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207 Cards in this Set

  • Front
  • Back
What is EMTALA?
The initial intent of EMTALA was to address the allegation that some hospitals were transferring, discharging, or refusing to treat patients who did not have insurance.
What is by far the most commonly abused opiate?
Heroin
Name the various forms of opiates:
Heroin, methadone, morphine, codeine, oxycodone, fentanyl (China white), and black tar (a potent form of heroin)
When is an alcoholic most likely to develop delirium tremens?
Often occurs 3-5 days after the last drink

DT is characterized by disorientation, fever, and visual hallucinations.
Signs of opiate withdrawal:
Strong craving for the drug, yawning, tears, diarrhea, abdominal cramping, piloerection, and rhinorrhea.
What airway securing maneuver should be used in a patient with a cervical spine injury?
Jaw Thrust
What is asystole?
Cardiac standstill with no cardiac output and no ventricular depolarization; it eventually occurs in all dying patients.
Name conditions that can cause asystole:
MI complicated by VF or VT that deteriorates to asystole

Near drowning

Suffocation

Hyperkalemia

Hypothermia

Sedative-hypnotic overdoses (secondary to respiratory depression)

Work-up of asystole:

ABG, potassium level
Endotracheal intubation during CPR
Central venous access or interosseous access
ACLS drug (epi and atropine)

What are the 3 drugs approved by the AHA for the treatment of asystole in adults?
Epinephrine, vasopressin, and atropine
The goal in using these agents is to enhance sinoatrial activity and to improve conduction through the SA or AV node by reducing vagal tone via muscarinic receptor blockade.
Anticholinergic drugs
Parasympatholytic agent used to eliminate vagal influence on SA and AV nodes. Not effective for infranodal third-degree heart block.
Atropine
Considered the single most useful drug in cardiac arrest:
Epineprine

Used to increase coronary and cerebral blood flow during CPR.

May enhance automaticity during asystole.

Can be used for bradycardia in adult and pediatric patients.
Has vasopressor and ADH activity.

Increases water resorption at distal renal tubular epithelium (ADH effect) and promotes smooth muscle contraction throughout vascular bed via stimulation of V1 receptors, thus the vasopressor effect.
Vasopressin
TRUE or FALSE: There is no benefit to defibrillation or pacing in asystolic arrest
TRUE
What is the management for asystole?
ACLS drugs and CPR
During CPR, what is the ratio of compressions to breaths that should be given?
30 compressions followed by 2 breaths;
During CPR (ACLS guidelines), how may chest compressions should be delivered each minutue?
100
When should CPR be stopped on a patient?
Time down > 20 minutes

3 Rounds of epinephrine given

3 Rounds of atropine given

Signs of rigor
Name some clinical signs/sx's of acute upper airway obstruction
Stridor
Hot Potato or muffled voice
Drooling
Use of accessory muscles
Retractions
Hypoxia (late finding)
Agitation/Anxiety/AMS
DDX of acute upper airway obstruction
Angioedema
Anaphylaxis
Foreign Body
Trauma
Inhalation/Ingestion injury
Retropharyngeal abscess
Epiglottitis
Peritonsillar Abscess
Ludwig's Angina
What deficiency is assoc'd with the hereditary form of angioedema?
C1 inhibitor deficiency
What is the tx for the hereditary form of angioedema?
Give C1 inhibitor concentrate or FFP
Treatment of non-hereditary angioedema
Tx is similar to that for allergic reactions:

-H1 (Benadryl) or H2 blockers
-SubQ epinephrine
-Removal of the triggering agent
TRUE or FALSE:

Most patients w/ angioedema will require intubation.
FALSE!
What is the most common age for young children to ingest foreign bodies?
6 months - 4 years old
What is the GOLD STANDARD for the diagnosis/treatment of foreign object ingestion in a small child?
Bronchoscopy
What is a complication of foreign body aspiration in small children seen on CXR?
Hyperinflation of one lung -

If the object lodges in the mainstream bronchus, it can create a ball-valve --> resulting in hyperinflation of one lung
The cornerstone of acute asthma management
Beta-agonists
A patient arrives to the ER complaining of SUDDEN ONSET dyspnea. What is on your differential?
Pulmonary embolus
Pneumothorax
TRUE or FALSE:

An acute MI can present with SOB without chest pain.
TRUE

This is common in elderly and diabetic patients. You can still have a heart attack without experiencing chest pain.
Name the likely condition based on the presenting sx:

1. Dyspnea on exertion

2. Orthopnea/PND
1. CHF, COPD

2. CHF
Other than asthma, what other conditions can present with wheezing on lung exam?
Foreign body

Pulmonary edema (cardiac wheezing)

Pulmonary infection

PE

Anaphylaxis
TRUE or FALSE:

A CXR is always indicated in pts with asthma exacerbations.
FALSE

Only get a CXR if you suspect a complication(s) during this exacerbation or if you suspect an alternative dx other than asthma
What labs/studies/imaging should you order in a pt presenting with dyspnea?
EKG (acute MI)

CBC (anemia)

CMP/BMP

Cardiac markers (MI)

BNP (CHF, pulmonary edema)

ABG (metabolic abnormalities) - but not generally necessary
The 3 Hallmarks of Asthma
1. Airway constriction

2. Airway inflammation

3. Increased secretions
Treatment of Asthma exacerbation
1. Beta-agonists (albuterol 5 mg nebs x3 or continuous neb) - to treat bronchoconstriction

2. Corticosteroids (systemic, pednisone 40-60mg/day) to treat airway inflammation

3. Ipratroprium (atrovent) - to decrease airway secretions and smooth muscle tone
Are leukotrienes effective in the treatment of acute asthma exacrerbations or in chronic asthma?
Chronic asthma
TRUE or FALSE:

Antibiotics are useful in the treatment of acute asthma exacerbations.
FALSE!
If an asthma patient should have to be intubated, what is the induction agent of choice?
Ketamine
TRUE or FALSE:

Intubating an asthma patient helps to decrease mortality by 50%.
FALSE!!!! Intubating asthma pts INCREASES mortality by 50%!
Name some risk factors for severe exacerbation/death from asthma?
Prior intubation

Prior ICU admission

Multiple hospital/ER visits for asthma

Current use of systemic steroids

Frequent use of rescue inhalders (MDI)

Comorbidity
Treatment of CHF exacerbation:
Nitrates - to reduce preload

Furosemide - for diuresis

Morphine - reduce preload

ACE-I - Captopril

Nesiritide (recombinant B-type natriuretic peptide) - causes arterial & venous vasodilation & natriuresis

Dialysis (in renal failure pts)

CPAP/BiPAP
TRUE or FALSE:

In a pt with CHF exacerbation and elevated blood pressure, the pt should receive BP meds to decrease BP
FALSE b/c most of the other therapies to treat CHF will subsequently reduce bp.
TRUE or FALSE:

Anorexia will always be present in pts who present with appendicitis.
FALSE.

1/3 of all pts presenting with appendicitis do no report loss of appetite.
What is obstipation?
The inability to pass stool or flatus for more than 8 hours despite a perceived need.

This is usually indicative of intestinal obstruction.
What are the 2 most commonly missed surgical causes of abdominal pain?
1. Appendicitis
2. Intestinal obstruction
Name some common diseases that can mimic an acute abdomen:
Pneumonia
DKA
Food Poisioning
PID
TRUE of FALSE:

Plain radiographs (xrays) are always indicated in pts who present with abdm pain.
FALSE.

Abdominal xrays produce the highest yield in pts with ileus, obstruction, free air under the diaphragm due to perforated viscus, and intussusception.
What is the most common diagnosis in a pt who presents to the ER with abdominal pain?
Abdominal pain of UNKNOWN cause!
A pt presents with SUDDEN onset of abdm pain. What are the likely causes?
Perforated viscus

Vascular catastrophe

Uteral stone

Ruptured ectopic pregnancy

Ovarian torsion

Ruptured ovarian cyst
Common indications for obtaining plain radiographs of the abdomen in a pt with abdm pain
Foreign body

Intestinal obstruction
What test is required of EVERY woman of reproductive age who comes to the ER c/o abdominal pain?
Urine pregnancy test (B-hCG)
What is the risk of developing cancer secondary to being exposed to radiation from a CT scan in the following women:

1. Age 70
2. Age 30
3. Age 15
1. 1 in 3,330 CT scans will cause cancer

2. 1 in 1,000 CT's

3. 1 in 500 CT's

(The younger the pt who is exposed to radiation, the higher the risk of developing cancer)
What labs tests should you order in pts presenting with abdominal pain?
CBC
CMP/BMP
Lipase
Hepatic function
What 2 symptoms are most likely to be seen in a pt with gastroenteritis?
Nausea AND vomiting
Name a metabolic etiology that can cause abdominal pain
DKA

Uremia

Hypercalcemia

Porphyria
Name a toxicology etiology that can cause abdominal pain
Lead or iron poisoning

Black widow spider bite
Name an ENT etiology that can cause abdominal pain
Streptococcal pharyngitis
Name a genitourinary etiology that can cause abdominal pain
Testicular torsion, ovarian torsion
Name a cardiovascular etiology that can cause abdominal pain
Acute MI
Name a pulmonary etiology that can cause abdominal pain
Pneumonia (especially basilar pna's)
Common causes of abdominal pain in the elderly
AAA

Diverticulitis

Ischemic Bowel

Biliary tract disease
Name the condition:

Abdominal pain out of proportion to physical exam
Mesenteric Ischemia
TRUE or FALSE:

Research studies have shown that giving pain medication to pts w/ abdominal pain does not alter the diagnostic accuracy of tests/studies.
TRUE
TRUE or FALSE:

Pts seen in the ER with c/o abdm pain who are discharged should not be sent home on narcotics for pain control.
TRUE
Common causes of abdominal pain in the elderly
AAA

Diverticulitis

Ischemic Bowel

Biliary tract disease
Name the condition:

Abdominal pain out of proportion to physical exam
Mesenteric Ischemia
TRUE or FALSE:

Research studies have shown that giving pain medication to pts w/ abdominal pain does not alter the diagnostic accuracy of tests/studies.
TRUE
TRUE or FALSE:

Pts seen in the ER with c/o abdm pain who are discharged should not be sent home on narcotics for pain control.
TRUE
Minimum diagnostic criteria for Pelvic Inflammatory Disease
Cervical motion tenderness

Bilateral adnexal tenderness

Lower abdominal tenderness
Are most cases of PID mono- or polymicrobial?
Polymicrobial (N. Gonorrhea, Chlamydia, E.Coli, Peptostreptococcus, Gardinerlla)
When should a woman with PID be admitted to the hospital for further treatment?
-If the pt is pregnant
-Pt appears toxic
-Dx is uncertain
Suspected pelvic abscess, IUD, or recent instumentation
-Immunocompromised (HIV, chemo, etc)
-Pt is not compliant to do further f/u as outpatient
Outpatient tx of PID
Ceftriaxone (Rocefin) 250 mg IM x1 dose

plus. . .

Doxycycline 100 mg PO BID x14 days

OR . . .
Levofloxacin 500 mg PO BID x 14 days, plus Clindamycin or Metronidazole to improve anerobic coverage
Management of Eclampsia/Severe Preeclampsia:
Delivery of the baby (definitive tx)
Magnesium: 2-6 gm IV bolus, then 2 gm
ABC's
Fetal Monitor
OB/Gyn consultation
If a woman who has eclampsia continues to have elevated blood pressure (especially if the DBP remains > 110 mmHg), what other drugs can you give to lower bp?
Hydralazine
Labetolol
In a woman whom you suspect has PID, you are going to obtain a UA to r/o UTI. How should you obtain the urine sample?
You should get a in/out catheter-obtained sample.

Clean catch urine samples are not acceptable because the urine can easily be contaminated from vaginal secretions
In a patient who has overdosed on Tylenol, when should you check a Tylenol level?
4 hours after the last ingestion
What labs/studies should you check in a pt who has overdosed on prescription medication?
Check a Tylenol level 4 hours after the last ingestion (normal is < 30 mcg/mL)

Check a salicylate (aspirin) level

Check a total CK level (to check for rhabdomyolyisis)

Check a EKG (arrhythmias, QT prolongation, etc.)

Urine drug/tox screen

Call the Poison Center
What are the top 3 complications from overdosing on prescription medications that lead to the most morbidity and mortality?
Aspiration pneumonia

Rhabdomyolysis

Anoxia
What lab will help you identify rhabdomyolysis in a pt with drug overdose?
Presence of RBC's on urine dipstick, despite not seeing microscopic blood
First line agents in the treatment of toxin-induced seizures
Benzodiazepines

Barbituates
What is the antidote for the following drug overdose:

Tylenol (Acetaminophen)
N-acetylcystiene
What is the antidote for the following drug overdose:

Beta blockers
Glucagon
What is the antidote for the following drug overdose:

Cyanide
Amyl nitrate, sodium nitrite, sodium thiosulfate
What is the antidote for the following drug overdose:

Ethylene glycol
Ethanol, fomepizole
What is the antidote for the following drug overdose:

Lead
EDTA
What is the antidote for the following drug overdose:

Opioids
Naloxone (Narcan)
What is the antidote for the following drug overdose:

ASA
sodium bicarbonate
What is the antidote for the following drug overdose:

organophosphates
atropine, pralidoxime
What is the minimum dose of acetaminophen that can cause toxic liver injury?
7.5 gm (150 mg/kg body wt) in adults

200 mg/kg in children
During what phase of acetaminophen toxicity does the pt experience RUQ pain and a rise in hepatic enzymes?
Phase II (24-72 hrs post ingestion)
During what phase of acetaminophen toxicity is a pt most likely to die from their overdose?
Phase III (72-96 hrs post ingestion)

Hepatic necrosis, encephalopathy, and jaunduce
How does N-acteylcystiene work in the detox of acetaminophen overdose?
NAC is a precursor of glutathione and as such, increases glutathione conjugation of NAPQI.
What area of the liver is the most susceptible to injury from acetaminophen overdose and why?
Centrilobular - b/c this area contains the most p450 but the least gluathione
What toxins can be removed via dialysis?
Alcohols
Lithium
Theophylline
Salicylates (aspirin)
What are the Centor criteria for dx of Group A Strep pharyngitis (GAS)?
1. Fever
2. NO cough!
3. Tonsillar exudates
4. Anterior cervical lymphadenopathy

pts scoring 0-1 unlikely to have GAS infection, and pts w/ a score of 4 are more likely to have GAS
Most cases of pharyngitis are caused by viruses. What are the most common viral etiologies?
Adenovirus (commonly assoc'd with conjunctivitis)

CMV

EBV

Cocksackie virus
You have a pt who presents with pharyngitis and is now developing difficulty breathing. You think his airway might become compromised. After assessing ABC's, you decide to do further testing with imaging. What imaging should you order?
Lateral neck film should be taken in patients with suspected epiglottitis or airway compromise.
What is the main reason abx are given to treat GAS pharyngitis?
The main reason they are given is for prevention of acute rheumatic fever.

Abx have been shown to only shorten the duration of illness by 1 day!
A 23 yo old male presents to the ER with c/o breathlessness, wheezing, chest tightness, and coughing that began after exposure to some household cats (which he is severely allergic to). What is the most likely dx?
Acute asthma exacerbation
DDX of wheezing
Asthma
COPD
Foreign body aspiration
CHF
Anaphylaxis
Epiglottitis
Reactive airway dz
Viral respiratory infection
Vocal cord dysfunction
What are the important questions to ask a pt who presents with asthma exacerbation?
-Previous hospitalizations for asthma
-Previous need for intubation
-Increase in the number of ER visits for asthma
-Exposure to triggers (allergens, cold air, exercise)
-Increased use of inhaler
At what temperature is fever defined?
38.0 C = 100.4 F
Name the gold standard method for taking a child's temperature
Rectal temperature
Name some serious bacterial infections (SBI) commonly seen in infants/children
Meningitis
Septicemia
Bone and Joint infections
UTI
Pneumonia
Bacterial gastroenteritis
Infants 0 - 28 days with a fever w/o a source require what type of work up?
Full sepsis workup
What tests comprise a full sepsis workup (done on febrile children age 0-28 days)?
CBC
Blood Cx
U/A
Urine cx
LP
Empiric Abx
Admit to hospital

Also get CXR if respiratory sx are present, and stool analysis for WBC if diarrhea is present
Name some common causes of pediatric fever due to viruses:
Varicella

Measles

Mumps

Adenovirus

Coxsackievirus (Herpangina, Hand-Foot-Mouth dz)

Croup

Influenzae

Brochiolitis
Name some common causes of pediatric fever due to bacterial infections:
Pneumonia
Meningitis
Septic Arthritis
Osteomyelitis
Lymphadenitis
Cellulitis
Bacterial enteritis
What criteria are used to risk stratify low-risk pediatric patients who present with fever?
Rochester criteria
Philadelphia criteria
What are the Rochester Criteria for Pediatric pts with fever?
Clinical Criteria:
--Term infant, previously healthy, uncomplicated nursery stay
--Non-toxic appearing
--No signs of bacteria infection on exam

Lab Criteria:
--WBC count 5-15,000/mm3, <1,500 bands/mm3, band:neutrophil ratio <0.2
--Urine showing <5 WBC/hpf, neg Gram stain, or neg leukocyte esterase and nitrites
--If diarrhea +, <5 WBC/hpf in stool
--CSF <8 WBC/mm3, and neg Gram stain
What antibiotic treatment option should you start in a pediatric patient who meets all of the Rochester criteria?
Outpatient management with Ceftriaxone 50 mg/kg IV/IM and have the pt reevaluated in 24 hrs
What are the top 3 causes of occult bacteremia in children ages 3-36 months?
#1 Streptococcus pneumoniae (85% of occult bacteremia in this age group)

#2 Haemophilus influenzae

#3 N. meningitidis
You are evaluating a 12 month old child who is well-appearing and has a fever without a source. Should you obtain a CBC and blood cultures?
No! It is not necessary in this case.
You are evaluating a child who is 24 months old with fever. They appear toxic. What should your management of this pt be?

Would your management change if the same pt was non-toxic?
Admit the pt, perform a full workup!

If the pt is non-toxic, you should only begin a thorough workup when their fever is 39 C (102.2 F)
TRUE or FALSE:

UTI's are almost always occult in children < 2 yrs of age.
TRUE
You have a child who is 18 months old who you suspect has a UTI. How should you obtain a urine sample for testing?
Get a cath specimen (suprapubic or trans-urethral) b/c getting a clean catch sample is impossible!

Always get a urine cx if you are able to get a urine sample.
TRUE or FALSE:

The majority of pneumonias in infants and young children are bacterial in origin.
FALSE!

Most etiologies are viral (RSV, parainfluenza, Chlamydia)

But, children with high fever and leukocytosis are more likely to have a occult bacterial pneumonia
When should a pt receive a tetanus shot?
If it has been more than 5 years since their last tetanus shot.
What patients should receive tetanus immune globulin (TIG) as opposed to tetanus toxoid?
Pts who have incomplete tetanus immunization (< 3 injections)
Risk factors for venous thomboembolism
Previous hx of DVT
Malignancy
Advanced age (>60 yrs)
Recent operation during past 4 weeks
Bed rest > 3 days
Immobilzation
What is the most frequent EKG finding in persons with suspected pulmonary embolus?
Sinus tachycardia
What is the importance of getting a CXR in pts who are suspected to have an pulmonary embolus?
To rule out other causes of dyspnea such as pneumonia, pneumothorax, CHF
If you have a patient with a DVT who cannot receive anticoagulation therapy, what other option do you have to prevent blood clots from reaching the lungs?
IVC filter
Name this condition:

Sudden onset of cough and dyspnea w/ exertion, blood-tinged sputum, tachycardia, rales/crackles, and low-grade fever.
Pulmonary embolus
In the diagnosis of PE, does the d-dimer test have greater positive predictive value or negative predictive value?
Negative predictive value (meaning, if the d-dimer level is low/normal in a person suspected to have PE,it is not likely they have a PE)
Treatment for pulmonary embolism
Start with IV heparin followed by bridging to warfarin
What is syncope?
A sudden and brief LOC with loss of postural tone (arrhythmic, no movement!) with spontaneous AND complete recovery (unlike seizures where there is a post-ictal state)

The pt must wake up WITHOUT any intervention.
Name some conditions that are often mistaken for syncope:
AMS
Intoxication (alcohol, drugs)
Stroke
Seizure
Common prodrome of syncope
Nausea
Diaphoresis
Lightheadedness
What are the two most dangerous accompanying conditions with syncope that you should be worried about?
Syncope with chest pain (cardiac) or with dyspnea (pulmonary)
TRUE or FALSE: Most pts with syncope do not require a head CT
TRUE

Get a head CT if the pt has syncope with other neurological symptoms
Most common cause of syncope
Neurocardiogenic
What are the 2 causes of isolated syncope?
Cardiac and neurocardiogenic
What are some distinguishing factors in identifying cardiac vs neurocardiogenic forms of syncope
Cardiac
Risk factors for bad outcomes at 1 year post-syncopal episode in pts who presented to the ED with syncope
Abnormal EKG
Age > 45
Hx of CHF
Hx of ventricular arrhythmia
What type of hallucinations are assoc'd with delerium? With psychosis?
Delerium - visual

Psychosis - auditory
What are the components of a Coma cocktail
Glucose - start D50 fluids

Naloxone (Narcan) - pts with narcotic overdose

Thiamine - alcoholics

*This cocktail is not often used
TRUE or FALSE:

Polypharmacy is not a common cause of altered mental status.
FALSE!
A unilateral, dilated pupil in a comatose pt is concerning for what type of brain abnormality?
Uncal herniation
A bilateral, fixed, and dilated pupils in a comatose pt is concerning for what type of brain abnormality?
Anoxic brain injury
Non-reactive pinpoint pupils in a comatose pt even after administration of Narcan is concerning for what type of brain abnormality?
Pontine insult
You are evaluating a pt in the ED who just suffered a seizure. What oral physical exam findings are consistent with a dx of seizure?
Bilateral lateral tongue lacerations (from biting down on the tongue during the seizure)
Diagnostic workup for acute stroke
EKG - to establish the rhythm

Glucose - to assess for hypoglycemia

Head CT - to determine the presence of intracranial hemorrhage, old CVA, or acute changes assoc'd w/ stoke
Acute therapy for stroke
IV TPA
Intraarterial TPA
Tight glucose control
Decompressive Hemicraniotomy
What are the inclusion criteria for administering thrombolytics in pts with acute stoke?
Age >18

Clinical dx of acute ishemic strokestroke based on measureable neurological deficits

Symptom onset is less than 180 minutes from the time of administration of thrombolytics
Absolute contraindications for the administration of thrombolytics in pts with acute stroke
--Minor or rapidly improving stroke symptoms

--SBP > 180 or DBP > 110 mmHg

--Any hx of prior ICH

--Head CT that shows intracranial bleeding or areas of hypodensity (suggestive of hemorrhage)
What preventative therapy should be started in pts who have previously suffered a stroke?
ASA

Platelet aggregation inhibitors (Plavix, Ticlid --> used in pts who cannot take ASA or who have had a stroke while on ASA)
Conditions that can mimic acute stroke
Hypoglycemia
Todd's paralysis
Complex Migraines
Conversion d/o
Treatment of active seizure
Benzodiazepines (lorazepam, diazepam) --> when doses of benzos are maxed out, use fosphenytoin or phenobarbital

Oxygen via non-rebreather mask

Put bedrails up to protect the patient
Work up of new-onset seizure
Electrolytes
Non-contrast head CT
Outpatient EEG
TRUE or FALSE:

A pt who has suffered a first time seizure should be discharged on anti-epileptic drugs
FALSE

Only start anti-epileptic drugs when the pt has had multiple seizures
TRUE or FALSE:

First time seizures provoked by alcohol withdrawal, sleep deprivation, metabolic or drug related causes should be treated with anti-epileptic drugs.
FALSE
First line drug therapy for treatment of active seizure that had lasted longer than 2 minutes
Benzodiazepines via IV route --> lorazepam (Ativan) is usually the first choice
Most COMMON cause of first trimester bleeding

Most SERIOUS cause of first trimester bleeding
Threatened abortion

Ruptured ectopic abortion
Name this type of abortion:

Closed internal cervical os with vaginal bleeding in the 1st trimester
Threatened abortion
Name this type of abortion:

Internal cervical os is open on speculum examination
Inevitable abortion
Name this type of abortion:

Products of conception present in the cervical os or the vaginal canal
Incomplete abortion
Name this type of abortion:

Conceptus dies, but is not passed with retention of the products of conception in utero
Missed abortion
The current standard medical treatment of unruptured ectopic pregnancy is?
Methotrexate (MTX) therapy
What are the most likely etiologies for a patient who presents to the ED "found down"?
T - trauma, temp
I - infection
P - psychiatric
S - space occupying lesion, stroke, SAH, shock

A - Alcohol
E - Endocrine, electrolytes, epilepsy
I - Insulin, diabetes
O - opiates, oxygen
U - uremia, hypertensive encephalopathy
What is the most important question to ask any female of reproductive age who presents to the ED with c/o sharp RLQ pain?
Is she pregnant or not!!!
A positive urine pregnancy test corresponds to what serum concentration of bHCG?
10
What should initial TREATMENT be in a female pt of child bearing age who presents to the ED with c/o RLQ pain and nausea.
Hydration with IV fluids

Anti-emetics (Zofran, Phenergan)

Pain medication
You have treated a female pt of child bearing age who presented with crampy lower abdm pain and nausea. You have determined that she is well enough to be discharged. When (time frame) should the pt return to the ED if her sx's worsen/don't improve?
Return if sx's do not improve within 8-12 hours
Name the most common causes of bleeding in a NON-PREGNANT woman?
Trauma

Hormonal irregularities (DUB)

Fibroids

Depo-provera

If post-menopausal, always think endometrial cancer until proven otherwise
Name the most common causes of bleeding in a PREGNANT woman?
Ectopic pregnancy

Abortion (Threatened, Spontaneous)

Molar pregnancy (if uterus is large for dates)
At what beta hCG level should an intrauterine pregnancy be visible on transvaginal ultrasound?
> 1500
Early in pregnancy, how often should the beta hCG level double
Q48-72 hours

If levels are lower, this indicates an abnormal IUP (but cannot distinguish ectopic from failing IUP)
TRUE or FALSE:

In early pregnancy, a beta hCG level that is below normal (for expected gestational age) can be used to distinguish an ectopic pregnancy from a failing IUP.
FALSE!
TRUE or FALSE:

All pregnant bleeding women and those pregnant women who are involved in a trauma should receive a Rhogam work up.
TRUE

In early pregnancy, give 50 mcg IM
After the 1st trimester, give 300 mg IM
What is a spontaneous abortion?
Termination of pregnancy before 20 week gestation or before the fetus could reach 500 gm.
TRUE of FALSE:

A woman with a complete abortion will still have vaginal bleeding.
FALSE! All bleeding has stopped, cervical os is closed, products of conception have been expelled.
In comparison of the presentation of ectopic pregnancy vs. spontaneous abortion, when does crampy abdominal pain usually occur?
EP - pain is usually the first and most prominent symptom!

Spontaneous AB - pain usually occurs AFTER onset of bleeding
Risk factors for developing an ectopic pregnancy include:
PID

IUD

Previous ectopic

Tubal ligation

Infertility treatment
Which patient is more likely to be having an ectopic pregnancy?

Pt A: Crampy, unilateral lower quadrant pain that occurred before the onset of vag bleeding

Pt B: Crampy abdm pain that began after onset of vag bleeding, pt has non-tender adnexa on physical exam
Patient A
Management of ectopic pregnancy should include what?
Hydrate with IV fluids

Pain control

OB consult

Methotrexate if early in pregnancy and pt is minimally symptomatic

Follow serial hCG's if dx is in question
Top 3 clinical signs of preeclampsia
Hypertention > 140/90 or > 30/15 from baseline

Proteinuria

Edema (usualy face and hands)
Name the 2 classes of drugs that you should use to perform rapid sequence intubation in the EG
Use a paralytic (succinylcholine) and a sedative (etomidate)
How long should you assess for breathing in a pt whom you have found down in the field before administering 2 rescue breaths?
Assess breathing for 10 seconds

An occasional gasp of air does not count!
During cardiopulmonary resuscitation, how many breaths should you deliver to the pt per minute?
8-10 breaths per minute
What doses of epinephrine and atopine should be used in the treatment of asystole?
Epi 1 mg IV push

Atropine 1 mg IV push
In a pediatric patient who has gone into cardiac arrest, if you cannot establish IV access, what is the next best option to obtain vascular access?
Intraosseous line
What distinguishes anaphylaxis from an anaphylactoid reaction?
In anaphylaxis:
--prior exposure to the allergen is necessary.
--Histamine release mediated by IgE
--Can be triggered by a SMALL exposre

Anaphylactoid rxns:
--no prior exposure to the allergen is necessary
--Histamine is released directly (no IgE required)
--Large systemic exposure is required
TRUE or FALSE:

For treatment of MILD forms of anaphylaxis, IV epinephrine should be used/
FALSE

Use IM epineprine at 0.3-0.5 mg of 1:1000 dilution Q 3-5 minutes
What dilution of epinephinre should be used for SEVERE cases of anaphylaxis?
0.1 mg of 1:100,000 dilution epinephrine
Most causes of pulseless electrical activity are a result of what type of disorders?
Profound metabolic disorders
In patients presenting with cardiac chest pain, what is their goal pain rating on a pain scale? Why?
Only pts with cardiac pain should the goal be 0/10 because the presence of any chest pain indicates that myocardial damage is still occurring.
For patients with non-cardiac pain, what should be their goal for pain relief
?/10
0-3/10
What age child is old enough to begin using the visual analog pain scale (different smiley faces with pain expressions)
Age 6-7 yrs and up
What is the difference between pain relief and analgesia?
Analgesia is COMPLETE absence of pain

Pain management is the reduction of perceived pain, but the pt may still be able to experience/feel some degree of pain
The best route of pain medication delivery is what?
IV because IM injections cannot be titrated, painful injections, and has erratic absorption
TRUE or FALSE:

How a pt responds to pain medication always depends on their age, weight, and sex.
FALSE! Factors that affect how a pt responds to pain include:

--number of opioid receptors
--Pt's psychological state
--Pt's previous attitude/experience toward pain
--Extent of neurtotransmitter release
TRUE or FALSE:

All people have the same number of opioid pain receptors.
FALSE! We have different concentrations of mu, delta, kappa, and sigma opioid receptors.
Name the form of opioid receptor involved with increased respirations and mydriasis
Sigma
Name the form of opioid receptor involved with euphoria, urinary retention, dependence, tolerance, and bradycardia
Mu
Name the form of opioid receptor involved with diuresis
Kappa
What is the generic name for Dilaudid?

How many times stronger is it compared to morphine?
Hydromorphone

7.5 x as strong as morphine, but has a slower onset than morphine
What opioid is assoc'd with the highest incidence of hypotension?
Hydromorphone (dilaudid)

*Risk of hypotension is due to histamine release
What morphine analog is 100x stronger than morphine?

Is this drug assoc'd with hypotention? Why or why not?
Fentanyl

Not assoc'd with causing hypotension, therefore not assoc'd with a histamine release
The most constipating of all the opioids is. . .
Codiene
What is the generic name for Demerol?
Meperidine
What is the generic name for Darvocet?
Propoxyphene
What is the generic name for Toradol?
Ketorlac
10 mg of morphine = how many mg of dilaudid?
1 mg
10 mg of morphine = how many mg of dilaudid?
1 mg