Emergency Medicine

Front 1

basic life support measures

Back 1

1) assess responsiveness
2) call for help
3) postiion face up on flat surface
4) open the airway
5) assess breathing (if no breathing, perform 2 rescue breaths)
6) check carotid pulse 5-10 seconds (if no pulse, give 30 compressions and two ventilations until help arrives)

Front 2

asystole and dysrhythmia etiology

Back 2

"Hi 5, T5": hypoxia, hypo/hyperkalemia, hypothermia, hypoglycemia, hypoveolemia, trauma, toxins, tamponade, tension pneumothorax, thrombosis

Front 3

advanced cardiac support

Back 3

if pulseless + shockable --> shock + 5 cycles of CPR + 1mg epi every 3-5min until pulse present
if pulseless + not shockable --> 5 cycles of CPR + 1mg epi + 1mg atropine until electrical activity then check pulse;

Front 4

shockable rhythms

Back 4

ventricular fibrillation and ventricular tachycardia

Front 5

unshockable rhythms

Back 5

asystole, pulseless electrical activity

Front 6

signs of hemodynamic instability

Back 6

hypotension, chest pain, altered mental status, CHF

Front 7

general measures of tachycardia with pulses

Back 7

ABC, O2, identify rhythm on ECG, identify reversible causes

Front 8

hemodynamically unstable patient with pulse and tachycardia

Back 8

perform immediate cardioversion
IV access and sedation
until stable

Front 9

hemodynamically stable patient with pulse and tachycardia, narrow QRS, regular rhythm

Back 9

vagal maneuvers or adenosine
if converts --> probable SVT, treat recurrence with adenosine
if doesn’t convert --> probable atrial flutter, ectopic atrial tachycardia
control rate with diltiazem or betablockers

Front 10

hemodynamically stable patient with pulse and tachycardia, narrow QRS, irregular rhythm

Back 10

probable A-fib or MAT; control rate with diltiazem or betablockers

Front 11

hemodynamically stable patient with pulse and tachycardia, wide QRS, regular rhythm

Back 11

if VT --> amiodarone 150mg IV over 10min, repeat as needed
if SVT --> adenosine and check for rhythm conversion

Front 12

hemodynamically stable patient with pulse and tachycardia, wide QRS, irregular rhythm

Back 12

if WPW --> avoid nodal blocking agents adenosine, digoxin, CCB
consider amiodarone 150mg over 10min

Front 13

basic algorhythm for tachycardia with pulses

Back 13

general measures --> check if stable --> check QRS --> check rhtyhm regularity

Front 14

miosis as sign of toxicity

Back 14

sugests clonidine, barbiturates, opiates, cholinergics, pontine stroke

Front 15

mydriasis as sign of toxicity

Back 15

sugests sympathomimetics, anticholinergics

Front 16

dry skin as sign of toxicity

Back 16

sugests anticholinergics

Front 17

wet skin as sign of toxicity

Back 17

cholinergics, sympathomimetics

Front 18

blisters as sign of toxicity

Back 18

barbiturates, carbon monoxide

Front 19

common signs of toxicity

Back 19

miosis, mydriasis, dry skin, wet skin, blisters

Front 20

measures for toxic ingestion management

Back 20

induced vomiting
lavage
charcoal
whole bowel irrigation
dialysis
cathartics
forced diuresis
naloxone/dextrose/thiamine

Front 21

induced vomitting

Back 21

ipecac can only be used 1-2 hours after toxic ingestion (limited use)
not indicated in children or for caustic substances

Front 22

lavage

Back 22

indicated in those with mental status
preceded by intubation
used 1 hour after ingestion (limited use)
contraindicated for caustic substances

Front 23

charcoal

Back 23

used if patient arrives more than 1-2 hours after ingestion; decreases absorption and increases removal of absorbed substance

Front 24

whole bowel irrigation

Back 24

used when many pills are seen on x-ray; 1-2 liters/hour of GoLytely via gastric tube

Front 25

dialysis for toxicity management

Back 25

used for ehtylene glycol, lithium overdose, methanol poisoning, aspirin overdose, theophyline overdose and there is coma, hypotension or apnea

Front 26

cathartics

Back 26

useful only when charcoal is used; generally wrong answer

Front 27

forced diuresis

Back 27

alkaline diuresis is only useful for salicylates and phenobarbital

Front 28

naloxone/dextrose/thiamine administration

Back 28

given to any patient who ingested substance and has altered mental status

Front 29

acetaminophen toxicity stages

Back 29

gastritis, nausea, vomitting 12-24 hours after ingestion; 24-48 hours: asymptomatic period with subclinical elevation of transaminases and bilirubin; 48-72 hours: jaundice, abdominal pain, hepatic encephalopathy, renal failure and death

Front 30

acetaminophen toxicity treatment

Back 30

N-acetyl-cysteine preferably within first 8 hours
activated charcoal
no gastric emptying
after 24 hours of ingestion no treatment can prevent or reverse toxicity

Front 31

methanol ingestion sources

Back 31

paint thinner, sterno, photocopier fluid, solvents, windshield washer solution

Front 32

ethylene glycol ingestion sources

Back 32

car antifreeze

Front 33

methanol and ethylene glycol metabolism

Back 33

methanol + alcohol dehydrogenase --> formaldehyde + formic acid
ethylene glycol + alcohol dehydrogenase --> oxallic acid/oxalate

Front 34

general signs of alcohol intoxication

Back 34

confusion, ataxia, lethargy, drowsiness, slurred speech

Front 35

isopropyl alcohol intoxication

Back 35

ketonuria, ketonemia, without acidosis and no increased anion gap

Front 36

methanol intoxication specific signs

Back 36

visual disturbances, blindness

Front 37

ehtylene glycol intoxication specific signs

Back 37

renal failure and oxalate crystals/stones in urine

Front 38

alcohol intoxication diagnosis

Back 38

determine specific alcohol levels in blood
oxalate crystals in urine and ↑BUN/creatinine are characteristic of ethylene glycol
ethylene glycol and methanol produce increased anion gap metabolic aciosis different from isopropyl alcohol which is normal

Front 39

alcohol intoxication treatment

Back 39

fomepizole is alcohol dehydrogenase inhibitor which decreases toxic metabolites

Front 40

carbon monoxide poisoning presentation

Back 40

dyspnea, tachypnea, shortness of breath, headache, nausea, dizziness, confusion, syncope, chest pain, arrhythmia, hypotension

Front 41

carbon monoxide poisoning diagnosis

Back 41

carboxyhemoglobin levels
arterial blood gases (metabolic acidosis with normal PO2)
↑CPK
pulse oximetry not helpful
CO poisoning might present similar to hypoglycemia, if glucose is normal, raise suspicion of CO

Front 42

carbon monoxide poisoning treatment

Back 42

removal from source of exposure, 100% O2, hyperbaric O2 if CNS or chest pain

Front 43

caustic substance intoxication presentation

Back 43

oral pain, drooling, odynophagia, abdominal pain
esophageal injury and gastric perforation may occur

Front 44

caustic substance intoxication diagnosis

Back 44

by history of exposure and upper endoscopy if ingested

Front 45

caustic substance intoxication management

Back 45

wash out mouth, eyes or skin with large volumes of cold water
follow eye wash out with fluorescein corneal exam
don't induce emesis or neutralize substance
charcoal and steroids are not effective

Front 46

digoxin toxicity etiology

Back 46

from suicide attempt or accidental overdose; hypokalemia predisposes to toxicity

Front 47

digoxin toxicity presentation

Back 47

nausea, vomitting, diarrhea, anorexia
blurred vision, color abnormalities
hallucinations
confusion
arrhythmia

Front 48

digoxin toxicity diagnosis

Back 48

history + ECG looking for any arrhythmia
check for hyperkalemia

Front 49

digoxin toxicity management

Back 49

repeated doses of charcoal, digoxin antibodies, potassium correction
pacemaker might be necessary for refractory bradycardia or 3rd degree heart block

Front 50

opiate intoxication

Back 50

respiratory depression
respiratory acidosis
miosis
constipation
bradycardia
hypothermia
hypotension
treat with naloxone

Front 51

cocaine intoxication

Back 51

hypertension, hemorrhagic stroke, MI, arrhythmia, seizures
pulmonary edema is specific to crack
treat with benzodiazepines for acute agitation
combined alpha/beta blockers such as labetalol or alpha blockers such as phentolamine
avoid beta blockers

Front 52

benzodiazepine intoxication

Back 52

somnolence, dysarthria, ataxia, stupor
death is not from respiratory depression but concomitant ethanol or barbiturates
flumazenil antidote is not always used due to seizures from withdrawal

Front 53

barbiturate intoxication

Back 53

hypothermia, loss of deep tendon reflexes
loss of corneal reflexes, coma and death from respiratory depression
no EEG activity can be seen
no specific antidote but increase urinary excretion with bicarbonate

Front 54

hallucinogens

Back 54

marijuana, LSD, mescaline, peyote, psilocybin, PCP (angel dust)

Front 55

hallucinogen toxicity

Back 55

delirium and bizarre behavior
anticholinergic effects (flushed skin, dry mouth, dilated pupils, urinary retention)
PCP may cause seizures
treat severe intoxication with benzodiazepines

Front 56

lead sources

Back 56

ingested paint, soil, dust, drinking water

Front 57

lead metabolism

Back 57

absorbed from GI tract, skin or inhalation
5-10% in blood (mostly in RBC)
80-90% in bones, remainder in brain and kidneys

Front 58

lead poisoning presentation

Back 58

adults: abdominal pain, anemia, renal disease, neurologic manifestations
children: abdominal pain, anemia, lethargy, seizures, coma, irreversible mental retardation and cognitive damage

Front 59

lead poisoning diagnosis

Back 59

best test is blood lead levels (<10ug/dL is normal)
lead lines at metaphyseal plate of long bones in children
anemia
azotemia

Front 60

lead poisoning treatment

Back 60

removal of source
chelators (EDTA, dimercaprol, penicillamine or succimer)
acute poisoning: charcoal + urination

Front 61

mercury poisoning

Back 61

interstitial pneumonitis from inhalation
irreversible neurologic symptoms (tremors, excitability, memory loss, delirium, insomnia)
GI symptoms from ingestion
treat with succimer or dimercarprol

Front 62

salicylates intoxication presentation

Back 62

tinnitus
nausea, vomitting, gastritis
hyperventilation, noncardiogenic pulmonary edema
hyperthermia, CNS toxicity
lactic metabolic acidosis with increased anion gap

Front 63

salicylates intoxication diagnosis

Back 63

most specific test is aspirin level
suggestive is elevated anion gap metabolic acidosis but blood may have ↑pH, ↓pH or normal
chest x-ray may be normal or pulmonary edema

Front 64

salicylates intoxication management

Back 64

if within 1 hour of ingestion, gastric decontamination + charcoal
mainstay of therapy is alkalinization of urine with aggressive fluid resuscitation
dialysis is sometimes used

Front 65

tricyclic antidepressant intoxication presentation

Back 65

anticholinergic (dry mouth, tachycardia, dilated pupils, flushed skin)
cardiac (wide QRS, ventricular tachycardia)
CNS (altered mental status, seizures)

Front 66

tricyclic antidepressant intoxication diagnosis

Back 66

serum drug levels is most specific but EKG is more important to do first

Front 67

tricyclic antidepressant intoxication management

Back 67

within hours --> charcoal
bicarbonate if cardiac toxicity
don't use flumazenil to reverse concomitant benzodiazepine overdose because it leads to seizures

Front 68

head trauma presentation

Back 68

headache, amnesia, loss of consciousness
focal findings are most common with epidural hematomas, then subdural hematomas and contusion

Front 69

head trauma diagnosis

Back 69

CT scan always
hemorrahge is visible immediately
subdural hematoma is crescent-shaped
epidural hematoma is lens-shaped
if focal findings consistent with radiculopathy or spinal tenderness --> cervical spine x-ray
concussion diagnosis is loss of consiousness + normal head CT

Front 70

head trauma treatment

Back 70

if intracrannial hemorrhage --> hyperventilation to a PCO2 of 30-35
osmotic diuretics and elevation of head of the bed
maintain cerebral perfusion by keeping blood pressure 110-160mmHg

Front 71

subarachnoid hemorrhage presentation

Back 71

acute --> sudden headache, loss of consiousness (50%), focal neurologic symptoms (30%)
long-term --> focal deficits, seizures, rebleeding, hydrocephalus, stroke

Front 72

subarachnoid hemorrhage diagnosis

Back 72

intial best test is CT scan which has 90-95% sensitivity within first 24 hours
if CT is normal and SAH is still suspect --> lumbar puncture for absence of red cells
angiography to determine site for surgery
inverted or enlarged T-waves on ECG are not alarming

Front 73

subarachnoid hemorrhage management

Back 73

maintain blood pressur at 110-160mmHg
nimodipine to prevent spasm and stroke
angiography to determine site of bleeding for surgical correction
shunt if hydrocephalus is present

Front 74

skin burns classification

Back 74

first-degree --> skin is intact
second-degree --> blister formation
third-degree --> destruction of skin appendages and pain receptors which result in relative lack of pain

Front 75

burn presentation

Back 75

altered mental status, dyspnea, headache and chest pain suggest carbon monoxide poisoning
stridor, hoarseness and dyspnea suggest laryngeal edema
soot in nose and mouth suggests impending airway compromise

Front 76

rule of nines for burns

Back 76

arms and head are 9% each
chest, back and legs are 18% each
patchy burns estimated with width of hand which is 1%
watch out for circumferential burns which compromise circulation

Front 77

diagnosis work-up of burns

Back 77

aside from actual burn, determine carboxyhemoglobin levels in severe burns
chest x-ray and/or bronchoscopy to determine respiratory injury extent

Front 78

definition of severe burns

Back 78

combined second and third-degree burns >20% in adults or >10% in old or young
OR third-degree burns >5% of body surface

Front 79

burn injury management

Back 79

if signs of respiratory injury --> intubation is initial step
if carboxyhemoglobin is elevated --> 100% O2
Ringer lactate fluid rescucitation using Parkland formula
H2 blocker prophylaxis, topical silver sulfadiazine to prevent infections
grafts as needed

Front 80

Parkland formula

Back 80

4ml of ringer lactate for each % BSA burned per Kg; give 1/2 in first 8 hours, 1/4 in second 8 hours, 1/4 in third

Front 81

heat stroke

Back 81

lost ability to romeve heat from body
excessive body temperature elevation
confusion, disorientation, nausea, blurred vision, seizures
hemoconcentration, ↑BUN/creatinine, rhabdomyolysis, anuria, DIC, lactic acidosis
place body in cool temperature, water and fan + IV fluid replacement

Front 82

malignant hyperthermia

Back 82

idiopathic reaction to any anesthetic specially halothane and succinylcholine
rhabdomyolysis and hyperthermia
treat with dantrolene

Front 83

neuroleptic malignant syndrome

Back 83

reaction to phenothiazines, chlorpromazine, haloperidol
muscular rigidity, hyperthermia, ↑CPK, encephalopathy, rhabdomyolysis
treat by removing agent + bromocriptine or dantrolene

Front 84

hypothermia

Back 84

core body temperature <35C
lethargy, confusion, weakness, arrhythmias with J-wave elevation (may mimic ST elevation)
treat with warm bed, bath or blankets
rescucitation efforts from pulselessness can go on beyond 10 minutes until temperature >35C

Front 85

nonionizing radiation

Back 85

infrared, ultraviolet and microwave; present primarily as burns

Front 86

ionizing radiation

Back 86

bone marrow depression with infections and bleeding
permanent sterility in males around 4-5Gy
nausea and vomitting 100% at 3Gy
supportive therapy with antiemetics, transfusions, colony-stimulating factors, antibiotics as needed

Front 87

electrocution presentation

Back 87

local 1st, 2nd and 3rd degree burns
ventricular fibrillation (AC current)
aystole (DC current, lightning)
respiratory arrest (injury to medulla or respiratory muscle paralysis)
neurologic damage
loss of consiousness and amnesia in 75% of lightning cases
renal failure from dehydration and rhabdomyolysis
cataracts in 5-30%

Front 88

electrocution treatment

Back 88

cardiopulmonary resuscitation, fluid replacement, local wound care

Front 89

types of drowinig

Back 89

dry drowning from laryngospasm, fresh water drowning, sea water drowning

Front 90

fresh water drowning

Back 90

hypotonic water alters surfactanct and causes collapse
water is absorbed and results in hypervolemia, hemodilution and hemolysis
lungs have little water

Front 91

sea water drowning

Back 91

hypertonic water draws fluid into lungs resulting in pulmonary edema, systemic hypovolemia, hemoconcentration

Front 92

near drowning presentation

Back 92

coma
agitation
cyanosis
coughing
sings of pulmonary edema (tachypnea, tachycardia, rales)

Front 93

near drowning lab exams

Back 93

arterial blood gases show hypoxia and hypercabia and metabolic acidosis

Front 94

drowning management

Back 94

removal from water
ABCs (first step)
endotracheal intubation
O2
positive pressure mechanical ventilation (most effective)

Front 95

drowning ineffective treatments

Back 95

abdominal thrusts, antibiotics, steroids

Front 96

anaphylaxis presentation

Back 96

hives rash (urticaria), angioedema and swelling, dyspnea, stridor, tachycardia, hypotension, hemodynamic collapse

Front 97

anaphylaxis management

Back 97

antihistamine diphenhydramine
if hemodynamic instability --> epinephrine, IV fluids, antihistamines and steroids

Front 98

cat and dog bites

Back 98

treat with exploration, debridement, irrigation, proper wound care
prohylactic antibiotic of choice is amoxicillin/clavulanate