Review Flashcards

Question

Wells for PE (7)

Answer 1

1. Sx of DVT 2. PE most likely diagnosis 3. HR >100 4. Immobilization 3+ days or surgery in last 4w 5. Previous PE/DVT 6. Hemoptysis 7. Malignancy w/in 6 moths

Answer 2

Pts 21+ with sx suggestive of ACS. Cannot use if hypotension, new ECG changes, life expectancy <1y 1. Suspicious hx - slightly, moderate, highly 2. ECG - Normal, Non-specific repolarization disturgbance, ST depression 3. Age - <45, 45-64, >65 4. RF - None, 1-2, 3+ or hx of atherosclerosis (RFs: BMI >30, smoking, fam hx <65, prior MI/CVA/CABG/TIA 5. Initial trop: Normal, 1-3xnormal, >3x normal Score <3 with negative repeat trop can be d/c'd home with outpatient follow up

Answer 3

Teardrop shaped pupil Subconjunctival hemorrhage Decreased visual acuity RAPD Seidel sign

Answer 4

Eye patch Ophtho consult Prophylactic antiobiotics Tetanus Analgesics and antiemetics

Answer 5

Swinging the light from one eye to the other, the affected eye will constrict when the light is shone in the unaffected eye but will dilate when the light is shone back towards the affected eye - signifies unilateraloptic nerve or retinal disease

Answer 6

Anything that affects the blood flow or nerve: - Optic neuritis - Globe rupture - GCA with ischemia - Optic nerve tumor - CRVO or CRAO - Retinal detachment - Retrobulbar hematoma - Acute angle closure glaucoma

Answer 7

1. Call ophtho 2. Intermittent digital massage with quick release 3. ASA 4. Inhalation of CO2/O2 or breath through paper bag 5. Topical beta blocker 6. Acetazolamide 7. Nitro 8. Hyperbaric osxygen 9. Consider intra-arterial lytcs

Answer 8

No specific treatement although ASA often recommended. Follow up with ophtho in 24h.

Answer 9

1. Lateral canthotomy if: - IOP >40 - proptosis - decreased visual acuity - RAPD Give timolol, mannitol, acetazolamide and timolol

Answer 10

Will see hazy cornea, mid fixed dilated pupil, conjunctival injection, N/V, halos around lights, blurred vision, rock hard globe, cell and flare 1. Call optho 2. Beta blocker - Timolol to reduce production of acqueous humor 2. Alpha agonist - brimonidine to constrict ciliary vessels 3. Carbonic anhydrase inhibitor Acetazolamide IV to decrease acqueous humor production 4. Topical cholinergic - Pilocarpine to cause myosis and decrease angle ultimately increasing drainage 5. Hyper osmotic agent - mannitol 6. Well lit room to avoid dilation 7. Hourly IOP checks

Answer 11

1. Elevated HOB 2. Eye shield 3. Avoid NSAIDs, ASA, anticoagulants 4. If elevated IOP give cycloplegics (atropine), steroids, betablockers, acetazolamide and consider mannitol 5. If sickle cell keep pressure <24 6. Call ophtho ***Always check for siedel sign prior to doing pressures

Answer 12

- elderly - female - far sighted - recent trauma - recent eye surgery - recent med causing dilation of pupil (anticholinergics, antimuscarinics, antidepressant, antipsychotic, antihistamines)

Answer 13

- Unstable patients - Active GI malignancy - Extensive clot burden

Answer 14

Decreases toxin production

Answer 15

Motor: Ataxia, dysmetria, nystagmus Speech: Dysarthria Other: Dizzy, diplopia, dysphagia, horners PCA/Brainstem/Cerebellum/Vertebrobasilar arteries

Answer 16

MCA, ACA, carotids Motor: Hemiparesis - facial droop, unilateral arm and leg weakness Speech: Receptive (wernicke's) or expressive (Broca's) aphasia Other: Sensory deficits, homonymous hemianopsia

Answer 17

Glucose >33 Plasma osmolality >320 pH >7.3 Ketones normal or increased Bicarb >15 T2DM More dehydrated Confused Develops over longer period of time

Answer 18

- Don't start insulin for 1h - Gentle IV fluid boluses - No bicarb (only if arrested) - No insulin bolus

Answer 19

Anchoring bias - prioritize data that supports initial impression Confirmation bias - process info by looking at the data that fits beliefs Recency bias - using recent cases Premature closure - tendancy to stop inquiry once a possible solution is found Bandwagon effect - idea is followed because everyone is doing it Zebra retreat - rare diagnosis features prominantly on a differential but the physician retreats for various reasons Attribution error - overemphasize personal characteristic and ignore situational factors

Answer 20

Clinical pre-requisites: - No reversible causes/confounding factors - Normothermia - Compatible neuroimaging - No intoxications - Normal BP Exam findings - Coma - Absent pupillary relfex - Absent corneal reflex - Absent oculovestibular reflex - Absent jaw jerk - Absent gag, suck, root - Absent cough with tracheal suction - Apnea

Answer 21

- Lack of consent - Cancer in organ - Religious beliefs - Transmissible diseases Only absolute = patient or POA declines

Answer 22

1. Informed - Explain procedure or treatment Understand risk and benefit Presented with alternatives 2. Voluntary 3. Capacity Not needed if emergency

Answer 23

Understand procedure, risks, benefits Appreciate how the information applies to their situation Reason through the choices to make a decision Communicate a consistent choice

Answer 24

- No specific age - Based on minor's maturity - If lacks capacity, parents' guardian can make decision - Physicians must report if parents refuse a treatment that is medically necessary

Answer 25

- Skill set errors (e.g. unfamiliar with pediatric dosing) - Environmental errors (e.g. busy emergency department, lidocaine with different % being stored together) - Task-based errors (e.g. work overload, double checking of medication) - Personal factors (e.g. fatigue, illness, emotional distress) - Teamwork failure (e.g. breakdown in communication when asking for medication/ supervision of learners)

Answer 26

- Study population is not generalizable: --- Only one center of patients --- Specifically a university health center with further potential bias re: health, financial and education status - No mention of baseline characteristics (i.e. sexual activity status, comorbidities) - No mention of other known risk factors for recurrent UTI (i.e. structural abnormalities, frequency of recurrence) - No discussion of initial antibiotics given

Answer 27

- Wrist extension (20 degrees) [1] - MCP flexion (90 degrees ) [1] - PIP extended [1] - Ulnar gutter splint “Z-splint”

Answer 28

- Restore volar tilt, normal is ~11 deg, neutral acceptable - Restore length, normal is ~1 1mm radial height - Restore radial inclination, normal is ~22 deg - Intraarticular step deformity of less than 2 mm

Answer 29

- Age >35 years old - History of cardiac disease (including: MI, CHF, CABG, cardiomyopathy, structural/ischemic heart disease, VT, ICD/pacer) - Family history of sudden cardiac death

Answer 30

- No response to vagal maneuvers - Cannon A waves (JVP assessment) - Variation in arterial pulse - Variable first heart sound

Answer 31

- Prepare and check transport vitals monitoring equipment - Ensure adequate pumps for medication administration - Ensure at least 2 large bore IVs are patent and secured - Ensure airway secured, prepare associated airway transport equipment - Insert Foley catheter to monitor urine output - Temperature control in place (warm environment)

Answer 32

- T wave flattening/ inversion - U waves - Prolonged QT interval - Sinus bradycardia - Heart block (SA, AV) - ST depression - Ventricular arrhythmias

Answer 33

- Lithium serum level > 3.5 mEq/L (chronic) - Little change in lithium level or clinical picture after 6 hours of IV saline administration - Rapidly increasing serum lithium levels - Severe neurologic toxicity: altered LOC, seizures, etc. - Patients with renal failure (unable to excrete) - Patients with CHF, pulmonary edema, or cirrhosis (unable to tolerate high volume loads)

Answer 34

- CBC - LFTs - Hep B surface antigen (HbsAG) (acute or chronic infection) - Hep B surface antibody (Anti-Hbs) (immunity) - Total hepatitis B core antibody (anti-HBc) (previous or ongoing infection) - HIV level - Hepatitis C Ab

Answer 35

- Sexual assault (unknown source - assume high risk) - High risk exposure via sexual contact - High risk exposure via needle sharing/ IVDU - Needle stick

Answer 36

- Advanced maternal age - Young maternal age <20 - Low SES - Primiparous - Molar pregnancy or multiple gestation - IVF - PMHx or FMHx of gestational HTN/pre-eclampsia - Previous gestational diabetes - Hypertension - Obesity - Hypercholesterolemia - Chronic renal disease - Inherited thrombocytopenia - Connective tissue disease - Antiphospholipid syndrome - Diabetes - Cocaine use

Answer 37

Maternal: - Eclampsia - Severe HTN - Pulmonary edema - ACS - CVA - HELLP syndrome - Placental abruption

Answer 38

Fetal: - Oligohydramnios - IUGR - IUFD - Reversed end-diastolic umbilical artery flow - Placental insufficiency - Preterm birth

Answer 39

- Supportive therapy: artificial tears, analgesia, and cold compresses - Antiviral therapy PO (acyclovir/valacyclovir/famciclovir). IV if immunocompromised - Topical antibiotics considered for prevention of secondary infection - Consideration of corticosteroids in consultation with ophthalmology - Consideration intravitreal antiviral (foscarnet) for acute retinal necrosis in consultation with ophthalmology

Answer 40

Dextrose and octreotide

Answer 41

- Afib - Aflutter with variable conduction - multifocal atrial tachycardia

Answer 42

Sinus tachy VT - rate >120 SVT with BBB

Answer 43

Afib w/BBB Afib w/WPW

Answer 44

Junctional escape rhythm - <40 Junctional bradycardia - 40-60 Accelerated junctional rhythm - 60-100 Ventricular escape rhythm 20-40 AIVR 40-130 often self resolving, don't give anything as amio/procainamaide and lido will cause asystole

Answer 45

Age/4 in years +4

Answer 46

3 x tube size

Answer 47

Age 6mo - 6y Simple: Temp >38 Last less than 15 mins No focal sx Do not reccurr in 24h Complex Last >15 mins can have focal features can recurr

Answer 48

an event occurring in an infant younger than 1 year when the observer reports a sudden, brief, and now resolved episode of ≥1 of the following: (1) cyanosis or pallor; (2) absent, decreased, or irregular breathing; (3) marked change in tone (hyper- or hypotonia); and (4) altered level of responsiveness.

Answer 49

- GA >32w and 45 corrected - >60 days - No CPR - lasted less 1 min - first event

Answer 50

Hyperkalemia Hyponatremia Hypoglycemia Treatment: o IV fluid o Glucose – Rule of 50: 5 mL/kg D10W (infant) or 2 mL/kg of D25W (child), or 1 mL/kg of D50W (adolescent) o Hydrocortisone: 25 mg (neonate/infant), child 50 mg, adolescent/adult 100 mg

Answer 51

Adults - canned foods Infants - raw honey Construction sites and inhaled spores, black tar heroin Mechanism: No release of Ach. Dysphagia, ptosis, respiratory failure Treatment: Supportive, intubation, Botulism anti-toxin.

Answer 52

Pain out of proportion Treatment: - Calcium

Answer 53

Alpha 2 agonist - suppresses alpha - mimic opioid overdose: aLOC, resp depression, miosis, hypotension, bradycardia - Class: oxymetalazine, nasal decongestants, visine - Supportive care - Sometimes naloxone can work

Answer 54

>20mg/kg of elemental iron >60mg/kg is lethal Stage 1: 0-6h GI upset Stage 2: 6-24h Improvement of symptoms Stage 3: 6-72h shock, metabolic acidosis Stage 4: 12-96h fulminant liver failure Stage 5: 2-8w bowel obstruction from GI scarring WBI Defuroxamine

Answer 55

Dorsal columns = proprioception and vibration Spinothalamic tract = temp and pain Corticospinal tracts = motor

Answer 56

The upper limit of normal diameter of the bowel is generally accepted as 3cm for the small bowel, 6cm for the colon and 9cm for the caecum - Small bowel: Rapid onset, N/V - Large bowel: Intermittent abdo cramping, complete constipation, no flatus

Answer 57

Acute colonic pseudo-obstruction - Masive colonic dilatation - No mechanical obstruction - Often occurs post op or in elderly patients with comorbidities - Tx: decompression +/-neostigmine

Answer 58

acute blurred vision, photophobia, perilimbic scleral injection

Answer 59

eye burning or itching without visual changes, scleral and conjunctival hyperaemia

Answer 60

Treatment: 1. Fluid status 3. Goal Hgb 80-90. Transfuse if <60 4. Platelet transfusion if <10 5. Dialysis if renal failure or severe overload 6. Management of HTN with CCB 7. Watch for seizures. Use benzos, then keppra 8. If primary HUS can do plasma exchange 9. Avoid antibiotics unless sepsis or concurrent PNA Classic triad: 1. Anemia (MAHA) 2. Thrombococytopenia 3. AKI Shiga toxin causes damage to the glomerular endothelial cells, causes cell lysis and activates cytokines, platelets and the coagulation cascade. Thrombi form in smaller vessels and RBCs get damaged which causes MAHA

Answer 61

For ascending cholangitis (biliary tract infection caused by stones, strictures or malignancy): - Jaundice, RUQ pain, Fever - Add hypotension and AMS for pentad

Answer 62

MOANS: - Mask seal, obesity, obstruction, age, no teeth, stiff

Answer 63

SLAP HER Sepsis Lung abscess ARDS Parapneumnoic effusion Hypotension Empyema Resp failure

Answer 64

Signs of severe respiratory distress (eg, indrawing, grunting, RR >60/min) Supplemental O2 required to keep saturations >90% Dehydration or history of poor fluid intake Cyanosis or history of apnea Infant at high risk for severe disease (Table 4) - Infants born prematurely (<35 weeks’ gestation), <3 months of age at presentation, Hemodynamically significant cardiopulmonary disease, Immunodeficiency Family unable to cope

Answer 65

RF: Pregnancy Epidemic exposure Lack of immunization Close contact with an infected individual Bortadella pertussis Airborne

Answer 66

Sepsis, pneumonia, trauma, burns, pancreatitis, toxins Berlin Definition of ARDS: ○ Acute onset of respiratory symptoms (<1 week) ○ Bilateral opacities on chest x-ray or CT (not explained by another cause) ○ Respiratory failure not fully explained by cardiac failure or fluid overload ○ Moderate to severe impairment of oxygenation (PaO₂/FiO₂ ratio <300mmHg with minimum of 5 cm H20 PEEP) Presentation: Non-cardiogenic pulmonary edema, hypoxia, diffuse lung findings with mutlifactorial cause Prone, ECMO

Answer 67

Submassive - RV strain/dysfunction/new ECG changes/elevated trop or BNP Massive - Sustained hypotension <90 for >15 mins or needing pressors; drop in 40mmHg from baseline SBP, symptomatic brady, cardiac arrest

Answer 68

Compartment syndrome Rhabdomyolysis Inhalation injury Acidosis Cyanide poisoning Carbon monoxide poisoning ARDS

Answer 69

Make sure you calculate the replacement based on the time of the burn not arrival to the ED

Answer 70

Circumferential burns Burns on face, hands, genitals Partial TBSA >20% adults or 10% in peds Full thickness >5% High voltage electrical burns Inhalation injury

Answer 71

- Circumferential torso with restricted ventilation - Circumferential extremities with vascular compromise - Compartment pressure >30mmHg - Elevate limb

Answer 72

6. IVF - Use RL. 1. 2cc x kg x %TBSA. 1/2 in first 8h from time of burn, other half in next 16h. Monitor urine output (goal 0.5-1cc/kg/hr in adults and 1-2ml/kg/hr in peds) and target HR <110. Does not include superficial burns. For adults >20%, peds >10% 2. In peds give 3cc x kg x TBSA plus maintenance if <5y. Can also give D51/2NS if pt is <20kg. 3. **Consider colloids if burns >40% in adults or >30% in peds. This will reduce abdominal compartment syndrome 4.

Answer 73

WILLIAM MORROW in V1 and V6`

Answer 74

Orthodromic AVRT: - Vagal maneuvers - adenosine - CCB - beta blockers Antidromic AVRT: - Always consider VT in this situation. It is wide! - AVOID AV nodal blockers - Procainamide okay Afib w/AVRT - Procainamide or cardiovert only If unstable cardiovert ***AV nodal blockers contraindicated in antidromic AVRT and afib w/AVRT as they can trigger vfib by increasing conduction down accessory pathway

Answer 75

Atrial rate >600/min Ventricular rate 100-160

Answer 76

Atrial rate ~300/min Ventricular rate ~150 in 2:1

Answer 77

Irregular rhythm due to firing from at least 3 different atrial foci, bombarding the AV node with multiple impulses - Usually underlying pulmonary or cardiac diseases, electrolyte imbalances, or sympathetic overstimulation - Will have irregularly irregular rhythm with at least 3 p wave morphologies, changing PP, PR or RR intervals - Treat underlying cause, lyte replacement, bronchodilators and O2 if underlying pulm disease - DO NOT CARDIOVERT OR USE ANTIARRYTHMICS

Answer 78

Non-sustained <30s Sustained >30s Causes: >50 due to MI or IHD - hypothermia - hypoxia - lyte disturbance - drugs - hypertrophic cardiomyopathy Mimics: - SVT w/ aberrhancy - Antidromic AVRT - Afib in WPW - Severe hyperK ECG: - usually wide QRS w/regular rhythm - VT more likely than SVT w/abherrancy if: AV dissociation (P and QRS different rates, capture beats, fusion beats If unstable with pulse, start at 100J If stable: - Cardioversion w/sedation - Second lines: procainamide, amiodorone, lidocaine

Answer 79

Causes: PROLONGED QT - hypoK, hypoMag, hypoCa - antipsychotics - antiarrythmics - antibiotics - structural heart disease Rate 160-250 Unstable: defibrillate @ 200J Stable: Mag 2g IV then start infusion at 1-2g/hr - May need overdrive pacing to terminate - Stop offending agents

Answer 80

Ustable non-perfusing rhythm that results in chaotic, disorganised ventricular activity

Answer 81

Causes: - Reperfusion rhythm - Complete heart block - Ischemic heart disease - Severe SA or AV node dysfunction Def: rhythm originative below the ventricles w/ >6 sequential ventricular escape beats. 30-40/min Usually self terminates

Answer 82

● Atrioventricular junctional rhythm is an abnormal rhythm that originates in the AV junction instead of the SA node. ● The AV junction takes over as the primary pacemaker of the heart, generating its own electrical impulses to initiate ventricular contractions. ● ≥6 sequential junctional escape beats Usually due to CHR, myocarditis, ACS, hyperK or meds 45-60bpm Treat underlying cause Atropine or pacing if necessary

Answer 83

History ECG Age Risk Factors Troponin

Answer 84

- Phosphodiesterase inhibitor w/in 24h - Inferior MI (concern for RV involvment) - Severe AS

Answer 85

■ Inferior: II, III aVF (right coronary artery occlusion) ■ Anterior: V2, V3, V4 (LAD occlusion) ■ Lateral: V5, V6, I, aVL (left circumflex artery occlusion) ■ Septal: V1, V2 (proximal LAD occlusion) Posterior: L circ or RCA. Only need 0.5mm of STE. Get posterior leads if you have depression in V1-4 or tall R waves in V1-3

Answer 86

STE III > II + V1 STD in V2 Often present hypotense

Answer 87

1. DeWinter T waves - LAD - The hallmark feature of De Winter T waves is a marked upsloping ST depression in the precordial leads (V1-V6). ■ De Winter T waves are also accompanied by symmetrically peaked T waves in the same leads. 2. Hyperacute TW 3. Elevation in aVR with diffuse STD - Left main

Answer 88

1. Concordant ST elevation >1mm in any lead 2. Concordant STD >1mm in any of leads V1-3 3. Excessive discordant STE (>25% of QRS)

Answer 89

1. Prior ICH 2. Suspected aortic dissection 3. Ischemic stroke <3 months ago unless within last 4.5h 4. Active bleeding diathesis 5. Intracranial malignancy or AVM 6. Significant closed head injury or facial trauma in last 3 months 7. Intracranial surgery within 2 months

Answer 90

1. Anticoagulants 2. Uncontrolled HTN >180/110 3. PUD 4. Pregnancy 5. Infective endocarditis 6. Liver disease 7. Major surgery in last 3 weeks 8. Ischemic stroke >3months ago

Answer 91

1. Papillary muscle rupture - reduce afterload and surgery. Often present in shock with new murmur 2. Ventricular aneurysm - ● Due to a focal weakening of the ventricular wall after a transmural MI ● Often presents with heart failure ● ECG may show persistent ST elevations ● Treatment: manage CHF; anti-coagulate due to thrombus risk; surgical repair if ventricular arrhythmias or CHF symptoms refractory to treatment 3. Septal wall rupture - reduce afterload and surgery 4. Myocardial rupture - treat w/IVF and surgery 5. Tamponade 6. Arrythmias 7. Dressler's

Answer 92

Chest x-ray ○ Enlarged cardiac silhouette ○ Vascular congestion (upper lobe diversion, akin to JVD) ○ Interstitial edema (Kerley B lines; short fat horizontal) ○ Alveolar edema (fluffy) ○ Pleural effusions (loss of costophrenic angle)

Answer 93

● Diuretics if fluid overloaded ○ Ex: furosemide ○ Reduces preload ● Nitrates (e.g., nitroglycerin) ○ Reduces preload and afterload ○ Contraindication: phosphodiesterase 5 inhibitor use ○ Caution: hypotension ● Nitroprusside ○ Reduces afterload ● ACE inhibitors (angiotensin-converting enzyme inhibitors) ○ Reduce afterload ○ Commonly used to treat HFrEF ● Inotropes if hypotensive/shock ○ Norepinephrine ■ Vasopressor and inotropic agent ■ Reduced risk of arrhythmia compared to other agents ○ Dopamine ○ Epinephrine ○ Dobutamine

Answer 94

Thyrotoxicosis Chronic anemia Wet beri beri (thiamine def) Pregnancy AVM Caused by high cardiac output for a long period of time. will have dilation on echo. Order metabolic panel, TSH. Treat as low output Hf

Answer 95

Usually due to L heart failure, COPD, pulmonary fibrosis, ILD, OSA, PE Sx: Elevated JVP pedal edema abdo distension S3 Treatment: - Manage lung disease - Diurese if overloaded - O2 to reduce pulmonary artery pressure - Pulmonary vasodilators to reduce RV afterload - May ned inotropic support with milronone or dobutamine

Answer 96

○ Often idiopathic ○ Ischemic heart disease ○ Genetic ○ Viral (e.g., Coxsackie B, parvovirus B19, and human herpes virus 6) ○ Protozoan (e.g., Chagas disease due to Trypanosoma cruzi) ○ Alcohol, cocaine, or amphetamine abuse ○ Peripartum ○ Nutritional deficiencies (e.g., thiamine) ○ Toxins (e.g., chemotherapeutic agents such as doxorubicin)

Answer 97

- classic systolic murmur at LLSB due to LVOT obstruction - murmur increases during valsavla and with standing due to decreased venous return which reduce the size of the LV. Decreases with squatting and lifting legs which increase venous return - ECG may have dagger Q's in lateral leads, LV hypertrophy - Treat with betablockers, ICD

Answer 98

Stage 1: PR depression in II, aVR, V4-6 and diffuse ST elecation Stage 2: Normalization of PR and ST Stage 3: TWI Stage 4: Normalization

Answer 99

Downsloping TP segment in pericarditis

Answer 100

Beck's triad: - Elevated JVP - Muffled heart sounds - Hypotension ECG: - Tachycardia - Electrical alternans (alternating QRS amplitude) - Low voltage Treatment: - Pericardiocentesis - IVF to improve R heart filling - Avoid intubation if possible as positive pressure with increase intra- thoracic pressure and decrease venous return

Answer 101

- Blood goes to systemic circulation a the expense of pulmonary blood flow. Often triggered by crying, agitation, pain or hypovolemia - Treatment: 1. O2 2. Knees to chest 3. Keep baby calm 4. Fluid bolus to increase preload 5. Morphine to relax pulmonary infundibulum 6. Phenylephrine to increase SVR 7. Prostaglandin E1 8. Need surgery

Answer 102

Appropriate - Increasing frequency of VT or VF; Worseing LV dysfunction, MI Inapporpriate - SVT; double counting large T waves as QRS compleses; sensing non-cardiact activities

Answer 103

pumps blood from LV to rest of body - End stage CHF - Bridge to transplant Complications: - Pump thrombus - Suction event - Device failure - dysrhythmia

Answer 104

- Severe reversible cardiac/pulmonary failure - ARDS - Cardiomyopathy - Hypothermia - Drowning - Drug toxicity/overdose - Refractory hypoxemia - Cardiogenic shock - Massive PE - Bridge to destination therapy - Heart/lung transplant

Answer 105

- Fever - ischemia - post-cardioversion - hypo/hyperK - hypothermia - meds (BB, CCB, nitrates) - alcohol - cocaine

Answer 106

- ACS/ STEMI - Pericarditis - Myocarditis - Hyper K+ - Left ventricular aneurysm - Coronary artery vasospasm - HCM - LBBB - Ventricular-paced rhythm - Early benign repolarization - Brugada - Hypothermia - SAH/ CNS injury - Aortic dissection - Post electrical cardioversion

Answer 107

- Neurologic deficits - Variation in arm BPs (>20mmHg) - Variation in radial pulses - HTN - New aortic regurgitation murmur (decrescendo diastolic murmur) - Signs of pericardial effusion/tamponade (muffled heart sounds, pulsus paradoxus, JVD, hypotension) - Shock

Answer 108

MAP = SBP + 2(DBP)/3

Answer 109

H – Hypertension, heart anatomy (valvular, myocarditis, effusion, cardiomyopathy) E – endocrinopathies (e.g. thyroid)* A – anemia* R – rheumatic disorders T – toxins (cocaine, ETOH, chemo)* F – failure to take medications * A - arrhythmia I – infection*, infarction, ischemia L – lung pathology (COPD, PE, pneumonia) E – electrolyte abnormality* D – diet, diaper (pregnancy)*

Answer 110

P - PE, pulmonary disease, post op I - Ischemic heart disease, idiopathic*, infectious R – Rheumatic valvular disease/ any valvular disease A – Anemia, alcohol*, age* T – Thyroid, toxins E – Elevated blood pressure*, electrolyte abnormalities S – Sleep apnea*/ obesity *, sepsis

Answer 111

- Aortic Dissection - Acute Pulmonary Edema/ Heart Failure - ACS - ARF - Severe pre-eclampsia - Hypertensive encephalopathy - SAH/ intracranial hemorrhage - Ischemic stroke - MAHA

Answer 112

- Arterial narrowing - AV nicking - Retinal hemorrhages - Cotton wool spot/patch - Exudates - Papilledema/ optic disc swelling

Answer 113

- Ischemia - Hyperkalemia - Hypothermia - Hypothyroidism - Structural heart disease - Infiltrative (amyloid, hemochromatosis, sarcoid), - Autoimmune - Lyme disease/infectious/myocarditis - Cushings/Increased ICP

Answer 114

- Beta- Blockers - Calcium-channel blockers - Digoxin (digitalis glycosides) - Organophosphates (any cholinergic medication e.g. physostigmine) - Alpha-agonist (clonidine) - Class III anti-arrhythmics (e.g. amiodarone) - Class I anti-arrhythmics (e.g. procainamide)

Answer 115

Spilled teacup

Answer 116

Widening between the scaphoid and lunate ( >3mm is suggestive, >5mm is diagnostic)

Answer 117

All the carpals are “out”, only carpal bone in anatomic position is the lunate ***FOOSH + acute carpal tunnel = perilunate dislocation until proven otherwise Missing perilunate dislocations can result in median nerve palsy, pressure necrosis and longterm wrist dysfunction

Answer 118

Chip off on xray. ○ If FOOSH and isolated they are typically stable, need resting splint ○ If they fall on back of hand, more worrisome for dorsal capsular avulsion

Answer 119

Be suspicious of this if: - ulnar styloid looks displaced - crepitus and or blocking on pronation/supination - piano key sign of ulnar styloid - fovea sign - point tenderness over ulnar capsule, palmar to extensor carpi ulnaris tendon

Answer 120

○ Tenderness over hook of hamate, get a carpal tunnel view or Hook of Hamate view ○ Hook of hamate fractures are rare but more likely to have non-union ○ Typical mechanism is indirect from club sport or swinging sport ○ Management: immobilize (ulnar gutter, MCPs in flexion, ICPs in extension) and refer to hand

Answer 121

○ Finger held flexed position ○ Pain with passive extension ○ Fusiform or sausage shaped swelling ○ Pain along flexor side - Usually from puncture wound

Answer 122

● Isolated ulnar fracture ● Mechanism: struck on ulnar side of forearm ● Risk of non-union ● Management: long-arm posterior splint

Answer 123

● Annular ligament slips and radial head subluxes ● Typical age group: 6 months - 5 years ● Mechanism: Typically after arm is pulled, sometimes due to a fall ● Exam: mild pain, can’t supinate arm, no swelling ● Imaging NOT needed if Hx and P/E consistent ○ Need x-ray if not able to reduce ● Reduction: ○ Supinate/Flexion ○ Hyper-pronation ● Post-reduction → ensure moving well, achieve full supination

Answer 124

Rule of 2: If more than 2 cm displaced or fractured in more than 2 pieces it is more likely to be operative due to risk of non-union

Answer 125

● Weber A: Below the level of the ankle joint ○ Stable fracture ● Weber B: Fracture at the level of the ankle joint ○ May be unstable especially with pain on medial side, splint in posterior slab and make non-weight bearing, follow up with ortho ● Weber C: Above the level of the syndesmosis ○ Treated surgically

Answer 126

● 5th metatarsal fracture ● Dancer’s: base of 5th metatarsal ○ Stable injuries, can weight bear with stiff-soled shoe ● Jones: at the junction of the metaphysis and diaphysis ○ Stress fracture or inversion injury ○ 10-15% non-union rate ○ Managed by local ortho preference, can be managed without surgery ● 5th metatarsal shaft fracture is common ○ Managed with boot (if sensation is intact)

Answer 127

● Bohler's angle should be 20-40 degrees ● 8-10% have bilateral calcaneus fractures ● May be associated with other injuries (eg, plafond, knee, hip, thoracolumbar spine fractures) ● Mechanism of injury: typically younger person with fall from height or older adult who fall on weak bone ● Exam: pain with squeeze of calcaneus, plantar bruising ● Can evaluate on CT scan or extra x-ray views (Harris view)

Answer 128

- Factor VII, VII, XIII - Fibrinogen - vWF - Albumin Give in: vWF hemophilia A if factor not available DIC Massive transfusion

Answer 129

Landmark distal or proximal wrist crease (0.5 points) Landmark just radial to palmaris longus OR 1⁄2-1cm ulnar to flexor carpi radialis (1.5 points) The median nerve is located between the tendons of the flexor palmaris longus (between the flexor carpi ulnaris and radialis tendons) and the flexor carpi radialis (the most lateral tendon in the wrist). The flexor palmaris longus tendon may be identified by asking the patient to oppose the thumb and fifth finger with the wrist flexed. The median nerve can be blocked just lateral to this tendon. (Uptodate: accessed May, 2023)

Answer 130

- All factors - Fibrinogen - vWF Give in: DIC Mass transfusion Warfarin reversal Hemophilia where factor not available (not vWF as very little in FFP)

Answer 131

- Factor VIII Concentrate - DDAVP (monitor for hyponatremia, water retention) - causes release of vWF which carries factor VIII - Recombinant factor VIIa - Cryoprecipitate (1u/kg will increase activity level by 2%) - TXA for minor bleeding - If needing to give lysis for STEMI, treat them with lysis but give 100% factor VIII replacement along with TNK. - In the setting of head trauma - order CT head and prophylactically give Factor VIII - For MSK injuries, you want to immobilize the joint

Answer 132

Treatment: - Factor IX replacement (1u/kg will increase activity by 1%) - Activated PCC (Octaplex) - Recombinant factor VIIa - FFP

Answer 133

- Can give desmopressin intranasally. You can also use desmopressin in hemophilia A patients because vWF is a carrier of Factor VIII so release of the vWF from endothelium results in increased VIII and decreased breakdown of VIII -vWF - Antifibrinolytics like TXA prevent conversion of plasminogen to plasmin inhibiting breakdown of clots (2nd or 3rd line) - Estrogens increase vWF and FVIII. Can use IV in trauma - Cryoprecipitate

Answer 134

Factor Xa inhibitors – PCC (50mg/kg up to 300u) Dabigatran – Praxbind or PCC UFH or LMWH – Protamine Warfarin – Vitamin K and PCC or FFP if you don't have PCC. You have to give Vit K because PCC is transient and vit K replacement allows for vit K dependent factors to be repleted

Answer 135

1. MM - Rouleaux 2. Non-Hodgkins Lymphoma - Reed Sternberg cells 3. AML - Auer rods

Answer 136

● Real emergency! ● WBC > 100K, usually AML or CML in blast crisis ● Viscous blood plugs circulation ● Symptoms: severe hypoxia, headache, dizziness, visual changes, AMS → SICK! ● Tx: induction chemotherapy ○ Temporize with leukapheresis ○ Allopurinol (prevent TLS), hydroxyurea

Answer 137

Aortic rupture / Aortic wall rupture (“hemorrhage” insufficient to get credit) Pericardial tamponade Inferior ischemia causing right wall dysfxn (1 point) Inferior ischemia causing brady/heart block (1 point) Acute aortic insufficiency (1 point) Pseudohypotension (ie. BP drops in one arm only) (1 point)

Answer 138

abruption placentae disseminated intravascular coagulopathy acute renal failure hepatocellular injury/ liver rupture intracerebral hemorrhage transient blindness cardiorespiratory arrest aspiration pneumonitis acute pulmonary edema postpartum hemorrhage HELP syndrome

Answer 139

Pyridoxine

Answer 140

Chance fracture Duodenal injury Pancreatic injury Splenic laceration Liver injury Rib fractures Hollow viscous injury Mesenteric injury

Answer 141

-Epinephrine infusion -Other vasopressors (dopamine/vasopressin etc) -Glucagon (for beta blocker use) -Methylene blue (for vasoplegia)(some studies in cardiac literature of its use as an inhibitor of nitric oxide synthase and guanylate cyclase) -ECMO (Extracorporeal membrane oxygenation

Answer 142

C1 esterase (Berinert) FFP (fresh frozen plasma) Danazol Bradykinin antagonist (eg. icatibant) C1 inhibitor (plasma-derived) Ecallantide, a kallikrein inhibitor (available only in the United States)

Answer 143

Landmark at distal or proximal wrist crease (0.5 points) Infiltrate just deep to flexor carpi ulnaris tendon, being cautious about ulna artery located radially (1.5 points) The ulnar nerve runs between the ulnar artery and flexor carpi ulnaris tendon (the most medial tendon in the wrist). This tendon is just superficial to the ulnar nerve. A needle is placed under the tendon, close to its attachment just above the styloid process of the ulna, and advanced 5 to 10 mm (figure 12). Three to 5 mL of LA is injected at this location. An additional 2 to 3 mL of LA may be injected subcutaneously above the tendon in order to anesthetize the cutaneous branches of the ulnar nerve.When using ultrasound, the ulnar artery is identified, and the ulnar nerve is located medial to this vessel. Once identified, 3 to 5 mL of LA is injected to surround the nerve.

Answer 144

Pasturella multiceda - Amox clav - Pen allergic = septra or doxy + flagyl

Answer 145

Complication: Axillary nerve damage Assessment: Lateral deltoid sensory assessment / Chevron sign assessment

Answer 146

anterior inferior glenoid labrum/rim fracture associated w/anterior shoulder dislocation

Answer 147

posterolateral humeral head compression fracture

Answer 148

IBD Group A Strep infection Sarcoidosis Meds: Estrogens/OCPs, sulfonomides, PCNs, bromides/iodides Yersinia, campylobacter, salmonella infections Histoplasmosis, coccidiomycosis infections Bechets syndrome Sweet syndrome Chlamydial infection Mycoplasma infection TB Malignancies (AML, Hodgkins, carcinoid, pancreatic CA) Pregnancy

Answer 149

- Results valid with a potential for real impact on the patient’s health - Frequent health problem - Intervention feasible - Randomized trial - Properly blinded - Comparable groups - Proportion analyzed declared - Analyzed with intention to treat - Clinically and statistically significant - Your patient is similar enough to population studied (external validity) - Proper Allocation concealment - Was there bias?

Answer 150

Unlike sensitivity and specificity, the PPV and NPV are dependent on the population being tested and are influenced by the prevalence of the disease. (1 point) OR The PPV is the probability of having the disease if the test is positive; Sensitivity is the probably that the test will be positive if the disease is present (1 point)

Answer 151

- Well appearing - Due to impaired platelet production from T cell mediated destruction Treatment: - Steroids - IVIG - Splenectomy - Rituximab

Answer 152

- Ill appearing - long platelet chains clog blood vessels preventing RBC passage resulting in hemolysis - "Evil Pentad" - fever, MAHA, CNS findings, low platelets, renal failure - RF: Quinine, clopidogrel, female, HIV, SLE - ADAMSTS13 deficiency (ADAMSTS13 cleaves vWF, if you don't have this you have giant platelet plugs floating) Treatment: - FFP - PLEX - Steroids if PLEX delayed - Do not give plts as will worsen emboli

Answer 153

- 6mo to 4y - Triad: MAHA, thrombocytopenia, renal failure - Caused by E. coli 0157:H7 - RF: unpasturized fruits/jice, rare meat, petting zoo, daycare - Classic presenation is 3-7 non-bloody diarrhea then bloody diarrhea - Labs: Will have shistocytes, thrombocytopenia, elevated UC bili and LDH, negative Coombs - Treatment: Supportive w/IVF pRBCs if Hgb <6 or unstable; dialysis for anuria; eculizumab. - No abx as can increase toxin releas - No plts

Answer 154

5-14 days Tx: - Stop heparin - No plts - No coumadin until plts normalize - Change to direct throbmin inhibitor like dabigatran

Answer 155

- Consumption of clotting factors and platelets ***Massive inflammation → endothelial damage → cytokine release (TNF, IL‐6) → impaired anticoagulation & consumption of clotting factors - Decreased blood flow to organs causing failure - Consequence of another disease

Answer 156

Low platelets Elevated dimer Low fibinogen Elevated INR

Answer 157

HUS TTP HIT

Answer 158

Vaso-occlusive: - Acute dactylitis - Acute chest syndrome Heme: - Hemolysis - Aplastic crisis - Splenic sequestration Infection: - Think encapsulated (s.pneumo, h. flu)

Answer 159

Acute: >150mg/kg or ~10g in an adult Chronic: >3-4g/day

Answer 160

Stage 1: <24h GI upset, elevated acetaminophen Stage 2: 8-36h elevation in liver enzymes Stage 3: 2-4 Acute liver failure Stage 4: >4d recovery

Answer 161

GI upset CNS yellow/green vision and haloes around lights

Answer 162

Opioid mimic Supportive care Can try naloxone but variable response

Answer 163

Hypocalcemia Hypomagnesemia Hyperkalemia QTc prolongation VT

Answer 164

Stage 1: GI upset, hematemesis Stage 2: Lethargy, hypotension, acidosis Stage 3: cyanosis, coagulopathy, seizure Stage 4: hepatic failure Stage 5: Gastric scarring and gastric outlet obstruction

Answer 165

- Oxidation of Fe2+ to 3+ - Chocolate blood - L shift of oxygen dissociation curve - In nitrites, topical anestethics, well water - Treat with methylene blue

Answer 166

Acetylcholinesterase inhibitor SLUDGE Decontaminate AC Atropine Pralidoxime

Answer 167

Octreotide

Answer 168

Insulin Ethanol Sulfonylureas Salicylates Beta blockers Quinine

Answer 169

Beta blockers - Will result in unopposed alpha

Answer 170

Photophobia, ciliary flush, pain, decreased acuity Tx: Dilate pupil, steroids, analgesics

Answer 171

Blocked tear duct along inferomedial aspect of eye and infection of lacrimal system often caused by staph aureus Sx: tears that don't drain, purulent discharge Tx: warm compress, oral abx

Answer 172

Inflammation of cornea - bacterial, viral, fungal, checmical injury Treat: artificial tears, topical antibiotics, cycloplegics, antivirals

Answer 173

Pus in eye Treat with antibiotics and ophtho referral

Answer 174

Infection of deep eye structures - Pain and vision loss - Most commonly cuased by occular surgery, penetrating injury Tx: CALL OPHTHO for intraocular and systemic antibiotics

Answer 175

Results from a problem with flow of aqueous humor through the trabecular meshwork and canal of Schlemm --> back-up and too much fluid builds up --> increased IOP --> damage of optic nerve

Answer 176

Open angle = chronic. RF= age >40, fam hx Acute angle closure glaucoma - painful vision loss, headache, nausea, halos. - Precipitated by pupillary dilation - Fixed mid dilated pupil and hazy cornea - Elevated IOP Tx: IV carbonic anhydrase inhibitor (acetazolamide) Topical beta blocker (timolol) Osmotic diuresis (mannitol) Pilocarpine

Answer 177

Check EOM!!! for nerve entrapment Check IOP Check for dipilopia Check for infraorbital nerve involvement - numbness of cheek/upper lip CT orbits. Can also get Waters view xray but not as good. Treatment - need ophtho, plastics

Answer 178

CRAO CRVO Retinal hemorrhage Retinal detachment Vitreous hemorrhage CVA

Answer 179

- Acute angle closure glaucoma - Iritis - Corneal Ulcer - Temporal arteritis - Optic neuritis - Globe rupture - Retrobulbar hematoma

Answer 180

Peripheral: - BPPV - Labyrinthitis - Vestibular neuritis - Menieres Central - CVA - TIA - MS - Acoustic neuroma - AVM Other: - CO - Gentamicin tox - Orthostatic vitals

Answer 181

Necrotizing infection that can spread to cartilage and bone. Can progress to meningitis, encephalitis, brain abscess and cavernous venous thrombosis Sx: Pain out of proportion with trismus. - Washout/debride or talk to ENT to do this - IV abx - Need bone scan/CT

Answer 182

- Choking on blood

Answer 183

- Topical B-blocker - Topical alpha-agonist - Carbonic anhydrase inhibitor IV/PO - Hyper-osmotic agent IV (mannitol) - Topical miotic (pilocarpine)

Answer 184

- Reduction in intraocular pressure of >25% or < 35mmHg

Answer 185

- sympathomimetic use (cocaine, meth) - trauma - smoking - hypertension, - heavy alcohol use - previous abruption - advanced maternal age - high parity

Answer 186

- acute vaginal bleeding - fetal distress - lethal fetal anomaly - chorioamnionitis - preeclampsia or eclampsia, - sepsis - DIC

Answer 187

Painful vaginal bleeding Complications: DIC, fetal demise ● Apparent vs Concealed ○ Apparent: seen on ultrasound, presents with vaginal bleeding ○ Concealed: not seen on ultrasound, no vaginal bleeding ● Sx: painful vaginal bleeding (typical, but not all cases), back pain, abdominal pain ● Diagnosis: fetal stress testing; ultrasound not sensitive enough ● Tx: Csection preferred

Answer 188

HTN + proteinuria + >20w

Answer 189

Mild: - 140-160/90-110 - Proteinuria >300-5g in 24h - Can have hyperreflexia Severe: - >160/>110 - Proteinuria 5g/24h - Creatinine and LFTs elevated - Headaches, blurred vision, RUQ pain, clonus

Answer 190

- volume loss that causes symptoms of hypovolemia - a need for transfusion of packed red blood cells - >500ml/24h - 10% drop in the hematocrit

Answer 191

“Tone” - Uterine Atony: - Two-handed uterine massage - Pharm: oxytocin, ergots, prostaglandins “Trauma” - Birth Trauma: - Repair lacerations “Tissue” Retained POC/placenta: - Uterine digital exploration - Manual extraction "Thrombin" - Blood products, reverse coagulopathy

Answer 192

B12 = Neuro sx (IBD, vegan, PPI) Folic acid = NO NEURO SX (alcoholic, phenytoin)

Answer 193

Central Obesity/Collagen weakness Urinary free cortisol elevated Striae HTN/hyperglycemia/hirsutism Iatrogenic Neoplasms Glucose Intolerance

Answer 194

Causes: Primary = Addisons, CAH Secondary = pituitary, decreased ACTH Tertiary = Hypothalamic disease Primary ■ Acute: Shock, Abdominal Pain, Fever (atypical; look for infection), Hypoglycemia, Hyperpigmentation (buccal) ■ Chronic: fatigue, weight loss ○ Secondary/Tertiary: Hyponatremia, Hypoglycemia (more common); no hyperpigmentation (no elevated ACTH); less hypotension; less common: hypotension, GI symptoms; NO hyperpigmentation

Answer 195

G - growth hormone O - oxytocin A - ADH T - TSH F - FSH L - LH A - ACTH P - Prolactin (Prolactinomas treated with bromocriptine, all others treated with surgery)

Answer 196

Neuroblastoma (kid, abdominal mass, HTN) Pheochromocytoma (BP, HA, palpitations) Thyroid Disorders & Parathyroid D

Answer 197

1. Methimazole/Propylthiouracil - blocks new hormone synthesis 2. Iodides (potassium iodine ) - blocks release of thyroid hormone. 1H AFTER thianomides. Iodide can act as a substrate for more production so must block the synthesis first 3. Glucocorticoid - prevents peripheral conversion of T4 to T3 4. Beta blocker - target HR 100

Answer 198

- metabolic and multi organ decompensation from uncorrected hypothyroid Hypothermia AMS Brady Hypoventilation Treatement - Supportive care - Stress dose of hydrocortisone 100mg q6h - Thyroid hormone replacement with T4 500mcg IV loading then 50-100mcg daily IV or PO; T3 10mcg IV loading then 10mcg q4h for 24h then q6h. Thyroid hormone replacement is controversial (Avoid T3 in people with CAD) - Treating precipitating factors

Answer 199

Heat loss: - Environmental - avalanche, homeless, submersion - Induced vasodilation - drugs, carbon monoxide, alcohol Decreased production: - Endocrine - hypopituitarism, hypothyroid, hypoglycaemia, hypoadrenal - Neuromuscular - extremes of age, impaired shivering - Erythrodermas - psoriasis, burns, eczema - Impaired thermoregulation - Other - trauma, sepsis

Answer 200

Grade 1: no blisters or cyanosis Grade 2: clear blisters, distal cyanosis Grade 3: hemorrhagic blisters and cyanosis up to first joint Grade 4: Hemorrhagic blisters and more profund cyanosis

Answer 201

1. Remove from cold 2. Rewarm in circulating water bath at 38-42 degrees for 20-30mins 3. Analgesia 4. Tetanus 5. Abx if severe 6. Illoprost 7. IV TPA - talk to plastics first

Answer 202

Continued cooling of core temperature during initial stages of rewarming from hypothermia. Attributed to return of cold blood from extremities to core.

Answer 203

painful skin lesions that can be blue nodules due to capillary damage for cold or damp air that is not freezing Tx: Rewarm, bandage, elevation nifedipine, prostaglandin E1, topical/systemic steroids

Answer 204

Trenchfoot = mild inflammatory skin condition due to wet and cold - Treatment = drying, rewarming, elevating and avoid future freezing - Complications = prolonged/permanent numbness, hyperhidrosis, cold insensitivity, chronic pain, gangrene

Answer 205

- Rabies IG 20 IU/kg - as much into the wound then the muscle - Rabies vaccine on day 0, 3, 7 and 14d into site away from rabies immunoglobulin

Answer 206

Sepsis should be defined as life-threatening organ dysfunction caused by a dysregulated host response to infection. Septic shock should be defined as a subset of sepsis in which particularly profound circulatory, cellular, and metabolic abnormalities are associated with a greater risk of mortality than with sepsis alone. Patients with septic shock can be clinically identified by a vasopressor requirement to maintain a mean arterial pressure of 65 mm Hg or greater and serum lactate level greater than 2 mmol/L (>18 mg/dL) in the absence of hypovolemia.

Answer 207

High or low temp >38 or <36 HR >90 RR >20 WBC >12 or <4 Need 2+ Septic shock = SIRS + hypotension despite fluid resucitaiton

Answer 208

Inflatable pressure bag for hyperbaric oxygen. Temporizing measure

Answer 209

Decrease in barometric pressure --> decreased arterial O2 --> tissue hypoxia -->cerebral vasodilation --> AMS/HACE (usually at >2500m Tx: 1. Descend 2. Acetazolamide (creates bicarb diuresis and a metabolic acidosis so the body increases minute ventilation. Body is currently in a state of resp alkalosis) 3. Dexamethasone 4. Hyperbaric oxygen in Gamow bag

Answer 210

Hypoxia → pulmonary vasoconstriction→ pulmonary HTN→ noncardiogenic pulmonary edema Tx: Descent Hyperbaric oxygen if descent not possible Oxygen Nifedipine or Phosphodiesterase inhibitors to decrease pulmonary hypertension

Answer 211

○ Conscious and shivering ○ Tachycardia ○ Tachypnea ○ Nausea or ileus ○ Ataxia, clumsiness, slowed response to stimuli, dysarthria

Answer 212

○ Impaired consciousness, may or may not be shivering ○ Bradydysrhythmias or atrial fibrillation ○ J-wave (Osborn wave) on ECG Osborn ○ Hypoventilation ○ Bronchorrhea ○ AMS or lethargy

Answer 213

○ Unresponsive ○ Bradycardia/asystole/susceptible to ventricular fibrillation ○ Hypotension ○ Pulmonary edema ○ Areflexia

Answer 214

Coagulation necrosis - create eschar that may limit damage eg. ○ Sulfuric acid, hydrochloric acid, hydrofluoric acid, acetic acid, formic acid

Answer 215

Liquefication necrosis - potential for deep burns eg. Lye, lime, cement, ammonia, bleach

Answer 216

Tell parents to watch for labial artery bleeding 5-14d after when excar separates

Answer 217

Lichtenberg marks (see pic) - not a burn Keraunoparalysis - transient pulseless leg, self resolving ICH Hyphema Rhabdo Posterior shoulder dislocation Tympanic membrane perf

Answer 218

Hypoxia - pulmonary edema - emesis and aspiration

Answer 219

- Immersion > 10 min - Warm water drowning (> 20 degrees C) - Presence of cardiac arrest (pulseless or absence of respiratory effort upon rescue) - Delay to CPR (e.g. no bystander CPR, unwitnessed) - Delayed time to first breath - Drowning secondary to another medical cause (ex. myocardial infarction)

Answer 220

- Appropriate pain control - Wound care instructions: Dressing changes/ elevation - Activity restrictions - Splinting of extremity - Planned follow-up with plastic surgery/ wound care clinic - Follow-up if signs of infection/ symptoms of compartment syndrome or pain not well controlled

Answer 221

- Continued cooling of core temperature during initial stages of rewarming from hypothermia. Attributed to return of cold blood from extremities to core.

Answer 222

- Anticholinergic toxidrome - Sympathomimetic toxidrome - Salicylate poisoning - Serotonin syndrome - Malignant hyperthermia - Neuroleptic malignant syndrome - Withdrawal states (benzodiazepines, alcohol)

Answer 223

o Red cell casts --> glomerulonephritis or vasculitis o WBC casts --> pyelonephritis or acute interstitial nephritis (AIN) (eosinophils) o Granular casts or renal tubular epithelial cells --> acute tubular necrosis (ATN) o Hyaline casts (no cellular contents) --> Pre or postrenal causes of acute renal failure o Oxalic acid crystals -> ethylene glycol o Oval fat bodies or fatty casts --> nephrotic syndrome (heavy proteinuria)

Answer 224

o Appendicitis o Diverticulitis o Biliary colic o Intestinal obstruction o Abdominal aortic aneurysm o Retroperitoneal adenopathy o Tumor o Ovarian cyst o Endometriosis

Answer 225

o Ischemic: pO2 is < 30, pCO2 > 60, and pH < 7.25 o Non-ischemic pO2 > 30, pCO2 < 60, and pH > 7.25

Answer 226

- Female gender - Uncircumcised males - Younger age - Fever >39°C or fever duration >24-48 h - Previous UTI - Sexual abuse/ Sexual activity - Urinary tract pathology - Recent urologic instrumentation - Neurogenic bladder

Answer 227

- Can also have CNS effects, GI (colitis, necrosis, perforation), cardiac, pancreas and liver. * - CNS (altered mental status, seizures, coma, stroke, hemiparesis, and cortical blindness) * - GI (severe hemorrhagic colitis, bowel necrosis, perforation) * - Cardiac (cardiac dysfunction may be due to fluid overload, hypertension, or hyperkalemia) * - Pancreas (glucose intolerance) * - Liver (Hepatomegaly, increased serum transaminases)

Answer 228

- Clear, legible charting - Avoiding ambiguous abbreviations, symbols or dose designations (ie. ug vs mg, QD vs QID) - Avoid trailing zeros, include zeros before a decimal (ie. 5 mg, not 5.0 mg and 0.5 mg, not .5 mg) - Verify/ confirming allergies - Reviewing home medications/ medication reconciliation - Collaboration with pharmacy - Use of standardized protocols

Answer 229

- Infection surrounding site - Increased ICP - Bleeding diathesis (plts <20, anti coagulated, INR >1.5) - Shock/unstable - Focal neuro deficit - Papilledema

Answer 230

- Concern for brain malignancy - ie hx of cancer or focal neuro deficit - Concern for brain abscess - Concern for CVA - Age >60 - Immunocompromized - Focal neuro deficit - Papilledema - Deteriorating LOC

Answer 231

Primary TB can look like any pneumonia or can be atypical o Reactivation TB may have apical lesions o Ghon complex = calcified primary focus, Ranke complex = Ghon complex + calcified hilar lymph node = healed primary TB

Answer 232

Isoniazid: injuries nerves and hepatocytes!check LFTs, can cause neuropathies, can also cause refractory seizures Rifampin = orange body fluid Pyrazinamide Ethambutol = optic neuritis (red-green loss)

Answer 233

- History of toxic shock syndrome - Prolonged use of menstrual products (ex. super absorbent tampons; menstrual cups such as the DIVA Cup) - Contraceptive sponges - Intrauterine devices - Diaphragm contraceptive use - Vaginitis - Compromised skin barrier (burn, skin injury, incision site, bites) - Recent respiratory infection (associated with Strep & Staph) - Recent delivery, miscarriage, or abortion (risk for retained products)

Answer 234

Infection by Staphylococcus aureus or streptococcus pyogenes that produces toxins, leading to cytokine & inflammatory cell over-activation. This causes capillary leak, which leads to hypotension, rash, and end-organ damage.

Answer 235

1. Fever > 38.9 C 2. Rash with diffuse macular erythroderma 3. Desquamation 1-2 weeks after rash onset 4. Hypotension (SBP <90 mm) 5. Multiorgan involvement, defined as at least three of the following: -i. GI (vomiting or diarrhea) -ii. Muscular (severe myalgias or CK >2x upper limit of normal) -iii. Mucous membrane involvement (conjunctival, oropharyngeal, or vaginal hyperemia) -iv. Renal (AKI, pyuria without UTI) -v. Hepatic (signs of liver injury with ALT/AST/Bili elevation) -vi. Hematologic (PLTs low < 100,000/mcL) -vii. Neurologic (alteration in consciousness without focal neurologic signs when fever and hypotension are absent)

Answer 236

Ophthalmic, Maxillary and Mandibular branches Treat with NSAIDs and opioids in ED 1. Carbamazepine 2. Baclofen or lamotrigine are second line 3. Gabapentin for refractory 4. decompressive sx or botox

Answer 237

Avoid in unknown OD/Tox – Na channel blockade effects can precipitate torsade's, VT, arrest ETOH withdrawal seizures

Answer 238

Can be infused at a faster rate Less hypotension/cardiac arrhythmias Can be given IM

Answer 239

Pred 60-80 x 7 days Antivirals for severe cases Eye lubricants, shields, tape. No patches

Answer 240

Carotid or vertebral artery dissection until proven otherwise

Answer 241

- Dissection (carotid/vertebral) - Drug use (cocaine, methamphetamine) - Cardioembolic (valvular heart disease, arrhythmia, endocarditis) - Structural cardiac abnormalities (patent foramen ovale, atrial septal defect, cardiomyopathies) - Inflammatory conditions ( vasculitis, SLE) - Inherited hypercoaguable states (protein C, Protein S, antithrombin, Factor V Leiden) - Acquired hypercoaguable states (pregnancy, OCP, malignancy, DIC, antiphospholipid) - Hematolologic (polycythemia vera, sickle cell) - Trauma - Nonatherosclerotic angiopathies (Fibromuscular dysplasia, migraine-induced)

Answer 242

- Infection (UTI, pneumonia, sepsis, CNS) - Hypo/hyperglycemia - Trauma (including head, burns) - CNS pathology (Stroke/structural lesion) - Urinary retention/constipation - Medications/polypharmacy (many examples) - Withdrawal states (e.g. alcohol, benzodiazepines) - Electrolyte disturbance (hyponatremia, hyperkalemia, etc) - Hypo/hyperthyroidism - Systemic organ failure (cardiac, renal, liver, pulmonary) - Hypoxia/Hypercarbia - Nutrient deficiencies (thiamine, B12) - Adrenal insufficiency - Heavy metals

Answer 243

- Haloperidol - Risperidone - Quetiapine - Olanzapine

Answer 244

-- infection -- recent surgery/anesthesia -- emotional or physical stress, -- electrolyte imbalance -- temperature extremes -- pregnancy/childbirth -- Antibiotics

Answer 245

Estimating weight by age: Wt = (Age x 2) + 10 HR and RR: 0-1 : 140 and RR 40 1-4: HR 120 and RR 30 4-12: HR 100 and RR 20 >12: HR 80 and RR 15 BP: Neonate: 60 Infant 70 1-10: (Age x 2) + 70 >10: 90

Answer 246

* Cold shock: hypotensive and vasoconstricted - use epinephrine (need more Beta-1 support due to children having high SVR and decreased cardiac function) * Warm shock: hypotensive and vasodilated - use norepinephrine (need increased SVR)

Answer 247

= erythema on abdominal wall o Very concerning = necrotizing fasciitis of the abdominal wall o Risk for sepsis and peritonitis

Answer 248

hypoxia/ cyanosis!! - administer prostaglandin E1

Answer 249

acidosis/shock (not responsive to fluid) - administer prostaglandin E1

Answer 250

IVF NPO Replete glucose Control seizures Correct hyperammonemia (may need dialysis) Correct lytes Treat for sepsis

Answer 251

Abdo pain Red current jelly stools - Palpable abdominal mass ("sausage-shaped') in RUQ - GI bleeding - Previous episodes - Recent illness or infection - Abdominal distension - Irritability - Abdominal guarding - Blood on rectal exam Age 3mo-2y Tx air enema

Answer 252

- Motor function: -- Flexor Pollicis Longus (FPL): Okay sign/flexion of distal phalanx of thumb --Flexor Digitorum Profundus (FDP) to Index and Middle Fingers: Flexes the distal interphalangeal joints of the index and middle fingers --Pronator Quadratus (PQ): Pronates the forearm Most common injury in supracondylar fractures

Answer 253

- Flexible fiberoptic Laryngoscopy/Bronchoscopy - Esophagoscopy

Answer 254

Focal neuro deficits Concurrent blunt neck trauma

Answer 255

■ Part of frontal lobe passes under falx cerebri ■ Causes abnormal gait (think of homunculus—where are the legs?

Answer 256

■ Uncus of temporal lobe passes under cerebellar tentorium ■ Compression of ipsilateral CN 3 → fixed and dilated pupil ■ Contralateral hemiparesis

Answer 257

■ → Bilateral pinpoint pupils, bilateral Babinski’s signs, CN VI palsy ■ → Decorticate and decerebrate posturing

Answer 258

■ Rare ■ → pinpoint pupils, paralysis, death

Answer 259

Between dura and arachnoid Bridging veins ● Acute (<14 days since injury) – rapid LOC, +/- lucid period ● Chronic (>14 days) – gradual decrease in consciousness and altered mental state

Answer 260

○ Periorbital ecchymosis (raccoon eyes), mastoid ecchymosis (Battle sign) ○ Otorrhea, rhinorrhea, hemotympanum ○ CN VII deficits, hearing problems, vertigo

Answer 261

● Le Fort I and stable Le Fort II: ○ ENT or facial surgery consult and possible discharge ● Le Fort III and IV: ○ Admission and IV antibiotics (especially if CSF leak) ○ Consider awake intubation and be prepared for cricothyrotomy

Answer 262

● Orbital pain, globe injury, ↓visual acuity ● Diplopia or limited ocular movement due to entrapment ● Enophthalmos or proptosis (retrobulbar hematoma) ● Infraorbital paresthesia due to damage to the infraorbital nerve ● Facial or orbital CT if significant clinical findings ○ Teardrop sign on coronal images ● Waters’ view ○ For low-risk patients or when CT is unavailable ○ May show fluid in the maxillary sinus Tx: antibiotics to prevent sinus infection, avoid nose blowing, refer to surgery, check for retrobulbar hematoma

Answer 263

Mandibular pain, malocclusion, trismus, decreased TMJ motion, lower lip paresthesia (mandibular nerve injury) Treatment Closed fractures → ○ Barton bandage (ace wrap around head/mandible for stabilization) ○ Urgent outpatient follow-up with oral/maxillofacial surgery Open fractures → ○ Admit for operative repair + antibiotic prophylaxis (eg. penicillin or clindamycin)

Answer 264

Treatment ● Ellis Class I ○ Routine dental follow-up for aesthetic repair ● Ellis Class II ○ Cover dentin with calcium hydroxide ○ Dental follow-up in 1-2 days ● Ellis Class III ○ Cover with calcium hydroxide dental cement ○ Consider prophylactic penicillin or clindamycin ○ Dental follow-up in 1-2 days

Answer 265

○ Ellis Class I – through the enamel ○ Ellis Class II – through enamel + dentin ○ Ellis Class III – through enamel + dentin + pulp

Answer 266

Associated with seat belt sign T10-L2 Flexion/unstable. Need surg

Answer 267

Dorsal column - vibration/proprioseption Lateral corticospinal tract - upper motor neuron Anterior horn - lower motor neuron Spinothalamic - pain/temp

Answer 268

C6 = first dorsal web space, C7 = middle finger, C8 = pinky, T4 = nipple, T10 = belly butTEN (umbilicus), L1 = inguinal

Answer 269

■ Diminished reflexes → lower motor neuron ■ Hyperactive or intact reflexes → upper motor neuron

Answer 270

■ Clavicles to the cricoid cartilage ■ Lungs, esophagus, trachea, spinal cord, thoracic/proximal carotid vessels ○ Zone I: CTA of neck and chest, esophagoscopy, bronchoscopy

Answer 271

■ Cricoid to the angle of the mandible ■ Most common area of penetrating injury ■ Carotid + vertebral arteries, jugular veins, esophagus, trachea, larynx, spinal cord ○ Zone I: CTA of neck and chest, esophagoscopy, bronchoscopy

Answer 272

■ Angle of the mandible to the base of the skull ■ Distal carotid/vertebral arteries, pharynx, spinal cord CTA of neck + head

Answer 273

Rule of 2's: If more than 2 cm displaced or fractured in more than 2 pieces it is more likely to be operative due to risk of non-union ○ Displaced distal clavicle fractures tear the coracoclavicular ligaments and tend to have a painful nonunion → treated surgically If proximal 3rd, look for thoracic injuries

Answer 274

Muffled heart sounds Elevated JVP Hypotension Tachycardia Pulsus paradoxus (>10 drop in SBP during inspiration) Narrow pulse pressure Pericardial friction rub US: PCE Distended ivc Diastolic collapse of RA and RV Elevated JVP

Answer 275

○ Blurred/elevated hemidiaphragm ○ Hollow viscus (gastric bubble, air-fluid level) in chest ○ Mediastinal shift away from hernia ○ Atelectasis on side of hernia ○ Pathognomonic = coiling of NG tube in thorax ○ CXR commonly abnormal but not diagnostic

Answer 276

Test with lithmus Alkali burns ■ pH>7.2 ○ Acid burns ■ pH<7.0 Fluorescein AFTER irrigation

Answer 277

○ Irrigate ■ At least 30 min with normal saline or lactated Ringer’s (Morgan lens is helpful) ■ Check pH 5-10 min after irrigation ■ Continue irrigation until pH is within normal limits ○ Topical antibiotics ■ Erythromycin ointment for minor injuries ■ Fluoroquinolone for severe injuries ○ Ophthalmology evaluation in ED for severe burns, otherwise within 1 day ■ Optho may recommend prednisolone ophthalmic

Answer 278

○ Saline eye drops or other ocular lubricants ○ Ophthalmology follow-up in 24 hours if intractable pain or vision loss

Answer 279

Leave FB in if present Elevate HOB Eyeshield NO PRESSURE to eye Tetanus IV Abx

Answer 280

Age Myopia Hx of cataract removal Prior diagnosis History of vitreous detachment

Answer 281

○ IOP > 35 mmHg ○ ↓ acuity ○ Proptosis ○ Afferent pupillary defect ○ Ophthalmoplegia

Answer 282

Digital block C/I Need debridement w/in 6h Antibiotics

Answer 283

Mallet finger (inability to extend the distal interphalangeal joint): ■ Extensor tendon disruption with or without avulsion of a bony fragment from the distal phalanx ■ Due to forced flexion of DIP (eg. ball striking extended digit) ○ Boutonniere deformity: extensor tendon slip at PIP → PIP flexion and DIP extension ○ Jersey finger: FDP avulsion → can’t flex the DIP

Answer 284

- Documented ventricular fibrillation (VF) or polymorphic ventricular tachycardia (VT). - Family history of sudden cardiac death at <45 years old . - Coved-type ECGs in family members. - Inducibility of VT with programmed electrical stimulation . - Syncope. - Nocturnal agonal respiration.

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