Karteikarten
PB
Karten in diesem Stapel (102)
- 1Reversible causes of Cardiac arrestH's: hypovolemia, hypoxia, hydrogen, hypo/hyper K, hypothermia
T's: Tension, tamponade, thrombosis, toxic, - 2Well's criteria3 - suspect PE
3 - clinical signs of DVT
1.5 - bedridden
1.5 - HR > 100
1.5 - hx of DVT/PE
1 - malignancy
1 - hemoptysis - 3Wells score interpretationScore > 7
Score > 2-6
Score < 2.0 - 4Perc criteriaHAD CLOTS: hormone therapy, age > 50, DVT hx, Cough, LE swelling, hypoxia, Tachycardia, surgery/trauma
- 5LEMONSLook, evaluate, mallampati, obstruction/obesity, neck
- 6MOANSmask seal, obst/obesity, age > 50, no teeth, stiff lungs
- 7epi for anaphylaxisEpinephrine:
•IM 1:1000 IM near the reaction site
•Adult: 0.3-0.5 mL q5 min, titrated to effects
•Peds: 0.01 mL/kg, q5 min, titrated to effects
•EpiPen 0.3 mL or EpiPen Jr 0.15 mL in anterolateral thigh - 8epi IV for anaphylaxisIV 1:100,000 at 1 ml per minute titrated to effects
•To make 1 mL of 1:1000 in 1L bag of NS) - 9other meds for anaphylaxisAlbuterol 2.5mg/Atrovent 0.5 Nebulizer
•Diphenhydramine 50 mg (Peds 1 mg/kg) IV/PO
•Ranitidine: 50 mg IV (150 mg PO) (Peds 1 mg/kg IV/PO)
•Methylprednisolone 125-250 mg IV (Peds 1-2 mg/kg/IV) - 10Hyperkalemia Differential Diagnosis: (SLEEP)Shift: acidosis, burns, insulin deficiency, succinylcholine, digoxin, beta-blockers
•Load: supplements, hemolysis, GI bleed, rhabdomyolysis, transfusions, chemotherapy
•↓ Excretion: renal failure, ACE inhibitor, hypoaldosteronism, spironolactone
•Pseudo: hemolysis, tourniquets - 11Hyperkalemia tx: kayexalate doseageKayexalate 15-30 g PO, or 50 g PR (ped: 1 g/kg) with sorbitol
- 12hypothermia temp rangesSevere: (28°C/82°F)
Moderate: (32°C/90°F)
Mild: (35°C/95°F) - 13hypothermia warming goal>35C
- 14hypothermia: don't declare untilDon’t declare until 35°C/95°F and dead.
- 15status asthmaticus 1st treatmentAtivan 0.1 mg/kg IV/IM (at 2mg/min); repeat q5min x4 (↑ duration)
•OR Valium 0.2 mg/kg IV (at 5 mg/min); rpt q5min x4 (faster onset) - 16Status asthmaticus 2nd line•Second Line Treatment:
•Fosphenytoin 20 (15-20) PE/kg IV/IM load at 150 PE/min OR
•Phenytoin 20 (15-30) mg/kg IV load at 50mg/min
•Give over 20 minutes usually (Propylene glycol diluent causes ↓ BP, dysrhythmias if rapidly infused.
•9 mg/kg load if already on Dilantin
•May give simultaneous with benzos
•But not in same line & no glucose in line (precipitates)
•Phenobarbital 20 (10-20) mg/kg IV at 50 mg/min. - 17ACS tx:NTG 0.4mg q5 x 3 sprays
lovenox 1mg/kg sq or heparin 60U/kg bolus then 12U/kg heparin
Emergent PCI if available (90 minutes of arrival)
•Thrombolytic (If no PCI in 90 minutes): - 18CVA t-PA doseDose: 0.9mg/kg (max 90mg)- give 10% as bolus dose followed by an infusion lasting 60 minutes.
•If not a tPA candidate and no ICH, then give ASA 325. - 19hemorraghic CVA anti HTN eNicardipine gtt, start at 5mg/h, titrate
•Labetalol 10-20mg IV push q20min to max 150mg5 - 20RSI status asthmaticuslidocaine 1.5mg/kg 3mins prior
ketamine 1-2mg/kg IV
succ
Propofol gtt 0.1-0.2 mg/kg/min + Fentanyl gtt 0.5-1.5mcg/kg/min - 21rsi peak flow rate•Peak Flow
•<70% abnormal (Av adult ♂ <450, ♀ <325)
•<40% severe (Av adult ♂ <260, ♀ < 180)
•PaO2, SaO2 (<90% severe), EtCO2 - 22HTN encephalopathy txLabetolol 20mg IV, double dose q10 min until goal achieved (max 300mg). Consider infusion 1-2mg/min
- 23aortic dissection txEsmolol 500mcg/kg IV ovr 1 min, then 50mcg/kg/min gtt. Target HR 60-80
AND
•Nitroprusside: 0.25-10 mcg/kg/min OR
Target is SBP <120
•Alternatively, use Labetalol as single-agent therapy. 5-20 mg bolus 20-40 mg q10-15 min - 24Immediate Action Items: Increased Intracranial Pressure2.Mannitol 1gm/kg, followed by 0.25gm/kg q6 H (hold for serum osmolality >320)
3.Hypertonic saline 3% 250ml bolus - 25First 15 Minutes: AMS, tx for menigitiswGet LP & Treat For Menigitis:
•Dexamethasone 10 mg IV
•Rocephine 2 gm IV
•Vancomycin 1 gm IV
•Acyclovir 10 mg/kg IV
•Consider Flumazenil 0.2 mg IV q1 min, only for known ingestion - 26NAC treatment for APAP toxNAC: PO or IV
PO: 140mg/kg, then 70mg/kg q4h x17 doses
IV: 150mg/kg IV over 30min, then 50mg/kg over 4h followed by 100mg/kg over 16h
Stop when APAP <10ug/ml and normal LFTs and INR - 27ASA tox doseAcute Toxic Dose: single ingestion of >150mg/kg
•150-300 mg/kg – Mild
•300-500 mg/kg – Moderate
•>500 mg/kg – Likely Fatal - 28ASA tox indications for dialysisLevel >100mg/dL in acute intoxication
•Level >50mg/dL in chronic intoxication - 29TCA tox tx.Treatment (Based on QRS >100msec):
1.Consider 1 dose activated charcoal 1g/kg if mental status
2.NaHCO3: (dysrhythmias or hypotension): 1-2 amps IV push (1mEq/kg for peds) pH goals: 7.45-7.55
3.Pressors: Dopamine or norepi for refractory ↓ BP
4.Treat altered mental status with early elective intubation, as acidosis worsens the condition. - 30CO tox tx: Hyperbaric O2 indications:Age >50yrs
•COHgb >25%
•Loss of consciousness
•Syncope
•Cerebellar or Focal Neuro Findings
•Cardiovascular Depression or Ischemia
•Metabolic Acidosis
•Pregnancy - 31benzo tox tx3.Flumazenil 0.2 mg IV over 30 sec, wait 3 min for response → 0.3 mg over 30 sec, wait 3 min → 0.5 mg over 30 sec then q1min to (max of 3 mg) → 0.5 mg q1 min (max of 5 mg)
- 32anticholin tox pathophysInhibits acetylcholinesterase → ↓ destruction of acetylcholine
- 33anticholin tox sx:dumbbels
diarrhea/diaphoresis, urination, miosis, bradycardia, bronchospasm, emesis, lacrimation, salivation - 34anticholin tox txatropine: Start with 1-2 mg and double q5 minutes
2-pam: 1-2gm in NS IV over 30min
benzo for seizure - 35Antidotes: Lead•BAL= Dimercaprol 4mg/kg IM q4h
- 36Antidotes: Iron•Deferoxamine:
•1 gm IM - 37Antidotes: Toxic AlcoholsEthylene Glycol or Methanol
•EtOH gtt (Goal EtOH level is 100 mg/dL):
•10% mixed in D5W
•Load 7-10 mL/kg
•Then maintenance at 1-1.5mL/kg/hr)
•Fomepizole:
•Load 15mg/kg
•Then 10 mg/kg IV q12 x 4 - 38BB tox txGlucagon:
•2-5 mg IV q10 min
•May require large doses, intubate early PRN. - 39Ca blocker tox txGoal is to drive Ca to 14 mg/dl.
•Ca-gluconate 20-60 mL of 10% solution IV q15 min x 4
•CaCl2 (if central line) 10-20 mL of 10% solution q15 min x 4
•Consider IV infusion (0.5 meq/kg/hr)
•Glucagon 2-5 mg IV
•Insulin 0.1 – 10 U/kg/hr IV with D50 1-3 amps/hr or D5 or D10 to maintain euglycemia - 40cyanide tox txHydroxocobalimine/Cyano-kit 5 gm
- 41Antidotes: MethemaglobinemiaMethylene blue 1mg/kg IV of 1% solution
•Reduces the iron from a 3+ state to a 2+ state.
•Avoid in G6PD patients as it can cause hemolysis. - 42Toxidrome: Opiate WithdrawalYAWNED
Yawning
Agitation
Wet – Sweating
Nausea/Vomiting/Diarrhea
pilo-Erection
Don’t sleep - 43Toxidrome: Ethanol WithdrawalSSSSHHT
Sweaty
Sweaty
Shakes - Tremors
Seizures
HTN
Hallucinations
Tachycardia - 44Toxidrome: TCATachycardia
Hypotension
Widened-QRS
Anti-Cholinergic Symptoms
Seizures - 45Norepinephrine (doses and indicationsStart 2-4 mcg/min (0.025 – 0.05 mcg/kg/min)
•Indications: Distributive (septic), Obstructive, or Cardiogenic shock - 46Phenylephrine (doses and indications)0.1 – 0.5 mg IV q 15 min
- 47Epinephrine (doses and indications)Start 2-4 mcg/min (0.025 – 0.05 mcg/kg/min)
•Indications: Cardiac arrest, anaphylactic shock, severe bronchospasm or larygospasm - 48Vasopressin (doses and indications)Start 0.1-0.4 U/min
•Indications: As an adjuvant therapy with NE or dopamine in treatment of septic and other forms of shock - 49Nitroprusside (doses and indications)Start 0.25-10 mcg/kg/min, and titrate to MAP
•Indications: Acute afterload reduction in aortic dissection, acute decompensated CHF, renal failure, and other hypertensive emergencies - 50Nitroglycerin (doses and indicationsStart 40-60mcg/min (0.5 – 0.75mcg/kg/min) and titrate to desired MAP
•Indications: Acute decompensated CHF, unstable angina, or acute MI - 51Esmolol (doses and indications0.5 mg/kg IV over 1 min
•Then followed by 0.05 mg/kg/min gtt - 52Labetalol (doses and indicationsAortic Dissection:
•5-20 mg bolus
•Then up to 20-40 mg q10-15 min
Hypertensive Emergencies:
•Load 20 mg IV over 2 minutes every 10 minutes
•Then 40-80 mg IV every 10 minutes to max of 300 mg OR
•Drip at 1-2 mg/min - 53proprofol doseageInduction
•Peds: 2.5-3.5 mg/kg IV
•<55 yo: 2-2.5 mg/kg IV
•>55 yo: 1-1.5 mg/kg IV
•Maintenance
•Peds: 0.125-0.3 mg/kg/min IV
•<55 yo: 0.1-0.2 mg/kg/min IV
•>55 yo: 0.05-0.1 mg/kg/min IV - 54ketamine dosageInduction
•1-4.5 mg/kg IV
•6.5-13 mg/kg IM
•Sedation
•1-2 mg/kg IV
•Chronic Pain
•0.1-0.4 mg/kg IV - 55versed doses and indications•Induction:
•0.3 mg/kg IV
•Sedation of Intubated Patients:
•0.1-0.5 mg/kg IV q10-15 min PRN - 56Succinylcholine (dose, onset & duration)1.5 mg/kg IV
30-60 seconds
2-10 minutes - 571 (0.6-1.2) mg/kg IV 1-2 minutes 30-60 minutesRocuronium (dose, onset & duration)
- 58Vecuronium (dose, onset & duration)0.1 mg/kg IV
3-5 minutes (unless premed)
20-35 minutes - 59Morphine (doses and indicationsSedation of Intubated Patient:
•0.1 mg/kg IV
•Pain Control
•Adults: 0.05-0.1 mg/kg IV load then 0.8-10 per hr IV (↓ dose for elderly) - 60Fentanyl (doses and indications)Sedation of Intubated Patient:
•1 mcg/kg IV
•Sedation of Intubated Patient:
•1 mcg/kg IV
•Pain Control
•Adults: 50-100 mcg/kg q 1-2 hrsPain Control
•Adults: 50-100 mcg/kg q 1-2 hrs - 61Ativan (doses and indications)•Sedation of Intubated Patient:
•0.05 (0.02-0.06) mg/kg IV q6° PRN
•Status Epilepticus
•Adult: 4 mg IV
•Peds: 0.05-0.1 mg/kg IV - 62Precedex (doses and indications)•Sedation of Intubated Patient:
•Load 1 mcg/kg IV
•Maintiance 0.2-0.7 mcg/kg/hr IV - 63RSI PremedicationsLOAD Lidocaine 1.5mg/kg IV Opioid =Fentanyl 3mcg/kg IV Atropine (Peds or rebolus sux): 0.02mg/kg IV Defasiculating medications: 10% dose Rocuronium 0.1mg/kg Vecuronium 0.01mg/kg Sux 0.15mg/kg IV
- 64There are 3 key fractures: to see on shoulder dislocationHill-Sachs lesion →
humeral head is damaged
by the sharp anterior rim
of the glenoid.
2. Bankart fracture → a
fracture of the inferior
glenoid rim from impaction
of the dislocated humeral
head.
3. The most common is a
fracture of the greater
tuberosity of the humerus. - 65types of shoulder reductionstimson
traction-countertraction
scapular rotation
external rotation - 66types of posterior elbow reductiontraditional traction method
minford and beattie (186) - 67transvaginal ultrasound goalTransvaginal
1.Find cornual flare (uterus-fallopian tube junction), ovaries are lateral.
2.Scan left to right.
3.Transverse- same orientation as CT scan
4.Longitudinal- scan left to right
5.Empty bladder helps - 68gestational age and US works to see4: gest sac: 1500 HCG
5: yolk sac
6: fetal pole - 69aorta and iliac diametersSTANDARD FINDINGS – Measure from outer wall to outer wall. To include luminal clot.
PATHOLOGY
1.Aorta >3 cm
2.Iliac Arteries >1.5 cm
3.Abdominal Free Fluid - 70SIRS criteriaSIRS Criteria:
• Temp >38.3 or <36
• HR >90
• RR >20 or PaCO2 <32
• WBC >12,000 or <4000 or >10% bands - 71types of sepsisSIRS Criteria:
• Temp >38.3 or <36
• HR >90
• RR >20 or PaCO2 <32
• WBC >12,000 or <4000 or >10% bands
Sepsis: SIRS and a presumed or documented focus of infection
Severe Sepsis: Sepsis complicated by organ dysfunction, hypotension before fluid challenge, or lactate ‚4 mmol/L
Septic Shock: Sepsis with persistent hypotension, despite 2-3 L of fluid IV, this is where Early Goal Directed Therapy is best. - 72correct for serum sodium in hyperglycemiaSerum Sodium Correction:
Add 1.6 mEq/L Na+ for each
100 mg/dL Glucose >100 - 73Discuss the management of difficult vaginal delivery due to shoulder dystocia:HELP: Call for OB, peds, anesthesia
2.Episiotomy: Cut large episiotomy
3.Lithotomy position: McRobert’s maneuver
4.Pressure over the suprapubic area
5.Enter the vagina
6.Rubin’s maneuver: push most accessible shoulder toward fetal chest
7.Wood’s maneuver: Grasp axilla or fetal hips and corkscrew fetus to rotate shoulder under symphysis pubis
8.Remove posterior arm:
9.Splint, sweep, grasp, and pull arm to extension through the vagina across the face - 74Discuss the management of difficult vaginal delivery due to breech presentation:Breech:
1.Generous episiotomy
2.Knee flexion and sweep out legs
3.Pull out 10-15cm of umbilical cord after umbilicus clears the perineum (allows for more room to work)
4.Support the infant by the bony pelvis
5.Keep face and abdomen away from the symphysis pubis, and rotate if necessary to deliver the most accessible arm
6.Mauriceau maneuver: insert fingers into the fetal mouth to flex the neck and draw in the chin. This avoids fetal head extension which can cause spinal cord injuries. - 75Discuss the management of difficult vaginal delivery due to multiple gestation:Multiple Gestation:
1.Determine the lie of each twin.
2.Twin A is non-vertex or breech – C section for both.
3.Twin A is vertex and twin B is non-vertex - manipulate the 2nd twin to vertex.
4.If twin B not come within minutes of twin A, then assess twin B with ultrasound to determine presentation and cardiotocographic monitoring. - 76neonatal resuscitationreview
- 77Discuss the indications and tools needed for newborn intubation:Meconium suctioning in NON-vigorous baby
2. Diaphragmatic hernia
3. Prolonged PPV
Laryngoscope Sizes:
Blade Age
No. 1 Full Term
No. 0 Preterm
No. 00 Extreme Preterm
Newborn Intubation:
Tube Weight Age
2.5 mm <1 kg <28 wks
3.0 mm 1-2 kg 28-34 wk
3.5 mm 2-3 kg 35-38 wk
4.0 mm >3 kg >38 wks - 78neonate fever organism to considerOrgansims to consider → GBS, Listeria, E. Coli
- 79neonate fever abxEmperic Antibiotics:
•Amp 25 mg/kg IV plus either
•Gent 2.5 mg/kg or Cefotaxime 50 mg/kg IV
•Add Vancomycin if NICU baby
•Acyclovir 20 mg/kg if risks exist - 80Describe the evaluation of a fever in a infant 1-3 months of age:29-90 Days: (Fever is >38.0°C or >100.4°F)
•Septic workup → CBC, UA, Urine, Blood, (LP optional, but must perform if antibiotics will be given)
•Emperic Antibiotics:
•Amp 25 mg/kg IV plus either
•Ceftriaxone 100 mg/kg IV (Meningitis dosing)
•Add Vancomycin if GBS resistance is common
•If toxic or positive findings on septic workup → Emperic Amtobiotics & Admission
•If non-toxic and negative septic workup → 24 hour outpatient follow up with ±IM Ceftriaxone - 81Indications for Thoracotomy:Operating Room:
Initial chest tube output of >1500 ml
Chest tube output > 200 mL/hr x 6 hr
Hemopericardium with vital signs
Severe tracheobronchial injury - 82Hard Signs of vascular injury (need immediate OR)Hard Signs of vascular injury (need immediate OR)
•Neurological deficit
•Shock
•Pulsatile bleeding
•Expanding hematoma +/- airway compromise
•Bruits or thrills
•Loss or diminished distal pulse
•Hemothorax - 83penetrating neck zonesZone 3: above angle of mandible
Zone 2: cricoid to angle of mandible
Zone 1: base of neck to cricoid - 84intervention per zonesZone 3:
•Aniography is procedure of choice to rule out vascular injury, both diagnostic and therapeutic.
•Zone 2:
•Platysma violated go to the OR for exploration.
•Otherwise, color-flow Doppler, positive take to OR or angiography.
•CT scan of neck if clinically stable and airway secured with ETT.
•Zone 1:
•Angiography &/or Doppler to r/ocarotid injury
•Direct laryngoscopy to rule out tracheal or laryngeal injuries (soft tissue neck or CT scan if stable and airway already secured with ETT)
•Esophagram with gastrograffin (1st) followed by barium if negative, or CT scan of chest (equally sensitive)
•Esophagoscopy (rigid) for any concerns of upper esophageal injury. - 85Retropharyngeal space:Retropharyngeal space:
•7mm at C2
•22mm at C7 - 86Atlanto-Dens Space:Atlanto-Dens Space:
•3mm adult, 5mm child - 87Describe the common C-spine injury patterns (6 items) and neurological exam findings of a C-spine injury (4 items):Clay shoveler’s fx = lower spinous process fx
•Hangman’s fx = spondylolisthesis C2/C3
•Flexion teardrop fx = ant/inf VB fx
•Extension teardrop fx = Avulsion C2
•Jefferson burst fx = C1 arch fx
•Hyperextension injury = no fx, soft tissue edema only
Common Neurological Exam Findings:
•C4 Neck/spontaneous breathing
•C5 Shoulder and arm/shrug shoulders
•C6 Thumb/elbow flexion
•C7 Third digit/elbow extension - 88In the lateral ankle view below name the bones and describe how to find and use Bohler’s angle:Bohler’s angle range: 25°-40°
Suspect fracture if <25°
Obtain CT at that point - 89In the AP mortis ankle view below name the bones and describe the anatomic relationships:Tibiofibular Clear Space <5 mm
Tibio-Fibular Overlap ≥10 mm
Lateral Malleolar Fractures below the tibiotalar joint (Weber A) usually only require casting & follow up. Above it should have Ortho consult. - 90For which ankle fractures is orthopedic consultation in the ED recommended?unimalleolar fx with displacement and/or ligament rupture
All bimalleolar fractures
All trimalleolar fractures
All intra-articular fractures with step deformity
All open fractures
All pilon (comminuted fracture of the distal tibia) fractures - 91lis franc fxDx Lis Franc Injury:
1)Plantar bruises in area.
2)>1 mm between 1st & 2nd metatarsal heads
3)Avulsion fx at the base of the 2nd metatarsal on the medial side. - 92jones fx5th metatarsal fx distal to the joint between the proximal 4th & 5th metatarsals (i.e. Jones fx) needs to be non weight bearing with ortho f/u in ~2 days for surgical eval
- 93elbow fx xr1. Hourglass Sign/Figure Of 8
2. Anterior Fat Pad (Sail Sign)
•Sail Sign + Trauma = Intraarticular Fracture.
•No Trauma = Inflammatory Intraarticular Fluid
3. Posterior Fat Pad – always abnl, implies fx
4. Anterior Humeral Line – middle ⅓ of capitellum
5. Radio-capitellar Line – middle ⅓ of capitellum
6. Inspection Of The Radial Head
7. Distal Humerus Examination
8. Olecranon & Ulnar Examination - 94Describe the types of supracondylar elbow fractures and which need surgery:Classification:
•Type I: non-displaced frx; splint with follow up 24°-48°, do the same for tenderness without discernable fracture.
•Type II: displaced with intact posterior cortex, may need surgery
•Type III: displaced with no cortical contact, in ED ortho consult , likely surgical - 95bones in the wristS Scaphoid
L Lunate
Tq Triquetrum
P Pisiform
Tm Trapezium
Tz Trapezoid
C Capitate
H Hamate - 96ECG intervalsIntervals
•PR 120-200ms (3-5 sm box)
•QRS < 120ms (3 sm box)
•QTc prolonged >450 ♂, >470 - 97•Low voltage criteria on ecgAmplitude of QRS: <5mm (1large box) in all limb leads OR <10mm in all precordial leads
- 98LBBB criteria on ECGBroad, monomorphic S waves in V1.
Broad, monomorphic R waves in I and V6, with no Q waves. - 99RBBB criteria on ECGQRS wide (≥ 0.12 sec)
•If all criteria are met except QRS <0.12 then incomplete RBBB
•rSR’ in V1 or wide R wave or a qR pattern
•Bunny ear pattern.
•Wide, slurred S wave in lateral leads (I, aVL, V5, V6) - 1001st degree av blockPR > 0.20 sec
- 101QRS wide (≥ 0.12 sec) •If all criteria are met except QRS <0.12 then incomplete RBBB •rSR’ in V1 or wide R wave or a qR pattern •Bunny ear pattern. •Wide, slurred S wave in lateral leads (I, aVL, V5, V6)This continues until on of the P waves reaches the node at a point when it is will not conduct the impulse so it drops a beat.
- 102Second-Degree (Mobitz II) Heart BlockIn it the PR interval remains constant, but there are still intermittent dropped QRS complexes.