FINAL

Question 1

Hyperglycemia

Answer 1

-UTI, yeast infection, balanitis

-No acidosis/ketosis -> uncomplicated hyperglycemia:
-IV fluids!
-consider insulin
-consider metformin on d/c

-neg ketones, AG, pH

Question 2

DKA

Answer 2

-D- diabetes- BS >250
-K- Ketosis- blood beta-hydroxybutyrate -> ketonuria
-A- Acidosis (metabolic anion gap)- pH <7.35, low bicarb <15

-Insulin deficiency → hyperglycemia → hyperosmolality → osmotic diuresis & loss of electrolytes → hypovolemia -> lipolysis & ketogenesis (burning for energy) -> acidosis -> increase gluconeogenesis -> worsens

-Triggers:
-Infection!, infarction!, indiscretion! (dont take meds)
-IUP, Illicit drugs, Iatrogenic, Idiopathic

-within 24 hrs and are directly related to:
-HYPERGLYCEMIA
-VOLUME DEPLETION
-ACIDOSIS

-Weakness, confused, AMS
-Blurry vision
-!N/V
-!Abdominal pain
-!Dehydration: Poor skin turgor, dry mucous membranes, tachycardic, orthostatic HoTN, sand paper tongue
-!Rapid/deep breathing (kusmals): compensatory respiratory alkalosis -> this is what kills
-Acetone odor

Question 3

DKA vs HHS labs

Answer 3

-DKA:
-glucose > 250 (hourly)
-pH < 7.3
-Bicarbonate < 15 (VBG q 2hr)
-Anion gap >10-12
-+ Ketones (serum & urine)
-Beta-hydroxybutyrate >3 (ketones)
-pseudohyponatremia -> high glucose pushes Na into cells but overall Na is normal
-K is low, normal, high but TOTAL K is low!!!!
-high BUN (dehydration)
-ECG- precipitating MI, hypo/hyperkalemia
-CXR- precipitating PNA/CHF

-HHS:
-marked hyperglycemia (600-1000s)
-high serum osmolarity (>320)
-mild/NO ketoacidosis (bc still some insulin)
-AMS!
-very mild acidosis pH >7.25
-older pts with T2DM

Question 4

DKA treatment

Answer 4

-1. FLUIDS
-1st line
-tx dehydration and dilutes hyperglycemia/acidosis
-perfuses kidneys to pee out sugar
-LR/plasmalyte -> 2L bolus rapid over 0-2hrs
-continuous drip 200mL/hr
-too much fluid -> cerebral edema (in kids -> give mannitol or hypertonic saline)

-2. POTASSIUM
-PO or IV K
-!if Mg is low -> 2g IV
-K < 3.3 -> hold insulin until K > 3.5 and GIVE K (20-40/hr)
-K 3.3-3.5 -> GIVE K (20-30/hr) WHILE STARTING INSULIN -> goal K is 4-5
-K > 5.3 -> NO K REPLACEMENT, recheck in 2hrs, start insulin (will close anion gap)

-3. INSULIN
-stops lipolysis/ketosis -> corrects acidemia
-!dont NOT start until you know K
-0.1 U/Kg/hr IV! (no bolus)
-If glucose !drops to < 250-300 mg/dL -> !switch fluids to D5NS or D5 ½ NS @ 50-200 mL/hr and ↓ insulin rate to 0.05U/kg/h

-!!Continue infusion until:
-D: glucose <200
-K: Anion gap ≤12 ± 2 or beta-hydroxybutyrate <1mmol
-A: pH≥7.3 or serum bicarbonate ≥15
-Tolerating PO

-INSULINS PURPOSE IS TO STOP ACIDEMIA NOT TO LOWER SUGAR
-KEEP GIVING INSULIN UNTIL ANION GAP IS GONE -> IF SUGAR STARTS TO GET LOWER BEFORE ANION GAP IS CLOSED GIVE SUGAR

Question 5

hyperglycemia hyperosmolar syndrome

Answer 5

-T2DM, elderly, infection, MI, stroke
-!Longer prodrome than DKA (days-weeks)
-!Severe dehydration (> DKA)
-!AMS
-!Abnormal neurologic function

-Often assoc:
-Renal insufficiency
-Gram neg sepsis or PNA
-GI bleed

-Typically NO:
-Abdominal pain
-Kussmauls respirations
-Acetone odor
-BC NO ACIDOSIS

-Tx:
-rehydration
-give K, Mg, phosphate as needed
-SubQ insulin

Question 6

hypoglycemia

Answer 6

-brain works on sugar -> stroke like sx
-sx start at sugar <60
-Sweaty, anxious, tremors, palpitations, dizzy
-HA, irritable, drowsiness, AMS, difficulty speaking
-bc AMS/malnutrition/alcoholic -> dont realize sx
-factitious hypoglycemia- normal/low peptide C -> too much insulin
-sulfonylureas, meglitinides, & insulin can cause hypoglycemia

-Tx:
-give glucose!
-oral preferred
-IV dextrose (D50/adults, D25/kids, D10/infants)
-IM glucagon 1mg

-add Octreotide for recurrent episodes (sulfonyurea) -> inhibits insulin

Question 7

hyperthyroidism / thyroid storm

Answer 7

-high CO & and low SV -> activates RAAS -> reabsorb Na to increase preload -> LVH and CHF
-hyperphagia w/ wt loss
-palpitations, afib, dyspnea
-proximal muscle weakness
-diplopia
-dysphagia, dysphonia, neck full
-pretibial swelling
-decrease menses, libido, gynecomastia
-elderly -> SUBTLE sx, depression, wt loss, fatigue
-cachexia

-THYROID STORM:
-triggers- surgery, trauma, infection, PE, untreated, DKA, MI, pregnancy, amiodarone, CT contrast
-hyperthyroid + end organ damage -> CLINICAL DX
-!Hyperthermia- 104-105F
-!*CNS symptoms: AMS- Agitation, confusion, delirium, seizures, stupor, coma
-!CDV- Tachyarrhythmias, chest pain, CHF (crackles)
-GI/Hepatic- N/V, diarrhea

-Dx:
-CXR- pulmonary edema
-US- nodules, increased flow
-ECG- arrythmias
-thyroid peroxidase antibodies- graves ds
-hyperglycemia, hyperkalemia, LFTs, leukocytosis, leukopenia

Question 8

hyperthyroid / thyroid storm tx

Answer 8

-ABCs & Supportive care (bc prob suspect sepsis first):
-Fluids (even high output HF will probably need fluids)
-Consider glucose due to low glycogen reserves

-Manage agitation/seizures if present:
-Benzodiazepine: Midazolam 5-10mg IV q5min as needed

-!!Cooling:
-Cooled IV fluids, external cooling!, APAP
-Do NOT! treat fever with NSAIDs or salicylates (ASA) -> acetaminophen

-1. beta blockers - propranolol or esmolol (blocks T4 -> T3)
-1. thioamides- methimazole or propylthiouracil (PTU) -> pref in pregnancy
-PTU blocks thyroid synthesis but ALSO blocks T4 -> T3 -> preferred over methimazole
-2. corticosteroids- hydrocortisone -> give in cooccurring adrenal insufficiency repletes cortisone too!
-3. iodine- 1 hr after thioamide therapy (lugols)

-cooling measures, beta-blocker, thioamide, glucocorticoid!, followed by iodine 1 hour later
-Do NOT delay tx for U/S
-Search and tx for underlying cause including sepsis

-no improvement in 24-48hrs -> thyroidectomy

Question 9

hypothyroid / myxedema coma

Answer 9

-macroglossia
-puffy hands
-ascites

-MYXEDEMA COMA:
-multiorgan failure
-triggers: hypothermia, infection (blood cx), stroke, MI, trauma, CHF, GIB, missed meds, surgery
-older women in winter
-Hypothermia (<96)
-AMS!
-Hypotension!
-!hypoglycemia
-!hyponatremia
-precipitating factor
-ABG- shallow respiration -> hypercapnia and hypoxia
-!ECG- Bradycardia!, heart block!, long QT!, torsades de pointes!, ventricular arrythmias!
-torsades -> mag sulfate
-low voltage from pericardial effusion
-cardiogenic shcok
-fluid retention -> puffy eyelids, lips, tongue
-cortisol to r/o adrenal crisis

Question 10

hypothyroid / myxedema coma tx

Answer 10

-STEROIDS:
-Hydrocortisone -> jump start adrenals
-Send off cortisol before dosing

-REPLACEDMENT OF THYROXINE:
-IV levothyroxine (T4): Gold standard
-Not PO! (Bc AMS and GI is not moving)

-SUPPORTIVE CARE:
-Fluids
-Warming
-Correct hypoglycemia and hyponatremia
-ICU

Question 11

Calculate corrected sodium level

Answer 11

-1.6 mEq should be added to the reported Na for every 100 mg of glucose >100 mg/dL
-Example:
-Na 130, glucose 350
-1.6 x 2.5 = 4
-4 + Na 130 = 134 mEq/L corrected sodium

Question 12

hyperkalemia

Answer 12

-3.5-5.0 normal
-MCC- renal failure
-Acidosis, drugs (spironolactone, BB, ACE, ARBs, K supplements), rhabdo, hemolysis (fictitious)

-muscle weakness
-lethargy
-GI sx
-paresthesias
-SOB
-anxiety/irritable
-arrythmia

-ECG:
-arrythmia- long QRS, Vfib
-cardiac arrest
-increased membrane excitability
-peaked T waves
-prolonged PR intervals
-flattened P waves
-ectopic beats, escape rhythms

-Mild 5.5 – 5.9 mEq/L
-Moderate 6.0-6.9 mEq/L
-Severe >7.0 mEq/L

-Tx:
-cardiac monitor -> STAT ECG
-if ECG changes -> IV calcium
-insulin + D50 -> if glucose > 250 or unknown
-or beta 2 agonist- albuterol
-K excretion -> IV fluids to dilute, furosemide, sodium zirconium cyclosilicate!!! or sodium polystyrene sulfonate (kayexalate-not used bc necrosis and takes 4hrs)

-def tx- hemodialysis

-spironolactone

Question 13

Activated charcoal administration, whole bowel irrigation,
urinary alkalinization, and hemodialysis

Answer 13

-CHARCOAL:
-direct binding -> doesnt affect anything in blood (alcohol)
-within 1 hour
-acetaminophen
-CI: AMS, ileus, obstruction

-Poorly binds: Heavy Metals:
(iron, lead, mercury), Lithium, Cyanide, Hydrocarbons (pesticides), Liquids (Alcohols, Alkali / Acids, Caustics)

-WHOLE BOWEL IRRIGATION:
-MC
-flush out GI with diarrhea
-polyethylene glycol (miralax)
-Good for sustained release like iron, lithium, lead, drug packers
-CI- ileus or obstruction

-URINE ALKALINIZAITON:
-things already been absorbed
-indications: Salicylates! (ASA), phenobarbital, INH
-urine goal pH 7-8
-sodium bicarb infusion
-CI- renal failure, pulmonary edema, cerebral edema, volume overload

-HEMODIALYSIS:
-good for low protein binding, low molecular wt, small volume of distribution, water solubles
-drugs that already absorbed
-works for most things
-I-STUMBLED:
-!Isopropyl alcohol, iron, INH
-!Salicylates
-Theophylline
-Uremia
-Methanol
-Barbiturates
-Lithium
-!Ethanol/ethylene glycol
-Depakote (valproic acid)

Question 14

Anticholinergics overdose

Answer 14

-MCC- antihistamines, antidepressants (TCAs), anti-psychotics
-atropine, phenothiazines, parkinsonian drugs, scopolamine, jimsonweed

-!Blind as a bat, mad as a hatter, red as beet, dry as a bone, hot as Hades”
-Blurry vision, delirium, flushed skin!, dry skin, hyperthermia
-mydriasis (dilated pupils!), hypoactive bowel, urinary retention, agitation, seizures

-ECG: sinus tachy (common), wide complex tachycardias, ventricular dysrhythmias, torsades de pointes
-Wide QRS >100ms, terminal R wave, right axis deviation

-Tx:
-supportive- fluids and cooling
-BENZODIAZEPINES
-consider physostigmine!! for refractory sx of seizures, hyperthermia, dysrhythmias -> CI in heart block and TCA overdose

-ventricular dysrhythmias -> lidocaine, amiodarone
-torsades -> Mg
-wide complex tachy -> sodium bicarb!!!

Question 15

Tricyclic antidepressants (TCA)

Answer 15

-self poisoning
-Ex: Amitriptyline, nortriptyline, cyclobenzaprine
-Inhibits reuptake of norepinephrine and serotonin, sodium, histamine, muscuarinic, alpha 1, potassium, GABA

-Blood or urine TCA
->5mg/kg – average toxic dose
->10-20mg/kg- severe

-!!3 C’s = Cardiac abnormalities, Convulsions, Coma
-Anticholinergic effects
-CV effects: hypotension, tachy, wide QRS, V-tach, torsade’s

-!!!!ECG - most useful in determining severity
-!sinus tachy
-!wide QRS >100ms (seizures)
-prolonged QT
-!Wide terminal R wave in aVR
-hypotension

-Tx:
-ABCs
-intubation bc LOC
-NG tube -> charcoal!
-QRS >100ms, ventricular dysrhythmia -> !!!Sodium bicarb IV bolus -> infusion! -> lidocaine! if refractory + arryhthmia
-hypotension -> crystalloids! + norepinephrine (reverse alpha1 blockage)
-seizures -> (GABA-A inhibition) -> benozos!! (diazepam, phenobarbital) -> !!!physostigmine!!! if refractory

Question 16

Cholinergic

Answer 16

-Causes: !Organophosphate poisoning (insecticides)!, chemical warfare agents (nerve gas like sarin)
-!!!Killer Bs: Bradycardia, Bronchospasm, and Bronchorrhea
-weakness, fasciculations, resp failure, wheezing
-people that work with chemicals or landscapers (insecticides)
-VERY WET PTS

-SLUDGE- saliva, lacrimation, urine, diarrhea, GI dysmotility, emesis
-DUMBBELLS- diaphoresis, urine, miosis, bradycardia, emesis, lacrimation, lethargy, salivation
-nictoinic effects- fasciculations, weakness, paralysis

-Tx:
-!Decontamination -> use PPE
-ABCs
-elevate head of the bed
-Antidotes: ATROPINE! and 2-PAM (PRALIDOXIME)!
-Atropine -> reduce muscarinic effects
-2-5 mg q 5-10 min until !secretions are dry!
-Increases HR

-Pralidoxime or 2-PAM -> reverse paralysis and fasciculations

Question 17

Opioids

Answer 17

-Death by apnea!
-pinpoint pupils + not breathing = opioids
-Resp depression! (<12), miosis, lethargy, hypotension, coma, noncardiogenic pulmonary edema, N/V in opioid naïve patients, ileus
-some cause agitation and dilated pupils such as dilaudid, Demerol, diphenoxylate

-Causes: morphine, heroin, fentanyl, Demerol, codeine, diphenoxylate (Lomotil), propoxyphene (Darvon), hydrocodone (Vicodin), Percocet (careful of Tylenol addition), etc.
-Caution: Clonidine can mimic opioid overdose (pinpoint pupils and hypoventilation) -> also reversed with high dose naloxone (10mg)

-dx- urine can be positive 2-4 days after

-Tx:
-NALOXONE
-Intranasal: 1mg each nostril (total 2mg)
-IV start with 0.4mg if mild-moderate depression, 2mg if apneic
-repeat q 2-3 mins up to 10mg due to opioid longer half life

Question 18

toxidrome charts

Answer 18

Question 19

hypoglycemia and serotonin syndrome toxidrome chart

Answer 19

Question 20

toxic alcohol

Answer 20

-Ethanol < isopropyl alcohol < ethylene glycol < methanol
-anion gap or high osmolar gap -> methanol and ethylene glycol
-osmolal gap - measured osmolarity (given) - calculated osmolarity (Na x2 + glucose/18 + BUN/2.8 + ethanol/4.6)
->10 is BAD

-anion gap + osmolol gap = ethylene glycol or methanol
-osmol gap ONLY = isopropyl

-METHANOL:
-paint thinner, car window wash, wood alcohol, gas tank additive
-sx delayed 12-18 hrs
-!Blindness from disc hyperemia!, seizures, resp failure, N/S, pancreatitis, visual changes, ataxia, AMS

-Tx:
-1. !!Fomepizole (4-methylpyrazole)
-excretes via kidneys
-temporizing until dialysis
-2. !Ethanol- competitive inhibition
-!!Dialysis and bicarbonate if severe acidosis + refractory to 4-MP or ethanol therapy

-ETHYLENE GLYCOL:
-antifreeze, moonshine, paints, solvents, windshield wiper fluid
-will have no smell
-oxalic acid -> forms calcium oxalate crystals! -> acidosis and kidney injury
-<12 hrs: Intox + CNS depression!! w/o odor
-12-24 hrs: Tachy, HF/pulm edema
-24-72 hrs: ATN, anuria, flank pain, hypocalcemia, hematuria
-Wood’s lamp - green glowing urine, d/t calcium oxalate crystals

-Tx:
-FOMEPIZOLE
-HEMODIALYSIS if severe
-THIAMINE & PYRIDOXINE
-Both are consumed in the metabolism of ethylene glycol and need supplementation

-ISOPROPYL ALCOHOL:
-Rubbing alcohol (mouthwash, ginseng shots, NyQuil)
-CNS depression worse than ethanol
-Ketosis with normal glucose,
-!Hemorrhagic gastritis, pulmonary edema, hypoglycemia
-Severe hypotension
-Supportive care, don’t give alcohol
-Hemodialysis (if severe)

Question 21

acetaminophen (paracetamol) overdose

Answer 21

-!toxic dose = >150mg/kg
-Hepatic metabolism via CYP450 to NAPQI –> highly toxin that damages liver
-Normally, NAPQI combines with thiols to produce non-toxic metabolites
-In overdose -> thiol stores are depleted -> NAPQI accumulates
-NO characteristic PE findings

-stage 1- first 24hrs -> N/V, abdominal pain

-stage 2 (latent)- 24-48hrs, GI sx resolve (asymptomatic!), hepatic/renal dysfunction begins (high AST/ALT bilirubin INR)

-stage 3- 3-4 days, LFTs peak, coagulopathy, renal failure, fulminant hepatic failure, encephalopathy, sepsis, coma, death

-stage 4: 4 days-2wks, recovery if survive stage 3

-Dx:
-!LFTs (serial)
-Coagulation profile (PT/PTT/INR)
-CBC
-anion gap, ABG
-Renal study
-APAP LEVEL
-!>140u/mL 4 hours after ingestion is TOXIC -> tx with NAC
-Rumack-Mathew normogram -> for !Acute SINGLE ingestion ONLY (4-24hrs) -> need to know exact timing

-Tx:
-ABCs
-activated charcoal within 8-12 hrs
-Antidote: !N-acetyl-cysteine (NAC)! -> Dose: 140mg/kg!
-Detox and decrease NAPQI
-Very effective when given EARLY – !within 8hrs of ingestion!
-Equally effective at 1hr vs 7hrs post ingestion
-still indicated in late presentations >24hrs

-Dialysis (rare)- severe (>1000mg/L), AMS, metabolic acidosis, elevated lactate

-Transplant = liver failure
-d/c if unintentional, no hepatotoxicity, down trend APAP that nontoxic after tx (<150 @ 4hrs or below nomogram)

Question 22

NAC indications

Answer 22

-Significant reported ingestions (single ingestion >150mg/kg)
-4 hour level (or more) APAP lies above the nomogram cutoff (>140mcg/mL)
-APAP ingestion presenting close to the 8hr cut off
-Evidence of hepatotoxicity presumed to be from APAP
-A serum APAP >10mcg/mL and unknown ingestion time

-There is technically no “cut off” time to start NAC

Question 23

alcohol

Answer 23

-NOT toxic
-CNS depressant- down regulates GABA and upregulates NMDA
-!intox- 80-100mg/dL
-always r/o other causes of AMS -> POC glucose, consider head CT, fx (trauma), other drugs, electrolytes, ammonia, etc.
-!Ataxia, slurred speech, horizontal nystagmus, alcohol on breath (AOB)

-Tx- supportive

-Wernickes encephalopathy:
-B1 (thiamine) deficiency
-tachy, HTN, tremor, hallucination, seizures, delirium tremens
-triad = oculomotor abn (CN6 palsy), ataxia, global confusion
-COAT- confusion, ophthalmoplegia, ataxia, thiamine def
-tx- IV thiamine for 3 day

-Korsakoff syndrome:
-untreated wernickes
-RACK- retrograde amnesia, anterograde amnesia, confabulation, korsakoff psychosis

Question 24

alcohol withdrawal (also benzos and barbs)

Answer 24

-CNS hyperexcitation
-tachy, HTN, diarrhea, mydriasis, insomnia, cramps, diaphoresis, piloerection

-6-12 hrs: early uncomplicated -> minor sx- anxiety, intention hand tremors that dont fatigue, tongue fasciculations, insomnia -> ASK WHY
-tx- benzos

-12-24hrs: hallucinosis -> hallucinations (tactile > auditory or visual)

-24-48hrs: seizures -> generalized tonic-clonic convulsions
-chronic alc (not binge)
-r/o head trauma/bleed, poisoning, epilepsy, CNS infection, metabolic
-tx- benzos only

-48-72hrs: delirium tremens -> !disorientation/confusion!, hallucinations, hyperthermia, hyperreflexia, tachy, resp alk, low K and Mg
-mortality 5%
-ABN CONCIOUSNESS/COGNITION
-A&O = not delirium tremens
-Tx- benzos, fluids, thiamine, multivit, Mg, dextrose
-diazepam, lorazepam, midazolam, chlordiazepoxide, phenobarbital (if resistant), propofol if intubation

-Dx- CIWA score

Question 25

common trauma from alcoholism

Question 26

ASA overdose

Answer 26

-Aspirin, Oil of wintergreen, Bengay, Air fresheners, mouthwash -Toxic = 300mg/kg -!Acute toxicity: N/V, tachy, tachypnea!, fever -!Chronic toxicity: Tinnitus, GI irritation, AMS -Severe: Cerebral and pulmonary edema, hypoglycemia causing seizure -Labs: ABG/VBG!!!, ASA level, Acetaminophen level, BMP, LFTs -!!Primary resp alk + Anion gap metabolic acidosis -E.g. ↑ pH 7.44 | ↓ PCO2 26 | ↓ HCO3 18 -Salicylate level ≥ 30mg/dL -Cause of death: Cerebral edema (seizure), pulmonary edema (ARDS), metabolic acidosis / resp alk -Tx: -ABCs, IV, O2 PRN, monitor -glucose for CNS hypoglycemia -!Decon: Activated charcoal -!Urine alkalinization with !SODIUM BICARB! infusion (urine pH > 8) -check K -> hypokalemia prevents alkalinization -DONT do in CHF or renal failure pts bc of volume load -goal serum pH of 7.45-7.55 or a urine pH of 7.50-8.0 -Hemodialysis!: -!!pulmonary edema, cerebral edema (severe confusion/AMS, seizure, coma), renal failure, acidemia, level >100mg/dL (acute) or > 60mg/dL (chronic)

Question 27

Agents and antidotes

Answer 27

-beta blocker OD -> glucagon, insulin + dextrose, intralipid fat emulsion therapy if refractory -iron- GI upset, kids -> IV crystalloid, antiemetics, whole bowel irrigation, DEFEROXAMINE (severe) -rat poison = warfarin -> lavage, charcoal, vitamin K, FFP, PCC -benzo -> flumazenil -heparin -> protamine

Question 28

Understand the 5 common causes of hypotension in trauma, how to recognize them (signs, symptoms, E-FAST imaging, advanced imaging), and emergent management for each: i. Hemorrhagic ii. Tamponade iii. Tension pneumothorax iv. Neurogenic v. Toxicologic

Answer 28

-HEMORRHAGIC - MCC death -TAMPONADE- EFAST -TENSION PNX- listen -NEURO- spinal cord injury -TOXICOLOGIC

Question 29

ABCDE

Answer 29

-MOA -> PRIMARY SURVEY (ABCDE, c-collar, monitor, xray, efast, labs) -> 2NDARY SURVEY (head to toe, AMPLE) -> IMAGING (once stable) -> DISPO -Airway: -GCS <8, stridor, drooling, burns, expanding hematoma -Breathing: -equal B/L breath sounds -trachea deviation -crepitus @ neck/chest -fail chest- >=2 consectuvie ribs in >= 2 places -> supportive tx -Circulation: -2 large bore IVs -pulses, BP -IVF, massive transfusion -GOAL MAP >=80 -tourniquet, pressure, pelvic binder -Disability & dextrose: -pupils -neuro- GCS -4 extremity movement -brain or spinal cord injury -hypoglycemia!!, ETOH, drugs -ICH -Exposure/environment: -naked!!! -warm blankets -burns, toxins, urethral meatus, finger in every orifice -log roll (4 people)- check the back, c collar

Question 30

EFAST

Answer 30

-use for explained hypotension in trauma -visualize 10 structures/spaces in 4 areas -RUQ- hepatorenal -1. morrisons pouch -2. hemothorax -3. liver tip -MC place for fluid -check this first -shark fin sign -+ spine sign is bad -LUQ- splenorenal -4. btwn kidney and spleen -5. btwn spleen and diaphragm -6. hemothorax -7. spleen tip -+ spine sign is bad -Subxiphoid- cardiac -8. pericardium -9. heart chambers (RV) -Suprapubic- -10. pouch of douglas (btwn uterus and rectum) / rectovesical pouch -+ anterior and lateral pleural spaces -> pneumothorax or pleural effusion -pelvic fx and retroperitoneal bleed require CTA for dx

Question 31

EFAST- fluid in lungs on RUQ/LUQ

Answer 31

TOP PIC: -Normal RUQ ultrasound -Spine should only extend up until the lung border -Lung should have mirror artifact -Air is mucking the view of the spine above the diaphragm -> spine sign -BOTTOM PIC: -Large pleural effusion in RUQ +Spine sign = can see the spine above the diaphragm due to pleural fluid allowing sound waves to penetrate -black between the lung and diaphragm = pleural effusion maybe

Question 32

Concussion

Answer 32

-TBI: hematoma, SAH, contusion, diffuse axonal injury -2ndary phase caused by impaired cerebral blood flow -> edema, bleed -GCS tx and severity is guided by GCS -GCS 3-8 -> severe, CT -GCS 9-12 -> moderate, head CT -GCS 13-15 -> mild TBI (canadian ct rules) -Neg CT - mild TBI, concussion -Positive CT- specific dx based on findings -Tx: -return to play -> cleared by neurologist -if worsening HA, vomiting, AMS, bruising around eyes/ears, seizures -> Return to ED

Question 33

c-spine injury

Answer 33

-image c-spine injury if neuro deficit / GCS depressed -> use NEXUS / canadian CT spine rules otherwise -you want alignment of anterior and posterior contour line and spinolaminar line -Pre-hospital c-collar does not mandate imaging -Canadian CT spine rules requires: -GCS=15 (intoxication is OK if alert and cooperative) -Vital signs are stable -Neuro exam is normal -No known c-spine disease or prior surgery -alert, stable -!!!CT non contrast is 1st line for moderate-high risk pts w/ cervical injury -if no sx / CT neg and high suspicion -> MRI -> good for soft tissue, cord, ligaments -IMAGING DOES NOT R/O SCI -no sx + neg CT -> cleared -> advise movement

Question 34

spinal cord injury (SCI)

Answer 34

-Sensory (ascending): -position, vibration, light touch- dorsal columns -pain (pinprick), temp- ventral columns, spinothalamic -Motor (descending): -corticospinal -S1-S2- buckle my shoe (achilles) -L3-L4- kick the door (patella) -C5-C6- pick up sticks (biceps) -C7-C8- lay them straight (triceps) -L1-L2- cremasteric -S3-S5- anal wink -Anterior cord- -b/l motor paralysis + loss of pain and temp -LE > UE -central cord- -elderly, hyperextension of neck, chin hits ground -UE > LE -> hand weakness, CAPE-like -B/L loss of light touch, pain, temp below lesion -Brown-sequard- -penetrating trauma -ispilateral motor, proprioception, vibration loss -contralateral pain and temp loss

Question 35

TBI canadian head CT rules vs PECARN

Answer 35

-GCS 13-15 + at least 1 of following: -LOC -Amnesia to head injury event -Witnessed disorientation -Exclusion criteria: -Age <16yo -Blood thinners -Seizures after injury, or, anticoagulation use -PECARN: -<2yo and 2-16yo -CT if: -GCS<15  -AMS -Signs of skull fracture (basilar skull fx >2yo) -consider in kids with: -LOC from head trauma -Non-frontal hematoma or acting differently and <2 yo -Vomiting from head trauma -Severe headache -Severe mechanism: -MVC + [Ejection, rollover, vs. pedestrian, death at scene ] -High impact object -Fall >3ft (<2yo) or >5ft (>2yo)

Question 36

head bleeds

Answer 36

-EPIDURAL: -progressive obtundation (N/V, HA, LOC) -unequal pupils (dilated on side of clot) -cushings -> HTN, brady, irregulat resp -hernaiation -MI -does not cross suture lines -heterogenous appearance -> active bleed -Tx- surgery -SUBDURAL: -btwn brain and dura -higher mortality than epidural -crosses suture lines, does NOT cross falx -elderly- personality changes, focal deficit -surgery -if small, subacute, neuro intact -> observe -SAH traumatic: -increase ICP either from hemorrhage or hydrocephalus from obstruction of ventricular system (3rd) -Dx- CT within 6 hrs -if CT neg and >6hrs -> LP or CTA -Tx: -R/O aneurysmal cause! -> require surgery -!Reverse coagulopathy -Warfarin reversal: PCC, FFP, Vit K -UFH, LMWH: Protamine sulfate -Thrombocytopenia: Platelets -BP systolic < 160mmHg -Reduce ICP - Hypertonic saline -Prevent cerebral vasospasm- Nimodipine -Dispo: Neuro ICU -Intraparenchymal -trauma or non-trauma (malignant HTN) -often evolve over hrs/days -mass effect common -small vessles -Tx: definitive airway, reverse anticoag, control BP (dont allow hypotension), control ICP

Question 37

brain hernation

Answer 37

-classic presentation- ipsilateral fixed dilated pupil and contralateral hemiplegia -cushing reflex- HTN, brady, irregular respiration -if seziures -> benzo -reverse anticoagulation -keep SBP ~ 160 -raise HOB -mannitol -hypertonic saline -hyperventilation -ventriculostomy

Question 38

Signs and symptoms of basilar skull fractures

Answer 38

- fx of Skull base -Serious and life-threatening complications -Hemotympanum – 1st sign -Raccoon eyes - delayed -Battle sign - delayed -“Halo” sign -Anosmia -EOM defects -Hearing loss -loss of balance -Carotid artery or vertebral artery injury -Cervical spine injury

Question 39

facial trauma: orbital floor fx

Answer 39

-aka orbital blowout fx -may entrap !inferior rectus muscle! -> !vertical stabismus! (one eye deviated up) -numb on middle face (maxillary branch of trigeminal runs thru inferior orbital groove) -blunt or penetrating trauma -pain with eye movement -floor- diplopia! and/or nausea -roof- forehead numbness -proptosis or enophthalmos -widened intercanthal distance -bradycarida!- oculocardiac reflex causes dec HR when pressure apple to extraocular muscles -Dx: -!CT no contrast -CT indicated if bony tenderness, step off, crepitus, entrapment -PE- acuity, fields, IOP, slit lamp, EOM -ophthalmology consult for dec acuity, widen intracanthal space (fx), orbital comartment syndrome (rock hard eyelids), CSF, entrapment esp if causing oculocardiac reflex -r/o brain bleed, c-spine fx, CSF leak, entrapment syndrome, airway -Tx: -elevated HOB -ice pack for first 48hrs -nasal decongestants, corticosteroids -complications -> surgery -do NOT blow nose

Question 40

Hyphema treatment

Answer 40

-RF- sickle cell -> exchange transfusion -more blood can cause staining and increase IOP -Tx: -Place clear eye shield -Elevate head of bed -tx bleeding disorders ->1/2 -> admit and ophtho -<1/2 -> expedited outpt ophtho eval

Question 41

corneal abrasions, corneal lacerations and globe ruptures

Answer 41

-CORNEAL ABRASION: -ask ab contacts -if central -> dec acuity -dx- fluorescein stain and woods lamp -eyelid EVERSION! -Tx- topical antibiotics (erythromycin, tobramycin, gentamycin) -cipro if contacts -tetracaine for pain in ED -24-48hr ophtho f/u -NO shields, steroids, contacts, tetracaine (at home) -CORNEAL LACERATION: -Full thickness laceration of the anterior chamber -MC sharp -teardrop pupil -flat anterior chamber -seidels sign- fluorescein swirls due to leaking aqueous humor -DO NOT TONO PEN (check IOP), DO NOT PATCH (do shield) -Tx- immediate consult -IV antibiotics, analgesia, anti-emetics, tetanus -GLOBE RUPTURE: -Full thickness laceration of the globe -MC blunt -teardrop pupil -flat anterior chamber -seidels sign- fluorescein swirls due to leaking aqueous humor -DO NOT TONO PEN (check IOP), DO NOT PATCH (do shield) -Tx- immediate consult -IV antibiotics, analgesia, anti-emetics, tetanus, imaging for globe

Question 42

nasal congestion, sinusitis, allergic rhinitis, nasal polyps, septal hematomas b. Differentiate between nasal polyps and a septal hematoma (based on description or picture)

Answer 42

-Nasal Congestion: -Sinusitis: -purulent -facial pain ->10 days -Allergic rhinitis: -clear -itchy -pale, boggy mucosa -Nasal polyps: -chronic congestion -dec smell -mobile lesions -pale -aspirin exacerbated -Septal hematoma: -blood btwn perichondrium and cartilage -worst morbidity of nose -complications: abscess, necrosis, saddle nose, perforation -Tx- I&D w/ b/l packing -augmentin, removal 2-3days

Question 43

auricular hematoma

Answer 43

-Sudden blood btwn ear cartilage and perichondrium -cartilage necrosis -> cauliflower ear -Cauliflower ear -> hearing loss due to loss of shape, and cosmesis -Tx: -Prompt drainage, prevent reaccumulating -Inject local anesthesia -Perform I&D -If small (<2cm) and < 48hrs -Early needle aspiration and PRESSURE dressing -Nonsurgical dressing: Padding behind and on top of ear and wrap gauze -> 12-48hrs -Bolsters! are alternative -Two rolls of tefla dressing covered in antibacterial ointment -If larger (>2cm) or present for 2-7 days -I&D, ENT referral -If > 7 days -> refer to ENT

Question 44

Signs and symptoms of an arterial injury to an extremity b. Acute management of a suspected arterial injury

Question 45

Rhabdomyolysis

Answer 45

-acute breakdown and necrosis of MUSCLE -Causes: -TRAUMA/COMPRESSION -Prolonged immobilization -Seizures -Burns -Compartment syndrome -meds (STATINs MC), substance abuse (amphetamines), infections (influenza), metabolic or genetic factors -triad- muscle pain, weakness, dark urine -non-specific sx- fever, malaise, n/v, tachy, abd pain, oliguria -Dx: -LABS: -↑ CPK (>20,000) !!! -↑ LDH -!Hyperkalemia, phos -Hypocalcemia -+/- AKI -U/A: MYOGLOBINURIA !!!! -Red/Brown/Pink/Dark urine that is heme (+) but no RBCs on microscopy!!!!! -EKG: +/- hyperkalemia if severe -Tx: -IVF to flush out myoglobin -Treat any hyperkalemia!! -Severe -> dialysis -Complications: -ACUTE KIDNEY INJURY and ATN due to excess myoglobin

Question 46

compartment syndrome

Answer 46

-CRITICAL reduction in blood flow to tissue -MC in lower limbs -MC long bone fx -> tibia -Circumferential thermal burns -Tight casts -RF: Bleeding disorders or anticoagulation -OPEN fx can get compartment syndrome -CAN occur in low-energy or atraumatic injuries (drug overdose) -Late or missed presentation: -Myonecrosis, Rhabdo, Contracture, Sensory loss, Infection, Non-union, Amputation, Death -Pain out of proportion -> 1st and most reliable finding -within hrs or within 48hrs of insult -Unrelieved with initial measures -!!Worse with passive stretching -Paresthesia's -!!Tense compartments -Not usually swollen -6 P’s as it progresses -Dx: -Perform and document serial exams (q 30 mins) -Absolute compartment pressure > 30 mmHg or -Delta pressure < 30 mm Hg (delta = diastolic BP – compartment pressure) -Tx: -Early recognition -!!Consult ortho, trauma, or acute care surgery for emergency surgical fasciotomy -Prior to surgery: -Remove all dressings / splints / casts -Keep limb at neutral level -High flow oxygen -Improve BP with IVF -Give opioid analgesics! -incisions left open to recheck in 24-48hrs -> assess need for debridement -Monitor for rhabdo and renal injury

Question 47

Painless mono vision loss: amaurosis fugax, CRAO, CRVO, optic neuritis (can be painful on movement), retinal detachment, vitreous hemorrhage, stroke

Answer 47

-central retinal artery occlusion: -usual stroke RF -preceded by amaurosis fugax -afferent pupillary defect (swinging light test) -fundoscopy- pale retina, cherry red spot, fixed, dilated -tx- ASAP optho consult (anterior chamber paracentesis), admit with stroke work up -gentle massage globe- dislodge emboli -dec IOP- acetazolamine, mannitol, timolol -inc CO2- hyperventilation -inc O2- 100% nonrebreather ->2hr -> vision loss -central retinal vein occlusion: -DVT of eye -fundoscopy(pic)- blood and thunder hemorrhage, cotton wool spots, macular/optic disc edema -check b/l dont miss papilledema -tx- ASA, lower IOP, steroids, urgent consult -retinal detachment: -flashers & floaters -lower curtain -ocular US -check visual fields -grey retina with folds, vitreous hemorrahge (cant r/o w/ fundoscopy) -tx- emergent ophtho consult -vitreous hemorrhage: -abn neovascularization -> bleed -red haze, cobwebs, shadows -worse in morning -check IOP, pupillary reflex -ocular US -tx- underlying cause -optic neuritis: -MS -afferent pupillary defect -painful EOM -optic disc swelling -MRI or CT head -loss of color / vision -ocular US -tx- IV steroids, neuro or ophtho consult

Question 48

Painful mono vision loss: Glaucoma, temporal arteritis, corneal ulcer/abrasion, uveitis, iritis , endopthalmitis

Answer 48

-glaucoma: -acute (painful), chronic (not painful) -IOP > 20 -tx- miotics, lower IOP -temporal arteritis: -3/5: >50yo, HA, temporal tenderness/dec pulse, ESR >50, bx + -polymyalgia rheumatica- proximal limb weakness -may have afferent pupillary defect -pale edematous optic disc -tx- No vision loss- high dose prednisone -Vision loss- solumedrol IV -iritis: -h/o autoimmune ds or trauma -slit lamp -tx- pain control, steroids -

Question 49

funduscopic and/or ultrasound findings in retinal detachment, vitreous hemorrhage, CRAO and CRVO?

Answer 49

-RETINAL DETACHMENT: -Fundoscopy- pale, grey retina with folds, vitreous hemorrahge (cant r/o w/ fundoscopy) -US- hyperechoic membrane floating inside vitreous -> moves with eye movement -VITREOUS HEMORRHAGE: -Fundoscopy- neovascularization, red haze, cobwebs, shadows -US- snowstorm appearance- hyperechoic -CRAO: -fundoscopy- cherry red spot, pale retina -arteries are narrow -US- wnl -CRVO: -fundoscopy- blood and thunder -> diffuse retinal hemorrhage, dilated tortuous veins -flame hemorrhages -optic disc edema -US- wnl

Question 50

Acute angle gluacoma

Answer 50

-!Red/painful eye, vomiting, HA, AMS -!Precipitated by dark room, or using mydriatics -Canal of Schlemm is narrowed, cannot drain fluid -Vision threatening -Systemically unwell -Steamy hazy cornea -!Mid-dilated, non-reactive pupil -!Elevated IOP >40-70 (normal 10-21mmHg) -May have a rock hard globe -Tx: -Emergent ophthalmology consult -Pain control -↓ IOP: mnemonic STAMP -Supine- lower head of bed -Timolol: eye drops -Acetazolamide 500mg IV (carbonic anhydrase inhibitor) -Mannitol 1g/kg IV (osmotic decompression ) -Pilocarpine eyedrop

Question 51

periorbital vs. orbital cellulitis vs. retrobulbar hematoma

Answer 51

-PRESEPTAL: -Staph, group A strep, strep pneumo -injury (scratches, bug bites), local spread from URI, stye, blepharitis, conjunctivitis -Fever, erythema, lid edema -Young = do a septic workup -PO Augmentin, clinda -POST-SEPTAL: -2ndary spread (sinusitis, dental infections, dacryocystitis, orbital surgery, endogenous sources) -Staph, strep, pseudomonas, enterococcus, H. flu -Proptosis, Ptosis -Limited EOM (diplopia) -Chemosis -Suspect compression optic neuropathy if afferent pupillary defect, ↓ visual acuity, visual field deficit and ↑ IOP -Clinical dx -> confirm w/ CT -blood cultures -Tx: IV clinda or cefuroxime, admission, ophtho consult for possible debridement -Complications: Meningitis, abscesses, cavernous sinus thrombosis, CN deficits, orbital compartment syndrome -RETROBULBAR HEMATOMA(pic): -Blunt trauma -> hematoma behind eye -Proptopsis -Decrease visual acuity -Non-reactive pupil -IOP>40 -Tx- Lateral canthotomy, emergent

Question 52

red eye

Answer 52

-conjunctivits: -spares the ring around the pupil -episcleritis: -self limited -blanches with phenylephrine -> dx and differentiates from scleritis -scleritis: -rare but emergent -> vision threat -pain, blurry vision, photophobia -sclera edema, violet/blue globe -underlying autoimmune ds -tx- oral steroids, NSAIDs, emergent ophtho -anterior uveitis/iritis: -inflammation of internal structures -Etiology: Infectious, post-traumatic, autoimmune (associated with HLA-B27)!! -sudden, unilateral deep pain -!direct and consensual photophobia -> painful constriction -miosis -ciliary flush -slit lamp - cell and flare (WBC in anterior chamber (hypopyon) -> foggy) -tx- topical cycloplegics (dilate pupil) and topical steroids -anesthetics dont work bc its deep -ophtho consult -keratitis: -inflammation of cornea -vision blurry, red -perilimbic flush - not as deep as ciliary flush -UV keratitis- welders, fluorescein shows superficial punctate! keratitis) -> tx- no ophtho consult -> patch, cycloplegics, topical, antibx -!!corneal ulcer- contact lens (pseudo) -> SOFT/HAZY white EDGES (unlike sharp abrasion) -> EMERGENCY / IV antibx -tx- prophylactic antibx -call ophtho -NO steroids for HSV

Question 53

Epistaxis

Answer 53

-!Hold pressure below nasal bridge -> ENTIRE fleshy part -Should be uncomfortable -Tongue depressor option -Lean head slightly forward -Ice on forehead or occiput -Wait 10-20 mins -Look in nose and throat -Tx options: -!Afrin spray (oxymetazoline) + pressure + time = manages majority of bleeds -Anterior bleed (MC)- Silver nitrate cautery (never on septum) -Anterior nasal packing: Surgicel/Surgiflo, Vaseline gauze, xeroform gauze, Merocel, Nasal tampon -Refractory tx, severe, anticoag -Posterior bleed or persistent -> Foley or 7.0cm size rhinorocket -ENT consult / transfer

Question 54

Acute otitis media and its complication mastoiditis

Answer 54

-AOM: -hearing loss -impaired mobility of TM -buldging/red -if perf -> drainage / crust -bullous myringitis = blisters on TM (mycoplasma) -tx- analgesics, hydration, antibx, consider t-tube -complication- mastoiditis, meningitis, facial nerve paralysis, intracranial abscess -MASTOIDITIS: -abscess in mastoid bone -proptosis of ear -thin-cut CT temporal bone -2wks antibx -possible surgical drainage -complications- meningitis, skill osteomyelitis, venous sinus thrombosis, brain abscess, facial nerve palsies

Question 55

Acute otitis externa and its complication malignant otitis externa

Answer 55

-Swimming, excessive ear cleaning, hearing aids, headphones -!Pseudomonas!, S. epidermis -Significant drainage, debris, granulation tissue in EAC -Must check TM, should be normal -Tx: -Debridement -Topical antibiotics: neomycin/hydrocortisone suspension, ciprodex -Consider ear wick (merocel) placement if very swollen -OTITIS EXTERNA (necrotizing) (malignant) -Osteomyelitis of temporal bone/skull, rapidly progressive -Pseudomonas aeruginosa -immunocompromised (DM) -!!Exquisite pain and discharge, out of proportion -radiate to jaw -Granulation tissue and bony-cartilaginous junction is pathognomonic -Possible CN7 palsy -CT and admission most often -4-6 wks of ORAL ciprofloxacin (topical not enough)

Question 56

Ludwigs angina

Answer 56

-Emergency! -> sepsis, airway compromise -Causes: dental infection/procedure , polymicrobial -Rapid cellulitis of floor of mouth -Pain, drooling, dysphonia, fever, trismus, hot potato voice, stridor (late sign) -!Cellulitis of redness, brawny neck edema -!Raised firm area under the tongue -> tongue protrusion or elevation (no tongue swelling) -!Neck/throat tenderness -!Submandibular “woody” induration, crepitus, tenderness -Often CT scan of neck, labs -Intubate early -broad spectrum IV antibiotics -PROMPT ENT / oral surgery consult for possible surgical I&D, ICU admission

Question 57

retropharyngeal abscess vs peritonsillar abscess

Answer 57

-PERITONSILLAR ABSCESS: -20-40yo -Recent or current strep, acute tonsillitis -!Muffled “hot potato” voice -!Uvula deviation -!Trismus = cannot open jaw d/t pterygoid muscle irritation -!fluctuant, swollen, red, loss of landmarks -May be drooling, halitosis -Dx: Clinical! -> can get CT or U/S -Def tx = drainage!: Needle aspiration vs. I&D -Obtain wound culture -Complication: hitting the carotid -Send home with antibiotics !(clindamycin or ampicillin/sulbactam 10-14 days) -RETROPHARYNGEAL ABSCESS: -young <5yo -recent strep, OM, tonsillitis, Post op (dental, endoscopy), trauma (fish bone) -Sore throat, fever, neck pain, dysphagia, odynophagia, neck stiffness (meningitis mimic) -!Pain / limitation of neck extension/flexion -Unilateral posterior pharyngeal edema & erythema -Stridor, pooling secretions, sniffing position, voice change -> bad -Dx: Lateral neck XR or CT scan w/ contrast! -Tx: -Antibiotics (clindamycin) -ENT consult (surgical incision & drainage) -Intubate if signs of impaired airway -Complication: Mediastinitis, Lemierre’s syndrome, Obstruction

Question 58

pharyngitis, mono, exudative tonsillitis

Answer 58

-sore throat- Usually viral URI! -dysphagia, referred pain to ears, neck, jaw, fevers, chills, myalgias -tonsil enlargement, posterior pharynx injected/red, cervical lymphadenopathy -Intervention: +/- throat cx, cbc, bmp, monospot, flu -Meds: OTC NSAIDs, salt-water gargles, lozenges, consider decadron 10mg IM for severe pain -Exudative tonsillitis: -Strep throat -Centor criteria (fever, exudates, no cough, anterior cervical LAD) -tx- Amoxicillin -Mono: -EBV; less common CMV, HIV, HBV, toxo -Fever, fatigue, tonsillar exudate, anterior or posterior! cervical LAD -Monospot (heterophile antibody test) -> low sensitivity and high specificity -Doesnt work in <5yo -> bc no antibodies -Refrain from sports 21 days

Question 59

stridor: epiglottitis (supraglottiis) and croup

Answer 59

-EPIGLOTTITIS: -Etiologies: -HiB (Haemophilus influenzae B) * before vaccines -Strep or staph aureus -RAPID onset 12-24 hrs of: -Fever -Sore throat -Muffled voice -stridor -Anxious and ill-appearing -Dx: -before even examine -> CALL -Lateral neck XR: Thumbprint sign -Tx: -Early airway management -Emergent ENT consult -O2, nebulized meds -IV Ceftriaxone (3rd gen cephalosporin) -Admit if airway compromise -CROUP (laryngotracheitis): -barking -NO DROOL -low fever -worse at night -Dx- XR- steeple sign -Tx- humidified O2, nebulized racemic epi and albuterol!!!, observe 2 hrs -low O2 sat, young (<3mo)- nebs, steroids, admit -Other stridor in kids: -Anaphylaxis -Foreign body -Neck abscess -Congenital abnormalities compressing the airway -angioedema -> steroids, diphendydramine, famotidine, epinephrine IM if airway compromise

Question 60

Reversal agents

Answer 60

-vit K doesnt work fast -> use PCC or FFP + vit K -Indications for reversal: --Major bleeding in a critical site: -Intracranial bleed -Intraperitoneal bleed -Retroperitoneal bleed -Pericardial tamponade (from bleed) -Hemothorax -GI bleeding -Intramuscular (e.g. compartment syndrome, limb loss) -Intraarticular -things you cant apply pressure to -Hemodynamic instability -SBP <90 mmHg or decrease >40mmHg -Syncope -Hgb drop of ≥ 2 g/dL from bleed -Requiring ≥2 U PRBCs -Likely okay to watch and wait: Menstrual bleed, Epistaxis, Mild GI bleeding, Cutaneous bleeding

Question 61

methemoglobinemia: presentation, diagnosis and management

Answer 61

-Rare condition -Fe2+ -> Fe3+, “functional anemia” -Methemoglobin cant bind O2 -Causes: Nitrites (food), Topical anesthetics, Pyridium, Dapsone, Reglan -Severity = Concentration of methemoglobin ->10% = cyanosis , dusky skin -20-50% = fatigue, tachycardia, dizziness, dyspnea, chest pain ->50% = AMS, seizures, fatality -Labs: -Methemolgobin on comprehensive blood gas -Often normal PaO2 -!!SpO2 ~85% unresponsive to supplement O2 -Tx: Methylene blue!!! + Stop offending agent -Methylene blue CI in G6PD deficiency -Methylene blue is a MAO-I and can cause serotonin syndrome in pts on SSRI or SNRIs

Question 62

Sickle cell anemia: management. Differentiating vaso-occlusive, aplastic crisis, splenic sequestration and acute chest syndrome.

Answer 62

-Homozygous HgS = most serious form -Sxs do not appear until 4mo of age when HgF is replaced by the abnormal HbA -Short RBC half life = chronic anemia (normal = 12-18) -they live in chronic anemia -> hmg 6-8 -Recurrent splenic infarcts -> decline in spleen by 4-12mo -> susceptibility to encapsulated bacteria -Triggers: infection, dehydration, stress, extreme temperatures -ACUTE COMPLICATIONS: -Hypotension/tachycardia: -!!Sepsis -!!Splenic sequestration -!!Aplastic crisis -Severe pain: -!Acute chest syndrome -!Priapism -!!Vasoocclusive crisis (VOC) * dx of exclusion -Abdominal pain: -!Splenic sequestration -SOB: -!Acute chest syndrome -Acute anemia: -!Aplastic crisis -!Splenic or hepatic sequestration -!Acute chest syndrome -Fever: -!Acute chest syndrome -!Vasoocclusive crisis -!Infection / Sepsis (think encapsulated organisms)

Question 63

Neutropenic fever syndrome

Answer 63

-Neutropenia = Low absolute neutrophil count (ANC) -!!!!ANC ≤ 500 cells/microL -Fever (IDSA definition)= -!>1hr of ≥100.4°F (38°C), OR -!Single elevated temp ≥101.0°F (38.3°C) -Common in CHEMOTHERAPY -MC infections: GI, blood, skin, lungs, Urinary tract -but Fever or malaise may be only presenting sx -ANC reaches a nadir (lowest point) 5-10 days after chemo -Hematologic cancers ↑ risk of neutropenic fever -!Dx: -Thorough PE: -check for mucositis -Defer rectal until after antibiotics (infection risk) -Look for local infection: -Labs -Blood cultures x 2 (before antibiotics if possible) -CXR / Sputum cultures -UA / Urine culture -Consider CT abd, pelvis, chest -Consider GI panel -Maintain isolation and barrier precautions -pts are immunocompromised! -> may be no S&S -Tx: -Resuscitate and tx as sepsis if necessary -Fever + Neutropenia is a med emergency -High risk pts or sick pts will require !broad spec IV antibx and admission! -stay until ANC resolves -> 2 weeks -Low risk pts that are well appearing can be considered for outpt antibx tx with !Augmentin and ciprofloxacin! after 4 hr observation period

Question 64

sickle cell management

Answer 64

-ABCDE -Maintain O2 >95% -Early and aggressive pain control -Utilize incentive spirometer -> encourges deep breath despite pain -> prevents acute chest syndrome -Lab tests: -CBC w/ diff -BMP w/ LFTs -!!RETICULOCYTE count- would be higher in these pts normally -> if aplastic crisis it will be lower -Lactate dehydrogenase (LDH)- if its high it can mean hemolysis -Consider: CXR (fever, respiratory symptoms, chest pain), Viral swab, blood culture (if fever), UA, Urine culture, CSF analysis or synovial fluid analysis in the setting of fever -ALWAYS EVALUATE: -Cardiopulmonary symptoms -Hemoglobin level -Reticulocyte count -Biomarkers, imaging and laboratory testing (such as elevated reticulocyte count) are unreliable indicators of pain severity

Question 65

vaso-occlusive crisis

Answer 65

-MC manifestation of SCD -vitals can be normal even in pain -Can occur in any system: -pulmonary arterial tree (CP, SOB) -Coronary arteries (STEMI) -CNS (HA, strokes) -MSK (dactylitis, bone pain, VTE) -Kidneys (CKD/ESRD, Hematuria etc) -mild !fever and leukocytosis! -!bony infarctions! -Fat embolism -> ARD, petechia, AMS, renal/liver failure -Vasoocclusive Pain crisis- MC pain @: long bones, lower back -Stroke -Acute chest syndrome -Papillary necrosis -Avascular necrosis -Ulcers -Dactylitis: -Painful and swollen hands/feet - < 2yo -Usually 1st presentation -Tx: -Analgesia -Re-eval q15-30 mins -Consider PCA pump -Add Benadryl q4-6 hrs for itching -Gentle hydration to euvolemia: -D5 ½NS @ 1.0-1.5x maintenance (hypotonic) -Do NOT IV bolus -> avoid overhydration -> pulmonary edema -SPO2 at least 95% -Dispo: -Admit if required ≥2 doses of narcotics -Discharge if pain controlled, with PO meds

Question 66

SCD: splenic sequestration

Answer 66

-Splenic vasoocclusion traps large amount of RBCs in spleen -> splenomegaly -LUQ pain, splenomegaly, hypotension/shock -acute anemia -Children! < 5yo mostly -Fever -Shock: HR, RR, BP, poor perfusion -Supportive findings: -!Acute anemia (drop HGB of ≥2g/dL from baseline) -!!Normal or ↑ reticulocytosis -!Thrombocytopenia (d/t trapping) -range from minor to major -> progress to shock and death within hrs -Supportive tx: Fluid resus, cautious pRBC transfusion, elective splenectomy -Admit

Question 67

sickle cell: acute anemia: aplastic crisis

Answer 67

-fever, low Hgb, reticulocyte <1 -Severe and sudden drop in hgb AND reticulocytes -Assoc with parvo b19 -Fever, pallor, fatigue, lethargy, shock dyspnea -Labs: Pancytopenia -Anemia with HGB ~3-6 g/dL (normal 12-16g/dL) -!!Reticulocytopenia (as low as 0%) (normal 0.5-2.5%) -most important aspect of tx: simple RBC transfusion!! -Dispo: Admit! until bone marrow production is resumed

Question 68

Acute hemoglobin drop + low reticulocyte count = Acute hemoglobin drop + normal/high retic + abdominal pain =   Sickle cell disease + hypoxemia = Painful and swollen hands and fingers = Management for patient with sickle cell crisis and focal neuro deficits consistent with stroke = Most common cause of osteomyelitis in sickle cell?

Answer 68

-aplastic crisis -splenic sequestration -acute chest syndrome -dactylitis -transfusion -salmonella

Question 69

SCD: acute chest syndrome

Answer 69

-Can occur anytime after VOC -Treat before occurs -> Incentive spirometry, Analgesia -!!MCC of morbidity and mortality in SCD (10%) -!!!!Fever, cough!, chest pain!, dyspnea, hypoxia!, wheeze, rib/sternum pain -Tachypneic, rales, wheezing, effusion, low O2 -CXR: !New pulmonary opacity! -multilobar infiltrates -Tx: -!Antibiotics - make sure ischemic tissue isnt getting infected -Pain control -Supplemental O2 >95% -Incentive spirometry -Consider transfusion guided by hematologist -!Admit due to high chance of respiratory failure -Transfusion indications: -mild- 1-2 units PRBC simple transfusion -Severe- exchange transfusion: -Pts with hx of severe acute chest syndrome requiring exchange -diffuse acute chest X-ray finding -Oxygenation continues to worsen despite simple transfusion -Hypoxemia is particularly severe (ex. < 85%) -Evidence of other organ systems being involved, especially multiorgan failure

Question 70

stroke evaluation

Answer 70

-0 mins= arrive -<10mins= ABCs and POC glucose, last well known, exam -supplement O2 if <94% -NIH stroke scale -<15mins= notify stroke team -<25mins= Head CT or MRI -tells us if hemorrhagic or ischemic -> helps guide BP management -get CTA immediately if ischemic -MRI for posterior -<45mins- Interpretation of scan, decide tPA -<60mins- IV alteplase within 3-4.5hrs from sx onset -Labs: Coagulation, CBC, BMP, lipids, A1C, T&S -ECG- afib, large strokes you can see deep TWI and prolonged QT (ICP)

Question 71

stroke tx plan

Answer 71

-tPA: - !< 3hrs since onset of sx (<4.5 in select individuals) -!≥ 18yo -if tPA head bleed complication -> 10u cryo + 6U platelets -Dual anti-platelet therapy: -Minor strokes (NIHSS ≤5) do not always receive tPA -Initiate DAPT within 24hrs of sx onset -ASA + clopidrogel/ticagrelor -Endovascular therapy (EVT)/ Intra-arterial thrombectomy -Embolectomy or angioplasty with catheters -Indicated in LARGE VESSEL OCCLUSIONS! (LVO) in the ANTERIOR CIRCULATION! -done up to 24 hours! after sx onset -even if patient received tPA -Indications: -<6hrs from sx onset (but up to 24 hrs) -High baseline function prior to sx onset -Minimal tissue damage on CT -NIHSS score > 6 -tPA CI: -Absolute: -!ICH on CT -Presentation- sus of SAH -!Neurosurgery, head trauma, or stroke in previous 3mo -Uncontrolled HTN (>185/>110)! -!Hx of ICH -Known intracranial arteriovenous malformation, neoplasm, or intracranial aneurysm -!Active internal bleeding -Suspected or confirmed endocarditis -Known bleeding diathesis with platelet count < 100,000/μL -Elevated PTT with heparin administered in last 48hrs or oral anticoagulants -Glucose < 50 mg/dL or >400mg/dL -Relative CI: -Recent GI or urinary tract bleeding (past 21 days) -Minor or rapidly improving stroke sx -Major surgery or serious nonhead trauma in past 14 days -Seizure at stroke onset -Recent arterial puncture at a noncompressible site -Recent LP -Post-MI pericarditis -Pregnancy

Question 72

Large vessel occlusion (LVO) syndrome

Answer 72

-Anterior cerebral artery (ACA)- contralateral WEAKNESS IN LEG > arm/face -Middle cerebral artery (MCA)- contralateral WEAKNESS IN ARM/FACE > legs -dominant side (MC left) = aphasia -non-dominant side (MC right) = hemineglect -Posterior circulation stroke- -posterior cerebral, basilar, vertebral arteries -dizzy/vertigo, ataxia, nausea, diplopia, dysarthria -contralateral homonymous hemianopsia (loss of half of visual field on same side)

Question 73

stroke: posterior vascular territory

Answer 73

-Vertebral artery supplies brain stem and cerebellum -Branches of vertebral artery: AICA, Basilar artery, PCA, PICA -Crossed-findings are classic = Ipsilateral CN palsy + contralateral hemiplegia -!5 D’s: dizziness (vertigo), dysarthria, dystaxia, diplopia, dysphagia -!LOC, N/V, ataxia, nystagmus -Require MRI for dx!!!! -“Locked in syndrome” -Basilar artery infarction -Quadriplegia, can’t speak or swallow. Eyes are spared, and patients are awake and cognitively ware.  -Posterior inferior cerebellar artery (PICA) = Wallenberg’s syndrome -Dysphagia, dysphonia -hiccups -Ipsilateral CN deficits with contralateral pain/temp loss -ipsilateral Horner syndrome -ipsilateral gait Ataxia with a tendency to fall to affected side, nystagmus, vertigo -dysmetria- failure of finger to nose

Question 74

cervical artery dissection

Answer 74

-MCC of stroke in <50yo -RF- trauma, chiropracter, connective tissue disorder, migraines, infection, OCP, smoking, post partum -!can cause intramural hematomas and emboli -> TIA/CVA sx -sudden -!Head/face/jaw pain (74%) -!HA and/or neck pain (57-90%) -Horner’s syndrome (25%) (just miosis/ptosis) -CN palsy (8-16%) (mostly CN 12,9)- rare -Sx of ischemic stroke (weakness, numbness, vision changes) -Pulsatile tinnitus (16-27%) -Carotid artery dissection vs vertebral artery dissection: -Carotid: -Anterolateral aspect of neck -Radiates to jaw/face/head -Neuro sx- often contralateral -Partial Horner’s syndrome -CN deficit 9 +12 (contralateral) -MCA/ACA stroke sx -Transient monocular blindness (amaurosis fugax) -Retinal artery occlusion -Vertebral: -Unilateral, posterolateral neck and occiput -Neuro sx- contralateral or b/l -Posterior circulation stroke sxs -Vertigo, diplopia, visual field deficits -Wallenberg syndrome- Dysmetria, ataxia, ipsilateral hemiplegia, contralateral loss of pain and temp sensation

Question 75

cervical artery dissection dx and tx

Answer 75

-Gold standard for imaging = digital subtraction angiography (rarely used) -!!Bc tend to present as stroke: -!non contrast CT head 1st -!then -> CTA neck ± MRA neck to determine involved vessel -Tx of extracranial cervical artery dissections: -Antiplatelet (ASA) or anticoagulation (LMWH) -Consider endovascular stenting -Intra-cranial do NOT get anticoagulated (no heparin/warfarin) due to risk of SAH, can still get anti-platelets

Question 76

a. Differentiate between primary headaches and emergent causes of headaches b. Know the signs, symptoms, work up, imaging findings, treatments for each c. Describe the epidemiology and clinical presentation of subarachnoid hemorrhage (SAH), its diagnostic workup, and approach to management