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225 Cards in this Set
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Tx dystonic reaction
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diphenhydramine 50IM/IV or benztropine 2mg IV/po.
Can recur acutely. |
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Alcohol w/drawal sx
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6-8h after drinking, tachy, HTN, tremors, anxiety, agitation
Hallucinations 24h after drinking, auditory/visual/tactile Global confusion 1-3d after drinking |
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List lifethreatening causes of acute psychosis
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WHHHIMP: Wernicke's, hypoxia, hypoglycemia, HTN encephalopathy, ICH, meningitis/encephalitis, poisoning
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What are the clinical findings to suggest glomerulnephritis
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Oliguria, HTN, pulmonary edema, urine sediment w/ RBCs, WBCs, protein, and RBC casts.
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#1 cause of intrinsic renal failure
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ATN 90% from ischemic injury (#1) or nephrotoxic agent. Less frequent causes 10-20% (vasculitis, malignant HTN, acute GN, allergic interstitial nephritis)
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Name common nephrotoxins
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aminoglycosides, NSAID, contrast dye, myoglobin
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What is the eponym for idiopathic scrotal edema and how is it treated?
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Fournier's gangrene is polymicrobial inf of subQ characterized by widespread tissue necrosis. Tx broad ABx and immed surgical debridement.
vanco, metronidazole, zosyn |
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How does the pain from epididymitis differ from prostatitis
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Epididymitis: pain begins in scrotom/groin and radiates along spermatic cord. It intensifies rapidly, associated w/ dysuria, and is releaved w/ scrotal elevation (Prehn's sign)
Tx: <35 yo tx STDs (rocephin 125mg IM and azithro 1gm/doxy >35 yo cipro 500mg BID x14d or IV zosyn 3.375. If UTI/anal intercourse give cipro or IV zosyn. Tx partners. Urology referral. Prostatitis: c/o freq, dysuria, urgency, bladder outlet obstruction, and retention, may have low back pain, perineal pain, assoc w/ fever, chills, arthralgias, myalgias Tx: bactrim DS BID x10-28d or cipro 500mg BID x14-28d If <35yo tx gonorrhea and chlamydia. If toxin consider fluoroquinolones +3rd gen cephalosporin. If urinary retention consult urology for suprapubic cath. Tx partners. Urology referral. |
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How does treatment of epididymitis differ by age
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<35 yo tx STD w/ ceftriaxone 125mg IM and doxy po. >35 tx for E coli and Klebsiella with bactrim
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What are the common organisms of prostatitis
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E coli 80%, Klebsiella, Enterobacter, Proteus, Pseudomonas in 20%
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When are the 2 peaks of torsion
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1st year and puberty
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What's the definitive diagnostic test for torsion
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ER surgical exploration. Although radionuclide imaging and doppler may be helpful, they are time-consuming and accuracy is operator dependent. Warm ischemia time for testicular salvage may be <4h, once diagnosis entertained, immed urology consult and surgical exploration required.
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When is retrograde urethrogram necessary in the evaluation of a patient with a penile fx?
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A penile fx= rupture of corpus cavernosum w/ tearing of the tunica albuginea that results from blunt trauma to the erect penis. Urethral injury occurs in ~10% of pts w/ penile fx. Pts w/ hematuria, blood at urethral meatus, or inability to void need retrograde urethrogram to r/o urethral injury.
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Tx priapism
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Analgesia, sedation, hydration
Oral pseudoephedrine 30-60mgpo Phenylephrine 250-500mcg Q5min dirctly into corpora cavernosa (may substitute epinephrine 10-20mcg), ice packs, urology for aspiration of cavernous bodies |
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Describe acute glomerulonephritis
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hematuria
proteinuria oliguria anuria edema HTN HOPE HA |
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What is the proper position to transport prego trauma patient
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spinal backboard tilted 30degrees to L to prevent supine hypotension syndrome
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What's the clinical significance of fixed and dilated pupils in drowning victim
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Don't give up. 10-20% presented w/ coma and fixed and dilated pupils recover completely. Asx pts should observe 6hrs.
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What % of dog and cat bites are infected
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Dog 10%, pasteurella multocida
Cat 50%, pasteurella multicida |
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6 yo child presents w/ HA, fever, malaise, and tender regional lymphadenopathy about a week after a cat bite. A tender papule develops at the site. What is the dx?
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Cat-scratch disease. ~3d-6wk following ite/scratch and papule typically blisters and heals with eschar formation or transient macular or vesicular rash may develop.
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What are the indications for antivenin in black widow spider envenomation
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severe pain, symptomatic HTN, prego w/ moderate/severe envenomations.
Antivenin avoid in pts on BB b/c if anaphylaxis occurs it will be hard to treat |
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Pt brought to ED w/ h/o bite wound on mental ward. What bacterium most likely?
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Eikenella corrodens most common in hosp/institutionalized. Staph/strep most common overall.
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What is the frequency of eye injuries in lightning strike victims?
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1/2 structural eye lesions. Cataracts #1 and develop w/i days-yrs. Unreactive dilated pupils not equal to death b/c transient autonomic instability may occur
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What is #1 otologic injury in lightning strike?
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50% have TM rupture. Hemotympanum, basilar skull fx, and acoustic and vestibular deficits may also occur
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What is the #1 arrhythmia found in hypothermia
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afib.
Also PAT, prolonged intervals, decreased P wave amplitude, T wave changes, PVCs, humped ST segment adjacent to QRS (osbourne) |
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14 yo football player presents to ED w/ h/o lightheadedness, HA, N/V. Exam HR 110, RR22, BP 90/60, afebrile. Profuse sweating. What's dx?
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Heat exhaustion. Tx NS IVF.
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Tx heatstroke
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cool sponge, fan, ice packs groin and axilla
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Compare entrance and exit wounds of AC and DC
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AC: entrance and exit wounds same size
DC: small entrance and large exit NB: not all agree |
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Tx treatment options are available for pts who are bleeding and have liver disease
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PRBC
Vit K FFP Plt transfusion DDAVP |
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What options are for tx pts w/ RF and coagulopathy
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dialysis, optimize hct w/ recombinant human erythropoietin, transfuse with PRB, demopressin, conjugated estrogens, cryo and plts if life-threatening hemorrhage
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What 2 conditions assoc w/ most devastating form of DIC
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Neisseia meningitidis sepsis and acute myelogenous leukemia (promyelocytic M3 type)
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What are clinical complications of DIC
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bleed, thrombosis, purpura fulminans
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What 5 lab studies would be most helpful in estabishing dx of DIC
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Prothrombin prolonged, plt low, fibrinogen low, fibrin split products elevated, ddimer elevated
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What are the most common hemostatic abnormalities in pts infected with HIV
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thrombocytopenia and acquired circulating anticoagulants, ~prolongation of aPTT
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What is the pentad of TTP
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Fever, thrombocytopenia, neuro sx, renal insufficiency, MAHA
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What is the leading cuase of death in hemophilacs
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AIDS
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What types of clinical crisis are seen in patients with sickle cell disease
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Vasoocclusive (thrombotic)
Hematologic (sequestration, aplastic) Infectious |
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What is the most common type of sickle cell crisis
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vasoocclusive with avg of 4 attacks/y
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What % of patients with sickle cell disease have gallstones
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75% but only 10% symptomatic
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Which is the only type of vasoocclusive crisis that is painless
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CNS crisis. Most commonly kids are afflicted with cerebral infarction and cerebral hemorrhage develops in adults.
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What are the major causes of GIB in cancer patients
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Hemorrhagic gastritis and PUD
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What are the mainstays of therapy for a patient with sickle cell crisis
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hydration, d51/2ns, analgesia, oxygen (only if hypoxic, monitor cardiac (if CP/h/o heart disease)
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What is the single most useful test in ascertaining the presence of hemolysis and a nl marrow response
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reticulocyte count
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What is the most common clinical presentation of TTP
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Neuro symptoms: HA, confusion, CN palsies, coma, seizures
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What is the currently approved emergency replacement therapy in ED for massive hemorrhage
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type specific uncrossed blood available in 10-15min, type o neg
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What condition should be suspected in pt with multiple myeloma who presents to ED with paraparesis, paraplegia, and urinary incontinence
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acute spinal cord compression. Condition primarily occurs with multiple myeloma and lymphoma but also with carcinomas of lung, breast, prostate
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Lab abnormalities of DIC
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Inc PT, Inc FSP, Dec fibrinogen, Dec plts
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What is the appropriate tx for life-threatening hypercalcemia of 16mg/dL
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NS 5-10L/d, furosemide 80mg IV Q1-2h, watch for hypokalemia, consider glucocorticoids if obtunded/comatose, consider calcitonin and mithramycin.
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What blood product is given when coagulation abnormality unknown
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FFP
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Which agent can be used for treating mild hemophilia A and vWD type 1
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D-Amino-8. DDAVP (D-arginine vasopressin) induces a rapid rise in F8 levels.
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What is the minimal beta-hcg titre for an experience u/s person should be able to visualize a viable IUP
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Transvaginal >1500
Transabd >6500 |
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#1 cause of maternal mortality
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thromboembolism with risk inc throughout pregnancy with peaking at 5x nonpregnant controls during postpartum period
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Against how much fetomaternal hemorrhage does the standard 300microgram dose of RhoGAM protect
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~30ml of whole blood. Following trauma, FMH should always be considered and order a quantitative Kleihauer-Betke assay to determine amt of FMH and then calculate the appropriate RhoGAM dose.
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What is the #1 presentation of ectopic pregnancy
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Amenorrhea followed by pain
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How does a spontaneous abortion most commonly present
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Pain followed by bleeding
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What is the #1 finding on pelvic exam in a patient w/ ectopic pregnancy
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unilateral adnexal tenderness
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When can abd u/s find an intrauterine gestational sac
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Gestational sac 5th week
Fetal pole 6th week Embryonic mass w/ cardiac motion 7th week |
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What is most common cause of TSS
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S aureus
Others: Group A strep, pseudomonas aeruginosa, strep pneumonia |
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What criteria are necessary for the dx of TSS
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All must be present:
T>38.9C/102F, rash, SBP<90 and orthostasis, involvement of 3 organ systems and negative serology for RMSF, hepB, measles, leptospirosis, VDRL |
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What type of rash develops in TSS
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blanching erythrodermal which resolves in 3days and is then followed by desquamation (full-thickness) typically b/t 6-14d with peeling prominent on hands and feet
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How should a patient with TSS be treated
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IVF!!! pressure support, FFP/transfusions, vaginal irrigation w/ iodine/saline, antistaphylococcal PCN or cephalosporin wiht anti-beta-lactamase activity (nafcillin/oxacillin), rifampin should be considered to eliminate carrier state
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Define preeclampsia
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HTN after 20wk EGA with generalized edema/proteinuria
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Define eclampsia
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Preeclampsia + grand mal seizures/coma
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Should BP be lowered acutely in preeclampsia
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Dangerous HTN >170/110 should be lowered with hydralazine 10mg IV or labetolol followed by gtt. Definitive tx for preeclampsia and eclampsia is delivery
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When can a transfaginal and an abd u/s ID intrauterine sac
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transvaginal 31-32d, abd 5wks
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24 yoF, 10wk pregnant, with bleeding per vagina c/o N/V/abd pain. BP 150/100 and uterus which is larger than dates. Labs show proteinuria. What's the dx?
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Molar pregnancy. Uterus may be larger or smaller than expected dates
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RF's for placenta previa
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prior c/s, previous placenta previa, multiparity, multiple induced abortions, multiple gestations
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What are the RF's for abruptio placenta
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smoking, HTN, multiparity, trauma, previous abruptio placenta, drug use
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What are the SSx of abruptio placentae
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Placental separation b/f delivery assoc w/ vaginal bleeding 78%, abd pain 66%, and tetanic uterine CTX, uterine irritability, fetal death
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Is life-threatening hemorrhage b/c of trauma during pregnancy most often intra- or retroperitoneal?
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Retroperitoneal
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24 yoF, 10wk pregnant, with bleeding per vagina c/o N/V/abd pain. BP 150/100 and uterus which is larger than dates. Labs show proteinuria. What's the dx?
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Molar pregnancy. Uterus may be larger or smaller than expected dates
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RF's for placenta previa
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prior c/s, previous placenta previa, multiparity, multiple induced abortions, multiple gestations
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What are the RF's for abruptio placenta
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smoking, HTN, multiparity, trauma, previous abruptio placenta, drug use
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What are the SSx of abruptio placentae
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Placental separation b/f delivery assoc w/ vaginal bleeding 78%, abd pain 66%, and tetanic uterine CTX, uterine irritability, fetal death
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Is life-threatening hemorrhage b/c of trauma during pregnancy most often intra- or retroperitoneal?
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Retroperitoneal
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What are the 2 distinct causes of toxic epidermal necrolysis (scalded skin syndrome)?
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Staphylococcal and drugs/chemicals. Both begin w/ appearance of patches of tender erythema followed by loosening of skin and denuding to glistening bases.
SSSS is common in kids <5yo and is caused by toxin that cleaves w/i the epidermis under the stratum granulosum |
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How is SSSS distinguished from scalded skin syndrome that is caused by drugs/chemicals
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Pathology. In drug/chemical etiologies, skin separates from dermoepidermal junction. This drug-induced TEN carries 50% mortality as a result of fluid loss and 2ndary infection.
Microscopic exam SSSS, intraepidermal cleavage occurs along w/ few acantholytic keratinocytes. In nonstaphylococcal type, cellular debris, inflammatory cells, adn basal cell keratinocytes are present |
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Tx SSSS
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Oral or IV penicillinase-resistant PCN, potassium permanganate or drsgs soaked in 0.5% silver nitrate, and fluids. STeroids and silver sulfadine are contraindicated.
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Mechanism of tetanospasmin
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Enters peripheral nerve endings and ascends the axons to reach the brain and spinal cord where it binds to 4 areas of NS:
1) anterior horn cells of sc: impairs inhibitory interneurons resulting in neuromuscular irritability and generalized spasms 2) sympathetic NS: sweating, labile bp, tachy, peripheral vasoconstriction 3) myoneural junction: inhibits relase of acetylcholine 4) binds to cerebral gangliosides: thought to cause seizures. |
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What is #1 cause of cas gangrene
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Clostridium perfringens
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What is an ABI and its significance
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ankle SBP compared to higher of 2 bracheial artery pressures (Denominator). Normal is >1. 0.5-0.9=obstructive disease of single peripheral arterial segment (claudication), <0.5 indicates multiple arterial segments are obstructed, <0.9 in trauma indicates arterial injury
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What technical factors can effect accuracy of ABI
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Probe pressure, probe placement which should be longintudinal to the vessel and 30- to 60- degree angle to the skin surface, too rapid deflation of BP cuff, and arterial wall calcifications
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What technical factors can effect accuracy of ABI
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Probe pressure, probe placement which should be longintudinal to the vessel and 30- to 60- degree angle to the skin surface, too rapid deflation of BP cuff, and arterial wall calcifications
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What technical factors can effect accuracy of ABI
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Probe pressure, probe placement which should be longintudinal to the vessel and 30- to 60- degree angle to the skin surface, too rapid deflation of BP cuff, and arterial wall calcifications
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Tetanus
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Nontetanus prone wounds
*Unknown or <3shots=Td *3 or more shots w/ last shot 0-10yrs= none *3 or more shots w/ last shot >10yrs ago= Td Tetanus prone wounds: Unknown or <3shots: Td+TIG 3 or more shots in 0-5yrs: none 3 or more shots 5-10yrs: Td 3 or more shots and last shot >10yrs: Td |
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U/S abnl of acute cholecystitis
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wall thickening, surrounding fluid, gallstones, murphy's sign, air in biliary tree
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#1 site of ectopic
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ampullae of fallopian tube
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Adv and Disadv of DPL
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Adv: low complication rate
Disadv: invasive, time consuming, can't ID retroperitoneal injury, significant FP rate |
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6 RF's of ectopic pregnancy
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advanced maternal age, PID, prior ectopic, h/o pelvic surgery/tubal ligation, IUDs, invitro
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Incidence of IUP and extrauterine pregnnacy
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1/30,000
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Only true diagnostic sign of ectopic w/ ultrasound
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fetus with cardiac activity outside the uterus. Complex masses and fluid in cul-de-sac can be seen in other conditions (ie pelvic abscess, ruptured ovarian cyst)
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Role of ultrasound in detecting placenta previa and abruption
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Not sensitive for abruption and use primarily to r/o placenta previa in 3rd trimester vaginal bleeding. Uterine CTX, incorrect technique, and overfilled bladder can result in FP's.
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Describe shape and vessel origin in SDH and epidural hematoma
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SDH crescent, bridging veins, are hyperdense relative to brain and b/c isodense to brain in 1-3wks
EDH is biconvex, ~arterial, does not cross skull sutures but can cross tentorium/midline |
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Test of choice for evaluating and staging renal trauma
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IV CT
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What 2 studies can detect torsion and differentiate it from epididymitis, orchitis, or torsion of appendix testis.
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Technetium 99m nuclear study and duplex
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Laryngeal fx suggested by finding hyoid bone elevated above what cervical level on xray
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C3
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In kids >1yo where are fbo in airway usually located
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Trachea and mainstem bronchus
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In child w/ malrotation, what is the most likely age of presentation, the common complication, and the SSx that are usually present
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<12mo
Volvulus is #1 complication SSx: vomiting, blood streaked stools, abd pain Corkscrew appearance on xray |
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Presentation of SSSS
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after uri/conjunctivitis, 1st lesions tender red, scarlatiniform, usually on face, neck, axillae, and groin, skill peels off in sheets and +nikolsky's
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What's a +Chvostek's sign
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twitch in mouth when tap facial nerve in front of ear but present in 10-30% nl individuals. Eyelid muscle contraction with this maneuver is said to be dx of hypocalcemia
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Trousseau's sign
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carpal spasm w/ bp cuff on UE at pressure above systolic for 3min
Extend at interphalangea joints and flex at metacarpopharlangeal joints More reliable than chvostek's sign Can also be positive in hypomagnesmia, severe alkalosis, strychnine poisoning |
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Charcoal is not helpful in
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alcohols, ions, acids, bases
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Describe Debakey system
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I=ascend and descend
II=ascend III=decent distal to L SC artery |
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#1 rhythm in pediatric arrest
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bradycardia
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Features of slipped femoral capital epiphysis
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injury ~adolescent, rupture presents w/ insidious development of knee/thigh pain and painful limp. Frequently hip motion is limited esp internal rotation.
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Common concerns of anterior shoulder dislocation
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Axillary nerve injury, axillary artery injury in elderly, compression fx of humeral head (Hillsack's deformity) rotator cuff tear, fx of anterior glenoid lip, fx of greater tuberosity
Most common Excessive abduction and ext rotation (acute in trauma) Detached labrum w/ or w/o bony fragment (Bankhard) leads to subsequent joint instability Impression fx or divet on posterior humeral head from abutment against anterior glenoid rim may occur "Hill-Sach's lesion" contributes to instability <20yo high rate recurrence Exam w/ squaring of shoulder, severe shoulder pain, loss of normal deltoid contour, dec ROM. Xray true AP, Y view of scapular wing, axillary view Tx: sling and swathe immobilize in 30 degrees ext rotation as ext rotation dec recurrence; NSAIDS; narcotics; f/u ortho 3-5d; no sports til f/u |
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Posterior dislocation etio, exam, and tx
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rare 3%, severe int rot and adduction; sz, electrocution, FOOSH
Exam: arm held tightly at side and int rot, can't ext rotate/abduct, fullness palp posteriorly. Xray: may appear nl on AP, loss of nl elliptical overlap b/t glenoid and humeral head, light bulb sign on internal rotation of greater tuberosity on AP, Axillary and Y essential for dx If high suspicion, get CT Sling and swathe, NSAIDs 1st line for pain, narcotics, f/u ortho 305d |
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Technique for shoulder reduction
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IV sedative/analgesic
gentle, steady external rotation of shoulder w/ elbow flexed (provide minimal traction inline with humerus) over several min until hand in same plane as torso; do not force; stop intermittently when pain occurs; After ext rot to 90 deg, reduction often achieved, if not, abduct arm while in 90deg ext rot while maintaining elbow traction; if still fails, place pt in prone position w/ affected arm hangin over side of table, tie 5-10lb wt to wrist and as shoulder muscles relax, reduction often achieved |
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Defn Monteggia fx/dislocation
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Fx proximal ulna and dislocation of radial head
Tx: ORIF Get forearm, elbow, and wrist. GRUM |
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Describe Galeazzi's fx/dislocation
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radial shaft fx w/ dislocation of distal radioulnar joint
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Describe the clinical characteristics of carboxyhemoglobin concentrations, specifically for ranges of near 10%, 10-20%, near 30%, 40%, 50%, 60%, and 70%
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10%: Frontal HA
10-20%: HA and dyspnea 30%: nausea, dizziness, visual disturb, fatigue, impaired judgment 40% syncope and confusion 50% coma and sz 60% resp failure and hypotension 70% lethal |
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Appropriate tx cyanide poisoning
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amyl nitrite, sodium nitrite IV, follwed by sodium thiosulfate IV and pt should be on 100% O2
OR hydroxocobalamine IV Cyanide poisoning: closed space fire, suicide w/ coma, artificial nail remover ingestion, fruit seeds, nitroprusside use for extended periods (polishing/pesticide/photography/fumigation) Sx: HA, SOB, confusion, N/V, blurry vision, abd pain Cherry red skin, cyanosis, bitter almond odor, mydriasis, tachy then brady, AG met acidosis, levels don't correlate w/ toxicity |
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Describe botulism intoxication
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C botulinum, affects myoneural junction and prevents release of acetylcholine. Principal by ingestion of foods that have been inadequately prepared
#1 neuro sx bulbar musculature, neuro sx usually occur w/i 24-48h of ingestion of contaminated foods. Musc paralysis and weakness usualy spread rapidly to involve all muscles of trunk and extremities. It is important to distinguish between botulism poisoning and myasthenia gravis. This distinction can be made by using edrophonium test usually performed by neurologist. |
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In pt <10yo and >50yo with both deep partial-thickness and full-thickness burns, what % of total BSA must be burned b/f referral to burn center
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10%
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In pt b/t 10-50yo with both dee partial-thickness and full-thickness burns, what % of TBSA must be burned before referral to burn center
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20%
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Poor prognostic signs on admission of pt with pancreatitis include
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>55yo
Glucose >200 LDH >350IU/L AST >250U/L DO NOT ORDER AMYLASE |
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What test is best to confirm dx of Boerhaave's
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esophagram w/ water soluble contrast medium
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SSx of Boerhaave's
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Substernal and L sided CP w/ h/o forceful vomiting leading to spon esoph rupture
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Kanavel's 4 signs of infection digital flexor tenosynovitis
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tenderness along tendon sheath
finger held in flexion pain on passive extension of finger finger swelling |
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What sx are assoc w/ regional enteritis
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(crohns and granulomatous ileocolitis)
Pts with regional enteritis may present w/ fever, abd pain, wt loss, diarrhea. Fistulas, fissures, and abscess may be noted. UC on other hand ~ has bloody diarrhea |
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Pt bitten by wild raccoon. What's the tx?
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Wound care
Tetanus RIG 20IU/kg (1/2 at bite site and 1/2 IM) HDCV 1cc IM (d 0,3,7,14) Report to CDC, public health dept |
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What animals are most common vectors of rabies in the world? In the US?
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Dogs in world. Skunks in US then bats, raccoon, cow, dog, fox, cat
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A septic appearing adult has a 1cm diameter skin lesion w/ necrotic, ulcerated center, and erythematous surrounding region. What's the likely pathogen?
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Pseudomonas aeruginosa
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Ottawa Knee rules
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1. can't walk 4 steps immed/in ED
2. patellar tenderness 3. fibular head tenderness 4. older than 55yo 5. inability to flex >90degrees |
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Tarsometatarsal fracture/dislocation
(aka lisfranc's) |
tarsal-metatarsal joint=lis franc's joint
multiple forms base of 2nd metatarsal and attachment to medial cuneiform are most commonly affected carefully document neurovasc status requires admission and ortho consult for ORIF |
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Calcaneus fx
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common avulsion fx from forced dorsiflexion, intraarticular most common
Calculate boehler angle (intersection of posterior to middle facet and anterior to middle facet (nl 20-40degrees) <20 or more than 5 degrees different from other side consider fx Caused by fall from ht on feet often and high assoc w/ vertebral fx 75% intraarticular and involve subtalar joint Tx: consult podiatry/ortho, if intraarticular fx closed vs open tx is controversial Displaced fx's require ORIF If extra-articular can cast in slight plantar flexion for calcaneal |
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Talus fx
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Mech: forced dorsiflexion, blood supply tenuous and high incidence of AVN, no muscular/tendon insertions on talus
Tx: 1. Nondisplaced: SLC 8-12wks and NWB 2. Displaced w/ subtalar dislocation/subluxation: reduce, cast, ORIF if nonanatomical 3. Displaced w/ talar body or head dislocation: ORIF |
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Metatarsal Fractures
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1. Proximal metatarsal: forced plantar flexion, treatment closed reduction and casting if nondisplaced vs ORIF if displaced
2 metatarsal shaft: reduce to avoid transfer metatarsalgia and if reduction unacceptable, ORIF, straight leg walking cast (long let in ED) 3. metatarsal head fx: fall from ht/hitting break in MVA. Tx reduce and cast vs pinnint 4. Jones fx: transverse base of 5th metatarsal fx, high incidence of non-union and req 4-6wk NWB SLC, late ORIF if required 5. Pseudo-Jones: avulsion 5th metatarsal at insertion of peroneus brevis tendon. Tx 2-3wk SLWC or pad foot and place in shoe/air cast and crutches; aka dancer's fx 6. Stress fracture (March): 2nd and 3rd metatarsals w/ neg xrays initially; splint, crutches, rest, ortho |
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Phalanx fx
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nondisplaced buddy tape, post-op shoe/walking boot cast; displaced do closed reduction after digital block and buddy tape.
Open: debride, ABx (dicloxacillin500mg po Q6h) and early f/u. |
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What is best view for dx lunate and perilunate dislocations
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lateral xray of wrist
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Mnemonic for hand
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some lovers try positions that they can't handle
scaphoid, lunate, triquetrium, trapezium, trapezoid, capitate, hamate |
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1st, 2nd, 3rd choice of anti-sz in kids
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phenobarb, phenytoin, carbamazepine
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What's the drug of choice for febrile sz
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Bz then phenobarb
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#1 cause of LGIB painless in infant/child
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Meckle's diverticulum
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16mo old child w/ bilious vomiting, distended abd, and blood in stool. Dx?
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Malrotation of midgut
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What are some possible complications of sodium bicarb therapy
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Hypokalemia
Paradoxical CSF acidosis Impaired O2 dissociation Na overload |
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Differentiate b/t nonketotic hyperosmolar coma and DKA
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Nonketoti hyperosmolar coma: glucose high, often >800, serum osmolality is also ver high with avg ~380. Nitroprusside test negative.
DKA glucose often in range of 600, serum osmolality ~350, nitroprusside test positive |
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What focal signs present in pt with nonketotic hyperosmolar coma
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Hemisensory deficits or hemiparesis. 10-15% have sz.
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#1 cause of hyperthyroidism
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Grave's (toxic diffused goiter)
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#1 precipitating cause of thyroid storm
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pulmonary infection
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Common setting of myxedema coma
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elderly, winter, stimulated by infection/stress
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#1 cause of hypothyroidism
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overtreatment of grave's with Iodine or subtotal thyroidectomy
#2 is autoimmune hashimoto's thyroiditis |
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How can primary hypothyroidism be distinguished from secondary
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Primary TSH are high and pts often have h/o thyroid surgery and may have goiter
In secondary, TSH low or normal and no h/o surgery/goiter |
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What EKG finding expected in myxedema coma
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bradycardia
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What is primary adrenal insufficiency
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Addison's disease (failure of adrenal cortex)
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Defn Waterhouse-Fredrickson syndrome
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septicemia 2/2 to meningococcemia w/ assoc bilat adrenal gland hemorrhage. Pt will had petechial rash, purpura, shaking chills, severe HA
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What does Addison's do to cortisol and aldosterone
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Lowers both cortisol and aldosterone.
From low cortisol get N/V/anorexia/lethargy/hypoglycemia/waterintox/inability to w/stand minor stress w/o shock. Low aldosterone->hyponatremia, dehydration, hypotension, syncope |
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SSx adrenal crisis
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abd pain, hypotension, shock.
Tx: hydrocortisone 100mg IV bolus and 100mg to 1st liter of D5NS |
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Most common site fbo in pediatric esophagus
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cricopharyngeal narrowing
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Thyrotoxicosis can be treated with???
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PePID
Propranolol IV 1mg/min up to 10mg PTU 1gm IV Iodine 1g Q12h IV Dexamethasone 10mg IV |
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Fx of proximal fibular shaft assoc with...
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Medial ankle fx or sprain
=Maisonneuve fx (widened mortise and no fx seen in ankle. |
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Ankle fx exam
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Use ottawa ankle rules
palpate medial and laterally and perform stress tests to assess stability and if fx of fibula with medial tenderness, get eversion stress xray to look for widening medial suggesting disruption of deltoid and unstable injury; palpate entire length of fibula as fx's can occure quite proximally Stable injury=isolated to either medial/lateral ankle Unstable injury=disruption both medially and laterall Exp's: 1. Bimalleolar fx: medial and lateral malleolar fx 2. Trimalleolar fx: medial, lateral, and posterior tibia fx: trimalleolar fx 3. Lateral malleolar fx w tear of deltoid |
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Ankle tx
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stable fx: cast, early wt bearing, convert to brace when comfortable
unstable: consult ortho, reduce, splint, RICE, requires ORIF If bimall/trimall fx and dislocation, r/o overlying skin integrity, check pulses, mortise disruption. Need early reduction w/ in-line traction, splint, consult ortho, admit for ORIF |
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Ottawa ankle rules
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1. can't bear weight 3 steps immediately and in ED
2. lateral malleolar tip or posterior aspect tenderness 3. medial malleolar tip or posterior aspect tenderness If 1 get xray |
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Ottawa foot rules
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1. can't walk 3 steps immed/in ed
2. navicular bone tenderness 3. 5th metatarsal tenderness |
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Tarsal fx
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rare, usually multiple, navicular bone most common, non-displaced require immobilization and urgent ortho consult.
Displaced fx or fx and dislocation or other associated foot injuries require ER ortho consult |
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SSx spinal shock
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Complete loss of sc function b/l injury, flaccid paralysis, complete sensory loss, areflexia, and loss of autonomic function. Pts are ~brady, hypotensive, hypothermic, vasodilated.
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Tx mycoplasma
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patchy denisities in entire lobe.
Assoc w/ s/t pneumoceles, abscess, cavity, effusion. Tx: erythromycin |
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Where is the most likely location of Boerhaave's
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L posteriolateral region of midthoracic esophagus
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SSx UC
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fever, wt loss, tachycardia, pancolitis, 6 bloody BM's/day
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2 fairly common conditions in peds that produce cardiac syncope
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Aortic stenosis (not cyanotic)
TOF (cyanotic |
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2 unique findings in TOF
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Boot-shaped heart on xray, exercise intolerance relieved by squatting, TOF is treated by placing pt in knee chest position and giving morphine
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SSx of AS in child
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exercise intolerance, CP, systolic ejection click w/ crescendo, descrescendo murmur, radiating to the neck with a suprasternal thrill. No cyanosis!
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Signs of L sided HF in a child
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Inc RR, SOB, sweating during feeding
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What is the single most common cause of CHF in 2nd week fo life
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Coarctation of the aorta
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What are the SSx of Reye's syndrome
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Irritable, combative, lethargic, RUQ pain, h/o influenzae B or recent chicken pox, papilledema, hypoglycemia, sz. Labs show hypoglycemia and elevated ammonia >20xnl, bilirubin is NORMAL!
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What is the #1 cause of periorbital cellulitis in a 2yo child?
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#1 cause is H influenzae
#2 is S aureus |
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Which is the most appropriate drug for pt with low CO and pulmonary edema
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dobutamine
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In a humeral shaft fracture, which nerve is most commonly injured?
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radial nerve
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What is the most common dysrhythmia in a child
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PAT
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What are some common causes of inc AG
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MUDPILES CAT
Methanol (visual disturb and 2.6mg/dL inc osmolar gap 1mOsm/L) Ethanol 4.3mg/dL adds 1mOsm/L to gap Ethylene glycol: calcium oxalate/hippurate crystals in urine. 5mg/dL inc 1mO2m/L to gap Carbon monoxide, aspirin high levels, toulene. Other causes of lactic acidosis: INH, cyanide, sodium nitroprusside, sorbitol, toulene Other causes of met acidosis: toluene, iron, sulfuric acidosis, short bowel syndrome (D-lactic acidosis), formaldehyde |
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Causes of normal AG metabolic acidosis
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Diarrhea, ammonium chloride, RTA, renal interstitial disease, hypoadrenalism, ureterosigmoidostomy, acetazolamide
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Causes of respiratory alkalosis
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pH >7.45 and pCO2<35
hyperventilate from shock/sepsis/trauma/asthma/PE/anemia/hepatic failure/heat stroke or exhaustion/emotion/asa poisoning/hypoxemia/prego/inappropriate mechanical ventilation. Alkalosis shifts O2 curve to left, causes cerebrovasc construction, and kidneys compensate by excreting bicarb. |
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How to treat pt w/ hypertrophic cardiomyopathy w/ CP and nl VS except HR 140
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B-antagonists are first line and CCB second line.
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Management of neurogenic shock
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Replacement of volume deficit then pressors
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Elderly male presents with ataxia, confusion, amnesia, ocular paralysis. Pt apathetic to situation and otherwise nl neuro exam. Etiology?
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Wernicke-Korsakoff's syndrome
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Posterior MI on EKG
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ST depression on V1-V2 and large R wave
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Best tx for unstable pt with WPW presenting with rapid afib
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shock
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Best treatment for verapamil-induced bradycardia
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calcium chloride 10%, 10-20ml IV
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Most common cause of valvular induced syncope in elderly?
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AS
Vasovagal is most common overall. |
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SSx and EKG assoc w/ lithium toxicity
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Tremor, weakness, flattening of T-waves
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Pt with orbital fx. What are the SSx?
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#1 diplopia caused by entrapment of inferior rectus and inferior oblique muscles and resultant paralysis of upward gaze
In addn worry about inferior orbital nerve damaged with paresthesia of lower lid, infraorbital area, and side of nose |
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Signs of upper motor neuron lesion
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Involves the corticospinal tract and gives paralysis with initial loss of muscle tone then increased tone resulting in spasticity, +babinski, increased DTRs.
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Which condition commonly presents with ocular bulbar deficits
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Botulism poisoning. Pts with myasthenia gravis may present similarly. Diphtheria toxin may rarely produce similar deficits.
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SSx of myasthenia gravis
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weakness, fatigability with ptosis, diplopia, blurred vision are 1st sx in 40-70%. Bulbar muscle weakness is often common w/ dysarthria and dysphagia.
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Key features of vertebrobasilar insufficiency
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Vertigo nearly always positional, provoked by certain head positions. Nystagmus ~ accompanies the vertigo. Other signs of arteriosclerosis may be found.
Usually older and may occur with other sx of BS ischemia, visual sx being most common |
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What disease would you expect in a patient with 2wk h/o lower limb weakness
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GBS usually ascending weakness begins in LE.
With botulism poisoning, weakness is descending. CN are typically affected 1st with MG. |
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Mortality of Wernicke's encephalopathy
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10-20%. Tx with IV thiamine. Sx include ocular palsies, nystagmus, confusion, and ataxia
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What therapy should be used for a patient with hemophilia A who suffers a head injury?
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Cryoprecipitate and keep total volume as low as possible.
Cryo has inc F8 complex and less volume than FFP. |
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Treatment of hemophilia
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Rx before CT if suspect IICH/severe bleed
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Hemophilia A: 1U of F78/kg body weight
Very mild bleed consider DDAVP Hemophilia B: 1U F9/kg body weight Very mild bleed consider FFP 20cc/kg but F9 still agent of choice Admit all major bleed, head & neck trauma, hemarthrosis, deep lac, persistent joint bleeding; d/c minor bleeds (must immobilize hemarthrosis) Cryoprecipitate if no factor available as has increased concentration of F8 compared to FFP |
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Sx of sigmoid volvulus
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Psych/elderly and suffer from severe chronic onstipation. Intermittent cramping, lower abd pain, progressive abd distension.
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Describe sx of intussusception
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3mo-2yo majority 5-10mo. More common in boys. Area of ileocecal valve ~source.
Supine AXR with paucity of air |
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Signs hyperthyroidism
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fever, tachy, wide pulse pressure, CHF< shock, thyromegaly, tremor, weak, liver tender, jaundice, stare, pretibial myxedema, AMS
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What are the lab and radiologic findings of duodenal injury
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Retroperitoneal air and increased amylase
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What is the current therapeutic regimen for tx of meningitis in a neonate
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cefotaxime and ampicillin
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Formula for change in potassium with pH
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Every 0.1 increase in pH, K drops 0.5mmol/L
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Tx AKA
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Sx N/V/abd pain 24-72h after last drink; poss abd pain.
From inc mobilization of FFA to acetoacetate adn beta-hydroxybutarate Tx: NS and glucose As acidosis is corrected, K may drop. |
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Sx of optic neuritis
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Variable oss of central vision with centra scotoma and change in color perception. Eye pain. Margins blurred from hemorrhage and blind spot inc
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Antidote for ethylene glycole
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fomepizole, ethanol, or dialysis
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Antidote for Fe ingestion
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Deferoxamine
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SSx acute pericardial tamponade
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Triad: dec bp, tachy, elevated CVP/JVD. Can indicate PTX/tamponade but if muffled heart tones suspect tamponade
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What EKG is associated with tamponade
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Total electrical alternans
Pulsus paradoxus is nonspecific Muffled heart tones are subjective and are difficult to appreciate |
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How does chronic pericardial effusion appear on CXR
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watter bottle
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Tx myxedema coma
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IV thyroid replacement, IV glucose, hydrocortisone, consider water restricting
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Lid lag associated with
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thyrotoxicosis
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Describe pt with acute narrow-angle closure glaucoma
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Nausea, HA, vomiting, abd pain.
Visual acuity is markedly diminished. Pupil is semi-dilated and nonreactive. Glassy haze over cornea and eye red and painful. IOP elevated |
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Tx acute narrow- angle glaucoma
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Attack depends more on duration and less on absolute pressure
acetazolamide/timoptic, Mannitol, Pilocarpine, iridectomy Reduce pressure: 1. Timoptic 0.5% 1gtt q30min x2doses 2. Carbonic anhydrase inhibitors acetazolamide 500mg po/IV then 250mg Q6h 3. Apraclonidine (alpha 2 agonist) 1 gtt Q30min x2doses Reduce volume Glycerol 1ml/kg po, or isosorbide 100g po, or mannitol 1g/kg IV (good for pts w/ N/V) Open angle Pilocarpine 2% blue eyes vs 4% om brown eyes and 1gtt q15min for 1-2hrs Stat optho for iridotomy on both eyes |
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Tx hyphema
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Admit, HOB 30 degrees, eye shielf and avoid read/tv, antiemetics, sedatives prn, avoid anti-plt meds
If inc IOP give timolol, brimonidine (alpha agonist), acetazolamide (carbonic anhydrase inhibitor topical and po), IV mannitrol. *Avoid hyperosmotics and diamox in sickle cell Cycloplegic (atropine) Surgery if complete or uncontrolled IOP |
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Grading of Hyphema
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Grade 1 <1/3
Grade 2 <1/2 Grade 3 < all Grade 4 total clotted blood R/o rupture, fbo, orbital fx |
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SSx retinal detachment
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Myopic and will c/o seeing curtain across eye, flashing lights, black dots, or sudden change in vision.
Fundo: detached area gray in comparison to nl pink retina. |
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Tx retinal detachment
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Bilat eye patch, strict bedrest, consult optho for laser photocoagulation
Stabilize vitals and prepare for possible surgery. If inflammatory gie sterois/NSAID Treat underlying conditions Need repair 2/i 24h |
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Standard dose of atropine in kid
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0.02mg/kg
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Dose of bicarb in kids in arrest
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1mEq/kg
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Expected nl SBP in kids
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age x2 +90
age x2 +70 SBP term newborn is around 60mmHg |
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Child dose of epi
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0.01mg/kg/dose
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SSx kawasaki's
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high spiking fever, conjunctivitis, morbilliform rash, strawberry tongue, erythema of distal extremities with cervical adenopathy.
Disease of mucocutaneous LN's. Hospitalize to r/o myocarditis, pericarditis, and coronry aneurysms. Asa tx. |
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Initial ABx for child with epiglottitis (aka supraglottitis)
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Sit upright
Fiberoptic NT intubation preferred, ER orotracheal intubation/needle cric if necessary (1psi/kg pressure) Lateral neck xray, fiberoptics in OR Ceftriaxone 100mg/kg/d IV No steroids and no racemic epi Secure airway first then place IV Triad: drool 80%, dysphagia, resp distress |
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Characteristics of posterior hip dislocation
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Posteriorly directed force applied to flexed knee
Extremity shortened, int rotated, and adducted Acetabular fx's assoc w/ this injury 90% of hip dislocations are posterior |
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Characteristics of anterior hip dislocation
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hip neutral to slight flexion = abduction and ext rotation
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Tx hip dislocation
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r/o femoral head/acetabulum fx prior to reduction maneuver
Risk of avascular necrosis inc with time dislocated Procedural sedation. Assistant stabilizes pelvis by applying counter-traction to anterior iliac crest while surgeon flexes hip 70degrees in slight abduction while pulling in line with femur. Get post-reduction xray and may require CT to r/o intra-articular bone fragment or acetabular fx or femoral head fx. |
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Procedural sedation
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Midazolam (Versed)
0.02-0.1 mg/kg IV initially; if further sedation is required, may repeat with 25% of initial dose after 3-5 min; not to exceed 2.5 mg/dose (1.5 mg for elderly persons) and 5 mg cumulative dose (3.5 mg for elderly persons) Onset 1-2 min. Lasts 30-60 min. SE resp depression, hypotension when rapidly given or combo w/ fentanyl. Reverasal= flumazenil Fentanyl 1-2 mcg/kg slow IV push (over 1-2 min); may repeat dose after 30 min. Onset 1-2 min, lasts 30-60 min May cause chest wall rigidity, apnea, respiratory depression, or hypotension Etomidate *0.1-0.2 mg/kg slow IV push over 30-60 sec *Onset < 1 min, lasts 3-5 min. *Commonly causes myoclonus, pain upon injection, adrenal suppression (typically no clinical significance unless repeated doses are used within a limited time span); may cause nausea, vomiting, and lower seizure threshold; does not alter hemodynamics; causes a slight to moderate decrease in intracranial pressure that only lasts for several minutes; useful for patients with trauma and hypotension Propofol *0.5-1 mg/kg IV loading dose; may repeat by 0.5-mg increments q3-5min. Onset < 1 min. Lasts 3-10 min. Provides rapid onset and recovery phase, and brief duration of action; has anticonvulsant properties; can rapidly cause deepening sedation. Causes CV depression and hypotension. |
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Medications down ETT
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narcan, atropine, valium, epi, lidocaine
NAVEL |
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Features of central cord syndrome
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Typically occurs with hyperextension injuries in older patients with spondylosis, degenerative changes, or stenosis in c-spine.
Weakness more in arms than legs |
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Features of anterior cord syndrome
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Compression of anterior cord causing complete motor paralysis and loss of pain and temp distal to lesion
Posterior columns are spared (light touch and proprioception) |
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How does MG present
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Sx: weakness voluntary muscles, usually EOM.
Dx confirmation relies on edrophonium (2mg IV)/Tensilon test. Can cause brady/heart block and positive response confirms. Distinguishes MG from cholinergic crisis. If muscarinic SE's (fasciculations, inc weakness, discont and give 0.5mg atropine). Positive response confirms MG. Tx: pyridostigmine 60mg po, prednisone 60mg po, treat any fever (as worsens MG), thymectomy, plasmapheresis PRN, IV gamma globulin, neuro Tx: |
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SSx of PICA (posterior inferior cerebellar artery syndrome
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cerebellar dysfunction (vertigo, ataxia, dizziness)
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