MTB 2 CK - Emergency Flashcards
(155 cards)
1
Q
you see a guy pass out in front of you. you shake him and he is unresponsive. what is the first thing you do?
a. start chest compressions
b. feel for pulse
c. look, listen, and feel for breathing
d. call 911
e. precordial thump
A
d. call 911
ACLS steps:
- check responsiveness
- activate emergency response + get an AED
- circulation (check pulse, start compressions/cpr)
- defibrillate (check for shockable rhythm w AED)
2
Q
CPR
-how many chest compressions per min?
A
100
3
Q
another term for unsynchronized shock?
another term for synchronized shock?
A
defibrillate
cardiovert
4
Q
algorithm for Asystole/PEA
pulseless
A
CPR - Epi - Shock
CPR - Epi - Shock
5
Q
algorithm for Vfib + pulseless Vtach
A
Shock - CPR – Shock - CPR - Epi – Shock
or
Shock - CPR - Epi
6
Q
pt w Vtach has a pulse + is stable
-next step?
A
IV Amiodarone
or
IV Procainamide, or IV Sotalol
7
Q
pt w Vtach has a pulse + chest pain
-next step?
A
cardiovert / Synchronized Shock
8
Q
signs of hemodynamic instability in Vtach - 4
A
SOB / CHF
low BP
chest pain
Confusion
9
Q
torsades is equal to which type of arrhythmia
A
Vtach
10
Q
causes of torsades
A
QT prolongation:
hypoMg, hypoK
drugs: TCA’s. Lithium, Antipsychotics, amiodarone/procainamide
macrolides: azithromycin
11
Q
when is Gastric Lavage most useful
A
ingestion
12
Q
Dangers of gastric lavage
A
Altered mental status: aspiration
Caustic ingestion: burning of the esophagus and oropharynx
13
Q
Ipecac Usage
A
Never in the hospital.
Can be used at home
14
Q
Cathartics
A
Not a good answer (sorbitol). Speeding up GI transit time does not eliminate ingestion without absorption
15
Q
Forced Diuresis Tx
A
Also not a good answer. Can often lead to pulmonary edema.
16
Q
pt has acute AMS or unresponsiveness for unknown reason
-best next step?
A
- Naloxone + Dextrose + Thiamine
2. Intubate
17
Q
Benzodiazepine overdose
A
Flumazenil, acute withdrawal can cause seizures so be careful
18
Q
TX for pt w unknown pill overdose
A
Charcoal
(superior to lavage and ipecac)
toxins in blood drop fast
19
Q
charcoal will not work in what overdose?
A
*Lithium* iron cyanide lead alcohols
20
Q
what symptoms indicate dialysis?
A
apnea *HoTN* renal failue liver failure coma
21
Q
bicarb diuresis is TX for 2 overdoses
A
aspirin
phenobarbital
22
Q
Acetaminophen Toxicity & Fatality levels?
-what about in toxicity in alcoholics?
A
Toxicity: 8-10 g
Fatality: 12-15 g
- 4g
23
Q
what lab value to watch in acetaminophen toxicity?
A
PT
24
Q
What do with toxic levels of acetaminophen
A
N-acetylcysteine
25
Overdose of acetaminophen more than 24 hours ago
No therapy possible
26
AST 2500, ALT 1800
| - alcohol or acetaminophen?
acetaminophen
| alcohol is 2:1 & more like 300:150
27
If amount of ingestion is unclear...
Get a drug level
28
Charcoal and N-acetylcysteine
Charcoal won't make N-acetylcysteine ineffective. No contraindication.
29
Most likely dx:
Tinnitus and hyperventilation
Respiratory alkalosis progressing to metabolic acidosis
Rental toxicity and altered mental status
Increased anion gap
Aspirin overdose
30
Aspirin and lactate production
Interferes with oxidative phosphorylation and results in anaerobic glucose metabolism (producing lactate)
31
Aspirin multisystem toxicity
Causes ARDS
Interferes with PT production and raises PT time
Metabolic acidosis from lactate
32
Tx of Aspirin Toxicity
Alkalize Urine
| -increase rate of aspirin excretion.
33
Blood gas in aspirin overdose
Respiratory alkalosis with a decreased CO2 and bicarb level (because of metabolic acidosis rising)
Ex: 7.46, CO2 22, Bicarb 16
34
```
pill overdose:
confusion & lethargy
mydriasis
RR 7
HR 115
EKG - wide QRS
DX?
next step?
```
TCA overdose
-bicarb
35
Tricyclic Overdose Suppression of Seizures
Benzodiazepines. So if you reverse benzos with flumazenil and the pt ingestion a lot of TCAs you open them up for seizing.
36
Best initial test to detect TCA toxicity
EKG will show widening of QRS complex. QT prolongs as well until torsade de pointes.
37
Sodium bicarbonate in TCA overdose
Bicarbonate protects heart against arrhythmia, has no effect on increased urinary excretion (as in aspirin)
38
TCA toxicity symptoms leading to death
Seizures and arrythmia
39
TCA toxicity smptoms
Anticholinergic effects:
Dry mouth
Constipation
Urinary retention
40
Caustics ingestion (drain cleaner, acids, alkali)
TX?
-next step?
*Fluids*
-Endoscopy
(Giving the opposite will cause an exothermic reaction and make the perforation/damage worse)
41
Most common cause of death in fires
CO poisoning
42
Cause of death in CO poisoining
*MI*
| CO is like anemia in that it removes carrying capacity/functional RBCs
43
Blood gas in CO poisoining
PO2 is normal because it can't release. Because oxygen not released to tissues you get lactic/metabolic acidosis.
Ex: 7.35, pCO2 26, HCO3 18
44
Most accurate test in carbon monoxide toxicity
Level of carboxyhemoglobin
45
Best initial tx for carbon monoxide toxicity
100% oxygen
| *hyperbaric oxygen* - CNS & cardiac symptoms, metabolic acidosis
46
Methemoglobinemia
Oxidized hemoglobin that is locked in the ferric state.
| Brown and will not carry oxygen
47
Which drugs can cause methemoglobinemia
Benzocaine and other anesthetics
Nitrites and nitroglycerin
Dapsone
48
Blood color in CO vs. Methemoglobinemia
CO - abnormally red
| Meth - abnormally brown
49
Dx Test and Tx for Methemoglobinemia
Methemoglobin level
Best initial tx is 100% oxygen
Most effective therapy is methylene blue (decreased half life of methemoglobin)
50
```
DX:
diarrhea
urinary incontinence
muscle weakness
bradycardia
bronchospasm
emesis
lacrimation
salivation
sweating
seizures
```
organophosphates
Nerve gas
(prevents breakdown of ACh)
*flu-like sxs w/o fever*
51
First step in organophosphate tx
1. Atropine
(blocks effects of ACh that is already increased. Dries up respiratory secretion.)
2. Pralidoxime
(reactivates acetylcholinesterase, which won't act fast enough in an acute reaction.)
52
pt w HTN, DM, & systolic dysfunction is admitted for 2 days of NVD. he is dehydrated, and his glucose is 180.
-next best step
digoxin level
| *have to think that pt is on dig in systolic HF*
53
which electrolyte value *leads to* digoxin toxicity?
*Hypok*
| incr digoxin binding
54
Digoxin toxicity *leads to* what electrolyte abnormality?
| -next step?
*HyperK*
(digoxin has taken up all binding sites)
tx - digoxin Ab's + bicarb/insulin
55
Most common presentation for digoxin toxicity
GI problems (*N/V/abdominal pain*)
Hyperkalemia
Confusion
*Visual disturbance* such as yellow halos around objects
Rhythm disturbance (bradycardia, atrial tacycardia, AV block, ventricular ectopy)
56
most Accurate test for digoxin toxicity
Digoxin level!
57
Best initial test for digoxin toxicity
EKG + potassium level
| EKG shows downsloping of the ST segment
58
Most common arrhythmia in digoxin toxicity
*Atrial tachycardia w variable AV block*
59
indication for digibind
CNS sxs
Cardiac sxs
K >5 + sxs
60
Most likely dx:
*Abdominal pain*
Renal tube toxicity (ATN)
*Anemia*
Peripheral neuropathies such as wrist drop
CNS abnormalities such as *memory loss* and confusion
Consider lead poisoning
61
Most accurate test for lead poisoning
Lead level
62
BEst initial diagnostic test for lead poisoning
Increased level of free erythrocyte protoporphyrin
63
Most accurate test for sideroblastic aenmia
Prussian blue stain, detects increased iron built up in RBC mitochondria
64
Tx of lead poisoning
```
Chelating agents. Succimer is he only oral form of lead chelator.
Ethylenediaminetetraacetic acid (EDTA) and dimercaprol (BAL) are parenteral agents.
```
65
Adverse effects of mercury poisoning
Inhaled mercury vapor - lung toxicity presenting as interstitial fibrosis
Neurological problems - nervous, jittery, twitchy, sometimes hallucinatory
66
Tx for mercury poisoning
No therapy to reverse pulmonary toxicity
| Chelating agents: dimercaprol and succimer can be effective
67
intoxication + blurry vision?
Methanol
| - causes blindness
68
Similarities with Methanol and Ethylene Glycol
```
Intoxication
Metabolic acidosis
INcreased anion gap
Osmolar gap
Treated wtih fomepizole and dialysis
```
69
Sources of Methanol vs. Ethylene Glycol
Methanol - wood alcohol, cleaning solutions, paint thinner
| Ethylene glycol - antifreeze
70
Toxic metabolite in Methanol vs. Ethylene Glycol
Methanol - formic acid/formaldehyde
| Ethylene glycol - oxalic acid/oxalate
71
Presentation of the Methanol vs. Ethylene Glycol
Methanol - ocular toxicity
| Ethylene Glycol - renal toxicity
72
Initial diagnostic abnormality of Methanol vs. Ethylene Glyco.l
Methanol - retinal inflammation
| Ethylene glycol - hypocalcemai, envelope shaped oxalate crystals in urine
73
Osmolar Gap
Increased in methanol and ethylene glycol. Also regular alcohol.
Expected osmolarity:
Serum osm = 2Na + BUN/2.8 + glucose/18
74
Best intial tx for methanol and ethylene glycol toxicity
```
Fomepizole
-(inhibiting alcohol dehydrogenase
prevents production of toxic metabolites)
Dialysis
- remove toxins
```
75
TX of Snake Bites?
*Immobilization* (decr movement of venom)
| Tx - antivenim
76
Black widow Spider bite
Abdominal pain, muscle pain
Hypocalcemia
Tx. Calcium, antivenin
77
Brown recluse spider bite
Local skin necrosis, bullae, and blebs
No lab abnormalities
Tx with debridement, steroids, and dapsone
78
Dog, cat, and human bites
TX?
infections?
*Amoxicillin/clavulanate* - (Augmentin)
Tetanus vaccination booster if more than 5 years
Dogs and cats: *Pasteurella* multocida
Humans: *Eikenella* corrodens
79
prophylaxis after human bites?
| animal bite?
HIV + HBV
| tetanus + rabies
80
Rabbies prophylaxis includes what?
human diploid cell vaccine
+
HR16 passive immunity
81
Head trauma with LOC management
Head CT first, without contrast.
82
Subdural and epidural hemotoma
Can only be distinguished with CT.
| Epidural related to head fracture
83
Lucid interval
Second LOC occurring soon after initial.
| Epidural + subdural hematoma
84
Concussion TX?
wait *24 hrs* before returning to work
| observe for mental status changes
85
Contusion Tx
Majority no treatment needed, severe may need surgical debridement
86
Subdural and epidural TX
| Large hematoma
*Intubation + hyperventilation*
Mannitol
Drainage
87
Hyperventilation in Hemotoma
Decreases pCO2, leading to a constriction of cerebral circulation. This decreases volume and decreases pressure.
88
Mannitol
Osmotic diuretic that decreases intravascular volume. Limited benefit.
89
Definition of Intracranial Hemorrhage
Compression of ventricles or sulci
Herniation with abnormal breathing/unilateral dilation of pupil
Worsening mental status or focal findings
90
```
Most likely dx and tx:
Head trauma
No focal finding
No lucid interval
Normal CT
```
Concussion
| Tx: No specific tx, observe at home for lucid interval or new focal findings
91
```
Most likely dx:
Head trauma
Rarely focal
No lucid interval
Ecchymoses on CT
```
Contusion
| Tx: No specific treatment; observe in hospital
92
```
Most likely dx:
Head trauma
+/- focal findings
+/- lucid interval
Venous, crescent
```
Subdural
| Tx: Drain large ones
93
Most likely dx:
+/- focal findings
+/- lucid interval
Arterial, biconvex or lens shaped hematoma
Epidural
| Drain large ones
94
Indications for stress ulcer prophylaxis
Head trauma
Burns
Endotracheal intubation
Coagulopathy (platelets
95
Best initial therapy for burns
100% oxygen to treat smoke inhalation and carbon monoxide toxicity
96
Etiology of death in burns
Airway burn or volume loss.
97
Intubation of Burn Pts Indications
Stridor, Hoarseness, Wheezing
(indicate Laryngeal edema)
Burns inside the nasopharynx or mouth
98
Volume replacement in burns
Lactate ringers
1/2 required in the first 8 hours
1/4 in second 8 hours
1/4 in third 8 hours
4 mL for each percent of surface area
99
Surface area percentages of burn victims
Head - 9%
Arms - 9% each
Legs 18% each
Chest or back - 18% each
Each hadn width is one percent of BSA
100
Most common cause of death several weeks after burn
Infection - give prophylactic topical antibiotics (silver sulfadiazine) NOT IV antibiotics
101
```
Most likely dx and tx:
Exertion
High outside temperatures
*Normal body temp*
Normal CPK and potassium level
```
Heat cramps/exhaustion
| Tx - oral fluids + electrolytes
102
```
Most likely dx and tx:
Exertion
High outside temperatures
*Elevated body temp*
Elevated CPK and potassium
```
Heatstroke
| Tx - *cool down* - (spray w water)
103
Most likely dx and tx:
Antipsychotic medications
Elevated temperature
Elevated CPK and potassium
Neuroleptic malignant syndrome
Dantrolene or dopamine agonist:
Bromocriptine or cabergoline
104
Most likely dx and tx:
Anesthetics administered systemically
Elevated temperature
Elevated CPK and potassium
Malignant hyperthermia
| Tx: Dantrolene
105
```
Most likely DX?
Intoxicated person
Low body temperature
J waves on EKG
-*next step?*
```
Hypothermia
| -*fingerstick glucose*
most common 2ndary cause of hypothermia is hypoglycemia
106
most common secondary causes of hypothermia? - 3
hypoglycemia
hypoThyroid
sepsis
107
Best initial test for hypothermia?
| MCC of death?
EKG
| Cardiac arrhythmia
108
Management of Drowning
*Positive Pressure Ventilation*
| NO STEROIDS OR ANTIBIOTICS
109
Specific types of drowning
Salt: acts like CHF - wet, heavy, lungs
| Fresh water: causes *hemolysis* from absorbing hypotonic fluid into the vasculture
110
Initial management of cardiac arrest
Open airway, head tilt, chin lift, jaw thrust.
GIve rescue breaths if not breathing
Check pulse and start ches tcompressions if pulseless.
111
When to give precordial thump
Within 10 minutes of witnessed arrest.
112
Management of pulseless activity
CPR
113
Asystole tx
After CPR
*Epinephrine* (or vasopressin)
Will shunt blood to critical areas like heart and brain
114
Unsynchronized Cardioversion
VF and VTach without pulse
115
When to give epinephrine during arrest (VF)
Two unsynchronized cardioversions, then epinephrine/vasopressin followed by another electrical shock.
116
When to give amiodarone/lidocaine (VF)
Given after 2 shocks, epi, schock. Amiodarone first choice.
117
Managing VTach
Pulseless VT: Same way as VF
| Hemodynamically Stable: Amiodarone, lidocaine, procainamide, THEN cardiovert.
118
VF management
Shock, drug, shock, drug, shock, drug, CPR the whole time
119
Hemodynamically unstable Vtach
Perform electrical cardioversion several times, followed by medications such as amiodarone, lidocaine, or procainamide.
120
Hemodynamically unstable definition
chest Pain
Dyspnea
Low BP
Confusion/AMS
121
VT with a pulse
SYNCHRONIZED CARDIOVERSION
122
pt is unresponsive, no pulse + sinus bradycardia EKG
DX?
next 2 steps?
```
Pulseless Electrical Activity (PEA)
(heart electrically normal, no motor contraction)
1. CPR
2. *IV Epinephrine* (up to 3 x)
-- same as Asystole --
```
123
which 2 causes of pulselessness are *non-shockable*?
Asystole + PEA
124
Most likely arrhythmia:
Palpitations, dizziness, lightheadedness
Exercise intolerance/dyspnea
Embolic stroke
Atrial
| AFib most common arrhythmia in the Untied States
125
causes of Asystole & PEA
Hypoxia, Hypothermia, Hypovolemia, Hypoglycemia, Hyper/HypoK+
Tamponade, Tension pneumothorax,, Toxins (metabolic acidosis), Thrombosis (PE, ACS)
126
Tx of hemodynamically unstable atrial arrhythmias
Synchronized cardioversion (prevents deterioration into VT and VF)
127
pt has Afib & is stable
| -next step?
```
IV *Diltiazem* / Verapamil
or
IV *Metoprolol / Esmolol*
or
Digoxin (*EF
```
128
Next step fter rate control, in AFib
```
*Aspirin* (CHADS of 1)
or
*Warfarin* (CHADS of 2+)
or
Dabigatran (Pradaxa)
or
Rivaroxaban (Xarelto)
```
(ANTICOAGULATE)
129
what conditions indicate electrical cardioversion in a pt w Afib? - 3
(after rate control & anticoagulation)
1st episode of AFib
worsening sxs
hemodynamically unstable
(RHYTHM)
130
which drugs can be used for cardioversion?
| electrical cardioversion is preferred
```
Ibutilide, flecainide, procainamide
or
sotalol - (*CAD* w/ normal EF)
or
amiodarone, Dofetilide -w (CAD w *EF
```
131
Afib for > 2days
| -what can you do before discharge?
* TEE*
a. NO CLOT?
- IV Heparin + *Cardioversion*
b. CLOT?
- IV Heparin + *Return in 3 wks*
132
when to use Heparin in Afib
Current Visible Clot in atrium
133
Non-anatomical causes of Afib
Alcohol
caffeine
cocaine
transient ischemia.
134
CHADS2
Aspirin
| If it were 2 or higher, warfarin, dabigatran, rivaroxaban
135
SVT Tx
1. valsalva, carotid massage, dive reflex, ice immersion
2. Adenosine
BB (metoprolol), CCB (diltiazem) or digoxin if adenosine not effective
136
Most likely dx:
SVT alternating with ventricular tachycardia
SVT that gets worse after diltiazem or digoxin
Observing the delta wave on the EKG
Wolff-Parkinson-White Syndrome
| Preexcitation syndrome with early depolarization of the ventricle
137
Most accurate test for WPW
Cardiac electrophysiology (EP) studies
138
Acute therapy of WPW
Procainamide or amiodarone
| only if WPW currently presenting
139
Chronic therapy for WPW
Radiofrequency catheter ablation, curative for WPW.
| EP studies tell you where anatomic defect is
140
contraindicated drugs in WPW
Digoxin and CCB
| block normal AV node and promote alternate pathways
141
arrhythmia in a COPD pt?
| TX?
Multifocal Atrial Tachycardia
tx - O2, IV Diltiazem or Verapamil
(avoid BB's)
142
pt w HR of 52 is lethargic
| -next step?
IV Atropine
2nd line: Transcutaneous pacing, Epi, Dopamine
143
pt w HR of 19 has normal hx & physical
| -next step?
nothing
* only treat symptomatic pt's*
- fatigue
- HoTN
- LOC
- dizzy
144
which AV blocks get a pacemaker?
Mobitz II
| 3rd degree
145
Third degree AV block Tx
Pacemaker (most effective tx for bradycardia)
146
First Degree AV Block Tx
Extended PR - can treat sx with atropine
147
Second degree Type I
Mobitz I or Wenckebach - progressively lengthening that leads to a dropped beat. Commonly a part of normal aging.
148
Second degree Type II
Mobitz II - just drops a beat with no lengthening (warning). Mobitz II can progress into a third degree AV block. EVERYONE GETS A PACEMAKER
149
Tx for post MI VTach
Fix ischemia, do an angiography for angioplasty or bypass
150
Risk of recurrence of VTach factor
Left ventricular function is the most important correlate of the risk of recurrence
151
Caustic ingestion managament
Check for perforation (CXR or lung sounds). Endoscopy to assess damage. Don't give charcoal because caustic ingestion causes DAMAGE and you're not trying to prevent systemic absorption.
152
TX for BB overdose?
glucagon
153
TX for CCB overdose?
calcium
154
mj juice - aka?
| joke
propofol
155
EKG changes in SAH?
diffuse T wave inversions
