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1
Q

Push Dose Epinephrine:
- How to create

A
  • Take 10mL syringe of saline with only 9mL of saline
  • draw 1mL of cardiac epi (1:10,000 | 0.1mg/mL)
  • This creates 10 mcg/mL
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2
Q

Push Dose Epinephrine:

  • Onset
  • Duration
  • Dose
A

Onset: 1 minute
Duration: 5-10 minutes
Dose: 0.5-2mL (5-20mcg) q2-5 minutes

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3
Q

Convulsive Status Epilepticus:
1st Line Treatment

A 
IM Versed (0.2-0.5mg/kg, max 10mg), single dose
IV Ativan (0.1mg/kg, max 4mg), repeat x1
IV Valium (0.15-0.2mg/kg, max 10mg), repeat x1
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4
Q

Convulsive Status Epilepticus:
2nd Line Treatment

A 
IV Fosphenytoin 20mg PE/kg, max 1500 mg PE / dose 
IV Valproate (40mg/kg, max 3000mg) 
IV Keppra (60mg/kg, max 4500mg) 
IV phenobarbital (15mg/kg)
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5
Q

Convulsive Status Epilepticus:
3rd Line Treatment

A

Repeat Second Line treatments
Anesthetic dosing thiopental, versed, pentobarb, propofol

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6
Q

Coronary Vessels to EKG Lead:

  • LAD
  • LCx
  • RCA
A

Coronary Vessels to EKG Lead:

  • LAD –> V1-V4
  • LCx –> V5-V6, I, aVL
  • RCA –> II, III, aVF
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7
Q

Coronary Vessels to EKG Lead:

  • V1-V4
  • V5-V6, I, aVL
  • II, III, aVF
A

Coronary Vessels –> EKG Lead:

  • V1-V4 –> LAD
  • V5-V6, I, aVL –> LCx
  • II, III, aVF –> RCA
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8
Q

Axis: Right on EKG

A

QRS down in I
QRS up in aVF

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9
Q

Axis: Left on EKG

A

QRS up in I
QRS down in aVF

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10
Q

If on AC, what’s the management for epistaxis?

A

If on AC, do RESORBABLE packing for epistaxis as per American Academy of Otolaryngology Jan 2020 guidelines.

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11
Q

New CHF. Cause most likely?

A

Valvular disease.

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12
Q

CHF + Prosthetic heart valve. Cause?

A

Valve thrombosis.

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13
Q

Seizure - physical exam findings that’s most specific.

A

Lateral tongue bite is 100% specific for seizure. But only 25% sensitive. (Using on population with transient LOC / syncope)
Tip of tongue and lips biting are more likely psychogenic than real seizure.

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14
Q

How to differentiate *cardiogenic pulmonary edema* from *noncardiogenic pulmonary edema* (pneumonia, fibrosis, TB, etc.)

A

Cardiogenic pulmonary edema: thin/regular pleural line

Non-cardiogenic pulmonary edema: thickened, irregular pleural line.

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15
Q

Myocardial injury

A

troponin I elevation; acute injury if there’s a rise/fall.

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16
Q

Myocardial infarction

A

acute myocardial injury + mycocardial ischemia signs (symptoms of ischemia, new EKG changes, pathologic Q-waves, imaging abnormality, finding coronary thrombus)

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17
Q

Cardiac necrosis progresses in what direction?

A

sub-endocardial (inside) –> sub-epicardial (outside)

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18
Q

Importance of Type II MI

A
  • higher frequency of women > men
  • higher mortality (short + long term) than Type I MI
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19
Q

(Obvious stuff): 3 reasons for
Type II elevation

A

Inadequate supply
Inc demand
can’t get the supply to the demand

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20
Q

Frequency of ST-elevation in Type II MI

A

3-24%

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21
Q

“Stable” troponin elevation definition

A

<20% variation of troponin values

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22
Q

Recurrent MI

A

Repeat MI AFTER 28 days

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23
Q

Re-infarction MI

A

Repeat MI BEFORE 28 days

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24
Q

Frequency of post-operative cardiac injury

A

35% of patients have elevation of troponin
17% have an elevation and rising pattern suggesting evolving myocardial injury.

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25
Takotsubo's syndrome: mortality
Inpatient mortality is same as STEMI (4-5%; from cardiogenic shock, ventricular rupture, malignant arrhthmias)
26
% of STEMI that is actually Takotsubo's syndrome
1-2% of suspected STEMI; 90% are post-menopausal women
27
EKG findings in Takotsubo's syndrome
STE: 44% STD: \<10% TWI: 12-24 hours after, will develop deep, symmetric TWI and QTc-prolongation
28
Takotsubo's resolves in what percent
85-90% have complete resolution.
29
Takotsubo's vs Acute MI: 2 most important features for differentiation
QTC \> 500 in acute phase for TTS and normalization of LV funciton after 2-4 weeks for TTS
30
Which is more important? Absolute changes in assay or relative changes in measurement
absolute changes are the most important. Use a lower cut-off for women, higher for men. Don't use an age-related cutoff
31
This diffuse pattern is suggestive of Left main disease or Multivessel disease
STD \> 1mm in 6 leads +/- STE in AVR or V1 Hemodynamic compromise
32
STD \> 1mm in 6 leads +/- STE in AVR or V1 Hemodynamic compromise
This diffuse pattern is suggestive of Left main disease or Multivessel disease
33
EKG manifestations suggesting Acute MI (in the absence of LVH/BBB)
STE in 2 contiguous leads; \>1mm in all leads except V2-V3. (use \>2mm in male\>40; \>2.5mm in male \<40; \>1.5 in all females) STD: new horizontal or down-slopping STD \> 0.5mm in 2 continguous leads or TWI: \>1mm in 2 continuous leads with prominent R-wave or R/S ratio \> 1
34
Absence of STE in V1-V6 Tall, prominent, symmetric T-waves V1-V6 Upsloping STD \> 1 mm V1-V6 STE \> 1 mm in aVR Symmetric, deep (\>2 mm) TWI in V3-V4
Signs of LAD Occlusion
35
Signs of LAD Occlusion
Absence of STE in V1-V6 Tall, prominent, symmetric T-waves V1-V6 Upsloping STD \> 1 mm V1-V6 STE \> 1 mm in aVR Symmetric, deep (\>2 mm) TWI in V3-V4
36
STE in aVR \> 1 mm
Anterior (LAD) or inferior STEMI Sign of increased 30 day mortality in acute MI
37
Isolated STD \> 0.5 mm in V1-V3 could be a sign of \_\_\_\_
Left circumflex occlusion
38
Left circumflex occlusion could be hinted at on an EKG by \_\_\_
Isolated STD \> 0.5 mm in V1-V3
39
Locations for posterior EKG leads (V7-V9)
V7: left posterior axillary line V8: left mid-scapular line V9: left paraspina border
40
Cutpoint for STE in posterior leads
For V7-V9 use 0.5 mm STE
41
V7-V9 with \>0.5 mm STE or STD \> 0.5 mm in V1-V3
Left circumflex occlusion or infero-basal ischemia / posterior MI
42
New name for posterior MI
Old name for infero-basal MI
43
Old name for infero-basal MI
New name for posterior MI
44
Left circumflex occlusion or infero-basal ischemia / posterior MI EKG findings
V7-V9 with \>0.5 mm STE or STD \> 0.5 mm in V1-V3
45
EKG changes associated with PRIOR MI
- Any Q-waves in V2-V3 \> 0.02s or QS complex V2-V3 - [Q-wave \> 0.03s and \>1mm deep] or [QS complex] in [Leads I, II, aVL, aVF, V4-V6] OR [in any 2 contiguous leads] - R-wave \> 0.04s in V1-V2 and R/S\>1 with a concordant positive T-wave in absence of conduction defect.
46
QS complex is normal in which lead
V1
47
LBBB Criteria
QRS duration of \> 120 ms Dominant S wave in V1 Broad monophasic R wave in lateral leads (I, aVL, V5-V6) Absence of Q waves in lateral leads (I, V5-V6; small Q waves are still allowed in aVL) Prolonged R wave peak time \> 60ms in left precordial leads (V5-6)
48
Appropriate discordance on EKG
The ST segments and T waves always go in the \*opposite\* direction to the main vector of the QRS complex
49
Inappropriate concordance on EKG
J-point and ST-segment elevation in positive leads and J-point and ST-segment depression in negative leads
50
Normal Axis = QRS axis between
-30° and +90°
51
Left Axis Deviation = QRS axis
less than -30
52
Right Axis Deviation = QRS axis
greater than +90°
53
Extreme Axis Deviation = QRS axis between
-90° and 180° (AKA “Northwest Axis”)
54
Axis: Normal on EKG
QRS up in I QRS up in aVF
55
Axis: extreme axis deviation on EKG
QRS down in I QRS down in aVF
56
ECG Criteria for Left Anterior Fascicular Block (LAFB)
Left axis deviation qR complexes in leads I and aVL rS complexes in leads II, III, aVF QRS duration normal or slightly prolonged (80-110 ms) Prolonged R wave peak time in aVL \> 45 ms Increased QRS voltage in the limb leads
57
Features consistent with sodium-channel blockade
Interventricular conduction delay — QRS \> 100 ms in lead II Right axis deviation of the terminal QRS: * Terminal R wave height \> 3 mm in aVR * R/S ratio \> 0.7 in aVR TCA Overdose: Usually sinus tachycardia 2/2 muscarinic (M1) receptor blockade.
58
TTP Classic Pentad
Fever Thrombocytopenia Anemia (microangiopathic, hemolytic) Neurologic findings (confusion, difficulty speakin,g headaches, vomiting, etc) AKI
59
Hip dislocation Which nerve damaged? Loss of sensation in posterior leg and foot Loss of dorsiflexion or plantarflexion Loss of deep tendon reflex at ankle
Sciatic nerve injury (occurs in 10% of hip dislocations)
60
Hip dislocation Which nerve damaged? Loss of sensation over thigh Weakness of quadriceps Loss of DTR at knee
Femoral nerve injury
61
Hip dislocation Which artery is damaged? Hematoma Loss of pulses Pallor
Femoral artery injury
62
Kanavel's criteria
1. Tenderness of flexor tendon 2. Symmetrical / fusiform swelling of finger 3. Flexed posture of finger 4. Pain with passive extension
63
1st line oral medication Raynaud's phenomenon
nifedipine or amlodipine | (long-acting dihydropyridine CCB)
64
Fox's sign
eccchymosis of upper lateral thigh; inferior to the inguinal ligament The ecchymosis is parallel with, but distal to the inguinal ligament with a well demarcated upper border defined by attachment of the membranous layer of the superficial fascia (Scarpa’s fascia). Most often occurs in patients with retroperitoneal bleeding, usually due to acute haemorrhagic pancreatitis.
65
Stabler's sign
ecchymosis over the inguinal ligament. in neonates, think neonatal adrenal hemorrhage
66
Bryant's sign
ecchymosis of the scrotum Think retroperitoneal bleeding
67
Gold standard to dx Placental Abruption
Tococardiography
68
What is this?
Epsilon wave
69
Altered Mental Status (AMS) Etiology AEIOU TIPS Mnemonic
Alcohol, acidosis Endocrine, epilepsy, electrolytes, encephalopathy Infection Opiates, overdose Uremia Trauma Insulin Poisoning, psychosis, pharmacology Stroke, seizure, syncope
70

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