Tiny Tips - Boringem

Front 1

Approach to altered mental status

Back 1

IS IT MEATS

Front 2

Intubation preparation

Back 2

STOP I C BARS
Suction
Tubes
Oxygenate
Prepare with Preload, Position, Pharmacy (drugs), Post-intubation plan
IV's
CO2 monitoring
Bougie & Blades
Alternate airway
Rescue airway
Surgical airway

Front 3

Diagnosing the cause of an alarming ventilator

Back 3

D - Dislodged tube
O - Obstructed tube (mucous plug, blood, kink)
P - Pneumothorax
E - Equipment failure (ventilator, tubing, etc)
S - Breath Stacking [breath] (Auto-PEEP)

Front 4

CHF treatment

Back 4

POND
Positive-pressure ventilation
Oxygen
Nitroglycerine
Diuretics

Front 5

Ingestions that are not absorbed by activated charcoal

Back 5

PHAILS-O
Pesticides
Hydrocarbons
Acids/Alkalis/Alcohols
Iron
Lead/Lithium
Solvents

-

Oil of wintergreen

Front 6

Causes of anion-gap metabolic acidosis

Back 6

KULT
Ketones
Uremia
Lactate
Toxins

Front 7

Hydrocarbon additives that require GI decontamination

Back 7

CHAMP
Camphor - seizures
Halogenated HC - dysrhythmias/hepatotoxicity
Aromatic HC - bone marrow suppression/cancer
Metals (arsenic, murcury & lead)
Pesticides - cholinergic crises/seizures/resp depression

Front 8

Mass casualty triage protocol

Back 8

Use the START (Simple Triage And Rapid Treatment) Protocol
Remember with ABCD

Front 9

PERC Rule

Back 9

Apply if clinical gestalt = low risk for PE
HAD CLOTS
H - Hormone (estrogen) use
A - Age > 50
D - DVT or PE history (have they HAD CLOTS?)
C - Coughing blood
L - Leg swelling disparity
O - O2 sats < 95%
T - Tachycardia (>100bpm)
S - Surgery or Trauma (recent)

Front 10

CATCH Rule - High Risk Criteria

Back 10

WIGS

W - Worsening Headache
I - Irritability
G - GCS <15 2 hours after the injury
S - Suspected open/depressed skull #

Front 11

CATCH Rule - Medium Risk Criteria

Back 11

SDH

S - Skull #
D - Dangerous mechanism (MVC, fall >3ft or 5 stairs, bike accident without helmet)
H - Hematoma (boggy)

Front 12

Causes of Seizure

Back 12

STATUS EPILEPsy

S - alicylates / S eizure med noncompliance / S trychnine
T - ricyclic Antidepressants
A - VM / A cute hydrocephalus / A nticholinergics
T - rauma / T raumatic bleed (ICH, SDH)
U - remia (Renal Failure)
S - trychnine / S ugar (low glucose) / S epsis (meningitis)

E - lectrolytes (Hyponatremia, Hypocalcemia)
P - esticides
I - ctogenic foci (e.g. post TBI, post stroke)
L - ithium / L idocaine intoxication
E - clampsia / E tOH withdrawal
Psy - Psy chogenic Non-Epileptic Seizures (formerly known as ‘pseudo seizures’)

Front 13

Signs of Delirium (for Confusion Assessment Method, CAM)

Back 13

AIDA

A - cute and fluctuating
I - nattention
D - eficit cognitively (memory, orientation, language)

D - isturbance perceptually

Not caused by dementia

Front 14

What is needed for a safe discharge plan?

Back 14

No RISKS

R - oaming/wandering
I - mminent danger (falls/fire setting)
S - uicidal ideation
K - inship and relationship (abuse and/or supports)
S - afe driving, S ubstance misuse, S elf neglect

Front 15

Diagnostic criteria of major depressive disorder

Back 15

MDD classified as 5 or more of these symptoms occurring most days over a 2 week period along with a change in function. MUST have depressed mood or loss of interest/function.

SIGECAPS

S - leep
I - nterest
G - uilt
E - nergy
C - oncentration
A - ppetite
P - sychomotor slowing
S - uicidal ideation

Not a mixed episode, due to anxiety, caused by a general medical condition, or consistent with bereavement (<2 months from loss)

Front 16

Approach to the Alarming Ventilator

Back 16

D - Disconnect the patient from the ventilator +/- provide gentle pressure to the chest (assess for and treat breath Stacking and Equipment failure)
O - Oxygen (100%) and manual ventilation with a bag (check compliance by squeezing the bag: difficult bagging suggests Pneumothorax or Obstructed tube, very easy bagging suggests Dislodged tube or Equipment failure due to a deflated cuff)
T - Tube position/function (see if the tube has migrated to assess for Dislodged tube; pass a bougie or suction catheter through to see if the tube is Obstructed)
T - Tweak the vent (prevents breath Stacking by decreasing respiratory rate, decreasing tidal volume or decreasing inspiratory time)
S - Sonography (assess for pneumothorax, mainstem intubation, plugging)

Front 17

Ottawa SAH Rule

Back 17

A - Age > 40y
N - Neck pain/stiffness
T - Thunderclap onset

L - LOC
E - Exertion onset
a
F - Flexion decreased

Front 18

Ring enhancing lesions on Head CT

Back 18

MAGICAL DR

M - Metastatic lesions
A - Abscess / Parasite (Neurocysticercosis, Tapeworm)
G - GBM
I - Infarction
C - Contusion

A - Acute Disseminated Encephalomyelitis

L - Lymphoma

D - Demyelinating disease
R - Radiation necrosis

Front 19

Anterior cord syndrome; causes

Back 19

Like a car - if it smashes the front the engine won't work (paralysis and pain) but instruments/GPS will (vibration/proprioception)

Causes - Dissection and aorta surgery (Artery of Adamkiewicz), hypotension, vasospasm, thrombosis

Front 20

What are the NEXUS Criteria?

Back 20

2 Exam
-Neurologic deficit
-Midline cervical tenderness

3 Credibility
-Normal GCS
-Not intoxicated
-No distracting injuries

Front 21

Unstable C-Spine Fractures

Back 21

Jefferson Bit Off A Hangman's Tit And Pinky

J efferson fracture (burst fracture of C1 seen on odontoid view)
B ilateral Facet Joint Dislocation (look for a step on the lateral, FLEXion mechanism)
O dontoid 2 or 3 (odontoid view neck or body fracture)
A tlanto-occipital / A xial dissociation (head detached with wide spinous process separation)
H angman's fracture (see break around the spinolaminar line at C2. HyperEXTENSION)
T eardrop (break of anteroinferior part of the spinal body, most often HyperFLEXion)

A ny fracture-dislocation

P osterior neural arch of C1

Front 22

Approach to bradycardia

Back 22

DIE!
Drugs (BB, CCB, Dig)
Infarction
Electrolytes (especially K!)

Front 23

Rashes that start on the palms

Back 23

Sifting Rocks Scabbed Emma's Hands
Siphylis
RMSF
Scabies
EM
Hand/foot/mouth (Coxsackie)

Front 24

Rashes with a + Nikolsky sign

Back 24

Stevie got scalded by TEN PV'd nickels
Steven-Johnson Syndrome
Staph Scalded Skin Syndrome
Toxic Epidermal Necrolisis (TEN)
Pemphigus vulgaruS (PV)
Nikolsky

Front 25

Rashes with vesicle / bullae

Back 25

Old man with BPPV fell into a pool of necrotizing gonorrhea
Bullous Pemphigoid / Pemphigus Vulgarus
Necrotizing fasciitis (hemmorhagic)
Gonorrhea (disseminated)

Front 26

Rashes with petechiae / purpura

Back 26

Henoch the Tick gave Meningitis to DICk the purple drug addict
Ricketsia (RMSF)
Meningococcemia
DIC (purpural fulminans)
Endocarditis

Front 27

Exam findings of serotonin syndrome

Back 27

CHAARM
C NS dysfunction
H yperthermia/Hyperreflexia
A utonomic dysfunction (tremor, myoclonus) / A taxia
R igidity
M yoclonus

NOTE: NMS does NOT have myoclonus or hyperreflexia!!!

Front 28

Depression symptoms

Back 28

SIGECAPS
Sleep
Interest
Guilt
Energy
Concentration
Appetite
Psychomotor slowing
Suicidal Ideation

Front 29

Suicidal ideation assessment

Back 29

SAD PERSONS scale correlates with the decision to admit to psychiatry. Does not predict risk of future suicidality.

S ex (male) - 1
A ge <19 or > 45- 1
D epressed diagnosed or features suggestive - 2
P revious serious attempt or psych care - 1
E thanol abuse or street drugs - 1
R ational thought (not) - 2
S eparated, widowed, divorced - 1
O rganized plan or serious attempt - 2
N o social support - 1
S tated future intent - 2

<6 - Outpatient

>6 - ED psych evaluation

>9 - Psych admission

Front 30

Major and minor criteria for Rheumatic Fever. Treatment.

Back 30

Jones criteria (requires evidence of strep infection + 2 major or 1 major/1 minor)

Evidence of strep infection:

1. Elevated ASOT or other streptococcal antibodies

2. Positive throat culture for Group A beta-hemolytic streptococci

3. Positive rapid direct Group A strep carbohydrate antigen test

4. Recent scarlet fever.

MAJOR

J - oints - polyarthritis of large joints (knees, elbows, wrist, ankles)

<3 - carditis (murmurs, effusions, cardiomegaly, CHF)

N - Nodules - subcutaneous on extensor surfaces (wrist, elbow, knees, spine)

E - Erythema marginatum (painless, non-pruritic)

S - Sydenham's Chorea

MINOR

F - Fever

A - Arthralgias

C - CRP

E - ESR

P - PR interval increased

Treatment

-Penicillin 500mg adults / 250mg peds x 10 days or Benzathine penicillin 1.2million U adult or 600thousand U children IM; long-term prophylactic antibiotics

-Aspirin

Front 31

Criteria for diagnosing Endocarditis

Back 31

Duke's criteria ()

BE FIVER (+ if 2 major, 1 major 2 minor, 5 minor)

B - Blood cultures (2 positive with typical pathogens)

E - Echo lesions (vegetation, perivalve abscess, prosthetic valve dehisence, new regurgitation)

F - Fever (>38)

I - Immunologic (Roth, Osler, rheumatoid factor)

V - Vascular (Janeway, septic emboli, conjunctival hemorrhage)

E - eccentric blood culture (single positive culture unless organism does not cause IE) and echo (consistent with IE but do not meet criteria)

R - risk factors (IVDU, prosthetic valve)

Front 32

San Francisco Syncope Rule

Back 32

CHESS

CHF

Hematocrit <30%

ECG

SOB

Systolic BP <90

Front 33

Dangerous ECG findings on an ECG of a patient with syncope

Back 33

Prolonged QT

WPW

Brugada

HOCM

Ischemia

Front 34

Causes of hyperacute T waves

Back 34

Ischemia

Hyperkalemia

Pericarditis

LVH

LBBB

Benign early repolarization

Front 35

Causes of tall R wave in v1

Back 35

Posterior MI

RBBB
RVH

WPW type A

Children and adolescents

Dextrocardia

Front 36

Causes of ST elevation on ECG

Back 36

STEMI

Printzmetal's

LBBB

LVH

Pericarditis

Hyperkalemia

Brugada

PE

Celebral hemorrhage

Pacing

BER

Front 37

How can VT be distinguished from SVT with aberrancy?

Back 37

Brugada criteria (note: not good enough to use in real life):

1. Absence of any RS complexes in the chest leads
2. RS duration (measured from beginning of R to deepest part of S wave) greater than 100 msec
3. AV dissociation (often present but overlooked; may be best appreciated in inferior limb leads and V1-2)
4. Specific VT morphologic criteria

Front 38

What are the common pacemaker malfunctions?

Back 38

Failure to capture - lead displacement or break, block or battery

Oversensing - sensing T waves or extracardiac stimulus

Undersensing - poor lead connection or break, small amplitude, poor contact

Inappropriate rate - battery, response to atrial dysrhytmias

Front 39

What is the code for pacemaker type?

Back 39

Chamber paced - A, V, D

Champer sensed - A, V, D

Response to sensing - Inhibit pacing (V or A and V) or Trigger pacing (old)

Programming - simple, programmable, rate adaptive, communicating, none

Antitachy response - pace or shock or dual

Front 40

Complications of ICD and pacemaker placement

Back 40

Infection of wound

Infection of pouch

Thrombophlebitics

Chronic thrombosis

Front 41

Indications for a pacemaker

Back 41

High level block (2nd or 3rd degree):

-And symptomatic brady

-And asystole >3s (AFib pauses >5s)

-Following AV ablation

-With neuromuscular disease

-Intermittently block and bi or trifascicular block

-With exercise

Front 42

Indications for an ICD

Back 42

1. Cardiac arrest from VF or VT not caused by a reversible event
2. Spontaneous sustained VT
3. Syncope of undetermined origin with inducable VT or VF
4. Nonsustained VT with coronary artery disease, prior myocardial infarction, left ventricular dysfunction, and inducible VF

Front 43

Etiology of Pericarditis

Back 43

-Infectious (Viral - Coxsackie, Echovirus, HIV; Bacterial - Staph, Strep, TB; Fungal - Histoplasmosis; Parasite, Rickettsia)

-Postinjury (Trauma, Surgery, Myocardial infarction [Immediate or Dressler's], Radiation)

-Metabolic diseases (Uremia, Myxedema)

-Systemic diseases (Rheumatoid arthritis, Systemic lupus erythematosus, Sarcoidosis, Scleroderma, Dermatomyositis, Amyloidosis)

-Tumors (Leukemia, Lymphoma, Melanoma, Mets)

-Medications (Procainamide, Hydralazine)

-Aortic dissection

Front 44

List the hypertensive emergencies and their ideal treatment (goal)

Back 44

-ACS - nitroglycerine, labetolol (Asymptomatic)

-Heart failure - nitroglycerine, furosemide (25% reduction)

-Dissection - esmolol & nitroprusside OR labetolol (<140/90)

-Ischemic stroke - nicardipine, labetolol (<180/110 for lytic)

-Intracerebral hemorrhage - nicardipine, labetolol (25% reduction)

-Hypertensive encephalopathy - nicardipine, labetolol (25% reduction)

-Kidney injury - fenoldopam, nicardipine (25% reduction)

-Preeclampsia - magnesium and labetolol (<160/110 and asymptomatic)

-Sympathetic crisis - phentolamine (25% reduction)

Front 45

What features distinguish orbital cellulitis from periorbital cellulitis?

Back 45

Proptosis, opthalmoplegia, and visual changes (look for afferent pupillary defect secondary to increased IOP).

Front 46

Differential diagnosis for a NAGMA

Back 46

HARDUPS

Hyperalimentation / TPN

Acetazolamide

RTA

Diarrhea

Ureteral diversion

Pancreas

Spironolactone

Front 47

Niacin deficiency

Back 47

aka Vitamin B3 and results in Pellagra

4D’s:

Diarrhea

Dermatitis

Dementia

Death

Front 48

Thiamine deficiency

Back 48

aka vitamin B1

Wernicke's Encephalopathy- WACO: ataxia, confusion, opthalmoplegia

Korsakoff's Psychosis - irreversible short-term memory loss

Beri-beri - high output heart failure secondary to vasodilation and fistula formation

Front 49

Cobalamin deficiency

Back 49

aka vitamin B12

Megaloblastic anemia

Neurologic changes (paresthesias, ataxia, clonus, memory loss)

Psychiatric (depression, psychosis)

Folate looks the same except NO neurologic changes and it happens faster.

Front 50

Causes of non-cardiogenic pulmonary edema

Back 50

IS NOT THE HEART

I nhaled Toxins (Ammonia, Chlorine, Phosgene, Nitrous oxide)
S IRS / Sepsis / Septic Shock

N eurogenic (seizure, strangulation, trauma, SAH)
O verdose (Heroin, methadone, cocaine)
T hyrotoxicosis

T rauma
H eat (Smoke! Remember to also consider carbon monoxide!)
E lectrocution

H igh altitude pulmonary edema
E mbolism (clot, air, amniotic fluid, fat), E clampsia
A SA toxicity (also opiates, TCA, amiodarone)
R eperfusion or Re-expansion pulmonary edema (or Rocky Mountain Spotted Fever*)
T ransfusion

Front 51

Diagnostic criteria of Multiple Myeloma

Back 51

-Monoclonal plasma cells or plasmacytoma in the bone marrow

-Monoclonal protein in blood or urine

-Organ dysfunction (CRAB criteria)

C - HyperCalcemia

R - Renal failure

A - Anemia

B - Bone damage (lesions or osteoporosis)

Front 52

What cancers cause bone mets?

Back 52

Painful Bones Kill These Suckers

Prostate

Breast

Kidney

Thyroid

Skin

Also Lungs

Front 53

Hard signs of vascular injury

Back 53

HARD Bruit

Hypotension

Arterial Bleed

Rapidly expanding hematoma

Deficit (pulse/neuro)

Bruit/thrill

Front 54

Criteria to call a febrile seizure simple

Back 54

Fever >38.5

6 months to 6 years

1 episode in 24 hours / per illness

Duration <15 minutes

Generalized

No neurological history

Front 55

HELLP Syndrome

Back 55

Severe form of pre-eclampsia

Labs

H emolysis

E levated

L iver enzymes
L ow

P latelets (<100)

PE

-Jaundice, edema, hypertension, tachycardia, dehydration, tachypnea

Treatment

-Consider steroids, BP control -> delivery is definitive

Front 56

Kawasaki Disease criteria and treatment

Back 56

Warm CREAM

Warm - fever >5 days

C - Conjunctival injection (bilateral, non-exudative)

R - Rash (primarily on trunk; erythematous, maculopapular, morbilliform - no crusting or vesicles)

E - Erythema of palms / soles; Edema of hands / feet; periungal desquamation

A - Adenopathy (cervical, >1.5cm, unilateral)

M - Mucous membrane changes (lips and oral cavity dry and fissured; erythematous mucousa; strawberry tongue)

Treatment - ASA and IVIg; watch for Coronary Artery Aneurysm

Front 57

Tetrology of Fallot cardiac anomolies

Back 57

-Boot shaped heart (Fall over your own Boots)

-Pulmonary hypertension, VSD, RVH, Overriding Aorta

-Ductal dependent lesion that crash after PDA closes (2-10 days, treat with PGE1 0.1mcg/kg/m)

Tet spells (knees to chest to increase SVR and O2 to decrease PVR)

Front 58

Congenital Adrenal Hyperplasia abnormalities

Back 58

21-hydroxylase deficiency

Low Na and High K

Virulized females, small penis in boys

Treat with glucose and hydrocortisone

Front 59

Abuse fracture patterns

Back 59

ANY in a child <1yo

Bucket

Corner**

Diaphysis of humerus, radius, femur, tibia (especially <3yo)

Rib**

Scapular**

Spinous process**

Sternum**

Skull (stellate)*

Vertebral*

Digits*

Multiple* or Bilateral

Different stages of healing*

Front 60

Psychological signs of child sexual abuse

Back 60

Very broad definition

Regression

Acting out

Sexualized behavior

Disclosure

Front 61

The crashing neonate

Back 61

THE MISFITS

T rauma / abuse

H eart disease / H ypothermia / H ypoxia

E ndocrine (CAH, hyperthyroid)

M etabolic (hypoglycemia, hyponatremia, hypocalcemia)

I nborn errors (ammonia)

S epsis (most common!)

F ormula mishaps

I ntestinal catastrophes (volvulus, NEC, diaphragmatic hernia)

T oxins (home remedies)

S eizures

Front 62

Cyanotic heart disease

Back 62

Increased lung markings

1-Truncus arteriosis

2-Transposition of the great arteries

5-Total anomalous venous return

Decreased lung markings

3-Tricuspid atresia / pulmonary atresia

4-Tetrology of Fallot

Front 63

Congenital heart disease: Obstructive Lesions

Back 63

Also happen with closure of the duct, but NOT cyanotic. Give them 0.1mcg/kg/m of PGE1

Coarctation of the aorta

Hypoplastic left heart syndrome

Interrupted aortic arch

Aortic stenosis (critical)

Front 64

List some symptoms of lead poisoning; Treatment

Back 64

LEADeNN

L - Lead lines

E - Encephalopathy (Neuro! seizures)

A - Anemia with basophilic stippling (Heme!)

D - Drop (wrist)

i

N - Nephro tubular fibrosis; proteinurea; Fanconi syndrome

G - G I (Nausea / vomiting / abdo pain / liver damage)

Treatment: WBI, Dimercaprol (BAL) and CaNa2-EDTA (with 2nd dose) for acute/symptomatic; PO Succimer (DMSA) and Penicillamine for chronic

Front 65

Outline the phases of iron poisoning, a rare complication, and treatment

Back 65

Remember: Gluconate 13%, Sulphate 20%, Fumarate 30% Fe

I GI effects (hemorrhagic GI effects) x 6 hours

II Quiscient x 12 hours

III Systemic (vasodilatory shock; negative ionotrope, hepatorenal dysfunction with impaired oxidative phosphorylation)

IV Liver failure

V Resolution (GI scarring, stomach obstruction)

Complication: Weirdly facilitates growth of Yersinia enterocolitica - can cause sepsis

Treatment: WBI, IVF, Deferoxamine (if GIB, AGMA, shock, AMS, >90umol/L, seen on x-ray; watch for hypotension/ARDS/ATN/Yersinia sepsis)

Front 66

Pelvic avulsion fractures (muscle attachments and bony anatomy)

Back 66

Front 67

Anticholinergic Toxidrome

Back 67

Blind as a bat (Mydriasis)

Mad as a hatter (Altered mental status)

Red as a beet (vasodilation, flushed)

Hot as a hare (febrile)

Dry as a bone (no secretions/diaphoresis)

Bowel and bladder lose their tone

Heart runs alone (tachycardia)

Atropine, antihistamines, scopalamine, antipsychotics

Front 68

Cholinergic Toxidrome

Back 68

SLUDGE and the killer B's

Salivation

Lacrimation

Urination

Defication

Gastro upset

Emesis

Bradycardia, Bronchorrhea, Bronchospasm

Also mioisis and lethargy

Organophosphates, carbamates, mushrooms

Front 69

Approach to CT Head

Back 69

Blood Can Be Very Bad

Blood

Cisterns

Brain

Ventricles

Bone

Front 70

Approach to CXR

Back 70

ABCS

Airway

Breathing (lungs)

Cardiac (heart)

Skeleton and Soft tissues

Front 71

Substances that are radioopaque on x-ray

Back 71

CHIPES

C hloral hydrate / C alcium carbonate

H eavy metals (Zn, Li, Barium)

I ron / I odide

P henothiazines / P lay dough

E nteric coated

S olvents (halogenated)

Front 72

Associations with Ciguatera toxicity

Back 72

Big fish (grouper, barracuda)

-Anticholinesterase (cholinergic) effects

-Gastroenteritis

-Hot/cold reversal of sensation or cold allodynia

-Teeth feel loose

-Brady / resp arrest

Treat with antihistamines (treat the itch), atropine, amitryptaline (allodynia), mannitol (controversial)

Front 73

Associations with Scombroid

Back 73

Poorly refrigerated fish (Tuna, mahi mahi)

Histidine in decomposing fish gets broken down into histamine; treat with antihistamine

-Rapid flushing to head/face/torso

-Gastroenteritis

-Metallic taste in mouth

Front 74

What is VATER Syndrome?

Back 74

AKA VACTERAL Association, these conditions occur together more commonly than would be expected otherwise

Vertebral anomolies

Anal atresia

Cardiac defects

Tracheo-esophogeal fistula

Esophageal atresia

Renal anomolies

Limb defects

Front 75

DDx for febrile and altered mental status patients

Back 75

SWEAT

Sepsis

Withdrawal

Endocrine (thyroid) & Environment (heat stroke)

Agitated delirium

Toxidromes (sympathimetic, anticholinergic, amphetamines, salicylates, SS, NMS, MH, strychnine, hallucinogens)

Front 76

General approach to the intoxicated patient

Back 76

ABCDDDEF

Airway

Breathing

Circulation

Dextrose

Decontamination

Diagnosis (ECG, VBG, acetaminophen, ASA, osmolality, EtOH)

Exposure (features of toxidrome)

Elimination (enhance it)

Find an antidote

Front 77

TCA mechanisms of action; OD treatment

Back 77

TCA

Thinker

1 – Indirect GABA antagonism (seizures)
2 – Serotonin reuptake inhibition (serotonin syndrome and agitated delirium)
3 – Norepinephrine reuptake inhibition (initial hypertension and agitated delirium)

Cardiac

4 - Na channel blockade in phase 0 of cardiac depolarization (wide QRS - associated with Sz & arrhythmia, impaired inotropy)
5 – K efflux blockade prolonging phase 3 of cardiac repolarization (long QT)
6 – Alpha-1 adrenergic blockade causing vasodilation (hypotension)

Anti

7 – Anticholinergic (delirium, seizures, sedation, coma, prolonged gastric emptying, anhidrosis)
8 – Antihistamine (sedation)
9 – Antidepressant (this actually results from the Norepi/Serotonin reuptake inhibition, but it balances out the acronym!)

Treatment: HCO3 alkalinization to competitively inhibit Na blockade and decrease TCA affinity for Na channel

Front 78

Sternbach's criteria for serotonin syndrome

Back 78

Recent serotonergic med/med increase, no recent neuroleptics, no other cause, and 3 CAN features

Cognitive

-Agitation, Confusion, Delirium, Hypomania

Autonomic instability

-Tachy, HTN, shiver, diaphoresis, mydriasis, diarrhea

-Neuromuscular activity

Fever, ataxia, tremor, hyperreflexia, myoclonus, muscular rigidity

Front 79

Plants and animals containing cardiac glycosides

Back 79

FLOWeRY BF

Foxglove

Lily of the valley

white Oleander

Weed of milk

Red squill

Yellow oleander

Bofo toad

Firefly

Front 80

What are the indications for monitoring/ admission after electrical injury?

Back 80

Clinical

-Cardiac arrest, LOC, hypoxia, chest pain, suspected conductive injury, other injury requiring admission

ECG

-Abnormal or dysrhythmia has occurred

Risk factors

-Known CAD

-Risk factors for CAD

Front 81

What is the feathering cutaneous burn caused by a lightning strike called?

Back 81

Lictenburg figure

Front 82

How do high voltage electrical injuries differ lightning injuries?

Back 82

More often, high voltage electrical injury causes
-Muscle necrosis

-Rhabdomyolysis

-Compartment syndrome

-Kissing burns

-Mouth burns

But does not cause

-Lictenburg figures

-Karaunoparalysis

Front 83

How do humans transfer heat?

Back 83

Conduction - from a warmer to cooler object through direct physical contact

Convection - loss to circulating air and water molecules

Radiation - transferred by electromagnetic waves

Evaporation - conversion of liquid to gas

Front 84

Contrast heat cramps, heat edema, heat syncope, prickly heat

Back 84

Cramps - due to fluid replacement with hyptonic fluids

Edema - vasodilation causes pooling which leads to swelling

Syncope - vasodilation and dehydration lead to decreased CO and fainting

Prickly heat - obstruct the sweat pores, staph infection, vesicular rash - treat with chlorhexidine cream

Front 85

What is the difference between classic and exertional heatstroke?

Back 85

Classic is in older people with chronic disease in high temperatures, sweating is absent, rhabdo and ARF are rare, lactate is BAD

Exertional is in young people exerting themselves, sweating is common, rhabdo and ARF are common, and lactate is less bad

Front 86

List the ways that a patient can be rewarmed from hypothemic states

Back 86

Active external:

-Bair hugger, AV anastomosis, hot water immersion, heating pads, hot water bottles, radiant heat lamp, negative pressure rewarming

Active internal

-Humidified ventilation, warm IVF, thoracic bladder gastric myocardial or colonic lavage, peritoneal dialysis, ECMO +/- diathermy

Front 87

Causes of syncope

Back 87

P ressure (hypotensive causes)

A rrhythmias - Bradyarrhythmias, Tachyarrhythmia's (SVT, NSVT, A.F.), pacemaker malfunctions

S eizures

S ugar (hypo / hyperglycemia)

O utput (cardiac) - AS, PS, MS, IHSS, Cardiomyopathies, Atrial Myxoma, Cardiac Tamponade, Aortic Dissection, MI, CHF

O 2 (hypoxia) - PE, Pulm HTN, COPD exacerbation, CO poisoning

U nusual causes - Anxiety, Major depressive disorder, Panic disorder, Hyperventilation syndrome, Somatization disorder

T ransient Ischemic Attacks & Strokes, CNS dz's

Front 88

Describe the Haddon matrix

Back 88

Matrix to assess and modify factors related to injury

HAVE

Host

Agent

Vector/Environment

Before, during, and after injury

Front 89

List 3 strategies used to decrease injuries

Back 89

The E's

Education - teaching at risk populations how to prevent injury

Engineering - design safety into the environment (e.g. highway design)

Enforcement - of laws requiring safer behavior (e.g. seatbelts)

Front 90

Hemiparesis ipsilateral to a pupil blown secondary to increased ICP

Back 90

Kernohan's notch syndrome secondary to uncal herniation compressing the contralateral cerebral peduncle. It results in 'false localization'

Front 91

Layers of the scalp and associated hemorrhage

Back 91

SCALP

Skin

Connective Tissue (Caput succedaneum)

Aponeurosis galea

Loose areolar tissue (Subgaleal hematoma)

Periosteum (Cephalohematoma limited by sutures)

Front 92

How can we assess for pseudosubluxation on pediatric c-spine x-rays?

Back 92

Most commonly C2-C3

Look at spinolaminar (Swischuk's) line drawn from anterior cortex of the C1 to C3 spinous process. If the line is >2mm anterior to the anterior cortex of C2 suspect a posterior element fracture.

Front 93

Differences in the pediatric versus adult airway

Back 93

Also note that kids often desat shortly after intubation - be sure to provide PEEP to maintain their smaller than normal FRC

Front 94

Anatomic differences in pediatric patients that change response to trauma

Back 94

-Small size = more multitrauma

-Less protective fat/muscles = more internal organ injuries (liver, spleen, kidneys)

-Elastic chest wall = lung injury without #

-Open growth plates = different fracture patterns

-Large surface area = quicker hypothermia

-Faster metabolic rate = quicker desat, hypoglycemia

-Better at maintaining BP = tachy as only sign of shock

-Bigger head-to-body, thin skull, less myelin = more head injuries

-More elastic vertebral column = more SCIWORA

-Bigger head = higher fulcrum = C2-3 versus C6 injuries more common

Front 95

Anatomic difference in pregnant patients that change response in trauma

Back 95

Airway - more friable and edematous mucosa, lower esophageal sphincter tone, increased abdominal girth

Respiratory - higher RR = greater minute ventilation and lower CO2; higher diaphragm = lower FRC (quicker desat) and req's higher chest tube

Cardiac - Increased blood volume, tachycardia, decreased PVR, increased venous congestion/pressures, lots of blood to uterus, aortocaval compression when supine

Heme - dilutional and Fe-deficiency anemia; hypercoaguable

Abdomen - displaced contents; decreased sensitivity of exam for peritonitis; ALP doubles; decreased GB contractility (increased gallstones; weight gain

Nephro - bladder is extrapulvic after 12 weeks; decreased GFR; polyuria and hydropnephrosis due to bladder compression

MSK - widened pubic symphesis (4 -> 8mm)

Front 96

How can we assess for atlanto-occipital dislocation on pediatric c-spine x-rays?

Back 96

Use power's ratio (should be <1):

Basion to anterior cortex of C1 spinous process

Opisthion to posterior cortex of dens

Also Basion-Dens (BDI) & Basion to posterior axillary line (BAI should be <12mm

Front 97

Tube sizes in pediatrics

Back 97

Broselow tape

ETT = (age/4) + 4 (uncuffed - drop 0.5-1 size for a cuffed tube)

Chest tube = ETT size x 4

Foley / NG tube = ETT size x 2

Front 98

Anatomic difference in elderly patients that change response in trauma

Back 98

General - on medications

Cardiac - decreased reserve, can't increase HR

Pulmonary - decreased compliance and increased chest wall rigidity, brittle bones

Neurologic - brain atrophy increases mobility and shearing of bridging veins (SDH); dura is fused so less EDH

Derm - skin is thin and brittle, easier to lacerate and tear, forms ulcers quicker

MSK - osteopenia so increased fractures, decreased joint mobility, spinal stenosis

Front 99

Approach to hyponatremia

Back 99

Front 100

Effects of typical antipsychotics

Back 100

HOT DAMN

Fever

Dopamine receptor blockade

Alpha blockade

Muscarinic blockade

Na/K channel blockade (wide QRS and long QTc)

Front 101

Addictions that can kill in withdrawl

Back 101

ABBA

Alpha blockers (clonidine)

Benzo's

Barbiturates

Alcohol

Front 102

Nicotinic stimulation effects

Back 102

Monday - mydriasis

Tuesday - tachycardia

Wednesday - weakness

tHursday - hypertension

Friday - fasciculations

Saturday - seizures

And the 3 C's

Confusion

Convulsions

Coma

Front 103

Oxygen toxicity symptoms

Back 103

VENTIAC

V ertigo

E uphoria

N ausea

T innitus

I mpaired judgement

A LOC (Altered LOC)

C onvulsions

Front 104

Lake Louise criteria for AMS

Back 104

Front 105

Lake Louise criteria for HACE

Back 105

Front 106

Lake Louise criteria for HAPE

Back 106

Front 107

The TIMI (NSTEMI) Score

Back 107

2 or more episodes of angina in past 24h

7 days history of ASA use

C AD (known and >50%)

A ge > 65

R isk factors (>3)

T roponin

S T changes

Gives 14 day risk of death, MI, or need for revascularization (0-1 = 5%; 6-7 = 40%)

Front 108

Predictors of difficult BVM

Back 108

B eard

O bstructed / O bese / O SA

N eck stiffness / N eck mass

E xpecting (pregnant)

S tridor / S nores

Front 109

Predictors of difficult intubation

Back 109

L ook externally

E valuate 3-3-2

M allampati

O bstruction / O besity

N eck mobility (decreased)

Front 110

Predictors of difficult cric

Back 110

S urgery

H ematoma / H ave infection (abscess)

O besity

R adiation

T rauma / T umor

Front 111

Predictors of difficult LMA

Back 111

R estricted mouth opening

O bstruction

D istored airway anatomy

S tiff lungs / Neck

Front 112

What are the lines of the cervical spine?

Back 112

Front 113

How do you assess for pseudosubluxation in the pediatric C-spine?

Back 113

Swischuk's line (anterior arch of C1-C3 is within 2mm of C2)

Front 114

Cervical spine fracture mechanisms

Back 114

All are flexion, except:

Vertical Compression - Burst & Jefferson

Extension - C1 neural arch, Hangman, Extension teardrop

Flexion-rotation - Unilateral facet, Rotary atlantoaxial

Front 115

Sensory spinal levels

Back 115

Front 116

Motor spinal levels

Back 116

Front 117

Reflex spinal levels

Back 117

Front 118

Describe the motor deficit in central cord syndrome, causes

Back 118

It is MUDdy!

Motor > sensory

Upper > lower

Distal > proximal

Causes - hyperextension injury of neck, elderly with spinal stenosis

Front 119

Signs of aortic dissection on CXR

Back 119

Wide CHAPPLA1N

Wide mediastinum (8cm AP, 6cm PA, >25% chest width at aortic knob)

C alcium sign

H emothorax

A ortic knob obscured

P aratracheal stripe widened

P leural cap

L eft mainstem bronchus depressed

A ortic window lost

1 st rib fracture

N G deviates to the right along with trachea

Front 120

Occlusive and nonocclusive arterial injuries

Back 120

Occlusive

-Transection

-Thrombosis

-Arterial spasm (reversible)

Nonocclusive

-Intimal flap

-Pseudoaneurysm

-AVM

-Compartment syndrome

Front 121

Diagnostic aid for a migraine

Back 121

Migraine is likely with two or more of the POUND criteria:

-P ounding

-hO urs lasts (4-72)

-U nilateral

-N ausea and vomiting

-D ebilitating

Front 122

International Headache Society Migraine Definition (without aura)

Back 122

1 --> 4 to 72 hours

2 --> At least two of the following:

-Aggravation by or causing avoidance of routine physical activity

-Moderate or severe pain intensity

-Pulsating quality

-Unilateral location

3 --> During headache, at least one of the following:

-Nausea and/or vomiting

-Photophobia and phonophobia

4 --> Not attributed to another disorder

5 --> History of at least five attacks fulfilling above criteria

Front 123

Causes of pancreatitis

Back 123

I GET SMASHED

I diopathic

G allstones

E thanol

T umors (pancreas, ampula, choledochal)

S corpion stings

M icro - Bacterial (Mycoplasma, Camylobacter, TB), Viral (Mumps, Coxsackie, Rubella, Varicella, CMV, hepatitis, EBV), Parasites (ascaris, echinococcus)

A utoimmune (SLE, PAN, Crohn's)

S urgery / trauma

H yperlipidemia / H ypercalcemia (hyperparathyroid)

E mboli / ischemia

D rugs / toxins (ethanol, azathioprine, lasix, HCTZ, estrogens, valproic acid, tegetrol, APAP, ASA, sulfonamides)

Front 124

Types/causes of diarrhea

Back 124

MMISO

M alabsorption (short gut, CF, IBD, celiac, lactose intolerant)

M otility (DM, neuromuscular, scleroderma)

I nflammatory - cellular damage causing secretion; can be hemorrhagic (enterohemorrhagic E Coli, Salmonella) or IBD, autoimmune, chemo

S ecretory (Toxin-mediated chloride secretion: Enterotoxic E Coli, Shigella, Salmonella, Vibrio, C Diff; does not decrease with fasting)

O smotic (altered gut flora from Noro or Rotavirus; ingestion of sorbitol or lactulose; decreases with fasting)

Front 125

Causes of occult irritability in children

Back 125

FAT SHIC

F racture

A buse

T esticular torsion

S urgical abdomen (hernia)

H air tourniquet

I mproper feeding

C orneal abrasion / C olic

Also: diaper rash, anal fissure

Front 126

Dermatologic findings in pediatric seizures due to neurocutaneous disorders

Back 126

Cafe au lait - Neurofibromatosis

Ash leave - Tuberous sclerosis

Port au Wine Staine - Sturge-Weber

Front 127

Appearance assessment of the pediatric assessment triad

Back 127

TICLS

Tone

Interactivity

Consolability

Look/gaze

Speech/cry

Front 128

Lateral soft tissue x-ray findings of epiglottitis

Back 128

AAA PBL on TV

A ir fluid level

A ryepiglottic fold swelling

A rytenoid swelling

P revertebral tissue swelling

B allooning of the hypopharynx

L oss of L ordosis

T humbprint epiglottis

V allecula obliteration

Front 129

Approach to the striderous child

Back 129

Supraglottic

-Congenital (Micrognathia, Macroglossia, Choanal atresia)

-Acquired (Retropharyngeal abscess, Epiglottitis)

Glottic

-Congenital (Laryngeal web, Vocal cord paralysis, Laryngeomalacia)

-Acquired (Laryngeal papilloma)

Subglottic

-Congenital (Subglottic stenosis, Hemangioma)

-Acquired (Croup, Subglottic stenosis)

Tracheal

-Congenital (Tracheomalacia, Tracheal stenosis, vascular ring)

-Acquired (Bacterial tracheitis, Foreign body)

Front 130

Signs of retrobulbar hemorrhage and indications for lateral canthotomy

Back 130

DIP A CONE (DIP is primary indications; A CONE is secondary)

D ecreased VA

I ncreased IOP (>40)

P roptosis

A fferent pupillary defect

C herry red macula

O pthalmoplegia

N erve head pallor

E ye pain

Front 131

Medical treatment of increased IOP

Back 131

ABCDPS

A lpha 2 agonist (Apraclonidine 1% - decrease production and increase outflow)

B eta blocker (Timolol 0.5% - decrease humor production)

C holinergic (Pilocarpine 1% - constricts pupil and opens trabecular meshwork)

D iuretics (acetazolamide decrease production and increase flow / mannitol - increased drainage)

P rostaglandins (Latanoprost - increase outflow)

S teroids (Prednisone acetate 1% - decrease inflammation)

Front 132

Indications for referral to opthalmology of an eyelid laceration

Back 132

The 5 L's

L id margin

L acrimal system

L evator or canthal tendons

L oss of tissue

L eaking of fat

Front 133

DDx for sudden visual loss

Back 133

Anatomic

Anterior chamber - hyphema, hypopiom, glaucoma

Iris/lens - lens dislocation, iritis

Posterior chamber - posterior vitreous detachment or hemorrhage

Retina - Retinal detachment, central venous occlusion, central arterial occlusion

Neuro-opthalmologic - pre-chiasm (optic neuritis due to ischemia/compression/toxin), chiasmal (tumor), post-chiasm (CVA, tumor, AVM, migraine), visual cortex (CVA)

Front 134

Kanavel signs of flexor tenosynovitis

Back 134

Fingers held in slight flexion

Fusiform (symmetrical) swelling

Pain to palpation of flexor tendon

Pain on passive extension

Front 135

Hand motor testing

Back 135

Radial nerve - wrist extension (get wrist drop)

Posterior interosseous branch of the radial nerve - thumb extension (get Monkey hand)

Median nerve - thumb opposition to fingers

Anterior interosseous branch of the median nerve - OK sign (thumb IP flexion)

Ulnar nerve - Froment's paper sign; finger abduction and adduction (get Claw hand)

Axillary nerve - Shoulder abduction

Front 136

Hand sensation testing

Back 136

Radial nerve - dorsal 1st web space

Median nerve - volar tip of D2

Ulnar nerve - volar tip of D5

Axillary nerve - deltoid distribution

Front 137

Back pain red flags

Back 137

Infectious - fever, IVDU

Fracture - history of trauma

Cancer - weight loss, history of cancer

Cauda equina - urinary retention, fecal incontinence, saddle anesthesia, distal weakness

Nocturnal pain

Front 138

Indications for lumbar spine x-rays

Back 138

M alignancy

A ge (<18 or >50)

F ever

I mmunocompromised

N euro deficits (progressive)

D uration (>4-6 weeks)

W eight loss

I VDU

T rauma

Front 139

Lines of the pelvis x-ray

Back 139

Front 140

One pill can kill

Back 140

Alpha blocker (clonidine)

Antihyperglycemic agents (sulfonylureas like gliclazide, glyburide)

Beta blockers

Barbiturates

Calcium channel blockers / Camphor / Chloroquine

Digoxin

Hypoglycemic agents (sulfonylureas)

MAO-I

Methadone

Methyl salicylate

Theophylline

TCA

Toxic alcohol

Iron

Lomotil

Front 141

Drugs that cause seizures

Back 141

WITH LA COPS

W ithdrawal / Wellbutrin

I NH

T heophylline / TCA
H ypoglycemic agents

L ithium / L ocal anesthetics / L ead

A nticholinergics

C holinergics / C amphor

O rganophosphates

P CP

S alicylates / Sympathomimetics

Front 142

Drugs MDAC is appropriate for

Back 142

Please Quit Drinking the AC Dummy

Phenobarb

Quinine

Dapsone

Theophylline / TCA (maybe)

ASA (concretions)
Carbamezapine

Digoxin (maybe) / Dilantin (maybe) / Dabigitran

Consider more in sustained release formulations

Front 143

Dialyzable drugs

Back 143

A BIT SLIME

A rsenic / ANTS (BB's Atenolol / Nadolol / Timolol / Sotalol)

B arbiturates

I soniazid

T heophylline

S alicylates

L ithium

I ctogenic drugs (Valproate, Phenobarb, Carbamezapine)

M ethanol

E thylene glycol / E thanol

D abigitran

Front 144

Indications for reduction of a distal radius fracture

Back 144

Step >1mm

Radial inclination <15 degrees (normal 22)

Volar tilt less than 0 degrees (normal 10-25)

Decreased radial height (normal 11mm, loss of 2mm relative to other side is short)

Front 145

Clavicle fracture's requiring orthopedic consultation

Back 145

The rule of 2's

>2 cm displacement

2 or more pieces

<2cm from either end of the clavicle

>2cm of shortening

2 good 2 be true

Front 146

Shoulder dislocation techniques

Back 146

Stimson - prone, arm hanging with weight x 20 minutes

Traction-countertraction - sheet under arm for countertraction, abducted arm

FARES - supine, slow abduction with flexion/extension until 90 degrees then external rotation

Milch - supine at 45 degrees, external rotation and abduction to 90/90 then longitudinal traction

Scapular manipulation - can be added to traction/countertraction and Stimson, rotate inferior tip medially

Cunningham - seated, shoulders adducted, elbow flexed with shoulder on provider shoulder, massage of bicep at mid-humeral level

Front 147

Open fracture classification and management

Back 147

Gustillo classification system

I - <1cm, clean, tx with 1st gen cephalosporin

II - >1cm, minimal soft tissue damage, tx with 1st gen cephalosporin

IIIa - significant soft tissue damage with adequate coverage, 1st gen cephalosporin and aminoglycoside (gentamicin)

IIIb - significant soft tissue damage with INadequate coverage, same tx as IIIa

IIIc - open # with vascular injury , same tx as IIIa

Add Pen G or Clinda if concern for anaerobes (farm injury) and Cipro if concern for salt water (pseudomonas)

Irrigate, cover, splint without reduction UNLESS N-V compromise

Front 148

Femoral nerve injury

Back 148

Motor - weak knee extension, can't climb stairs or get up from sitting

Sensory - varies, most reliable superomedial to patella

Reflex - decreased patellar

Front 149

Sciatic nerve injury

Back 149

Motor - paralysis of hamstring (knee flexion) and all muscles below the knee

Sensory - posterior thigh and below the knee

Reflex - decreased Achilles tendon

Front 150

Hip reduction techniques

Back 150

Allis - patient supine with hip and knee flexed to 90 degrees, get on bed and provide vertical upward traction while someone holds the pelvis to the bed. Works for posterior and anterior-obturator (femoral head seen over obturator foramen).

Stimson - patient prone with one leg hanging off of the bed, flex hip and knee to 90 degrees, vertical downward traction while someone holds the pelvis/pushes down on the femoral head.

Whistler - patient supine, arm under knee of dislocated hip with arm on opposite knee (both legs flexed at the hip/knee) to use opposite leg as a fulcrum. A modification of this is the Captain Morgan with your leg under the patient's knee instead of your hand.

Front 151

Kocher criteria to distinguish septic arthritis from transient synovitis

Back 151

With 0-4 criteria the likelihood is: 2%, 9.5%, 35%, 73%, 93%

-Non weight bearing

-ESR >40

-WBC >12

-Fever > 38.5

CRP >20 is also predictive

Front 152

Ottawa Knee Rule

Back 152

Get x-rays if:

Age >55

Inability to transfer weight 4 times at time of injury OR in ED

Inability to flex to 90 degrees

Patellar tenderness

Fibular head tenderness

Front 153

Ottawa Ankle Rule

Back 153

Applied to acute ankle injuries with malleolar pain (not hindfoot, forefoot, upper fibula)

-Pain to posterior edge of the lateral malleolus from its distal part and 6cm proximal

-Pain to the posterior edge of the medial malleolus from its distal part and 6cm proximal

-Unable to weight bear 4 steps immediately after the injury and in the ED

Front 154

Ottawa Foot Rule

Back 154

-Pain over the navicular bone

-Pain to the base of the 5th metatarsal

-Unable to weight bear 4 steps immediately after the injury and in the ED

Front 155

How do you calculate Boehler's angle?

Back 155

A = Posterior tuberosity

B = Apex of posterior facet

C = Apex of anterior process

Front 156

Bones at high risk of AVN

Back 156

-Head of femur (Legg-Calve-Perthes syndrome in children generally 4-10yo)

-Head of humerus

-Scaphoid

-Capitate

-Lunate (Kienbock's disease)

-Patella

-Talus

-Navicular (Kohler's disease)

-Second metatarsal

Front 157

DDx for non-accidental trauma in children (fractures and bruising)

Back 157

-Osteogenesis Imperfecta

-Rickets

-Scurvy

-Menkes' Kinky Hair Syndrome

-Hypervitaminosis A

-Hypoparathyroidism

-Congenital Syphilis

-Pathologic fractures

-Birth fractures

-Metaphyseal cupping & spurring (normal variant - bilateral, diaphyseal, smooth)

-Periosteal new bone formation (normal variant - especially to the femur)

-Cultural practices (Cupping, Coining, Spooning)

-Bleeding disorders (hemophilia, vWD, HSP)

-Mongolian spots

-Hemangioma

-'Tattooing'

-ITP

-HSP

-Secondary syphilis

Front 158

Diagnostic criteria for staph toxic shock syndrome

Back 158

DR FrOH (NO culture needed)

D esquamation of the skin (begins during recovery phase after 1-2 weeks;

R ash (blanching, macular, erythematous, NOT itchy, fades before desquamation)

F ever (>38.9)

r

O rgan systems (>3/7 involved: CNS, mucous membranes, GI, renal, hepatic, heme, MSK)

H ypotension (sBP < 90 or < 5th percentile in children)

Front 159

Diagnostic criteria for strep toxic shock syndrome

Back 159

You going to the strep SHO?

S erology (isolation from a sterile [definite] or nonsterile [non-definite] site)

H ypotension (sBP<90 or <5th percentile)

O rgan systems (>2/6 involved: Renal, Heme, Liver, Lung, Rash, Soft tissue necrosis)

Front 160

Determining capacity

Back 160

C ommunication

U nderstanding

R easoning

V alues

E mergency

S urrogate

Front 161

When can implied consent be assumed

Back 161

-Patient does not have capacity to express their preferences (CURV)

-Immediate action is required (E)

-No surrogate decision maker (S)

Front 162

Signs of Lithium toxicity

Back 162

SNAP MUD

S eizures

N /V/D

A taxia

P arkinsonian

M yoclonus

U MN

D elirium/D ecreased LOC

Chronic: nephrogenic DI and hypothyroidism and SILENT (syndrome of irriversable lithium effectuated neuro toxicity - cerebellar dysfunction, EPS, dementia)

Look for LOW AG

Front 163

Infections requiring airborne precautions

Back 163

Respiratory TB

Measles

SARS
Smallpox / Monkey Pox / Varicella (chickenpox and disseminated zoster)

+/- Ebola and TB (during aerosolizing procedures)

Front 164

AIDS-defining illnesses

Back 164

Heme

-CD4<200

Malignancies

-Kaposi's Sarcoma

-Lymphoma

-Cervical cancer (invasive)

Neuro

-HIV-associated encephalopathy

-Progressive multifocal leukoencephalopathy

-Toxoplasmosis of brain

Fungal infection

-Candida (esophageal or pulmonary)

-Histoplasmosis

-Cryptococcus

-Coccidiomycosis

Protozoa infection

-PJP pneumonia

-Isosporiasis

-Toxoplasma gondii

-Cryptosporidium

Viral

-HSV (persistent, pneumonia, esophagitis)

-CMV (except spleen/liver/lymphatics)

Bacterial infection

-Tuberculosis

-Mycobacterium avium complex

-Salmonella sepsis

-Recurrent bacterial infections

Front 165

SIRS

Back 165

HR > 90

RR < 20 OR PaCO2 <32

T < 36 OR > 38

WBC <4 OR >12 OR >10% bands

Front 166

Definition of ARDS

Back 166

As per the 2012 Berlin Definition

-Respiratory symptoms started or worsened acutely with the last week

-PaCO2 / FiO2 ratio 200-300 = mild, 100-200 = moderate, <100 = severe

-Bilateral pulmonary infiltrates (CXR or CT)

-Not in cardiac failure / no fluid overload

Front 167

Malaria: Organism, Vector, Incubation, Presentation, Complications, Diagnosis, Treatment

Back 167

-Organism: Plasmodium Falciparum is most dangerous (also Ovale, Vivax, Malariae)

-Vector: Female anopheles mosquito

-Incubation: 8-28 days

-Presentation: Fever in the returning traveler, anemia, constitutional (weak, dizzy, N/V/D, lethargy, myalgia, arthralgia, CP, abd pain, SOB)

-Complications: cerebral/seizures, encephalopathy, ARDS, ARI, DIC, anemia, acidosis, hypoglycemia

-Diagnosis: Thin and thick peripheral blood smears q8-12h x 3d; also PCR/dark field microscopy; U/S shows splenomegaly/papilledema

-Treatment: Chloroquine if sensitive; otherwise quinine & doxycycline

Front 168

Lyme disease: Organism, Vector, Incubation, Presentation, Diagnosis, Complications, Treatment

Back 168

-Organism: Borrelia Borgdorferi (spirochete)

-Vector: Ixodes Tick

-Incubation: Tick must attach long enough (>36 hours) or be engorged

-Presentation: 1st stage (days-weeks) erythema migrans & flu-like symptoms/HA; 2nd stage (3-5 weeks) with fluctuating meningoencephalitis/bilat Bells palsy, conduction block/pericarditis, arthritis, keratoconjunctivitis; 3rd stage (>1y) with fatigue syndrome, encephalopathy, radiculopathy, acrodermatitis, and arthritis

-Diagnosis: Tick bite, IgM+ from 3-6 weeks, IgG+ >1 month (send both)

-Complications: Can get Jarisch-Herxheimer reaction when tx started

-Treatment: prophylax within 72h in endemic areas (>20% ticks +) if adult tick on for >36h/engorged - use Doxy 200mg x1; treat with Doxy 200mg BID x 28d (Amoxil in <8/pregnant; Ceftriaxone if meningitis)

Front 169

Rocky Mountain Spotted Fever: Organism, Vector, Incubation, Presentation, Diagnosis, Complications, Treatment

Back 169

-Organism: Rickettsia Rickettsii

-Vector: Rocky Mountain Wood Tick

-Presentation: Sudden onset fever followed by N/V/abd pain/HA. Gets into vessels and releases tPA & vWF causing microthrombi and vascular permeability. Petechiae develop on wrists/hands then spread inward. Also cardiac (AVB, myocarditis), pulmonary (ARDS), neurologic (meningismis, transient deficits due to microinfarcts), renal (microinfarcts), heme (DIC).

-Diagnosis: Serology not positive for 1/52 but req'd for conclusive Dx. Also PCR+ or skin bx at 4-10 days (immunoflorescence +). Probable if clinical criteria; Confirmed with lab.

-Complications: Death due to renal failure then ARDS/myocarditis/DIC in 25% if not treated

-Treatment: Doxycycline 100mg po bid until asymptomatic x 3d or 7 days. Steroids if severe.

Front 170

Things that shift the oxygen-hemoglobin dissociation curve

Back 170

CADETS turn right and fall down

(right shift and decreased oxygen affinity)

C - CO2

A - Acid

D - 2,3 DPG

E - Exercise

T - Temperature

S - Sickled Hb S

NOTE: CO shifts to the left

Front 171

Diagnostic criteria for delerium

Back 171

4 criteria:

-Inability to focus/Inattention

-Fluctuating course

-Cognitive deficit (memory, disorientation, language) or perceptual disturbance not caused by dementia

-Evidence that it is caused by a medical condition, ingestion, or withdrawl

Front 172

Diagnostic criteria for dementia

Back 172

1 - Memory impairment AND

2 - One of aphasia, apraxia, agnosia, impairment in executive functioning

-Causing significant impairment

-NOT due to delerium

Front 173

Treatment of active TB

Back 173

RIPE (side effects) x 9 months!

R ifampin (orange body fluid)

I soniazid (INH injures nerves and hepatocytes)

P yrazinomide

E thambutol (E=eyes - optic neuritis; can't distinguish red/green)

Front 174

Treatment for hyperkalemia

Back 174

C BIG K Drop

C alcium (stablize)

B eta agonist / B icarbonate (shift)

I nsulin (shift)

G lucose

K ayexalate (eliminate)

D iuretics - Furosemide (eliminate)

R enal dialysis (eliminate)

o

p

Front 175

GBS: Cause, Presentation, Diagnosis, Complications, Treatment

Back 175

Cause: idiopathic, often secondary to Campylobacter, Mycoplasma, CMV or EBV - results in antibodies to nerves

Presentation: progressive ascending symmetric weakness and areflexia; Miller-Fischer variant starts centrally (areflexia, ataxia, opthalmoplegia with III/IV/VI affected). Also has autonomic dysfunction (tx brady with atropine; use short acting for hypertension, fluids for hypotension)

Diagnosis: CSF elevated protein, normal glucose and WBC

Complications: respiratory compromise req'ing intubation if FVC <20ml/kg or NIF <30mL/kg

Treatment: IVIg or plasmaphoresis

Front 176

Myasthenia Gravis: Cause, Presentation, Diagnosis, Complications, Treatment

Back 176

Cause: Antibodies to post-synaptic ACh receptors (take spots & destroy them); set off by BB/ CCB/ Thyroxine/ Steroids/ Surgery/ Trauma/ Infection

Presentation: Ptosis, Diplopia, Dysarthria, Dysphagia, Blurred vision with spared pupils, resp failure. Treated patients can present with cholinergic crisis.

Diagnosis: Tensilon test, ice to eyes, NIF (<15 intubate)/FVC (<15 intubate); check for anti-AChR antibodies

Treatment: Plasma exchange or IVIg (neostigmine and/or thymectomy for chronic); intubate with cisatracurium (Hoffman degradation)

Front 177

DDx of bulbar neuropathy

Back 177

-Myasthenia gravis

-Lambert-Eaton myasthenic syndrome

-ALS

-Miller-Fisher variant GBS

-Elapidae (coral snake) or Hydraphidae (sea snake) envenomation

-Botulism

-Lyme disease

-Organophosphate poisoning

-Congenital syndrome

-Penicillamine toxicity

Front 178

Gram stain results of bacteria

Back 178

Staph: Gram+ cocci in singles, doubles, tetrads or clusters

Strep: Gram+ paired diplococci (other strep in pairs/chains)

Listeria: Gram+ rods single or chains

Moraxella caterrhalis: Gram- diplococci

Neisseria: Gram- paired diplococci

H Flu: Gram- coccobacilli

E Coli: Gram- rods

Pseudomonas: Gram- rods

Front 179

Angina Classification

Back 179

Canadian Cardiovascular Society

I - No limitation of ordinary activity

II - Mild limitation. Symptoms at >1-2 blocks or >1 flight of stairs.

III - Moderate limitation. Symptoms at <1-2 blocks or <1 flight of stairs.

IV - Severe limitation. Symptoms at rest.

Front 180

Definition of stable angina

Back 180

Predictable

Transient (<15m)

Reproducible with activity

Relieved with rest/nitro

Front 181

Definition of acute MI

Back 181

-Rise and fall of troponin with: ischemic symptoms, Q waves, ST/T changes, coronary artery intervention

-Pathological evidence

Front 182

Types of myocardial infarction

Back 182

I - ischemia due to a primary coronary event (plaque rupture or dissection)

II - supply-demand ischemia

III - sudden cardiac death with symptoms of MI

IV - MI with coronary instrumentation

V - MI with CABG

Front 183

At risk for an atypical presentation of MI

Back 183

Aunt Jemima with dementia

-Elderly

-Diabetic (from all the syrup)

-Non-white

-Female

-Dementia

-Hyperlipidemia (from all the sausages)

Also: No prior history of MI, history of stroke, /CHF, no family history

Front 184

Liver transplant criteria in acetaminophen-induced and non-acetaminophen-induced fulminant hepatic failure (King's College criteria)

Back 184

Acetaminophen induced

pH <7.3 or lactate >3 after 12h of resuscitation

Lactate >3.5 after 4h of resuscitation

OR all 3 of:

-Cr >300

-INR >6.5

-Grade 3-4 hepatic encephalopathy

Non-acetaminophen induced

INR >6.5

OR 3/5 of:

J aundice >1 week prior to encephalopathy

A ge <10 or >40

N on-A non-B hepatitis

E tiology: indeterminate or drug reaction

B ilirubin >300mmol/L

I NR >3.5

Front 185

Sgarbossa Criteria

Back 185

In setting of LBBB, the criteria for calling AMI is >3 points:

>1mm concordant STE (OR 25, 5 points)

>1mm STD in v1, v2, v3 (OR 6, 3 points)

>5mm discordant STE (OR 4.3, 2 points)

Also look at ST (baseline to T) / S (top of S to baseline) ratio <-0.25

Front 186

Classification of AMI severity

Back 186

Killip classes

1 no failure

2 crackles, S3, elevated JVP

3 frank pulmonary edema

4 cardiogenic shock, hypotension, vasoconstriction (oligurea & cyanosis)

Front 187

What are the target times for ACS?

Back 187

Door

Data (10m)

Decision

Drug (lytic 30m, PCI 90m in center)

Front 188

What is the Ashman phenomenom?

Back 188

-Seen in supraventricular tachyarrhythmias (generally AFib)

-Long R-R interval (has long refractory period) followed by a short R-R interval results in part of the right bundle being refractory

-Get a RBBB waveform that looks like a PVC

Front 189

Mechanisms for arrhythmias

Back 189

-Increased automaticity (ischemia, electrolytes, drugs)

-Reentry (req's 2 conduction pathways with different responsiveness and conduction speed)

-Triggered (early afterpolarizations in brady/long QTc; treat by increasing HR vs late afterpolarizations in tachy/increased Ca; treat by slowing HR and decreasing Ca)

Front 190

Antiarrhythmic types/actions

Back 190

Some Buggers Kill Cats

S odium channel blocker (a block fast, b block inactivated phase, c block both) - procainamide/TCA/cocaine, lidocaine/phenytoin, flecainide/dilantin

B eta blocker - propranolol/esmolol

K potassium channel blocker - amiodarone/sotalol

C alcium channel blocker (slow) - verapamil/diltiazam

Front 191

How does Digoxin work?

Back 191

1 - Blocks Na/K ATPase leading to increased intracellular Ca++ (increased inotropy, tachyarrhythmias)

2 - Increases vagal tone (anti-arrhythmic, bradyarrhythmias)

Front 192

Non-compensatory pause vs compensatory pause

Back 192

Non-compensatory pause: sinus node is reset and beat following the aberrant beat occurs at the same R-R interval as it would have if it came after a regular beat.

Compensatory pause: sinus node is NOT reset. One sinus beat is not conducted (meets refractory AVN) and the next is. The next beat comes after exactly 2x the standard R-R interval.

Front 193

DDx for irregular SVT

Back 193

-AFib

-MAT

-Atrial flutter/tachy with variable conduction

-Parasystole

-Extrasystoles

Front 194

Contraindications to ED Cardioversion of AFib

Back 194

1 - Lasted > 48 hours

2 - Rheumatic heart disease

3 - Mechanical valve

4 - History of stroke/TIA

Front 195

Risk stratification for AFib - who needs anticoagulation?

Back 195

CHADS2

C HF

H ypertension

A ge > 75 (2 points)

D iabetes

S troke before (2 points)

V ascular disease

Age 65-74

Sec (female)

0 = nil; 1 = ASA or anticoagulant (1/3%/y); 2 = anticoagulant (2.2%/y)

Front 196

Strong predictors of VT in a rapid wide-complex tachycardia

Back 196

-AV Dissociation

-Fusion beats

-Capture beats

-QRS >0.16

-R to nadir of S >0.14

-Extreme left axis

-Josephson's sign (notching near the nadir of the S wave - a smaller R prime than R)

Brugada and Griffith criteria are too unreliable for use and likely cause harm

Front 197

Congenital vs Adult Torsades

Back 197

Congenital: precipitated by tachycardia, catacholamine excess, and delayed afterpolarization, treat with beta blockers, associated with Romano-Ward syndrome (LQT1 K channel and LQT3 Na channel) and Jervall & Lange Nielson (LQT1 K channel) syndrome

Adult: precipitated by bradycardia, early afterpolarization, treat with beta agonists, associated with drugs

Front 198

Drugs that prolong QT

Back 198

Antidysrhythmics Ia, Ic, III: procainamide, propafenone, amiodarone

Antibiotics: azithromycin, ciprofloxacin

Antipsychotics: haloperidol

Antiemetics: ondansetron, metoclopramide

Anticonvulsants:

Antihistamines:

Antifungals:

Antimalarials: chloroquine

Antidepressants: TCA, citalopram

Analgesia: Methadone

Also, hypoCa, hypoMg, hypoK

Front 199

Effect and indications for use of a magnet on a pacemaker

Back 199

Changes a standard pacemaker to VOO mode and turns off defibrillation in an ICD/pacemaker

-Atrial tachycardia with rapid ventricular rate

-Runaway pacemaker (re-entry tachycardia)

-Bradycardia due to oversensing

Front 200

Causes of ICD malfunction

Back 200

Frequent shocks

-Shocking SVT

-Oversensing T waves

-Having frequent VF/VT (hypoK, hypoMg, Ischemia, drug-induced)

Inadequate shocks (dizzy/syncope)

-Undersensing VT

-Shocks not strong enough

-Inadequate backup pacing for brady

Cardiac arrest

-Likely VF did not respond to defibrillation

-May have not detected VF (change parameters)

Front 201

Anemia differential approach

Back 201

Decreased production

-Lack of stimulation (renal disease, chronic disease)

-Unfunctional marrow (infiltrative disease: amyloid, metastasis; marrow disorders: aplastic, myelofibrosis; blood cancers: lymphoma, leukemia; tox: heavy metals, clozapine)

-Lack components (B12, Folate, Fe)

Increased destruction

-Intravascular (mechanical: prosthetics and microangiopathic DIC/TTP; transfusion reaction: ABO, antibodies; defects: G6PD, sickling)

-Extravascular (abnormal RBC: spherocytosis, thalassemia)

Front 202

Causes of sideroblastic anemia

Back 202

Impaired production of porphoryn; leads to anemia and excess Fe in RBC's (Fe ring in sideroblasts)

-Toxins: Lead, Alcohol & INH

-Premalignant condition in elderly (often get AML)

-Malignancy

-RA

-Pyridoxime deficiency

Front 203

Paroxysmal nocturnal hemglobinuria

Back 203

Definition - Stem cell defect with abnormal sensitivity of RBCs, neutrophils and platelets to complement

Diagnosis - Get hemosiderinurea, low RBC/Plt/Neutrophils, chronic hemolysis

-Luekocyte alkanine phosphatase levels are elevated

-Complications: thrombosis of arteries and hepatic vein. Also MUST transfuse with WASHED RBC's or compliment on them will lead to lysis.

Front 204

Encapsulated bacteria

Back 204

Even SSome Nasty Killers Have Capsular Protection

E coli (some strains)

S trep pneumoniae

S almonella typhi

N eisseria meningitidis

K lebsiella pneumoniae

H aemophilus influenzae

C ryptococcus neoformans (yeast)

P seudomonas aeruginosa

Front 205

Equipment required for a neonatal resuscitation

Back 205

Be prepared for baby WOBLIES

W armer / polyethylene bag - all babies

O xygen (blended) - for persistent hypoxia

B ag and mask - if HR<100, gasping, apnea give 40-60 bpm with PPV

L aryngoscope (0 or 1 McGill or Mac) and ETT (3.5) - for meconium suctioning, ineffective/prolonged BVM, chest compressions

I ncubator for transport

E pinephrine 0.01-0.03mg/kg / 0.1-0.3mL of 1:10,000

1:1,000 = 1mg/mL

1:10,000 = 0.1mg/mL

S uction

Front 206

Does the baby need resuscitation?

Back 206

Term?

Breathing or crying?

Muscle tone?

If yes, no resuscitation needed

Front 207

Neonatal CPR

Back 207

CPR is indicated if the infant's HR is <60bpm despite 30s of adequate PPV.

Chest compression rate is 90/minute

Breathing rate is 30/minute (q 3 chest compressions)

Epinephrine is used if HR <60bpm after 30s of CPR (dose 0.1-0.3mL/kg of 1:10,000 epi IV)

Front 208

When should an infant not be resuscitated?

Back 208

-<24 weeks / SFH < umbilicus

-<500g birth weight

-Anencephaly

-Known chromosomal abnormalities incompatible with life (trisomy 13 or 18)

-Stop resuscitation at 10m if there has been no HR or respiratory effort

Front 209

Causes of ascending paralysis

Back 209

Goes BOTTOM VP

G BS

B uckthorn / B-virus (Herpes Simiae)

O rganophosphate (extremity exposure)

T ick paralysis

T oxic neuropathies (DM, EtOH, B-vitamin deficiencies, Buckthorn)

M etabolic (hyperkalemic periodic paralysis)

V iral (Rabies, CNS VZV/CMV, West Nile)

P olio

Front 210

Causes of hemolytic anemia (low haptoglobin, high LDH)

Back 210

Intrinsic:

-Enzymes (Pyruvate Kinase or G6PD)

-Membrane (Spherocytosis, Elliptocytosis, PNH)

-Heme (Thallasemia, Sickle Cell)

Extrinsic

-Mechanical (Microangiopathic - DIC/TTP/HUS/Vasculitis/Preeclampsia)

-Other (valves, march)

-Immunologic

--> Alloimmune (ABO IgM intravasc / Rh IgG extravasc)

--> Autoimmune (Reticular neoplasms [CML, CLL, lymphoma, myeloma], Inflammatory (SLE/RA/PAN/UC), Drugs (quinine, quinidine, methyldopa, PCN/cephalosporins, sulfa), Infectious (CMV/EBV/Mycoplasma/Coxsackie/Hepatitis), Thyroid,

Environmental (hyperthermia, brown recluse bites, freshwater drowning, burns, snakes, malaria)

Abnormal sequestration (hypersplenism)

Front 211

Pentad of TTP

Back 211

CRAFTY

C NS changes (fluctuating seizures, paresthesias, altered LOC)

R enal failure (ARI, hematuria, proteinuria)

A nemia (microangiopathic hemolytic with schistocytes)

F ever

T hrombocytopenia (Plts 10-50)

Front 212

Erythema nodosum causes

Back 212

BELTY SLIPS

B ehcets

E strogen

L ofgran's

T B

Y = V iral (#2)

S trep (#1)

L ymphoma (NHL) and Leukemia

I BD

P CN

S ulpha

Front 213

Define and give a DDx for ALTE. How many kids with ALTE have SIDS?

Back 213

ALTE is an acute, unexpected change in an infant's breathing (apnea, choking, or gagging), appearance (color change), or behavior (loss of muscle tone) that frightens the observer.

Prevalence peaks at 10-12 weeks but can occur in children <1yo.

ALTE's not correlated with SIDS!

-Neuro - Seizures/Hydrocephalus

-Cardiac - Arrhythmia, Congenital heart disease

-Respiratory tract infection (Pertussis, RSV)

-GI - GERD (Sandifer syndrome)

-Metabolic - Hypoglycemia, inborn errors of metabolism, hyponatremia

-Sepsis - pneumonia, UTI

-Heme - anemia

-NAT

-Factitious illness

-Toxins

Front 214

HUS vs TTP vs DIC

Back 214

HUS

-Caused by Shiga toxin of O157:H7

-Renal symptoms predominate

-Consumptive (elevated DDimer decreased haptoglobin but normal LDH)

-Children with bloody diarrhea

-Plasmapheresis ineffective

TTP

-Caused by lack of ADAMTS13 (? autoimmune) not cleaving vWF precursor

-Neuro symptoms predominate

-Adults

-Non-consumptive (normal DDimer/Haptoglobin/fibrinogen but elevated LDH)

-Schistocytes

-Treat with plasmaphoresis or plasma exchange

DIC

-Consumptive: low fibrinogin and fibrin levels; high DDimer

-Bleeding and clotting at the same time; ultimately bleed when factors gone

-Schistocytes, anemia, thrombocytopenia

-Caused by multiple underlying disorders

Front 215

Treatment options in patients with vWD

Back 215

1 - Tranexamic acid or Aminocaproic acid (plasmin inhibitors - 5g po/iv)

2 - DDAVP (releases vWF and F8 from endothelium - 0.3mcg/kg SC/IV or 1.5mg nasal spray x 2)

3 - Humate-P F8 concentrate (need to ensure it has enough vWF)

4 - Cryoprecipitate (not recommended due to potential for viral transmission)

Front 216

Describe how factors should be replaced in Hemophilia A and B

Back 216

Generally use F8 & F9 concentrate, respectively.

Give 0.5IU/kg/% activity needed for F8 repeat q12h prn

Give 1IU/kg/% activity needed for F9 repeat q24h prn

Mild: Laceration, epistaxis, early hemarthrosis, hematuria - want 5-10% - empiric 12.5U F8

Moderate: Traumatic epistaxis/MM laceration, soft tissue/muscle hematoma, latehemarthrosis, hematuria - want 20-30% - empiric 25U F8

Severe: GIB, neck/sublingual bleeding, RP or intra-abdominal bleed, HI, majortrauma, CNS bleed, sx procedure - want >50% - empiric 50U F8

Front 217

Bleeding reversal agents for Aspirin, Clopidogrel, Ticegralor, Warfarin, UFH, LMWH, Dabigatran, Rivaroxaban, Apixaban, t-PA/lytic

Back 217

Aspirin: DDAVP for minor, platelets for major

Clopidogrel/Ticegralor: DDAVP for minor, platelets for major

Warfarin: Depends. Hold if not bleeding. Hold + vit K po if have time. Hold + vit K IV + FFP (15mL/kg or 2-4U) OR PCC 50IU/kg

UFH: Protamine sulfate 1mg per 100U

LMWH: Protamine sulfate 1mg per 1mg

Dabigatran: PCC 50IU/kg, try FEIBA, vitamin K, Tranexamic acid (1g IV), dialysis (only 33% protein bound); send TT (thrombin time to confirm cause)

Rivaroxaban/Apixaban: PCC 50IU/kg; try tranexamic acid (1g IV), NO dialysis; send anti-Xa level to confirm cause

t-PA/thrombolytic: FFP 2U q6h x 4; Cryoprecipitate x 10U; Tranexamic Acid 1g; Platelets 1 adult; DDAVP 0.3mcg/kg IV; Protamine to reverse any heparin; treat ICP; be prepared to treat seizures

Front 218

Causes of heart failure

Back 218

HEART FAILED

H ypertension

E ndocarditis / E nvironment (heat wave

A nemia

R heumatic heart disease

T hyrotoxicosis

F ailure to take meds

A rrhythmia

I nfection / I schemia / I nfarction

L ung (COPD, PE, Pneumonia)

E ndocrine (Pheochromocytoma / Hyperaldosteronism)

D ietary indiscretions (salt / fluid)

Front 219

Heart failure classes

Back 219

NYHA Functional classes for CHF

I - Asymptomatic with ordinary physical activity

II - Symptomatic with ordinary physical activity

III - Symptomatic with less than ordinary physical activity

IV - Symptomatic at rest

Front 220

Organisms responsible for endocarditis

Back 220

Staph aureus (especially in right sided / IVDU)

Strep viridans

Strep bovis (association with GI malignancies)

Enterococcus (add vanco and watch for resistance)

HACEK - haemophilus atrophilus, actinobacilus, cardiobacterium hominus, eikenella corrdons, kingella kingae (often chronic IE, hard to culture)

Immunocompromised fungal - Candida/Aspirgillus

Front 221

ECG changes of pericarditis and how are they different than MI

Back 221

1 - PR depression and diffuse STE (hours to days)

2 - Normalization of ST segments and flattening of T waves

3 - Deep, symmetrical T wave inversion

4 - ECG reverts to normal (sometimes T waves remain inverted)

Different than MI: non-anatomic pattern, concave up, no Q waves, no dynamic worsening

Front 222

Distinguishing murmur of AS vs HOCM

Back 222

AS is more likely to have insufficiency on top of other findings.

Valsalva (increased intrathoracic pressure decreases pre and afterload) - HCM louder and AS quieter

Squat (increased SVR increases pre and afterload) - HCM quieter and AS louder

Front 223

Prognostic factors for pancreatitis

Back 223

Ranson criteria (on admission) - mortality for 1-2 = 1%; 3-4 = 15%; 5 = 50%

Non-gallstone / Gallstone

A GALL

A ge >55yo / >70yo

G lucose >11 / >12

A ST >250 / >250

L DH >350 / >400

L eukocytes >16 / >18

BISAP score

Urea > 8.92

Impaired mental status

>2 SIRS criteria

Age >60

Pleural effusion

Front 224

Transfer to a burn center

Back 224

ABA

-Partial thickness burn 10% BSA (2nd degree)

-Any 3rd degree burn

-Burns to face, hands, feet, genitalia, perinium, joints

-Electrical (including lightning)/ Chemical/ Inhalational burn

-Pre-existing medical conditions that complicate management

-Children at a location that can not care for children

-Cocomitent burn and trauma where the burn is the greatest danger

-Burn injury in patients requiring social, emotional, rehabilitative intervention

Front 225

Dive injuries

Back 225

On descent

-Ear barotrauma (inner, middle, external)

-Mask squeeze (facial barotrauma)

-Sinus barotrauma

At depth

-Oxygen toxicity

-Contaminated gases

-Hypothermia

-Nitrogen narcosis

On ascent

-Alternobaric vertigo

-AGE

-Pneumothorax/ Pneumomediastinum/ Alveolar hemorrhage

-GI barotrauma

-Barodontalgia

Front 226

Dive injuries requiring a recompression chamber

Back 226

-AGE

-DCS I and II

-Contaminated gases (CO)

Front 227

Arterial embolism vs thrombosis

Back 227

Embolism

-Source of emboli

-Sharp demarcation (no collaterals)

Thrombosis

-History of claudication

-Contralateral findings of partial occlusion

-Diffuse atherosclerosis (lots of collaterals)

Front 228

Causes of CVL obstruction

Back 228

Complete

-Clots

-Precipitant

-Mechanical obstruction

Withdrawl

-Against vessel wall

-Vein thrombosis

-Fibrin sheath

-Ball-valve thrombus

Intermittent

-Pinching between clavicle and 1st rib

Front 229

Well's DVT Criteria

Back 229

DImPLES and the 3 C's (-2 points if an alternative diagnosis is as likely) - Likely if 2 or more

D VT previously

I mmobilization (paralysis, plaster)

P ain (along deep venous system)

L eg swelling (entire leg)

P itting edema (to only the affected leg)

S urgery (last 3m)

C ancer (palliative or treated in past 6m)

C alf swelling (>3cm circumference difference

C ollateral veins (visible and nonvaricose)

Front 230

Well's PE Criteria

Back 230

Likely if 4 or more

D VT signs and symptoms

A lternative less likely

M alignancy

P revious P E/DVT

H emoptysis

I mmobilization

hR > 100

Front 231

Contraindications for fibrinolytic in STEMI and PE

Back 231

1-Dissection?

Stroke

2-Prior ICH?

3-Ischemic stroke in last 3m?

Bleed

4-Known vascular lesion? (AVM)

5-Known intracelebral neoplasm?

6-Significant head/facial trauma in last 3m?

Can't Clot

7-Active bleeding

8-Bleeding diatheses?

Front 232

Gas laws (Pascal, Boyle, Charles, Dalton, Henry)

Back 232

Pascal - Pressure on a fluid is transmitted equally throughout

Boyle - P1V2 = P2V2

Charles - V1/T1 = V2/T2

Dalton - Pt = P1 + P2 + P3 ...

Henry - The amount of gas dissolved in a liquid (solubility) is proportional to the partial pressure of that gas above the liquid

Front 233

Reasons to modify the dose of adenosine

Back 233

-Patient weight (obese, pediatrics), need more or less

-Heart transplant (don't use it)

-Methylxanthines (theophylline) stimulates receptors, need more

-Carbamezapine, needs less

-Dipyradamole prevents breakdown, needs less

-CVL delivery, need less

Front 234

Causes of priapism

Back 234

Penile trauma (high flow)

Medical conditions

-Sickle cell

-Leukemia

-Spinal cord injury

-G6PD deficiency

-Thalassemia

Medications

-ED - papaverine and PGE-1

-Phosphodiesterase inhibitors - sildenafil

-Antipsychotics - chlorpromazine, clozapine

-Antidepressants - SSRI's - trazodone

-HTN - HCTZ

-Mood/convulsant - Valproic acid

-Recreational - alcohol, cocaine, amphetamines, heroin

Front 235

Toxic levels: ASA, APAP, Iron, Digoxin, Lithium, Lead, Methanol, Ethylene Glycol, TCA, Theophylline

Back 235

ASA

Dose: 200mg/kg dose

Levels (rule of 7's): Therapeutic 0.7-2.1; signs/symptoms >2.8; bicarb >3.5; dialysis chronic >3.5mmoL/L and Acute >7mmol/L

APAP

Dose: 200mg/kg/24h dose; >150mg/kg/d for 48h; >100mg/kg/d for 72h

Level: >1000mmol/L

Iron

Dose: 20-40mg/kg (mild); 40-60mg/kg (mod); >60mg/kg (severe)

Level: >90mmol/L

Digoxin

Dose: 0.1mg/kg

Level: >19mmol/L acute; >12mmol/L chronic

Lithium

Level: >4mmoL/L acute; >2.5mmoL/L chronic

Lead

Acute level: >3.4 (IV chelation)

Chronic level: >2.2 (PO chelation)

Methanol

Dose: 0.15mL/kg of 100%

Level: >6mmol/L toxic; >15mmol/L HD

Ethylene Glycol

Dose: 0.2mL/kg of 100%

Level: >3mmol/L toxic; >8mmol/L HD

TCA

Dose: >5mg/kg

Theophylline

Level: >100mcg/mL acute; >60mcg/mL chronic HD

Front 236

Contrast Dilated, Hypertrophic, Restrictive, Takotsubo, Peripartum Cardiomyopathies (cause, treatment)

Back 236

Dilated: Mostly idiopathic but caused by ethanol, smoking, HTN, pregnancy, infection (myocarditis). Treated with pre and afterload reduction (ACEi, diuretics, PPV)

Hypertrophic: Caused by HOCM, AS, CAD, HTN. Treated with afterload reduction (BB). Must maintain preload!

Restrictive: Caused by amyloidosis, sarcoidosis, hemochromatosis, scleroderma, radiation, glycoven-storage diseases (Fabry/Gaucher). Treat underlying cause. Optimize preload (fluids).

Takotsubo: Caused by ? stress hormones. Treat as MI (indistinguishable from anterior STEMI) then BB and ACEi until recovery.

Peripartum: Caused by pregnancy (3 months before delivery to 6 months after). Treat afterload (hydralazine/labetolol until delivery, ACEi/BB after), preload (nitro), and contractility (digoxin) until recovery.

Front 237

Arteriosclerosis obliterans vs Thromboangiitis obliterans

Back 237

Arteriosclerosis: blue toe syndrome, claudication, ischemic rest pain in an elderly (>50) vasculopath (DM, smoker, HTN, cholesterol). Requires intervention if they have pain at rest. Can have distal ulcers.

Thromboangiitis: aka Buerger's disease, get painful erythematous nodules and decreased pulse in peripheral arteries. Only most commonly in male smokers 20-40yo and cure is stopping smoking completely.

Front 238

Distinguish vasogenic skin ulcers

Back 238

Arterial - distal to ankle, shiny, hairless, unswollen skin and thick nails. Less painful when dependent.

Venous - proximal to ankle, ++ swelling, weaping. Less painful when elevated.

Neurotrophic - sites of repeated trauma that they don't feel. Heels, toes, plantar surface. Not painful.

Hypertensive - on lateral malleolus, hemorrhagic bleb becomes an ulcer. Very painful.

Front 239

Vascular complications of IV drug use

Back 239

AV fistula and pseudoaneurysms (from 'hitting pink')

Unilateral hand edema (obliteration of superficial venous circulation)

Distal ischemia (severe burning pain distal to injections; possibly FB, talc, precipitate - nothing works to fix it; can need amputation)

Infected pseudoaneurysm (infected mass after hitting artery, reason that we assess abcesses for pulsatility)

Front 240

Extensive ileofemoral DVT: Names and diagnosis

Back 240

Phlegmasia Cerulia Dolens - swollen, congested, painful, cyanotic leg due to iliofemoral occlusion. Treat with thrombectomy.

Phlegmasia Alba Dolens - painful white leg secondary to arterial spasm that results from iliofemoral occlusion. Looks like arterial occlusion. Worse then cerulia. Treat with thrombectomy.

Front 241

APGAR Score

Back 241

A ppearance (pink, acrocyanosis, cyanosis)

P ulse (>100, <100, absent)

G rimace (sneeze/cough/pull away, grimace, no response)

A ctivity (active, arms/legs flexed, limp)

R espirations (good crying, weak cry, absent)

Front 242

Diagnosis and management of oncologic emergencies: febrile neutropenia, SVC syndrome, Tumor lysis syndrome, Hyperviscosity syndrome, Hypercalcemia

Back 242

Febrile neutropenia: Oral Temp >38.3 (x1) or 38.0 (x1h) with ANC<1 or expected <0.5 (biggest drop 5-10 days post chemo). NO rectal temps. Treat with Tazocin x 14d if stable + vanco/gent if not stable.

SVC syndrome: Present with periorbital edema, plethora, facial swelling, arm swelling, dyspnea. Diagnose with CT. Treat with radiation/chemo or stent (stent best).

Tumor lysis syndrome: See hyperkalemia, hyperphosphatemia, hyperuricemia, hypocalcemia. Treat with IVF +/- urinary alkalinization if acidic +/- dialysis. Can also try rasburicase with consultations. Allopurinol can prevent but not treat.

Hyperviscosity syndrome: Lab can't run tests. Happens with MM, Waldenstrom's Macroglobulinemia, Leukemia. Present with CNS/vision changes. Treat with exchange transfusion, plasma/leukopheresis.

Hypercalcemia: Due to mets or parthyroid-like hormone. Treat with hydration, furosemide, bisphosphonates, calcitonin.

Front 243

Indications for dialysis in tumor lysis syndrome and risk factors

Back 243

Indications for dialysis

-Phosphate >3.2

-Potassium >6

-Uric acid >590

-Creatinine >880

-Volume overload

-Symptomatic hypocalcemia

Risk factors

-LDH > 1500

-Advanced disease

-Preexisting renal dysfunction

-Acidic or concentrated urine

-Preexisting volume depletion

-Youth

Front 244

Synovial fluid interpretation (Color, Viscosity, WBC/mm3, Differential, Culture)

Back 244

Front 245

Special tests for the shoulder (Jobe, Drop arm, Neer's, Hawkin's, Painful arc, Lift off, Lift off lag, Yergason's, Speed's)

Back 245

Supraspinatus

Jobe's: 90 degrees abd, 30 degrees anterior to coronal plane, internally rotated/pronated - weakness or pain = supraspinatus involvement.

Drop arm test: passive abduction to 90 degrees. If can't be maintained, possible large supraspinatus tear.

Supraspinatus/Impingement

Neer's: Hand stabilizing scapula, passive flexion to 180 degrees. Pain towards 180 degrees indicates impingement.

Hawkin's: imagine a hawk being held on an arm (90-90 flexion at shoulder/elbow) then internally rotate and see if there is pain. Indicates impingement.

Subacromial bursitis

Painful arc: Abduction with pain from 70-100 degrees indicates subacromial bursitis.

Subscapularis

Lift off test: assess for tear by putting internally rotated hand on back, holding elbow, and getting patient to lift off.

Lift off lag: assess for rupture by doing same but passively lifting off and seeing if patient can maintain.

Biceps

Yergason's sign: Flex elbow to 90 and have patient try to supinate against resistance. Pain is positive.

Speed's test: Extend elbow and supinate forearm. Flex shoulder against resistance. Pain is positive.

Front 246

Types of hypersensitivity reactions

Back 246

ACID

I A naphylaxis - IgE-mediated degranulation of mast cells and basophils

II C ytotoxic - IgG mediated complex fixation

III I mmune complex - IgG or IgM antigen-antibody complex deposition

IV D elayed - T cell mediated

Front 247

Causes of cavitating lesions

Back 247

CAVITY

C ancer (metastasis)

A utoimmune (Wegener's granulomatosis, Rheumatoid Arthritis, Sarcoidosis)

V ascular (PE, septic emboli, infarction)

I nfection (TB, MRSA, SA, Klebsiella, Fungal)

T rauma (pneumatocele)

Y outh (congenital things; bronchogenic cyst)

Front 248

Treatment of common Tinea (capitis/barbae, kereon, versicolour, unguinum, pedis, other)

Back 248

Tinea capitis/barbae: Itraconazole 250mg po od x 4/52; Selenium Sulphide shampoo 2x weekly

Kerion: As per tinea, plus Keflex 500mg po qid (if infected) and Prednisone 1mg/kg/d x 1/52

Tinea versicolour (Malassezia Furfur): Selenium Suphide shampoo (q monthly for prophylaxis) +/- Fluconazole 400mg po x 1

Tinea unguinum: Penlac (antifungal painted on nail) trial; Ketoconazole 200mg po od x 6 months +/- surgical nail removal

Tinea pedis: Clotrimazole 1% bid x 6 weeks

Tinea (other areas): Clotrimazole 1% bid x 3 weeks

Front 249

Treatment of candidiasis (Thrush, Cutaneous, Vulvovaginal)

Back 249

Thrush: Adults Nystatin (100,000U/kg) swish and spit 5mL po qid until resolved x 1/52. Infants the same but 'paint the mouth' qid x 7 days. Fluconazole if immunocompromised.

Cutaneous: Dry regularly, zinc oxide prn, 1% hydrocortisone prn, Nystatin (100,000U/kg) cream bid-qid OR Clotrimazole 1% qid x 6/52. Can also use Fluconazole 100mg od x 2/52.

Vulvovaginal: Clotrimazole intravaginal OTC. Can also use Fluconazole 150mg po x 1.

Front 250

Indications for emergent decompression of a subdural hematoma

Back 250

-Midline shift >5mm

->1cm thick

-GCS decreased by 2 or more since the time of the injury

-Fixed dilated pupils

-ICP >20mmHg

Front 251

Define SIDS, apnea, pathological apnea, apnea of infancy, apnea of prematurity, periodic breathing

Back 251

SIDS: sudden infant death in a child without historical, physical, laboratory, or postmortem findings that explain the death. Peaks at 3-5 months (90% <6 months)

Apnea: cessation of air flow (central, obstructive, mixed)

Pathologic apnea: apnea lasting >20s with bradycardia, cyanosis, hypotonia

Apnea of infancy: pathologic apnea with no identifiable cause

Apnea of prematurity: pathologic apnea associated with pre-term delivery (generally resolves by 37 weeks)

Periodic breathing: breathing pattern with 3 or more pauses each lasting >3s with 20s of normal breathing surrounding them.

Front 252

Gout vs Pseudogout (crystals, risks, treatment)

Back 252

Gout

-Negatively birefringent needle urate crystals

-Risks: obesity, DM, HTN, diuretics, alcohol, meat, seafood, beer, legumes

-Treat: allopurinal (production), probenacid (excretion) chronically; colchicine 1.2/0.6/0.6, NSAIDS, steroids acutely

Pseudogout

-Positively birefringent rhomboid calcium pyrophosphate crystals

-Risks: hyperparathyroid, hypothyroid, hypoMg, hypoPO4, Wilson's, Hemochromatosis

-Treat: As for gout except steroids > NSAIDs/Colchicine; also treat underlying cause but does not affect course.

Front 253

What is Still's disease? Treatment?

Back 253

Multisystem inflammatory disorder characterized by fever, arthritis, sore throat, myalgias, pericarditis, hepatitis, splenomegaly, and salmon colored rash that occurs ONLY with the fever.

Treat with NSAIDs, Steroids, IVIg

Front 254

What are the seronegative spondyloarthropathies?

Back 254

-They are RF NEGATIVE and HLA B27 POSITIVE . Generally involve the axial skeleton (not extremities)

PAIRS -

P soriatic arthritis (affects smaller joints, sausage fingers and psoriasis)

A nkylising spondylitis (males, back pain, sacroiliitis, bamboo spine)

I nflammatory bowel disease

R eiters syndrome / reactive arthritis (post GU chlamydia or GI shigella, salmonella, campylobacter, yersinia infection)

Front 255

Medial and lateral epicondylitis

Back 255

Medial - Pitcher's/Golfer's Elbow

-Flex wrist then try to pronate against resistance - pain to medial epicondyle

Lateral - Tennis

-Extend and supinate wrist then try to flex against resistance - pain to the lateral epicondyle (Cozun test)

Both - treat with rest, RICE, PT

Front 256

Criteria for the diagnosis of lupus

Back 256

Require 4/11

ANA is quite sensitive (good rule-out); anti-DS-DNA & anti-Sm are quite specific (good rule-in)

-Malar rash

-Discoid rash

-Oral ulcers

-Photosensitivity

-Nonerosive polyarthritis

-Serositis (pericardial or pleural effusion)

-Renal disorder (nephrotic or nephritic)

-Neurologic disorder (seizures or psychosis nos)

Hematologic disorder (low Hb, WBC, platelets)

-Immunologic disorder (anti-dsdna, anti-sm, LAC, anticardiolpin, false + syphilis serology)

-Positive ANA

Front 257

Drugs that cause drug-induced lupus

Back 257

Cardiac: procainamide, amiodarone

HTN: hydralazine, methyldopa

Antimalarial: quinidine

Antimicrobial: nitrofurantoin, penicillin, INH, sulfonamides, tetracycline

Anticonvulsant: phenytoin

Antithyroid: PTU

Antipsychotic: lithium, chlorpromazine

Gout: allopurinol

Front 258

Diagnostic criteria for giant cell arteritis

Back 258

If you have 2 treat and get biopsy, if you have 3 just treat.

1 - >50yo

2 - new onset localized headache

3 - ESR >50

4 - abnormal biopsy with mononuclear infiltration or granulomatous inflammation

Also presents with visual changes, palpable temporal artery, jaw claudication, headache

Front 259

What is serum sickness (pathophys, cause, presentation, treatment)?

Back 259

-Type III hypersensitivity response with immune-complex complement fixation in vessel walls.

-Associated with penicillin, sulpha, NSAIDs, Dilantin, Procainamide

-Get erythema to fingers/toes, then urticaria, lymphadenopathy, arthralgias, constitutional symptoms 7-21 days after exposure.

-Give steroids if severe

Front 260

DDx for target lesions

Back 260

Pityriasis rosea (herald patch with salmon colored central clearing)

Tinea corporis (very well defined)

Erythema multiforme (dark center, clearing, dark halo)

Urticaria (raised, migratory)

Erythema marginatum (dark center, clearing, dark halo similar to multiforme but there is only 1 and it is much bigger)

Secondary syphilis

Front 261

MRSA risk factors

Back 261

J ail

S ports

H omeless / H ealthcare

I VDU

R esidence

C rowded

Front 262

Antibiotics effective against MRSA

Back 262

Clindamycin

Septra

Doxycycline

Vancomycin

Linezolid

Cefepime

Ceftobiprole

Daptomycin

Tigecycline

Front 263

Treatment of pediculitis (lice) and scabies

Back 263

Both

-Simultaneously treat the patient, sexual partners, family members, clothing, furniture and homes

-Clothes should be washed in hot water and dried in a hot dryer. Other things can be frozen for 5 days.

Lice (phthiraptera - pediculosis

-Permethrin (Nix) 1% shampoo for 10m on day 1 and 8 while avoiding conditioner for 2 weeks

Scabies (sarcoptes scabiei mite)

-Permethrin 5% cream applied for 8-14h on day 1 and 8

Front 264

Syphilis (Stages, Diagnosis, Treatment)

Back 264

Stages

-Primary - painless chancre (papule -> 1cm ulcer) with painless lymphadenopathy

-Secondary - 6 weeks to 6 months post-exposure, symmetrical non-pruritic macular/papular rash to palms and soles, can have condyloma lata around genitals, fatigue, lymphadenopathy, exanthem, myalgia, pharyngitis

-Latent - Nil

-Tertiary - gummas, granulomatous ulcerative lesions on skin, liver, bones, brain; Argyll-Robertson pupil; Tabes Dorsalis; Thoracic aortic aneurysm

Treatment

-VDRL is positive after primary syphilis. Used for screening (false positives in SLE, thyroiditis, lymphoma, post-vaccine, mycoplasma, mono, hepatitis, measles, malaria, pregnancy)

-FTA used for diagnosis (flouresence treponomal antibody test)

Treatment

-Primary & secondary: Benzathine penicillin 2.4 million U IM; VDRL goes non-reactive after ~12 months

-Latent or tertiary: treat weekly x 3

-Watch for Jerisch Herscheimer reaction

Front 265

Pemphigus vulgaris vs bullous pemphigoid

Back 265

PV

-Autoimmune reaction affecting patients 50-60yo generally on penicillamine, captopril or rifampim

-Present with oral bullae -> painful ulcers then skin bullae -> painful ulcers

-Diagnose with history, + Nikolski sign, + Tzank smear

-Treat with high dose prednisone (100-300mg/d), immunosuppresants, plasmapheresis

BP

-IgG autoimmune reaction of those ~65yo. Less sick than PV.

-Present with tense, fluid-filled blisters and a negative Nikolski sign. Mucous membrane involvement is possible but less frequent than PV.

-Treat with prednisone and other immunosuppresants for 2-5 years and it generally resolves.

Front 266

Canadian C-Spine Rule

Back 266

Front 267

Indications for dialysis in renal failure

Back 267

AEIOU

A cidosis / A lkalosis (note: HCO3 can precipitate tetany/convulsions in the setting of hypoCa)

E lectrolyte abnormalities (HyperK, HyperMg, HyperCa - MM)

I ngestions that are dialyzable

O verload of fluid (CHF, pulmonary edema, severe HTN)

U remia (pericarditis, N/V, lethargy)

Front 268

Bacteria causing UTI's

Back 268

KEEPPSSS

K lebsiella (institutionalized, newborns)

E nterococcus (institutionalized)

E coli (>80% of UTI's)

P roteus (3-11yo)

P seudomonas

S taphylococcus saprophyticus (can be normal skin flora in perineum)

S erratia

S almonella

Front 269

UTI treatment length

Back 269

Uncomplicated lower tract - 3 days with nitrofurantoin, cefixime, cipro, septra

Complicated lower tract - 7 days (diabetes, sickle cell, immunocompromised) with cefixime, cipro, septra

Pregnancy lower tract - 10 days with cefixime or nitrofurantoin (avoid near term due to hemolytic anemia) or septra (avoid near term due to hemolytic anemia, jaundice, kernicterus)

Upper tract - 10-14 days with cefixime or ceftriaxone

Front 270

Types of kidney stones and causes

Back 270

Calcium oxalate 75% - excess calcium (milk alkali syndrome, high dietary intake, antacids, increased PTH). Oxalate increases in radiation enteritis, IBD, and ethylene glycol ingestion.

Struvite 15% - infection with urea-splitting organisms (pseudomonas, proteus, klebsiella, staph)

Hyperuricemia 10% - gout, tumor lysis syndrome, hematologic malignancies. they are radioluscent.

Cysteine 1% - inborn error of metabolism

Struvite, urate, and cysteine stones can form staghorn calculi.

Front 271

5 locations of urinary obstruction

Back 271

Renal calyx

UPJ (uretopelvic junction)

Pelvic brim

UVJ (uretovesicular junction)

Vesicular orifice

Front 272

Acute scrotal pain / swelling differential and physical exam features

Back 272

Pain

-Testicular torsion - negative cremasteric reflex

-Torsion of the testicular appendage (appendix testis or appendix epididymis) - blue dot sign

-Epididymitis - Prehn's sign

-Trauma

-Orchitis

-Testicular tumor WITH hemorrhage (normally tumor is not painful)

-Inguinal hernia (if incarcerated/strangulated)

Swelling

-Varicocele (bag of worms)

-Ideopathic scrotal edema

-Hydrocele

Front 273

Causes of varicocele

Back 273

Venous varicocities of spermatic veins (bag of worms)

-Right spermatic vein -> IVC - generally caused by IVC compression or thrombosis

-Left spermatic vein -> left renal vein - generally caused by RCC

Front 274

Approach to priapism

Back 274

Determine low (painful) or high (not painful) flow

Treatment of low flow

->4h duration requires treatment

-Noninvasive tx - walk up stairs (decrease flow to penis), ice packs, compress

-PO treatment - terbutaline 5-10mg PO (beta agonist)

-Analgesia with dorsal nerve block

-Aspiration of cavernosum

-Injection of alpha agonist (phenylephrine) or methylene blue

-Sicklers get O2 and hydration as well

Treatment of high flow

-Angiography, surgical shunt, if painful can do block

Front 275

Causes of false positive hematuria

Back 275

Myoglobin

Porphyria

Bilirubinuria

Munchausen's

Menstrual blood

Meds

-Nitrofurantoin

-Dilantin

-Rifampin

-Quinine

Foods

-Food coloring

-Beets

-Rhubarb

-Berries

Front 276

Nephrotic vs Nephritic syndrome

Back 276

Nephrotic - HALEH

H ypoalbuminea

A lbuminurea (>3.5g/d proteinuria)

L ipiduria

E dema

H yperlipidemia (and clotting - produce increased clotting factors)

Nephritic - PHAROH

P roteinuria (<3.5g/d)

H ematuria (micro or macroscopic)

A zotemia (increased urea/Cr)

R BC casts

O liguria (<400mL/d)

H ypertension

Front 277

Causes of amenorrhea

Back 277

-Hypothalamic - exercise, stress, anorexia, hypothalamic tumor, GnRH deficiency

-Pituitary - primary hypopituitarism, Sheehan syndrome, pituitary tumor

-Ovarian dysfunction - PCOS, gonadal dysgenesis (Turner's), menopause, radiation/chemo

-Endocrine - Hyperprolactinemia, hyper/hypothyroidism, Cushing's, hyperandrogenism (PCOS)

-Obstruction - imperforate hymen, cervical stenosis

Front 278

Definition and causes of menorrhagia and metrorrhagia

Back 278

Menorrhagia is prolonged (>7d) or heavy (>80cc) bleeding

Metrorrhagia is bleeding at irregular intervals (e.g. between periods

Non-structural (COTIPE)

C oagulopathy

O vulatory dysfunction (ovulation, anovulation, exogenous steroids)

I atrogenic (OCP) / I nfectious (endometritis, cervicitis, vaginitis)

P regnancy (implantation, ectopic, abortion, molar)

E ndometriosis

E ndocrine (Cushing's)

Structural (PLAMT)

P olyps

L eiomyoma

A denomyosis

M alignancy (Endometrial / Cervical / Ovarian cancer)

T rauma (sexual abuse, foreign body)

Front 279

Treatment of unstable (stable) uterine bleeding

Back 279

-Premarin 25mg IV q4-6h until bleeding stops along with an antiemetic (2.5mg PO bid-qid - follow up with progesterone for normal withdrawal bleeding OR 5-4-3-2-1 regular OCP's/day then 1 pill x 7 days, then 4 day period and restart)

-Tranexamic acid 1g IV (1g PO tid-qid while menstrating)

-Intrauterine foley to tamponade bleeding

-OR - D&C / Hysterectomy

Front 280

Causes of false BhCG test

Back 280

False positive

-Post-menopausal (usually <10)

-Abortion (x 60 days)

-BhCG secreting tumor (hydratiform mole)

-Exogenous source (e.g. to induce ovulation)

-Incomplete abortion, abortion with 2nd fetus, abortion with heterotopic ectopic

False negative

-Dilute urine early in gestation

Front 281

DDx for hematuria (>5RBC / hpf)

Back 281

Hematological/Cardiac

-Sickle cell (infarcts)

-Coagulopathy

-Endocarditis

Renal

-Glomerular - primary glomerulonephritis (post-strep) or secondary glomerulonephritis (HUS, TTP, Lupus nephritis, HSP, Beurger's disease, Wegener's, Goodpastures, microscopic polyangitis)

-Nonglomerular - trauma, pyelonephritis, AIN, RCC, infarct, AVM, Polycystic Kidneys, Exercise

Postrenal

-Ureter - stone, TCC

-Bladder - trauma, TCC, cystitis

-Prostate - prostatitis, BPH, prostate cancer

-Urethra - Foley, urethritis

False

-Myoglobin

-Menstration

-Traumatic cath

-Drugs (rifampin, nitrofurantoin, chloroquine/hydroxychloroquine)

-Feeds (beets, berries, food coloring)

Front 282

DDx for proteinuria

Back 282

Glomerular (can be >10g/d)

-Nephrotic syndrome, minimal change disease, membranous GN, focal segmental glomerulosclerosis, Post-strep GN, IgA nephropathy

Tubular (generally <2g/d)

-UTI

-AIN

-Sickle cell

Overflow

-Multiple myeloma, Waldenstrom's macroglobulinemia, Amyloidosis

Other

-Orthostatic proteinuria

-Pregnancy

-Exertion, stress

Front 283

What is ATN and its diagnostic criteria?

Back 283

Acute Tubular Necrosis

-Death of the tubular epithelium of the kidney

-Generally caused by toxins (HHS, rhabdo, hemolysis, aminoglycosides, contrast) and hypoperfusion (shock)

-See FENa >1%, Urine Na >40

Front 284

Requirements for the use of methotrexate in an ectopic pregnancy

Back 284

-Patient is hemodynamically stable

-Tubal mass is <3.5cm

-No FHR

-No signs of rupture (FF)

-BhCG <1200-5000

Front 285

Shoulder dystocia: problem, risk factors, diagnosis, treatment

Back 285

Problem: vertical (rather than oblique) shoulder orientation of fetus (sacropubic)

Risk factors: maternal obesity, DM; fetal macrosomia; pregnancy post-date, prolonged 2nd stage

Diagnosis: can not deliver either shoulder, turtle sign

Treatment: HELPER

H elp (obs, anesthesia, neonatal)

E pisiotomy (oblique) / E mpty bladder

L egs flexed (McRoberts maneuver)

P ressure suprapublically to push the anterior shoulder down and to the side

E nter vagina (Rubin - post most accessible shoulder toward fetal chest; Woods - rotate 180 degrees Rubin plus spin the opposite hip the other direction)

R emove posterior arm (grab hand and sweep arm across the chest and deliver it with the shoulder; can have humerus and brachial plexus injury)

Other:

-Break the babies clavicle

-Symphesotomy

Front 286

BLS Termination of Resuscitation

Back 286

No defibrillation by AED

No ROSC prehospital

Not witnessed by EMS

Front 287

ALS Termination of Resuscitation

Back 287

No defibrillation (AED or manual)

No ROSC prehospital

Not witnessed by EMS or bystanders

No bystander CPR

Front 288

Risk factors for death due to asthma

Back 288

Asthma history

-Intubation/ICU admission for asthma

-Hospitalized 2 or more times in past year

-To ED 3 or more times in past year

-Hospitilization/ED visit in past month

->2 MDI canisters of B-agonist/month

-Using or withdrawing from corticosteroids

-Difficulty perceiving asthma severity/symptoms

Social history

-Low socioeconomic status

-Psychosocial problems

-Illicit drug use (especially cocaine/heroin)

Comorbidities

-Cardiovascular disease

-Chronic lung disease

-Psychiatric disease

Front 289

Definition and classification of COPD

Back 289

Irreversible, progressive airway destruction secondary to an abnormal inflammatory response.

Chronic bronchitis: productive cough for >3 months in the past 2 years; high pCO2

Emphysema: destruction of the lung parenchyma due to imbalance of elastase/antielastase from inflammation; low pCO2 (breath a lot to maintain pO2)

4 classes in the Gold Classification - all have FEV1/FVC < 70%

I Mild FEV1>80%; no symptoms

II Moderate FEV1<80%; AECOPD and SOBOE

III Severe FEV1 <50%; affects QoL

IV Very Severe FEV1 <30%; R heart failure

4

Front 290

Define AECOPD. What decreases mortality in COPD?

Back 290

An acute Exacerbation of COPD is characterized by the Antonisen criteria: 1) increased dyspnea, 2) sputum production, or 3) sputum purulence. Generally need 2/3 to treat.

Mortality in COPD is decreased by 1) quitting smoking and 2) chronic oxygen therapy

Front 291

Indications for intubation and mechanical ventilation?

Back 291

-Respiratory arrest

-Decreased LOC despite maximal therapy

-Cardiovascular instability

-NIPPV failure or unable to use (exclusion criteria)

-Severe dyspnea

-Severe tachypnea

-Life-threatening hypoxia

-Severe acidosis / hypercapnea

-Severe illness requiring respiratory support

Front 292

Complications of posterior nasal packing

Back 292

BAD NOSE

B radycardia
A sphyxia / Aspiration / Arrest
D ysrhythmia

N ecrosis of mucosa, palate / Nasorespiratory reflex
O titis Media
S hock (Toxic Shock)
E ustachian tube dysfunction

Front 293

Distinguish epiglottitis, peritonsillar abscess, retropharyngeal abscess

Back 293

Lingual tonsillitis - hot potato voice, pain on tongue depression, scalloped anterior valecula

Epiglottitis - hyoid tenderness and muffled (not hoarse) voice, sniffing position

Peritonsillar abscess - hot potato voice, drooling, hallitosis, trismus, inferomedially displaced tonsil

Parapharyngeal abscess - same as peritonsillar except can have Horner's and oral/nasal/aural bleeding from carotid.

Retropharyngeal abscess - supine with head extended, neck pain, meningismus, cri du canard (duck quack voice)

Front 294

Complications of deep space infections of the posterior pharynx

Back 294

Airway compromise

Mediastinitis

Pericarditis

Pneumonia

Empyema

Lemierre's syndrome (jugular vein thrombophlebitis)

Horner's (sympathetic chain)

Carotid artery erosion or pseudoaneurysm

Cavernous sinus thrombosis

Mastoiditis

Otitis

Meningitis

Brain abscess

Front 295

How does O2 increase the speed of PTx resolution?

Back 295

Decreases the partial pressure in the blood and as per Henry's gas law this results in the N2 from the PTx being resorbed more quickly into circulation. It increases resorbtion from 1-2%/d to 4-8%/d

Front 296

How do you calculate the size of a PTx in %?

Back 296

((A + B + C)/3) x 10%

Front 297

What are light's criteria?

Back 297

Distinguishes between exudative and transudative effusion

Exudative have at least one of:

Pleural fluid >2/3 of upper level of normal serum LDH

Pleural LDH/serum LDH >0.6

Pleural protein/serum protein >0.5

Highly sensitive, less specific for exudate

Front 298

Causes of miscarraige

Back 298

Two main:

-Chromosomal anomolies

-Uterine malformations (leiomyoma, bifid uterus, uterine scarring, cervical incompetence)

Other:

-Increased maternal/paternal age

-Low pre-pregnancy BMI

-History of miscarriage

-History of vaginal bleeding

-Maternal stress

-Increased parity

-Autoimmune disease

-Endocrine disorders (DM)

-Maternal infections

-Maternal toxin ingestion (cocaine, EtOH)

Front 299

Categories of hypertension in pregnancy

Back 299

Hypertension in pregnancy: >140/90

Preeclampsia: A disorder of pregnancy characterized by hypertension and new/worse proteinuria, adverse conditions during pregnancy that is thought to be due to endothelial dysfunction

Types of hypertension in pregnancy

Chronic hypertension: dx'd before 20 weeks

Gestational hypertension: dx'd after 20 weeks and no proteinuria

Pre-eclampsia with chronic hypertension: proteinuria (>300mg/24h) and BP >160/110 in a patient with known hypertension

Pre-eclampsia: proteinuria (>300mg/24h) and BP >140/90

Front 300

Amniotic fluid embolism: pathophysiology, major causes, presentation

Back 300

Pathophysiology: release of amniotic fluid into the circulation causing an anaphylactoid reaction

Causes: labor, amniocentesis, uterine manipulation (version), placental separation. Can also occur during miscarriage/abortion and spontaneously.

Presentation: hypoxemia due to plugging of pulmonary vessels, cardiovascular collapse, non-cardiogenic pulmonary edema, DIC

Treatment: aggressive ventilatory and hemodynamic support. Plasma exchange to remove cytokines. Delivery of fetus.

Front 301

Diagnostic algorithm for PE in pregnancy

Back 301

If leg symptoms -> compression U/S (treat if pos)

If no leg symptoms or U/S neg -> CXR

If CXR clear -> V/Q scan

If V/Q inconclusive -> CTPE

If CXR abnormal -> CTPE

If CTPE neg -> stop

Front 302

Hyperemesis gravidarum: definition, onset,

Back 302

Definition: emesis that causes starvation metabolism with weight loss, dehydration, ketonuria, and ketonemia

Onset: 6-20 weeks

Pathyphys: unsure, associated with increased B-hCG, molar pregnancy, and multiple gestation

Management: fluid rehydration, enteral nutrition, diclectin (doxylamine and B6) up to 8 tabs/d then gravol then zofran/maxeran then methylprednisone

Front 303

What is a teratogen? What characteristics of a drug increase its ability to cross the placenta?

Back 303

Any chemical, pharmacologic, environmental or mechanical agent that can cause deviant or disruptive development of the conceptus

Characteristics that increase crossing the placenta

Size (small), ionization (uncharged), protein binding (free drug), pKa (weak organic acids get caught in fetal base-ness), lipid solubility (more soluble)

Front 304

List 10 teratogens

Back 304

Heavy metals/toxins: Lead, CO, Iodine

Anticoagulant: Warfarin

Antiarrhythmics: Amiodarone, Quinine

Anti-inflammatories: NSAIDs, misoprostol

Antiepileptics: Phenytoin, VPA, carbamazepine

Chemotherapeutics Busulfan, methotrexate, thalidomide

Anti-hypertensives: ACEI, ARBs

Dermatologic: Retinoic acid derivatives

Androgens/Estrogens: OCP, HRT, diethylstilbestrol

Antipsychotics: Lithium

Drugs of Abuse: EtOH, cocaine

Antibiotics: Erythromycin, tetracycline,

aminoglycosides

Front 305

Distinguish true labor from false labor

Back 305

True labor

-cyclic uterine contractions of increasing frequency, duration, and strength

-cervical dilation

-bloody show

False labor (Braxton-Hicks contractions)

-no cervical dilation or effacement

-intact membranes

-do not escalate in frequency, duration or strength

-not sensed by external monitors

Front 306

What is assessed on pelvic exam in true labor? How can fontanelles be distinguished?

Back 306

Cervical dilation, cervical effacement, presenting part, station of presenting part, orientation of presenting part

The anterior fontanelle has 4 sutures while the posterior fontanelle has 3. OA is the most common presentation.

Front 307

Steps to breech delivery

Back 307

-Get a C-section instead

-Call obstetrics

-Monitors

-Rule-out prolapsed cord

-Open pelvis (knees wide)

-Episiotomy

-When abdomen is through pull out 10-15cm of cord to try to avoid it getting trapped

-Grasp neonate by the pelvis and direct face/abdomen away from the symphysis

-Keep the next flexed forward (do not let it extend!! Causes spinal cord injury)

Front 308

Umbilical cord prolapse: diagnosis and treatment

Back 308

Diagnosis: see the cord on pelvic, suddenly non-reassuring FHR

Treatment: emergency C-section, mother in knee to chest position with head down, fingers elevate presenting part, Foley to install 500-750 cc of fluid into bladder, replace cord above the presenting part

Front 309

Uterine inversion: risk factors, diagnosis and treatment

Back 309

Risk factors:

-Primip

-Oxytocin use

-fundal implantation

-forceful traction on umbilical cord

-MgSO4 use

Diagnosis

-Severe abdominal pain

-Visualization of the uterus at the os or in the introitus

Treatment

-Do NOT remove the placenta while the uterus is out

-Give tocolytics (terbutaline, MgSO4, halogenated anesthetics to relax the uterine ring

-Replace uterus

-Then start oxytocin

Front 310

DDx for diffuse wheeze

Back 310

Pulmonary

-Lower airway

o Congenital: CF, Bronchopulmonary dysplasia

o Trauma: FB, Aspiration

o Infectious: Pneumonia, Bronchiolitis, COPD

o Inflammatory: Anaphylaxis

o Vascular: PE

o Degenerative: Sarcoidosis

-Upper airway

o Congenital: Vascular ring

o Trauma: FB, Caustic ingestion

o Infectious: Epiglottitis, Croup, Retropharyngeal abscess

o Inflammatory: Anaphylaxis, Angioedema

o Neoplastic

o Vascular ring

Extra-pulmonary

-CHF

-ARDS

Front 311

Asthma severity classifications

Back 311

PEFR

Mild >70% predicted

Moderate 40-70% predicted

Severe <40% predicted

Life threatening <25%

Front 312

Side effects of steroids

Back 312

SHORT TERM

o Insomnia

o Mood alterations or Psychosis

o GI upset

o Increased appetite/weight gain

o Fluid retention

o Hyperglycemia

o Hypokalemia

LONG TERM

o Hyperglycemia

o Osteoporosis

o Thin skin, easy bruising, poor wound healing

o Rare: HTN, PUD, AVN, Allergic reaction

o Adrenal suppression if > 4 courses/year

Front 313

Soft signs of arterial injury in neck trauma

Back 313

FOAHHDDS
F ocal neuro deficit
O ropharnygeal blood
A irleak from chest tube
Hemoptysis / Hematemesis
H ematoma (non-expansive)
D ysphagia / Dysphonia
D yspnea
Subcutaneous Air (or mediastinal Air)

Front 314

Risk factors for primary and secondary PTx

Back 314

Primary:

-Tall, skinny, male smokers with Marfan's and Mitral valve prolapse at altitude

Secondary:

-Airway: cystic fibrosis, asthma, COPD

-Infectious: TB, PJP, lung abscess, necrotizing

-Interstitial: sarcoid, fibrosis, pneumoconioses, tuberous sclerosis

-Neoplasm: primary or metastatic

-Miscellaneous: endometriosis, pulmonary infarction

Front 315

When is a diagnostic thoracentesis indicated?

Back 315

Unexplained pleural effusions

Pneumonic and parapneumonic effusions

-Pneumonia with a parapneumonic effusion >10mm wide on decubitus films

-Loculated pleural effusion

-Thickened pleural core

Diagnosis of a possible malignancy

Front 316

Indications for bicarbonate therapy

Back 316

-pH <7.1

-HCO3 <12

-Refractory hypotension (to pressors)

-TCA toxicity

-ASA toxicity

-Phenobarb overdose

-Ethylene glycol and methanol ingestion

Empiric dose is 1 mEq/kg with 1/2 as a bolus and 1/2 over 4 hours

Front 317

How can bicarbonate cause a paradoxical intracranial acidosis? Other complications?

Back 317

Paradoxical CNS acidosis

-HCO3 diffuses over the BBB slowly

-HCO3 in the plasma is converted by carbonic anhydrase to CO2 which is then blown off to decrease pH

-This CO2 can diffuse quickly over the BBB decreasing the CNS pH

-With the improved pH the RR is decreased increasing CO2 which again crosses the BBB

Other complications

-Hypernatremia

-Hyperosmolarity

-Hypocalcemia

-Hypokalemia

Front 318

Metabolic alkalosis: causes

Back 318

Causes: hypovolemia, hypokalemia, hypochloremia

DDx:

-Volume contracted (saline responsive, urine Cl<10): Vomiting, diarrhea, NG suction, diuretics

-Normal or expanded volume (saline unresponsive, urine Cl>10): primary hyperaldosteronism (Conn's), secondary hyperaldosteronism (CHF, cirrhosis, nephrotic syndrome, Cushing's, Barter's, Licorice, ectopic ACTH)

-Other: milk-alkali syndrome, citrate, nonparathyroid hypercalcemia

Treatment

-Saline responsive: fluid and acetazolamide

-Saline resistant: replace K and spironolactone (aldosterone antagonist)

Front 319

Definition of DKA

Back 319

Due to a lack of insulin and increase in glucagon leading to hyperglycemia, osmotic diuresis, and ketoacidosis.

Glucose >13.9mmol/L (peds <11)

pH <7.3

HCO3 <18 (peds <15)

Serum or urine ketones

Front 320

How does iodide bolus affect thyroid hormone production?

Back 320

2 possible effects:

Wolff-Chaikoff effect: excess iodide inhibits ion trapping, thyroglobin iodination, and blocks the release of thyroid hormone

Jod-Basedow effect: in patients with Graves or multinodular goiter who are iodine deficient it can induce hyperthyroidism

Front 321

Thyroid storm: cause, precipitants, and treatment

Back 321

Cause: increased T3/T4 over a prolonged period of time increases B receptors and sympathetic surge activates them all at once.

Precipitants:

-Trauma (burns, surgery, thyroid trauma)

-Vascular (MI, CVA, PE, CHF)

-Toxicologic (Iodine, radiocontrast, hormone ingestion, amiodarone, stopping therapy, ASA, chemo, pseudoephedrine, OP's)

-Sepsis

-Metabolic: hypo or hyperglycemia

-Pregnancy

-Psych: mania, emotional crisis

Treatment:

-Decrease hormone production with PTU 1g po

-Decrease release of preformed hormone with Saturated Solution of Potassium Iodide (SSKI) 5 drops 1h after PTU; Li works too

-Beta blockade with propranolol 1-2mg IV q15m

-Prevent T4->T3 conversion with hydrocortisone 100mg IV

-Prevent enterohepatic circulation with cholestyramine

-Prevent entry of thyroid hormone into cell with L-Carnitine

-Supportive care with cooling, benzos, acetaminophen

-Remove thyroid hormones with plasmapheresis, dialysis, plasma exchange

-Treat precipitant

-Admit to ICU

-Thyroid surgery or ablation

Front 322

Myxedema coma: cause, precipitants, and treatment

Back 322

Cause: severe longstanding hypothyroidism with a precipitant

Precipitants:

-Trauma, burns

-Vascular: CVA, GIB, MI

-Toxicologic: lithium/iodide (decrease release), narcotics, benzo's, barbiturates

-Metabolic: hypoglycemia, hyponatremia, hypoxia, DKA, hypercapnea

-Cold exposure

Treatment

-ABC's - note macroglossia/mucosal swelling

-IVF - watch Na and glucose (often need to be added)

-Thyroid hormone - T4 if old/cardiac hx (T4 300-500ug IV bolus); T3 if young (T3 10-20ug IV bolus). Can also give a bit of each.

-Hydrocortisone 100mg IV

-Rewarming

-Treat precipitant

Front 323

Treatment of upper and lower esophageal foreign body

Back 323

Upper:

-Magill forceps / Glidescope

-Foley

-Bougienage

-Endoscopy

Lower:

-Pop

-Glucagon

-Maxeran

-Nifedipine

-SL nitro

-Midazolam sedation

-Endoscopy

Front 324

Indications for immediate endoscopy of an esophageal foreign body

Back 324

-Complete obstruction (unable to handle secretions)

-Respiratory distress (FB in esophagus can compress trachea)

-Sharp objects

-Impacted for 24 hours

-Coins in the proximal esophagus

-Alkaline button batteries

-Failure of medical treatment

-Coins in children <2yo (relative)

Front 325

Complications of esophageal FB's

Back 325

-Abscess

-Tracheo-esophageal fistula

-Aorto-enteric fistula

-Perforation and mediastinitis / pneumothorax / pneumomediastinum

Front 326

Indications for immediate removal of a foreign body in the stomach

Back 326

>2.5cm wide

>5cm long

Sharp

Toxic (e.g. lead)

>3-4 weeks impaction

90% of objects that make it to the stomach make it all the way through. If past the pylorus things can generally be left alone (then require surgery rather than endoscopy). Remove if hasn't moved in 3-4 weeks.

Front 327

Indications for surgery to remove a foreign body in the small intestines

Back 327

>99% of these pass without problem

-Hasn't moved for >7 days

-Hasn't passed in >4 weeks

->1 industrial strength magnet (not a fridge magnet)

Front 328

Grades and treatment of hepatic encephalopathy

Back 328

Grades

I - Depression, irritability, disordered sleep, mild cognitive dysfunction

II - Lethargy, disorientation, asterixis

III - Somnolence, disorientation, confused speech

IV - Coma

Treatment

-Stop all sedatives / CNS depressants

-Correct hypokalemia (allows ammonia to be excreted renally)

-Remove GI protein (treat bleed, decrease protein intake, treat constipation)

-Give lactulose 30mL qid (becomes lactic acid and traps NH4+ and decreases transport time)

-Flagyl or Clarithromycin to kill NH3 producing gut flora

-Acarbose to decrease NH3 production

-MARS

Front 329

How does lactulose correct hepatic encephalopathy? What are other treatments?

Back 329

Lactulose is converted to lactic acid, acidifying the bowel contents. This converts ammonia (NH3) to ammonium (NH4+) and its positive charge keeps it trapped in the lumen.

Remove other sources of protein (e.g. NG for GIB, protein-restricted diet)

Clarithromycin or Flagyl (alter gut flora to decrease ammonia production)

Acarbose (changes bacterial activity to decrease ammonia)

Front 330

What is the SAAG? How is it interpreted?

Back 330

SAAG = serum-ascites albumin gradient (serum albumin - ascites albumin)

This replaces the distinction between transudate/exudate

SAAG<11 = inflammation or decreased oncotic pressure (Carcinomatosis, TB, Pancreatic or biliary ascites, nephrotic syndrome)

SAAG>11 = portal hypertension (Cirrhosis, Alcoholic hepatitis, portal-vein thrombosis, Budd Chiari, liver mets)

Front 331

Diagnosis of SBP. Differentiating primary versus secondary bacterial peritonitis

Back 331

Diagnosis:

-PMN >250 cells/mm3

-Positive culture

-Ascites fluid pH <7.34 or a gap between blood pH of >0.10

Primary:

-Protein <10

-Prior SBP

-Bili >42mmol/L

-Platelets <98

-Single bacteria cultured

Secondary:

-Protein >10

-Glucose <2.8

-LDH > upper limit of normal serum LDH

-Multiple types of bacteria cultured

Front 332

The triad and tetrad of ascending cholangitis

Back 332

Charcot's triad:

-Fever

-Jaundice

-RUQ pain

Raynaud's pentad:

-Charcot's triad plus altered mental status and shock (hypotension/tachycardia)

Front 333

Sonographic findings of an abnormal TV ultrasound

Back 333

-BhCG >3000 and no gestational sac

-Gestational sac >13mm and no yolk sac

->5mm crown rump length and no fetal heart tones

-No fetal heart tones after 10-12 weeks

-Gestational sac >25mm and no fetus

Front 334

Risk factors for ectopic pregnancy

Back 334

PMHx - PID, previous ectopic or abortion, tubal surgery, infertility, abnormal anatomy

Patient factors - smoker, age

Pregnancy factors - has IUD, embryo transfer fertility treatments

Front 335

What is a molar pregnancy? What are the types? How does it present

Back 335

-Disordered proliferation of chorionic villi

Two types:

-Complete hydatidiform mole: absence of fetal tissue

-Incomplete hydatidiform mole (much less common): fetal tissue with focal trophoblastic hyperplasia

-Can also get choriocarcinoma (responds well to chemo, can metastasize)

Presentation

-Hyperemesis gravidarum

-Crazy high BhCG

-Snowstorm U/S

Front 336

Numbness or pain to the outer side of the thigh associated with pregnancy or obesity

Back 336

-Meralgia paresthetica

-Due to compression of the lateral femoral cutaneous nerve of the thigh as it passes the inguinal ligament

Front 337

Cause and treatment of postpartum hemorrhage

Back 337

Cause:

-Tissue - retained products, accreta (placental villi adhere to myometrium) / increta (enter the myometrium) /percreta (through the myometrium) make more likely

-Tone - diagnosis of exclusion

-Trauma - perineal tears, vulva/vaginal epithelium trauma, uterine inversion, uterine rupture

-Thrombin - vWD, coagulopathy, DIC

Treatment

Uterine massage

Repair lacerations

Remove products of conception

Oxytocin - run 40U/1L fast; 10U IM

Misoprostol (PGE1) - 800-1000mcg PR

Hemabate (PGFalpha) - 250mcg IM

Pack uterus

Foley in uterus

Embolize vessels

D&C

Hysterectomy

Front 338

Types of lactic acidosis

Back 338

A - tissue hypoxia

B1 - systemic disorders (DM, renal insufficiency, leukemia, sepsis)

B2 - substance associated (biguanides, methanol, salicylates, INH)

B3 - heritable metabolic disease

Front 339

Risk factors, presentation, and treatment of cerebral edema in DKA

Back 339

Risk factors

-New onset diabetes

-Children <5yo

-Extremely ill on presentation

-Treated with HCO3

-Excessive fluid replacement

-Rapidly dropping serum osmolality

Presentation

-HA

-Behavioral changes

-Incontinence

-Seizures

-Autonomic (BP and temp)

Then coma, respiratory arrest, death

Treatment

-Mannitol 1-2g/kg over 15m

-Decrease IVF and insulin rate

-Intubate, hyperventilate, CT head

NB - cause is unknown - ? idiogenic osmoles

Front 340

4 characteristics that determine the toxicity of a hydrocarbon; Effects of toxicity short term and long term

Back 340

VVSS

-Viscosity (lower more toxic)
-Volatility (higher more toxic)
-Side chains (halogenated more toxic)
-Surface tension (lower more toxic)

Primary toxicity through aspiration - get bronchospasm, disruption of surfactant, displacement of oxygen, alveolar damage -> V/Q mismatch, hypoxia, alveolar dysfunction, resp failure

Also sensitizes myocardium (arrhythmias & sudden sniffing death syndrome - tx w BB), CNS effects (euphoria acutely, dementia and cerebellar dysfunction chronically), RTA, hepatic necrosis, blood cancers

Front 341

Diagnostic criteria of HHS

Back 341

Glucose >33

Sosm >320

pH >7.3

HCO3 >15

Front 342

Complications of long-term DM

Back 342

Infection (immunocompromised secondary to decreased neutrophil and lymphocyte activity)

Diabetic foot

Insulin allergy (must go desensitization or change type)

Cutaneous manifestations (diabetic dermopathy, dermal hypersensitivity at injection sites as well as hypo or hypertrophy, acanthosis nigrans, necrobiosis lipoidica diabeticoricum, xanthoma diabeticorum)

Macrovascular complications (CAD, CVD, PVD)

Microvascular complications (Nephropathy, Retinopathy, Neuropathy)

Front 343

Causes of rhabdomyolysis

Back 343

Traumatic

-Crush

-Compartment syndrome

-Excessive exertion

Non-traumatic (relate to lack of ATP)

-Electrolytes (HypoK or HypoP)

-Ischemia

-Congenital ATP deficiency due to inborn errors of metabolism

-Environmental (electrical injury, heat stroke, hypothermia, rattle snake bite)

-Endocrine (pheochromocytoma, DKA, HHS, hypo/hyperthermia)

-Toxin (SS, NMS, statins, alcohol)

-Infections (all types)

-Seizures

-Rheumatic (polymyositis, dermatomyositis, Sjogren's)

Front 344

Thyroid diseases

Back 344

Hyperthyroid

-Graves (TSH receptor antibodies)

-Toxic multinodular goiter (multiple overactive and big areas, can cause SVC syndrome)

-Toxic adenoma

-Acute thyroiditis (gland is tender)

--> Autoimmune (Hashimoto's antibody to thyroid peroxidase; Postpartum; Sporadic)

--> Infectious (De Quervian's viral; suppurative bacterial)

--> Drug induced (amiodarone, iodine, interferon, lithium)

-Pituitary adenoma

-Gestational trophoblastic / germ cell tumors (create TSH-like hormone)

Hypothyroid

-Hypothalamic and pituitary underactivity (tumors, Sheehan's, amyloidosis, sarcoidosis, radiation)

-Late thyroiditis (as per above)

-Iatrogenic (thyroidectomy, ablation, lithium, iodine, amiodarone)

-Congenital (causes cretinism)

Front 345

Primary versus secondary adrenal dysfunciton

Back 345

Primary is a disease of the gland itself and affects all 3 functions (glucocorticoids, mineralocorticoids, androgens)

-See hyperpigmentation, hyperkalemia, hyponatremia, salt craving, and acidosis from the lack of aldosterone / excess ACTH

Secondary is a disease of the pituitary and does NOT affect mineralocorticoids (regulated by the RAAS)

-Still get hyponatremia, but it is due to increased ADH

Both

-Hypotension

-Depression, delerium, HA, abdominal pain, emesis, hypoglycemia, hyponatremia (differnet reasons), hypercalcemia, fevers, ARF

Front 346

Steroid equivalency (hydrocortisone, prednisone, methylprednisolone, dexamethasone)

Back 346

Hydrocortisone = 1

Prednisone/Prednisolone = 4

Methylprednisolone = 5

Dexamethasone = 25

Front 347

Esophageal narrowings and risk factors for obstruction / dysphagia

Back 347

Narrowings

-Upper esophageal sphincter (cricopharyngeus)

-Aortic arch

-Left mainstem bronchus

-Lower esophageal sphincter

Causes of obstruction / dysphagia

Poor dentition (they don't chew)

Intrinsic

-Esophageal carcinoma

-Shatzki's ring

-Peptic stricture

-Esophageal web

Extrinsic

-Cardiomegaly

-Aortic aneurysms or anomylous right subclavian

-Goiter

-Mediastinal tumor

-Enlarged lymph nodes

-Zenker's diverticulum

Neuromuscular (Neuro - head trauma, brain tumor, CVA, Alzheimer's, Parkinsons, MS, ALS, Myesthenia; Muscular - achalasia, scleroderma)

Toxic (Lead or EtOH)

Infectious (Bacteria - diptheria, botulism, syphilis, tetany OR Viral - rabies, polio)

Front 348

What is Mackler's triad? How can the problem be diagnosed?

Back 348

Suggests esophageal rupture

-Subcutaneous emphysema

-Chest pain

-Vomiting

Diagnose with contrast study. Use gastrograffin if no risk of aspiration (safer but less sensitive test; pneumonitis if aspirated) THEN barium (worse inflammatory response through perforation). Try CT if normal or unsafe to do.

Front 349

Contributors to thte development of GERD and evidence-based ways to get rid of it

Back 349

-Decreased sphincter tone (anticholinergics, caffeine, benzo's, nicotine, nitrates, peppermint, chocolate, estrogen, progesterone)

-Decreased esophageal motility (DM, achalasia, scleroderma)

-Increased intraabdominal pressure (pregnancy, obesity)

-Decreased gastric emptying (anticholinergic, diabetic gastroparesis, outlet obstruction)

Evidence-based treatments: weight loss and bed elevation (also try no eating before bed, stop smoking/etoh, change relevant meds, smaller meals)

Front 350

Eradication treatment for H Pylori

Back 350

Triple:

Clarithromycin 500bid / Amoxicillin 1000bid OR Metronidazole 500bid/ PPI x 10-14d

OR

Quadruple:

Bismuth subsalicylate (pepto-bismol) 525qid / metronidazole 250qid / Tetracycline 500qid / PPI x 10-14d

Front 351

Poor predictors of outcome in upper esophageal bleed

Back 351

Components of the Rockall score

Age >60

Heart failure

Ischemic heart disease

Renal failure

Liver failure

Metastatic cancer

Gastric cancer

Vigorous bleeding

Front 352

DDx for transaminitis

Back 352

-Structural:

o Inflammatory/ Autoimmune/ Infiltrative: autoimmune hepatitis (PBS, PSC), NASH (? d/t insulin resistance), amyloid

o Vascular: Budd-Chiari (thrombosis of hepatic veins or IVC/SVC), portal vein thrombosis, ischemia, CHF

o Congen/Degen: neonatal hepatitis

-Toxicology: acetaminophen, EtOH, INH, iron, phenytoin, ecstasy (autoimmune hepatitis)

-Infection:

o Viral: HAV, HBV, HCV, HDV, HGV, EBV, CMV

o Protazoan: amoeba

o Toxoplasmosis

o Associated with bacterial sepsis

-Metabolic: Wilson’s disease (copper overload), Reye’s syndrome, hemochromatosis

-Pregnancy: Fatty liver of pregnancy

-GI: gallstones, strictures, cholangitis, biliary/pancreatic cancer, annular pancreas (obstructive causes)

Front 353

Hepatitis serology

Back 353

Hep A

-For acute infection send HAV IgM

-For chronic infection send HAV IgG

Hep B

-For acute infection send HBV sAg and HBV cAb IgM

-For chronic infection send HBV cAb IgG

-For vaccine immunity send HBV sAb

Hep C

-HCV Ab

Front 354

Hepatitis post-exposure prophylaxis

Back 354

A: HAIg to unvaccinated close personal contacts, childcare workers/attendees (people who wipe their bum), similar food-borne source in last 2/52

B: HBIg to:

-unvaccinated / low titer recipients exposed to source that is HBV sAg + OR high risk

-neonates with HBV sAg + mothers

C: N/A

Front 355

Signs of cholecystitis on ultrasound

Back 355

-Stones / biliary sludge

-Wall thickening (2-4mm)

-Distension of GB (>4cm wide or 10cm long)

-Pericholecystic fluid

-Air in the GB wall (emphysematous or gangrenous cholecystitis)

-Murphy's sign (sonographic)

Front 356

Treatment of hyponatremia with focal neurologic symptoms, seizure, or coma. Complication of rapid correction.

Back 356

Hypertonic (3%) saline 100mL over 10m then 100mL over the next hour (approximately 3mL/kg total)

After this aim to correct by 0.5mEq/L/h if chronic, 1mEq/L/h is okay if acute

Complication: central pontine myelinolysis

Front 357

Causes, diagnosis and treatment of SIADH

Back 357

Lung masses

-Cancer, pneumonia, TB, abscess

CNS disorders

-Infection (meningitis, abscess), mass (subdural, postop, CVA)

Drugs

-Thiazides, narcotics, oral hypoglycemic agents, barbiturates, neoplastic agents, vasopressin

Diagnosis - low Sosm (<280), high Uosm (>100) with no other explanation

Treatment - water restriction, treat cause

Front 358

Causes of hypocalcemia

Back 358

-Hypoparathyroidism (congenital, maternal, thyroid surgery, radiation)

-Tox (chemo, HF, ethylene glycol, furosemide)

-Hyperphosphatemia, tumor-lysis syndrome

-Malnourished, alcoholism

Front 359

Conditions that can cause a false positive lipase result (not pancreatitis)

Back 359

Many false positives at standard cutoff. Quite specific at 5x standard level, but down to 60% sensitivity. 2x cutoff is best for maximal sensitivity/specificity.

-Cholecystitis

-Bowel obstruction

-Peritonitis

-Duodenal ulcer

-DKA

-Trauma

-Post ERCP

-Idiopathic

Front 360

x-ray and ultrasound findings of pancreatitis

Back 360

x-ray

-Pleural effusion

-Pancreatic calcification

-Free air (? due to perf'd something)

-Ileus

-ARDS

Ultrasound

-Occasionally can see CBD stone and/or enlarged hepatic duct (suggesting distal obstruction)

Front 361

Causes of simple and closed loop SBO

Back 361

Top 3:

-Adhesions

-Hernias

-Cancer

Intrinsic - congenital, IBD, radiation enteritis, cancer, intussusception, hematoma

Extrinsic - hernias, adhesions, volvulus, compressing tumors, abscesses, hematomas

Intraluminal - FB, gallstones, bezoar, barium, ascaris

Front 362

X-ray signs of intussusception

Back 362

Crescent sign

Target sign

Abdominal mass (no air in one area - usually RUQ) / No liver edge sign

Air fluid levels (SBO)

Dilated loops of bowel (SBO)

NOTE: In adults (as opposed to children) you do not want to reduce this with enema as it is often caused by cancer and this can result in seeding

Front 363

X-ray signs of mechanical SBO, closed loop obstruction, ileus. Normal measurements of bowel.

Back 363

Mechanical

-Dilated proximal loops and flattened distal loops

-Sharply angulated or step-ladder loops of small bowel

-Multiple air-fluid levels

-'String of pearls' (pockets of gas trapped in the plicae semicircularis when the bowel is full of fluid)

Closed-loop

-Coffee bean sign (U-shaped bowel loop also seen in sigmoid volvulus)

-Pseudotumor sign (fluid filled loop resembling a mass)

Ileus

-Dilated loops throughout the entire bowel including the colon

-Dilation less prominent

-Air fluid levels less prominent

Bowel measurements:

-Small 3cm

-Large 6cm

-Cecum 9cm

Front 364

Causes of mesenteric ischemia and risk factors

Back 364

-Arterial embolism ~50% - mostly SMA (CAD, valvular disease, AF, aneurysms, dissections, coronary angiography) - needs embolectomy

-Arterial thrombosis >15% - mostly SMA and have h/o abdominal angina (elderly, PVD, hypertension) - needs revascularization, heparin

-Venous thrombosis <15% (same risk factors as DVT/hypercoaguability; Factor V Leiden most common) - needs heparain, thromboplasty

-Non-occlusive - 20% (all shock states, cocaine, vasopressors; >50yo)

Lactate is highly sensitive

CT angiography is most helpful diagnostic test; Angiography is gold standard and early angiography decreases death

Front 365

Modified Alverado score, WBC/CRP, U/S and CT for Appy

Back 365

Alverado score

History:

-Migration of pain to the RLQ

-Anorexia

-N or V

PE:

-T>37.3

-RLQ tender (2 points)

-Rebound tenderness,

Labs

-Leukocytosis (2 points)

-Left shift

Interpretation:

-Treat if >7; Image if 4-7; Unlikely if 4 or less

Labs

-WBC<10 and CRP<12 have a -LR of 0.09 (very sensitive) but less helpful in peds.

U/S

-75-95% sensitive, 85-95% specific - operator dependent but 1st choice for kids/women

-See non-compressible, thick-walled (>2mm), dilated (>6mm), thickened mesentary, pain with compression, appendicolith

CT

-95% sensitivity and specificity

Front 366

Rome III criteria for IBD

Back 366

Recurrent abdominal pain/discomfort for at least 3d in the past 3m associated with 2/3 of:

-Improvement with defecation

-Onset associated with a change in stool frequency

-Onset associated with a change in stool appearance

Front 367

Causes of large bowel obstruction

Back 367

1 - Colorectal cancer

2 - Volvulus

3 - Diverticulitis

4 - Extrinsic compression from mets

Also:

Abscess, stricture due to chronic ischemia, fecal impaction, IBD, CF, Hirschsprung's, body packers/stuffers, Ogilvie's (pseudo-obstruction)

Front 368

AXR findings of large bowel obstruction

Back 368

Distended colon

Air-fluid levels

Cecal dilation >12cm has increased risk of perforation

Front 369

Volvulus types, risk factors, x-ray findings

Back 369

Gastric: hiatal hernia, either between 40 and 50yo or <1yo. Often have diaphragmatic defects, gastric ulcer or cancer, adhesions, paralyzed diaphragm. Can't pass NG tube!!

Cecal: pregnancy, 'coffee bean sign' pointing to LUQ, also can have air-fluid levels in the small bowel, paucity of colonic gas. Treatment surgical.

Sigmoid: elderly, psych/neuro disease, institutionalized, constipation, high fiber diet, 'coffee bean sign' pointing to RUQ, bird's beak contrast. Treatment endoscopic detorsion or surgery.

Front 370

Crohn's versus colitis

Back 370

Crohn's affects mouth to anus / Colitis large colon and rectum only

Crohn's commonly found in terminal ileum and colon / Colitis starts at rectum and moves proximally

Crohn's is transmural / Colitis is superficial mucosa

Crohn's has skip lesions / Colitis is continuous

Crohn's gets primary sclerosing cholangitis / Colitis gets colon cancer

Front 371

Extra-intestinal manifestations of IBD

Back 371

ULCERATIVE

U rinary stones

L iver cirrhosis / sclerosing cholangitis

C holelithiasis

E rythema nodosum / erythema multiforme / pyoderma gangrenosum

R etardation of growth

A rthralgias / arthritis / ankylosing spondylitis

T hrombophlebitis

I atrogenic (steroids)

V itamin deficiency

E yes (uveitis, episcleritis)

Also pulmonary fibrosis

Front 372

Intestinal manifestations of IBD

Back 372

COLITIS

C ancer

O bstruction

L eakage / perf

I ron deficiency

T oxic megacolon

I nanition (wasting)

S tricture

Also: abscess, fistula

Front 373

What is toxic megacolon? What causes it? What's the treatment?

Back 373

Inflammation of the smooth muscles of the colon leads to dilation and perforation if untreated. Patients look toxic and have dilated colon on AXR (>6cm).

Often due to infection (C Diff gets po vanco or po/iv flagyl; other gets ceftriaxone/flagyl), IBD (gets tazo and steroids), antimotility agents (anticholinergic or opioid - stop them). May need OR.

Front 374

What is required to prove negligence in a malpractice suit?

Back 374

-Health care provider has a duty of care

-That duty of care is breached by breaking the standard of care

-The patient is harmed

-There is a direct link between the breach and the harm

Front 375

Mimics appendicitis

Backpacker's diarrhea

Raw/undercooked poultry

Associated with GBS

Diarrhea and seizures

Associated with Reiter's

Raw oysters/shellfish

Prolonged diarrhea

Dysentry without fever

Fried rice

GI and neuro

Cold allodynia / hot/cold reversal

Worse after EtOH ingestion

Mayo/potato salad

Eggs

Back 375

Mimics appendicitis: campylobacter and yersinia

Backpacker's diarrhea: giardia lamblia, campylobacter

Raw/undercooked poultry: campylobacter

Associated with GBS: campylobacter

Diarrhea and seizures: shigella

Associated with Reiter's: salmonella

Raw oysters/shellfish: vibrio parahemolyticus, plesiomonas

Prolonged diarrhea: yersinia, aeromonas, parasite

Dysentry without fever: e coli O157:H7

Fried rice: bacillus cereus (toxin mediated)

GI and neuro: ciguatera toxin

Cold allodynia / hot/cold reversal: ciguatera toxin

Worse after EtOH ingestion: ciguatera toxin

Mayo/potato salad: staph aureus

Eggs: salmonella

Front 376

Bacterial causes of diarrhea; antibiotic treatment

Back 376

CSS Yalk Constantly - So Believe Every Child Vomiting And Pooping

C ampylobacter

S higella - treat dysenteriae for public health

S almonella - treat typhi and all food handlers for public health

Y ersinia

C lostridium jejuni

S taph aureus (toxins)

B acillus cereus (toxins)

E coli (toxins)

C difficile and perfringins (toxins)

V ibrio cholera (toxins) and parahemolyticus

A eromonas

P lesiomonas

Toxin-producing generally do not respond to antibiotics

Antibiotics for severe infectious diarrhea with no evidence of HUS with cultures pending - children cefixime/azithro x 3-14d; adults cipro x 3-14d

Front 377

Causes of free fluid in the abdomen

Back 377

-Blood

-Urine

-Peritoneal dialysis fluid

-Ascites

> Liver disease - cirrhosis, alcoholic hepatitis, portal vein thrombosis, Budd-Chiari, liver mets (SAAG>11)

> Abdominal or ovarian malignancies / carcinomatosis (SAAG<11)

> TB peritonitis (SAAG<11)

> Pancreatitis (SAAG<11)

> Nephrotic syndrome (SAAG<11)

> CHF

> Hemodialysis

Front 378

Internal hemorrhoid classification and treatment

Back 378

1st degree - sense of fullness, no prolapse, medical management

2nd degree - prolapse during defecation and spontaneously reduce, medical management

3rd degree - prolapse spontaneously and during bowel movement, reduce spontaneously, medical or surgical management

4th degree - permanent prolapse with risk of thrombosis, surgical repair

Front 379

Medical and surgical hemorrhoid treatment

Back 379

Medical: WASH

W arm water

A nalgesia (topical nifedipine, lidocaine for external; internal controversial)

S tool softeners

H igh fiber diet

Surgical: sclerotherapy, hemorrhoidectomy, banding

Front 380

What is the anal fissure triad? Treatment?

Back 380

Deep ulcer

Sentinal pile (hypertrophic edematous skin tag)

Enlarged anal papilla

Treatment with WASH (warm water, analgesia with nitro/lidocaine/nifedepine, stool softeners, high fiber diet) as per hemorrhoids.

Front 381

Types of rectal abscess

Back 381

-Supralevator (high and deep)

-Intersphincteric (internal, above pectinate line)

-Ischiorectal (lateral; may be able to drain in ED - controversial)

-Perianal and Perirectal (only ones we'd drain in ED)

Always tx with tetanus; Abx if DM/ immunocompromised/ valvular disease

Front 382

Causes of fecal incontinence

Back 382

Pediatric

-Congenital (meningocele, myelomeningocele, spina bifida)

-Post-op imperforate anus

-Sexual abuse

-Neuro (demential, spinal cord injury, autonomic neuropathy from DM, pedental nerve damage from surgery/obstetrics, Hirshsprung's)

-Trauma to sphincter

-Mass (colorectal cancer, foreign body, hemorrhoids, fecal impaction)

-Medical (rectal prolapse, diarrhea, IBD, laxatives)

Front 383

Gastroenteritis bugs that require treatment

Back 383

1) Culture positive, 2) immunocompromised, and 3) not improving

Also:

-Shigella dysentariae (even if asymptomatic - public health)

-Yersinia (even if asymptomatic - public health)

-Salmonella typhi in food handlers, healthcare workers, severe colitis, <3m/o, >50yo

-Bacillus anthracis

-C difficile

-Giardia Lambia

-Entamoeba histolytica

Front 384

When can anti-diarrheal medications be given?

Back 384

AVOID in <2yo and those with fever or dysentery (blood +/- pus or mucous)

Consider in patients with severe symptoms along with antibiotics

Front 385

Diarrhea history - key questions

Back 385

Travel - parasites

Antibiotics - c diff

Ingestions - food poisoning

Well-water - parasites

Infectious contacts - virulent bacteria

Pets at home - salmonella

Front 386

DDx for bilateral CNVII palsy

Back 386

Gosh, bilateral CNVII isn't just B2E2LLS3

GBS (Millar-Fischer variant)
Basilar Skull # / Bacterial Meningitis
EBV / CMV

Ethylene glycol toxicity
Lyme
Leukemia
Sarcoidosis / Syphillis / Sarcoma, Kaposi’s

Front 387

Characteristics of self-induced knife wounds

Back 387

-Multiple superficial incisions to trunk/arms/face

-Multiple superficial stabs to trunk/arms/face

-Parallel incisions on the non-dominant side of the body in close proximety to each other

-Sparing of sensitive areas

-Linear or curved incisions toward the hand inflicting the wound

-Intact clothing covering the wound

-Evidence of similar prior wounds

Front 388

Types of abuse

Back 388

3 categories:

-Domestic

-Institutional

-Self

Multiple types

-Physical

-Emotional

-Sexual

-Neglect

-Abandonment

-Financial

-Factitious disease (Munchausen's by proxy)

Front 389

Risk factors for child abuse

Back 389

Child

-Premature

-Difficult temperament

-Developmental delay or chronic medical condition

-Social isolation

Caregiver

-EtOH or substance abuse***

-Abused as a child

-Intimate partner violence

-Mental illness

-Single parent

Demographic

-Low SES

-Ethnic minority

Front 390

Shaken baby syndrome; imaging studies

Back 390

-Generally <1yo; can be <3yo

-No evidence of impact

-SDH and SAH

-On fundoscopy see retinal hemorrhages (>75%), papilledema due to increased ICP

CT is better for SAH, imaging of intracranial injuries, easier to perform. MRI is better if subacute/chronic, deel cerebral injuries, extraaxial fluid, smaller SDH's

Front 391

Historical indicators of child abuse

Back 391

-Magical injuries

-Inconsistent story

-Inconsistent with childhood development (can't bruise if can't cruise; 3 week-old 'rolling' off of a table)

-Unexplained delay in seeking care

-History does not explain the injury

Front 392

Risk factors for HIV transmission via sexual intercourse

Back 392

Victim

-Anal > vaginal

-Coexisting STD's or genital lesions

-Trauma evident

-Ejaculate on mucous membranes

-Cervical ectopy

-Active menstration

-Currently pregnant

Assailant

-Foreskin

-Primary infection

-Late stage infection

-Viral load in genital tract

-STI's or genital lesions

-Not on HAART

-Multiple offenders

-Incarcerated, homosexual, bisexual

Front 393

Risk factors for interpersonal violence

Back 393

Victim

-Demographics (<35yo, female, immigrant, separated or divorced)

-Environment (low SES, homeless, previous exposure to violent caretakers)

-History (disabled, previous physical or sexual assault)

Perpetrator

-Demographics (young)

-Societal (low income, unemployed, low SES, low academic achievement, criminal behavior)

-Psych (low self-esteem, personality disorder, emotional dependence, insecure)

-Substance abuse

-History (abused as a child, violence in family of origin, history of TBI)

Front 394

Medical problems on DDx with interperesonal violence

Back 394

-Depression, PTSD, suicidal ideation

-Headaches

-Stress-related illnesses

-EtOH / substance abuse

-Trauma in pregnancy

-Chronic pain

-STI/HIV

Front 395

Historical indicators of elder abuse

Back 395

Implausible mechanism of injury

Inconsistent history between patient and caregiver

Delay to presentation

Unexplained injuries

Elder being called 'accident prone'

Past history of frequent injuries

Noncompliance with meds, appointments, directions

Caregiver does not know patient's history/meds

Caregiver answers all questions

Caregiver/patient reluctant to give answers

Strained patient/caregiver interactions

Poor living situation

Front 396

Diagnostic criteria for a manic episode

Back 396

Manic episodes are characterized by a >2 week period with elevated/irritable mood and >3 of the following

GST PAID

G randiosity

S leep (decreased)

T alkative

P leasurable activities / P ainful consequences

A ctivity

I deas (flight of)

D istractable

Is not mixed, causes marked impairment or requires hospitalization, not due to a general medical condition.

Front 397

Anxiety definitions: Anxiety, Panic attack, Agoraphobia, Social phobia, Phobia, OCD, Generalized anxiety, PTSD, acute stress disorder

Back 397

-Anxiety: a specific unpleasurable state of tension that forewarns the presence of danger (uneasiness stems from the anticipation of some imminent danger, the source of which is unknown or unrecognized)

-Panic attack: discrete period of sudden onset of intense apprehension, often associated with feelings of impending doom

-Agoraphobia: Anxiety about place or situations from which escape might be difficult (fear of being along in public places).

-Panic disorder with agoraphobia: Pts have recurrent unexpected panic attack and become fearful of situations where they might occur

-Specific phobia: irrational fear of something that is perceived as dangerous (normal in children)

-Social phobia: anxiety d/t social or performance situations

-Obsessive-Compulsive Disorder: Obsessions → stress or anxiety which is relieved by a compulsive behaviour

-Generalized anxiety disorder: persistent, excessive anxiety or worry for > 6 months

-Post-traumatic stress disorder: Heightened arousal and avoidance of stimulus following a significant traumatic exposure

-Acute stress disorder: similar to PTSD occurring immediately in the aftermath of an extremely traumatic event

Front 398

Predictors of organic anxiety disorders

Back 398

Predictors

-Onset after 35yo

-Lack of childhood, personal, or family history of anxiety/phobias

-Lack of avoidance behavior

-Absence of live events that would exacerbate anxiety

-Poor response to anxiolyticsiD

Front 399

Disorders that can manifest as anxiety

Back 399

Substance abuse: sympathomimetics (caffeine, amphetamine, cocaine), hallucinogens (LSD, PCP, Ecstasy, marijuana)

Withdrawl: depressants (benzos, barbiturates, EtOH)

Cardiac: arrhythmias, mitral valve prolapse

Endocrine: hypo/hyperthyroid, hypoglycemia, pheochromocytoma, hyperadrenocortism

Resp: asthma, PE

Medications: alpha agonists, theophylline, corticosteroids, thyroid hormone

Front 400

What is somatization disorder?

Back 400

Somatization disorder

-Unexplained physical symptoms beginning before 30yo

-At least 4 sites of pain, 2 GI symptoms, 1 reproductive/sexual symptom, 1 neurologic symptom

-Not explained by another medical condition

-Not intentionally feigned/produced

Risk factors

-Women, low SES, alcoholism, addictions, poor education, interpersonal problems

Front 401

What is conversion disorder?

Back 401

-A somatoform disorder

-Sudden onset of a single symptom not under the patient's control and often associated with la belle indifference

-Generally neurological (motor: tremors, paralysis, pseudoseizures, aphonia, ataxia; sensory: anesthesia, blindness, tunnel vision)

-Often a psychiatric coping mechanism

Front 402

What is somatization? List the somatoform disorders.

Back 402

Somatization

The unconscious experience and communication of psychological distress through physical symptoms.

-Somatization disorder

-Conversion disorder

-Pain disorder

-Hypochondriasis

Front 403

What is hypochondriasis? Treatment?

Back 403

4 key features:

-Symptoms are more than the organic disease that is evident

-Fear of disease and conviction that one is sick

-Preoccupied with their body

-Persistent and unsatisfying pursuit of medical care

Treatment

-Reassurance, legitimize, share diagnostic uncertianty, assure ongoing care, avoid drugs that cause dependency, come up with realistic treatment goals focused on symptom control, arrange single-physician follow-up

Front 404

Compare factitious disorder, Munchausen's Syndrome, Munchausen's syndrome by proxy, Malingering,

Back 404

Factitious disorder: symptoms and signs produced or feigned in the absence of external benefit to take on the sick role, IS a mental disorder, unmarried educated women <40yo with healthcare background.

Munchausen's: a form of factitious disorder, wide variety of illnesses with intent of gaining hospital admission, hospital shoppers, believe they are very important, initially praise care -> become disruptive -> rage and AMA

Munchausen's by proxy: a form of factitious disorder where illness produced/feigned in a child. Persistent presentations with symptoms that stop when perperator is removed. Parents work in healthcare. Notify protective services and consult psych for mother.

Malingering: Malingerers ARE motivated by external incentives! Not a mental disorder. Assume somatization unless otherwise proven. Often medicolegal context, discrepancy between findings and disability, poor cooperation, antisocial behavior. Don't want to get better; gaming the system.

Front 405

Diagnosis of schizophrenia

Back 405

>2 of these symptoms for >1 month

-Delusions (if delusions bizarre counts as 2)

-Hallucinations (if running commentary counts as 2)

-Disorganized speech

-Disorganized or catatonic behavior

-Negative features (avolition, poverty of speech, flat affect)

As well as:

-Sharp deterioration

-Disturbance for >6 months (with prodrome)

-Other causes ruled out

Front 406

Complications of neuroleptic use and treatment

Back 406

-Orthostatic hypotension - alpha blockade, give fluids

-Acute dystonia - cholinergic, treat with anticholinergic benztropine (cogentin) 1-2mg IV/IM +/- benadryl

-Akathisia - motor restlessness, decrease dose or try beta-blocker

-Parkinsonism - can be indistinguishable from Parkinson's, tends to resolve over time, decrease dose or start parkinson's meds

-Tardive dyskinesia - occurs over years, bad, choreathetoid movements (tongue, grimace, writhing), no known treatments, try switching to atypical or benzo's

-NMS

Front 407

Symptoms (in order) of NMS, medications that cause it, treatment

Back 407

MR HA

altered M ental status (agitated or catatonic)

R igidity (lead pipe, tremor)**

H yperthermia**

A utonomic instability

**rigidity and increased temp are necessary for diagnosis**

Medications: typical and atypical antipsychotics, lithium, withdrawl from Parkinson's medications, maxeran

Treatment: Benzo's, stop neuroleptics, bromocriptine/dantroline/amantidine, cool, ICU, electroconvulsive therapy (Seriously? Seriously??)

Front 408

Simple vs complex skull fracture

Back 408

Simple:

-Linear not crossing suture lines

-<2mm of separation

Complex:

-Linear crossing suture lines

->2mm of separation

-Stellate

-Comminuted

-Depressed

-Compound

-Diastatic

Front 409

Triad of shaken baby syndrome

Back 409

-Subdural hematoma

-Cerebral edema

-Retinal hemorrhages

Front 410

DDx for retinal hemorrhages

Back 410

-Vaginal delivery (resolve in 10-14 days)

-Bleeding disorders

-AV malformations

-Meningitis

-Severe accidental head injury

Front 411

Physical exam signs of sexual abuse

Back 411

-Unexplained vulvar bruising

-Hemorrhage

-Hymenal or vulvar tears

-Loss of hymen out to the margin of the vagina

-Signs of STI's (gonorrhea, chlamydia, hsv2, syphilis, trichomonas)

Can get HPV, HSV1, Gardnerella vaginosis, Hepatitis B/D and AIDS without assault.

Front 412

Bronchiolitis treatments

Back 412

-Oxygen - yes if hypoxic

-IVF - yes if dehydrated

-Beta agonists - not generally recommended (perhaps 10% responders, atopic people more likely)

-Steroids - no

-Epinephrine - some bad evidence that it can help prevent hospitalization, but not enough evidence to use it

-Epi and steroids together - may be a synergistic response, but more evidence needed. NOT recommended.

-Nebulized hypertonic saline - evidence moving towards its use, but it is still not in the guidelines

Front 413

Inadequate view of prevertebral soft tissue in children

Back 413

-View taken on EXpiration

-Flexed or neutral (rather than extended) neck

Front 414

Esophageal button battery - mechanisms of injury

Back 414

-Current from the battery forming a circuit

-Release of hydroxide

-Pressure necrosis due to esophageal foreign body

Front 415

What are the goals / indications of PSA?

Back 415

Analgesia

Anxiolysis

Sedation

Immobility

Amnesia

Front 416

Crisis vs psychiatric emergency

Back 416

Crisis: acute emotional upset arising from situational or developmental problems that results in temporary inability to cope

Psychiatric emergency: acute behavioral disturbance related to severe mental or emotional instability or dysfunction requiring medical intervention

Front 417

HEADSS social history

Back 417

H ome

E ducation

A fter school

D rugs

S exual history

S uicidal thoughts/attempts

Front 418

Mental status exam

Back 418

Appearance

Attitude

Behavior

Mood

Affect (appropriateness, lability, eye contact)

Orientation (date/time/place)

Speech

Thought process (disorganized)

Thought content (delusions)

Perceptions (hallucinations)

Cognition (memory, content of thought, preoccupations, coherent speech, ability to reason, insight, judgement)

Insight

Judgement

Suicidal ideation

Homicidal ideation

Capacity (CURVES)

Front 419

Substance dependence

Back 419

WITHDraw IT

W ithdrawal

I nterest or Important activities neglected

T olerance

H arm to physical and psychosocial are known but they continue to use

D esire to cut down, control it

I ntended time using exceeded

T ime spent to acquire it is too much

Front 420

Pediatric vs adult bones

Back 420

-Thicker and more stable periosteum

-Faster healing with less immobilization

-Better remodeling capability and vascularity

-Growth plates weaker than ligaments

-More porous and pliable

Front 421

Toddler's fracture characteristics

Back 421

-Minimal or no history of trauma

-Red flags for NAT are: more transverse fracture with an associated fibular injury

-Generally 9m to 3y of age

-On physical exam spiral oblique axial load provokes pain (put axial load and twist ankle)

-Generally treat with an above knee backslab - sometimes don't need anything.

Front 422

Seven pulmonary complications of pneumonia

Back 422

-Pleural effusion / empyema

-Pneumothorax

-Lung abscess

-Bronchopleural fistula

-Necrotizing pneumonia

-Pneumatocele

-Acute respiratory failure

Front 423

How long are these pediatric rashes congagious for? (varicella, rubella, measles, parvovirus)

Back 423

-Varicella - 2 days before until lesions are all crusted over

-Rubella - 1-2 weeks before they present with rash

-Measles - 5 days before and 4 days after

-Parvovirus - a week before until the rash starts

Front 424

DDx for poor R wave progression on an ECG

Back 424

-Old anterior MI

-Lead displacement

-LVH

-LBBB

-LAFB

-WPW

-Dextrocardia

-Tension PTx with mediastinal shift

-Congenital heart disease

Front 425

Define delusion, hallucination, and disorganized speech

Back 425

Delusion: Firm, fixed, false belief not in keeping with a person's cultural upbringing that are often religious, somatic, or persecutory.

Hallucination: Sensory experience that only exists to the person experiencing it.

Disorganized speech: Loosening of associations with shifts between topics. Can be circumstantial, tangential, neologisms, perseveration, or word salad.

Front 426

Schizophrenia negative symptoms

Back 426

Alogia

Affect (flat)

Avolition

Front 427

Types of dystonic reaction and treatment

Back 427

-Buccolingual (tongue protrusion)

-Torticollus (Head deviation)

-Oculogyric (upward eye deviation)

-Opisthotonus

-Laryngospasm

Treat with benztropine (cogentin) 1-2mg +/- benadryl 50mg both IM/IV - continue for 48h with q6h po doses

Front 428

Indications for psychiatric admission

Back 428

Psychiatric condition that makes the patient:

-Significant risk of harm to self or others

-Lack of capacity to cooperate with outpatient treatment

-Inadequate psychosocial support for safe outpatient treatment

-Comorbid condition/complication makes outpatient treatment unsafe (withdrawl, acute psychosis, bizarre behavior)

Front 429

Criteria for involuntary admission for mental health reasons

Back 429

1 Suffering from a mental disorder

2 Likely to harm themselves or others or substantially deteriorate physically or mentally

3 Unsuitable for admission other than as a formal patient (not willing to come voluntarily)

Front 430

Delirium vs Dementia vs Psychosis (vitals, onset, course, hallucinations, orientation, delusions, speech, movements, psychomotor)

Back 430

vitals - delirium ABnormal, dementia normal, psychosis usually normal

onset - delirium acute, dementia slow/insidious, psychosis acute

course - delirium fluctuates, dementia slowly progresses, psychosis stable

hallucinations - delirium visual & auditory, dementia, dementia no, psychosis auditory

orientation - delirium no, dementia maybe, psychosis usually

delusions - delirium transient, dementia yes, psychosis yes

speech - delirium incoherent, dementia normal, psychosis usually coherent

movements - delirium asterixis/tremor, dementia apraxia/intention tremor, psychosis absent

psychomotor - delirium variable, dementia variable / agitated, psychosis variable agitation

Front 431

Physiologic changes in the elderly leading to altered pharmacodynamics

Back 431

GI

Decreased motility / absorption

Decreased hepatic metabolism / albumin for binding

Decreased hepatic blood flow / metabolism

MSK

Increased adipose and decreased lean body mass / smaller Vd

Decreased total water / altered Vd

GU

Decreased GFR / decreased elimination

Front 432

Selected physiologic changes of aging and effects

Back 432

-Neuro: Altered autonomic/neurotransmitter function leads to orthostatic hypotension and slowing mental function

-Skin atrophy: decreased insulation, increased injury, increased infection

-Decreased sweat glands: increased hyperthermia

-Bone loss: increased fractures

-Decreased antibodies and cell mediated immunity: increased infections

-Decreased Tv, compliance, resp drive, diffusion capacity: increased CO2, decreased O2

-Decreased hepatic function, blood flow and enzyme function: altered metabolism of drugs

-Decreased renal function, total water, vasopressin response: decreased renal elimination, drug excretion

-Decreased GI mucosa and HCO3: increased gastric ulcers and perf

Front 433

Reasons Cancer patients are at increased risk of infection

Back 433

Decreased immune function

-Physical barrier breakdown (mucositis, indwelling catheters, cytotoxic effects on GI cells)

-Functional asplenia / splenectomy (heme cancers)

-Neutropenia (chemo, radiation, bone marrow suppression)

-Decreased T and B cell function (disease and chemo)

Increased exposure

-Invasive procedures

-Prophylactic abx decreases normal flora

Front 434

Neutropenic infections and associated pathogens

Back 434

Ulcerative oral lesions: Strep viridans, herpes, candida

Necrotizing skin lesions: pseudomonas, aeromonas, aspergillus, mucormycosis

Black eschar: mucormycosis, aspergillus

Abd pain, distension: typhlitis (neutropenic enterocolitis) due to pseudomonas, e coli, clostridium

Perineal pain: Gram - bacilli, anaerobes

Front 435

Infections associated with decreased cell mediated immunity

Back 435

Important in transplant and HIV

Bacteria - Listeria, Legionella, Nocardia, TB

Viruses - CMV, HSV, VZV, EBV

Fungi - Coccidiomycoses, Blastomycoses, Histoplasma, Cryptococcus

Parasites - Toxoplasma, Strongyloides

Front 436

Phases of transplant rejection

Back 436

Hyperacute - periop or immediate postop, relates to ABO or other antibody mismatch, get organ failure and SIRS

Acute - first months after transplant, host vs graft disease, mild systemic symptoms and minimal pain, dysfunction of organ

Chronic - gradual deterioration due to inflammation over years

Front 437

How can alcoholism be screened for?

Back 437

CAGE questionnaire

C ut down?

A nnoyed?

G uilty?

E ye opener needed?

2/4 require further investigation

Front 438

Define alcoholism

Back 438

No good precise definition. Multifactorial chronic disease with various presentations affecting health, function, relationships

At least 3/6 of WITHDraw IT (withdrawal / tolerance lumped together to make 6)

Front 439

Zero order vs First order kinetics

Back 439

-Zero - constant amount per unit of time (alcohol at low levels, acetaminophen at high levels, salicylates at high levels)

-First - constant proportion per unit of time (CO, alcohol at high levels due to Microsomal Ethanol Oxidizing System, acetaminophen at low levels, salicylates at low levels)

Front 440

Why does EtOH withdrawl occur?

Back 440

-Regular use decreases glutamate and increases GABA causing increased glutamate receptors and decreased GABA receptors

-CNS is hypersensitive to glutamate when EtOH stops

Front 441

Physiologic effects of long term EtOH abuse

Back 441

Heart - HTN, CHF, cardiomyopathy, arrhythmias

Lung - pneumonia due to aspiration, decreased airway reflexes

GI - esophagitis, mallory-weiss/boorhaave's, fatty liver/hepatitis/cirrhosis, pancreatitis, diarrhea, vitamin deficiency

CNS - symmetrical polyneuropathy, Wernicke encephalopathy, Korsakoff dementia, cerebellar degeneration

ID - immunosuppression, neutropenia

Metabolic - insulin resistance, electrolyte abnormalitiies, AKA

Heme - anemia, neutropenia, thrombocytopenia due mostly to malnutrition; decreased clotting factors due to liver failure

Front 442

Drugs that cause disulfiram-like reaction with EtOH

Back 442

-Inhibit aldehyde dehydrogenase leading to buildup of acetaldehyde

ABx - metronidazole, nitrofurantoin, sulfonamides, some cephalosporins

DM - sulfonylureas (gliclazide)

Front 443

Acyanotic heart diseases

Back 443

CAP VAP

C oarctation

A S

P S

V SD

A SD

P DA

Front 444

Causes of hydrocephalus

Back 444

Obstructive - proximal to arachnoid granulations

-Masses (abscess, granuloma, tumor)

-Aquaduct stenosis

-Congenital (Dandy Walker, Chiari malformations)

Non-obstructive - arachnoid granulations

-Infection (meningitis, cysticercosis)

-Hemorrhage (SAH, IVH, traumatic)

-Choroid plexus papilloma

Normal pressure hydrocephalus (idiopathic)

Front 445

Amiodarone side effects

Back 445

P eripheral neuropathy

P hotosensitivity

P ulmonary alveolitis

P igmentation of skin

P eripheral conversion of T4 to T3 inhibited (hypothyroid)

Front 446

At risk or hazardous drinking (men, women, elderly)

Back 446

Men: 14/week or 4/session

Women: 7/week or 3/session

Elderly: 7/week or 1/session

Front 447

Pathophysiology of AKA

Back 447

-Alcoholics don't eat and use all of their NADH metabolizing EtOH so they can't make glucose

-With glucose low insulin isn't produced

-Ketones are produced but, without NADH, beta hydroxybutyrate can't be converted to acetoacetate/acetone

-BHB gets elevated (~3-6:1 ratio)

-Treat with fluid, thiamine, glucose, potassium - as corrected serum ketones will increase (acetoacetate is detected)

Front 448

AHA chain of survival

Back 448

5 links

1 Early recognition of arrest and activation of EMS

2 Early CPR

3 Rapid defibrillation

4 Effective ALS

5 Integrated post arrest care

Front 449

On-line vs off-line medical control

Back 449

Off-line

-Protocols (standing orders, practice guidelines, treatment protocols)

-Education (initial and ongoing for all provider levels including dispatch; curriculum, evaluation, administration, revision)

-Quality improvement (review/observe performance, remediation, develop time standards)

-Other (medico-legal, research, debriefing, complaints)

Online

-Concurrent direction of field team by protocol or consultation

-Has medico-legal responsibility for orders

-Can be centralized (one site handles all) or decentralized (hospital receiving patient)

Front 450

When can EMS not transport a patient

Back 450

-Patient with capacity that refuses

-Obvious signs of death

-Danger to crew

Front 451

Treatment of a crush injury in search and rescue

Back 451

-Patients tend to decompensate 4-6h after being extricated

-Circulation reaches crushed limbs releasing toxins systemically causing hypovolemia, hyperkalemia, dysrhythmia

-Require aggressive early fluid resuscitation (prior to extrication) and treatment of hyperK/rhabdo while preventing hypothermia

Front 452

Principles of TCCC?

What are the leading causes of preventable death in tactical trauma?

How are the combat zones classified and how does this affect care?

Back 452

TCCC = Tactical Combat Casualty Care

1- prevent additional casualties

2- accomplish mission

3- save maximum lives

4- minimize morbidity of injured

Causes of death

-Airway compromise (cric)

-Hemorrhage (tourniquets)

-Tension PTx (decompress)

Zones

-Hot - tourniquet (no airway or C-spine management)

-Warm - not under direct fire - cric, decompression, IV and hemorrhage control, CPR, analgesia, abx

-Cold - evacuation area - standard ATLS treatment

Front 453

Components of surge capacity and critical substrate for hospital operation

Back 453

Surge capacity:

S taff

S tuff

S tructure (physical location and infrastructure)

Hospital operations:

3 S's plus:

Communication

Transportation

Managerial support

Front 454

Describe the PICE nomenclature

Back 454

PICE = Potential Injury Creating Event

Assign 3 prefixes:

A - static, dynamic (stable vs unknown/escalating number of casualties)

B - controlled, disruptive, paralytic (local resources not overwhelmed, overwhelmed requiring augmentation, overwhelmed requiring reconstitution)

C - local, regional, national, international

Assign a PICE stage based on the projected need for outside aid:

0 - none

I - small (on alert)

II - moderate (on standby)

III - large (on dispatch)

Front 455

Components of the incident command structure

Back 455

I FLOP

I ncident command (overall management)

F inance (records on personal/resources, payment to vendors, costs alternatives)

L ogistics (provision of facilities, services, materials)

O perations (tactical law enforcement, fire, EMS, triage; manages staging areas)

P lanning (collection, evaluation and dissemination of operation/resource status; coordinates meetings)

Front 456

Phases of disaster plan

Back 456

Mitigation - reduce impact of any hazards

Preparedness - training exercises, resource catalog

Response - assessment of situation and coordination of resources

Recovery - debrief and return to normal operations

Front 457

TWhy are children at increased risk from weapons of mass destruction?

Back 457

-increased RR = increased susceptibility to airborne agents

-short = heavy chemicals travel low to the ground increasing exposure

-greater surface area to volume ratio and decreased skin thickness = increased proportional absorption

-decreased fluid reserves and increased metabolic rate = increased dehydration from V/D and increased toxicity from some exposures (I131)

Front 458

Types of weapons of mass destruction

Back 458

Chemical - nerve agents (sarin/vx), mustard gas

Biological - anthrax, plague, botulism, tularemia, smallpox, ricin

Radiation - simple or dispersal

Nuclear - BOOM

Explosive - BOOM

Front 459

Types of radiation exposure

Back 459

Irradiation - no need to decontaminate / threat to staff

Internal contamination - isolate patient, secretions, body fluid, staff

External contamination - decontaminate by removing clothes, soap and water, PPE until cleared

Additional management - involve radiation safety officer, appropriate decontamination PREhospital, triage based on condition not exposure, in nuclear fallout give everyone potassium iodide

Front 460

Bacillus anthracis (Anthrax) - transmission, types, treatment

Back 460

Gram + spore forming bacilli

Transmission - inhalational (high mortality), cutaneous, oropharyngeal, gastrointestinal

Inhalation - flu like symptoms (fever, cough) over 2-10 days then abrupt deterioration (sepsis, shock, hemorrhagic mediastinitis, dyspnea, stridor); diagnose with CT chest (cultures are late); 50% die with treatment; no human-to-human spread

Cutaneous - spores into open wound; after 1-5 days get a papule, vesicle, black eschar; need to prevent dissemination; can culture or do serology

GI - rare; eating contaminated meat; nausea, vomiting, fever, lymphadenitis, acute abdomen; 50% die

Oropharyngeal - sore throat and neck swelling; dysphagia and respiratory distress

Treatment - cipro OR doxy PO if cutaneous and non-toxic; if toxic cipro/docy + 2 of rifampin/clindamycin/impipenem IV x 60 days along with Vaccine

Front 461

Yersinia pestis (plague) - types. ddx for buboes, treatment, prophylaxis

Back 461

Gram - bacilli

Can be pneumonic (infectious! from inhalation), bubonic (buboes!! from flea bite), or septic (release of endotoxin; bubonic can become septic in 50% and septic can become pneumonic)

DDx for buboes - tularemia (francisella), cat scratch disease (bartonella), staph/strep

Treatment - IV or PO cipro and doxy

Prophylaxis - PO cipro or doxy

Front 462

Variola virus (smallpox) - infectious period, quarantine, diagnosis, types, DDx, treatment, prevention

Back 462

Aerosolized highly infectious virus

-Infectious from time of rash to when the scabs fall off (1-2 weeks)

-Exposed people must be quarantined x 17 days

-Diagnosis - all lesions are the SAME age! Classic look. Febrile prodrome (major criteria)

-Types - Major (30% mortality; severe rash/toxicity), minor (1%; minor rash/toxicity), hemorrhagic (>90%; petichial), and malignant (>90%; no pustules; no scabs if patient recovers)

-DDx - varicella, monkeypox, HSV

-Treatment - cidofovir

-Prevention - variola vaccine within 3 days in healthy population; VIG IM also given to high risk people

Front 463

Classes of chemical warfare agents

Back 463

Nerve gas (sarin - highly volatile and acts within seconds, tabun, VX - liquid only, requires dermal exposure, manifests up to 18h later) - organophosphate so treat with Atropine to dry secretions and pralidoxime to prevent aging

Vesicants (blistering agents - mustard gas gives bullae resembling 2nd degree burns; airway/mucosal injury is dose dependent; decontaminate with 1:10 hypochlorite (bleach); death from secondary infection)

Blood agents (cyanide - treat with hydroxycobalamin)

Pulmonary agents (phosgene and chlorine - cause choking and inflammation, no treatment except supportive)

Front 464

When would it be reasonable to send a physician with an EMS flight crew?

Back 464

-Complicated, undifferentiated patient

-Challenging airway

-Obstetrical case

-Procedure (chest tube, CVL)

-Mass trauma (for help!)

-ICU to ICU transfers

Front 465

START Triage Diagram

Back 465

Front 466

Toxins with characteristic odors:

Freshly cut hay -

Garlic -

Bitter almonds -

Rotten eggs -

Pears -

Glue -

Fruity -

Wintergreen -

Back 466

Freshly cut hay - phosgene

Garlic - arsenic, organophosphates

Bitter almonds - cyanide

Rotten eggs - H2S

Pears - chloral hydrate

Glue - toluene, solvents

Fruity - EtOH, acetone, isopropyl alcohol

Wintergreen - methyl salicylate

Front 467

Indications and contraindications for whole bowel irrigation

Back 467

Body packers

Sustained release

Charcoal doesn't work

High-risk hydrocarbons (CHAMP)

-Camphor
-Halogenated HC
-Aromatic HC
-Metals (arsenic, mercury & lead)
-Pesticides

Contraindicated in bowel obstruction, unable to protect airway, hemodynamically unstable

Front 468

Toxic DDx for pinpoint pupils

Back 468

Organophosphates

Opioids

Clonidine

Phenothiazines

PCP

GHB

Front 469

Antidotes

Acetaminophen

Anticholinergics

Arsenic, Lead, Mercury

Benzo

Black Widow Spider Bite

Beta Blockers

Calcium Channel Blockers

Cyanide

Digoxin

Ethylene Glycol

Hydrofluoric acid

Iron

Isoniazid

Lead

Methanol

Methemoglobin forming agents

Opioids

Organophosphates, Carbamates

Rattlesnake bite

Serotonin Syndrome

Sulfonulureas

TCAs

Valproic Acid

Back 469

Acetaminophen - N-acetylcysteine

Anticholinergics - Physostigmines

Arsenic, Lead, Mercury - British anti-Lewisite, D-Penicillamine

Benzos - Flumazenil

Black Widow Spider Bite - Lactrodectus antivenin

Beta Blockers - Glucagon, HIE, Lipids

Calcium Channel Blockers - Calcium, Glucagon, HIE, Lipids

Cyanide - Hydroxycobalamin, Sodium thiosulfate, Sodium nitrate

Digoxin - Digibind

Ethylene Glycol - Fomepizole, Pyridoxine, Thiamine

Hydrofluoric acid - Calcium gluconate paste (make with lubricant), IM, intra-arterial, with Bier block, IV +/- dialysis

Iron - Deferoxamine

Isoniazid - Pyridoxine

Lead - DMSA (succimer), EDTA

Methanol - Fomepizole, Folic Acid

Methemoglobin forming agents - Methylene blue

Opioids - Naloxone

Organophosphates, Carbamates - Atropine 2-4mg q5m, Pralidoxime 1g q1h; decontaminate with 5% hypochlorite

Rattlesnake bite - CroFab antivenin

Serotonin Syndrome - Cyproheptadine

Sulfonulureas - Octreotide (inhibits insulin release), Glucagon, Glucose

TCAs - Bicarbonate

Valproic Acid - L-Carnitine

Front 470

Stages of acetaminophen toxicity; how it is metabolized

Back 470

Stages

1 0– 24h - NV, anorexia, diaphoresis & malaise; May be completely asymptomatic

2 24-48h - NV, RUQ and epigastric pain, Transaminitis

3 48-96h - Fulminant hepatic failure – encephalopathy, coma, coagulopathy

Hypoglycemia, Metabolic acidosis

MODS: Sepsis, renal failure (25% of pts with severe hepatotoxicity), cerebral edema

4 - 4-14d - Liver enzymes return to normal; recovery

Mechanisms of metabolism

-Glucuronidation 40-60%

-Sulfation 20-40%

-Direct renal excretion 5%

-CYP450 2E1oxidation pathway 5-15% (toxic pathway)

Front 471

When can the Rumack-Mathew nomogram not be used?

Back 471

* Time of ingestion cannot be established
* >24h after the ingestion
* <4h from ingestion
* Chronic ingestion
* ?Extended release prep

Front 472

Acid-base disturbances in salicylate toxicity; treatment

Back 472

-Respiratory alkalosis (early) - stimulates respiratory center in medulla

-Respiratory acidosis (late) - prolonged high ASA levels depress drive / LOC (preterminal)

-Metabolic alkalosis - dehydration, emesis, diaphoresis (contraction alkalosis)

-AGMA - early salicylates are a weak acid; late uncoupling of oxidative phosphorylation, increased lactate

Treatment: IVF rehydration, K replacement (needed to alkalinize urine), HCO3 to alkalinize urine to trap salicylates, dialysis for AMS, hepatic/respiratory/renal failure, rising salicylate, failure to respond/unable to use (fluid overload) to conservative tx

Front 473

TCA OD treatment and treatments that are contraindicated

Back 473

-AC / MDAC

-HCO3 if QRS >100, Terminal RAD >120, Refractory hypotension, Ventricular dysrythmias, Seizures - bolus until improvement or pH >7.5

-Benzo's for seizures

-Consider lidocaine for arrhythmias (all others contraindicated)

-Cool prn

-MgSO4 / overdrive pacing for long QT

-Consider lipid emulsion in refractory cases

-Physostygmine, flumazenil and most antiarrhythmics are contraindicated

Front 474

Drugs that can cause serotonin syndrome

Back 474

Increased 5HT can occur through a number of different mechanisms:

* ↑ 5HT release: ecstasy, mirtazepine
* ↓ 5HT reuptake: SSRIs (citalopram), some narcotics (meperidine, dextromethorphan, tramadol, methadone), trazodone, venlafaxine, cocaine
* ↓ 5HT breakdown: MAOI (selegine), clonazepam

Also lithium

Front 475

Compare NMS, SS and MH problem / treatment

Back 475

NMS

* Lack of dopamine
* Rx: Stop drug, Cool, Hydrate, Benzos, Paralyze with Non-depolarizing, Bromocriptine, Amantidine, Dantrolene

SS
* Too much serotonin
* Rx: Stop drug, Cool, Hydrate, Benzos, Paralyze with Non-depolarizing, Cyproheptadine

MH
* Congenital Ca2+ regulation problem in the sarcoplasmic reticulum
* Precipitated by inhaled anesthetics or depolarizing muscle relaxants
* Rx: Stop drug, Cool, Hydrate, Dantrolene

Front 476

Mechanism and 3 presentations of MAO-I toxicity; treatment

Back 476

Mechanism - prevents breakdown of NE / Epi

Presentations:

Overdose - latent for 12-24h, then neuromuscular and cardiovascular excitation, then deplete catecholamines and crash

Food/MAO-i interaction - quick onset sympathomimetic crisis with HTN/HA that is short-lived (cheese, meat, fish, wine, beer, sauerkraut)

Drug/MAO-i interaction - quick onset sympathomimetic/serotonergic crisis that lasts as long as the drug (serotonin and sympathetic drugs)

Treatment - OD (benzo's for agitation, cool, phentolamine for early; IVF and pressors for late), Food (phentolamine), Drug (same as OD with extras if serotonin syndrome)

Front 477

Digoxin: mechanism, ECG findings, toxic presentation, treatment

Back 477

Mechanism - 1) increased automaticity due to increased intracellular Ca due to blockage of Na/K ATPase and 2) increased vagal tone causing decreased HR

ECG Findings - see U waves with scooped ST and shortened QTc

Common: PVC's, AVB with increased ventricular automaticity, atrial tachy and vent brady due to ABV

Rare: AF with slow ventricular rate, bidirectional VT

NEVER: AF with rapid ventricular response

Toxic presentation -

Metabolic: Hyperkalemia (accumulates due to all of the blocking of Na/K ATPase - predicts outcome!!)

GI: Nausea, vomiting, anorexia

CNS: lethargy, confusion, weakness (acute) and headache, delirium, yellow-green halos, snowy vision

Treatment - digifab! Lidocaine as antiarrhythmic if necessary (increases AV conduction and decreases automaticity), decrease shock energy and don't TV pace, avoid calcium (stoneheart)

Front 478

Indications and dosing of DigiFab

Back 478

Indications

-Levels of Dig (19nmol/L acute, 12nmol/L chronic) or K (>5mmol/L)

-Rhythms (ventricular or hemodynamically unstable brady)

-Ingestion of 10mg or >0.1mg/kg (child), cardiac glycoside with dysrhythmia, co-ingestion of cardiotoxic drug

Dosing

-Empiric - Acute 10 vials; Chronic 5 vials; Arrest 20 vials; Plant 10-20 vials

-Amount: Amount ingested (mg) x 0.8 (bioavailability) / 0.5 (vials needed / mg)

-Steady state

Note that digifab WRECKS the levels! (Bound is counted the same as unbound)

Front 479

Treatment for BB and CCB OD

Back 479

Charcoal

Atropine

Calcium

Glucagon

Catecholamines (Isoproterenol, dopamine for BB; norepi or epi for CCB)

Vasopression

Insulin (1U/kg then 1U/kg/h) / Glucose (D50 amp then 0.5g/kg/h)

Lipid emulsion (1.5cc/kg bolus then 0.25cc/kg/h infusion)

Balloon pump

ECMO

Front 480

How does lipid emluslion work?

Back 480

3 theories:

-Lipid sink

-Lipids as an energy source

-Increased intracellular calcium

Front 481

Grades of caustic esophageal injury by endoscopy, contraindications to endoscopy

Back 481

Grade 1 (1°): edema and hyperemia

Grade 2 (2°):

2a = noncircumferential

2b = near-circumferential superficical ulcers, friability, white membrane, hemorrhage

Grade 3 (3°): transmural involvement with deep injury, necrotic mucosa, perforation

Increased grade = increased stricture

Contraindications - perforation! Do scope at 12-24h to optimize avoidance of this in significant ingestions. Can do earlier in ? ingestions. Surgery for perf!

Front 482

Complications of caustic ingestion

Back 482

Acute

Airway burn -> Laryngeal edema

Perf'd esophagus -> Mediastinitis

Perf'd stomach -> Peritonitis

GI bleed

Delayed

-Esophageal stricture

-Pyloric obstruction

-Esophageal cancer (1000x)

Front 483

Effects and treatment of cocaine. Who needs admission? Why does it cause MI's?

Back 483

Releases DA, NE, Epi and 5HT and decreased pre-synaptic reuptake of NE, DA, 5HT

-NE: vasoconstriction by stimulating alpha receptors (alpha agonist)

-Epi: increases myocardial contractility and heart rate by stimulating B1 receptors (B agonist)

Fast Na channel blockade → local anesthesia + ↑ cardiac depolarization (↑ QRS)

Similar to TCAs; acts as a class Ia antidysrhtymic (blocks the fast Na channels; binds quickly during phase 0)

Vasoconstriction and platelet aggregation d/t ↑ endothelin production and ↓ nitric oxide production

Treatment: Benzo's (no haldol due to anticholinergic), Cooling, Phentolamine (1mg prn), IVF, intubate/paralysis prn, ASA/heparin/nitro if ACS

Admission: CAD or CAD risk factors, chest pain, cardiogenic shock, elevated cardiac markers, ECG changes, arrhythmias

Why does it cause MI's? Vasoconstriction, increased cardiac demand, decreased filling time, increased platelet aggregation

Front 484

Stimulant induced chest pain

Back 484

Cardiac

-Endocarditis

-Pericarditis

-Ischemia/infarction

-Stent thrombosis

Non cardiac

-Pneumothorax

-Pneumomediastinum

-Pneumopericardium

-Aortic dissection

-Pulmonary infarction

-Infection

Foreign body

Front 485

HEART score

Back 485

History - slight 0/ moderate 1 / high 2

ECG - normal 0 / nonspecific 1 / ST depression 2

Age - <45 0 / 45-65 1 / >65

Risk factors - none 0 / 1-2 1 / >2 2

Troponin - < limit 0 / 1-3x limit 1 / >3x limit 2

Front 486

Methanol ingestion: metabolism, complications, treatment

Back 486

Metabolism: to formaldehyde then formic acid (detoxified with folate)

Complications: putaminal necrosis (in basal ganglia -> parkinsonism), optic neuropathy (blindness), increased free radicals, AGMA (formic acid and lactate due to cytochrome oxidase dysfunction)

Treatment: block conversion with fomepizole, HCO3 to keep formic acid trapped in serum; Folate to aid in decontamination, HD (if suspect ingestion, ph<7.3, HCO3<20, OG>10, >15mmol)

Front 487

DDx of osmolar and anion gap

Back 487

Methanol

Ethylene glycol

DKA

SKA

AKA

Lactic acidosis

Uremia

Front 488

Ethylene Glycol ingestion: metabolism, complications, treatment, stages of toxicity

Back 488

Metabolism: to Glycoaldehyde -> Glycolate -> Glyoxylate -> Oxalate -> Calcium Oxalate

Complications: AGMA (due to glycolic acid and lactate due to cytochrome oxidase dysfunction), hypocalcemia (chelation), crystal nephropathy, CNS punctate hemorrhages and aseptic meningoencephalitis, myonecrosis

Treatment: Block with fomepizole, HCO3 to keep ethylene glycol trapped, give Pyrodoxine, Thiamine, Magnesium to aid detoxification; correct hypocalcemia, HD > 8mmol

Stages of toxicity: I acute neurologic, II cardiopulmonary, III renal, IV delayed neurological

Front 489

Ethylene glycol vs methanol

Back 489

Methanol gives visual symptoms more often

Methanol targets basal ganglia/putamen (EG more diffuse)

Ethylene glycol causes hypocalcemia

Ethylene glycol causes calcium oxylate crystals

Front 490

Serotonergic agents

Entactogens

Dissociative agents

Back 490

Serotonergic agents: LSD, psilocybin (mushroom); panic attacks, psychosis, flashbacks

Entactogens:

-Amphetamines, MDMA; hyperthermia, hyponatremia, SIADH

-Bath salts; halucinogen and sympathomimetic

-Mescaline; like LSD but with N/V

Dissociative agents:

-PCP, ketamine; seizures, hyperthermia

-Dextrometorphan; dissociative, opioid, and serotonergic (SS)

Front 491

Arsenic (gas, acute, chronic)

Mercury (elemental, inorganic, organic)

Back 491

Arsenic
-Arsine gas gives hemolysis & ATN

-Acute salts give encephalopathy, ARDS, dysrhythmias, N/V/D

-chronic salts give sensory neuropathy, Mee's lines, sideroblastic anemia, cancer.

>Tx with WBI, BAL (IM), DMSA (PO)

Mercury

-Elemental vapor (ARDS, pneumonitis) or injection (CNS/renal toxicity) or ingestion (nil)

-Inorganic ingestion (ATN, gastroenteritis) or chronic (neurasthesia, nephritic syndrome, gingivostomatitis) > BAL (IM) / DMSA (PO)

-Organic ingestion/dermal (neurotoxicity, ataxia, tremor, dysarthria) > DMSA (PO) but NOT BAL

Front 492

Sudden sniffing death syndrome

Back 492

-Happens in HC use. Blocks the delayed rectifier-K channel resulting in long QTc and ventricular arrhythmias.

-Upregulation of catecholamine receptors on myocardium and sensitization; sudden surges of catecholamines from adrenaline surge.

-Consider avoiding epi in this type of a code.

-After resuscitated give benzo's, Mg, beta blockers, overdrive pacing

Front 493

List simple asphyxiants, pulmonary irritants, cellular toxins

Back 493

Simple asphyxiants: NO, CO2, N2, methane

Pulmonary irritants: Low solubility (Phosgene, NO2 - mucous membranes - upper airway) Medium solubility (Chlorine) High solubility (Ammonia, HF, HCl, H2S, SO2 - lower airway); considered nebulized HCO3

Cellular toxins: CN, H2S, CO

Thermal injury: smoke inhalation

Front 494

Cyanide toxicity and treatment

Back 494

Get AGMA with a crazy high lactate; MSOF

Treatment: hydroxycobalamin to form cyanocobalamin (B12) 5g empirically. Historically used amyl nitrite (if no IV) or sodium nitrite (if IV) to make methemoglobin and then Na thiosulfate to make excretable thiocyanate. ONLY thiosulfate or hydroxycobalamin in fires

Front 495

CO treatment; hyperbaric indications

Back 495

t1/2 on room air 4.5h; 100% 1.5h; hyperbaric 30m

Indications for hyperbaric oxygen: COHb >25% (anyone), >15% pregnant/child; symptoms (syncope/seizure/AMS/AMI/focal neuro/dysrhythmia); consider in other cases -> Does NOT decrease mortality; may decrease neuro sequelae

Front 496

Drugs that naloxone can reverse

Back 496

Opioids (all)

Clonidine

Tramadol

EtOH

Valproic acid

Front 497

Cholinergic drugs

Back 497

Organophosphates

Carbamates

Edrophonium/Tensilon for Myesthenia Gravis

Donepizil/Aricept for Parkinsons

Urocholine for bladder spasms

Physostigmine

Front 498

Toxic seizures: effect of glutamate, GABA, benzo's, barb's, EtOH, pyridoxime

Treatments for benzo, barb OD

Back 498

-Glutamate excites; GABA inhibits w Cl channel, Benzo's potentiate GABA (need it!), Barb's and EtOH keep Cl channel open longer (no GABA needed!). GABA is made by Glutamine using Pyridoxime

Barb OD: respiratory depression! Intubate and treat with MDAC

Benzo OD: flumazenil generally not recommended especially if ictogenic coingestants, seizure disorder, withdrawl, paralyzed

Front 499

Gamma hydroxybutyrate uses, effects, presentation

Back 499

-Used recreationally, for date rape, and for bodybuilding

-Affects dopamine release (inhibits and releases) and binds GABA

-Present with decreased LOC, respiratory effort, emesis and mioisis. Rapidly fluctuating LOC and agitation.

Front 500

What is DRESS? Treatment?

Back 500

Drug Rash with Eosinophilia and Systemic Symptoms

Found in anticonvulsant hypersensitivity (carbamezapine, phenytoin, lamotragine, phenobarb). Usually in first 2months of therapy. Can cause MOSF (nephritis, carditis, pneumonitis) as well as tight blisters, morbilliform rash, facial edema.

Treatment

Withdrawl of the causative drug. Steroids are controversial. Consider NAC.

Front 501

Phases of cold injury / frostbite and treatment

Back 501

Prefreeze: <10 degrees, loss of sensation, endothelial leak

Freeze-thaw: extra-cellular ice crystal formation, extracellular shift of fluid, cells can begin to die

Microvascular collapse: intravascular sludging, hyperviscosity, thrombosis, ischemia, necrosis

Treatment: rapid warming in 37-39 degree water, do NOT let refreeze or partial thaw; pain control; watch for afterdrop; tetanus; consider abx and splinting; stop smoking; consider thrombolytic or sympathectomy

Front 502

Non freezing injuries

Back 502

Frostnip - superficial injury, no tissue death, resolves with warming

Chilblains - repetitive dry cold, cold 'sores' to face and hands (erythema, pruritis, edema), can ulcerate, more likely in Raynaud's & APLS, can tx with nifedipine

Trench foot - prolonged wet cold >0 degrees. Wet socks. Rubor when dependent, pallor when elevated (vasomotor paralysis). Painful. Can get bullae.

Front 503

Sequelae of frostbite

Back 503

Neuropathic

-CRPS

-Dysesthesia /paresthesia /anesthesia /hypesthesia

-Heat/cold sensitivity

-Hyperhidrosis

-Raynaud's

MSK

-Atrophy

-Compartment syndrome

-Rhabdomyolysis

-Stricture

-Necrosis

-Amputation

Derm

-Edema

-Lymphedema

-Ulcers

Miscellaneous

-Afterdrop

-Electrolyte abnormalities

-ATN

-Sepsis

Front 504

Dive injuries on descent, at depth, on ascent, and require decompression therapy

Back 504

Descent: IEBT, MEBT, EEBT, Facial barotrauma, barosinusitis

Depth: Contaminated gases, Nitrogen narcosis, Oxygen toxicity

Ascent: Arterial gas embolism, Pulmonary edema, Barotrauma (alternobaric vertigo, pneumothorax, pneumomediastinum, barodontalgia, GI barotrauma)

After surfacing: DSC

Decompression therapy: DCS I, DCS II, Arterial gas embolism, contaminated gas (CO)

Front 505

Acute mountain sickness / high altitude cerebral edema treatment

Back 505

-Descent or discontinue ascent

-Hydration

-No smoking

-Tylenol / Advil

-Oxygen

-Prochlorperazine - stimulates hypoxic ventilatory response

-Acetazolamide - prevents periodic breathing at night; helps adapt by excreting HCO3

-Dexamethasone - decreases swelling

Front 506

High altitude pulmonary edema treatment

Back 506

-Descent

-Salbutamol

-Oxygen

-Nifedepine - decreases pulmonary vasoconstriction

-Sildenafil - decreases pulmonary vasoconstruction

-Hyperbaric oxygen or CPAP

Front 507

Physiological changes associated with high altitude acclimitization

Back 507

-Increased HR, BP, and venous tone due to catecholamine release

-Increased hemoglobin (due to increased Epo and fluid shift)

-Increased 2,3 DPG and right shift of O2 dissociation curve (more O2 for tissues)

-Increased minute ventilation (decrease PaCO2 and increased PaO2)

-Increased renal excretion of HCO3

Combined these last two are:

-Hypoxic ventilatory response (hypoxia induces hyperventilation which blows down PaCO2 causing kidneys to compensate by excreting HCO3)

Front 508

Clinical features of heat stroke

Back 508

-Temperature >40.5

-CNS dysfunction (delirium / coma)

-High output CHF

-Centrilobular necrosis in liver (AST / ALT >10,000)

-Elevated lactate

-Rhabdomyolysis

-ATN

-Coagulopathy / DIC

-Hypocalcemia and Hyponatremia

Front 509

Differentiating features between heat stroke and heat exhaustion

Back 509

-Heat stroke has neurological symptoms

-Heat stroke has a temperature >40.5

-Heat stroke AST and ALT are much more elevated (in the 10000's) - elevated LFT's are a common lab abnormality in both

Front 510

Temperature of hypothermic physiological changes

Back 510

28 - VF

30 - ACLS meds effective

32 - shivering loss

34 - ataxia and apathy

Front 511

Compare DCS I vs II

Back 511

DCS I (the bends) affects MSK, skin, lymphatics. Get cutis marmorata, periarticular pain, peau d'orange,

DCS II (any other organ system:

CNS (spinal or cerebral)

Inner ear (staggers - similar to IEBT)

Pulmonary (chokes)

Fetal

Front 512

Signs of hypothermia on ECG

Back 512

-Osborne waves

-Shivering artifact

-Bradycardia

-Prolonged PR, QRS, QTc

-Ectopic ventricular beats

-Atrial fibrillation

-AVB's

-VT/VF/Asystole

Front 513

What effect does warming the blood of a hypothermic patient have on the patient's ABG results? (pH, pO2, PCO2)

Back 513

pH - lower

pO2 - higher

pCO2 - higher

Front 514

Contraindications to high altitude travel

Back 514

4

-COPD

-Pulmonary hypertension

-CHF

-Sickle cell

Relative contraindications

-Pregnancy

-Radial keratotomy

-Seizure disorder

-Previous altitude sickness

Front 515

Treatment of frostbite

Back 515

-Pain control

-Warm the limb in 37-39 degree water (do not allow partial rewarming or refreezing)

-Warm the patient with monitors

Consider thrombolytics, heparin, tetanus, antibiotics, smoking cessation, debridement

Front 516

Hypothermia stages

Back 516

Mild 34-36

Moderate 30-34

Severe <30

Front 517

Indications for active rewarming in hypothermia

Back 517

Moderate or severe hypothermia

No shivering

Cardiovascular instability

Co-morbidities (DM, trauma, endocrine)

Failure to rewarm

Toxicologic hypothermia

Septic hypothermia

Infants and elderly

Front 518

Risk factors for decompression sickness

Back 518

-dehydration

-prolonged dive

-inexperienced diver

-not using dive tables

-multiple dives in a short period

-depth of dive

-flying after diving

-exceeding no-decompression limits

-elderly

-obesity

-cold after diving

Front 519

Define: Drowning, Immersion syndrome, Diving reflex

Back 519

Drowning

Respiratory impairment from submersion/ immersion in liquid that can cause morbidity and death

Immersion syndrome

Syncope or cardiac arrest following sudden immersion in water with a more than 5 degree change from core temperature (results in a vagal response +/- vasoconstriction)

Diving reflex

The immersion of the face in cold water shunts blood to the heart and brain producing apnea and bradycardia and prolonging the duration of submersion tolerated

Front 520

What factors indicate a poor prognosis following drowning / near-drowning?

Back 520

-Temperature of patient

-Age (young) <3

-Duration of submersion > 5 min

-Pulse (presence of)

-Neurologic status at time of arrival to ED

-Bystander CPR delayed > 10 min

-Acidosis

-Fixed, unreactive pupils

-GCS 3

Front 521

Pathophysiology of arterial gas embolism following scuba diving

Back 521

At depth there is an increased solubility of nitrogen which accumulates in the body while the diver is at depth (Henry's law). Upon rapid ascent, the nitrogen comes out of the solution resulting in bubbles which collectively form a gas embolism (Boyle's law)

Front 522

Stages of wound healing

Back 522

Coagulation - hours - 2 days

Collagen - days - peaks at 7 days; 60% strength at 4 weeks

Contraction - begins at 4 days

Epithelialization - new skin; can complete over sutured lacerations within 48 hours

Front 523

Indications for admission of a fight bite

Back 523

Patient

-Immunocompromised

-DM

-Unreliable patient

Wound

-Signs of infection

-Open >24 hours

-Penetration of joint/tendon sheath

-Bone involvement

-FB

Treatment

-Clavulin as an outpatient; Tazocin as an inpatient

Front 524

Drugs that can cause methemoglobinemia and its treatment

Back 524

Nitrates (NTG, nitroprusside)

Local anesthetics (eg benzocaine, lidocaine, prilocaine)

Dapsone

Primaquine

Antimalarials (quinine, chloroquine)

Paraquat

Naphthalene

Methylene blue

Treatment: Methylene Blue - reduces Fe3+ back to Fe2+

Front 525

Drugs that require quantitative measurement for treatment in overdose

Back 525

Acetaminophen

Ethylene glycol

Methanol

Digoxin

Carbon monoxide

Lithium

Aspirin

Theophylline

Valproic acid

Front 526

Contraindications to succynilcholine

Back 526

PMHx

-MH (any time)

-Pseudocholinesterase deficiency (anytime)

Recent PMHx

-Burns (>10%, >5 days until healed)

-Crush injury (>24h)

-Stroke/denervation with paralysis (>5 days to 6 months)

-NM disease (>6 months)

Current presentation

-HyperK (any time)

-Cholinergic toxicity

Front 527

Consideration for deciding to give AC

Back 527

(1) Toxin can be bound by AC

(2) Ingestion <1h generally, sometime <2h or longer (especially if ingestion slows gastric motility)

(3) Protecting airway

(4) No known antidote

(5) No bowel obstruction / ileus

(6) Ingested substance / amount likely to be toxic

Front 528

Pathophysiology of carbon monoxide toxicity

Indications for hyperbaric oxygen in carbon monoxide toxicity

Back 528

Pathophysiology

-CO binds to cytochrome 4 of ETC causing cellular asphyxiation

-displaces O2 and shifts oxyhemoglobin curve to left

-binds to myoglobin causing rhabdomyolysis

HBO

>25% carboxyHb level

>15% carboxyHb level in pregnant or children

CVS instability

Neurological symptoms

Front 529

Mechanisms of NAC in acetaminophen toxicity

Back 529

(1) Glutathione precursor

(2) Glutathione substitute

(3) Enhances sulfation pathway leading to non-toxic metabolites

(4) Antioxidant effects and free radical scavenger

(5) Enhances hepatic microcirculation

Front 530

Treatment of box jellyfish sting

Back 530

-Box jellyfish antivenom

-Verapamil IV

-Remove nematocysts with razor / credit card after deactivating with vinegar

-Analgesia

Front 531

How is volume of distribution calculated?

Back 531

Ingestion (mg) / Concentration (mg/L) = Distribution (L)

Distribution (L) / Patient weight (kg) = Vd (L/kg)

Very low (<1) = dialyzable

High = not dialyzable

Front 532

Drugs that most commonly cause adverse reactions in elderly patients

Back 532

-Cardiovascular

-Diuretics

-Non-opioid analgesics

-Hypoglycemics

-Anticoagulants

-Sedatives

Front 533

Drug side effects: Delirium, Syncope, GIB, Tinnitus

Back 533

Delirium

-Benzodiazepines (lorazepam, diazepam)

-Opioids (morphine, fentanyl)

-Hypoglycemics (glyburide, insulin)

-CVS (BB, CCB)

-Anticholinergics (benadryl)

Syncope

-Antiarrythmics (IA, IC, II, III, IV)

-Antibiotics (quinolones, macrolides)

-Antipsychotics (chlorpromazine, haloperidol), --Diuretics via electrolyte disturbance

-Antihypertensives (Clonidine, nitrates)

-Hypoglycemics (glyburide, insulin)

GI bleeding

-Anticoagulants (coumadin)

-Antidepressants (SSRI)

-NSAIDs (toradol)

-Steroids

Tinnitus

-Salicylates

-Lithium

-Diuretics (Furosemide, Acetazolamide)

-Aminoglycosides

-Antimalarials (chloroquine, quinine)

Front 534

Theophylline (mechanism of action, presentation in toxicity, cause of death, treatment)

Back 534

Mechanism:

1) PDE inhibitor - raises cAMP

2) Adenosine antagonism → cardiac effects

3) direct beta- and alpha-adrenergic agonism

Presentation:

-GI - Nausea/Vomiting

-CVS - Tachydysrhythmias

-Resp - Tachypnea & resp alkalosis, ALI

-CNS - Seizure, anxiety / Agitation

-MSK - Rhabdomyolysis

-Metabolic - AGMA (lactate), hypoK, hypoMg, hyperglycemia

Cause of death:

-Arrhythmia in chronic

-Status epilepticus in acute

Treatment:

-MDAC if early

-Dialysis or charcoal hemoperfusion

Front 535

Heroin: drug complications, IVDU complications, adulterant complications

Back 535

Drug

- Seizure, Coma, Death

- Apnea/hypoxia, Non-cardiogenic pulmonary edema

- Bradycardia, Hypotension

- Hypothermia

IVDU

- HIV, Hep B, Hep C

- Sepsis, Endocarditis

- Cellulitis, Abscess

- DVT, Thrombophlebitis

Adulterant

- Botulism

- Enterobacter agglomerans (cotton fever)

- Agranulocytosis (levamisole)

- Sepsis/infection

Front 536

Name 3 amide and ester local anesthetics

Back 536

Amides

Bupivicaine, lidocaine, prilocaine

Esters

Tetracaine, Benzocaine, Cocaine

Front 537

ECG findings of lithium toxicity; drugs that cause lithium toxicity

Back 537

ECG findings

-QT prolongation

-Sinus Bradycardia

-T-wave inversion or flattening

-ST depression

-U wave

-SA block

-First degree AV block

Drugs that cause lithium toxicity

-ACE inhibitor - Ramipril

-ARB - Valsartan

-NSAID - Naproxen

-Diuretics - Lasix, thiazides

Front 538

Indications for laparotomy in penetrating abdominal trauma

Back 538

DIE Unstable PIG!!

D iaphragmatic injury

I mplement in situ
E visceration

Unstable (especially if FAST / DPL +)

P eritoneal signs
I ntraperitoneal air

G I hemorrhage / G SW to abdomen

Front 539

Most common abdo injury in stab wound

Most common abdo injury shooting

Most common abdo injury blunt trauma

Back 539

Most common abdo injury in stab wound

Liver

Most common abdo injury shooting

Small bowel

Most common abdo injury blunt trauma

Spleen

Front 540

Indications for reimplantation of amputation; contraindications to reimplantation; relative contraindications to reimplantation

Back 540

Indications of replant

-Multiple Digits

-Single digit between PIP & DIP (insertion of tendons between there)

-Thumb

-Wrist/forearm

-Sharp amputation proximal to elbow

-All pediatric amputations

Absolute contraindications to reimplantation

-Crush injury

-Unstable patient

Relative contraindications

-Severe multilevel

-Self inflicted

-Extremes of age

-Serious comorbidity

-Proximal to PIP

Front 541

Signs of urethral injury. Most reliable in female?

Back 541

-high riding prostate

-blood at the meatus

-open pelvic fracture

-Scrotal hematoma

-Penile Hematoma

-perineal hematoma

-failure to pass foley x 1

-Fractured penis

In female the most reliable sign is inability to pass a Foley catheter

Front 542

False positive free fluid on FAST

Back 542

-peritoneal dialysis

-ascites

-physiologic free fluid in female

-urine from bladder rupture

-Ruptured Ectopic Pregnancy

-PID

-fluid in bowel or stomach

-mesenteric fat

-Operator inexperience

Front 543

False negative free fluid on FAST

Back 543

250-500mL of fluid must be present to be visible on FAST (Sn 60-99%; Sp 80-99%)

-small volume

-Early in trauma

-Adhesions

-Timing (not enough preceding time supine)

-Operator inexperience

Front 544

Most common fractures in the elderly (UE and LE)

Back 544

UE

-Distal radius (50%)

-Proximal humerus (30%)

LE

-Hip

Front 545

Clinical and radiographic findings of an orbital fracture

Back 545

Clinical findings

-Enophthalmos

-Diplopia

-Inability to gaze upward; Pain or Restrictions of EOM

-Step deformity palapable

-Subcutaneous emphysema

-Infraorbital nerve anesthesia

Radiographic

-Tear drop sign (opacification in the shape of a tear at the bottom of the orbit)

-AFL in maxillary sinus

-eyebrow sign (lucency in the shape of an eybrow at the top of the orbit)

Front 546

Clinical findings of anterior chamber trauma

Back 546

-Hyphema

-Flare

-Iridodialysis

-Ciliary flush

-Sluggish Pupil (cyclitis)

-Deep anterior chamber from posterior displacement of iris

-Seidel's sign

Front 547

Slit lamp findings of blunt trauma to the sclera or lens

Back 547

-Abrasion - Positive Fluroscein uptake

-Scleral laceration

-Positive Siedel’s

-Subconjunctival hematoma

-Iridodonesis (iris movement with eye movement - due to lens dislodgement)

Front 548

Slit lamp findings of penetrating globe injury

Back 548

-Decreased Anterior Chamber depth

-Positive Siedel’s

-Hyphema

-Scleral laceration

-Bloody chemosis

-Retained implement (FB)

-Corneal Laceration

-Teardrop pupil

-Iris prolapse

-iris transillumination defect due to vitreous hemorrhage

Front 549

ECG changes seen in massive head injury

Back 549

-Bradycardia

-Deep T-wave inversion

-ST seg Elevation

-ST seg depression

-QT Prolongation

-PR Prolongation

-RBBB / incomplete RBBB

-Junctional Rhythm, Sinus Dysrhythmias, Sinus Tachy

-U wave > 1mm

Front 550

Physical exam findings of basilar skull fracture

Back 550

-Racoon Eyes

-CSF Otorrhea

-CSF Rhinorhea

-Hemotympanum

-Battle Sign

-Acute hearing loss (CN8 injury)

-Bilateral CN 7 palsy (looks like ‘bilateral bells’)

-blood in the external auditory canal

Front 551

Systemic manifestations of hydrofloric acid exposure

Back 551

-Metabolic Acidosis

-Hypocalcemia

-Dysrhythmias

-Seizures

-Tetany

Front 552

Clinical criteria for massive hemothorax

Back 552

->1500 mL immediate output blood from chest tube

->200mL/h drainage x 2-4h

-Absent breath sounds, dullness to percussion, and shock with or without tracheal deviation

Front 553

Causes of persistent air leak on a chest tube

Back 553

-Tracheobronchial transection

-Bronchopulmonary fistula

-**Incomplete insertion of chest tube**

-Leak in the chest tube system

Front 554

Canadian CT Head Rule (high risk, low risk, inclusion criteria, exclusion criteria)

Back 554

Front 555

Contraindications to cricothyrotomy

Back 555

-Laryngeal #

-< 8 yoa

-anterior neck hematoma

Front 556

Physiologic changes that affect the pregnant trauma patient

Back 556

-Gravid uterus compresses IVC (supine hypotension)

-Baseline diastasis of pubic symphysis

-laxity of pelvic ligaments

-Physiologic anemia

-Increased blood volume allowing for greater compensation for blood loss but rapid deterioration when reach maximal compensation

-increased minute ventilation

-Relative hypocarbia

-Higher resting HR

-Higher resting RR, blood gas with PCO2 30, HCO3 21

-Lower FRC

-Abdominal viscera protected by uterus and difficult to examine (abdo exam unreliable)

Front 557

2 additional management considerations in the initial resuscitation of the pregnant trauma patient

Back 557

-Supine hypotension due to compression of IVC by uterus (lean to the left 30 degrees)

-Feto-maternal hemorrhage - do type and Kleihauer-Betke test and treat with WinRho prn

Front 558

Complications and non-pharma treatments of rib fractures

Back 558

Complications:

-Pneumothorax

-Hemothorax

-Pain

-Pneumonia

Non-pharma treatments:

-Incentive spirometry

-Coughing / Deep breathing exercises

-IPPV

-Internal Fixation

Front 559

Factors affecting the rate of heat transfer between objects

Back 559

-Duration

-Transfer Coefficient of objects

-Temperature Differential

-Heat Capacity

-Conductivity of tissues

Front 560

Risk factors for falls in the elderly

Back 560

-Poor vision

-Poor coordination

-Position hypotension

-Poor hearing

-Cachexia

Front 561

Reasons for non-compliance with medications in the elderly

Back 561

-Dementia

-Polypharmacy

-Increased side effects

-Financial constraints

Front 562

NEXUS Rule

Back 562

NSAID

-No N euro deficits

-No S pinal tenderness

-No A ltered LOC

-No I ntoxication

-No D istracting injury

Front 563

Low to high dose trauma imaging

Back 563

Least

CXR

Abdo Flat Plate

KUB

RUG

CT Abdo

Most

Front 564

How to perform a retrograde urethrogram

Back 564

-Flex hip/knee

-Displace penis from midline

-Shoot KUB

-Toomey syringe with water-soluble contrast (60ml)

-Infuse over 1 min, KUB during last 10ml

Front 565

Treatment of arterial air embolism

Back 565

-Trendelenburg or LLD position

-Needle aspiration

-Thoracotomy

-Aspiration via central line

-Compression of source vessel

-IVF

Front 566

What is the appropriate imaging study for penetrating flank trauma?

Back 566

CT-Chest/Abdo/Pelvis with Contrast (triple phase - oral / IV / rectal)

Front 567

Hyphema grading system

Back 567

Micro - just anterior chamber RBC's

I - <1/3

II - 1/3 - 1/2

III - >1/2

IV - full (eight ball hyphema)

Front 568

Complications and management of hyphemas

Back 568

Complications

-Traumatic Glaucoma

-Synchiae

-Staining of cornea

-Rebleed

-Blindness

Management

1) Conservative Mgt - HOB up, metal shield

2) Long acting cycloplegic (homatropine, Atropine)

3) Stop anticoagulants, ASA; avoid NSAIDs

4) Manage IOP (traumatic glaucoma)

5) R/O globe rupture

Front 569

Components of informed consent

Back 569

CAPACITY

-Capacity assessment (CURVES)

DISCLOSURE

-Nature of the treatment

-Benefits and risks of the treatment

-Common/dangerous side effects of the treatment

-Alternatives to the treatment (including not having anything done) and their likely outcome

VOLUNTARY

-Consent given voluntarily and without coercion

Front 570

Zone 1 of the neck and associated injuries

Back 570

Angle of mandible to occiput (upper neck)

jugular

Lung

Trachea

superior mediastinal vessels

Spinal cord

Thoracic duct

Thyroid

Subclavian artery

Carotid artery

Vertebral artery

Esophagus

Front 571

Zone 2 of the neck and associated injuries

Back 571

Zone II - Angle of jaw to cricoid cartilage

Recurrent Laryngeal N.

Larynx

Pharynx

Thyroid cartilage

Esophagus

Spinal Cord

Carotid

Jugular

Vertebral

Vagus nerve

Recurrent laryngeal nerve

Front 572

Zone 3 of the neck and associated injuries

Back 572

Zone I - cricoid to clavicles and suprasternal notch

Brain Stem (IX-XII)

Carotid

Jugular

Parotid gland

Vertebral Artery

Spinal Cord

Salivary glands

Front 573

Indications for operative management of penetrating neck trauma

Back 573

-Hard signs in zone 2

-Unstable

-Transcervical gunshot wound

-Platysma violation in zone 2 (relative)

Front 574

Anatomic locations commonly involved in traumatic aortic injury

Back 574

-Isthmus (Ligamentum Arteriosis)

-Root (Ascending distal to the Aorta)

-Distal descending at the diaphragm

Front 575

Immediate management of a pressure gun injury

Back 575

Cleanse

Splint

Td

Analgesia

Antibiotics

Examine for compartment syndrome

Plastics for admission

Front 576

What key feature distinguishes spinal and neurogenic shock?

Back 576

-SPINAL SHOCK – bulbocavernosus reflex lost; refers to neuro symptoms

-NEUROGENIC SHOCK - shock that occurs due to disruption of sympathetic outflow; bradycardic

Front 577

Intra vs Extraperitoneal bladder injury (mechanism, location, treatment, clinical, cystogram)

Back 577

Mechanism

Intra: Blunt

Extra: Penetrating

Location

Intra: Dome

Extra: Anterior

Treatment

Intra: OR

Extra: Foley unless bladder neck, rectal, vaginal injury (then OR)

Clinical

Intra: hematuria, anuria, pain, meatal blood, peritonitis and abdominal distension

Extra: hematuria, anuria, pain, meatal blood, pelvic fracture

Cystogram

Intra: enhances colon and other intraperitoneal structures

Extra: remains in pelvis

Front 578

Uncal herniation (anatomy, pathophysiology, physical exam)

Back 578

Anatomy - Ipsilateral uncus of the temporal lobe herniates down through the tentorium

Pathophysiology - Compresses ipsilateral CN III and cerebral peduncle of midbrain

PE - decreased LOC, ipsilateral blown pupil, ipsilateral 'down and out' gaze, contralateral paralysis (opposite in Kernohan's notch syndrome)

Front 579

Descending transtentorial herniation (anatomy, pathophysiology, physical exam)

Back 579

Anatomy - expanding lesion in the vertex / frontal / occipital poles or diffuse swelling

Pathophysiology - Cerebrum and midbrain pushed down through the tentorium

PE - decreased LOC, small but reactive pupils, posturing, sunset eyes (can't move up)

Front 580

Cerebotonsillar herniation (anatomy, pathophysiology, physical exam)

Back 580

Anatomy - tonsils herniate through the foramen magnum

Pathophysiology - cerebellar or large cerebral mass push brain down compressing the brainstem

PE - decreased LOC, flaccid quadriplegia, posturing, respirations cease

Front 581

Define flail chest and how it causes respiratory compromise

Back 581

A flail chest has at least 3 continuous ribs, 2 breaks each. This results in paradoxical breathing and inadequate inspiration / expiration. It is also very painful

Front 582

PE findings of tension pneumothorax

Back 582

Mediastinal shift

Decreased AE to affected side

Tracheal Deviation

Subcutaneous emphysema

Hypotension

JVD

Front 583

Benefits and drawbacks of ultrasound in trauma

Back 583

Benefits

-No transfer required

-Less resource intensive (Less expsenive)

-Available in trauma suite (Bedside)

-Easily repeated

-No contrast

-No radiation

-No need for IV Access

-Quick

-Non-invasive

-Sensitive to ~250mL (variable)

Drawbacks

-Does not visualize parenchyma, retroperitoneum

-Poor at identifying hollow viscous

-Compromised by subcut air

-False negatives - ascites

-User-dependent

Front 584

Injuries associated with lap belts

Back 584

-Chance #

-Pancreatic Injury

-Duodenal Injury

-Mesenteric Injury

-Bladder injury

Front 585

Common blast injuries

Back 585

-Hollow viscous

-Dismemberment

-TM rupture

-Air embolism

-Pneumothorax

-Blast lung

Front 586

Lab changes in pregnancy

Back 586

Leukocytosis

Relative anemia

Low Hematocrit

PCO2 down
Bicarb down

Elevated D-Dimer

Increased fibrinogen
Low Creatinine

Front 587

PDA - when does it close?

PGE1 - indications and complications

Back 587

Closure

-Physiologic at 10-15 hours

-Anatomic at 30 days

PGE1 indications

-Cyanosis refractory to oxygen

-Refractory shock

-Refractory cyanosis AND shock

Complications

-Apnea

-Fever

-Brady

-Seizures

-Flushing

-Hypotension

-Decreased platelet aggregation

Front 588

NRP algorithm - indications for entering and 6 steps

Back 588

Enter algorithm if problem with Term / Tone / Breathing

1 - Warm, position airway, dry, stimulate x 30s

2 - If SpO2 not at target - supplemental O2 prn

3 - If HR<100, gasping, apnea, O2 not rising - Assist breathing with PPV x 30s

4 - If HR<60 - ETI and Chest compressions (rate of 90; 3:1 compression:breath ratio)

6 - If HR still <60 - Epinephrine, consider hypovolemia or PTx

Front 589

Targeted preductal SpO2 after birth

Back 589

1m - 60-65%

2m - 65-70%

3m - 70-75%

4m - 75-80%

5m - 80-85%

10n - 85-95%

Front 590

Indications for neonatal intubation, tube size

Back 590

6 reasons

HR< 60

Meconium aspiration in a flat baby

Ineffective or prolonged PPV

Congenital diaphragmatic hernia

<1000g

Delivery of meds

Tube size 3.5 if TERM

Front 591

The H's and T's

Back 591

5 H's

H ypoxia

H ypovolemia

H ydrogen ion (acidosis)

H ypo / H yper kalemia

H ypothermia

5 T's

T ension pneumothorax

T amponade

T oxins

T hrombosis (pulmonary)

T hrombosis (coronary)

Front 592

Doses of inotropes / vasopressors (epi, norepi, dopamine, dobutamine, phenylephrine)

Back 592

Epinephrine - 0.05-0.5mcg/kg/m

Norepinephrine - 0.05-0.5mcg/kg/m (5-20mcg/m push)

Dopamine - 5-20mcg/kg/m

Dobutamine - 5-20mcg/kg/m

Phenylephrine - 5-20mcg/m push

Front 593

Mixing push-dose epinephrine and phenylephrine

Back 593

Epinephrine

1mg / vial

1mcg/mL in 1L

10mcg/mL in 100mL

100mcg/mL in 10mL

Phenylephrine

10mg / mL

100mcg/mL in 100mL

40mcg/mL in 250mL

Front 594

BLS: trained provider vs untrained provider

Back 594

Both

-AED

-911

-Trade

Untrained provider

-Hands only CPR (2 inches or 1/3 of chest) at 100/m

Trained provider

-30:2 compressions:breaths if 1 OR 2 providers at 100/m in adults

-15:2 compressions:breaths if 2 providers at 100/m in children

Front 595

CPR with advanced airway

Back 595

Both adults and children

-8-10 breaths/m (q 6-8s) with each breath lasting 1s and not synchronized with compressions (don't stop!)

Front 596

BLS Choking

Back 596

<1y

-Alternate 5 back slaps and 5 chest thrusts until unresponsive

1 to puberty

-Abdominal thrusts until unresponsive

Puberty to adult

-Abdominal thrusts UNLESS pregnant or obese (then chest thrusts) until unresponsive

All

-If unresponsive with no or agonal breathing begin CPR

-Check mouth for FB q breath stop

Front 597

Key etCO2 readings during CPR

Uses in CPR

Back 597

Key readings:

If <10 improve CPR or patient dead

If >40 expect ROSC

Key uses:

-Monitor quality of CPR

-Monitor tube placement

-Monitor for ROSC during CPR (will see increase >= 40mmHg)

-Determine if ROSC unlikely (persistently <10mmHg)

Front 598

Characteristics of benign early repolarization

Back 598

Diffuse

Temporally stable

Highest in V2-5

Concave up

QRS notched at J point

Concordant T's

Front 599

DDx of inverted T's

Back 599

Normal in children / persistent juvenile pattern

Intracranial hemorrhage

Myocardial infarction

BBB

Strain in ventricular hypertrophy

Hypertrophic cardiomyopathy

PE

Front 600

Indications for rescue PCI

Back 600

4 indications

CP not resolved

Persistent ST elevation (especially of >50%)

Hemodynamically unstable

Front 601

Indications to transfer a patient for primary PCI

Back 601

-First medical contact to needle time can be <120m

-Contraindications to lytic

-Presented >12h post onset of CP

-Ventricular dysrhythmias

-Requires rescue PCI (CP, hemodynamically unstable, persistent STE >50%)

Front 602

Risk of bleeding on an anticoagulant

Back 602

HAS BLED

H ypertension

A bnormal liver/renal function

S troke history

B leeding predisposition

L abile INR

E lderly (>65)

D rugs / EtOH usage

Front 603

Causes of high output heart failure

Back 603

AV fistula

Pregnancy

Cirrhosis

Anemia

Beriberi

Thyrotoxicosis

Paget's disease

Front 604

Echo findings of tamponade

Back 604

-RA compression

-RV collapse

-Hepatic vein dilation

-Dilated IVC (no collapse with respiration)

-Abnormal TV and MV flow velocities

Front 605

Causes of culture negative endocarditis

Back 605

HACEK

H aemophilus aphrophilus

A ctinobacillus

C ardiobacterium hominus

E ikenella corrodens

K ingella Kingae

Front 606

IJ central line complications and treatment

Back 606

1) Air embolism - supportive care, fluids, aspirate air, thoracotomy

2) Dysrhythmia - pull back insulting device (wire, line)

3) Pneumothorax - chest tube, O2, aspiration, Hiemlich valve

4) Arterial puncture with finder needle - with draw

5) Hematoma - pressure

6) Bleeding - pressure

7) Right atrial or ventricular perforation - Cardiac surgery consult

Front 607

3 causes of no detectable etCO2 in cardiac arrest

Back 607

-Dislodged/misplaced tube

-Obstruction of tube (massive PE) or pulmonary edema

-Prolonged arrest or downtime

-Severe asthma

-Large glottic air leak

-Equipment failure

-Transient decrease expected after administration of epinephrine (vasoconstricts pulmonary blood flow)

Front 608

Indicators of inadequate blood flow during CPR

Back 608

-Carotid or femoral pulse not palpable

-CPP <15mmHg

-EtCO2 <10mmHg

-ScvO2 <30%

-Art line DBP <20mmHg

Front 609

Contraindications to CPR

Back 609

-DNR

-Danger to bystander

-Irreversible death (Rigor mortis, decomposition, decapitation, lividity)

In neonates (anencephaly, trisomy 13/18, <400g, <23 weeks, SFH < umbilicus)

Front 610

Contraindications to IO line at a specific site

Back 610

-Osteoporosis

-Osteogenesis imperfecta

-Fractured bone

-Recent IO site

-Needle insertion through areas of cellulitis, infection, burns

Front 611

Complications of an IO line

Back 611

-Fracture

-Fat embolism

-Pain with infusion

-Compartment syndrome

-Skin sloughing

-Osteomyelitis

-Epiphyseal damage

Front 612

Physical exam findings of aortic dissection

Back 612

-Hypertension

-Pulse Deficit

-BP differential between two limbs

-Signs of cardiac Tamponade

-Stroke like syndrome

Front 613

Complications of aortic dissection

Back 613

-Pericardial Tamponade

-Inferior MI

-Aortic valve insufficiency

-Ischemia

-> spinal (Art of Adamkiewcz)

-> ischemic stroke

-> mesenteric ischemia

-> renal ischemia

Front 614

Signs of SAH on CT scan

Back 614

-Blood in the basilar cisterns

>> Interpeduncular [anterior to pons just superoposterior of the suprasellar]

>> Suprasellar cistern [star sign]

>> Prepontine cistern [just inferoposterior suprasellar anterior to the pons]

>> Ambient cistern [bottom star legs around the midbrain]

>> Sylvian fissue

>> Anterior interhemispheric fissure

-Isodense basilar cisterns

-Hydrocephalus (temporal horns and infundibulum of 3rd ventricle)

-Reflux of blood into the 4th ventricle

Front 615

Hunt & Hess grading system for SAH

Back 615

0-5 (prognosis good for 0-1; intermediate 3; poor 4-5)

0 - Unruptured

1 - Asymptomatic / headache

2 - mod-severe headache, nuchal rigidity, nothing focal

3 - decreased LOC, mind focal deficit

4 - stupor, hemiparesis

5 - coma, decerberate

Front 616

Etiology of nontraumatic SAH

Back 616

B CARMEN

B lood dyscrasias

C avernous angioma

A VM

R uptured saccular aneurysm

M ycotic aneurysm

E xtension from intraparenchamyl

N eoplasm

Front 617

Noncontrast CT findings of stroke

Back 617

Acute (cytotoxic edema)

-visualization of the clot/embolism (e.g. hyperdense MCA sign) - immediate

-loss of grey-white distinction (e.g. lentiform nucleus and insular ribbon) - 1-3h

-Low attenuation of grey matter

-Effacement of the sulci

Subacute (vasogenic edema)

-Wedge shaped area of low attenuation of both gray and white

-Mass effect (3-5 days)

Chronic (3 weeks - 1 year)

-Resorption of infarcted area (looks like CSF)

-Volume loss (negative mass effect dilating the ventricles)

Front 618

Classic stroke neurological findings (AMA, MCA, PCA, Lacunar, Verterbrobasilar, Basilar, Cerebellar)

Back 618

AMA - contralateral weak/numb legs > hand/face

MCA - contralateral weak/numb hands/face > legs

PCA - contralateral visual field and light touch

Lacunar - pure motor OR sensory

Vertebrobasilar - ipsilateral cranial nerve and contralateral weakness

Basilar - 'Locked in' syndrome (normal mental status and blinking, can't move voluntary muscles)

Cerbellar - dysmetria, dysdiadokinesia, can't walk, N/V

Front 619

Brown-Sequard Syndrome deficits, causes

Back 619

Deficits: ipsilateral proprioception / vibration / motor; contralateral pain and temperature

Causes: penetrating injury, cord compression

Front 620

West Nile Virus: type of virus, vector, diagnosis, presentation

Back 620

Type: Flavivirus

Vector: Birds (crows/ravens/jays) and Culex mosquitos

Diagnosis: WNV IgM in serum or CFS (crossreacts with infection / immunization for Japanese encephalitis virus serocomplex - St. Louis encephalitis; dengue)

Presentation: Most often fever, malaise, myalgias, headache, nausea, emesis, rash, lymphadenopathy. Occasionally in the elderly (>70) get weakness -> paralysis; meningitis -> encephalitis; morbidity/mortality.

Treatment: supportive.

Prevention: mosquito repellents, reducing mosquito numbers

Front 621

4 tributaries to Kiesselbach's plexus, causes of anterior epistaxis

Back 621

-Anterior ethmoidal artery

-Septal branch of superior labial artery

-Nasopalatine branch of sphenopalatine artery

-Greater palatine artery

Causes

-Traumatic

-Cocaine

-Vasculitis

-Platelet

-FB

-Polyp

Front 622

When do the facial sinuses become aerated?

Back 622

Birth - ethmoid and mastoid antrum

3y - sphenoid and mastoid air cells

6y - frontal

10y - maxillary

Front 623

Distinguish Le Fort I, II, III

Back 623

I - through maxilla; maxilla moves forward when pulled

II - through nasal bridge, orbits, lacrimal bones, maxilla; nose and maxilla move forward when pulled

III - nasal bridge through orbits (ethmoid, maxilla, orbital walls) and zygomatic arches; face moves forward when pulled

Front 624

Zones of the hand

Back 624

Key zones:

I - Mallet finger

III - Boutonniere deformity

V - Fight bite

Front 625

Acceptable angulation for Boxer's fracture and metacarpal shaft

Back 625

Boxer's: 10-20-30-40 rule (D2-5)

Shaft: 10 degree in 2-3 and 20 degrees in 4-5

Front 626

x-ray signs of posterior shoulder dislocation

Back 626

Internal rotation

Lightbulb / Drumstick sign

Loss of overlap of humeral head on glenoid

Increased distance between glenoid and head of humerus

Trough sign (reverse Hill-Sachs lesion)

Front 627

Injury and associated nerve damage:

-Elbow fracture

-Shoulder dislocation

-Sacral fracture

-Acetabular fracture

-Hip dislocation

-Knee dislocation

-Lat tib plateau fracture

Back 627

Elbow fracture - Median or ulnar

Shoulder dislocation - Axillary

Sacral fracture - Cauda equina

Acetabular fracture - Sciatic

Hip dislocation - Femoral

Knee dislocation - Popliteal

Lat tib plateau fracture - Peroneal

Front 628

LE motor nerve testing

Femoral

Saphenous

Sciatic

Tibial

Common peroneal

Superficial peroneal

Deep peroneal

Sural

Back 628

Femoral - Knee extension

Saphenous - N/A

Sciatic - Knee flexion

Tibial - Foot plantar flexion

Common peroneal - N/A

Superficial peroneal - Foot eversion

Deep peroneal - Dorsiflexion of foot / toe extension

Sural - N/A

Front 629

LE sensory nerve testing

Femoral

Saphenous

Sciatic

Tibial

Common peroneal

Superficial peroneal

Deep peroneal

Sural

Back 629

LE sensory nerve testing

Femoral - anterior thigh / knee

Saphenous - medial foot

Sciatic - N/A

Tibial - sole of foot

Common peroneal - N/A

Superficial peroneal - dorsum of foot

Deep peroneal - first web space

Sural - lateral foot

Front 630

Signs of pulmonary edema on CXR

Back 630

10 classical findings:

1. Cephalization of Vascular markings (marked pulmonary redistribution)

2. Enlarged Heart Shadow - Cardiomegaly

3. Prominent Azygous Vein

4. Bat wing hilum

5. Kerley A lines

6. Kerley B lines

7. Kerley C lines

8. Peribronchial Cuffing

9. Pleural Effusion

10. Interlobar Fissure lines

Front 631

Differences between the adult and pediatric C-spine

Back 631

1. a proportionally heavier head
2. higher fulcrum of flexion

3. Less neck muscle mass

4. lax ligaments, allowing for more mobility at C1-C2;

5. incomplete ossification / un-fused physes;

6. horizontally inclined articular facets that facilitate sliding.

7. Anterior wedging of vertebral bodies

8. Pseudosubluxation of C2 on C3

9. Secondary ossificaiton centres may mimic avulsions

10. Variable interspinous distances

11. Widening of the pre-dental space (up to 5mm)

12. Lateral displacement of the masses C1 on C2

13. instability of atlanto-axial joint

14. SCIWORA - due to flexibility of bone

Front 632

DDx for elevated troponin

Back 632

1) Myocardial Infarction

2) Myocardial contusion

3) Chronic renal insufficiency for Troponin T

4) PE

5) Myocarditis

6) Acute heart failure

7) Perimyocarditis

8) Sepsis, ARDS, end organ strain

9) post-Cardiac procedure (cath, Surg, ablation)

10) Cardiomyopathy (Tako-tsubo)

11) Sympathomimetic drugs (cocaine!)

12) Aortic Dissection

13) Radiation therapy

Front 633

Eponym

Aviator’s

Barton’s

Bennett’s

Boxer’s

Chance’s

Chauffeur’s

Clay shoveler’s

Colles’

Cotton’s

Pseudo-Jones

Dashboard

Dupuytren’s

Essex-Lopresti

Galeazzi’s

Hangman’s

Jefferson

Jones’

Le Fort

Lisfranc’s

Maisonneuve

March

Monteggia’s

Nightstick

Pilon

Rolando’s

Salter-Harris

Segond

Stener

Smith’s

Teardrop

Tillaux

Back 633

Aviator’s - Vertical # neck of talus with subtalar dislocation

Barton’s - Intra-articular wrist #-dislocation; dorsal or volar

Bennett’s - Oblique intra-articular # through base 1st MC

Boxer’s - # neck of 4th or 5th MC

Chance’s - Lumbar vertebral # through spinous process, pedicles, and vertebral body

Chauffeur’s - # radial styloid

Clay shoveler’s - # tip spinous process C6 or C7

Colles’ - # distal radius with dorsal displacement and apex volar angulation

Cotton’s - Trimalleolar #

Pseudo-Jones - # base 5th MT, < 15 mm from proximal end (insertion peroneus brevis)

Dashboard - # posterior rim of the acetabulum

Dupuytren’s - #-dislocation of the ankle

Essex-Lopresti - Radial head # with dislocation of DRUJ

Galeazzi’s - # radial shaft with DRUJ dislocation

Hangman’s - # pars interarticularis of C2

Jefferson - Burst # C1

Jones’ - Transverse # 5th MT base, > 15 mm from proximal end

Le Fort - Maxillary #

Lisfranc’s - #-dislocation of tarsometatarsal joint

Maisonneuve - # proximal fibula, disrupted syndesmosis, # medial malleolus

March - Stress # of metatarsal

Monteggia’s - # proximal ulna, dislocation radial head

Nightstick - # of ulna, radius or both

Pilon - ankle # & distal tibial metaphyseal #, usually w/ intraarticular comminution

Rolando’s - Comminuted # base of 1st MC

Salter-Harris -Epiphyseal # in children

Segond - Avulsion of lateral tibia associated with ACL tear

Stener - Avulsion ulnar corner base proximal phalange in thumb

Smith’s - # distal radius with volar displacement (reverse Colles’)

Teardrop - Wedge-shaped # of anteroinferior portion of vertebral body

Tillaux - Avulsion # anterolateral portion of distal tibial epiphysis in adolescents

Front 634

Complications of fractures

Back 634

Hemorrhage

Vascular injury

Nerve injury

Compartment syndrome

Volkmann’s ischemic contracture

Avascular necrosis

RSD

Fat embolism syndrome

Fracture blisters

Front 635

Complications of immobilization

Back 635

Pneumonia

DVT/PE

UTI

Wound infection

Decubitus ulcers

Muscle atrophy

Stress ulcers

Front 636

Life or limb threatening ortho emergencies

Back 636

Open fracture

Fracture/dislocation with major vascular disruption

Major pelvic fracture

Hip or knee dislocation

Compartment syndrome

Front 637

Grades of acromioclavicular joint separation

Back 637

I - AC ligament sprain

II - AC ligament rupture; CC ligaments sprained but intact. Joint space widened and slight ↑ displacement of clavicle

III - Complete rupture of AC and CC ligaments, muscle attachments. Joint space widened and CC distance ↑

IV - Similar to III, but clavicle → posterior into trapezius

V - Similar to III, but clavicle → upwards even more

VI - Similar to III, but clavicle → inferiorly

Front 638

Indications for angiography with a pelvic fracture

Back 638

-Hemodynamic instability with –ive DPL or FAST

-Large pelvic hematoma or active contrast extravasation on CT

-Large/expanding RP hematoma seen at laparotomy

-≥ 4 units blood transfused for pelvic bleeding in 24 h, or ≥ 6 units in 48 h

Front 639

DDx of the painful hip

Back 639

-SCFE

-Perthes’ disease

-Bursitis

-Tendonitis

-Toxic synovitis

-Septic arthritis

-OA

-Arterial insufficiency

-AVN femoral head

-DVT

-Ligament injury (hip, knee)

-Occult fracture

-Tumour (lymphoma)

-Referred pain (spine, knee)

Front 640

Classification of tibial spine fractures

Back 640

I Incomplete avulsion without displacement

II Incomplete avulsion with minimal displacement

IIIA Complete avulsion with displacement

IIIB Complete avulsion with displacement and rotation

Front 641

Causes of traumatic hemarthrosis of the knee

Back 641

ACL injury

PCL injury

Patellar subluxation/dislocation

Peripheral meniscal tear

Osteochondral fracture

Capsular tear

Front 642

DDx of presumed ankle sprain

Back 642

-LCL sprain

-Peroneal tendon dislocation

-Osteochondral talar dome #

-Talar post process #

-Talar ant process #

-Talar lateral process #

-Calcaneus ant process #

-Midtarsal joint injury

-Base 5th MT #

Front 643

Foot injuries requiring ortho consult

Back 643

-Open #

-Fracture-dislocation

-Major talar head/neck/body #s

-Lisfranc injuries

-Most GSWs

-Compartment Syndrome

Front 644

Ankle fractures that require ortho consult

Back 644

-Displaced medial, lateral, or posterior malleolus

-Bimaleolar fractures and equivalent (Deltoid ligament, syndesmosis rupture)

-Trimalleolar

-Intraarticular with step deformity

-Open #

-Pilon #

-Fracture dislocation

-Open fracture

-SH III, IV, V

Front 645

Causes of compartment syndrome

Back 645

Increased content:

-Bleeding (Vascular injury, Coagulation disorder, Anticoagulant use)

-↑ Capillary filtration (Reperfusion post-ischemia, Trauma, Intensive muscle use, Burns, Intra-arterial injection, Orthopedic surgery, Snakebite)

-↑ Capillary pressure (Intensive muscle use, Venous obstruction)

↓ Compartment Volume

- Closure of fascial defect

- Excessive limb traction

- Tight cast, dressing, splint

- Lying on limb

Miscellaneous

-Infiltrated infusion

-Pressure transfusion

-Leaky dialysis cannula

-Muscle hypertrophy

-Popliteal cyst

Front 646

DDx solid, lucent bone lesions

Back 646

-Metastasis/Myeloma



-Aneurysmal bone cyst


-
Solitary bone cyst

-Fibrous dysplasia


-Osteoblastoma


-Giant cell tumour (EPIPHYSIS adults)

-Chondroblastoma (EPIPHYSIS children)

-Hyperparathyroidism (brown tumour)

-Hemangioma


-Infection


-Non-ossifying fibroma


-Eosinophilic granuloma/Enchondroma

Front 647

Age and associated bony malignancies

Back 647

Age (years)

Tumour

< 1 - Neuroblastoma

1-10 - Ewing’s (tubular bones)

10-30 - Osteosarcoma, Ewing’s (flat bones)

30-40 - Primary histiocytic lymphoma,
fibrosarcoma, parosteal osteosarcoma, malignant giant cell tumor, lymphoma

> 40 - Metastatic carcinoma, multiple myeloma, chondrosarcoma

Front 648

Splint complications

Back 648

-Pressure necrosis – may occur as early as 2 hours

-Tight cast => compartment syndrome >> Univalving = 30% pressure drop

>> Bivalving = 60% pressure drop

>>Also need to cut cast padding

-Abrasions / Cellulitis

-Loss of reduction

-Thermal Burns → avoid plaster > 10 ply and water > 24°C

-DVT/PE: ↑ in lower extremity #

-Joint stiffness → Leave joints free when possible and splint in in position of function

Front 649

Presentation of fat embolism

Back 649

1.Respiratory distress (earliest and most common manifestation)

2.Neurologic manifestation (confusion, ↓ LOC)

3.Thrombocytopenia

4.Petechial rash

5.Fever, tachycardia, jaundice, retinal changes and renal involvement may occur

Fat in urine in 50% within 3 days

Front 650

List of ECG changes to look for in the syncope patient

Back 650

QT BRIDE is Hot

She makes your heart race and you feel like passing out - arrhythmias (brady, tachy, AFib, AFlutter, blocks, bifasicular/trifasicular blocks VT...etc) any irregular rate or rhythm

QT - long/short QT

B - Brugada

R - Right sided strain (RBBB, s1q3t3, inverted T-waves V1-V4, tachy, Right axis deviation)

I - Ischemia

D - Delta wave (WPW)

E - Epislon wave (ARVD)

H - Hypertrophy - HOCM, LVH (AS, DCM)

Front 651

Pertussis incubation, phases, prevention, treatment, complications

Back 651

Incubation: 1-3 weeks

Phases:

-Catarrhal (1-2 weeks) - rhinorrhea, fever, malaise. Infective.

-Paroxysmal (2-4 weeks) - staccato cough (40-50x/d) worse at night/cold. Whoop on inspiration between coughs, Emesis after cough. Infective.

-Convalescent (months) - residual coughing

Prevention - immunization and boosters

Treatment - Azithromycin x 3-5days to prevent spread within 3 weeks of onset (6 weeks for pregnant, <1y). Not infective after 5 days.

Complications - pneumonia, encephalopathy, earache, seizures. 1.6% fatality rate in infants <1y.

Front 652

Complications of coughing paroxysms in pertussis

Back 652

Periorbital edema

Subconjunctival hemorrhage

Petechiae

Epistaxis

Hemoptyis

Subcutaneous emphysema

Pneumothorax

Pneumomediastinum

Diaphragm rupture

Umbilical or Inguinal hernia

Rectal prolapse

Front 653

Tetanus definition, complications, management

Back 653

Definition:

Acute onset of hypertonia or painful muscular contractions (usually of the muscles of the jaw and neck) and generalized muscle spasms without other apparent medical causes,

Complications:

Respiratory failure, autonomic dysfunction, MSK spasms (Long bone fractures; tendon rupture; Subluxations, Dislocations (esp TMJ)), rhabdomyolysis

Management:

-Supportive treatment with intubation, GABA blockade (Benzos, Midaz, Propofol +/- Dantrolene, Magnesium), alpha blockade (phentolamine)

-Toxin treatment with Human Tetanus IG 500U (administer AWAY from Td shot)

-Infection treatment with debridement, Flagyl 500 mg IV q6h (7.5mg/kg for children)

Front 654

Tetanus prophylaxis

Back 654

-Clean or dirty wound and immunized (x3 and up to date) - nothing

-Clean wound and unimmunized - Td

-Dirty wound and unimmunized - Td and TIG

Front 655

Botulism cause, types, diagnosis, treatment

Back 655

Cause: toxin produced by clostridium botulinum; inhibits acetylcholine release

Types: infant, food, wound, inhalation

Diagnosis: toxin in blood, toxin or bacteria in stool / wound culture, EMG (supportive)

Treatment: Source control (if infection), Intubate if FVC<15mL/kg; Trivalent equine antitoxin (adults) or Baby BIG (infants), NG tube (for ileus), treat autonomic dysfunction prn

Front 656

Contraindications to LP

Back 656

-skin or soft tissue infection at puncture site.

-Likelihood of brain herniation (mass lesion, papilledema)

-INR>1.5

-Plt < 50

Front 657

Indications for CT pre-LP

Back 657

-Immunocompromised

-ALOC (GCS <14)

-Seizure in past 7 days

-Focal neurologic signs

-Papilledema

-PMHx of CVA, mass lesion, focal infection, head trauma, CNS Sx

Also consider age >60, severe HA/N/V, suspected brain bleed or lesion.

Front 658

Empiric treatment for meningitis

Back 658

<1m: Ampicillin (Listeria) & Cefotaxime (Kernicterus)

1-50y or basal skull: Ceftriaxone & Vancomycin

>50y: Ampicillin (Listeria), Ceftriaxone, Vancomycin

Instrumentation or penetrating trauma: Vancomycin & Ceftazidime

Front 659

Treatment of toxic shock

Back 659

As for sepsis: fluids, vasopressors, O2, ventilation, steroids, source control

Penicillin and clindamycin (stops toxin synthesis) and IVIg (especially for staph TSS)

Front 660

Rabies mechanism, stages and management

Back 660

Mechanism:

-Travels up nerves at a rate of 8-20mm/d to the brain (Negri bodies) and salivary glands (infect others), causes cytokine storm and serotonin hyperactivity.

Stages:

I Incubation

II Prodrome (1d-1w)

III Acute neurological illness - can be furious (80% - hyperactive then lethargic, hydrophobia, salivation, spasms), dumb (20% - limb weakness, fever, looks like GBS), or non-classic (Thailand; brainstem/ motor/ sensory deficits pronounced; seizures)

IV Coma (7-10d following acute neuro)

V Death (2-3d following coma)

Prophylaxis

-Scrub and clean wound then rinse with povidone-iodine

-If vaccinated give additional doses at 0 and 3 days-If unvaccinated give 20U human RIG near bite (and far from vaccine) then vaccine at 0,3,7,14,28 days

Management

-Ketamine (inhibits viral replication?)

Front 661

Rabies carriers and PEP

Back 661

Most to least common:

-Bats, Raccoons, Skunks, Foxes (assume rabid unless none in area or lab neg - give PEP)

-Dogs/cats/ferrets (observe x10d if caught; PEP if caught and suspected rabid; consult public health if escaped and not suspected)

-Rodents/lagomorphs (no proven transmission - no PEP)

Front 662

Measles incubation, symptoms, complications

Back 662

-Exposure

-10 days later get cough, coryza, conjunctivitis, koplik spots and fever

-4 days later get rash

-Contagious 5 days before the rash and 4 days after

-Complications include otitis media, encephalitis, pneumonitis and 20 years later Subacute Sclerosing Panencephalitis

Front 663

Mumps incubation, presentation, complications, treatment

Back 663

Incubation - 18 days (and lasts 7-10)

Presentation - fever, myalgias, malaise, parotid swelling, orchitis, meningitis

Complications

-Orchitis, Meningitis, GBS, Transverse myelitis, Deafness, Pancreatitis, Mastitis, Oophoritis, Myocarditis, Arthritis

Treatment

-IVIg if meningitis/pancreatitis

Front 664

Workup for Parvovirus B19 exposure in pregnancy

Back 664

-Get Parvovirus IgG and IgM levels

-If only IgG+ patient is immune; no acute infection

-If only IgM+ patient has an acute infection - refer to OBGYN and U/S for ? hydrops

-If neither IgG or IgM no acute infection

Front 665

HIV prophylaxis - bugs and drugs

Back 665

1. PCP (Septra)

2. Toxo (Septra)

3. TB (INH)

4. MAC (Azithro)

5. CMV (Gancyclovir)

Front 666

High risk HIV exposures

Back 666

Exposures

1. Percutaneous needles (deep injuries, blood on device, venipuncture)

2. Mucous membrane

3. Sexual contact

Contact (Triple therapy PEP)

1. Patient has symptomatic HIV

2. AIDS

3. Acute seroconversion

4. High viral load

Front 667

How to remove ticks

Back 667

1 - “Tweezer” method: Grasp w/ Tweezers close to skin, slow and steady, ensure removal of head; keep for inspection

2 -“Straw Knot” Subtle but constant upward pressure on the string once the tick is "caught" with the knot.

3 - Excisional technique – excise tick with the tissue around it – cut elpitically, close with simple interrupted

4 - Kill with viscus lidocaine

a. Grasp with blunt forceps as near to attachment as possible

b. Gentle upward traction to remove (no squeezing or jerking)

Front 668

Unilateral CNVII palsy

Back 668

Infectious

-Lyme

-Bell’s Palsy

-Ramsay-Hunt

-Viral (VZV, HIV)

-Otitis Media / Externa / Mastoiditis

Trauma

-Middle Ear Barotrauma

-Facial laceration

Brain

-Schwannoma

-MS

-Brainstem lesion or mass (aneurysm)

Weird

-Diabetic Neuropathy

-Sarcoidosis

Front 669

Limping child

Back 669

Rheumatic / Inflammatory

-JRA – usually polyarticular arthritis

-Rheumatic fever – usually polyarticular arthritis

-Ankylizing spondylitis

-HSP

-Gout or pseudogout

Congenital / Mechanical

-Sickle cell

-Limb length discrepancy

-Developmental dysplasia

-Legg-Calve-Perthes

-SCFE

-Osgood Schlatter

-Femoro-patellar syndrome

Trauma

-Toddler's fracture

-NAT

-Hemarthrosis – traumatic or spontaneous

Cancer

-Osteochondroma

-Ewing's sarcoma

Infection

-Osteomyelitis

-Transient (toxic) synovitis – 3 mo-6yrs, usually hip

-Reactive arthritis – Strep, Chlamydia, Salmonella, Shigella, Lyme, Yersinia, viruses

Referred pain

-Appendicitis

-Testicular torsion

Front 670

Gas in tissues (infectious)

Back 670

-Clostridia (perfringens, septicum)

-Gram negatives (E. coli, Klebsiella, Enterobacter)

-Anaerobes (Peptostreptococcus, B. fragilis)

-Peptococcus

-Group A Streptococcus

Front 671

Aquatic skin infections: fresh, salt, tropical

Back 671

Fresh - aeromonas hydrophilia (cipro)

Salt - vibrio velnificans (cipro)

Aquarium - mycobacterium marinum (TB meds - RIPE)

Front 672

Cavernous venous thrombosis: cause, presentation, treatment

Back 672

Cause: preceded by trauma, bacteremia, or local (facial, dental, sinus, ear) infection

Presentation: headache, CN III V IV VI VIII findings (deaf, dizzy, EOM, diplopia, facial movements), periorbital edema, exopthalmos, decreased LOC, death

Treatment: antibiotics and anticoagulation

Front 673

Pneumonia definitions: CAP, HAP, VAP

Back 673

CAP: no hospital or LTC stays for 14 days before presentation

HAP: new infection >48h after arrival in care facility

VAP: new infection >48h after intubation

Healthcare associated: home IV antibiotics, dialysis, wound care, immunocompromised, chemotherapy, nursing/LTC, hospital for 2 days in past 90 days

Front 674

Pneumonia admission decision score

Back 674

CURB 65

C onfusion

U remia (BUN > 7mmol/L)

R espiratory rate greater than 30

B lood Pressure < 90/60

65 years of age or more

If 2 consider admit; 3 consider ICU

Front 675

High risk for endocarditis

Back 675

-Prosthetic heart valve

-Hx of endocarditis

-Unrepaired cyanotic CHD (including palliative shunts, conduits)

-Completely repaired CHD with prosthesis during first 6 months post op

-Repaired CHD with residual defect (at or near site) of prosthetic valve

-Cardiac valvulopathy in a transplanted heart

-HCM

-MVP with regurgitation

-IVDU

Front 676

Reportable STI's

Back 676

CCHAGS

-C hancroid

-C hlamydia

-A IDS/HIV

-G onorrhea

-S yphilis

Front 677

Painful vs painless genital lesions

Back 677

BlouCH (painful)

Behcet's

C hancroid

H SV

Some Lesions On my Dong

S yphilis

L GV

O ncologic (SCC)

D onovanosis

Front 678

Diagnostic criteria for PID

Back 678

Major

-CMT

-Adnexal Tenderness

-Uterine Tenderness

Minor

-Oral temp > 38.3

-AbN cervical or vag discharge

-WBC on wet mount of prep

-Elevated ESR

-Elevated CRP

-Lab documentation of G+C

Front 679

PID requiring admission

Back 679

-Cannot exclude surgical emergency (e.g. appendicitis)

-Pregnancy

-Tubo-ovarian abscess

-Severe illness with vomiting or high fever

-No clinical response to PO meds in 24-48 h

-Unable to FU or tolerate outpatient regimen

Front 680

DDx for dysuria in peds

Back 680

Infection: UTI, pinworm, vaginitis (gardneralla, trichomonas, candida, STI), balanitis, pinworm

Trauma: self-induced, sexual abuse, straddle injury

Irritation: bubble bath, soaps, douches, foreign body

Other: labial adhesions, renal stones

Front 681

Peripartum infections that cause maternal or fetal morbidity

Back 681

Toxoplasmosis

Others (syphilis, Hep B, Coxsackievirus, EBV, VZV, HPV)

Rubella virus

CMV

HSV

Front 682

DDx neonatal hyperbilirubinemia

Back 682

Unconjugated

-Benign: Physiologic (1st), Breast Feeding (2nd due to dehydration with late milk in 1st week), Breast Milk (due to inhibition of hepatic enzymes in 2-3 weeks)

-Hemolysis: ABO, hematoma breakdown, spherocyte, elliptocyte, sickle cell, G6PD, PK

-Sepsis: TORCH, UTI

-Obstructive: Meconium ileus, Hirschsprung's, Pyloric stenosis, Duodenal atresia

-Metabolic/genetic: Hypothyroid, Gilbert, Crigler-Najjer

Conjugated

-Sepsis: TORCH, UTI, Listeria, TB, Hep B, VZV, HIV, Coxsackie

-Obstructive: Biliary atresia, choledochal cyst, bile duct stricture, primary biliary cirrhosis

-Metabolic/genetic: Gaucher's, Galactosemia, Nieman-Pick, alpha-1 antitripsin

Miscellaneous: drugs, toxins, TPN

Front 683

Practical approach to the crashing neonate

Back 683

SCRAMS

S epsis

C ardiac

A buse

M etabolic

S urgical emergencies

Front 684

List of conditions causing immunocompromise

Back 684

HIVED ARMS ITCH

H IV

I VDU

V ascular insufficiency

E thanol use

D M

A splenia

R F

M alnutrition

S teroid use

I mmunizations lacking

T ransplant

C ancer

H epatic Failure

Front 685

Antibiotics for bites

Back 685

Human - Eikenella Corridens - give Clavulin (Clindamycin + [Septra OR Levo] if allergic); resistant to 1st gen cephalosporins

Cat - Pasturella multicoda - give Clavulin (Septra or Levofloxacin if allergic); resistant to Clindamycin/1st gen cephalosporins

Dog - Polymicrobial (staph, strep, anaerobe) and Capnocytophagia Canimorsus - give Clavulin (admit with 3rd gen cephalosporin if elderly, asplenic, immunocompromised)

Front 686

Assessment of infectious risk of a dog bite

Back 686

Dog’s Characteristics

-immunization status of dog

-behavior of dog

-endemic area

-provoked attack

Patient Characteristics

-immunization status of patient (incl. tetanus)

-medical comorbidities in patient

-immunocompromsie in patient

-irrigation of wound

Front 687

Bacterial sinusitis: presentation, causes, complications

Back 687

Presentation of sinusitis:

-Purulent nasal secretions

-Purulent posterior pharyngeal secretions

-Mucosal erythema

-Periorbital edema

-Tenderness overlying sinuses

-Air-fluid levels on transillumination of the sinuses (60% reproducibility rate for assessing maxillary sinus disease)

-Facial erythema

Bacterial more likely to have:

-Severe presentation

-Double sickening

-Extra-sinus manifestations

-Persisting/worsening after 10 days

Causes:

-S. pneumoniae

-H. influenzae

-M. catarhallis

Complications:

-Venous sinus thrombosis

-Lemierre’s

-Meninigitis/abscess

-Orbital cellulitis

-Facial cellulitis

-Optic Neuritis

-Periorbital abscess

-Blindness

-Proptosis

Front 688

Ludwig's angina: presentation, bacteria, treatment

Back 688

Presentation

-SIRS

-Elevation of the floor of the mouth / tongue

-Pain to submental, sublingual, submandibular compartments

-Poor / infected dentition

Bacteria

-Multibacterial: staph, strep, anaerobes, bacteroides

Treatment

-High dose penicillin + metronidazole

-Ceftriaxone + clindamycin

Front 689

Sinus venous thrombosis: signs and organisms

Back 689

Signs:

-Presents with fever and headache

-Can have proptosis (opthalmic vein), mydriasis, CN 3,4,6 palsy, Periorbital edema and eye pain

-Progress to altered mental status, meningeal signs, seizure, coma

Organisms:

-Strep, Staph, Moraxella, Hemophlius, Bacteroides, Fungi

Front 690

Risk factors for TB

Back 690

1) HIV

2) Close quarters (military, native american, LTC)

3) travel to endemic area

4) homeless

5) IVDU

6) Close contact with patient with TB

7) Occupational exposure

8) Foreign born

Front 691

Needlestick injury: worrysome pathogens, prevalence of transmission

Back 691

Worrysome pathogens

1) Hep B up to 30% (if HBs & HBe +ve; only 2-5% if only HBs +ve)

2) Hep C up to 3% (1-2%)

3) HIV up to 0.3% percutaneous / 0.09% mucocutaneous

Prophylaxis: injection of blood, needlestick from known + patient, sexual assault

No prophylaxis: random needlestick or spitting

Front 692

Physical exam findings of central retinal artery occlusion; treatment

Back 692

PE

-Cherry red spot

-Pale retina

-RAPD

-Decreased visual acuity

Treatment

1. Globe Massage

2. IOP Mgt (Acetozolamide, Mannitol)

3. Anterior Chamber Paracentesis

4. Thrombolytics (tPA)

5. Bag hyperventilation or carbogen (increase PC02)

Front 693

Physical exam findings of central retinal venous occlusion

Back 693

-Blood and thunder

-Disk edema

-Dilated tortuous veins

-Decreased visual acuity;

-RAPD (if ischemic)

Front 694

Physical exam findings of iritis

Back 694

- red eye

- ciliary flush

- flare

- consensual photophobia

- acutely - decreased IOP

Front 695

Causes of sudden hearing loss

Back 695

Infectious:

-Mumps

-Measles

-Influenza

-HSV

-Herpes zoster

-CMV

-Mono

-Syphilis

Drugs (ototoxic)

- Aminoglycosides – Gent, Amikacin

- Loop diuretics – Lasix

- ASA

- Indomethacin

- Chemotherapeutic agents (Cisplatin, Methotrexate)

- Quinine

Vascular (sludging)

-Macroglobulinemia

-Sickle cell disease

-Leukemia

-Polycythemia

-Fat emboli

-Hypercoagulable

Conductive:

- Cerumen

- Foreign Body

- OM

- OE

- Barotrauma

- Trauma

- Neoplasm

Front 696

Optic neuritis: physical exam, conclusive diagnosis, associated condition, Treatment

Back 696

PE - see RAPD and red desaturation

Conclusive diagnosis - MRI

Associated condition - MS

Treatment - Solumedrol IV

Front 697

Plexus associated with posterior epistaxis and its tributatries; cause of posterior bleed

Back 697

Woodruff's plexus, tributaries:

-Sphenopalatine artery

-Posterior ethmoidal artery

Causes:

-Anticoagulation

-Blood dyscrasia

-Rupture of carotid aneurysm

-HTN

-Ca

-Trauma

Front 698

Subluxed tooth: management, complication

Back 698

Management:

-Pain control

-Soft diet

-Setting and stabilization of the tooth

-Dental referral

Complication

-Osteomyelitis

-Loss of tooth

-Alveolar fracture

Front 699

Organic versus functional blindness

Back 699

Functional

-Can't write own name

-Difficulty with finger apposition

-Optokinetic reflex intact

Front 700

Causes of RAPD

Back 700

-Ischemic optic neuropathy (CRAO or CRVO)

-Optic neuritis

-Optic nerve compression (orbital tumours or dysthyroid eye disease)

-Retrobulbar hematoma

-Trauma

-Asymmetric glaucoma

Front 701

Conductive vs sensorineural hearing loss

Back 701

Conductive

-Weber: Lateralizes toward affected side (conduction louder to affected side)

-Rinne: BC is > AC

-Caused by cereneum impaction, perf'd TM, cholesteatoma

Sensorineural

-Weber: Lateralizes away from affected side (conduction louder to normal side)

-Rinne: AC is > BC (or normal)

-Caused by acoustic neuroma, meniere's disease

Front 702

Admission criteria for epistaxis

Back 702

-Posterior bleed/balloon

-Bilateral posterior pack

-Hemodynamic instability

-Associated facial trauma/ polytrauma

-Severe coagulopathy

-Significant comorbidity

-No follow up/psychosocial concern

Front 703

Otitis externa: bacterial cause, treatment, risk factors

Back 703

Causes: pseudomonas (!!), staph, gram negatives, fungal

Treatment: Ciprofloxacin / ciprodex + clavulin

Risk factors: immunocompromise, DM, trauma, AIDS, elderly

Front 704

Acute necrotizing ulcerative gingivitis

Back 704

Risk factors: immunocompromise, smoking, local trauma, stress/fatigue

Presentation: trench mouth, fever, malaise, LA, ulcerating of papillae, gray pseudomembrane, pain, hallitosis

Cause: anaerobes (fusobacterium, spirochetes)

Management: saline rinses, analgesia, abx (penicillin or erythromycin), dilute hydrogen peroxide rinses, dentistry f/u

Front 705

Indications for hyphema admission

Back 705

Rebleed

Elevated IOP

>50% (grade III)

Decreased VA

Child abuse

Noncompliant

Front 706

Management of otitis media

Back 706

<6 months - antibiotics

6 months to 2y - antibiotics if certain; observe if uncertain

2y - antibiotics if severe; observe if uncertain

Observe = reassess in 48-72h

Front 707

DDx of neck masses

Back 707

Inflammatory

-Adenitis (Bacterial, Viral, Fungal)

-Cat-scratch disease

-Tularemia

-Local skin infection

-Sialoadenitis

-Thyroiditis

-TB

Congenital

-Branchial cleft cyst

-Thyroglossal duct cyst

-Dermoid cyst

Neoplastic

-Benign

-Malignant (Sarcoma, Salivary gland, Thyroid, Lymphoma)

Metastasis (1° ENT cancer, Lung, Esophageal)

Front 708

What is the NRP pyramid?

Back 708

-Assess if resuscitation needed, warm, position and clear airway, dry and stimulate

-O2

-PPV

-Intubation

-Chest compressions

-Drugs

Front 709

Atropine in pediatrics: indications, mechanism and complications

Back 709

Indications:

1.

Post-intubation bradycardia

2.

Symptomatic Bradycardia secondary to vagal tone

3. Neonatal intubation – as prophylaxis

4. Cholinergic toxidrome

Mechanism - decreases vagal tone speeding sinus/atrial and AV conduction. Onset is 1-2m and it lasts 2-4m.

Complications - can get a paradoxical bradycardia in low (<0.1mg) doses

Front 710

Pediatric vs adult CPR: 1 rescuer ratio, 2 rescuers ratio, rate, depth, monophasic J, biphasic J, Epi dose, Amiodarone dose

Back 710

1 rescuer ratio - 30:2 both

2 rescuers ratio - 30:2 adult, 15:2 peds

rate - 100 both

depth - 2 inches adult, 1/3 of chest AP diameter peds

monophasic J - 360J adult, 2 then 4J/kg peds
biphasic J - 200J adult, 2 then 4J/kg peds

Epi dose - 1mg adult, 0.01mg/kg peds

Amiodarone dose - 300mg adults, 5mg/kg peds

Front 711

Treatment of Tetrology of Fallot

Back 711

Knee to chest / squat (increased SVR)

IVF (increase preload)

Anxiolytic (benzo/fentanyl) (decrease RR and PVR)

NaHCO3 (correct acidosis - maybe)

Phenylephrine (increased SVR)

Propranolol (increased preload)

100% O2 (decreased PVR)

Front 712

Abnormal bloodwork in Kawasaki's disease

Back 712

-Elevated ESR / CRP

-Sterile pyuria

-Decreased Hb

-Elevated WBC

-Plt>450

-Decreased albumin (<30)

-Elevated ALT

Front 713

Common causes of renal failure in children

Back 713

-Post-strep GN

-HSP

-Pyelonephritis

-Obstructive Nephropathy (VUR)

-Lupus Nephritis

-Minimal change disease

Front 714

Explain the hyperoxia test

Back 714

If a hypoxic child presents and is put on 100% O2 and the sats don't improve, it is likely a cardiac / shunting problem. If it improves to PaO2 >150 or by >10% SpO2 it is likely a pulmonary problem.

Front 715

Exposure prophylaxis (Pertussis, Varicella, Yersinia Pestis, Measles, Hepatitis A, Meningococcus)

Back 715

Pertussis - macrolide for close contacts

Varicella - Varicella Ig if unimmunized and immunocompromised OR pregnant within 72h of exposure; vaccine if unimmunized

Yersinia pestis (plague) - ciprofloxacin or doxycycline

Measles - Measles Ig within 6 days if not immunized (and pregnant, immunocompromised, <12months) OR MMR within 3 days

Hepatitis A - HAIg to unvaccinated close personal contacts, childcare workers/attendees (people who wipe their bum), similar food-borne source in last 2/52

Meningococcus - Ciprofloxacin for adult close contacts, Rifampin for pediatric close contacts

Front 716

Causes of pediatric GI bleed

Back 716

-NEC

-Ingested Maternal Blood (Cracked Nipple)

-Milk Protein Allergy

-Reflux esophagitis

-Meckel’s

-Intussuception

-Infectious Gastroenteritis

-Anal Fissure

-IBD

-Blood dyscrasia

-Child Maltreatment

-Polyps

-Toxic ingestions

Front 717

Treatment of neonatal unconjugated and conjugated bilirubinemia?

Back 717

Unconjugated

-IVF rehydration

-IV antibiotics

-Exchange transfusion / plasmapheresis

-Phototherapy

Conjugated

-IVF rehydration

-IV antibiotics

-Exchange transfusion / plasmapheresis

-Abdominal ultrasound

-Surgical consult

-IVIg (if ABO incompatibility)

Front 718

Croup vs bacterial tracheitis

Back 718

Bacterial tracheitis is:

-Inspiratory AND expiratory stridor

-Does not respond to treatment

-Toxic appearance

-Hypoxia/Cyanosis

-Shaggy trachea on x-ray

-Copious secretions following intubation

Front 719

Causes of congenital stridor

Back 719

- treacher-collins

- pierre-robin

- laryngomalacia

- tracheomalacia

- vascular ring

- unilateral or bilateral vocal cord palsy

- laryngeal web

- down syndrome

- hypothyroidism

- glycogen storage disease

- lingual thyroid

- choanal atresia

- mediastinal mass

- tracheal stenosis

Front 720

Causes of HSP

Back 720

-Viruses (EBV, Measles, Mumps, Rubella, Chickenpox, Parvovirus B19)

-Bacteria (Shig, Salmonella, Campylobacter, Mycoplasma, GAS)

-Drugs (ampicillin, erythromycin, penicillin, quinidine, quinine)

-Insect stings

Front 721

Post-strep glomerulonephritis: presentation, diagnsosis, treatment

Back 721

Presentation: hypertension, hematuria, edema, AKI

Diagnosis: confirm strep with serology, ASOT, Creatinine, U/A

Treatment: treat volume overload (Lasix, Dialysis); hypertension (ACEi, Dialysis), Strep (Penicillin)

Front 722

Causes of descending paralysis

Back 722

“Got BOMBED”

G BS (MF Variant)

B otulism

O rganophosphate (HEENT exposure)

M yasthenia Gravis

B rainstem (Pontine infract)

E aton Lambert

D iphtheria

Front 723

Stroke mimics

Back 723

-Todd’s Paralysis (postictal)

-Hemiplegic migraine

-Bell’s Palsy

-Hypoglycemia/DKA/HONK

-MS

-Hypertensive encephalopathy

-Wernicke's

-Central venous sinus thrombosus

-ICH - SAH/SDH/EDH

-Brain tumor

-Conversion disorder

-Meningitis/Encephalitis/Abscess

Front 724

Define TIA; Risk for stroke following TIA

Back 724

Transient neurological symptoms due to ischemic etiology that ‘typically’ resolve within 60 minutes of onset. Must result in complete recovery to qualify as TIA.

ABCD2 score

A ge > 60

B P>140 and/or DBP>90

C linical - Speech (1 point) Unilateral Weakness (2 points)

D M

D uration 10-60m (1 point) >60m (2 points)

7 day risk score:

0-3 = 1%

4-5 = 6%

6-7 = 12%

Front 725

Central vertigo vs peripheral vertigo

Back 725

Central:

-Positive HINTS

-Insidious onset

-No N/V, mild severity

-Associated with other neurological symptoms

-No auditory symptoms

-Nystagmus not fatiguable, vertical or rotatory

-No change with head position

Peripheral:

-Severe

-Sudden onset

-Associated with Nausea / Vomiting

-Normal other neurologic symptoms

-Fatiguable Horizontal Nystagmus

-Positive Dix-Hallpike

Front 726

Causes of hypoMg

Back 726

Redistribution - TPN, refeeding, pancreatitis, DKA correction

Extrarenal losses - Vomiting, Hyperemesis Gravidarum, Anorexia, Bulimia, Diarrhea, sweating, burns, fistula, hyperaldosteronism

Renal losses - Diuretics (Loop Diuretics, amphoteracin, EtOH), Bartter’s, Osmotic Diuresis, DKA

Inadequate intake - Malnutrition, Malabsorption, Alcoholism, Critically unwell

Toxins - Cisplatin, Hydrofluoric acid

Front 727

Post-LP headache

Back 727

Needle used

-Whitacre

-Quincke

Cause

-Big needle

-Too much fluid drawn

-Traumatic needle

-Stylet not replaced

-Bevel not longitudinal

Treatments

-Analgesia

-Caffeine

-IVF

-Blood patch

Front 728

Drugs that cause thrombocytopenia

Back 728

1) Septra

2) Quinine

3) NSAIDS

4) Heparin (unfractionated, LMWH)

5) HCTZ

6) Amiodarone

7) Abciximab (GpII b IIIa inhibitor)

8) Rifampin

9) Ethambutol

10) Dilantin

11) Valproic acid

12) Ethanol

Front 729

Transfusion reactions (immune, non-immune)

Back 729

Immune

-Febrile non-hemolytic 1:300

-Hemolytic (ABO incompatability) 1:40,000

-Delayed hemolytic

-Anaphylactic 1:40,000

-Urticarial 1:100

-TRALI 1:40,000

-Transfusion-related immunomodulation (TRIM) - immunocompromised following

-Post-transfusion purpura

Non-immune

-Citrate toxicity (hypoCa)

-HyperK

-Hyperthermia

-Dilutional coagulopathy

-TACO 1:700

-Transfusion of pathogens (Hep B 1/50,000; Hep C 1/2,000,000; HIV 1/2,000,000; bacterial 1/20,000)

Front 730

Transfusion complications (immediate, delayed, massive)

Back 730

Immediate

-Acute hemolytic reaction

-Febrile non-hemolytic reaction

-Anaphylactic reaction

-Urticarial

-TACO

-TRALI

Delayed

-Delayed hemolytic

-GVHD

-Infectious transmission (bacterial, Hep B/C, HIV, Syphilis, Malaria)

Massive

-Citrate toxicity (hypoCa)

-HyperK

-Hypothermia

-Dilutional coagulopathy

Front 731

Factors contained in FFP

Back 731

Factors 2, 5, 7, 8, 9, 10, 11, 12, 13

Front 732

Infectious agents transmitted by blood products and their risks

Back 732

Bacterial - 1:20,000-50,000

Hep B - 1:153,000

Hep C - 1:2.3 million

HIV - 1:7.8 million

HTLV

CMV

WNV Rare

Prion dz Rare

Front 733

Effect of diseases on clotting: HUS, TTP, DIC, Hemophilia, vWD

Back 733

HUS - decreased Plt; increased BT

TTP - decreased Plt; increased BT

DIC - increased INR/PTT/BT; decreased Plt

Hemophilia - increased PTT

vWD - increased BT

Front 734

Emergent presentations of sickle cell disease

Back 734

-Acute chest crisis

-Priapism

-Stroke

-MI

-Splenic sequestration

-Infection/sepsis

-Aplastic anemia

-Pain crisis

Front 735

Hemophilia % classifications

Back 735

Mild 6-49% activity

Moderate 1-5% activity

Severe <1%

Front 736

Mucosal edema: DDx and treatment

Back 736

DDx

-Anaphylaxis

-Hereditary angioedema

-ACE-i induced angioedema

Tx

-Epi

-Benadryl

-Steroids

-C-1 esterase inhibitor

-FFP

Front 737

Options for LA in lidocaine allergy

Back 737

-Use code lidocaine (preservative-free)

-Use ester local anesthetic (benzocaine, tetracaine)

-Use Benadryl

-Test dose pre-use

-Use skin glue and/or steri-strips to close wound

Front 738

Side effects of sulpha drugs

Back 738

-Erythema Nodosum

-Erythema Multiforme

-SJS

-TEN

-Hypersensitivity vasculitis

-DRESS

-Anaphylaxis

-Allergic carditis

Front 739

Diabetic drugs: name, mechanism

Back 739

Insulin - opens GLUT channels so cells can use glucose

Glyburide - stimulates insulin release

Metformin - sensitizes cells to insulin +/- decreases intestinal absorption

Acarbose - prevents glucose absorption from intestines

Rosiglitazone - sensitizes cells to insulin

Front 740

Drugs that cause hypoglycemia

Back 740

Diabetic drugs

-Glyburide

-Insulin

-Metformin

-Acarbose

-Rosiglitazone

HTN / Heart drugs

-Beta-blocker overdose (Propranolol)

-MAOi

-ASA

Abuse

-Methanol

-EtOH

Front 741

Conn's syndrome

Back 741

Primary hyperaldosteronism from an adrenal adenoma or adrenal hyperplasia. Can also get from an aldosterone producing tumor. Secondary hyperaldosteronism is from a renin-producing tumor or renal artery stenosis.

Presentation: hypertension, hypokalemia, and alkalosis.

Diagnosis: CT abdomen, serum aldosterone, serum renin. Can also do urine lytes, TTKG

Treatment: Spinrolactone (aldosterone antagonist) and ACEi

Front 742

Causes of urinary retention

Back 742

Obstructive

1. BPH

2. Stone

3. tumour

4. gross hematuria

5. FB

6. Phimosis

7. Paraphimosis

8. Meatal stenosis

CNS

1. Spinal Cord Injury

2. Neurogenic shock

3. Spinal Epidural Hematoma

4. Syringomyelia

5. DM

6. MS

Infectious

1. Prostatitis

2. UTI

3. Tabes Dorsalis (Syphillis)

4.Urethritis

5. Balanophthis

Medications

1.anticholinergic

2.anti histamines

3.Narcotics

4.TCA (anticholinergic + antihistamine)

5.alpha agonists

6. antipsychotics (Haldol)

7. NSAIDs

Other

1. Priapism

2. Penile Fracture

3. Ureteric laceration

4. Lazy bladder syndrome

Front 743

Indications for admission of renal colic

Back 743

1. infected stone

2. pregnant

3. septic

4. intractable vomiting

5. severe pain

6. urinary extravasation

7. Hypercalcemic crisis
8. Single kidney

Front 744

Causes of hypercalcemia

Back 744

CHIMPANZEES

C a supplementation

H yperparathyroidism

I atrogenic (Li, thiazines)

M ilk-alkali syndrome

P aget’s

A cromegaly, A ddison’s

N eoplasm

Z ollinger-Ellison

E xcess Vit A

E xcess Vit D

S arcoidosis

Front 745

Steps for accessing a fistula if necessary

Back 745

1) No tourniquet!

2) Sterile/Clean Prep

3) Firm steady pressure for 10 min after

4) Document thrill before/after

5) continuous infusion to maintain laminar flow and prevent stasis

6) avoid puncturing posterior wall of vessel

Front 746

Post trauma care in the pregnant patient

-Observation

-Describe test

-How much Rhogam

Back 746

-Continuous fetal monitoring x 4 hours

-Kleihaur Betke test for feto-maternal hemorrhage (if Rh- 50mcg if <12 weeks, 300mcg if <16 weeks; then calculate)

-U/S for hemorrhage

-NST (best test for abruption - see fetal distress); if >3 contractions in a 1h period observe for 24h; if >12 cxns/h high risk for abruption

Front 747

Risk factors for preeclampsia; Predictors of eclampsia

Back 747

Person

-Adv. Mat. Age

-Younger than 20

-New Partner

-Low SES

-Obesity

-Cocaine

Pregnancy

-Primiparous

-Molar preg or mult gestation

-IVF

PMHx

-Hypertension

-Hypercholesterol

-Previous PIH

-Previous GDM

-Connective Tissue Disease

FHx

-Family hx of PIH

-Inherited Thrombocytopenia

Predictors of eclampsia

-elevated WBC, ALT, Creatinine

Front 748

Adverse conditions that qualify hypertension in pregnancy as preeclampsia

Back 748

Maternal symptoms

-persistent or new/unusual headache

-visual disturbances

-persistent abdominal or right upper quadrant pain

-severe nausea or vomiting

-chest pain or dyspnea)

-maternal signs of end-organ dysfunction (eclampsia, severe hypertension, pulmonary edema, or suspected placental abruption)

Abnormal maternal laboratory testing

-elevated creatinine

-elevated AST, ALT or LDH with symptoms

-platelet count <100x109/L

-serum albumin < 20 g/L

Fetal morbidity

-oligohydramnios

-intrauterine growth restriction

-absent or reversed end-diastolic flow in the umbilical artery by Doppler velocimetry

-intrauterine fetal death).

Front 749

Treatment of PID

Back 749

Oral: Ceftriaxone 250mg IM then Doxy 100mg / Flagyl 500mg po bid x 14d

IV: Cefoxitin 2 q6h IV + Doxycycline 100mg IV q12h

Front 750

Treatment of PE, cholecystitis, appendicitis, pyelonephritis in pregnancy

Back 750

PE

-LMWH (Enoxaparin) and admission

Chole

-Ceftriaxone / Flagyl IV

-Gravol / Maxeran / Ondansetron

-IVF

Appy

-Ceftriaxone / Flagyl IV

-Gravol / Maxeran / Ondansetron

-IVF

Pyelo

-Ceftriaxone / Ampicillin IV

-Gravol / Maxeran / Ondansetron

-IVF

Front 751

Ultrasound findings in ectopic pregnancy

Back 751

-Ectopic fetal heart activity

-Ectopic fetal pole

-Moderate or large cul-de-sac fluid without IUP

-Adnexal mass* without IUP

-Indeterminate

-Empty uterus

-Nonspecific fluid collections

-Echogenic material

-Abnormal sac

Front 752

Diagnosis and causes of SROM

Back 752

Causes:

-UTI

-Infection (choriaminoitis, Bacterial vaginosis, GBS)

-Trauma

-Incompetent Cervix

-Cigarette Smoking

Diagnosis

-Perform sterile speculum exam vaginal exam, pooling in posterior fornix

-Nitrazine test (Blue = +) – false pos with semen and urine in vagina

-Ferning – false positives with blood (if >10% blood), semen, fingerprints or cervical mucus

Front 753

RUQ pain in pregnancy / RUQ pain and jaundice in pregnancy

Back 753

RUQ pain in pregnancy

-Hepatitis

-Cholestasis of pregnancy

-Choledocholithiasis

-Cholecystits

-HELLP

-Acute Fatty Liver of Pregnancy

-Capsular hematoma

-Appendicitis

RUQ pain and jaundice

Cholestasis of Preg

Acute Fatty Liver of Pregnancy

Front 754

Indications and Contraindications to tocolysis

Back 754

Indications

-Preterm premature labour with

-High risk for safe transport

Contraindications

-Chorioamino

-Acute vaginal bleed

-Fetal demise

-Eclampsia

-Sepsis

-DIC

Front 755

Reasons for treatment failure of an appropriate antibiotic

Back 755

-Wrong dosage

-Wrong duration

-Noncompliance

-Immunocompromise

-Local resistance patterns

Front 756

PE Xray, ECG, echo findings

PE predictors of mortality

Back 756

XRay

-Normal

-Hampton's hump (wedge shaped opacity)

-Westermark's sign (oligemia of distal vasculature)

-Pleural effusion

ECG

-Normal

-S1Q3T3

-RBBB

-RAD

-P-pulmonale

-Anterior ST depression / T wave inversion

Echo

-Normal

-Dilated RV

-Bowing of septum into LV

-McConnell's sign

-Dilated IVC

Increased mortality

-Troponin

-BNP

-SpO2 <95% on RA

-Echo with RV strain / dilation

-Shock / hypotension

Front 757

etCO2 for tube placement

-False positives

-False negatives

Back 757

False positives

-Carbonated beverage in stomach (should wash out after 6 BVMs)

-Recent BVM ventilation

-Administration of bicarb (first 5-10 min after administration)

Possible False Negatives

- Prolonged arrest

- Equipment failure (cuff leak, expired)

- Complete obstruction at level trachea or both bronchi

- Severe asthma

- Massive PE

Front 758

Vent settings for an asthmatic

Back 758

RR - 6-10

Vt - 5-8mL/kg

Minute ventilation - low

PEEP - 2.5-10 (match iPEEP)

Flow - 100L/m (high)

I:E ratio - 1:4-6

Front 759

Causes of pleural effusion

Back 759

Transudative

-CHF

-Nephrotic syndrome

-Liver cirrhosis

-Myxedema

-Malnutrition / hypoalbuminemia

-Peritoneal dialysis-SVC obstruction

-PE

Exudative

-Malignancy

-Pneumonia

-ARDS

-Pancreatitis

-Rheumatic (RA / SLE)

-Esophageal rupture

-Uremia

-PE

Front 760

Mechanisms for hypoxic respiratory failure (examples)

Back 760

-Decreased pO2 (climber at altitude)

-Decreased minute ventilation (opioid OD, obesity, GBS, MG, hypoMg/PO4)

-Decreased diffusion capacity (COPD)

-Shunting (congenital heart disease)

-V/Q mismatch (PE, pneumonia, pulm edema)

Front 761

Management options for a pneumothorax

Indications for a chest tube

Indicators of treatment failure

Back 761

Options

-100% Oxygen

-Aspirate and re-xray

-Heimlich valve

-Chest tube

Indications

- Bilateral PTX

- Traumatic

- Hemopneumothorax

- PPV

- Tension

- Large

- Transport/HBO

- Respiratory symptoms

- Failure of conservative treatment

Failure

- Persistent or expanding PTX

- Persistent airleak

- Clinical deterioration (worsening SOB)

- Recurrence when CT removed

Front 762

Approach to the alarming ventilator

Back 762

DOTTS

D – Disconnect the patient from the ventilator +/- provide gentle pressure to the chest (assess for and treat breath Stacking and Equipment failure)
O – Oxygen (100%) and manual ventilation with a bag (check compliance by squeezing the bag: difficult bagging suggests Pneumothorax or Obstructed tube, very easy bagging suggests Dislodged tube or Equipment failure due to a deflated cuff)
T – Tube position/function (see if the tube has migrated to assess for Dislodged tube; pass a bougie or suction catheter through to see if the tube is Obstructed)
T – Tweak the vent (prevents breath Stacking by decreasing respiratory rate, decreasing tidal volume or decreasing inspiratory time)
S – Sonography (assess for pneumothorax, mainstem intubation, plugging)

Front 763

Mallampati classification

Back 763

1 -> visible tonsillar pillars, fauces, uvula, soft and hard palate

2 -> visible uvula (except tip), fauces, soft and hard palate

3 -> visible soft and hard palate and base of uvula

4 -> visible hard palate only

Front 764

Techniques for airway management after a failed intubation

Back 764

- LMA/supraglottic airway

- OPA/NPA + BVM

- intubating LMA

- Cricothyrotomy

- Fiberoptic - glidescope, bronch, light wand

Front 765

Pros / Cons of BiPAP in respiratory failure

Back 765

Pros

- No sedation required

- Less risk of VAP/decreased risk nosocomial infection

- Preserves airway reflexes

- No blunt airway trauma

- In CHF, decreases WOB, ETT, LOS, ICU admission, increases CO

- In COPD, decreases ETT, LOS, ICU admission, mortality

Cons:

- No airway protection

- Pressure necrosis

- Aerophagia

- Claustrophobia

- Trauma to eyes (corneal abrasions)

- Aspiration

Front 766

General criteria for low-risk outpatient care

Back 766

VC SERF

Vitals normal

Comorbidities (none)

Support system in place

Emergency care accessible

Reliable patient

Follow-up arranged

Front 767

Reasons abdominal pain is difficult to diagnose in the elderly

Back 767

-Abdominal musculature decreases - less likely to show rebound or guarding

-Omentum is thinner and less likely to contain intra-abdominal process

-Increased rate of atherosclerotic disease - decrease in blood flow leading to increased perforation

-Dementia - unable to localize pain and difficult historian

-May not present with fever or a WBC - immunosenescence

-General physiological changes

Front 768

For pancreatitis:

-Management principles

-Local complications

-Systemic complications

Back 768

Management principles

1. Aggressive IV resuscitation, analgesia and antiemetics

2. Initial bowel rest and then early enteral feeding

3. Monitor electrolytes and replace as needed

4. Early Imaging (U/S) to rule out biliary tract source

5. Consider antibiotics

6. Manage complications (local and systemic)

7. Stress ulcer prophylaxis

Local complications

1. Pseudocyst

2. Pancreatic necrosis

3. Pancreatic abscess

Systemic complications

1. DIC

2. ARDS

3. ARF

4. Hypocalcemia

5. Shock

6. Hyperglycemic

Front 769

Causes of non-anion gap metabolic acidosis

Back 769

H yperalimentation

A cetazolamide

R TA

D iarrhea

U reto-enteric fistula

P ancreatico-duodenal fistula

S aline

E ndocrine (hyperparathyroid)

A rginine (excess TPN)

S pironolactone

Front 770

Potential treatments of upper GIB

Back 770

1) Pantoloc

2) Octreotide

3) Ceftriaxone

4) Erythromycin

5) Vitamin K

6) Vasopressin

7) EGD (EsophagoGastroDuodenoscopy)

8) Blakemore

9) Interventional radiology

10) Surgery

Front 771

Acute angle closure glaucoma - definition

Back 771

NOBy MICCS

Symptoms (2 of)

-N /V

-O cular pain

-B lurring vision with halos

Signs (3 of)

-M id-dilated nonreactive pupil

-I OP greater than 21 mm Hg

-C onjunctival injection

-C orneal epithelial edema

-S hallower anterior chamber

Front 772

Complications of physical restraints

Back 772

1) Asphyxia

2) Abrasions

3) Compartment Syndrome

4) Aspiration

5) Death

6) Fracture

7) Skin breakdown

Front 773

Anorexia behavioural characteristics

Back 773

1. Excessive exercise

2. ‘Type A’ perfectionist oriented personality

3. Restricting

4. Purging

5. Body dysmophia, fear of gaining weight, lying re: intake

6. Laxative abuse

7. Food- refusal, preoccupation, lying re:intake, denial of hunger

8. Depression

9. Social isolation

Front 774

Characteristics that predispose to violent behavior

Back 774

-male

-hx violence

-substance abuse

-Poor impulse control or anger control

-acute psychosis

-Mania

-head injury

-Dementia

-hypoxia

-Metabolic disorder

Front 775

Features of drug seeking behavior

Back 775

Frequent

-Multiple visits for the same complaint

-Changes appearance or alias between visits

Focus

-Unbearable pain

-Focused on getting pain medicine not determining the underlying problem

-Allergic to narcotic alternatives

-Requesting specific medication

Stories

-GP unavailable

-Lost prescription

-Presents with common unverifiable conditions (toothache, renal colic, abdominal pain)

-Creative complaints / explanations

Front 776

Addressing the patient leaving AMA

Back 776

-Determine that they have capacity

-Get 'consent' for them to leave AMA - explain risks/benefits/alternatives and ensure that they are not leaving under duress

-Ensure they know that they will be welcomed back if they choose to return

-Document the encounter and discussion

-Have others (nurses) corroborate the information in their notes

Front 777

Intoxicated colleague

-immediate responsibilities

-behavioral characteristics suggesting substance abuse

Back 777

Immediate responsibilities

-Report to CPS

-Relieve them from their duties

Behavioral characteristics

13. Heavy `wastage`of drugs

14. Inappropriate prescription of large narcotic doses

15. Insistence on personal administration of parenteral narcotics to patients

11. Uncharacteristic deterioration of handwriting and charting

18. Alcohol on breath

1. Personality changes

2. Loss of efficiency and reliability

3. Increased sick time and other time away from work

4. Patient and staff complaints about physician`s changing attitude or behaviour

5. Indecision

6. Increasing personal and professional isolation

7. Physical changes

8. Unpredictable work habits and patterns

9. Moodiness, anxiety, depression, suicidal thoughts or gestures

10. Memory loss

12. Unexpected presence in hospital when off duty

16. Long sleeves when inappropriate

17. Frequent bathroom use

19. Wide mood swings

Front 778

Goals of ED triage

Back 778

Top priority

-To quickly assess (2-3m) all patients as they arrive in the ED

-To rapidly identify patients with urgent, life threatening conditions.

-To insure the right care at the right time from the right provider

-To determine the most appropriate treatment area for patients presenting to the ED.

-To reduce morbidity associated with medical conditions through early interventions

-To initiate infection control procedures (TB, infectious childhood diseases)

Other

-To decrease congestion in emergency treatment areas.

-To provide ongoing assessment of patients.

-To provide information to patients and families about expected care and waiting times

-To contribute information that helps to define departmental acuity.

-To make a rapid initial assessment of the patients’ needs

-To identify patient with subtle presentation with potential for serious outcome

-To prioritize treatment in accordance with the severity of their medical condition

-To reduce delay in treatment and reduce risk of further injury or deterioration

Front 779

CTAS system

-What does CTAS stand for?

-How was it derived?

-What are the levels and time they need to be seen in?

-What is it predictive for?

Back 779

Canadian Triage and Acuity Scale - derived from ICD diagnoses with modifiers

1 - Resuscitation - immediate assessment

2 - Emergent - 15m

3 - Urgent - 30m

4 - Less urgent - 60m

5 - Non-urgent - 120m

CTAS predicts:

-Need for consultation

-Need for CT

-Need for admission

-LOS

Front 780

Conditions that require mandatory reporting

Back 780

Level 1 (immediate call)

ABCDeFGHS

-Anthrax, Botulism / Bites from suspec animals, Cholera, Diptheria, e, Food poisoning (Shigella, Typhoid fever, E coli with verotoxin), Febrile with travel, Gastroenteritis at institutions, Hepatitis A, Smallpox

-Measles, Meningitis (bacterial - neisseria meningitidis, H influenzae)

Level 2 (immediate report - vaccine preventable and GI)

-Mumps, Rubella, Pertussis

-Amebiasis, campylobacter, giardia, listeria, salmonella, trichinossis, tularemia

Level 3 (next working day - STI's)

-Chancroid, Chlamydia, Gonorrhea, Hepatitis B & C, HIV, Syphilis

Front 781

Presentations that require mandatory reporting

Back 781

-Child Abuse or Neglect

-Long-Term Care and Retirement Homes

Sexual Abuse of a Patient

-Facility Operators: Duty to Report, Incapacity, Incompetence and Sexual Abuse

-Births, Still-births and Deaths

-Communicable and Reportable Diseases

-Controlled Drugs and Substances

-Community Treatment Plans

-Gunshot Wounds

Front 782

What is the purpose of risk management?

Back 782

Purpose

-Mitigate harm

-Prevent medical error

Front 783

What is a critical incident?

What is critical incident stress?

What is the goal of critical incident debriefing?

Back 783

Critical incident

-An unintended event that occurs when health services are provided to an individual and results in a consequence to him or her that:

1 are serious and undesired (death, disability, injury or harm, unplanned admission to hospital or unusual extension of a hospital stay

2 does not result from the individual’s underlying health condition or from a risk inherent in providing health services.

Critical incident stress

A situation which causes a person to experience unusually strong emotional reactions which have the potential to interfere with their ability to function either at the scene or later.

Goals of debriefing

Allow participants to discuss freely the events and articulate emotions in a safe environment.

Front 784

Steps of critical incident debriefing

Back 784

-Introduction of intervenor and establishment of guidelines

-Invites participants to introduce themselves (while attendance at a debriefing may be mandatory, participation is not)

-Details of the event given from individual perspectives

-Emotional responses given subjectively with personal reaction and actions

-Discussion of symptoms exhibited since the event

-Assure participants that any symptoms (if they have any at all) are a normal reaction to an abnormal event and "generally" these symptoms will diminish with time and self-care

-Identify individuals who are not coping well

-Informal discussion (generally over a beverage and treat) resumption of duty where individuals are returned to their normal tasks

-Additional assistance is offered at the conclusion of the process

Front 785

Conditions appropriate for a clinical decision unit

Back 785

* have evidence for decreased costs / improved or similar outcomes as formal admisison

* abdo pain - for imaging or reassessment

* chest pain

* Asthma

- CHF

- AFib

- Grade I Dehydration

* GI Bleed

* DVT

* Trauma (Blunt or Penetrating Chest or Abdo)

* Pyelonephritis

- Pneumonia

Front 786

Vital signs requiring transfer to a trauma center

Back 786

CDC 2011

-RR < 10 or RR > 29

-SBP <90

-GCS < 13

Front 787

Mechanisms requiring transfer to a trauma center

Back 787

CDC 2011

Falls

-Adults: >20 feet (one story is equal to 10 feet)

-Children: >10 feet or two or three times the height of the child

High-risk auto crash

-Intrusion, including roof: >12 inches occupant site; >18 inches any site

-Ejection (partial or complete) from automobile

-Death in same passenger compartment

-Vehicle telemetry data consistent with a high risk of injury

Auto vs. pedestrian/bicyclist

-thrown, run over, or with significant (>20 mph) impact

Motorcycle crash

->20 mph

Front 788

Injury patterns requiring transfer to a trauma center

Back 788

-All penetrating injuries to head, neck, torso and extremities proximal to elbow and knee

-Flail chest

-Pelvic fractures

-Combination of trauma with burn

-Two or more proximal bone fractures

-Limb paralysis

-Amputation proximal to wrist and ankle

Front 789

Premorbid conditions requiring transfer to a trauma center

Back 789

-Pregnancy > 20 weeks

-Age > 55 and all children

-Bleeding disorder

-Patient on anticoagulation

-End-stage renal disease requiring dialysis

-EMS provider judgment

Front 790

Thoracotomy indications and contraindications in thoracic trauma

Back 790

ABSOLUTE

Any - Unresponsive hypotension (BP <70mmHg)

Penetrating - arrest with previously witnessed cardiac activity

Blunt - Rapid exsanguination from chest tube (>1500ml)

RELATIVE

Penetrating - arrest WITHOUT previously witnessed cardiac activity

Blunt AND penetrating NON-thoracic - arrest with previously witnessed cardiac activity (pre-hospital or in-hospital)

CONTRAINDICATIONS

-Blunt thoracic injuries with no witnessed cardiac activity
-Multiple blunt trauma
-Severe head injury

Front 791

Potentially live-saving interventions that are part of an ED thoracotomy

Back 791

-Pericardotomy

-Cardiac massage

-Cross-clamping of the aorta

-Repair cardiac defects

-Hemorrhage control with foley or finger

-Pulmonary hilar twist (compress or cross-clamp pulmonary hilum)

Front 792

Fixed vs Rotary transport

Back 792

Fixed advantages

-Can travel greater than 300 km

-Can fly faster Faster

-Pressurized

-Less noise

-More space for crew and equipment

-Less affected by turbulence

-Instrument flight rules / fly in worse weather

Rotary advantages

-Can fly directly to scene

-Can reach scenes that ground/fixed wing can not

-Can fly directly back to hospital

Front 793

Biologic agents that have potential as weapons

Back 793

-Anthrax

-Botulism

-Brucellosis

-Smallpox

-Plague (yersinia pestis)

-Tularemia

-Viral hemorrhagic fevers (Ebola and Marburg)

-Q fever

-Viral encephalopathy

Front 794

Febrile traveler incubation periods

Back 794

1-3 weeks

-Plasmodium falciparum 6-30d; vivax 8d-3y

-Dengue fever 3-14d

-Spotted fever ricketsiae 3-21d

-Meningococcemia 2-10d

-Acute HIV 8-28d

-Ebola and other hemorrhagic fevers 2-21d

4-6 weeks

-Hepatitis A 15-50d, E 26-42d

-Schistosomiasis 4-6 weeks

-Amebic liver abscess weeks to months

>6 weeks

-Hepatitis B 60-150d; C6 6-10 weeks

-Tuberculosis weeks-years

Front 795

Ebola: transmission, incubation

Back 795

Transmission - when infected bodily fluids or contaminated objects come into contact with mucous membranes or non-intact skin

Incubation - 2-21 days

Presentation - fever, malaise, myalgias, headache, pharyngitis, conjunctivitis, abdominal pain, emesis, diarrhea. Hemorrhage, shock, death 6-16 days from onset.

Workup - viral serology, culture and PCR. Thin smears for meningitis (BUT NOT THICK UNTIL EBOLA RULED OUT), rapid antigen malaria assay. Standard septic workup +/- stool culture/ova/parasites, NP swabs, hepatitis/dengue serology.

Treatment - supportive. IV hydration. PPE.

Front 796

Hunter criteria for serotonin syndrome

Back 796

Taken a serotonergic agent and meet one of the following conditions:

-Spontaneous clonus

-Tremor AND hyperreflexia

-Inducible OR ocular clonus plus:

--> Agitation

--> Diaphoresis

--> Hypertonism AND temperature > 38 °C (100 °F)

Front 797

Type 1 error

Type 2 error

Alpha

Beta

Back 797

Type 1 error = rejection of a true null hypothesis (a "false positive") - think dude with a + preg test

Type 2 error = failure to reject a false null hypothesis (a "false negative") - think pregnant lady with a - preg test

Alpha = the probability of a type 1 error

Beta = the probability of a type 2 error

Front 798

Absolute risk reduction

Relative risk reduction

NNT / NNH

Back 798

ARR = Experimental event rate - Control event rate

RRR = ARR / Control event rate

NNT or NNH = 1/ARR

Front 799

Likelihood ratios

Back 799

LR's use the sensitivity and specificity of the test to determine whether a test result usefully changes the probability that a condition (such as a disease state) exists.

+ = Sn / (1-Sp)

- = (1-Sn) / Sp

Front 800

PPV and NPV

Sensitivity and Specificity

Receiver-Operator Curve

Back 800

PPV - The proportion of people that have a positive test who HAVE the disease

NPV - The proportion of people that have a negative test who DO NOT have the disease

Sensitivity - The proportion of people who HAVE a disease who have a positive test.

Specificity - The proportion of people who do NOT have a disease who have a negative test.

ROC - charted with Y = sensitivity and X = 1-specificity; used to determine optimal cutoff value for tests

Front 801

Validity

Assessment of validity in a meta-analysis and RCT

Back 801

Validity - the extent to which a concept, conclusion or measurement is well-founded and corresponds accurately to the real world

Meta-analysis

-Appropriate question

-Comprehensive lit search

-High quality, reproducible studies included

-Heterogeneity and bias ruled out (Funnel and Forrest plots)

RCT

-Randomization

-Concealed allocation

-Blinding

-Similar groups

-Complete follow-up

-Meet recruitment target or stopped early / late

-Intention to treat analysis

Front 802

Intention to treat analysis

Per protocol analysis

Back 802

ITT - patients are analyzed in the initial groups that they are assigned to (regardless of whether they cross over)

PP - patients are analyzed based on the treatment they received; crossovers and loss to follow-up are excluded

Front 803

Study types: Cohort Study, Case Report, Meta-analysis, Clinical Decision Rule, Case Control

Back 803

Cohort study - Choose a group of people with similar characteristics/exposures and then follow them to observe whether they get the disease, compared to a control group/general population.

Case Report - The report of a single interesting case in detail.

Meta-analysis - Comparing and combining the information from several studies to identify patterns and effects that cannot be seen in multiple single studies.

Clinical Decision Rule - A series of attributes (Hx, Px findings) that, when taken together, alter the likelihood of a person having a disease process. Usually derived through a regression analysis of observational data, they must be derived, validated.

Case Control - A longitudinal (usually retrospective) study when you identify a bunch of ‘cases’ and matched controls without an outcome of interest and then try to map back to the ‘cause’ (exposure, RF) that may have lead to the disease.

Front 804

Define power. How is power used in study design? How is power used in critical appraisal? What affects the power?

Back 804

Power = 1 - beta; the probability of a type II error. e.g. when studies are underpowered they are likely to be 'falsely negative' and miss a true effect.

Study design:

To estimate the needed sample size needed to show a treatment effect and reject the null hypothesis.

Critical appraisal:

To confirm that the study has the required number of study subjects to make the conclusions that the authors are proposing.

Affect power:

-Level of alpha / significance (power decreases with higher levels of certainty)

-Sample size (power increases with the sample)

-Treatment effect (larger it is, less power needed)

Front 805

Confidence intervals

P values vs CI's

Back 805

A measure of the range of variability around an estimated parameter. Are generally 95%, meaning 19 out of 20 replications of the study will have an estimate of the parameter of interest within the confidence interval.

P-values tell you if something is different, CIs illustrate the precision and magnitude of the likely difference.

Front 806

Breakdown DDx of red eye

Back 806

Extra-orbital

(e.g. orbital cellulitis, cavernous sinus thrombosis, carotid-cavernous fistula, cluster headache)

External eye

(e.g. eye lid and conjunctival disease)

Internal eye

(e.g. iritis, glaucoma)

Front 807

DDx of the painless red eye

Back 807

diffuse —
usually this is an eyelid abnormality as most cases of conjunctivitis are painful: e.g. blepharitis, ectropion, trichiasis, entropion, eyelid lesion (e.g. tumour, stye)

localised —
e.g. pterygium, corneal foreign body, ocular trauma, subconjunctival hemorrhage

Front 808

DDx of the painful red eye

Back 808

abnormal cornea —
e.g. herpes simplex keratitis, corneal ulcer, marginal keratitis, corneal abrasion,

-abnormal eyelid —
e.g. chalazion/ stye, acute blepharitis, herpes zoster ophthalmicus

-diffuse conjunctival injection —
e.g. viral conjunctivitis, allergic conjunctivitis, bacterial conjunctivitis, dry eyes, acute glaucoma

-ciliary injection/ scleral involvement —
e.g. scleritis

-anterior chamber involvement —
e.g. acute anterior uveitis (iritis), hypopyon, hyphema

Front 809

Features suggestive of internal eye pain

Back 809

-severe eye pain (unrelieved by topical anesthetics)

-impaired vision

-poorly reactive pupils

-abnormal slit lamp examination +/- abnormal intra-ocular pressure

Front 810

Features suggestive of external eye pain

Back 810

-pain sensation is usually itching, gritty, scratching, or burning (not a deep-seated ache)

-pain is significantly improved by topical anesthetics

-eye discharge is common (watery, mucoid or purulent depending on etiology)

-photophobia and blepharospasm may be present

-visual acuity is usually normal or near-normal
(there may be some blurriness)

-preauricular lymphadenopathy may be present (e.g. viral or chlamydial conjunctivitis)

Front 811

Signs of eye pain without a serious origin

Back 811

-cornea clear

-anterior chamber clear

-pupils normal in size and reactivity

-visual acuity normal or near-normal

-extraocular eye movements normal

-proptosis absent

* eyeball is not tender on palpation

Front 812

Classic descriptions:

-Acute angle closure glaucoma

-Iritis

-Scleritis

-Orbital cellulitis or cavernous venous sinus thrombosis

Back 812

Acute angle closure glaucoma

-mid-dilated unreactive pupil, steamy cornea, peri-orbital pain , nausea/vomiting and increased intra-ocular pressure

Iritis

-small irregular pupil, deep-seated eye pain that is worse on eye movement and accomodation, consensual photophobia and positive slit lamp signs of flare and cells

Scleritis

-deep-seated eye pain that is worse at rest and at night, pain on palpation of the eye and violaceous appearance of the sclera

Orbital cellulitis or cavernous venous sinus thrombosis

-proptosis, congested chemosis, painful external ophthalmoplegia, and visual loss with a relative afferent pupillary defect

Front 813

-Severe eye aching
-Prominent photophobia
-Impaired vision
-Cloudy cornea
-Corneal opacification
-Circumcorneal conjunctival injection
-Cloudy anterior chamber
-Pain on eyeball palpation
-Proptosis
-Impaired, or painful, extraocular eye movements
-Fever, toxic appearance
-Hyperpurulent discharge from an “angry” eye
-Prominent nausea and vomiting
-Small, irregular, poorly-reactive pupil
-Fixed mid-dilated pupil
-Increased intra-ocular pressure
-History of connective tissue disease, or granulomatous disease

Back 813

Severe eye aching
Iritis, keratitis, acute angle-closure glaucoma, scleritis, orbital cellulitis, cavernous sinus thrombosis (CST)

Prominent photophobia
Iritis, keratitis

Impaired vision
Iritis, keratitis, acute angle-closure glaucoma, orbital cellulitis, CST

Cloudy cornea
Keratitis, acute angle-closure glaucoma

Corneal opacification
Keratitis – chemical or infectious

Circumcorneal conjunctival injection
Iritis, keratitis

Cloudy anterior chamber
Iritis

Pain on eyeball palpation
Scleritis (+++), orbital cellulitis, CST

Proptosis
Orbital cellulitis, CST, posterior scleritis

Impaired, or painful, extraocular eye movements
Orbital cellulitis

Fever, toxic appearance
Orbital cellulitis (+), CST (++)

Hyperpurulent discharge from an “angry” eye
Gonococcal conjunctivitis/endophthalmitis

Prominent nausea and vomiting
Acute angle-closure glaucoma

Small, irregular, poorly-reactive pupil
Iritis

Fixed mid-dilated pupil
Acute angle-closure glaucoma

Increased intra-ocular pressure
Acute angle-closure glaucoma, iritis (secondary complication)

History of connective tissue disease, or granulomatous disease
Iritis, scleritis

Front 814

Large vessel vasculitis

Back 814

Large vessel:

-Takasayu's - pulseless disease, renovascular hypertension

-Giant cell - temporal artery headache, amaerosus fugax

Front 815

Medium vessel vasculitis

Back 815

Medium vessel:

-Polyarteritis nodosa - mostly CNS/GI necrotizing arteritis, no venous involvement, non-granulomatous, palpable purpura, hypergammaglobulinemia, ANCA negative

-Buerger's disease - aka thromboangiitis obliterans, 20-40yo male smokers, painful dark phlebitis migrans nodules

-Kawasaki disease - Warm CREAM, pediatrics

Front 816

Small vessel vasculitis

Back 816

Small vessel

-Goodpasture's - anti-GBM antibody +, alveolar hemorrhage, glomerulonephritis (RPGN). c-ANCA negative (unlike Wegener's)

-Microscopic polyangitis - alveolar hemorrhage, glomerulonephritis, nerve involvement. NOT granulomatous (unlike Wegener's). p-ANCA+ (unlike Goodpasture's)

-Wegener's granulomatosis - necrotizing granulomatous with upper resp (sinusitis, otitis, ulcers, tracheal stenosis), lower resp (bilat nodular infiltrates with cavitation), renal (RPGN), can have multiple other sx's, c-ANCA +

-Churg-Strauss - asthma attacks, allergic rhinitis, eosinophilia. Constrictive pericarditis.

-Behcet's - uveitis (also optic neuritis, iritis), apthous ulcers, genital ulcers.

-HSP - IgA mediated hypersensitivity vasculitis mostly in <20yo. Fever, lower extremity palpable purpura, abd pain (occasionally intussusception), glomerulonephritis, arthralgias.

Front 817

Suppurative and non-suppurative strep complications

Back 817

Suppurative

-Peritonsillar abscess

-Retropharyngeal abscess

-OM / Mastoiditis

-Sinusitis

-Cervical adenitis

-Osteomyelitis

-Meningitis

Non suppurative

-Rheumatic fever

-Scarlet fever

-Post-strep glomerulonephritis

-Erythema nodosum

-Toxic shock syndrome

-PANDAS (pediatric autoimmune neuropsychiatric disorder associated with group A streptococcus)

Front 818

ITP: what is it, presentation, acute vs chronic, treatment, when to transfuse

Back 818

What is it?

Autoimmune condition with antiplatelet antibodies

Presentation:

epistaxis, bleeding from gums, menorrhagia, prolonged bleeding time; most complications if platelets <20 (head bleeds if <5)

Acute/Chronic:

Acute follows an infection and resolves in <2m; Chronic persists >6 months

Cause:

most often a preceding infection or idiopathic. Can get from leukemia, heparin, cirrhosis, HIV, Hep C

Treatment:

Steroids, possibly Azathioprine, IVIg, WinRho (if Rh+ - breaks down RBC's instead of Plt's), splenectomy

Transfuse:

only give platelets in severe bleeding!

Front 819

Risk factors for SIDS

Back 819

Maternal

-Smoking and drug use, Low SES and education, <20yo, black/native, no prenatal care

Prenatal

-Prematurity, IUGR, low birth weight, multiple births, smoking

Postnatal

-Smoking, prone sleep, loose bedding, soft surface, cosleeping, warm ambient temperature, infection, cardiac anomolies

Front 820

Bleeding in pregnancy

Back 820

Abnormal pregnancy

-Miscarraige

-Molar pregnancy

-Ectopic pregnancy

Bad for baby

-Vasa previa

-Placenta previa

-Placental abruption

Other

-Vaginitis

-Post-coital

-Cervical lesion

Front 821

Ultrasound findings in a NORMAL pregnancy

Back 821

Gestational sac, 5, 1000

Yolk sac, 6, 2500

Fetal pole, 7, 17,000

FHR, 8

Front 822

FDA classifications of pregnancy risk for drugs

Back 822

A - controlled studies showing no risk

B - animal studies no risk, no controlled human studies

C - adverse effects in animals, no human studies

D - evidence of risk, use if benefits > harms

X - contraindicated in pregnancy

Front 823

Factors linked to preterm labor

Back 823

Demographic andPsychosocial

-Extremes of age

-Low SES

-Tobacco use

-Cocaine abuse

-Psychosocial stressors

Reproductiveand Gynecologic

-Prior preterm delivery

-Multiple gestation

-Endometrial cavity anomaly

-Cervical incompetence

-1st trimester bleeding

-Placental abruption or previa

Infections

-UTI

-Bacterial vaginosis

-Nonuterineinfections

Front 824

Risk factors for Idiopathic Intracranial Hypertension

Back 824

-Obesity

-Lupus

-PCOS

-Sleep apnea

Medications

-OCP

-Anabolicsteroids

-Tetracyclines

-VitaminA

Front 825

Diagnostic criteria for Idiopathic Intracranial Hypertension

Back 825

1. Signs/symptoms of ↑ ICP with absence of localizing signs

2. No mass or ↑ ventricles on neuroimaging

3. No suspicion of venous sinus thrombosis on neuroimaging

4. ↑ ICP on opening pressure (> 20 cm H2O)

5. Normal cell count and protein on LP

Front 826

Causes of cerbral venous thrombosis

Back 826

Infectious

-Sinusitis

-OM

-Facial cellulitis

-Systemic infections

Noninfectious

-Injury to cerebral venous system (Trauma, Surgery, Tumour)

-Dehydration

-Hypercoagulability

Front 827

DDx thrombocytopenia (not drugs)

Back 827

Decreased production - Marrow infiltrate, Aplastic anemia, Viral (measles), Drugs, Radiation, B12/folate def

Destruction - ITP, TTP, HUS, DIC, Viral infection

Sequestration - ↑ Spleen, Hypothermia

Loss - Hemorrhage, HD, Extracorporeal circulation

Front 828

Hemostatic abnormalities in liver failure

Back 828

-Factor deficiency

-2° ↓ protein synthesis

-Vitamin K deficiency

-2° malabsorption

-Thrombocytopenia

-↑ Fibrinolysis

-↓ Fibrinogen

-Anemia

Front 829

Classes of vWD and treatment

Back 829

Class I - quantitative defect - DDAVP

Class II - qualitative defect - Factor VIII and cryoprecipitate
Class III - no vWF - Factor VIII and cryoprecipitate

Front 830

Causes of DIC

Back 830

-Infection (bacterial, viral, fungal)

-Cancer (adenocarcinoma, lymphma, leukemia)

-Trauma

-Shock

-Liver disease

-Pregnancy (amniotic fluid embolism, HELLP)

-ARDS

-Transfusion reactions

-Crotalid envenomation

Front 831

Conditions that can be treated with plasmapheresis

Back 831

Weakness syndromes

-Guillain-Barré syndrome

-Myasthenia gravis

-Lambert-Eaton Syndrome

Vasculitides

-Goodpasture's syndrome

-Granulomatosis with polyangiitis

-Microscopic polyangiitis

-Behcet syndrome

Hyperviscosity syndromes

-Cryoglobulinemia

-Paraproteinemia

-Waldenström macroglobulinemia

Other

-Pemphigus vulgaris

-Thrombotic thrombocytopenic purpura

-Hemolytic uremic syndrome

-Possibly SJS / TEN

Front 832

Avalanche: Most common cause of death, prognostic characteristics, treatment

Back 832

Cause of death

1 Asphyxia

2 Trauma

3 Hypothermia

4 Combination

Prognostic

-Buried >35m with an obstructed area

-Arrested when extricated

-Core temp <32 degrees

-K<8 (good prognosis for hospital discharge)

Treatment

-Consider ECMO if potential for good outcome

Front 833

Causes of hypercapnea

Back 833

Decreased drive - CNS disease, sedatives, exogenous toxins

Neuromuscular diseases

Thoracic cage diseases - kyphoscoliosis, obesity

Increased deas space - COPD

Front 834

Causes of cyanosis

Back 834

Central

-Decreased sat (altitude, hypoventilation, V/Q mismatch, impaired O2 diffusion, shunt)

-Hb abnormality (methemoglobin, sulfhemoglobin, CO)

Peripheral

-Arterial obstruction, venous obstruction, cold exposure, redistribution

Front 835

PRAM characteristics

Back 835

Suprasternal indrawing

Scalene retractions

Wheezing

Air entry

Oxygen saturation

Front 836

Causes of hypernatremia

Back 836

Decreased H20 intake - altered thirst perception (altered LOC), inability to obtain water

Increased H20 less

-GI - V/D/suctioning

-Renal - tubule defect, osmotic diuresis, diabetes insipidis

-Dermal - excessive sweating, burns

-Hyperventilation

Increased Na intake

-Exogenous - Na tablets, bicarb, hypertonic saline, inappropriate formula

-Renal - increased reabsorption due to hyperaldosteronism, Cushing's, corticosteroids

Front 837

Causes of diabetes insipidis

Back 837

Central - idiopathic, head trauma, tumor, ICH, infection

Nephrogenic - PCKD, renal dysplasia, congenital

Systemic - SCD, sarcoidosis, amyloidosis

Drugs - amphotericin B, lithium, dilantin, aminoglycosides

Front 838

Causes of hypokalemia

Back 838

Decreased intake

Increased losses

-Renal (increased aldosterone, corticosteroids, RTA, licorice)

-Gastrointestinal

-Dermal

Shifts - vomiting, diuretics, hyperventilation, insulin, B2 agonist, hypokalemic periodic paralysis

Drugs - PCN, Levodopa, Li, amphoteracin, Dopamine

Front 839

Causes of hyperkalemia

Back 839

Pseudo - hemolysis, increased platelets, increased WBC's

Increased intake - supplements, stored blood

Decreased excretion - ARF, tubular defects, hypoaldosteronism

Shifts - acidosis, hyperkalemic periodic paralysis, Drugs (beta blockers, digitalis, succynilcholine)

Cell injury - rhabdo, tumor lysis, burns, crush, hemolysis

Front 840

Causes of hypocalcemia

Back 840

Decreased albumin

Decreased magnesium

PTH insufficiency or resistance

Sepsis

Fat embolism

Vitamin D insufficiency

Chelation (PO4, citrate, free fatty acids in pancreatitis, HF poisoning)

Front 841

Causes of hypermagnesemia

Back 841

Renal failure

Increased absorption - hyperparathyroid, hypothyroid, adrenal

Mg load - laxatives, enemas, antacids, untreated DKA, tumor lysis, rhabdomyolysis, management of eclampsia

Front 842

RTA vs pre-renal failure

Back 842

Prerenal: normal or hyaline casts, UNa<20, FENa<1%, Uosm>500

ATN: brown or granular casts, UNa>40, FENa>1%, Uosm<500

Front 843

Causes of prerenal failure

Back 843

Volume depletion (GI losses, diuretics, bleeding, insensible)

Volume redistribution (3rd spacing, CHF, cirrhosis)

Decreased cardiac output (MI, valve, cardiomyopathy, hypertension meds)

Arterial disease (thrombosis, emboli)

Front 844

Causes of intrinsic renal failure

Back 844

GN (microscopic polyangitis, Goodpasture's, Wegener's, HSP, SLE, postinfectious)

Tubular (ATN, nephrotoxins - aminoglycosides, contrast, heme pigment, myeloma chains)

Interstitial (AIN, SLE, sarcoid, lymphoma)

Vascular (HTN, HUS, TTP, PAN, scleroderma)

Front 845

Causes of post-renal failure

Back 845

Intrarenal / ureteral - stone, malignancy, oxalate crystals, sloughed papilla

Bladder - stone, clot, BPH, cancer, neurogenic bladder

Urethra - phimosis, stricture

Front 846

Urine casts

Back 846

Hyaline - dehydration, proteinurea, exercise

WBC - paranchymal inflammation

RBC - glomerulonephritis / vasculitis

Fatty - nephrotic syndrome

Granular - ATN

Front 847

Criteria for BV diagnosis

Back 847

Need 3/4 (Amsel criteria)

-Thin, white, homogenous discharge

-Clue cells

-pH >4.5

-Fishy odor before/after KOH

Front 848

BV vs Trichomonas vs Candida

Back 848

BV - pH >4.5, gray-white malodorous discharge, clue cells on wet mount, treat with Flagyl 500 bid x 7d

Trichomonas - pH >4.5, yellow-green frothy discharge, trichomonads on wet mount, treat with Flagyl 2g x 1

Candida - pH <4.5, white curds, hyphae on wet mount, treat with Fluconazole 150mg x 1 or PV agents

Front 849

Complicated UTI

Back 849

Male - dysuria usually UTI, if true UTI generally have an anatomic abnormality (prostate hypertraphy)

Anatomic abnormality - catheter, stent, stones, neurogenic bladder, PCKD, instrumentation

Recurrant UTI - >3/year

Nursing home resident

Neonate

Immunocompromised

Front 850

Indications for imaging in UTI

Back 850

1st episode in children (<2yo or male get ultrasound)

Atypical presentation

Severe symptoms

Females with recurrent infections

ARF

Renal colic with obstruction

Sepsis

Front 851

Prostatitis: cause, acute vs chronic, treatment

Back 851

Cause: gram negative KEEPS

Acute: usually with cystitis, irritative voiding, fever

Chronic: recurrent UTI with same organism

Treatment: Cipro x 30d or Septra DS x 30d

Front 852

Factors affecting stone passage

Back 852

Size (5mm 98% in <4w; 5-7 60%; >7 40%)

Shape (spiculated less likely)

Location (can be in calyx, UPJ, pelvic brim, UVJ, vesicular orifice)

Obstruction (complete pass less than incomplete)

Front 853

Pill esophagitis: risk factors and common causes

Back 853

Risk factors

-Old age

-Decreased esophageal motility

-Extrinsic compression

-Increased pill size

-Gelatin coated

Common causes

-Tetracyclines

-Antivirals

-ASA / NSAIDs

-KCl

-Quinidine

-Bisphosnates

Front 854

Causes of esophageal perforation

Back 854

Iatrogenic - operations / scopes

Boerhaave's - intraesophageal pressure increased

Trauma - penetrating, blunt (rare), caustic ingestion

Foreign body

Barrett's esophagus

Zollinger-Ellison syndrome

Tumor - extrinsic or intrinsic

Aortic aneurysm

Front 855

Things that damage the mucosal barrier

Back 855

-Cigarettes

-EtOH

-Steroids

-H pylori

-NSAIDS

-Stress / shock

Front 856

Organic versus functional psychosis

Back 856

I give MADFOCS about this

M emory deficits (organic - recent; functional remote)

A ctivity (organic - psychomotor retardation, tremor and ataxia; functional - repetitive activity, rocking, posturing)

D istortions (organic - visual; functional - auditory)

F eelings (organic - emotional lability, functional - flat)

O rientation (organic - disoriented; functional - oriented)

C ognition (organic - islands of lucidity, can occasionally focus; functional - continuous scattered thoughts, unable to focus)

S ome other things (organic - age>40, sudden onset, abnormal exam, abnormal vitals, aphasia, decreased LOC; functional - age<40, gradual onset, normal PE, normal vitals, normal LOC)

Front 857

Mental illnesses associated with depression

Back 857

Neuro - parkinson's, CVA, MS, head trauma

Life threatening/altering - Cancer, HIV, CAD, MI, ESRD, dialysis

Endocrine - hypo/hyperthyroid, Cushings, Addisons, DM

Substance abuse

Front 858

DDx for somatoform disorder

Back 858

Endocrine (hyperparathyroid, thyroid disorders, Addison's, insulinoma, panhypuitarism)

Toxicology (botulism, CO, heavy metal toxicity)

Neuro (MS, myesthenia gravis, GBS)

Other (porphyria, Lupus, Wilson's disease, Uremia)

Front 859

Criteria for Munchausen's by proxy

Back 859

-Apparent illness produced by the parent

-Child presents repeatedly

-Perpetrator does not acknowledge etiology

-Illness disappears when separated

Front 860

Characteristics of malingering

Back 860

-Medicolegal context of presentation

-Discrepency between claimed disability and objective findings

-Poor cooperation during exam

-Not compliant with treatment

-Antisocial personality disorder

Front 861

Patients at LOW risk for suicide

Back 861

-Few risk factors-Supportive and stable home environment-Contracts to safety-Family/friend available to patient-Follow up appointment planned-No gun in home

Front 862

Noninfectious causes of fever of unknown origin

Back 862

Collagen-vascular - JRA, SLE, RA, UC, Kawasakis, vasculitis

Cancer - Lymphoma, leukemia, Wilms tumor

Drug induced - Serum sickness, PTU, TB agents, anticonvulsants

Miscellaneous - Environmental, Thyrotoxicosis, Familial fevers, Lyme

Front 863

Low risk criteria for infants 4-12 weeks with fever

Back 863

-Previously healthy

-Nontoxic appearance

-No focal infection

-Good social situation

-WBC 5-15 <1.5 bands

-Normal U/A <5 WBC/hpf

-Diarrhea <5 WBC/hpf

Front 864

Pediatric cardiac vs respiratory cause of central cyanosis

Back 864

Cardiac - comfortable breathing, worse with crying, no improvement with O2

Respiratory - uncomfortable breathing, better with crying, improvement with O2

Front 865

Ductal dependent lesions

Back 865

Require aorta -> pulm flow

-TOF

-Tricuspid atresia

-Pulmonic atresia

-Transposition of the great arteries

-Hypoplastic right heart

Require pulm -> aorta flow

-Coarctation

-AS

-Hypoplastic left heart

Front 866

Sinus tachycardia vs SVT features

Back 866

Sinus

-Has stimulus (dehydration, pain, fever)

-P waves

-HR variability

-Beat to beat variability (irregular R-R)

-<220 in infants and <180 in children

SVT

-No precipitant

-No P waves

-No HR variability

-Beat to beat variability (constant R-R interval)

-HR>220 in infants and >180 in children

Front 867

Indications for additional workup of jaundiced infants

Back 867

-Within 24h of birth

-Conjugated

-Rapidly rising

-No response to phototherapy

-Level approaching exchange threshold

-Lasts >3 weeks

-Toxic appearance

Front 868

Risk factors for NEC

Back 868

-Prematurity

-Aggressive enteral feeding

-Hypoxic insult at birth

-Infections

Front 869

Indications for IVF in pediatric gastroenteritis

Back 869

-Shock

-Severe dehydration

-Deterioration with ORT

-Intractable vomiting

-Failure to rehydrate with ORT in 8h

Front 870

Seizure mimics in children

Back 870

-Newborn jitters

-Breath holding spells

-Sandifer's syndrome

-Syncope

-Tics

-Dystonia

-Sleeping disorders (myoclonus, narcolepsy, night terrors)

Front 871

Radiographic findings of Legg-Calve-Perthes disease

Back 871

Initially - small head, wide joint space, subchondral crescent sign, irregular physis

Fragmentation - fragmented epiphysis with lucencies and densities

Reossification - return to normal density with irregular shape

Healed - residual deformity

Front 872

STI's and likelihood of pediatric sexual abuse

Back 872

Always - gonorrhea and syphilisUsually - chlamydia, HSV, trichomonasPossibly - HSV, scabies, pediculosis, BV

Front 873

Causes of monocular diplopia

Back 873

Iridodialysis

Lens dislocation

Refractive error

Malingering

Front 874

Horner's syndrome: definition, presentation, causes

Back 874

Definition

-Loss of ocular sympathetic innervation due lesion anywhere in cervical sympathetic chain (hypothalamus > brainstem > cervical cord > chest > carotid sheath > cavernous sinus > orbit)

Presentation

-ptosis, miosis (worse in the dark), anhidrosis

-

Causes:

-CNS: strokes, tumor, headache syndromes, brachial plexus trauma (during delivery)

-RESP: lung carcinoma, Pancoast tumor

-CVS: carotid dissection

-H+N: otitis media, herpes zoster

Front 875

Indications and contraindications for pupillary dilation

Back 875

Indications

-Need for better fundoscopic exam

-Prevention of synechiae (iritis)

-Decreased pain (iritis - relax ciliary muscles)

Contraindications

-Need to monitor pupils

-Shallow anterior chamber

Parasympatholytic cycloplegics (shortest to longest)

-Tropicamide 1% (4h)

-Cyclopentolate 1% (6-25h)

Sympathomimetics

-Phenylephrine 2.5% (3h)

-Cocaine 5% (2h)

-Homatropine, scopolamine, atropine

Front 876

Complications of ocular chemical burns

Back 876

-Perforation

-Scarring

-Adhesions of lid to globe (symblepharon)

-Glaucoma

-Cataracts

-Retinal damage

Front 877

Ultraviolet keratitis: causes, presentation, treatment

Back 877

Causes:

-Sun lamps, tanning booths, snow/watter reflection, Welder's arc

Presentation

-Latent for 6-10h then FB sensation, tearing, photophobia, decreased VA, conjunctival injection, diffuse punctate lesions

Treatment

-Short acting cycloplegic, antibiotic, oral analgesia, education, follow up with optho

Front 878

Indications to consult optho for corneal FB

Back 878

-Removal of rust ring

-Large area of visual axis involved

-Deeply embedded

-Risk of perforation

-Multiple FB's

Front 879

Traumatic iridocyclitis: pathology, presentation

Back 879

Pathology - blunt injury to globe with inflammation and spasm of the ciliary body and iris (basically traumatic iritis)

Presentation - deep eye pain, photophobia, perilimbal conjunctivitis / ciliary flush, cells and flare

Treatment - steroids and cycloplegic (and optho)

Front 880

Lens dislocation: cause, risk factors, clinical findings, treatment

Back 880

Cause - Occurs following AP trauma with disruption of the zonule fibers

Risk factors- Marfan's, Homocystinuria, Tertiary syphilis

Findings - painless, monocular diplopia or blurred vision with iridodonesis, phacodenesis, irregularly shaped lens

Treatment - optho

Front 881

Globe rupture: clinical findings

Back 881

Clinical: eye pain, decreased visual acuity, bloody chemosis, 360 degree SC hemorrhage, teardrop pupil, Seidel, deep anterior chamber

Treatment: optho consult, tetanus, antibiotics (tazo), antiemetics, CT if FB

Front 882

Complications of FB's (plastic, glass, metal, organic, iron, copper)

Back 882

Plastic, glass, metal - inert; don't remove

Organic - endopthalmitis; remove

Iron - siderous oxidation of ocular tissue leading to visual loss; remove

Chalcosis - sterile inflammatory reaction to copper; remove

Front 883

Opthalmia neonatorum: definition, causes and timeline

Back 883

Chemical: day 1 due to erythromycin at birth; do nothing

Gonorrhea: Day 2-5, Cefotaxime and topical

Chlamydia: Day 5-14, erythromycin po q6h

HSV 1,2: Day 2-15, IV acyclovir

Front 884

Hordeolum, chalazion, dacrocystitis, blepharitis

Back 884

Hordeolum (stye): acute localized swelling of an eyelid due to obstruction of the glands of Zeis; tx with warm compresses x15m q4-6h

Chalazion: focal inflammatory lesion due to obstruction of meibomian gland (can result from hordeolum); tx by optho with excision/steroid injection

Dacrocystitis: inflammation of medial lacrimal sac; can progress to periorbital cellulitis; tx with clavulin and compresses

Dacroadenitis: inflammation of the lateral lacrimal gland (lateral 1/3 of upper lid); can progress to orbital cellulitis; tx with clavulin and compresses

Blepharitis: matted red eyelid margins, FB sensation, burning; tx with clean with shampoo bid, warm compresses, artificial tears

Front 885

Atopic dermatitis diagnostic criteria

Back 885

AKA eczema

Itchy skin +

-flexural involvement

-generalized dry skin

-H/O asthma or hay fever

-Onset of rash before 2yo

-Flexural dermatitis

Front 886

Treatment of impetigo

Back 886

can be staph or strep

Mild - fucidin or mupirocin (2% tid)

Moderate/Severe - Keflex or Cloxacillin

Bullous (staph only!) - Cloxacillin or erythromycin (if MRSA risks consider clinda or septra)

Front 887

Diagnosis and treatment of disseminated gonorrhea

Back 887

Presentation - present with fever, asymmetric migratory tenosynovitis/arthralgias, urethritis, cervicitis and characteristic gun-metal blue rash

Diagnosis - Fluorescent-antibody staining of lesions (gram stain and culture are poor), swabs of cervic/urethra, rectum, pharynx (if all 3 swabbed is 75% sensitive, joint tap (50% sensitive), blood cultures (poor), test partner

Treatment - Ceftriaxone 2g IV q24h x 3-7 days (until clinical improvement) then Cefixime 400mg po od or Cipro 500 po bid for rest of 7 days. Should probably admit.

Front 888

SSSS vs TEN vs SJS - distinguishing features and treatment

Back 888

All can have Nikolsky's sign but SSSS is through the epidermis and TEN is deeper through the plane of the epidermis/dermis. TEN and SJS can be distinguished histologically.

All can be deadly, SSSS worse in adults (30%) than kids (5%)

SJS usually has mucous membrane involvement before rash

Treatment of SSSS is cloxacillin / staph antibiotic. SJS and TEN must stop offending agent, fluid resuscitate, infection control (mostly supportive in burn center), and IVIG! Can consider plasmapheresis.

Front 889

Things that cause EM, SJS and TEN

Back 889

Drugs

-Antibiotics - Sulpha and PCN's

-Anticonvulsant - Phenytoin, Carbamazepine, Barbiturates

-Antiinflammatory - ASA, Allopurinol, NSAIDS

Post vaccination (polio, measles, smallpox, tetanus, diptheria)

Lymphoma

Front 890

Erythema nodusum definition, symptoms, treatment

Back 890

A hypersensitivity vasculitis of the venules of the subcutaneous layers of the skin (inflammatory reaction of dermis and adipose tissue as well).

Characterized by painful, subcutaneous nodules that last 3-8 weeks along with fever, malaise, and arthralgias.

Treatment: NSAIDS, elevate legs for pain, wear stockings, Potassium iodine (weird!), and steroids (if severe)

Front 891

Traveler's diarrhea: definition, organisms, investigations

Back 891

Definition - history of travel and >3 stools/24h +/- fever, abdominal cramps, emesis

Organisms

-Bacteria 50-80%. Specifically E coli (ETEC), Shigella (Mexico/Africa), Campylobacter (Asia), Salmonella (Europe)

-Viruses 0-20%. Specifically Adenovirus, rotavirus.

-Protozoa <5%. Giardia, Entamoeba.

Investigations - Stool C&S +/- C Diff if: fever, tenesmus, gross blood, planned Abx. Ova and parasites if >10-14 days of symptoms.

Treatment - Hydrate. Loperamide if no contraindications. Cipro 500bid x 3d or Azithro 500mg od x 3d but likely not justified unless bloody, severe, and not likely to be E Coli.

Front 892

Causes of bloody diarrhea

Back 892

- Aeromonas

- Salmonella

- Shigella

- Yersinia

- Campylobacter

- E Coli with shiga-like toxin (0157:H7)

- Entamoeba histolitica

Front 893

Who gets stool cultures for diarrhea?

Back 893

Standard Sal, Shig, Camp, Yer, EColi 0157 cultures:

-Bloody diarrhea

-LTC patient, healthcare worker, food handler, daycare worker

-Severe dehydration, fever, underlying illness

Additions

-If antibiotics in past 3 months - add C Diff toxin assay

-If nausea prominent - add noro / rota / advenovirus test

-If shellfish ingestion - add vibrio culture

-If >7 days - add ova and parasites

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Features suggestive of E Coli O157:H7

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-Nonbloody diarrhea for 3 days THEN bloody diarrhea

-No fever

-5 stools/24h

-Abdominal tenderness

-Pain worsens on defecation

-No granylocyte count increase on WBC