EM2 Flashcards
How to correct hyponatremia + coma/seizures
150 mL 3% NS bolus over 5 min (or 1 amp bicarb) (may repeat X 1)
Repeat serum sodium (goal is no more than 6 mmol/6h)
Saline lock IV
Foley –> u/o >100mL/h? –>if yes, 1 mcg DDAVP
Goals of correction of hyponatremia
6 in 6 hours for severe symptoms, then no faster than 6 mmol/day (up to 12/day safe by some sources)
Necrotizing Soft Tissue Infections
- Type I: Polymicrobial, most common.
- Type II: Monomicrobial (MRSA, GAS, clostridium)
- Type III: V. vulnificus (seawater)
- Can spread as quickly as 1”/h
- Pain out of proportion.
- Pain/edema beyond area of redness
- Crepitus (30%)
- Xray shows superficial gas but not deep
- CT with contrast ~ 90% but 20% false-positive
- non-enhancing deep tissues
Chance of successful passage of ureteral stone based on size
98% stones <5 mm pass within 4 weeks
60% stones 5-7 mm pass within 4 weeks
39% stones >7 mm pass within 4 weeks
Malaria
Incubation ~30 days, but with partial chemoprophylaxis and incomplete immunity, can show up even 1 year after travel (~1% cases)
Often periodic fevers preceded by myalgias, headaches, and almost any other symptom. Classically Q48h, but can present very atypically.
Normocytic anemia (hemolysis), may have mild LFT/Cr, WBC elevation or depletion
Dx: thick + thin smear for malaria Q 12-24h for three sets
LP will be nonspecific
Opioid Equivalencies
Morphine 5 mg IV = 15 mg PO (MS Contin Q8-12h)
Dilaudid 0.75 mg IV = 3.75 mg PO
Oxycodone 10 mg PO (oxycontin Q8-12h)
Codeine 100 mg PO
Composition of Tylenol #1,2,3,4
T#1 = tylenol 300 mg + codeine 8 mg + caffeine 15 mg T#2 = tylenol 300 mg + codeine 15 mg + caffeine 15 mg T#3 = tylenol 300 mg + codeine 30 mg + caffeine 15 mg T#4 = tylenol 300 mg + codeine 60 mg
Composition of percocet
Percocet = 325 mg/5 mg oxycodone
Dosing of Tramadol, Tramacet (composition)
Tramadol 50-100 mg PO Q6h or 100 mg ER daily max 300 mg/day, adjust by 100 mg no quicker than q5 days
Tramacet (325 mg Tylenol + 37.5 mg Tramadol) i-ii tabs Q4-6h
ABRS Tx Algorithm
Sinusitis Steroid Nasal Spray Dosing
INCS Mometasone furoate (Nasonex)
50 mcg/spray 17g (120 sprays) per bottle
Age 3-11: 1 spray each nostril once daily
Age >=12: 2 sprays each nostril BID, increase to 4 BID if inadequate response
Oral Candidiasis Treatment
Nystatin swish and swallow: 400,000-600,000 units QID X 7-14d (adults & children, different for infants); response within 24-48 hours.
if no response/poorly tolerated then fluconazole 200 mg day 1, then 100 mg daily X 14 d
Apthous Stomatitis Treatment
oracort dental paste 0.1% TID X 7-14 days m: 5 g
Insulin Correction Factor
100/Total Daily Dose
Antibiotics for acute cholecystitis
Flagyl 500 mg IV (Q6h)
Ceftriaxone 1 g IV (Q24h)
3 I’s (causes) of DKA
Infection, Infarction, Insulin
Dose of PO morphine for acute pain
Morphine, 0.3 milligram/kg PO
Dose of PO Dilaudid for acute pain
Hydromorphone, 0.06–0.08 milligram/kg PO
(4-5 mg PO)
MI & LBBB
Doesn’t matter if new or old.
If CHF or HD instability –> cath/lytic
If stable, apply Sgarbossa criteria
A. Concordant STE 1 mm in any lead (~90% accurate, take to cath)
B. Concordant STD 1 mm in V1-V3, only need 1 lead (~90%, take to cath)
Modified C (Smith’s). ST discordance >25% (cath)
MI & Pacemaker (LBBB pattern)
Doesn’t matter if new or old.
If CHF or HD instability –> cath/lytic
If stable, apply Sgarbossa criteria
A. Concordant STE 1 mm in any lead (~90% accurate, take to cath)
B. Concordant STD 1 mm in V1-V3, only need 1 lead (~90%, take to cath)
C. Discordant STE >5 mm any lead (~60%, consider other factors, speak with cardio) applies also and is even more specific than other criteria.
sTE aVR
STE in aVR + aVL = 95% specific for LMCA stenosis
STE in aVR + V1 = LMCA or prox. LAD stenosis
If STE in aVR > STE in V1 then LMCA stenosis
If STE in aVR > 1.5 mm then >75% mortality
LMCA stenosis has 70% mortality, no medical therapy is effective, time to cath is crucial, PCI decreases mortality to 40%
Diagnosis of Acute Pericarditis
Two of:
- Chest pain consistent with pericarditis (pleuritic, worse with lying down, relieved with leaning forward)
- Pericardial friction rub
- Typical ECG changes
- Pericardial effusion of more than trivial size
Disposition of Acute Pericarditis
Consider admission if:
- temp >38.5, trauma, troponin (myopericarditis), OAC, immunosuppressed, or large effusion
- Competitive athletes: no sports until 3 months (6 months for myopericarditis) after resolution symptoms and cleared by MD
- Regular athletes: no sports until resolution symptoms
Flomax Dosing, precautions
Tamsulosin 0.4 mg PO daily (may increase to 0.8 mg daily after 2-4 weeks if poor response).
Watch for hypotension with first dose and after interrupting therapy.
Do not start if planned eye surgery (floppy iris syndrome).
Avoid with severe sulfa allergy.
Tuberculosis
- assume infectious –> airborne isolation, negative pressure, N95 for visitors, surgical mask for patient outside of room, call IPAC
- outpatient: home isolation pending lab results + call PH
- active TB –> specialist referral
- CXR
- sputum X 3 for TB (AFB smear - 24h), NAAT (48h), and culture (1-4 weeks). May collect sputum on same day 1h apart.
- If CAP but suspecting TB, use Amox/Clav, do not use quinolones (they are active against TB and may mask test results)
- test for HIV if +ve
HIV Testing
HIV Ab test
95% sensitive within 30 days
5% will take up to 3 months
HIV Ag/Ab Combo EIA
reduces time to detection to 0-20 days, lab dependent
INSTI POC test
Sens/Spec 99.8%/99.5% at 3 months post-exposure
Workup for fever in the returning traveler
CBC, diff, malaria thick/thin Q12-24h X 3, LFT’s, culture everything for typhoid, NP swab for influenza, urinalysis, CXR, serology (hold red top or specify for dengue, chikungunya, Rickettsia, etc.)
de Winter T waves
Proximal LAD occlusion –> STEMI equivalent, call cath lab
