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Board / Inservice Review Part 3

Department of Emergency Medicine University of Pennsylvania Health System. Board / Inservice Review Part 3. Angela M. Mills, MD. Thoracic/ Respiratory 8%. A-a Gradient. Alveolar-arterial gradient (RA) 150 – pCO 2 / 0.8 = pAO 2 pAO 2 – paO 2 = A-a gradient normally <10 mmHg

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Board / Inservice Review Part 3

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  1. Department of Emergency Medicine University of Pennsylvania Health System Board / Inservice Review Part 3 • Angela M. Mills, MD

  2. Thoracic/ • Respiratory • 8%

  3. A-a Gradient • Alveolar-arterial gradient (RA) • 150 – pCO2 / 0.8 = pAO2 • pAO2 – paO2 = A-a gradient • normally <10 mmHg • Pure hypoventilation does not cause increased A-a gradient • Ventilation perfusion mismatching most common cause of increased A-a gradient • Shunt cannot be corrected by supplemental O2

  4. Hypoxemia • Hypoventilation • Right to left shunt • Ventilation-perfusion mismatch • Diffusion impairment • Low inspired oxygen

  5. Epiglottitis • Mean age higher • Strep pyogenes & Staph aureus • Subtle presentation • Stridor may not be present • Severe sore throat • Normal exam

  6. Epiglottitis

  7. Tracheostomy Complications • Accidental decannulation • Tube obstruction • Infection • Bleeding tracheo-innominate fistula • Tracheal stenosis

  8. Pleural Effusion • Transudate = plasma (2 A’s) • ultrafiltrate of plasma with ↓ protein • hydrostatic pressure or ↓ oncotic pressure • most common  CHF • Exudate  high protein • pleural inflammation • most common  infection

  9. Pneumomediastinum • Spontaneous • Valsalva, drugs • Mediastinal crepitation  Hamman’s crunch • 50-80%

  10. Pneumomediastinum

  11. Pneumothorax • Tall, thin male smoker • Acute pleuritic CP  95% • SOB  85% • Decreased BS  85%

  12. Pneumothorax • 1¼ % intrapleural air absorbed / day • Not all need CT in 1º PTX • 20% or greater need CT • 2 º PTX need CT • COPD, TB, CA • Traumatic PTX needs CT

  13. Pneumothorax

  14. Tension PTX • Large bore needle over catheter • 2nd intercostal space MCL • CXR NEVER right answer

  15. Tension PTX

  16. ARDS • Rapid labored breathing • Exclude CHF • CXR  diffuse infiltrates, normal-size  • Sepsis, shock, trauma, aspiration, drugs • ABGs

  17. Hemoptysis • Differentiate from hematemesis • Chronic bronchitis, neoplasm • ICU, bronchoscopy • Massive hemoptysis  surgery • Bleeding side down • ABCs

  18. Asthma • All that wheezes is not asthma • CHF, FB, COPD, upper airway obst • PEF • B-agonists, corticosteroids • Epinephrine  life threatening dz

  19. COPD • Smoking • Exertional dyspnea • Chronic productive cough • Avoid mech vent if poss • B-agonist, corticosteroids • Low dose O2

  20. Pneumonia • CAP  pneumococcus, Mycoplasma, Legionella, H.flu, viral • Legionella  high fever, dry cough, abd pain, n/v/d • Chlamydia  mild, subacute • Mycoplasma  “walking” PNA • PNA + bullous myringitis + rash + arthralgia • Pregnancy  think Varicella

  21. Pneumonia • < 60 yo  macrolide OR doxy OR 3rd gen fluoroquinolone • > 60 yo and/or comorbid  3rd gen fluoroquinolone, macrolide + 2nd gen cephalosporin

  22. Pneumococcus • Fever, rigors, rusty sputum, pleurisy • Lobar infiltrate • ↑ PCN resistant (4-5%) • 3rd generation fluoroquinolone

  23. Pneumonia

  24. Lung Abscess • Suppuration/ necrosis  cavity AFL • Risk factors  ETOH abuse, 90% have periodontal disease • Clindamycin

  25. Lung Abscess

  26. Tuberculosis • Mycobacterium  aerobic rod • Multiple drug resistance • 4 drug therapy • Most common sx  fever • Night sweats, mild cough, fever, malaise • Cavitary lesions in upper lobes • Parenchymal infiltrates, hilar and mediastinal nodes, pleural effusion

  27. DVT / PE • Virchow’s triad • venous stasis + trauma to vasc endothelium + hypercoaguable state • Risk factors • trauma, immob, surg, CA, prior DVT/PE • Dyspnea, chest pain • Tachypnea, tachycardia • VQ scan • High pre-test + high prob = 96% PPV • Low pre-test + low prob = 96% NPV • all others need more studies

  28. PE

  29. Toxicology • 4%

  30. Toxicology • Know your toxidromes! • ABC’s + resuscitation / supportive • Coma cocktail  • O2 + naloxone + D50 + thiamine • Hypotension responsive to IVF + Trendelenberg in most cases • Gastric emptying/lavage  limited use

  31. Toxicology • Activated charcoal does not bind  • iron, lithium, hydrocarbons, solvents, pesticides, acid, alkalis, alcohols • first dose with sorbitol • Hemodialysis  I STUMBLE • isopropyl alcohol, salicylates, theophylline, uremia, methanol, barbiturates, lithium, ethylene glycol • Whole bowel irrigation  SLIM • sustained release, stuffers, lithium, iron, metals (heavy)

  32. Opioids • ↓CNS (coma), ↓pupils (miosis) • ↓HR, ↓RR, pulmonary edema • Supportive, ventilate • Naloxone • Opiate T ½ > naloxone T ½

  33. Sympathomimetics • Agitation, diaphoresis • ↑ T, ↑HR, ↑BP, ↑pupils (mydriasis) • Seizures, MI, rhabdo • Cocaine, amphetamines • RX  sedation, cooling • avoid B-blocker  unopposed alpha

  34. Cholinergic • “Wet”  Salivation, lacrimation, diaphoresis, n/v, bronchorrhea • SLUDGE • Bradycardia, fasciculations • Insecticides, organophosphates • RX  airway, atropine, pralidoxime (2-PAM)

  35. Anticholinergic • Mad as hatter, blind as bat, dry as bone….. • AMS, mydriasis, dry flushed skin, urinary retention, ↑T, ↑HR, ↓BS, rhabdo • OTC cold/sleep-aid meds, jimsonweed, amanita mushrooms • RX  supportive • Physostigmine  resistant hallucinations, seizures, muscle rigidity, symptomatic tachycardia

  36. Salicylates • AMS, ↑T, ↑HR, ↑RR, diaphoresis, tinnitus, AG met acidosis • mixed early resp alkalosis, late met acidosis adults • ASA, oil of wintergreen • RX  mult dose AC, alkalinize urine, HD

  37. Hypoglycemia • AMS, diaphoresis, seizure, bizarre behavior, ↑HR, ↑BP • Insulin, sufonylureas • RX  D50, glucagon

  38. Methanol • ↓CNS, visual disturbance, abd pain • visual loss with nonreactive pupils & disc hyperemia • “snowstorm” • Drunk w/o breath odor • AG acidosis, osmolar gap • RX  ETOH, fomepizole, folate

  39. Ethylene Glycol • CNS (drunk) + cardiac failure (CHF, ↓ BP) + renal • Hypocalcemia • Calcium oxalate crystals • AG acidosis, osmolar gap • RX  ETOH, fomepizole

  40. Iron • GI bleeding • KUB • 5 stages • 1-6 hrs  n/v, gib • 6-24 hrs  sx resolve • 1-2 days  shock, acidosis, MOF • 2-5 days  hepatic failure • 4-6 weeks  gastric outlet obstruction • RX  deferoxamine

  41. Digitalis • Dysrhythmias • Yellow-green halo visual finding • Treat hyperkalemia • ECG  PAT with block, regular afib, high –grade AV block • RX  Fab fragments • 10 vials if amt ingested unknown

  42. TCA • Anticholinergic + CNS + Cardiac • ECG  ST, wide QRS, prolonged QT, terminal R wave in aVr • Benzos for agitation or sz • RX  alkalinize serum • ↓ BP, wide QRS, vent dysrhythmias • Admit ↓CNS, QRS>100, tachyarrhythmias

  43. Acetaminophen • Sx’s / hepatotoxicity delayed • Toxic dose  7.5 gm (140 mg/kg) • Toxic level  140 mcg/ml at 4 hours • RX N-acetylcystein (NAC, Mucomyst) • Fully protective 8-10 hrs • Partially protective 24 hours • 140 mg/kg PO  70 mg/kg x 17 doses

  44. Antidotes • Arsenic BAL • Lead  BAL, EDTA • Cyanide amyl nitrite pearl  Na nitrite  Na thiosulfate • Methanol  ETOH, fomepizole • Ethylene glycol  ETOH, fomepizole • Iron  deferoxamine

  45. Antidotes • Organophosphates  atropine, 2PAM • INH pyridoxine (B6) • intractable seizures + met acidosis • Digoxin  Fab fragments (Digibind) • CO  high flow O2, HBO • CCB  calcium, glucagon • B-blocker  glucagon • Acetaminophen  NAC

  46. Alkalinize • Serum  TCA • Urine  salicylates, barbiturates, chlorpropamide

  47. OB/GYN • 4%

  48. GYN • Females childbearing age  pregnant until proven otherwise • First trimester bleeding  ectopic until proven otherwise

  49. Infections • Cervicitis, salpingitis, PID • Gonorrhea, chlamydia • Fitz-Hugh-Curtis syndrome • PID + RUQ pain + jaundice • Vulvovaginitis • Trichomonas, Gardnerella, Candida • Treat asymptomatic bacteruria in pregnancy • Macrodantin  1st & 2nd trimester • Ampicillin  3rd trimester

  50. P&B / P&C • Identify IUP  w/u over • Identify ectopic  w/u over • ß-hcg >2000 w/o US IUP  ectopic until proven otherwise

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