ECEs: Neck up, peripheral, & systemic Flashcards Preview

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Flashcards in ECEs: Neck up, peripheral, & systemic Deck (143)
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1

What is altered mental status?

Decrease in LOC

2

What is the DDx for altered mental status (overal mnemonic)?

DIMS:
Drugs
Infection
Metabolic
Structural

3

What are some drug-related causes of altered mental status? (4 categories; name at least 1 example of each)

Abuse (opiates, benzos, alcohol, illicit drugs)
Accidental (carbon monoxide, cyanide)
Prescribed (Beta-blockers, TCAs, ASA, acetaminophen, digoxin)
Withdrawal (Benzos, EtOH, SSRIs)

4

What are some infectious causes of altered mental status? (2 categories, 3 examples each)

CNS: meningitis, encephalitis, cerebral abscess
Systemic: sepsis, UTI, pneumonia, skin/soft tissue, bone/joint, intra-abdominal, iatrogenic (indwelling lines or catheter), bacteremia

5

What are some metabolic causes of altered mental status? (4 categories, 1 example each)

Kidneys: electrolyte imbalance, renal failure, uremia
Liver: hepatic encephalopathy
Pancreas: hypoglycemia, DKA, HHS
Thyroid: hyper or hypo

6

What are some structural causes of altered mental status? (3 categories, 2 examples each)

Cardiac: ACS, dissection, arrythmias, shock
Brain: Stroke, Sz, hydrocephalus, surgical lesions
Bleeds: any ICH -- epidural hematoma, subdural hematoma, SAH; acute or chronic

7

What are important components of the history in altered mental status?

Collateral from family/friends/EMS
Onset, progression
Preceding events
Comparison to baseline
Trauma
PMHx, Rx

8

What are important components of the initial/acute physical exam in altered mental status?

Standard rapid assessment:
ABCs, primary survey
vitals including temp & glucose
rapid neuro exam (GCS, focal deficits)

9

What labs would you order for altered mental status?

CBC, lytes, BUN/Cr, LFTs, INR/PTT, serum osmolality, VBG, troponin, urinalysis, drug levels

10

What tests (non-BW) would you order for altered mental status?

ECG, CXR, CT head

11

How do you acutely manage altered mental status, in general?

Supportive + Treat underlying cause
Universal antidotes
Broad spectrum Abx
Warm/cool, BP control
Consider admitting for workup

12

What are the universal antidotes?

dextrose, oxygen, naloxone, thiamine

13

What are the 3 most common primary types of headache?

Migraine, Cluster, and Tension

14

What is the typical presentation of migraine?

POUND: Pulsatile, Onset 4-72h, Unilateral, N/V, Disabling
photo/phonophobia, recurrent, +/- aura

15

What is the typical presentation of cluster headaches?

Unilateral sudden sharp retro-orbital pain
<3h
Usually at night
Autonomic: congestion, rhinorrhea, lacrimation, facial flushing
pseudo-Horner's syndrome (ptosis, miosis, anhidrosis, and hyperemia)
precipitated by EtOH, smoking

16

What is the typical presentation of tension headache?

tight band-like pain, tense neck/scalp muscles, precipitated by stress or lack of sleep

17

What is the intracranial DDx for headache?

Bleed: epidural, subdural, subarachnoid, intracerebral
Infection: meningitis, encephalitis, brain abscess
Increased ICP: mass, cerebral venous sinus thrombosis

18

What is the extracranial DDx for headache?

Acute angle closure glaucoma
Temporal arteritis
Carotid artery dissection
CO poisoning

19

What are red flags for headache?

Sudden onset
Thunderclap
Exertional onset
Meningismus
Fever
Neuro deficit
Altered mental status

20

What are the symptoms of increased ICP?

persistent vomiting
headache worse lying down and in the morning

21

What components of the physical exam are important for assessing headache?

Vitals, detailed neuro exam
Neck flexion for meningeal irritation
Eye exam (slit lamp, IOP)
Temporal artery tenderness

22

What investigations should be done for headache?

Most benign headaches do not require further investigation.
Neuroimaging based on Ottawa SAH rule.
LP: if CT head -ve, but suspicion of SAH
ESR/CRP if ?temporal arteritis

23

What is the Ottawa SAH Rule?

Decision rule to rule out SAH.
Use in: Alert patients ≥15 years old, new severe atraumatic headache, maximum intensity within 1 hour.

If any of the following features, SAH cannot be ruled out:
- Age≥40y
- Neck pain or stiffness
- Witnessed LOC
- Onset during exertion
- Thunderclap headache (instantly peaking pain)
- Limited neck flexion on exam

24

How do you manage benign headaches in the ED?

Fluids: no clear evidence, but consider if dehydrated
Antidopaminergic agent: Metoclopramide 10mg IV
Analgesic: Acetaminophen 1g po
NSAIDs: Ketorolac 15-30mg IV or Ibuprofen 600mg po
Steroids: Dexamethasone 10mg po/IV (rebound migraine prophylaxis)

25

What is the current (2016) definition of sepsis?

Life-threatening organ dysfunction caused by dysregulated response to infection

26

What is SIRS? What are the criteria?

Systemic Inflammatory Response Syndrome
2 or more of:
T < 36 or > 38.3
HR > 90
RR > 20 or CO2 < 32
WBC < 4 or > 12

27

What history is important for sepsis?

Associated symptoms
Full ROS
Comorbidities
(Trying to ID a focus)

28

What physical exam components are important for workup of sepsis?

Vitals
Volume status
Look for a focus

29

What is the full septic workup? (Labs and other tests)

Labs:
CBC, lytes, extended lytes
BUN/Cr
LFTs
VBG, Lactate
INR/PTT
Blood/urine C&S
Tests: ECG, CXR

30

What is the RUSH exam (for sepsis)?

Imaging protocol: "Rapid Ultrasound for Shock and Hypotension"
Includes:
heart (parasternal long view, 4 chamber)
IVC view
Morrison’s (RUQ) and splenorenal (LUQ) views
bladder window
aorta
pneumothorax