Common ER Presentations Flashcards
<div>Indications for admission in syncope</div>
“<div><span>Absolute</span>:(must admit)</div> <ol> <li>Chest pain</li> <li>Hx of CHF or valvular lesions</li> <li>Unexplained SOB</li> <li>Serious ECG findings:</li> <ol> <li>VT</li> <li>QT prolongation</li> <li>Ischemia or new BBB</li> </ol> </ol> <div></div> <div><span>Relative</span>:(consider admit)</div> <ol> <li>Age > 45</li> <li>Pre-existing CV or congenital heart disease</li> <li>FHx of sudden death (Brugada)</li> <li>Exertional syncope (HOCM, critical AS)</li> <li>Serious comorbidities (DM)</li></ol>”
Ix for syncope
ECG<div>Preg test</div><div>HCT</div><div>Electrolytes</div><div>Glucose</div>
D/C instructions for pt with syncope
No driving<div>No operating heavy machinary</div><div>Avoid working in heights</div>
<div>Describe the San Francisco Syncope Rule:</div>
“<div>5 points: (<span>CHESS</span>) </div> <div></div> <div>1. History <span>CHF </span></div> <div>2. <span>Hematocrit</span> <30% </div> <div>3. Abnormal <span>ECG </span></div> <div>4. <span>SOB</span> on history </div> <div>5. <span>SBP</span> <90 at triage</div>”
Life threatening causes of abd pain
Ruptured EP<div>Ruptured AAA</div><div>Mesenteric ischemia</div><div>Intestinal obstruction</div><div>Perforated viscus</div><div>Acute appendicitis</div><div>Ascending cholangitis</div><div>Complicated diverticulitis</div>
List 6 life threatening causes of acute pelvic pain in women
PID<div>Tubo-ovarian abscess <br></br>Ectopic pregnancy <br></br>Hemorrhagic ovarian cyst (ruptured) <br></br>Appendicitis <br></br>Bowel/uterine perforation</div>
Red flags for Back pain
“<b><u>History</u></b>:<div>Trauma</div><div>Sudden</div><div>Acute</div><div>Children</div><div>Syncope</div><div>Sweating</div><div>Fever</div><div>Neurological deficit</div><div>Immune compromised</div><div>IVDU</div><div><br></br></div><div><b><u>PMH</u></b>:</div><div>Cancer</div><div>Steroid use</div><div><br></br></div><div><b><u>Examination</u></b>:</div><div>Unstable vitals</div><div>Unequal BP in extremities</div><div><br></br></div><div>Diastolic murmur in aortic ares (AI)</div><div>LL pulse deficit</div><div>Pulsatile abd mass</div><div>Focal bone tenderness</div><div>ROU</div><div>Loss of rectal sphincter</div><div>Focal LL weakness</div>”
6 emergent causes of back pain:
Aortic dissection <br></br>Cauda equina syndrome <br></br>Epidural abscess / HEMATOMA <br></br>Meningitis <br></br>Ruptured or expanding abdominal aortic aneurysm <br></br>Spinal fracture with subluxation causing CORD or ROOT impingement
Back pain and involved disc space
“<b>L5</b>:<div>Decrease sensation of 1st webspace in foot<div>Weak extension of the great toe and NORMAL reflexes</div></div><div><br></br></div><div><b>S1:</b></div><div>Decreased sensation to lateral foot and small toe <br></br>Weak plantar flexion +/- ankle jerk reflex loss<br></br></div>”
Major categories can impact and disrupt normal cortical function
<b>I. Substrate deficiency</b> <br></br> a. Hypoxia <br></br> b. Hypoglycemia<div><br></br><b>II. Neurotransmitter dysfunction</b> <br></br> a. Endocrine disease <br></br> b. Hepatic failure <br></br> c. CNS sedatives <br></br> d. EtOH <br></br> e. Poisons <br></br><br></br></div><div><b>III. Circulatory dysfunction</b> <br></br> a. Shock</div>
List the Major Categories for the differential diagnosis of Confusion/Coma
“<b>DIMES</b><div><br></br></div><div><b>Drugs (OBs and 5Cs):</b></div><div> Opiates</div><div> BB</div><div> CO poisoning</div><div> Cyanide</div><div> Cyclic antidepressants</div><div> Cardiac glycosides</div><div><br></br></div><div><b>Infections</b></div><div> Meningitis, encephalitis</div><div> Sepsis and septic shock</div><div><br></br></div><div><b>Metabolic</b></div><div> Hypoglycemia</div><div> DKS,HONK</div><div> Hyper or hypo T4</div><div> Kidney failure</div><div> Liver failure</div><div><br></br></div><div><b>Environmental</b></div><div> High altitude</div><div> Heat stroke</div><div> Hypothermia</div><div></div><div><b>Structural</b></div><div> ICH</div><div> Stroke</div><div> ACS</div><div> Shocks</div><div> PE</div><div> Hypertensive encephalopathy</div><div> Trauma, head injuries</div>”
Organic vs Psychological Confusion
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Critical causes of Confusion
Shock and hypoxia<div>Hypoglycemia</div><div>CNS infections</div><div>Htsive encephalopathy</div><div>Raised ICP (medical, surgical)</div>
Miosis (pin point pupil) causes:
Pontine hge<div>Intoxication:</div><div> Opioids</div><div> Clonidine</div><div> Cholinergic toxidrome</div>
<div>Important questions to ask in ALOC</div>
<ul> <li>When were they last seen normal? </li> <li>How was their health prior to being altered? </li> <li>Had they any specific cardiovascular, respiratory, urinary, or neurologic complaints of note? </li> <li>How did they become altered? Was it a sudden or gradual event?</li></ul>
Best pain stimulus to evaluate GCS
“Interphalangeal pressure<div>(Apply pressure with a pen/pencil to the lateral outer aspect of the proximal or distal</div>interphalangeal joint (lateral aspect of the patient’s finger or toe) for 10 to15 seconds to <br></br>elicit a response.)”
What simple tests can you use to assess concentration at the bedside?
Repeat digits forward and backward<div>Listing the months in reverse order OR spell a commonly used backward<br></br></div>
<div>List 5 emergent and 4 critical diagnoses that cause confusion</div>
<div>Critical </div>
<div>● Failure to oxygenate </div>
<div>● Failure to ventilate </div>
<div>● Hypoglycemia </div>
<div>● Elevated ICP with impending herniation </div>
<div></div>
<div>Emergent </div>
<div>● Toxic ingestion/Substance withdrawal </div>
<div>● Infection (esp. meningitis/encephalitis) </div>
<div>● Hypo/hyper calcemia, hepatic encephalopathy, uremia, etc. </div>
<div>● Endocrine disease (thyroid/adrenal) </div>
<div>● Structural brain lesion (stroke/bleed/mass) </div>
<div>Non-neurologic Weakness</div>
<ul> <li>Alterations in plasma volume (dehydration)</li> <li>Alterations in plasma composition (glucose, electrolytes)</li> <li>Derangement in circulating red blood cells (anemia or polycythemia)</li> <li>Decrease in cardiac pump function (myocardial ischemia)</li> <li>Decrease in systemic vascular resistance (vasodilatory shock from any cause)</li> <li>Increased metabolic demand (local or systemic infection, endocrinopathy, toxin)</li> <li>Mitochondrial dysfunction (severe sepsis or toxin-mediated)</li> <li>Global depression of the central nervous system (sedatives, stimulant withdrawal)</li></ul>
<div>List 5 non-emergent causes of peripheral neuropathy</div>
<div>1. Connective tissue disorder </div>
<div>2. External compression (entrapment syndrome, compressive plexopathy) </div>
<div>3. Endocrinopathy (diabetes) </div>
<div>4. Paraneoplastic syndromes </div>
<div>5. Toxins (alcohol) </div>
<div>6. Trauma </div>
<div>7. Vitamin deficiency</div>
<div>List four factors that blunt the febrile response:</div>
<div>1. Advanced Age </div>
<div>2. Immunosuppression </div>
<div>3. Malnutrition </div>
<div>4. Chronic Disease</div>
<div>Benefits of the febrile response include:</div>
<div>● Increased chemotaxis </div>
<div>● Decreased microbial replication </div>
<div>● Improved lymphocyte functioning </div>
<div>● Direct inhibition of bacterial or viral growth</div>
<div>Pitfalls of the febrile response include:</div>
<div>● Increased oxygen consumption </div>
<div>● Increased metabolic demands </div>
<div>● Protein breakdown </div>
<div>● Increased gluconeogenesis </div>
<div>These are problematic in patients with poor physiologic reserve.</div>
What is the most accurate measure of core body temperature
the thermistor of a pulmonary artery catheter, <br></br>rectal temperature measurements<div>bladder thermistors</div>
risk factors for stroke
Cavernous Sinus Process
CN III, IV, VI, with retro-
orbital pain, conjunctival
injection, possible
periorbital/facial numbness
methylene blue
- subarachnoid or intracranial hemorrhage (ICH),
- cerebral venous thrombosis
- cervical artery dissection.
venous thrombosis?
ii. Part of this area is OUTSIDE the blood brain barrier
iii. Activated by:
1. Hormones
2. Peptides
3. Medications
4. Toxins (opiates, digitalis, chemotherapy agents, salicylate, dopamine)
- Persistent altered mental status
- Fever
- Recent trauma
- Persistent headache
- History of cancer
- Anticoagulant use
- Suspicion or known history of AIDS
- Age > 40 years
- Presence of partial complex seizure
2. Pre-excitation
3. Shortened PR
4. Prolonged QTc
5. ST Elevation (regional and diffuse)
7. Right ventricular strain pattern
8. Electrical alternans
2. Male gender
3. History of CHF
4. History of CVD or serious dysrhythmia
5. History of structural heart disease
6. Family history of early (<50 years) sudden death
7. Syncope without prodrome
8. Exertional syncope
9. Dyspnea or shortness of breath
10. Syncope during supine position
11. Hypotension - systolic BP <90 mmHg
12. Abnormal EKG
13. Anemia with HCT <30% or hemoglobin <90 g/L
2. Pre-existing cardiovascular or congenital heart disease
3. Family history of sudden death
4. Serious comorbidities (e.g., diabetes mellitus)
5. Exertional syncope
• Shunting of venous unsaturated hemoglobin into arterial circulation
• Decreased arterial oxygen saturation
● Increased pH
● Decreased 2,3 DPG
● Increased methemoglobin
● Presence of sulfhemoglobin
● Decreased pH
● Increased 2,3 DPG
● Sulfonamide derivatives
● Gastrointestinal sources (seen in cases of bacterial overgrowth)
