EM Clerkship podcast Flashcards
(83 cards)
1
Q
Toradol
-dose
A
10,15,30,60mg q6h
therapeutic ceiling of 10mg
2
Q
Syncope: full approach
A
6-6-6
1. Look for 6 high risk EKG: QT-BRIDE QT Brugada Right heart strain Ischemia Delta waves (WPW) Epsilon (ARVD)
- 6 HIGH RISK Hx findings (CHESS + FH)
CHF Hct <30 Elderly SOB SBP <90 FH of sudden cardiac death
- 6 Deadly syncope mimics:
SAH PE GI Perf/Ectopic AAA Aortic Dissection MI
3
Q
Non-preg vag bleeding:
(Preg test negative)
approach, steps
A
- Pelvic exam
- Labs: CBC, Coags, TSH
- U/S
- Tx with NSAIDs (helps vag bleeding and pain)
- Tx DUB with hormones–Progesterone OCP. This stabilizes hormone axis, builds endometrium, and when pt stops taking, will bleed and finish cycle.
4
Q
Vertigo, approach
A
- DESCRIPTION typical of Central vertigo?
central: mild, vague, non-specific
peripheral: severe, sudden, N/V - SXS typical of Central? (4 DANGEROUS D’s)
Diplopia, Dysphagia, Dysarthria, Dysmetria - RISK FACTORS for Central?
- stroke, trauma, etc - NEURO EXAM consistent with Central?
- Tx
- central: MRI, CT Head/neck
- peripheral: meclizine
5
Q
Priapism: what are types? and difference
A
- High flow ( non ischemic)
- not painful
- trauma, malformations, etc
- Urology c/s - Low flow (ischemic, COMPARTMENT SYNDROME)
- painful, 50% chance future ED
- Drugs, Sickle cell
- Do bedside pressure release
6
Q
Chest pain: ACS questions to always ask, specific for ACS
A
4 specific findings
- worse with exertion
- radiation to right shoulder
- vomiting
- diaphoresis
7
Q
Toxicology approach:
- tox exam?
- tox labs?
A
- airway
- hx
- FOCUSED TOX EXAM: Vitals, Skin, Pupils
- GET MED LIST, and bottles
- Tox labs:
- EKG, LFTs, BMP
- Blood levels (APAP, aspirin, ETOH)
- UDS (?)
8
Q
Procedural sedation meds (5)
- dose, dose for adult
- onset, duration
- pros, cons
A
- Versed (combine with Fentanyl)
0.05 mg/kg, 2mg adult
3-5min, 30-60min
no analgesia, resp depress, hypotension - Fentanyl (combine with Versed)
1 mcg/kg, 70mcg adult
<1min, 30-60min
minimal hypotension, low sedation - Propofol
1mg/kg (0.5 redose q3min), 70 mcg adult and 35mcg
<1min, 3-5min
Hypotension (have IVF), resp depress - Etomidate
0.015 mg/kg, 10mg adult
30-60 sec, 5-10 min
No hypotension, myoclonus, N/V - Ketamine
1-2mg/kg, 70mg adult
1-3 min, 10-15 min
Emergency rxn, laryngospasm, hypersalivation
9
Q
Leg trauma: What not to miss?
A
Maisonneuve fx:
spiral fx of prox 1/3 fibula, and tear of distal tib-fib intraosseous membrane. (often assoc ankle fx)
10
Q
ABCs: BREATHING–Steps to remember
A
Hypoxia kills quickly! Give O2 in 2 ways:
- Add FiO2
If pt breathing: Non-rebreather mask
If NOT breathing: Bag-Valve mask - Add PEEP
If pt breathing: BIPAP
If NOT breathing: Intubation
11
Q
Dental Pain, approach
-dx to know (3)
A
- number the tooth
- choose dx (pulpitis, gingivitis, periapical abscess)
- pain meds
- consider abx (Pen VK for periapical abcess and bad gingivitis, none for pulpitis)
can do inf alveolar nerve block
12
Q
Stroke: approach
A
- last known well?
- fingerstick glucose!!!
- CT Head
- NIHSS
- give TPA if no contraindications
13
Q
C-Spine injury, approach, steps, decision rule
A
- Airway+C-spine (put cervical collar)
2. Apply NEXUS: "SPINE" CT if any positive Spinal midline tenderness Painful distracting injury Intoxication Neuro deficit Encephalopathy
- If NEXUS negative: move head 45 left/right, and touch chin to chest. Can clear C-Spine. Otherwise leave on C-Collar
14
Q
Neck soft tissue injury: approach
- blunt
- penetrating
- what are Hard signs
A
blunt: get CTA if:
- neuro deficit
- forceful impact to neck
- Fx of basilar skull, facial bone, or c-spine
penetrating (of platysma):
- if unstable–> OR
- if stable, Hard signs –> OR
- stable, no Hard signs –> CTA
Hard signs: "HARD Bruit" Hemoptysis/hematemesis/hypotension Art bleeding Rapidly expanding hematoma Deficit (neuro Bruit
15
Q
Fingertip injuries:
- approach, steps?
- what kinds of repair scenarios?
A
If any 5 injury criteria met, needs Hand consult. Otherwise:
- Tetanus needed?
- XR finger (Fx or foreign body?)
- Digital block, clean wound
- Repair scenarios (3)
- partial amputation–sew back on
- full amputation, tip good–sew back on
- full amputation, tip not good–put abx ointment, then wrap it up - F/u with hand surgeon in few days
16
Q
First 5 minutes of crashing pt
5 steps per podcast
A
- Vitals
- ABCs, rapid
- 3 stat RN orders: IV, monitor, draw blood (hold it for now)
- 3 stat meds to consider:
naloxone, ativan, epi - 3 stat tests, bedside:
EKG, preg, fingerstick glucose
17
Q
PERC
A
Think Wells, very similar. 8 total, 3 different.
- Unilateral leg swelling (ie Clinical signs/sxs DVT)
- HR >100
- Age >50
- O2 <95%
- Hx of DVT/PE
- Recent surgery/trauma
- Hemoptysis
- Estrogen
18
Q
Chest pain: PE questions to always ask
A
5 questions to cover Wells and PERC:
- Hx blood clot?
- Recent surgery/trauma?
- Hemoptysis?
- Cancer?
- Estrogen?
19
Q
Pre-eclampsia
-what labs to always order?
A
- LFTs (HELLP)
- CBC (low platelets, hemolysis)
- UA (look for protein)
- BMP
20
Q
Urethral injury:
posterior is usu caused by?
ant usu caused by?
A
post: pelvic fx, rapid decel trauma
ant: straddle injury
21
Q
Dilaudid IV/IM
-dose
A
0.015 mg/kg
1mg in adults q2h PRN
22
Q
GU injury, trauma: approach, steps
-Injury types to know
A
- get Pelvic Xray first
- Look for blood in perineum
- UA, looking for hematuria (amount does not correlate with severity)
1) kidney injury–CT w/ con
2) ureter–CT w/con
3) bladder–retro cystogram
4) urethra (post/ant)–retro urethrogram
23
Q
PE:
approach
A
- everyone with possible signs/sxs enters “pathway”
- exclude everyone with OBVIOUS other cause
- Wells to risk stratify.
If low risk, PERC.
If med, D-dimer or CT now
If high, CT now, consider empiric anticoag
24
Q
Tylenol OD
- phases
- what shows on labs and sxs?
A
- Day 1–ingestion
high APAP level, nl LFTs, asx maybe nausea - Day 2–Valley
mild elevation APAP, mild elevation LFTs
-RUQ pain, jaundice - Day 3–Sever
low APAP level (absorbed), high LFTs
-symptomatic - death (70% survive)
25
Aspirin OD:
- what labs abnormal?
- how to tx? mild vs severe
- mixed met acid and resp alk on Blood gas
mild: alkalinize urine (Na HCO3)
severe: dialysis
26
AMS Differential:
| -and, what labs/imaging/tx based on it?
AEIOU TIPS
```
Alcohol--BAL, thiamine
Electrolytes/Endocrine--BMP, TSH
Ischemia (Cardiac)--EKG, Trops
Opiates--naloxone
Uremia
```
Trauma--CT Head
Infxn--CBC, LP, CXR, UA
Poisoning--tox labs
Stroke/seizure--CT Head, full neuro exam
27
HyperCa+ sxs
Bones, stone, groans, psychiatric overtones
28
What is most common factor with missing PE dx?
What % of pts admitted for COPD actually have PE?
What % of pts admitted for syncope, unknown cause, have PE?
Infiltrate on CXR (infarcted lung can look like PNA)
1 in 4!
1 in 6!
29
Fingertip injuries:
| hand surgeon c/s criteria (5)
1. infection
2. contaminated
3. fx
4. if you can see bone
5. extends past cuticle
30
Hyperkalemia, tx
C BIG K Di/Di
Calcium chloride 1 amp (can use Ca gluconate if have time)
Beta agonist (and Bicarb)
Insulin+Glucose (D50)
Kayexalate
Diuresis
Dialysis
31
Pre-eclampsia tx and meds
Magnesium (beware low reflexes)
| reduce BP with labetalol or hydralazine
32
contraindications to NSAIDs: (5)
1. pregnant
2. GI ulcer
3. elderly
4. cardiac
5. Renal
33
Norco
- dose
- max
q4-6h
5,7.5,10-325
34
Wells score
| and points? what is low and high risk
7 things: 3 exam, 4 history
1. Clinical signs/sxs of DVT--3
2. PE is #1 dx or equally likely--3
3. HR>100--1.5
4. Hx of DVT/PE--1.5
5. Recent surgery/immobilization--1.5
6. Hemoptysis--1
7. Cancer--1
Low: <2
High >6
35
Lac (eval)
| -approach, steps
4 steps:
1. Hx--5 things, thinking about infection risk
- Chronic dz
- Age of wound
- location
- mech
- foreign body/contamination?
2. Tetanus?
3. Exam:
- include motor/sensory/cap refill distal to wound
4. Xray? (search for foreign bodies)
36
Face injury: Dangerous thing for each facial area (6)
Forehead: Sinus wall fx (internal frontal sinus wall)
Eyes/Orbits: Orbital blowout fx with trapped extraocular muscles
Nose: Septal hematoma
Zygoma (cheekbone): Tripod fx
Maxilla: Le Fort fx
Mandible: Lac inside mouth
37
Face injury, basic approach
1. airway of course
2. CT maxillofacial w/o contrast
3. supportive care (that's it)
- pain meds, ice, stop bleeding
4. Abx, consider in sinus and open fx
5. consult
38
Epistaxis:
| Do what? in what order of steps? (4)
1. clear nose, visualize bleed
2. spray Afrin (can repeat)
3. Cauterize with Silver Nitrate (can provide local anesthesia by soaking gauze in 4% lido or cocaine, leave in nose 10 min)
4. Pack nose with gauze
39
Non-pregnant vag bleeding:
| -think what DDX categories?
1. Structural
- esp MALIGNANCY in post menopausal
- also fibroids, polyps, adenomyosis
2. Coagulopathy (20%)
3. Hormonal (DUB, anovulatory bleeding)
40
Severe sepsis criteria:
- big 2
- others (6)
Septic shock criteria
Sepsis with organ dysfunction:
BP<90 or -40 below baseline
Lactate >2
```
Cr>2
Bili >4
Plt <100k
INR >1.5
UOP <0.5ml/kg/h for 2h despite adequate resus
```
Acute lung injury (paO2/FiO2 ratios)
Septic shock:
1. lactate >4, OR
2. Hypotension not responsive to IVF
41
1st trimester vag bleeding:
after pregnancy test positive,
-what tests need to get everytime?
5 tests:
1. CBC
2. T+S (both for transfuse and Rhogam)
3. Quant HCG (1500 discrim)
4. UA (if asx UTI, must tx in preg)
5. U/S, Pelvic
42
Epistaxis: locations of bleed and cause (2)
which is MCC
which is most severe
1. Anterior: kiesselbach's plexus, MCC
| 2. post: sphenopalatine artery (most severe)
43
Chest pain life-threatening differential (6 cardiopulmonary)
heart: ACS, tamponade
lungs: PNA, PTX
vascular: PE, aortic dissection
also esophageal rupture
44
Ibuprofen
- dose
- max
400-800mg q6-8h
| -max 3200mg
45
Narcotics:
| what are the 5 Rx rules?
1. Check database!
2. Never for chronic non-CA pain
3. Never for acute flares of Chronic pain
4. Unless acute pain now, do not rx in pts who are already Rx'ed narcotics or sedatives (eg BZDs)
5. 3 days max!
46
STEMI: what steps to do?
| -include drugs and their doses
1. call STEMI alert
2. stop Platelets
- Aspirin 325mg
- Plavix 600mg
3. stop Coag cascade
- Heparin 60U/kg (max 4000 U)
4. Cath lab
Other drugs:
- Nitro 0.4mg SL q5min (x3 doses)
- Nitro gtt 10mcg/min (titrate UP)
- morphine 4mg IV q5min PRN pain
47
HA: Differential?
King, Queen, 3/3/3
KING: SAH
QUEEN: Meningitis
3 Killers in BRAIN:
- Stroke
- Hematoma
- Tumors/elevated ICP
3 Killers in VESSELS
- Arterial dissection
- Brain DVT
- Temporal arteritis
3 Killers in MISCELLANEOUS
- Glaucoma
- Preeclampsia
- CO poisoning
48
Laceration eval:
| -what to know about when doing XR for foreign body?
Wood does not show up on XR
49
Aspirin OD:
when to suspect?
what are sxs?
"great mimicker of EM," can look like sepsis with abd pain
ASA does 2 things: stim brain, and stim GI
Brain:
tachypnea (most classic), fever, AMS
GI:
Abd pain, N/V
50
```
Head injury: approach
DDx?
important Hx
important Exam
next step
```
1. Big 5
- skull fx
- epidural, subdural hematoma
- SAH
- parenchymal injury (concussion)
2. important Hx
- mechanism
- LOC?
- blood thinners?
3. Exam
- GCS
- pupils
- basilar skull fx signs (battle's sign, raccoon eyes, CSF rhino/otorrhea, hemotympanum)
4. Canadian Head CT rule
51
Sore throat:
- approach:
- life threatening ddx?
1. CENTOR criteria
2. if GAS, amox/pen
3. steroids
4. consider Mono
```
Big 4 life-threatening:
Ludwig's
PTA
RPA
Epiglottitis
```
52
Pre-eclampsia: what's def?
| who to check?
BP >135/85, plus proteinuria
| Check BP on every pregnant female >20 weeks
53
Canadian Head CT rule (7)
- GCS <15, 2h post injury
- Suspected open or depressed skull fx
- Basilar skull fx signs
- vomiting x2
- Age >65
- Amnesia, >30 min retrograde prior to event
- "dangerous" mech (auto v ped, fall >3ft, ejected from car)
54
Tylenol:
- dose
- max
650mg q4-6h
| max 3-4g/day
55
CENTOR criteria
| -how scoring works
1. Fever >38
2. No cough
3. Tender LAD
4. Tonsillar exudate
5. Age <15 (>45 is -1 point))
1 point: no further testing
2: optional
3: do rapid strep/culture
56
Leg trauma, Ottawa rules:
Foot
Ankle
Knee
Foot:
- unable to bear weight after injury/in ED
- TTP navicular
- TTP 5th metatarsal
Ankle:
- unable to bear weight after injury/ED
- TTP 6cm post lat malleolus
- TTP 6cm post med malleolus
Knee:
- unable to bear weight after injury/ED
- TTP patella
- TTP prox head of fibula
- unable to flex knee 90 degrees
57
C-spine fractures
Jefferson Bit Off A Hangman's Tit
```
Jefferson fx
Bilateral facet d/l
Odontoid fx
Atlantooccipital d/l
Hangman's fx
Teardrop fx
```
58
Pregnancy injury, trauma:
| approach, steps
1. Left lateral decubitus (pressure off vessels)
2. Palpate fundus.
if you can feel fundus above umbilicus, >20weeks. beware Abruption
3. OB U/S
- look for abruption/free fluid
4. T+S (assess Rh status)
5. FHR monitoring for all >20weeks. Help f/o Abruption
59
Sgarbossa's criteria
LBBB plus:
1. Concordant ST elevation >1mm in leads with positive QRS
or
2. Concordant ST depression >1mm in leads with negative QRS in V1-3
or
3. Discordant ST elevation (>5mm) in leads with negative QRS
60
Pre-eclampsia
| -Sxs to know and ask?
Big 4:
1. HA
2. vision change
3. abd pain
4. swelling
61
Priapism: approach (5 main steps)
1. Prepare
- 19 and 21G needles, Penile nerve block
2. Drain
- 19G needle at 3/9 o'clock, aspirate
3. Send VBG
4. Irrigate
- 21G more proximal (stil 3/9 o clock), inject NS, aspirate from 19G
5. Phenyl
- Inject
62
Dangerous mechs of Canadian Head CT
1. auto v ped
2. ejected from car
3. Fall, >3 ft
63
Morphine IV/IM
| -dose
0.1mg/kg, q3-4h
| approx 7mg in adults
64
Heart injury, trauma:
| 3 critical dx, how to dx and what tx?
Tamponade--U/S, pericardiocentesis, then thoracotomy if doesn't work
Dissection--(CXR widening, unequal pulses), CTA, esmolol, then nitroprusside. then surg c/s
Cardiac contusion--(check EKG, trops, admit for monitoring for arrhythmias)
65
Lung injury, trauma:
| 3 critical dx
Tension PTX
open PTX
hemothorax
all chest tube
66
ABCs: CIRCULATION--Steps to remember
Think: Tank, Clogged pipes, Broken pipes, Pump
1. Fill Tank
- IVF
2. Consider Clogged pipes
1) tamponade (U/S, pericardiocentesis)
2) tension PTX (clinical or U/S, needle decompress+chest tube)
3) PE (clinical or CT or U/S, TPA)
3. Squeeze Broken pipes
- Pressors
4. Check Pump
- EKG
- ischemia: cath lab
- arrythmia: shock
67
AMS approach steps:
1. airway
2. POC labs: Fingerstick glucose, EKG, Pregnancy
3. consider Naloxone (0.4mg)
4. AEIOU TIPS
68
SIRS, qSOFA
T 36-38
HR >90
RR>20
WBC 4-12
SBP <100
AMS (GCS<15)
RR >22
69
Sepsis steps:
1. Sepsis? (SIRS vs qSOFA, with source)
2. Severe sepsis? Give 3 hour bundle (3h, 3 things)
- Lactate, Blood cx, Abx.
- admit ICU
3. Septic shock? (hypotensive or lactate>4)
GIVE 30ml/kg IVF
4. Still hypotensive:
PRESSORS
70
Hemoptysis
| -approach
Think 3 types:
1. super mild, streaky
2. scary, but stable
3. tons of blood, crashing
1. probably bronchitis. Almost NTD. Do CXR to screen for other causes. D/C home with f/u
2. Workup: Labs + CT
- CBC, coags, BMP, UA
3. INTUBATE, BRONCH, CONSULT (Ct surg or IR)
71
Back pain:
- Approach, what to ask, ddx
- what meds for pain
Simple: Red flags, then XR and MRI. Otherwise, no imaging and outpt.
Big 5!
1. Aorta (AAA, dissection)--tearing pain, abnormal pulses
2. Infxn--F/C, IVDU, immunosuppress--HIV, DM
3. Cord compress--full neuro exam, esp post void residual rectal tone
4. Fx--trauma?
5. CA--CA questions
MSK Pain: no opiates. naproxen or Flexeril. Tell pt to keep walking
72
SOB: approach to thinking DDx
Go by anatomy (not complete ddx):
Upper airway: obstruction, anaphylaxis--stridor
Lower airway: asthma, COPD
Alveoli: PNA, pulm edema
Blood: anemia, acidosis (sepsis, DKA), Toxins (eg aspirin)
Vessels: PE
Heart: MI/ACS, CHF
73
Abd pain:
- general approach, things to be aware of per podcast
- core 8 labs
- dispo
1. Risk stratify (elderly, immunocompromised, diabetic are high risk)
2. Consider GU causes (do GU exam!)
```
3. Core 8 labs:
CBC, BMP
LFT, Lipase
EKG, Troponins
UA, UPreg
(Lactate, blood cx, and Urine cx as necessary)
```
4. Imaging
5. Dispo: f/u in 12-24h, in ED if necessary!
74
Hemoptysis
| -ddx
Bronchitis--mcc
TB--mcc world
PNA
PE
CA
Vasculitis (eg wegeners, goodpasture)
75
ABC's: AIRWAY--Steps to remember
1. SUCTION!!
2. move tongue
- head tilt, jaw thrust, chin lift
- NP, OP airways
76
Upper GI bleed
- ddx?
- hx
- labs, workup
king/queen: varices, PUD
HISTORY! for risk factors:
Varices: liver dz, alcohol use
PUD: NSAID use, steroids
2 IVs
CBC, CMP (look for high BUN), Coags, T+S,
Protonix
If varices suspected: abx and octreotide
77
COPD/Asthma
| -all txs
10 things in order:
1,2,3: duonebs, steroids
4,5 for COPD: BIPAP and abx
```
6 mag sulfate (relaxes stuff, think OD no reflexes)
7 ketamine (helps calm pt, reduce spasm)
8 epi (think as systemic albuterol)
9 heliox
10 intubate
```
78
Seizure: how to take hx
be as detailed as you can. include TIME:
Tongue biting
incontinence
med change
ETOH
79
status epilepticus
| -what order of meds
1. BZD
2. AED. can try up to 3. fospheny, keppra, depakote
3. If 30 min no result, then start drip to sedate. Versed, propofol, or phenobarb. Pt now sedated
4. do continuous EEG
80
What rhythm assoc with WPW that is dangerous?
Irregular wide complex tachycardia.
WPW with Afib
Don't use AV blockers.
81
Crystalloids vs Colloid:
how much fluid stays intravascular?
ECF: how much intravascular?
Crystalloid: 1/4. so 1L is 250cc
Colloid: 3/4. so 0750cc
ECF: 1/4 intravascular, 3/4 interstitial
82
anaphylaxis:
- criteria?
- dose adult/peds Epi
- what home med to be aware in anaphylaxis? and what to know
- other meds
2 organ systems:
skin, pulm, CV (hypotension), GI
1: 1000 0.3-0.5 ml Epi (0.3 in epipen)
0. 01mg/kg for peds (0.15 in pedipen)
BB can cancel out Epi. If Epi no response, give antidote to BB (glucagon 1-3mg q5min)
benadryl 50, famotidine 20/ranitidine 50, solumedrol 125
83
Bradycardia
- ddx
- tx
```
'HE DIES'
hypoT
elevated ICP
DRUGS
ISCHEMIA
ELECTROLYTES
sick sinus
```
0.5mg atropine, up to 3mg
Epi gtt
Transcut pacing
