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167 Cards in this Set
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Name the 4 steps in the examination sequence for evaluating hand injury.
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1. Observe posture at rest
2. Observe active function 3. Assess loss of sensation a. Sweat b. awareness of pain c. 2 point discrimination 4. Inspect wound in sterile, bloodless field. |
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What do you always need to rule out when a patient presents to the ED with a subungal hematoma?
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Fractured phalanx. Get an Xray.
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What is nail trephination?
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Making a hole in the nail to evacuate a large subungal hematoma.
Anesthesia usually not required |
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What is the treatment for nail avulsion?
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1. Digital block
2. Removal of nail 3. Recover with nail or sterile gauze 4. Close with suture |
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Why is assessment of hand extensor tendons so difficult?
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Function is often retained with up to 90% laceration.
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This collection of pus is often seen after trauma such as pulling a hangnail or nailbiting.
What is the treatment? |
Paronychia.
Incision and Drainage |
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What is the likely cause of chronic/occupational paronychia?
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Candida albicans
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What is the most common viral infection of the hand?
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Herpetic Whitlow
Grouped vesicles with an erythematous base |
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What is the most common cause of felon?
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(Abscess of distal phalanx fat pad)
Staph aureus |
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Name 2 signs you might see in a patient with suppurative tenosynovitis.
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1. Swelling, erythma, tenderness over tendon sheath
2. Exquisite pain on passive movement of tendon 3. Flexed posture of finger at rest 4. Symmetric swelling of finger |
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What are the 2 main general goals in fingertip injury?
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1. Maintain length and appearance
2. Maintain function |
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What is the treatment for a fingertip injury of 1cm or less, that does not involve exposed bone?
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Healing by secondary intention
Serial dressing changes |
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What is the most favorable angle for a fingertip injury to preserve length, sensation and function?
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Dorsal. (transverse and volar are worse)
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When can a fingertip injury involving the bone be trimmed and left to heal by secondary intention?
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If bone involvement is less than 0.5 cm and tissue loss is less than 1cm.
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When should you give a digital block and remove the nail in a fingertip injury?
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Partial avulsion
(no need in subungal hematoma. Trephination suffices) |
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What instructions should you give the patient for wound care/maintenance once you have repaired a nail bed injury?
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Leave dressing for 5-7 days, or until wound check.
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Name 3 reasons you should cut a ring off someone's finger right away if it is acting as a tourniquet.
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1. Decreased sensation (2 point discrimination)
2. Decreased perfusion (poor capillary refill) 3. Underlying fracture |
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What kind of imaging should you order first to look for soft tissue FB in the hand?
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Under penetrated Xray
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Define puncture wound
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wounds whose depth exceeds the diameter of visible surface injury.
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What is the most common contaminant of a puncture wound?
What if it's in the foot through an athletic shoe? |
Staph aureus
Pseudomonas |
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Who should get prophylactic abx after a puncture wound?
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High risk pt (diabetic, PVD, immunocompromised, etc)
High risk injury (mechanism, missle) |
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What is the most serious complication of puncture wounds?
Name 3 others |
Osteomyelitis
Deep tissue infection Cellulitis Localized abscess |
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What is the most important thing you can do for a patient with a complex hand injury to ensure they can get to surgery as soon as possible?
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NPO status
Then make sure tetanus is current, give prophylactic abx (ie Ancef) |
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What are 2 complications if felon is left untreated?
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1. Osteomyelitis
2. Flexor tenosynovitis |
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What is the most common contaminant of a puncture wound?
What if it's in the foot through an athletic shoe? |
Staph aureus
Pseudomonas |
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Who should get prophylactic abx after a puncture wound?
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High risk pt (diabetic, PVD, immunocompromised, etc)
High risk injury (mechanism, missle) |
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What is the most serious complication of puncture wounds?
Name 3 others |
Osteomyelitis
Deep tissue infection Cellulitis Localized abscess |
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What is the most important thing you can do for a patient with a complex hand injury to ensure they can get to surgery as soon as possible?
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NPO status
Then make sure tetanus is current, give prophylactic abx (ie cephazolin-Ancef) |
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What are 2 complications if felon is left untreated?
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1. Osteomyelitis
2. Flexor tenosynovitis |
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why is flexor tenosynovitis a surgical emergency?
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Can result in loss of finger or hand function
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While waiting for the hand surgeon to consult, what can you do for the patient with flexor tenosynovitis?
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1. Give prophylactic IV abx
2. Elevate and immobilize hand 3. Culture any drainage |
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When should you give abx after draining a cutaneous abscess?
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Associated cellulitis
At risk host Facial (danger zone) Perineal |
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What is the most common cause of skin and soft tissue infection in ERs nationwide?
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community aquired MRSA
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Name 3 abx you might use in the ER to treat CA MRSA.
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1. TMP-SMX
2. Macrolides 3. Clindamycin |
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Where do you find a pilonidal abscess?
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Along the gluteal fold, resulting from an embryonic pilonidal sinus.
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This is an infected apocrine sweat gland's terminal follicle.
Name 3 common locations. |
Hidradenitis Suppuritiva
1. Axilla 2. Groin 3. Perianal |
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Name 2 microbial species that may cause infection following a dog or cat bite.
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1. Pasteurella
2. Capnocytophaga |
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What is the usual cause of this form of cellulitis that is painful, indurated, bright red with clear borders?
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(Erysipelas)
Group A Strep |
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What are the 3 types of necrotizing infections?
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Type 1: polymicrobial, most common. Gas present
Type 2: Strep pyogenes (Group A beta-hemolytic) and MRSA. "Flesh eating". No gas Type 3: Clostridium perfringes. Gas gangrene |
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Define Hypertensive emergency
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severe HTN with acute impairment of an organ system.
manage this in minutes |
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Define Hypertensive Urgency
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Severe elevation in BP without evidence of organ damage.
manage this in days |
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Name the 4 major organ systems affected first by severe hypertension.
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1. CNS
2. CV 3. Renal 4. Gravid uterus |
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What do you suspect when there is a discrepancy between arm and leg BPs?
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AAA
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What do you suspect when there is a discrepancy between two arm BPs?
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Coarctation of the aorta (narrowing at ligamentum arteriosum)
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This hypertensive emergency results in cerebral hyperperfusion.
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Hypertensive encephalopathy
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What is the drug of choice for hypertensive emergency?
Name 3 other options |
Sodium nitroprusside (Nipride)
Labetalol Clonidine Hydralazine |
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What is the safe rate of reduction in BP in hypertensive emergency?
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No more than 25% in an hour
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This medication used for hypertensive emergency is particularly useful because it is safe in RENAL FAILURE and does not cause reflex tachycardia as BP comes down.
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Labetalol (a beta blocker)
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IV Magnesium sulfate is the first therapeutic choice to treat preeclampsia. What is the next option?
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Hydralazine
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How long must the brain be hypoperfused in order to cause syncope?
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3-5 seconds
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Name 3 noncardiac causes of syncope.
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1. orthostatic
2. situation 3. reflex-mediated (emotional, vasovagal) 4. ectopic pregnancy 5. Psychiatric 6. Neurologic |
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What is the most common cardiac structural cause of syncope?
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Aortic stenosis
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What is the most reliable information you can get from the patient to determine if an episode was a seizure or syncope?
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How the pt felt afterward.
-confusion post-ictal -no confusion post-syncope |
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At what age is it safe to start giving a child small, smooth food items, as they are no longer likely to aspirate them?
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5 yo
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Where is the most common location for a FB aspirate to settle?
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Right mainstem bronchus
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If you hear
1. Stridor 2. Wheezing where is the obstruction? |
1. Upper airway
2. Bronchial |
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Name 3 imaging studies you might order to investigate a FB obstruction.
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1. Xray (inspiratory and expiratory views)
-can add fluoroscopy, live swallow study 2. Laryngoscopy 3. Bronchoscopy |
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Once you have identified an obstructing FB in the airway, what tool should you grab to get it out?
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Magill forceps
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What is the average age of the pt with epiglottitis?
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45. (Strep pyogenes or Staph aureus)
No longer pediatric b/c of widespread Hib vaccine. |
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This patient classically presents sitting in the tripod position, is drooling and febrile, and looks toxic. He isn't talking, and the family reports he won't eat or drink anything because his throat hurts so bad. What is the dx? What other sign can you elicit on physical exam to reinforce your dx?
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Epiglottitis
Also extreme hyoid motion tenderness |
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What sign is classically seen on lateral Xray in a pt with epiglottitis?
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Thumbprint sign
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What can you do for the pt with severe epiglottitis while you wait for the OR?
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1. Give oxygen, racemic epinephrine, helox nebulizer
2. abx 3. Delay intubation, the patient will need endotracheal intubation in the OR. |
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What is the #1 cause of stridor in pediatric patients?
What is the cause? |
Croup
Viral (parainfluenza) |
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Name 3 signs you might observe in a pt with croup.
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1. Nasal flaring
2. Sternal Retractions 3. Tripoding 4. Cyanosis 5. Tachypnea |
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What is the treatment for croup?
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1. Dexamethasone
2. Oxygen (or helox, racemic epi if severe) 3. Croup tent May need to intubate if it's really bad. |
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Define ludwig's angina
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An infection of the submandibular region and floor of mouth leading to cellulitis. The tongue becomes elevated and posteriorly displaced.
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What is the most common cause of ludwig's angina?
How do you treat this? |
Abscess of lower molar (ie following dental extraction)
Aggressive abx, abscess drainage, ENT consult, ICU admission |
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What is the most common cause of angioedema presenting to the ER?
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Drug induced
1. ACEI 2. Beta-lactams 3. Sulfonamides |
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Name 3 things you can do for the pt with angioedema.
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1. IV corticosteroids and antihistamines
2. Epinephrine (watch out for CV risk factors) 3. FFP (maybe if ACEI, definitely if inherited type angioedema) 4. Maintain airway, orotracheal preferred. |
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What is the classic triad of sxs for asthma?
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1. Wheeze
2. Cough 3. Dyspnea |
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What value for pulse ox indicates severe asthma?
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<91%
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How do you determine whether to give oral steroids to an asthmatic in the ER?
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Peak flow is <70% expected
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If the asthmatic in the ER is starting to become fatigued from the work of breathing, what should you do?
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Mechanical ventilation. Fatigue puts the pt over the edge to respiratory failure.
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Define chronic bronchitis
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Chronic productive cough for at least 3 mo in at least 2 consecutive years.
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Name 3 exacerbators that could land a COPD pt in the ER.
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1. Noncompliance with meds/tx
2. Environmental exposure (ie smoking) 3. Increased bronchospasm/inflammation 4. Infection 5. CV deterioration |
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Why is pCO2 not considered abnormal until it is above 50 (nl 35-45) in a COPD pt?
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COPD pts have a baseline hypercarbia because of chronic lung obstruction. Have altered body chemistry
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Name 3 findings you might expect on EKG in a COPD pt.
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1. Right axis deviation
2. RAE 3. Ischemic changes 4. MAT |
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Name 3 common causes of PN in a COPD pt.
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1. Pneumococcus
2. M Cat 3. H flu |
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You can help a COPD pt breath by using a CPAP or BiPAP, but what must you remember to do first? And if this isn't possible?
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Aggressive suction
If positive pressure breathing isn't an option, pt must be intubated. |
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What is the most severe manifestation of CHF?
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Acute pulmonary edema
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Describe the 4 categories of the New York Heart Association's functional classification of CHF.
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I Not limited by nl activity
II Ordinary activity results in sxs such as dyspnea, fatigue III Marked limitation in nl activity IV Sxs occur at rest or minimal activity |
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Describe CHF type in terms of preload and afterload.
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Systolic failure- afterload sensitive
Diastolic failure- preload sensitive |
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What is the best physical exam finding that indicates CHF?
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S3 "kentucky"
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Name a noncompliance reason for CHF in the ER
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1. Med noncompliance
2. Excess intake of water and/or sodium |
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Name a cardiac cause of CHF in the ER
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1. New Arrhythmia, ie Afib
2. Acute coronary syndrome |
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Name an iatrogenic cause of CHF in the ER.
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1. Inappropriate therapy reduction
2. Use of BB, CCB, NSAIDS 3. Antiarrhythmic agents (within 48 hours) |
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Name 3 noncardiac reasons a pt might present with CHF in the ER.
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1. PE
2. Systemic infection 3. High output states |
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Why might a noncompliant pt with ESRF present to the ER with CHF?
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Volume overload from missed dialysis
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What numerical BNP correlates to definite heart failue?
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>250
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What is the most effective, fastest acting way to reduce both preload and afterload in a pt with CHF in the ER?
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Nitrates
(But watch out for recent sildenafil use, AS, tamponade) |
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What is your second line therapy for treating CHF in the ER?
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ACEI
-enalapril IV -captopril SL |
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This therapy is important, but 3rd line tx for CHF in the ED.
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Loop diuretic
-furosemide, bumetanide (remember delayed effect, will not see diuresis for 20-90 min) |
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How might CPAP or BiPAP help a pt in CHF in the ER?
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1. Reduced venous return (preload)
2. Recruits alveoli 3. Decreased work of breathing |
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what are some contraindications to beta blockade in the pt with chest pain in the ER?
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1. HR<55
2. Systolic BP <90 3. Rales above lower 1/3 of lung fields 4. Advanced AV block 5. Hx of asthma |
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When someone presents to the ER with chest pain, you have to think about these 7 life threatening causes.
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1. MI/angina
2. Esophageal rupture 3. Ao dissection 4. PE 5. Spontaneous PTX 6. Pneumomediastinum 7. Pericarditis/Tamponade |
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Name the 7 cardiac risk factors you need to ask about when evaluating chest pain in the ER?
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1. Fam hx
2. Hyperlipidemia 3. HTN 4. CAD 5. DM 6. Smoking 7. Cocaine use |
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If a pt presents to the ER with atypical chest pain and you obtain a negative thallium stress test, can you safely discharge the pt?
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Yes.
There is a very low incidence of subsequent cardiac event. |
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What is the mortality rate if you miss an MI and send a pt home from the ER?
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26%
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Name 4 things to look for on EKG when evaluating a pt for chest pain in the ER.
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1. ST elevation (transmural infarction indicated)
2. ST depression 3. Q waves 4. Inverted T waves |
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What 3 cardiac enzymes should you order? When should they be repeated?
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1. Troponin
2. CKMB 3. Myoglobin q 3-6 hours |
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Where do you look for the infarction on EKG?
1. Lateral wall 2. Inferior wall 3. Anterior wall |
1. I and avL, V5-V6
2. II, III, and avF 3. V1-V4 |
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What is the first thing you should do when you note hypotension in a pt with suspected MI?
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Give IVF, maximize preload.
Possible RV infarction, not enough blood is getting around to tissues. |
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Why might a pt with suspected MI present with bradycardia?
What other constitutional sxs do you expect? |
Vagal stimulation slows HR.
Nausea and vomiting, also mediated by vagus nerve. |
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This is the most deadly kind of MI, and thrombolytics are not effective to treat it.
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LAD obstruction, anterior wall MI
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A pt with suspected MI presents tachycardic and in CHF due to a failing LV. What can you give this patient for their biggest problem right now before you can get the cath lab ready?
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Pt is in cardiogenic shock.
Give dobutamine to increase contractility and get more blood out to tissues. Tachycardia will get worse. |
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What is the last EKG change to develop after an acute MI?
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Inverted T waves
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Name the 2 main choices for antithrombin therapy.
How do you reverse them if a bleeding complication occurs? |
1. Heparin
2. LMWH (lovenox) Protamine |
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Name 3 antiplatelet agents useful in treating MI.
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1. ASA
2. Abciximab (reopro) IV, useful if pt is going for PCI 3. Clopidogrel |
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When do thrombolytics used to treat MI have maximum effect? What must you see on EKG before administering t-PA?
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Within the first hour of CP
ST elevation or new LBBB |
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What is the door-to-balloon time for PCI according to the AHA?
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90 minutes
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This pt classically presents with tearing chest pain that radiates to the back and is so severe the pt is writhing on the cart.
What other physical exam finding is significant to support your dx? |
Aortic dissection
Neurologic sxs: paraplegia (limb ischemia), CVA, paresis, HYPERTENSION |
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How can you quickly distinguish AAA from aortic dissection?
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AAA-hypotension, blood leaking into abdomen
Ao dissection-hypertension |
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Name 4 risk factors for PE
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1. Fam hx, or prior PE
2. OCP use or pregnancy 3. Period of immobilization 4. Thrombophlebitis, smoking |
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Name 2 lab values that will be abnormal in PE most of the time.
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1. ABGs- pO2<80%
2. Widened A-a gradient 3. D-dimer |
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What is the most frequent abnormal CXR finding in PE?
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(mostly normal)
Atelectasis with elevated hemidiaphragm |
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When should you give thrombolytics to treat a PE?
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Only if the pt is hemodynamically unstable, or massive PE.
Otherwise anticoagulation is the tx. |
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What does Hamman's crunch indicate?
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Pneumomediastinum palpable along chest wall, neck.
Think about esophageal rupture |
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This cause of chest pain is classically aggravated by lying supine and relieved by tripoding.
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Pericarditis
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What is the most common physical finding in pericarditis?
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Pericardial friction rub.
(fever may be present) (JVD may be present if effusion is large enough) |
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What will you see on EKG with pericarditis?
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1. Diffuse ST elevation in all leads
2. PR segment depression 3. Electrical alternans (as heart swings back and forth in chest wall) (no reciprocal changes!) |
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What are the 2 most common endocrine causes of altered behavior?
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1. Hypoglycemia
2. Thyroid disease |
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What does AEIOU TIPS help you remember?
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Reasons for altered behavior in the ER
A- alcohol and drugs E- endocrine and electrolyte I- insulin O- oxygenation U- uremia (renal failure) T- trauma (head injury) I- infection (meningitis) P- psychiatric S- stroke, seizure, shock |
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Name 3 reasons for hypothermia plus AMS
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1. Hypothyroid
2. Hypoglycemia 3. Sepsis |
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Name 3 reasons for fever plus AMS.
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1. Thyrotoxicosis
2. Sepsis 3. Meningitis 4. Drug-induced (ecstasy) |
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Name 2 toxicologic reasons for pinpoint pupils
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1. Narcotics
2. Organophosphates |
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Name 2 reasons for dilated pupils
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1. Stimulants
2. Anticholinergics 3. Withdrawal from sedatives |
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Name the innervation:
1. Patellar reflex 2. Biceps 3. Triceps 4. Achilles |
1. L3, L4
2. C5, C6 3. C7, C8 4. S1, S2 |
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Repeating 3 objects immediately after showing them is a cognitive test of what?
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Registration
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Define delerium
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Alteration in consciousness
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Define dementia
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A problem in the brain that makes it hard to learn, remember and communicate.
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Name 3 causes of reversible dementia.
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1. Hypothyroidism
2. Chronic drug intoxication 3. Vitamin deficiency (B12, folate) 4. MDD 5. Subdural hematoma |
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How can you chemically treat acute psychosis/agitation in the ER?
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Haldol 5mg IV
Lorazepam 2mg IV |
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Fever, muscle rigidity and AMS 5 days after beginning tx with Haldol should raise suspicion for what?
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Neuroleptic Malignant Syndrome
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What are the features of NMS (FEVER) and how do you treat it?
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F- fever
E- encephalopathy (AMS) V- vitals unstable (Autonomic instability) E- Elevated enzymes (CPK, leukocytosis, transaminitis) R- rigid muscles Antipyretics don't work, physically cool the pt. Stop neuroleptic, give lorazepam for muscle rigidity, aggressive hydration to prevent renal failure, consider a dopamine AGONIST |
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Serotonin Syndrome looks just like NMS, with what exception?
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Normal lab values
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What is the mean arterial pressure?
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1/3(SBP-DBP)+DBP
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Name 3 signs/symptoms of hypertensive encephalopathy
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Loss of integrity of blood brain barrier.
1. N/V 2. AMS, confusion, drowsiness, seizures 3. HA Requires immediate BP reduction by 20-25%. Use sodium nitroprusside first line 0.3mcg/kg/min. Can titrate up to max of 10mcg/kg/min drip. Second line may be labetalol, IV nitroglycerin |
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List some pros and cons of using labetalol for hypertensive urgency
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Pros: Slow, steady decrease in BP. Onset of action within 5-10 minutes. Safe in renal failure (metabolized in the liver).
Cons: Nonselective beta blocker, has alpha blocking activity to lower pressures in the periphery. Caution in patients with asthma, COPD, may cause bronchospasm Dose: 20mg IV load, then 2mg/min drip 200mg PO Total dose max is 300mg IV |
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List some pros and cons of using clonidine for hypertensive urgency
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a central acting alpha agonist that works to decrease amount of circulating catecholamines
Pros: onset 30-60 minutes, slows HR, causes mild sedation Cons: may cause rebound hypertension Dose: 0.1 or 0.2mg PO X1, may repeat Q 1hour until max of 0.7mg. |
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List some pros and cons of using hydralazine for hypertensive urgency
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Pros: direct arteriolar dilator, works in 10 minutes. a good choice in pregnancy
Cons: may cause reflex tachycardia. Risk of hypotension in half the population who are "slow acetylators" Dose: 10-20mg IV |
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The first line agent for HTN emergency is Nipride. List some pros and cons
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Pros: Dilates arteries AND veins, reducing both afterload and preload, resulting in decreased myocardial oxygen demand. Fast acting, within 1-2 minutes, metabolized in 3-4, so needs to be on drip.
Cons: Cannot be used in pregnancy because is crosses the placenta Dose: 0.3mcg/kg/min, titrated up to max of 10mcg/kg/min |
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IV Nicardipine may be used as a second line agent for inpatient hypertension, but shows most promise in what area?
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Sub arachnoid hemorrhage
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Nifedipine, a dihydropyridine CCB used to be one of the most frequently used medications for hypertensive urgency/emergency in the ER. Why is it no longer considered an option?
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Was never FDA approved for short-acting treatment. Carries risk of serious adverse reactions like CVA, ACS.
Contraindicated for use to treat HTN, angina or MI. |
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In what order to cardiac enzymes rise?
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1. myoglobin after 1-2 hours
2. CKMB and troponin next |
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List 2 post-MI serious mechanical complications that may occur
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1. Papillary muscle rupture, acute mitral regurgitation and CHF
2. Free wall rupture of ventricle, then tamponade |
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Why might a patient with aortic dissection present with paraplegia?
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Spinal cord ischemia from hypotension
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Name 3 reasons other than PE to have elevated D-dimer
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1. Cancer
2. Infection 3. Pregnancy 4. CHF |
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When can PTX be managed conservatively with oxygen
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Small: <20%
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What is the treatment acutely for tension PTX?
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Needle aspiration/decompression followed by tube thoracostomy
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Why is the esophagus more prone to rupture than the rest of the GI tract?
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Only place that does not contain a serosa layer
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According to the San Francisco Syncope rules, when should a patient be admitted for further workup?
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1. Hx of CHF
2. Abnormal EKG 3. Dyspnea 4. Hct <30 5. Hypotension |
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Choose an IV antibiotic for skin/soft tissue infections.
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Ancef (
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What should you do with the distal end of an amputation until it can be surgically reattatched?
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Keep it on wet ice
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Why must a rectal exam always be performed when draining a perianal abscess?
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Must assess for anorectal involvement
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Give 3 examples of skin/soft tissue antibiotic coverage for MRSA
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1. Bactrim DS
2. Clindamycin 3. Macrolides (Azith, Erythromycin) 4. Linezolid |
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Directions for follow up after abscess I&D?
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Remove packing in 2 days/48 hours.
Replace packing if still draining. |
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Describe cellulitic skin
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Erythematous, tender, warm, swollen.
Check for regional lymphadenopathy. |
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Give 3 abx options for skin/soft tissue infection where MRSA is not a suspected source.
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1. Cephalexin (or IV Ancef (cefazolin))
2. Macrolide 3. Dicloxacillin (or IV nafcillin) 4. 2nd gen FQ |
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What organisms should you cover in human bites when choosing abx?
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Staph
Strep Eikenella Anaerobes Use Augmentin or Clinda + Bactrim |
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What is the typical bacteria that causes erysipelas?
What abx? |
Group A strep
PCN or erythromycin for allergy |
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What organism should you consider in the patient with cellulitis and hx of exposure to seawater?
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Vibrio vulnificus- a GNR
Can also be contracted by consuming shellfish |
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What organism should you consider in the patient with cellulitis and hx of exposure to freshwater?
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Aeromonas hydrophila- a GNB
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Name 3 things in your differential if you see vertical nystagmus?
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1. Wernicke's encephalopathy
2. Brainstem legion 3. congenital |
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What are you testing when doing the anterior drawer and talar tilt tests at the ankle?
Squeeze test? |
Integrity of ATFL
Integrity of CFL If squeezing tib and fib together at mid calf causes ankle pain, suspect syndesmosis injury |
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List some risk factors for suicide
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1. Male gender
2. Age >55 3. Concurrent medical illness 4. Social isolation 5. Fam hx 6. White race |
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Define schizophrenia
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Psychotic syndrome present for at least 6 months, with at least 1 month of active symptoms present most of the time.
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What is dystonia?
Dyskinesia? |
Dystonia: sustained muscle contractions cause twisting and repetitive movements or abnormal postures
Dyskinesia: involuntary movement |
