inservice review 2006 high yield facts
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Inservice review 2006 High 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 - PowerPoint PPT PresentationTRANSCRIPT
Inservice review 2006High yield facts
Steven T. Dorsey, MDDepartment of Emergency Medicine
The Cleveland Clinic FoundationMetroHealth 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
DKAEstimated 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 Eyes
4 Open3 Voice2 Pain1 No response
GCS Verbal
5 Oriented4 Confused3 Inappropriate2 Sounds1 None
GCS Motor
6 Follows commands5 Localizes4 Withdraw3 Decorticate2 Decerebrate1 None
GCS example18 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 voiceVerbal = 3, inappropriateMotor = 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 charcoal
1 – 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 GIQuiescentLiver failure/metabolic derangement/acidosisChronic 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-acetylcysteineAKA Acetadote150 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
AlcoholsMethanol formaldehyde(toxic)
formic acid CO2, H2O
(toxic)
Dialysis always an option for methanol and ethylene glycol
ADH
folateETOH and 4MP
saturate
Isopropyl alcoholIsopropanol acetone ketonuria
exhaled
Does not cause acidosis Twice as intoxicating as ETOH Irritating to gastric mucosa; hematemesis
Myasthenic crisisWeakness
Ptosis, diplopia, dysarthria, head droopingWorsens 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 insecticidesThus overstimulates the autonomic nervous system, somatic musculature, and CNSClinically, SLUDGE (muscarinic symptoms) + nicotinic symptoms (cramps, weakness) + altered mental statusTreatment
Boatloads of atropine2-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 I
Up to 15% blood volumeMinimal symptoms
Class II15 to 30% loss, or 750 to 1000 ccTachycardia, tachypnea, narrowed pulse pressure
Hemorrhage Class III
30 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
1818
Parkland formula 4cc/kg/%TBSA
½ over the first eight hours, rest over 16 hours
Pediatric burn formula*Maintenance plus 3cc/kg/%TBSA
Diagnostic peritoneal lavage Indications
Altered sensoriumEquivocal examYour ultrasound is broken*
ContraindicationsAbsolute - need for laparatomyRelative – 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 resuscitationHR > 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
AB
Adrenal insufficiency Symptoms
Weakness, anorexia, hyperpigmentation (primary AI only,) weight loss, abd pain, nausea, vomiting
TherapyIVFHydrocortisone 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 minutesConsider hyperbaric for comatose/sick victims of carbon monoxideBeware 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 syndromeUsually < 5 yearsNephropathy, microangiopathic hemolytic anemia, thrombocytopeniaAssociated with E.coli 0157:H7, Salmonella, and Shigella gastroenteritisIntussusception, hypertension, CNS effectsPallor, 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/INRTherapy – 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 illnessStaphlycoccal – 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 anaphylaxisMild 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” fractureVery unstableDiving injuries
Extension mechanism can cause same injury, often in elderly who fall on their chin
“Clay shoveler’s” fractureStableC7>C6>T1Hyperflexion, interspinous ligament avulses part of spinous process
Bilateral facet dislocationVery unstableBest seen on oblique views
“Hangman’s fracture”UnstableTraumatic spondylolyis of C2
Atlanto-occipital dislocationUnstableAlmost always fatalTearing of all ligamentous connections between C1 and occiput
Jefferson FractureUnstable Four part burst fracture of C1Associated with axial load / diving Lateral masses shifted laterally on odontoid view
Odontoid fracture Type IStableTip of dens avulsed
Odontoid fracture Type IIUnstableMost common Transverse fracture at base of odontoid
Odontoid fracture Type IIIPotentially unstableFracture through body of C2 involving both articular facets
Compartment SyndromePallor, paresthesias, paralysis, pulselessness, and painNormal pressures 0 to 8 mm Hg>30 mm Hg requires fasciotomy
HIV drug side effectsCrixivan (Indinavir)AZT (Zidovudine)ddI (Didanosine)FoscarnetEpivir (Lamuvidin)
Renal stonesVomitingPancreatitisNephrotoxicitycough
Other drugs that should make you suspicious . . .
PhenothiazinesWarfarinPhenytoinSulfonylureas
Antihistamines-AzolesStatinsSulfas (including celocoxib, furosemide)
Presentations that should make you suspicious for drug reactions
RashesBleedsSyncopeArrhythmiaHypoglycemia
RubellaProdrome low grade fever, sorethroat, headache, malaisePink or red maculopapularFace, then neck, then trunk and extemitiesMay be coalescentSuboccipital and retroauricular nodes
Fifth Disease4 to 10 year oldsErythema infectiosumParvovirus B-19Slapped cheek (spares eyelids, chin, perioral area)Then discrete “lacy” trunk and extremity rash
Rubeola (measles)Fever, cough, rhinorrhea, conjunctivitis, photophobiaDay 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
RoseolaSix months to three yearsHHV 6Exanthem subitum3 to 4 days of high feverThen defervescense and 1 to 2 day maculopapular rash (trunk to extremities)
Rocky Mountain Spotted FeverRickettsia RickettsiAbrupt fever, myalgias, fatigueStarts on palms, soles, wrists, anklesThen goes centralBecomes palpable and red, then petechial within 3 daysChloramphenicol and tetracycline
Kawasaki’s diseaseFever (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 - treatmentIVIGAspirinEcho (serially)
Henoch-Schonlein purpuraPeaks at 4 – 5 years, winter/springSkin – palpable purpura, gravity dependentNephropathy (may cause lasting damage)GI – vomiting, bleeding, intussusception Joint swelling, extremity and facial edemaTreatment: supportive, steroids (efficacy not proven)
Central cord syndromeOld person fall and go boomArm > leg involvementHyperextensionLigamentum flavum
Two RSI drugs that increase ICPKetamineSuccinylcholine
Seizures not responding to standard therapy
Think TCAs Avoid IA anti-arrhythmics Sodium bicarbonate
Or Isoniazid Pyridoxime
Euvolemic hyponatremiaSIADH = inappropriately [urine]Psychogenic polydipsia = dilute urine
Steroids in meningitisDexamethasone 10 mg IV* before or as first dose of antibiotics is givenPediatric dose : 0.15 mg/kg* Give Q 6 hours until causative organism is known
Acute mountain sicknessSymptoms 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
HACESymptoms of acute mountain sickness plus altered mental statusManagement:
Immediate descent (or hyperbaric) Dexamethasone O2 Acetazolamide
HAPEImmediate descent or hyperbaricO2 (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 – 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