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EM Final Study Guide > Pages 21-30 > Flashcards

Pages 21-30 Flashcards

1
Q

Csf Findings in Bacterial meningitis?

A 
Opening Pressure: Elevated
White Blood Cell count: 1,000-10,000*
Neutrophils: >80%
Glucose: Reduced
Protein: Elevated
Gram Stain: Bacteria
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2
Q

Csf Findings in Viral meningitis?

A 
Opening Pressure: Normal 
White Blood Cell count: Less than 300
Neutrophils:  1- 50%
Glucose: Normal 
Protein: Normal 
Gram Stain: Nothing
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3
Q

Csf Findings in fungal meningitis?

A 
Opening Pressure: Elevated 
White Blood Cell count: Less than 500
Neutrophils:  1- 50%
Glucose: Normal 
Protein: Elevated 
Gram Stain: Nothing
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4
Q

Treatment order in meningitis patients needing CT?

A

Prior to CT:

  1. Blood cultures should be drawn
  2. Steroids
  3. Empiric antimicrobial therapy
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5
Q

Rx encephalitis?

A

Supportive Care

*HSV encephalitis: ACYCLOVIR

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6
Q

IV emperic meningitis rx based on age?

A
  1. Less than 1 month: Ampicillin + Cefotaxime or Gent
  2. 1-3 months: Ampicillin and Cefotaxime
  3. Children over 3 months: Dexamethasone b4 Cephalosporin + Vancomycin
  4. 50 years or younger: Dexamethasone b4 Cephalosporin + Vancomycin
  5. Over 50: Dexamethasone b4 Cephalosporin + Vancomycin AND Ampicillin
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7
Q

Presentation subarachnoid hemorrhage?

A
  1. Acute onset thunderclap HA
    - Typically occipital or unilateral
    - Significant portion also have a warning (sentinel) HA
  2. LOC
  3. Vomiting
  4. Neck stiffness
  5. Seizure
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8
Q

RF SAH?

A
  • FH = 3- 5 x Risk
    1. Recent exertion
    2. Hypertension
    3. Excessive alcohol consumption
    4. Sympathomimetic use
    5. Cigarette smoking
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9
Q

Diagnosis SAH?

A
  1. CT: 7% not visualized on initial head CT
  2. LP:
    - Absence or clearing of blood.
    - Xanthochromia
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10
Q

How to analyze blood in LP of SAH?

A
  1. Normal CSF does not contain RBCs
  2. Many sources state that if # RBC decreases by 50% from tube 1 to tube 4, blood attributed to tap trauma
    - However, this decrease can occur in SAH as well
    - Tap should only be labeled ‘traumatic’ if 4th tube is fewer than 5 RBCs per HPF
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11
Q

What is xanthochromia?

A

Yellow or pink discoloration of supernatant once the CSF is centrifuged

  • Results from breakdown of RBC
  • Determined by visual inspection or spectrophotometry
  • Presence of xanthochromia highly sensitive of SAH
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12
Q

Next step if CT or LP consistent with SAH?

A

Angiography is necessary

- Conventional digital subtraction angiography (DSA) is gold standard

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13
Q

Mgmnt SAH?

A
  1. Assess and reassess ABCD’s
  2. Discontinue or reverse anticoagulation
  3. Prevent hypotension and hypoxemia
  4. Control ICP
  5. Seizure prophylaxis
  6. Treat fever and infection aggressively
  7. Control blood glucose: target 140-185
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14
Q

How do you control ICP?

A
  1. Monitor/lower BP in consult w/ neurosurg
  2. Elevate head of the bead to 30 degrees
  3. Provide sedation and analgesia
  4. If signs of rapidly rising ICP or herniation: mannitol or mild hyperventilation: target CO2 ~ 30 mmHg
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15
Q

When are epileptic patients prone to seize?

A
  1. Medical noncompliance: most common cause
  2. Sleep deprivation
  3. Emotional or physical stress
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16
Q

Causes of secondary seizure?

A
  1. Hypoglycemia: most common cause
  2. Hyponatremia
  3. Alcohol withdrawal, drugs, toxins
  4. Trauma
  5. Tumor
  6. Infection
  7. Eclampsia
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17
Q

Diagnosis mimicking seizure?

A
  1. PNES

2. Syncope

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18
Q

Lab tests in seizure patient?

A 
First time:
1. HcG
2. CMP
3. Head CT
4. MRI / EEG - outpatient
Recurrent: (above plus)
1. Phenytoin
2. Carbamazepine
3. Phenobarbital
4. CT head only if seizure quality is different or in status epilepticus 
5. Continuous EEG if status
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19
Q

Vitals in alcohol withdrawal?

A
  1. Tachycardia
  2. Hypertension
  3. Hyperthermia
  4. Tachypnea
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20
Q

Drugs causing seizures?

A
  1. Isoniazid: TB patients
  2. TCAs - widened QRS
    - Prominent terminal R in AVR
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21
Q

Characteristics of PNES?

A
  1. Rhythmic, controlled shaking activity
  2. Ability to talk or follow commands during the seizure
  3. Recall of a seizure that involves both sides of the body
  4. Lack of a postictal period
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22
Q

What is status epilepticus?

A

Single unremitting seizure w/ duration longer than 5-10 min or frequent clinical seizures w/o interictal return to baseline

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23
Q

Rx Status epilepticus?

A
  1. First line: Benzos (usually lorazepam)
  2. Second: fosphenytoin/phenobarbital/VPA
  3. Third: versed/pentobarbital/propofol infusions
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24
Q

Dosing of Benzos in seizure?

A

2 mg of lorazepam or midazolam every 2-5 min until seizures controlled

25
Q

Dosing of other meds in seizures?

A

Diazepam: 5 mg Pq 2-5 min (also available PR)
Phenytoin: 15-20 mg/kg PO/IV
Fosphenytoin: 15-20 phenytoin equivalents/kg IV
Phenobarbital: 20 mg/kg IV (use single dose of 60-120 mg PO for oral load)
Valproic acid: 15-45 mg/kg IV

26
Q

Rx for secondary seizures?

A

Eclampsia - Magnesium sulfate
Hyponatremia - Hypertonic saline
Isoniazid - Pyridoxine
Hypoglycemia - Dextrose

27
Q

Cholecystitis presentation?

A
  1. Biliary colic: may radiate to the back, r. flank/scapula
  2. RUQ or epigastric pain
  3. N/V may
  4. Pain is burning, pressure-like, or heavy
  5. Occur in relation to the ingestion of fatty meals
28
Q

Ddx acute Cholecystitis?

A
  1. Choledocholithiasis
  2. Cholecystitis
  3. Cholangitis
29
Q

What is Charcot’s triad?

A
  1. RUQ pain
  2. Fever
  3. Jaundice
    - Seen in 70% cholangitis patients
30
Q

What is Murphy’s sign?

A

Ask patient to breathe out then gently hand below costal margin at mid-clavicular line

  • Patient then inspire
  • If patient stops breathing in (as the gallbladder is tender and, in moving downward, comes in contact with the examiner’s fingers) and winces with a “catch” in breath, test is positive
  • Good sensitivity (63-90%)
  • Low specificity (45-65%)
31
Q

Efficacy of US in cholecystitis?

A
  1. Sensitive: Over 95%

2. Less sensitive under 80% for choledocholithiasis

32
Q

What level of dilation of bile duct are we looking for?

A

Greater than 6mm in adults or 8mm in elderly)

  • Choledocholithiasis
  • Cholangitis
33
Q

What level of gallbladder wall thickening do we look for?

A

5mm or greater

34
Q

When is ERCP needed?

A

To diagnose and treat diseases of the biliary and pancreatic ducts

35
Q

Rx Biliary colic?

A
  1. NSAIDS and/or narcotics
  2. IVF
  3. Antiemetics
36
Q

Abx Cholangitis?

A

Ampicillin/sulbactam

37
Q

Appendicitis presentation?

A
  1. Vague epigastric or periumbilical pain followed by:
  2. Anorexia, n/v
  3. Migration of pain to RLQ
    * Only 1/2 - 1/3 present in this manner
    - Retrocecal appendicitis: vague and poorly localized pain - Pelvic appendicitis:midline or L.-sided pain
38
Q

When is vomiting more indicative of appendicitis?

A

If it comes after pain

39
Q

Presence of fever in appendicitis?

A

Fever typically absent during initial onset of pain

- Commonly develops within 24 hours

40
Q

WBC useful in appendicitis?

A

Not really

41
Q

US sensitivity in appendicitis?

A
  • 75 to 90% sensitive
    Findings suggestive of appendicitis include: noncompressible lumen, a diameter greater than 6mm, absence of gas in the lumen, appendicoliths, and a thickened wall
  • CT more sensitive and can rule out other causes
42
Q

Presentation ruptured AAA?

A
  1. Pain
  2. Hypotension
  3. Pulsatile abdominal mass
43
Q

Target BP in rupured AA?

A

Systolic between 90 and 100

44
Q

Blood to use while waiting for crossmatch?

A

O-

45
Q

What is pain out of proportion to exam indicative of?

A

Mesenteric Ischemia:

Patient may be screaming in pain, but their abdomen is soft with no guarding or rebound

46
Q

Causes and Rx mesenteric ischemia?

A
  1. Embolus: thrombolytics during angiography
  2. Mesenteric artery thrombosis: start heparin then same as above
  3. Mesenteric vein thrombosis:
  4. Nonocclusive ischemia: treat underlying cause
47
Q

Dx in mesenteric ischemia

A

CT angiography

- Angiography can also be used and is therapeutic

48
Q

Signs of mesenteric ischemia on imaging?

A

Circumferential thickening of the bowel wall, bowel dilatation, bowel wall attenuation, and mesenteric edema

49
Q

Meds to stop in mesenteric ischemia?

A

Vasoconstrictors

50
Q

What is papaverine?

A

Can be given during angiography to increase blood flow to bowel that is not perfusing well by reducing mesenteric vasoconstriction

51
Q

Most common cause SBO?

A
  1. Tumors
  2. Adhesions
  3. Hernias
  4. Strictures
  5. Intussusception
  6. Chrons
  7. Volvulus
52
Q

What is inability to pass gas indicative of?

A

SBO

53
Q

Multiple air-fluid levels are seen along with distended loops of small bowel?

A

Bowel obstruction

54
Q

Diagnosis of orthostatics?

A

Systolic drop of more than 10 or a pulse increase of more than 20

55
Q

What is elevated BUN indicative of?

A

GIB: due to degraded blood being absorbed in GI tract. A BUN/Cr ratio greater than or equal to 36 is suggestive of UGIB

56
Q

Most common causes LGIB?

A
  1. Angiodysplasia

2. Diverticulosis

57
Q

What does a A 99mTechnetium labeled red cell scan do ?

A

Looks for source of lower GI bleed

58
Q

Rx varices?

A
  1. Octreotide

2. Abx in patients with known cirrhosis

EM Final Study Guide (29 decks)

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