EM Topics Final Flashcards
(276 cards)
1
Q
oxygenation is a ____ process affected by ______ and _______
A
passive, V/Q mismatch, PEEP, percentage inhaled oxygen
2
Q
what is a shunt
A
lack of gas diffusion in the presence of blood flow
3
Q
what is dead space
A
lack of blood flow to a functioning alveolus
4
Q
transudate example
A
pulmonary edema
5
Q
dead space examples
A
PE, low cardiac output
6
Q
what is PEEP
A
positive end expiratory pressure that keeps the alveoli open at the end of expiration to improve alveolar compliance
7
Q
next step if nonrebreather isn’t improving oxygenation
A
add PEEP
8
Q
oxygenation is NOT affected by
A
tidal volume
9
Q
CO2 exchange is affected by
A
tidal volume, respiratory rate
10
Q
minute ventilation
A
tidal volume x respiratory rate
11
Q
ideal tidal volume
A
6-8 cc/kg of ideal body weight
12
Q
CPAP influences ____
A
oxygenation
13
Q
BiPAP influences _____
A
ventilation
14
Q
infectious causes of airway compromise
A
epiglottitis, retropharyngeal abscess, Ludwig’s angina
15
Q
retropharyngeal abscess presentation
A
difficulty moving neck, +/- muffled voice, febrile
16
Q
what is Ludwig’s angina
A
deep space infection below tongue with woody induration (submandibular or sublingual space)
17
Q
epiglottitis population affected
A
unvaccinated against strep pneumo/h flu
18
Q
how to position airway in adults
A
bring external auditory meatus to the level of the sternal notch with jaw thrust/head-tilt chin lift
19
Q
how to position pediatric airway
A
same as adults but will probably need to put towels under shoulders instead
20
Q
basic airway adjuncts
A
nasopharyngeal airway, oropharyngeal airway
21
Q
OPA contraindications
A
gag reflex
22
Q
NPA contraindications
A
massive midface trauma
23
Q
how to size an NPA
A
tip of nose to bottom of earlobe
24
Q
how to size an OPA
A
corner of mouth to earlobe
25
size of BVM bag
approx 1 liter
26
how much to ventilate someone with BVM
approximately 450 cc
27
how to hold BVM mask to patient's face
EC or thumbs down grip with 2 hands whenever possible
28
ventilation frequency with BVM
once every 5-6 seconds (10 times per minute)
29
consequences overventilation
overwhelm lower esophageal sphincter causing gastric insufflation
30
what is true of exhalation vs inhalation with BVM
give the patient at least twice as long to exhale
31
Airway continuum
positioning, supplemental O2, +/- suctioning/beta agonists, NIPPV, adjunctions, supraglottics, intubation, surgical
32
predictors of dangerous intubation
O2<93%, hypotension, acidosis (HOP killers)
33
why does intubation compromise hemodynamics
sedation/paralytics, PPV suppresses the negative intrathoracic pressure that draws blood into the right side of the heart (venous return), vagal nerve stimulation
34
how to mitigate negative hemodynamics of intubation
resuscitate before you intubate
35
difficult airway mnemonic
LEMONS
36
what does LEMONS stand for
look externally, evaluate 3-3-2, mallampati, obstruction, neck mobility, saturation
37
3-3-2 rule
3 fingers of mouth opening, 3 fingers worth of space between tip of chin and thyroid cartilage, 2 fingers between bottom of chin and thyroid cartilage
38
mallampati 1
can see entire uvula
39
mallampati 2
can see most of uvula
40
mallampati 3
cannot see uvula but can see upper part of back of throat
41
mallampati 4
cannot see uvula or back of throat
42
grade 4 airway
cannot see any epiglottis
43
Miller blade
straight blade, pins epiglottis up blindly
44
Macintosh blade
curved blade, lifts epiglottis by putting pressure on hyoepiglottic ligament
45
tube size adult male
8.0-8.5
46
tube size adult female
7.5-8.0
47
tube size peds
broselow tape or (age/4) + 4 for uncuffed tube or 3.5 if cuffed
48
ET tube depth
3 x size of ETT or 22 at the teeth
49
blade size for intubating adults
3-4
50
blade size for intubating peds
00-3
51
how to inflate ETT balloon
5-10 cc (no more than 25 cc)
52
induction agents aka
sedatives
53
what induction agent has the least hemodynamic effect
ketamine and etomidate
54
what paralytics are used the most
succinylcholine, rocuronium
55
succinylcholine MOA and cautions
depolarizing neuromuscular blocker (causes all myocytes to depolarize). Can cause hyperkalemia in people with predisposition (CKD, crush injury, myasthenia gravis)
56
succinylcholine duration
3-5 minutes
57
rocuronium/vecuronium MOA and cautions
nondepolarizing neuromuscular blocker, longer acting (1 hour) - must adequately sedate
58
how to lift laryngoscope
up and forward
59
what to do after intubation
secure tube, confirm placement (listen to breath sounds, end tidal CO2/capnography), set vent, get chest x-ray, post-intubation sedation/pain control
60
what happens if tube is too deep and how can you tell
will likely end up in right mainstem bronchus, will hear breath sounds on the right but not on the left
61
how deep should tube appear on chest x-ray
3-5 cm above carina (between carina and clavicles)
62
vent settings
10-20 breaths per minute, 6-8 cc/kg ideal body weight for tidal volume
63
what to do if airway is going bad
go back to last thing that worked
64
extraglottic airway examples
LMA, king, combitube, i-gel
65
extraglottic airway uses
cardiac arrest, primary device for difficult airway, backup device for intubation
66
extraglottic airway advantages
easy to place, 97% effective
67
extraglottic airway disadvantages
not good for distorted airways (anaphylaxis, expanding hematoma, etc), not good for preventing aspiration if there is massive bleeding/vomit, not good if high airway pressures are needed
68
how to troubleshoot a tube
DOPES
69
DOPES
displacement, obstruction, pneumothorax, equipment, stacked breaths
70
what is breath stacking
people with obstructive breaths don't get enough time to exhale so air builds up in lungs which diminishes venous return
71
indications for surgical airway
can't intubate and can't oxygenate. It is not necessary to attempt intubation first if it is very unlikely to succeed
72
surgical airway in peds
needle cric (transtracheal jet ventilation) or tracheotomy
73
disadvantage to needle cric
ventilation is poor, can be a stopgap for 30-40 minutes
74
inner incision site for cric
cricothyroid membrane
75
vital signs of the eye
vision, pressure, pupil
76
how to measure eye pressure
tonometer
77
what does afferent pupillary defect indicate
optic nerve problem until proven otherwise
78
afferent pupillary defect aka
marcus gunn pupil
79
how afferent pupillary defect look on exam
neither pupil will constrict when light is shined in the affected eye, both pupils will constrict when light is shined in the unaffected eye
80
what intraocular pressure increases risk for disk ischemia and atrophy
>20
81
steps for unanticipated intubation difficulty
stay calm, call for help, plan/communicate next steps, alternate airway techniques with each attempt
82
what is DART
difficult airway response team
83
when to activate DART
signs of extremely difficult airway, excessive hypoxia during intubation attempts, poor BVM compliance, failed attempt by experienced intubator, displaced tracheostomy, crisis situation with inadequate equipment
84
normal intraocular pressure
12-20 mmH20
85
causes of high IOP
glaucoma, increased ICP, trauma
86
causes of low IOP
globe rupture
87
what does teardrop pupil indicate
sign of ruptured globe until proven otherwise - points toward rupture location
88
eye exam steps
vision/pressure/pupil, EOM, visual field, lids/lacrimals, conjunctiva/sclera, cornea, lens, anterior chamber, fundus
89
biggest mistake in fluoroceine exam
not using enough
90
steps in fluoroceine exam
remove contacts, put fluorosceine and tetracaine onto a strip and place in tear reservoir, allow pt to blink
91
risk factor for lens dislocation
connective tissue disorder
92
common cause of exophthalmos
hyperthyroidism
93
complication of exophthalmos
chronic keratitis
94
ptosis causes
Horner's syndrome, stroke, muscular weakness
95
preseptal cellulitis aka
periorbital cellulitis
96
septal cellulitis aka
orbital cellulitis
97
how to differentiate preseptal vs septal cellulitis
septal is more likely to have pain with eye movement and vision changes, definitive diagnosis is with CT
98
what to worry about with periorbital ecchymosis
retrobulbar hematoma that will damage optic nerve as it grows
99
retrobulbar hematoma treatment
lateral canthotomy
100
causes of disconjugate gaze
blowout fracture, muscle tear
101
what commonly accompanies disconjugate gaze
double vision
102
disconjugate gaze management
refer to ophthalmology
103
what is blepharitis
inflammation of eyelids, typically due to blockage of oil glands along base of eyelashes
104
blepharitis ssx
red eye, crust along eyelid
105
blepharitis tx
warm compresses, hygiene
106
what is chalazion
generally chronic bump on eyelid (not at the edge) due to blockage of oil gland
107
chalazion pathogen
polymicrobial
108
chalazion tx
refer to ophthalmology, warm compresses
109
what is pterygium
growth over the conjunctiva, often due to chronic sun exposure
110
pterygium tx
none unless vision loss is present
111
subconjunctival hemorrhage causes
trauma, sneezing, heavy lifting, vomiting
112
subconjunctival hemorrhage tx
none, will reabsorb
113
common cause of corneal ulcer and concerning pathogen
contact lenses, pseudomonas
114
corneal ulcer tx
refer to ophthalmology
115
corneal ulcer complications
scarring, vision loss
116
dendritic lesion cause
herpes simplex or zoster (depending on who you ask)
117
dendritic lesion complications
scarring, can block aqueous humor circulation leading to glaucoma
118
dendritic lesion tx
refer to ophthalmology
119
UV keratitis onset
sudden
120
UV keratitis tx
toradol/lidocaine drops
121
UV keratitis prognosis
usually heals quickly
122
corneal scratch appearance on fluorosceine exam
ice rink sign: multiple scratches in linear pattern
123
corneal scratch tx
evert lid and remove foreign body, maintain high suspicion for penetrating injury/rupture globe if associated with high velocity injury
124
uveitis/iritis causes
RA, lupus, reiter's syndrome
125
what is uveitis/iritis
inflammation of anterior chamber
126
uveitis/iritis diagnosis
white cells on slit lamp exam
127
uveitis/iritis tx
steroids
128
what is hyphema and what usually causes it
blood in anterior chamber, trauma
129
hyphema concern
globe rupture until proven otherwise
130
what is hypopyon
pus in anterior chamber
131
hypopyon tx
abx injections into eye
132
most common age-related lens opacity
cataracts
133
cataracts presentation
otherwise asymptomatic progressive blurred vision
134
common cause of lens dislocation
blunt trauma
135
lens dislocation presentation
monocular diplopia, grossly blurred vision
136
lens dislocation tx
surgery
137
detached retina presentation
usually unilateral rapid vision loss, may or may not be in curtain pattern, +/- shower of floaters/flashes
138
detached retina risk factors
age > 50, nearsightedness, cataract extraction, blunt trauma
139
detached retina diagnosis
US
140
detached retina tx
if vision is gone, nonemergent. If vision is not gone, emergent ophthalmology consult
141
acute angle glaucoma ssx
severe pain in eye or forehead, red eye, decreased/blurred vision, rainbows, halos, severe HA, N/V
142
acute angle glaucoma physical exam
fixed mid-sized pupil with cloudy cornea, injected sclera, decreased peripheral vision, IOP >40
143
acute angle glaucoma tx
acetazolamide 500 mg IV then PO, topical timolol, pilocarpine (alpha agonist), refer to ophthalmology
144
open angle glaucoma ssx
gradual vision loss, blind spots, halos, mild HA/eye pain
145
steps of trauma triage
1. Physiologic criteria 2. anatomic criteria 3. MOI criteria 4. Other
146
trauma criteria physiologic
GCS<14 SBP<90, RR <10 or >29
147
trauma criteria anatomic
proximal penetrating injuries, chest wall instability, crushed/degloved/pulseless extremity, amputation, pelvic fracture, open fracture, paralysis
148
trauma criteria MOI
Falls (>20 ft adults, 3x child's height/10 ft peds), high risk MVC
149
high risk MVC definition
ejection, death of another passenger, high-speed based on vehicle telemetry, intrusion (>12 inches roof, 18 inches anywhere), auto vs pedestrian/motorcycle >20 mph
150
trauma criteria other
Peds, anticoagulated, burns, time sensitive, ESRD, pregnancy>20 weeks, EMS provider judgment
151
Goal of primary survey
identify and temporize life threats within 15-30 seconds
152
major elements of primary survey
Airway, breathing, circulation, disability, exposure
153
elements of airway in primary survey
protect c-spine, ask a question to determine airway patency, look for abnormal findings, provide temporizing or definitive management
154
elements of breathing in primary survey
listen to lung sounds, observe work of breathing, palpate chest wall, assess SpO2. Supplemental oxygen, assisted ventilations, needle decompression or chest tube PRN
155
elements of circulation in primary survey
look for signs of shock, control hemorrhage, IV/IO access, monitor BP/pulse, FAST exam
156
elements of disability in primary survey
simplified neuro exam (pupils, gross movement/sensory), GCS, rectal (if suspicion of spinal or pelvic injury)
157
elements of exposure in primary survey
undress, observe for wounds/deformities/odors, logroll to examine back
158
elements of secondary survey
AMPLE, head-to-toe exam
159
GCS major components
eye opening, verbal, motor
160
elements of eye opening in GCS
4: Spontaneous 3: Opens to verbal stimuli 2: Opens to painful stimuli 1: Does not open
161
elements of verbal in GCS
5: Appropriate speech 4: Confused 3: Inappropriate words 2: Random sounds 1: Silent
162
elements of motor in GCS
6: Follows commands 5: Localizes to pain 4: Withdraws from pain 3: Decorticate posturing 2: Decerebrate posturing 1: No movement
163
AMPLE stands for
allergies, medications, past medical history, last meal/menses/tetanus, Events leading up to injury
164
when this the earliest splinting/wound exploration and repair can occur during trauma?
during secondary survey
165
labs to order for trauma
point of care: pregnancy, hemoglobin, BGL. Others: CBC, CMP, coags, type and cross. +/- ETOH and tox only if it will impact care.
166
trauma imaging
plain films (esp chest and pelvis), selective use of CT, repeat FAST exam
167
at what GCS should you start thinking about intubation due to inability to manage own airway
8-9
168
how do you calculate GCS in someone who is intubated
add up motor and eye opening scores and put T for verbal
169
"the box" of penetrating chest injuries
greater risk of major organ damage: bordered by clavicle, intracostal cartilage, midclavicular line
170
what to do if penetrating chest injury but stable with normal imaging?
observe for 6 hours and then repeat imaging
171
when will CXR show pulmonary contusion
may not see it for several hours
172
management of flail chest
pain management, pulmonary toilet, maintain normovolemia, +/- intubation
173
flail chest is associated with what injury
pulmonary contusion
174
management of pericardial tamponade
pericardiocentesis, thoracotomy, pericardial window
175
what to consider when chest injuries are below the nipple line
may have injured diaphragm, intraabdominal injury
176
ssx of ruptured diaphragm
bowel sounds heard in chest, respiratory distress
177
imaging for ruptured diaphgragm
CXR, need CT if on right side
178
ruptured diaphragm management
surgical
179
pneumothorax with crepitus and subq air suggests what
ruptured tracheobronchial tree
180
ruptured tracheobronchial tree management
balloon occlusion of affected bronchus, avoid high lung pressures, surgery
181
ruptured aorta MOI
severe deceleration impact or lateral acceleration
182
ruptured aorta CXR
loss of aortic contour, need CT for definitive diagnosis
183
ruptured aorta management
most dead on arrival, avoid HTN using beta blocker w/vasodilator, call cardiothoracic surgery
184
stepwise management for stable abdominal injury
FAST, then CT, the operate if free air, extravasation of oral contents, solid organ injury
185
what is the trauma triage of death
acidosis, coagulation, hypothermia
186
criteria for tx of APAP OD
if blood levels >150 after 4 hours, treat with 140 mg/kg N-acetylcysteine
187
when is NAC tx most effective for APAP OD
within 8 hours
188
what is true of NSAID overdoses
they are generally associated with low morbidity/mortality because they require a huge amount
189
are stable transfers subject to EMTALA
no
190
for how long is the sending hospital responsible for Pt they are transferring
until care is assumed by receiving hospital
191
when must a receiving hospital accept transfer of specialty Pt
if they have the capability to treat Pt and sending hospital does not
192
what counts as a medical screening exam for EMTALA purposes
whatever is required to rule out an emergency medical situation and can be performed by any trained/qualified hospital personnel
193
EMTALA definition of emergency medical condition
acute ssx with sufficient severity such that absence of care could reasonably expect to result in placing health in serious jeopardy, serious impairment to body function, serious dysfunction of any body part/organ
194
who is most likely to sue you?
patients who leave AMA
195
requirements for someone to leave AMA
must understand the risks and be of sound mind
196
what is best to obtain from children prior to caring for them>?
assent
197
95% of malpractice suits are for what
negligence
198
what is capacity and where is it determined
the ability to make a reasoned, legally binding decision by weighing risks/benefits and alternatives. Determined at bedside
199
criteria for negligence
duty to act, breach of standard of care, damages occurred, and those damages were a direct result of the breach of standard of care
200
definition of standard of care
what a reasonable PA would do
201
which toxic spider bites are initially painless
brown recluse
202
indication for antivenom in crotalid bites
progressing edema
203
what test to get in women of childbearing age with abdominal pain
serum HCG
204
ectopic pregnancy most common location
ampulla of fallopian tube
205
ectopy pregnancy presentation
sudden abdominal pain (can be mild or severe, lateral or diffuse), kehr sign (shoulder pain), vaginal bleeding, amenorrhea, +/-syncope/shock,
206
ectopic pregnancy diagnosis
TVU if serum HCG levels are high enough: empty uterus with adnexal mass/free fluid
207
definition of spontaneous abortion
loss of pregnancy before 20 weeks, loss of fetus <500 g
208
when do most spontaneous abortions occur
< 8weeks
209
most common cause of spontaneous abortion
chromosomal abnormalities
210
most common presenting complaint with spontaneous abortion
vaginal bleeding +/- abdominal pain
211
spontaneous abortion diagnosis
pelvic exam
212
what is a threatened abortion
pregnancy-related bloody vaginal discharge or frank bleeding during 1st half of pregnancy without cervical dilation
213
what is an inevitable abortion
vaginal bleeding with open cervical os
214
what is incomplete abortion
passage of only parts of products of conception
215
when are incomplete abortions most likely to occur
6-14 weeks
216
what is missed abortion
fetal death at <20 weeks without passage of fetal tissue within 4 weeks
217
tx for missed/incomplete abortion
D&C
218
what is septic abortion
evidence of infection during any stage of abortion
219
what is molar pregnancy
genetically abnormal fetus that will never progress
220
what is HELLP syndrome
clinical variant of preeclampsia consisting of hemolysis, elevated liver enzymes, low platelets, abdominal pain. +/-HTN
221
what type of exam to avoid during 3rd trimester
sterile speculum exam, TVUS
222
what HR is indicative of fetal distress
<110, >160
223
cardiac views in FAST exam
subcostal (most common), parasternal
224
what is preeclampsia
new onset HTN after 20 weeks
225
preeclampsia risk factors
prior HTN, nulliparity, DM, <20 or >35
226
preeclampsia ssx
generalized edema, proteinuria, new renal insufficiency, weight gain >5 lbs in 1 week, headache, vision changes, dyspnea
227
preeclampsia when to deliver
37 weeks or 34 weeks if severe
228
meds for preeclampsia
magnesium to prevent seizures, BP control: nifedipine, methyldopa, labetalol, hydralazine
229
what is placental abruption
partial or premature separation of placenta from uterine wall
230
placental abruption risk factors
maternal HTN, smoking, alcohol, cocaine, abd trauma (may be minor)
231
placental abruption ssx
sudden onset, painful third trimester vaginal bleeding with contractions, fetal distress, tender/rigid uterus
232
placental abruption diagnosis
transabdominal US
233
what is placenta previa
abnormal placental placement over cervical os
234
placenta previa ssx
painless bright vaginal bleeding, typically large volume
235
placenta previa management
delivery via c-section if it hasn't moved prior to delivery
236
what is PROM
rupture of membranes before onset of labor
237
PROM diagnosis
sterile speculum exam with pH>7 and ferning pattern on smear
238
PROM management
may need to induce if labor does not occur within 18 hours, may lead to chorioamnionitis
239
SAGE mnemonic for tox emergencies
supportive care, antidotes, gastric decontamination, enhanced elimination
240
elements of coma cocktail
dextrose, O2, narcan, thiamine
241
MUDPILES-CAT
methanol, uremia, DKA, paraldehyde, iron/INH, lactic acidosis, ethylene glycol, salicylates, CO/CN, alcohol, toluene
242
what does a combined anion and osmolar gap suggest
poisoning by methanol or ethylene glycol
243
phase I APAP OD timing and ssx
30 mins-24 hours, N/V
244
phase II APAP OD timing and ssx
24-72 hours, RUQ pain, elevated PT and liver transaminases
245
phase III APAP OD timing and ssx
72-96 hours, centrilobular necrosis
246
phase IV APAP OD timing and ssx
4 days- 2 weeks, complete resolution
247
sodium channel blocker examples
TCAs, benadryl, cocaine, propranolol
248
sodium channel blocker ssx
shock, AMS, long QRS, terminal R in aVR
249
ddx of abd pain in early pregnancy
all non-pregnancy causes plus corpus luteal cyst, ectopic pregnancy, nonviable intra-uterine pregnancy
250
ectopic risk factors
PID, tubal ligation, previous ectopic, IUD, assisted repro
251
classic ectopic triad
abdominal pain, vaginal bleeding, amenorrhea
252
infectious tests in PROM
GC/chlamydia, BV, group B strep
253
most common cause of postpartum hemorrhage
uterine atony
254
most common otitis media pathogen
strep pneumo
255
most common cause of pediatric hearing loss
serous otitis media
256
what is serous otitis media
presence of fluid in middle ear space without evidence of infection
257
most common cause of posterior epistaxis
HTN
258
which type of sinusitis is more likely to cause intracranial complications and what ssx suggest this
acute frontal sinusitis, HA/confusion/eyelid pain
259
most common intracranial complication from rhinosinusitis
meningitis
260
what is Pott's puffy tumor
osteomyelitis of the frontal bone, usually with overlying soft tissue "doughy" swelling of the forehead
261
MAP =
COxSVR
262
what is shock index and what does it mean
heart rate/SBP. A persistent value >1 indicates impaired left ventricular function and carries a high mortality rate
263
normal lactate level
<2
264
SIRS criteria
2 or more of: hyper or hypothermia, HR> 90, RR>20, WBV> 12 or <4
265
hemodynamic changes in hypovolemic shock
decreased preload, increased SVR, decreased CO
266
hemodynamic changes in cardiogenic shock
increased preload, increased afterload, increased SVR, decreased CO
267
hemodynamic changes in obstructive shock
decreased preload, increased SVR, decreased CO
268
hemodynamic changes in distributive shock
decreased preload, decreased SVR, mixed CO
269
what is neurogenic shock
sudden loss of vascular tone and sympathetic response leading to poor perfusion. Cool/clammy above level of injury, warm/dry below
270
which crystalloid allows for some buffering of acidemia
LR
271
which crystalloid may caise hyperkalemia in renal insufficiency
LR
272
risks of NS
can induce hyperchloremic metabolic acidosis when given in large amounts.
273
for every 1 l of blood lost, you need ____ to replace it
3 L isotonic crystalloid
274
in what class shock do you need to start blood products
class III (AMS, hypotension)
275
when massive transfusion protocol used
greater than 10 units of PRBCs in first 24 hours
276
massive transfusion protocol
1:1:1 ratio of PRBC:FFP:Platelets, with calcium
