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266 Cards in this Set
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Describe the cellular malfunction that occurs in shock.
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Oxygen consuption exceeds delivery from bloodstream. Ischemia results, and cells start metabolizing anaerobically, producing lactic acid byproducts. Inflammatory mediators and free radicals accumulate
Acidosis plus hypotension plus cell death |
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Give 3 examples of obstructive shock
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1. Massive PE
2. Tension PTX 3. Cardiac tamponade 4. Aortic stenosis 5. Air embolism |
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What is the most common type of distributive shock?
Name the 3 others. |
1. Septic
2. Anaphylaxis 3. Drugs/Poisoining 4. Neurogenic |
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Name 2 conditions in which you would see pulsus paradoxus.
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(change in pulse strength with respirations:weaker with inhalation)
1. Asthma 2. Cardiac tamponade |
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What numbers change in positive orthostatic hypertension?
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SBP drops >20
HR increases >30 |
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Kussmaul's sign
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paradoxical swelling of neck veins with inspiration
1. right ventricular dysfunction 2. impaired venous return 3. Tension PTX 4. Massive PE |
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Cullen's sign
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periumbilical ecchymosis
1. ectopic pregnancy 2. hemorrhagic pancreatitis 3. ruptured spleen 4. leaking AAA |
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Grey-Turner's sign
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flank ecchymosis
1. hemorrhagic pancreatitis 2. leaking AAA |
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What murmur do you expect to hear with acute papillary muscle rupture?
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Acute Mitral regurg.
Systolic murmur radiating to axilla |
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Name 2 reasons to check a quick bedside glucose in a suspected shock patient?
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1. AMS
2. Children (20% of critically ill children were hypoglycemic) |
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Westermark sign
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pulmonary oligemia
vasoconstriction distal to embolus, vasodilation proximal |
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Hampton's hump
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wedge shaped consolidation
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What is a normal urine output?
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0.5-1cc/kg/hr
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What are the ABCDEs of managing shock?
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Airway
Breathing Circulation Disability (ie spinal cord injury) Expose (undress and inspect pt) |
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How much fluid should you start for resuscitation in and adult? Child?
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1-2L bolus
20cc/kg bolus continually monitor for response |
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What is the 3:1 rule when using LR to replace fluid loss?
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Only 30% of LR stays intravascular. Need to replace 3X the volume of blood lost.
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What should you do if your attempts at fluid resuscitation do not improve your patient in shock?
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consider ongoing/severe blood loss
order angiography or immediate surgical intervention |
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At what H/H should you consider blood transfusion?
How much will one unit improve the numbers? |
Hgb<10
Hct<30 1 unit of blood raises Hgb by 1, Hct by 3 |
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How much of the left ventricle is infarcted if the pt is in cardiogenic shock?
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>40%
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Name 3 medications commonly given for MI that will make hypotensive cardiogenic shock worse?
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1. MSO4
2. NTG 3. Beta Blockers |
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Compare and contrast dopamine and dobutamine in the context of cardiogenic shock.
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Dobutamine- improves contractility and diastolic coronary blood flow without huge increase in HR. Use for SBP >100
Dopamine-can produce a profound increase in HR and increased myocardial oxygen demand. Use the lowest dose possible! Use for SBP 70-100 |
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Electrical alternans on EKG points to what cardiac cause?
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Pericardial tamponade
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What is a good empiric abx therapy for septic shock in the ER?
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Ceftriaxone plus gentamicin
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What can you give to increase SVR in the patient with persistent septic (distributive) shock after fluids fail to improve hypotension?
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Vasopressors
-dopamine -norepinephrine (not dobutamine, which is cardiac specific) |
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Name the 3 most common causes of anaphylactic shock
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1. Abx
2. Radiocontrast agents 3. Hymenoptera stings |
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What can you give for anaphylaxis besides epinephrine?
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Antihistamines
1. diphenhydramine 2. Ranitidine Corticosteroids Albuterol Glucagon (if pt is on BB) |
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What is the neurologic finding in neurogenic shock?
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Unapposed vagal tone from disrupted sympathetic outflow. Acute.
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What physical exam findings distinguish neurogenic shock from the others?
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Skin is warm and dry (may need dopamine)
Bradycardia (may need atropine) |
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What can you do quickly to support the pregnant patient in shock?
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Place mother in left lateral decubitus position, to take pressure off of IVC, increase return to heart.
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How long does the maturation stage of wound healing last?
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The scar changes from 24 days up to 1 year after injury
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Name the first 3 stages of wound healing.
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1. Inflammatory 0-3 days
2. Destructive, epithelialization 2-5 days 3. Proliferative, granulation 3-24 days |
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What factor has the most negative effect on wound healing in general?
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INFECTION
also lack of blood supply, peripheral location |
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What local anesthetic should you use if you want the fastest numbing action?
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Lidocaine (onset almost immediate,lasts 1-2 hours)
Bupivicaine (Marcaine)(onset 10 min, lasts 6-8hrs) |
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Name the areas where adding epinephrine to local anesthetics to control bleeding is contraindicated.
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1. Fingers
2. Toes 3. Ears 4. Penis |
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What is the maximum adult dose of lidocaine (Xylocaine)?
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30cc of 1% lidocaine sol.
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Name 3 ways to decrease the pain of injecting a local anesthetic like lidocaine.
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1. Inject slowly
2. Warm lidocaine 3. Mix in some bicarb to decrease burning sensation |
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If a pt is allergic to lidocaine, what can you use instead?
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An esther formulation anesthetic, like procaine or tetracaine.
If the allergic agent is unknown, can use dilute diphenhydramine, though it hurts to inject and doesn't work as well. |
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What should you use to irrigate a wound?
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Normal saline medium pressure is least toxic to tissue
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Name 2 kinds of absorbable (internal) sutures.
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Vicryl
Chromic |
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What is the maximum adult dose of lidocaine (Xylocaine)?
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30cc of 1% lidocaine sol.
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Name 3 ways to decrease the pain of injecting a local anesthetic like lidocaine.
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1. Inject slowly
2. Warm lidocaine 3. Mix in some bicarb to decrease burning sensation |
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If a pt is allergic to lidocaine, what can you use instead?
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An esther formulation anesthetic, like procaine or tetracaine.
If the allergic agent is unknown, can use dilute diphenhydramine, though it hurts to inject and doesn't work as well. |
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What should you use to irrigate a wound?
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Normal saline medium pressure is least toxic to tissue
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Name 2 kinds of absorbable (internal) sutures.
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Vicryl
Chromic |
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Name 3 types of non-absorbable (external) sutures
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1. Nylon
2. Prolene 3. silk-easy knot tying but highest tissue reactivity |
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When would you consider staples for wound closure?
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Straight lesions in areas of low tension (scalp, knee)
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How do you suture an ear injury?
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Never suture cartilage. Align the cartilage and suture over it.
Drain perichondral hemorrhage and apply pressure dressing. |
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What is the role of deep sutures?
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Reduce wound tension
Close dead spaces where fluid can collect Contained fully in dermis |
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What should you do to treat a possible rabies exposure?
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HRIG-rabies immune globulin
HDCV-active immunity (given at 0,3,7,14,28 days) |
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What is the rule of nines?
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Documents percentage of body surface involved in burn.
Head-9% Arm and hand-9% Anterior trunk (bilat)-18% |
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What is the "cheater's" way to estimate total body surface area for burns?
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The surface of your palm is about 1%
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What degree burn is sunburn?
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1st degree. Epidermal involvement only. no blisters, erythema blanches to pressure
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If you see blisters, what is the most likely degree of burn?
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2nd degree. "Superficial partial thickness" Epidermal and dermal involvement with sparing of follicles and sweat glands.
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Define a deep partial thickness burn.
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Deep dermis is involved, can be difficult to distinguish from full thickness burn. Skin appears waxy and white with red elements. Will likely scar.
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What do you suspect when a pt presents to the ER with a severe burn that is painless?
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Third degree burn, full thickness, all the way down to subcutaneous fat. Skin is pale, painless and leathery. Will not heal spontaneously unless extremely small. Need grafting.
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What is a fourth degree burn?
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So deep it involves muscle, tendon and bone. Potentially life threatening, worry about rhabdomyolysis, renal failure, hypovolemia, sepsis.
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List 3 signs/sxs that indicate smoke inhalation injury has occured?
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1. Singed nasal hairs
2. Carbonaceous sputum 3. Cough/stridor 4. Lacrimation |
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What is the Parkland formula?
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Calculates fluid resuscitation needs after burn. Give LR from the TIME OF INJURY. Half over first 8 hours, the rest over the next 16
4mL x kg x %TBSA |
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When would you apply cool compress for a burn injury?
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ASAP after burn. can reduce thickness of skin damage if applied within an hour of injury.
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When would silver sulfadiazine (silvadene) be contraindicated in burn care?
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Sulfa allergy
Pregnancy Facial burn |
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How bad is the burn if you are considering admission to burn center for treatment?
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Partial thickness >15% in adults, 10% kids
Full thickness >2% Burns involving face, hands, feet, perineum Circumferential burns |
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What should you do if your pt has not been vaccinated for HepB, and has just been blood exposed?
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HBIG (immune globulin)
initiate HepB vaccination series |
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What temperature defines fever in the
1. 2mo child 2. >2mo child? |
1. 38C (100.4)
2. 39C (102.2) |
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Why do we take fever in the neonate so seriously?
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Inability to combat infection, bloodborne disease due to immaturity of reticuloendothelial system
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When do we give the first round of immunizations to children?
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2 months (HepB can be started at birth)
Until vaccinations are started, children are especially vulnerable. |
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What vaccines are recommended to start at 2 mo?
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1. Rotavirus (1/3)
2. DTaP (1/5) 3. Hib (1/4) 4. PCV (1/4) (prevnar/pneumovax) 5. IPV (1/2) 6. HepB (1/3) if not already started at birth |
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It makes sense not to give a live, attenuated vaccine to children under the age of 12 mo because of a developing immune system. What live vaccines are started at 1 year of age?
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1. Varicella (1/1 if under 12, 1/2 if older than 13)
2. MMR (1/2) |
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You find positive blood cultures in a well appearing child with a fever of 38.5C. You cannot find any focus of infection despite exhaustive search. What might be the diagnosis and how do you treat?
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Occult bacteremia-usually transient and resolves without abx, however 1-3% chance of developing SBI.
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When should you admit a child with a fever for further observation/evaluation?
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Child is ill appearing
Child is under 36mo requires full sepsis workup and admission |
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Quickly dose an anitpyretic for a 20kg child.
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1. APAP: 10-15mg/kg q 4hr. (may give 30mg load in ER). =200-300mg q 4hr.
2. Ibuprofen: 5-10mg/kg q 6hr. =100-200mg q 6hr. |
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Always get a birth history when evaluating a febrile child under 2 years of age. Name 3 risk factors for neonatal sepsis.
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1. Premature rupture of membranes
2. Low birth weight 3. Prematurity/Resuscitation at birth |
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What is paradoxical irritability, and what could it indicate?
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Infant cries when handled, is quiet when left alone.
Could be a sign of nuchal rigidity, meningitis. |
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Why is evaluating the child aged 0-4 weeks old so difficult?
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Physical exam unreliable
Very sick child may appear well Fever may be only sign of SBI Finding a minor focus of infection does not r/o SBI |
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You are seeing a 3 week old infant in the ER with a fever of 39C (102.2), and admit her for IV abx (mandated for 0-4 wks old). What 3 organisms are the most likely cause of her infection?
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1. Listeria
2. E. coli 3. Group B Strep |
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It is no longer mandated to admit a febrile child aged 4-8 wks. After a FULL WORKUP for sepsis, what criteria can you use to decide whether to discharge the pt?
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Rochester Criteria. All must be ok:
1. Full term, well appearing infant with no medical problems, no previous abx treatment. 2. WBC btwn 5-15,000 3. No WBCs on urinalysis or lumbar puncture 4. Nl CSF gram stain 5. Nl CXR 6. Reliable caregivers and follow-up. |
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What are the 2 most likely organisms to cause fever in the 4-8 week old child?
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1. Strep pneumoniae
2. N. meningitidis |
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Give a good empiric abx therapy to cover sepsis in
1. 0-4 wk old 2. 4-8 wk old 3. 2-36 mo old |
1. Amp/ceftriaxone or Amp/Gent
2. Ceftriaxone (plus Amp if need to cover for Listeria) 3. Ceftriaxone plus Vancomycin |
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Miosis
Mydriasis |
pinpoint pupils
dilated pupils |
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You do a bedside accucheck glucose level on a pt that comes in to the ER with AMS. What should you do if it comes back <60?
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Give 2mL/kg D50W IV
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A 100mg IV dose of thiamine is given to help Wernicke's encephalopathy when the pt has evidence of long term alcohol abuse or malnutrition and what other symptom?
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Any of the following:
Acute confusion Decreased LOC Ataxia Opthalmoplegia Memory disturbance Hypothermia with hypotension DTs |
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Name a few drugs that cause QT prolongation
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Azithromycin
FQ TCAs Amiodarone Antipsychotics |
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What does decontamination of the poisoned patient refer to?
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Eye and skin contamination
and Gastric emptying |
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Give an example of a substance the pt might be contaminated with that could be detrimental to the entire ER staff?
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Pesticides
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How long should you irrigate the eyes after chemical burn?
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2L NS immediately, then check pH.
If alkali burn (worst and deepest), irrigate for 1-2 hours, until pH returns to normal (7) |
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Name the most serious and most common alkali contamination in the eyes.
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Most serious- ammonia
Most common- lime |
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what is the average amount of fluid used for gastric lavage?
How much of the toxic substance can be removed? |
2-3L
35-65% |
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Gastric lavage is only indicated in select situations. Name the indications
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1. Very recent ingestion of potentially lethal substance (within 1 hour)
2. Lethal dose is not absorbed by charcoal |
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Name 2 substances that do not bind activated charcoal after ingestion.
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Lithium
Iron |
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What is a clear indication for activated charcoal administration?
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Ingestion of any drug know to adsorb to the charcoal
or After unknown ingestion with protected airway |
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Name 2 cathartics you would use to DECREASE TRANSIT TIME THROUGH THE GUT
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Sorbitol
Magnesium citrate |
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Name 3 contraindications to using a cathartic to minimize absorption of a toxic substance.
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1. Ingestion of substance causes diarrhea
2. Children <5yo 3. Intestinal obstruction 4. Ingestion of caustic material 5. Renal dysfunction |
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What substance is used to do a whole bowel irrigation, and why doesn't it cause severe electrolyte imbalance?
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Polyethylene glycol (GoLytely)
is osmotically balanced, does not cause fluid electrolyte shift |
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Name 3 indications for whole bowel irrigation.
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1. Heavy metal ingestion: Li, Fe, Pb (don't bind to charcoal)
2. Body packers of drugs in condoms 3. Enteric coated or Sustained release medications |
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Making the urine alkaline by administering IV sodium bicarbonate will help to maximize elimination of certain intoxications. Name 3 substances this would work in.
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1. Salicylates
2. TCAs 3. Methanol 4. Certain herbacides 5. Phenobarbital |
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Giving boluses of 1-2mEq/kg sodium bicarb will alkalinize the urine. How can you maximize this dose to continually infuse bicarb?
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Continuous infusion of D5W and sodium bicarb at double the maintenance dose
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Name 3 contraindications to alkalinizing the urine to help excrete toxins.
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1. Renal dysfunction
2. Hypokalemia 3. Cannot tolerate volume or sodium overload |
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Hemodialysis to remove toxins is reserved for potentially life threatening substances that are not easily removed in other ways. Name 3 indications
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1. Lithium
2. Theophylline 3. ethylene glycol 4. Methanol 5. Salicylates |
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Hemoperfusion, the extracorporeal filtration of blood through charcoal filter can remove protein bound toxins. What substance is it most useful for?
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Barbituates
digitalis, methotrexate |
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Describe the 3 characteristics of the opioid toxidrome.
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HEROIN/MORPHINE
1. Respiratory depression 2. Miosis 3. CNS depression to profound coma |
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What repiratory complication is often seen in opioid intoxication?
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pulmonary edema
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Why do you have a little extra time to give activated charcoal in opioid ingestion?
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Decreases gastric motility/emptying
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How often can you give doses of naloxone (narcan) to a pt with suspected opioid intoxication?
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Up to 2mg q 2-3min 3 times.
is short acting, may need to retreat. |
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Describe the anticholinergic toxidrome.
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Dry as a bone-decreased salivation
Hot as a hare-hyperpyrexia Red as a beet-cutaneous vasodilation Blind as a bat-mydriasis Mad as a hatter-delirium *may also be tachycardia, urinary retention, myoclonic jerking, decreased/absent BS |
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Name 3 common anticholinergic meds that cause anticholinergic toxidrome
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1. Benztropine
2. Scopolamine 3. Atropine (eye drops with red tops) |
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Name 3 antihistamines that can cause anticholinergic toxidrome
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1. Diphenhydramine
2. Chlorpheniramine 3. Promethazine 4. Hydroxyzine 5. Meclizine |
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TCAs, hallucinogenic mushrooms, antispasmodics and antipsychotics can all cause what toxidrome in overdose?
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Anticholinergic
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Describe the cholinergic or insecticide toxidrome
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"SLUDGE BBB"
salivation lacrimation urination defecation gastric emptying emesis bradycardia bronchospasm bronchorrhea |
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Name 3 classes of substances that can cause the cholinergic/insecticide toxidrome
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1. Organophosphates (irreversible inhibit cholinesterase)
2. Carbamates (reversible inhibit cholinesterase) 3. Cholinergic meds (physostigmine, green top eyedrops) 4. Nerve gasses |
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Name 4 treatment options when you observe the cholinergic/insecticide toxidrome.
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1. 2PAMCl breaks down organophosphates and carbamates
2. Atropine for resp sxs 3. Furosemide for pulm edema 4. Diazepam for seizure |
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Describe the sympathomimetic toxidrome. What is the most common cause?
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"total body overdrive"
-tachycardia, diaphoresis, mydriasis, psychosis -later hyperthermia, hypertension, seizure, vascular accidents (cocaine) cocaine |
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Name 3 drugs that can produce sympathomimetic effects.
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1. Pseudoephedrine
2. Ephedra 3. Methamphetamines 4. Amphetamines 5. Cocaine 6. MDMA 7. PCP |
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Why are beta blockers contraindicated in pts with sympathomimetic toxidrome?
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Unapposed alpha receptor stimulation
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What is the number one cause of drug ingestion fatality?
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TCAs
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Name 3 possible findings on EKG in anticholinergic overdose.
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1. sinus tachycardia
2. QRS prolongation (>100ms)-give sodium bicarbonate 3. Ventricular arrhythmias-give lidocaine 4. Narrow QRS supraventricular tachydysrrhythmias resulting in hemodynamic deterioration- give physostigmine over 2-5 min |
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Why can you give charcoal/maybe do gastric lavage in a pt with anticholinergic overdose hours after the ingestion?
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Anticholinergic effects include delayed gastric motility
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What are the caveats to administering physostigmine for seizure, dysrrhythmia or agitation to a patient with anticholinergic overdose?
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Must get EKG beforehand
No prolonged PR interval No prolonged QRS |
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Is hemodialysis indicated for anticholinergic overdose?
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No, dialysis and hemoperfusion are ineffective.
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what does physostigmine do?
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the only reversible acetylcholinesterase inhibitor that directly antagonizes CNS manifestations of anticholinergic activity
-useful in intractable seizure -useful in agitated delerium -must have EKG checked before giving! |
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Describe the sedative toxidrome
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1. Resp depression
2. Depressed mental status 3. Hypotension and hypothermia |
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What 2 substances are the most common causes of sedative OD?
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1. BZDs
2. Barbituates then GHB, GBL |
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How much of a sedative drug must a pt take to achieve severe toxicity? What are the early signs of overdose?
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10X the hypnotic dose
Ataxia, incoordination Nystagmus Slurred speech |
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If you see skin lesions with a sedative toxidrome, what substance do you suspect?
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Phenobarbital, barbituates
clear vesicles and bullae on erythematous base |
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Activated charcoal is indicated for all sedative intoxications except?
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GHB and GBL
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How is a barbituate ingestion treated differently for elimination from the body?
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Alkaline diuresis
hemodialysis/hemoperfusion indicated |
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what is the antidote for BZD overdose?
what is the major risk with administering it? |
Flumazenil
increases risk for seizure, get EKG first to make sure it wasn't a TCA OD. Not as useful in a chronic BZD user |
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This poison is the leading cause of pediatric ingestion mortality. How are they classified?
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Hydrocarbons
Toxic: halogenated and aromatics Nontoxic:gas, kerosene, paint thinner, lubrication oil, etc. |
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Many body systems are hit by hydrocarbon ingestion. Which is the most serious?
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1. Respiratory distress
CNS:decreased LOC, euphoria CV:syncope, SCD GI: N/V, sore throat |
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What abnormal lab findings might you expect in a hydrocarbon ingestion?
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Leukocytosis within 48 hours
Anion gap acidosis Hypomagnesemia, hypophosphatemia Elevated LFTs |
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Decontamination of the GI tract is generally not recommended for hydrocarbon ingestion. What substances are the exception?
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"CHAMP"
Camphor (can cause seizures) Halogenated HCs (arrhythmia and hepatotoxicity) Aromatic HCs (myelosuppression, malignancy, CNS toxicity) M Heavy metals Pesticides |
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When can you discharge the patient with a nontoxic hydrocarbon ingestion?
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Must observe the pt for 6 hours!
Clean CXR Good oxygenation |
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What are the main systems affected by TCA overdose?
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Cardiac (arrhythmia-wide QRS, tachy, HYPOtension)
GI (anticholinergic effects, delayed emptying) CNS (ataxia, confusion, hallucination) RESP (pulm edema, ARDS, aspiration) |
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Why should you set mechanical ventilation to hyperventilate the pt with a TCA overdose?
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Metabolic or resp acidosis
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How do you treat a wide QRS dysrhythmia, as in TCA overdose?
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1. Urinary alkalinization by administering bicarb via IV
2. second line therapy lidocaine |
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What is a toxic dose of APAP?
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>140mg/kg in 24 hours
or >7.5g in 24 hours |
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Name the 4 stages of APAP toxicity.
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1. first 24 hours, minimal signs and sxs.
2. days 2-3, RUQ pain, tachycardia, hypotension, abnormal LFTs 3. days 3-4, fulminant hepatic failure, coagulopathy, encephalopathy 4. 4 days to weeks: recovery if survive stage 3 |
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What is the antidote to APAP overdose?
When should it be given? |
NAC (N-acetylcysteine/Mucumyst)
Anytime a level measured is above the toxicity line on the nomogram, or level in body is rising. Check serial levels at 4,6,8 hours out from ingestion. Is 100% effecitve if given within 8 hours of ingestion |
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Describe the salicylate toxidrome.
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Tinnitus
Tachypnea Vomiting Fever AMS |
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Why is the pt with ASA overdose tachypnic?
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Compensating for an anion gap acidosis. there is direct stimulation of respiratory drive centers by the salicylate
Remember to hyperventilate the pt when you intubate them to avoid acidemia |
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What are the main dangers with ASA overdose?
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1.RESP-pulmonary edema, resp arrest
2.CARD-tachycardia, hypotension, dysrhthmia 3.GI-hemorrhage, perf, pancratitis, hepatitis 4.HEME-DIC 5.Hypokalemia (in response to metabolic acidosis and urinary alkalinization) |
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When monitoring a pt with ASA overdose, how often should you draw serum levels?
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every 2 hours until ASA level drops
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What is the best method for enhanced elimination of ASA in overdose?
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Hemodialysis
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Name some reasons for a high anion gap acidosis.
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"MUDPILES"
methanol uremia (renal failure with high BUN) DKA Paraldehyde Iron and isoniazid Lactic acid Ethylene glycol and ethanol Salicylates |
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Give 2 reasons for prerenal acute renal failure
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1.Dehydration, volume depletion, redistribution of body fluids (ascites, shock)
2.Cardiac failure |
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Give 3 reasons for intrinsic ARF
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1.Acute tubular necrosis (ATN)
2.Thrombosis, ischemia to renal tissue (TTP, DIC) 3.Poststreptococcal glomerulonephritis (PSGN) |
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Give 3 reasons for postrenal ARF
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Obstruction in the urinary tract
1.Phimosis 2.Urethral stricture 3.Blood clots, stones, tumors 4.Prostatic hypertrophy 5.Neurogenic bladder |
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In what patient population is UTI most likely to lead to sepsis?
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Neonates and elderly
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When does UTI required a surgical consult?
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In children under 4 years old
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What organism is most implicated in UTI?
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E.coli
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Define UTI relapse
Define UTI reinfection |
Relapse-same organism causes UTI within 1month
Reinfection-sxs recur during 1-6 month period |
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What is a complicated UTI
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Pt has underlying renal or neurological disease
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Some people have a genetic predisposition to UTIs, and women get more UTIs. Give 2 reasons
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Bacteria in bladder increases 10x after sex
Loss of lactobacillus with age Spermacide enhances growth of E.coli Genetic uroepithelial E.coli binding glycolipids |
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What will pyuria show on microscopic U/A?
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>10 WBCs per hpf with few or rare squamous cells
WBC casts |
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Name 3 risk factors for pyelonephritis
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1. Renal calculi
2. Anatomic abnormality 3. Recent instrumentation 4. Prostatitis or Prostatic hypertrophy |
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What is the rule of 2s for pyelonephritis?
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Deciding whether or not to admit the pt. Can go home if:
2L fluid 2 doses pain meds on board 2g ceftriaxone fever drops 2 points tolerates 2 glasses of water 2 weeks of reliable outpt treatment |
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What is the easiest way to determine whether a suspected scrotal abscess is localized to the scrotal wall or involves intrascrotal organs?
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Ultrasound
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Fournier's gangrene often causes a scrotal abscess. What caused this and how will you treat?
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Start empiric broad abx therapy, is usually polymicrobial (G+/G-)
Consult urology Starts from indroduction of bacteria through scrotal skin, urethra, rectum |
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What is the ER treatment for balanoposthitis?
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Cleansing and antifungal cream. Do not break adhesions from reattatchment of foreskin.
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What is the treatment for phimosis, or unretractable foreskin?
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Circumcision
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What is the danger with paraphimosis?
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Glans edema and venous engorgement. Can lead to arterial compromise.
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What must you do before discharging the child with a penile hair tourniquet?
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Assure urethral integrity and distal penile blood flow.
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What tissue tears during penile "fracture"?
How will you know? |
Tunica albuginea
Penis will be swollen, discolored, tender |
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How is penile fracture treated?
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Urology consult-they will come and evacuate hematoma, suture tunica albuginea back together.
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What should you find on physical exam in a pt with Peyronie's disease?
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Thickened dorsal plaque.
refer to urology. |
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What is dupuytren's contracture?
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fixed flexion contracture of the hand, fingers cannot be fully extended.
Associated with Peyronie's disease |
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blue dot sign
how do you confirm the diagnosis? |
torsion of the appendix testis
Doppler ultrasound |
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How do you treat torsion of the appendix testis?
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Most calcify and degenerate in 2 weeks, surgery generally not necessary.
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What is the most likely cause of epididymitis?
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<40 yo STD- DOXYCYCLINE/ROCEPHIN
>50 urinary pathogen: E.coli, Klebsiella due to BPH or strictures. CIPRO/LEVAQUIN |
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What is "chemical" epididymitis, and who gets it?
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Epididymitis in young boys secondary to retrograde reflux of sterile urine into tail of epididymis.
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Describe 3 signs/sxs of epididymitis.
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1. Testicular pain/swelling
2. Abdominal/inguinal canal pain 3. Pain relief with recumbent position |
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What dangerous condition can epididymitis left untreated progress to?
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Epididymoorchitis or scrotal abscess.
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Name a congenital anomaly that can predispose to testicular torsion. Which side is more likely to torse, and how do you fix it?
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cryptorchidism, or undescended testis
LEFT Anchor testis to gubernaculum |
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What age group of men is most likely to get testicular torsion?
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Men <30. Peak age 12-18 years old.
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Prehn sign
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Elevation of the painful or swollen testis does not produce relief. Sign for testicular torsion
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When do you worry testicular torsion has been picked up late in the game?
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Scrotum is swollen. Acutely, there is often no swelling.
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When performing the "opening of a book" maneuver to detorse a testicle, how do you know when you have fixed the problem?
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Pain relief for the pt. May need to untwist several revolutions
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Name 3 populations of patients likely to get renal and ureteral stones.
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1. Hyperparathyroidism
2. Men 3rd-5th decade of life 3. Genetic predisposition Highest frequency during warmest 3 months of the year! |
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What is the most common composition of renal/ureteral stones?
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Calcium oxalate or phosphate
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What type of renal stone is associated with infection by urea-splitting bacteria?
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Struvite
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Name the 2 most common areas of obstruction caused by renal/ureteral stones
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1. Uretopelvic junction
2. Uretovesicular junction |
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The pt with renal stones often presents with N/V, diaphoresis and flank pain that radiates where?
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Ipsilateral testicle or labia
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Does hematuria have to be present on U/A to diagnose renal/ureteral stones?
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No, absent in 10% of cases
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What is the preferred imaging for renal/ureteral stones?
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CT of abdomen and pelvis
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When should you admit the pt with renal/ureteral stones?
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Associated infection
Fever Persistent vomiting |
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Rule out the common and the deadly. What are the 3 most life threatening gyn emergencies?
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1. Ruptured ectopic
2. Ruptured hemorrhagic cyst 3. Ruptured tuboovarian abscess |
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Name 3 risk factors for spontaneous abortion?
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1. Maternal age
2. Paternal age 3. Parity |
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How much blood is estimated to be lost when a woman says she has soaked a pad with blood?
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20-30 mL
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Describe the appearance of the cervix with threatened and spontaneous abortion.
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Threatened- cervix is closed, with mild bleeding
Spontaneous-cervix is open and passing blood clots, conception products |
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What is Fitz-Hugh-Curtis Syndrome?
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Complication of PID, causing inflammation of Glisson's capsule, a thin layer of CT around the liver. =elevated LFTs
Will see violin string adhesions. |
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At what level of B-HCG should a fetus be visible within the uterus?
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2000-3000
Always repeat levels to see whether there has been a fetal demise, should double q2-3 days |
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What is the major cause of morbidity and mortality with ectopic pregnancy?
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Hemorrhage
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This problem is caused by spasm of the adnexal organs or developmental abnormalities of pelvic organs, allowing them to twist
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Ovarian torsion
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What is the difference between visceral and parietal abdominal pain?
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Visceral-dull, poorly localized, often midline. Stimulation of stretch receptors in hollow or solid viscera
Parietal-sharp, well localized pain, irritation of peritoneal fibers |
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If you are concerned about a SBO, what piece of history is especially important to ask about?
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Past surgeries, any possibility of adhesions?
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Name 2 common recurrent abdominal pain complaints where the pt will tell you "this feels the same as last time"
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Renal colic
Diverticulitis |
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Name 2 causes of abdominal pain that have nothing to do with GI!
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Pneumonia
MI (esp elderly, DM) |
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Carnett's sign
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Have pt do a sit up to determine source of abdominal pain. If relief with ab flexion, pain is intra-abdominal. If pain is increased, is extra-abdominal/peritoneal.
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Hover sign
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Pt feels pain when you "hover" your hand above the abdomen. Indicates nerve origin rather than abdominal cause
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High pitched, tinkling bowel sounds
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Bowel obstruction
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What does involuntary guarding on physical exam of the abdomen indicate?
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Peritoneal irritation
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Where will pain from acute cholecystitis refer?
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From RUQ to right shoulder
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History of gradual onset periumbilical pain (visceral) that progresses to constant RLQ pain (parietal)
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Appendicitis
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When a pt presents with vomiting as a symptom associated with abd pain, what history is important to elicit about the timing?
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Pain before vomiting-appendicitis
Pain after vomiting-Boerhaaves, Mallory-Weiss |
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Point 1/3 medially from ASIS to umbilicus.
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McBurney's point.
tenderness here indicates appendicitis |
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What will the position and demeanor of the pt be when peritoneal irritation is present?
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Pt will prefer to lie still
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Name 2 exceptions to the idea that appendicitis should elicit pain over McBurney's point.
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1. Pregnancy-appendix displaced, RUQ pain
2. Retro-cecal appendix-pain on rectal examination |
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Rosving's sign
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Pain in RLQ elicited when palpating LLQ.
appendicitis |
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Obturator sign
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RLQ pain with internal/external rotation of right hip
appendicitis |
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Iliopsoas sign
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RLQ pain with hyperextension of the right hip
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If you suspect appendicitis, what is your first choice for imaging to confirm?
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CT
Even if it's not appendicitis, have 2/3 chance of finding another problem on CT. |
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What is an appendolith?
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Pathognomonic for appendicitis, a fecal ball causing infection
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What is the most common diagnosis for ER abdominal pain in the pt >50 yo?
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Biliary tract emergency
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What does biliary colic indicated?
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cystic duct obstruction
post-prandial RUQ pain radiates to back/shoulder lasts 30min-several hours |
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Name 3 risk factors for cholelithiasis
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1. Female
2. Obesity 3. Post massive wt loss 4. DM 5. Race: NA>hispanic>white 6. Hemolytic disorders |
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Cholelithiasis can be difficult to distinguish from dyspepsia, what could you do to separate the two?
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Antacid challenge?
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What can you do for the pt with suspected cholelithiasis in the ER? They may need to schedule elective surgery for later.
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IV hydration
IV analgesia IV anti-emetics |
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What happens in cholecystitis?
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Obstruction in cystic duct causes inflammation, distension, edema of GB.
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Name the 4 typical agents that may cause bacterial infection in cholecystitis.
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1. E.coli
2. Klebsiella 3. Enterobacter 4. Enterococci and anaerobes |
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Why does acute acalculous cholecystitis have higher morbidity and mortality?
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Tend to be sicker, get gangrene and perforation.
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Name 3 risk factors for biliary sludging, causing acalculous cholecystitis.
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1. DM
2. HIV 3. TPN, prolonged fasting 4. Vascular disease |
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You'll probably get a spectrum of labs when you suspect cholecystitis. When will LFTs be useful in the diagnosis?
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If they are >5x elevated, suspect choledocholithiasis.
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Name 3 indications for urgent surgical consultation for cholecystitis.
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1. Empyema
2. Emphysematous cholecystitis 3. Perforation 4. Associated pancreatitis or peritonitis |
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Name 3 risk factors for choledocholithiasis
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1. prior biliary injury
2. PSC 3. Cystic biliary disease 4. sphincter of oddi dysfunction (SOD) 5. Asians with parasites |
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Choledocholithiasis causes obstruction of conjugated bilirubin getting out of the liver. What consequences do you expect systemically?
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1. Jaundice- a late finding
2. clay colored stools 3. Dark/tea-colored urine |
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What diagnostic test could you order for choledocholithiasis that would also be therapeutic?
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ERCP with endoscopic sphincterotomy
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What is ascending cholangitis?
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bacterial infection superimposed on an obstruction of the biliary tree. leads to bacteria reflux into lymphatics and hepatic vessels
-stones -neoplasm |
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Charcot's triad
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1. RUQ pain
2. fever 3. jaundice Indicates cholangitis |
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Reynold's pentad
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Charcot's (RUQ pain, jaundice, and fever) plus
4. shock 5. AMS indicates 100% mortality if cholangitis is not treated. |
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Name the 2 most common causes of acute pancreatitis
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1. Alcoholism
2. Gallstones blunt trauma, infection, super high hypertriglyceridemia, autoimmune |
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What patient population is at highest risk for pancreatitis?
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Middle aged AAs
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What imaging should you order to investigae suspected complications of pancreatitis, remembering pancreatitis itself is a clinical diagnosis?
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CT
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Name 3 complications of pancreatitis that would warrant getting a CT.
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1. Pseudocyst
2. Abscess 3. Hemorrhage |
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What enzyme to you expect to be most elevated in acute pancreatitis?
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Lipase
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Who should you call to drain a peri-pancreatic abscess?
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Interventional radiology
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Name 3 things you can do for the pt with acute pancreatitis in the ER to begin their recovery.
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1. NPO
2. IV hydration 3. anti-emetics 4. Analgesics 5. PPIs 6. Observation for EtOH withdrawal |
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Name 3 hallmarks of SBO
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1. Colicky pain
2. Abdominal distension 3. Vomiting of undigested food progressing to vomiting of feculent material |
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s/p surgery is the most common preceding finding in adult SBO. Name 3 ways children can get SBO.
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1. Meckels Diverticulum
2. volvulus 3. Intususception |
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What is the reasoning behind giving IV fluids to the pt with SBO in the ER?
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When obstruction occurs, bowel becomes ischemic. Pump up the vessels with fluid to prevent vascular ischemia.
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Name the 2 main causes of PUD
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1. H.pylori
2. NSAIDS |
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Why do we give standard PPIs to postsurgical patients?
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Decreased incidence of stress/inflammation associated PUD
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Where are most peptic ulcers located?
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Duodenum>stomach
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What imaging will you order if you suspect perforated PUD?
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Abdominal series (plain film) looking for free air. Always order lat decub also.
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What imaging should you order to investigate complaints of renal colic?
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CT urogram without contrast
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When should you consult urology for a renal/ureteral stone?
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When it is >5mm
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Name 3 risk factors for diverticulitis
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1. low fiber diet
2. steroid use/NSAIDs 3. Age >40 |
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Who would you admit for an acute exacerbation of diverticulitis?
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1. Peritoneal signs
2. SIRS 3. Complication (perf, abscess) get IV abx and bowel rest |
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What abx regimen would be sufficient for an acute exacerbation of diverticulitis?
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Metronidazole
or Cipro |
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Name 3 risk factors for mesenteric ischemia/infarction
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1. Age
2. Hypercoagulable state, prior DVT 3. Afib 4. CHF 5. Atherosclerosis 6. Liver disease |
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What is the most common location for mesenteric ischemia/infarction?
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SMA occlusion by thrombus or embolus
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Describe the presentation of the pt with mesenteric ischemia/infarction.
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1. Severe, poorly localized abd pain
2. Pain refractory to narcotic analgesics 3. Abd exam is normal |
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What is ascending cholangitis?
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bacterial infection superimposed on an obstruction of the biliary tree. leads to bacteria reflux into lymphatics and hepatic vessels
-stones -neoplasm |
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Charcot's triad
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1. RUQ pain
2. fever 3. jaundice |
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Reynold's pentad
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Charcot's (RUQ pain, jaundice, and fever) plus
4. shock 5. AMS indicates 100% mortality if cholangitis is not treated. |
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Name the 2 most common causes of acute pancreatitis
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1. Alcoholism
2. Gallstones blunt trauma, infection, super high hypertriglyceridemia, autoimmune |
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What patient population is at highest risk for pancreatitis?
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Middle aged AAs
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What is ascending cholangitis?
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bacterial infection superimposed on an obstruction of the biliary tree. leads to bacteria reflux into lymphatics and hepatic vessels
-stones -neoplasm |
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Charcot's triad
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1. RUQ pain
2. fever 3. jaundice |
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Reynold's pentad
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Charcot's (RUQ pain, jaundice, and fever) plus
4. shock 5. AMS indicates 100% mortality if cholangitis is not treated. |
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Name the 2 most common causes of acute pancreatitis
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1. Alcoholism
2. Gallstones blunt trauma, infection, super high hypertriglyceridemia, autoimmune |
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What patient population is at highest risk for pancreatitis?
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Middle aged AAs
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Name 3 risk factors for AAA
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1. SMOKING
2. Elderly male 3. Atherosclerosis 4. HTN 5. 1st degree relative with AAA 6. CT/collagen tissue disease |
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What do you suspect when you find unequal or absent femoral pulses on PE of the pt with abdominal pain? What imaging test will you order?
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AAA rupture
Bedside US. Do not send unstable pt to CT |
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What is the most common cause of upper GI bleed?
Name 3 others |
PUD
1. Erosive gastritis/esophagitis 2. Esophageal/gastric varices 3. Mallory-Weiss tears |
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What is the most common cause of lower GI bleed?
Name 3 others |
Diverticular disease
1. AVMs 2. IBD 3. Anorectal disease (hemorrhoids, fistula, fissure) 4. Neoplasia |
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How can labs help you distinguish upper vs lower GI bleed?
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BUN elevated in UGI bleed
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List the 4 mechanisms of diarrhea.
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1. Increased secretions
2. Decreased absorption 3. Increased osmotic load 4. Increased motility |
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What time length divides acute and chronic diarrhea?
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3 weeks
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