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USMLE Step 2 CK-Emergency Medicine Flashcards

Step 2 Emergency Medicine (84 cards)

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0
Q

What are 5 thoracic causes of immediate death?

A

1) tension pneumothorax
2) cardiac tamponade
3) open pneumothorax
4) massive hemothorax
5) airway obstruction

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1
Q

What is included in the primary survey of a trauma pt?

A 
ABCDE
Airway
Breathing
Circulation
Disability
Exposure
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2
Q

How is a massive hemothorax defined?

A

place chest tube and defined as >1000cc of immediate blood return or >200/hr for >2-4hrs

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3
Q

How is massive hemothorax tx?

A

volume resuscitation followed by surgery to repair the site of bleeding

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4
Q

How are isotonic fluids replaced?

A

Isotonic fluids (NS or LR) are repleted in a 3:1 ration (fluid to blood loss).

  • start w/ fluid bolus of 1-2L in adults
  • recheck vitals and the continue repletion as indicated
  • if still tachycardic or hypotensive, after the first 2L of isotonic fluid, transfusion w/ pRBCs may be indicated
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5
Q

What are the classic signs of cardiac tamponade?

A
  • JVD
  • hypotension
  • muffled heart sounds
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6
Q

What is a secondary survey?

A

full exam after determine pt is stable

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7
Q

If suspect hemoperitoneum or tamponade, what should be done?

A

FAST scan

  • Morrison’s pouch: R kidney and liver
  • splenorenal recess: L kidney and spleen
  • pouch of Douglas: posterior to bladder
  • pericardium
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8
Q

What is the work-up for penetrating neck trauma?

A

1) intubate early
2) immediate surgical exploration is mandatory for pts w/ shock and active ongoing hemorrhage from neck wounds
- all wounds that violate the platysma are considered true penetrating neck trauma.
- assess based on neck zones (3)
- –1) above angle of mandible
- –2) between angle of mandible and cricoid
- –3) below cricoid
3) Continue dx work-up w/ appropriate tests
- angiography or aorta
- carotid/cerebral arteries
- CT scan of the neck w/ or w/o CT angiography
- Doppler U/S
- contrast esophagography/esophagoscopy
- bronchoscopy

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9
Q

What are the emergent chest injuries?

A 
tension pneumothorax
cardiac tamponade
open pneumothorax
massive hemothorax
flail chest
airway obstruction
aortic disruption
diaphragmatic tear
esophageal injury
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10
Q

What should be suspected if previously stable chest trauma pt suddenly dies?

A

air embolism

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11
Q

Should impaled objects in the chest be removed?

A

no, leave any impaled object in place until pt is taken to the OR, as such objects may tamponade further blood loss

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12
Q

What are the indications for open thoracotomy?

A

pts w/ penetrating chest trauma that leads to cardiac arrest, provided that the pt arrested in the ED or shortly before arrival

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13
Q

What suggests aortic dissection in chest trauma pts?

A

new diastolic murmur

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14
Q

What are indications for immediate exploratory laparotomy?

A
  • gunshot wounds (some pts who are stable can be managed conservatively)
  • stab wounds in a hemodynamically unstsable pt
  • pt w/ peritoneal signs or evisceration
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15
Q

What should be done w/ pts with suspected vascular injuries?

A

arteriography and surgical mgmt

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16
Q

How can nerve injuries be tx?

A

surgical repair

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17
Q

What are the most impt first steps in tx of contaminated wounds?

A

early wound irrigation
tissue debridement
THEN
Abx and tetanus prophy

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18
Q

What are the complications of epidural hematomas?

A

epidural hematomas expand and cause herniation and death

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19
Q

What kind of injury occurs in rapid decerlation trauma?

A

coup-contrecoup injuries

- bleed is noted at the site of impact and across from the point of impact

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20
Q

What equate child abuse in head imaging?

A

subdural hematoma coupled w/ retinal hemorrhages

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21
Q

What are typical signs of child abuse?

A

spiral fractures in the limbs
bucket-handle fractures
bruises
rib fractures

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22
Q

What is the classic cause of aortic disruption?

A

rapid deceleration injury

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23
Q

How do aortic disruption pts present?

A

aortic disruption who are seen in the ED usually have a contained hematoma w/in the adventitia
- laceration is the most common just proximal to the ligamentum arteriosum

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24
What conditions are risk factors for weak aortic wall?
Marfan's syndrome syphilis Ehlers-Danlos syndrome
25
What kind of skeletal injuries are assoc w/ aortic disruption?
first and second rib, scapular, and sternal fractures
26
What is a flail chest?
three or more adjacent ribs fractured at 2 points, causing paradoxical inward movt of the flail segment w/ inspiration
27
How does a flail chest present?
presents w/ crepitus and abnormal chest wall movt. Abnormal chest wall movt may not be appreciated if pt is splinting b/c of pain
28
How is a flail chest tx?
O2 narcotic analgesia respiratory support including intubation and mechanical ventilation surgical fixation of chest wall is generally needed
29
What are complications of a flail chest?
respiratory compromise due to underlying pulmonary contusion
30
What are the most commonly injured organs following blunt abdominal trauma?
spleen and liver
31
What are clues of pancreatic rupture?
suspected after a direct epigastric blow (handlebar injury)
32
What kind of trauma is often missed?
diapragmatic rupture Kehr's sign: referred shoulder pain due to diaphragmatic irritation (classically on the left due to spleen rupture) radiographs may demonstrate abd viscera in the thorax
33
What are the most commonly injured GU organs in trauma?
kidneys - renal contusion - laceration - fracture - pedicle injury
34
What are signs of urethral injury?
blood at urethral meatus | high-riding "ballotable" prostate or lack of prostate
35
What should be done if urethral injury is suspected?
perform retrograde urethrogram to r/o injury before a Foley catheter is placed
36
How should pelvic or retroperitoneal hematomas be approached?
Do not explore! | Follow w/ serial hemoglobin and hematocrit
37
How is asystole tx?
epinephrine and atropine
38
How is VFib or pulseless VTach tx?
unsynchronized shock w/ 360J-->360-J shock-->epinephrine-->360-J shock-->amiodarone or lidocaine-->360-J shock-->epinephrine Vasopressin can be given in place of the 1st or 2nd dose of epinephrine - amiodarone, lidocaine, procainamide, or sotalol may be used for stable Vtach
39
How is pulseless electrical activity tx?
epinephrine or vasopressin; simultaneously search for the underlying cause and provide empiric tx Give atropine for bradycardic PEA only
40
How is supraventricular tachycardia tx?
If unstable, perform synchronized electrical cardioversion If stable, control rate w/ vagal maneuvers (Valsalva maneuver, carotid sinus massage, or cold stimulus) If resistant to maneuvers, give up three doses of adenosine followed by other AV nodal blocking agents (CCBs or B-blockers)
41
How is Afib/flutter tx?
If unstable, synchornized electrical cardioversion starting at 100J If stable, control rate w/ diltiazem or B-blockers and anticoagulate if duration is >48hrs Elective cardioversion may be performed if <48hrs; or need to anticoagulate and perform TEE prior to conversion Do not give nodal blockers if there is evidence of WPW syndrome on EKG
42
How is bradycardia tx?
If sx, give atropine and consider dopamine, epinephrine, and glucagon If Mobitz II or third-degree heart block is present, place transcutaneous pacemaker pads, and have atropine at the bedside. A temp transvenous pacemaker may be required for hemodynamically unstable pts
43
What are the possible causes of pulseless electrical activity?
``` 5Hs and 5Ts Hypovolemia Hypoxia Hydrogen ion: acidosis Hyper/HypoK other metabolic Hypothermia ``` ``` Tablets: Drug OD, ingestion Tamponade: cardiac Tension pneumothorax Thrombosis: coronary Thrombosis: PE ```
44
What are causes of abrupt excruciating pain?
``` biliary colic ureteral colic MI perforated ulcer ruptured aneurysm ```
45
What are causes of rapid onset of severe, constant pain?
acute pancreatitis mesenteric thrombosis, strangulated bowel ectopic pregnancy
46
What are causes of gradual steady pain?
``` acute cholecystitis acute cholangitis acute hepatitis appendicitis acute salpingitis diverticulitis ```
47
What are causes of intermittent, colicky pain, crescendo w/ free intervals?
``` early pancreatitis (rare) small bowel obstruction IBD ```
48
What is the psoas sign?
passive extension of the hip leading to RLQ pain
49
What is the obturator sign?
passive internal rotation of the flexed hip leading to RLQ pain
50
What on KUB was suspicious of appendicitis?
evidence of fecalith or loss of psoas shadow
51
what on abd CT is suggestive of appendicitis?
periappendiceal stranding or fluid; enlarged appendix
52
What is a first degree burn?
``` only epidermis involved area is painful and erythematous No blisters capillary refill intact Looks like sunburn ```
53
What is a second degree burn?
epidermis and partial thickness of the dermis are involved. | area is painful and blisters are present
54
What is a third degree burn?
epidermis full thickness of the dermis, and potentially deeper tissues are involved area is painless, white, and charred
55
What conditions should cyanide poisoning be suspected?
closed-space fires w/ burning carpets and textiles
56
What kind of poisoning should be suspected w/ pts w/ inhalation injury?
carbon monoxide poisoning
57
What is the rule of 9s?
Estimate % BSA in adults - head and each arm = 9% - back and chest each = 18% - each leg = 18% - perineum = 1%
58
What supportive measures should be started for burn pts?
tetanus stress ulcer prophy IV narcotic analgesia
59
What is the Parkland formula?
Fluids for first 24hrs = 4 (pt weight in kg x %BSA) 50% over 8hrs 50% over next 16hrs
60
What is fluid goal during fluid repletion?
1cc/kg/hr of UOP
61
What antimicrobial prophy should be used?
topical silver sulfadiazine and mafenide
62
What infectious complication is seen w/ burn pts?
pseudomonal infection
63
What are indications to transfer pt to burn center?
- full thickness burn >5% of BSA - partial thickness burn >10% BSA - any full or partial burn over critical areas (face, hands, feet, genitals, perineum, major joints) - circumferential burns; chemical, electrical, or lightning injury; inhalation injury - any special psychosocial or rehabilitative care needs
64
What are the 5 Ws of postoperative fever?
``` Wind - atelectasis - pneumonia Water - UTI Wounds - wound infxn - abscess Walking - DVT Wonder drugs - drug rxn ```
65
What measures can be taken to decrease risk of post-op fever?
``` incentive spirometry pre-and post-op abx short term Foley catheter use early ambulation DVT prophy (anticaogulation, compression stockings) ```
66
What are the major causes of hypovolemic shock?
``` trauma blood loss dehydration w/ inadequate fluid repletion third spacing burns ```
67
What are the major causes of cardiogenic shock?
CHF arrhythmia structural heart disease (severe mitral regurg, VSD) MI (>40% of left ventricular fxn)
68
What are the major causes of obstructive shock?
cardiac tamponade tension pneumothorax massive PE
69
What are the major causes of septic shock?
bacteremia (esp gram neg organisms)
70
What are the causes of anaphylactic shock?
bee stings meds food allergies
71
What is the cardiac output and peripheral vascular resistance profile of hypovolemic shock?
CO decreased PVR increased PCWP decreased
72
What is the cardiac output and peripheral vascular resistance profile of cardiogenic shock?
CO decreased PVR increased PCWP increased
73
What is the cardiac output and peripheral vascular resistance profile of obstructive shock?
CO decreased PVR increased PCWP increased
74
What is the cardiac output and peripheral vascular resistance profile of septic shock?
CO increased PVR decreased PCWP decreased
75
What is the cardiac output and peripheral vascular resistance profile of anaphylactic shock?
CO increased PVR decreased PCWP decreased
76
How is hypvolemic shock tx?
replete w/ isotonic solution (LR or NS) and blood in a 3:1 (fluid to blood) ratio
77
How is cardiogenic shock tx?
Identify cause and treat if possible | Give inotropic support w/ pressors such as dopamine (if hypotensive) or dobutamine (if not hypotensive)
78
How is obstructive shock tx?
tx the underlying cause: - pericardiocentesis - decompression of pneumothorax, thrombolysis
79
How is septic shock tx?
administer broad spectru abx measure CVP and give fluid until CVP= 8 Give pressors (dopamine or norepinephrine) Obtain cultures prior to admin of abx if possible
80
How is anaphylactic shock tx?
Give diphenhydramine | If severe, 1:1000 epinephrine
81
What is the stereotypic EKG sign for hypothermia?
J wave (Osborn wave)
82
How does CO poisoning present?
``` hypoxemia cherry-red skin (rare) confusion headaches Severe: coma or seizures Chronic: flu-like sx w/ generalized myalgias, nausea, HA ```
83
What conditions need to be r/o in cases of hyperthermia?
malignant hyperthermia and NMS - halothane exposure (malignant hyperthermia) - neuroleptic exposure (NMS) Tx: dantrolene

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