Complete Emergency Med Objectives

Potential complications of Acute MI

• Complication(s) occur in >50% of MIs and they're all pretty awful..... *Cardiogenic shock* - 70% mortality =( ♣ Main cause- extensive MI w/ decr. CO ♣ s/sx: hypotension, confusion, cool skin, oliguria, metabolic acidosis ♣ tx= O2 + IV NS + Inotrope (Dopamine or Dobutamine) *CHF*- ♣often develops years later; left vs right HF depends on artery involved *Ventricular Septal Rupture* ♣develops w/in 1 week; Anterior MI most at risk ♣patho: rupture at the margin of the necrotic and non-necrotic myocardium--> left to right shunting (incr. blood flow to pulmonary system w/ decreased flow to body) ♣s/sx: shock, new murmur, abrupt severe CHF ♣ dx: Echo or pulmonary artery catheter ♣ tx: surgery + stabilize (vasodilators, inotropes) -be more aggressive if shock is in play *Myocardial Rupture* ♣ occurs w/in 1-2 wks ♣ patho= mechanical failure of an infarcted ventricular wall ♣ s/sx: sudden death in a silent MI; abrupt hypotension, hemopericardium and death from cardiac tamponade +/- pulseless electrical activity ♣ dx: clinically (sudden death), echo & pericardiocentesis ♣ tx: immediate surgery, pressors, expand intravascular volume *Acute Mitral Regurg.* ♣ causes: defective papillary muscle, many others ♣ dx: confirm via echo ♣ tx: -if hemodynamically stable, decrease afterload to increase forward flow (nitrates, diuretics) -if papillary muscle ruptured, need emergent surgery *Systemic or Pulmonary Embolization* ♣ often occur w/in 10 days ♣ s/sx: depend on the artery occluded; acute unexplained dyspnea or tachy., stroke if cerebral vasculature ♣ tx: O2, anticoagulation +/- surgery -if massive PE w/ RHF or shock, do thrombolytics *Pericarditis* ♣ pericardial inflammation w/in 1 wk (if > 1 wk, may be d/t Dressler syndrome= autoimmune) ♣ patho= inflammatory response to necrotic tissue o s/sx: often asymptomatic + friction rub o Dx: EKG shows diffuse ST elevation & diffuse PR seg depression o Tx: NSAIDS

Heat related emergencies come down to which 3 factors?

■ *Exogenous heat gain* - direct sunlight, ambient temp, high humidity ■ *Increased endogenous heat production* - febrile illness, physical activity, drugs (cocaine, meth, TAD) ■ *Decreased heat dispersion* - dehydration, CVD, clothes, obesity, old people, drugs

4. Given a patient scenario, appropriately order and interpret the following laboratory studies: LFT

■ AST/ ALT - hepatocellular injury ■ Bilirubin (Direct and indirect) ■ ALP - obstruction ■ GGT - obstruction ■ Albumin

D-dimer (FYI)

-Fibrin split product -Circulating half-life for 4-6 hours -80-85% sensitivity and 93-100% negative predictive value for PE -False positives: Pregnant patients, malignancy, advanced age >80 years, hemorrhage, AMI, hepatic impairment, postpartum <4 weeks, surgery w/i 1 week, sepsis, CVA, collagen vascular diseases

Be familiar with components of the Glasgow Coma Score

"less than 8, intubate" 14-15: minor injury 9-12: mod injury < 9: severe injury (comatose) levels of consciousness review: -awake alert aware -clouding of consciousness -*confusional state* - disorientation, bewilderment, and difficulty following commands -*lethargy* - severe drowsiness in which the patient can be aroused by moderate stimuli -*obtundation* - slowed responses to stimulation, cannot be fully aroused -*stupor* - only vigorous and repeated stimuli will arouse the individual, mostly unresponsive -*coma* - state of unarousable unresponsiveness

2. Discuss the presentation, pathophysiology, evaluation and emergency management of the following bites/stings: • Snakes

* General* ● *Crotalids: Pit Vipers:* snakes with heat sensing pits in the nostrils (water moccasins, rattlesnakes, copperheads) ○ *Most common cause of snake bites in US* ● *Elapids: Coral Snakes* ● *Crotalids and Elapids are 2 types of venomous snakes in US* ● Half of envenomations are admitted ● Dry bites are 25% of time *Presentation* ● *Crotalids:* ○ Edema ○ Hemorrhage ○ Necrosis around the bite as well as distant from the site in severe envenomation ○ Systemic signs: hemolysis, thrombocytopenia, coagulopathy, vomiting, and rarely respiratory failure with cardiovascular instability or collapse ○ Neurotoxic signs: oral paresthesia, weird taste, fasciculations, AMS, szrs ● *Elapids:* ○ May produce few or no early local signs of envenomation ○ Neurologic (paresthesias, blurred vision, dysphagia, hypersalivation, ptosis, and respiratory depression) may appear after a delay of 12-24 hours *Management of Snake Bites* ● *Emergency First-Aid:* ○ Many of the most well-known first-aid measures are no longer recommended ○ Cryotherapy, tourniquets and incision and suction have not been shown to be helpful and may cause more harm ○ Best management: transport pt to nearest hospital, immobilize the bitten part as if it were a fracture, keep patient on strict bed rest ○ If severe envenomation, emergency medical service may place a constriction band, however if patient is stable a constriction band is not recommended ○ Outline and time progression of any swelling and ecchymosis! ● *Hospital Measures* ○ Assess patient's respiratory and cardiovascular status ○ Monitor ABCs ○ Check CBC, electrolytes, coagulation profile, and urine myoglobin ○ Type and crossmatch blood ○ Give crotalid vs Elapid antivenom and update tetanus ○ *Coral Snakes vs Kind Snakes : Red touches yellow, you're a dead fellow, red touches black, friend of jack.*

2. Discuss EMTALA laws, and apply them to various emergent scenarios

*"COUGH COUGH"* ○In the 1980s, a large number of indigent patients were being transferred from private to public hospitals for economic reasons. ●Some were being transferred despite being medically unstable. ○In 1986 congress responded to this patient dumping by passing legislation requiring hospitals participating in Medicare or Medicaid to conduct a proper medical screening examination on all patients presenting to the ED for treatment. ○*EMTALA = Emergency Medical Treatment and Active Labor Act* ●Enacted as part of the Consolidated Omnibus Reconciliation Act of 1985 that places several obligations on EDs: ●A medical screening exam must be performed by a qualified medical personnel to look for emergency medical conditions for *all* patients who come to the ED. ○The triage nurse cannot perform a medical screening exam, they cannot tell a patient whether or not their condition is an emergency. ●Anyone presenting to an ER must be given an appropriate medical screening exam by a qualified medical person to determine if he/she is suffering from an emergency medical condition. ●If an emergency medical condition is present, the hospital is obligated to provide the patient with treatment until he/she is stable or transferred in accordance with the statutes directives. ●*So what is an emergent medical condition?* ●One that manifests itself by acute symptoms of sufficient severity (including severe pain) such that the absence of immediate medical attention could reasonably be expected to result in. ●Placing the health of the individual or unborn child in serious jeopardy. ●Serious impairment to bodily function. ●Serious dysfunction of any body part or organ. ●Pregnant women in active labor must be admitted and treated until delivery is completed unless transfer under the statute is appropriate. ○*Transfers Before Stabilization:* ●Patient has been treated and stabilized as much as possible within the capabilities of the presenting hospital. ●Medical benefits of transfer outweigh the risk of transfer (in writing by an MD). ●Receiving hospital has been contacted and agrees to accept the transfer and has the facilities necessary to treat the patient. ●Patient has medical record from transferring hospital. ●Transfer is carried out with the use of qualified personnel and equipment. ●Hospitals generally cannot transfer patients until their condition has been stabilized. ●*Few exceptions:* ○If a patient requests to be transferred and is fully informed of the consequences of being moved. ○If a physician feels that the medical benefits exceed the risk of transfer.

4. Compare and contrast the following upper extremity injuries in terms of presentation, evaluation, management and possible sequelae: • Forearm fractures

*Monteggia* *MU*GR *What* -Ulnar fracture with Radial head dislocation *MOI* -FOOSH with hyperpronation (Fall on out stretch hand) *Imaging* See xray photo *Treatment* -ORIF (open reduction internal fixation) *Galeazzi* MU*GR* *What* Fracture of radius with distal Ulnar dislocation *MOI* -FOOSH with elbow bent *Imaging* -See xray photo *Treatment* -ORIF (open reduction internal fixation) -Possibly Closed reduction if non displaced

1. Outline the role of a PA in an emergency room setting (you may interpret the section on emergency physicians as it relates to physician assistants).

*"Masters and mistresses of negotiation, creativity, and disposition"* ○We are utilized in a variety of ways: ■Main ER ■Fast Track ■Trauma Center ■Catastrophes ○PAs regularly provide care and makes medical treatment decisions based on real-time evaluation of a patient's history; physical findings; and many diagnostic studies, including multiple imaging modalities, lab tests and EKGs. ○Data suggest that the critical need of ER providers requires more incorporation of PAs in the OR. Many small ERs are already staffed by PAs with supervising physicians available only by phone. Many of the ER physicians are not actually board certified EM. ○An EM PA requires a large skill set to treat a wide variety of injuries and illnesses, ranging from the diagnosis of an upper respiratory infection or dermatologic condition to resuscitation and stabilization of trauma or coding patient. ○Often the only source for under served populations as a last resort for healthcare. ○EM PAs must be able to practice emergency medicine on patients of all ages, ranging from infants to geriatrics. ○Responsibility includes: ■Laceration repair, I & D, Chest tube placement, ACLS, PALS, Sedation, Arthrocentesis, Casting/Splinting, Central line placement, Intubation, Reduction of dislocations, IO needle placements, Lumbar puncture, X-Ray, lab, and EKG interpretation, Slit lamp exams, tonometry.

Identify the common physical findings (and toxidrome if one exists), describe the effect on the patient's system, laboratory work up and management: • *Anticholinergics*

***COUGH, COUGH SLIDE!*** (know this stuff) Note: The book/powerpoint do NOT describe the effect on the patients system. Don't bother learning it. Examples: Phenothiazines, antihistamines, antiparkinson's, tricyclic antidepressants, *Jimson Weed* ------------------------------------ PATIENT PRESENTATION: *Symptoms of toxicity include:* -Dryness of the mouth -Thirst/difficulty in swallowing -Blurring of vision *Physical signs include:* -Dilated pupils -Flushed skin -Tachycardia -Fever -Delirium -Myoclonus -Ileus -Flushed appearance -Antidepressants and antihistamines may induce convulsions. *The traditional saying goes like this:* (see picture and memorize it!) -*"Hot as Forrest Delikowski"* -*"Blind as a bat"* -*"Dry as a bone"* -*"Red as a beet"* -*"Mad as a hatter"* ------------------------------------ TREATMENT: A. EMERGENCY AND SUPPORTIVE MEASURES -*Administer activated charcoal* -*External cooling,* sedation, or neuromuscular paralysis in rare cases, is indicated to control high temperatures B. SPECIFIC TREATMENT For severe anticholinergic syndrome (eg, agitated delirium): -*Give physostigmine salicylate SLOWLY intravenously over 5 minutes* with ECG monitoring Caution: -Bradyarrhythmias and convulsions are a hazard with physostigmine administration -Should be avoided in patients with cardiotoxic effects from tricyclic antidepressants or other sodium channel blockers.

5. Define traumatic brain injury and discuss the signs and symptoms, diagnosis, and management of mild traumatic brain injury (mTBI).

*ABCs* - Establish a Glasgow Coma Scale Score - Minor head injury = GCS 13-15 and *LOC, amnesia, or confusion* *Canadian Head CT Rule* (only 16-64 yo patients) - CT of the head is required for patients with minor head injury if any of the following variables are present: *GCS <15 at 2 hours post-injury *Suspected open or depressed skull fracture *Two or more episodes of vomiting **Amnesia before impact* of at least 30 minutes Dangerous mechanism: - Pedestrian struck by motor vehicle - Occupant ejected from motor vehicle - Fall from an elevation of three or more feet or five stairs *Concussion* - a trauma-induced alteration in mental status that may or may not include loss of consciousness - hallmarks of concussion = *confusion & amnesia* - management is refraining from strenuous activity - history of concussion indicates longer recovery time

Pharmacological treatments of asthma and COPD (FYI)

*B-Adrenergic Agonists*: mainstay of treatment for asthma and COPD -MC used are short-acting B2-selective agents -> cause rapid relaxation of bronchial smooth muscles, resulting in bronchodilation, and reducing airflow obstruction. -Albuterol and metaproterenol are used most often *Anticholinergics*: Ipratropium nebulized solution. Frequently mixed with albuterol. *Systemic corticosteroids*: Known to inhibit both inflammatory cell recruitment and the release of inflammatory mediators into the airways. -Although these meds don't change ED management, they reduce rate of relapse in mod-severe exacerbations *Antibiotics*: typically not indicated for mild asthma unless evidence of infection. -Patients with acute exacerbation of COPD, presenting with worsening dyspnea and increased cough and sputum production, usually benefit from antibiotics. *Magnesium sulfate*: direct relaxing effect on bronchial smooth muscle and helps stabilize many inflammatory mediators. -In pt. w. severe asthma, magnesium (in conjunction with ongoing treatment), may help improve airway obstruction and avoid intubation) *Ketamine*: significant bronchodilator and can be used to facilitate intubation in severely agitated patients with refractory disease (status asthmaticus)

2. Discuss the presentation, pathophysiology, evaluation and emergency management of the following bites/stings: • Black widow and brown recluse spiders

*Black Widow ● The Spider - Latrodectus mactans ○ Only the female is dangerous, *shiny black with a red hourglass marking on her back* ○ The venom is a neurotoxin that results in presynaptic neurotransmitter release *Clinical Findings ○ Characteristic symptoms occur within 10-60 minutes ○ Severe pain in the bitten extremity and muscle spasms of the abdomen and trunk ○ *COUGH:: abdominal pain and wall rigidity:: COUGH* ○ Diffuse paresthesia, muscle fasciculation, piloerection, diaphoresis ○ May see headache, nausea, vomiting, hyperactive DTRs, ptosis ○ Symptoms peak at 2-3 hours after the bite and may last up to 3-7 days ○ May see severe hypertension, tachycardia, death ○ Blanched lesion with red perimeter and central punctum *Treatment ○ Dx from Hx ○ Mild: tetanus, cound care, oral analgesia ○ Mod to Severe: Narcotic analgesics, immobilization and loose compression dressing ○ Antivenom should be reserved for seriously ill infants and older patients ○ Observe patient for 12-24 hours due to common recurrence of hypertension and muscle spasms *Brown Recluse* ● The Spider - Loxosceles reclusa ○ *Dark, violin-shaped area on its back, 6 evil eyes* ○ It is found in old wood piles, attics, closets, etc. ○ The venom contains sphingomyelinase D, a cytotoxin, that causes local tissue destruction by destroying endothelial cells ■ Has a hemolytic component and may disrupt nerve impulses *Clinical Presentation* ○ *Pain begins at site 1-4 hours after bite, initially painless* ○ Erythematous area with a central pustule or hemorrhagic vesicle may be seen ■ *Bull's eye lesions - "Red, white, and blue sign"* ■ May see associated LAD and fever ■ Associated with progressive necrosis ○ A generalized systemic reaction, called loxoscelism, may occur 24-48 hours after the bite ■ Fever, malaise, arthralgias, rash, hemolysis *Treatment* ○ Dx from Hx ○ People love to confuse CA MRSA infection for a spider bite ○ Loxosceles antivenom... not in the US. ○ Tetanus prophylaxis and local wound care

1. Discuss the presentation, pathophysiology, evaluation and emergency management of the following: • Lightning injuries

*General* ○ 2/3 survive. 2/3 survivors have permanent side effects. 1/3 who don't survive usually die on site from cardiac arrest. ○ Unidirectional electricity flow ○ Asystole is most common arrhythmia afterwards ○ Lightning injuries can result not only in burns but also multiorgan dysfunction ○ Strike events cluster in the summer months and mid afternoon with 84% being male *Clinical Findings* ○ Expose patient, look for entry/exit points ○ EKG and monitoring ○ Labs and imaging per hosp protocols *Treatment* ○ Higher resuscitation success rate than other cardiac pts. Maintain airway and begin cardiopulmonary resuscitation ○ Immobilize - anticipating traumatic injury ○ Fluid not often needed unless burns present ○ Admit PRN

Describe the presentation, differential diagnosis, evaluation and emergency management of the following conditions: • *Penetrating chest wounds*

*Causes* - Stab wounds (Usually ascending aorta) - Gunshot (Usually descending thoracic aorta) - Impalement injuries As much info about the type of weapon, length or caliber, distance from the weapon, and amount of hemorrhage is very helpful. *Presentation* / *Physical Exam* *This one may be difficult to recognize* - They have been shot or stabbed - They will be gushing blood - They will be in lots of pain *Diagnosis* - Clinical Obvi - CXR (Radiopaque markers at the sites of wound entry and exit) - FAST exam (US) - Angiography *Treatment* - Most patients are hemodynamically unstable --> *ABC's ASAP's* - IV fluids and blood transfusions - Evaluation of Cardiac tamponade and intervene if needed - NEVER remove impaled objects in ED (Wait for the OR) - OR if surgical removal or objects or intervention is needed. For minor asymptomatic patients observe of 3 hours, and discharge after a repeat negative X-ray

1. Compare and contrast the various types of *skull Fractures*

*Closed* Dx: Noncontrast CT TX: close observation to detect development of epidural hematoma F/U: consider admission or extended observation w/ isolated closed skull fx and no incidence of brain injury *Open* Laceration+fracture= high risk of infection Dx: Noncontrast CT Tx: Neurosurge consult, ABX if surgeon wants them Admit *Depressed* Dx: Inspection/palpation, CT Tx: Evaluate for intracranial injury, ABX (high infection risk) Admit, Surgery

4. Compare and contrast the following upper extremity injuries in terms of presentation, evaluation, management and possible sequelae: • Wrist fractures

*Colles* *What* Distal radius fracture with Dorsal displacement *MOI* FOOSH *Physical exam* -Wrist pain *Imaging* -Radiograph the wrist -Will see the radius dorsal displacement (radius moved anterior to the palm) *Treatment* -If nondisplaced --> Splint with sugar tong or cast for 6 weeks -If displaced --> Closed reduction and sugar tong splint or cast --> recheck in 3 weeks with Xray, if it is displaced then it requires ORIF *Smiths* STUPID SMITH *What* Distal radius fracture with palmar displacement *MOI* FOOSH but the hand is the weird way with wrist curled *Physical exam* -Wrist pain *Imaging* -Radiograph the wrist -Will see the radius palmar displacement (radius moved posterior to the palm) *Treatment* -If nondisplaced --> Splint with sugar tong or cast for 6 weeks -If displaced --> Closed reduction and sugar tong splint or cast --> recheck in 3 weeks with Xray, if it is displaced then it requires ORIF

Describe the presentation, differential diagnosis, evaluation and emergency management of the following conditions: • *Commotio Cordis* (NOT AN OBJECTIVE)

*Commotio Cordis* Condition of sudden cardiac death or near sudden cardiac death after blunt, low-impact chest wall trauma in the absence of structural cardiac abnormality. When the blunt trauma occurs right at the upstroke of the T wave, it can send the heart into Ventricular Fibrillation Young male athletes (5-18 YO) at highest risk - Occurs most often in baseball, softball, and hockey Death is usually instantaneous and successful resuscitation is uncommon

Describe the presentation, differential diagnosis, evaluation and emergency management of the following conditions: • *Thoracic aortic injury (TAI)*

*Cough Cough* Common cause of death in blunt trauma - 80% of patients die at the scene - Most often descending segment of the aorta *Causes* Rapid deceleration and shearing forces associated with: - Motor vehicle accidents - Falls - Crush injuries *Presentation* - Chest pain - Back (Intrascapular) pain - Dyspnea - Hoarseness - Extremity pain (Due to ischemia) *Physical Exam* - *Intrascapular murmur* - Pulses differences in arms and legs *Diagnosis* - CXR (mediastinal widening, indistinct aortic knob) - CT (Gold Standard) - TEE can be useful and fast as well *Treatment* - BP stabilization (meds) - Surgical repair ASAP

8. Regarding *dental emergencies*, identify scenarios that require specialty care vs. those that could be managed in the ED, create a differential diagnosis, treatment plan for each, and identify appropriate follow up care

*Dental Concussion* Trauma but NO increased mobility Tx: Follow up with a dentist, not emergent *Dental Subluxation* Increased mobility, but without displacement of the tooth. Bleeding from the gingival sulcus is noted. Tx: Follow up with a dentist, not emergent *Dental Avulsion* Tooth is completely displaced and out of the socket You may find a dry socket of a clot Tx: 1) Keep pt calm. 2) Find the tooth and pick it up by the crown (the white part) (Avoid touching the root) 3) Wash it briefly (10 seconds) under cold running water and re position it in the socket 4)If this is not possible, place the tooth a glass of milk or a special tooth storage media 5)Needs *emergent dental evaluation* Note)*If there is an avulsion but no tooth can be found, GET A CHEST XRAY*

Dental fractures (chipped teeth)

*Ellis I*-Fracture confined to enamel with *NO dentin visualized*, they are usually non painful TX: Dental follow up, Repair mainly for cosmetic reasons *Ellis II*- Fracture confined to enamel & *dentin is visualized* Cover tooth with calcium hydroxide paste then aluminum foil F/up within 24 hours *Ellis III*- Fracture includes enamel, *dentin & pulp are visualized*. Hurts like a MFer. Tx: Dental emergency, Tell them they are stupid for coming to the ED..*go to the dentist*. If not fixed the root will die, the tooth will become discolored, and they will need a root canal

1. Discuss the presentation, pathophysiology, evaluation and emergency management of the following: • Burns

*First-Degree Burns* *Clinical findings and treatment* ○ *Simple burns (redness without blistering) Epidermis only. * ○ Treated with cold tap water rinse and analgesia ○ Soft, non-irritating wrap to protect and immobilize the hand ○ Return or telephone follow up in 1-2 days, heals in 1 wk *Second-Degree Burns* *Clinical findings and treatment* ○ Blisters = *partial thickness (second-degree)* ○ Divided into superficial (epidermis and dermis) and deep (PLUS sweat and follicle glands). ○ Retain cutaneous sensation ○ Blisters should be aspirated or unroofed and debrided ○ *Silver sulfadiazine (Silvadene)* applied topically ○ For sulfa-allergic- bacitracin or neomycin ○ Bulky dressing and splinted in functional position ○ Tetanus prophylaxis must be current ○ Heals in 3-4 wks, some scars, maybe grafts *Disposition* ○ Extensive burns or marked edema- refer emergently to hand specialist for evaluation ○ See patient every 1-3 days for dressing change *Third-Degree Burns* *Clinical findings and treatment* ○ Full-thickness burn, down to fat ○ Painless ○ Require bulky, loose, sterile dressing with anti-infective agent such as Silvadene ○ Tetanus prophylaxis must be current ○ 2 large bore IVs and O2 ○ Debride blisters, remove eschar ○ Transfer PRN ○ If circumferential burns, check pulses, escharotomy as needed. *Disposition* ○ If burn is extensive or over the dorsum of a joint, refer the patient emergently to hand specialists ○ Needs surgery ○ Significant scars *Fourth Degree* ● Da muscles and bone ***For best outcome of all, refer to burn center*** *Fluid resuscitation:* ○ No universal standard, but many start with Ringer's lactate. Other fluids may be used like hypertonic saline, albumin or plasma, Plasmanate, dextran ○ *HALF is given in the first 8 hours from the TIME OF THE BURN, the rest over the remaining 16 hours* ○ *Parkland formula 4 mL/kg per %TBSA per 24 hrs. * ○ Urine output should be* 0.5 mL/kg per hour* for adults, and 1 mL/kg per hour for children ● *Note:* From the time the severe burn patient enters the ED it will only continue to worsen over the first 24 hours. They may seem fine, and then decompensate quickly.

1. Discuss the presentation, pathophysiology, evaluation and emergency management of the following: • Electric shock & burns

*General* ● *Electric shock* → current flow (voltage) through the body ○ Young men and children ○ Kids lick *outlets*... MC COD ○ *Alternating current (common in household outlets)*= changing voltage that causes tetanic muscle contractions, preventing the victims separation from the source → Fatal arrhythmias ○ *Direct current* = unidirectional flow, high voltage power line in contact with a metal object. Victim is "grounded" and allowed flow through the power line to the ground, through the worker ○ Entrance wound is usually leathery, exit wound is more burned or "explosive" looking, *hard to know what happened in the body between the points. * *Clinical Findings* ● *Electric Shock* ○ Momentary or prolonged loss of consciousness, V. Fib most common arrythmia ○ Seizures, deafness, blindness, aphasia, neuropathy ○ Multiple orthopedic injuries may be seen ● *Electrical Burns* ○ Skin necrosis, sloughing may take several days ○ Third spacing of fluid may occur with internal organ injury *Treatment* ● *Electric Shock* ○ Free the victim from the current ASAP with the power turned off, drag the victim away carefully using nonconductive materials ○ Check cardiac and ventilatory function, CPR if victim is apneic or pulseless ● *Electric Burn* ○ Treat tissue burns conservatively ○ Direction and extent of tissue injury may not be apparent for 7-10 days ○ Treat circulatory shock, if present, with IVF ■ CK-MB enzymes may be falsely elevated ○ Monitor cardiac rhythm ○ Mannitol if there is an inadequate urine output in spite of aggressive hydration *Disposition* ○ Hospitalize patients who have lost consciousness or experienced cardiac or respiratory arrest, or those with ischemic chest pain, myoglobinuria, or burn wounds

1. Discuss the presentation, pathophysiology, evaluation and emergency management of the following: • Chilblains

*General* ● Occurs with exposure to *nonfreezing temperatures* ● More common in children and women as well as people with any form of peripheral vascular disease *Clinical Findings* ● *Red painful skin lesions* common on the ears, nose, hands, and feet ● Can occur up to 12 hours after exposure ● Painful edema, erythema, cyanosis, plaques and nodules to bare skin ● Pruritus or burning paresthesia ● Aggravated by excessive warmth ● With continued exposure, may progress to scarring, fibrosis, and atrophy *Treatment* ● Supportive, conservative management ○ Elevate, rewarm, and gently bandage the affected part ○ Allow it to warm gradually at room temperature ○ Protect the area from trauma and secondary infection ○ Blue tender nodules may form while healing

1. o Compare and contrast the presentation, pathophysiology, evaluation and emergency management of the following: • Intestinal obstruction

*General:* ● *Small Bowel Obstruction* ○ Pathophysiology- *ADHESIONS*, strangulated and incarcerated inguinal hernias ● *Large Bowel Obstruction* ○ Pathophysiology- *NEOPLASMS*, followed by diverticular disease then sigmoid volvulus *Presentation* ● *SBO & LBO* ○ Diffuse abdominal pain that is crampy, colicky, *intermittent and severe* ○ N/V ○ Can't fart, can't poop ○ Change in character to constant and severe pain may indicate perforation or bowel ischemia ○ Vomiting is frequently bilious and will be feculent (yikes) with distal and long-standing obstruction *Evaluation* ● *SBO & LBO:* ○ Distended tender abdomen with occasional high-pitched bowel sounds on auscultation ○ *3 view plain X-ray* shows dilated loops of bowel with air-fluid levels *(flat, upright, and CXR)* ■ *Small intestine:* transverse linear densities that extend *completely* across the bowel lumen (plicae circularis) ■ *Large intestine:* seen peripherally in the abdomen, larger in diameter, and contains the short, blunt, and thick projections *(haustra)* that arise from the bowel wall and extend only *partially* into the lumen ○ *If XR is (+) , get CT w/ contrast * f/u to better see block or neoplasm *Emergency Management* ● *SBO>LBO more emergent* ● CBC, BMP ● Nasogastric suction and IV hydration ● Early surgical consultation

2. Discuss the presentation, pathophysiology, evaluation and emergency management of the following bites/stings: • Jellyfish

*General:* ● 3 types that cause vast majority of the morbidity and mortality: Box jellyfish, Irukandji jellyfish, and Portuguese man-o-war (photo) ● Extreme pain both locally and distant from the sting site ● Nematocysts from the tentacles cling to human skin ● *Linear red urticarial lesions in a few minutes* ● Super painful ● Systemic signs including nausea, vomiting, autonomic changes, and paralysis ● Death is usually caused by respiratory paralysis or drowning secondary to limb paralysis *Treatment ● Aimed at combating nematocysts effects ● *Vinegar to affected areas (acetic acid)* - inactivate nematocysts ● Or isopropyl alcohol or baking soda slurry - inactivate nematocysts ● Shave with shaving cream, sticky tape, skin scraping - remove nematocysts ● Topical anesthetics, antihistamines, steroids PRN ● No prophylactic abx needed

2. Discuss the presentation, pathophysiology, evaluation and emergency management of the following bites/stings: • Bee and wasp stings

*General:* ● Bees, wasps , hornets and ants are members of the order Hymenoptera *Pathophysiology:* ● The venom causes hemolysis and destruction of platelets and leukocytes ● Also capable of destroying vascular endothelium and necrosing skeletal muscle *Clinical Findings:* ● *LOCAL REACTION*:Most common effect. Small pruritic and urticarial-type lesion that also causes pain ● 10% have a large local reaction greater than 5 cm, lasts 10 days ● *TOXIC REACTION:* Patients who experience multiple stings or who are taking B-adrenergic blocking drugs may experience more severe systemic reactions ● *TOXIC REACTION*: Very Severe (50 or more stings): hemolysis and rhabdomyolysis with subsequent renal failure, thrombocytopenia, disseminated intravascular coagulopathy, and liver dysfunction ● *ANAPHYLACTIC REACTION:* in 15 min typically. Urticaria -> wheezing -> vomiting -> shock -> LOC ● *DELAYED REACTION:* 10-14 days later *Management:* ● Remove stings or fragments by *scraping, not with forceps or squeezing* ● Apply topical ice packs, wash area with cold water ● Oral pain control- diphenhydramine and tetanus prophylaxis usually all that is necessary for small or large local reaction *Mild systemic:* ○ IV diphenhydramine, IV corticosteroids ○ Short period of monitoring to allow early intervention for progression to anaphylaxis *Anaphylaxis:* ○ Intubation, IV access, aggressive fluid resuscitation, aerosolized B-agonists for bronchospasm, subQ or IM Epinephrine, and possibly pressor agents *Toxic Reactions:* ○ All the above with possible blood products, dialysis and extensive hospital care

2. Discuss the presentation, pathophysiology, evaluation and emergency management of the following bites/stings: • Scorpion stings

*General:* ● Most scorpions are harmless, producing only local envenomation reactions ● C. exilicauda/sculpturatus in the US ○ May produce severe systemic toxicity ○ Small and yellowish, has a small tubercle at base of stinger ● Most stings are accidental *Pathophysiology:* ● C. exilicauda contains a neurotoxin that may produce severe systemic symptoms *Clinical Findings:* ● Initial sting is intensely painful with little or no erythema or swelling ● Light percussion of the wound causes intense pain ● Although pain and paresthesias generally resolve within 4 hours, local symptoms may persist for several days ● Systemic envenomation: N/NE release = HTN, tachy, hyperpyrexia = MI ○ CNS effects generally consist of confusion, restlessness, and dystonic reactions ● Bites get graded.... But I don't care.... But they are in the photo if you care. *Management:* ● Ice may relieve local pain (avoid intense cooling) ● Oral analgesia ● Observe 4 hours ● Tetanus? ● Severe: Admit

3. Compare and contrast *malignant hypertension and hypertensive emergency and urgency*

*HTN Urgency*= severely elevated BP in absence of s/sx, lab findings, or end-organ damage -dx: full-workup they get all the labs to r/o any signs of organ damage -*tx:* 1. control BP w/ *oral meds*: Clonidine, Captopril, or Labetolol 2. discharge to f/u w/ PCP --->if D/C w meds, usually HCTZ is 1st line *HTN Emergency aka Malignant Hypertension*= elevated BP causing sxs or lab evidence of end-organ damage - MC organs effected= brain, heart, kidneys (i.e. AMS= hypertensive encephalopathy, intracranial hemorrhage, aortic dissection, AKI, blurry vision) -*tx*= rapid but controlled reduction in BP via *IV meds* o Goal= decr MAP by 25% w/in 1 hour of presentation (avoid rapid, severe drops in BP bc can cause stroke) o *IV MEDS:* Mr. I says the first 2 are the ones most commonly used ♣ *Labetolol*= alpha & beta blocker (useful in pregnancy and hemorrhage/stroke pts) ♣ *Hydralazine*= vasodilator used mainly in pregnancy ♣ *Nitroprusside*= vasodilator (works in seconds) "rescue drug"; AE= cyanide toxicity ♣ Fenoldopam= useful in pts w/ kidney dz as alternate to nitroprossude ♣ Enalaprilat= ACEi (useful in stroke or HF pts) as alternative to nitroprusside ♣ Nicardipine= CCB useful in subarachnoid hemorrhages and ischemic stroke pts ♣ Esmolol= BB useful in aortic dissections

Discuss the differential diagnosis for a patient presenting to the emergency department with a *headache*, and create a plan for the initial evaluation and treatment. Presentation, pathophysiology, evaluation and emergency management of • Headache: Meningitis & Subarachnoid Hemorrhage

*Headache* DDX: *do not miss*: meningitis, SAH, subdural/epidural hematoma, ICH, temporal arteritis, cerebral abscess, tumor other causes: cluster HA, tension HA, migraine, HTN, pseudomotor cerebri, post LP, pheochromocytoma, nitrates, etOH withdrawal, sinusitis, VZV, fever, TMJD, cervical spine dz *evaluation*: - if trauma: see head trauma cards - if seizures: see seizure card - if FND: get CT/imaging, work up for stroke/tumor/abscess (see stroke card) - if new HA with acute onset: if stiff neck work up for meningitis (see below) and SAH - if new/acute onset HA with NO meningeal signs: -r/o HTN crisis, eclampsia -r/o temporal arteritis (tenderness, jaw claudication, ESR) -r/o eye/ear/sinus/teeth dz -if mult pts from same site: r/o CO poisoning, toxin exposure -if all negative look for misc causes: viral syndrome, post-trauma HA, trigeminal neuralgia *Meningitis* *presentation*: HA, neck stiffness, AMS, fever, N, seizure, petechial or purpuric skin lesions *pathophys*: -bacterial infxn through contiguous or hematogenous spread, or direct inoculation -viral - HSV, enteroviruses, HIV, EBV, mumps - see ID cards *evaluation*: - Brudzinski's sign (neck flexion) - Kernig's sign (straight leg raise) - LP (CT before LP if FND/ papilledema/ AMS/seizures/hx of CA or HIV) - LP positive results: cloudy, high wbc > 1000 with high PMNs, increased protein, high pressure, glucose <40% serum - blood cultures *emergency management*: - IV abx based on age group ASAP (before CT or LP results if highly suspected) - supportive: airway, PRN anticonvulsant/ restraint, +/- corticosteroids in kids with H. flu - see ID cards for specific abx tx *Subarachnoid Hemorrhage* -see stroke card

Compare and contrast the presentation, pathophysiology, evaluation and emergency management of neurological emergencies including: • Stroke • Ischemic and Hemorrhagic

*ISCHEMIC Stroke* *presentation*: abrupt onset of hemiparesis, monoparesis, or quadriparesis, dysarthria, ataxia, vertigo, monocular or binocular visual loss, diplopia, numbness -neuro signs reflect involved region of brain (MCA MC ant circulation infarct) *pathophys*: occlusion of cerebral blood supply by thrombi or emboli, MC causes are atherosclerotic dz and cardiac abnormalities (a-fib) *evaluation*: -*Noncontrast CT ASAP* (dark = ischemic) -to determine cause: ECG, carotid doppler US, MRA, CBC, PT/PTT, CMP, lytes, fingerstick glucose, ESR -<50 y/o order: protein C/S, antiphospholipid abs, factor V Leiden mutation, ANA, ESR, RF, VDRL/RPR, lyme serology, TEE -NIH Stroke Scale, PE (head, eyes, oral, neck, heart, skin, neuro) *emergency management*: -protect airway, O2, IV fluids -IV t-PA within 3 hrs of onset of sx, within 1 hour of arrival to ED contraindications: > 4.5 hours, BP > 185/110, recent bleeding, anti-coagulated (INR > 1.7), plts < 100,000, > 1/3 cerebral hemisphere affected/ high NIHSS score, or hx of trauma/sx - if > 3 hrs, give ASA - Mannitol or hypertonic saline and head elevation if increased ICP from cerebral edema - +/- seizure prophylaxis - phenytoin *HEMORRHAGIC Stroke* *presentation*: *Intracerebral hemorrhage*: abrupt onset of FND, worsens over 30-90 min, more likely to have HA, N/V, altered LOC than ischemic -more likely to have seizures and increased ICP than ischemic *Subarachnoid hemorrhage*: sudden, severe, thunderclap HA, no FND, transient LOC, N/V, visual changes, nuchal rigidity *pathophys*: occlusion of cerebral blood supply by hemorrhage -ICH - bleeding into parenchyma, MC cause is HTN -SAH - bleeding into CSF, outside of parenchyma, MC causes are berry aneurysms, trauma, AV malformation *evaluation*: -*Noncontrast CT ASAP* (white = hemorrhage) -plts, PT/PTT -NIH stroke scale, glasgow coma score - if CT neg, get LP to r/o SAH - blood in CSF and xanthochromia (yellow) - MRA/CTA to detect site of bleeding for sx clipping *emergency management*: -protect airway, O2, IV fluids -gradual BP reduction if > 160/105 with labetalol - Mannitol, sedation, and head elevation if increased ICP from cerebral edema - +/- surgical decompression for ICH, *surgical clips/ endovascular coiling for SAH* - CCB to prevent vasospasm in SAH - nifedipine/nimodipine - seizure prophylaxis - phenytoin

Physical Exam Abdominal Tests

*Iliopsoas* - aka Psoas sign - Pain with movement of retroperitoneal iliopsoas muscles indicates appendix inflamation - Supine, attempt to flex right hip against resistance OR - Left lateral side, passively hyperextend right hip - for both, pain = (+) *Obturator* - Moves obturator muscles which will stretch inflammed appendix - Flex right hip and knee, internally rotate the hip (ankle away form body) - Pain = (+) *Rovsing's* - Pressing in LLQ causes pain in the RLQ (near McBurney's Point) because stretching the peritoneum tugs on the inflamed portion connected to the appendix. *Rebound Tenderness* - Sharply releasing the deep palpation hurts more than the actual pressing *Murphy's* - Pressing into the liver/gallbladder as patient inhales, delving under the rips - pain = (+) *Hop Test* - Have patient (typically child) stand up and jump up, landing flat on their feet - significant pain = (+) - You can also say "Did every bump on the drive here make the pain worse?" *Rectal* - Look for gross blood on exam - Examine for gross blood in the vault - Use guaiac test to check for occult (aka hidden) blood *Extra Abdominal Exams* - always make sure to also check lungs, heart, and private jibbly bits Acute Abdominal pain is < 1 wk Like ortho, point with 1 finger

Discuss the indications for intubation

*Indications* -*Respiratory insufficiency*: apnea, hypoxia, hypoventilation -*Airway obstruction*: foreign body, fixed mass, traumatic deformity, continued bleeding, secretions or emesis -*Inability to protect airway*: altered mental status, loss of normal airway reflexes -*Need for hyperventilation*: head injury, metabolic acidosis in critically ill or injured patient -*Anticipated or impending airway compromise*: shock, multiple trauma, need for sedation of paralysis

3. Discuss legal principles and common legal problems encountered in the emergency department.

*LEGAL PRINCIPLES* ○Malpractice is a civil law issue which is a subset of professional negligence. ○*Negligence:* failure to do something that a reasonable person in a similar situation would/would not do. ○*Duty of Care:* obligation to provide treatment according to accepted standards of care. EMTALA falls in this category. ○*Breach of Duty:* the obligation to provide treatment with knowledge, skill, and care ordinarily used by a reasonably well-qualified practitioner practicing in similar circumstances. ○*Proximate Cause:* the patient condition more likely than not would not have happened if the negligence of the defendant had not taken place. ○*Damages:* compensation awarded the plaintiff as a result of the loss or injury suffered. ○*Statute of Limitations:* a law which specifies the time within which a lawsuit must be initiated. 2 years in most states. If the time has passed the claim will forever be barred. ○*Res Ipsa Loquitur:* "the thing speaks for itself." Arose in response to medical professionals notoriously unwilling to testify against one another. Circumstantial evidence may be used when direct evidence is within the control of the defendant. *LIABILITY FOR THE ACTS OF OTHERS* ○*Vicarious Liability:* a physician or hospital may be liable for negligent conduct of employees or agents (not just self). ○*Good Samaritan laws:* statutes enacted to protect health care professionals who render aid in the scene of an emergency from civil liability. Meant to encourage assistance in emergency situations. Act reasonably in good faith, without compensation, and without gross negligence or harmful intent. ○*COMMON LEGAL PROBLEMS* ■*ISSUES OF CONSENT* ●Doctrine of Informed Consent: must discuss with patient the following (diagnosis, nature and purpose of tx, risks and expected outcomes, alt. txs and their risks, and consequences of no tx). Make sure pt is competent. ●The unconscious/unstable patient: *"Implied Consent"* ●Intoxicated patients: consent given through a surrogate until mental capacity returns. ●Police Custody: consent must still be obtained. ●Minors: generally parental consent required, however (see Section 5) for exceptions. ●Patient Refusal to Consent: competent patients have the right to decide what will be done with their bodies. Inform of risks and sign release of liability if they leave ED against advise. ●Consent of Blood Alcohol Samples: If patient doesn't allow it and they have been arrested under influence, then drivers license is suspended. ■*PSYCHIATRIC EMERGENCIES* ●Baker act: Harmful to others or self. So many factors involved, risk of harm to third parties, risk of self harm (patient), excessive force, etc. ■*FOLLOW UP* ●Abandonment: patient cannot be terminated from care without consent and sufficient opportunity to secure services at another facility/practice. ●Instructions must be given, and follow up care provided. ●Help set up PCP and Specialist care when possible. ●NO DIAGNOSES OR TX PROVIDED OVER THE PHONE ■*REPORTABLE EVENTS* ●Animal bits, STDs and various communicable diseases, child/elder abuse, sexual assault, gun/stab wounds, receipt of patients who are dead on arrival (DOA).

7. Formulate a differential diagnosis and treatment plan for an extracranial head injury. Some examples include *scalp laceration and hematoma.*

*Large scalp lacerations:* Can be life threatening. The scalp is highly perfused so you can bleed to death quickly. Tx:Shave the area around the LAC, CT before closure, then irrigate, and staple quickly. *Hematoma:* If significant mechanism of injury or LOC= CT scan Tx= Ice, elevation, NSAIDS D/C home

Traditional Stratification of PE Severity (Massive vs Non-massive) FYI

*Massive PE* -Defined as PE resulting in systemic hypotension -5% of patients diagnosed with PE -30-60% mortality -General consensus that thrombosis is indicated if no contraindications *Non-massive PE* -95% of patients -Mortality rate of <5% -Most patients will go on to have an unremarkable course, require only anticoagulation if no contraindication -Patients with abnormal RV function may benefit from more aggressive treatment (thrombolytics), but highly controversial (Markers of RV dysfunction include Echo, which is best method, and biomarkers: troponin, BNP)

1. When presented with a clinical scenario, construct and defend an appropriate differential diagnosis involving a person with head or neck trauma.

*Mechanism of injury is important1* Blunt head trauma or multiple injuries from blunt or penetrating trauma --> *vertebral column injuries until proven otherwise* Differential Diagnosis: - Airway injury - Esophageal injury --> hematemesis, dysphagia, odynophagia - Vascular injury-->external or internal (hematoma!) - *Nerve injuries:* 1. Vagus, Recurrent Laryngeal - voice abnormalities 2. Spinal Accessory - SCM and trapezius weakness 3. Hypoglossal - tongue deviation to side of injury 4. Phrenic - using accessory respiratory muscles 5. Facial nerve branches: temporal, zygomatic, buccal, mandibular, trigeminal, auditory, & lingual - Parotid gland injury/Stenson's duct - Eye injury --> evaluate with slit lamp *raccoon eyes* - basilar skull or ethmoid fracture* - Nasal injury --> septal hematoma = emergency! *If CSF rhinorrhea --> CT & neurosurgery consult* - Ear injury: Hemotympanum, blood in external canal, CSF otorrhea, posterior auricular hematoma (Battle's sign), facial nerve palsies, & sensorineural hearing loss --> *temporal bone fracture*

1. Discuss the presentation, pathophysiology, evaluation and emergency management of the following: • Near drowning

*NOTE:* There seems to be some controversy between calling things drowning vs near drowning. Some say drowning means dead so this kid had a near drowning, others say nope... dat idiot done drowned. Juuuust ask around when you rotate what they call it so you look like you know what's up. *General* ● Affects children disproportionately with residential pools and shallow water drowning ● Young males > Females for mortality *Clinical Findings* ● Spontaneous return of consciousness after brief CPR ● May be unconscious, semiconscious, cyanotic, apneic, tachypneic, wheezing, Vomiting ○ *Pink froth from the mouth and nose indicates pulmonary edema* ○ Decerebrate or decorticate posturing in comatose patients ● *Post immersion syndrome: Some patients may be asymptomatic and then progress into respiratory failure within 6-24 hours* ● *Involuntary breathing may occur under water = aspiration = flooded alveoli impaired gas exchange = washed out surfactant = bacteria/algae/sand are complications = pulmonary edema = metabolic acidosis * *Diagnosis* ● Clinical, history ● CXR may show aspiration, late findings may show pulmonary edema or ARDS ○ Routine CXR before discharging to evaluate for pneumonia *Treatment* ● Extract victim from the water and place in the prone position ● Perform CPR promptly ● C-spine immobilization, clear at hospital ● Monitor pulse ox ● Significant coughing, dyspnea, tachy, concern for ARDS = admit ● Severe → hypoxic encephalopathy, cardiac arrest = admit

3. Discuss the initial management and evaluation of a patient presenting with abdominal pain.

*Obstain history* ■ Past medical history ● Similar episodes in the past ● Other medical problems ■ Past surgical history ● Adhesions, hernias, tumors ■ Medications ● Antibiotics, NSAIDs, acid blockers ■ GYN/Uro ● LMP, bleeding, discharge ■ Social History ● Tobacco, EtOH, drugs, home situation, agenda *Physical Exam* ■ General appearance ● "Sick vs not sick" ● Mobile vs still ● Obvious pain or discomfort ■ Vital signs ■ Inspection ● Distention, scars, bruises ■ Auscultation ● Present, hyper or absent bowel sounds ■ Palpation ● Often most helpful ● Tenderness vs pain ● Start away from painful area ● Guarding, rebound, masses ■ Signs ● Iliopsoas, obturator, Rovsing, Murphy's, Hop test ■ Extra-abdominal exam ● Pelvic or scrotal ● Lungs ● Heart ■ Rectal ● Look for occult blood (guaiac test)

Discuss the presentation, pathophysiology, evaluation, emergency management and potential complications of the following: *Aortic Dissection*

*Patho:* -tear in intima --> blood btwn. intima and adventitia. -the dissection propagates and a 2nd tear often occurs--> false lumen ♣ 90% occur in Rt lateral wall of ascending aorta; 2nd MC site=origin of left subclavian artery *RF:* -HTN, trauma, pregnancy, connective tissue disorders, cocaine, coarctation of aorta, weak media layer *s/sx:* acute tearing or ripping CP radiating to back, pulse differential, aortic regurg murmur, +/- bruits ♣ bowel infarction may be initial sx ♣ neuro involvement (often manifests as stroke) ♣ Ascending dissections can cause tamponade & hemoperricardium *dx:* ♣ CT= test of choice ♣ TEE= great for proximal dissection ♣ CXR: most have widened mediastinum *classification:* • Stanford (MC): divides into Type A (involve ascending aorta) vs Type B (do not involve it) • Debakey system: Type I, II, III, IIIb I: ascending & descending thoracic aorta involvement II: only ascending III: only descending IIIb: descending + abdominal aorta *Tx:* - emergent surgery regardless of location -decr. HR & BP: IV esmolol then IV nitroprusside --->BB is started 1st to blunt the reflex tach w/ nitroprusside infusions

Discuss the presentation, pathophysiology, evaluation, emergency management and potential complications of the following: *Acute MI*

*Patho:* plaque rupture from subendothelium-->thrombus that occludes artery --> myocardium ischemia +/- infarction -->Less common causes: vasculitis, emboli, cocaine *s/sx:* o substernal squeezing/pressure progressive CP often begins at rest o atypical presentation- DM, elderly, female pts. *dx:* o EKG ASAP! (w/in 10 mins) & Cardiac Enzymes ♣ Troponin= 3 PRO complex in striated muscle; 2 units (I & T) are most specific • Elevate in 2-6 hours, peak in 1-2 days, normalize in 7-10 days ♣ Myoglobin= most sensitive EARLY marker but poor specificity • Elevates in 1-3 hours, peaks in 4-12 hours, normalizes in 1-3 days ♣ CK-MB: rarely used; nonspecific *Tx: goal= reperfusion of ischemic myocardium* *2 options: thrombolysis (plasminogen activators) or percutaneous coronary intervention (PCI) * BUT FIRST STABILIZE & GIVE MEDS o Tele, O2, 2 IVs o Meds 1. Aspirin chewed= 1st & most impt med 2. Nitro (0.4 mg) sublingually ----> Repeat if no relief in 5 mins. Don't let SBP drop <90 3. Beta-Blocker THEN REPERFUSE o Thrombolytic therapy: IV bolus t-PA (tissue plasminogen activator)= altepase & ----->Before admin get labs ----->Done if PCI not possible w/in 90 mins. But benefit decreases w/ increased time -----> ½ life is 5 mins so must use IV heparin via other IV site to prevent reocclusion ♣ Absolute C/I: hx of hemorrhagic CVA (or TIA w/in last year), intracranial neoplasm, active internal bleeding, suspected aortic dissection o PCI (angioplasty): cardiac cath to assess & restore vessel potency (door to balloon < 90 mins) ♣ Better survival than thrombolytics

3. Compare and contrast various intracranial injuries including concussion, * subdural hematoma*, and traumatic SAH.

*Pathophys:* *Venous in nature*, trauma or a hard sneeze rupture a bridging vein in between the arachnoid and dura mater causing a slow bleed. Still an emergency, but they are usually not going to die as quick as a epidural hematoma *Sx:* Slow neuro deterioration *Dx:* Concave in appearance on CT, Buzzword is *CRESCENT SHAPED* (does extend beyond suture lines) Can be acute, chronic, or Acute on chronic *TX* Need Emergent NSG consultation Surgery

1. Discuss the presentation, pathophysiology, evaluation and emergency management of the following: • Immersion syndrome "Immersion Foot, Trench foot"

*Pathophysiology* ● Caused by prolonged immersion in cold water ● Alternating vasospasm and vasodilation results in initial cold and anesthetic feet followed by blistering and ulceration *Clinical Findings* ● Affected parts are first cold and anesthetic ● Hyperemia follows after 24-48 hours and the parts become warm with intense burning and tingling pain ● Blistering, swelling, redness, ecchymoses, ulceration ● Post hyperemic phase occurs after 2-6 weeks and causes the limbs to become cyanotic with increased sensitivity to cold *Complications* ● Lymphangitis, cellulitis, thrombophlebitis, wet gangrene *Treatment* ● Rewarming by gradually exposing affected parts to air ○ Do not soak or massage the skin ● Wound care ○ Elevation, pillows, antimicrobials if infection occurs

1. Compare and contrast the various types of skull and facial fractures *Orbital Floor Fractures*

*Pathophys:* -Typically caused by a direct blow to the central orbit -The walls of orbit are weaker than your eyeball, so in trauma, this breaks before your eye does -Orbital rim remains intact *Physichal Exam:* • enophthalmos - eye sinks backwards due to decreased orbital volume • diplopia - due to extra-ocular muscle entrapment *The affected eye cannot look the away from the entrapment* • orbital emphysema - swelling and crepitus around eye due to air buildup, especially when fracture is into an adjacent paranasal sinus • malar region (cheekbone) numbness *Inferior orbital wall* (aka orbital floor) -Most common -*Pulse drops to 30 BPM* when attempting to look up -Often associated with fractures of the medial wall as well. -Must be treated within Hours or your eyeball starts to die. Trapdoor fractures: small orbital floor fx with clinically significant muscle entrapment, but without nausea, vomiting, pain. Seen in kids. *Superior Wall* -Pure superior blow-outs are uncommon. -Often have additional intracranial bleeding/swelling - Life threatening because the superior orbit is basically your anterior fossa *Tx:* ABX Surgery if: significant enophthalmos, significant diplopia, muscle entrapment, and large area fractures. Superior Orbital- LIFE THREATENING! require immediate additional neurosurgery consultation.

3. Compare and contrast various intracranial injuries including concussion, *epidural hematoma*, and traumatic SAH.

*Pathophys:* -This bleed is arterial in nature, and is often due to the *middle meningial artery* -Patients rapidly deteriorate (arteries pump blood fast) -Some have a "lucid interval" (initial LOC, then lucid, then LOC again) - hernitation from pressure can cause death rapidly *Sx:* *Cushings response*- *HTN, bradycardia, and Anasocoria* indicate increased pressure and herniation 1)*Anasocoria*-compression on the retinal nerve blocks parasympathetic fibers on the outside of the nerve first on the *same side of the injury* and cause dilation 2)HTN- (Ex 200/90) body senses that it needs to keep the brain perfused and increases BP to counteract increased intracranial pressure 3)Bradycardia-Bodies response to the HTN *Dx:* Blood on CT is *Convex in appearance* (doesn't extend beyond suture lines) *Tx:* Neurosurgical Intervention (Need Emergent Neurosurgery consultation) Elevate Head Of Bed 30 degrees Mannitol 1gm/kg Herniation Tx: Decrease blood flow to the brain by hyperventilating the pt on a ventilator. The body responds to hyperventilation by decreasing blood flow

3. Compare and contrast various intracranial injuries including *concussion*, epidural and subdural hematoma, and traumatic SAH.

*Pathophys:* Minor TBI *Concussion grades:* Grade 1:Transient confusion, No LOC, Sx resolve in 15 minutes Grade 2:Transient confusion, No LOC, Sx last more than 15 minutes Grade 3: ANY LOC *SX:* imaging negative, nonfocal neurologic exam, usually sports related HA, dizziness, confusion, nausea, vomiting, lethargy, amnesia from the traumatic event 91% back to baseline in 7 days *Dx:* Based on HX ,imaging negative, *Tx:* *Keep the pt from re injuring before asymptomatic*-period of vulnerability following impact= *Second impact syndrome* causes rapid, usually fatal, neurologic decline

6. Create a differential diagnosis and treatment plan for the various skull and/or facial fractures *basilar skull fracture*

*Pathophys:* Fx at base of skull, typically at petrous portion of temporal bone *Sx:* Blood from fractures seeps into skin and TM. *Raccoon Eye's,Battle Sign, Hemotympanum, double halo sign* (drainage that is blood and CSF) Also note CSF leak. Cranial nerve defects, facial paralysis, decreased auditory acuity, dizziness, tinnitus, *TX: *abx are controversial, Admit for observation, neurosurgeon consult

1. o Compare and contrast the presentation, pathophysiology, evaluation and emergency management of the following: • Bowel perforation

*Pathophysiology* ○ Typically= perforated peptic vs duodenal ulcer (upper pain) or perforated diverticula (lower pain) ○ Complication of : Appendicitis, Diverticulitis, Stomach Ulcer, Gallstones, Infection, IBD, cancer *Presentation* ● *Sudden, explosive onset of severe*, agonizing mid- or lower- abdominal pain ● N/V ● Fever ● Abdomen is rigid and tender ● Watch for shock! *Evaluation* ● 3 view abdominal XR series (see photo, dat free air under the diaphragm) ● *No time for CT, go directly to OR* ● Leukocytosis *Emergency Management* ● Treat shock with IVF ● Obtain blood and urine cultures ● CBC, BMP, coags ● Begin antibiotics, broad (esp anaerobic and gram -) ● Hospitalize for immediate surgery

1. o Compare and contrast the presentation, pathophysiology, evaluation and emergency management of the following: • Acute suppurative cholangitis

*Pathophysiology* ● A complication of cholecystitis and choledocholithiasis ● *SURGICAL EMERGENCY*, associated with bacteremia and septic shock ● Suppurative means pus forming *Presentation* ● Pain, jaundice, fever *(Charcot's triad),* mental confusion and shock (Reynaud's pentad when all 5) ● Requires *two components:* ○ Presence of a biliary obstruction ○ Infected biliary tract *Evaluation* ● RUQ Ultrasound shows dilated, obstructed intrahepatic biliary ducts *Emergency Management * ● ABCs ● 2 large-bore IVs ● 2L IVF bolus ● Broad spectrum antibiotics (anaerobic and gram - coverage) ● Foley catheter to monitor urine output ● Emergent surgical consultation vs GI for ERCP

1. o Compare and contrast the presentation, pathophysiology, evaluation and emergency management of the following: • Retroperitoneal hemorrhage

*Pathophysiology* ● Blood in the retroperitoneal space ● Major trauma or secondary to minor trauma in individuals with defective clotting factor resulting from medication or disease ● May occur after invasive femoral procedures such as catheterization *Presentation* ● Back pain, abdominal pain, possible abdominal bruising *Evaluation* ● Positive Psoas sign ● Possible Grey Turner sign (b/l flank bruising) ● Abdominal CT localizes the bleeding *Emergency Management * ● Treat shock with IVF and cross-matched whole blood ASAP ● Correct coagulation defects with platelets or clotting factors as needed ● Admit: active hemorrhage, clotting abnormalities, severe pain ● Otherwise, conservative management

1. o Compare and contrast the presentation, pathophysiology, evaluation and emergency management of the following: • Peritonitis

*Pathophysiology* ● Occurs almost exclusively in patients with preexisting large-volume ascites, especially those with cirrhosis or nephrotic syndrome *Presentation* ● Symptoms vary ● Fever, abdominal pain, tenderness ■ *Evaluation* ● Blood culture and abdominal paracentesis for gram-stained smear, CBC, fluid culture ● PMN cell count > 250 is highly suspicious for spontaneous bacterial peritonitis and is an indication for initiation of empiric antibiotics *Emergency Management * ● Hospitalize for diagnostic evaluation and treatment ● Treat shock, if present, with IVF ● Culture blood and peritoneal fluid first and then begin broad spectrum parenteral antibiotics

1. Discuss the presentation, pathophysiology, evaluation and emergency management of the following: • Hypothermia

*Pathophysiology* ● Core Temp *<35C/95F* ● Can be caused by several things, #1 in US is drugs *Clinical Findings* ● *Mild: 90-95*F.* Excitation phase, so vitals are all increased. ( tachy, tachypnea, hyperventilation, ataxia) ● *Moderate: < 90*F. *Rates all slow. Shivering stops around 88*F. CNS depression, undressing. ● *Severe: < 82*F. *Pulm edema, oliguria, coma, hypotension. ● Lethal EKG changes (Osborn waves) ● Decreased resp rate = coughing and low gag reflexes = aspiration PNA *Treatment* ● ACLS - CPR. maybe delay if temp below 82F (might be super brady). Also hypothermic heart is sensitive to movement (V-Fib) ● Arrythmias usually correct with rewarming ● 2 large bore IVs ● Treatment often guided by labs and depends on type of hypothermia ● Dextrose if hypoglycemic ● Thiamine if alcoholic ● Thyroid hormone for hypothyroidism ● Labs: Cardiac, basic, EKG, and serum lactate ● Rewarming: ○ *Passive external warming* - remove from environment ○ *Active external warming* - warm water, heated blanket ○ *Active core/internal rewarming* - Warm IVF, warm air, warm gastric lavage ○ *Extracorporeal blood warming* - for serious (hyperK, rhabdo, frozen extremities) blood shunted through external heating

1. o Compare and contrast the presentation, pathophysiology, evaluation and emergency management of the following: • Abdominal Aortic Aneurism

*Pathophysiology* ● Dilatation of the arterial wall commonly due to medial degeneration (usually atherosclerosis) ● Aneurysm >3 cm; *needs repair >5 cm* *Presentation* ● Back, abdominal, or flank pain is the most common initial symptom ● *½ with "ripping or tearing" pain through sternum* ● Hypotension, pulsatile mass--often a late finding ● If ruptured, abrupt severe pain in epigastrium and back ○ Ripping or tearing pain *Risk factors* ● Family history of AAA ● Male gender ● Age > 70 years ● Smoking ● Hypertension *Evaluation* ● Emergency bedside ultrasound ● CT scan *Emergency Management* ● ABCs - start O2 ● Prevent hypotension and shock ● 2-3 large bore IVs ● 2-3 L of IVF ● Type and Cross, get 8-10 units PRBCs ● Consult vascular ○ *SURGICAL CONSULTATION* = Mortality is ~100% without surgical intervention

1. Discuss the presentation, pathophysiology, evaluation and emergency management of the following: • Heat stroke (Major)

*Pathophysiology* ● Dysfunction of the heat regulating mechanism ● Hyperpyrexia (> 105*F) and CNS dysfunction, +/- anhidrosis ● *COUGH COUGH, this is different from exhaustion because this has CNS involvement* *Clinical Findings* ● AMS, elevate core body temperature ● Extremely high body temperature rapidly causes widespread damage to body tissues with significant rhabdomyolysis and multiorgan dysfunction ● Illness and death result from destruction of cerebral, cardiovascular, hepatic, and renal tissue ● Headache, dizziness, nausea, diarrhea, visual disturbances, hot and flushed skin ● Hyperventilation may cause initial respiratory alkalosis which is generally followed by metabolic acidosis *Laboratory Findings* ● Get all the labs. Basic, cardiac, coags, tox screen, EKG, CXR, CT head, maybe LP ● Hemoconcentration, decrease blood coagulation, evidence of DIC, hypoprothrombinemia, hypofibrinogenemia, thrombocytopenia ● Hyperkalemia associated with acute renal failure due to rhabdomyolysis ● Scantily concentrated urine containing protein, tubular casts, and myoglobin - "machine oil urine" ● AKA... dey messed up. *Treatment* ● Initial Normal Saline or LR 20mL/kg or 1L ● Rapid cooling (antipyretics do nothing because it's not a hypothalamus problem) ○ Cooling blanket, ice packs, spray patient with water under a fan, ice bath ○ If temperature cannot be lowered rapidly, initiate peritoneal lavage with cold potassium-free dialysate (invasive but rapid) ○ If patient requires dialysis, extracorporeal blood cooling ○ Benzodiazepines to control shivering ○ Can stop when temp is under 104*F ● Cardiovascular support ● Maintain urine output- Place catheter ● Monitor core temp

1. o Compare and contrast the presentation, pathophysiology, evaluation and emergency management of the following: • Appendicitis

*Pathophysiology* ● Inflammation of the appendix ● Caused by luminal obstruction leading to intraluminal pressure, continued mucosal secretion, bacterial invasion by normal flora→ inflammation ● Increased pressure leads to arterial stasis and tissue infarction *Presentation* ● Periumbilical or localized pain in RLQ ● anorexia, nausea, vomiting, fever *Evaluation* ● Pain at *McBurney's point* ● *(+) Rovsing's sign* ● (+) Rebound ● (+) Psoas ● (+) obturator ● Labs: CBC, BMP, UA w/ leukocytosis ● *CT abd/pelvis w/ contrast* or ultrasound ● Mantrels Scoring System used to determine likeliness of appendicitis *Emergency Management* ● Hospitalize and prepare for surgery ● Administer analgesia and IVF ● If appendix is intact → perioperative antibiotics ● Ruptured appendix → IV antibiotic therapy for several days _

1. o Compare and contrast the presentation, pathophysiology, evaluation and emergency management of the following: • Acute Cholecystitis

*Pathophysiology* ● Inflammation of the gallbladder, most likely due to a stone obstruction *Presentation* ● Like biliary colic, but worse ● *RUQ pain* ● Occurs *after a meal* (probably greasy) ● Loss of appetite, N/V, low F *Evaluation* ● Ultrasound shows dilatation of bile ducts, thickening of gallbladder wall, and pericholecystic fluid is common ● US is sensitive, specific and preferred ● *Murphy's sign* (hands or US) ● Leukocytosis *Emergency Management * ● NPO ● Inset NG tube and attach to continuous suction if patient is vomiting ● Antiemetics have little effect ● IVF and pain control ● Administer empiric abx if patient has signs of infection (fever) ● Hospitalize and obtain surgical consultation ● NOTE: If patient has symptomatic choelithiasis, you can discharge them home since there is no infection. Patient doesn't need admission. Patient may object, but they are perfectly able to follow up for an elective cholecystectomy as their pain is likely chronic.

1. o Compare and contrast the presentation, pathophysiology, evaluation and emergency management of the following: • Gastroenteritis

*Pathophysiology* ● Inflammation of the lining of the intestine *Presentation* ● Mild/severe cramping and pain ● N/V/D and retching *Evaluation* ● Abdomen with generalized discomfort ● ABSENT Involuntary guarding, localized tenderness, and peritoneal signs ● LABS: Stool tests for blood, leukocytes, and culture *Emergency Management * ● NO anti-diarrheals ● Severe or dehydrated = admit ● Discharge the rest home with supportive and rehydration instructions

1. Discuss the presentation, pathophysiology, evaluation and emergency management of the following: • Heat edema (Minor)

*Pathophysiology/Clinical Presentation* ● Self-limited, hands and feet with swelling and tightness ● Due to muscular and cutaneous vasodilation combined with venous stasis ● Interstitial fluid accumulates in the lower extremities *Treatment* ● No treatment necessary ● Elevation of lower extremities, +/- support hose ● No positive effects from diuretics ● Last up to 6 wks

1. Discuss the presentation, pathophysiology, evaluation and emergency management of the following: • Heat cramps (Minor)

*Pathophysiology* ● Painful muscle contractions ● Primarily due to salt depletion and manifested by painful spasms of the voluntary muscles of the abdomen and extremities ● Self limited *Clinical Findings* ● Painful spasms ● Muscle fasciculations may be present ● Skin may be moist or dry, skin may be warm or cool ● Core temperature is normal or slightly elevated *Treatment* ● Oral fluid and salt replacement with salt solution ○ Very mild cases → gatorade ○ Severe cases → IV normal saline ● Give supplementary potassium as dictated by serum levels ● Place patient in a cool place and massage sore muscles gently

1. o Compare and contrast the presentation, pathophysiology, evaluation and emergency management of the following: • Pancreatitis

*Pathophysiology* ● Risk factors: alcoholism, gallstones, idiopathic, ERCP, trauma, infectious, medications *Presentation* ● Acute onset of severe, unrelenting epigastric pain radiating to the back that is worse when supine ● Or Dull achy epigastric pain with eating ● Pain is occasionally present in the RUQ ● Nausea and vomiting *Evaluation* ● *Ranson's Criteria for diagnosis* ○ On admission: ■ age>55, WBC>16,000, Glucose>200, AST>250, LDH>350 ○ At 48 hrs: ■ Calcium<8, Hematocrit fall>10%, BUN of 1.8, Base deficit >4, PO2<60, Fluid > 6L ● Decreased or absent bowel sounds ● Worst TTP in epigastrium ○ Elevated serum amylase and lipase (Lipase > amylase) ● Abdominal CT *Hemorrhagic Pancreatitis (rare)* ○ Gray Turner Sign ■ Bluish to purplish discoloration of the flank ○ Cullen Sign ■ Periumbilical bluish to purplish discoloration *Emergency Management* ● NPO, NGT, Pain meds, bowel rest, IVF ○ *Discharge: *Mild pancreatitis, tolerating PO, not first episode, only slight lipase elevation, pain control ○ *Admission:* Not able to tolerate PO, intractable pain

1. Discuss the presentation, pathophysiology, evaluation and emergency management of the following: • Heat exhaustion (Major)

*Pathophysiology* ● Systemic reaction caused by either primary water loss or primary sodium loss due to prolonged heat exposure, due to sodium depletion, dehydration, accumulation of metabolites, or a combination of these factors---It rapidly leads to heat stroke *Clinical Findings* ● Symptoms of dehydration, but* CNS symptoms are not seen* ○ Tachycardia, hypotension, diaphoresis ● Headaches, nausea, vomiting, malaise, muscle cramps, dizziness, fatigue, syncoe ● Temp up to 104*F... rectally. ● *MENTAL STATUS NORMAL* ● Two types (usually you get a mix): Hypernatremic (primary water loss) and hyponatremic (primary sodium loss) ● Measure serum electrolytes and renal function *Treatment* ● Diagnosis of exclusion ● Place the patient in a cool place and give adequate cool water and salted fruit drinks ● If patient is unable to drink fluids, give via IV ● REST and volume/electrolyte replacement

1. o Compare and contrast the presentation, pathophysiology, evaluation and emergency management of the following: • Renal colic

*Pathophysiology* ● Type of pain caused by Urolithiasis (kidney stones) ● Most stones are calcium ● White male 20-50yo *Presentation* ● Sudden, severe flank pain, often radiating laterally around to the groin, followed by hematuria--unilateral ● Constant, dull ache may be present between episodes ● Nausea, vomiting, restlessness *Evaluation* ● A hx of stone passage may occur ● CVA tenderness and a benign abdominal exam ● Urinalysis shows blood, crystals or infection ● Urine culture if infection suspected ● Imaging is not always necessary, but abdominal x-ray can show renal stones ● *Non-contrast helical/spiral CT is the standard *diagnostic modality *Emergency Management* ● Control pain with NSAIDs and narcotics ● Oral or IV fluids recommended ● Admit if obstructing stones with signs of infection, renal dysfunction or severe sx

1. o Compare and contrast the presentation, pathophysiology, evaluation and emergency management of the following: • Pyelonephritis

*Pathophysiology* ● UTI was asymptomatic or untreated and now it's spread to the kidneys. "Upper UTI" *Presentation* ● Dull flank pain ● Dysuria ● urinary urgency/frequency ● N/V/Fever/Chills ● *CVA tenderness* *Evaluation* ● UA/ UC ● Clinical diagnosis ● CT may show perinephric stranding with mild hydro *Emergency Management* ● Uncomplicated: Oral Abx and discharge (Levo, Cipro, Bactrim) ● Admit: Old/young, preggo, male, intractable N/V ○ Observe, IV hydration, parenteral antibiotics (Cefepime, piperacillin-tazobactam) Don't confuse with Nephrolithiasis which is kidney stones in the kidneys.

1. o Compare and contrast the presentation, pathophysiology, evaluation and emergency management of the following: • Mesenteric ischemia

*Pathophysiology* ● Variable: thrombus, embolus, vasoconstriction or venous thrombosis ○ Chronic : stenosis or occlusions ● Mesenteric Blood Flow affected: Celiac artery, SMA, or IMA ○ *Sudeck's (sigmoid colon) and Griffith's points (Splenic flexure):* common locations for colon ischemia ● This is a rare diagnosis but when missed can be fatal, always have a high index of suspicion in patients with a hx of atherosclerosis disease, cardiac dysfunction or recent arterial catheterization *Presentation* ● *Sudden onset of severe, diffuse abdominal pain* the the mid- or lower abdomen ○ Poorly localized pain, out of proportion to examination, and severe, often not relieved by narcotics ● N/V/D w/ gross or occult blood in the stool ○ Weight loss due to rapid bowel emptying *Evaluation* ● Physical exam findings may be absent ● As condition progresses, distention and signs of systemic toxicity develop ● Labs: Leukocytosis, hemoconcentration, azotemia and acidosis (elevated lactic acid) ● *Gold standard: CT angiogram* *Emergency Management * ● Hospitalization and immediate surgical consultation ○ Restored flow by bypass or embolectomy, resection of nonviable ● Treat shock and hemoconcentration with IVF and abx

1. o Compare and contrast the presentation, pathophysiology, evaluation and emergency management of the following: • Biliary colic

*Pathophysiology* ● stone moves from gb -> biliary tract -> obstruction *Presentation* ● The "F's": female, fat, forty ● Postprandial pain begins abruptly, then fades over hours ● Colicky attack - persistent pain extends across the right upper abdomen, may refer to the scapula *Evaluation* ● Careful hx shows prior attacks like this ● Gallbladder may be palpable ● RUQ Ultrasound shows stones, dilated GB or cystic duct *Emergency Management * ● If no complications (acute cholecystitis, ascending cholangitis, choledocholelithiasis, or pancreatitis), no treatment required ● Pain control, antiemetics, oral hydration and nutrition ● Refer for possible elective cholecystectomy

3. Compare and contrast various intracranial injuries including concussion, epidural and subdural hematoma, and traumatic *SAH. (sub arachnoid hemorrhage*)

*Pathpys:* Bleeding in between the Arachnoid mater and Pia mater due to trauma or 2/2 aneurysm rupture Not space occupying in nature, but can lead to increased ICP due to *blockage of CSF* flow in ventricles *Sx* *Thunderclap*, worst headache of my life *Dx:* Look for blood in the ventricles and increased ICP on CT (note: a little white dot in the ventricles is normal) If CT is normal, check *CSF* for *xanthecromia* (yellow fluid =blood breakdown) *Tx* -Treat HTN SBP <140 -Correct coagulopathy -Evaluate for Hydrocephalus (wide ventricles on CT) - Seizure Prophylaxis -monitor ICP

Compare and contrast the presentation, pathophysiology, evaluation and emergency management of the following: *COPD* Fun fact: Cigarette smoking account for approx 90% cases of COPD

*Presentation* -*Chronic bronchitis* is defined *clinically* as the presence of chronic cough, sputum production, and assoc. with heavy smoking. Pt. have increased lung volumes and barrel-shaped chest with increased lung markings and CXR. -*Emphysema* is defined *physiologically* as an abnormal permanent enlargement of air spaces distal to the terminal bronchioles, without obvious fibrosis. -Typically thing, pursued lips, accessory muscle use more prominent. -CXR usually shows paucity of lung markings reflecting tissue destruction. -*History*: Cough, sputum production, dyspnea -*Physical*: Hypoxia, tachypnea, tachycardia, bilateral wheezing, accessory muscle use, rales and rhonchi *Pathophysiology* -Respiratory infections are triggers for most COPD exacerbations *Evaluation* -*Pulse ox*: change from baseline values more useful than absolute value (and better give better info regarding oxygenation than do blood cases because available in real time) -*ABG*: not routinely performed unless severe exacerbation, altered mental status (most pt. on home oxygen have chronic respiratory acidosis with metabolic compensation) -*PFTs*: much lesser role of COPD compared with asthma (less airway obstruction reversibility) -*BMP, CBC*: limited utility -*BNP*: may be useful if CHF is in the differential -*CXR*: routinely ordered in pt.s with COPD exacerbations. -->Reveals chronic changes: hyperinflation, decreased vascular markings, small cardiovascular silhouette -->May demonstrate acute treatable cause of deterioration: Pneumonia, pneumothorax, tumor *Emergency Management* -Intubation/non-invasive ventilatory support if needed -*O2* to maintain SaO2 >/= 90% -*Corticosteroids* -*Bronchodilators*: short-acting inhaled beta-agonists and anticholinergics are mainstays of ED therapy (albuterol and ipratropium admin simultaneously -synergistic effects) -*Antibiotics*: Beneficial in pt with mod-severe exacerbations (as opposed to bronchitis) -->Target therapy to S. Pneumonia, H. influenza, M. Catarrhalis with *Azithromycin*, Doxy, 3rd gen ceph, amor/clauv -Consider MgSO4 in severe exacerbations -Admit if significant worsening from baseline, inadequate response to ED tx, comorbidities, inability to ensure f/u. -Discharge with corticosteroids, bronchodilators, antibiotic, f/u with PCP *Be careful of CO2 Narcosis in pt. with advanced COPD when giving oxygen.

Compare and contrast the presentation, pathophysiology, evaluation and emergency management of the following: *Airway obstruction: Epiglottitis* Fun facts: -Due to widespread use of the Hib vaccine, epiglottitis is now more common among adults than children.

*Presentation* -Children: High fever, -Adults: usually present w/ 2-3 days of steadily worsening throat pain, difficulty swallowing, and fever. *Pathophysiology* -*H. influenzae b* is the most common and tends to cause more severe presentation -Staph, Strep and other viral pathogens are also associated *Evaluation* -Keep child calm! NO IV sticks. If pt. is stable, get lateral soft tissue neck X-ray -> may demonstrate enlarged epiglottis (*thumbprint sign*- see picture). X-ray does not r/o diagnosis. *Diagnosis* -*Fiberoptic laryngoscopy* (gold standard) -Lateral soft tissue neck x-rays are up to 90% sensitive -->Epiglottic width =/> 8mm consistent with diagnosis "thumb printing" *Emergency Management* -All pediatric patients should be intubated for airway protection. (or anyone unstable) -Admit and give IV abx and fluids -Begin 3rd generation cephalosporin + vancomycin or clindamycin

Compare and contrast the presentation, pathophysiology, evaluation and emergency management of the following: *Pneumonia* (specifically community-acquired)

*Presentation* -Cough, dyspnea, fever, rigors, malaise -Hemoptysis, night sweats -Chest pain, altered mental status (AMS), decline in function -Comorbid conditions: immunosuppression, pulmonary disease, exposures -Immunization (pneumococcal, flu) -Recent antibiotic use, hospitalization, intubation *Pathophysiology* -S. pneumoniae: MC -H. influenzae: common in COPD, immunocompromised hosts -M. pneumoniae: very common in previously health, young patients -Klebsiella: alcoholics, diabetics -S. aureus: uncommon cause of CAP, but associated with recent flu infection -Legionella: commonly seen in clusters, GI symptoms are common -Viral, fungal, TB, Pneumocystitis *Evaluation* -*Physical exam* -->Vital signs: pulse ox, tachypnea, tachycardia, fever, hypotension with severe illness -->Evidence of alveolar fluid and/or consolidation: rales, diminished breath sounds, dullness to percussion, egophony (bronchial congestion causes bronchi, wheeze) -*Chest radiograph* -->Lobar pattern: S. pneumoniae, K. pneumoniae, H. influenzae, occasionally in atypicals -->Interstitial pattern: viruses, atypical (M. pneumo, C. pneumo), Pneumocystitis -->Cavitation: anaerobes, S. aureus, gram negative rods, fungal, *COUGHING POINT* think *TB* until proven otherwise when you see cavitation. -*Lab eval*: CMP, CBC (not necessary in all patients) -*Blood cultures*: good for immunocompromised, sepsis or septic shock, risk factors for endovascular infection -*Sputum cultures*: limited to pt. with suspected infection by unusual pathogens, severely ill patients -*Risk-stratification* tools to guide disposition decision: -->PORT score (determines 30 day pneumonia mortality via risk class with score) -->CURB-65: gives 30 day mortality based off points: 1 pt each for *C*onfusion, *U*rea (BUN >20 mg/dl), *R*espiratory rate >30/min, *B*lood pressure <90 mmHg, Age > *65* (2=admit, 3=ICU) *Emergency Management* -Hypoxemic patients generally admitted -Outpatient tx with no sig. comorb. or recent abx: Azithromycin, clarithro, doxy -Outpatient tx with comorb or abx w/i last 3mo OR inpatient: Respiratory fluoroquinolone (levofloxacin), B-lactam (high dose amox, augmentin, or 3rd gen ceph) + azithromycin -Severe CAP (ICU admin) tx: potent systemic B-lactam (ceftriaxone, cefotaxime, or ampicillin-sulbactam) PLUS either respiratory FQ or azithromycin -Risk for Pseudomonas (structural lung dz, frequent steroid use): antipseudomonal B-lactam (piperacillin-tazobactam, cefepime, imipenem) + FQ -Risk for MRSA (ESRD, IVDU, recent flu, recent FQ use): in addition to above treatment add vancomycin OR linezolid -Suspected Pneumocystits: high dose bactrim

Compare and contrast the presentation, pathophysiology, evaluation and emergency management of the following: *Airway obstruction: Peritonsillar Abscess* Fun facts: -Most common deep-space infection in throat; most common in young adults

*Presentation* -Difficulty swallowing, hot potato voice, foul smelling breath, truisms (lockjaw) -Unilateral soft palate swelling and uvular deviation *Pathophysiology* -Progression of bacterial tonsillitis *Evaluation/Management* -Needle aspiration confirms the diagnosis and is therapeutic. -Larger abscesses may require I&D by ENT -Treat with Augmentin or Clindamycin

Compare and contrast the presentation, pathophysiology, evaluation and emergency management of the following: *Pulmonary embolism* Fun facts: Traditionally difficult to diagnose -> missed diagnosis results in large number of malpractice claims -> fear of this causes frequent (negative) testing with potential (unnecessary) negative outcomes

*Presentation* -Dyspnea, pleuritic chest pain, anxiety, cough, hemoptysis, diaphoresis, syncope -Classic triad: hemoptysis, dyspnea, pleuritic pain (not very common, >20%) *Pathophysiology* -Virchow's triad: hypercoagulability, stasis, vessel injury -Venous emboli: typically from the lower extremities, dislodge from site of origin -Pulmonary vascular resistance abruptly increases, causing increased RV dilation and dysfunction (elevated troponin and BNP predict mortality) -Progressive right heart failure is the usual immediate cause of death from PE *Evaluation* -Using *vital signs*, history and physical, and chest x-ray to determine your pretest probability (PTP) of PE: 1. High PTP: Patients in whom PE can be reliably excluded only by imaging 2. Low-Moderate PTP: Patients sage for exclusion via negative D-dimer 3. Patients with such low pretest probability that no test is indicated -*EKG*: moderate to severe PE results increased PA and RV pressures, resulting in evidence of right heart strain on EKG -->Tachycardia, atrial arrhythmias, complete and incomplete RBBB, precordial T wave inversions, S1Q3T3 pattern (EKGs have limited sensitivity and specificity) -*Chest X-Ray*: (see picture) -Primarily used to rule out alternative explanation for patient's symptoms. -->Westermark's sign: dilation of the pulmonary vessels proximal to the embolism along with collapse/cutoff of distal vessels -->Hamptoms Hump: triangular or rounded pleural-based infiltrate with the apex toward the hilum (area of infarction) -Neither are commonly observed *Estimating Pretest Probability* -Clinical decision rules: Wells criteria, Geneva score, Modified Geneva score -PE Rule-Out Criteria: identifies low risk population who don't need PE eval *COUGHING POINT* Diagnosis -If high pretest probability, proceed directly to CT scanning -If low-moderate pretest probability, obtain D-dimer step in workup --> If D-dimer is below cutoff, PE is effectively excluded --> If D-dimer is elevated, proceed to CT scanning -If concern against Chest CT, consider V/Q scan, lower extremity venous doppler, empiric treatment if sufficiently high pretest probability *Emergency Management*: -Options for initial phase of anticoagulation: -->LMWH (e.g. enoxaparin (Lovenox)) -->UH (bolus with subsequent drip) -->Fondaparinux (Arixtra) anticoag -->Oral Xa inhibitors: apixaban (eliquis), rivaroxaban (xarelto) -Subsequently, anticoagulant can be accomplished with any of the above agents, warfarin, dabigatran (pradaxa), or egoxaban (savaysa) -Consideration of thrombolysis/mechanical clot removal -->Definitely indicated in patients with hypotension -->Consider in patients with RV dysfunction on echo, elevated troponin/BNP (No mortality benefit in these patients, but possible improvement in functional outcomes -->IVC filter placement in patients with contraindicated to anticoagulation or recurrent thrombus despite adequate anticoagulation

Compare and contrast the presentation, pathophysiology, evaluation and emergency management of the following: *Pulmonary hypertension* (Pulmonary arterial hypertension= PAH) (Not covered in lecture)

*Presentation* -Exertional SOB or syncope -Pulmonary venous htn from CHF causes SOB while lying flat, PAH does not. -Loud pulmonic closure, P2 -Peripheral edema may occur *Pathophysiology* -Pulmonary hypertension may be secondary to another lung d/o such as COPD, left-sided heart dz, or recurrent pulmonary thrombolic dz. -Pulmonary arterial hypertension (PAH) is not a secondary result but includes familiar types and those assoc. with collagen vascular disease (scleroderma), HIV, toxic exposures -->Characterized by remodeling of pulmonary circulation with occlusion of the lumen in the medium-sized and small pulmonary arteries -->Afterload of right ventricle increases as this occurs, which causes an obstruction flow in pulmonary arterial tree and increases pressure as the right ventricle attempts to compensate. *Evaluation* -PAH may be identified with echocardiogram, but dx requires measurements of pressure and flow with a Swan-Ganz catheter. (Pulmonary artery wedge pressure should be less than 15 mm Hg and the pulmonary artery pressure greater than 25 mm Hg to make the diagnosis) -Absence of congestive changes on chest X-ray *Emergency Management* -Treat underlying condition -->Prostaglandins (Prostacyclin): lasts only 3-5 minutes, administered by continuous infusion in severe disease (vasodilator) -->Phosphodiesterase Type 5 inhibitors: vasodilator, used to treat erectile dysfunction, but also effective in mild-mod PAH From study guide: -->Endothelin receptor antagonists -->CCBs

Compare and contrast the presentation, pathophysiology, evaluation and emergency management of the following: *Airway obstruction: Ludwig's Angina* Fun facts: Surgery is required for patients who do not respond to antibiotics; dental examination and removal of affected teeth; high aspiration complication rate

*Presentation* -Fever, dysphagia, mouth floor/neck swelling, often assoc. with voice change *Pathophysiology* -Progressive infection of the connective tissues of the floor of the mouth and neck, which begins in the submandibular space. -Most commonly caused by infection originating in area of 2nd or 3rd molars *Evaluation* -Exam reveals bilateral *submandibular swelling*, elevation of the tongue, dysphonia -CT scan most useful to confirm diagnosis *Emergency Management* -Position pt upright and protect airway as dictated by clinical appearance via fiberoptic guidance -IV antibiotic coverage for polymicrobial and anaerobic oral flora (e.g. ampicillin-sulbactam, clindamycin) -Book says: ticarcillin-clavulante or piperacillin-taxobactam with clinda or metronidazole.

3. Discuss the presentation, pathophysiology, evaluation and emergency management of the following: • Compartment syndrome Cough cough

*Surgical Emergency* Caused by bleeding/swelling into a confined compartment that cuts off blood supply (Tibia is the most common) -Look for the 5 P's: (clinical diagnosis) *P*ain *P*oikilothermia (cold) *P*ulselessness *P*allor (pale) *P*arathesia (numbness) Stryker needle is used to measure the pressure in each compartment: Change in pressure= DBP- Compartment pressure If the pressure change is less than 30 mmHg --> Fasciotomy

What are the SIRS criteria- Cough cough

*Systemic Inflammatory Response Syndrome:* Need 2 or more of the following: -Temperature ≥38oC or ≤36oC -HR >90 beats/min -Respirations ≥20/min -WBC count ≥12,000 or ≤4,000 or >10% immature neutrophils SIRS + infection = Sepsis

Compare and contrast the presentation, pathophysiology, evaluation and emergency management of the following: *Pulmonary edema* (Not covered in lecture)

*Presentation* -If cardiogenic -> gradually increasing pulmonary edema, intermittent chest pain, dyspnea -->Frank pulmonary edema may occur with left heart failure and present with dyspnea at rest, cyanosis, frothy sputum -->May be accompanied by wheezing, loud S3, rhonchi and rales -If noncardiogenic -> edema more abrupt and more severe, severe respiratory distress *Pathophysiology* -*Cardiogenic* causes: often a result of acute decompensated heart failure -->rapid accumulation of fluid within the lung's interstitial and/or alveolar spaces, which is the result of acutely elevated cardiac filling pressures -->Primary etiologic factor is a rapid and acute increase in left ventricular filling pressures and left atrial pressure. -*Noncardiogenic* causes: most likely ARDS *Evaluation* -CXR: interstitial and sometimes alveolar edema -BNP will increase in CHF, differentiates cause of pulmonary edema from COPD -Focused history, echo, lab, (sometimes pulmonary capillary wedge pressure) can be used to distinguish cardio from noncardio. *Emergency Management* -Noncardiac: Treat underlying disease, supportive care (mechanical ventilation, hemodynamic monitoring, fluid management) -Cardiac: -->Noninvasive positive pressure ventilation (NIPPV): CPAP/BiPAP can decrease need for intubation, alveoli kept open with pos pressure and work of heart is reduced. -Furosemide (Lasix) -Nitroglycerine (vasodilator in severe CHF, reduces preload and after load), nitroprusside (if cause of CHF is directly related to hypertensive emergency), enalaprilat, or nicardipine -ACE or ARB inhibitors to decrease after load

Compare and contrast the presentation, pathophysiology, evaluation and emergency management of the following: *Airway obstruction: Foreign Bodies*

*Presentation* -Initial phase may include choking and coughing -Subsequent lodging may result in the following: -->*Laryngeal* (larger objects): airway obstruction, hoarseness or aphonia -->*Tracheal* (larger objects): coughing, wheezing -->*Bronchial*: (80-90%, and commonly right side) cough, unilateral wheezing, focally decreased breath sounds *Pathophysiology* Young children at highest risk (1-3y/o): lack molars for proper grinding of food, lack swallowing and glottic closure coordination *Evaluation* -Assessment begins with observation for tachypnea, air movement, stridor, retraction, agitation or lethargy, and cyanosis. -Initial test: 2 view CXR (frequently normal- most foods not radiopaque) -Unilateral hyper expansion, lobar atelectasis, pneumonia suggest foreign body. *Emergency Management* -Oxygen should be administered to all patients with foreign body aspiration. -Total obstruction = Heimlich >1y/o, back blows/chest thrusts in younger. -Attempt to remove object under with direction from laryngoscopy -->If unsuccessful, rigid bronchoscopy -Partial obstruction: Air movement and object cannot be visualized -> rigid bronchoscopy. -Bronchial obstructions often do not require intubation

Compare and contrast the presentation, pathophysiology, evaluation and emergency management of the following: *Asthma*

*Presentation* -Most patients present with exacerbations of known disease -History: cough, wheezing, SOB, chest tightness, sputum production, worse at night (*Reversible with bronchodilators*) -Physical: Tachypnea, tachycardia, hypoxia, end-expiratory wheezing w/ prolonged expiratory phase, decreased breath sounds *Pathophysiology* -Attacks frequently precipitated by URI, exercise, allergen *Evaluation* -*Peak flow* rate (PFR) assists in triaging severity of exacerbation -*Chest X-ray*: little utility in pt. with est. diagnosis and no h&p consistent with pneumonia. -->Should be obtained in pt. with status asthmaticus or patients with no prior history of wheezing. -*BMP*: useful for those on continuous nebulizers to monitor K+ -*CBC*: little/no utility (WBC increase with left shift is expected w/i 2hr of steroid administration) *Emergency Management* -*Corticosteroids*, PO preferred if able to tolerate (Prednisone) -Simultaneously give *COUGHING POINT* *bronchodilators*: inhaled beta-agonist (best), anticholinergics, magnesium, systemic beta-agonists -Generally admit pt. with PFR <40% after ED therapy, >70& can be discharged -If discharged, provide 3-5 days of prednisone, refill albuterol, ensure f/u with PCP

Compare and contrast the presentation, pathophysiology, evaluation and emergency management of the following: *Pneumothorax* (Not covered in lecture)

*Presentation* -Pleuritic chest pain, acute-onset dyspnea, tachypnea, decreased breath sounds on affected side. -Tympani elicited by chest percussion of the effected -Possible tracheal deviation and displacement of point of maximal impulse (PMI) to opposite side. *Pathophysiology* -Abnormal collected of air within the pleural space -May be classified as either spontaneous (primary or secondary), traumatic, or iatrogenic -->Primary spontaneous: in pt. w/o clinically apparent lung dz (often young, tall men, 20-40y/o, usually smoke) -->Secondary: complication of preexisting underlying lung dz such as COPD, pneumonia (PCP), CF, asthma, TB -->Traumatic: blunt or penetrating chest trauma -->Iatrogenic: may occur during subclavian line placement, thoracentesis, or following lung/pleural bx (or result from barotrauma during positive pressure ventilation) *Evaluation* -*CXR (frontal view)* shows *lung collapse* and air in pleural space. Small amounts of fluid may also be present in pleural space. -Chest CT will often be helpful in identifying associated pathology, such as pneumocystis pneumonia or differentiating pneumothorax from emphysematous blebs in patients with COPD. *Emergency Management* -Small pneumothorax will usually resolve without treatment -Secondary generally require chest tube drainage -Traumatic: most have hemothorax, see section 3 quizlet -Immediate thoracostomy is indicted for bilateral pneumothoraces.

Compare and contrast the presentation, pathophysiology, evaluation and emergency management of the following: *Airway obstruction: Angioedema*

*Presentation* -Swelling of lips, face, & tongue *Pathophysiology* -Can be idiopathic, hypersensitivity reaction.. -Two subtypes exist: 1. Hereditary form (usually due to C1-esterase deficiency or defect) 2. Acquired: Most commonly secondary to ACE-Is (and ASAs), and can occur after years of use *Evaluation* -Extensive or progressive edema mandates *establishment of a definitive airway* and supply oxygen if sat is <90%. *Emergency Management* -Antihistamines, steroids, +/- epinephrine -->ACE-I mediated attacks generally do not respond to these treatments -->Hereditary angioedema also generally does not respond to these treatments -FFP may be effective, Recombinant C1 esterase inhibitor, Bradykinin B2 receptor antagonist (icatibant), Kallikren inhibitor (ecallantide)

Compare and contrast the presentation, pathophysiology, evaluation and emergency management of the following: *Acute respiratory distress syndrome*

*Presentation* -Usually appears w/i 6-72hr of inciting event and rapidly worsens -Typically present with dyspnea, cyanosis, diffuse crackles -Respiratory distress including tachypnea, tachycardia, diaphoresis, and use of accessory muscles *Pathophysiology* -Accumulation of fluid in the alveoli with resulting severe *hypoxia* -Etiology must *not be cardiac*! -Complex pathophysiology: Endothelial damage, loss of surfactant, inflammation, accumulation of proteinaceous material -May results from a direct insult or systemic illness -Causes: sepsis, *aspiration*, inhalation injury, burns, DIC, TTP, embolic phenomena (PE, air, fat, amniotic fluid), pancreatitis, transfusion reaction, drug reaction (ASA phenothiazines, TCAs, opioids, chemo drugs, amiodarone), radiation injury, eclampsia, high altitude exposure, near drowning *Evaluation* -Diagnostic Criteria -->Onset within 1 week of clinical insult -->Diffuse bilateral pulmonary infiltrates -->Impaired gas exchange with a gradient between the inspired and arterial PO2 (PaO2/PiO2 ratio <300 for acute lung injury and <200 for ARDS), PEEP or CPAP =/> 5cm H2O -Rales are the primary physical findings on auscultation of the chest. *Emergency Management* -Treat the underlying cause -Supplemental oxygen -Intubation and mechanical ventilation: avoid barotrauma and O2 toxicity -->Limit peak inspiratory pressure -->Low tidal volume -->Titrate FiO2 to keep SaO2 in the 85-90% range. -Maintain circulation

Compare and contrast the presentation, pathophysiology, evaluation and emergency management of the following: *Aspiration*

*Presentation* -Within min to hours after aspiration, the patient develops productive cough, dyspnea, fever, leukocytosis, and rales on chest auscultation. -Consider this diagnosis in patients with transient alterations in level of consciousness: dementia, delirium, seizures, CVA, drug into, head trauma -Most commonly occurs in individuals with chronically impaired airway defense mechanisms: includes impairment of gag reflex, coughing, ciliary movement, and immune mechanisms, all of which aid in removing infectious material from the lower airways. *Pathophysiology* -*Aspiration pneumonitis*: Acute, chemical lung injury, resulting from the inhalation of gastric contents -*Aspiration pneumonia*: Development of an infiltrate when a patient inhales material from the oropharynx colonized by upper airway flora. -Cause by typical lung pathogens: S. pneumonia, S. aureus, H. influenzae (Hospital acquired more likely involve staph, pseudomonas) *Evaluation* -Chest X-ray *Emergency Management* -Supportive care, clear airway -Prophylactic antibiotics generally not recommended in case of aspiration pneumonitis -No role for corticosteroids -Treat aspiration pneumonia as you would pneumonia based on setting it was contracted (community vs healthcare-associated) -In addition, anaerobic coverage is typically used to complement traditional pneumonia treatment. Management from book: -Respiratory support (supplemental O2) as necessary based on ABG (or pulse ox) and clinical findings. -If pt. has significant dyspnea or respiratory distress, immediately establish airway control with intubation and mechanical ventilation. -Aspirated foreign bodies in kids -> bronchoscope for dx and tx

Compare and contrast the presentation, pathophysiology, evaluation and emergency management of the following: *Airway obstruction: Retropharyngeal Abscess* (prevertebral abscess) Fun facts: -Historically a condition affecting young children, but sometimes seen in adults. (Mainly affects children <6) -Abscess may rupture into mediastinal or pleural spaces

*Presentation* Fever, sore throat, neck pain/stiffness, dysphagia, "hot-potato" voice, stridor if severe *Pathophysiology* Typically polymicrobial: anaerobes, Staph are more common flora. *Evaluation* -Pain with forced side-to-side movement of thyroid cartilage -Widened pre vertebral space/anterior displacement of trachea by diffuse soft tissue mass on lateral soft tissue neck x-ray (see picture) -CT scan with IV contrast if plain x-ray not definitive *Emergency Management* -Stabilize airway, ENT consult -IV antibiotics (to cover mixed oral and anaerobic infection) -Large abscesses will require I&D

2. Discuss the presentation, pathophysiology, evaluation and emergency management of the following bites/stings: • Animal

*Presentation* ● 90% are *filthy dogs*. Spoiler alert... probably a pit bull mix ● *DOGS:* ○ Rapidly progressive cellulitis that is easily identifiable within 24 hours ○ Pasteurella Multocida and S. Aureus ○ Anearobic bacteria most often ● *CATS:* ○ Pasteurella Multocida in 80% (often don't need to culture) ○ Cellulitis often within 24 hours *Management * ● *DOGS:* ○ Explore and gently clean wound after anesthesia, FB? Infected? Get cx. ○ Repair uninfected if < 12 hrs (not hand/foot/face or puncture) ○ Avoid glue (too air tight) ○ Amoxicillin-clavulanate up to 5 days (prophylaxis, longer if infected); If penicillin allergic → Clindamycin + Fluoroquinolone, if puncture, complex or hand/face then best to start abx in 3 hours! ○ Tetanus? Known dog? Rabies? ○ f/u 1-2 days, admit if systemic infection signs or at risk. ● Children → Clindamycin + Bactrim ● *CATS:* ○ Don't repair unless on face. ○ Same drugs as dogs. ○ f/u and admit same as dogs *Cat Scratches (not an objective)* ○ Bartonella Henselae ○ Fever, enlarged tender lymph nodes 1-3 wks later ○ Abx trx varies on systemic sx, varies between azithromycin, doxy, and rifampin

2. Discuss the presentation, pathophysiology, evaluation and emergency management of the following bites/stings: • Human

*Presentation* ● Infected "fight-bite" wounds ● >3cm is from adult *Pathophysiology* ● A wound over the MCP joint is likely to represent a *closed-fist injury (CFI)* bite wound sustained during an altercation, concern for tenosynovitis ● Polymicrobial: mixed anaerobes, streptococci, S. aureus, and Eikenella corrodens *Evaluation* ● Look for injuries to the extensor tendon or joint capsule ○ Any violation mandates ortho consult *Management* ● Irrigate and debride- explore thoroughly, test FROM ● Xray - FB, bone injury, gas, osteomyelitis ● Don't suture close. Dress and elevate. ● Antibiotics, prophylaxis and for infection ○ *AUGMENTIN*. Amoxicillin-sulbactam, cefoxitin, ticarcillin-clavulanate ○ Penicillin-allergic ■ Clindamycin + Bactrim ■ Clindamycin + fluoroquinolones ● Admit if infection is severe ● Otherwise discharge with 24 hr f/u

Compare and contrast the presentation, pathophysiology, evaluation and emergency management of neurological emergencies including: • Bell's Palsy

*presentation*: unilateral, facial paralysis of entire side, abrupt onset <48 h, can have post auricular pain *pathophys*: peripheral CN VII paralysis, unknown/HSV cause *evaluation*: clinical (facial weakness from UMN lesion/CNS tumor - eye can close, forehead can wrinkle) *emergency management*: - 70-85% recover < 1 month - Prednisone 40-60 mg/d PO x 10 d (or 5 days, then taper x 5 days) - +/- Acyclovir - artificial tears when awake, tape eye closed at night - f/u with neuro, ENT, or PCP

2. Discuss the presentation, pathophysiology, evaluation and emergency management of the following bites/stings: • Sting rays

*Presentation* ● Intense local pain and moderate swelling with bleeding ○ Pain radiates centrally and can be so severe as to cause disorientation ● Systemic symptoms occur within 30 minutes of the sting and include: nausea and vomiting, weakness, tachycardia, diaphoresis, vertigo, and muscle cramps ● If envenomation is severe, can cause syncope, paralysis, hypotension, cardiac arrhythmias, and death *Pathophysiology* ● When disturbed, stingrays splash upward with a muscular tail that carries 1-4 venomous stingers ● Injury involves a traumatic wound and envenomation ● Envenomation occurs when the tail of the stingray releases venom into its victim *Management* ● Irrigate the wound and remove any obvious pieces of foreign matter ○ Initiate basic first aid to prevent necrosis, ulceration, and infection ● Anesthetize the wound ○ Soak the wound in hot water to tolerance for 30-60 minutes ■ *Stingray venom is heat labile and may be denatured in hot water* ○ If heat fails to relieve the pain → lidocaine ● Explore the wound ○ Wound exploration and x-ray to ensure removal of all tissue fragments ○ Close the wound loosely around drains or pack open ● Give antibiotics ○ Standard tetanus prophylaxis ○ Treat with bactrim, cipro, or tetracycline for 7 days

1. o Compare and contrast the presentation, pathophysiology, evaluation and emergency management of the following: • Perforated peptic ulcer

*Presentation* ● Sudden severe upper abdominal pain ● Pain may subside when peritoneal secretions dilute the leaking gastric contents but it will return later and progressively worsen ● Severe distress with shallow breathing and knees drawn up to the chest ● Upper abdominal tenderness with board-like rigidity of the abdomen *Evaluation* ● Three-view acute abdominal series including an upright chest, upright, lateral decubitus ○ May show *free air under the diaphragm* ● CT if x-rays are nondiagnostic *Emergency Management * ● Nasogastric tube for drainage of gastric acid ● IVF and broad spectrum IV antibiotics ● Hospitalize for immediate surgery

Compare and contrast the presentation, pathophysiology, evaluation and emergency management of the following: *Airway obstruction: Croup* aka laryngotracheobronchitis Fun facts: -Lecturer said cold air helps this. -Exclusively a disease of children -MC cause of stridor in pt presenting to ED

*Presentation/Evaluation* -Progresses more slowly than epiglottis -Peak incidence in 2yr of life -*Barking cough*, stridor, prodromal URI symptoms, subglottic swelling (below cords @ cricoid cartilage) *Pathophysiology* -Predominant cause is *parainfluenza virus* *Evaluation* -Physical Examination: underlying viral infection (low grade fever) -*Steeple sign* on CXR (see picture) *Emergency Management* -Book says initial therapy is nebulized saline. -*Racemic epinephrine* in moderate to severe cases -Observe Pt for atleast 3 hours -*1 dose dexamethasone*

1. o Compare and contrast the presentation, pathophysiology, evaluation and emergency management of the following: • Ectopic pregnancy

*Risk Factors* ● Prior ectopic pregnancy, history of STDs (especially PID), smoking, IUD use, progestin only birth control pills, implanted progestin contraception *Presentation* ● Abdominal pain, amenorrhea, vaginal bleeding ● Once ruptured, sudden, continuous and severe unilateral abdominal or pelvic pain that may be referred to the shoulder ● Occasional nausea and vomiting, no fever *Evaluation* ● Pelvic exam shows unilateral doughy mass and tenderness on movement of the cervix ● Pelvic ultrasound ● Quantitative serum hCG *Emergency Management* ● Treat shock or hypotension with IVF and blood ● Hospitalize for emergent surgical intervention

Compare and contrast the presentation, pathophysiology, evaluation and emergency management of neurological emergencies including: • Seizures • Status epilepticus

*STATUS EPILEPTICUS* *presentation*: prolonged seizure lasting 5-15 min or cont./mult seizures without periods of consciousness *pathophys*: excessive discharge of excitatory neurotransmitters in cortical neurons, or lack of inhibition, many different conditions/causes *evaluation*: CMP, LFTs, CBC, tox screen, magnesium, pregnancy test, fingerstick glucose, ABG, LP if fever *emergency management*: - place nasopharyngeal airway and give oxygen - prevent injury, pad environment - *lorazepam* 2-4 mg (8 max) or Diazepam 5-10 mg IV Q 3-4 min in adults - if can't IV, diazepam rectally, endotracheally, or intraosseously - if seizure persists give *fosphenytoin* 20 mg/kg IV infusion - *refractory status epilepticus* - seizure cont. after 1st and 2nd line tx within 60 min of onset - drugs for RSE: phenobarbital, midazolam, propofol, valproic acid, levetiracetam, pentobarbital (need intubation and EEG) - tx underlying condition (trauma, hemorrhagic stroke, CNS tumor, hypoxia, meningitis, hypoglycemia, drug overdose/withdrawal, fever) *new onset seizure* (not prolonged) *evaluation*: serum Na, glucose, pregnancy test, *head CT* -extensive lab work-up only if persistent change in mental status or FND *management*: -tx as above - can discharge if returned to baseline, normal CT/labs. no preventative anti-epileptic drugs, no driving - eclamptic seizure: magnesium sulfate 4-6 g IV loading dose, then infusion *known seizure disorder* *evaluation*: measure anticonvulsant lvls - labs only if persistent change in mental status or FND *management*: outpt f/u to manage med dose/change - see neuro quizlet for long term management of epilepsy - Absence: can lead to nonconvulsive status epilepticus, tx with *IV valproate*

Discuss the procedure for intubation

*Steps in Rapid Sequence Intubation* (Think the 5 P's): 1. *P*reparation: -Place oxygen on patient -Assess for difficult airway -Ensure: good suction (x2), good IV access, monitors in place, respiratory therapist in room -Gather necessary equipment (and assess functionality) -Begin positioning patient 2. *P*reoxygenation: -Place high flow O2 on spontaneously breathing patient for at least 3 min -Alternatively, can have an alert patient take 8 full vital capacity breaths with high flow O2 -Consider additional placement of nasal cannula with high flow oxygen 3. *P*aralysis and Induction: -Paralytics -->*Succinylcholine*: fast onset, short duration of action. CI with malignant hyperthermia history, rhabdomyolysis, hyperkalemia, burn or crush injures >3 days old -->Non-depolarizing agents (rocuronium, vecuronium): slightly slower onset, longer duration, especially for vecuronium -Induction agents -->*Etomidate*: No CV depression, theoretical risk of adrenal suppression -->Midazolam: mild CV depression -->Propofol: CV depression -->Ketamine: may increase ICP, may be benefit in reactive airway disease, no CV depression 4. *P*lacement and proof: -Direct visualization of tube passing through cords -Capnography -Fogging of tube (not as great for proof) -Bilateral axillary epigastric auscultation (over top of chest and over stomach helpful) 5. *P*ost intubation management: -Secure tube -CXR to evaluate placement -Place NG/OG tube to decompress stomach -Continue sedation

6. Given a patient scenario, appropriately order and interpret the following laboratory studies: Cardiac Markers (Troponin, CKMB, CK, CRP)

*Troponin* ● When measured with older generation, elevated troponin levels can be detected *6-12 hrs after MI*, peaking at about 24 hrs, followed by a gradual decline over next 2 weeks ● Can detect troponins as early as 3-4 hrs ● Increased the sensitivity of point-of-care troponin testing in patients who present initially to ED with symptoms suggestive of ischemia and myocardial damage ● Re-check troponins 6-12 hrs and up to 24 hrs after initial assessment *CKMB* ● An isoenzyme of creatine kinase primarily released from the myocardium but also found in skeletal muscles ● CKMB levels increase with myocardial damage *CK* ● Creatine kinase or creatine phosphokinase ● Enzyme found in the brain, skeletal muscles, and heart ● An elevated level is seen in heart attacks, heart muscle damage, and skeletal muscle or brain damage *CRP* ● An acute phase reactant ● Made by the liver and released into the blood within a few hours after tissue injury, the start of an infection, or other cause of inflammation ○ Inflammatory marker

Types of Pain

*Visceral* = VAGUE (crampy, achy, diffuse, poorly localized, organs) *Somatic* = SPECIFIC (sharp, lancinating, well localized, skin/tissue/muscles) *Referred* = RADIATING (distant from site of generation) General note that has nothing to do with this card. In general, no matter the abdominal complain, if you are unable to get your patient to tolerate food/liquids and they continue to throw up... they are getting admitted.

Discuss the presentation, pathophysiology, evaluation, emergency management and potential complications of the following: *Aortic Aneurysm*

*WHAT IS AN ANEURYSM:* An artery that is greater than 2x its normal diameter *RF:* male, 70 y/o, smoker, HTN, fam hx *s/sx:* -*Classic triad*= acute onset abdominal or flank pain, pulsatile mass, hypotension (but this is only seen in 50% of pts.) *dx:* -US or CT w/ contrast *tx:* -O2, IV crystalloids, type & cross, surg consult (only definitive tx) *complications:* -spontaneous rupture (80% mortality rate) -If it ruptures into peritoneal space, mortality is high fast -<4cm= rare to rupture

Discuss the presentation, pathophysiology, evaluation, emergency management and potential complications of the following: *Angina*

*WHAT:* CP (usually substernal) d/t O2 demand > myocardial O2 supply. *3 types: stable, unstable, atypical* *1. Stable aka angina of effort* -consistent pattern of discomfort, frequency and precipitating factors (activities w/ increased O2 demand) -relieved by rest or nitro -tx= sublingual Nitro (0.4 mg) at onset or prophylactically before activities that regularly precipitate angina. *2. Unstable* - patient previously free of pain, or change in pattern or frequency (ie longer lasting or precipitated by less intense activity or at rest) -less responsive to rest & nitro -dx: EKG-nonspecific changes, cardiac biomarkers are negative -tx: aspirin, nitro, BB, heparin, GP2B3A inhib *3. Atypical aka Prinzmetal aka Variant* - cause: sudden, reversible, conoary artery obstruction or spasm - commonly at rest or awakens from sleep (no precipitating cause) -dx: transient ST elevation that's reversed w/ nitro *DO NOT USE NSAIDS TO TX ANGINA B/C THEY INCREASE MORTALITY!!!! *

4. Compare and contrast the following upper extremity injuries in terms of presentation, evaluation, management and possible sequelae: • Scaphoid fracture

*What* -Fracture of the scaphoid bone in wrist *MOI* -FOOSH (fall on out stretch hand) -May just feel like a wrist sprain *Physical exam* -*Anatomical snuff box tenderness* *Imaging* -see xray (may take 3 weeks to appear) -If they have snuff box tenderness but no Xray finding it is STILL a scaphoid fracture. -CT can be used if still in question *Treatment* -Thumb spica for 6-12 weeks -If proximal scaphoid fracture or displaced --> ORIF

4. Compare and contrast the following upper extremity injuries in terms of presentation, evaluation, management and possible sequelae: • Felon

*What* -Infection of the Pulp of the finger -Typically caused by Staph Aureus *MOI* -Puncture wound -Diabetics (finger sticks) *Physical exam* -See photo *Imaging* Xray if concern about spread into bone or flexor sheath *Treatment* -I&D -Antibiotics

4. Compare and contrast the following upper extremity injuries in terms of presentation, evaluation, management and possible sequelae: • Tendon Injuries (Flexor tenosynovitis) *Cough Cough*

*What* Bacterial infection of the flexor tendon sheath *MOI* Puncture wound *Physical exam* Kanavels Signs: (1) *pain on passive digital extension* (2) flexed position of the digit (3) symmetric swelling of the digit, which may include the palm (4) tenderness with palpation along the flexor tendon sheath. *Treatment* -Surgical emergency!!!! -Incise, Irrigate, drain -IV antibiotics

1. o Discuss the presentation, pathophysiology, evaluation, emergency management and potential complications of the following: *Acute coronary syndrome*

*What:* spectrum of diseases: UA, NSTEMI, STEMI *Patho:* supply-demand imbalance: blood flow insufficient to meet metabolic needs of myocardium *Dx:* labs alone can't definitely rule this out. Need stress test, echo, and cath -->Acute MI can be r/o w/ serial troponins & serial EKGs BUT UA cannot be.

Discuss the presentation, pathophysiology, evaluation, emergency management and potential complications of the following: *Pericarditis*

*causes:* -Viral or bacterial infxns -Uremia -Trauma -MI *s/sx:* -CP exacerbated by lying down & *relieved by sitting up and leaning forward* -pleuritic CP -fever & symptoms of underlying dz, *dx:* -echo= most sensitive & specific -EKG: diffuse ST elevation and PR depression -*pericardial friction rub* (85%) *Tx:* -NSAIDS -if unstable, central venous pressure catheter & detect signs of tamponade -Consider pericardiocentesis, especially if signs of infxn.

(not an objective) Epidural Vs subdural anatomy

*middle meningial artery*- common cause of epidural hematoma

Compare and contrast the presentation, pathophysiology, evaluation and emergency management of neurological emergencies including: • Guillian-Barre syndrome

*presentation*: -often URI or gastroenteritis precedes polyneuropathy by 1-3 weeks (Campylobacter jejuni, H. flu, mycoplasma, EBV, VZV, CMV) -symmetric motor weakness, begins in LE, progressive ascending weakness, involved CNs by 1-3 days -can have numbness or paresthesias in stocking-glove distribution or muscle pain -absence of deep tendon reflexes -CN VII MC, bilat facial weakness -autonomic dysfunction - hypo or HTN, tachy, flushing -dyspnea, dysphagia, malaise *pathophys*: uncertain; immune-mediated demyelination and axonal degeneration slows nerve impulses *evaluation*: - CSF from LP: elevated protein with normal wbc - CBC, UA, CMP, HIV, monospot, PFTs *emergency management*: -respiratory muscle weakness --> respiratory failure --> needs ET intubation and ventilation -*high dose IVIg or plasmapheresis* -*PREDNISONE CONTRAINDICATED* -need to be admitted

Discuss the presentation, pathophysiology, evaluation, emergency management and potential complications of the following: *Pericardial Effusion*

*what:* collection of excess fluid (transudate, blood, infectious) in pericardial sac; can be acute or chronic *causes:* -pericarditis, post-MI, trauma, mets *s/sx:* similar to pericarditis; may be asymptomatic or have sx's related to cause *dx:* CXR-fluid, echo to confirm, EKG- electrical alternans, distant heart sounds, pericardiocentesis for fluid analysis if unsure about cause *tx:* -treat the underlying cause if hemodynamically stable. if not, drain fluid therapeutically *complications:*- can cause tamponade

Discuss the presentation, pathophysiology, evaluation, emergency management and potential complications of the following: *Cardiac Tamponade*

*what:* compression of heart d/t accumulation of fluid in pericardial space faster than the pericardium can accommodate it by distention -effect= decreased ventricular filling --> decr. CO--> shock *Main Cause:* penetrating injuries *s/sx:* -*Becks triad= hypotension, JVD, muffled heart sounds* -early: reflex tachycardia & incr. systemic vascular resistance -late: CO & BP drop (decompensated) -pulsus paradoxus -Kussmauls: increased JVP w/ inspiration (normally it decreases) which reflects the increased CVP -often coexisting sxs of pericarditis or pericardial effusion *dx:* 1. echo- swinging heart & collapse of RA and RV on expiration. Diastolic collapse of RV= diagnostic!! 2. *EKG: electrical alternans*, low voltage QRS (d/t effusion which is often present) *Tx:* -Decompensated (life-threatening emergency): O2, crystalloid solution for BP, IV dopamine, pericardiocentesis -Compensated: O2, central venous pressure catheter, IV crystalloid solution -Do not give diuretics or preload redxn (nitrates) to control venous congestion bc it will cause hypotension

Discuss the presentation, pathophysiology, evaluation, emergency management and potential complications of the following: *CHF*

*what:* inability of heart to maintain CO to meet systemic demands -main cause= ischemic heart disease; others- HTN, -patho & compensatory mechanisms: i don't think this is relevant for EM but see cardio cards for more info. *left vs right* o left= more common, fluid backs up into lungs d/t dsfxnl LV. -->sx: dyspnea, orthopnea, PND, cough, weight gain, tachy, JVD, pulmonary edema o right= main cause is left heart failure, other causes are Pulm HTN, lung dz; fluid backs up in body b/c failing RV -->sx: JVD, peripheral edema *systolic vs diastolic* o systolic- MC, pumping problem, reduced EF (<55%), weak & enlarged heart o diastolic- filling problem, preserved EF (55%+) *Dx:* -CXR: cardiomegaly, pulmonary edema/effusions, Kerley B lines -echo: confirms EF -Elevated BNP: from ventricle myocardium -Increased venous pressure, hepatojugular reflux, rales, peripheral edema, S3 gallop *Tx:* -preload reduction: nitrates, diuretics (furosemide) -afterload reduction: ACE/ARBs, nitro -inotropes: dobutamine/dopamine (incr. contractility) sodium restricted diet, diuretics (furosemide), -ACEi & BB reduce mortality

9. Given a patient scenario, appropriately order and interpret the following laboratory studies: Lipase & amylase

- Amylase is elevated in many conditions - no specificity for pancreatitis and many other things (pretty much a useless test) Usually will just order Lipase: more specific/sensitive ■ Elevation could indicate a pancreatic disorder ● Lipase > amylase

2. Describe the proper evaluation and management for a person with head or neck trauma.

- Assume spinal cord injury! - Optimal position for examination and immobilization is *supine* - Proper transport of patient requires 3 people ABCs: *Airway*: - Direct visualization of entire airway while immobilizing C-spine until spinal column injury is ruled out. - *DO NOT try chin lift maneuver* - Jaw thrust is ok - *Rapid Sequence Intubation is method of choice* *Breathing*: - Monitor gas exchange with periodic ABGs *Circulation*: - NEVER remove impaled foreign bodies - *Direct pressure* is the mainstay for stopping bleeding - If direct pressure does not work --> clamp w/ hemostats or figure 8 suture to stop arterial bleed - DO NOT use circumferential neck dressings *Treat Shock*: - If hypovolemic --> *give 2 large bore (16 gauge) IVs* - Keep patient supine - If unresponsive to volume resuscitation --> *Phenylephrine is the therapy of choice* *Atropine* for *severe bradycardia* - Open fractures and virtually any significant injury to the eye, ear, or salivary gland should be hospitalized and treated by the appropriate specialty - Platysma injury is divided into zones I, II, and III. *Zone II injury --> surgery!* Hospitalization for spinal injury if: - Neurologic deficit - Potentially unstable vertebral column - Subluxation of vertebral bodies - Severe pain requiring parenteral meds

5. Compare and contrast the following upper extremity injuries in terms of presentation, evaluation, management and possible sequelae: • Hip dislocation

-*90%* are *POSTERIOR* dislocations *present with* -pain -inability to bear weight -visible deformity with hip in *slight flexion* and *internal rotation* (*adduction* and shortening) -Ex: head-on car accident when knee is driven against dashboard *Imaging* -AP and transpelvic lateral radiographs are usually diagnostic. -*Treatment*: Close reduction *within 6 hours* or open reduction if closed reduction within 6 hours not possible. -If Hip not reduced within 6 hours greatest risk is Avascular necrosis

1. Describe the approach to a patient with a suspected toxic ingestion

-*A thorough history from many sources is the key to toxicologic diagnosis* -Common toxidromes (syndromes caused by a certain level of a certain drug) should guide judicious use of antidotes -*Minimally symptomatic patients do not benefit from toxicology screening or extensive laboratory investigation* -*Good supportive care is the key to management* ------------------------------------ REMEMBER YOUR ANION GAP CALCULATION: *Na+ - (Cl- + HCO3)* -Normal is 8-16 mEq/L -Helps us ID *causes of metabolic acidosis -*I really don't think this will be on the exam, just emphasized in lecture!* -Inhalants include CO, cyanide, toluene -Metformin can lead to lactic acidosis -Toluene is a mix b/c of renal tube acidosis & HCO3 loss MUDPILES Methanol, Metformin Uremia DKA Ion, Inhalants, Isoniazide, Ibuprofen Lactic acidosis Ethylene glycol, EtOH ketoacidosis Salicylates, Starvation ketoacidosis, Sympathomimetics ------------------------------------ WHEN IS A TOX SCREEN ACTUALLY USEFUL? -*APAP (tylenol) & ASA is ALWAYS useful* -*[Serum Drug] can help guide therapeutic windows* -*EtOH is RARELY useful*

2. Discuss the indications and utility of the bedside abdominal ultrasound

-*The FAST exam (Focused assessment with Sonography for Trauma)* ● Morison's pouch (right upper quadrant) ● Cardiac ● Splenorenal (left upper quadrant) ● Bladder and pelvis -Abdominal Aorta ● Checking for AAA -Biliary System ● Looking for gallstones ● Viewing the common bile duct -First-Trimester Pregnancy ● Diagnose pathologies like ruptured ectopic pregnancies ● Demonstrate the presence of viable intrauterine pregnancy ● Transabdominal and transvaginal options -Ultrasound-guided procedures ● Foreign body removal ● Thoracentesis and paracentesis ● Pericardiocentesis ● Peripheral access ● Central venous access ● US-guided abscess drainage

*Pneumonia: Pneumocystitis* FYI

-Associated with *CD4 count <200* -More *indolent* course than bacterial -Classic radiographic appearance is bilateral interstitial infiltrates -->Wide variation in appearance, may be lobar pattern or completely normal -Serum *LDH* level >220 U/L has high sensitivity -Treatment wit corticosteroids in addition to antibiotics (high dose *Bactrim*) recommended in those with HIV and hypoxemia

*Tuberculosis* Cough Cough Cavitations

-At risk populations include immunocompromised, incarcerated, homeless -CXR may reveal hilarious lymphadenopathy -->Upper lob consolidation is also suggestive (ghon complex consolidation) -Initiate respiratory isolation early And remember *cavitation* is TB until proven otherwise.

Wells Criteria for PE

-Clinical evidence of DVT (3) -PE most likely diagnosis (3) -HR>100 (1.5) -Immobilization >3 days or surgery within 28 days (1.5) -Prior DVT or PE (1.5) -Active Malignancy (1) -Hemoptysis (1) If >4 points -> Imaging If <4 points -> D-dimer

10. Describe the management of head injuries in the intoxicated patient.

-Same as anyone else, don't blow them off as "drunk" -Evaluate them more closely than sober Pt's as they might not feel or report head trauma -If altered get ETOH level

1. Compare and contrast the various types of skull and facial fractures *temporal bone Fx*

Pathophys:*High energy mechanisms required, often causing severe brain injury* Sx: Hearing loss, facial nerve injury, intracranial injury, dizziness, hemotympanum, External clinical signs often absent Dx: CT of face and head, C spine imaging TX: maxface surgeon, ENT, *neuro consult, admit*

5. Compare and contrast the following upper extremity injuries in terms of presentation, evaluation, management and possible sequelae: • Tibial plateau fracture

-Usually occur to lateral aspect -Due to Axial loading -Look for decreased joint ROM, increased pain, and hemarthrosis -This is intraarticular and needs orthopedics consult immediately -May be associated with peroneal nerve and popliteal artery injuries -CT scan is helpful in planning treatment -High suspicion for compartment syndrome Difficult to see on Xray so CT is usually indicated -Immobilize, Keep patient non weight bearing, consult orthopedics, Watch for compartment syndrome.

5. Compare and contrast the following upper extremity injuries in terms of presentation, evaluation, management and possible sequelae: • Hip fracture

-You can bleed to death from a hip fracture. -Place a Pelvic binder on the hips to compress the pelvis if they are hemorrhaging. Get A/P and Lateral X-rays Stabilize Pt assess Neurovascular status and get orthopedics involved

What are the *6 life threatening conditions* that must be ruled out in the *primary survey* in a case of chest trauma?

1) Airway Obstruction 2) Tension Pneumothorax 3) Open Pneumothorax (Sucking Chest Wound) 4) Flail Chest 5) Massive Hemothorax 6) Cardiac Tamponade FIND IT, FIX IT!!!

Be familiar with components of the *NIH Stroke Scale*

13-item scoring system with neuro exam, language, LOC components max score is 42 = devastating stroke 0 = normal 1-4 : *minor stroke* 5-15: * mod stroke* 15-20: *mod-sev stroke* > 20: *severe stroke* dont memorize, but here is the scale 1a. *level of consciousness* 0 - alert, 1 - drowsy, 2 - stuporous, 3 - comatose 1b. LOC questions: ask month and pt's age 0 - both correct, 1 - 1 correct, 2 - neither correct 1c. LOC commands: close eyes and make a fist 0 - both correct, 1 - 1 correct, 2 - neither correct 2. Best *gaze* 0 - normal, 1 - partial gaze palsy, 2 - forced deviation 3. *visual fields* 0 - no visual loss, 1 - partial hemianopia, 2 - complete hemianopia, 3 - bilateral hemianopia 4. *facial paresis* 1 - minor paralysis, 2 - partial, 3 - complete 5-8. Best *motor* (each arm and leg) 0 - no drift, 1 - drift, 2 - some effort against gravity, 3 - no effort against gravity, 4 - no movement 9. *limb ataxia* 0 - absent, 1 - present in 1 limb, 2 - 2 limbs 10. *sensory* (pinprick) 0 - normal, 1 - partial loss, 2 - dense loss 11. best *language* 0 - no aphasia, 1 - mild to mod, 2 - severe, 3 - mute 12. *dysarthria* 0 - normal, 1 - mild-mod, 2 - severe 13. *neglect/inattention* 0 - no abnormality, 1 - partial neglect, 2 - complete

4. Compare and contrast the following upper extremity injuries in terms of presentation, evaluation, management and possible sequelae: • Shoulder dislocations

90% of shoulder dislocations are dislocated anteriorly (pushed forward through weak spot) *MOI* - Exceeding normal range of motion in external rotation and abduction - Direct posterior blow on the shoulder *Clinical Presentation* - Painful shoulder DUH - Arm held supported at the side *Physical Exam* - Sulcus sign = visible dimple under the acromion due to the absence of the humeral head. - humeral head may be palpable under the coracoid or in the axilla. - Range of motion will be extremely painful and limited. *Imaging*: X-ray - Bankart lesion (anterior glenoid labrum tear) - Hills-Sachs lesion (Compression fracture of the posterolateral humeral head)(see photo) *Treatment* - Reduce the head of the humerus -Keep arm Adducted at patients side then slowly Externally rotate until it reduces. -Always assess nerve and blood flow pre and post reduction -Worried about axillary nerve and artery damage

Imaging for various intracranial bleeding

A: Epidural B: Subdural C: Brain Contusion D: Intraparenchymal

2. Discuss the emergency department procedure for evaluating and treating a patient with a limb injury.

ALWAYS START WITH ABCDE's (Primary survey) Once those are set move onto Secondary survey: Quick physical from head to toe looking for step offs obvious Fx or dislocations (consider reduction to avoid AVN) Check anal sphincter tone apply pressure to pelvis A/P and Laterally to assess for Fx of pelvis.

Compare and contrast the presentation, pathophysiology, evaluation and emergency management of neurological emergencies including: • Altered mental state/Acute Confusional State

Acute Confusional State = *Delirium* = acute period of cognitive dysfunction due to a medical disturbance or condition -AMS, diminished lvl of consciousness, and confusion can be caused by same conditions *presentation*: altered/fluctuating LOC (preserved in dementia), hallucinations, disoriented, tremor, rapid onset (hours-daze), "sundowning", abnormal vital signs, +/- agitated/combative *pathophys*: -diffuse injury to brain due to metabolic, systemic, or toxic d/o (infxn, meds/drugs, post-op, etOH, lytes, liver/renal, seizures, hypoxia, hyperthermia, endocrine, malnutrition) or -intracranial structural lesions (hemorrhage, hematoma, infarction, tumor, hydrocephalus, herniation, abscess) *evaluation*: -mental status exam, PE, vitals, CMP, CBC, magnesium, B12, thiamine, UA, LP if febrile, fingerstick glucose, +/-ABG, +/- tox screen -ECG, CT, +/- gastric decontamination *emergency management*: -maintain airway, O2 PRN, restrain PRN -tx underlying cause if known -IV thiamine, 50% dextrose if hypoglycemic, naloxone -tx shock with IV NS, hypercapnia/hypoxemia with O2, tx hypo/hyperthermia, tx severe HTN -Haloperidol for agitation/psychotic behavior -supportive

Anaphylactic shock: Causes Presentation/ Clinical findings Management

Allergic reaction to something *Presentation:* -Bronchospasm -Laryngeal edema -Cardiac dysrhythmia -Hypotension -Airway edema -GI distress -Confusion *Management:* *EPINEPHRINE* "Cough Cough" Antihistamines & Corticosteroids Fluids

(Not an objective) Intracerebral Hemorrhage and ICH score

Bleeding inside the cerebrum To determine mortalility take GCS and add up 4 factors from table. If score is above 4 mortality= 97% Tx: They take you off sedation to see if you are already brain dead or not, if not a catheter is stuck through your brain, into a ventricle, which is emergently drained.

Cardiogenic shock: Causes Presentation/ Clinical findings Management

Cardiac dysfunction that fails to profuse body *Causes:* (pump problem) -MI -CHF -HOCM (Hypertrophic cardiomyopathy) -myocarditis -Vavlular dysfunction -Dysarrythmias -Myocardial contusion (heart bruise from MVA) *Presentation:* -Tachy or brady -Possible abnormal EKG -Tachypnic -JVD -Decreased urine output -Pale -delayed capillary refill -Syncope/ orthostatics *Management:* -Treat the cause See next card

What type of shock do the following examples fall into? Myocardial ischemia Valvular dysfunction Hypertrophic cardiomyopathy Myocardial contusion Myocarditis CHF Dysrythmias

Cardiogenic Shock

Obstructive shock: Causes Presentation/ Clinical findings Management

Circulatory obstruction is the issue *Causes:* -Tension pneumo -Pericardial tamponade -PE *Presentation:* *Tension pneumothorax* -unilateral decreased breath sounds -unilateral chest hyperresonance -tracheal deviation *Pericardial tamponade* -hypotension -JVD -Pulsus paradoxus (Drop in SBP on inspiration) -Kussmaul's sign (increased JVD on inspiration) *Massive PE* -chest pain -syncope -tachypnea -hypotension *Management:* Tension pneumo- Needle decompression (immediate and short term, longer term is chest tube) Pericardial tamponade- Pericardiocentesis Massive PE- when the PE causes shock you are indicated to use *TPA*

What type of shock do the following examples fall into? Neurogenic shock Anaphylaxis Liver failure Toxic ingestion Septic shock Adrenal insufficiency

Distributive shock

Describe the presentation, differential diagnosis, evaluation and emergency management of the following conditions: • *Tension Pneumothorax*

Develops when a one-way valve air leak occurs from either lung or the chest wall. Air enters pleural space but cannot escape, which collapses the nearest lung and shifts the mediastinum to the opposite side. *Causes* - Blunt chest injury - Positive-pressure injury - Small penetrating wound *Presentation* - Respiratory Distress - Tachypnea - Hypoxia *Physical Exam* - Hyperresonance to percussion - Decreased or absent breath sound on affected side. - Deviated trachea *Diagnosis* - Clinical Diagnosis (See presentation / PE) *Treatment* - Treat Immediately (Don't wait for an X-ray) - *Tube thoracostomy* If tube is not available: - *Needle Decompression (with a large bore needle)* - Admit and observe

Describe the presentation, differential diagnosis, evaluation and emergency management of the following conditions: • *Diaphragmatic hernia*

Diaphragmatic hernia = *Causes* - Direct trauma - Rupture due to pressure in the abdomen or thorax Left side is 3X more likely to herniate than the right(because the liver is on the right) Many are missed on initial trauma evaluation, and may continue to be missed until GI contents become obstructed, incarcerated, strangulated or perforated about the diaphragm *A torn diaphragm will not heal spontaneously* *Presentation* - May be asymptomatic or signs of bowel obstruction - Delayed presentation is common with nonspecific respiratory or bowel complaints *Diagnosis* - CXR (Elevation of diaphragm border, Pleural thickening, possibly Nasogastric tube in chest cavity(see photo)) *Treatment* - *Surgical reduction of the hernia and repair of the diaphragm*

5. Compare and contrast the evaluation and management of blunt abdominal trauma, penetrating abdominal trauma, gunshot wounds to the abdomen, and stab wounds to the abdomen.

Don't you remember this from the PPT? Me neither. Cause it's not there. Not sure how he would test on this. There are SO MANY other abdominal diseases to questions about. But anyways... *Blunt Abdominal Trauma* ■ Occurs most frequently with *motor vehicle collisions* ■ *Evaluation* ● Presence of a "seat-belt" sign ● Evaluate for intra-abdominal injuries such as intestinal perforations and mesenteric tears ● Evaluate lumbar spine - associated with transverse lumbar spine fractures ● If there is large or moderate amount of free fluid without evidence of solid organ injury, suspect a hollow organ injury ■ *Management* ● Laparotomy *Penetrating Abdominal Trauma* ■ *Evaluation* ● Any wound inferior to a line drawn transversely between the nipples should be treated as having the potential for intra-abdominal trajectory ■ *Management* ● Give enough fluids to maintain a systolic BP of 90 mmHg ● Tetanus booster ● Antibiotic therapy *Gunshot Wounds to the Abdomen* ■ *Evaluation* ● Determine whether there is intraperitoneal invasion ● Surgical consultation ■ *Management* ● Early surgical consultation for all abdominal gunshot wounds ● If patients present with hypotension despite crystalloid resuscitation → immediate exploratory laparotomy, blood transfusion, tetanus booster, antibiotics that cover abdominal flora ● If patient is stable and intraperitoneal invasion has been rule out → conservative treatment *Stab Wounds to the Abdomen* ■ *Evaluation* ● DPL CT, laparoscopy ■ *Management* ● Violated peritoneum → tetanus booster, antibiotics, fluid resuscitation, exploratory laparotomy ● Non-violated peritoneum → discharge with local wound care instructions

Identify the common physical findings (and toxidrome if one exists), describe the effect on the patient's system, laboratory work up and management: • *Opiates*

EFFECT ON PATIENTS SYSTEM: -Decrease central nervous system activity and sympathetic outflow by acting on opiate receptors in the brain ------------------------------------ CLINICAL FINDINGS: Mild intoxication is characterized by: -*Euphoria* -*Drowsiness* -*Decreased LOC* -*Miosis (constricted pupils)* This is a HUGE HINT (Exception to this is Demerol) More severe intoxication: -*Hypotension* -*Bradycardia* -*Hypothermia* -*Coma* -*Respiratory arrest* -->Death is usually due to apnea or pulmonary aspiration of gastric contents. -->Many opioids, including fentanyl, tramadol, oxycodone, and methadone, are not detected on routine urine toxicology "opiate" screening. ------------------------------------ TREATMENT: A. EMERGENCY AND SUPPORTIVE MEASURES -*Protect the airway and assist ventilation* -*Administer activated charcoal for RECENT large ingestions* B. SPECIFIC TREATMENT -*Reversal by naloxone* (titrate until the patient starts to breathe on their own/awaken the patient and maintain airway protective reflexes) Caution: -The duration of effect of naloxone is only about 2-3 hours. *Repeated doses may be necessary for patients intoxicated by long-acting drugs such as methadone* -Continuous observation for at least 3 hours after the last naloxone dose is mandatory. FYI: Buprenorphine is a partial agonist-antagonist opioid used for the outpatient treatment of opioid addiction.

Identify the common physical findings (and toxidrome if one exists), describe the effect on the patient's system, laboratory work up and management: • *Acetaminophen*

EFFECT ON THE PATIENTS SYSTEM: After absorption, a very small amount of acetaminophen is metabolized to a highly toxic reactive intermediate. This toxic intermediate is normally detoxified by cellular glutathione. With acute acetaminophen overdose (greater than 150-200 mg/kg, or 8-10 g in an average adult), hepatocellular glutathione is depleted and the reactive intermediate attacks other cell proteins, causing necrosis. ------------------------------------ PHYSICAL FINDINGS: *Shortly after ingestion patients MAY have nausea/vomiting* However... *Usually no other signs of toxicity until 24-48 hours after ingestion!* -Hepatic necrosis -Jaundice -Hepatic encephalopathy -Acute kidney injury -Death ------------------------------------ DIAGNOSIS: -*The diagnosis after acute overdose is based on measurement of the serum acetaminophen level* -*Plot the serum level versus the time since ingestion on the acetaminophen nomogram* -From lecture: *Acute is defined as ingesting >4 grams in 24 hours* -Typically *no need to test before 4 hours*, unless already showing signs of toxicity. ***Nonmogram is ONLY used for acute ingestions*** ------------------------------------ TREATMENT: -*Administer activated charcoal only if it can be given within 1-2 hours of the ingestion* -*If the serum or plasma acetaminophen level falls above the line on the nomogram treatment with N-acetylcysteine (NAC) is indicated!* -*NAC can be given orally or intravenously*. --->*Orally, it must be administered for 72 hours. It smells like Connor (disgusting) and makes 50% of patients vomit.* --->If scent de Connor makes the patient vom-bomb, consider IV NAC. --->*IV NAC is administered over 21-hours in varying doses* (you don't need to know these doses) BOOK: Treatment with N-acetylcysteine (NAC) is *most effective if it is started within 8-10 hours after ingestion.* LECTURE: "Interestingly, no increased risk of hepatotoxicity no matter what level of APAP *so long as NAC given within 6-8 hrs*"

Cough Cough what does a posterior fat pad sign signify

Either a radial head Fx or It can be present in a supra condylar fracture Posterior fat pad sign is always pathologic.

Describe the presentation, differential diagnosis, evaluation and emergency management of the following conditions: • *Esophageal tear/perforation*

Fairly rare, but when they do occur 20% of patients die Lethal if unrecognized du to secondary infection Usually occur during high-speed car collisions and are associated with other serious thoracic injuries *Causes* - Blunt trauma, *Presentation* Suspect in patient with serious neck, back, or abdominal injury - Throat pain - Dysphagia - Odynophagia - Hoarseness - Choking - Chest pain - Hematemesis - Dyspnea *Physical Exam* - Neck redness/swelling - Unexplained tachycardia - Subcutaneous emphysema of neck or chest (Air collects out of the airway and under skin (SEE PHOTO)) - Bloody NG tube contents *Diagnosis* - CXR (Pneumomediastinum, Widened mediastinum, Left pleural effusion - Barium swallow with esophagoscopy (Best diagnostic tool) *Treatment* - Aggressive surgical management (prevent spread of infection) - Nonoperative management (drainage, ABX) for very minor injuries

Describe the presentation, differential diagnosis, evaluation and emergency management of the following conditions: • *Flail chest*

Flail Chest - Occurs when a segment of the chest does not have bony contiguity with the rest of the thoracic cage. - Flail segment moves inward on inspiration, while the rest of the chest moves outward (paradoxical chest wall) → reducing tidal volume *Causes* - Blunt force trauma *Presentation* - History of trauma to the rib cage - Respiratory Distress - Tachypnea with shallow respirations (due to pain) *Physical Exam* Possibly: - Paradoxical chest wall movement - Crepitus with breathing *Diagnosis* - Clinical *Treatment* If unstable = Intubation and mechanical ventilation If stable = - First lIne = supplemental O2 - Pain control (Morphine or fentanyl) - Supportive Surgical fixation only when thoracotomy is being preformed for other injuries No External chest wall supports (They worsen respiratory function)

5. Compare and contrast the types of Le Fort fractures. (cough cough)

Get a CT *Lefort I*- Most common, Horizontal fx of the maxilla at the level of the nasal floor. Sx: Malocclussion (teeth not even) Tx: Maxolofacial surge Consult, D/C with analgesics *Lefort II*- Fx through the nasal bones, maxilla, and infraorbital rim Sx: mobility of nose into dental arch Rarely ariway complications Tx: Maxolofacial (OMFS) surge Consult, D/C with analgesics Lefort III- Fractures through the zygomaticofrontal suture and frontal bone above the nose (you can move their face around) Tx:Airway management is critical - Usually intracranial trauma, evaluate brain and spine -Asses visual acuity (high incidence of blindness) - Maxilofacial surgery

4. Compare and contrast the following upper extremity injuries in terms of presentation, evaluation, management and possible sequelae: • Upper arm fractures

Humeral shaft Fx -Classical mechanism= FOOSH *Presentation* -Pain, deformity, decreased mobility at shoulder ● Assess vascular status→ brachial artery ● Assess for radial nerve injury and wrist drop ● X-ray confirms diagnosis Conservative management- splint /sling Ortho referral.

What type of shock do the following examples fall into? Traumatic hemorrhage Ruptured ectopic Burns GI bleeding Vaginal bleeding Nausea/ vomiting 3rd spacing Excessive diuresis Heat related illness

Hypovolemic shock Give fluids!

About this section

I know this looks like a lot, but this section is 20 completely new diseases/concepts for us to learn and some of them seem like they directly involve saving a life, and frankly I didn't want to half ass and be a future accessory to murder. So read what you want, I doubt the test will so super in depth. Know a black widow vs brown recluse at least. Colors are hard.

4. Create a plan for the initial evaluation and treatment of a patient presenting with abdominal trauma

IDK bruh.... go check literally all of the previous abdominal emergency cards...

PE Rule Out Criteria (FYI)

If there is a low clinical suspicion for PE in addition to: -Age <50 -Pulse <100 -SaO2 >94% -No prior PE or DVT -No unilateral LE edema -No hemoptysis -No use of exogenous estrogen -No trauma or surgery within 4 weeks

Minor Head injuries: When do you CT? (Canadian Head CT Rule) Cough cough

If you answer yes to any of these questions then DO A CT High Risk (Neurological Intervention) -GCS <15 at 2 hours post-injury -Suspected open or depressed skull fracture -Any sign of basilar skull fracture -Two or more episodes of vomiting - Age > 65 Medium Risk (Brain Injury on CT) - Amnesia before impact of 30 minutes or more - Pedestrian struck by motor vehicle - Occupant ejected from motor vehicle - Fall from an elevation of three or more feet or five stairs

Treatment options for cardiogenic shock

In general: -Be careful with fluids, go slow as it may worsen a weak heart -*Ventilation support* can decrease mortality (less work to breath since machine is doing it) If Valvular Dz --> Fix the valve If Tachyarrythmia -Cardioversion if unconscious -Adenosine if conscious -AV blockers (esmolol or Diltiazem) If Bradyarrythmia: -Atropine -Dopamine/ epinephrine drip -Percutaneous pacing (long term management) If you have STEMI and cardiogenic shock at same time?!?!?!?! -Percutaneous coronary intervention (*PCI*) is the #1 thing to do- Cough Cough Best Pressor? (need to increase BP by clamping down on all blood vessels) -Norepinephrine Best Inotrope? (Increase contractility of the heart) 1. Dobutamine 2. Milrinone

Distributive shock: Causes Presentation/ Clinical findings Management

Inappropriate Vasodilation throughout your body *Causes:* -Sepsis -Anaphylaxis -Liver failure -Neurogenic -adrenal insufficiency -Toxic ingestion *Presentation:* You got this! (similar sx as above) *Management* Fix underlying Use Norepinephrine to increase pressure Use 02 use Antibiotics

Discuss the role of thoracotomy in the emergency department.

Indication for an ED Thoracotomy: 1) Penetrating thoracic wound with agonal state or recent loss of vital signs, deterioration, or cardiac arrest after care has been initiated 2) Uncontrolled hemorrhage from thoracic inlet or out of a chest tube 3) Need of open cardiac massage or occlusion of the descending thoracic aorta to provide increased blood flow to the heart and brain 4) Suspected subclavian vessel injury with intrapleural exsanguination Contraindications: - No qualified surgical backup is present - Penetrating trauma with no signs of life in the field - Blunt trauma with no signs of life on arrival in the ED

Describe the presentation, differential diagnosis, evaluation and emergency management of the following conditions: • *Open Pneumothorax* (AKA Sucking Chest Wound)

Intrathoracic and atmospheric pressure equilibrate so the lung is unable to generate negative pressure to inspire. *Causes* - Large penetrating thorax wounds *Presentation* - Severe Hypoxia *Physical Exam* - A large, sucking hole is seen in the chest wall *Diagnosis* - Obvious clinical diagnosis *Treatment* - *Occlusive dressing* that allows air escape, but not entry - Start 100% O2 - Once stable, Chest tube and wound closure

SBO or LBO?

LBO - Haustra inflamed, lines don't cross all the way

5. Compare and contrast the following upper extremity injuries in terms of presentation, evaluation, management and possible sequelae: • Malleolar fractures

Lateral malleolar- Inversion injury Patient presents with point tenderness, swelling, difficulty ambulating X ray for Diagnosis Treatment: Simple fractures → Posterior short leg splint with stirrups, crutches with no weight bearing, ortho f/u Refer to orthopedics if displaced or open Medial Malleolar- Eversion injury If they present with medial malleolar pain ALWAYS check for Maisonnouve Fx by palpating proximal fibula and imaging the knee Xray for diagnosis Treatment: Simple fractures → Posterior short leg splint with stirrups, crutches with no weight bearing, ortho f/u Refer to orthopedics if displaced or open

1. Differentiate between limb threatening and non-limb threatening emergencies

Limb threatening emergencies include: 1. Amputations 2. Compartment syndrome These are the compartments you can bleed into: 1. Chest 2. Pelvis 3. Thigh 4. Abdomen Worst closed fractures in terms of bleeding: (Normal human has ~5.5 L of blood) 1. Pelvic Fx 2. Femur Fx 3. Spine Fx 4. Leg Fx 5. Arm Fx

How do you calculate MAP? Cough Cough

MAP= (SBP-DBP)/3 + DBP example Pt is 130/90 (130-90)=40 40/3= 13.3 13.3 + 90 = MAP = 103 mmHg

2. Given a patient with a head or facial injury, formulate a differential diagnosis, a plan for the evaluation and management of this patient and identify any potential red flags.

Management: 1st- ALWAYS GET ABCD!!! Airway, Breathing, Circulation, Deficits Use the glasgow coma Scale to determine deficits A: Hypoxia=higher mortality All pts w/ THIS get 100% O2 B: ABG to assess respiratory status; Hypocapnea= decreased cerebral blood flow, Hypercapnia= also increased morbidity and mortality C: Hypotension= increased mortality; Maintain MAP of *90mmHg* with warmed IV lactated ringer's or NS and blood Use the glasgow coma Scale to determine deficits

Describe the presentation, differential diagnosis, evaluation and emergency management of the following conditions: • *Hemothorax*

Massive Hemothorax = The rapid accumulation of greater than 1000 - 1500 ml of blood or 1/3 or more of the patient's blood volume in the chest cavity VERY FATAL When involving the great vessels - 50% die immediately - 25% live 5 - 10 minutes - 25 % live 30 minutes or longer *Causes* Penetrating Injury to the: - Chest Wall - Great vessels - Lung *Presentation* - Respiratory Distress - Tachypnea - Hypoxia *Physical Exam* On affected side - Dullness to percussion - Decreased breath sounds - Narrow pulse pressure *Diagnosis* - *Clinical + CXR* (can have ground glass appearance) *Treatment* - *Tube thoracostomy ASAP* - Autotransfusion if blood loss is greater than 1 L - Continuing blood loss = Surgery

Glasgow coma scale refresher

Maximum 15 (normal person) Minimum 3 (dead) under 8=intubate

5. Compare and contrast the following upper extremity injuries in terms of presentation, evaluation, management and possible sequelae: • Knee injury (meniscus, MCL, ACL)

Meniscus- Mcmurray and Aplay tests Joint line tenderness on medial aspect ACL- Lachmans and anterior drawer Xray to check for segond Fx MCL- Valgus stress test

4. Describe the common findings in a patient with minor head injury

Minor Abrasions, lacerations, contusions...

Describe the presentation, differential diagnosis, evaluation and emergency management of the following conditions: • *Sternum Fractures*

Most common in postmenopausal females (osteopenia) *Causes* - Direct blow to the sternum *Presentation* / *Physical Exam* - Pleuritic midline chest pain - Focal tenderness - Pain with respiration, but no pulmonary compromise - Pulmonary or Myocardial contusions may accompany *Diagnosis* - Clinical - Possible CXR *Treatment* - Symptom management (Pain control) - Encourage deep breathing Admit if evidence of other more serious injuries

Describe the presentation, differential diagnosis, evaluation and emergency management of the following conditions: • *Rib fractures*

Most common injury in blunt thoracic trauma *Causes* - Motor vehicle accidents Pain due to the fracture can lead to: - Hypoventilation - atelectasis - retained secretions - pneumonia *Presentation*/*Physical Exam* - Localized pain - Crepitance - Pain with inspiration - Dyspnea *Diagnosis* 1st: CXR (50% can't be seen on X-ray) 2nd: CT *Treatment* - Rapid mobilization (continuous body positioning and oscillation) - Respiratory support (Ventilation or incentive spirometry) - Pain management Admit if old with diseased lungs

5. Compare and contrast the following upper extremity injuries in terms of presentation, evaluation, management and possible sequelae: • Tibial fracture

Most common long bone fracture Increased risk for compartment syndrome Commonly associated with fibular Fx Get X-rays You know what to do people You got this!

1. Compare and contrast the various types of skull and facial fractures *Mandibular Fractures*

Ring like structure= fracture in 2 or more places (2nd most common facial Fx, nose is 1st) Dx: Ct or Pannorex- specialized x-ray for teeth/mouth. Not in all hospitals Sx: (does it feel normal when you bite down?) Limited opening Deviation on opening the mouth Malocclusion Trismus Pain Anesthesia of lip Tx: Update Tetanus Cover with Abx (PCN, clindamycin, erythromycin) *Closed Nondisplaced*= If no airway compromise= Analgesia and D/C home *Open/displaced/Airwaycompromise*= Maxilofacial surgery

Describe the presentation, differential diagnosis, evaluation and emergency management of the following conditions: • *Myocardial contusion*

Myocardial contusion = Distinct areas of hemorrhage in the heart muscle tissue - May lead to conduction defects, dysrhythmias, or decreased cardiac output *Presentation / Physical Exam* May be asymptomatic, suspect with history of high-velocity blunt chest trauma Could have: - Chest pain - Subtle ECG changes - Hypotension *Diagnosis* - ECG changes (Possibly sinus tachycardia, ST and T wave changes, or RBBB) *Treatment* - Supportive care - Admit and monitor (unless normal ECG and no evidence of other thoracic injury)

Identify the common physical findings (and toxidrome if one exists), describe the effect on the patient's system, laboratory work up and management: • *Calcium Channel Blockers*

NOT MUCH IN BOOK ABOUT THIS...ONLY WHAT IS BELOW ------------------------------------ CLINICAL PRESENTATION: -*Bradycardia* -*Atrioventricular (AV) nodal block* -*Hypotension* -*Hyperglycemia* (common due to blockade of insulin release) -With severe poisoning, cardiac arrest may occur. ------------------------------------ TREATMENT: A. EMERGENCY AND SUPPORTIVE MEASURES -*Administer activated charcoal for recent ingestion* -*Whole bowel irrigation* (prevents absorption of the drug) should be initiated as soon as possible if the patient has ingested a sustained-release product B. SPECIFIC TREATMENT -*Treat symptomatic bradycardia with atropine, isoproterenol, or a transcutaneous cardiac pacemaker*. -*For hypotension, give calcium chloride* -High doses of insulin along with sufficient dextrose to maintain euglycemia have been reported to be beneficial (but no studies yet).

2. Compare and contrast *STEMI and NSTEMI*

NSTEMI: partially occlusive; ST depression or T wave inversion STEMI: transmural occlusion; ST elevation or new LBBB in presence of sx's -->both have positive cardiac markers

4. Compare and contrast the criteria involved in the NEXUS and Canadian C-Spine Rules for radiographic evaluation of possible injury. COUGH COUGH

National Emergency X-Radiography Utilization Study (NEXUS) Imaging is unnecessary if all 5 are satisfied: 1. No neurologic abnormalities are present 2. The patient has normal mental status 3. There is *no evidence of intoxication* 4. There is no posterior midline cervical spinal tenderness 5. There is no distracting painful injury Canadian C-spine Rules (*more specific & sensitive*) - *See picture* If neck imaging is needed: - Get *AP, lateral, and odontoid* - Get *swimmer* view for better view of *C6-T1* - Flexion/extension views NOT recommended - Neurologic symptoms not explained by x-ray or CT --> get MRI to evaluate for cord compression

1. Compare and contrast the various types of skull and facial fractures *Nasal fractures*

Need to be evaluated and treated by HEENT surgeon Check for a *septal hematoma*- septum expands as blood drains into it, blood isn't supposed to be here, so it becomes necrotic, needs to be drained (by HENT) and given abx ASAP Tx: assess for airway control epistaxis, reduce fractures, Give oral analgesics, nasal decongestants f/u with otolaryngologist in 1 week

1. Given a patient scenario, appropriately order and interpret the following laboratory studies: CBC

Not sensitive and specific for any one condition - may help guide you but it wont dx one specific dz Checking for bleeding or infection ■ Red blood cells ■ white blood cells -Elevated in infection, stress and cancer ■ hemoglobin - protein responsible for transporting oxygen. 4 per Hgb ■ hematocrit - volume of blood occupied by erythrocytes (3x Hgb) ■ platelets - repair injury to the vascular endothelium *Lymphocytes:* -B cells - from the bone marrow • Provides humoral immunity - recognize free antigen and mature into plasma cells -T cells - from the thymus • Orchestrates immune system's response to infected or malignant cells *Lymphocytosis:* • Mainly viral illness - CMV, EBV, MMR, flu, hepatitis, HIV (early), TB, Toxo, lymphomas, lymphocytic leukemias *Lymphopenia:* • Bone marrow suppression and HIV *Monocytes:* Phagocytic cell that has a single well-defined nucleus and fine granulation in the cytoplasm Elevated in pregnancy, asplenic state, certain infections, inflammatory conditions, AML *Eosinophils:* Stain red, granules Eosinophilia: • Allergies, parasites, cancer (blood and solid), adrenal insufficiency, rheumatologic conditions *Iron Panel:* o Ferritin = iron stores o TIBC/Transferrin = protein available to bind and transport Fe *Iron deficiency anemia:* o Iron and iron sat = low o TIBC = high/normal *Anemia of chronic disease (ACD):* o Iron and iron saturation = normal to low o TIBC = low

1. o Compare and contrast the presentation, pathophysiology, evaluation and emergency management of the following: • Pelvic inflammatory disease

Note this is a spectrum of infections of the female upper reproductive tract; may include Salpingitis, Endometritis, Tubo-Ovarian Abscess, Pelvic Peritonitis, Perihepatitis (Fitzhugh-Curtis Syndrome) *Pathophysiology* ● Spectrum of Infection of the uterine tubes, usually due to gon/clap (10-20% will progress to PID) *Presentation* ● Gradual onset lower abdominal pain with associated vaginal discharge and/or bleeding ● Headache, nausea, vomiting, high fever, tachycardia ● Exquisite CMT = "chandelier sign" *Evaluation* ● Trans-vag US with thick fallopian tubes ● Laprascopy - gold standard for dx - tubal edema with exudate on tubal surface ● Serum hCG ● Elevated ESR or CRP *Emergency Management * ● Empiric treatment (COUGH COUGH) ○ *Outpt Tx:* -Ceftriaxone PLUS Doxy x 14 days ○ *Inpt Tx:* -cefotetan OR cefoxitin PLUS doxy -Clinda PLUS gentamycin ● Hospitalize: Prego, IUD, abscess, immunosuppressed, failed outpt, severe ● Surgery is abdominal symptoms persist or patient's condition deteriorates ● All partners need G/C trx ● Attempt to remove IUD after Abx started.

1. Compare and contrast the various types of skull and facial fractures *zygomatic fracture* (and tripod fractures)

Pathophys: Blow to the cheekbone Tripod fracture: 1) zygomatic arch 2) inferior orbital rim, 3) maxillary sinus walls /lateral orbital rim Sx: Flattened cheekbone, lower eyelid swelling Painful/limited opening of the mouth Tripod Fx can cause lateral rectus entrapment, visual disturbances, intraorbital artery and CNV disruption Tx: ABX, Surgical consult, ORIF,

Identify the common physical findings (and toxidrome if one exists), describe the effect on the patient's system, laboratory work up and management: • *Ethanol*

Note: Lecture didn't really touch on this. This is straight from the book. Deal with it. EFFECT ON THE PATIENTS SYSTEM: -Depresses the central nervous system reticular activating system, cerebral cortex, and cerebellum. -Causes the patient to have a really fun night. ------------------------------------ CLINICAL FINDINGS: Mild intoxication produces: -*Euphoria* -*Slurred speech* -*Ataxia* (the loss of full control of bodily movements) -Hypoglycemia (possibly) -*Bradycardia* -*Hypotension* With more severe intoxication: -*Stupor* (a state of near-unconsciousness or insensibility) -*Coma* -*Respiratory arrest* Death or serious morbidity is usually the result of pulmonary aspiration of gastric contents. *Diagnosis and assessment of severity of intoxication are usually based on clinical findings and history*. ------------------------------------ TREATMENT: A. EMERGENCY AND SUPPORTIVE MEASURES: -*Administer activated charcoal if the patient has ingested a massive dose and the airway is protected*. B. SPECIFIC TREATMENT (know this, mainly) -*Supportive (fluids, glucose, vitamins, O2)* -*Protect the patients airway*

What type of shock do the following examples fall into? PE Tension Pneumo Cardiac tamponade Valve lesion Atrial thrombus Amniotic fluid emboli

Obstructive shock

Describe the presentation, differential diagnosis, evaluation and emergency management of the following conditions: • *Cardiac tamponade*

Occurs when Arterial, ventricular or atrial injury cause blood to leak into the pericardium Increased intrapericardial pressure compresses the heart, which decreases cardiac output, venous return, and cardiac filling Because the pericardium is not very distensible, small amount (200 mL) can cause tamponade *Causes* Most often penetrating injury *Presentation/ Physical Exam* NONSPECIFIC Usually: - Tachycardia - Narrow pulse pressure Possibly Beck's triad: - Hypotension - Muffled heart tones - Distended neck veins - On CXR = enlarged heart *Diagnosis* - *Ultrasound / Echocardiogram* (FAST Exam) - If unavailable, CT *Treatment* Unstable = Thoracotomy Stable = U/S guided Pericardiocentesis

2. Given a patient scenario, appropriately order and interpret the following laboratory studies: BMP

Order upon hospital admission, if fluid status is in doubt, or if patient is on a medication that effects electrolytes (diuretics) or especially if they've been vomiting. ■ Sodium ■ Potassium ■ Chloride ■ Bicarbonate ■ BUN- Rough measure of Glomerular Filtration Rate ■ Creatinine - elevated means lower GFR ■ Glucose Na, K, Cl, Co2, BUN, Creat, Glucose Naughty Killer Clowns Cause (my) Buns to Create Glue (aka they make me poop my pants) BMP with LFTs vs ordering a CMP. What is the difference? If you want a breakdown of bilirubin, you need LFTs, so if the liver is directly in question, obtain the BMP plus LFTs

1. Compare and contrast the various types of skull and facial fractures *Frontal Sinus fractures*

Pathophys: High energy mechanism, consider intracranial and C spine injury Always eval for another fx somewhere, Sx: Contusion, swelling, ecchymosis, lacerations of forehead, crepitus over sinus, CSF rhinorrhea Dx: Axial and coronal CT, C spine imaging TX: elevate head to decrease venous pressure and ICP, consult maxfacial surgeon and neurosurgeon, ophtho

3. Describe the procedure and discuss the rationale for "clinically clearing" a patient from cervical spine precautions (backboard and cervical collar).

See next card: If all NEXUS criteria met, no C-spine collar needed

9. Explain the emergent management of a minor head trauma in both the *pediatric* and adult populations. *PECARN*

Pediatric Head Injury/Trauma Algorithm for when to send to CT. *KNOW THIS CHART* Also, if in doubt For Peds Skull fractures, you can use a bedside ultrasound to quickly scan for skull fractures. If US is positive then send to CT

Compare and contrast the presentation, pathophysiology, evaluation and emergency management of the following: *Tension pneumothorax*

Please see Emergency Med 3: Chest trauma cards.

Hypovolemic shock: Causes Presentation/ Clinical findings Management

Problem is low intravascular volume *Causes:* -Burns -Bleeding -Vomiting -3rd spacing (peritonitis) -Excessive diuresis *Presentation* -Tachycardia -Hypotension -Pale -delayed capillary refill -Syncope/ orthostatics Management: 1. ABC's 2. *FLUIDS* "Cough Cough" (Normal saline or LR) Rapid bolus of fluids 20cc/kg over 20 min. Reassess vitals 4. Give Blood if they are losing blood 3. Correct the underlying cause

Describe the presentation, differential diagnosis, evaluation and emergency management of the following conditions: • *Pulmonary contusion*

Pulmonary contusion = Injury of the lung tissue with hemorrhage and edema without associated laceration - Most common intrathoracic injury in non penetrating chest trauma - Typically at the site of impact - Often in conjunction with rib fractures and fail chest *Presentation* - Hypoxia (degree correlates to the size of the contusion) - Dyspnea - Hemoptysis - Tachycardia *Physical Exam* - Other evidence of chest injury (Fracture, bruising, decreased breath sounds, crackles) *Diagnosis* - CXR If CXR is inconclusive and suspicion is high --> CT *Treatment* Supportive care - IV fluids - Supplemental O2 Admit and monitor (unless minor contusion, young and healthy) If severe --> mechanical ventilation

SBO or LBO?

SBO - lines are 100% circumferential and air fluid levels present

3. Discuss the presentation, pathophysiology, evaluation and emergency management of the following: • Traumatic amputation

STOP THE BLEEDING IMMEDIATELY: Direct pressure first Add tourniquet if needed. -Sharp, guillotine injuries are best candidates for reimplantation -Keep amputated part clean, moisten with saline, and put on ice (don't let it freeze) -Cooling will help increase viability of amputated part up to 12-24 hours Get them to surgery/ orthopedics consult Treat as an open Fx and give Abx

Describe the presentation, differential diagnosis, evaluation and emergency management of the following conditions: • *Traumatic Asphyxia* (NOT AN OBJECTIVE)

Severe crush injury of the thorax or abdomen can cause retrograde flow of blood from the right heart into the great veins of the head and neck *Presentation / Physical Exam* - Purplish-bluish color of the face and neck - Subconjuntival and retinal hemorrhages - Possible loss of consciousness *Treatment* - No specific treatment except oxygenation - Admit and observe and treat other injuries that occurred at the time of the incident

Identify the common physical findings (and toxidrome if one exists), describe the effect on the patient's system, laboratory work up and management: • *Carbon monoxide*

TELL ME ABOUT CO, FORREST! -*Carbon monoxide is a colorless, odorless gas produced by the combustion of carbon containing materials*. -Poisoning may occur as a result of suicidal or accidental exposure to automobile exhaust, smoke inhalation in a fire, or accidental exposure to a machine. ------------------------------------ EFFECT ON THE PATIENTS SYSTEM: -*Carbon monoxide avidly binds to hemoglobin*, with an affinity approximately 250 times that of oxygen! -This results in *reduced oxygen-carrying capacity and altered delivery of oxygen to cells*. ------------------------------------ CLINICAL FINDINGS: At LOW carbon monoxide levels (hemoglobin saturation 10-20%), victims may have: -*Severe headache* -*Dizziness* -*Abdominal pain* -*Nausea* At HIGH levels: -*Confusion* -*Dyspnea* -*Syncope* -Hypotension, coma, and seizures are common with saturation levels greater than 50-60%. -->Survivors of acute severe poisoning may develop permanent neurologic and neuropsychiatric deficits. -->Carbon monoxide poisoning should be suspected in any person with severe headache or acutely altered mental status ------------------------------------ DIAGNOSIS: -*Diagnosis depends on specific measurement of the arterial or venous carboxyhemoglobin saturation* -Levels do not always correlate with clinical symptoms. -The patients history will probably be pretty obvious as to how they got exposed to CO. Pay attention to it. ------------------------------------ TREATMENT: -*Maintain a patent airway and assist ventilation, if necessary* -*Remove the victim from exposure* -*Administer 100% oxygen by tight-fitting high-flow reservoir face mask or endotracheal tube* -The half-life of the carboxyhemoglobin (CoHb) complex is about 4-5 hours in room air, but is reduced dramatically by high concentrations of oxygen!

OJC, not an objective. Why the pulse drops in an inferior orbital fracture

The pulse dropping is a clinical sign of true entrapment (he "bradied down" gets a facial surgeons attention) The trigeminal nerve wires into the vagus nerve, and damage to trigeminal nerve in entrapment causes the heart to slow down. If this happens you only have hours to decompress before stuff starts dying

A NOTE BEFORE YOU READ MY QUIZLET: *PLESE READ*

There is a lot of information in the section. Don't get overwhelmed. *All the information you really need to know for the exam is BOLDED for you to study from*. Don't get caught in the weeds. Read the other information once just so you understand the material being presented better. The important information from the book, lecture powerpoint, past study guides in included in this Quizlet. Also. The lecturer stated that activated charcoal wasn't that useful...but it is listed as "useful" all over in this chapter. I have included it where the book said it could/should be utilized. Typically, it is only effective if the patient RECENTLY ingested a drug orally! Also, I doubt beta blocker or calcium channel blockers will be on the exam (but don't study at your own risk). They are pretty difficult to diagnosis and treat, it would seem.

4. Compare and contrast the various classifications of emergent patients

Three Classifications: ○*Critical* → Patient has life or limb threatening emergency and has a high probability of death if immediate intervention is not begun. ○*Emergent* → Patient has symptoms of injury or illness that will likely progress in severity if treatment is not quickly begun. ○*Non-Urgent* → Patient has symptoms with low probability of progression to a more serious condition.

Neurogenic shock: Cough Cough Causes Presentation/ Clinical findings Management

Trauma to spinal cord causes loss of sympathetic tone! Look for anatomic defect in spine. Book says to always look for other causes of shock (ie may be hemorrhaging internally) *Presentation:* *Hypotension* Peripheral vasodilation *Bradycardia* *Management:* Start with 2 IV boluses of 20cc/Kg each If still in shock then add -Atropine for Bradycardia -Dopamine for pressure +/- Alpha agonist (phenylephrine) can also constrict the vessels to up BP GOAL is MAP > 85 mmHg (MAP= diastolic (systolic-diastolic) /3) (Don't confuse with spinal shock which is like a temporarily stunned spinal cord with no physical injury)

Discuss alternatives to intubation

Try to avert from intubation with: -Continuous positive airway pressure (CPAP) -Bilevel positive airway pressure (BiPAP) -->Indications for CPAP/BiPAP: hypercarbic respiratory failure from COPD, cariogenic pulmonary edema, hypoxic respiratory failure -->Contraindications for CPAP/BiPAP: cardiac or respiratory arrest, inability to cooperate/protect airway, high risk for aspiration (inability to clear secretions, severe upper GI bleed), hemodynamic instability, facial deformity/trauma precluding mask fit, upper airway obstruction -If the tube cannot be passed, your next step is to determine if you can effectively ventilate the patient. -->If yes, call for help and consider *LMA* placement. -->If no, Cricothyrotomy Alternatives to intubating: -Laryngeal mask airway (LMA): Easier to maintain than bag-valve-mask, and reduced, but does not eliminate, aspiration risk. The LMA is a semirigid tube with a distal inflatable balloon mask that is inserted blindly into the hypopharynx. The mask lies over the larynx and seals around the glottic opening. -Bag-valve-mask ventilation -Fiberoptic laryngoscopy -Retrograde intubation -Cricothyrotomy

Describe the presentation, differential diagnosis, evaluation and emergency management of the following conditions: • *Tracheobronchial injury*

Uncommon but severe when it does happen - 80% of patients die before they reach the hospital *Causes* - Motor vehicle accidents - Crush injuries *Presentation* /*Physical Exam* Common missed in initial eval - Acute respiratory distress - Dyspnea - Subcutaneous emphysema of neck and upper thoracic area - Hoarseness - Hemoptysis - Hypoxia - *Persistent pneumothorax (even with chest tube)* *Diagnosis* - CXR (Showing SubQ emphysema, pneumomediastinum, pneumothorax and peribronchial air) - Bronchoscopy *Treatment* - Endotracheal intubation - Bronchoscopy to localize and repair the damage

5. Compare and contrast the following upper extremity injuries in terms of presentation, evaluation, management and possible sequelae: • Femoral fracture

Usually due to High energy trauma if you see one of these with no trauma then suspect a pathologic Fx Assess for internal bleeding Check neuro status Get A/P and Lateral X-rays Control pain and give fluids Traction should be applied to the leg consult orthopedics for ORIF

Identify the common physical findings (and toxidrome if one exists), describe the effect on the patient's system, laboratory work up and management: • *Serotonin*

WHAT: -*Drug-induced overstimulation of serotonin* -Triad of CNS dysfunction, autonomic disturbance, & neuromuscular effects -Especially consider if the patient has access to *SSRI's or MAOI's* -*Serotonin syndrome may occur if patients receiving MAO inhibitors are given other serotonin-enhancing drugs* -The serotonin syndrome has also been reported in *patients taking selective serotonin reuptake inhibitors (SSRIs) in large doses or in combination with other SSRIs* ------------------------------------ CLINICAL PRESENTATION: (see pic) Serotonin syndrome is characterized by: -*Fever* -*Agitation* -*Delirium* -*Diaphoresis* -*Hyperreflexia* -*Clonus* (spontaneous, inducible, or ocular). -*Hyperthermia* (can be life-threatening) ------------------------------------ TREATMENT: -*Cyproheptadine* IV or Oral. It is a first generation antihistamine that blocks serotonin production. (This is the treatment from book) -Muscle relaxants (Benzodiazepines can help control agitation, seizures and muscle stiffness) -*Dantrolene* (another muscle relaxant) was said to be THE treatment in lecture...but he mentioned nothing else. -*Oxygen/IV fluids* -*Maintain airway* NOTE ABOUT SEROTONIN SYNDROME (FYI): Important difference from Neuroleptic malignant syndrome (NMS)... -NMS usually days or weeks (not as acute as SS) -NMS usually hyperthermia, rigidity & rhabdo -NMS assoc w/ multi-organ failure

Identify the common physical findings (and toxidrome if one exists), describe the effect on the patient's system, laboratory work up and management: • *Beta-Blockers*

WHAT: -*The most toxic beta-blocker is propranolol* -Propranolol not only blocks beta-1 and beta-2 adrenoceptors, but also has direct membrane-depressant and central nervous system effects. ------------------------------------ CLINICAL FINDINGS: The most common findings with mild or moderate intoxication are: -*Hypotension* -*Bradycardia* Uncommon findings are: -Seizures/coma -Conduction disturbance (wide QRS interval) similar to tricyclic antidepressant overdose. ------------------------------------ DIAGNOSIS: *The diagnosis is based on typical clinical findings and history*. Routine toxicology screening does not usually include beta-blockers! ------------------------------------ TREATMENT: A. EMERGENCY AND SUPPORTIVE MEASURES -*For drugs ingested within an hour of presentation administer activated charcoal*. B. SPECIFIC TREATMENT -*For persistent bradycardia and hypotension give glucagon intravenously* -->Glucagon is an inotropic agent that acts at a different receptor site and is therefore not affected by beta-blockade. -*Membrane-depressant effects (wide QRS interval) may respond to boluses of sodium bicarbonate* -*Intravenous lipid emulsion has also been used successfully in severe propranolol overdose.*

Identify the common physical findings (and toxidrome if one exists), describe the effect on the patient's system, laboratory work up and management: • *Salicylates*

WHAT: -Salicylates (aspirin, methyl salicylate, bismuth subsalicylate, etc) are found in a variety of over-the-counter and prescription medications. ------------------------------------ EFFECT ON PATIENTS SYSTEM: -Salicylates uncouple cellular oxidative phosphorylation, resulting in anaerobic metabolism and excessive production of lactic acid and heat -Also interfere with several Krebs cycle enzymes. -*A single ingestion of more than 200 mg/kg of salicylate is likely to produce significant acute intoxication* -*Poisoning may also occur as a result of chronic excessive dosing over several days* ------------------------------------ CLINICAL FINDINGS: Acute ingestion: -*Nausea/vomiting* Moderate intoxication: -*Hyperpnea* (deep and rapid breathing) -*Tachycardia* -*Tinnitus* -*Elevated anion gap metabolic acidosis*. Serious intoxication: -*Agitation* -*Confusion* -*Coma* -*Seizures* -*Cardiovascular collapse* which results in death ------------------------------------ DIAGNOSIS: -*Diagnosis of salicylate poisoning is suspected in any patient with metabolic acidosis* -*Confirmed by measuring the serum salicylate level* -Patients with levels greater than 100 mg/dL (1000 mg/L or 7.2 mcmol/L) after an acute overdose are more likely to have severe poisoning. -The arterial blood gas typically reveals a *respiratory alkalosis (early) with an underlying metabolic acidosis (late)*. ------------------------------------ TREATMENT: -*Administer activated charcoal orally* -*Metabolic acidosis is treated with intravenous sodium bicarbonate* -->This is critical because acidosis (especially acidemia, pH < 7.40) promotes greater entry of salicylate into cells, worsening toxicity. -*Hemodialysis* (indicated for patients with severe metabolic acidosis, markedly altered mental status, or significantly elevated salicylate levels) -*Supportive care*

Identify the common physical findings (and toxidrome if one exists), describe the effect on the patient's system, laboratory work up and management: • *Tri-cyclic antidepressants*

WHAT: -Tricyclic and related cyclic antidepressants are among the most dangerous drugs involved in suicidal overdose. -These drugs have anticholinergic and cardiac depressant properties ------------------------------------ CLINICAL FINDGINGS: -*Signs of severe intoxication may occur abruptly and without warning within 30-60 minutes after acute tricyclic overdose* Anticholinergic effects include: -*Dilated pupils* -*Tachycardia* -*Dry mouth* -*Flushed skin* -*Muscle twitching* Quinidine-like cardiotoxic effects include: (pic) -*QRS interval widening* -*Ventricular arrhythmias* -*AV block* -*Hypotension* -*Torsades de pointes* -Seizures -Coma The included picture shows: A: Delayed intraventricular conduction results in prolonged QRS interval (0.18 s). B and C: Supraventricular tachycardia with progressive widening of QRS complexes mimics ventricular tachycardia. QRS >100ms predictive of Sz QRS >160ms predictive of VT ------------------------------------ DIAGNOSIS: -*The diagnosis should be suspected in any overdose patient with anticholinergic side effects, especially if there is widening of the QRS interval or seizures* -For intoxication by most tricyclic antidepressants, the *QRS interval correlates with the severity of intoxication more reliably than the serum drug level* -Do not forget about the possibility of serotonin syndrome (see other card) ------------------------------------ TREATMENT: A. EMERGENCY AND SUPPORTIVE MEASURES -Admit all patients with evidence of anticholinergic effects (eg, delirium, dilated pupils, tachycardia) or signs of cardiotoxicity. -*Administer activated charcoal after RECENT large ingestions* B. SPECIFIC TREATMENT -*Bolus IV sodium bicarbonate* -->Sodium bicarbonate *(COUGH COUGH, KNOW THIS STUFF)* provides a large sodium load that alleviates depression of the sodium-dependent channel -*IV fluids* -Prolongation of the QT interval or torsades de pointes is usually treated with intravenous magnesium or overdrive pacing.

Identify the common physical findings (and toxidrome if one exists), describe the effect on the patient's system, laboratory work up and management: • *Amphetamines*

WHAT: Amphetamine derivatives and related drugs include: -Methamphetamine ("crystal meth," "crank") -MDMA ("Ecstasy") -Ephedrine ("herbal ecstasy") -Methcathinone ("cat" or "khat"). EFFECTS ON PATIENT SYSTEM: -Amphetamines (and cocaine) produce central nervous system stimulation and a generalized increase in central and peripheral sympathetic activity. -The onset of effects is most rapid after intravenous injection or smoking. ------------------------------------ CLINICAL FINDINGS: (see pic) Presenting symptoms may include: -*Anxiety* -*Tachycardia* -*Hypertension* -*Diaphoresis* -*Dilated pupils* -*Agitation* -*Muscular hyperactivity* -*Psychosis* The diagnosis is supported by finding amphetamines or the cocaine metabolite benzoylecgonine in the urine ------------------------------------ TREATMENT: A. EMERGENCY AND SUPPORTIVE MEASURES -*Maintain a patent airway and assist ventilation* -*Rapidly lower the body temperature in patients who are hyperthermic* -*Give intravenous fluids* B. SPECIFIC TREATMENT -Treat agitation, psychosis, or seizures with a *benzodiazepine such as diazepam or lorazepam intravenously.* -*Phenobarbital intravenously* for persistent seizures

1. Discuss the pathophysiology and etiology of shock

What is Shock: A state where *perfusion* does not match the needs of the body AKA pressure problem 4 Types of Shock: 1. Hypovolemic 2. Cardiogenic 3. Distributive 4. Obstructive

Describe the presentation, differential diagnosis, evaluation and emergency management of the following conditions: • *Systemic Air Embolism* (NOT AN OBJECTIVE)

When lung parenchyma is lacerated, this can cause direct communication between air passages and blood vessels. Is causes air to enter the systemic circulation which can cause circulatory arrest (decreased profusion) *Causes:* - Penetrating Lung Trauma *Presentation / Physical Exam* - Hemoptysis After positive pressure ventilation = - Circulatory dysfunction - CNS dysfunction (Focal neuro abnormalities) (AKA they are getting worse the more air they get) - Air in the retinal vessels (seen in a fundoycopic exam) *Diagnosis* - Air in ABG (arterial blood gas) *Treatment* - Selective lung ventilation (Air to the good lung) If severe - Thoracotomy and clamping the hilum of the affected lung

4. Given a patient scenario, interpret the presentation, physical examination, laboratory studies, EKG and radiologic studies.

already covered in here. see lab quizlet for more info.

8. Given a patient scenario, appropriately order and interpret the following laboratory studies: UA

■ Appearance, Color, Sediment o Glucose - uncontrolled diabetes o Bilirubin - liver problem, coca-cola urine o Urobilinogen- this without bilirubin, think hemolysis o Ketones - starvation, keto diet, fat breakdown, DKA (with high glucose too) o Blood - bladder cancer, rhabdomyolysis - can be whole blood, hemoglobin or myoglobin o Leukocytes - pyuria o Nitrite - very specific for UTI (specific bacteria turn nitrate into nitrite) o Protein - little bit seen with fever or exercise is ok, but lots or more than once: nephropathy? o Bacteria- infection o WBC- more than 3 seen in HPF = (+) for pyuria o RBC - whole RBCs are not normal, but can be seen if the patient is menstruating o Hyaline casts - pretty common in elderly, those who exercise regularly, those with fever, etc. o WBC casts - pathognomonic pyelonephritis o RBC casts - almost always a marker for glomerulonephritis

3. Given a patient scenario, appropriately order and interpret the following laboratory studies: CMP

■ BMP PLUS: ■ Estimated GFR ■ Albumin ■ AST/ALT ■ Total Bilirubin ■ Calcium ■ Total Protein ■ Alkaline Phosphatase ■ Anion Gap

4. Compare and contrast the following upper extremity injuries in terms of presentation, evaluation, management and possible sequelae: • Nursemaid's elbow (subluxation of radial head)

■ General: This is a very common elbow injury that is unique to young children (2-3 YO) ■ Mechanism of injury: axial traction on a pronated forearm with the elbow extended. A portion of the annular ligament slips over the head of the radius and slides into the radiohumeral joint. ■ Often from picking child up by one arm, helping them out of car seat, pulling on uncooperative child, or parents swinging the child by the arm. *Diagnosis:* ● Typically readily apparent given the mechanism of action. ● Children *not using the affected arm.* Holding it bent against their side ● No witnessed fall or trauma ● The arm is without ecchymosis, *no significant point tenderness* nor edema * Treatment: * ● *Joint reduction is easily performed in the ED.* Hold elbow and grasp firmly. Hyperpronate forearm and feel for popping in the elbow. If it doesn't work then Supinate and flex the arm. If it fails after 2-3 attempts, consider X ray. ● Rarely complications seen ● Child will cry immediately from pain, but *completely improve in next 5-10 minutes* and start using arm normally again. ● Warn parents of potential recurrence.*

1. Discuss the presentation, pathophysiology, evaluation and emergency management of the following: • Frostbite

■ Injury of the tissues due to freezing and forming ice crystals ■ Classification of injury is applied after rewarming because the extent of injury is difficult to predict initially *Classification* ● *First Degree* ○ Freezing without blistering. Peeling is occasionally present. ● *Second Degree* ○ Freezing with clear blistering ● *Third Degree* ○ Freezing with death of skin, hemorrhagic blisters, and subcutaneous involvement ● *Fourth Degree* ○ Freezing with full-thickness involvement (including bone). Ultimate loss or deformity of body part *Clinical Presentation* ● Common on nose, ears, face, hands ● Tissue appears white or blue-white , is firm or hard, cool to the touch, and generally insensitive ● Skin loses sensation at around 10 C ● Mild frostbite - numbness, paresthesias, pruritus, lack of fine motor control ● Severe frostbite - decreased range of motion, blister formation, prominent swelling *Treatment* ● Treat associated systemic hypothermia first ● Remove restrictive clothing ● Don't rub the area ● Rewarming ○ *Superficial* - apply constant warmth by exerting gentle pressure with a warm hand ○ *Full -thickness *- Rewarm with body temp circulating water 10-30 min ○ Avoid Dry air heat, can dry out tissue ● Resuscitation - if fluid depleted ● Protection of Injured Part, separate digits and wrap in dry sterile gauze ● No one agrees on how to treat frostbite blisters. ● Anti-infective Measures ○ Penicillin prophylaxis ○ Whirlpool therapy to cleanse the skin and debride superficial dead tissue

1. o Compare and contrast the presentation, pathophysiology, evaluation and emergency management of the following: • Ruptured ovarian cyst

■ Ovarian also called follicular and corpus luteum cysts. Mostly fluid filled sacs. ■ High risk for torsion ■ OCP will stop future cysts, but not fix current cysts. *Presentation* ● Sudden, severe pelvic or lower abdominal pain ● Patient is afebrile without leukocytosis ● Tenderness may be elicited over the affected ovary *Evaluation* ● No masses on pelvic exam ● US Transvag or abdominal ● Serum hCG negative *Emergency Management* ● Observe and administer analgesics ● Confirm diagnosis with ultrasound and discharge with close follow up ● For other cysts: observe if < 6cm, if >6cm or symptomatic, refer to GYN

10. Given a patient scenario, appropriately order and interpret the following laboratory studies: UA/ Serum HCG

■ Pregnancy test

7. Given a patient scenario, appropriately order and interpret the following laboratory studies: BNP

■ Secreted by ventricles of the heart in response to excessive stretching of heart muscle cells ■ Release is modulated by calcium ions ■ Normal level rules out acute heart failure in the ER ■ Used to aid in the diagnosis and assessment of severity of heart failure, high in CHF (ANP released from atria of the heart)

5. Given a patient scenario, appropriately order and interpret the following laboratory studies: ABG

■ pH ■ PO2 ■ PCO2 ■ HCO3 *Metabolic acidosis* -anion gap vs non anion gap - AG= Na - (HCO3 + Cl) - Causes of anion gap acidosis are MUDPILES (methanol, uremia, DKA, AKA, ingestions, lactic acidosis, ethylene glycol, salicylates )

3. Discuss legal principles and common legal problems encountered in the emergency department. (CONTINUED)

○*MINORS CONTINUED* ●Laws are constantly changing from state to state ●Emaciated minors have right to consent (been married, live alone, financially independent, have children of own). ●No parental consent or notification is needed for sexual health and/or reproduction related to medical care (STDs, contraception, etc). ●Implied consent depending on the severity of the condition. ●MSE may be performed prior to parental notification in certain circumstances *THINGS TO CONSIDER* ●The Medical Record: Purpose (record information regarding patient care, delineate level of care for billing, medicolegal documentation). *"If it wasn't documented, it wasn't said/done."* ●Expert Witness: provide testimony of standard care in malpractice cases. ●Harvesting of Organs for Transplantation: refer to hospital regulations.

5. Discuss unique aspects and principles of emergent medical treatment as compared to traditional medical treatment.

○Secure the ABCs. ○Consider or give Naloxone, or get an Accucheck. ○Get a Pregnancy Test. (Unless Gestation Formula is tested on an exam, then just assume!!) ○Assume the worst. ○Do not send unstable patients to the radiology department. ○Look for common red flags. ○Trust no one, believe nothing (sometimes even the triage nurse). ○Learn from your mistakes, be humble. ○Do unto others as you would do unto your family (that includes coworkers). ○When in doubt, always err on the side of the patient. *BOOK* ○Limited time ○Limited information ○Concern is not diagnosis but rather what is life or limb threatening ○Time is of the essence ○Must be patient advocate ○Specialty consultations difficult ○Must decide if stable to return home or if need admitted ○Must give a detailed follow up plan when necesary ○Often deal with death issues

How do you estimate TBSA of thermal injuries? COUGH COUGH

● Rule of 9s. See photo. ● Arms = 9 each. Legs = 18 each. Torso front = 18. Torso back = 18. Head = 9. Giblets = 1.