depression Temor, incorodination, apraxia II: Behavioral changes, poor memory, sleep Asterixis, slowed speech, ataxia III: Confusion, somnolence, amnesia Hypoactive reflexes, clonus, nystagmus, rigidity IV: Stupor/coma Dilated pupils derebrate, oculocephalic reflex

Pathophysiology of drowing

Submersion Panic/Breath holding Hypoxia Gasp Aspiration Surfactant destruction Alveolar collapse V/Q mismatch ALI Hypoxia/metabolic acidosis CV collapse Neuronal injury Death

Rhoadenese

Sulfur transfersase enzyme which converts cyanide and cyanomethemoglobin to thiocyanate which is renally cleared

Admit criteria in submersion victim

Symptomatic History of apnea or hypoxia dysrhythmia Abnormal CXR

ICU Acquired Weakness

Syndrome of generalized limb weakness that develops while the patient is critically ill and for which there is no alternative explanation other than the critical illness itself

Variables that are calculated using pulmonary artery catheter

Systemic vascular resistance Stroke volume Oxygen delivery Oxygen consumption Pulmonary vascular resistance Left ventricular stroke work index Right ventricular stroke work index

Key SCI Level for Autonomic Dysreflexia

T6 Related to greater splanchnic nerve T5-T9

DDX of cavitary lesions on CXR

TB fungal (aspergilloma) bacterial (Staph, Klebsiella, MAC, Pseudo, Legionella), bronchogenic ca (SCC) PCP PE Wegener's COPD neurofibromatosis

Differential diagnosis of sodium channel blockade toxicity

TCA Benadryl Type 1a antiarrhythmics (quinidine, procainamide) Type 1c antiarrhythmics (flecainide, encainide) Antimalarials (hydroxychloroquine<chloroquine, quinine) Propranolol Carbamazepine Cocaine Propoxyphene Cyclobenzaprine

Transmembrane pressure (TMP)

TMP = pressure gradient across the filter membrane, i.e. the difference in pressure between the blood compartment and the dialysate compartment. Transmembrane pressure (TMP) = (Filter pressure + Return pressure) / 2 - (Effluent pressure)

Risk factors for ludwig's angina

TRAUMA - Mandibular fracture - FB - Laceration to floor of mouth - Tongue piercing - Traumatic airway procedure INFECTION - Dental infection - Jaw OM - Sepsis Oral Malignancy

Risk factors for MDR-tuberculosis

TREATMENT RELATED Previous failed treatment course Failure to respond to treatment Poor adherence IMMUNOSUPRESSION HIV IVDU EXPOSURE TO MDR-TB Close contact with MDR-TB Immigration form area with endemic MDR-TB CXR Cavitaty lesion on CXR EPIDEMIOLOGIC Homeless Prison MALNUTRITION Gastrectomy/illeal bypass surgery

Signs and Symptoms of a more serious febrile transfusion reaction

Temperature >39 Hypotension/shock Tachycardia Rigors/chills Anxiety CP Back pain Hemoglobinuria Oliguria Bleeding from puncture sites Nausea/vomitting

Indications for an Intra-Aortic Balloon Pump

The IABP can be used whenever there is cardiac pump failure if: it may resolve spontaneously, or a corrective procedure is planned. Examples: - cardiogenic shock - post bypass - post MI - cardiomyopathy - severe IHD awaiting surgery or stenting - severe acute MR awaiting surgery - prophylactically in high risk patient pre stenting/ cardiac surgery - miscellaneous (i.e. post myocardial contusion which is expected to recover with time)

Diagnosis of HLH

The diagnosis of HLH requires a molecular diagnosis consistent with HLH or 5 of 8 of the below criteria 1. Fever 2. Splenomegaly 3. Cytopenias affecting at least 2 lineages: a. Hemoglobin < 90 b. Platelets < 100 c. Neutrophils < 1.0 4. Hypertriglyceridemia and/or hypofibrinogenemia a. Triglycerides >265 mg/dL b. Fibrinogen <150 mg/dL 5. Hemophagocytosis in bone marrow, spleen, or lymph nodes 6. Low or absent NK cell activity 7. Ferritin >500 mg/L 8. sCD25 (ie, sIL2R) >2400 U/mL

Ventricular Stroke Volume Worked (Left and right)

This is the work performed by the ventricle to eject the ejection fraction (Afterload - Preload) X (SVI X 0.0136)

Critical Oxygen Delivery

Threshold value below which oxygen consumption becomes delivery dependent because oxygen extraction ratio can no longer increase

Classic features of Heparin Induced Thrombocytopenia

Thrombocyopenia Platelet fall >50 percent and nadir ≥20,000 Timing Onset 5 - 10 days (<1 day if recent heparin) Thrombosis New thrombosis or skin necrosis after heparin No other cause identified

Indications for plasmapharesis

Thrombotic thrombocytopenic purpura (TTP) Atypical haemolytic uremic syndrome (aHUS) Guillain-Barré syndrome Myasthenia gravis Antiglomerular basement membrane disease (Goodpasture syndrome) Anti-neutrophil cytoplasmic antibody (ANCA)-associated rapidly progressive glomerulonephritis Cryoglobulinemia Recurrent focal segmental glomerulosclerosis Hyperviscosity syndrome Pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections and Sydenham's chorea Antibody mediated rejection post solid organ transplantation Desensitization prior to ABO incompatible organ transplantation Wilson's disease (fulminant)

Seizure prophylaxis in head injury

Tickling the Brain -Depressed skull fracture -Penetrating brain injury -Acute subdural hematoma -Acute epidural hematoma -Acute intracranial hemorrhage Seizure History -Seizure at the time of injury -Seizure at emergency department presentation -Prior history of seizures Injury Severity -Paralyzed and intubated patient -Severe head injury (Glasgow Coma Scale score 8 or lower)

Estimating radiation exposure and prognosis

Time to onset of GI Sxs is also prognostically significant

Causes of Acute Emergent Weakness with Potential for Respiratory Compromise

Toxic • Botulism • Buckthorn • Paralytic shellfish toxin • Tetrodotoxin • Tick paralysis • Metals (As, Th) Infectious • Polio • Diphtheria Autoimmune • GBS • Chronic inflammatory demyelinating polyneuropathy • MG Metabolic • Dyskalemic syndromes o Acquired o Familial • ↓ PO4 • ↑ Mg • Porphyria

Differential of focal cerebral dysfunction in HIV patient

Toxoplasmosis PML CNS Lymphoma

Acute Fatty Liver of pregnancy

Transaminitis, Hyperbilurbinemia, Hyperglycemia DIC Emergent delivery and supportive care

DDX of dyspnea during transfusion

Transfusion associated circulatory overload (TACO) Tranfusion related acute lung injury (TRALI) Anaphylaxis

Post-Transfusion Purpura

Transfusion of platelet antigen-positive RBCs, plasma, or platelets to a patient who is lacking the same platelet antigen. Autologous platelet destruction occurs but the mechanism is unclear Tends to occur 5-10 days after transfusion Test for platelet specific antigen IVIG

Anatomy of Facial Nerve

Traverses internal auditory meatus with CN VIII → exits temporal bone at stylomastoid foramen → parotid gland → branches

Types of Endoleak

Type I - leakage due to incompetent seal at proximal or distal anastomosis sites Type II - leakage into aneurysm sac 2° to branch vessels back-filling Type III - leakage due to failure at anastomosis of stent components Type IV - leakage through graft material

Universal Classification of Myocardial Infarction into 5 types

Type I: Spontaneous myocardial infarction -> intraluminal thrombus in one or more of the coronary arteries Type II: Myocardial Infarction Secondary to an Ischaemic Imbalance - Vasopasm/endothelial dysfunction - Fixed atherosclerosis and supply/demand imabalance - Supply/demand imbalance Type III: Cardiac Death Due to Myocardial Infarction Type IV: Related Coronary angiography or stent thrombosis Type V: Related to CABG

Pathology of ulcerative colitis (UC) versus Corhn's (CD)

UC: Superficial, continous inflammation of rectum/large bowel CD: Transmural inflammation, skip lesions that can affect entire gastrointestinal tract

Urinary chloride in work-up of metabolic alkalosis

UCl < 20 -> Volume depleted kidney is retaining sodium

Indications for intubation in burn patients

Upper airway obstruction Muscle fatigue suggested by a high or low respiratory rate Hypoventilation (Pco2 > 50 mm Hg and a pH < 7.2) Hypoxemia despite 100% O2 Inability to handle secretions Patient obtundation Impending/anticipated airway obstruction

CK levels in rhabdoymyolysis

Usually peak in 1 to 3 days At least 5,000 to get excited

Oxygen Extraction Ratio

VO2/DO2

Seizure causing medications

WITH LA COPS Withdrawal INH/Gyrometra/MMH Theophylline/TCA Hypoglycemia/Hypoxia Lithium/Lead/Local Anesthetics Anticholinergics Camphor/Cholinergics/CO/CN Organophosphates PCP Salicylates/Sympathomimetics

Roth Spots

White-centered retinal hemorrhages - Platelet-fibrin thrombus

Time of alcohol withdrawal and DTs

Withdrawal - As early as 6 hours after last drink -> up to 7 days Seizure - 6 - 48 hours after alcohol cessation DTs After 3 - 14 days of abstinence

Risk factors for primary spontaneous pneumothorax

Young Healthy Cigarette smoking Tall Male Marfan's MVP Familial Changes in ambient pressure

Risk factors for tumor lysis sydnrome

Younger Age CANCER RELATED Initiation of chemotherapy for heme onc Advanced disease with abdominal involvement High serum LDH (>1500U/L) DEHYDRATION RELATED Pre-exsisting renal insufficency Acidic Urine Concentrated Urine Pre-exsisting volume depletion

Contraindications to Whole Bowel Irrigation

a/w compromised HD instability intestinal obstruction/ileus GI perforation/pathology intractable vomiting dehydration

Treatment to consider in hemophilliac with inhibitors

aPCC (octoplex) rFVIIax

Ashman phenomenon

aberrant ventricular conduction due to a change in QRS cycle length in atrial fibrillation, when a relatively long cycle was followed by a relatively short cycle, the beat with a short cycle often has right bundle-branch block (RBBB) morphology. refractory period depends on the heart rate; longer cycle lengthens the ensuing refractory period, and, if a shorter cycle follows, the beat ending it is likely to be conducted with aberrancy

Risk factors for underlying vascular abnormalities in patients with ICH

age <65 years female sex nonsmoker lobar ICH intraventricular extension absence of a history of hypertension or coagulopathy.

Methemoglobin

altered state of hemoglobin in which the ferrous (Fe++) irons of heme are oxidized to the ferric (Fe+++) state. The ferric hemes of methemoglobin are unable to bind oxygen. In addition, the oxygen affinity of any remaining ferrous hemes in the hemoglobin tetramer is increased As a result, the oxygen dissociation curve is "left-shifted

Recommended intervention for choking infants (<1 year of year of age) who have severe obstruction but are concious

alternating 5 chest thrusts and 5 back blows

Definition of Organ dysfunction in sepsis

an acute change in total SOFA score2 points consequent to the infection. ~10% mortality in patients with infection

Metabolic abnormalities in alcoholic ketoacidosis - Abnormalities - Causes

characterized by: (1) AGMA (2) Elevated serum ketones (3) Normal to low glucose Caused by: (1) Extracellular fluid volume depletion (2) Glycogen depletion (3) elevated ratio of the reduced form of nicotinamide adenine dinucleotide (NADH) to nicotinamide adenine dinucleotide (NAD +) The decreased ratio of NAD+ to NADH has the following implications: - Impaired conversion of lactate to pyruvate - Impaired gluconeogenesis because pyruvate is not available as a substrate - A shift in the hydroxybutyrate (β-OH) to acetoacetate (AcAc) equilibrium toward β-OH

Chronic bronchitis

chronic productive cough for three months in each of two successive years in a patient in whom other causes of chronic cough (eg, bronchiectasis) have been excluded

Contraindications to LP

coagulopathy (INR >1.5, Plt <50 000, Heparin <24 hrs, Bleeding Diatheses) overlying infection ↑ ICP

When to consider vasculitis

considered in patients who present with systemic or constitutional symptoms in combination with evidence of single and/or multiorgan dysfunction

Acute Liver Failure

development of severe acute liver injury with encephalopathy and impaired synthetic function (INR of ≥1.5) in a patient without cirrhosis or preexisting liver disease

How a co-oximter works

device that uses spectrophotometry to measure relative blood concentrations of oxyhemoglobin, carboxyhemoglobin, methemoglobin, and reduced haemoglobin

Anaphylactoid reaction

direct release of preformed mediators of mast cells independent of IgE

Complications of pericardiocentesis

dysrhythmia PTX lung laceration myocardial perforation CA/IMA laceration liver injury

Typical LP findings in guillan barre syndrome

elevated cerebrospinal fluid (CSF) protein with a normal white blood cell count albuminocytologic dissociation

Dialysis dose in CRRT

equivalent to the effluent rate in ml/kg/hour Effluent rate is the ultrafiltration rate for haemofiltration (CVVH) or the sum of ultrafiltration rate and dialysis rate for CVVHDF

Units of radiation

express the dose of radiation absorbed in living tissue 1 Grey = 1 joule of radiation absorbed per kilogram of tissue 1 Grey = 100rad = 100rem 1 Sievert = equivalent biologic effect F(X) of dose, radiation type, and biological tissue

Consequences of thoracic aortic dissection

extension up or down rupture cororonary artery occlusion -> vessel branch occlusion aortic regurgitation pericardial effusion / tamponade

Cryoprecipitate indications

fibrinogen replacement in acquired hypofibrinogenemia (Less than 1.0g/L) Consider for Factor VIII or von Willebrand Disease if alternative products not available

Correcting calcium for albumin

for every 10 ↓ in albumin then ↑ calcium by 0.2

Definition of Congestive Heart Failure

heart cannot pump enough blood to meet metabolic demands of body, or requires ↑ filling pressures to accomplish goal.

Prophyaxis after exposure to meningitis cases: H Influenzae (Rifampin X 4 days) N meningitidis (Cipro/Ceftri/Rifampin)

household contact, or intimate non-household contact (mucosal exposure to oral secretions), day care contacts, airline passengers sitting next to positive person for >8 hours Health care worker only if mouth-to-mouth, endotracheal intubation, or nasotracheal suctioning

Ultrafiltration

hydrostatic pressure forces a liquid through a semipermeable membrane.

Side effects of digibind

hypoK exacerbation of CHF ↑ventricular rate + afib Allergic reaction

Complications of chronic DM

i) Nephropathy Retinopathy Neuropathy - lower motor neuron - autonomic II) Atherosclerosis Thromboembolic disease (CAD, CVA, PVD)

Effects of Anti-Thrombin III

inhibits the serine proteases (factors II, IX, X, XI, and XII); its anticoagulant action is dramatically enhanced by heparin

Jodd-Basedow effect

iodine load can induce hyperthyroidism, especially if iodine-deficient (TMG, latent Graves')

Definition of brain death

irreversible cessation of all functions of the entire brain, including the brain stem

Management of diptheria

isolate Protect airway Anti-toxin Macrolide ABx Vaccination booster

Catastrophic Antiphospholipid Antibody Syndrome

life-threatening autoimmune disease characterized by disseminated intravascular thrombosis resulting in multiorgan failure. By definition involves 3 or more organ systems Rx: - Anticoagulation - Immunsupression/glucocorticoids - Plasma exchange

Definition of sepsis

life-threatening organ dysfunction caused by a dysregulated host response to infection

Sieving Coefficent - Definition - Determinants

measure of how easily a substance passes from the blood compartment to the dialysate compartment in a hemofilter. - Molecule size of the solute - Protein binding of the solute - Charge of the solute and filter membrane - Size and pores in the filter membrane

Indications for methylene blue in nitrate overdose

metHgb>30% significantly symptomatic: - tachypnea - tachycardia - acidosis - hypotension * CI in patients with G6PD deficiency > may need exchange transfusion

Blue Toe Syndrome

microemboli from cholesterol crystals leading to livedo reticularis and painful, cyanotic toe(s) with intact pulses

Adverse effect associated with Gadolinium for MRI in patients with chronic renal insufficency

nephrogenic systemic fibrosis Skin involvement: symmetrical, bilateral fibrotic indurated papules, plaques, or subcutaneous nodules that may or may not be erythematous Systemic involvement: Muscle and organ fibrosis

Primary hemostasis

o Adhesion to endothelial connective tissue mediated by factor VIII (vWF) → primary platelet plug o Release ADP and thromboxane A2 → vasoconstriction and aggregation o Stabilize and accelerate the coagulation cascade

Potential complications of physical restraint

o Aspiration o Positional asphyxia o Circulatory obstruction of hands/feet with neurovascular sequelae o Wrist/ankle/neck/chest/abdo laceration o Rhabdomyolysis o ↑ distress of patient o Sudden unexpected death o Hypoventilation with resultant respiratory embarrassment, atelectasis, pneumonia o Prolonged use may lead to DVT

5 types of botulism

o Food-borne (canned goods) -> Toxin o Infant (honey or corn syrup) -> Spore o Wound (black tar heroin) -> Spore o Unclassified (PPI, decreased GI motility) -> Spore o Inadvertent (Botox) -> Toxin

Principles of TB Drug Therapy

o Must use multiple drugs to which MTB is susceptible o Drugs must be taken regularly o Treatment must continue for a sufficient time period

Symptoms of hypokalemia

o Neuromuscular (usually <2.5mEq/L) - paresthesias, ↓ reflexes, fasciculations, myalgias, muscle weakness, paralysis (<2mEq/L), lethargy, depression, irritability, confusion, rhabdomyolysis o CVS: palpitations, dysrhythmias (1st/2nd degree HB, afib, PVCs, vfib, asystole), ECG changes (T wave flattening, ST depression, U waves) o GI: N/V, distension, ileus o Renal: polyuria/polydipsia, inability to excrete acid load

Risk factors for atypical presentation of ACS

older age female gender, nonwhite ethnicity dementia previous history of congestive heart failure (CHF) or stroke

Miller-Fisher Variant of guillan barre

ophthalmoplegia, ataxia, and areflexia

Toxic acute acetaminophen ingestion

over 8 hours: >150 mg/kg or >7.5 g in adults,

Modified king's college criteria

pH < 7.3 or In a 24h period, all 3 of: (1) INR > 6.5 (PT > 100s) + (2) Cr > 300mmol/L + (3) grade III or IV encephalopathy Modified include lactate lactate >3.5 mmol/l after early resuscitation (4 h) OR lactate > 3.0 mmol/ after 12h fluid resus

Criteria for stopping IV insulin in DKA

pH>7.3 AG closing tolerating po fluid

Medications to avoid in TCA overdose

physostigmine BB type 1A, 1C phenytoin

Classic (inflammatory demyelinating) Guillian Barre

progressive, fairly symmetric muscle weakness accompanied by absent or depressed deep tendon reflexes - parasthesias - respiratory muscle weakness - pain - bulbar weakness - dysautonomia

Precipitants of decompensation with mitral stenosis

rapid afib pregnancy anemia infection ↑ thyroid

Pharmacodynamics

relationship between drug concentration at the site of action and the resulting effect, including the time course and intensity of therapeutic and adverse effects What the drug does to the body

Diagnosis of Hyperglycemic hyperosmolar nonketotic syndrome

serum osmolarity > 320mosmol/L serum glucose > 33mmol/L profound dehydration (elevated urea:creatinine ratio) no ketoacidosis

Signs of severe airway obstruction that necessitate intervention for choking victims

silent cough cyanosis inability to speak or breathe Severe resp distress with stridor

Sepsis 3.0 Definition of septic shock

subset of sepsis in which underlying circulatory and cellular/metabolic abnormalities are profound enough to substantially increase mortality (>40%) sepsis with persisting hypotension requiring vasopressors to maintain MAP and having a serum lactate level >2 mmol/L despite adequate volume resuscitation

Definition of Locked-in Syndrone

substantially paralysed but conscious, and can usually communicate using movements of the eyes or eyelids wakefulness/awareness maintained brainstem pathology which disrupts the voluntary control of movement

Organophosphate - Intermediate Syndrome

syndrome of delayed muscle weakness resulting in respiratory failure without cholinergic features or fasciculations Occurs 1 - 4 days following cholinergic crisis

Fick Principle

the total uptake of a substance by the peripheral tissues is equal to the product of the blood flow to the peripheral tissues and the arterial-venous concentration difference (gradient) of the substance. VO2 = CO(CaO2-CvO2)

Pericardiac reserve volume

the volume that would just distend the pericardium

Pharmacokinetics

time course of drug absorption, distribution, metabolism, and excretion What the body does to the drug

Convenction

transport of a solute across a membrane along with solvent (by "solvent drag").

Diffusion

transport of solute across a membrane, along a concentration gradient.

Risk factors for Cerebral Venous Sinus Thrombosis

trauma infection hypercoagulability pregnancy drugs (OCP, ecstasy, androgens, steroids) dehydration neurosurgical procedures vasculitis CTD

Bidirectional ventricular tachycardia

ventricular dysrhythmia characterised by a beat-to-beat alternation of the frontal QRS axis Characteristic of severe digoxin toxicity

ECHO Features of RV Strain

· RV dilatation > 1:1 (normal ratio right: left ventricle is < 0.6:1) · Right ventricular systolic dysfunction TAPSE <16mm · McConnell's sign - mid RV wall hypokinesis with apical sparing · Moderate to severe tricuspid regurgitation · Paradoxical septal wall motion towards the left ventricle · Pulmonary artery dilatation · Atrial dilatation · Right heart thrombus or thrombus in transition · Lack of respiratory variation of the inferior vena cava

MOA of epinephrine

α-agonist effects: 1) ↑ PVR 2) ↑vasoconstriction 3) ↓ mucosal edema β1-agoinst effects: 1) +ve inotropy/chronotropy B2-agonist effects: 1) bronchodilation 2) stabilizes mast cells & basophils

Subtypes of Guillan Barre Syndrome

• AIDP (Inflammatory demyelinating)* • Miller Fisher syndrome • Acute motor axonal (AMAN) • Acute motor/sensory axonal (AMSAN)

Asthma patients to consider trial of non-invasive ventilation

• Clinical judgment suggesting that asthma is likely to respond to treatment in a few hours or less • High work of breathing - Breathing rate > 30 breaths/minute - Use of accessory muscles of breathing - Obvious dyspnea • Progressive fatigue • Patient alert, cooperative • Patient able to perform spirometry or peak expiratory flow measurement (level I evidence) • Oxygen saturation > 90% on room air (level I evidence) • PCO2 < 45 mm Hg (level I evidence) • No excessive coughing or phlegm • No vomiting • Hemodynamic stability

Delerium Diagnosis

• Definition: acute/subacute cognitive dysfunction 2° to an underlying medical disorder • Patients have disturbances in (1) cognition (disorientation, memory deficits), (2) perception (psychosis), and (3) consciousness (inability to focus attention)

Pathophysiology of methanol

• Formic acid binds iron and inhibits cytochrome oxidase • Methanol metabolism depletes ATP • Lactic acid accumulation • Lipid peroxidation (Free radicals) • Disturbance of proteolytic/anti-proteolytic balance • Acidosis allows more formic acid to enter cells (circulus hypoxicus)

Causes of purpura

• HUS / TTP • DIC • Meningococcemia • RMSF • Vasculitis (HSP) • Malignancy (AML, lymphoma) • Polycythemia vera • Drug induced (ASA, Chloramphenicol, Lasix, Dig, HCTZ, INH, Sulfa, Rifampin, Pen, Phenobarb

Organ effects of toxin induced hyperthemia

• Hepatic necrosis • Rhabdomyolysis with myoglobinuric renal failure • Cerebral edema • DIC

Potential causes of death in asthma exacerbation

• Overwhelming airway obstruction • Extreme hyperinflation causing asphyxia • Pulmonary barotrauma (e.g., tension pneumothorax) • Cardiac ischemia, dysrhythmia, heart failure • Complications of disease (e.g., nosocomial infection, cerebral edema, air embolism)

Threshold levels for brain death apnea testing

• PaCO2 ≥ 60 mmHg, and • PaCO2 ≥ 20 mmHg rise above baseline, and • pH ≤ 7.28

Components of best look laryngoscopy

• Patient positioning optimized • Laryngoscopist's positioning optimized: • Optimal muscle relaxation • Appropriate blade tip location • Appropriate laryngoscope lift • Head lift • External laryngeal manipulation • Release cricoid pressure • Use of an adjunct to DL

Journal of American College Cardiology - Post Arrest Catheterization Article: Unfavorable features

• Unwitnessed arrest • No bystander CPR • Initial rhythm: Non-VF • >30 min to ROSC • Ongoing CPR • Age >85 • End stage renal disease • Noncardiac causes (e.g.,traumatic arrest) • pH <7.2 • Lactate >7

Complications unique to PA Catheter

• Ventricular Arrhythmia • Thromboembolic events • Mural thrombi in the right heart • Air embolism from ruptured balloon • Pulmonary infarction • Endocarditis of the pulmonary valve • Right bundle branch block • AV Block • Knotting • Damage to the valves • Pulmonary artery rupture

Burn Unit Referal Criteria

• ≥ 20% TBSA partial and/or full thickness at any age • ≥ 10% TBSA partial and/or full thickness for ages ≤ 10 and ≥50 • Full thickness burns ≥ 5% TBSA at any age • Burns to hands, face, feet, joints, genitalia, perineum • Electrical burns • Chemical burns • Inhalation injury • Burns with patients who require special social, emotional, or rehabilitation care • Burns with comorbidity Anticoagulation Immunosuppression Pregnancy Diabetes Other significant medical problems

Risk factors for abdominal aortic aneurysm

↑ Age Male sex PVD or CAD Smoking First degree relative with AAA Femoral or popliteal aneurysm (especially bilateral popliteal)

When to admit anaphyaxis

↓ BP upper airway involvement prolonged bronchospasm chronic ß blockade severe reaction

Causes of hypernatremia

↓ H2O Intake Disordered thirst perception Inability to obtain H2O • ALOC ↑ H2O Loss GI - V/D, suctioning, 3rd space Renal • Tubule conc defect • Osmotic diuresis (glucose, mannitol) • DI* • Post-obstruction Dermal • Excessive sweating • Severe burns Hyperventilation ↑ Na Intake Exogenous Na intake • Na tablets • NaHCO3 • Hypertonic NS • Improper formula ↑ Na reabsorption • Hyperaldosteronism • Cushing's • CAH • Corticosteroids

Causes of hypokalemia

↓ Intake ↓ dietary intake Impaired absorption ↑ Losses Renal • Hyperaldosteronism (1° Conn's, adrenal hyperplasia; 2° CHF, cirrhosis, nephrotic) • Bartter's (hyper-renin) • Licorice • ↑ corticosteroids, Cushing's • RTA II/I • Obstructive • Na-wasting • Drugs (diuretics, aminoglycosides, mannitol, ampho B, cisplatin) Gastrointestinal (V/D, villous adenoma) Dermal (sweat, burns) Transcellular Shifts Alkalosis • Vomiting (K loss NOT due to V) • Diuretics • Hyperventilation Insulin, ß2 agonists Hypokalemic periodic paralysis (familial, thyrotoxic) Miscellaneous Acute mountain sickness Anabolic state

Types of Pulmonary Hypertension

● Group 1 - Primary PAH ● Group 2 - PH due to left heart disease ● Group 3 - PH due to chronic lung disease and/or hypoxemia ● Group 4 - Chronic thromboembolic pulmonary hypertension (CTEPH) ● Group 5 - PH associated with hematologic disorders, systemic disease other than connective tissue disorders, metabolic or miscellaneous disorders, or unclear multifactorial mechanisms

Features of an optimized Intra-Aortic Balloon Pump

● inflation of the balloon occurs at the dicrotic notch (forming the sharp 'V') ● the slope of rise of augmented diastolic waveform is straight and parallel to the systolic upstroke ● the augmented DBP at balloon deflation exceeds or is equal to end-systolic BP ● the end-diastolic BP at balloon deflation is lower than the preceding unassisted end-DBP by 15-20 mmHg ● the assisted SBP (following a cycle of balloon inflation) is lower than the previous unassisted SBP by 5 mmHg

World Federation of Neursurgery SAH Grading Scale

●Grade 1: GCS score 15, no motor deficit ●Grade 2: GCS score 13 to 14, no motor deficit ●Grade 3: GCS score 13 to 14, with motor deficit ●Grade 4: GCS score 7 to 12, with or without motor deficit ●Grade 5: GCS score 3 to 6, with or without motor deficit

Urine Cells and Casts as diagnostic clues - Hyaline - RBC - WBC - Fatty - Granular - Crystals

♣ Hyaline - seen with dehydration or exercise; ARF in this setting represents prerenal azotemia ♣ RBC - glomerulonephritis or vasculitis ♣ WBC - renal parenchymal inflammation • AIN (urine eosinophils), papillary necrosis, pyelonephritis ♣ Fatty - heavy proteinuria such as in nephrotic syndrome, GN ♣ Granular - cellular remnants and debris eg. ATN. Can also see renal tubular epithelial cells as well ♣ Uric acid crystals non-specific, oxalic acid or hippuric acid in ethylene glycol poisoning