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What is the mechanism of action of buprenorphine?

Partial opioid agonist


What happens if buprenorphine is given to someone who is currently high? What about if they are sober?

Will precipitate some withdrawal in someone who is high, will get someone who is sober a little high. Easiest way to think about it - it will bring people to a particular level.


What is in suboxone? Why?

Subuxone is buprenorphine and naloxone. The naloxone if there primarily so people don't crush it up and inject.


What are the three primary treatments for opioid use disorder?

1. Methadone
2. Buprenorphine
3. Naloxone


Why don't people like taking naltrexone?

Have to detoxify before initiating. For this reason, might be particularly good for people initiating right out of prison.


1. What is a simple ECG sign of right axis deviation?
2. In the setting of this previous ECG finding, what additional finding would indicate RVH?
3. What ST-T findings are typical for RVH?

1. Deep S wave in I
2. Large R wave in V1
3. Deep and narrow T wave inversions in V1, V2, and V3 (I think?)


What critical finding does this ECG show?

Terminal QRS distorsion in V3. It is diagnosis o LAD occlusion. TQRSD is defined as the absence of BOTH an S-wave and a J-wave in leads V2 or V3


If a patient has atrial fibrillation and is not on AV nodal blocking medications and has a normal heart rate, what should the concern be?

AV node disease. It is normal in A-fib for a healthy AV node that is not under the influence of meds to transmit beats


What are the typical symptoms of arsenic poisoning?
How are people usually exposed?

Vomiting, diarrhea, abdominal pain, fluid loses to the point of hypotension. Hypersalivate, garlicky odor. Acute encephalopathy, delirium, seizure, coma. Liver failure, renal failure, ARDS, arrhythmia can occur in severe cases. Peripheral neuropathy and pancytopenia develop after the acute illness.

Worldwide, groundwater is the most common exposure. Commercial forms found in pesticides, alloy strengthening materials, paint pigments.


Why is identifying right ventricular MIs important?

1) Higher mortality
2) More likely to be hypotensive
3) Much more nitroglycerin sensitive


1) What is the best was to diagnose right ventricular MI?
2) What is a suboptimal way?

1) Right sided ECG. ST elevation in V4, V5, V6 is indicative of RV MI
2) V1 (thought right sided ECG is way better). If there is no ST depression in V2, then elevation in V1 is relatively specific (~85%) for RV MI. If there is ST depression in V2, then ST depression in V1 is not specific for MI, as there may be a posterior MI also impacting the ST segment in V1


With a pediatric both bone forearm fracture, how should the bone be reduced?

If the periosteum is intact, don't distract the bones, simply realign. If the periosteum is broken, then may need to be distracted.


Bones of the mid and hind foot
4 bones in a row from medial to lateral in the mid foot?
1 bone posterior to that row?
Two bones in the posterior foot?

Medial Cuneiform, Intermediate Cuneiform, Lateral Cuneiform, Cuboid
Navicular is posterior to the cuneiforms (it's medial)
Talus, Calcaneus


Describe the main physical exam finding in primary syphilis

Chancre. Appears between 3 and 90 days (median 21) after infection. Begins as a papule and then ulcerates, usually 1 to 2 cm diameter with a raised edge. Supposed to be painless, though I've seen one that was painful.


What are the primary physical exam findings of secondary syphilis?

1. Constitutional symptoms (malaise, fever, sore throat, anorexia, headache)
2. Adenopathy
3. Rash. Classically diffuse macular or papular rash involving the entire trunk and extremities, including palms and soles, sometimes mucosal surfaces
4. A variety of other systems can be involved as well - hepatic, renal, ocular, neurologic


To what extent does the degree of CK elevation predict renal failure or other severe outcomes in rhabdomyolysis?

Not very well. Under a few thousand, probably okay. In the tens of thousands, increases the risk. Other factors may take a bigger difference. There is a prediction rule that is described in an article, and in uptodate.


What are epiploic appendages?

Small outpouchings of fat-filled, serosa-covered structures present on the external surface of the colon projecting into the peritoneal cavity. Each appendage encloses small branches of the circular artery and vein that supply the corresponding segment of the colon. A person may have 50 to 100.


What is epiploic appendagitis?

Torsion of the appendage when it is abnormally long and large. Acute torsion causes ischemia and infarction with aseptic fat necrosis and spontaneous venous thrombosis. Causes acute or subacute lower abdominal pain, usually on the left. CT is the diagnostic test of choice.


What are the criteria for diagnosis of serotonin syndrome? What are the criteria called?

The Hunter criteria. Someone must have taken a serotonergic agent and exhibit at least one of the following.
- Spontaneous clonus
- Inducible clonus PLUS agitation or diaphoresis
- Ocular clonus PLUS agitation or diaphoresis
- Tremor PLUS hyperreflexia
- Hypertonia PLUS temperature above 38ºC PLUS ocular clonus or inducible clonus


how sensitive and specific are the Hunter criteria for diagnosis of serotonin syndrome?

84% sensitive, and 97% specific when compared to the gold standard of diagnosis by a medical toxicologist


What are two ways serotonin syndrome can be differentiated from NMS?

1. Time course - serotonin syndrome develops over a day, NMS over days to weeks.
2. Activity - muscles have elevated activity (e.g. hypereflexia) in serotonin syndrome, sluggish and rigid in NMS


What are three mainstays of treatment for severe salicylate overdose?

1. Alkalinize the urine
2. treat central hypoglycemia
3. dialysis (for level over 80, or clinical factors such as cerebral edema)


How does time course of when a tonsillectomy bleed occurs impact what is going on?

Bleeds within the first 24 hours can be big and are from lack of control at the surgical site. Can be really bad. Bleeding around days 5 or 6 are usually from the scab falling off and the blood is venous oozing. Still need ENT.


How do you manage a tonsillectomy bleed?

Can try direct pressure by putting 2x2s on there. But really, don't try to deal with it yourself, get ENT in there. If you need to intubate (which you shouldn't normally need to), be really careful not to exacerbate the bleeding.


What are the steps to set up and use the Neopuff / T piece?

1. Connect the neopuff to the space on the warmer that says neopuff
2. PEEP should be about 5. Put the mask on your hand, then the dial will read out your peep
3. Peak inspiratory pressure (PIP) should be about 20. Tap your finger on the top of the neopuff, and the dial will read out the PIP. You can adjust the dial until it gets to about 20.


What are the basic steps in neonatal resuscitation?

(look at the chart on the wall!)
1. Warm, dry, stimulate
2. If HR < 100, give positive pressure ventilation until HR gets > 100
3. If HR stays below 100, reposition the baby to try to open the airway
4. If HR remains below 100, time to intubate
5. If HR goes below 60, need chest compressions and can start giving epic
All of these steps are done in 60 seconds interval


What are adequate oxygen saturations in a newborn?

60% at 60 seconds, and 85% at 5 minutes. Neonates are transitioning and don't need to have perfect sats initially.


How should bladder lavage for hypothermia be done

Infuse 100ml to 200ml or warmer saline. Optimal time to leave is is unknown, but 1 to 2 minute is reasonable. Then remove.