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Inservice review 2006 High yield facts

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

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Inservice review 2006 High yield facts

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  1. Inservice review 2006High yield facts Steven T. Dorsey, MD Department of Emergency Medicine The Cleveland Clinic Foundation MetroHealth Medical Center

  2. 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

  3. Study hard, do your best

  4. Study hard, do your best But if you bomb, you’ll break my heart, Fredo

  5. And not just my heart

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

  7. GCS • Eyes • 4 Open • 3 Voice • 2 Pain • 1 No response

  8. GCS • Verbal • 5 Oriented • 4 Confused • 3 Inappropriate • 2 Sounds • 1 None

  9. GCS • Motor • 6 Follows commands • 5 Localizes • 4 Withdraw • 3 Decorticate • 2 Decerebrate • 1 None

  10. 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

  11. GCS = • Eyes = 3, to voice • Verbal = 3, inappropriate • Motor = 5, localizes • = 11

  12. tPA for stroke – NINDS inclusion criteria • > 18 years • Symptoms under three hours • Normal PT/PTT

  13. 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

  14. 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)

  15. Thrombolytics for AMI – indications (AHA/ACC 2004) Class IIa1. 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)

  16. Contraindications to thrombolysis (AHA/ACC 2004) • Fair game

  17. Intussusception • 3:1 male • 5 – 9 months • Ileocolic junction • Sausage-shaped mass • Currant jelly stools • Plain films (U/S), hydrate, NGT, barium enema

  18. Pyloric stenosis • 5:1 male • 3 to 6 weeks • Projectile vomiting • Palpable olive

  19. Lithium Acids Alkali Potassium Iron Pesticides Hydrocarbons Alcohols Charcoal doesn’t absorb . . .

  20. 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

  21. Ingestion • Activated charcoal • 1 – 2 grams/kilogram* • Multiple dose may work for theophylline, phenobarbital, tegretol, dilantin, digoxin • Gastric lavage • Consider for large ingestion, if less than one hour, opiates*, anticholinergics* • Risks include aspiration, perforation *slow motility

  22. 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

  23. Iron toxicity – Four stages • GI • Quiescent • Liver failure/metabolic derangement/acidosis • Chronic GI effects

  24. 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

  25. Intravenous N-acetylcysteine • AKA Acetadote • 150 mg/kg IV, then 6.25 mg/kg/hr for 16 hours*

  26. 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

  27. Alcohols Methanol formaldehyde(toxic) formic acid CO2, H2O (toxic) • Dialysis always an option for methanol and ethylene glycol ADH ETOH and 4MP saturate folate

  28. Isopropyl alcohol Isopropanol acetone ketonuria exhaled • Does not cause acidosis • Twice as intoxicating as ETOH • Irritating to gastric mucosa; hematemesis

  29. Myasthenic crisis • Weakness • Ptosis, diplopia, dysarthria, head drooping • Worsens with repetition • Worse with heat, better with cold • Tensilon 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)

  30. Cholinergic insecticides • Inhibit acetylcholine esterase • Organophosphates • Carbamates • Bind reversibly, don’t penetrate CNS • Edrophonium, physostigmine are carbamates • Acetylcholine is the neurotransmitter at motor end plates, all preganglionic autonomic synapses, post-ganglionic parasympathetic synapses, and some CNS synapses

  31. 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

  32. 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

  33. Hemorrhage • Class I • Up to 15% blood volume • Minimal symptoms • Class II • 15 to 30% loss, or 750 to 1000 cc • Tachycardia, tachypnea, narrowed pulse pressure

  34. Hemorrhage • Class III • 30 to 40%, approx. 2000 cc • Tachycardia, tachypnea, altered mental status, drop in systolic pressure • Class IV • > 40% loss • Immediately life threatening • Decreased urine output

  35. Rule of 9s

  36. Rule of 9’s

  37. Rule of 9’s • Head = 9 • Each arm = 9 • Each leg = 18 • Trunk front = 18 • Trunk back = 18

  38. Rule of 9’s 9 9 9 • Head = 9 • Each arm = 9 • Each leg = 18 • Trunk front = 18 • Trunk back = 18 18 x 2 1 18 18

  39. Parkland formula • 4cc/kg/%TBSA • ½ over the first eight hours, rest over 16 hours • Pediatric burn formula* • Maintenance plus 3cc/kg/%TBSA

  40. Diagnostic peritoneal lavage • Indications • Altered sensorium • Equivocal exam • Your ultrasound is broken* • Contraindications • Absolute - need for laparatomy • Relative – previous abd surgery, morbid obesity, advanced cirrhosis, coagulapathy • Foley and NGT first

  41. 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

  42. Apgar score

  43. 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

  44. Neonatal resuscitation Supportive care HR > 100 and pink Apnea or HR < 100 BVM* HR < 60 HR > 60 BVM* Chest compressions HR < 60 Epinephrine *Or intubation

  45. 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

  46. 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

  47. 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”

  48. 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

  49. Aortic dissection • Stanford classification • A = ascending • B = descending / distal to left subclavian artery • Debakey classification • I = A + B • II = A • III = B A B

  50. Adrenal insufficiency • Symptoms • Weakness, anorexia, hyperpigmentation (primary AI only,) weight loss, abd pain, nausea, vomiting • Therapy • IVF • Hydrocortisone 100 – 200 mg IV* OR decadron IV (doesn’t mess up Cosyntropin stim test)

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