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144 Cards in this Set

  • Front
  • Back
What should be the primary survey of a patient with AMS
Oxygen, Monitor, IV access

Dexistick-->administer glucose
Narcan
When dealing with AMS, before dx established, what can you give
COMA Cocktail: D.O.N.T.

Dextrose ~ 1 amp D50 IV
Oxygen ~ 100% non-rebreather
Naloxone ~ 2 mg IV
THiamine (B1) ~ 100 mg IV
acute mental status changes differential
1) defect in glucose control or other electrolyte abnormality
2) increased ICP
3) poisoning
4) infection
5) hypoxia/ hypercarbia
6) environmental exposure (hypo-hyperthermia)
what is difference between AVPU and GCS
GCS is for trauma patients and AVPU describes patients level of consciousness during primary survey

do full neuro on non-trauma patient
What does AVPU stand for?
A = awake and alert
V = responds to verbal stimuli
P = responds to painful stimuli
U = unresponsive
GCS
Eye Opening:
~spontaneous = 4
~to voice = 3
~to pain = 2
~none = 1

Best Verbal Response
~oriented = 5
~confused = 4
~ innapropriate words = 3
~incomprehensible words = 2
~none = 1

Best Motor Response
~obeys commands = 6
~localizes pain = 5
~withdraws to pain = 4
~flexion to pain = 3
~extension to pain = 2
~none = 1
Coma
neither arousal nor awareness is present
delirium
increased alertness, confused, disoriented

but with psychomotor agitation, and hallucinations
Characteristics of a metabolic etiology of AMS
-rapid deterioration over a few hours
-metabolic and drug-related causes are most common for acute changes (70-80%)
-no focal neuro deficits
-reactive and equal pupils usually point to a metabolic cause
Asymmetric reactive pupils
Normal variant
One pupil fixed and dilated
Acute hemorrhage
Both pupils pinpoint and minimally reactive
-exposure to insecticides
-heroin overdose
Efferent parasympathetic fibers travel with which nerve
CN III (oculomotor)
Afferent limb of pupillary reflex arc
CNII (optic)
Efferent sympathetic fibers travel with which nerves
superior cervical ganglion via the carotid sympathetic plexus
How does a mass effect pupil size
Compression on the third nerve will cause loss of parasympathetic input-->unopposed sympathetic input-->pupillary dilatation
What do lesions at the level of the pons do to pupillary size?
interrupt sympathetic fibers as they pass through MLF on their way to cervical sympathetic plexus-->unopposed parasympathetic input-->pinpoint pupil
5 general indications for head CT in patients with AMS
1) Trauma
2) SAH
3) Focal Neuro deficits
4) Papilledema
5) Other causes are ruled out
Retinal hemorrhage
Subarachnoid hemorrhage
hemotympanum
Battle's sign
basilar skull fracture
Pupil dilatation and contralateral hemiparesis
Impending uncal herniation
Absence of Doll's eyes
Brainstem dysfunction
Oculocephalic reflex
Doll's eyes (normal)- eyes will remain looking straight ahead

Painted on pathologic

Requires intact CN III (oculomotor) and CN VIII (vestibular)
Oculovestibular
Cold water calorics

COWS (intact cortex)
->cold-water causes fast nystagmus opposite the stimulus, warm water will cause movement towards the stimulus

Barbituates and sedatives may abolish this
Immediate management of patient with possible incranial process
ABC OMI

1) mannitol 1 gm/kg IV
2) head CT
3) immediate neurosurg consult
4) endotracheal intubation and hyperventilation
Syncope
Sudden, temporary loss of conciousness and loss of postural tone with spontaneous recovery

-fall in BP leading to impairment of cerebral perfusion that cannot be overcome by autoregulatory mechanisms
What drop in % of cardiac output is necessary to cause unconciousness in healthy adult
Systolic BP <50

-cardiac output has to drop to 50%
What type of mechanical or obstructive cardiac disease can cause syncope
1) IHSS
2) CHF
3) PE
4) Cardiac Tamponade
historical features of seizure
Pre-seizure:
1) aura or prodrome
2) precipitants
3) Hx of seizures

At time of Seizure:
1) tonic-clonic activity
2) tongue biting
3) incontinence

Post-seizure:
1) Incontinence
2) post-ictal confusion
3) gradual recovery of MS
3 primary cardiac etiologies that would cause syncope due to bradycardia
1) sick sinus (tachy-brady) syndrome
2) 2nd or 3rd degree heart block
3) pacemaker malfunction
What should you do in every patient with orthostatics?

What labs would be helpful
rectal and orthostatics

CBC and BUN/Cr
Differential Diagnosis of AMS and Coma
AEIOU TIPS

A = Alch and other toxins
E = endocrine, electrolytes
I = insulin (DM)
O = oxygen/opiates
U = uremia

T = trauma, temperature changes
I = Infection
P = psychiatric/ porphyria
S = SAH/ space-occupying lesion
With acute STEMI, what does evidence support
1) call cath
2) ASA
3) One dose of LMWH, followed by unfractionated heparin IV
4) If going to cath, then IIb/IIIa inhibitor is beneficial

-can add O2 and give morphine

-If give Plavix-->irreversible platelet inhib, so cannot do CABG during this time

-Beta-blocker are contraindicated in patients with:
hypotension
bradycardia
asthma/copd
acute CHF
What percentage of patients with MI have chest wall tenderness
15%
What are the most common sx of PE:
-pleuritic chest pain (88%)
-dyspnea (84%)
-cough (50%)
-hemoptysis (30%)

massive PE (>60% pulmonary capillary bed)
-syncope, hypotension, RHF
How do you calculate A-a gradient?
What is normal
A-a gradient = 150 - [PaO2 + (1.2 x PCO2)]

nl is <15mmHg
What is the value of EKG in "ruling out" MI as cause of chest pain
-only has PPD; only helpful if shows new changes
-can only be used to rule in ischemia, not rule out
-20-50% patients with acute MI have NL or non-specific EKG on presentation to ED
Immediate tx of PE
supportive therapy, oxygen, and heparin anticoagulation
What is use of ELISA D-Dimer for PE
Very high sensitivity and NLR
Patient with chest pain and bradycardia/ hypotension
1) atropine 0.5mg IV
2) Fluid bolus of 250 cc NS
3) IV morphine for pain relief when BP imporved
4) serial repeat vitals
Therapy for tension Pneumothorax
needle decompression followed by
tube thoracostomy
Dissection of the thoracic aorta
control hypertension with sodium nitroprusside and beta-blocker
Unstable angina
Give sublingual nitro and beta-blocker to maximize myocardial oxygen delivery and minimize demand
Treatment for inferior MI with posterior infarction
-Oxygen
-Fluid bolus with normal saline prior to nitro administration
-Nitro sublingual followed by IV nitro if pain continues
-**ASA 325mg po
-Beta-blocker IV
-**heparin IV bolus then maintenance drip
-Morphine IV as needed for pain
-Immediate catheterization or thrombolytic therapy
-IV GP IIb/IIIa inhib if going to cath lab
-cath
-admit to CCU or ICU
changes on EKG with unstable angina
ST-T changes
describe how the results of CPK with MB influence therapy and dispo.
MB fraction is more specific for myocardial damage, but it takes 6 hrs from time of infarction to begin to see rise in CKMB or troponin
What do you do if a patient with acute MI cannot go to cath lab for >1 hr
give thrombolytics
What are some signs that a patient may need active airway management
-tolerating oropharyngeal airway (loss of gag reflex)
-breathing shallowly-->hypoventilation
-s/p blunt head injury with persistent depressed mental status--> may indicate intracranial process--> needing hyperventilation to decrease intracranial pressure
How do you estimate ET tube size in infants and children?
up to age 15:

16 + age (in yrs)/ 4 = ET tube size

for those >15 yrs of age -->7.5 - 8 cm
What blade do you use to intubate
#3 or #4 Miller or Macintosh
What do you do if you cannot visualize cords while intubating, despite using various laryngoscope blades and repositioning techniques
1) Use LMA (laryngeal mask airway)
2) Intubate over a bronchoscope
3) Intra-oral palpation and intubation over a lighted stylet
Name the 4 life-threatening Gynecologic emergencies
-Toxic Shock
-Ruptured hemorrhagic cyst
-Ruptured ectopic
-ruptured TOA
What are importnat parts of GYN hx
-LMP and timing of 2 or more immediate past menstrual periods
-changes in recent menstrual patterns
-amount of bleeding
If LMP is normal and patient is <4wks passed LMP....
...low chances of pregnancy complications since spontaneous abortions and ectopics do not occur before first missed period
When can urine enzyme immunoassay be used to detect pregnancy
2-4 wks after conception
When can serum enzyme immunoassay be used to detect pregnancy
1 wk after conception
3 most common presenting sx of ectopic

incidence
abdominal pain, amenorrhea, vaginal bleeding

20/1000
Pregnant patient with abdominal pain:

-what are the 7 serious causes of abdominal pain
1) ECTOPIC
2) THREATENED Ab
3) Inevitable/incomplete Ab
4) Complete Ab
5) Ruptured Corpus Luteum ( can exist up to 8th wk of pregnancy)
6) Molar Preg
7) Non-gyn (appendicitis)
Common serious gynecologic conditions causing abdominal pain in non-preg patient
1) PID
2) Ovarian torsion
3) Mittelschmerz: in patients with regular 28-33 day cycle; occurs at days 14-16 with pain lasting <1 day
4) Ruptured corpus luteum cyst
What test COULD be ordered on patient with + pregnancy test and abd. pain to confirm dx
1) quant: increases 66% every 2 days
(15% ectopics have nl incr,10% nl preg have abnl incr)
2) US
3) culdocentestis
when can US be used to visualize pregnancy?
Abd US: (>6500 hCG)
-5th wk: gestational sac
-6th wk: fetal pole
-7th wk: fetal heart motion

Vaginal US: (>2000 hCG)
-can detect IUP @ 3 wks
tx of ectopic
1) O2
2) Type and screen
3) RhoGam testing
4) Surgery
tx of threatened Ab
1) bed rest
2) vaginal rest
3) RhoGam test
4) return if worsening sx (incr pain, bleeding, lightheadedness)
5)f/u with OB/GYN next 2 days
tx of inevitable/incomplete Ab
-D + C
-RhoGam
tx Ruptured Corpus Luteum
-surgical intervention with ovarian cystectomy
-outpatient tx contraindicated unless approved by OB
Differential for vaginal DC
1) vulvovaginitis
2) cervicitis
3) PID
How dx PID
Clinically:
~Abd pain
~adnexal pain
~cervical motion tenderness
~purulent cervical dc
~fever

onset is usually shortly after menstrual flow
What lab test should you order with a suspected dx of PID
1) preg. test
2) gram stain of DC (N. gon are g- diplococci
3) Culture of DC: for N. gon and C. trach
4) CBC: WBC
5) UA: if cystitis suspected
How distinguish TOA from PID
TOA will have adnexal mass on exam or patient returning after 2 days of outpatient tx has failed to improve sx
Outpatient Tx of PID
Ceftriaxone 250mg IM and doxycycline 100mg bid for 10-14 days

-reevaluate in 2 days
Admission criteria for PID
1) TOA
2) temp > 100.4
3) pregnancy
4) poor po tolerance
5) IUD in place
6) failure to respond to ABx after 48 hrs
7) uncertain dx
8) upper peritoneal signs (F-H-C syndrome)
9) WBC > 12,000
If patient only has STD exposure, what is tx
Ceftriaxone 125mg IM
and
Azithromycin 1 gm PO
Admission criteria for pyelo:
If elderly, debilitated, serious underlying dz, too toxic, -->admit

Rule of 2s:

Young, healthy female with uncomplicated pyelo:
give:
-2 liters IV fluid
-2 Tylenol #3
-2nd gen quinolone IV
-2hrs of obs

-If during 2 hr obs time, patient has
2glasses of water
2 degree decrease in fever

can be dc'd with:
-2 wks of levaquin po
-2 day f/u to ensure improvement
4 major types of kidney stones
1) Ca (oxalate or Phos) 75%
2) Mg-Amm-Phos 10%
3) Uric Acid 10%
4) Cystine/other 5%
When admit with kidney stone
1) infxn with obstruction
2) One kidney with obstr
3) undontrolled pain
4) intractable emesis
5) large stone (>6mm only 10% chance of passing)
order of appearance of sx in appendicitis
Pain, anorexia, n/v, change in bowel habits, fever
Dz that can give elevated amylase
-Peptic ulceration
-Liver dz
-SBO
-Common duct stones
-Bowel infarction
-ectopic
-acute ethanol intox
Differential in acute appendicitis
acute chole
UTI or pyelo
ureteral stone
Yersinia enterocolitica
PID
Ectopic
Mesenteric Lymphadentitis
Management of appendicitis
Fluids
Abx: Single dose of cefoxitin
Pain meds: Morphine sulfate 5-10mg IV
How to stabilize for AAA
-2 large bore IVs
-crystalloid bolus of 1-2liters
-Type and cross 4 units PRBCs
-STA call to vascular surg
Tx of perforated gastric ulcer
-volume repletion with isotonic crystalloids
-transfusion of PRBCs prn
-NG tube to empty stomach
-pain relief (5-10mg morphine sulfate IV)
-IV H2 blockers or PPIs
-IV ABx and surg
If patient only has STD exposure, what is tx
Ceftriaxone 125mg IM
and
Azithromycin 1 gm PO
Admission criteria for pyelo:
If elderly, debilitated, serious underlying dz, too toxic, -->admit

Rule of 2s:

Young, healthy female with uncomplicated pyelo:
give:
-2 liters IV fluid
-2 Tylenol #3
-2nd gen quinolone IV
-2hrs of obs

-If during 2 hr obs time, patient has
2glasses of water
2 degree decrease in fever

can be dc'd with:
-2 wks of levaquin po
-2 day f/u to ensure improvement
4 major types of kidney stones
1) Ca (oxalate or Phos) 75%
2) Mg-Amm-Phos 10%
3) Uric Acid 10%
4) Cystine/other 5%
When admit with kidney stone
1) infxn with obstruction
2) One kidney with obstr
3) undontrolled pain
4) intractable emesis
5) large stone (>6mm only 10% chance of passing)
order of appearance of sx in appendicitis
Pain, anorexia, n/v, change in bowel habits, fever
Dz that can give elevated amylase
-Peptic ulceration
-Liver dz
-SBO
-Common duct stones
-Bowel infarction
-ectopic
-acute ethanol intox
Differential in acute appendicitis
acute chole
UTI or pyelo
ureteral stone
Yersinia enterocolitica
PID
Ectopic
Mesenteric Lymphadentitis
Management of appendicitis
Fluids
Abx: Single dose of cefoxitin
Pain meds: Morphine sulfate 5-10mg IV
How to stabilize for AAA
-2 large bore IVs
-crystalloid bolus of 1-2liters
-Type and cross 4 units PRBCs
-STA call to vascular surg
Tx of perforated gastric ulcer
-volume repletion with isotonic crystalloids
-transfusion of PRBCs prn
-NG tube to empty stomach
-pain relief (5-10mg morphine sulfate IV)
-IV H2 blockers or PPIs
-IV ABx and surg
narcotic toxidrome
-constipated
-bradycardic
-lethargic
-miosis
-coma
Anticholinergic toxidrome
-dry as a bone
-mad as a hatter
-red as a beet
-hot as a hare
-blind as a bat
Cholinergic toxidrome
-salivation
-lacrimation
-urination
-defecation
sympathetic toxidrome
tachycardic, increased bowel sounds, diaphoretic
tx of anticholinergic syndrome
physostigmine
supportive care
-benzos
tx of cholinergic syndrome
pralidoxime
TCA overdose
QRS prolongation, inhibition of norepi and serotonin, alpha-blockade

tx with sodium bicarb and MG for torsades

obs 6 hrs
Common precipitants of asthma
1) PE
2) CHF
3) Mold
4) URI
Most common complication in pregnant asthmatic
undertreatment by physician
Differential dx of Wheezing
Asthma
Stasis/PE
Toxin
Heart/CHF
Mechanical: foreign body
Allergy
Tumor
Infection
Congen
When should CXR be ordered in an asthmatic with wheezing
Chest pain, fever, productive cough
How treat CHF exacerbation
1) NO
2) NO
3) NO
4) Lasix
5) Morphine 2mg IV
How do you tell if a patient has a pure respiratory acidosis
change in pH of 0.08 for every change in pCO2 of 10
Wheezes, tachycardia, pleuritic chest pain
PE
JVD, wheezes, rales, peripheral edema
CHF
Inspiratory wheezing, fever, sore throat
epiglotitis
wheezing, non-productive cough, irritant exposure
asthma
When should intubation be considered in asthmatics
confused or rising CO2;

pO2 on 100% O2 = <50
pCO2 > 50
absolute contraindications to DPL
entry and exit wounds
When agitated, what fluids should a patient be resusitated with
blood
and NS
How do you resuscitate during hemorrhagic shock
2L NS--> 2L NS-->Blood 2U-->Blood 2U
How do you resuscitate during AOS
1L NS-->1L NS-->pressors (dopamine/Norepi)
How do you resusitate kids in hem. shock
20cc/kg-->20cc/kg-->10cc/kg PRBCs
Where perform needle decompression
mid-clavicular line, 2nd intercostal
Where perform chest tube
mid-axillary 5th intercostal
Beck's triad is WHAT?
JVD; hypotension; decreased heart sounds

how treat?
U/S guided needle decompression of pericardial tamponade
WHat do you do when a patient's status acutely changes
ABC
What if a stab wound occurs under the nipple line
Abd U/S
How do you calculate fluid replacement for burn victims
TSA x Wt X 4 = 24hrs + maintanence
A patient's hand equals what percent of BSA
1%
what does each area of the body correspond to in BSA for burns

Infant?
head: 9%
each arm: 9%
front torsoe: 18%
back torsoe: 18%
penis: 1%
Each leg" 18%

Infant: legs are 13.5% each; head is 18%
When does a patient have to be transferred to burn center
>20% second degreee burns

>3% third degree burns
WHat are the 1/2 lives of CO
RA = 4hrs
100% O2 = 40 min
HBO2 = 4 min
How do you treat burns
1) Pain meds (Morphine)
2) clean sheets
3) IV NS
What are the 5 P's of Rapid Sequence Intubation
Preparation (Et tube, blade, suction)
Preoxygenation
Pretreatment
Paralysis (SUCCS for defascifculations + atomadate for sedation)
Pass the Tube
What is a septic workup for a child
1) UA
2) Blood cx
3) CXR
4) CBC
5) lytes
6) Consider LP

If 2 mo and under do everything and admit
Most common organisms for 0-2month old meningitis and tx
1) GBS
2) E. Coli
3) Listeria

Ceftriaxone and Ampicillin
with steroids at or before abx
3mo --> 103 y/old
1) S. Pneumo
2) H. flu
3) N. Mening

Ceftriaxone and Vanco + steroids
Most common causes of seizures at 6mo - 3 yrs:
1) febrile seizures
2) meningitis
3) tauma
4) tox
5) space-occupying
Most common 0-6mo
1) congen
2) metabolic
3) meningitis
4) hypocalc
5) hypoxemia
6) SIDS
tx for seizures
1) ativan 1mg
2) ativan 1mg
3) ativan 1mg
4) ativan 1mg
5) phosphenytoin
6) phenobarb
7) intubate
common causes of stridor in children
1) retropharyngeal abscess
2) croup
3) foreign body
tx of acute-angle glaucoma
-timolol
-acetazolamide
-->decreases production by ciliary body

-pilocarpine-->causes miosis
Class I hem shock
(0-15%) volume

-bolus of 2L NS
Class II hem shock
(16-30%) volume

-incr HR

-bolus 2L NS
Class III hem
cerebral hypoxia-->agitation

NS + blood

(31-40%)
Suture used with face
6.0 or 7.0
Suture used with scalp/extensor surfaces
3.0 - 4.0
Human bite
Augmentin 20 - 40 mg/kg daily dividded TID for 7 days
Fracture of proximal phalanx of 4th and 5th digits (boxer's)
short ulnar gutter
Fracture of first and second digits (proximal phalanx) and metacarpals
radial gutter
fractures of scaphoid and proximal phalanx and metacarpal of thumb
thumb spica splint
AMPLE Hx
Allergies
Medications
PMH
Last Meal
Event