Inservice review 2006High 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
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
DKA
Estimated 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
Eyes4 Open
3 Voice
2 Pain
1 No response
GCS
Verbal5 Oriented
4 Confused
3 Inappropriate
2 Sounds
1 None
GCS
Motor6 Follows commands
5 Localizes
4 Withdraw
3 Decorticate
2 Decerebrate
1 None
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
GCS =
Eyes = 3, to voice
Verbal = 3, inappropriate
Motor = 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 charcoal1 – 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
GI
Quiescent
Liver failure/metabolic derangement/acidosis
Chronic 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-acetylcysteine
AKA Acetadote
150 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
Alcohols
Methanol formaldehyde(toxic)
formic acid CO2, H2O
(toxic)
Dialysis always an option for methanol and ethylene glycol
ADH
folateETOH and 4MP
saturate
Isopropyl alcohol
Isopropanol acetone ketonuria
exhaled
Does not cause acidosis
Twice as intoxicating as ETOH
Irritating to gastric mucosa; hematemesis
Myasthenic crisisWeakness
Ptosis, diplopia, dysarthria, head drooping
Worsens 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 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
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 IUp to 15% blood volume
Minimal symptoms
Class II15 to 30% loss, or 750 to 1000 cc
Tachycardia, tachypnea, narrowed pulse pressure
Hemorrhage
Class III30 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
18
18
Parkland formula
4cc/kg/%TBSA½ over the first eight hours, rest over 16 hours
Pediatric burn formula*Maintenance plus 3cc/kg/%TBSA
Diagnostic peritoneal lavage
IndicationsAltered sensorium
Equivocal exam
Your ultrasound is broken*
ContraindicationsAbsolute - need for laparatomy
Relative – 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 resuscitation
HR > 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
A
B
Adrenal insufficiency
Symptoms Weakness, anorexia, hyperpigmentation (primary AI only,) weight loss, abd pain, nausea, vomiting
TherapyIVF
Hydrocortisone 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 minutes
Consider hyperbaric for comatose/sick victims of carbon monoxide
Beware 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 syndrome
Usually < 5 years
Nephropathy, microangiopathic hemolytic anemia, thrombocytopenia
Associated with E.coli 0157:H7, Salmonella, and Shigella gastroenteritis
Intussusception, hypertension, CNS effects
Pallor, 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/INR
Therapy – 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 illness
Staphlycoccal – 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 anaphylaxis
Mild 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” fracture
Very unstable
Diving injuries
Extension mechanism can cause same injury, often in elderly who fall on their chin
“Clay shoveler’s” fracture
Stable
C7>C6>T1
Hyperflexion, interspinous ligament avulses part of spinous process
Bilateral facet dislocation
Very unstable
Best seen on oblique views
“Hangman’s fracture”
Unstable
Traumatic spondylolyis of C2
Atlanto-occipital dislocation
Unstable
Almost always fatal
Tearing of all ligamentous connections between C1 and occiput
Jefferson Fracture
Unstable
Four part burst fracture of C1
Associated with axial load / diving
Lateral masses shifted laterally on odontoid view
Odontoid fracture Type I
Stable
Tip of dens avulsed
Odontoid fracture Type II
Unstable
Most common
Transverse fracture at base of odontoid
Odontoid fracture Type III
Potentially unstable
Fracture through body of C2 involving both articular facets
Compartment Syndrome
Pallor, paresthesias, paralysis, pulselessness, and pain
Normal pressures 0 to 8 mm Hg
>30 mm Hg requires fasciotomy
HIV drug side effects
Crixivan (Indinavir)
AZT (Zidovudine)
ddI (Didanosine)
Foscarnet
Epivir (Lamuvidin)
Renal stones
Vomiting
Pancreatitis
Nephrotoxicity
cough
Other drugs that should make you suspicious . . .
Phenothiazines
Warfarin
Phenytoin
Sulfonylureas
Antihistamines
-Azoles
Statins
Sulfas (including celocoxib, furosemide)
Presentations that should make you suspicious for drug reactions
Rashes
Bleeds
Syncope
Arrhythmia
Hypoglycemia
Rubella
Prodrome low grade fever, sorethroat, headache, malaise
Pink or red maculopapular
Face, then neck, then trunk and extemities
May be coalescent
Suboccipital and retroauricular nodes
Fifth Disease
4 to 10 year olds
Erythema infectiosum
Parvovirus B-19
Slapped cheek (spares eyelids, chin, perioral area)
Then discrete “lacy” trunk and extremity rash
Rubeola (measles)
Fever, cough, rhinorrhea, conjunctivitis, photophobia
Day 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
Roseola
Six months to three years
HHV 6
Exanthem subitum
3 to 4 days of high fever
Then defervescense and 1 to 2 day maculopapular rash (trunk to extremities)
Rocky Mountain Spotted Fever
Rickettsia Rickettsi
Abrupt fever, myalgias, fatigue
Starts on palms, soles, wrists, ankles
Then goes central
Becomes palpable and red, then petechial within 3 days
Chloramphenicol and tetracycline
Kawasaki’s disease
Fever (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 - treatment
IVIG
Aspirin
Echo (serially)
Henoch-Schonlein purpura
Peaks at 4 – 5 years, winter/spring
Skin – palpable purpura, gravity dependent
Nephropathy (may cause lasting damage)
GI – vomiting, bleeding, intussusception
Joint swelling, extremity and facial edema
Treatment: supportive, steroids (efficacy not proven)
Central cord syndrome
Old person fall and go boom
Arm > leg involvement
Hyperextension
Ligamentum flavum
Two RSI drugs that increase ICP
Ketamine
Succinylcholine
Seizures not responding to standard therapy
Think TCAs Avoid IA anti-arrhythmics
Sodium bicarbonate
Or Isoniazid Pyridoxime
Euvolemic hyponatremia
SIADH = inappropriately [urine]
Psychogenic polydipsia = dilute urine
Steroids in meningitis
Dexamethasone 10 mg IV* before or as first dose of antibiotics is given
Pediatric dose : 0.15 mg/kg*
Give Q 6 hours until causative organism is known
Acute mountain sickness
Symptoms 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
HACE
Symptoms of acute mountain sickness plus altered mental status
Management: Immediate descent (or hyperbaric)
Dexamethasone
O2
Acetazolamide
HAPE
Immediate descent or hyperbaric
O2 (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