1
Q
What interview technique should you use if someone is profoundly SOB?
A
yes/no questions
2
Q
What are asthma risk factors? (5)
A
- Current steroid use/recent withdrawal
- comorbid conditions
- serious psyc illness (dx-dx interactions, poor-self care)
- illicit drugs (COCAINE)
- low socioeconomic class)
3
Q
What are risk factors fro death from asthma? (5)
A
- Prior intubations
- previous ICU admissions for asthma
- recent/frequent ED visits for asthma
- Use of 2+ albuterol inhalers in past month
- use of air conditioning
4
Q
What are warning signs for severe asthma exacerbation? (7)
A
- Peak flow under 180 L/min
- PaO2 under 60mmHg
- PCO2 over 45mmHg
- mental status change
- cardiac arrhythmias
- pulsus paradoxus over 20mmHg
- pneumothorax
5
Q
What SaO2 do you want to keep as asthmatic patient above?
A
95
6
Q
What do you want to be continually monitoring on an asthmatic patient?
A
Pulse ox
7
Q
What is the MOA of albuterol? (4)
A
- Relaxes bronchial smooth muscle
- decrease histamine release
- inhibit microvascular leakage into airways
- increase mucocilliary clearance
8
Q
How often should you eval an asthmatic patient?
A
after EACH treatment (subjective response, PFT)
9
Q
What are common SE of albuterol?
A
tachycardia, tremor, anxiety
10
Q
What is an alternative to albuterol is someone is allergic to it?
A
levoalbuterol
11
Q
What class of drug is albuterol?
A
B2 agonist
12
Q
What class of drug is levoalbuterol?
A
B2 agonist with some B1 activity
13
Q
What is the MOA of steroids in regards to asthma exacerbation?
A
- Inhibit airway inflammation
- reverse B-R downregulation
- block leukotriene synthesis
- Inhibit cytokine production and adhesion protein activation
14
Q
In simple terms, how do steroids help with asthma exacerbation?
A
speed recovery and reduce recurrence!
15
Q
What route of steroid admin has NO role in acute asthma exacerbations?
A
inhaled!
16
Q
What is a drug commonly given during asthma exacerbation that produces beonchodilation but also has cardiac SE?
A
epinephrine
17
Q
Who do you have to be careful of giving epinephrine to?
A
elderly peeps
18
Q
What is an alternative to epi that can be given for asthma exacerbations that has LESS CARDIAC SE?
A
terbutaline
19
Q
What are 3 other drugs that aren’t commonly used for asthma exacerbations but were in the ppt?
A
- theophylline
- Mg sulfate (relaxes smooth muscle)
- Heliox
20
Q
What is status asthmaticus?
A
severe, prolonged asthma attack which can not be broken by usual treatment
21
Q
What can status asthmaticus lead to?
A
severe acidosis
22
Q
What should be done before crisis of cardiac arrest in status asthmaticus?
A
Intubation
23
Q
What are criteria for admission for asthma exacerbation? (5)
A
- FAILURE OG POST-TREATMENT PFT to increase by 15 percent above initial value, or absolute PFT under 200
- Repeat visit w/n 3 days with no improvement of sxs
- changes in MS
- persistent hypoxia
- persistent increase in work of breathing
24
Q
What are the 3 steps in COPD management?
A
- Medication therapy and supplemental O2
- positive pressure ventilation
- Intubation
25
How do you tx COPD? (4)
1. Bronchodilator (ipratropium)
2. Steroids (start ASAP for all exacerbations)
3. NIPPV (bipap)
4. High-flow oxygen
26
What should you do ASAP for any patient that has mentat status change, increased resp. distress w/cyanosis and acute detrioration?
Intubate ASAP!
27
What are criteria for hosp admission for COPD? (5)
- marked increase in rxs instability
- onset new physical signs (cyanosis, peripheral edema)
- failure of initial med management to end exacerbation
- new arrhythmias
- older age
28
What do you have to be careful of when giving a patient high-flow oxygen in COPD patients?
excessive O2 can cause resp. depression and resp. arrest secondary to loss of hypoxia-induced ventialtory drive?
29
What can cause a young person to have COPD?
alpha-1 antitrypsan deficiency syndrome
30
What are 3 take home points on COPD?
1. give as much O2 as needed
2. Steroids and lots of nebs
3. avoid intubation at all costs
31
What are risk factors for a spontaneous pneumothorax?
- tall, thin, male
| - smokers
32
What is the most common part of the lung affected by spontaneous pneumothorax?
apex (top)
33
What are sxs of spontaneous pneumothorax?
- abrupt onset pleuritic chest pain and dyspnea
| - decreased breath sounds
34
What is tx for spontaneous pneumothorax?
Depends on size and location!
- usually, do nothing and repeat cxr in 24hrs
- need decompression for emergent situations
- thoracic referral
35
What so you have to be worried about with a trauma pneumothorax?
tension pneumothorax
36
Do the sxs of pneumothorax usually correlate with extent of collapse?
nope
37
How do you treat trauma pneumothorax?
- emergent needle decompression
| - chest tube placement
38
Patient presents with pleuritic chest pain, dyspnea and hemoptysis?
classic triad of pulmonary embolism
39
What are risk factors for PE?
- recent long-travel
- recent surgery
- recent immobilization
- hemoptysis
- h/o cutting d/o
- hx cancer
40
What is the first step in dx suspected PE?
determine pretest probability
41
What happens if the patient had a high pretest probability for PE?
STRAIGHT TO IMAGING!
42
What happens if the patient has a low pretest probability?
PERC
43
What are the components of PERC? (8)
Need to say yes to ALL:
- under 50
- HR under 100
- O2 sat on room air over 94 percent
- no hx DVT/PE
- no recent trauma/surgery
- no hemoptysis
- no exogenous estrogen
- no clinical sxs of DVT
44
What happens if the patient doesn't pass PERC?
IMAGING
45
What happens if patient passes PERC?
Wells criteria
46
What are the wells criteria? (7)
- clinical sxs of DVT (3)
- PE most likely dx (3)
- surgery/bedridden for 3 or more days w/n 4 weeks (1.5)
- hx DVT/PE (1.5)
- HR over 100
- hemoptysis (1)
- active cancer (tx w/n 6 months) (1)
47
What score classifies as a LOW risk wells score?
under 4
48
What score classifies as a moderate risk wells score?
4.5-6
49
What score classifies as a high risk wells score?
over 6
50
What happens if patient is moderate-high risk Wells Score?
IMAGING
51
What happens if patient is LOW-risk wells score?
D-Dimer to r/o PE!
52
What is the imaging test of choice for PE?
- CT chest with IV contrast
| - VQ scan
53
What is tx for PE?
- oxygen
- pressor if BP unstab;e
- fibrinolysis
- anticoag
54
When will d-dimer usually be positive?
Pregnancy
55
What are common pneumonia pathogens?
- H. influenzae
- Klebsiella
- Staph
- Legionella
56
How do you treat pneumonia?
- Oxygen!
| - abx EARLY! (macrolides, quinolone)
57
When should you consider admission for someone with pneumonia?
- VS unstable
- bilateral pneumonia
- significant comorbidities
- immunecompromised
- elderly
58
What are the 5 steps for a medical provider in domestic violence?
1. screening
2. assessment
3. intervention
4. documentation
5. referrals
59
What are victims of DV more at risk for?
- stroke
- heart disease
- asthma
- alcoholism
60
What are feelings victims of DV feel?
- want abuse to end, but not relationship
- still love abuser
- have no support from family/friends
- have children w/abuser and fear safety for them
61
When should you screen for DV?
screen at EVERY visit!! (explain that you ask everyone these questions)
62
What should you do for assessment of DV?
- injuries, pattern of abuse
- immediate safety (safe houses)
- danger and potential lethality
- potential suicide/homicide risk
63
What are injuries and patterns of abuse? (5)
- injury inconsistent w/hx (fractures)
- bruising (multiple areas, different stages of healing, symmetrical)
- burns
- abrasions (scratches, forearms)
- pattern injury (hand print, objects)
64
Where are common areas of injuries of DV? (6)
- back of head
- neck/shoulders
- face
- posterior arm
- thighs
- butt
65
What is validation during DV visit?
- express concern for health and safety privately
- offer support/service
- RESPECT choices
66
How should you document DV?
- use direct quotes as much as possible
- document PE findings on body map
- take pictures w/patients consent
- ask patient if they want to report
67
What is the most lethal form of DV?
strangulation
68
What is the best predictor for future homicide victims?
strangulation
69
What percent of DV victims have experienced stangulation?
50 percent
70
What structures are affected during strangulation?
- carotid arteries
- jugular veins
- tracheal occlussion
71
What are sxs of strangulation?
- voice change (hoarseness)
- difficult/painful swallow
- memory loss/mental status change
- loss of bladder/bowel control
72
What is a physical exam finding of strangulation?
PETECHIAE (face, eyes, eyelids)
73
What can patients of strangulation die from?
death by carotid dissection
74
What imaging should you get for strangulation pts?
MRV CTA
75
What are factors that can attribute to child abuse? (7)
- parents immaturity
- lack of parenting skills
- poor childhood experiences
- social isolation
- frequent crises
- drug/etoh problems
- domestic violence
76
What are risk factors for child abuse? (9)
- DV w/n fam
- parent psych problems
- parent substance abuse
- parent hx abuse
- mental/physical disability
- low birth weight
- excessive crying/colicky baby
- frequent trauma w/abusive head trauma
- twins/multiple gestations
77
What are red flags for child abuse? (5)
- injuries w/o hx trauma
- changing hx from historian
- different hx from one historian to the next
- explanation inconsistent w/injury
- delay in seeking care
78
How should you prep child for physical looking for abuse?
undress child completely
79
What should you ALWAYS do in exam for abuse?
- fundoscopic (retinal hemorrhage)
- intraoral exam (petechiae)
- anogenital exam
80
Where are NON-accidental bruises found?
- trunk
- ear
- neck
- cheeks
- butt
- SYMMETRIC
81
What are locations of accidental bruises?
- front of body
- bony prominences
- extremities
- forehead
82
At what age should you NOT see bruising?
under 6 months old
83
What are characteristics of NON-accidental burns?
- immersion patterns
- sharp demarcation
- dorsal hands
- back
- butt
- feet
84
What are characteristics of accidental burns?
- asymmetric
- irregular borders
- face, neck
- upper torso
- palms
- fingers
85
What percent of fractures in children under 18 months are from abuse?
85 PERCENT
86
When should it abuse until proven otherwise?
non-ambulatory child w/humerus, femur, rib fx
87
What should you do when you find an abuse injury in a child?
get full skeletal survey to look for additional fractures
88
What is an ocular injury from abusive head trauma?
retinal hemorrhage
89
What is the best imaging to use when looking for abusive head trauma?
CT
90
Who is abdominal trauma from abusive more common in?
toddlers
91
What is mandated reporting?
In children under 6 months, or non-ambulatory, MUST report:
- fracture
- bruising
- subdural hematoma
- burns
- poisoning
- injury w/substantial bleeding
- any confirmed abuse
92
What is the ACE study?
look for correlation between abuse and long-term health sequelae
93
What else should you consider if you are suspecting abuse? (4)
- osteogenesis imperfecta
- mongolion blue spot (butt)
- coining/cupping (linear/round marks)
- moxibustion (circular red burns)
94
What are different forms of elder abuse? (7)
- physical
- emotional (verbal/nonverbal acts that cause intimidation, pain)
- sexual
- financial
- neglect (disregard for basic requirements and safety, lack of care/supervision)
- abandonment
- self-neglect
95
What is RADAR?
```
R- routinely ask questions
A- ask questions in private
D- document findings (body map, photos)
A- assess for safety
R- resources and review options
```
96
What should you do if you suspect elder abuse?
report to adult protective services
97
What should you do if confirmed elder abuse?
- report to adult protective services
- alert law enforcement (physical and sexual)
- safety planning/admission
98
What is a SAFE?
sexual assault forensic examiner (healthcare provider who has trained to provide medical/forensic care, collection of forensic evidence and testify in court as expert witness)
99
What is a sexual assault advocate?
support person who can be present in ED w/patient and continued support after
100
What are the components of a sexual assault forensic exam? (6)
1. history taking
2. physical assessment
3. evidence collection
4. documentation
5. assure advocate can be present
6. appropriate f/u, safety planning, post d/c support/tx
101
How soon does a forensic kit need to be done after assault?
5 days
102
How long can a kit remain anonymous?
90 days
103
What can you do if a patient refuses a speculum exam?
blind vaginal swabs
104
What do you do to visualize anatomy and hymenal ring?
labial traction
105
Who should you NEVER do a speculum exam on?
pre-pubescent female
106
What do you need to do after you have done a kit?
maintain chain of custody
107
Who should do the kit if a SAFE is not available?
ED clinician and nurse
108
What are long-term sequelae of sexual abuse? (4)
- depression
- drug/etoh use
- PTSD
- 13x suicide risk
- IMPORTANCE OF ADVOCATE!
109
What can be given for PG prophylaxis?
- plan B
| - Ella
110
How long after assault can PG prophylaxis be given?
up to 5 days after assault
111
Who should you report child sexual assault to?
Spurunk
112
What are the most common STIs from sexual assault?
- Trich
- BV
- gonorrhea
- chlamydia
113
What do you give for gonorrhea prophylaxis?
ceftriaxone IM
114
What do you give for chlamydia prophylaxis?
Azithromycin PO single dose
115
What do you give for trich and BV prophylaxis?
flagyl PO ince
116
What do you have to instruct patient when prescirbing flagly?
Don't take if have dranken etoh w/n 24hrs, and don't drink alcohol for at least48 hrs after
117
What do you do for HBV prophylaxis?
- immunized: no tx
- non-immunized: vaccine now, 1-2 months, 4-6 months
- high risk: IgG and vaccine
118
When should PEP be contemplated?
- unprotected vaginal/anal intercourse
- oral receipt of fluids/blood
- victim who is going to be compliant/finish course
119
How soon does PEP need to be started?
w/n 72hrs
120
What are common SE's of PEP drugs?
- hepatoxicity
- naseau
- fatigue
- myalgias
- rash
- bone marrow suppression
121
Why do most patients stop PEP?
SE
122
What baseline labs should be gotten before starting PEP?
- HIV now, 3 months, 6 months (with counseling)
- CBC
- CMP
123
What medications are used for PEP?
Truvada and Kaletra (2 tabs BID for 4 weeks)
124
What is the most common cause of abdominal pain in children?
constipation
125
A person presents with ABRUPT, localized pain that is increased with swallowing. The onset was preceded by violent emesis.
Perforated esophagus
126
What is a complication of perforated esophagus?
SubQ emphysema present
127
What are common causes of a perforated esophagus?
- 50-60percent iatrogenic
- 15 percent Boerhaavens (alcoholics, bulimics)
- 10-15 percent FB
128
What are risk factors for gastric ulcers? (3)
- heavy NSAID/ASA use
- ETOH
- smoking
129
How do you tx gastric ulcers?
- GI cocktail
- IV
- PPI/H2 blocker
130
What is a mallory-weiss tear?
partial thickness tear of esophagogastric junction
131
How do you dx mallory-weiss tear?
EGD
132
How do you treat mallory-weiss tear?
conservative managment
133
Patient presents with RUQ pain after fatty meals that radiates to right shoulder/scapula?
colelithiasis
134
How do you dx cholelithiasis?
transabdominal US
135
Patient presents with chills, fever and severe post-meals that radiates to right shoulder and has a positive Murphys sign
Acute cholecystitis
136
How do you dx acute cholecystitis?
US (thickened GB, pericholecystic fluid)
137
How do you treat acute cholecystitis?
- surgery is definitive tx (keep pt NPO)
| - IV mefoxin, nausea meds, pain meds
138
Patient presents with intermittent, colicky pain radiating to back with fever/chills, jaundice and pancreatitis/sepsis
choledocholithiasis
139
What is the most common cause of acute cholecystitis?
gallstones
140
How do you dx and tx choledocholithiasis?
ERCP (and IV abx)
141
What is the most common cause of pancreatitis?
gallstones (then ETOH)
142
What are complications of pancreatitis?
- abscesses
| - necrotic pancreas
143
Patient presents with severe, unrelenting pain radiating to back. The pain is worse lying down and better sitting slumped forward with decreased/absent bowel sounds?
acute pancreatitis
144
What lab findings do you expect to find with acute pancreatitis?
- 3x elevated LIPASE
| - 3x elevated ALT
145
What is Ranson's Criteria?
prognosis for acute pancreatitis
146
What is tx for acute pancreatitis?
- NPO
- IV hydration with LARGE amounts of fluids
- IV nausea/pain meds
- abx controversial but likely helpful
147
What are risk factors for AAA?
- old age
- HTN
- family hx
- atherosclerosis
148
How much does an AAA grow every year?
1-1.5 cm/year
149
What is the PE exam of AAA?
palpable, pulsatile, non-tender mass on abd palpation
150
When do you not need to operate on AAA?
asymptomatic and under 5cm
151
Patient with periumbilical pain out of proportion to exam?
ischemic bowel
152
Where does ischemic bowel usually happen?
"watershed" areas of intersecting circulation (splenic flexure, rectosigmoid junction, ascending colon)
153
What are risk factors for ischemic bowel?
- Over 60yo
- afib
- hypercoagable
- vasculitis
- sickle cell
- TPP
- recent AAA surgery
154
How do you dx ischemic bowel?
CT w/ oral and IV contrast
155
How do you treat ischemic bowel?
- surgery (NPO)
- broad spectrum abx (zosyn)
- NG tube
156
What is mesenteric adenitis?
inflammation of lymph nodes located in intestines/abd wall
157
Who is mesenteric adenitis most common in?
children/young adults with periumbilical pain
158
What is the most common cause of mesenteric adenitis?
infection
159
How do you treat mesenteric adenitis?
Supportive (self-limited)
160
Who is appendicitis rare in?
under 5yo
161
What are complications of appendicitis?
-perforation and diffuse peritonitis
162
When is appendicitis difficult to dx?
PG
163
How do you dx appendicitis?
- US in children
| - CT scan w/PO and IV contrast
164
Where do most diverticulitis happen?
sigmoid colon (90 percent)
165
What is NOT a clear risk factor of diverticulitis?
DIET
166
What causes invasion of colonic bacteria in diverticulum?
fecolith
167
What are complications of diverticulitis?
- mural abscess
| - micro-perforation
168
How do you treat diverticulitis?
ABX (CIPRO AND FLAGYL)
169
How do you dx diverticulitis?
CT with PO and IV contrast
170
Patient presents with N/V, hyperactive bowel sounds, pencil stools (diarrhea), distended abd?
small bowel obstruction
171
What are etiologies of bowel obstructions?
- adhesions
- neoplasms
- Bezoars
- intussception
- volvulus
172
How do you dx bowel obstruction?
KUB w/ upright abdomen (air-fluid levels)
173
How do you treat bowel obstruction?
- NG tube
- surgery (NPO)
- pain meds
174
What is Grey-Turner sign?
Bruising on side of abdomen
175
What is Cullens sign?
bruising around the belly button
176
Patient presents with bloody, mucous diarrhea?
UC
177
What does tenting indicate on PE?
broken clavicle
178
What part of the clavicle is usually broken?
distal 1/3
179
What should you check for with a broken clavicle?
pain at SC joint (if there is that is sign for sternal fracture, and deeper injury)
180
How do you treat broken clavicle?
sling dat shit
| suggest sleeping upright
181
Patient presents with point tenderness and bump at AC joint and NO sulcus sign?
AC separation
182
How do you treat AC separation?
sling dat shit
183
What is actually broken in a shoulder fracture?
humeral head
184
Who are shoulder fractures common in?
elderly
185
How do you treat shoulder fracture?
sling dat shit and refer to ortho
186
What is the most common direction of shoulder dislocation?
Anterior
187
What causes posterior dislocations?
seizure, electrocution
188
What is the most common MOI of shoulder dislocations?
FOOSH
189
What is a common PE finding of someone with a shoulder dislocation?
sulcus sign (right under AC joint)
190
What is a Hill-Sachs deformity?
Notch on humeral head (seen on xray)
Makes reduction difficult
191
What are neurovascular findings of someone with shoulder dislocation?
- may have tingling in fingers
| - vascular should be NORMAL
192
What should you ask in PMH with someone with shoulder dislocation?
- prior dislocations
| - how long has shoulder been out?
193
What xrays do you need to dx dislocation/reduction?
PA AND LATERAL (y-view)
194
What shouldn't a patient with a recently reduced shoulder do?
externally rotate and ABduct (aka brush hair)
195
What should be done once the shoulder is reduced?
- post--reduction films
- check neurovascular
- shoulder immobilizer
- ortho f/u!!
196
What is the key PE finding in rotator cuff tears?
limited ROM
197
How do you treat rotator cuff tear?
Sling dat shit and refer to ortho
198
What is a bad type of elbow fracture?
supracondylar (do not heal well-- need ortho referral ASAP!)
199
What is an anterior fat pad sign?
Always present but usually flush with bone--> if fracture SAIL SIGN
200
What is posterior fat pad?
Pathognomic for fracture (only present if fracture present)
201
What should you be concerned with for any elbow injury?
neurovascular injury
202
What should you always do when someone has a wrist fracture?
palpate anatomic snuffbox
203
What should you do if you suspect a scaphoid fracture?
spica cast
204
Patient presents with pain with motion of thumb?
Dequervains tenosynovitis
205
How do you diagnose Dequervains?
Finkelstein's
206
How do you treat Dequervains?
- NSAIDs
- splints
- cortisone injection
- surgery- fasiotomy
207
How do you dx carpal tunnel?
- Tinnels (tapping)
| - Phalens (reverse praying)
208
What don't you want to miss with a wrist fracture?
- Monteggia
| - Galiazzi
209
What is a Monteggia fracture?
fracture of proximal 1/3rd of ULNA w/dislocation of head of radius (end to wrist fracture)
210
What is Galiazzi fracture?
fracture distal radius w/distal radioulnar joint and intact ulna (2nd to wrist fracture)
211
What are most common bones to fracture/dislocate?
fingers
212
Patient presents with instability of MCP (thumb) joint with weakness of pinch grasp and ecchymosis of thenar eminence
Gamekeeper's thumb
213
What is a gamekeeper's thumb?
Ulnar collateral ligament (UCL) torn
214
How do you treat gamekeepers thumb?
spica splint and ortho referral
215
What is the only stable type of pelvic fracture?
Type 1
216
What is common presentation of pelvic fracture?
elderly fall and can't walk
217
How do you treat unstable pelvic fractures?
surgery
218
Patient presents with leg shortened and externally rotated?
hip fracture
219
Patient presents with leg shortened and internally rotated?
hip dislocation
220
What is actually broken in a hip fracture?
femoral head
221
What is garden classification used for?
hip fractures
222
What are the classification levels of hip fractures?
1: incomplete
2: complete with no dislocation
3: complete w/ partial dislocation
4: complete w/ full dislocation
223
What should you watch out for with hip fracture?
acetabular fx
224
How do you treat hip fracture?
- all get admitted
| - foley catheter
225
What is the usual cause behind hip dislocations?
hip replacements
226
What do you need to do with hip dislocation?
check vascular flow!!
227
What is classic PE finding of hip dislocation?
leg shortened and INTERNALLY rotated
228
What is the hallmark of treatment for femur fractures in the ED?
traction (hare) splint
229
What is the most common meniscus to be torn?
medial meniscus (because connected to MCL)
230
What are PE findings of someone with a meniscus tear?
- joint line tenderness
| - Apley's
231
xray shows fracture on of knee on side of patella
tibial plateau fracture
232
Why are tibial plateau fractures high risk?
poor healing
233
How do you treat knee dislocation?
DO NOT REDUCE WITHOUT ORTHO
234
What should you always check with ankle injuries?
check mortise alignment
235
What is the classic fibular fx?
lateral malleoulus fx
236
What should you watch for with bi/tri malleolar fx?
compartment syndrome!
237
What is the PE test for an achilles rupture?
Thompsons test
238
How do you treat an achilles rupture?
splint in full plantar flexion
239
What is the usual MOI for calcaneal injuries?
Jump from height
240
What should you do if you have a calcaneal fracture?
check other side!! (usually bilateral)
241
What else should you do if you have a calcaneal fracture?
Examine spine!!!
242
Patient presents with upward displacement of tongue, trismus, drooling and dyspnea
Ludwig's angina
243
What are risk factors for Ludwig Angina?
- poor dentition
| - immunocompromised
244
What is Ludwig's angina?
soft tissue infection of submandibular region of anterior neck
245
How do you treat Ludwig's Angina?
- EARLY airway management
| - PCN G IV + flagyl IV
246
Patient presents with "hot potato" voice, tripod position and drooling but oral exam reveals nothing
Retropharyngeal Abscess
247
What is the most common cause of retropharyngeal absecesses?
Heamfluenza (hib vaccine)
248
How do you dx retropharyngeal abscess?
soft tissue lateral neck xray
249
What are you looking for on xray of retropharyngeal abscess?
swelling between trachea and anterior spine
250
How do you treat retropharyngeal abscesses?
Penicillinase resistant PCN (Oxacillin, cephalosporin)
251
Patient presents with sore throat, trismus and hot potato voice
epiglottitis
252
What do you look for on xray to dx epiglottitis?
Thumb sign
253
How do you treat epiglottitis?
- cefuroxine, ceftriaxone, bactrim
| - steroids
254
Who is at risk of getting epiglottitis?
unimmunized
255
Patient presents with uvula deviation, trismus, stridor and drooling
peritonsillar absecess
256
How do you treat peritonsillar abscess?
- Needle I and D
- IM Pen VK
- recheck in 24hrs
257
How should you treat dental pain in ED?
- dental block (preiapical, infraorbital, inferior alveolar)
- temporary dental filling
- abx
- pain management
- dentist referral
258
What should you check if you have a dental abscess?
check teeth and neck
259
How do you treat dental abscess?
- DON'T DRAIN
- refer to oral surgery ASAP
- cover with abx
260
Patient presents with red/bulging TM and a normal canal
acute otitis media
261
What shouldn't you do if TM ruptures?
give oto-toxic drugs
262
What should you always do if someone presents with AOM?
examine/percuss mastoid
263
What are common pathogens of otitis externa?
- P. aeruginosa
- S. aureus
- often polymicrobial
264
What are common pathogens of mastoiditis?
- S. pneumo
- Group A strep
- S. aureus
- M. catarhallis
265
Why is mastoiditis so concerning?
COMPLICATIONS:
- MENINGITIS
- brain abscess
- epidural abscess
266
What can mastoiditis present with?
CN VI, VII, V palsy
267
How do you dx mastoiditis?
CT mastoid bone (swiss cheese appearance)
268
How do you treat mastoiditis?
- ENT for hearing analysis
- non-toxic--> treat like AOM
- Toxic--> zosyn, recephin, clinda
269
What should you always check for in someone who presents with nasal trauma?
septal hematoma
270
What is complication of septal hematoma?
septum will breakdown and cause disfiguration
271
How do you treat septal hematoma?
ENT referral
272
What is the common place to get epitaxis?
Kiesselbach's Plexus (anterior)
273
What is the clinical presentation of a posterior nose bleed?
blood in back of throat
274
What is treatment of epitaxis?
- mechanical
- vasoconstrictors (cocaine)
- inserter devices (caution TSS)
- cautery
275
Patient presents with posterior LAD
mono
276
What abx do you want to avoid with mono?
amoxicillin (rash)
277
What is the centaur criteria?
criteria to ID bacterial infection
278
What are the 4 centaur criteria?
- hx fever
- tonsillar exudates
- tender ANTERIOR cervical adenopathy
- absence of cough
279
What should you do with a centaur score of 0-1
no abx or culture
280
What should you do with a centaur score of 2-3 points?
culture and abx until find out result of culture
281
What should you do if centaur score is 4?
abx, no culture needed
282
Patient presents with pain over parotid gland and duct blockage?
parotiditis
283
How do you treat parotiditis?
- salivary agents
| - dicloxicillan if concern for infection
284
Patient presents with inspiratory stridor, sealbark cough, and resp. distress
croup (laryngotracheatis)
285
When is croup most common?
fall, early winter
286
What is the most usual pathogen of croup?
Parainfluenza type 1
287
How do you dx croup?
Steeple sign on xray
288
How do you treat croup?
- single dose decadron
| - mod-severe: racemic epi, o2, IV fluids
289
What drugs have narrow therapeutic indexes?
- digoxin
- TCA
- lithium
- warfarin
- theophylline
290
What blood test is most likely to change initially in overdoses?
INR, LFTs
291
Who should you have a high suspicion for overdoses in?
elderly (polypharm)
292
What are the 4 EKG changes you are looking for in an overdose?
1. QT prolongation
2. Wide QRS (>100ms)
3. Terminal R-wave aVR
4. high-grade block
293
What is the ddx for metabolic acidosis w/widening anion gap?
MUDPILES
294
What are MUDPILES?
```
M- methanol
U- uremia
D- DKA
P- propylene glycol
I- infection/isoniazid
L- lactic acidosis
E- ethylene glycol
S- salicylates
```
295
Patient presents with Kussmals breathing, tinnitus, pulmonary edema and hypotension
ASA overdose
296
What is the M-M prediction of ASA?
under 150mg/kg: non-toxic-mild
150-300 mg/kg: mild-moderate
300-500 mg/kg: serious toxicity
Over 500 mg/kg: potentially life-threatening
297
What labs will change first in an ASA overdose?
LFT's
298
When should you get serum salicylate?
Repeat q2hrs for first 6hrs
299
What should you be careful of with salicylate serum levels?
careful when under first 6hrs
300
What do you want to monitor with an ASA overdose?
urine pH
301
What do you want to keep urine pH at with an ASA overdose?
7.5- 8
302
How do you change urine pH?
BICARB
303
What other tests should you get during an ASA overdose?
- ABG (metabolic acidosis common)
- EKG
- CXR
304
How do you treat ASA overdose?
Dialysis
305
What is the most widely used OTC med?
tylenol
306
What is the max daily dose of tylenol in adults?
4g/day (90 mg/kg)
307
What is the most common cause of ACUTE liver failure in the US?
Tylenol overdose
308
Who has a better chance of surviving an acetaminophen overdose?
Under 5yo (more glutathione)
309
What is a really important thing to remember with tylenol toxicity?
DELAYED TOXICITY
310
What worsens a tylenol overdose?
co-ingestion with ALCOHOL
311
Why does alcohol make it worse?
Glutatione exhausted more quickly and NAPQI is made instead, which ruins liver
312
What are the 3 phases of tylenol overdose?
1. 0-24hrs (asymptomatic, N/V, subclinical LFT's)
2. 18-72hrs (RUQ pain, continue rise LFTs)
3. 72-96hrs (jaundiced, coagulopathy, fatality, liver necrosis, renal failure)
313
What is the timing of drawing serum tylenol levels?
draw initial and then post-4 hrs
314
What can be used to predict prognosis of tylenol overdose?
Rumack-Matthew nomogram
315
Why is glucose a good thing to check during tylenol overdose?
glucose
316
What does lactate level check for?
motarlity
317
What is TOC for tylenol overdose?
NAC
318
What is the time you want to give NAC w/n?
8hrs post-ingestion (anytime if PG)
319
What are the criteria for a liver transplant? (4)
1. pH under 7.3
2. grade 3 plus encephalopathic
3. PT over 100
4. Cr over 3.4
320
What are psych med overdoses hard to dx?
They present similar to psyc illness
321
Why are psych meds overdosed on frequently?
low therapeutic index
322
What are common psych meds that are overdosed on?
- amitriptyline
| - lithium
323
What meds can you commonly get levels on?
- lithium
- tegretol (carbamazepine)
- depakote
324
Patinet presents with agitation, tremor ridigity, sweating, hyper-reflexia, ataxia?
serotonin syndrome
325
What is the anticholinergic toxidrome?
- Hot as a hare
- Blind as a bat
- Dry as a bone
- Mad as a hatter
- Red as a beet
326
What should you look for in someone with an overdose of psych meds?
look for rhabdo
327
How do you treat psych med overdose?
- Benzos
- BP control
- Cooling
328
How long does an opiate take if taken IV?
10 min
329
How long dose an opiate take if taken IM?
30-45min
330
How long dose an opiate take if taken PO?
90 min
331
How long does opiate take if taken transdermal?
2-4hrs
332
What do you have to be careful of with narcan and heroin?
Narcan half-life shorter than heroin half-life
333
What should you do if there was an oral opiate overdose?
GI decontamination
334
If patient is still altered after narcan what should you consider?
- other ingestion
| - anoxic brain injury
335
What are the classic EKG findings in someone with a TCA overdose?
- wide QRS
| - terminal R-wave in aVR
336
Who should you not prescribe TCA's to?
- uncontrolled mental illness
| - hx suidice attempts
337
What are TCA's usually prescribed for?
- sleep
- enuresis
- OCD
- ADD
- anxiety
338
When is peak absorption of TCAs?
1 hr
339
What is the toxic dose of TCA's?
10-20 mg/kg
340
How do you treat TCA overdose?
- O2, IV, monitor
- bicarb (even if not acidotic)
- intubation is key if severe OD
- seizure precautions
- gastric lavage/charcoal
341
Why is ethylene glycol poisonous?
EG itself is not toxic, but is metabolized using ADH and converted to glycolic acid
342
How do you treat ethylene glycol overdose?
give alcohol (takes up ADH)
343
How does someone with an ethylene glycol OD present?
- Kussmals breathing
- tachypnea
- AMS
344
How do you work up ethylene glycol OD?
- obtain serum level
| - calculate serum osmolarity
345
What are the conversion factors for serum osmolarity
ethylene glycol: 6.2
Methanol: 3.2
Ethanol: 4.6
346
What is TOC of ethylene glycol?
Fomepizide (expensive, hard to get)
347
Patient presents with bradycardia and severe hypotension
verapamil
348
What is a toxic level of verapamil?
over 1g
349
What are dx findings of someone with verapamil OD?
high-grade blocks on EKG
350
What is TOC for verpamil OD?
10 percent CaCl (pressor support)
351
What is the legal limit for alcohol?
80
352
What do you have to keep in mind with face trauma?
Appearance of wound does NOT correlate to severity of injury (may be asymptomatic at first)
353
What are the borders of the anterior triangle?
Scm, midline of neck, mandible
354
What are the borders of the posterior triangle?
Scm, trapezius, clavicle
355
Where is zone 1 of neck?
base of neck
356
Where is zone 2 of neck?
middle of neck
357
Where is zone 3 of neck?
superior aspect of neck
358
Which zone has carotid/vertebral arteries, jugular vein, larynx and C-spine?
Zone 2
359
Which zone has trachea, vertebrae bodies, catodies, jugular and CN IX-XII?
Zone 3
360
Which zone has subclavian, aortic arch, trachea and C-spine roots?
Zone 1
361
What is the most common cause of penetrating traumas?
GSW/knife
362
Which caliber weapon causes the most damage?
LOW CALIBER (low velocity, SHREDS)
363
What are PE findings of penetrating trauma?
- expanding hematoma
- pulsatile bleeding
- signs of CVA
- shock unresponsive to fluids
- bruit/thrill
364
Does presence of pulse exclude vascular injury?
NOPE
365
What are signs of underlying injury from blunt trauma?
- hematemesis
- odynophagia
- SubQ emphysema
366
What should you do it there is injury to platysma?
Don't wait to image, ASAP trauma surgery!
367
What is the best imaging to pick up c-spine fractures?
CT
368
What should you do to avoid air embolus?
trendenlenburg position
369
What do you have to consider if there is a neuro deficit?
carotid/vertebral artery injury
370
What imaging should you get if someone has had blunt trauma?
CT
371
What is the usual MOI of a frontal bone fx?
blow to head
372
What else can happen with a frontal bone fx?
can involve sinuses
373
What is the weakest aspect of the skull?
orbital floor
374
What are complications of orbital floor fractures?
- hernation of orbital contents
| - entraps inferior rectus muscle
375
What imaging should you get to see orbital floor fracture?
non-contrast CT
376
What do you want to look for with a nasal bridge fracture?
septal hematoma
377
What can nasoethmoidal fx cause damage to?
- medial canthus
- lacrimal gland
- basofrontal duct
- cribiform plate
378
What can you see on PE with nasoethmoidal fx?
- telecanthus
| - CSF rhinorrhea
379
What is important to know in nasoethmoidal fx?
- mechanism
- exam
- gestault
380
What does PE of zygomatic arch fx look like?
- tender
- crepitus
- decreased mandible ROM
381
What are the Lefort classifications of Maxillary fx?
1: facial edema, mobility of palate and teeth
2: telecanthus, mobility of maxilla, epitaxis, CSF rhinorrhea
3: facial elongation/flattening, movement of facial bones, CSF rhinorrhea
382
What type of mandible fx is commonly overlooked?
condyle fx
383
What PE exam can you do to test for mandible fx?
tongue blade test
384
How many adult teeth are there?
32
385
How should you store avulsed tooth?
-in milk! Do not scrub tooth!
386
How do you tx dental fx?
-temp dental filling/dental block
387
What should you check for in someone with trauma?
- coumadin
| - alcohol
388
What should you do if there is a fx through the siinuses?
prescribe abx
389
Why type of facial fx needs neurosurgery?
nasoethmoidal
390
What type of facial fx needs mandatory opth consult?
orbital blowout
391
What are etiologies of subconjunctival hemorrhage?
- trauma
- valsalva
- spontaneous
392
What is tx of subconjunctival hemorrhage?
none, will heal on own in 2 weeks
393
What shoudl ou always do when someone presents with a corneal abrasion?
document lids everted
394
What should you always ask in patient with corneal abrasion?
Contact lenses (can't wear while healing)
395
How do you dx corneal abrasion?
flourescin dye w/ woods lamp
396
how do you tx corneal abrasion?
E-mycin ointment, pain meds
opth referral
397
How do you remove FB from eye?
- cotton tip applicator
- 18g needle
- algar brush (vibrator)
398
When should you NOT attempt to remove FB?
- Rust
- Full-thickness FB
- Over pupil (risk of scarring)
399
What must you r/o if there has been blunt trauma around the eyes?
ruptured globe
400
What should you look for with blunt trauma to the eyes?
- Flatness of anterior chamber
- hyphema
- EOM's
401
What is the vessel that causes hyphemas usually?
Iris root vessel
402
what do you need to do to see a hyphema?
elevate head of bed and allow blood to settle
403
What should you do if there is a hyphema?
-measure and control IOP (tono pen)
404
How do you treat hyphema?
MANDATORY opth referral
405
What is an elevated IOP?
Over 20
406
Where is the most common spot to have a blowout fracture?
orbital floor
407
What imaging do you need to get to see blow out fracture?
CT
408
What should you not do if you suspect a ruptured globe?
measure IOP
409
How do you tx ruptured globe?
- Stat optho referral
| - IV cephalosporin and patch eye
410
Patient presents with superficial punctate keratitis?
flash burn
411
When does flash burn typically present?
6-12hrs after injury
412
How do you dx flash burn?
floursecin with slit-lamp
413
How do you treat flash burn?
- E-mycin oitment
- pain meds
- cycloplegics
414
Is bacterial or viral conjunctivits more common?
viral
415
What is the most common cause of blindness in the Western World?
Herpes Keratitis
416
How do you treat herpes keratitis?
NO STEROIDS
mandatory opth consult
417
Patient presents with eye pain, HA, and STEAMY pupil?
Acute angle closure glaucoma
418
What are sxs of acute glaucoma?
- eye pain
- redness
- blurred vision
- N/V
- intermittent halos
419
What are signs of acute glaucoma?
- IOP over 21
- conjunctival infection
- corneal epitherlial edema
- mid-dilated, nonreactive pupil
420
How do you treat acute glaucoma?
RAPID decreased IOP (acetazolamide, BB (timolol), apraclonide/brimonidine)
ASAP opth referra
421
How do you dx acute glaucoma?
2 sxs, 3 signs
Emergency Medicine
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