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143 Cards in this Set

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Case 1
A 15 year old girl presents to the emergency room very upset because she recently broke up with her boyfriend. She states that she “took some pills” several hours ago. Her mother is very upset because she found an empty bottle of Tylenol in her daughter’s bedroom.
Gastric lavage, activated charcoal, decontaminate, look at nomogram

Mucomyst, HCO3
Case 2
An 18 month old female is brought into the ER by her mother. The baby has had multiple episodes of vomiting and some non bloody diarrhea over the past 24 hours. Mom is very concerned because she has noticed the baby is not as active as she normally is. The child is afebrile.
Suspect rotavirus
IV fluids: 20 ml/kg bolus
lactate or ringers
Case 3
A 62 year old male smoker with a past medical history of HTN and DM presents to the ER with a 1 hour history of crushing chest pain radiating to the left arm. He is nauseated and has vomited twice, and appears diaphoretic.
PE: VS – T 98.6, P 106 and regular, R 20, and BP 150/100
He appears anxious but is alert and oriented X3
Cardiac exam reveals a rapid heart rate with a regular rhythm
Lungs are clear to auscultation
Extremities reveal no CCE(clubbing/cyanosis/edema)
suspect MI
always look for atypical MI
Diabetics and women don't usually have typical sx
MI risk factors:
Male
______
DM
_______
smoker
HTN
Case 4
A 2 yo male is brought in by his mother. The child has been vomiting, looks sick, and doesn’t respond to IV needle stick.
VS: T 104 P 120 R 20 BP 80/60

inc T = _______ risk

_________until proven otherwise

neonate inc risk of ___

Get LP and CBC later!
bacteremia

meningitis

GBS

biggest mistake is delaying abx
Case 5
A 65 year old male COPD patient comes to the emergency room saying “I can’t breathe”.
His respiratory rate is 36 and he is noted to be using his accessory muscles to breathe.
His pulse ox is 80%(hypoxemic)

resp arrest can lead to ______

tx w _________
cardiac arrest

trach tube: O2, breathing tx, possible breathing machine
Case 6
A 22 year old male is in transit to the emergency room by ambulance. EMS has identified him as the unrestrained driver in a head on motor vehicle accident. They inform you by radio that his vehicle sustained severe damage, including a “bulls eye” break to the windshield on the drivers side as well as a broken steering wheel…..at this point the radio transmission from EMS is lost

don't remove collar: c spine injury - damaged cord - paralysis

Look at: (3)

Check:__________
1. head
2. c spine
3. chest

airway w/ c-spine control
breaths (pneumothorax?)
Fall from height DDX:
heel fx
torn aorta
lumbar spine fx
A 26 year old male power and light company worker is in the ER because while at work he was hit in the face with a hot energy line. His physical exam reveals that he has an entry wound on his face and an exit wound on his left leg.

Check _______ first! Then ________.
Airway first then intubate.
(whether chemical or regular burn)
A 14 year old male is brought into the ER with abdominal pain. He gives a history of vague pain and nausea starting about 8 hours ago. Since that time, the pain has become more severe and has shifted into the right lower abdomen. On the way to the hospital, he noted that the bumps in the road made his pain worse.

DDX and tests:

Nontypical presentations: (3)
Appendicitis
McBurney's point
Tap on heel
Obturator/Psoas sign
Jump on right leg

retrocecal appendix, elder, diabetics
Case 9
A 12 year old male is brought into the ER by ambulance due to injury sustained in a soccer game. Upon colliding with another player he experienced severe leg pain.
PE reveals that the tibia is protruding through the skin in the lower left leg with blood spurting from the large laceration caused by the bone.

TX:
Airway
Breathing
*Circulation* - use direct pressure
open fx = _______
can lead to ________
use gauze and ________
ortho emergency
osteomyelitis
Ancef IV
one compartment builds pressure. Inc pressure compresses nerves and circulation.
compartment syndrome
Case 10
A 44 y.o. female presents to the ER with a sudden onset of palpitations, rapid heart rate, and lightheadedness. She denies chest pain or SOB.
PE: vitals T 99º, P 190, Resp 20 BP 120/80
She is alert and oriented X3 and appears slightly anxious
Cardiac: RR but rapid Lungs: Clear
Extremities: no CCE


EKG = >150 and regular
Paroxysmal Supraventricular Tachycardia (PSVT)
vagal stimulation_________

cardioversion in shock pt to prevent__________

if in v fib, __________
valsalva, cough

R on T phenomena

defibrillate
CARDIOTHORACIC TRAUMA
___ of all trauma deaths

Mortality is increased with multiple trauma

i.e head injury, thoracic injury and abdominal injury---which may not be immediately diagnosed. A perforated viscous, for example can lead to peritonitis, sepsis and death.
1/4
Penetrating trauma is usually a ____________
surgical consult
Blunt trauma requires a _____—if patient is stable

If pt has a blunt trauma injury, but is unstable/ in shock a ________is mandated. This means something BIG is bleeding and the sooner the surgery the better the outcome for the patient.
CT scan

surgery consult
ABC/ “Oh MY”
The rule to all trauma—establish the ABC’s and think OMI.
“Oh My” = OMI _______
Establishing adequate ________ are top priority – give 100% oxygen.
Fluid resuscitation
(Oxygen, Monitor, IV)

airway and oxygenation
IV fluids
Fluid resuscitation as needed with _________(________ site preferred)

Initially 1-2 liters of ____________ for adults or 20 ml/kg for children. If not responding to crystalloid fluids-- then __________(type specific or O negative).
2 large bore peripheral IV’s
antecubital

LR(lactated ringers) or NS(normal saline)

blood transfusion
The Primary Survey of a Trauma Patient (ABCDE)
“A” Establish Airway with C-SPINE CONTROL.
“B” for breathing
“C” for circulation—IF bleeding apply direct pressure
“D” for _________–assess neuro status
“E” for _______. Pt should be fully exposed to assess any hidden trauma.
disability

exposure
Life threatening Cardiothoracic Injuries
1. _______________
2. Open Pneumothorax
3. _____Chest
4. Massive __________
5. Pericardial Tamponade
Tension Pneumothorax
Flail
Hemothorax
_____________
Trauma to the chest that results from a wound which acts as a valve that allows air to enter the pleural cavity, but prevents it from being able to escape.

This is a CLINICAL DIAGNOSIS –pt will die before you get the chest xray!!!!!!!!
Tension Pneumothorax
Clinical Features of a Tension Pneumothorax
Pt is in severe distress
On exam, patient may have subcutaneous _________.
Usually patient is _________(unstable).
Trachea will be deviated _______from side of pneumothorax
Hyperesonant on percussion of affected side
Neck veins may be distended, BUT may not be if patient is hypovolemic
May present as ____on monitor
emphysema
hypotensive and tachycardic
AWAY

PEA (PULSELESS ELECTRICAL ACTIVITY)
TREATMENT OF TENSION PNEUMOTHORAX
Patient needs RAPID ________ of the chest.
Insert large bore needle (14 gauge) into the ________ space in _________line –go ________the rib to avoid the blood vessels and nerves that are located on the bottom of the rib.
needle decompression
2nd intercostal
midclavicular
above
Tension Pneumothorax
INSERT CHEST TUBE
Put in chest tube (generally the larger the better, especially if dealing with a hemothorax). Insert at the level of the ______line or ____ IC (intercostal space) just anterior to the ________ line.
REMEMBER that an untreated simple pneumothorax may become a tension pneumothorax, especially if a patient is put on a ventilator –so put chest tube in beforehand.
nipple
5th
midaxillary
The goal of a chest tube is to ________the lung and improve _________.
re-expand
oxygenation/ventilation
OPEN PNEUMOTHORAX

“___________”

This is a large defect of the chest wall, causes _________leading to __________ failure (decrease O2/increase CO2)
SUCKING CHEST WOUND
ineffective ventilation
respiratory
Treatment of Open Pneumothorax
Apply sterile ________ and occlude defect. Tape on 3 sides, leave one side open to act as flap valve until _______ is inserted.

Insert chest tube _______ from wound site
saline soaked gauze
chest tube

REMOTE
FLAIL CHEST
Occurs with significant trauma to the chest wall causing multiple rib fractures in __ places on same rib.
Causes impaired ventilation – (chest wall movement is disrupted---i.e. paradoxical chest wall motion; moves ________ during inspiration and ________during expiration)
2
inward
outward
FLAIL CHEST
Patient becomes hypoxic for 2 additional reasons:
1. The underlying injury to the lung (_________)
2. __________ from wound causes patient to refrain from breathing deeply.
pulmonary contusion
Pain
HYPOVENTILATION = ___________
Note on rib fractures – the greater concern is underlying _________ If 1st or 2nd rib fractured – the major mechanism caused this trauma and there will likely be critical injury to the underlying structures (i.e. the great vessels and lungs).
HYPOXEMIA

organ injury (lung, spleen, liver, and kidney in lower rib fractures).
Treatment of FLAIL CHEST
Obtain optimal ___________
________ resuscitation – be careful not to over resuscitate with fluids the injured lung can not tolerate this volume, Requires careful monitoring.
Control patients’ pain with _________
A _______ may be indicated if lung expansion needed (for example a patient with a small pneumothorax that requires mechanical ventilation).
oxygenation and ventilation
Fluid
analgesics
chest tube
Heat Illness:
400 deaths/yr in US
extemes of ___ are at highest risk

_____ - mild swelling of hands & feet
______ - prickly macular papular rash on clothes areas of body
_____ - brief, intermittent muscle cramps fatigued by heavy work
TX: remove from heat & give _______ (PO or IV NS if severe)
age

heat edema

prickly heat

heat cramps

electrolytes
Heat Exhaustion:
basically is ________ (water and/or salt)

Symptoms:
weakness, fatigue, HA, N/V
fever up to 104
may have syncope (check for ______ & _______)
volume depletion

injuries & other causes
Heat Exhaustion: TX
____ - usually can give 1-2L in ER & discharge
May give age 15+ _____ as bolus at 500ml/hr until 1-2L given (slower in elderly & pts w/ CHF)
Check electrolytes and _____ to exclude rhabomyolysis
Admit if elderly or have comorbid condition b/c may progress to _______
IV fluids

500 mL

CPK level

heat stroke
Heat Stroke:
T > _____, anhidrosis (may be absent), and ________ (altered mental status & possible seizure)

2 kinds - signs/symptoms are identical: ________ & ________
105

CNS dysfunction (differentiates stroke from exhaustion)

exertional & nonexertional
Heat Stroke:

Exertional -
_______ pt, runner on a hot day, may not be ________

Nonexertional -
______ during a summer heat wave with no AC

Represents a failure of thermal homeostasis
sweating usually stops
TRIAD
younger

volume depleted

elderly

hot skin (often dry), high fever, neuro sx
Heat Stroke: _______
toxins
infections
thyroid storm
DKA
malignant hyperthermia
alcohol withdrawl
status epliepticus
DDX
Heat Stroke: TX
_______ (intubate if necessary)
Check labs (5)
IV fluids, lactated ringers at ____ ml/hr for elderly
measure core temp (_______)

__________:
disrobe pt completely
cooling tent (fans)
spray with tepid water
ABC/OMI

CBC, Chem 12, EKG, Glucose, CPK

250 ml/hr

rectally

Cooling Techniques
Heat Stroke: Goal
reduce core temp to _____ quickly
when temp is ___ you can stop cooling techniques to avoid overshoot
treat seizures w/ _______
admit to ICU
104

102.2

benzodiazapines
Insect Bites & Stings:
can cause ________ - usually >10 stings
N/V, HA or fever
no urticaria or bronchospasms
if a pt is allergic to beestings, 1 sting can be _______

Anaphylactic shock:
Begins in < ___ min after sting
itching eyes & skin, facial flushing, urticaria, wheezing, airway obstruction, hypotension
____ mediated reaction
toxic reaction

fatal

10 min

IgE
Insect Bites & Stings: TX
ABC/OMI
DOC: if stable give _______
0.3-0.5 ml for adult
0.01 ml/kg for child
_______ 50 mg slow IVP - blocks H1 receptors
________ if wheezing
_______ 50 mg IVPB or Tagamet - blocks H2 receptors
________ if needed for hypotension, IVF
5-20 mcg/kg/min - titrate until BP is _____
Remove stinger
Admit if anaphylaxis - some have rebound attack
Prescribe ______
Refer to allergist for _________
epinephrine SQ

Benadryl

Albuterol nebulizer

Zantac

Dopamine

100

Epi pen

immunotherapy
Spiders:
most abscesses are not spider bites - majority is ______

two bad spiders -
Black widow - _______ symptoms
Brown recluse - _______ symptoms (more common)
MRSA abscess

immediate

delayed
Spiders: Brown recluse bite
bite is _______
develops blister in _____
_____ occurs over next 3 days
can threaten digits, even limbs
may require months to heal
may need _______

TX:
local wound care, ______
_______ may help
________ effective
treat secondary infxn with antibiotics
painless

24 hrs

necrosis

plastic surgeon

tetanus shot

dapsone

hyperbaric oxygen
Spiders: Black widow bite
releases a ______
_____ bite
causes _______ & ______

TX:
ABCs, local wound care
Anti-venom very effective - _______ after test dose
_______, _______ & _______ may be helpful
neurotoxin

painful

muscle cramps & HTN

1-2 vials/30 min

pain meds, muscle relaxants & calcium
Snake bites:
______ snakes are identified by elliptical pupil & trangular head and big tail (water moccasin, rattlesnake, copperhead)

_______ snakes are identified by round pupil, round head & double row of subcandal plates in tail

red on yellow, kill a fellow
red on black, friend of jack
poisonous

nonpoisonous
Snake bites:
Envenomation is a clinical diagnosis - hallmark is ________

_______ - swelling & erythema, not systemic signs, normal labs
_______ - swelling, erythema, ecchymosis & systemic symptoms (N/V, hyopTN, tachycardia, tachypnea)
_______ - all of the above, swelling & ecchymosis are spreading rapidly, severe CNS changes, hypoTN, abnormal coag studies
swelling

minimal

moderate

severe
Snake bites: TX
ABCs
no suction cups or cuts into wound
_________ band may be helpful
_______ as directed until symptoms improve (no test dose needed)
initially 4-6 vials slow IV, up rate as tolerated over 60 min
watch out for ________ - consult surgeon
observe pit viper bite pt for ____, discharge if no evidence of envenomation after 8-12 hrs
constriction

Crofab

compartment syndrome

8 hrs
Snake bites: Coral snake bite TX
venom is a _______ - doesn't cause local injury
symptoms take ____ to develop - admit for observation for 24-48 hrs
causes death by _______
treat early even if symptoms haven't developed with ___ vials of anti-venom for coral snakes
if symptoms appear - admit to ICU
neurotoxin

12 hrs

respiratory depression

3 vials
Mosquitos Bite:
1/150 infected with West Nile
symptoms of ________ - HA, N/V, fever, anorexia
TX - _________
recommend your pts wear long pants & long sleeve shirt
______ containing insect repellants are the best
keep nails clean & short
secondary infxn staph abscess (MRSA)
encephalitis

supportive

DEET
Animal & Human Bites:
_______ are the worst, then cats then dogs
#1 animal most likely to cause rabies - _______
domestic cats & dogs unlikely to transmit rabies, rodents don't

if you ahve a person bitten by an unknown dog or cat that was not captured:
_______ immune globulin
series of rabies vaccines
give ____ if not up to date
if allergic - give tetanus immunoglobulin _____ IM + Td shot
also give the combo if pt has never received a Td shot
beware of laceration on ______ - ask specifically if they were in a fight
human bites

racoons

rabies

Td

250 units IM

knuckles
Animal & Human Bites:
with cat bites -
mainly _______ wounds
get infected quickly due to anaerobes such as _________
DOC: _________
if PCN allergic - _________ or ________

with dog bites -
abrasions, laceration, & puncture wounds
______ thoroughly
don't _______ bite wounds unless you have to (ex. face)
local wound care, _______
if extensive, consult plastics
puncture

Pasturella multicide

Augmentin

Clindamycin or Flagyl

clean

suture

antibiotics
OB emergencies less than 20 weeks / 1st trimester bleeding
Differential Diagnosis:
Spontaneous _________
________ Pregnancy
Gestational Trophoblastic Disease (neoplastic):
a. _______ Pregnancy - noninvasive
b. Choriocarcinoma - invasive
Abortion

Ectopic

Molar
1st Trimester Bleeding
Spontaneous abortion or miscarriage
*most common pregnancy complication*: 20 – 40% of pregnancies abort spontaneously

Five categories:
_______ – painless vaginal bleeding without dilatation of internal os.
________ – usually painful vaginal bleeding with dilatation of internal os but no appearance of products of conception.
________ – painful vaginal bleeding with partial protrusion of products of conception.
_______ – Painless abortion in which all products of conception pass.
_______ – Passage of products of conception does not occur for a prolonged period after fetal death (painful or painless)
Threatened

Inevitable

Incomplete

Complete

Missed
Etiology and Management of Spontaneous Abortion

Etiology
_________ abnormalities account for the majority
greater than 12% occur in women under 20 years of age and greater than 50% occur in women 45 years of age and older.

Management
threatened: if cardiac activity, 95% continue beyond 1st trimester
inevitable or incomplete: time or ______
complete: no additional treatment necessary if POC are completely expelled, do an ___
missed: can do _____ & ____ workup and then time or D&C

_______ SHOULD BE CONSIDERED FOR ANY RH NEGATIVE WOMAN HAVING A SPONTANEOUS ABORTION.
DOSAGE IS ____ OF THE IMMUNE GLOBULIN IM.
chromosomal

D & C

US

septic & DIC

RHOGAM

300 MCG
Ectopic Pregnancy
Risk Factors:
Prior PID or STD
Prior _____ pregnancy
History of pelvic surgery
_________ treatments ie.IVF
Failed tubal ligation

Ectopic pregnancy accounts for 9% of all ________.

Diagnosis:
90% have ____, usually on side of ectopic
80% have _________
80% have __________.
50% have pelvic mass on exam
HCG normal doubling time is ___ hours
_________ is less than 5 ng/ml suggestive of abnormal IUP/ectopic.
_______ – the gold standard and used in combination with quantitative HCG values

If the quantitative HCG is greater than _____ and no IUP is seen with endovaginal ultrasound … SUSPECT ECTOPIC PREGNANCY
tubal

Infertility

maternal deaths

pain

amenorrhea

vaginal bleeding

48 hrs

Progesterone

Ultrasound

2000
Ectopic Pregnancy Treatment
If very early, can give single dose of ___________
If patient is unstable, ABCs, oxygen, monitor and 2 large bore IVs. Draw blood for CBC, type and match. Stat OB/GYN consult for ________.
Consider rapid ________ in ED
Usually patient has __________.
Laparoscopy for stable patients.

AXIOM 1 - Consider ectopic pregnancy in any reproductive age female with _________
AXIOM 2 - Have a low threshold for ordering a ____ in any reproductive age female presenting for medical care.
methotrexate

laparotomy

ultrasound

hemoperitoneum

low abdominal pain

UPT
3rd Trimester Bleeding: __________
Placenta completely or partially covers the internal os of the cervix.
Placenta previa should be suspected in any third trimester patient presenting with _________, particularly bright red blood per vagina.
Incidence: 1/250 live births
Bleeding - ________ in origin.
often painless and bright red.
Major threat to the life of the mother.

Risk factors:
Previous ________
Multiparity
Advanced ________
Large placental surface (ie ____)
Placenta Previa

painless vaginal bleeding

maternal

C-section

maternal age

twins
3rd Trimester Bleeding: Placenta Previa
Management of placenta previa
3rd trimester patients presenting with vaginal bleeding initially should be evaluated with ______ prior to any speculum or bimanual examination to rule out placenta previa (ie no vaginal exams!)
Patients should be ________ after the first episode of vaginal bleeding. The goal is to get the baby to viability and ultimately lung maturity. The patient may need to be given _______ if premature and delivery is imminent.
If a patient in labor presents with vaginal bleeding and an ultrasound shows a previa, patient should be set up for __________ immediately.
Discuss risks of blood transfusion and need for _______ at time of delivery.
Delivery by C-section should be considered as soon as _________ is documented.
Increases risk of abnormal ________ (accreta, percreta and increta) with increased risk of hysterectomy
ultrasound

hospitalized

steroids

emergency C-section

hysterectomy

lung maturity

placenta
3rd Trimester Bleeding: ___________
Premature separation of a normally implanted placenta
Complicates 1% of all pregnancies.
Most common cause of intrapartum _________.
(as opposed to placenta previa where the risk is to the mother).
Causes permanent _________ impairment in 14% of surviving infants.
Recurrence risk of 5 to 16 percent.
Abruptio Placenta

fetal death

neurological
3rd Trimester Bleeding: Abruptio Placenta
Risk Factors:
HTN/PIH/Preeclampsia
Maternal _______
Multiparity
______ induced
Trauma
Rapid ________ of uterine cavity

Signs and Symptoms:
___________ in 80% of patients.
Abdominal pain
Uterine __________
Uterine tenderness
Fetal _______
Coagulopathy/maternal shock

Abruption is graded from grade 1 to grade 3 with 3 being the most severe.
Smoking

Cocaine

decompression

Painful vaginal bleeding

contractions

distress
3rd Trimester Bleeding: Abruptio Placenta
Diagnosis:
Most often made based on clinical presentation.
Labs – ___ with platelets and ___ panel (fibrinogen, PT/PTT, D-dimer and fibrin split products) and type and cross for ___ units.
Ultrasound unreliable (may not show)
Rule out placenta previa and uterine rupture.

Management:
Consider ________ management and/or ________ therapy with mild abruption and premature fetus.
Moderate to severe abruptions indicate need for _______. 48% will deliver vaginally.
Continuous fetal monitoring, augmentation with ________ & ________ may be used.
Consider ______ for maternal/fetal indications.
Correct _________
CBC

DIC

4

expectant

tocolytic

delivery

pitocin and amniotomy

C-section

coagulopathy
3rd Trimester Bleeding: __________
500 – 1000 ml of blood loss in the initial 24 hours after delivery
Incidence: 5% of all vaginal deliveries

Etiology of postpartum hemorrhage (tone, trauma, tissue and thrombin):
Uterine _______ – 70%
Genital tract ______ & _________ – 20%
Retained _________ (late PPH greater than 24 hours) – 10%
_________ – 1%
Postpartum Hemorrhage (PPH)

atony

laceration & uterine inversion

placental tissue

Coagulopathies
3rd Trimester Bleeding: PPH Risk Factors
Uterine atony is associated with:
grand _________
uterine _________
prolonged _____ with pitocin or rapid labor
chorioamnionitis
general ________
_____ therapy

Uterine inversion - DON’T ________

Genital Tract Lacerations - vaginal/cervical (After delivery, you should examine the vagina and cervix thoroughly).

Retained placental tissue:
usually presents as delayed PPH
______ delivery
abnormal placenta
cord avulsion
multiparity
overdistention
labor
anesthesia
Mg SO4

PULL ON THE CORD

pre-term
3rd Trimester Bleeding: PPH TX
Determine etiology:
If atony, ABCs with IV access, analgesics, _______ (do 1st), _____ 20-40 units per liter IV fluid wide open. May give ______ 0.2mg IM and may repeat in five minutes. May give ______ 0.25 mg IM and may repeat x1. If patient is hypertensive, give prostin instead of methergine. If hemorrhage continues, proceed to OR (ligation, pack or hysterectomy).

If genital tract laceration – repair and examine for _______.

If retained placental tissue – OR for _______ and consider antibiotics. _____ helpful in diagnosing.

If uterine inversion – call for help and go to OR; rapid replacement and may require __________ or _________. If placenta is still attached, leave attached until uterus is back in place
bimanual compressions
pitocin
methergine
prostin

hematoma

curretage
Ultrasound

nitroglycerin or magnesium sulfate
Hypertensive Disorders in Pregnancy
15% of _______(number one cause)
Significant contributor to perinatal morbidity and mortality from direct fetal affects (IUGR, oligohydramnios, stillbirth, and preterm delivery).
Can either be maternal hypertension prior to pregnancy or pregnancy induced hypertension (PIH). Remember, ________ are contraindicated in pregnancy.

___: Hypertension that develops as a consequence of pregnancy and regresses postpartum – onset after 20 wks with BP greater than _____ measured twice at least 6 hours apart.
maternal deaths

ACE inhibitors

PIH

140/90
PIH:
1. HTN without ________

2. _________ with proteinuria
a. mild (BP greater than 140/90 with proteinuria greater than ______)
b. severe (SBP greater than 160 or DBP greater than 110 with proteinuria greater than ______ and/or evidence of end organ involvement)

3. Eclampsia – proteinuria along with ________
proteinuria

Preeclampsia

300 mg/24 hrs

5 g/24 hrs

seizures
Hypertensive Disorders in Pregnancy: Signs and Symptoms

Preeclampsia:
Patients may present with _____, ______ disturbances, _____(more than just pedal edema), ______ pain, hyperreflexia, in addition to elevated BP, or ______ of at least 5 lbs./week.

Eclampsia:
Signs and symptoms of _________ plus seizures
25% may occur _______ usually within ____ days

_____ Syndrome - hematologic and hepatic involvement:
Occurs in 10% of women with preeclampsia although 10-20% of women with HELLP are ________.
headache
visual
edema
abdominal
weight gain

preeclampsia
postpartum
seven

Hellp (Hemolysis, Elevated Liver enzymes & Low Platelets)
normotensive
Hypertensive Disorders in Pregnancy

Risk factors for PIH/Preeclampsia:
_________ of PIH
_________ have higher risk
2/3 of patients are _______
_______ maternal age
multiple ________
________ conditions: HTN, DM, SLE, and renal disease

Management of PIH / Preeclampsia:
If less than 37 weeks:
mild – evaluation of maternal and fetal condition/___________, possible hospitalization
severe - ______(regardless of gestational age)
If greater than 37 weeks: _____

Seizure Prophylaxis:
__________ loading dose over 20 minutes followed by maintenance infusion of 2 g/hr

Treat Hypertension with ________ 2.5 mg initially, followed by 5-10 mg every 10 minutes IV, or ________ 20 mg IV initial bolus, which repeat boluses of 40 to 80 mg if needed to a maximum of 300 mg for BP control.

*Definitive Treatment requires delivery of the fetus*
family history
African American women
primiparas
advanced
gestations
medical

expectant management
deliver
DELIVER

Magnesium Sulfate 4 g

Hydralazine
labetalol
Other OB emergencies
1. ________ - rupture of membranes prior to the onset of labor
- may be preterm or full term
Diagnosis is confirmed by vaginal fluid with pH greater than ____ and a _____ pattern on the smear. If preterm, use ________.
Patients with suspected PROM should be admitted.

2. ________ - labor prior to 37 weeks gestation
- occurs in 10% of deliveries and is the leading cause of ________
- consult OB/GYN for admission and decision regarding _______.
- exam should be done with ________ only

3. _____ in Pregnancy - treat as non-pregnant patient if severe trauma (ie ABCDE/OMI)
- if greater than ____ with minor trauma, even without abdominal pain at time of presentation, consult OB about monitoring in L & D.
Be suspicious of ______ if abdominal pain or tenderness.
Premature Rupture of Membranes (PROM)
6.5
ferning
sterile speculum

Preterm Labor
neonatal death
tocolytics
sterile speculum

Trauma
20 wks
abruptio placenta
GYN emergencies: Pelvic Inflammatory Disease
10 to 20/1000 women of reproductive age
Up to 25% develop long-term sequelae:
______ pregnancy
infertility
chronic ______

Diagnosis:
no historical, physical or laboratory finding is sensitive and specific for diagnosis.

CDC recommended criteria:
Minimum criteria (all three)- _______, _______, & _______ tenderness

Additional criteria:
Oral temperature greater than _____
Abnormal cervical/vaginal discharge
Elevated ___
Elevated ___
Lab documentation of _____
ectopic
pelvic pain

Lower abdominal, Adnexal, & Cervical motion

38.2 C
ESR
CRP
GC/Chlam
GYN Emergencies: PID Specific Criteria
may see __________ on transvaginal sonography or other radiologic test
laparoscopic abnormalities consistent with PID
endometrial biopsy showing _________

Inpatient Treatment (CDC 2006)
Regimen A:
______ 2 g IV q 12 hours OR
______ 2 g IV q 6 hours PLUS _______ 100 mg orally or IV q 12 hrs.

Regimen B:
________ 900 mg IV q 8 hrs
________ loading dose IV or IM 2mg/kg followed by MD of 1.5mg/kg q 8 hrs.
tuboovarian abscess
endometritis

Cefotetan
Cefoxitin
Doxycycline

Clindamycin
Gentamycin
GYN Emergencies: PID

OUTPATIENT TREATMENT (CDC 2006)

Recommended Regimen A
________ 500 mg PO qd x 14 days* OR
______ 400 mg PO bid x 14 days* WITH OR WITHOUT
________ 500 mg PO bid x 14 days
Levofloxacin

Ofloxacin

Metronidazole
GYN EMERGENCIES

AXIOM: consider _______ in young female with postcoital bleeding

AXIOM: consider _________ in any postmenopausal woman with vaginal bleeding. These patients need _______ before any hormonal therapy is given.
cervical carcinoma

endometrial carcinoma

endometrial biopsy
BURNS
Death is associated with:
increased _______
increased ___
concomitant ________ injury
______ sex

UP TO 20% OF PEDIATRIC BURN INJURIES RESULT FROM _____
NEARLY 70% OF PEDIATRIC BURN INJURIES ARE DUE TO _____

RISK OF BURNS IS HIGHEST IN THE _____ YEAR OLD AGE GROUP
_____ INJURIES ARE MORE COMMON IN WORKING-AGE ADULTS
DEATH RATE IN PATIENTS OVER ___ YEARS OF AGE IS MUCH HIGHER THAN IN THE OVERALL BURN POPULATION
burn size
age
inhalation
female

CHILD ABUSE
SCALDS

18-35
FLAME
65
Calculation of BSA Rule of 9s
ADULT:
palm of hand = 1%
head/upper extremities = __% x 3 (27%)
trunk (front and back) = __% x 2 (36%)
lower extremities = __% x 2 (36%)
perineum = (1%)
Total = 100%

CHILD:
Head = __%
Trunk = __% x 2 (36%)
Each arm = __% x 2 (18%)
Each leg = __% x 2 (28%)
Perineum = 1%
Total = 101%
9
18
18

18
18
9
14
TYPES OF BURNS: MINOR BURNS (EXAMPLE – SUNBURN)
partial thickness burns less than ___ BSA in adults or less than ___ BSA in children or older adults
full-thickness burns less than __ BSA

SIGNS - ____, Painful to touch, Skin will show mild _______

TREATMENT
can be treated as outpatient
small blisters should be left alone
large blisters should be __________
topical __________ should be used to prevent infection and sepsis – the most common agent is 1% _______
over-the-counter _______
usually heal w/out further treatment

If a first degree burn covers a large portion of the body, or the victim is an infant or elderly, seek emergency medical attention
10%
5%
2%

red
swelling

drained/debrided
antibiotics
silver sulfadiazine
pain meds
TYPES OF BURNS: MODERATE BURNS
Those not meeting criteria for major or minor
Involves the first __ layers of skin

SIGNS:
deep reddening of the skin
pain, ________
_______ appearance from leaking fluid
possible loss of some skin

TREATMENT:
require ________ admission preferably to a hospital with a burn unit
after evaluation, _______ should be placed over the burns
________ should not be used until the admitting service evaluates the wound
________ are not recommended
routine ________ prophylaxis should be administered
2

blisters
glossy

inpatient
sterile drapes
topical antibiotics
empiric antibiotics
tetanus toxoid
TYPES OF BURNS: MAJOR BURNS
Partial-thickness burns greater than ___ BSA in adults and ___ BSA in children less than 10 or adults older than 50
Full-thickness burns greater than ___ BSA

Significant burns to face, eyes, ears, genitalia, hands, feet, or major joints
Concomitant _________ or _________
20%
10%
5%

smoke inhalation or major trauma
Principles of Treatment
REMEMBER THE ABCs

Be particularly careful of:
_________ - intubate early (airway)
Burning plastics/Fires – __________: 100% O2 (breathing)
Associated ______ (jumping out the window, etc.)

MAJOR LIFE THREATS
Airway (swelling and closure)
Breathing (smoke and fumes will affect oxygenation)
_______(in major burns, this is critical because patient can become seriously dehydrated & need vigorous IV fluid resuscitation)
Associated injuries (jumped out of bldg. and has C-spine injury)
_________(later complication)

COMPARTMENT SYNDROME: ________
REMEMBER ________ & ________
Laryngeal edema
Cyanide/Carbon Monoxide
injuries

Circulation
Infection

ESCHAROTOMY
ANALGESIA AND TETANUS
Further Treatment (major burn)
Emergent priorities remain airway, breathing and circulation.
High-flow _____ should be administered
________ should be done if there are signs of airway compromise
At least ____ lines should be established over unburned areas

Initial fluid resuscitation:
ADULT: ___ ml/kg times the % of BSA burned per 24 hrs. Half is given over the first 8 hrs and the remainder over the next 16 hrs.
________ is recommended

CHILD: __ ml/kg x the % of BSA + maintenance fluids.

*GOAL OF IVF IS TO OBTAIN:
Normal Sensorium
Stable Vital Signs
Stable Urinary Output
__ cc/kg/hr in children
__ cc/hr in adults
oxygen
Endotracheal intubation
2 IV

2-4 ml/kg
Lactated Ringer’s solution
3 ml/kg

2 cc/kg/hr
40 cc/hr
Burns should be immediately _______ by immersion in cold water or application of cool compress
*Do not apply ___ directly to the wound*
Intravenous ________ should be administered early and titrated to the patient’s pain
________ agents should be used as an adjuvant in pain management
________ should be administered as indicated (usually as Td 0.5 ml IM)
cooled

ice

narcotics

Anxiolytic

Tetanus
_________: IF A CIRCUMFERENTIAL BURN AND VASCULAR OR RESPIRATORY COMPROMISE

ILEUS – use _____
ELECTROLYTES – Monitor frequently (esp ____)
UGI EROSIONS – Use _____ & ______ for physical stress ulcers
PAIN CONTROL – Use ________
Not protein bound and reversible with narcan
ESCHAROTOMY

NG tube
CPK
H-2 Blocker and antacids
morphine Sulfate
_________
(about 30% blood loss)(>1500ml of blood in chest cavity)
Usually means something big is bleeding and the sooner the patient is in the OR the better
Usually caused by penetrating trauma
It can result from sever blunt trauma as well
Massive Hemothorax
ABC- this is a B&C problem:

You must still make sure A is okay 1st
B-the blood in the _______ is compressing lung tissue & therefore interfering with oxygenation and ventilation
C- the bleeding is so sever that the patient can be in _______(Class II 15-30% blood loss)
pleural space

hypovolemic (hemorrhagic) shock
Clinical Features Massive Hemothorax

___________ abnormal but beware of early shock
Normal BP but ________, cool skin, clammy
Have absence of ________ sound and/or dullness to percussion on affected side
FAST (_______________)
Vital signs

tachycardia

breath

focused assessment sonogram in trauma
Management
ABC’s
Large chest tube (#__Fr. Or larger) inserted to decompress chest and allow lung to re-expand
Simultaneously, aggressive ___ resuscitation (3:1 amount of blood loss x3) and blood transfusion (type specific or O negative if unstable)
#38Fr

IVF
Get surgeon involved early
If initial amount of blood that drains when chest tube is put in is ≥ ______ml patient will require ________ in OR or if losing blood through tube at a rate of 200ml/hr for 2-4 hours or if physiological status is declining

Beware especially of penetrating wounds to the chest between the ________ anteriorly or between the _________ posteriorly
≥ 1500 ml
thoracotomy

nipples
scapulae
_____________
Monitor blood loss with chest tube
Admit to surgery
Hemothorax
____________
Injury to lung parenchyma causing edema and bleeding in alveolar spaces
Loss of lung structure and function
Developes over 24 hours causing poor gas exchange, increased PVR, and decreased compliance
50% of patients develop _____
Watch out for ___________ in blunt chest trauma patients
Pulmonary Contusion

ARDS

subtle, gradual respiratory failure
Blunt Cardiac Injury
Formerly called ________
8-71% of patients with blunt chest trauma
Monitor for _________all patients with blunt anterior chest trauma
Overnight
myocardial contusion
arrhythmias
Traumatic Aortic Disruption
Blunt chest trauma such as car wreck
May present with _______ pain
This pain increases as the ___________
chest or upper back

BP increases
Traumatic Aortic Disruption
______ scan if stable
Consult surgery stat if +; the sooner the patient is in the OR the better
_____ die at the scene
Of those that survive to the ER/Hospital 50% will die within 24 hours if not treated promptly
CT

80-90%
Traumatic diaphragmatic
Put NG tube in before chest x-ray
Surgery consult
Usually diagnosed easier if on _____ side
left
Tracheobronchial Tree Injury
Usually die at the scene
Often overlooked or diagnosed in ER
Definitive diagnosis: ________________
bronchoscopy
Chest Pain and Cardiac Emergencies
Chest pain accounts for 5% of ER visits
________ is the #1 cause of death in adults in U.S.
Risk factors for CAR
1.Male or post menopausal female
2.Age >__
3.Smoker
4.History of _____
5.History of DM
6.History of high cholesterol
7._________(metabolic syndrome)
8.Sedentary
9.________use - Can cause MI in much younger people with CAD by vasospasm
Coronary Artery Disease

> 40
Htn
Truncal obesity
Cocaine
Typical History
Chest pain lasting longer than just a few minutes in ________area radiating to left arm or shoulder or to neck, jaw, or straight through to back, nausea, vomiting, shortness of breath and diaphoresis

Beware of ________they don’t present with typical history/symptoms
Up to_____ may be silent

________- typically worse with exertion and relieved with rest
retrosternal

elderly, women, and diabetics

1/3

Angina
DDX of chest pain
____- always consider this as the diagnosis
___- high index of suspicion
_________-tearing or shearing chest pain
__________-listen for friction rub
______- improved with GI cocktail but be careful
_______- fever, cough, sputum production
________rupture
ACS
PE
Aortic dissection
Pericarditis
GERD
Pneumonia
Esophageal
Many Patients will have _________cause of chest pain but consider the worst diagnosis and work through the differential diagnosis
Don’t go by response to GI cocktail or palpation of chest wall tenderness
PE often normal
Be concerned if
-________(pulmonary edema)
-New murmur
musculoskeletal
Crackles
ER Management
ABC/OMI/VS/EKG
Rapid within _______ of arrival or prior to arrival
_______- prior to arrival
4 baby chew or 1 adult chew
No enteric coated
10 min

Asprin and O2
ER Management -continued
_______after stat EKG
_______if chest pain not relieved with nitro
EKG is best single test in ER
Remember that a normal EKG and normal 1st set of cardiac enzymes doesn’t rule out an MI (& certainly not significant CAD)
Divide EKG into 1 of 3 categories STEMI, NSTEMI, or low risk
If evaluation does reveal Acute MI prepare patient for ________therapy
i.e. fibrinolytic therapy or PCI
Remember time is muscle
Goal is the reperfuse and limit infarct size
Nitrates
Morphine
reperfusion
ER Management -continued
Make sure patient has no contraindications prior to fibrinolytic therapy - eg. Active GI bleeding
Do quick rectal as part of evaluation
Chest x-ray to rule out widened ________(aortic dissection)
Labs CBC, PTT, BMP, Cardiac enzymes, UDS if suspect cocaine
mediastinum
Adjunctive Treatment
_____
Heparin
_____ blockers
IV nitro (especially if HTN or pulmonary edema)
________(plavix) talk with your local cardiologist about this one
__________ inhibitors (Unstable angina/non STEMI especially those undergoing percutaneous coronary intervention {PCI})
MONA
Beta
Clopidogrel
Glycoprotein
If patient becomes unstable
ACLS
Two major complications of AMI: (2)____________

Door to needle time for _________therapy 30 min.

Door to ________ time for 1° PCI 90 min.
Dysrythmia
Cardiogenic shock

fibrinolytic

balloon inflation
__________
Alcohol and drug- intoxicated person and psych patients account for majority of cases

Tissue actually freezes
Frost Bite
Frost Bite - continued
1st degree- superficial, painful
2nd degree- superficial but _____________
---No tissue loss
3rd degree- deep with violaceous or hemorrhagic blisters, skin necrosis
-no _________
4th degree- deep skin, sub q, muscle
- initially mottled, deep red or cyonotic
- eventually dry, black
- tissue loss

________blebs-superficial
________blebs- deep
with blistering, numbness

sensation

Clear
Hemorrhagic
Frost Bite - Treatment
Rapid re-warming with circulating water at________ for 10-30 min.
Never allow thawed tissue to refreeze- much more tissue damage
Usually with ________ degree (deep) frostbite, end up with delayed amputation
42° (107° F)

3rd and 4th
Hypothermia
700 people die in the U.S. each year from hypothermia

Half of those who die are older than ___

__________ are highest risk
65

Infants and elderly
Hypothermia- Causes
-Cold environment
-________use
-Sepsis
-_____dysfunction
Drug alcohol
CNS
Hypothermia- Types
Mild Hypothermia- rectal temp. _____F
Moderate Hypothemria-______°F
Severe Hypothermia- _____°F
90-95°F

86-90°F

<86°F
Hypothermia- Clinical Findings
_________(increased urine output on exposure to cold)
EKG may have ________
Rhythm may go from normal sinus, to sinus bradycardia, to atrial fib, to V fib, to asystole

NO ONE IS DEAD UNTIL THEY ARE WARM AND DEAD
Cold diuresis
osborne wave (J Wave)
Hypothermia- Management
ABC’s – CPR if in _______OR________
Active vs. Passive re-warming depending on severity
O2 and IV fluids should be _________
Once patient is warmed most rhythm disturbances will resolve
If in V fib you may try defibrillation but if no response wait until temp. is >86F before shocking again
V fib or asystole

warmed
Hypothermia- Management continued
Medications:
Give _______100mg IV (many are alcoholics)
D50 if hypoglycemic
D10 in pediatrics
_________100mg if history of adrenal problems
thiamin
Hydrocortisone
Hypothermia- Management continued
Re-warming
________(if patient stable)
-remove all wet clothes
-Provide warm blanket
-Warm up room, ETC
passive
Active
________ immersion
Radiant ______

Active core re-warming (if patient unstable)
Warmed inhaled ______
Warmed IV ________
_______(GI, peritoneal, bladder, pleural, extracorporeal)
Warm water
heat

oxygen
fluids
Lavage
TOXICOLOGY: poisoning is the _____ leading cause of death in the U.S

As detailed a history as possible:
the substance(s) and the _____
the timing
the _____ of exposure
______ in which the patient was found (ex. presence of empty pill bottle, suicide note, drug paraphernalia)

Physical Exam:
pay careful attention to ______, general appearance, skin, pupils, mucous membranes, neuro exam (esp. mental status), heart, lung and GI systems
you may be able to identify a ______ – specific clinical signs and
symptoms particular to a certain toxin
third

amount
route
environment

vital signs
toxidrome
MANAGEMENT OF THE OVERDOSE PATIENT
ABCDE AND OMI:
If patient is having trouble breathing, _____.
Be prepared to intubate if the substance on which the patient overdosed will prevent him from being able to maintain his airway.
If abnormal _____, act immediately to correct them (eg. if hypotensive, give IV fluids and/or _______ as indicated).
If altered mental status, give 100 mg ______, Narcan and D50 (unless it is known that glucose is OK)
Obtain lab studies, ____ and X-rays as indicated.
Consider _____, UPT, electrolyte levels, glucose, acetaminophen and aspirin levels, and UDS.
Give emergency therapy for ______, agitation, follow ACLS protocols and for severe metabolic anomalies consider ______.
intubate

vital signs

vasopressors

Thiamine

EKG

ABGs

seizures

dialysis
CAN A SPECIFIC TOXIDROME BE IDENTIFIED?
IF SO, TREAT FOR A SPECIFIC TOXIN
For example: Patient presenting with CNS depression, miosis, and respiratory depression is consistent with ______ toxidrome and would be treated with intubation, ventilation and/or narcan.

If no toxidrome is immediately identified, carry out general procedures for any poisoned patient to _______ and eliminate the poison
opioid

decontaminate
DECONTAMINATION THE MAINSTAY OF THERAPY
If poison is on the skin, _____ and wash the skin with copious amounts of water.

Staff that takes care of this patient should be properly _______ & ______ to prevent contamination.

If poison is in the eyes, the eyes must immediately be flushed with irrigation solution until the ___ of the eye returns to normal.

GASTRIC DECONTAMINATION - 3 METHODS:
gastric ______
______ of toxin in the gut
______ of the bowel
undress

gowned and gloved

pH

emptying

adsorption

irrigation
GASTRIC EMPTYING:
ipecac is no longer used
gastric lavage ideally within __ hour of ingestion
* other indications in addition to recent ingestion would include an agent not absorbed by charcoal such as _______ or ______ , sustained release meds or, if ingestion amount exceeds the adsorption capacity of initial activated charcoal dosing
1

lithium or iron
Contraindications to gastric emptying:
______ ingestions (ie acids or bases)
if patient is too ______ and risk of complications is high
known small amount of drug that can easily be absorbed by _______

Complications:
_______ to pharynx, esophagus, stomach, tracheal aspiration, pulmonary hemorrhage or _______ or empyema
caustic

combative

charcoal

physical damage

pneumothorax
ADSORPTION OF TOXIN IN GUT:
with activated charcoal
use in all OD except
a. ______ OD (Li, Fe)
b. simple _______(gasoline)
c. _______
d. acids or bases

Multi-dose charcoal is useful if large amount of toxin. Dose is _______. First dose can be given with cathartic such as ______
elemental
hydrocarbons
alcohols

1-1.5 gm/kg
sorbitol
WHOLE BOWEL IRRIGATION:
especially helpful for __________, drug bezoar formation and ingested packets of ______ such as drug packers with cocaine or toxins unable to be absorbed by activated charcoal

administer 2 L/hr in adults or 50-250 ml/kg/hr in pediatric patients until rectal effluent is ______
sustained release tabs

drugs

clear
Manipulation of urinary pH – _________
Weak acids can be converted to an anion and therefore:
a. be unable to be reabsorbed hence they are ______ into urine
b. be bound to _______ so the free form is not available for its effects (eg TCAs)

Agents that are useful to treat with alkalinization:
1. chlorpropramide
2. ____
3. _______
4. _____
5. formate
6. herbicides
alkalinization

excreted

proteins

TCAs

phenobarbitol

salicylates
DIAGNOSTIC IMAGING IN TOXICOLOGY
Ingestion of an unknown toxin – Visualization of the Drug (Radiopacity = CHIPES)


ANTIDEPRESSANTS (TRICYCLICS)
Cause more deaths than any other class of prescription medicine
Cause of death is from _______
Chloral Hydrate
Heavy Metals (Hg, Pb, arsenic, thallium, Zn)
Iron
Psychotropics (Phenothiazine)
Enteric Coated
Sustained Release compounds


cardiotoxicity - prolonged QRS complex
SPECIFIC TOXINS AND THEIR TREATMENTS (ANTIDOTES)

DRUG
Tylenol
Aspirin
Iron
Elavil(TCA)
Cyanide
Carbon Monoxide
TREATMENT (ABC’s + _____)

Mucomyst (N-acetylcysteine)
Alkalinization (ion trapping)
Deferoximine
Alkalinization (change protein binding)
Nitrite followed by sodium thiosulfate
Oxygen - 4 hrs. or hyperbaric – 20 min
ALCOHOLS - Antidote for all alcohols is ______ – 15 mg/kg IV then 10 mg/kg q 12 hours

Methanol – causes severe _______ + osmol gap
Ethylene Glycol – causes __________ + an osmol gap
Isopropyl Alcohol – causes no acidosis but an ______
fomepizole (Antizol)

metabolic acidosis

calcium oxylate crystals

osmole gap
_________ insecticides are the most common cause of major toxicity among all pesticides.
They bind irreversibly to and inhibit _________ in the nervous system which leads to accumulation of neurotransmitters at the nerve synapses and neuromuscular junctions.

Causes SLUDGE syndrome
Treatment: ABCs plus _______ + 2 PAM (antidote for organophosphates)
Organophosphorus

cholinesterases

S – salivation
L – lacrimation
U – urination
D – defecation
G – gastrointestinal
E - emesis

atropine
MENINGITIS - The most common symptoms are:
______
______
______
PHOTOPHOBIA
CONFUSION
DROWSINESS
NAUSEA AND/OR VOMITING

Symptoms are more difficult to identify in babies. They may include fever,
fretfulness or _______, difficulty in _______ the baby, and the baby
refusing to ____
FEVER
HEADACHE
STIFF NECK

irritability
awakening
eat
VIRAL MENINGITIS - The most common type
Rarely _____ in persons with a normal immune system.
90% of the cases are caused by enteroviruses such as _______ & _______
These viruses are more common during the _________ & ________ months.
Herpes viruses and ______ can also cause viral meningitis.
Usually the symptoms last for _____ days and the patient recovers completely
fatal

coxsackie-viruses and echoviruses

summer and fall

mumps

7 to 10
BACTERIAL MENINGITIS
Can be quite severe and may result in _______, hearing loss or learning disability.
___________ & __________ are the leading causes.
Bacterial meningitis can be treated with a number of effective antibiotics but IT IS EXTREMELY IMPORTANT TO BEGIN TREATMENT EARLY IN THE DISEASE
brain damage

Streptococcus pneumoniae and Neisseria meningitidis
MENINGITIS/DIAGNOSIS
Triad - _______,_______,_______
Other sx - N/V, ________
Hallmark of DX is _____ - get an opening pressure
CSF shows _____ (PMNs >100/mL), decreased _______, increased ________
increased ____
HA, fever, nuchal rigidity

Photophobia

LP

WBCs

Glucose

Protein

ICP
TREATMENT OF MENINGITIS

PRETERM INFANTS LESS THAN 1 MONTH OLD
_______ (Listeria) & ________

INFANTS – 1 – 3 MONTHS
Ampicillin (Listeria) + (________ or ________), also consider _______(Neisseria)

¼ YR – 50 YRS
(Cefotaxime or Ceftriaxone) + _______

OLDER THAN 50 YRS, ALCOHOLICS, OR OTHER DEBILITATING DISEASE
(Cefotaxime or Ceftriaxone) + _________ + _________

HOSPITAL ACQUIRED MENINGITIS, MENINGITIS AFTER HEAD TRAUMA OR NEUROSURGERY OR NEUTROPENIC PATIENTS
_________ (Pseudomonas) + vancomycin

IMPAIRED CELL MEDIATED IMMUNITY (at any age)
________ + ________
Ampicillin and cefotaxime

cefotaxime or ceftriaxone, also dexamethasone

Vancomycin

Vancomycin + Ampicillin

Ceftazidine

Ceftazidine + ampicillin
ASTHMA - the most common chronic disease of childhood

RISK FACTORS FOR CHILDREN
______
family history of asthma
_______ household
low-income household
race (_____, ______ & _______ descent)
Pre-term

urban

African-American, Asian and Hispanic
ASTHMA PATHOPHYSIOLOGY
a chronic inflammatory disease
the hallmark of asthma is the reduction in airway _______ caused by smooth muscle contraction, vascular congestion, bronchial wall edema, and thick secretions.

Precipitants of an acute attack include:
_________ infection
environmental _______
medications
occupational exposures to industrial chemicals, _______ & emotional stress
diameter

viral respiratory tract

pollutants

exercise
ASTHMA: CLINICAL FEATURES
_______, chest tightness, wheezing, cough

Physical exam findings of a mild asthma attack include wheezing & a prolonged _______ phase. Wheezing does not correlate with the degree of airflow obstruction.

Patients with a severe exacerbation may present in a _______ position gasping for air with audible wheezing, diaphoresis, and using ________. Other signs of severe exacerbation include tachycardia, tachypnea, hypertension, and most importantly ______.
Dyspnea

expiratory

tripod

accessory muscles

hypoxia
ASTHMA: DIAGNOSIS

_______ is used to determine the severity of airflow obstruction
________ is an important tool for both daily and ED objective evaluation of peak flow obstruction. Ideally, both peak flow and pulse ox should be obtained before and after nebulized therapy.
________ is a noninvasive means for assessing and monitoring oxygen saturation during treatment, but does not help in predicting clinical outcomes.
________ may be used to assess for hypercapnia and respiratory acidoses. These are ominous and indicate extreme airway obstruction and fatigue with possible acute respiratory failure.
A ________ should be obtained if there is suspicion of pneumothorax, pneumomediastinum, pneumonia, or other concerns such as CHF, pleural effusions or pulmonary neoplasia.
Spirometry

Peak flow meter

Pulse oximetry

Arterial blood gases

chest X-ray
ASTHMA: ED TX - ABC AND OMI
IF RESPIRATORY FAILURE OR IMPENDING RESPIRATORY ARREST, ______ IMMEDIATELY
SUPPLY _______
IVs ARE IMPORTANT FOR ADMINISTRATION OF FLUIDS AND EMERGENCY MEDICATIONS
FOR SEVERE CASES, HAVE CONTINUOUS _______
DRAW BASELINE LABS INCLUDING _____ IN SEVERE CASES
GIVE _______ and/or _______ IN EITHER 3 NEBULIZED TREATMENTS 20 MINUTES EACH OR 1 HOUR LONG CONTINUOUS TREATMENT
IV _______ 125-250 MG OR PO _______ 40-60 MG FOR CORTICOSTEROID THERAPY
REMEMBER THAT IT TAKES SEVERAL HOURS FOR THESE TO ACTUALLY BEGIN TO WORK SO GET THEM ON BOARD EARLY
CONSIDER BOLUS IV FLUIDS AND ALSO CONSIDER IV _______ EARLY IN THE COURSE OF THERAPY
ALSO CONSIDER _______ SUBCUTANEOUSLY
A NEW TREATMENT WHICH SEEMS TO BE HELPFUL IS _______
INTUBATION AND MECHANICAL VENTILATION WITH PULMONARY CONSULTATION FOR THOSE IN FAILURE OR IMPENDING RESPIRATORY ARREST
INTUBATE
100% OXYGEN
PULSE OXIMETRY
ABGs
ALBUTEROL AND/OR ATROVENT
SOLUMEDROL
PREDNISONE
MAGNESIUM
EPINEPHRINE
HELIOX
MILD INTERMITTENT ASTHMA
Symptoms __ or less times a week
Asymptomatic and normal PEF between exacerbations
Exacerbations brief (3 hrs. to a few days), intensity may vary
Nighttime symptoms 2 or less times a month
FEV1 greater than or equal to ____ predicted
PEF variability less than 20%
TX: SHORT-ACTING BRONCHODILATOR (eg _______ INHALER + SPACER) PRN
2

80%

ALBUTEROL
MILD PERSISTENT ASTHMA
Symptoms more than 2 times a week, but less than 1 time a day
Exacerbations may affect ______
Nighttime symptoms more than __ times a month
FEV1 greater than or equal to 80% predicted
PEF variability 20-30%
TX: ADD A LONG TERM CONTROL AGENT (eg. low dose inhaled _________ -Qvar)
CONSIDER LEUKOTRYINE INHIBITOR (eg. ________ -Singulair)
CONSIDER mast cell inhibitor(e. _______ -Intal) Not as potent as above 2
activity

2

beclomethasone

montelukast

cromolyn
MODERATE PERSISTENT ASTHMA
Daily symptoms and daily use of ___________
Exacerbations affect activity
Exacerbations at least 2 times a week
FEV1 greater than or equal to ___ predicted
PEF variability greater than 30%
TX: LONG TERM CONTROL:
Daily medium-dose inhaled beclomethasone, triamcinolone, _________ or ________ with spacer
Leukotriene inhibitor
CONSIDER LONG-ACTING BETA-AGONIST, ________
QUICK RELIEF:
short-acting bronchodilator as needed for symptoms
increasing use of short-acting agents on daily basis indicates a need to modify the long-term control medications
inhaled short acting beta-agonists

60%

flunisolide or fluticasone

THEOPHYLLINE
SEVERE PERSISTENT ASTHMA
CONTINUAL SYMPTOMS AND LIMITED PHYSICAL ACTIVITY
FREQUENT EXACERBATIONS & NIGHTTIME SYMPTOMS
FEV1 GREATER THAN OR EQUAL TO 60% OF PREDICTED
PEF VARIABILITY GREATER THAN 30%
TX: LONG-TERM CONTROL
Daily high-dose inhaled beclomethasone, flunisolide, triamcinolone or fluticasone
Leukotriene inhibitor
Long-acting bronchodilator
Oral _______, 1 – 2 mg/kg per day not to exceed 60 mg/day x 7 days
Continue until patient shows improvement
QUICK RELIEF:
Short-acting beta2 antagonist inhaler; _______ as needed for breakthrough SX
Evidence is lacking that _________ produce added benefits to beta2- agonists in long-term therapy, but some patients respond who cannot tolerate these
prednisone

albuterol

anticholinergics