Inservice review 2006High yield facts

Steven T. Dorsey, MD

Department of Emergency Medicine

The Cleveland Clinic Foundation

MetroHealth Medical Center

General exam tips

Formulate your answer before you scan the choices

Lean towards aggression

Keep moving – later questions may clarify your confusion

No penalty for guessing

Study hard, do your best

Study hard, do your best

But if you bomb, you’ll break my heart, Fredo

And not just my heart

DKA

Estimated fluid deficit is 4 to 6 liters in adults, 10% in kidsMajor complication is cerebral edema, usually from too-rapid rehydration with hypotonic fluidsInsulin rate is 0.1 units/kg/hr Remember precipitants like AMI/acute ischemia

GCS

Eyes4 Open

3 Voice

2 Pain

1 No response

GCS

Verbal5 Oriented

4 Confused

3 Inappropriate

2 Sounds

1 None

GCS

Motor6 Follows commands

5 Localizes

4 Withdraw

3 Decorticate

2 Decerebrate

1 None

GCS example

18 year old motorcycle accident,only opens eyes when told to, says “F- you” when asked his name, and won’t follow commands to wiggle toes, but rather swings with his right arm toward the nurse putting in his left antecubital line

GCS =

Eyes = 3, to voice

Verbal = 3, inappropriate

Motor = 5, localizes

= 11

tPA for stroke – NINDS inclusion criteria

> 18 years

Symptoms under three hours

Normal PT/PTT

tPA dosing, acute strokeDOSES LIKELY NOT ON EXAM, JUST GOOD TO KNOW*

0.9 mg/kg, max 90 mg*

10% given as bolus, rest over one hour

Thrombolytics for AMI – indications (AHA/ACC 2004) Class I STEMI patients presenting to a facility without the capability for expert,

prompt intervention with primary PCI within 90 minutes of first medical contact should undergo fibrinolysis unless contraindicated. (Level of Evidence: A)

Class I1. In the absence of contraindications, fibrinolytic therapy should be administered to STEMI patients with symptom onset within the prior 12 hours and ST elevation greater than 0.1 mV in at least 2 contiguous precordial leads or at least 2 adjacent limb leads. (Level of Evidence: A)

2. In the absence of contraindications, fibrinolytic therapy should be administered to STEMI patients with symptom onset within the prior 12 hours and new or presumably new LBBB. (Level of Evidence: A)

Thrombolytics for AMI – indications (AHA/ACC 2004)Class IIa

1. In the absence of contraindications, it is reasonable to administer fibrinolytic therapy to STEMI patients with symptom onset within the prior 12 hours and 12-lead ECG findings consistent with a true posterior MI. (Level of Evidence: C)

2. In the absence of contraindications, it is reasonable to administer fibrinolytic therapy to patients with symptoms of STEMI beginning within the prior 12 to 24 hours who have continuing ischemic symptoms and ST elevation greater than 0.1 mV in at least 2 contiguous precordial leads or at least 2 adjacent limb leads. (Level of Evidence: B)

Contraindications to thrombolysis (AHA/ACC 2004)

Fair game

Intussusception

3:1 male

5 – 9 months

Ileocolic junction

Sausage-shaped mass

Currant jelly stools

Plain films (U/S), hydrate, NGT, barium enema

Pyloric stenosis

5:1 male

3 to 6 weeks

Projectile vomiting

Palpable olive

Charcoal doesn’t absorb . . .

Lithium

Acids

Alkali

Potassium

Iron

Pesticides

Hydrocarbons

Alcohols

Hemodialysis/hemoperfusion may work for . . .*

Lithium

Salicylates

Theophylline

Isopropyl alcohol

Ethylene glycol

*all of these have low molecular wt, low protein binding, small volume of

distribution

Ingestion

Activated charcoal1 – 2 grams/kilogram*

Multiple dose may work for theophylline, phenobarbital, tegretol, dilantin, digoxin

Gastric lavageConsider for large ingestion, if less than one hour, opiates*, anticholinergics*

Risks include aspiration, perforation

*slow motility

Iron ingestion

< 40 mg/kg elemental not likely to be toxic

Ferrous sulfate is 20% elemental

Treat with deferoxamine if

symptomatic AND level > 350 mcg/dl

-OR-

level of 500 mcg/dl

Iron toxicity – Four stages

GI

Quiescent

Liver failure/metabolic derangement/acidosis

Chronic GI effects

Acetominophen

Toxic dose is 140 mg/kg

-OR-7.5 grams

-OR-Level > 140 at 4 hours by nomogram

N-acetylcysteine dosing is 140 mg/kg, then 70 mg/kg q 4 hours X 17 doses*

Don’t wait for levels

Intravenous N-acetylcysteine

AKA Acetadote

150 mg/kg IV, then 6.25 mg/kg/hr for 16 hours*

Osmolality

2 Na + glucose + BUN + ETOH

Normal 285 – 295

Some agents that increase osmolal gap: methanol, ethylene glycol, isopropanol, ETOH, mannitol

18 2.8 4.6

Alcohols

Methanol formaldehyde(toxic)

formic acid CO2, H2O

(toxic)

Dialysis always an option for methanol and ethylene glycol

ADH

folateETOH and 4MP

saturate

Isopropyl alcohol

Isopropanol acetone ketonuria

exhaled

Does not cause acidosis

Twice as intoxicating as ETOH

Irritating to gastric mucosa; hematemesis

Myasthenic crisisWeakness

Ptosis, diplopia, dysarthria, head drooping

Worsens with repetitionWorse with heat, better with coldTensilon test

Test dose of 1 mg with monitoring then 8 mg IV

• Better = myasthenic crisis• Worse = cholinergic crisis from their meds (look for SLUDGE

that you missed)

Cholinergic insecticides Inhibit acetylcholine esterase Organophosphates Carbamates

Bind reversibly, don’t penetrate CNSEdrophonium, physostigmine are carbamates

Acetylcholine is the neurotransmitter at motor end plates, all preganglionic autonomic synapses, post-ganglionic parasympathetic synapses, and some CNS synapses

Cholinergic insecticides

Thus overstimulates the autonomic nervous system, somatic musculature, and CNS

Clinically, SLUDGE (muscarinic symptoms) + nicotinic symptoms (cramps, weakness) + altered mental status

Treatment Boatloads of atropine

2-PAM only for organophosphates, only works within 24-48 hours, and only on nicotinic symptoms

Electrical injuries

AC Causes tetany, can precipitate ventricular fibrillation

DC Causes single muscle spasm, often throws victim

Asystole

Lightning is like a massive brief DC current, death often due to respiratory arrest inducing a secondary cardiac arrest

Hemorrhage

Class IUp to 15% blood volume

Minimal symptoms

Class II15 to 30% loss, or 750 to 1000 cc

Tachycardia, tachypnea, narrowed pulse pressure

Hemorrhage

Class III30 to 40%, approx. 2000 ccTachycardia, tachypnea, altered mental status, drop in systolic pressure

Class IV > 40% lossImmediately life threateningDecreased urine output

Rule of 9s

Rule of 9’s

Rule of 9’s

Head = 9

Each arm = 9

Each leg = 18

Trunk front = 18

Trunk back = 18

Rule of 9’s

Head = 9

Each arm = 9

Each leg = 18

Trunk front = 18

Trunk back = 18

9 9

9

1

18 x 2

18

18

Parkland formula

4cc/kg/%TBSA½ over the first eight hours, rest over 16 hours

Pediatric burn formula*Maintenance plus 3cc/kg/%TBSA

Diagnostic peritoneal lavage

IndicationsAltered sensorium

Equivocal exam

Your ultrasound is broken*

ContraindicationsAbsolute - need for laparatomy

Relative – previous abd surgery, morbid obesity, advanced cirrhosis, coagulapathy

Foley and NGT first

DPL - Positives

Blunt trauma gross blood

feces

dinner

> 100,000 RBC/cc

> 500 WBC/cc

(+) gram stain

Penetrating trauma 5,000 – 10,000 RBC/cc

Apgar score

0 1 2HR absent < 100 > 100

RESP absent slow/irreg good/cryingTONE limp some flexion active

IRRITABILITY none grimace cough/cryCOLOR blue/pale mixed pink

Neonatal resuscitation

3 : 1 ratio of compressions to breaths

Medications indicated if HR < 60 despite adequate ventilation with 100% O2 and chest compressions

Narcan dose 0.1 mg/kg

Neonatal resuscitation

HR > 100 and pink

BVM*

BVM*

Chest compressions

Epinephrine

Supportive care

Apnea or HR < 100

HR > 60HR < 60

HR < 60

*Or intubation

PALS

BLS 30:2 ratio for lay rescuers of children, health care providers can do 15:2 ratio, 100 compressions/minute

SVT Adenosine 0.1 mg/kg, max 6 mg/kg Cardioversion 0.5 – 1 J/kg

PALS – Bradycardia/Pulseless arrest

Epinephrine IV/IO .01 mg/kg OR 0.1 cc/kg of 1:10,000 (ET dose 0.1 cc/kg of 1:1000)

Atropine .02 mg/kg Minimum 0.1 mg

Max 0.5 mg child, 1 mg adolescent

PALS VF/VT

Defibrillate 2 J/kg, 2-4 J/kg, 4 J/kg

Epinephrine

Amiodarone 5 mg/kg IV/IO*

Lidocaine 1mg/kg IV/IO*

“Drug-shock”

Adult BLS 2005– vent/comp ratio

Ratio is 30:2 for one or two rescuers UNTIL definitive airway is established, rate of 100 compressions/minute, compression depth 1.5 to 2 inches

Aortic dissection

Stanford classification A = ascending

B = descending / distal to left subclavian artery

Debakey classification I = A + B

II = A

III = B

A

B

Adrenal insufficiency

Symptoms Weakness, anorexia, hyperpigmentation (primary AI only,) weight loss, abd pain, nausea, vomiting

TherapyIVF

Hydrocortisone 100 – 200 mg IV* OR decadron IV (doesn’t mess up Cosyntropin stim test)

Thyroid storm - management

Antipyretics

Propranolol

PTU

Iodine (one hour after PTU)

Hydrocortisone 100 mg IV*Inhibits peripheral conversion of T4 to active T3

Drugs that precipitate heat stroke

Amphetamines

Cocaine

Anticholinergics

Phenothiazines

Anti-hypertensives

Hypothermia

Mild 33 - 35 C maximal shivering, slurred speech

Moderate 29 - 32 C altered mental status, incoordination, rigidity

Severe < 28 C mydriasis, Osborn waves, bradycardia

Tumor lysis syndrome

Symptoms Renal failure from hyperuricemia, arrhythmia, hyperkalemia, hypocalcemia

Management IVF, allopurinol, alkalinize urine, dialysis

Kanavel’s signs of tenosynovitis

Pain with passive extension

Sausage/circumferential swelling

Finger held flexed

Tender to palpation along sheath

Carbon monoxide

Room air half-life = 320 minutes

100% NRB = 80 minutes

3 ATM hyperbaric = 23 minutes

Consider hyperbaric for comatose/sick victims of carbon monoxide

Beware the whole family with headaches and gastroenteritis

Cyanide – Lilly kit

Methemoglobin

Nitrite + hemoglobin

CN- CN-MetHgb

Sodium thiosulfate thiocyanate Renal excretion

Pregnancy-induced hypertensionaka Pre-eclampsia

Moderate – hypertension > 140/90, proteinuria

Severe – thrombocytopenia, hypertension > 160/110, elevated liver transaminases

HELLP – Hemolytic anemia, Elevated Liver enzymes, Low Platelets

Hemolytic-uremic syndrome

Usually < 5 years

Nephropathy, microangiopathic hemolytic anemia, thrombocytopenia

Associated with E.coli 0157:H7, Salmonella, and Shigella gastroenteritis

Intussusception, hypertension, CNS effects

Pallor, petechiae, purpura

Thrombotic thrombocytopenic purpura

Altered mental status

Thrombocytopenia

Renal failure

Microangiopathic hemolytic anemia

Fever

Von willebrand’s disease

Most common inherited bleeding disorder

Autosomal dominant

Increases PTT and bleeding time, NOT PT/INR

Therapy – cryoprecipitate, DDAVP

Hemophilia A

X-linked recessive

Increases the PTT

Major bleeds require 50 units/kg of Factor VIII*

Cryoprecipitate and DDAVP also helpful

Hemophilia B (Christmas disease)

For major bleeds, 50 units/kg of Factor IX* or large doses of FFP

Cryoprecipitate not helpful

Food-related squirtsBacillus cereus – fried riceClostridium perfringens – cooked poultry or meat that is not refrigerated promptly

Most common bug in food-related illness

Staphlycoccal – starts within one to six hours of ingestion, heavy vomiting, resolves in six to eight hoursScromboid – whitefish, histamine-like symptoms, especially flushing and cramps

Adult anaphylaxis

Mild symptoms (not hypotensive per PEER VI question)

.3 - .5 cc 1:1000 SQ or IM

Ill/hypotensive 1 ml of 1:10,000 slow IVP (3 to 5 minutes) with caution (PEER VI) Alternate drip: 1 ml of 1:1000 in 250 ml D5W (or NS) makes 4 mcg/ml , run at 1 to 4 mcg/min

Peds anaphylaxis

.01 cc/kg 1:1000 SQ/IM up to .5 ml

Flexion “teardrop” fracture

Very unstable

Diving injuries

Extension mechanism can cause same injury, often in elderly who fall on their chin

“Clay shoveler’s” fracture

Stable

C7>C6>T1

Hyperflexion, interspinous ligament avulses part of spinous process

Bilateral facet dislocation

Very unstable

Best seen on oblique views

“Hangman’s fracture”

Unstable

Traumatic spondylolyis of C2

Atlanto-occipital dislocation

Unstable

Almost always fatal

Tearing of all ligamentous connections between C1 and occiput

Jefferson Fracture

Unstable

Four part burst fracture of C1

Associated with axial load / diving

Lateral masses shifted laterally on odontoid view

Odontoid fracture Type I

Stable

Tip of dens avulsed

Odontoid fracture Type II

Unstable

Most common

Transverse fracture at base of odontoid

Odontoid fracture Type III

Potentially unstable

Fracture through body of C2 involving both articular facets

Compartment Syndrome

Pallor, paresthesias, paralysis, pulselessness, and pain

Normal pressures 0 to 8 mm Hg

>30 mm Hg requires fasciotomy

HIV drug side effects

Crixivan (Indinavir)

AZT (Zidovudine)

ddI (Didanosine)

Foscarnet

Epivir (Lamuvidin)

Renal stones

Vomiting

Pancreatitis

Nephrotoxicity

cough

Other drugs that should make you suspicious . . .

Phenothiazines

Warfarin

Phenytoin

Sulfonylureas

Antihistamines

-Azoles

Statins

Sulfas (including celocoxib, furosemide)

Presentations that should make you suspicious for drug reactions

Rashes

Bleeds

Syncope

Arrhythmia

Hypoglycemia

Rubella

Prodrome low grade fever, sorethroat, headache, malaise

Pink or red maculopapular

Face, then neck, then trunk and extemities

May be coalescent

Suboccipital and retroauricular nodes

Fifth Disease

4 to 10 year olds

Erythema infectiosum

Parvovirus B-19

Slapped cheek (spares eyelids, chin, perioral area)

Then discrete “lacy” trunk and extremity rash

Rubeola (measles)

Fever, cough, rhinorrhea, conjunctivitis, photophobia

Day 2 - Koplik’s spots (bright red, blue-white centers)

Rash appears on day 3 to 5, erythematous, maculopapular, starts on back of neck and forehead hairline, then goes south

Roseola

Six months to three years

HHV 6

Exanthem subitum

3 to 4 days of high fever

Then defervescense and 1 to 2 day maculopapular rash (trunk to extremities)

Rocky Mountain Spotted Fever

Rickettsia Rickettsi

Abrupt fever, myalgias, fatigue

Starts on palms, soles, wrists, ankles

Then goes central

Becomes palpable and red, then petechial within 3 days

Chloramphenicol and tetracycline

Kawasaki’s disease

Fever (usually > 40C) for five days PLUS at least FOUR of the following:

Conjunctival injection

Mucous membrane findings (strawberry tongue, fissuring/cracking of lip, hyperemic pharynx)

Palm/sole edema and erythema (later desquamation)

Rash

Cervical adenopathy, with one node > 1.5 cm

Kawasaki’s disease - treatment

IVIG

Aspirin

Echo (serially)

Henoch-Schonlein purpura

Peaks at 4 – 5 years, winter/spring

Skin – palpable purpura, gravity dependent

Nephropathy (may cause lasting damage)

GI – vomiting, bleeding, intussusception

Joint swelling, extremity and facial edema

Treatment: supportive, steroids (efficacy not proven)

Central cord syndrome

Old person fall and go boom

Arm > leg involvement

Hyperextension

Ligamentum flavum

Two RSI drugs that increase ICP

Ketamine

Succinylcholine

Seizures not responding to standard therapy

Think TCAs Avoid IA anti-arrhythmics

Sodium bicarbonate

Or Isoniazid Pyridoxime

Euvolemic hyponatremia

SIADH = inappropriately [urine]

Psychogenic polydipsia = dilute urine

Steroids in meningitis

Dexamethasone 10 mg IV* before or as first dose of antibiotics is given

Pediatric dose : 0.15 mg/kg*

Give Q 6 hours until causative organism is known

Acute mountain sickness

Symptoms include headache plus at least one of the following:

Anorexia Nausea Vomiting Dizziness Insomnia Lassitude

Acute mountain sickness - management

Mild Descend 500 m, or hold current altitude and rest/acclimate, acetazolamide, anti-emetics, NSAIDS

Severe Descend or hyperbaric

Acetazolamide

Dexamethasone

HACE

Symptoms of acute mountain sickness plus altered mental status

Management: Immediate descent (or hyperbaric)

Dexamethasone

O2

Acetazolamide

HAPE

Immediate descent or hyperbaric

O2 (reduces PA pressure 30 – 50 %)

Nifedipine lowers PA pressure also, but does not increase partial pressure of arterial O2

Croatalid evenomationsNo Envenomation: No local or systemic manifestations.Minimal Envenomation: Local swelling and other local changes; no systemic manifestations; normal laboratory findings.Moderate Envenomation: Swelling progressing beyond the site of bite and one or more systemic manifestations; abnormal laboratory findings, for example, a fall in hematocrit or platelets.Severe Envenomation: Marked local response, severe systemic manifestations and significant alteration in laboratory findings Dose

Moderate - 2 to 4 vials antiveninSevere – 10, 20, up to 40 vials

CroFab vs. Antivenin PolyvalentAnaphylaxis risk/prepare!

Elapidae evenomationsChompers (cobra family)Venin blocks acetylcholine

Slurred speech Ptosis Midriasis Paralysis Respiratory failure

Few/no local reactionsEquine Antivenin

Micrurus fulvius

Visual stimuli

Visual stimuli

Visual stimuli

Visual stimuli

Dr. Horner

Visual stimuli

Visual stimuli

Visual stimuli

Visual stimuli

Kid’s butt with purple

spots – easy, right?

Visual stimuli

Visual stimuli

Your blind date from Connecticut . . .

Visual stimuli

Your blind date from hell

Your blind date from Connecticut . . .

Visual stimuli

Visual stimuli

Visual stimuli

Visual stimuli

Visual stimuli

Visual stimuli

Visual stimuli

Yellow on black – friend of Jack

Black on yellow – kill a fellow

Visual stimuli

Visual stimuli

Visual stimuli – Name the trisomy

Visual stimuli – Name the trisomy

Visual stimuli – Google search Queen, John

John Lewis Queen

And finally . . .

What band lead the Gallup poll as most popular for 1977, had the highest grossing tour of 1996, AND has more Gold records than the Beatles?

The ABEM philosophy?

Keep

It

Simple,

Stupid