E-med Review for Exam 1

1. E-med Review for Exam 1

2. Introduction to EM • What is a major cause of death in young people? • Trauma • What are some leading mechanisms of death due to trauma? • MVA, falls, drowning • What is included in the primary evaluation of a trauma patient? • Airway with c-spine control, breathing and ventilation, circulation and hemorrhage control, disability and neuro status, exposure and environmental control

3. Intro to EM • How many IV’s should be established in trauma patient and what fluid? • 2 RL wide bore, 14 g • What are some common sites of hemorrhage? • External, hemothorax, spleen lac, hemoperiteoneum, renal hematoma, liver lac, injury to great vessel

4. Intro to EM • What are two signs of basilar skull fracture? • Battle’s sign and raccoon eyes • Hot lights and cold steel refer to: • The golden hour • What x-ray studies are in protocol for trauma patient? • C-spine, chest, pelvis • When should the c collar be removed? • Only when c spine clear

5. Airway Emergencies • What is the classical presentation of GABS strep throat? • Sudden onset of sore throat, odynophagia, chills, fever, no cough or coryzal symptoms, tender anterior cervical adenopathy. • What are diagnostic tests? • Rapid strep antigen detection test, throat culture • What is the management? • Penicillin/ e-mycin.

6. Airway Emergencies • What is the classical presentation of mononucleosis? • Prodrome of malaise, anorexia, chill then fever, malaise, sore throat, posterior cervical adenopathy, enlarged spleen, rash possible. • What are the diagnostic test results? • Monospot, atypical lymphocytes on blood smear. • Treatment options? • Rest, fluids, analgesics, glucocorticoids

7. Airway Emergencies • Diphtheria? • Pseudomembranous Pharyngitis, severe sore throat, fever, cervical lymphadenopathy • Diagnostics for Diphtheria? • Culture on tellurite medium • What are the treatment options? • Antitoxin, antibiotics

8. Airway Emergencies • What are the clinical manifestations of peritonsillar abscess? • Etiology: strep most common, sore throat, worsening unilateral pharyngeal discomfort, pus in supratonsillar space, trismus, muffled voice, foul smelling breath, unilateral soft palate uvular deviation. Cervical lymphadenopathy • What is the management? • I/D, tonsillectomy, penicillin or clindamycin, augmentin, NSAIDS or pain relief

9. Airway Emergencies • What is the difference between complete and partial airway obstruction? • Partial: good air exchange, coughs, wheezing • Total: poor/weak exchange, stridor, cyanosis, aphonia • How is airway obstruction diagnosed? • Direct inspection with laryngoscopy

10. Airway Emergencies • How is it treated? • AHA foreign body protocol • Magill forceps, Surgical airway, Endotracheal intubation, bronchoscopy

11. Airway Emergencies • What are the benefits of oral intubation? • Airway, prevent aspiration, oxygenation, • What is the difference between the macintosh and the miller blade and the procedure for using each? • Macintosh: curved. Tip of blade into vallecula an lifted: indirectly lifts the epiglottis • Straight blade: Epiglottis lifted directly

12. Airway Emergencies • Indications for cricothyrotomy? • Acute laryngeal disease due to trauma, infection and prolonged intubation, not in children less than 12. • What are the clinical manifestations of angioedema? • Throat tight, dyspnea, cough, stridor, hoarseness, face, mouth, lips, tongue, extremities • Diagnostics: fiberoptic nasopharyngoscopy to assess for laryngeal edema. • What is the management? • Epi, antihistamines, steroids

13. Airway Emergencies • What is the etiology of epiglottitis? • Hamemophilus influenzae type B • How does a patient present with epiglottitis? • Worsening dysphagia, dysphonia, sore throat, fever, cervical adenopathy, drooling, stridor • Diagnostics? • Lateral soft tissue neck, edematous epiglottis, direct laryngoscopy • What is the management? • Intubation in the OR, IV cefuroxime.

14. Airway Emergencies • What is the etiology of croup? • Parainfluenza • What are clinical manifestations of croup? • Barking cough preceded by 2/3 days of respiratory infection, stridor, low grade fever, normal lung sounds • Diagnostics? • Anterior posterior soft tissue neck: steeple sign • Management? • Nebulized saline, racemic epinephrine, dexamethasone

15. Airway Emergencies • When evaluating for strangulation, always look for injury to:: • Cervical spine, airway • What are diagnostics used in strangulation? • Posterolateral neck xay, chest x-ray, direct laryngoscopy. • What is the management? • Assure airway protection, c spine precautions. Be aware of delayed signs and symptoms.

16. BCLS review • Adult: • What is the compression rate? • At least 100/min • How is the airway opened? • Head tilt, chin lift • How many breaths are given initially after opening the airway? • 2, lasting one second each

17. BCLS review • If you are alone, after establishing unresponsiveness you should: • Activate EMS and get AED • Then • Open the airway check for breathing (5-10 seconds) • Then • Give 2 full breaths • Then • Check pulse 5-10 seconds

18. BCLS review • What is the compression rate to ventilation rate for an adult? • 30:2 , 5 cycles • If you note a shockable rhythm? • Shock and then resume CPR for 5 cycles.

19. BCLS review • Child • Check responsiveness • Lone rescuer: 5 cycles of CPR prior to calling 911. If witnessed collapse then activate EMS first. • Open airway, 2 breathes • Check pulse for 10 seconds • Rescue breathing: 1:3, recheck pulse every 2 minutes • 30:2, 2 rescuer 15:2 • Defib only if child >1 year old.

20. BCLS review • Infant • Check for response, activate EMS • Head tilt chin lift • If no pulse or heart rate <60 then with signs of poor perfusion then: 15:2 if two man, 30:2 if one man. • Use 2 thumb encircling technique

21. BCLS review • Choking • Severe: no air exchange • Adult: abdominal thrusts. If unconscious begin CPR. • Infant: Conscious: 5 back slaps followed by 5 chest thrusts. If unresponsive then CPR. • Chain of survival: early access, early CPR, early defibrillation, early advanced care.

22. Anaphylaxis/ Respiratory Instrumentation • What is the pathophysiology behind Type I anaphylaxis? • Quick: 5-30min, IgE induced by antigens, first exposure is sensitization of mast cells, second exposure leads to degranulation and release of mediators • Effects of histamine? • Vasodilation: flushing, hypotension • Acetylcholine? • Smooth muscle spasm, abdominal cramping

23. Anaphylaxis/ Respiratory Instrumentation • Secondary response? • Mucosal edema, mucus secretion, bronchospasm

24. Anaphylaxis/ Respiratory Instrumentation • What are some clinical manifestations of anaphylaxis? • Dyspnea, wheezing, stridor, chest tightness, urticaria, pruritus, abdominal pain/ vomiting, hypotension, dizziness, syncope, angioedema • Treatment ABC’s. Intubation, oxygen, nebulized bronchodilators, IV fluids, epinephrine (antidote for chemicals released in anaphylaxis), antihistamines, steroids

25. Anaphylaxis/ Respiratory Instrumentation • What is an anaphylactoid reaction? • Not IgE, though similar to anaphylaxis. Follows first time exposure to radiocontrast, aspirin, NSAIDS, blood, opioids • Management: • Pre treatment with antihistamines/steroids

26. Respiratory Instrumentation • What is the BVM? What is the function of the BVM? • Provide oxygen, ventilation, protect airway • When should this devise be used? • Failure to protect airway, patient can’t protect airway, protect against aspiration, failure of other methods, patient tiring or likelihood of deterioration • How much oxygen is provided? • 15 l/min 100% oxygen

27. Respiratory Instrumentation • Where is the tube placed? • Between the vocal cords, confirm placement • What is the purpose of rapid sequence intubation? • Induce unconsciousness with muscular paralysis to provide optimal conditions for intubation. • Provides NMBA and sedative • How is placement of tube confirmed? • End tital CO2 detector, aspiration technique, CXR.

28. Respiratory Instrumentation • What is the purpose of laryngeal mask airway? • Ventilation of trachea with minimal air into esophagus • Esophageal combitube? • Easy and temporary, allows blind insertion. One lumen as an airway post esophageal insertion, other as tracheal airway. • What is CPAP? • Continuous positive airway pressure

29. Respiratory Instrumentation • What is the flow rate for simple face mask? • 40-60% oxygen, 8-12 l/min • nonrebreather? • 10-15 l/min, 80-100% oxygen • venturi mask? • Controlled amount of oxygen • Nasal cannula? • 20-40% oxygen, 1-6 l/min • Nebulizer: • Mist to airways. 6 l/min

30. Respiratory Instrumentation • Peek flow meter, pulse oximetry • What are the indications for endotracheal suctioning? • Coarse breath sounds, visible secretions in airway, aspiration, deteriorating blood gas values, sputum specimen

31. Hypertension Emergencies • What is pre-hypertension, stage I hypertension, stage II hypertension? • <120/80, 120-139/80-89, 140-159/90-99, >=160/100 • What are the clinical manifestations of essential hypertension? • Asymptomatic. Long term to kidneys, heart, eyes, brain, blood vessels • What is the management of stage I? • Thiazides, ACE I, ARB, BB, CCB • Stage II? • Two drugs thiazide and above

32. Hypertension Emergencies • What is the definition of hypertensive emergency? • B/P diastolic >115-130, associated with end organ damage to brain, heart, kidneys, eyes. • What is the definition of hypertensive urgency? • Imminent end organ damage. Reduce B/P over 24-48 hours . >180/120 • What is the definition of acute hypertensive episode? • Systolic >180, diastolic >110. Patient asymptomatic. No immediate treatment. Follow up needed

33. Hypertension Emergencies • What is transient hypertension? • Elevated B/P due to another condition such as anxiety, alcohol, cocaine • What are the symptoms of end organ damage? • CNS, cardiac, renal, optho. • What is hypertensive encephalopathy? • Vasospasm and brain edema • What are the clinical manifestations? • Neuro symptoms, visual symptoms, cardiovascular, renal. confusion, seizures, coma, Diastolic > 130

34. Hypertension Emergencies • What is the management of hypertensive encephalopathy? • Sodium nitroprusside. • What is malignant hypertension? • Acute and progressive end organ damage. CNS, optho, cardiovascular, renal • Treatment: lower B/P to prevent end organ damage. Use Sodium nitroprusside, labetalol, phentolamine, hydralazine for eclampsia

35. Hypertension Emergencies • What are the two types of strokes? • Ischemic/hemorrhagic • What is the clinical presentation? • Depends on area involved. Headache, dizziness, visual changes, dysphasia, LOC, abnormal neurological exam, hemiparesis or hemisensory deficit. MCA face and hand, ACA mostly leg and foot, PCA: mostly ocolomotor. Vertebral arteries: vertigo, N/V. • Most common artery is MCA

36. Hypertension Emergencies • What is the clinical presentation of subarachnoid hemorrhage? • HA, hypertension, LOC, vomiting, nuchal rigidity, focal deficits • What is the management? • Cerebral arteriography, supportive. • What is a TIA? • Symptoms less than 24 hours usually one hour • Amaurosis fugax • Management of TIA? • Antiplatelets, anticoagulants, endarterectomy

37. Hypertension Emergencies • What is the management of CVA? • CT to rule out intracranial bleed • CBC, electrolytes, coagulation studies, EKG, CXR (widening aorta) • ABC’s • Thrombolytics: for stroke >18, ischemic symptoms less than 3 hours, antiplatelet therapy. First reduce B/P to 185/110 with Labetolol. • Contraindications for thrombolytics; • Intracranial bleed, uncontrolled HTN,arteriovenous malformation, neurosurgery in past 3 months, pregnancy, clinical improved,.

38. Hypertension Emergencies • What is bell’s palsy? • 7th CN palsy • What are some clinical manifestations? • Facial weakness, articulation difficulties, weakness to one side of face and forehead • What is the management? • Prednisone, acyclovir, artificial tears.

39. Hypertension Emergencies • What are the clinical manifestations of a subdural hematoma? • Brain and dura. Progressive worsening headache, progressive neuro deficits • What are the clinical manifestations of a epidural hematoma? • Between dura and skull. Transient LOC, followed by lucid interval and then rapid deterioration.

40. Hypertension Emergencies • What is cushing’s triad? • Hypertension, bradycardia, respiratory pattern irregularity • What is the significance of raccoon eyes and battle sign? • Basilar skull fx • What is the management of epidural and subdural hematoma? • Mannitol, prophylactic antibiotics, surgical decompression.

41. Neurovascular Emergencies • What are some reasons for increased ICP? • Bleeding, edema, inflammation, tumor • What is the location for subdural bleeding? • Below the dura • Epidural? • Above the dura • What glasgow score correlates with severe brain injury? • Less than 8

42. Neurovascular Emergencies • What is the pathology of decorticate posturing? • Lession to corticospinal tract superior to brainstem. Flexion of elbows, wrists, fingers, plantar flexion of feet with extension and internal rotation of legs • What is the pathology of decerebrate posturing? • Lesions to brain stem. Extension of arms, flexion of wrists, jaw clenching, back arching, plantar flexion, neck extension, in response to pain or spontaneous.

43. Neurovascular Emergencies • What positioning is done for patient with herniation? • HOB 30 degrees, • Worst headache of life is: • Subarachnoid hemorrhage • What are clinical manifestations of meningitis? • Fever, neck stiffness, confusion

44. Neurovascular Emergencies • In a seizure what is tonic? • Muscle rigidity • Clonic? • Violent rhythmic jerking of extremities • Postictal? • Decreased LOC • What is a grandmal seizure? • Loss of consciousness, loss of bowel and bladder, cyanosis. Lasts more than 5 minute • If second seizure follow this is known as: • Status epilepticus

45. Neurovascular Emergencies • Focal seizures: • 1-2 min LOC, smacking lips, picking things, swallowing, postical • Petit mal? • Sudden lapse of consciousness. Small jerks of face or arms, no postical period • Febrile seizure due to: • Fever

46. Shock • What is the pathophysiology of shock? • Circulatory insufficiency leading to inadequate tissue perfusion, tissue injury and death • What are the categories of shock? • Causes that require infusion of volume, causes that require improvement in pump function, causes that require volume and vasopressor support, causes that require relief of obstruction, cellular poisons that need antidotes. • Percentage of blood loss: • >35% cardiac output and arterial pressure fall to zero

47. Shock • 10% can be asymptomatic • What are some compensatory mechanisms for shock? • Sympathetic mediated: tachycardia, vasoconstriction • What are some early compensated responses? • Tachycardia, tachypnea, pallor, decreased urinary output (ADH: vasopressin), AMS, thirst, • Decompensated: pale, weak rapid pulse, n/v/thirst, LOC, pupils dilated, severe acidosis, anuria, hypotension, acidosis.

48. Shock/ • What are the clinical manifestations of hypovolemic shock? • AMS, pale, clammy skin, oliguria, tachypnea, tachycardia, metabolic acidosis, management is ABC, control hemorrhage IV isotonic 1-2 liter, 20cc/kg bolus in peds, crystalloids, cross matched blood, vasopressors such as dopamine, norepinephrine is systolic <70p

49. Shock/ • Cardiogenic shock • What is the etiology? • MI, anterior wall. Decreased ejection and cardiac output • What are the clinical manifestations? • Chest pain, SOB, S3 (CHF), JVD, AMS, hypotension, tachycardia, pulmonary edema, decreased urine output • Management: ABC’s, teat MI, vasopressors (inotropic support (Dopamine/ Dobutamine, norepinephrine), intra-aortic balloon pump

50. Shock/ • Types of distributive shock • Septic, anaphylaxis, neurogenic • Septic: due to toxins which lead to loss of vascular tone, might not respond to fluid replacement, extremities warm and flushed • What is the managemet of septic shock? • ABC, broad spectrum antibiotics, sluids, norepinephrine, dopamine could be detrimental: heart working hard. • What is neurogenic shockSympathetic denervation. No actual blood loss.