in-service exam review 2009 emergency medicine

IN-SERVICE EXAMREVIEW 2009

EMERGENCY MEDICINEDavid Lee Pierce, M.D

Assistant Professor of Clinical Emergency MedicineUniversity at Buffalo

Objectives

• Review High Yield Material• Pass the exam

• ****Gives me the chance to study and stay one step ahead of interns

Mesenteric Ischemia/Infarction• Elderly• Atrial fibrillation• Excruciating Abd Pain• Abdominal Exam

Relatively Benign• (pain out of

proportion to exam)• Lactate Elevated• Phosphate Elevated• Leukocytosis > 15,000• Metabolic acidosis

Giardia• Diarrhea (no blood)• Hiking

• Crampy abdominal pain• Frothy awful smelling stool• Flatulence

• Stool Ova/Parasites

• Most common cause of parasitic disease in US

• Rx – Flagyl

Diarrhea1. Shigella2. Salmonella3. E.coli 0157:H74. Campylobacter5. Yersinia enterocolitis6. C. Diff7. Staph8. Bacillus cereus

1. Explosive diarrhea, seizures2. Eggs, poultry3. HUS,TTP, (beef or unpast. milk)4. #1 bacterial enteritis (Adults)5. Profuse watery diarrhea RLQ pain6. Hx of antibiotics 7. #1 Food Poison, ham, mayo 8. Fried rice

Diarrhea1. Vibrio cholera2. Vibrio parahemolyt.3. Scombroid

4. Ciguatera5. Entamoeba histolyica6. Giardia7. Cryptosporidium

1. Rice water diarrhea2. Raw seafood3. Histamine reaction, metallic,

bitter or peppery taste4. Hot/cold reversal, neuro findings5. Liver abscess (Only 1/3 diarrhea)6. Backpackers diarrhea 7. #1 chronic diarrhea AIDs

Wall thickening> 3 mm

Stone

Ultrasound of Cholecystitis

Sludge

Confirmatory Test? HIDA

Splenic injury• 20 yo F s/p MVC

• 11th rib Fx on left

• LUQ Pain

• Left shoulder pain• Kehr’s sign

(Phrenic Nerve)

• Most common organ injured in blunt abdominal trauma

Intussusception• 1 mo male

• Soft tissue mass• Colon cut-off

• Cyclical severe abdominal pain• Vomiting• Bloody stools (Current jelly)

• Dx/RX:– Contrast Enema

• Most common cause of bowel obstruction in first 2 years

Colonic Cut-Off

Gastrointestinal Pearls1. Level Cricopharyng. Muscle

2. #1 Level FB Child

3. Level Esophagus Terminates

4. #1 Level FB Adult

5. Globus hystricus

1. C6

2. C6

3. T11

4. T11

5. FB sensation throat

Gastrointestinal Pearls

1. Odynophagia

2. Dysphagia

3. Medication for Food Impaction

4. Size of Objects Require Removal?

1. PAIN with swallowing

2. DIFFICULTY swallowing

3. Glucagon (1mg IV2mg IV)

4. -5cm LONG -2cm WIDE -SHARP

Best Method Esophogeal FB Removal?

Button Batteries

1. Asymptomatic in stomach

2. In Esophagus

3. D/C Summary Instructions

1. Observe/ Repeat Xray

2. Emergent Endoscopy (Perforation in 4-6 h)

3. Stop eating button batteries!!

Foreign Body!!!

• Who’s your consultant?

• GI

• Esophageal FB

FB “Throat”

ENTTrachea

GIEsophagus

Boerhaave’s Syndrome• 45 yo male • Choking• Vomits large piece steak

• Severe Chest Pain• Unstable

• Stabilize• Surgery

NG TUBE

Mallory-Weiss Tear• 45 yo male • ETOH• Hiatal hernia

• Mult. Dry Heaves• Mild hematemesis• Vitals stable

• Rx: – Antiemetics– PPI

Sigmoid Volvulus• Elderly schizophrenic

• Chronic severe constipation

• Abdominal Distention

• “Bent Inner-Tube”– Loop out of the left side of the

pelvis and its superior aspect projects upward

• Rx: NGT, Surgery

Cecal Volvulus• 30 year old male• Marathon runner • Prior abdominal surgeries

• Sudden onset abdominal pain

– COFFEE BEAN shape– Several distended small bowel

loops

– Rx: NGT, Surgery

Midgut Volvulus• Newborn• Emesis• Abdominal Distention• Shock• “Birds Beak”

Lower GI Bleeding1. Elderly Lower GIB

2. #1 Congenital LGIB

3. Cirrhotic

4. AAA Repair then LGIB

1. Diverticulosis/ Angiodysplasia

2. Meckels Diverticulum

3. Esophageal Varices (Large volume)

4. Aortoenteric Fistula

SBO

• 50 yo female• Hx 20 surgeries• Hx Multiple Hernias

• Rx: ?• NPO• NGT• Surgery Consult

Most Common Obstructions

1. Small Bowel

2. Large Bowel

• Adhesions• Hernias• Neoplasm• Inflammation

(Crohn’s)

• Cancer• Diverticulitis• Volvulus

Free Air PeritoneumPerforation PUD

Cardiac-Acute Coronary Syndromes EKG 101

Einhoven’s Triangle

Anterior/Septal STEMI

*

Note Reciprocal Changes (ST depression)

*

Anterior/Septal STEMI

Anterior V1-V4 Septal V1-V2Left Anterior Descending (LAD)

Thrombus

Lateral Wall STEMI

Lateral Wall STEMI(aVL, I, V5, V6)

Circumflex Artery (Cx)

Lateral on Einhoven’s Triangle!

Where’s the Thrombus?LAD + Cirx = Left Main (WIDOW MAKER) or 2 critical lesions

Inferior Wall STEMI

*Reciprocal Changes

Inferior Wall STEMI

(II,III,aVF)Right Coronary Artery

Inferior on Einhoven’s Triangle!

Posterior Wall STEMI

Posterior Wall STEMI

• Treatment: • Same ACS • Fluids (Gentle on NTG)

• Often Accompanies an Inferior Wall MI

V1• Large R (> S wave) • ST Depression

(Equivalent to STEMI)

Heart Block and ACS

1. Heart Block-Inferior MI

2. Heart Block-Anterior MI

1. Second Degree Type 1 (Wenckebach)

1. 2nd Degree Type 22. High Grade AV Block

(Get Pacer Ready)

Aortic Pathology 101

Dissection• Intimal tear• Blood leaks into media

Aneurysm (True Aneurysm)• All 3 layers arterial wall

Ruptured Aneurysm (Leaking Aneurysm)

Thoracic Aortic Dissection

• 60 yo smoker • HTN• Sudden tearing CP• Crack Cocaine• Radiates to his back

• Cold Pulseless Arm• DIASTOLIC Murmur

• EKG STEMI (Inferior)

• CTA Chest

Thoracic Dissection

Debakey

Stanford

Treatment

Ascending DescendingMedical!! Medical!!Surgical!

• BBNitroprusside (Prevent reflex tachycardia)

or• Labetolol

Ruptured AAA• 80 yo Smoker HTN PVD

• Flank Pain• Scrotal swelling • Anesthesia Medial Thigh

• Pulsatile Mass• Unequal pulses• Hypotensive

• Airway• IV• T&C 10 Units• Surgery

Hypertensive Emergencies

1. HTN Encephalopathy

2. HTN Aortic Dissection

3. HTN Hemorrhagic CVA

4. HTN with SAH

1. BBNitroprusside or (Labetolol)

2. BBNitroprusside or (Labetolol)

3. Labetolol/ BB

4. CCB (Nimodipine)

Hypertensive Emergencies1. HTN with ACS

2. HTN Pulmonary Edema

3. HTN Eclampsia

4. Pheochromocytoma/MAOI

5. HTN Cocaine Intoxication

1. NTG, BB

2. NTG, Lasix, Morphine, CPAP

3. Magnesium, Hydralazine, BB

4. Phentolamine BB (No BB 1st-Unopposed alpha )

5. BZD, IVF (Labetolol)

Hypothermia

• Osborne (J) wave

Bidirectional VTach

Dig toxicity

Digoxin Toxicity

• Yellow Halos

• Nausea/ vomiting

Dig bind criteria1. K+ > 5.5

2. Cardiovascular collapse

3. Blocks (Mobitz II , 3rd Degree)

4. Ventricular Dysrhythmia

5. Dig level >10

• Dig Toxic + Hyperkalemic

• What medication contraindicated?

• Calcium Gluconate/Chloride!!– Worsens intracellular Calcium derangement

WPW

SHORT PR

DELTA WAVE

Cardiac-Pacemaker

Pace Sense Trigger Program Shock

Cardiac-Pacemakers

Effect of magnet on:

1. Pacemaker

2. AICD

1. Resets to Fixed Rate

2. Turns it Off

Cardiac-AICD

• #1 Electrolyte Abnormlality AICD Dsyrhythmias?

• Paddle over AICD during code?

• Hypomagnesemia

• Don’t place close to the AICD generator

Most Specific Troponin

Trop I most specific (~100%)

Ventricular Dysrhythmias

Ventricular Fibriallation Arrest

• 1st Thing you do?

Torsades

• What now?

• Shock

• Magnesium IV• Overdrive Pacing• Isoproterenol

Multifocal Atrial Tachycardia

Pulmonary Disease (COPD)

Treatment: Treat Underlying Pathology (COPD)

Multiple P Waves (Multiple Atrial Foci)

P1 P2 P3

Atrial Flutter

Saw-Tooth F-Waves

Supraventricular TachycardiaRhythm Breaks

PACSVT NSR PAC

Atrial Tachycardia

• Stable SVT (AVNRT)

• Stable AFib/ Aflutter

• Unstable

• Vagal Maneuvers • Adenosine 6mg 12mg 12mg• CCB/BB

• CCB/BB• Amiodarone• Ibitilide• Anticoagulate

• Cardioversion

Cardiomyopathy

1. Hypertrophic CM

2. Restrictive CM

3. Idiopathic Dilated CM

1. Beta Blocker

2. Diuretics/ Digoxin

3. Diuretics/ Digoxin/ Vasodilators

Tamponade

Beck’s Triad• Hypotension• Muffled Heart Sounds• JVD

Diff Dx• Tension PTX• Massive PE• Acute Pulm Edema• Severe Asthma

Pericardial DisordersDisorder

1. Pericarditis

2. Tamponade• (Stable Vitals)

• Hypotensive

• Penetrating Chest Trauma (No Vitals)

Treatment• ASA, NSAIDs

• IVF, Surgery Urgently (Window)

• IVF, Inotropes, Pericardiocentesis, Surgery Emergently

• ER Thoracotomy

Electrical Alternans Tamponade/ Large Pericardial Effusion

Pneumococcal Pneumonia

• Cough productive of rusty colored sputum

• Fever

• Single shaking chill

Lobar Infiltrate

Staph Pneumonia

• Cough• Fever• Hemoptysis

• Recent Influenza• Toxic appearance

Air Fluid Level

Legionella Pneumonia

• Non-Productive cough

• Elevated AST/ALT

• Hyponatriema

• Gram stain with PMN’s but no organisms

– Relative Bradycardia (Despite Fever)

– Diarrhea (GI Symptoms)***

Mycoplasma Pneumonia

• Non productive cough

• Clinically well appearing with awful CXR

• Rx: Macrolide

Atypical Pneumonias

1. Legionella (Macrolide)2. Mycoplasma (Macrolide)3. Chlamydia (Tetracyclines/Macrolide)

Klebsiella Pneumonia• Alcoholic

• Cough

• Black/maroon sputum

• Abscess/ Empyema

• Gram (-) bacilli in pairs

• Rx:– Cephalosporin + AG

PCP Pneumonia• Weight loss

• SOB

• Cough

• Hypoxic

• Bilateral Interstitial Infiltrates

• LDH Elevated

• Rx:– Bactrim

– Pentamidine

– Steroids if PaO2 < 70

Pneumonia with Abscess

1. Staph2. Klebsiella3. Pseudomonas

Upper lobe infiltrate? Think….

1. Aspiration

2. TB

3. Klebsiella

Peritonsillar Abscess

• MEDIAL TO CAROTID!!

• Sore throat• Drooling • Muffled Voice

• Organism?– Polymicrobial (GABHS)

• Rx:– Aspiration– Abx (PCN, Clinda)

Ludwigs Angina• Sore throat• Drooling • Muffled Voice• Swelling floor mouth• Chest Pain

• Organism?– Polymicrobial

(aerobic-anaerobic)

• Rx:– Airway! Airway! Airway!– ENT– ABX (clinda, unasyn)

Retropharyngeal/Prevertebral Abscess

• Sore throat• Drooling • Muffled Voice

• Neck Stiff• Extension more comfortable

• ENT• IV ABX (clinda/ unasyn)• Admit ICU

Greater than 6 mm prevert. tissue

ENT Trauma

Injury

1. Nasal Septal Hematoma

2. Ethmoid Fx (Cribiform Plate)

3. Hematoma Auricle

Complication

1. Avascular Necrosis

2. CSF Rhinorrhea/ Meningitis

3. Cauliflower Ear

Septal Hematoma• Complication?

– Septal Necrosis (cartilage death within 24 hours)– Saddle nose deformity

• Rx:– Surgical drainage, packing and antibiotics

Epistaxis

• Frequent cause?

Epistaxis

Anterior (90%)• Murocele • Rapid Rhino• Cautery has high

incidence return visits

Posterior (10%)• Epistat• ENT

Treatment1. Blow Nose**

2. Topical Anesthetic (Lidocaine/Cocaine)3. Vasoconstrictor (Neosynephrine)

4. Pressure5. Evaluate

Sinusitis1. Most common site

2. Cavernous Sinus thrombosis

3. Pott’s Puffy Tumor

4. Periorbital/Orbital cellulitis

1. Maxillary

2. Sphenoid (Ethmoid)

3. Frontal

4. Ethmoid

Acute onset. Diagnosis?

Angioedema

Which is the most common medication that causes angioedema?

ACE inhibitors

Facial Fractures

Tripod Fracture

• Zygomaticofrontal Suture

• Zygomatic Arch

• Infraorbital Foramen

• Punched in cheek

Flat cheekPeriorbital swellingDiplopiaAnesthesia of the cheek, upper teeth, lip and gums

Five clinical signs of basilar skull fracture

1. Periorbital ecchymosis (Raccoon eyes)

2. Retroauricular ecchymosis (battle’s sign)

3. CSF Otorrhea or rhinorrhea

4. Hemotympanum

5. CN I, II, VII, or VIII deficits

Ellis Type III Dental Fracture• Broken tooth • Blood on tooth (pulp involved)

• Rx?• Calcium Hydroxide Paste

Seat Belt Injuries

Chance Fx

Rectus Sheath Hematoma

Intestinal Perforation

Trauma Pearls

You see…

1. Blunt Abd. Trauma

2. Penetrating Abd. Trauma

3. Ustable after MCV/ Fall

4. Sternal Fracture

5. Pelvic Fracture

6. Lap Belt Mark

Think…

1. Spleen Laceration

2. Liver Laceration

3. Traumatic Aortic Rupt

4. Myocardial Contusion

5. Bladder Injury

6. Jejunal/Mesenteric Lac.

Painful ulcer

• Friable

• Jagged edges

• Inguinal Bubos

• Etiology– H. Ducrei

• Rx?– Azithro 1 gram or CTX 250 mg IM

Chancroid

Molar pregnancy• 10 week preg

• Hyperemesis

• HTN (Preeclampic Sx)

• Uterus is larger than expected

• B-HCG is higher than expected

• Ultrasound = snowstorm appearance

Abruptio Placenta• Painful bleeding during 3rd trimester• Severe Abdominal Pain• Hypotensive• Smoked Crack

• OB• Deliver

Pre-Eclampsia

• 3 rd Trimester Hypertension

• Proteinuria

• Edema

• Hypertriglyceridemia

• Treatment– Hydralazine

– Labetalol

– MgSO4 (eclampsia)

Trichomonas Vaginitis

• Strawberry cervix

• Profuse, yellow-green discharge

• Rx: – Flagyl

STD1. Strawberry cervix

2. Painful necrotic ulcer

3. Painless indurated ulcer

1. Beefy-red, velvety ulcers

1. Trichomonas

2. Chancroid

3. Primary Syphilis

4. Granuloma Inguinale

Toxicology - Antidotes1. Acetaminophen2. Beta blockers3. Bromides4. CCB5. Carbon monoxide6. Cholinergics7. Cyanide8. Digoxin

1. NAC2. Glucagon3. Chloride (NSS)4. Calcium, glucagon5. O26. Atropine, pralidoxime7. Nitrate, thiosulfate8. Digibind

Toxicology - Antidotes1. Methanol2. Ethylene glycol3. Iron4. Isoniazid5. Lead6. Arsenic7. Mercury8. Nitrites9. Opiates10. TCA11. Warfarin

1. ETOH, 5MP, dialysis2. ETOH, 5MP, dialysis3. Defuroxime4. Pyridoxine, Vit B65. BAL6. BAL7. BAL8. Methylene Blue9. Narcan10. Sodium Bicarbonate11. Vit K, FFP

Drugs that are Radioopaque

CHIPESC = Chloro Hydrate

H = Heavy Metals

I = Iron

P = Phenothiazines

E = Enteric Coated

S = Solvents

Drugs that are Dialyzable

BLIST MED1. Barbituates2. Lithium3. Isoniazide/Iron4. Salicylates5. Theophyline6. Methanol7. Ethylene Glycol8. Depakote

Charcoal

Useless• Lithium

• Alkali/Acids

• Heavy Metals

• Iron

Toxic Overdoses

1. Phenytoin

2. Iron

3. Lithium

4. NMS

5. Wernicke’s

1. Folate deficiency, osteomalacia, lupus like syndrome

2. Abdominal pain, hematemesis, coma and shock

3. Tremors, hyperreflexia, seizures, N/V/D

4. Altered MS, muscular rigidity, hyperthermia, rhabdo

5. Oculomotor deficits, ataxia, AMS

Caustics

Acid Ingestion• Coagulation Necrosis

Alkali Ingestion• Liquefaction Necrosis

(Worse/Deeper Burn)

Tylenol Toxicity (APAP)

1. Time 1st level

2. Charcoal/Cathartic?

3. Phases Poisoning?

4. Toxic Metabolite APAP?

5. Treatment?

1. 4 Hours After Ingestion

2. Yes (<1 Hour)

3. 4 Phases

4. NAPQI

5. NAC

Indication for Dialysis

• Acidosis

• Electolytes

• Ingestions (Toxins)

• Overload (Fluid)

• Uremic Symptoms

• A

• E

• I

• O

• U

Rotator Cuff Tears

• Subscapularis• Supraspinatus• Infraspinatus• Teres minor

• Most Commonly Injured?– Supraspinatus*

Nerve Injury with FracturesFracture

1. Humeral Shaft2. Elbow Fx3. Shoulder Dislocation4. Colles’/Smith’s Fx5. Sacral Fx6. Acetabular Fx7. Posterior Hip Dislocation8. Anterior Hip Dislocation9. Femoral Shaft Fx10. Knee Dislocation11. Lateral Tibial Plat. Fx

Nerve Injured

1. Radial2. Median/Ulnar3. Axillary4. Median 5. Cauda Equina6. Sciatic7. Sciatic8. Femoral9. Peroneal10. Peroneal/ Tibial11. Peroneal

You See…1. Scapular Fx

2. Supracondylar Fx

3. High-Pressure Injection (grease/paint gun)

4. Flexor Tendon Injury Finger (FDP)

Think…1. Associated Injuries

2. Volkmann’s Ischmic Contracture

3. Consult ortho immediately despite benign exam initially (amputation!!!)

4. Ortho Consult (OR repair)

Compartment Syndrome

• Pain out of proportion to injury (earliest sign)• Paralysis• Parasthesia• Pulselessness• Poikilothermia• Pallor

Normal Pressure = 10 mmHgAbnormal >30 mmHg

Lisfrank Fracture

• Fracture dislocation at the base of the 2nd metatarsal

•Unstable fracture•Keystone of Midfoot•Requires ORIF

Jones Fracture

• Fx 5th Metatarsal• High incidence of

delayed/nonunion

Amputated Digits

• Wrap Sterile Gauze moistened with NS

• Place in water-tight container

• Place container in ice water

Don’t Submerge in Ice Water!!

Anterior Hip Dislocations (10%)

• ABducted• Externally rotated• Flexed

Complication:• Femoral Vein/Artery

thrombosis Pulm Embolus

Posterior Hip Dislocation (90%)

• Flexed Knee strikes dashboard

• Short• ADDucted• Internally rotated• Flexed

• Avascular necrosis Femoral Head

Scaphoid Fracture

• Proximal or Distal Worse?– Proximal– (Blood supply is

distal)

• Complication?– Avascular Necrosis

• Thumb spica if unsure!

Bucket Handle Fracture

• R/O Child Abuse!

Galeazzi Fracture

• Distal Radioulnar dislocation

• Distal Radial Shaft

• ORIF

Monteggia’s Fracture

• Fracture Proximal 1/3 Ulna

• Dislocation radial head

• Draw line radial shaft• Should interect the

capitellum

• ORIF

Colle’s Fracture

Maisonneuve Fracture

•Consult or send home with splint?•Consult! (High energy injury)

Maisonneuve Fracture

Felon

• Staph Aureus• I&D• ABX

Flexor Tenosynovitis

• Organism?– Staph/Strep

• Rx?– Hospitalization– Ortho– IV ABX

(PCN/Cephalo)

Bell’s Palsy (CN 7 lesions)Peripheral• Unable to wrinkle forehead on same side

• Rx?

– Steroid burst

– Acyclovir

– Eye patch

Central• Able to move forehead on same side

• Dx?

– Brain Imaging (MRI)

Bilateral Bell’s Palsy Caused by?Lyme Disease

Jefferson’s Fracture (C1 Blowout Fracture)

Hangman’s Fracture (C2)• Bilateral C2 Pedicle Fractures

• Mechanism--Ext/Flex?– Hyperextension!

Anterior Cord syndrome

• Motor paralysis distal to the lesion

• Loss of pain and temperature

• Retention of posterior cord function – Vibration– Proprioception

• Flexion Injury

Central Cord Syndrome

• Paralysis – Upper > Lower Extremities

• Distal > Proximal

• Clumsy Hands

• Extension Injury

Brown Sequard Syndrome

• Penetrating injury

• Ipsilateral loss of motor, position, vibration, touch

• Contralateral loss of pain and temperature

Cauda Equina Syndrome

• Lower back pain

• Hyporeflexia

• Asymmetric finding

• Saddle anesthesia

• Decreased rectal tone

• MRI• Neurosurgery

In what situation is an MRI the emergent study of choice for back pain?

• Cauda Equina

• Spinal Epidural Abscess

Trigeminal neuralgia

• Facial pain (right side more common)

• Electrical shock like

• Lancinating pain

Treat: • Tegretol

Pontine hemorrhage

• Pinpoint pupils• Occipital Headache

• Hyperventilating

• Coma

• Decerebrate posturing

Anterior Cerebral Artery Infarct

• Contralateral Paralysis– Legs >> arms

• Gait disturbance

Middle Cerebral Artery

• Contralateral paralysis– Arms >> legs

• Expressive aphasia

• #1 CVA

Subdural

• HA

• Decreased LOC

• Crescent shape on CT

• Airway!

• Neurosurgery

• Reverse Anticoagulation

Epidural

• Head Trauma• Brief LOC• HA• Lenticular shape lesion• Temporal/Parietal skull fx

• Airway!• Manage BP• Neurosurgery• Reverse Anticoagulation

Temporal arteritis

• > 50 yrs old

• Eye pain

• Temporal HA

• Malaise

• Associated with Dz:– Polymyalgia rheumatica

Blood Test:• ESR

What is the most common complication?

• Blindness

Management?• Prednisone/Biopsy

Multiple Sclerosis

• Optic neuritis• Sensory symptoms that don’t follow a pattern• Female in 30’s with bizarre neuro findings

Double vision on lateral gaze

Kidney Stones

• <4 mm will pass

• 4-6 mm will pass

• >6 mm will pass

• 95%

• 50%

• 10%

Fournier’s Gangrene

• Immunocompromised• Diabetic• Polymicrobial (anaerobes)

• Treatment:– IVF– Broad spectrum antibiotics– Surgical debridement

Erythema Multiforme (Minor)

• Mycoplasma

• Malignancy

• Drugs (SOAP)– S = Sulfa

– O = Oral hypoglycemic

– A = Anticonvulsants

– P = PCN

Stage I Lyme Disease

• Annular erythematous lesion

• Spares palms and soles

• Associated with arthritis

• Erythema chronicum migrans

• Rx?

• Doxycycline

Retinal Artery Occlusion• Sudden painless monocular loss of vision

• Marcus-Gunn pupil – Dilated pupil unreactive to direct, reactive to indirect light

• Cherry red spot

Rx: • Digital massage• Cycloplegics• Acetazolamide• Ophtho

Diagnosis?

Papilloedema

Corneal Ulcer• Localized whitish

corneal infiltrate

• Organism?– Pseudomonas

• Rx: – Ophtho consult

– Antibiotics (Cipro)

– No contact lenes

Pterygium

Diagnosis?Hypopyon

Normal IOP

10- 21 mm hg

Retinal Detachment

• Painless loss vision

• Flashes of light

• Floaters

• Lowering of a curtain

Associated with:

• Myopia

• Trauma

• Marfan’s

Horner’s Syndrome

• Ptosis

• Miosis

• Anhydrosis

• Facial flushing

• Iris Heterochromia

Rotary nystagmus

Eye findings in a PCP Overdose?

Ramsey-Hunt Syndrome

• Vesicular rash Ear/ TM

• Bell’s palsy

• Loss of taste

• Caused by?– Herpes Zoster

Electrical Shock

• AC (Alternating)• Vfib

– Household and commercial

– Explosive exit wounds

– Worse effects with equivalent voltage

• DC (Direct)• Asystole

– Industrial, batteries, welding supplies

– Produces discrete exit wounds