EM extras Flashcards
what is the heart score used for?
ED scoring system that predicts likelihood of a person to have a major adverse cardiac event when the patient presents with chest pain
heart score system
Hx
highly suspicious 2
Moderately suspicious 1
slightly or non suspicious 0
ECG
significant ST depression 2
nonspecific repol disturbance 1
normal 0
Age
> 65 yr 2
45-65 1
<45 0
risk factors
>3 risk factors or hx of atherosclerotic dz 2
1 or 2 risk factors 1
no risk factors 0
troponin- one time*
>3x normal limit 2
1-3x normal limit 1
< normal limit 0
low risk 0-3 (1.7%)
moderate risk 4-6 (16.6%)
high risk 7-10 (50.1%)
life threatening differentials of chest pain (6)
PETMAC Pulmonary embolism esophageal rupture tension pneumo MI aortic dissection cardiac tamponade
some differentials of chest pain (not as emergent)
Gastroesophageal Reflux Herpes Zoster Thoracic Root Compression Panic Disorder Aortic Stenosis Mediastinal Mass Biliary Disease Costochondritis Pneumonia Rib Fracture Pleurisy Pneumothorax Pericarditis Lung Cancer Pneumomediastinum Splenic Infarction
most predictive signs of ACS? (4)
vomiting, diaphoresis, dyspnea, and radiation to both arms
all the lab tests automatically ordered for chest pain?
IV EKG cardiac monitoring chest x-ray CBC BMP/CMP troponin \+/- lipase
what meds do we give chest pt patients?
1) . aspirin 324 mg PO
2) . nitro 0.4ml SL every 5 mins up to 3 doses
3) . analgesia
4) . O2 if needed
treatment of STEMI
PCI is preferred
- CABG if occlusion >3 vessels, L main coronary occlusion, or low ejection fraction
- thrombolytic therapy if cant transfer pt to a PCI facility within 90 mins
what ED anticoagulation is used for pts with STEMI or NSTEMI
unfractionated heparin
aortic dissection symptoms (6)
tearing/ripping chest pain radiating to back pain dec peripheral pulses HTN new murmur (aortic regurg) neuro deficits
how to diagnose aortic dissection?
chest pain workup plus CTA chest
tx of aortic dissection
urgent surgery (unless distal dissection without complications- then medical management)
what are the ED goals for HR and BP (aortic dissection)? what meds to use?
HR- less than 60BPM -- esmolol BP- systolic BP 100-120 -- nicardipine **helps decrease shearing force on aorta
what triad is seen with cardiac tamponade?
beck’s:
muffled heart sounds +
increased jugular venous pressure +
hypotension +
signs and symptoms of cardiac tamponade?
dyspnea, fatigue, peripheral edema, shock
BECK’s TRIAD
how to diagnose and treat cardiac tamponade?
dx: beside US
tx: pericardiocentesis and then surgery
what is ACS?
acute plaque rupture and coronary artery occlusion causing myocardial ischemia
women, DM, and elderly patients might present with these ACS symptoms
weakness, abdominal pain, jaw pain, or dyspnea WITHOUT chest pain
ACS: ischemic EKG vs elevated troponin tells you what?
ischemic EKG = STEMI
high trop = NSTEMI
ACS EKG changes
STEMI- ST elevation
what are the two categories of mental status that can be altered?
1). content of consciousness- ORIENTATION
Or
2). level of consciousness- AROUSAL
types of orientation AMS and what are they?
confusion- alteration in content
delirium- acute alteration in content
dementia- chronic alteration in content
types of arousal AMS
sleepy, lethargic, obtunded, unconscious/coma
GCS
“red flag” high risk HA symptoms
AMS, seizures, fever, neuro symptoms, visual changes, neck stiffness, papilledema
Primary vs secondary brain injury (plus types)
primary- immediate and permanent damage to brain tissue by a traumatic event
*skull laceration, fractures, contusions, cerebral lacerations, ICH
secondary- response to initial mechanical trauma (maybe preventable and reversible)
*increased ICP, hypotension, hypoxia, hypothermia, electrolyte probs
signs and symptoms of epiglottitis?
Hot potato voice, respiratory distress, cherry red epiglottis (gentle visualization of epiglottis)
how to diagnose epiglottitis?
looking (GENTLY) or lateral neck film in extension and during inspiration
epiglottitis treatment?
1) . humidified O2, airway supplies, IV access
2) . Call ENT
3) . start empiric ABX (ceftriaxone)
4) . admit to ICU for ABX and airway management
presentation of tension pneumothorax?
- tracheal and great vessels deviation from affected side
- hyperresonance of affected side
- distended neck veins
- unequal breath sounds
- dyspnea
- tachycardic
- hypotensive
how to diagnose pneumothorax?
clinical diagnosis but can use US to confirm after decompression! see the barcode sign instead of the seashore
how to treat tension pneumothorax?
immediate needle decompression and chest tube placement plus
admit
treatment of small pneumothorax (15- 20% collapse)
if patient is stable then give O2 and observe. repeat CXR in 6 hours. If not getting worse, they can go home & be checked on
treatment for large pneumothorax?
chest tube placement and admit
hemothorax treatment
put a chest tube in and drain the blood, admit
CXR signs of a spontaneous pneumothorax?
1) . loss of lung markings in the periphery
2) . pleural line runs parallel to the chest wall (deep sulcus sign/deep lateral costophrenic angle)
difference between tension pneumo and cardiac tamponade on PE?
cardiac tamponade will have BILATERAL breath sounds present (TP will also have hyper resonance on percussion)
EKG sign of cardiac tamponade?
electrical alternans- alternating QRS amplitude seen in any or all leads with no changes to conduction pathway
Adult GCS system: categories and scoring
1) . eye opening
- spontaneous = 4
- to speech = 3
- to pain = 2
- no response = 1
2) . Verbal response
- A x O = 5
- disoriented conversation = 4
- speaking but non sensical = 3
- moans, weird sounds = 2
- no response = 1
3) . Motor Response
- follows commands = 6
- localizes pain = 5
- moves or withdraws to pain = 4
- decorticate flexion = 3
- decerebrate extension = 2
- no response
scoring 3-15
“T” after score means intubation
