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1
Q

What is the preferred imaging to diagnose a parapharyngeal abscess in the ED?

A

CT of the neck

Lateral neck x-ray are the preferred initial imagining modality for RPA but do not provide useful info for parapharyngeal infections

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2
Q

Smoke inhalation exposes patients to which toxins

2

A

Carbon monoxide
Hydrogen cyanide

Treat with sodium thiosulfate

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3
Q

Treatment of carbon monoxide inhalation

A

100% oxygen and hyperbaric oxygen in severe cases

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4
Q

Treatment for hydrogen cyanide inhalation

A
  1. Induction of methemoglobinemia with nitrites (pulls cyanide off ETC)
  2. Detoxification of cyanide with thiosulfate
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5
Q

How to evaluate for suspected urethral injury

A

Retrograde urethrogram to look for extravasation of contrast

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6
Q

How do you investigate suspected testicular torsion

A

US doppler with probe over testicular artery

In ED do emergent urologic consultation and urgent orchidopexy (within 6 hours ideally)

Twisted testicle causing venous occlusion and engorgement and infarction

Sx: acute onset severe scrotal pain, swelling, retracted testicle, absent cremasteric reflex

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7
Q

What happens to troponin I after acute MI

A

Highly specific for cardiac muscle
Rises between 3-6h post infarct
Peaks 12-24 h
Normalizes within 7 days

Specificity is excellent 6 hr post infarct
Sensitivity does not approach 100% until 12 h

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8
Q

Lung abscess occur most commonly in who

A

Aspiration in patients with poor oral hygiene

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9
Q

What are the criteria for pseudotumor cerebri?

A

Raised ICP with papilledema but without mass, hydrocephalus, infection or hypertensive encephalopathy

Criteria:
1. Symptoms of raised ICP
2. No localized signs except CN V1 palsy
3. Pt awake/alert
4. Normal neuroimaging
5. LP opening pressure >25 cm H20 wuth normal CSF
6. No better explanation for increased ICP

Dandy’s Criteria

MC presenting symptom is headache worse lying down and in AM

MC complication is permanent vision loss

Women of childbearing age more commonly affected

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10
Q

Which types of meningitis do you give close contact prophylactic antibiotics to?

A

N. meningitidis and Hib
Adult: Ciprofloxacin 500 mg po
Child: Rocephin IM or Rifampin PO

Alternative: Azithromycin

Both gram -

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11
Q

Alcohol dehydrogenase has the greatest affinity for?

A

Ethanol then
Methanol then
Etylene glycol

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11
Q

Treatement for ethylene glycol poisoning

A

Dialysis is definitive treatment
Fomepizole and ethanol drop are temporiing measures to inhibit alcohol dehydrogenase from changing alcohol to its toxic metabolites

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12
Q

What are the presenting clinical features of fungal Histoplasm capsulatum pulmonary disease?

A

Asymptomatic in most people, in endemic regions at least 80-90% has positive skin testing by age 20

Endemic to Mississippi and Ohio River valley

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13
Q

When is retrograde urethrogram used

A

Patients with syspected pelvic trauma or urethral injury

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14
Q

Findings suggestive of central vertigo

A

Acute onset
Continuous
Normal head impulse test
Multidirectional nystagmus
Skew deviation present

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15
Q

Formula for determining anion gap

A

Na - Cl - HCO3
Normal should be less than 12 mM/L

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16
Q

ECG findings in PE

A

Normal sinus is most common cardiac rhythm

Sinus tachycardia is the most common cardiac arrhythmia

S1 Q3 T3

A large S wave in lead I, a Q wave in lead III and an inverted T wave in lead III together indicate acute right heart strain. This pattern only occurs in about 10% of people with pulmonary embolisms and is similar to the ECG findings of a left posterior fascicular block, or LPFB. Recall that sinus tachycardia is actually the most common ECG finding during a pulmonary embolus.

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17
Q

Reversal of warfarin therapy or vitamin K deficiency in bleeding patient or in a patient requiring urgent (<6 hours) surgery

A

Prothrombin complex concentrate

Exist as dry powder
Stored at room temp
Can be prepared in minutes
Quick infusion time
Do not need ABO typing
Contain Vitamin K dependent coag factors, protein C/S

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18
Q

What is the quickest way to correct hyperkalemia

A

Nebulized albuterol
Activate NaKATPase via B2 receptor to shift potassium into cells
(These medications stimulate the cellular uptake of potassium, helping to lower blood potassium levels)

HOWEVER GIVE CALCIUM GLUCONATE FIRST
Calcium counteracts the effects of elevated potassium on cardiac cells and helps stabilize the heart’s electrical activity.

By administering calcium, the cell membranes in the heart become less excitable, reducing the risk of life-threatening cardiac arrhythmias associated with hyperkalemia. However, it’s important to note that calcium does not lower potassium levels but rather protects the heart from the harmful effects of high potassium.

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19
Q

Define biliary colic

A

Gallstone transiently impacted in the cystic duct causing intermittent pain

vs cholecystitis where the pain is constant

Tests: Lipase to determine if pancreatitis and bilirubin to determine if bile duct obstruction

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20
Q

Hallmark of necrotizing enterocolitis on AXR

A

Intramura air
Pneumatosis intestinalis

Can also have: free air, fixed loops, ileus, thickened bowel wall, portal venous gas

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21
Q

What is the progression of liver dysfunction based on liver function tests

A

Plalets down
INR up
Albumin down
Bilirubin up

The W

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22
Q

What is the triad of Horner syndrome and what is important to be ruled out in the differential?

A

Miosis, anhidrosis, ptosis
Must rule out carotid artery dissection (bc sympathetic chain is so close in proximity) with CT angiogram

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23
Q

What is the triad of mastoiditis

A

Otorrhea
Tendersness over the mastoid
Retroauricular swelling with protruding ear

Infection of mastoid cells, MC seen 2 weeks after onset of untreated AOM

Do a CT to investigate

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24
When is a tube thoracostomy indicated?
To drain abnormal air or fluid from the pleural space Pneumothorax (if large, progressive, pt is vented, tension pneumothorax), hemothorax, empyema, pleural effusion "Pneumothorax, hemothorax, pleural effusion too, Tube thoracostomy is what you gotta do!"
25
What are signs of radial nerve injury in fractures?
Drop wrist Sensory impairment on the dorsum of the wrist Difficulty with supination **Check during humeral shaft fractures**
26
What cardioprotective agent is given in hyperkalemia?
Calcium gluconate or calcium chloride | Stabilize cardiac myocyte membrane ## Footnote Hyperkalemia can cause bradycardia
27
MC etiology of encephalitis
Viral HSV, VZV, EBV, CMX, enterovirus, parechovirus, West Nile, influenza, other respiratory viruses, HIV, mumps, measles, rabies, polio ## Footnote Enteroviruses such as coxsackie account for more than half of all cases
28
Laparotomy is mandatory if penetrating trauma and?
Shock Peritonitis Evisceration Free air in abdomen Blood in NG tube, Foley or on digital rectal exam
29
Most comonly injured organs in penetrating abdominal injury
Small bowel Liver Colon/rectum Stomach
30
What age group has the highest rate of suicide completion?
Over age 75 Male White or Indigenous Windowed or divorced
31
Findings suggestive of central vertigo
Acute and continuous Normal head impulse test Multidirectional nystagmus Skew deviation present
32
Treatment for acute cholecystitis
IV AB
33
Treatment of beta blocker overdose
Glucagon, calcium cloride, insulin with dextrose, | Causes bradycardia, AV block, hypotension
34
Most common pediatric elbow fracture | FOOSH
Spracondylar fracture MC ~ 7 years old, rare in adults Can injury the median nerve Treat with long arm plaster slab If displaced > 50% then consider surgery
35
Clinical features of chorioamnionitis
Temperature Tachycardia Tenderness of uterus Foul discharge | RX IV Ampicillin gentamycin clindaycin ## Footnote Suspect in pregnant lady with PROM
36
How to tell if source of bleeding is fetal?
Apt test NaOH mixed with blood If supernatant turns pink it is fetal and if it turns yellow it is maternal
37
Classic neurological deficit in central cord syndrome
Upper extremity weakness greater than lower Caused by cervical motor axons being closer to the midline than the lumbar motor axons
38
What are the symptoms of anterior cord syndrome?
Deficit of **bilateral motor function and pain/temperature sensation** with sparing of vibration/position sensation
39
Treatment for S pneumoniae pneumonia in a pediatric patient
Amoxicillin or cefuroxime or cefotaxime
40
MC etiology of endocarditis of a prosthetic valve vs native valve
Coag negative Staph vs Streptococcus viridan
41
Classic triad of NPH | Normal pressure hydrocephalus
Wet - incontinence wacky - dementia wobbly - ataxia
42
Which antihypertensives are safe and effective in pregnancy for rapid control of BP?
Labetalol or hydralazine
43
How does ondansetron work?
Serotonin 3 receptor blocker that reduces intestinal fluid secretion | Used for diarrhea
44
What kidney stones are radiolucent?
Uric acid stones Occur 10% of the time
45
What is the FAST scan for?
Designed to assess for hemoperitoneum U/S of the RUQ, LUQ suprapubic and subxiphoid regions SX view is to check for effusion or tamponade
46
Managements of shoulder dystocia
McRoberts manuever and suprapubic pressure resolve 90% of cases Hyperflexion of the materal hips (mom's knees to chest) which moves the symphysis pubis over the fetal anterior shoulder ## Footnote Can further try to release the posterior shoulder by rotating it anteriorly with hand in the vagina, manual corkscrew, episiotomy, rollover (on hands and knees)
47
Nystagmus that changes direction based on the gaze direction is suggestive of what type of vertigo
Central cause
48
Where does the rash of meningococcemia start?
Petechiae of wrists and ankles (can also be light pink macules that become petechiae later) They look smudged and can have gray centers
49
What antibiotics are indicated for the most common pathogens in the neonatal period
Cefotaxime Ampicillin | GBS, streptococci, gram - bacilli, pneumococcus, Listeria
50
Describe the rash of RMSF
Starts on wrists and ankles then spread centrally to arms, legs, trunk, palms, soles 10% of patients are _spotless_ | Investigate with skin biopsy and serology (indirect fluorescent AB test) ## Footnote Treat with doxycycline
51
Symptoms of cholinergic toxidrome
SLUDGE Salivation, lacrimation, urination, defecation, GI upset, emesis BBB Bronchorrhea, bronchospasm, bradycardia Muscle weakness, flaccid paralysis | Rx atropine and pralidoxime
52
What malignancy is associated with hyperviscosity syndrome (leukostasis)?
AML - Severely elevated WBCs > 50 x 10^9 per L | Can occur in ALL, CML and CLL but only rarely symptomatic ## Footnote Leukostasis is a medical emergency - large number of blasts interfere with circulation and lead to hypoxia and hemorrhage and can cause diffuse pulmonary infiltrate, CNS bleeding, respiratory distress, AMS, and priapism Treat with cytoreductive therapy ie hydroxyurea
53
Next step in management if you suspect bacterial meningitis?
Give ANTIBIOTICS before the LP Dexamethasone + ceftriazone + vancomycin | Report to Public Health
54
When CD4 count drops to below 250 cells per mcl what infection is commonly seen in AIDS patients?
Pneumocutis pneumonia Funcgal opportunistic infection Extertional dyspnea, non productive cough, low grade fever, malaise | Treat with TMP SMX and add corticosteroid if Pa)2 < 70 mmHg ## Footnote 2nd line therapy = pentamidine
55
How to treat SSRI overdose
Generally benign in overdose causing mild GI and CNS symptoms and rarely causing cardiac abnormality
56
Most common complication of mitral stenosis
Atrial fibrillation This is due to severe atrial hypertrophy that results from the stenosed mitral valve preventing flow into the left ventricle
57
Treatment of tubo ovarian abscess
Ampicillin + clindamycin + gentamycin ## Footnote Abscesses 4-6 cm in diamete respond well to AB 85% of the time >10cm in diamete require surgery
58
Wernicke triad
Ataxia Confusion/delirium Ophthalmoplegia/nystagmus Can progress to Korsakoff which is anterograde amnesia and compensatory confabulation | Rx Thiamine
59
Treatment of magnesium sulfate toxicity | Mag sulfate is used is preeclampsia
Calcium gluconate
60
Common cause of epididymitis | Hint: two age groups
< 35 yo = N gonorrhea or C trachomatis > 35 yo or anal intercourse = E coli | Treat < 35 with ceftriaxone and doxy, treat >35 with ofloxacin or TMPSMX ## Footnote Sudden onset scroal pain and swelling with radiation to flank, relief of pain when lifting testicle, fever, normal cremaster reflex
61
What do macrolide drugs cover for? | Erythromycin, azithromycin and clarithromycin
Legionella, Chlamydia pneumoniae, Mycoplasma H influenza S pneumo
62
What neurological condition should be suspected in a fat, fertile female with diffuse headaches or visual symptoms?
Pseudotumor cerebri aka idiopathic intracranial hypertension ## Footnote Rx lifestyle change, acetazolamide to decrease CSF, thiazide/furosemide and if all these fail consider serial LPs or ventriculoperitoneal shunt placement Follow q2y, repeat imaging to monitor for tumor, ophthalmology follow up
63
HSP triad
Palpable purpura Abdominal pain Arthritis | Vasculitis of small vessels often with URTI 1-3 wk prior ## Footnote The rash of HSP is characteristic: A maculopapular eruption on the legs and buttocks and almost never involving the upper extremities or trunk.
64
Test of choice for diagnosing aortic dissection
CT angiogram | MRI is most specific but less convenient
65
Antipseudomonal antibiotics
Cephalosporins (ceftazidime, cefepime), beta lactam or beta lactamase inhibitors (piperacillin/tazobactam), monobactams (aztreonam), carbapenems (imipenem, meropenem), aminoglycosides, fluoroquinolones
66
Two types of necrotizing fasciitis
Type 1: polymicrobial (MC in immunocompromised) Type 2: monomicrobial, usually GAS (MC in healthy) | Rapidly spreading painful infection of fascia with necrosis of tissue ## Footnote Rx urgent surgical debridement of all necrotic tissue then penicillin + clindamycin or vancomycin + clindamycin
67
What does ampicillin-sulbactam cover
Anaerobes and gram -s
68
Treatment for beta blocker overdose
Supportive If having cardiovascular complications consider IV fluids, atropine, glucagon and calcium If still having problems consider epinephrine If STILL having problems use insulin and glucose ## Footnote Dialysis is worthless to try
69
MRSA treatment
Doxycycline
70
Indications for replantation
1. Age: kids better results than adults 2. Thumb and multiple digit are higher priority 3. Multiple LEVEL amputation is a **contraindication** 4. Clean cut have greater success 5. Avulsion and crush are **relative contraindications** 6. Wrist and forearm amputations 7. Single digit between PIP and DIP
71
Round, red, tender nodules asymmetrically arranged on shins, knees, arms with associated arthralgia and malaise
Likely erythema nodosum Acute or chronic inflammation of subcutaneous fat 40% idiopathic Other causes: sulfonamides, OCP, pregnancy, GAS, TB, Yersinia, sacois, Crohn's>UC, Hodgkin's ## Footnote Treat underlying cause, consider high dose ASA or NSAIDs (naproxen or indomethacin) and bed rest
72
LP findings in pseudotumor cerebri
- Increased opening pressure > 25 cm H20 - NORMAL CSF Side note: 6th cranial nerve most often affected which can cause double vision and headaches | Do MRI of brain ## Footnote Treat wth acetazolamide, thiazide, or durosemide and if all else fails do serial LPs with subsequent shunt placement
73
What to do for ASA overdose?
GI decontamination (charcoal), hydration, enhanced excretion Alkalinize urine with IV bicarb with a urine pH goal of 7.5 - 8 MAY NEED HEMODIALYSIS
74
What kind of surgery is done for pancreatitis?
Acute - can consider endoscopic sphincterotomy if severe gallstone pancreatitis but there are no other surgical options available, everything is supportive therapy Chronic - As above as needed but remember neither endoscopy nor surgery can improve pancreatic function
75
What are the four stages of hepatic encephalopathy?
1: apathy, restlessness, reversal of sleep wake cycles, impaired handwriting 2: asterixis, lethargy, drowsy, disoriented 3: stupor but rousable, hyperactive reflexes, upgong Babinski 4: coma (responds to pain only)
76
Most important sign of compartment syndrome? Symptom?
Sign = pain with passive stretch Symptom = pain out of proprtion to injury | rx remove constrictive dressings, elevate limb, urgent fasciotomy ## Footnote Pain (not relieved by analgesics), paresthesia, paralysis/pulselessness/pallor (late findings)
77
UTI treatment
Simple - TMP SMX or nitrofurantoin Complicated - cipro or ampicillin/gentamycin or ceftriaxone
78
Cause of asymptomatic urethritis
Non gonococcal (usually C. trachomatis) | Rx azithromycin or doxy + ceftriaxone (to cover for gonococcal in case) ## Footnote More common in men < 20 years old **treat partner too**
79
Features of neuroleptic malignant syndrome
FARM Fever Autonomic changes (increased HR/BP or sweaty) Rigidity of muscles Mental status change **Also seen in serotonin syndrome - distinguish by NMS does not have GI symptoms and there is severe global rigidity vs SS where the patient is twitchy and restless, flushed and HAS GI SYMPTOMS (vomiting, diarrhea, abd pain)** | PSYCHIATRIC EMERGENCY ## Footnote Rx stop drug, hydrate, cool, maybe dantrolene (muscle relax) or bromocriptine (DA agonist) Emerg book says benzos are also a treatmentbut not in TO notes so???
80
What is a myxedema coma?
Medical emergency - severe hypothyroidism - 40% mortality **Hallmark: decreased mental status and hypothermia** Also can have hyponatremia, hypotension, hypoglycemia, hypoventilation, bradycardia, non pitting generalized edema ## Footnote ADMIT TO ICU, corticosteroids, give L-thyroxine, mechanical vent if needed, vasopressors, rewarming, IV detrose, fluids MONITOR FOR ARRHYTHMIA
81
Throbbing pain vs stabbing pain in headaches
Throbbing on one side = migraine Stabbing behind or around eyes = cluster
82
Diagnosis and treatment of B pertussis
Diagnose = nasopharyngeal specimen with aspirate or swab and culture with Regan Lowe agar Can also do serology for antibodies Look for LYMPHOCYTOSIS on CBC Manage with macrolides (azithro, erthyro, clarithro) and give to household contacts Report to Public Health | Prolonged resp illness characterized by inspiratory **WHOOP** and cough ## Footnote Very contagious - becoming more common in older individuals (not often in younger because of vaccination) Vaccination DOES NOT confer lifelong immunity
83
Treatment of thyroid storm
Fluids, electrolytes, vaopressors Cooling blanket, acetaminophen Propanolol (but be careful in CHF) Glucocorticoids (stop peripheral conversion of T4 to T3) Cholestyramine (reduces enterohepatic recirculation of thyroid hormone) **PTU is the anti thyroid drug of choice and used in high doses**, give iodide 1 hour later (acute inhibits release of thyroid hormone) as sodium iodide, Lugol's solution or potassium iodide
84
qSOFA for septic shock criteria
- Respiratory rate ≥22/min - Altered mentation - Systolic blood pressure ≤100 mmHg

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