EM2

Question 1

How to correct hyponatremia + coma/seizures

Answer 1

150 mL 3% NS bolus over 5 min (or 1 amp bicarb) (may repeat X 1)

Repeat serum sodium (goal is no more than 6 mmol/6h)

Saline lock IV

Foley –> u/o >100mL/h? –>if yes, 1 mcg DDAVP

Question 2

Non-severe hyponatremia algorithm

Answer 2

Question 3

Goals of correction of hyponatremia

Answer 3

6 in 6 hours for severe symptoms, then no faster than 6 mmol/day (up to 12/day safe by some sources)

Question 4

Necrotizing Soft Tissue Infections

Answer 4

• Type I: Polymicrobial, most common.
• Type II: Monomicrobial (MRSA, GAS, clostridium)
• Type III: V. vulnificus (seawater)
• Can spread as quickly as 1”/h
• Pain out of proportion.
• Pain/edema beyond area of redness
• Crepitus (30%)
• Xray shows superficial gas but not deep
• CT with contrast ~ 90% but 20% false-positive
  
  • non-enhancing deep tissues

Question 5

Chance of successful passage of ureteral stone based on size

Answer 5

98% stones <5 mm pass within 4 weeks
60% stones 5-7 mm pass within 4 weeks
39% stones >7 mm pass within 4 weeks

Question 6

Malaria

Answer 6

Incubation ~30 days, but with partial chemoprophylaxis and incomplete immunity, can show up even 1 year after travel (~1% cases)

Often periodic fevers preceded by myalgias, headaches, and almost any other symptom. Classically Q48h, but can present very atypically.

Normocytic anemia (hemolysis), may have mild LFT/Cr, WBC elevation or depletion
Dx: thick + thin smear for malaria Q 12-24h for three sets
LP will be nonspecific

Question 7

Opioid Equivalencies

Answer 7

Morphine 5 mg IV = 15 mg PO (MS Contin Q8-12h)
Dilaudid 0.75 mg IV = 3.75 mg PO
Oxycodone 10 mg PO (oxycontin Q8-12h)
Codeine 100 mg PO

Question 8

Composition of Tylenol #1,2,3,4

Answer 8

T#1 = tylenol 300 mg + codeine 8 mg + caffeine 15 mg
T#2 = tylenol 300 mg + codeine 15 mg + caffeine 15 mg
T#3 = tylenol 300 mg + codeine 30 mg + caffeine 15 mg
T#4 = tylenol 300 mg + codeine 60 mg

Question 9

Composition of percocet

Answer 9

Percocet = 325 mg/5 mg oxycodone

Question 10

Dosing of Tramadol, Tramacet (composition)

Answer 10

Tramadol 50-100 mg PO Q6h or 100 mg ER daily max 300 mg/day, adjust by 100 mg no quicker than q5 days

Tramacet (325 mg Tylenol + 37.5 mg Tramadol) i-ii tabs Q4-6h

Question 11

ABRS Diagnosis Algorithm

Answer 11

Question 12

ABRS Tx Algorithm

Answer 12

Note: IDSA guidelines - Amox/Clav, quinolones, or doxy (not in kids) are first line.

Recommended not to use macrolides, Amoxicillin, TMP-SMX

Question 13

Sinusitis Steroid Nasal Spray Dosing

Answer 13

INCS Mometasone furoate (Nasonex)
50 mcg/spray 17g (120 sprays) per bottle
Age 3-11: 1 spray each nostril once daily
Age >=12: 2 sprays each nostril BID, increase to 4 BID if inadequate response

Question 14

Oral Candidiasis Treatment

Answer 14

Nystatin swish and swallow: 400,000-600,000 units QID X 7-14d (adults & children, different for infants); response within 24-48 hours.
if no response/poorly tolerated then fluconazole 200 mg day 1, then 100 mg daily X 14 d

Question 15

Apthous Stomatitis Treatment

Answer 15

oracort dental paste 0.1% TID X 7-14 days m: 5 g

Question 16

Insulin Correction Factor

Answer 16

100/Total Daily Dose

Question 17

Antibiotics for acute cholecystitis

Answer 17

Flagyl 500 mg IV (Q6h)

Ceftriaxone 1 g IV (Q24h)

Question 18

3 I’s (causes) of DKA

Answer 18

Infection, Infarction, Insulin

Question 19

Dose of PO morphine for acute pain

Answer 19

Morphine, 0.3 milligram/kg PO

Question 20

Dose of PO Dilaudid for acute pain

Answer 20

Hydromorphone, 0.06–0.08 milligram/kg PO

(4-5 mg PO)

Question 21

MI & LBBB

Answer 21

Doesn’t matter if new or old.
If CHF or HD instability –> cath/lytic
If stable, apply Sgarbossa criteria

A. Concordant STE 1 mm in any lead (~90% accurate, take to cath)
B. Concordant STD 1 mm in V1-V3, only need 1 lead (~90%, take to cath)
Modified C (Smith’s). ST discordance >25% (cath)

Question 22

MI & Pacemaker (LBBB pattern)

Answer 22

Doesn’t matter if new or old.
If CHF or HD instability –> cath/lytic
If stable, apply Sgarbossa criteria

A. Concordant STE 1 mm in any lead (~90% accurate, take to cath)
B. Concordant STD 1 mm in V1-V3, only need 1 lead (~90%, take to cath)
C. Discordant STE >5 mm any lead (~60%, consider other factors, speak with cardio) applies also and is even more specific than other criteria.

Question 23

sTE aVR

Answer 23

STE in aVR + aVL = 95% specific for LMCA stenosis
STE in aVR + V1 = LMCA or prox. LAD stenosis
If STE in aVR > STE in V1 then LMCA stenosis
If STE in aVR > 1.5 mm then >75% mortality
LMCA stenosis has 70% mortality, no medical therapy is effective, time to cath is crucial, PCI decreases mortality to 40%

Question 24

Diagnosis of Acute Pericarditis

Answer 24

Two of:

• Chest pain consistent with pericarditis (pleuritic, worse with lying down, relieved with leaning forward)
• Pericardial friction rub
• Typical ECG changes
• Pericardial effusion of more than trivial size

Question 25

Treatment of Acute Pericarditis

Answer 25

[![]()](http://s6.postimg.org/yvnyvpvxd/Acute_Pericarditis_Treatment.jpg)

Question 26

Disposition of Acute Pericarditis

Answer 26

**Consider admission if:** - temp \>38.5, trauma, troponin (myopericarditis), OAC, immunosuppressed, or large effusion - Competitive athletes: no sports until 3 months (6 months for myopericarditis) after resolution symptoms and cleared by MD - Regular athletes: no sports until resolution symptoms

Question 27

Flomax Dosing, precautions

Answer 27

Tamsulosin 0.4 mg PO daily (may increase to 0.8 mg daily after 2-4 weeks if poor response). Watch for hypotension with first dose and after interrupting therapy. Do not start if planned eye surgery (floppy iris syndrome). Avoid with severe sulfa allergy.

Question 28

Tuberculosis

Answer 28

- assume infectious --\> airborne isolation, negative pressure, N95 for visitors, surgical mask for patient outside of room, call IPAC - outpatient: home isolation pending lab results + call PH - active TB --\> specialist referral - CXR - sputum X 3 for TB (AFB smear - 24h), NAAT (48h), and culture (1-4 weeks). May collect sputum on same day 1h apart. - If CAP but suspecting TB, use Amox/Clav, do not use quinolones (they are active against TB and may mask test results) - test for HIV if +ve

Question 29

HIV Testing

Answer 29

**HIV Ab test** 95% sensitive within 30 days 5% will take up to 3 months **HIV Ag/Ab Combo EIA** reduces time to detection to 0-20 days, lab dependent **INSTI POC test** Sens/Spec 99.8%/99.5% at 3 months post-exposure

Question 30

Workup for fever in the returning traveler

Answer 30

CBC, diff, malaria thick/thin Q12-24h X 3, LFT's, culture everything for typhoid, NP swab for influenza, urinalysis, CXR, serology (hold red top or specify for dengue, chikungunya, Rickettsia, etc.)

Question 31

QTc Calculation

Answer 31

Qt (ms)/square root of preceding r-r (ms) Lead II or V5 best

Question 32

CAUTI Definition

Answer 32

Catheter in more than 2 days (or intermittent catheterization) and change in symptoms/condition + positive urine culture

Question 33

When to change catheter for suspected CAUTI

Answer 33

- Do not remove catheters placed post-op for GU surgery or for GU trauma - If catheter has been in \>2 weeks, take it out, replace it, and draw culture from new catheter

Question 34

How long to treat CAUTI for?

Answer 34

7 days

Question 35

Adult dose of Atarax (hydroxyzine)

Answer 35

25 PO QID

Question 36

Scabies Treatment

Answer 36

Permethrin 5% Cream from neck down (or whole body for immune compromise/kids) m: 30 g Apply at bedtime, wash off in morning. Wash linens + clothes in hot water in AM, treat all household contacts. or Ivermectin 200 mcgs/kg PO, repeat X 1 in 2 weeks plus Atarax, Hydrocortisone 1 or 2.5% 60 g Itching may last up to 6 weeks but should progressively get better.

Question 38

Name for bees, wasps, ants.

Answer 38

Hymenoptera

Question 39

Name for Poison Ivy

Answer 39

Toxicodendron

Question 40

de Winter T waves

Answer 40

Proximal LAD occlusion --\> STEMI equivalent, call cath lab

Question 41

When to treat influenza in pregnant women.

Answer 41

- treat all pregnant and postpartum women (up to 2 weeks) on spec with oseltamivir 75 mg PO BID x 5 days - rapid testing not sufficiently sensitive to rule out

Question 42

Treatment for epiglottitis

Answer 42

Ceftriaxone 2 g IV Solu-medrol 125 mg IV Humidified O2

Question 43

DDx of Altered LOC

Answer 43

* A — Alcohol/Acidosis * E — Endocrine * Epilepsy * Electrolytes * Encephalopathy * I — Infection * O — Opiates, Overdose * U — Uremia * T — Trauma * I — Insulin * P — Poisoning/Psychosis * S — Stroke/Seizure/syncope

Question 44

How many primary teeth?

Answer 44

20

Question 45

When do primary teeth erupt?

Answer 45

8-33 months

Question 46

How many permanent teeth?

Answer 46

32

Question 47

When do permanent teeth erupt?

Answer 47

7-13 years (wisdom up to early 20's)

Question 48

When do primary teeth fall out?

Answer 48

5-7 years

Question 49

How to tell a primary tooth from a permanent tooth?

Answer 49

Permanent teeth have * longer roots * yellow colour * mamelons (ridges --\> later wear down)

Question 50

Spectrum of disease in dental caries

Answer 50

Caries --\> reversible pulpitis --\> irreversible pulipits --\> pulpal necrosis/death --\> dental abscess

Question 51

Name for dental abscess fistulizing through gingival wall

Answer 51

Parulis

Question 52

Abx Choice for Ludwig's Angina

Answer 52

PipTazo or Clinda + Ceftriaxone

Question 53

TXA solution for post-extraction dental bleeding

Answer 53

* 500 mg tab in 10-20 mL sterile water *or* * 5 mL 100 mg/mL solution in 5 mL sterile water

Question 54

Mouthwas for ANUG

Answer 54

Chlorhexidine 0.1% BID

Question 55

Herpes Simplex (secondary infection) Treatment

Answer 55

Acyclovir 400 mg 5x/day X 5 days or Valacyclovir 2 g PO BID x 1 day Helps during prodromal phase

Question 56

How to estimate Uosm from Urinalysis

Answer 56

* Urine SG, take hundredths and thousandths spot as whole numbers and multiply by 35: (e.g. 1.005 = 5x35 = 175)

Question 57

Diabetes Insipidus

Answer 57

* Central (damage to ADH producing neurons) or Nephrogenic (receptors to ADH) * Acquired of congenital * Hypernatremia * Water-deprivation testing/ADH testing, not in ED

Question 58

Goal of correction for hypernatremia Danger of overcorrection

Answer 58

* \<48h (acute hypernatremia): 1 mEq/L/h * \>48h (chronic hypernatremia): 0.5 mEq/L/h * risk of cerebral edema and herniation with rapid overcorrection

Question 59

K+ Replacement

Answer 59

* Central line: KCl 20 mEq/L in 100 mL NS over 1 h * Peripheral line: KCl 10 mEq/L in 100 mL NS over 1 h, repeat x 3 * PO * KCl Elixir 20 mEq/15 mL PO * Slow-K 600 mg = 8 mEq * Micro-K (slow-release capsule) 600 mg = 8 mEq * K-lyte effervescent tablet = 25 mEq * K-Dur (20 mEq tab) * Daily max = 240 mEq/day * \*supplement Mg as well

Question 60

Mg+ Replacement

Answer 60

* Mg Rougier 15-30mL po tid-qid * Mg gluconate 1-2 tabs po tid-qid; 1 tab * Mg sulfate 5 g in 250mL NS (or D5W) iv over 5h or 2 g in 100 mL over 1h

Question 61

ED Treatment Hyperkalemia

Answer 61

* Calcium chloride 10% 5-10 mL IV (repeat up to 4x/h) * Calcium gluconate 10% 10-20 mL IV (repeat up to 4x/h) * NaHCO3 50-150 mEq IV * Ventolin Neb * Insulin 10 units regular (Humulin R) + 25 g D50W * Lasix 40-80 mg IV + 1-2 L NS bolus * Kayxelate 25-50 g PO/PR

Question 62

PO Replacement of Phosphate

Answer 62

Phosphate Novartis 1-2 tabs po bid-tid

Question 63

ED Treatment Hypercalcemia

Answer 63

* 1L NS/h for 2-4 hours, 3-4 L over first 24 hours * Lasix 20-40 mg IV, target UO 150-200 mL/h * For corrected Ca2+ \>3.0-3.5 * zolendronic acid 4 mg IV over 15 min

Question 64

ECG features favouring V-tach vs. SVT

Answer 64

* regular * AV dissociation * Capture/fusion beats * QRS \> 160 ms * -ve concordance (V1-V6)

Question 65

Vereckei Criteria for Vtach vs SVT

Answer 65

* any of these +ve in aVR = Vtach * initial R wave * initial R or Q wave \> 40 ms * notch present on initial descending limb of predominantly negative QRS * ratio of vertical distance travelled during initial 40 ms of QRS : distal 40 ms \< 1 * SVTAC if none of the above are +ve

Question 66

Pava criteria for Vtach vs SVT

Answer 66

* VT if time from isoelectric line to peak of R wave in lead II is \> 50 ms * SVTAC if not

Question 67

Vaughan-Williams Classification of Antiarrhythmic Medications

Answer 67

* Class I: Fast Na+ Channel Blockers * Ia (moderate) - procainamide * Ib (weak) - Lidocaine, phenytoin * Ic (strong) - flecainide, propafenone * Class II: beta-blockers * esmolol, labetalol, metoprolol, propranolol * Class III: K+ Channel Blockers * Amiodarone, ibutilide, sotalol (also a BB) * Class IV: CCB's * diltiazem, verapamil * Unclassified * digoxin, adenosine, atropine, isoproterenol, magnesium

Question 68

Dose of Procainamide

Answer 68

* 20-50 mg/min until arrhythmia controlled, hypotension occurs, QRS widens by \> 50 % original width, or 17 mg/kg is given (20 min-60 min for 70 kg patient). * Practically: 1 g at 20-50 mg/min * Maintenance: 1-4 mg/min

Question 69

Beta 1 vs Beta 2 receptors

Answer 69

* beta 1: heart muscle * beta 2: bronchi + vascular smooth muscle

Question 70

Esmolol

Answer 70

* Cardioselective BB * Onset 2-10 min, duration 10-30 min * 500 mcg/kg bolus over 1 min then 50 mcg/kg/min infusion, increase by 50 mcg/kg/min Q4 min, max 200 mcg/kg/min * may give two additional 500 mcg/kg boluses before increasing from 50 mcg/kg/min to 100 and from 100 to 150 * try not to discontinue abruptly

Question 71

Labetalol

Answer 71

* combined a₁ and non-selective beta blocker * beta \> alpha ~3:1 oral and 7:1 IV * 20 mg IVP over 2 min * 40-80 mg IV q 10 min (total 300 mg) * 2 mg/min infusion (total 300 mg) * PO * 200 mg PO, repeat in 6- 12 h, then 400-2400 mg /day (Q6-8h)

Question 72

Metoprolol

Answer 72

* cardioselective BB * 1.25 - 5 mg Q 5min IV, max 15 mg * 25-50 mg PO BID

Question 73

Bisoprolol

Answer 73

* cardioselective BB * 2.5-20 mg PO daily

Question 74

Amiodarone

Answer 74

* Class III but has properties of all 4 classes * lipophilic, large loading doses needed to saturate tissues until serum levels are maintained * long half-life (55 days) * max 30 mg/min, 2.2 g/day * ACLS * Pulseless Vtach/VF * 300 mg IV rapid bolus, repeat 150 mg x 1 PRN * Stable monomorphic VT, or polymorphic VT with normal QTc or SVT * 150 mg IV over 10 min then 1 mg/min for 6h then 0.5 mg/min for 18h

Question 75

Dihydropyridine vs. nondihydropyridine CCB's

Answer 75

* nondihydropyridine (Diltiazem, Verapamil) are cardioselective and good for rate control * dihydropyridine (amlodipine, nicardipine) are vascular selective and used for HTN