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Flashcards in MTB 2 CK - Emergency Deck (155):
1

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

d. call 911

ACLS steps:
1. check responsiveness
2. activate emergency response + get an AED
3. circulation (check pulse, start compressions/cpr)
4. defibrillate (check for shockable rhythm w AED)

2

CPR
-how many chest compressions per min?

100

3

another term for unsynchronized shock?
another term for synchronized shock?

defibrillate
cardiovert

4

algorithm for Asystole/PEA
(pulseless)

CPR - *Epi* - Shock
CPR - Epi - Shock

5

algorithm for Vfib + pulseless Vtach

Shock - CPR -- Shock - CPR - Epi -- Shock
or
Shock - CPR - Epi

6

pt w Vtach has a pulse + is stable
-next step?

IV Amiodarone
or
IV Procainamide, or IV Sotalol

7

pt w Vtach has a pulse + chest pain
-next step?

cardiovert / Synchronized Shock

8

signs of hemodynamic instability in Vtach - 4

SOB / CHF
low BP
chest pain
Confusion

9

torsades is equal to which type of arrhythmia

Vtach

10

causes of torsades

QT prolongation:
hypoMg, hypoK
drugs: TCA's. Lithium, Antipsychotics, amiodarone/procainamide
macrolides: azithromycin

11

when is Gastric Lavage most useful

ingestion

12

Dangers of gastric lavage

Altered mental status: aspiration
Caustic ingestion: burning of the esophagus and oropharynx

13

Ipecac Usage

Never in the hospital.

Can be used at home

14

Cathartics

Not a good answer (sorbitol). Speeding up GI transit time does not eliminate ingestion without absorption

15

Forced Diuresis Tx

Also not a good answer. Can often lead to pulmonary edema.

16

pt has acute AMS or unresponsiveness for unknown reason
-best next step?

1. *Naloxone + Dextrose + Thiamine*
2. Intubate

17

Benzodiazepine overdose

Flumazenil, acute withdrawal can cause seizures so be careful

18

TX for pt w unknown pill overdose

*Charcoal*
(superior to lavage and ipecac)
toxins in blood drop fast

19

charcoal will not work in what overdose?

*Lithium*
iron
cyanide
lead
alcohols

20

what symptoms indicate dialysis?

apnea
*HoTN*
renal failue
liver failure
coma

21

bicarb diuresis is TX for 2 overdoses

aspirin
phenobarbital

22

Acetaminophen Toxicity & Fatality levels?
-what about in toxicity in alcoholics?

Toxicity: 8-10 g
Fatality: 12-15 g
- 4g

23

what lab value to watch in acetaminophen toxicity?

PT

24

What do with toxic levels of acetaminophen

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