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58 Cards in this Set
- Front
- Back
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Coma cocktail |
(dextrose, naloxone, thiamine, oxygen) can be used without much fear of deleterious effects.
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5 major categories of delirium |
infection, metabolic/endocrine, neurological, cardiopulmonary, and toxicology/withdrawal state.
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Features of Focused Assessment With Sonagraphy in Trauma (FAST) |
- Emergency ultrasonography by use of the FAST examination can be performed at the bedside, therefore decreasing wait times for definitive treatment. - Assessment with the FAST examination can visualize as little as 100 mL of intraperitoneal fluid indicating possible intraperitoneal hemorrhage. |
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Safety Net in ED |
IV-O2-Pulse Ox - Monitor *This should be done while simultaneously gathering historical and physical examination data. |
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Which headache patients require CT? |
Most authorities would agree that all those with new-onset focal deficits require an emergent head CT. The American College of Emergency Physicians' (ACEP) clinical policy on acute headache suggests imaging 2 additional groups of patients: HIV patients with new-onset headache and those over 50 with new headache even with no focal neurologic deficits.
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When do you use CT prior to LP? |
Due to the risk of herniation, most sources suggest noncontrast head CT in those patients with abnormal neurologic examinations, papilledema, or abnormal mental status prior to LP.
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Workup for subarachnoid hemorrhage |
The workup starts with a noncontrast head CT. Despite the advances in technology, patients with negative head CT studies still require LP for further evaluation. The presence of red blood cells and/or the presence of the breakdown product of xanthochromia is diagnostic for SAH.
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Time course of subdural vs. epidural hematoma |
The time course of subdural hematoma is much slower than that of epidural hematoma, due to venous bleeding of disrupted bridging veins. It should be noted that the elderly and alcoholics are at higher risk due to cerebral atrophy. These patients often have a remote history of trauma extending back as far as 1 to 2 weeks.
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Diagnostic criteria for temporal arteritis |
Diagnostic criteria include age over 50, new-onset localized headache, temporal artery tenderness or decreased pulse, erythrocyte sedimentation rate >50 mm/h, and abnormal arterial biopsy. Three of the 5 criteria are required for diagnosis.
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Acute Glaucoma Treatment |
Treatment is based on 3 strategies and should be completed simultaneously with ophthalmology consultation. Aqueous humor production is decreased by administration of beta-blockers (timolol), alpha-adrenergic agonists, and carbonic anhydrase inhibitors (acetazolamide). Mannitol reduces the amount of vitreous humor and is rapidly effective in lowering intraocular pressure. Finally, definitive care requires iridectomy by ophthalmology.
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Hemorrhagic shock |
Disease characterized by global tissue hypoperfusion secondary to blood loss. It can be a complication of traumatic injury, gastrointestinal bleeding, and even from scheduled surgical interventions.
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Pathophysiology of hemorrhagic shock |
The pathophysiology of hemorrhagic shock is central to understanding balanced trauma resuscitation. Trauma victims who have had significant blood loss present to the hospital with acquired coagulopathy (from bleeding), metabolic acidosis (from shock), and hypothermia (from exposure and bleeding). All of these 3 factors are interdependent: acidosis and hypothermia contribute to coagulopathy; continued bleeding contributes to worsened shock and acidosis, which worsens coagulopathy and contributes to continued bleeding. The natural course of this disease is that hemorrhagic shock results in global tissue hypoperfusion (shock), organ dysfunction, and death.
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Damage control surgery |
the concept that early surgical intervention need not repair all the injuries—it is intended only to temporize the bleeding patient to allow resuscitation (and in some cases, evacuation to a different hospital) to occur
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hemostatic resuscitation
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use fresh frozen plasma and platelets empirically with packed red blood cells to replace the blood volume of a hemorrhaging patient
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Metabolic derangements that occur with blood transfusions |
Hyperkalemia and hypocalcemia are very common (hyperkalemia from lysis of blood cells in the blood storage process and from acute kidney injury, hypocalcemia from chelation with citrate in banked blood), and require treatment as they develop.
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Lung injury due to massive transfusion |
ARDS is characterized by noncardiogenic pulmonary edema, hypoxic respiratory failure, and bilateral edema on chest x-ray. It is likely a cytokine-mediated inflammatory disease of the lung. It remains difficult to distinguish clinically ARDS from TRALI, but the treatment for both conditions is identical.
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Abdominal Compartment Syndrome |
For patients who have not had their abdominal fascia left open, edema and fluid can increase the intra-abdominal pressure to impair venous drainage of intra-abdominal organs. Urine output falls, intrathoracic pressure rises, and bowel ischemia, acute kidney injury, and death can occur.
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Only therapy to improve survival in ARDS |
One of the complications of massive resuscitation is ARDS. Oxygenation can be improved by increasing mean airway pressure (PEEP) and increasing FiO2, but the only therapy shown to improve survival is low-tidal-volume ventilation.
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Ménière disease
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Ménière disease usually presents in elderly patients, but may begin at any age. Symptoms usually last 2 to 8 hours and recur several times per week or month. Tinnitus, hearing loss, and occasional unilateral ear fullness accompany the vertigo. The diagnosis is confirmed by ENT via glycerol testing and vestibular-evoked myogenic potentials.
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Vestibular neuronitis
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Vestibular neuronitis is thought to be viral is nature. Sudden vertigo, sometimes preceded by a viral illness, may be so intense that bed rest is required. The vertigo improves with time and does not recur.
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Vestibular ganglionitis
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Vestibular ganglionitis is also thought to be due to a virus such as varicella zoster. Inflammation in the vestibular ganglion causes vertigo, and the disease is associated with Ramsay Hunt syndrome, which causes deafness, vertigo, and facial nerve palsy. The presentation is often confused with BPV and Ménière disease. The confirmatory finding is grouped vesicles on an erythematous base found in the external auditory canal. Patients are treated with antivirals within 72 hours of vesicle appearance.
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Medications known to cause Ototoxicity and vestibulotoxicity |
aminoglycosides, erythromycin, fluoroquinolones, NSAIDs (especially aspirin), furosemide, certain chemotherapy agents, and antimalarials. |
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Most common cause of vertigo |
BPV is the most common cause of vertigo with an estimated incidence of 107 cases per 100,000 people per year.
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Most commonly used medications for peripheral vertigo? |
The most commonly used medications are meclizine, diazepam, and ondansetron.
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PO contrast v. IV contrast |
In general vascular and abscess investigations need IV contrast‐‐ GI, oral and sometimes rectal contrast. PO contrast takes 2 hours to traverse so most acute trauma series are done with IV contrast only. Stone CTs are non contrast and may visualize the appendix as well.
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Tardieu spots
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Facial petechiae
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Flail Chest |
A flail chest occurs when a segment of the thoracic cage is detached from the rest of the chest wall, resulting in suboptimal ventilation and oxygenation. Typically, several ribs are broken in one or more places.
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Management of flail chest |
Pain control and pulmonary toilet are initial standard therapy.
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Paradoxical movement of the flail chest |
Paradoxical movement of the flail segment is seen during the respiratory cycle in flail chest. As the rib cage expands with inspiration, the flail segment sinks into the chest. As it contracts in expiration, it balloons outward.
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EM Treatment of a tension pneumothorax |
Treatment requires rapid recognition of the tension pneumothorax, frequently without benefit of chest radiographs. A 14-gauge needle or larger should be placed over the superior rib surface of the second interspace in the midclavicular line. A rush of air with improvement of vital signs confirms the diagnosis. If there is no immediate improvement, do not hesitate to place a second needle in the next interspace. A chest tube should be placed immediately.
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Electrical alternans seen on a 12-lead ECG
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Pericardial effusion |
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Vital signs - potentially serious illness |
Heart rate > 120 or< 60 beats/minute Respiratory rate > 20 or< 10 breaths/minute Systolic blood pressure< 90 mmHg Temperature > 38 or< 35°C Hypoxia Altered mental status Hypoglycemia orhyperglycemia
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Broad complex irregular tachycardia at very rapid rates?
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Suspect AF with WPW!
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The combination of bradycardia, flattening and loss of P waves, QRS broadening and T wave abnormalities is highly suspicious for?
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Hyperkalemia |
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EKG Findings - sodium channel blockers (TCA) |
A QRS duration > 100 ms is predictive of seizures.
A QRS duration > 160 ms is predictive of cardiotoxicity. |
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TCA overdose management |
Serum alkalinisation with NaHCO3 to reverse pH-dependent toxicity. Intubation and hyperventilation aiming for alkaline arterial pH (e.g. 7.45 to 7.55). Seizure management with benzodiazepines. BP management with fluid boluses +/- pressors. |
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The combination of…
Widespread ST depression / T wave inversion Prominent U waves Long QU interval (> 500 ms)…. is highly suggestive of severe _______________ |
Hypokalemia |
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Biphasic T waves may be seen with both myocardial ischaemia (Wellens’ syndrome) and hypokalaemia. The main differentiating factor (apart from the clinical picture) is the direction of the T waves. Explain.
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Wellens’ biphasic T waves go UP then down.
Hypokalaemic T waves go DOWN then up. |
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attern of T wave inversions in the right precordial leads V1-4 plus the inferior leads (especially the rightward-facing lead III) is referred to as ???
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Right ventricular strain pattern **It is a marker of right ventricular hypertrophy or dilatation. |
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Substances that contribute most to osmotic pressure in the ECF? |
In human fluids, the substances that contribute the most to osmotic pressure in ECF are Na+ and the anions HCO3– and Cl–, plus glucose.
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Alcohol and gastric emptying |
High concentrations of ethanol in the stomach may cause pylorospasm delaying gastric emptying.
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Neurological effects of alcohol |
Enhances the inhibitory neurotransmitter γ-aminobutyric acid receptors and blockade of excitatory N-methyl-D-aspartic acid receptors
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Legal definition of intoxication for the purposes of driving a vehicle |
80 milligrams/dL (17 mmol/L) |
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Alcohol and orthostatic hypotension |
Ethanol causes peripheral vasodilation and flushed, warm skin. Vasodilation causes heat loss to the environment promoting hypothermia. Vasodilation may also lead to orthostatic hypotension and reflex tachycardia. Ethanol-induced hypotension is usually mild and transient, so significant or persistent hypotension warrants investigation for alternative causes. |
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Ethanol metabolism and NADH |
The metabolism of a significant amount of ethanol increases the NADH/NAD+ ratio, which then promotes the conversion of pyruvate to lactate, diverting pyruvate away from the gluconeogenesis pathway
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Metadoxine
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Metadoxine, which is not currently available in the United States but is available in Latin America, Mexico, Asia, Africa, and Eastern Europe, enhances the metabolism of ethanol and accelerates recovery.6,22Metadoxine is an ion pair between pyrrolidone carboxylate and pyridoxine. A dose of 900 milligrams IV is reported to double the rate at which ethanol blood levels decrease with time compared with the patient's own metabolism
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Which drug is discouraged in hypertensive emergencies except preeclampsia? |
Nifedipine is discouraged in the treatment of hypertensive emergencies except preeclampsia.
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Ankle-brachial index |
An ankle-brachial index <0.25 suggests possibly limb-threatening ischemia. Values between 0.41 and .90 suggest mild-to-moderate peripheral arterial disease. Normal values are 0.91–1.3
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Management of acute limb ischemia |
Once acute limb ischemia is suspected, the EP should obtain a vascular surgery consultation, before ordering confirmatory imaging. Current practice calls for immediate administration of IV unfractionated heparin: an 80 units/kg followed by an infusion of 18 units/kg/hour.
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Reperfusion injury in patients with occlusive arterial disease |
Patients with suspected occlusive arterial disease are at risk for reperfusion injury, which is characterized by myoglobinemia, renal failure, and peripheral muscle infarction. About one-third of deaths from occlusive arterial disease are secondary to the metabolic sequelae of revascularization. Baseline electrolytes, myoglobin, and creatine kinase should be ordered, as well as a coagulation panel.
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Carotid sinus hypersensitivity
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Direct pressure on baroreceptors in the carotid body may trigger an abnormal vagal response of bradycardia and asystole or a drop in BP without a decrease in heart rate.
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EKG findings of PE |
Sinus tachycardia is a common finding on ECG. As the severity of the PE increases, the right heart begins to work harder and the right-sided pressures increase. Once the RV systolic pressures exceed 40 mm Hg, the T-wave inversions, incomplete or complete RBB, and the classic S1 Q3 T3 patterns may emerge.
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Enalaprilat
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Enalaprilat is an intravenous ACE inhibitor that may be indicated in the treatment of patients with heart failure or acute coronary syndrome. Hypotension is the most common side effect with a first dose, so a preliminary test dose of 0.625 mg is recommended.
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Indications for thoracotomy
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Initial chest tube drainage of 1000 to 1500 cc of blood
200 cc/h of persistent drainage Patient remains hypotensive despite adequate blood replacement, and other sites of blood loss have been ruled out. Patient decompensates after initial response to resuscitation. Increasing hemothorax seen on chest x-ray studies. |
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GCS scale |
A score of 14 to 15 is associated with minor head injury, 9 to 13 indicates moderate, and 8 or less is associated with severe head injury.
**It is recommended to intubate patients with a GCS score of 8 or less for airway protection. |
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Quickest method of lowering ICP |
hyperventilation to produce an arterial Pco2 of 30 to 35 mm Hg will temporarily reduce ICP by promoting cerebral vasoconstriction and subsequent reduction in cerebral blood flow. The onset of action is within 30 seconds.
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Management of a patient in cardiogenic shock |
Patient should be stabilized with IV pressors since there is already pulmonary congestion evident on examination. A rapid workup including ECG, chest x-ray (CXR), laboratory tests, echocardiogram, and hemodynamic monitoring should help confirm the etiology and direct specific treatment of the underlying cause.
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Young athletes's response to hemorrhage |
Patients with excellent baseline physiological status (e.g., young athletes) may have such a robust compensatory response to hemorrhage that they appear stable and do not manifest tachycardia or hypotension even with significant hemorrhage. Signs of peripheral hypoperfusion and subtle mental status alterations may be the only clues that the severity of hemorrhage is greater than predicted based on hemodynamic parameters.
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