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1
Q

How many seconds does each little box in an ECG convert to?

A

40 msec

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2
Q

How many seconds is one big box?

A

200 msec

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3
Q

What is the upper limit of normal QTc?

A

M 440msec

F 460msec

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4
Q

What is a normal QRS complex length?

A

120 msec (0.12 s)

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5
Q

What is the rate?

A

80

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6
Q

What is the rate

What is this rhythm?

A

52 ish

Sinus bradycardia

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7
Q

What is the rhythm?

Do you need to do anything to this person?

A

1st degree block

No

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8
Q

What is the normal PR interval

A

120-200 msec

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9
Q

What is the rhythm?

A

2nd degree block, Mobitz I

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10
Q

What is the rhythm?

A

Mobitz type 2

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11
Q

How do you differentiate between types of 2nd degree heart block?

Which one is less dangerous?

A

Mobitz 1 - lengthening PR interval until there’s a dropped QRS

Mobitz 2 - high degree AV block

Mobitz 1 less dangerous than 2 (2 -> 3)

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12
Q

What is the rhythm?

A

Complete heart block (3rd degree)

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13
Q

What is the classification framework for tachycardias?

A

Narrow or Wide

Regular or Irregular

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14
Q

What is the rhythm?

A

Sinus tachycardia

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15
Q

What is the rhythm?

A

Supraventricular tachycardia

AVRT / AVNRT

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16
Q

What is the rhythm?

A

Atrial flutter with fixed block

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17
Q

What is the treatment for supraventricular tachycardia?

A

Adenosine

Cardioversion if unstable

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18
Q

How do you treat atrial flutter?

A

Cardioversion

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19
Q

What is the rhythm?

A

A fib

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20
Q

What is the rhythm?

What is the most common clinical cause/correlate?

A

Multifocal atrial tachycardia

Cor pulmonale

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21
Q

What is the rhythm?

A

A flutter with irregular block

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22
Q

What is the rhythm

A

Ventricular tachycardia

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23
Q

What can “convert” a narrow/regular tachy into something that “looks” like vtach?

A

LBBB or RBBB

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24
Q

What types of medications can cause this rhythm?

What types of electrolytes can also lead to it?

A

Torsades de pointes (QT prolongation)

Antimicrobials, antidepressants, anti-seizure medications

Hypo K+ or Hypo Mg++

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25
What is the intrinsic rate of depolarization of the atria? the AV node? the ventricles?
Atria \<60 AV 40-60 Ventricles (20-40)
26
What is this rhythm? What is the most common cause of this rhythm?
Accelerated junctional rhythm Digoxin
27
What is this rhythm?
Accelerated idioventricular rhythm
28
At what point do we consider multiple premature ventricular contractions a tachy?
A triplet
29
What does \_\_geminy refer to?
The number of beats between premature contractions
30
Why is transvenous pacing the next step after trying transcutaneous pacing?
Pain restricts the amount of current that you can deliver The current is less reliable / less effective?
31
25yo M with chest pain x 2 days. PMHX: none. BP 125/82. What is the rhythm? How do you manage this patient?
1st degree block Maybe some investigations--but not overly concerned (could do trops / electolytes / cxr but more likely non-cardiac cause of chest pain)
32
What's the rule for estimating rate based on the number of big blocks on ECG?
300/150/100/75/60/50/43
33
60yo F with chest pain and dyspnea for past hour. BP 85/40. What is the diagnosis? What do we need to manage them?
brady to 40s, 3rd degree block ABCs, pacing, call cardiology for pacemaker r/o ischemia?
34
62yo M chest pain and dyspnea for past 24 hours. PMHX: none. BP 85/55.. Diagnosis? Mgmt?
Brady to 30-40 Mobitz 2 Unstable / likely hypotensve, try atropine, pacing.
35
50yo F with chest pain x 24 hours. PMHX: none. BP 130/90. Dx? Mgmt?
Brady to 50 Mobitz 1 wenckebach If chest pain isn't ischemic sounding, then monitor / observe.
36
1. 62 yo F with chest pain and dyspnea on an ER stretcher. Nurse goes to check on patient. Had previously been talking, now unresponsive, no pulse. 2. 62 yo F with chest pain and dyspnea on an ER stretcher. Nurse goes to check on patient. Patient is talking and still has chest pain. O/E: BP 80/60, sats 92% RA. (Same rhythm as above.) 3. F with palpitations on an ER stretcher. Nurse goes to check on patient. Patient is talking. O/E: BP 124/86, sats 99% RA. (Same rhythm as above.) Dx? Mgmt?
230bpm VTach 1. Start CPR, shock, epi, shock, amio 2. get IV access, cardiovert 100J (give fentanyl) 3. adenosine 6mg bolus
37
82 year old M with chest pain. While waiting in the ambulance bay in ER, becomes unresponsive. Dx? Mgmt?
V fib ABCs, start cpr, shock, epi, shock, amio
38
45 yo M with confusion. Tells you to “go away” when you talk to him. Admits to 10 beer tonight, started on an antipsychotic 1 week ago. BP 80/50, sats 92% RA.
Torsades de pointes Sedation, cardioversion, give Mg++, get lytes
39
82yo F from home alone, found unresponsive. Pt was not answering son’s phone calls for 24h, so son went to check on her and called 911. EMS has been doing CPR on patient for 20 minutes, now in ER. Still no pulse. DDx, Mgmt.
PEA Epinephrine, continue CPR Treat underlying cause, POCU
40
30 yo M, palpitations for 2 hours. No other symptoms. PMHX/Meds/Allergies: none. BP 124/80. DDx Mgmt
rate 180, AFib Cardiovert (if \< 12 hrs if no Hx of stroke or TIA) or procainamide If \>48 hrs, do NOT cardiovert. beta blocker or calcium channel blocker
41
70yo F palpitations for 2 hours. BP 110/60. Dx ? Mgmt?
A flutter Cardiovert
42
22 yo M student. Palpitations for 6 hours. Got 2 hours of sleep last night, has exam today, drank 4 energy drinks. Talkative, BP 130/78, sats 98% R/A.
Adenosine 12mg bolus
43
22 yo M student. Palpitations for 6 hours. Got 2 hours of sleep last night, has exam today, drank 4 energy drinks. Talkative, BP 130/78, sats 98% R/A. Dx
Premature Ventricular Contraction
44
62yo F cough, fever, wheezing x 6 days. 50 pack-year smoker. PMHx: COPD. Puffers not helping. BP 106/68, RR 26, sats 96% r/a
Cor pulmonale
45
What are some classic ECG findings of PE?
Sinus tachycardia S1 ( negative deflection of the S wave in lead 1) Q3 (negative Q wave in lead 3) T3 (negative T wave lead 3)
46
What kind of axis deviation is expected with PE?
Right
47
What is the DDx for 2 day hx of sharp pleuritic chest pain x2 days in a 37yo F smoker?
PE Pneumothorax MSK (diagnosis of exclusion)
48
What investigation would be best to diagnose a PE?
CT pulmonary angiogram
49
How can you rule out a PE?
Wells \< 2 + Negative D-Dimer PERC rule (Age \<50, HR \< 100, O2 sat on RA \>94% with no suspicious clinical Hx or signs)
50
How do you manage a PE
Anticoagulation (e.g. DOAC, warfarin, LMWH / heparin) Thrombolysis (worried about intracranial bleeding risk - only give to hypotensive / hypoxic ppl) Send home with f/u for risk factors
51
What are the most likely diagnoses in this 60yo M with 5 day hx of exertional chest pain and a negative abdomen
ACS COPD
52
How do you differentiate between stable angina and an unstable angina on history?
Predictable pain with predictable exertion = stable angina
53
Would you expect to see ECG findings or a positive troponin in stable / unstable angina?
No
54
Where do you send someone with unstable angina? What further investigations are needed?
Admit for further workup Echo & stress test for risk stratification +/- angiogram; possible stenting.
55
How do you differentiate between NSTEMI and unstable angina?
Abnormal ECG with signs of ischemia.
56
What are the ischemic changes that can been seen on ECG in the context of NSTEMI?
ST depression P inversion
57
What does a positive troponin indicate + positive ECG findings?
NSTEMI or STEMI
58
Where do we send patients with STEMI?
Cath lab
59
When do you need serial troponin?
If it's taken too soon after the onset of chest pain, it's not reliable, if it comes back negative but 3+ hrs later should be good.
60
How do you manage ACS?
Antithrombotic: Aspirin 160mg chewed + clopidogrel / ticagrelor Anticoagulation: IV heparin Do not MONA indiscriminately.
61
What is the diagnosis?
STEMI
62
What can you do with a STEMI if you can't get to a cath lab.
Give fibrinolytic
63
32y trans male some SOB, 6 day hx of nausea and diarrhea, sharp bilateral shoulder pain x 1 day some chest pressure. bland Phx, mild tachycardia and tachypnea. What is the most likely diagnosis? What are the ECG changes?
Pericarditis. Diffuse ST elevation and depression of the PR interval.
64
How do you manage pericarditis?
R/o effusion with point of care u/s Treat underlying cause Give NSAID 14 days, steroid if refractory Send home with f/u
65
What investigations are indicated for suspected pericarditis?
ECG CXR CBC, ESR, CK/Troponin +/- echo
66
What are the 6 can't miss chest pains
ACS, PE, pneumothorax, aortic dissection, tamponade, esophageal perforation
67
How would you identify a scaphoid fracture on exam
Point tenderness in snuffbox and/or volar side opposite snuffbox
68
What do you need to do if you suspect scaphoid fracture?
Don't rely on imaging throw them in a thumb spica
69
What is the diagnosis?
Avulsion of the triquetrum
70
What is the diagnosis?
Lunate dislocation
71
What are the key questions to ask about when you have a fall?
Mechanism of fall, LOC?, hit your head? Vitals, GCS, Spine pain
72
What is the diagnosis? What is the sign? What is the management?
Occult radial head fracture Sail sign (anterior fat pad) Sling arm, try ranging in a few days.
73
What is the diagnosis? What do you want to probe?
Montaggia fracture (midshaft ulnar fracture, radial dislocation) Ask about IPV.
74
What is the diagnosis?
Galeazzi
75
What is your exam in the patient with a suspected hip fracture?
Look for a leg length discrepancy, rock the ankle, check distal neurovascular status.
76
What is the hand anatomy?
77
What is the anatomy?
78
What is the fracture?
Subcapital fracture
79
What is the diagnosis? What other fracture do you worry about?
Tibial avulsion Maisonneuve fracture (fibular head fracture)
80
What is the diagnosis? What do you worry about?
corner fracture of the femur nonaccidental injury
81
What is the salter harris classification?
2
82
What is the salter harris classification?
2
83
What is the salter harris classification
5
84
What is the acronym for the first things that need to happen with resus?
MOVIE Monitors - cycle blood pressure as fast as possible. Oxygen by nasal prongs Vitals 2 large bore IVs ECGs
85
What are the ABCDE..G?
Airway Breathing Circulation Disability (neuro, GCS, pupils) Environment (undress patient) Glucose
86
What are the 4 universal antidotes?
Dextrose, oxygen (titrate to pulse ox), thiamine, naloxone
87
What are 4 signs of basal skull fracture
Racoon eyes Battle sign (contusion behind ear) Blood in tympanic membrane CSF fluid leaking from nose
88
What is the dose of naloxone for overdose?
Start 0.2mg IM and titrate up
89
What do you do when you suspect an ingestion?
Call poison control consult
90
What labs are helpful in the suspected tox patient?
CBC, lytes glucose, BUN, Cr. LFTs, INR/PTT, serum osmolality, VBG, troponin, urinalysis, drug levels Ethanol level, acetaminophen / salicylate
91
What tests are indicated in the tox patient?
ECG in everyone CXR if you suspect inhalation or iron ingestion CT head if you suspect trauma
92
What is the differential for decreased LOC?
Structural (e.g. trauma, stroke, seizure) Metabolic abnormalities (e.g. glucose, electrolyte abnormalities) Cardiogenic / hypoxic Environmental (hyperthermia/hypothermia) Substances Infection Psychogenic
93
Once a tox patient has stabilized, what additional information do you want to seek out?
Type of exposure, time of exposure, intentional (suicidal ideation?) vs unintentional
94
what is the focused physical for the tox pt
eyes/ pupils gcs mucous membranes sweating bowel sounds urinary retention
95
What are the symptoms of a cholinergic poisoning?
DUMBBELS Diarrhea Urination Miosis Bronchospasm / bronchorrhea Bradycardia Emesis Lacrimation Salivation / sweating
96
What is the syndrome of anticholinergic poisoning?
Hot / Red / Dry / Mad / Blind
97
What toxins do you think about when you see continuous vomiting?
Iron, lithium, irritating toxin
98
When the patient presents with seizures, what agents do you think of?
Cocaine, TCA, isoniazid, theophylline
99
What would you see with a rat poisoning?
Coagulopathy
100
What do you suspect when a whole family comes in with a headache?
Carbon monoxide poisoning
101
How do you calculate an anion gap?
Na+ - Cl - HCO3 Normal \< 10 mmol.L
102
What is the differential for an anion gap metabolic acidosis?
MUDPILES CAT Methanol Uremia DKA Paraldehydes / paracetamol Iron Lactic acidosis Ethylene glycol Salicilates Carbon monoxide Aminoglycosides Toluene
103
How do you calculate an osmol gap?
2xNa + glucose + BUN + 1.25 EtOH (2 salts and a sugary BUN)
104
What is the ddx of an osmol gap?
Toxic alcohols | (e.g. ethylene glycol, methanol)
105
What are the indications and contraindications for activated charcoal?
\<2 hours from ingestion give 1 bottle (50g) Can't give to decreased LOC, no gut motility, if they need endoscopy.
106
When do you use a gastric lavage?
If patient is 100% going to die from the ingestion otherwise.
107
When is whole bowel irrigation indicated? What are contraindications?
Large tablets / things that don't bind to activated charcoal (metals, toxic alcohols) Unstable, unprotected airway, no bowel sounds, bowel perforation
108
What is the toxic ingestion limit for acetaminophen by weight?
150mg/kg
109
For acetaminophen ingestion what do you want to do?
Place on monitors, 2 lg bore IV, ECG Activated charcoal 4hrs after ingestion, get a 4hr acetaminophen level.
110
What is the curve that you reference with acteaminophen?
Rumack matthew nomogram
111
What is the antidote to ASA?
Bicarb (urine alkalinization) + hemodialysis
112
What is the antidote to toxic alcohols?
Fomepizole or ethanol hemodialysis
113
What can you give to reverse organophosphates or carbamates (and other cholinergic poisoning)
Atropine Diazepam for seizures
114
What drug leads to seizures that are benzo resistant? What can you give?
Isoniazid overdose Pyridoxine (B6)
115
How do you reverse warfarin overdose?
Vitamin K (nonemergent) PCC (emergent)
116
What do you give for digoxin overdose?
Digifab
117
What is the antidote to hydrofluoric acid?
calcium gluconate paste topically applied
118
TCA ingestion, what's the antidote?
Bicarb
119
What do you give for CO poisoning?
Oxygen, hyperbaric
120
What is the antidote for beta-blockers and calcium channel blockers?
Glucagon, calcium, high-dose insulin
121
What is the antidote to iron poisoning?
Deferoxamine
122
What is the antidote to heavy metals?
Chelators (BAL, then EDTA)
123
What is the antidote to cyanide poisonning?
Hydroxocobalamin, sodium nitrate, amyl nitrate and sodium thiosulfate (cyanide kit).
124
How do you assess eye opening for GCS
spontaneous 4/4 opens to sound ¾ opens to pressure (2/4) No eye opening (¼)
125
How do you score verbal response on the GCS
Oriented 5/5 Confused 4/5 Words 3/5 Sounds 2/5 None 1/5
126
What is the basic trauma series?
AP Chest AP Pelvis
127
What are is the Ddx for hypotension in trauma
1. hemorrhage 2. obstructive (tension pneumo, tamponade) 3. distributive (could be anaphylaxis that lead to trauma) 4. cardiogenic
128
How do you treat tension pneumo?
Long needle 2nd intercostal, midclavicular, straight in. Can go more lateral mid-axillary 4th intercostal Should hear whoosh and immediate increase in blood pressure Follow with chest tubeD
129
what's the diagnosis?
Hemothorax (supine)
130
What explains the opacification of the soft tissues on the left?
emphysema (air under the skin) hear crinkling when you feel
131
What is the diagnosis?
Aortic rupture
132
What is the pelvic injury?
Superior and inferior pubic ramus fractures.
133
What's this injury?
see below, fractured rami and R SI
134
When do you need to bind the pelvis?
any time that there is pelvic instability You want to bind around the level of the trochanters
135
What is the problem here?
Widening of pubic symphysis, acetabular fracture, SI joint dislocated
136
How do you approach the head CT?
Start outside in: scalp, soft tissue swelling, skull fracture / abnormality, meninges, grey/white matter, ventricles & cisterns.
137
What is the diagnosis?
Epidural hematoma
138
What is this? Is this acute or chronic? What else do you want to know?
Subdural hematoma Acute because fresh blood is hyperdense here Ask about whether they are on anticoagulants
139
What is the finding?
Subarachnoid bleed
140
What is the difference in management after CT between the spontaneous vs traumatic hemorrhage?
Spontaneous hemorrhage = ruptured aneurysm (want interventional radiology) Traumatic (supportive care, decrease ICP)
141
What are the 4 views of the FAST exam?
RUQ (pouch of morrison, interface between right liver and right kidney) Pericardial / subxyphoid (look for pericardial effusion) LUQ (spleen / left kidney) longitudinal pelvis (bladder, vaginal vault / uterus (blood below uterus) or prostate).
142
On ultrasound, what does fresh blood look like?
Black but might be fluid, might be ascites
143
How does FAST affect your management?
+ve FAST + unstable patient = laparotomy +ve FAST + stable patient = STAT CT chest abdo pelvis -ve FAST → serial FAST if not CT scanning or reassess.
144
What are potential sources of bleeding that can contribute to hypotension in the trauma patient?
Bleeding into hemithorax, abdomen, pelvis, or long bone fracture, or external bleed
145
What do we immobilize (e.g. splint)?
Fractures (& suspected) Soft tissue injuries Infections of hand/arm Inflammation (gout, tenosynovitis)
146
What types of injuries should be splinted with a radial gutter?
Distal radius or ulna fracture Closed reduction of Colles'
147
How do you splint a boxer's fracture (4/5th metacarpal head)
Buddy tape the finger to its larger neighbour, ulnar gutter with wrist in slight extension and MCP's at 90.
148
How do you mold a thumb spica? What's it good for?
“arm wrestle position” Use a thumb spica for suspected scaphoid fracture, thumb dislocation or ulnar collateral ligament injury.
149
What are the indications for a posterior slab / elbow?
Supracondylar fracture, elbow dislocation, radial head fracture, midshaft forarm fracture.
150
What would you use to immobilize a metatarsal, or ankle, or distal tib/fib fracture?
Below knee posterior slab,
151
What vaccination status do you want to obtain on hx for a laceration?
Tetanus
152
When discharging an older adult after a fall what must you ensure they can do?
Walk on their own
153
What are some intrinsic factors that can contribute to a fall?
Cardiac (ischemia, MI, arrhythmia) , vasovagal, neurological (stroke, seizure, diabetic neuropathy), metabolic (hyponatremia, hypoglycaemia), orthostasis, postural hypotension, vision or balance impairment (e.g. vertigo), anxiety / fear of falling
154
What are some extrinsic factors that can contribute to a fall?
Medications, substance use, safety issues in the home, inconsistent gait aid use, domestic violence
155
At what GCS score should intubation to protect the airway be considered?
“Intubate at 8”
156
What workup is suggested for an older adult who presents with a fall to the ED?
CBC, extended lytes, albumin, Cr, random glucose ECG Radiographs and CT head as needed.
157
What are the geriatric 5Ms?
Mind Mobility Meds Multi-complexity what Matters Most?
158
In addition to being able to manage their ADLs, what iADLs must the older patient be capable of managing in order to have a safe discharge home?
Meal prep, housework & managing their meds.
159
In addition to age, what other factors increase the risk of delirium? (9)
1. Male 2. Polypharmacy 3. Mild cognitive impairment 4. Dementia 5. Parkinson's 6. Hearing or visual impairment 7. Malnutrition 8. Dehydration 9. Complexity / comorbitidities
160
What are the diagnostic criteria for delirium? How do you use the CAM to screen for delirium?
AIDA 1. Acute and fluctuating course 2. Inattention 3. Disorganized thinking 4. Altered level of consciousness (1+2) AND (3 OR 4)
161
How do you distinguish between the 3 Ds of cognitive impairment?
Delirium : acute, fluctuating course, altered LOC Dementia : slow, progressive course, attention preserved. Depression: low mood persists for \>2 weeks, gradual course, consciousness / memory not affected.
162
What is an approach to investigating causes of delirium?
DIMES Drugs Infections Metabolic Environmental Structural
163
What are some nonpharmacological steps we can take to manage delirium?
Get the person to a quieter area (silence alarms). Make sure they have food and water. Orient them regularly, try to mimic day/night cycle with lights. Have a support person stay with them. Avoid urinary catheters and saline lock IVs. Avoid restraints. Keep the bed low. Promote movement
164
Under what circumstances are antipsychotics indicated for delirium?
Remember: they don't make delirium better and they have side effects! Only use them if there is **risk of harm** and pt not responsive to non-pharm approaches or if **agitation interferes with medical treatment** or if patient is experiencing **emotional distress** due to hallucinations/delusions.
165
What pharmacological options can be used for delirium?
Recommend 2nd gen antipsychotics before haldol, PO before IV Low doses Risperidone 0.25-0.5 mg PO BID PRN Quetiapine 6.25-25 mg PO BID PRN Haldol 0.25-0.5 mg PO BID

Clerkship (CC3) (12 decks)

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