EM M4 Flashcards
(155 cards)
1
Q
TF
Vitals are often normal in appendicitis
What % have fever at time of perf
A
T
Vitals often normal in appendicitis
Only 40% have Low grade fever at time of perf (low grade is 37-38… 98.6-100.4)
2
Q
TF
Pain prior to N/V suggests a surgical etiology
A
T
eg SBO
3
Q
TF
Female with appendicitis often has cervical motion tenderness
A
T
25% female appendicitis has cervical motion tenderness
4
Q
Why does peptic ulcer pain awaken pts at night but gone when waking in the morning
A
Gastric acid secretion peaks at ~2am and nadirs at awaking
5
Q
TF
Unrelenting pain over weeks to months suggests peptic ulcer disease
A
F
PUD pain usually exacerbating and remitting
6
Q
Hypertrophic pyloric stenosis typically presents At what age In what gender With what eating pattern What classic exam finding What diagnostic test
A
Hypertrophic pyloric stenosis age 2-6 wks of life gender 4x more male than female Vigorous appetitie but projectile non-bilious vom classic exam finding olive shaped mass diagnostic test ultrasound
7
Q
Intussusception typical age of presentation
A
5-12 months
Intussusception typical age of presentation
8
Q
Vomiting with apoendicitis?
A
Not usually, but can present atypically in young kids and elderly
9
Q
KUB detects what % of renal calculi
Helical CT is how sensitive and specific
What about ultrasound
A
60-70%
Renal calculi detected with KUB
Helical CT ^95% sns and sps for renal calculi *best test
Ultrasound not good for stones but good for hydronephrosis
10
Q
TF
Renal insufficiency contraindicates intravenous pyelogram
A
T
11
Q
Describe diverticulosis
A
“Sac-like protrusions of colonic mucosa through the muscularis”
12
Q
Old guy with mild diverticular pain and tenderness in the ED, no fever… discharge home on fiber and stool softeners or antibiotics? (And follow up with pcm)
A
If mild can treat as diverticulosis — fiber and stool softeners
If more severe and/or with fever or leukocytosis can treat as diverticuliis — 7-10 day abx, bowel rest and analgesia
13
Q
TF
Crohn’s often involves the rectum
A
F
Can involve any gi tract but rarely rectum
14
Q
How much do UC and Crohn’s increase the risk of colon cancer
A
UC x30 fold
Crohn’s only mildly
15
Q
TF
UC NEVER involves the small intestine
A
T
16
Q
Acute cholecystitis WBC Left shift? Transaminases Bili
A
WBC elevated with or without left shift
Transaminases and Bili typically normal
17
Q
Scapular pain common with what intraabdominal process
A
Acute cholecystitis
18
Q
TF
Increased parity is a risk for cholecystitis
A
T
Female fat forty fertilemultiparous fnative american
19
Q
2 most common causes of pancreatitis in usa
some other causes
TF alcoholic pancreatitis only in chronic alcoholics
A
1 gallstone pancreatitis 2 alcoholic pancreatitis - old or young, chronic or sporadic abuse Hypertriglyceridemia Pregnancy Trauma Cancer Atherosclerotic emboli Scorpion bite
20
Q
Cecal volvulus
Pathophys
Age of presentation
Marathon running a risk why?
A
Cecal volvulus
Abnormal fixation of right colon, cecum mobile to twist mesenteric axis
25-35 yo most common presentstion
Marsthon runners skinny with thin flexible mesentery for more mobility… (thin plus jostly i think)
21
Q
TF
Constipation predisposes to cecal volvulus
A
F 25-35yo Preg Prior surgery Marathon... not constipation...
22
Q
Causes of hepatic abscess
A
Anaerobes, gram negatives, entamoeba hystolytica
bacteroides, E. coli, Klebsiella, Pseudomonas, Enterococcus, anaerobic Streptococci, and E. histolytica
23
Q
Hepatic abscess Typrical causes Labs Cxr Tx
A
ypically caused by gram negatives, anaerobic Streptococci or Entameoba histolytica. Laboratory findings include elevations of WBC, bilirubin, alkaline phosphatase and serum aminotransferases. CXR may demonstrate a right-sided effusion and elevation of the right hemidiaphragm. Treatment with triple coverage antibiotics such as gentamicin, metronidazole and ampicillin should be instituted immediately, however consultation with a general surgeon, interventional radiologist, or gastroenterologist is necessary for definitive treatment, which is drainage of the abscess.
24
Q
TF
Age is a factor when considering admission for mild diverticulitis vs dispo home (abx bowel rest analgesia)
A
T
Consider admitting elderly for mild diverticulitis, hogher risk of complications
25
Most common causes and sites of esophageal perforation
1 iatrogenic — proximal pharyngoesophagela junction or distal ge junction
2 spontaneous — distal esophagus (90%)
Foreign body
Caustic ingestion
Blunt or penetrating trauma
Carcinoma
26
Foreign body impaction in esophagus a greater airway risk via edema or perf/mediastinitis risk?
Other complications
Air trapping?
Esophageal fb a greater perf/mediastinal risk
complications of esophageal foreign bodies are rare but serious. They include esophageal Erosion and Perforation, Mediastinitis, esophagus-to-trachea or esophagus-to-vasculature Fistula formation, Stricture formation, Diverticuli formation, and tracheal Compression (from both the esophageal foreign body and resultant edema or infection)..... Air trapping is a sign of a foreign body of the Airway. Rarely, airway foreign bodies act as one-way valves that could cause hyperinflation of a lung segment, with resultant bleb rupture and pneumothorax formation.
27
Tardive dyskinesia results from prolongued use of
Tardive dyskinesia results from prolongued use of antipsychotics
28
Features of neuroleptic malignant syndrome
Elevated temperature , lead pipe muscle rigidity, altered mental status, choreoathetosis, tremor, autonomic dysfunction — diaphoresis, labile blood pressure, dysrhythmia, incontinence
29
Temp over ___ is most likely not infectious
Temp over 105 is most likely not infectious
30
4 neurologic complications of antipsychotic use
Neuroleptic malignant syndrome
Tardive dyskinesia
Dystonia
Akithesia
31
EKG complication of haloperidol
Long qt
32
Potential side effects of haloperidol
Potential side effects of haloperidol include acute dystonia, prolonged QT interval, Parkinsonism, and akathisia.
33
What recreational drugs cause
Dilated pupils
Pinpoint pupils
Vertical nystsgmus
Dilated pupils - sympathomimetics like cocaine and amphetamines
Pinpoint pupils - opiods
Vertical nystsgmus - phencyclidine pcp
34
Best antipsychotic for severe agitaion
And dosing
And time to peak serum level
Haloperidou - Best antipsychotic for severe agitaion... high potency highly studied... no resp depression negligible anticholinergic rare hypotension which are all side effects of throdazine, and benzos can cause respiratory depression
5-10 mg IM q 10-30 minutes dosing
30 minutes time to peak serum level
35
```
Which of the following are/are not associated with violent agitation?
DM
Hypothyroid
COPD
Alcohol abuse
```
Hypothyroid can cause agitation but not violence like the others
36
Why chemically in addition to physically restrain the especially violent patient? Specific complications of restraints, which is life-threatening
Circulatory obstruction
Asphyxia
Rhabdomyolysis
Life-threatening metabolic acidosis from struggle against restraints can lead to cardiovascular collapse
37
First line chemical restraint for cobative patient? Why? If elderly?
5 mg of haloperidol (antipsychotic) IV/IM with 2 mg of lorazepam (benzodiazepine) IV/IM, repeated every 30 minutes as needed, is recommended for the combative patient who does not have contraindications to these medications.
Drugs with a relatively short half-life allowing for more careful monitoring of chemically restrained patients. Patients may be given multiple administrations of the restraining agent as needed.
Half doses should be used in the elderly.
38
Flumazenil can be used to temporarily reverse the ____ caused by ____ but also carries with it the risk of precipitating ____ and ____ in chronic ____ users. As a result, it is not recommended for routine use in patients with ____
Flumazenil can be used to temporarily reverse the Respiratory Depression caused by Benzodiazepines but also carries with it the risk of precipitating Withdrawal and uncontrollable Seizures in chronic benzodiazepine users. As a result, it is not recommended for routine use in patients with Altered mental status.
39
mnemonic can be used to recall the common causes of an increased anion gap metabolic acidosis:
```
CAT MUDPILES;
C - cyanide
A - alcoholic ketoacidosis
T - toluene
M - methanol
U - uremia
D - diabetic ketoacidosis
P - paraldehyde
I - isoniazid/iron
L - lactate
E - ethylene glycol
S - salicylates
```
40
Alcoholic presents agitated vomiting and altered with no detectable etoh and non gap metabolic acidosis, what is the likely agent
Isopropyl alcohol is metabolized via alcohol dehydrogenase to acetone which accumulates and causes significant ketosis but not an anion gap. Other toxic alcohols such as methanol and ethylene glycol are ultimately metabolized to formic and glycolic acids which cause toxic effects and an anion gap metabolic acidosis.
41
```
Hepatitis from alcoholic liver disease in ED
Vitamin to give
Electrolyte to replete
Comprbidity to check for
Assess nutrition with attention to...
Treatment is primarily...
```
Thiamine before glucose, Mag, check and treat gastritis, assess nutrition with attention to possible protein restriction, managment mostly supportive with fluids and electrolytes
Alcoholics often have low thiamine levels due to poor nutrition, and low glucose levels due to the suppression of gluconeogenesis by alcohol. Thiamine should always be replaced prior to glucose to avoid the potential complication of precipitating Wernicke’s encephalopathy. Magnesium levels may appear normal on laboratory testing, but alcoholics typically have low magnesium stores and should be given magnesium empirically unless contraindications for magnesium exist. Alcoholics should also be evaluated for gastritis and overall nutritional status and should be referred appropriately.
42
What type of hallucination suggests more functional ams than organic
Auditory hallucinations more functional
Tactile visual auditory can be organic
43
2 most common causes of dementia
1 alzheimers
| 2 vascular
44
Key difference between delirium and dementia
Altered consciousness with delirium
45
Top 4 nutritional/metabolic abnormalities to consider initially for ams
An acute confusional state can also be one of the protean manifestations of a metabolic or nutritional abnormality, including hepatic encephalopathy, acute renal failure, and diabetic ketoacidosis or hyperosmolarity.
46
Electrolyte disturbances that can cause altered mental status
Hypoglycemia
Hyper or hypo natremia
Hyper calcemia
47
Some key history to differentiate between functional and organic altered consciousness
Acuity, vitals, fluctuation, trauma, focal neurologic deficits, delusions illusions
Characteristics of organic causes include acute onset, abnormal vital signs, fluctuating level of consciousness, possibly signs of trauma, and/or focal neurologic signs.
Inorganic (functional) causes commonly illustrate chronic onset, stable vital signs, absence of trauma or focal neurologic symptoms, and/or delusions and illusions.
48
Hypertensive encephalopathy can cause coma and death in what time frame
Hypertensive encephalopathy can cause coma and death over hours... it is a medical emergency
49
When to give antihypertensiv meds to preggy with eclampsia
If diastolic bp ^110 after seizures controlled with Mag... don’t want to lower too much or too rapidly because uterine hypoperfusion
50
```
febrile seizure
Age
generalized tonic clonic activity?
Duration?
Post ictal state?
```
febrile seizure
Age 3mos to 5years
generalized tonic clonic activity? Sure
Duration? v15 min... think intracranial mass lesion or infection if longer
Post ictal state? No, think intracranial mass lesion or infection if not rapid regain of normal consciousness when seizure ends
51
How can alcohol affect seizure disorder
Can directly cause seizures via neurotixicity of itself and metabolites
Can predispose via head trauma, metabolic disturbance, and lower threshold
Can precipitate seizures with withdrawal
52
TF
| Delirium can be agitated and combative or calm and quiet
T
| Delirium swings both ways
53
Most common causes of delirium in elderly
Why minimize stimuli
Meds
Infectious
Metabolic
Minimize stimuli because difficulty processing stimuli
54
Dystonic reaction to neuroleptic medication
Incidence
Time to onset
Treat
Most common adverse effect of neuroleptics, 5%
Up to 48 hours after goven in ED or anytime during long term neuroleptic therapy
Dystonic reactions should be treated with IM or IV benztropine anticholinergic (Cogentin®), 1 to 2 mg, or diphenhydramine antihistamine (Benadryl®), 25 to 50 mg. Intravenous administration usually results in near-immediate reversal of symptoms. Patients should receive oral therapy with the same medication for 48 to 72 hours to prevent recurrent symptoms.
55
Manage Ellis II (enamel and dentin, yellowish tinge to fracture bed) and Ellis III (pinkish pulp and often blood exposed) tooth fractures in the ED
Immediate dental consult to avoid abscess formation
56
Guy punched in nose jas no ocular or maxillary issues, just nose deformity with A swollen, ecchymotic, tender nasal septum. Most appropriate initial step?
Incision and drainage of the sepatal hematoma followed by nasal packing
57
Pt hit in eye with racquet ball, now with diplopia with upward gaze deficit in affected eye... why?
Orbital floor fracture and entrapment
58
Normal body temperature
| Febrile body temperature
Normal 36-37 97-99
| Febrile 38 100.4
59
Tension pneumo... needle decompression or chest tube?
Needle decompression first and fastest
Chest tube after
60
Most sensitive test for nerve injury from finger trauma
And what is the O’Rain wrinkle test
Two point descrimination is most sensitive test for finger nerve injury
O’Rain wrinkle test involves putting finger in warm water and looking for reflex wrinkling of digital pulp indicating intact nerve
61
Ottowa ankle rules
What are they
Who are they for
For ADULTS
Inability to walk 4 steps at time of injury or in ED
tenderness over medial or lateral malleoli and posterior superior aspect
tenderness over navicular or base of 5th metatarsal
Any of above consider xray for ankle injury
62
What are the 2 site options for needle decompression of tension pneumo and which has lower risk of parenchymal injury
Anterior mid clavicular line 2nd intercostal space — less risk of parenchymal injury
Lateral mid axillary line 4th or 5th intercostal space — higher risk of parenchymal injury
63
Which is important vs contraindicated in ruptured globe, visual acuity test or intraocular pressure measurement?
Visual acuity important
Oculat pressure contraindicated — don’t press tonopen to eye — may exude vitreous
64
Define hyphema and hypopion
Hyphema blood in the eye
Hypopion pus in the eye
65
When may lateral canthotomy be indicated
Lateral (not medial) canthotomy is an emergency procedure that may be indicated in some patients with ocular injury and retrobulbar hematoma (with resultant traction on the optic nerve)
66
stab wound neck between sternal notch and cricoid cartilage, vitals stable wnl... manage
why
Zone 1 penetrating trauma gets angiography, esophogram, and observation (admission for obs)... physical exam unreliable and vascular carotid vertebral subclavian aorta.... trachea esophagus lung apices at risk
67
how high on thorax to require rule out of abdominal pain?
to 4th intercostal, diaphragm can rise that high
68
24 yo with liver laceration, hemodynamically stable -- conservative management or immediate laparotomy in OR?
conservative management
69
TF
| FAST is test of choice for diagnosing solid organ injury
F
| can only ID peritoneal fluid, CT to diagnose solid organ injury
70
flank trauma with hematuria, test to evaluate for urologic injury
CT AP w IV con AND TRANSURETHRAL con
71
who gets emergency thoracotomy in the ED?
penetrating chest trauma unconscious pulseless with detectable blood pressure
72
TF
| cardiac arrest due to blunt trauma is an indicationf for thoracotomy in the ED
F
dismal thoracotomy success rate in these patients... more for penetrating chest trauma unconscious pulseless with detectable blood pressure
73
young woman gunshot entry over right breast exit right axilla AFVSS conscious and alert
manage in 6 next steps
IV access, endotracheal intubation, simultaneous right chest tube, bedside ultrasound, portable cxr, admission to ICU if stable
74
guy stabed in mid axillary 10th intercostal space, dyspneic otherwise AFVSS, manage in 4 next steps
2 large bore IVs
chest tube
portable cxr
abdominal CT
75
Most common neurological finding associated with distal radius fracture
decreased sensation over hypothenar eminence
76
after lady with osteoporosis fall onto hip can't get up...
stuck in abduction external rotation think
stuck in internal rotation think
abduction external rotation think femoral neck fracture
internal rotation think posterior hip dislocation
77
treat knee dislocation in ED with absent dorsalis pedis and posterior tibial pulses, cool and pale foot
attempt reduction in ED to restore popliteal flow without waiting for ortho or transport to OR or arteriography.... attempted reduction comes first
78
bugs to cover in abx for human bite wound
strep staph and Eikenella Corrodens -- aggressive human mouth flora that frequently causes infection in first 24 hours after bite
79
how to describe gunshot wound in ED
| include entrance/exit?
meticulous description and/or photo, including tattooing (gunpowder), stellate tissue destruction (from gunshot gasses in contact shot)...
leave entrance/exit speculation to forensics
80
treat occult pneumothorax in trauma patient -- absent on cxr but small one noticed on ct
100% oxygen, most occult pneumothorax will resorb with oxygen
81
needle decompression for...
| heliox face mask for...
needle decompression for... tension pneumo
heliox (low density gas mixture of helium and oxygen) face mask for... reactive airway disease to reduce resistance to flow
82
best descriminator between high voltage and lightning injury
deep burns
| v5% of lightning injuries
83
when starting interferon alpha therapy for chronic hep C, consider also starting ___ because....
consider starting an SSRI with interferon alpha because interferon alpha has high rates of cns/psych side effects -- anhedonia, fatigue, anorexia, impaired concentration, sleep disturbance, and suicidal ideation
84
majority of suicide attempts involve...
minor injuries and drug overdoses
treatable by ED staff
85
TF
all states have laws giving law enforcement the right to place into custody any individual suspected of being a danger to themselves or others
T
all states have laws giving law enforcement the right to place into custody any individual suspected of being a danger to themselves or others
86
TF
| family sitters provide the best option for close observation of suicidal patients
F
| they may collaborate with the patient to leave the hospital
87
age distribution of suicide
bimodal
| 15-25 and ^65 (peaks at 60 for females)
88
TF
| females with breast implants are higher risk for suicide
T
89
most who commit suicide suffer from either ___ or ___
most who commit suicide suffer from either alcoholism or a diagnosable psychiatric illness
90
what psychiatric disorder is associated with the greatest risk of suicide?
panic disorder 40% risk
major depression 20%
schizophrenia 10%
PTSD also increased risk
91
```
rates of suicide with the following
panic disorder
major depression
schizophrenia
PTSD
```
panic disorder 40% risk
major depression 20%
schizophrenia 10%
PTSD also increased risk
92
define
silent suicide
occult suicide
parasuicide
silent suicide - slowly letting oneself die / killing oneself by nonviolent starvation or noncompliance with medical treatment etc
occult suicide - disguised as accident
parasuicide = attempted
93
most common cause of suicide by ingestion
antidepressant overdose
| - cyclic antidepressants most lethal
94
of antidepressants, which is most lethal if overdosed?
cyclic antidepressants (amitriptyline) most lethal antidepressants
95
treat subungual hematoma
drain with 18-guage needle or hot microcautery unit
96
how to remove non-insect foreign body from ear
irrigate with warm water (direct jet past object and bounce off tympanic membrane)
don't do this for bean or seed because may swell with water and cause pressure necrosis
97
what dementions of ingested foreign object merit endoscopic or surgical removal not to simply observe ingested foreign body progression with serial radiography
when to give up on serial radiographic obs
retreive ingested drug packages?
sharp (may cause perf)
^2cm width (may not pass pylorus or ileocecal valve)
long and rigid (may not pass right angles of duodenum
stop obs and retrieve if no progression 24hr
don't retreive ingested drug packages... risks of procedure, risk of rupture and overdose... observe closely in case rupture/overdose occurs...
98
when to consider needle drainage of skin abscess
facial abscess maybe
otherwise use linear incision
99
What suture angle maximizes skin eversion
90, perpendicular to skin
100
Treat bartholin cyst
Drain via word catheter through incision on vaginal mucosa
101
Grading scale for laryngeal patency
Cormack-Lehane 1-4
102
Name 2 laryngoscope blades
Macintosh and Milller
103
LMA in the setting of airways stands for
Laryngeal Mask Airway
104
What agent is often recommended (due to its bronchodilatory effects) as the induction agent of choice for intubation for asthmatic respiratory distress?
Ketamine is a dissociative anesthetic and relaxes bronchial smooth muscle, either by blocking parasympathetic effects or by increasing sympathomimetic stimulation. This relaxation can decrease airway resistance within minutes of administration. While the clinical relevance of ketamine's bronchodilation is subject to debate, most major texts mention it as an agent of choice for intubation of patients with reactive airways disease
105
Etomidate may cause transient ____ suppression and should be used with caution in ___ patients
Etomidate (induction agent for RSI rapid sequence intubation) may cause transient adrenal suppression and should be used with caution in septic patients
106
_____ is primarily indicated for induction when decreased myocardial contractility is a concern
Etomidate is a sedative, reduces anxiety and is cardio-protective. Therefore it is primarily indicated for induction when decreased myocardial contractility is a concern.
107
patients allergic to soy or eggs should not receive this induction agent for intubation
patients allergic to soy or eggs should not receive Propofol
108
```
Which of the following local anesthetics is characterized by average potency (lipid solubility), low toxicity and rapid onset of action?
A. procaine
B. tetracaine
C. bupivacaine
D. lidocaine
```
D. Lidocaine and bupivacaine are amides but the latter is much more potent, intermediate in onset and longer lasting. Procaine and tetracaine are esters and both are slow in onset, but tetracaine is applied topically and has a potency comparable to bupivacaine. Procaine is the least potent of the listed anesthetics
109
```
acute severe lower back pain which is worse with coughing. Her lower spine is tender to palpation. Three days prior she had a lower extremity surgical procedure performed under epidural anesthesia. Think..
A. Spinal epidural hematoma
B. Spinal epidural abscess
C. Adhesive arachnoiditis
D. Anterior spinal artery thrombus
```
A. The back pain in this patient is likely secondary to a space-occupying lesion in the spinal canal. Epidural hematoma is the most likely option since it was sudden in onset, worse with coughing and occurred soon after the procedure. Adhesive arachnoiditis (A) would be manifest as a progressive loss of nerve function. Anterior spinal artery thrombus would be expected to present with painless paraplegia (B). A spinal epidural abscess would be unlikely so soon after the procedure and is more gradual in onset. The patient is not immunosuppressed and she does not have a fever, rigors or sweats which can be seen in up to 75% of patients.
110
How and why to do regional nerve block for procedure of the plantar foot
Regional blocks for the plantar foot, since there is rich innervation and significant discomfort with injections into the soles. The posterior tibial nerve, located between the medial malleolus and Achilles tendon, supplies the medial portion of the sole and the medial side of the foot. The nerve runs next to the posterior tibial artery and is posterior to the pulse. A sural nerve block is frequently provided when anesthesia is desired for the heel and lateral foot.
111
```
Which of the following is an absolute contraindication to surgical cricothyrotomy?
A. Acute laryngeal disease
B. Bleeding diathesis
C. Age < 5
D. Massive neck edema
```
C. Given that surgical cricothyrotomy is often resorted to only after other techniques have been unsuccessful and/or the patient is not oxygenating or ventilating, most authors state that the only absolute contraindication is age. Because of the anatomic differences between children versus adults including the smaller cricothyroid membrane and the rostral funnel shaped more compliant pediatric larynx, surgical cricothyrotomy has been contraindicated in infants and young children. However, the exact age at which a surgical cricothyrotomy can be done is controversial and not well defined. Various textbooks list the lower age limit from 5 years to 12 years. Choices A, C, and D are all relative contraindications to cricothyrotomy but may be overlooked in an emergent situation when the first priority is to obtain an airway.
112
Where to use lidocaine only and avoid mix with epi for procedural local anesthesia injection
digits, tip of the nose, penis, and pinna. The rationale for this prohibition is that vasoconstriction in these regions (end arterial supply) can result in ischemic complications, especially if the patient has underlying peripheral vascular disease
113
TF
| High tension wound, use 6-0 suture
F
| if wound is subject to high tension, 6-0 suture or tissue adhesives are not optimal choices for closure
114
```
Which of the following is usually the earliest sign of lidocaine toxicity?
A. Nystagmus
B. Tonic-clinic seizures
C. Nausea/vomiting
D. Lightheadedness and dizziness
```
D. Toxic reactions to local anesthetics are usually due to intramuscular or intrathecal injection, or to an excessive dose. The maximal acceptable dose of lidocaine with and without epinephrine is 7mg/kg and 5mg/kg respectively. The initial symptoms of local anesthetic toxicity are lightheadedness and dizziness. Other symptoms noted are peri-oral numbness, tinnitus, progressive CNS excitatory effects including visual and auditory disturbances, shivering, twitching, and, alternatively, generalized clonic-tonic seizures. CNS depression can follow leading to respiratory depression or arrest.
115
Toxic reactions to local anesthetics are usually due to ____ or ____ injection, or to ____. The maximal acceptable dose of lidocaine with and without epinephrine is __mg/kg and __mg/kg respectively. The initial symptoms of local anesthetic toxicity are ____ and ____. Other symptoms noted are ____, ____, progressive ____ effects including ____ and ____ disturbances, ____, ____, and, alternatively, ____. ____ depression can follow leading to ____ or ____.
Toxic reactions to local anesthetics are usually due to intramuscular or intrathecal injection, or to an excessive dose. The maximal acceptable dose of lidocaine with and without epinephrine is 7mg/kg and 5mg/kg respectively. The initial symptoms of local anesthetic toxicity are lightheadedness and dizziness. Other symptoms noted are peri-oral numbness, tinnitus, progressive CNS excitatory effects including visual and auditory disturbances, shivering, twitching, and, alternatively, generalized clonic-tonic seizures. CNS depression can follow leading to respiratory depression or arrest.
116
Deep palm laceration
Vertical matress closure?
Topical adhesive closure?
Prophylactic abx?
Vertical mattress sutures are not recommended for the palm, as this technique places deep structures at risk. Topical skin adhesives are best avoided in the palm, which is prone to sweating and thus increasing the possibility of resultant wound dehiscence. Though many would recommend use of prophylactic antibiotics in a patient with a sufficiently deep palmar laceration, no controlled trials addres
117
Flumazenil should not be used on a patient exhibiting ____. Also co-ingestion of drugs with ____ properties (____) is associated with an increased risk of ____, presumably due to loss of the ____’s protective ____ effect when the ____ is administered. For similar reasons, flumazenil can theoretically precipitate ____ in patients who chronically take ____ or ____. The co-administration of flumazenil also risks ____ side effects for these patients.
Flumazenil should not be used on a patient exhibiting seizure activity. Also co-ingestion of drugs with pro-convulsant properties (cyclic antidepressants) is associated with an increased risk of seizures, presumably due to loss of the benzodiazepine’s protective anticonvulsant effect when the antagonist is
administered. For similar reasons (related to GABA effects) flumazenil can theoretically precipitate seizure activity in patients who chronically take benzodiazepines or chloral hydrate. The co-administration of flumazenil also risks cardiac side effects for these patients
118
What is the reversal agent for ketamine
There is no reversal agent for ketamine
119
TF
Flumazenil can be used for the acute reversal of benzodiazepine overdose in procedural sedation of children under 3 years old
T
Flumazenil can be used for the acute reversal of benzodiazepine overdose of patients of any age... just be careful if pet exhibiting seizure activity, taking a proconvulsant drug like cyclic antidepressants, or chronically taking bzds or chloral hydrate... can precipitate seizures
120
Chest wall rigidity and glottic spasm, which may make ventilation difficult, are unique complications seen with very high doses of ___ given rapidly (generally > __ mcg/kg). It has been observed at lower doses. This may not reliably be antagonized by ____ and may require ____ and ____ to enable adequate ventilation
Chest wall rigidity and glottic spasm, which may make ventilation difficult, are unique complications seen with very high doses of fentanyl given rapidly (generally > 15 mcg/kg). It has been observed at lower doses. This may not reliably be antagonized by naloxone and may require neuromuscular blockade and intubation to enable adequate ventilation
121
The Mallampati scale allows communication of ability to visualize structures of the ____, as a means of predicting ease of ____ and ____.
The Mallampati scale allows communication of ability to visualize structures of the posterior oropharynx, as a means of predicting ease of laryngoscopy and intubation.
122
smaller-diameter needle is associated with a lower incidence of post-lumbar puncture headache because it causes a _____
smaller-diameter needle (not larger) is associated with a lower incidence of post-puncture headache because it causes a smaller dural hole
123
```
Most common complication of LP
Laterality
Worse supine or sitting
Does position after procedure help prevent?
How to treat
Analgesics?
```
Post LP headache is most common complication
typically bilateral and worse when sitting up
Lying supine after does not seem to prevent but does decrease pain
Treat with bedrest and fluid intake;
keeping the patient supine to maximize intracranial CSF volume, use of oral caffeine, and for severe long-lasting headaches, autologous blood patch. The blood patch involves injecting one’s own blood at the LP site in order to form a clot around the meningeal puncture site to avoid further leakage.
Simple analgesics are commonly prescribed, but they have no apparent advantage
124
TF
| Tetanus immunization has no benefit for exposure ^24 hours past
F
| Tetanus immunization may have benefit if given up to several days after exposure, 24 hours is not too late so give it
125
The normal range of CSF glucose is __ to __ mg/dL, which is __% to __% of the glucose concentration in the blood. Ventricular fluid glucose levels are _ to _ mg/dL higher than in lumbar fluid. A ratio of CSF glucose–to–blood glucose of less than __ or a CSF glucose level below __ mg/dL is invariably abnormal. The ratio is higher in infants, for whom a ratio of less than __ is considered abnormal. _____ may mask a depressed CSF glucose level. With extreme _____, a ratio of 0.3 is abnormal. In patients with systemic _____, the ratio changes to 0.4:1.
The normal range of CSF glucose is 50 to 80 mg/dL, which is 60% to 70% of the glucose concentration in the blood. Ventricular fluid glucose levels are 6 to 8 mg/dL higher than in lumbar fluid. A ratio of CSF glucose–to–blood glucose of less than 0.5 or a CSF glucose level below 40 mg/dL is invariably abnormal. The ratio is higher in infants, for whom a ratio of less than 0.6 is considered abnormal. Hyperglycemia may mask a depressed CSF glucose level. With extreme hyperglycemia, a ratio of 0.3 is abnormal. In patients with systemic hyperglycemia, the ratio changes to 0.4:1.
126
A chest tube size of #__ French or greater would be indicated if the patient may have a hemothorax
Needle decompression involves placement of a #__ gauge needle in the 2nd intercostal space at the midclavicular line
A chest tube size of #28 French or greater would be indicated if the patient may have a hemothorax
Needle decompression involves placement of a #14 gauge needle in the 2nd intercostal space at the midclavicular line
127
Treat paronychia of the toe
| Surgery? Hospitalization? Antibiotics? Close follow up?
In cases where the paronychia is small, simple lifting of the eponychium (cuticle) may suffice; no digital block is necessary.
In a case complicated by relatively significant extension of purulence as well as cellulitis in the involved toe, more aggressive intervention, including removal of part of the nail, will necessitate digital block. The patient does not require hospitalization, but antibiotics and close follow-up (especially if there are complicating issues such as diabetes) are indicated.
128
TF
Suicidal patient or their guardian have the right to refuse emergency care, e.g. activated charcoal administration for acetaminophen ingestion
F
Suicidal patient or their guardian do not have the right to refuse emergency care
-- uncooperative patient may be intubated or NG tubed to give activated charcoal safely and agoid aspiration and pneumonitis
129
for which is gastric lavage indicated
| nortriptyline, kerosene, metoprolol, ibuprofen
nortriptylene.... contraindicated for hydrocarbons (risk of aspiration) and caustic ingestions... will hurt again on the way up
130
how to differentiate overdose with sympathomimetic like cocaine vs anticholinergic like jimson weed
sweating with sympathomimetic cociain not anticholinergic jimson weed... both cause delirium and mydriasis
131
Aspirin can cause increased ___ through direct stimulation of the medullary ___
Aspirin can cause increased Respiratory Drive through direct stimulation of the medullary respiratory center
132
signs of anticholinergic toxicity
warm flushed mydriatic dry psychotic
hot red blind dry mad
hot as hades, red as a beet, blind as a bat, dry as a bone, mad as a hatter (NOT diaphoretic... how you tell sympathomimetic from anticholinergic)
133
what substance is acute withdrawal most life threatening? alcohol, heroin, lithium, cocaine?
alcohol withdrawal most life threatening of these
134
is activated charcoal appropriate for any of the following?
lithium, drain cleaner, iron, acetaminophen
why/why not? how does charcoal work?
acetaminophen
-charcoal acts by adhering to most toxins, impairing absorption and enhancing elimination... but not heavy metals like lithium lead and iron... and not caustic ingestions because black charcoal impairs endoscopic eval and does not impair contact damage (only absorption damage)
135
how to look for amitriptyline overdose toxicity
QRS prolongation -- TCAs cause sodium channel blockade
among others... gaba antagonism, NE 5HT reputake inhibition, alpha blockade, aintimuscarinic/histaminic effects...
136
EKG abnorms with TCA toxicity
prolongation of any EKG intervals -- QRS most significantly (via Na and K channel blockade)... also ventricular dysrhythmias, right axis deviation also from NaC blockade
sinus tach (antimuscarinic)
137
3 common precipitants of lithium toxicity in patient chronically taking lithium
how to treat lithium toxicity
guided by drug level or clinical condition?
dehydration
over-diuresis
drug-drug interaction
treat with hemodialysis, guided by clinical condition not drug level
138
what to watch for when treating acute iatrogenic BZD-induced oversedation with flumazenil
watch for resedation as flumazenil half life is short
139
treatment mainstay for cocaine toxicity, eg agitation chest pain and HR 142... beta blocker? haloperidol or diphenhydramine?
benzodiazepines - lorazepam or diazepam titrated to agitation and adrenergic tone
NOT beta blockade -- unopposed alpha-adrenergic stimulation and worsening hypertension
NOT haloperidol or diphenhydramine -- can contribute to hyperthermia
140
3 classic findings of PCP intoxication
dramatic multidirectional nystagmus
htn
bizarre behavior
141
acid base disturbance with acute alicylate overdose
primary metabolic acidosis with primary respiratory alkalosis (direct stim of medullary chemoreceptor trigger zone and respiratory center)
(low HCO3, high Ph low pCO2 high O2)
142
toxic single ingestion dose of nonsustained release acitaminophen
what is antidote and how does it work
140mg/kg
antidote is N-acetylcysteine (when too late for charcoal) ... inhibits binding of NAPQI (toxic mediator) to hepatocytes where it would otherwise build up when glutathione stores deplete
143
how do acetaminophen levels inform managment of toxic ingestion
levels drawn at 4-20 hours can be plotted n teh RUmack-Matthew nomogram to guide NAC N-acetylcysteine antidote therapy based on potential for hepatic toxicity
144
classic presentation of digoxin toxicity
old person treated for CHF now with weakness, fatigue N/V/D confusion visual disturbance -- yellow/green halos around objects
145
clonidine MOA
| toxicity closely mimics..
clonidine - a2 agonist, antihtn
| toxicity mimics opioid toxicity - hypOtension, bradycardia, AMS, respiratory depression, miosis
146
which cause tachycardia and which cause bradycardia
| clonidine amitripryline nifedipine
amitriptylene - tachy (anticholinergic SE)
| clonidine nifedipine - brady
147
how does deferoxamine work
route
se
binds free iron - antidote for iron toxicity
IM or IV
vin rose urine... turns urine color...
148
methylene blue is antitode for...
methemoglobinemia
149
pyridoxine is antidote for...
isoniazid toxicity
150
glucagon can serve as antidote for...
bb ccb or insulin overdose
151
when to perform endoscopic assessment for caustic ingestion
early - because risk of procedurally-induced perforation increases with delayed endoscopy
152
neuro symptoms of lead toxicity
gi sx
skin sx
CNS encephalopathy, seizure, sleep disturbance, memory deficit
PNS paresthesias, wrist drop
GI colicky abd pain
bluish lead lines on gingiva
153
common iatrogenic causes of methemoglobinemia
why is it bad
what does pulse ox and blood look like
antidote
- nitrates/nitrites, local anesthetics, dapsone, phenazopyridine
- ox dissoc curve shift left won't let go
- pulse ox looks good (but real O2 sat bad), chocolate brown color blood
- methylene blue antidote
154
salicylates are absorbed from the ___ and typically have onset of action within ___
salicylates are absorbed from the Stomach and Small Bowel and typically have onset of action within 30 Min
155
TF
| opiate withdrawal is life threatening
F
uncomfortable - CNS excitation, diarrhea, abdominal cramping, vomiting mydriasis, tachypnea
not life-threatening
