PEM Sample Q part 2 Flashcards
(113 cards)
1
Q
Boyle’s law
A
(P1V1 = P2V2)
-volume of gas is inversely proportional to pressure (increased altitude = decreased pressure = increased volume of air) –> PTX will expand with higher altitude and may cause tension physiology
2
Q
Dalton’s law
A
partial pressure of a gas mixture is the sum of all the partial pressures of the gases within the mixture
- Increasing altitude = decreased atmospheric pressure = for any given FiO2, you will have a lower PaO2
Lower PaO2 causes increase in ventilation and thus decrease in PaCO2 (higher pH = shifts oxygen dissociation curve to L = increases PaO2)
3
Q
4 steps to carry-out prior to air transport
A
- NGT insertion to decompress stomach
- Chest tube placement for even small PTX
- Instill liquid into foley/ETT balloons
- Ensure adequate oxygenation
4
Q
Advantages of ground transport
A
- Less expensive
- Not dependent on weather
- Door to door transfer
- Better for shorter distances
- Less noise/vibration/thermal variances etc
5
Q
Disadvantages of air transport
A
- Cost
- Size of aircraft limits # of pts, equipment, personnel
- Weather dependent
6
Q
Management of Necrotizing Fasciitis
A
- Consult surgery: debridement
IV Abx: Ceftriaxone, Clindamycin, Vancomycin
7
Q
RF associated with Nec Fasc
A
- Omphalitis
- Varicella infection
- Immunocompromised state (leukemia, HIV, DM)
- Recent hx of trauma or surgery
- NSAID use
8
Q
3 precipitating events for thyroid storm
A
- Trauma
- Infections: pneumonia, URI, enteric infections
- Iodinated contrast studies
- Surgery
9
Q
Mngmt of Thyroid Storm
A
- Inhibiting thyroid hormone production: methimazole
- Cardiovascular support: propranolol
- Temperature: cooling measures (tepid washcloths, Tylenol)
10
Q
Complications of cooling post arrest
A
- coagulopathy
- bradycardia
- infection
11
Q
Indications for cooling s/p arrest
A
Limited data in children - persistent coma s/p out of hospital arrest; use 32-34 degrees
12
Q
10 ways to rewarm a patient
A
- Passive - remove wet clothing, warm room, warm blankets, warm IVF, bear hugger
- Active: ECMO, peritoneal lavage, pleural irrigation, bladder irrigation, warmed humidified air through canula
13
Q
DDx. knee pain in athlete
A
- Osgood-Schlatter: TTP at tibial tuberosity
- Singed-Larsen syndrome: TTP at inferior pole of patella
- Patellofemoral syndrome
- Osteochondritis dissecans
- SCFE
14
Q
DDx. leg weakness /paresthesias in gymnast
A
- Spinal cord tumor
- Spondylolisthesis
- Disc herniation
- Transverse myelitis
- Vertebral osteomyelitis/discitis
15
Q
Neurologic injury with anterior knee dislocation
A
Peroneal N –> foot drop
16
Q
Vascular injury with anterior knee dislocation
A
popliteal artery
17
Q
XR findings for hip joint effusion
A
- asymmetric widening > 1 mm in teardrop distance
18
Q
Medication Tx. Status epilepticus
A
- First line = IN/IV/IM Ativan or Midazolam, PR Diazepam
2. Second line: phenobarbital, phenytoin, fosphenytoin
19
Q
DDx status epilepticus
A
- Febrile seizure
- Electrolyte changes: hyponatremia, hypoglycemia
- Toxic ingestion: TCA antidepressant
- Cardiac dysrhythmia
- Meningoencephalitis
- Intracranial mass or hemorrhage
20
Q
3 indications for laparotomy in Blunt Abdominal Trauma
A
- Hypotension with (+) FAST or w/o other source of bleeding
- Free air or rupture of hemidiaphragm on XR
- Peritonitis
- Multisystem injuries with indication for craniotomy in presence of + DPL or + FAST
21
Q
Clinical findings in Neurogenic Shock (4)
A
- Hypotension
- Bradycardia
- Widened pulse pressure
- Flushed/warm periphery
22
Q
Most likely injured abdominal organs with blunt trauma
A
spleen > liver > kidney > pancreas
23
Q
5 factors that affect severity of electrical injury
A
- Frequency = AC > DC
- Intensity of current = higher voltage is worse
- Duration of contact
- Resistance (wet skin decreases resistance)
- If thrown a distance, associated injuries increase severity
24
Q
C/I to IO placement
A
- fracture at site of placement
- overlying skin infection
- bone dysplasia
25
Complications of IO placement
```
Complications:
- Fracture
- Compartment syndrome
- Osteomyelitis (if > 24 hours used)
- Subcutaneous abscess
- Skin necrosis
Pain
```
26
US measurements in pyloric stenosis
Thickness > 3 mm
| Length > 15-17 mm
27
EKG changes in hyperkalemia
1. peaked T waves
2. prolonged PR / QRS interval
3. Decreased amplitude of p waves
4. sine wave pattern
5. > 10: v.fib / asystole
28
Non-medication causes of hyperkalemia (4)
1. Tumor lysis syndrome
2. Hemolysis
3. Trauma / Burns / Crush injuries
4. Adrenal insufficiency
5. Renal insufficiency
29
Most emergent ED management of hyperkalemia
IV Calcium Gluconate 10% IV, 60-100 mg/kg, max 2 g
| others: insulin/glucose, albuterol, furosemide, kayexalate
30
RF for sepsis in newborn (5)
- Prolonged ROM
- Maternal infection - chorioamnionitis
- Maternal GBS (+) or Previous sibling with GBS (+) infection
- Birth outside of hospital setting
- Prematurity
31
Four causes of jaundice (non-hemolytic)
1. Gilbert's syndrome
2. Autoimmune hepatitis
3. Viral hepatitis
4. Cholangitis / cholelithiasis with obstruction
5. Acetaminophen overdose
32
3 clinical features of acute liver failure
- Jaundice / icterus
- Hepatomegaly / splenomegaly
- Encephalopathy
- RUQ pain
- Easy bruising/bleeding (coagulopathy)
33
Infant with vomiting, FTT, ammonia > 200 - 2 urgent ED management steps
1. Begin IVF with dextrose containing solution
2. Prepare for hemodialysis
3. Obtain labs including CBC, BMP, Liver panel, urine / serum organic acids, blood gas
34
Associated conditions with SCFE
- Hypothyroidism, GH supplementation, hypogonadism --> check TFTs, GH levels
RF: male, obesity, black
35
4 xray findings in SCFE
1. Steel sign
2. Widening of physis
3. Decreased height of epiphysis
4. Klein's line - lateral cortical line along femoral neck does not intersect the epiphysis
36
4 conditions assoc with rectal prolapse
1. Constipation
2. Cystic fibrosis
3. Crohn's disease / Ulcerative colitis
4. Hirschsprung disease
5. Intussusception
37
Causes of PID that are NOT STI
- childbirth
- Miscarriage /abortion
- IUD use
- Pelvic surgery or endometrial biopsy
- appendicitis
38
Minimum clinical criteria for PID
1. Sexually active pt with pelvic / lower abdominal pain with no other cause AND one of CMT, uterine TTP or adnexal TTP
39
Definitive clinical criteria for PID
1. Endometrial biopsy with histopathologic evidence of endometritis
2. Laparoscopic abnormalities c/w PID
3. US or MRI with thickening fluid filled tubes or tuboovarian complex
40
CF of salicylate toxicity
- Tachypnea
- Fever
- Tachycardia
- Tinnitus / vertigo
- Nausea /vomiting/diarrhea
AMS
41
MOA of succinylcholine
binds at nicotinic Ach-R at NMJ, is not broken down by Ach-esterase, thus does not allow motor unit to repolarize
Causes bradycardia by acting on PNS --> Ach-R --> M2 cholinergic R and sinus and AV nodes
42
C/I to succinylcholine
- hypersensitivity
- History of muscular dystrophy or myopathy
- Family hx or personal hx of malignant hyperthermia
- Hyperkalemia
- Significant trauma or burn (after acute phase)
- Ocular surgery, penetrating eye injuries or close angle glaucoma
- Pseudocholinesterase deficiency
43
Indications for arthrocentesis
- Concern for septic joint
- Traumatic hemarthrosis to relieve pain
- Joint effusion causing severe pain / limitation of function
44
C/I to arthrocentesis
- overlying skin infection
- Hemophilia
- Presence of fracture near joint site
45
Jefferson fx
burst of C1 --> axial load
46
Hangman's fx
fx of pedicle of C2 --> hyperextension
47
Cervical distraction injury
increase in atlantoaxial distance --> acceleration/deceleration injuries, NAT, difficult delivery
48
Unstable Cervical Fractures
- Jefferson, C1, axial
- Hangman's, C2, hyperextension
- Odontoid, type 2/3
- Bilateral facet dislocation
- Teardrop fx: flexion
49
MOA of Epi in CPR
increased arterial blood pressure and coronary perfusion pressure via alpha-1 adrenergic effects
Secondarily: inotropic (increases cardiac contractility)
50
LEAN mnemonic for ETT meds
L - lidocaine
E - epinephrine
A - atropine
N - naloxone
51
4 physical exam findings with rib fracture
- Tenderness on palpation
- Crepitus
- Chest wall deformity
- Ecchymoses of chest wall
- Sx of respiratory insufficiency: tachypnea, retractions, acc mm use
52
6 underlying thoracic injuries from rib fracture
- Pneumothorax
- Hemothorax
- Pulmonary contusion
- Pulmonary laceration
- Pericardial injury with pericardial tamponade
- Large vessel (subclavian A) laceration or tracheal lac in 1st rib fx
- Spleen / liver / diaphragm laceration
53
2 mechanisms of acidosis in severe asthma
ineffective ventilation = increased CO2 retained --> respiratory acidosis
- Salbutamol use = lactic acidosis --> metabolic acidosis
Also get lactic acidosis from hypoxia and tissue hypoperfusion
54
3 meds used to tx methanol ingestion
- Folic acid
- Ethanol
- Fomepizole
- Sodium bicarbonate
- Thiamine / pyridoxine (ethylene glycol)
55
Medium Risk - CATCH Head injury rule
- Any sign of basilar skull fx
- Large, boggy hematoma of scalp
- Dangerous MOI: MVC, fall from > 3 ft or 5 stairs, fall from bicycle w/ no helmet
56
High Risk - CATCH Head Injury Rule
- Hx of worsening headache
- GCS < 15 at 2 hours
- Suspected open or depressed skull fracture
- Irritability on examination
57
Locations for occult blood loss in trauma patients
- Retroperitoneal
- Scalp
- Pelvis
- Long bone fracture
- Chest
58
Qualities of heart murmur that require further work-up
- Harsh, diastolic murmur
- Grade >3
- Location: not apex or LLSB
- Radiation to back
59
Non-cardiac causes of heart murmur
- High output states: fever, anemia, hyperthyroidism
- Pulmonary HTN
Pregnancy
60
Topical meds you can use for T&A bleed
- Epinephrine 1:1000 - Oxymetazoline
- TXA (can use topical or IV)
* also give IVF, PRBC, pressors
61
Mngmt of post T&A bleed
- Suction
- Apply pressure to bleeding site (gauze + vasoconstrictor, use McGill forceps)
- Consider intubation to prevent aspiration
62
Chance fracture
```
lumbar fracture (through vertebral body, spinous process and pedicles) from flexion-distraction injury
Typically T12-L2
```
63
What types of injuries is a Chance fx assoc with? (4)
Associated with intraabdominal injuries
- Pancreas
- Duodenal hematoma
- Mesenteric pedicle injury
- Hollow viscous injury
64
6 signs/effects of ecstacy or MDMA use
CNS: euphoria, hyperactivity --> panic, psychosis
VS: hyperthermia, HTN, tachycardia
MSK: rhabdomyolysis, bruxism
Ocular: mydriasis --> blurry vision
Metabolic: hyponatremia (increased free water intake)
65
4 labs to guide massive transfusion protocol (1:1:1)
- CBC (Hb, platelets)
- Coags: PT/INR, PTT, fibrinogen
- Calcium (can get hypocalcemia)
66
Complications of massive transfusion protocol
- Metabolic alkalosis
- Hypocalcemia
- Hypothermia
- Hyperkalemia
67
4 steps to instruct parent on how to give epi-pen
1. Recognize signs/symptoms of anaphylaxis
2. Given in anterolateral thigh
3. Take cap off, swiftly insert needle, hold for 10 sec for med to release
4. Call 911 or proceed to closest ED immediately
68
Fever in transplant pt < 1 month post surgery
normal post surgical complications - wound infection or infection present before that was exacerbated by surgery, infection transmitted by allograft
69
Fever in transplant pt 1-6 mos post op
1. latent viral infections (CMV, EBC, HHV6, hepB/hepC)
| 2. Opportunistic infections: listeria, aspergillus, pneumocystis
70
Fever in transplant pt > 6 mos post op
community acquired infections (resp viruses), opportunistic infections
71
Mngmt of FAO
1. ABCs
2. IVF - bolus with normal saline --> D10 infusion to suppress lipolysis
3. Obtain blood work: VBG, glucose, ammonia
4. Avoidance of fasting
5. Oral carnitine replacement
72
What are the SIRS criteria?
1. Core temp > 38.5 or < 36
2. Increased HR > 2 SD or if < 1 yr old bradycardia
3. Increased RR or need for mechanical ventilation
4. Elevated /reduced WBC with > 10% bands
73
Signs/symptoms of severe colitis
- Severe abdominal pain / distension
- Bloody stool
- Fever
- Signs of dehydration (tachycardic, low BP, poor perfusion, dry MM)
- Signs of anemia (pale, low BP)
74
Extraintestinal manifestations of IBD (8)
- Oral: aphthous ulcers
- Eyes: uveitis
- Skin: erythema nodosum
- Joints: arthritis
- Liver: hepatitis, primary sclerosing cholangitis
- Venous thromboembolism
- Kidney stones
- Pancreatitis
- Low bone mineral density / osteoporosis
75
When do you start and stop deferoxamine?
START --> iron level > 500 mcg/dL, severely symptomatic patients, sig AG met acidosis
STOP -->usually 24 hours, when metabolic acidosis and shock are resolved; prolonged tx risks pulmonary toxicity from deferoxamine
76
5 stages of iron toxicity
1. GI symptoms: 6 hours - NV, pain
2. Latent recovery phase: 6-24 hours
3. Shock/metabolic acidosis: 6-72 hrs
4. Fulminant hepatic failure: 12-96 hrs
5. Recovery with GI scarring/obstruction (weeks later)
77
2 determinants of hydrocarbon toxicity
- High volatility (aspiration)
- Low surface tension (displaces surfactant)
- Low viscosity (aspiration)
78
What substances does activated charcoal NOT work on?
- Hydrocarbons
- Toxic alcohols
- Metals: iron, lithium
- Pesticides
- Solvents
79
Admission criteria for omphalitis (4):
- Signs of systemic illness
- Significant cellulitis/abscess
- Age < 2 months
- Tenderness, discharge
80
Pathogens - omphalitis (5)
- Polymicrobial
- Staph aureus
- GAS
- Gram negative: e.coli, klebsielle, proteus
anaerobes
81
Four causes of Methemoglobinema (not drug/chemical induced)
- Drinking well water
- Congenital: enzyme deficiency
- Infants < 6 months when exposed to dehydration, illness or topical anesthetics (inadequate enzyme levels)
- G6PD deficiency
82
What medications can cause methemoglobinemia?
Antibiotics: TMP-SMX, dapsone
Local anesthetics
Metoclopramide
Nitrates
83
What are some vagal maneuvers to try in SVT? (4)
- Bearing down x 15-20 secs
- Rectal stim w/ thermometer
- Blowing into straw
- Diving reflex: place bag of ice / water over nose and eyes x 35 sec OR in older kid - knees to chest, hold breath and bear down
*Contraindicated: carotid massage, orbital pressure
84
Medical mngmt of SVT
1. adenosine 0.1 mg/kg, second 0.2 mg/kg, max 6 then 12 mg
| 2. synchronized cardioversion (0.5 to 1 J/kg)
85
Criteria for dx of sinusitis (3)
1. Persistent nasal discharge > 10 days
2. Worsening cough, fever or discharge after period of improvement
3. Severe onset with fever > 39 sec or purulent nasal dc > 3 day
86
Electrolyte abnormalities seen in acute renal failure
- Hyperkalemia
- Hyperphosphatemia
- Hyponatremia
- Hypocalcemia
- Metabolic acidosis
87
2 complications of vaginal lacerations
- Assoc urethral tears
- Urinary retention from severe pain or injury
- Significant bleeding from deep vulvar lacerations
88
Life threatening complications of heat stroke (8)
1. Rhabdomyolysis
2. AKI
3. Hyponatremic dehydration
4. Liver failure --> Coagulopathy
5. High output cardiac failure
6. Pulmonary edema / 7. ARDS
8. Cerebral edema
89
3 signs of urethral injury
1. Blood at urethral meatus
2. Bruising of penis or perineum
3. High riding prostate
4. Urinary retention or inability to urinate
90
4 injuries associated with crack cocaine use
- Oral mucosal burns
- Laryngeal / airway burns
- Crack lung = interstitial fibrosis, noncardiogenic pulm edema
- Aspiration
91
Risk of using labetalol in sympathomimetic syndrome?
Labetalol is a BB which would result in unopposed alpha stimulation with increased HTN, cardiac output and cardiac ischemia
92
Causes of congenital stridor (7)
1. Laryngomalacia
2. Esophageal web/sling
3. Vascular ring/sling
4. Subglottic stenosis
5. Laryngeal N paralysis or vocal cord paralysis
6. Tracheal hemangioma
7. GERD
93
Newborn sepsis (bacteria, abx)
Group B strep, Strep pneumo, E.coli, Listeria
| Tx. Ampicillin + Cefotaxime
94
Infants/children sepsis (bacteria, abx)
Strep pneumo, Neisseria meningitis, H Flu, GBS
| Tx. Ceftriaxone, Vanco
95
Adolescent sepsis (bacteria, abx)
N.mening, s. pneumo
| Tx. Ceftriaxone, Vanco
96
Features of Organic Psychosis (6)
- Rapid onset (days to weeks)
- Disoriented
- Memory loss
- Visual/olfactory/tactile hallucinations
- May have abnormal VS or pathologic autonomic signs
- Fluctuating cognition and attentions
97
Concern for elevated ICP w/ impending herniation - mngmt?
1. HOB at 30 degrees elevated
2. Intubation with hyperventilation
3. Hyperosmolar therapy: 3% NS or mannitol
4. Decrease metabolic demand: ventilation, normothermia, normoglycemia, can allow permission HTN
5. Immediate neurosurgical consult
98
Indications for imaging in penetrating trauma of oropharynx?
- Location: lateral tonsillar pillar
- Continued bleeding
- Large, expanding hematoma
99
Adenosine - MOA, indication
MOA: slows conduction thru AV node
Indication: SVT
0.1 mg/kg --> 0.2 mg/kg (6 mg --> 12 mg)
100
Amiodarone - MOA, indication
5 mg/kg
MOA: class III antiarrhythmic, inhibits alpha and beta R, affects Na,K and Ca channels, prolongs AP and refractory period, decreases AV conduction
Indication: VT, refractory pulseless Vfib / VT
101
Clinical features SVC syndrome
- Plethora
- Facial edema
- JVD
102
Landmarks for Chest tube placement
```
5th intercostal space (between 4th and 5th rib), midaxillary line, at level of nipple, insert above lower rib, advance posteriorly in apical direction
- Secure with sutures
- Apply occlusive dressing
- Attach to drainage system (suction)
- Check placement on CXR
Measure output drainage
```
103
Complications of chest tube placement (8)
- Bleeding (injury to vessels)
- Infection
- Laceration of intraabdominal organs
- Subcutaneous emphysema
- Pain
- Reexpansion pulmonary edema
- Intercostal neuralgia/neuritis
104
What are two measures in the hyperoxia test?
- Measure level of PaO2 while breathing 100% O2
PaO2 < 100 mmHg and failure to increase systemic arterial oxygen saturation implied cardiac etiology (measure preductal - R radial AA)
105
Signs/symptoms of hypocalcemia (6)
- Muscle cramps (carpopedal spasm)
- Paresthesias (oral, hands/feet)
- Laryngospasm
- Bronchospasm
- Hypotension
- Dysrhythmias
106
Bones at risk of idiopathic avascular necrosis (5)
```
Tarsal navicular bone
Femoral head and condyles
Scaphoid
Metatarsal heads
Humeral
```
107
clinical features of acute liver failure
1. jaundice
2. scleral icterus
3. coagulopathy
4. hepatomegaly
5. encephalopathy
6. Constitutional: NV, fever, fatigue, pain
108
Risk factors for opioid addiction in teens
1. Chronic disease
2. History of abuse (physical / sexual)
3. Family member with addiction
4. Hx of mental health illness
5. Low SES/homelessness
109
Potential causes of jaundice (not hemolytic)
1. Medication/toxin induced - tylenol o/d
2. Autoimmune hepatitis
3. Cholangitis
4. Sepsis
5. Obstruction: biliary atresia, choledochal cyst, cholelithiasis
6. Primary sclerosing cholangitis (IBD)
7. Tumors of hepatobiliary system
110
anion gap formula
Na - (Cl + HCO3), normal < 10
111
Serum osmolarity formula
2Na + BUN/2.8 + Glucose / 18
112
fluid deficit formula
% dehydration x weight [ 1 kg = 1 L]
113
max lidocaine dose (ml) formula
max dose (mg/kg) x wt / 10 x 1 / conc %
