Emergency Medicine Topics
Terms in this set (257)
What is ventricular fibrillation and pulseless tachycardia?
Early defibrillation is the most important therapy for these rhythm
-Shock 360J for monophonic and 150-200J for biphasic
-Perform 2 mins of CPR in btw each shock
-Epinephrine 1mg IV q 3-5 minutes
-Amiodarone 300mg IV for VF or pulseless VT
What is asytole?
-Absence of any electrical activity of the heart
-MC cause on EKG is detached lead or malfunctioning equipment, so make sure all leads are asytole
DO NOT SHOCK --> give epi
What is bradycardia?
-HR < 60 bpm
-Unstable=hypotension, shock, CHF, pulmonary edema, SOB, cyanosis, lethargy, or chest pain
-Tx: ABCs, oxygen, IV access, cardiac monitor, EKG, portable CXR. Atropine 0.5 mg IV bolus every 3-5 minutes with max dose of 3 mg --> Transcutaneous pacing (needs sedation d/t pain) --> Dopamine or Epi to titrate acceptable HR/BP --> Transvenous pacing
Transplanted hearts are denervated and do NOT respond to Atropine (go right to pacing)
What is tachycardia?
-HR > 100 bpm
-Unstable=hypotension, AMS, signs of shock, ischemic chest discomfort, acute HF
-Tx: ABCs, oxygen, IV access, cardiac monitor, EKG, portable CXR.
If unstable-synchronized cardioversion. Narrow:50-100J. Narrow irregular: 120-200 for biphasic and 200J for monophonic. Wide regular: 100J. If stable-vagal maneuvers, adenosine if regular
What is atrial fibrillation and flutter?
-May be symptomatic or asymptomatic
-Tx: ABCs, oxygen, IV access, cardiac monitor, EKG, portable CXR.
If unstable-cardioversion. If stable-Diltiazem 0.25 mg/kg IV slowly over 2 minutes. Wait 15 minutes. IF no response, then increase diltiazem dose to 0.25 mg/kg IV slowly over 2 minutes then infusion 5-15 mg/h IV
. If no result consider a short acting beta blocker (Metoprolol, Esmolol, Atenolol)
What is paroxysmal supra ventricular tachycardia?
-HR is usually > 160 bpm
-EKG shows a narrow regular QRS complex
-Tx: ABCs, oxygen, IV access, cardiac monitor, EKG, portable CXR.
If unstable-cardioversion. If stable-vagal maneuvers (valsalva, carotid massage), adenosine 6mg rapid IV push
. If stable tachycardia and wide treat like ventricular tachycardia. If stable and narrow can rate control with diltiazem.
When adenosine contraindicated?
What is ventricular tachycardia (with a pulse)?
-Rate > 100 bpm per minute
-Wide QRS complexes are regular
-Readily converts to VFib (BAD!)
-Tx: ABC, oxygen, IV access, cardiac monitor, EKG, portable CXR. If stable-procainamide 20-50 mg/min IV until arrhythmia suppressed (avoid in CHF). Amiodarone 150 IV bolus over 10 mins. Sotalol 100mg IV (1.5 mg/kg) over 5 minutes.
What is hypotensive shock?
-Hypotension: SBP < 90 and DBP < 60
-Shock: inadequate tissue perfusions
-Shock can be either: 1.)
bradyarrhythmias (heart block, sinus brady) Tachyarrhythmias (sinus tach, a fib, a flutter, PSVT, VT) 2.) Pump problems (MI, cardiomyopathies, tamponade, pneumothorax) 3.)
(blood loss, GI losses, decreased urine output)
What are acid base disorders?
-Is the primary disorder acidosis (pH < 7.4) or alkalosis (ph > 7.4)
-Is the disorder respiratory-do pH and pCO2 move in opposite directions?
-Is the disorder metabolic-do pH and pCO2 move in the same direction?
-Is the disorder simple or mixed?
-Metabolic alkalosis: 1.) Loss of hydrogen ions: (diuretics, vomiting) or 2.) Gain of bicarb -Metabolic acidosis: DKA
-Respiratory acidosis: hypoventilation and ventilation-perfusion mismatch
-Respiratory alkalosis: hyperventilation 2/2 to anxiety, increased ICP, salicylate, fever, hypoxemia, sepsis, pain, pregnancy, CHF, pneumonia, asthma, liver disease
What is hypokalemia?
1.) Intracellular shifts (alkalotic states, insulin administration, glucose)
2.) Decreased intake (malnutrition)
3.) Increased losses (renal-diuretics, hyperaldosteronism, vomiting, diarrhea)
muscle weakness, hyporeflexia, respiratory paralysis, dehydration, increased likelihood of digitalis toxicity
-PE: EKG could should flattened/inverted T waves, U waves
-Tx: treat K levels when < 3 and treat patients 3-3.5 when they are at a high risk of arrhythmia
What is hyperkalemia?
1.) Hemolysis is MC!!!
2.) Decreased excretion-renal failure, ACE-I, K sparing diuretics
3.) Increased release-metabolic acidosis, trauma, rhabdo, tumor lysis
-Symptoms: N/V/D, muscle cramps, weakness, paralysis, areflexia, cardiac arrest
-PE: EKG changes depends on the level. Could cause peak T waves, PR and QT prolongation
calcium gluconate (membrane stabilizer), IVF (membrane stabilizer) insulin (shifter), beta agonist (shifter) lasix (excretor), sodium bicarbonate (excretor), dialysis (definitive)
What is hyponatremia?
-Pseudohyponatremia is caused by 1.) hyperglycemia 2.) hyperlipidemia 3.) hyperproteinemia
-Serum osmolality is divided based on fluid status
-Symptoms: early=nonspecific h/a, vomiting. Late=confusion, szs, coma, bradycardia
-Tx: for euvolemic and hypervolemic patients, water restriction may be appropriate, for patients with acute hyponatremia (< 2 days) should be corrected no faster than 1.0 mEq/L/h. Patients with chronic hyponatremia should be corrected no faster than 0.5 mEq/L/h
What is hypernatremia?
1.) GI losses: vomiting, diarrhea, decreased thirst
2.) Renal losses (DI, diuretics, renal disease)
3.) Inability to respond to thirst (d/t lack of access)
-Symptoms: irritability, lethargy, anorexia, and vomiting. If becomes really high than may begin to see ataxia, tremulousness, hypertonicity
-Tx: address fluid status with NS
How do you approach a trauma patients?
-ABCs and DEF
--Airway (can the patient talk?)
--Circulation (2 large bore IV (14 or 16), cap refill, pulse, skin color)
--Disability (rapid neuro exam)
--Exposure (undress patient)
--Foley (important to monitor urinary output)
-x-rays of the chest, pelvis, and lateral cervical spine
-CT of the head, neck, chest, abdomen, and pelvis
What is the fast u/s?
-Searches for free intraperitoneal fluid
-RUQ--> morrison's pouch (btw liver and kidney)
-LUQ --> splenorenal recess (btw spleen and kidney)
-Above rectum --> pouch of Douglas (suprapubic)
-Subxiphoid and parasternal (heart)
What is the nexus criteria?
-Posterior midline cervical spine tenderness
-Focal neuro deficit
-Painful distracting injury
What is the MC cervical spine fracture?
What is hemorrhagic shock?
-Tx: response to the initial fluid bolus should direct further resuscitative efforts. Early blood transfusion and surgical intervention should be considered in patients who fail to respond to initial fluid resuscitation
What is a hematoma?
-Collection of blood btw the dura and skull
Symptoms: ipsilateral fixed and slated pupil and contralateral hemiparesis
What is a spinal cord injury?
-Complete=no preservation of neurologic function distal to the level of injury
-Incomplete=perianal sensation, voluntary anal sphincter contraction, voluntary toe flexion
-PE: 1.) corticospinal tract-responsible for ipsilateral motor function tested via voluntary muscle contraction 2.) spinothalamic tract-responsible for contralateral pain and temperature sensation 3.) posterior (dorsal) columns-ipsilateral position and vibratory sense tested by tuning fork and position sense of fingers and toes
Anterior cord syndrome
: full or partial loss of b/l pain and temperature sensation and paraplegia. Seen in flexion injuries
: ipsilateral loss of motor function and posterior column function with contralateral loss of pain and temperature sensation
Central cord syndrome
: seen in hyperextension injuries
-Tx: ABCs, spinal immobilization, early neurosurgery consult. methylprednislone
What is cardiac tamponade?
-Usually seen in penetrating thoracic trauma or blunt trauma
muffled heart sounds, JVD, hypotension
electrical alternans on EKG
-Diagnosis: cardiac sonogram
What is a pneumothorax?
-Air in the pleural space
-Symptoms: chest pain, dyspnea, hyper resonance of affected side, decreased breath sounds of affected side
-Diagnosis: CXR, u/s has been shown to have higher sensitivity
-Tx: needle decompression
air entering the pleural space but being unable to escape. Causes ipsilateral lung collapse, mediastinal shift, impairing venous return and thus decreasing cardiac output and resulting in shock. Tx: needle decompression followed by tube thoracotomy
What is GU trauma?
-Suspect with straddle injury, penetrating injury to lower abdomen, falls from height
-Symptoms: flank or groin pain, blood at the urethral meatus, ecchymoses on perineum and/or genitalia, evidence of pelvic fracture, rectal bleeding, "high riding" prostate
-Diagnosis: hematuria, retrograde urethrogram, KUB
-Tx: don't foley them if they have any sign of urethral injury, hematuria (concomitant pelvic fracture)
What is the neuro exam?
-distinguishing two odors
-visual acuity, fundoscopy, pupillary reactions
-check pupillary reactions, ptosis, extra ocular movements
-controls superior oblique (SO4) - movement is down and in
-V1, V2, V3 sensation to face, check motor function of mastication (master, pterygoids, temproalis)
-controls lateral rectus (LR6) and abducts the eye
-check motor function of the face-puff out cheeks, smile, raise eyebrows. Check for facial asymmetry
-check auditory acuity, look for nystagmus
-gag reflex, controls taste on posterior 1/3 of tongue
-trapezius and sternocleidomastoid muscles (shrug shoulders and turn head against resistance)
Deviation indicates ipsilateral lesion
What is the pronator drift?
-Patient holds arms outstretched, palms upward, with eyes closed
-Pronation of the hand with downward drift of the arms is considered an abnormal sign-->
upper motor neuron lesion
What are the different reflexes?
What is a coma?
-Diffuse brain failure --> impaired consciousness
-Causes: AEIOU TIPS: alcohol, encephalopathy, endocrine, electrolyte abnormality, insulin dependent DM, opiates, uremia, trauma, infection, psychosis, space occupying lesion, stroke, shock
-ABCs, c-spine cervical collar, vitals, EKG
-PE: general exam, GCS, respiratory pattern, ocular exam (if pupils are reactive to light bilaterally then midbrain is probably intact). Pinpoint pupils=opioid toxicity or pontine dysfunction.
Fixed and dilated pupils=increased ICP with possible herniation
Doll's eye (patient turns head quickly to one side and observe eye movement. Normal: eyes move in opposite direction)=absence of motion suggests dysfunction in hemisphere of brain stem function
Oculo-vestibular testing: raise head to about 30 degrees and inject 20 cc cold saline in external auditory canal and if both eyes deviate with nystagmus with slow on side of cold saline and fast on the other side=patient is not comatose. Both eyes deviate towards cold saline=patient has coma with intact brain stem. No movement in either eye or lack of movement in contralateral eye=brain stem is damaged.
-Diagnosis: glucose, arterial blood gas, bytes, u/a, toxicology screen, EKG, head CT, LP
coma cocktail-DON'T: dextrose, oxygen, naloxone, thiamine
What is a stroke?
-Any vascular injury that reduces cerebral blood flow to a specific area of the brain
: occlusion of cerebral vessels
: neuro impairment d/t rupture of a blood vessel
, HTN, HLD, vasculitis, DM, smoking, cocaine use
-PE: HTN, bradycardia, abnormal breathing, do fundoscopic exam, neuro exam will help localize lesion
: contralateral weakness and numbness of arms > legs, aphasia
--ACA: contralateral weakness of legs > arms
--PCA: diplopia, sensory changes, subtle presentations like dizziness
--Vertebrobasilar artery: syncope, weakness, CN changes
-Diagnosis: CBC, lytes, cardiac markers, coags, u/a, CXR, EKG for Afib, CT to differentiate hemorrhagic vs. ischemic
but may be negative in ischemic strokes for 12 hours
, CTA is becoming more common, MRI for subtle ischemic infarcts
-Ischemic tx:: determine time of onset, STAT brain imaging, ABCs with supplemental oxygen, serum glucose control, temp control, call stroke team/neuro consult, do BP control, tPA therapy for ischemic
-Contraindications for tPA: SBP > 180, hx of hemorrhagic stroke, any stroke w/in the past year, suspected aortic dissection, active bleeding
-Hemorrhagic tx: ABCs, early intubation, treat SBP > 160 and DBP > 105. Treat with
nitroprusside, labetalol, or nicardipine
, control seizures (25% will seize) with lorazepam followed by fosphenytoin, glucose control,
prompt neurosurgical evaluation
. Anti platelet therapy for ischemic strokes, anticoagulation for embolic strokes, stop smoking, strict HTN control, control HLD and DM
What is a TIA?
-A transient episode of neuro dysfunction caused by focal brain, spinal cord, or retinal ischemia
-Symptoms: dysphagia, weakness/heaviness to the contralateral side
-Diagnosis: imaging of carotids (u/s, CTA, or MRA)
-Tx: work-up as below, education, IV heparin, warfarin, if all normal labs then ASA
-Further workup within 48 hours: MRI, echo, special blood (lupus anticoagulant, factor V Leiden)
What is loss of consciousness?
-Any measure of arousal other than normal
-Causes: poisons/toxins, insufficient oxygen or blood flow in the brain
-Coma=inability to make any purposeful response
-Lethargy=mildly depressed level of consciousness or alertness
-Diagnosis: CBC, toxic screen, EEG, electrolytes, CXR, CT and MRI if needed
-Tx: treat underlying cause
What is syncope?
-Vasodepressor: excessive vagal tone or impaired reflex control of the peripheral circulation. Transient LOC and postural tone. Diagnosis: orthostatic changes
-Orthostatic: impaired vasoconstrictive response to assuming upright posture leading to an abrupt decrease in venous return. Common with age, DM, blood loss/hypovolemia, diuretic therapy
-Cardiogenic: rhythm disturbances (SSS, AV block, tachyarrhythmias) or mechanical (HOCM, aortic stenosis)
What is a migraine h/a?
-Common: without aura
-Classic: with aura
-Symptoms: aura, slow onset, lasts 4-72 hours, worsen with exertion, unilateral and pulsating, N/V, photophobia, photophobia, osmophobia
-Tx: prophylaxis: tricyclics (amitriptyline, nortriptline), gabapentin, valproic acid, topiramate, beta blockers, calcium channel blockers. Acute: metoclopramide, compazine, NSAIDs, opioid, triptans (not with focal deficits)
What is a cluster h/a?
-Symptoms: severe, unilateral, appear in clusters, multiple attacks in same time of day or month, patients appear restless, ipsilateral conjunctival injection, lacrimation, nasal congestion, rhinorrhea, mitosis, and ptosis
-Tx: prophylaxis: verapamil, lithium, topiramate, valproic acid, gabapentin. Acute=100% oxygen, NSAIDs, steroids
What is a tension h/a?
-Muscle tension as a headache
-Symptoms: bilateral, nonpulasting, not worsened with exertion, no N/V, associated with neck or back pain
-Tx: prophylaxis: tricyclics, gabapentin, good posture, exercise, NSAIDs, muscle relaxant
What is subarachnoid hemorrhage?
-Trauma is the MC etiology
severe headache with a "thunderclap" onset, or this is the worst headache of my life
, N/V, photophobia, possible syncope, focal and diffuse neuro deficits
-Diagnosis: head CT without contrast. LP can be used if still clinical suspicion. Look for xanthochromia
-Tx: Nimodipine 60mg to prevent vasospasm, dexamethasone 10mg IV for cerebral edema, phenytoin to prevent szs, evaluate head of bed, admit to ICU
What is vertigo?
-The perception of movement when there is no movement. The patient typically describes the room as spinning or the sensation of falling
-Causes: BPPV, meniere's, vestibular neuritis, labyrinthitis, ototoxicity, 8th CN lesion, post traumatic, middle ear disease
-BPPV: transient vertigo precipitated by certain head motions.
-Symptoms: sudden onset, N, worse in the morning, normal ear exam
-Tx: antiemetics, antihistamines (
-Meniere's: symptoms are exacerbated into the perilymphatic space.
-Symptoms: deafness, tinnitus, vertigo, N/V, recurrent attacks, deafness btw attacks
-Tx: symptomatic with antihistamines, anti vertigo, and antiemetic, hydrochlorothiazide
-Labyrinthitis: infection of labyrinth
-Symptoms: hearing loss, peripheral vertigo
-Diagnosis: head CT or clinical
-Tx: symptomatic tx with antihistamines, anti vertigo, and antiemetic
-Posttraumatic vertigo: history of head trauma
-Symptoms: peripheral vertigo, N/V
-Diagnosis: CT for intracranial bleeding/hematoma
-Tx: symptomatic with antihistamines, anti vertigo and antiemetic agents
usually follows a URI
What is meningitis?
-Inflammation of the membrane surrounding the brain and spinal cord
-Symptoms: AMS, photophobia, h/a, fever, meningeal signs (nuchal rigidity, Kernig and Brudzinski signs)
-Diagnosis: LP, positive kernig sign (pain/resistance with extension of knee with hip flexed) or Brudinski sign (flexion of hips with neck flexion)
--< 2 months: group B, listeria, E. coli, Klebsiella, staph aureus
--2-50 years: strep pneumonia, H influenzae
--> 50 years: step pneumoniae, Listeria
-Tx: ceftriaxone. Ampicillin should be added for Listeria. Dexamethasone x 4 days.
What is encephalitis?
-Inflammation of the brain parenchyma secondary to infection
-Usually viral: Herpes (skin vesicles), EBV, arbovirus (bug bite), rabies (animal bite)
abnormal behaviors or personality changes
, szs, h/a, photophobia, focal neuro signs
-PE: exaggerated DTRs, spastic paralysis, stiff neck
-Diagnosis: CSF - lymphocytes, normal glucose
-Tx: supportive (tylenol) , acyclovir for herpes
What is guillain-barre syndrome?
Ascending peripheral neuropathy
-History of viral illness -->
-Symptoms: loss of DTR, distal weakness > proximal, weakness is symmetrical, numbness/tingling of the extremities
increased protein on CSF with normal glucose
plasmapheresis, IV immunoglobulin
What are szs?
-Abnormal electrical discharge of neurons causing a clinical episode of neurologic dysfunction
-Not epilepsy related causes: alcoholism, trauma, CNS infection, stroke, trauma, CNS infection, tumor
-Acute: roll patient to a semiprone position to allow gravity to pull the tongue and secretions of the airway, ABCs
-History is important!
-PE: check for injuries, look for signs of infection
-Diagnosis: routine labs, consider LP, consider CT of head
-Tx: prevention of injury, adequate oxygen, benzos are mainstay in active seizures, correct sub therapeutic levels of anticonvulsants, tx underling cause
--Generalized: involves LOC
-Tonic clonic (grand mal): LOC immediately followed by tonic (rigid) contraction of muscles then clonic jerking.
-Absence (petit mal): LOC without loss of postural tone. No postictal.
-Myoclonic: LOC with brief muscular contractions.
-Clonic: LOC with repetitive clonic jerks
-Tonic: LOC with prolonged contraction of body
--Partal (focal): involves focal area of abnormal electrical discharge
-Simple: abnormal focal neuro discharge which consciousness remains intact
-Complex: consciousness is altered, postictal period
What is status epileptics?
-Seizures occurring continuously for > 10 mins or two or more seizures occurring without full recovery of consciousness btw attacks
-Tx: convulsive=IV benzos (lorazepam or diazepam) followed by fosphenytoin if necessary. Non convulsive=valproic acid and phenobarbital.
What is acute sinusitis?
-Inflammation of the paranasal sinuses < 3 weeks duration
-Etiology: strep pneumoniae or H. influenzae
-Symptoms: pain over the sinuses, decreased sense of smell, fever, purulent nasal discharge, h/a, maxillary tooth pain, tenderness to palpation over affected area
-Tx: symptomatic tx, OTC decongestant can provide symptomatic relief, abx for those who don't improve with symptomatic relief (Amoxicillin or Augmentin)
What is blepharitis?
-Inflammation of the eyelids
-Etiology: anterior=staph, posterior=meibomian glands
-Symptoms: burning and itching of the eyes, maybe redness, no change in vision, eyelids show scaling and crusting
-Tx: supportive - lid scrubs with baby shampoo, warm compresses, topical erythromycin or bacitracin
What is a blow out fracture?
-Direct trauma to zygomatic prominence or soft tissue of the orbit - pressure blows out weak orbital floor.
MC is posterior and medial to the infraorbital groove
-Diagnosis: plain films, CT scan
What is conjunctivitis?
-Bacterial: step pneumoniae, staph aureus, h influenzae, chlamydia, gonorrhea (ocular emergency)
purulent discharge, pink-red eye
, foreign body sensation, eye crusting, no vision loss
-Diagnosis: culture and gram stain
-Tx: warm compresses, trimethoprim and polyxycin, gonorrhea=ceftriaxone, chlamydia=azithromycin or doxy
copious watery discharge, erythema, periauricular lymphaedopathy
-Tx: cool compresses, artificial tears
-Allergic: asthma, eczema, hay fever
-PE: injected, mucoid discharge
-Tx: topical mast cell stabilizer, cool compresses
What is a corneal abrasion?
-Superficial irregularities of the cornea
-Etiology: foreign bodies, injury, contact lenses
-Symptoms: foreign body sensation, pain, photophobia, redness, blurry vision
-PE: check visual acuity, red eye, fluorescein stain
(dilate pupil and relieve pain), topical erythromycin, tobramycin for contact lens wearers, follow up in 24 hours and avoid contacts for 1 week
What is an corneal ulcer?
-MC d/t infection by bacteria, viruses, fungi or amoebas
-Symptoms: pain, photophobia, tearing and
reduced vision, red eye with circumcorneal injection
What is dacryoadenitis?
-Infection of the lacrimal gland
-Symptoms: swelling, erythema, and pain at the lacrimal gland located at the temporal aspect of the upper lid
-Tx: I&D, topical bacitracin/erythromycin or systemic tetracycline, warm compresses, systemic analgesics
What is a foreign body in the eye?
-Test visual acuity first!!!!
-Symptoms: pain and irritation noted with eye movement, foreign body sensation, red eye, tearing, and blepharospasm
-Diagnosis: topical anesthetic and fluorescein to examine
-Tx: removal - sterile saline irrigation first and remove with fine gauge needle (avoid cotton tip applicator), polymyxin-bacitracin or erythomycin ointment
What is acute angle glaucoma?
-D/t an increased intraocular pressure, which results in optic nerve damage and loss of vision. Occurs only with closure of preexisting
extreme pain, blurred vision (halos around lights), N/V, h/a
eye is red, cornea is steamy, pupils moderately dilated and nonreactive to light
, elevated tonometry
IV acetazolamide (diamox) to low pressure then start topical pilocarpine, laser trabeculopalsty
What is hyphema?
-Hemorrhage into the anterior chamber
-Symptoms: pain, photophobia, decreased visual acuity
-Tx: fox shield, place patient at 45 degrees (keeps red cells from staining cornea), avoid ASA and NSAIDs
What is wet macular degeneration?
-More rapid onset and greater severity of vision loss, hemorrhages, and neovascularization
central vision loss
-Diagnosis: amsler grid chart, visual acuity
-Tx: laser photocoagulation
What is optic neuritis?
-Inflammation of the optic nerve
MCC etiology is MS
present with sudden loss of vision or blurry vision, pain with eye movement
What is orbital cellulitis?
-Periorbital: infection of the eyelids and periocular tissues - anterior to orbital septum
-Symptoms: tearing, fever, erythema, warmth, tenderness,
visual acuity, pupillary rxn and EOM are NORMAL
-Tx: augmentin, 1st generation cephalosporin
-Orbital: infection of the orbital soft tissue - posterior to orbital septum
-Symptoms: tearing, fever, erythema, warmth, tenderness,
pain with eye movement, decreased visual acuity, proptosis
-Tx: hospital, IV abx with 2nd or 3rd cephalosporins
What is papilledema?
-Optic disck swelling d/t increased intracranial pressure
-Symptoms: blind spot without loss of acuity
-Diagnosis: visual fields
and weight loss, may consider shunt
What is retinal detachment?
-Tear of the retina that is usually spontaneous
-MC location: superior temporal area
blurred vision in one eye becoming progressively worse (curtain came down over my eye), flashers and floaters, NO pain
-PE: retina is seen hanging in the vitreous
What is retinal vein occlusion?
-Symptoms: retinal hemorrhages
What is a foreign body in the ear?
-Remove firm materials with loop or hook
-Aqeous irrigation should NOT be performed in organic foreign bodies (beans, insects) --> swelling
-Fill the ear with lidocaine first if a bug
What is labrynthitis?
-Inflammation of the vestibular labyrinth
-Cause is unknown
Frequently follows a URI
acute onset of continuous, usually severe vertigo, hearing loss and tinnitus
-Tx: self-limiting, but may require diazepam, meclizine, or dimenhydrinate
What is epistaxis?
-Anterior epistaxis is MC in younger patients
-Posterior epistaxis is MC in older patients
-Etiology: trauma to nasal mucosa, FOB, allergic rhinitis, nasal irritants (cocaine, decongestants), pregnancy, infection
-Diagnosis: facial or nasal films may be considered in the setting of nasal trauma
-Tx: direct pressure of the nose for 10-15 mins, vasoconstrictive agents like phenylephrine or oxymetazoline can be used with other treatments, anterior nasal packing (nasal tampons, gauze packing, or balloon catheters)
--Posterior: MC thought to be d/t atherosclerosis
-Bleeding is often more severe than with anterior bleed
-Diagnosis: CBC, PT, and aPTT
-Tx: posterior nasal packing and commercial nasal packs and specialized hemostatic balloon devices are available
What is a foreign body in the nose?
-MC location is
anterior to the middle turbinate or below the inferior turbinate
-R > L
-Diagnosis: nasal speculum exam
-Tx: removal with adequate sedation if necessary, balloon catheter removal for poorly visualized objects, positive pressure techniques for occlusive foreign bodies
What is a hematoma of the external ear?
-Important for diagnosis to avoid cauliflower ear or canal blockage
-Tx: I & D but do not drain if > 7 days
What is otitis external?
-Infection of the external canal
pseudomonas aeruginosa and staph aureus
-MC in moist environments (summer, swimming pools, and the tropics)
-Symptoms: sense of fullness in the ear, white/green crusty discharge, pain on retraction, itching, decreased hearing, fever, buying or erythematous TM
-Tx: Polymyxin-neomycine-hydrocortisone ear drop suspension. Avoid water for 2-3 weeks after tx.
What is acute otitis media?
-Bacterial or viral infection of the middle ear usually 2/2 to a viral URI
-Etiology: strep pneumoniae, H influenzae, and Moraxella catarrhalis
-Symptoms: ear pain and sense of fullness, decreased hearing, dizziness, fever, poor feeding and irritability in infants
-Diagnosis: bulging of the TM, limited or absent mobility of TM, otorrhea
-Tx: acetaminophen, topical anesthetic drops (benzocaine), amoxicillin 80-90 mg/kg/day. Can do observation in children 6 months-2 years
What is mastoiditis?
-Bacterial infection of the mastoid process
It is usually a complication of acute otitis media in which the infection has spread
-Symptoms: swelling, erythema, tenderness, and fluctuant over the mastoid process, fever, earache, otorrhea, decreased hearing
-Diagnosis: CT scan
3rd generation (ceftraixone)
, ampicillin, possible surgical drainage
What is a dental abscess?
Tx: penicillin V and pain control, dental referral
What is pharyngitis?
-Infection of the pharynx and tonsils that rarely occurs in patients < 2 years
-Viruses are MCC -->
rhinovirus and adenovirus
-Bacterial MC agent is strep pyogenes
-Symptoms: erythematous tonsils, tonsillar exudates, enlarged and tender anterior cervical lymph nodes, palatal petechiae
-Diagnosis: throat culture
-Tx: IM penicillin 1.2 million units, 10 day course of oral penicillin
What is epiglottis?
-A life-threatening inflammatory condition of the epiglottis
and then strep
-Symptoms: high fever, dysphagia, stridor, drooling, dyspnea, tripod position
do not examine the oropharynx, thumbprint sign on lateral x-ray
-Tx: intubation as needed,
What is croup?
-Viral infection of the upper respiratory tract
-6 months-6 years
-Symptoms: stridor, barking cough, hoarse voice, fever
steeple sign on CXR
Dexamethasone 0.15-0.6 mg/kg IV, IM or PO, racemic epic if severe
What is peritonsillar abscess?
-Symptoms: sore throat,
, decreased oral intake, swollen erythematous tonsils, cervical lymphadenopathy
-Tx: abx against anaerobes (ceftriaxone), consider steroids to decrease inflammation, needle aspiration of abscess, ENT for complicated abscesses
What is pneumonia?
-CAP: an acute infection in patients who have not been recently hospitalized or residing in a nursing home
-HAP: those who have been recently hospitalized
, H influenzae, Klebsiella, Mycoplasma, Legionella, Chlamydia, staph aureus
-Viral: influenza, parinfluenza, adenovirus
-Aspiration: seen in the RLL
-Symptoms: tachypnea, tachycardia, rales, diaphoresis, dyspnea, chest pain, cough, hemoptysis
-Diagnosis: CXR shows lobar consolidation or patchy infiltrates, elevated WBC, blood cultures
-Tx: viral=supportive, bacteria=cefriaxone and azithromycin together or levofloxacin. Add clindamycin or metronidazole if anaerobic.
What is CHF?
-Acute pulmonary edema 2/2 to LV failure and/or volume overload
-Systolic dysfunction (MC): CO is low, pulmonary pressures are high --> pulmonary congestion and systemic hypo perfusion. Can potentiate arrhythmias and promotes cardiac remodeling (LV dilation and hypertrophy) and stimulates the renin-angiotensin system
--Causes: history of MIs, valvular heart disease, HTN, dilated cardiomyopathy, toxins (alcohol, lithium, cocaine), viral, heavy metals
-Diastolic dysfunction: impaired LV relaxation, symptoms are symptomatic with exertion when increased HR reduced LV filling time
--Causes: restrictive cardiomyopathy, sarcoidosis, HOCM, pericardial constriction, cardiac tamponade
-Symptoms: orthopnea, DOE, rales, cough, hemoptysis, wheezing, S3/S4 sound, tachycardia, diaphoresis
-Diagnosis: clinical, CXR shows
Kerley B lines
and cardiomegaly, elevated BNP, EKG shows LV hypertrophy, LBB, echo
-Tx: nitro to promote preload and ventilation, oxygen, CPAP or BiPAP, furosemide, ASA
What is a PE?
-Risks: age, obesity, smoking, HTN, OCP use, immobilization, neoplasm, pregnancy/postpartum, surgery/trauma, hyper coagulable state
-Symptoms: tachypnea, tachycardia, hypoxia, rales, diaphoresis, bulging neck veins, heart murmur, dyspnea, chest pain, apprehension
-Diagnosis: S1Q3T3 may be seen on EKG, but tachycardia is MC seen,
gold standard=pulmonary angiography
, V/Q scan for those who can't do a CT, CTA, d-dimer
oxygen and Heparin or LMWH
and coumadin, IVC filter who aren't anticoagulation candidates
What is pleural effusion?
-An abnormal amount of fluid in the pleural space (space that lies btw the chest wall and the lung)
MCC by CHF, infection and malignancy
-Two types: transudates and exudates
Transudates: vessel leakage into pleural space - CHF
, myxedema, nephrotic syndrome, SVC obstruction
Exudative: inflammatory process-infection, neoplasm, PE
, esophageal rupture, post surgery or trauma
-PE: dull/flat percussion, absent tactile fremitus, decreased breath sounds
Transudate: LDH < 200 u, fluid to blood LDH ratio < 0.6, fluid to blood protein ration < 0.5
, bilateral on CXR
Exudate: glucose < 60 mg/dL in section, neoplasms, RA, or pleuritis, cell count, gram stain
unilateral on CXR
-Tx: treat underlying cause, thoracocentesis can be both diagnostic and therapeutic
What is asthma?
-Disease in the tracehobronchial tree that is hyperactive to stimuli resulting in variable, reversible airway obstruction
-Exacerbations: ASA, BB, sports-induced, allergen induced, diet, stress, infections
-Symptoms: dyspnea, wheezing, cough, chest tightness. Severe: use of accessory muscles, tripod position, hypoxia, tachypnea, impending respiratory failure.
oxygen and albuterol nebulizers. Corticosteroids are added for moderate asthma. Severe: epi
. Consider BiPap or CPAP to help prevent need for intubation. Outpatient: montelukast (leukotriene inhibitors), mast cell stabilizers (cromolyn), methylxanthines (theophylline)
What is COPD?
-Either asthma, bronchitis, and emphysema
-Chronic bronchitis: excessive mucus for a minimum of 3 months for at least 2 consecutive years
-Emphysema: distention of the air spaces distal to the terminal bronchioles and destruction of the alveolar septa
-Risk factors: SMOKING, air pollution, occupational exposure, alpha-antitrypsin deficiency
-Symptoms of chronic bronchitis: hx of smoking and sputum production, overweight, cyanosis, RV failure, normal TLC, increased residual volume
-Symptoms of emphysema: exertion dyspnea, thin, tachypnea, prolonged expiratory phase with pursed lips, use of accessory muscles, increased total lung capacity and residual volume, decreased vital capacity
-Tx: oxygen, nebulized beta agonist, IV or oral corticosteroids, abx if underlying pneumonia. Chronic: stop smoking, nutrition, regular exercise, home oxygen if needed
What is TB?
-Mycobacterium tuberculosis in an intracellular, aerobic, acid-fast bacillus that infects humans
-Symptoms: usually asymptomatic, cough, night sweats, weight loss, hemoptysis, fatigue, anorexia -Diagnosis: PPD, CXR
-Tx: isolation, 4 drug therapy: isoniazid, rifampin, pyrazinamide, and ethambutol or streptomycin for 2 months
-Rifampin=orange body fluids
What is hemoptysis?
-Coughing up blood d/t bleeding from the lower respiratory tract.
MCC by bronchietasis
(abnormal and persistent dilation of major bronchi and bronchioles)
-Tx: oxygen, head of bed is elevated, codeine to control coughing, massive hemoptysis may require surgical intervention.
What is respiratory distress?
-Response to an insult to the lung which leads to capillary leakage producing severe hypoxia and reduced lung compliance
-Causes: trauma, sepsis, shock, toxic, exposures, and aspirations
-Tx: treat underlying cause and mainly supportive
What is RSV?
-Very important lower respiratory tract infection in children
-Common in cold weather
-Leading cause of bronchiolitis
rhinorrhea and pharyngitis -->cough, wheezing, and fever
, difficulty feeding
-PE: hyperinflation, crackles, wheezing, prolonged expiration
-Diagnosis: positive RSV antigen nasal,
-Tx: oxygen, bronchodilator, ribavirin
What is a foreign body in the lungs?
-MC in the major bronchus
-Occluded respiratory airway=sudden and severe respiratory distress
-Supraglottic or larynx=dyspnea, stridor, retractions, croupy cough, drooling
-Small airway=asymmetric breath sounds
-Trachea=dyspnea, stridor/wheezing, retractions, cough
-Bronchus=asymmetric chest movement, unilateral wheezing, cough
-Symptoms: cough or choking episode followed by wheezing --> think foreign body!!
-Diagnosis: inspiratory/expiratory CXR (normal in 80%), R and L decubitus films may show partial airway obstruction
-Tx: direct laryngoscopy or bronchoscopy
What is bronchiolitis?
-MCC affects children < 1 year of age
-Symptoms: respiratory distress, cough, wheezing, tachypnea, apnea. Symptoms DON'T improve after inhaler
-Diagnosis: clinical, x-rays could show hyperinflation, depressed diaphragms, patchy atelectasis, increased lung volumes
-Tx: supportive, oxygen. Ribavirin for severe.
What is acute bronchitis?
-Inflammation of the large airways of the tracheobroncial tree d/t an infectious agent
-MCC by viruses: adenovirus, influenza, parainfluenza, coxsackie
-Bacterial: bordatella, chlamydia, mycoplasma
Usually follows a URI
-Risk factor: smoking!!
cough preceded by URI symptoms (nasal congestion, sore throat, sneezing)
-PE: possible rales, crackles, wheezing
-Diagnosis: normal CXR
-Tx: stop smoking, rest hydration, azithromycin for atypical organisms
What is influenza?
-Systemic viral illness d/t influenza A and B
-Spread by respiratory droplets
toxic, abrupt onset of fever, chills, rigors, malaise, coryza and sore throat
-Diagnosis: leukopenia, viral culture
-Tx: symptomatic, oseltamivir (Tamiflu), inhaled zanamivir (Relenza)
What is chest pain?
-Emergent causes: ACS, aortic dissection, pericarditis, tension pneumothorax, PE, esophageal rupture, perforated peptic ulcer, pneumonia
-Cardiac causes: MI/ACS, coronary vasospasm, dissecting AA, pericarditis, myocarditis, aortic stenosis, HOCM, MVP
-Pulmonary causes: PE, pleuritis, mediastinitis, sponatenous pneumothorax, pneumonia, neoplasm, bronchitis
-GI causes: esophageal rupture, esophageal tear (Mallory-Weiss), esophageal spasm, reflux, pancreatitis, cholecystitis
-MSK: herpes zoster, costochondritis, rib fracture, myalgia, chest wall pain
-PE findings that increase likelihood of ACS: diaphoresis, N/V, S3, hypotension, lung crackles
What is a MI/STEMI/NSEMI/unstable angina?
-Unstable angina=chest pain lasts > 20 mins or more frequent from baseline, new onset and markedly limits physical activity, occurs at rest
-NSTEMI=unstable angina with elevated serum cardiac biomarkers
-Diagnosis: EKG-elevation of > 1 mm in ST segment in 2 or more contiguous leads or new LBBB, cardiac biomarkers, CXR, stress test, CTA
-Tx: ABCs, IV, oxygen, ASA, nitro SL, emergent percutaneous transluminal coronary angioplasty < 90 minutes. tPA is alternative, but carries higher risks.
--Myoglobin: 1-2 hour rise, 4-6 hour peak, returns to baseline within 24 hours
--Troponin: 3-6 hour rise, 12-24 peak, returns to normal in one week
-Risk stratification (TIMI score)
--Age > 65 yo
--3/6: male, MI in family < 50, smoking, HTN, DM, HLD
--ASA within last 7 days
--2+ anginal episodes within 24 hours
--ST elevation on EKG
--Elevated cardiac biomarkers
--Prior coronary artery stenosis > 50%
What is a first AV block?
-Prolonged PR interval (> 0.20 secs)
-Benign and asymptomatic
-Does not warrant further work-up
What is second degree AV block?
-Type 1: progressive prolongation of PR interval with each successive beat until there is a loss of AV conduction
-Type 2: random loss of conduction without change in PR interval
What is 3rd degree AV block?
-No conduction of atrial signal and p wave through to the ventricle
-Either congenital or acquired
-They need a pacemaker!
What is a left bundle branch block?
-Conduction blocked before anterior and posterior fascicles split
QRS duration > 0.12 sec, no Q waves in I, aVF, V5, and V6, large wide R waves in I, aVL, V5, and v6
What is right bundle branch block?
EKG: QRS duration > 0.12 second, triphasic QRS complexes, "rabbit ears" in V1 and V2, wide S waves in I, aVL, V5, and V6
What is atrial flutter?
-Rapid atrial depolarization (240-250 bpm) from an abnormal focus within the atria and variable ventricular conduction
What is atrial fibrillation?
-Very rapid atrial depolarization (350-600 bpm) from many ectopic atrial foci
-Etiology: HTN heart disease, ischemic heart disease, valvular heart disease, alcohol, thyrotoxicosis, lung disease, fever
-Rapid ventricular response gives ineffective systole (from poor filling) and subsequent heart failure/pulmonary edema, palpitations, or gain
-Presence of atrial fibrillation predisposes to atrial blood stasis and subsequent clotting which can embolize and cause stroke
irregularly irregular ventricular rhythm, narrow QRS complexes, ventricular rate can be rapid (uncontrolled)
-Tx: ABCs, IV, oxygen, control ventricular response, consider elective cardioversion if present for < 48 hours, if > 48 hours, anticoagulant for 4 weeks prior to cardioversion, emergency cardioversion for severe compromise refractory to meds, anticoagulation in new-onset is mandatory d/t risk of stroke
What is supra ventricular tachycardia?
-Narrow QRS complex tachycardia with regular RR intervals at a rate of 150-250 bpm
-MC pediatric dysrhythmia
-Symptoms: dyspnea, palpitations, angina, diaphoresis, weak or non palpable pulses, CHF, shock
-Diagnosis: narrow QRS complex,
tachycardia > 150 bpm and rhythm is regular (may or may not see p waves)
-Tx: ABCs, IV, oxygen, monitor, cardioversion if unstable, vagal menacers or adenosine for stable, diltiazem or verapamil for rate control
What is acute bacterial endocarditis?
-Bacterial infection of the endocardium
Fever, murmur, and IV drug use is endocarditis until proven otherwise
Positive blood culture-->strep viridian's, streptococcus bovid, staph aureus
Endocardial involvement on echo
-Risk factors: congenital heart disease, valvular heart disease, prosthetic valve, IV drug use, dialysis, previous hx
-Symptoms: fever, arthralgia, pleuritic chest pain, janeway lesions (nontender on palms), osler's nodes (tender on fingertip nodules), roth spots (retinal hemorrhages)
and then specific towards blood culture
What is cardiogenic pulmonary edema?
-Etiology: medication noncompliance (MC), excess salt intake, acute MI, sepsis
-Diagnosis: cardiomegaly on CXR, sinus tach or Afib on EKG, cardiac biomarkers, BNP
oxygen or BiPap, ASA, nitro, diuretics
What is pericarditis?
-Constrictive: fibrous reparative thickening of pericardial layers that restricts diastolic ventricular filling
-Acute inflammation: inflammation of pericardial tissue resulting in pain and effusion
-Symptoms: fever, pleuritic and positional chest pain, tachycardia, myalgias, shallow breathing, anxiety, pericardial friction rub, distant heart sounds
-Diagnosis: EKG shows
diffuse ST elevations
or diffuse T wave inversions,
elevated ESR and WBC counts
-Tx: r/o ACS,
NSAIDs for viral, post MI and idiopathic, abx for bacterial fungal, TB, and parasitic, surgical pericariectomy
What is a pericardial effusion?
-Excessive fluid in pericardial space
-Symptoms: asymptomatic when small, fever, pleuritic and positional chest pain, tachycardia, myalgias, shallow breathing, anxiety, pericardial friction rub, distant heart sounds, so similar symptoms as pericarditis, but vitals tend to be more pronounced
-Diagnosis: cardiomegaly on CXR,
-Tx: ABCs, IV, oxygen, pericardiocentesis if unstable, if stable then pericardial window
What is aortic stenosis?
-Valve hardening obstructs blood low from left ventricle
-Results in progressive LVH, decreased CO, hypertrophy, and later dilated cardiomyopathy
-Symptoms: DOE, angina, syncope on exertion, sudden death,
low-pitched crescendo-decrescendo murmur at the base radiating to the carotids
-Diagnosis: cardiomegaly on CXR, LVH on EKG,
-Tx: definitive=valve replacement, r/o ACS and CHF, ABCs, IV, oxygen, and monitor
What is aortic regurgitation?
-Regurgitation of blood flow back into the ventricle
-Causes: acute=infective endocarditis and aortic root dissection, chronic=rheumatic fever, AS, syphilis, reiter's syndrome
-Symptoms: dyspnea, angina, S3 heart sound,
high-pitched blowing diastolic murmur heard at the base
-Diagnosis: cardiomegaly in chronic, pulmonary edema without cardiomegaly in acute, EKG shows LVH with strain pattern in chronic, ischemic changes in acute,
-Tx: ABCs, IV, oxygen, monitor,
reduce after load with nitrates and diuretics
, valve replacement
What is mitral stenosis?
-Decrease blood flow from left atrium to left ventricle which results in atrial dilation, atrial fibrillation, HF, progressive pulmonary HTN, right HF
-Etiology: rheumatic fever
-Symptoms: DOE, orthopnea,
early diastolic opening snap followed by diastolic rumble at the apex
-Diagnosis: normal CXR, LAE on EKG with possible RAD or AFib,
-Tx: ABCs, IV, oxygen, monitor, surgery
What is mitral regurgitation?
-Regurgitation from left ventricle to left atrium during systolic which results in increased LV stroke volume with eventual LV dilation and dysfunction
-Acute causes: MI, endocarditis
-Chronic causes: rheumatic fever, appetite suppressant drugs (Fen-Phen), MVP, marfan
-Symptoms: dyspnea, tachycardia and tachypnea, angina, S3 and S3 heart sounds,
loud crescendo-decrescendo murmur btw S1 and S2 at the apex radiating to axilla
-Diagnosis: cardiomegaly on CXR for chronic, pulmonary edema for acute, LVH and LAE enlargement in chronic, ischemic changes in acute,
-Tx: ABCs, IV, oxygen,
nitrates, diuretics, morphine for pulmonary edema and reducing after load
, ACE, long-acting nitrates, and salt restriction for chronic
What is an abdominal aortic aneurysm?
-Atherosclerotic, thinned tunica media has decreased elastin fibers and forms aneurysm from HTN
-Risk factors: age > 60 yo, male, HTN, smoking, CAD, PVD, family hx
-Symptoms: abdominal pain, pulsatile abdominal mass, back/flank pain, tender abdomen, N/V, syncope
-Diagnosis: CXR can be normal, AXR may have calcification, EKG shows tachycardia,
u/s for unstable patients and CT for stable
-Tx: ABCs, 2 large bore IVs, oxygen, IV fluid if shock, unstable=rapid trasport to vascular surgery
What is aortic dissection?
-Tearing of the aorta d/t hypertensive "shearing forces" on an atherosclerotic vessel that infiltrate through the intimal and track or "dissect" btw the intimal and aventiital layers
-Type A: ascending aorta
-Type B: descending aorta
-Risk factors: HTN, connective tissue disease (Marfan, Ehlers-Danlos), male, congenital heart disease, pregnancy (3rd trimester), turner syndrome, cocaine use
sudden-onset tearing chest pain radiating to the back
, tachycardia, focal neuro deficits depending on involvement-stroke symptoms if carotid involvement
-PE: > 20 mmHg BP difference btw upper and lower extremities, may become pulseless or cold
-Diagnosis: EKG shows LVH with strain pattern, CXR/CT shows mediastinal widening,
Transesophgeal echocardiography (TEE) is study of choice (100% sensitive and specific)
, if not able to do TEE then
MRI/MRA is acceptable if stable
-Tx: ABCs, IV access with 2 large bores, oxygen, monitor,
antihypertensive meds Labetalol IV 0.25 mg/kg over 2 minutes and then nitroprusside 0.3-10 ug/kg/min, immediate surgical consult
What is peripheral arterial occlusion?
-A blockage in arterial flow compromises tissue distally and results in irreversible death within 4-6 hours
-Embolic sources (thrombus of cardiac origin breaks off and travels distally) and non embolic sources (atherosclerosis and plaque rupture with thrombus occlusion, vasospasm and/or arteritis)
-Risk factors: HTN, smoking, high cholesterol, DM, recent MI or Afib
"The 6 P's: pain, pallor, polar, pulselessness, paresthesias, paralysis
-Diagnosis: AFib or A flutter on EKG, cardiomegaly on EKG, lower limb vascular imaging like angiogram or MRA
immediate vascular surgery consult for possible thrombectomy and IV heparin
What is hypertensive urgency?
-SBP > 180 or DBP > 110 without evidence of end-organ damage
-MCC is noncompliance with medications
-Tx: oral agents
What is hypertensive emergency?
-HTN that causes end-organ damage
-Symptoms: signs of end organ damage--> hypertensive encephalopathy, eye (cotton wool spots, hemorrhage, papilledema), heart (LV failure and pulmonary edema d/t increased after load), acute renal failure, pregnancy (eclampsia), aortic dissection
-Diagnosis: elevated BUN and Cr, urinalysis, CBC, electrolytes, CXR shows pulmonary edema, LVH on EKG, CT shows bleed of edema
-Tx: reduce the MAP by no more than 25% within minutes-1 hour, for stable reduce to 160/110 within 2-6 hours, vasodilators (nitroprusside, nicardipine, hydrazine, enalapril, fenoldopam), adrenergic inhibitors (labetalol, esmolol, phentolamine)
Where is a foreign body most likely going to be dislodged?
-Children=C5 (cricopharynxgeus muscle)
-80% will pass spontaneously
-If in the 1/3 of esophagus (top 5 cm), it can be removed with Magill forceps and laryngoscope
-For distal esophagus, use IV glutton or sublingual nitro to relax and decrease LES tone
-Most alkaline batteries will pass into the stomach and be observed
-10% of button batteries will lodge in the esophagus and must be removed bc they are corrosive
What is abdominal pain?
-Visceral pain: vague, dull, and poorly localized
-Parietal pain: sharp, well-localized associated with rebound and involuntary guarding. Pain correlates with dermatomes
-Referred pain: afflicted location are perceived as originating from a site in which there is no current pathology
-Abdominal wall causes: hernia, rectus sheath hematoma
-Metabolic causes: DKA, hypercalecemia
-Infectious causes: herpes zoster, mono, HIV
-Drugs/toxins: lead poisoning
-Other: mesenteric ischemia
-Be careful in the elderly! They have unusual presentations, may not mount a WBC count or fever, and they often have comorbid disease
What is mallory-weiss tear?
-A partial thickness tear at the gastroesophageal junction associated with hematemesis
, hiatal hernia, gastritis
-Symptoms: prior history of vomiting, retching, or straining
-Tx: usually self-limiting
What is gastritis?
-Inflammation of the stomach
-Stress=severe medical or surgical illness including trauma, burns, hypotension, sepsis, or CNS injury
-MCC by chronic use of NSAIDs
-Symptoms: most are asymptomatic, but if symptomatic will show abdominal pain, N/V, or GI bleed
-Diagnosis: endoscopy for complaints of dyspepsia or upper GI bleed
-Tx: alcohol, cigarettes, caffeine, and citrus avoidance (6 weeks or so), H2 blocker or PPI
What is an upper GI bleed?
-Bleeding that is proximal to the ligament of Treitz
peptic ulcer (MC)
, gastric erosion, varices, mallory-weiss tear, esophagitis, or duodenitis
, or melena (dark tarry stool) with or without abdominal pain, check for hypotension, tachycardia, weakness, pallor, syncope, and diaphoresis
-Diagnosis: CBC, PT/PTT, cross and match, LFTs
-Tx: rapid assessment and management with ABCs, IV, oxygen, blood products for continued active bleeding or failure to improve vitals, NG lavage, GI consult, admit all unstable
What is peptic ulcer disease?
-Disruption of the mucosal defensive factors by acid and pepsin
infection with H pylori,
smoking, alcohol, NSAIDs, chemo, cocaine/crack use, Zollinger-Ellison syndrome
-Symptoms: pain is
burning, gnawing, dull, or hunger like, pain begins shortly after eating and pain is relieved by food or antacids
-Diagnosis: not diagnosed in the Ed, but treated empirically, endoscopy is used to diagnosed
-Tx: avoidance, eradicate the H pylori disease, pain relief with antacids given 1 hour before and 3 hours after meal, H2 blocks (cimetidine, ranitidine), and PPI are mainstay for noninfective. Infective=
PPI+amoxicillin+clarithromycin 500mg BID x 7-14 days
-Complications: perforation, gastric ulcer obstruction
What is inflammatory bowel disease?
-A chronic, inflammatory disease affecting the GI tract
-Two types: crohn's and ulcerative colitis
-Symptoms: see table
-Tx: supportive care, antidiarrheals, loperamide, sulfasalazine, corticosteroids, immunomodulators (azathioprine, methotrexate)
What is mesenteric ischemia?
-Lack of perfusion to bowel
-Risk factors: age > 50 years, valvular or atherosclerotic heart disease, arrhythmias (AFib), CHF, recent MI, critically ill patients with sepsis or hypotension, hyper coagulable states
MC location: SMA
pain out of proportion to findings
, sudden onset suggests arterial vascular occlusion by emboli, insidious onset suggests venous thrombosis
-Diagnosis: metabolic acidoses, elevated lactate,
angiography is gold standard
, MRA, AXR may reveal irregular thickening of the bowel wall (thumb printing)
-Tx: IVF, oxygen, NG to decompress bowel, abx to cover gut flora, surgery to remove emboli or necrotic bowel
What is ischemic bowel disease?
-Etiology: drugs, trauma, connect tissue disease
-Symptoms: acute abdominal pain, melena,
pain out of proportion to exam
-PE: abdominal distention
, elevated WBC, amylase and CPK
-Tx: surgery, heparin
What is a hernia?
-Protrusion of a structure through an opening that is either congenital or acquired
-Reducible=can be pushed back in
-Incarcerated hernia=irreducible hernia may be acute and painful or chronic and asymptomatic
-Risk factors: obesity, chronic cough, pregnancy, constipation, ascites, previous repair
-Direct=protrudes through the floor of Hesselbach's triangle, rarely incarcerates
-Indirect=MC, protrudes lateral to the inferior epigastric vessels, frequently incarcerates, history of palpable, soft mass that increases with straining
-Tx: may attempt to reduce incarcerated hernia, outpatient referral for surgery, avoid straining,
strangulated hernia required immediate surgery
What is acute hepatitis?
-Inflammation of the liver secondary to a number of causes
, toxins (acetaminophen, heavy metals, valproic acid, isoniazid, phenytoin, amiodarone, HAV, HBV, HCV, CMV, HSV, parasites
-Symptoms: RUQ tendereness, alcoholic history, liver enlargement, weakness, anorexia, N, abdominal pain, and weight loss
jaundice, pedal edema, palmar erythema, spider angiomata
-Diagnosis: thrombocytopenia, elevated bili, elevated SGPT > SGOT (viral)
-Tx: supportive, corrective lytes, supplement with thiamine and folate, high calorie and high protein diet, N-acetylcysteine for acetaminophen poisoning
What is cholangitis?
-Obstruction of the biliary tract and biliary stasis leads to bacterial overgrowth and infection
common duct stone
Charcot's triad of RUQ pain, jaundice, fever/chills
-PE: elevated WBC, elevated bili, and elevated alk phos,
u/s shows ductal dilation and gallstones.
Gas in the biliary tree=cholangitis-Tx: ABCs, IV hydration, lytes correction, abx,
surgery consult immediately
What is cholecystitis?
Obstruction of the cystic duct with pain lasting longer, fever, chills, N, and positive Murphy's sign
Fat, female, fertile, and forty
-Diagnosis: Alk phos, bili, LFTs, lytes, BUN, creatinine, amylase, lipase, CBC, plain films,
, HIDA scan if unsure,
positive murphy's sign
-Tx: uncomplicated=pain control and can go home, acute=ampicillin and amino glycoside and surgery service
What is acute pancreatitis?
-Inflammation and self-destruction of the pancreas by its digestive enzymes
gallstones and alcohol
, HLD, hypercalecemia, trauma, drugs-thiazide diuretics, steroids, viral (coxsackievirus, mumps)
abrupt onset of deep epigastric pain with radiation to the back
, they prefer to lean forward, N/V, anorexia, fever, tachycardia, jaundice
CT is preferred
-Tx: fluid, lytes correction, bowel rest, NG suction as needed
-Prognosis: based on Ranson's criteria
What is a large bowel obstruction?
, diverticular disease, volvulus, fecal impaction, adhesions, hernia, strictures (IBD)
-Symptoms: intermittent crampy abdominal pain, vomiting, abdominal distention,
absence of BM or flatulence for several days
-Diagnosis: AXR may show stepladder appearance of air-fluid levels, thickening of bowel wall, or loss of colonic markings (haustra), CT of abdomen to for a transition point-open vs. closed loop obstruction
-Tx: IVF, NG suction, early surgical consult
What is toxic megacolon?
-Associated with ulcerative colitis
-Symptoms: toxic appearing
-Diagnosis: colonic diameter > 6 cm on x-ray
-Tx: NG suction, surgery to prevent perforation if fails to improve
What is infectious diarrhea?
-80% of acute diarrheas
-Viral etiology: rotavirus, norovirus, adenovirus, CMV, HSV, coronavirus
-Bacterial etiology: shigella, salmonella, camp, e.coli, yersinia, c difficult, staph aureus, vibrio, chlamydia, gonorrhea
-E. coli --> travel's diarrhea --> bactrim or cipro
-Camp --> contaminated water or milk --> cipro or azithromycin
-Salmonella --> eggs and mild --> no tx
-Shigella --> day cares, bloody --> bactrim
-Giadria --> water-borne --> metronidazole
-Norovirus/rotavirus --> no tx
What is volvulus?
-Closed loop obstruction of the large bowel resulting from the bowel twisting on itself
-Sigmoid (MC) occurs in the elderly and is associated with chronic constipation
-Diagnosis: AXR shows a loop arising out of the LLQ like bird beak creating a dilated loop that resembles a bent inner tube towards the right side
-Tx: IVF, NG suction, early surgical consult, may consider abx if infection is present, sigmoidoscopy may be done to decompress the bowel
What is appendicitis?
-Inflammation of the appendix
, worms, granulomatous disease, tumors, calculus, adhesions
-Symptoms: pain usually begins periumbilical pain then migrates to the RLQ where it becomes more intense and localized (McBurney's point), anorexia, N/V, low-grade fever, RLQ pain with rebound tenderness and guarding
Rovsing's sign (pain in the RLQ when palpation pressure is exerted in the LLQ), Iliopsoas sign (pelvis pain upon flexion of the thigh), obturator sign (pelvic pain on sternal and external rotation of the thigh with the knee flexed)
-Diagnosis: leukocytosis, hematuria, pyuria, clinical, u/s, CT is the most sensitive
-Tx: prompt appendectomy, NPO, IVF, peri-op abx
What is diverticular disease?
-Saclike herniations of colonic mucosa occurring at the weak points in the bowel wall with increased luminal pressures
-Diverticulosis=massive painless lower GI bleeding
-Diverticulitis=fecal material lodges in diverticula, leading to inflammation and ischemia and mucosal erosion
-Etiologies: low fiber diet, chronic constipation, family hx
-Symptoms: rectal bleeding, anemia, hematochezia, LLQ pain with guarding, fever, diarrhea, anorexia, N/V
-Tx: ABCs, high-fiber diet and stool softeners, diverticulitis=IVF, NPO, NG suction
What is a lower GI bleed?
-Bleeding distal to the ligament of Treitz
, hemorrhoids, colon cancer/polyps, trauma, IBD, ischemic colitis, rectal disease
-Symptoms: hematochezia, abdominal pain, weakness, anorexia, melena, syncope, SOB
-Diagnosis: NG lavage, CBC, colonoscopy to localize and possibly limit bleeding
-Tx: ABCs, consider early/GI surgery consult for large bleed, surgery for unstable or refractory to medical therapy
What is an anal fissure?
-A linear tear of the anal squamous epithelium
-Symptoms: perianal pain during or after defecation
-Tx: sitz baths, stool softener, high-fiber diet, hygiene, and analgesics
What are hemorrhoids?
-Dilated veins of the hemorrhoidal plexus
-Internal=arise above the dentate line and usually insensitive
-External=below the dentate line, well innervated, painful!!
-Symptoms: external=painful thrombosis and tenderness to palpation, bright red bleeding. Internal=painless
-Tx: severe=excision of the local followed by sits baths and analgesics. Can use hydrocortisone, local anesthetic ointment, and sits baths
What is acute renal failure?
-Classified as pre renal, intrinsic, or post renal
: decrease in renal perfusion and decrease in GFR with normal tubular and glomerular function
--Etiology: hypovolemia, decreased CO, sepsis, third spacing, hypoalbuminemia, drugs (NSAIDs, ACE, nitrates)
urine sodium excretion < 10 or BUN to CR ratio > 20
--Tx: volume replacement, diuretics for CHF,
: obstruction anywhere from renal parenchyma to urethra
, neurogenic bladder, bladder neck obstruction, malignancy
--Tx: depends on etiology-foley catheter, percutaneous nephrostomy tubes for obstructing renal stones, urology consult if catheterization yields no urine
: insult to the kidney parenchyma from disease states, drugs, or toxins
--Etiology: IV contrast, surgery, trauma, shock, sepsis, drugs (amingolycoside abx, ACE, NSAIDs) , glomerulonephritis (streptococcal infection, SLE, wagerer's granulomatosis, polyarteritis nodosa, goodpasture syndrome, henoch-schonelin purpura, drugs)
-Diagnosis: muddy casts, RBC casts
-Tx: d/c offending agents, consider dialysis if severe, increase urine output in oliguric patients with hydration and diuretics
What is hematuria?
-Etiology: acute glomerulonephritis, BPH, AAA, renal vessel thrombosis, urologic cancer, renal cell carcinoma, rhabdomyosarcoma, urolithiasis/
, sickle cell, trauma, infection (STD/UTI, schistosoma)
-Diagnosis: u/a: initiation of stream=urethral source, end of the stream=prostate or bladder neck problems
What is nephrolithiasis?
, struvite, urate, cystine
-5 areas of obstructing: renal calyx, ureteropelvic junction, pelvic brim, urterovesicalar junction (MC), vesicular orifice
-Risk factors: meds (hydrochlorothiazide, acetazolamide, allopurinol, excess vitamins) male, dehydration, hot climate, family hx, gout, hyperparathyroidism, immobilization, recurrent UTI
-Symptoms: acute and severe pain, flank, abdominal, or back pain with radiation to the groin, patients are very restless and cannot sit. The course is waxy and waning, possible N/V, hematuria, low-grade fever, urinary urgency/frequency
, u/s, KUB, intravenous pyelogram
-Tx: <5=most pass freely, 5-8mm=15% will pass freely, >8mm=only 5% pass freely. Analgesia with NSAIDs and opiates prn, hydration, nifedipine or tamsulosin to dilate the urethra and pass the stone. May need a lithotripsy, cystoscopy, or ureteroscopy to mobilize obstructing stones.
-Admit: urinary extravasation, obstructing stone, infected stone, intractable pain, patients with a single kidney
What is incontinence?
-Stress: loss of urine with coughing, laughing, or sneezing. MCC by cystocele or uretherocele. Tx: kegel exercises, estrogen replacement, or surgery.
-Urge: sudden loss of urine and patient does not have time to make it to the bathroom. Tx: anticholinergic.
-Overflow: loss of urine d/t obstruction or neuro control. Tx: self-catheterization, cholinergic meds, alpha blockers
What is cystitis?
-Infection of the bladder
, enterobacter, klebsiella, staph, pseudomonas, proteus
-Symptoms: dysuria, frequency, urgency, suprapubic discomfort, foul-smelling, cloudy urine, if fever/chills --> pyelonephritis
-Diagnosis: nitrites, leukocyte esterase and bacteria, WBCs
-Tx: fluoroquinolone, bactrim, nitrofurantoin, cephalin, pyridium
What is pyelonephritis?
-Infection of the parenchyma of the kidney and often follows a UTI
-Etiology: e coli, proteus, klebisella, enterobacter, pseudomonas
fever, chills, flank/back pain, N/V, anorexia, dysuria, urgency
-PE: CVA tenderness, fever
-Diagnosis: u/a with culture,
, nitrite/leukocyte esterase, blood culture, CBC
-Tx: fluoroquinolone, ceftriaxone
What is urethritis?
-Gonococcal: neisseria gonorrhea
--Symptoms: mile to yellow purulent discharge, painful/burning urination
-Tx: ceftriazone + azithromycin or doxy
-Chlamydia: chlamydia trachoma's
--Symptoms: clear to cloudy urethral discharge, painful, burning urination
--Tx: azithromycin or doxy
culture of discharge is gold standard
What is glomerulonephritis?
-Damage of the renal glomeruli
-D/t deposits of inflammatory protein
-Etiology: good pasture, post infectious, IgA nephropathy, SLE, aport syndrome
-Symptoms: hematuria, tea-colored urine, oliguria or anuria, edema, HTN
positive ASO titer, RBC casts
, serum complement (C3) positive
-Tx: dialysis, treat underlying cause
What is testicular torsion?
-Definition: twisting of a testicle on its root
-MC in infants <1 and young boys in the peripubertal period
-Symptoms: usually occurs with strenuous activity, pain may be in the lower abdomen, inguinal canal, or testicle.
no cremasteric reflex
to look for flow to testicle (no flow, asymmetric testicle=TT)
immediate urology consult
, if manual detorsion does not work, immediate surgery is necessary to prevent death of testicle. TIME IS TESTICLE!
What is orchitis?
-Inflammation of the testicles
-Etiologies: mumps and syphilis
bilateral testicular pain, fever, N/V, myalgias
-Tx: symptomatic tx (pain management), disease-specific tx (abx for syphilis)
What is epididymitis?
-Inflammation of the epididymis
E. coli, chlamydia, gonorrhea
-Symptoms: gradual onset of lower abdominal or testicular pain, pyuria, fever, dysuria, urethral discharge
Positive Phren's sign (transient pain relief on elevating scrotal contents while recumbent)
-Tx: abx for infection x 10-14 days, bed rest, scrotal support, cold compress, NSAIDs, stool softener
What is prostatitis?
-Inflammation of the prostate
-Symptoms: chills, back pain, perineal pain, recurrent UTIs, dysuria, increased frequency and urgency
-PE: firm, warm, swollen, tender, boggy prostate
-Tx: 1 month of tx bc poor penetration into the prostate, acute=usual UTI abx, chronic=fluoroquinolones
Where is an UTI?
-Infection anywhere from kidney parenchyma (pyelonephritis) to urethral orifice (urethritis)
-Women > men
-Symptoms: pyuria, bacteriuria
-Diagnosis: dipstick positive for leukocyte esterase and nitrites, gross hematuria, urine culture and sensitivity, WBC. CT scan for children < 5 years, all male children, recurrent UTIs in women, fever for > 3 w/ tx, recurrent pyelonephritis
-Tx: bactrim, fluoroquinolones x 3 days for simple, 7 days for others
What are the different anticoagulation meds and tests?
: increased apTT, works on
, safe in pregnancy
: 10 x activity against factor 10a
: increased PT, works on
2, 5, 7
, do not use in pregnancy, needs to be bridged with heparin, vitamin K dependent
: intrinsic + extrinsic pathways. Increased in hemophilia A (factor 8), hemophilia B (factor 9), factor 11 and factor 12 (asymptomatic)
: intrinsic and common pathways. Increased in vitamin K deficiency, warfarin therapy, liver disease
: time to convert fibrinogen into fibrin. Elevated in DIC, liver disease, heparin therapy.
: time from start of skin incision to formation of clot. Elevated in
thrombocytopenia and vWD
What is aplastic anemia?
-D/t damage to stem cells
-Acquired: toxin, radiation, NSAIDs, chemo, chloramphenicol, EBV, CMV, parovrius B19
-Symptoms: weakness and fatigue
-PE: pallor, purpura, petechiae
-Tx: bone marrow transplant
What is hemolytic anemia?
-Coombs negative: hypersplenism. Primary - idiopathic. Secondary - acute/chronic infection, chronic inflammatory disease, congestive splenomegaly, myeloproliferative disorders, leukemia/lymphoma
-Etiology: DIC, TTP, HUS, prosthetic heart valves
-Chemical: dapsone, fresh-water drowning
-Physical: burns, snake bites
-Infection: malaria, EBV
-Symptoms: Raynaud's phenomenon with cold antibody
IgG and C3 on RBCs
Drug-induced: penicillin, quinidine, and methyldopa
, steroid, IV gamma globulin, splenectomy
What is hemophilia?
-Hemophilia A=factor 8
-Hemophilia B=factor 9 (Christmas disease)
-Symptoms: deep tissue bleeding
prolonged aPTT and normal bleeding time
, family history
recombinant factor 8 or 9
What is von Willebrand disease?
-Deficiency of von Willebrand factor
-MC inherited bleeding disorder
-Patho: vWF functions to allow platelets to adhere to the damaged endothelium and carry factor 8 in the plasma
-Symptoms: epistaxis, GI bleeding, easy bruising, menorrhagia, prolonged bleeding
prolonged bleeding time, prolonged aPTT
What is thrombocytopenia?
Platelet count < 140,000
-Etiology 1.) Increased destruction (ITP, TTP, HIV) 2.) Decreased production (leukemia, aplastic anemia)
-Symptoms: petechiae, purpura, heme-positive stool, recurrent epistaxis, gingival bleeding, menorrhagia, hepatosplenomegaly
-Diagnosis: CBC, PT/PTT, bleeding time
-Tx: depends on cause, no need to give platelets unless < 10,000
What is idiopathic thrombocytopenia purpura (ITP)?
-An autoimmune-mediated destruction of platelets
-Diagnosis: decreased platelets (<10,000), megakaryocytic in bone marrow, large platelets in peripheral blood
prednisone 1 mg/kg/day
, danazol, splenectomy is 2nd line therapy, if life-threatening bleeding: high-dose steroids, IVIG at 1 g/kg for 1 day
What is thrombotic thrombocytopenic purpura (TTP)?
-Life-threatening disorder d/t giant vWD proteins clogging up microvasculature causing sheering of RBCs and consumption of platelets
, pregnancy, drugs like penicillin, clopidogrel, H2 blockers, SLE, infection
fever, AMS, renal dysfunction, hemolytic anemia, thrombocytopenia, neuro signs
schistocytes and helmet cells
, anemia, thrombocytopenia, BUN/CR: azotemia, hematuria, red cell casts on u/a, elevated bili
do NOT tranfuse platelets, plasma exchange is mainstay
, ICU-->high mortality rate!
What is disseminated intravascular coagulation?
-Both fibrinolytic and coagulation cascades are activated
-Risk factors: infection, trauma, OB complications, malignancy, shock, heatstroke, drugs
-Symptoms: sites of recent surgery or phlebotomy bleed profusely and cannot be controlled
, elevated d-dimers, schistocytes
-Tx: treat underlying cause
What is sickle cell anemia/crisis?
-Genetic disease characterized by the presence of hemoglobin S in RBCs
-The distorted RBCs are inflexible and plug small capillaries --> occlusion and ischemia/infarction
-Diagnosis: new born screening,
, anemia, electrophoresis shows hemoglobin S
crisis=arthralgia and pain caused by vascular sludging and thrombosis, may be precipitated by infection, most are d/t faso-occlusive crisis infracting a particular organ
crisis=aggressive pain management
(no transfusion in acute setting)
What is SVC syndrome?
-Acute or subacute obstruction of the SVC d/t compression, infiltration, or thrombosis
malignant tumor is MC either from lung cancer or lymphoma
, catheters, pacemaker wires, thrombosis
-D/t lack of gravitational assistance with drainage (symptoms are more severe in the recumbent position and in the morning after sleep)
, facial swelling, head fullness, distended neck of chest wall veins, UE edema
-Diagnosis: CXR (mediastinal widening),
CT w/ contrast
, if mass=biopsy is definitive
-Tx: stridor with central airway obstruction or laryngeal edema and increased ICP are emergencies, in most cases elevating bed and steroids and diuretics to decrease swelling
What is dysmenorrhea?
-Painful menstruation which prevents performing normal activities
-Seconday=endometriosis, adenomyosis, PID, leiomyomata, adhesion
-Symptoms: defuse pain in lower abdomen, pain comes and goes, N/V, diarrhea, h/a
-Tx: NSAIDs for primary, treat underlying cause
What is a breast abscess?
-Painful collection of pus in the breast
-Often linked to mastitis, but can also be d/t nipple piercings or sores around nipples
-symptoms: localized pain, swelling, fever
-Tx: surgical drainage,
nafcillin, vanc, clindamycin
, if fever continues after abx then consider mastitis
-Mastitis: most common in lactating women. Sudden onset of fever, chills, malaise, and general body aches. There is erythema and tenderness. The area is indurated to palpation.
Almost always unilateral
. Tx: dicloxacillin and continue to breast feed.
What is amenorrhea?
-Primary=never menstruate at 14 w/o secondary sexual characteristics or age 16 with secondly sexual characteristics
-Secondary: previously menstruated but has not menstruated for the past 6 months
MCC is pregnancy
-Diagnosis: if hypothalamus-pituitary dysfunction-
FSH and LH decreased
. If ovarian failure-
FSH and LH increased
and response to progesterone challenge test
-Tx: if hypothalamus-puitary dysfunction: stimulate gonadotropin secretion (clomiphene citrate, menotropins). If withdrawal bleeding-use hormone replacement
What is dysfunctional uterine bleeding?
-Ovulatory: regular menstrual periods with inter menstrual bleeding --> OCPs, uterine fibroids
-Anoverulatory: hyper stimulated endometrium thickens and sheds irregularly
-Miscellaneous: carcinoma, polyps, lacerations, retained foreign bodies, endometriosis
-Tx: supportive, OCPs, gyn follow-up
What is pelvic inflammatory disease?
-Spectrum of inflammatory disorders of the female upper genital tract that includes endometritis, salpingitis, tubo-overian abscess, and pelvic peritonitis
-STD causes inflammation and scarring
-Leading cause of infertility
-Risks: young age, previous PID, multiple sexual partners, IUD placement in the first month, douching
lower abdominal pain, tenderness to pelvic exam, cervical motion and adnexal tenderness + fever, abnormal vaginal discharge, lab evidence of gonorrhea or chlamydia, or elevated ESR
cefotetan 2 IV every 12 hours or cefoxitin 2 g IV every 6 hours + doxy 100mg orally every 12 hours for inpatient. Ceftriaxone 250mg IM + Doxycycline 100mg BID x 14 days +/- Metronidazole
What is an ectopic pregnancy?
-The zygote implants outside the uterus (95% of the time it is in the fallopian tubes)
-Aborts when vascular supply to abnormal placenta is disrupted, but it may rupture
-Risks: age, previous hx, PID, race, STDs, IUD, smoking, tubal surgery or scarring
abdominal pain, vaginal bleeding, amenorrhea
hCG (doubles every 2-3 days in normal), u/s (presence of an echogenic adnexal mass, empty uterus, free fluid in the pelvis, cardiac activity outside the uterus)
-You can see the fetus in the uterus when the hcg level is around 1,000 (4-6 weeks gestation)
-Tx: methotrexate, surgery for unstable, Rh shot for Rh negative women
What are the different types of abortion?
Threatened: closed cervix but no passage of fetal tissue by history of exam
. Tx: bed rest for 24 hours, avoid intercourse, tampons, and douching until bleeding stops. Arrange outpatient follow up for repeat hCG/u/s in 24-48 hours.
Inevitable: vaginal bleeding with open cervical os but no passage of fetal products
. Tx: D&C
Incomplete: incomplete passage of fetal products btw 6-14 weeks of gestation
. Tx: D&C
Complete: complete passage of fetal products and placenta before 20 weeks
. Tx: supportive with outpatient follow-up for u/s to confirm abortion
What are ovarian cysts?
-Follicular cysts: first 2 weeks of menstrual cycle (MC)
--Symptoms: pain 2/2 to stretching of capsule/rupture of cysts.
-Corpus luteum cysts: last 2 weeks of menstrual cycle
--Symptoms: bleeding into cyst cavity may cause stretching or rupture of capsule. Associated with hemorrhage
-Polycystic ovaries: menses occur infrequent but are heavy and painful. Tx: OCPs
What is abruptio placentae?
-Premature separation of normally implanted placenta from uterine wall
-Risks: previous hx,
, abdominal trauma, cocaine, smoking, multiparty, advanced maternal age
vaginal bleeding with dark clots, abdominal PAIN
, uterine pain/irritability
fetal heart monitoring for signs of fetal distress
-Tx: immediate OB consult
What is placenta previa?
-Implantation of placenta overlying internal cervical os
-Risks: previous hx, prior c-section, multiple gestations, multiple induced abortions, advanced maternal age
PAINLESS vaginal bleeding, soft and contender uterus
to confirm the placenta location
do NOT perform a u/s, immediate OB consult
What is endometriosis?
-Presence of endometrial glands/stroma outside the uterus that may affect ovaries, fallopian tubes, bladder, rectum, or appendix
-Patho: "retrograde menstruation"
-Symptoms: pain most often occurs just before and during menses.
Triad: dysmenorrhea, dyspareunia, dyschezia
-Diagnosis: clinical, confirmed with laparoscopy
-Tx: pain management for acute with NSAIDs or opiates, hormonal therapy for long-term control, surgery for refractory cases
What is vaginitis?
: exposure to chemical irritant or allergen (douches, soaps, tampons, underwear, topical abx)
: decreased estrogen stimulation of vaginal leads to mucosal atrophy
: most common fungal infection caused by candida albicans. White "cottage cheese" discharge, beefy red swollen labia, pruritus, dyspareunia, dysuria. Diagnosis: pseudohyphae on KOH prep. Fluconazole 150mg single dose
Bacterial vaginosis: MC
, fishy-smelling itchy discharge, vaginal discharge + clue cells + pH > 4.5 + positive whiff test. Tx: Metronidazole 500mg BID x 7 days. Clindamycin cream if pregnant.
What is premature rupture of membranes?
-Rupture of fetal membranes before labor begins
-Symptoms: leakage of amniotic fluid prior to onset of labor at any stage of gestation
-Diagnosis: pooling of amniotic fluid in vaginal fornix,
nitrazine paper test (turns blue)
-Tx: If > 37 weeks = deliver w/in 24 hours, if fetus < 24, provider weighs risks vs. benefits
What is fetal distress?
-Variable decelerations: cord compression (abnormal) -Early decelerations=head compression (normal) -Accelerations=normal
-Late decelerations=placental insufficiency (abnormal)
-Fetal tachycardia could signal maternal fever
What is cellulitis?
-A local erythematous inflammatory reaction of the subcutaneous tissue following a cutaneous breach which leads to infection
strep progenes (MC)
, staph H. influenza if unimmunized, MRSA
-Symptoms: localized tenderness and swelling, warmth, erythema
uncomplicated: cephalexin or dicloxacillin x 10 or azithromycin 500mg x 5 days. IV abx for head, face, or immunocompromised: IV Cefazolin and nafcillin or oxacillin. Ceftriaxone or imipenem for severe.
MRSA: bactrim or clindamycin and IV Vanc if needed
What is septic arthritis?
-Infection of the joint space
staph aureus is MC
, pseudomonas if IV drug user
-Common in young children and elderly (bi-modal distribution)
MC joint is the knee
-Risk factors: RA, OA, risky sexual behavior
fever, chills, acute joint stiffness, recent urethritis, maculopapular or vesicular rash, pain with PROM, joint is warm, tender, and swollen with evidence of effusion
arthrocentesis shows WBC >50,000 with 75% agranulocytosis
elevated ESR and CRP
, x-rays to look for underlying osteomyelitis
IV abx (nafcillin, oxacillin), I & D, splinting of joint, analgesia, surgery in children
What is osteomyelitis?
-Inflammation or infection of the bone
IV drug users --> staph aureus or pseudomonas
--IV catheters --> staph aureus, staph epidermis, candida
--URI --> enterobacteriaceae
--Sickle cell --> salmonella
--DM --> staph aureus, staph epidermis, anaerobes
-Risks: trauma, immunocompromised, soft-tissue infection
pain, swelling, and warmth of the bone or joint, decreased ROM, fever
-Diagnosis: bone scan, x-ray shows periosteal elevation (w/in 10 days), blood cultures for causative agent,
-Tx: abx x 6 weeks, splinting of the joint
-Staph aureus --> nafcillin, oxacillin
-MRSA --> Vanc
-Enterococcus --> ampicillin
-E. coli --> cipro
-Pseudomonas --> cipro
-Anaerobes --> clindamycin
-Mixed --> bactrim
What is low back pain?
-DDX: fracture, AAA, cauda equina, tumor (cord compression), other (OA, MSK), infection (epidural abscess), disk herniation
: MC from osteoporosis. Also seen in chronic steroid use or patients with lytic bony metastases.
Height loss, sudden back pain after mild trauma, local radiation of pain
. X-ray will not show unless 25-30% loss of spine. Tx w/ NSAIDs and possible opioids short-term pain relief. Tx osteoporosis (WB exercises, estrogen replacement, bisphosphonates)
immunosuppressed, IV drug users, and elderly. MCC by staph aureus. Will have pain, fever, and progressive weakness.
Diagnosed by MRI. Emergent decompressive laminectomy can prevent permanent sequelae and long-term abx.
Spinal cord compression
: malignancy metastasizing to and destroying vertebral bodies and and extending into the epidural space causing cord impingement. MCC by prostate, breast, or lung cancer. Diagnosis is by MRI. Tx is high-dose steroids to control inflammation/edema. Surgery is good for single area of compression, but radiology for multiple areas of compression.
What is a herniated disc?
-MC affects L4-L5 and L5-S1.
limited spinal flexion. Pain and paresthesia with a dermatomal distribution. Specific neuro signs d/t nerve root involved. Radiation down the buttock and below the knee
What is caudal equina syndrome?
-Compression of the lumbar and sacral nerve roots that comprise the cauda equina.
saddle anesthesia, weakness with foot plantar flexion, lost of ankle reflexes, and sensory/motor disturbances, decreased anal sphincter tone, bowel and bladder incontinence or retention
-Tx: malignant=oncology consult, steroids, radiation or surgical decompression. Nonmalignant=bed rest and analgesia.
What is gout?
-A disorder in purine metabolism resulting in the deposition of urate crystals in joint spaces, resulting in joint inflammation and exquisite pain
-Risks: age, hyperuricemia, alcohol consumptions, thiazide diuretics
-Symptoms: acute onset of extreme pain in small joints accompanied by redness and swelling,
(inflammation of the first MTP joint)
negatively birefringent crystals in synovial fluid
, elevated uric acid levels
, steroids if NSAIDs are contraindicated. Allopurinol is used as prophylaxis, but do not give in acute attacks
What is a rotator cuff tear?
-Supraspinatus, infraspinatus, tere minor, subscapularis
-Symptoms: dull aching in shoulder,
difficulty reaching overhead
, weakness on external rotation and abduction
PROM normal and AROM is limited, positive drop test in severe tears
-Tx: NSAIDs, steroid injections, PT, surgical repair
What is an anterior shoulder dislocation?
-MC (97%) than posterior should dislocations
-Etiology: forcible external rotation and abduction of the arm
patient maintains shoulder in elevated position and resists internal rotation of arm
-Tx: closed reduction under conscious sedation, sling for 4 weeks, ROM exercise
What is a posterior shoulder dislocation?
-Not common (2%)
-Risk factors: lightning injury, seizures, anterior blow to shoulder or fall on outstretched hand
-Symptoms: arm is internally rotated and adducted
lightbulb sign (internally rotated proximal humerus)
-Tx: closed reduction under conscious sedation, sling for 4 weeks, ROM exercises
What is a supracondylar humeral fracture?
-Common in children and falls on outstretched hand
-Symptoms: deformity and tenderness
joint effusion on x-ray and presence of anterior or posterior fat pad on lateral x-ray
-Tx: associated with compartment syndrome requires
emergent ortho consult
-If they return with increasing pain think compartment syndrome!!
What is a colles fracture?
Distal radius fracture with dorsal angulation
-MCC by FOOSH
dinner fork deformity
for 4-6 weeks with solar flexion and ulnar deviation
What is a smith fracture?
-Distal radius fracture with volar angulation
-MCC by direct trauma to dorsal forearm
-Tx: surgery or cast in supination
What is a galeazzi fracture?
Distal 1/3 radial fracture with dislocation of distal radioulnar joint
-MCC by FOOSH in forced pronation or direct blow to back of wrist
What is monteggia fracture?
Proximal 1/3 ulnar fracture with dislocation of the radial head
-MCC by FOOSH or direct blow to posterior ulna
What is gamekeeper's thumb?
-Avulsion of ulnar collateral ligament of 1st MCP joint
forced radial abduction of the thumb
inability to pinch
pain with valgus stress to thumb
What is a mallet finger?
Rupture of extensor tendon at its insertion into base of distal phalanx
-Etiology: fracture of distal phalanx
-Symptoms: inability to extend DIP joint
splint finger in extension
for 6-8 weeks
What is a boxer's fracture?
-Fracture of neck of 5th metacarpal sustained in a closed-fist injury
ulnar gutter splint for 3-6 weeks
What is a scaphoid fracture?
-MCC by FOOSH
What is a lisfranc fracture?
-Fracture through base of 2nd metatarsal
What is a baker cyst?
-Cyst in the medial popliteal fossa
-Rupture can mimic symptoms of DVT
-Tx: underlying cause, symptomatic with NSAIDs
What are the knee ligament tears?
-Meniscal injury: joint line pain, effusion and locking/popping
-Ligament injury: popping to the knee, inability to bear weight and swelling
--ACL: positive lachman and anterior drawer
--PCL: positive posterior drawer
--MCL: positive valgus
--LCL: positive varus
-Tx: knee embolization, crutches, analgesics, ortho consult
What is a calcanea fracture?
-Usually occurs d/t fall from a heigh with patient landing on his feet
-Tx: posterior splint for non displaced, surgery for displaced
What is a jones fracture?
-Fracture of diaphysis of 5th metatarsal
-Usually occurs d/t force applied to ball of foot such as pivoting of dancing
-Tx: short leg cast for non displaced and surgery for displaced
What is a hip fracture?
-Associated with a high mortality rate w/in the first year (20-30%)
-Symptoms: hx of fall, inability to bear weight,
leg shortened and externally rotated
-Tx: risk for AVN, primary arthroplasty
What is an ankle fracture?
-Classified as unimalleolar, bimalleolar, and trimalleolar
-Diagnosis: ottawa rules
-Tx: ORIF for bimalleolar and trimalleolar
What is legs-calve perthes disease?
-Childhood hip disorder that involves AVN of femoral head
-MC in males
-Symptoms: analgesics, may or may not have hx of trauma or strenuous activity followed by sudden onset of limping and pain in the anterior groin, anterior thigh or knee.
Hip is held in external rotation and is limited in internal rotation
. May have buttock and thigh atrophy on affected side
-Tx: depends on severity, most are self-limiting, if ROM is limited then abduction cast is applied
What is slipped capital femoral epiphysis?
-The femoral head maintains its position in the acetabulum but the memorial neck is displaced anteriorly
-Etiology: hx of trauma, obesity, endocrine disorders
hip, medial thigh, or knee pain intermittently worsened with activity, hip may be held in external rotation and internal rotation is limited
-Diagnosis: x-rays with AP, lateral, and frogleg views show irregular widening of epiphyseal plate
What is osgood-schlatter disease?
-Symptoms: pain at tibial tuberosity, pain worsened by palpation and knee extension against resistance, prominent tibial tubercle, soft-tissue swelling
-Diagnosis: x-rays show prominence of the tibial tubercle
-Tx: self-limiting, NSAIDs, stretching of quads
What is salter-harris?
-Class 1: fracture through epiphyseal plate
-Class 2 (MC): fracture of metaphysis with extension into epiphyseal plate
-Class 3: intra-articular fracture of epiphysis with extension into epiphyseal plate
-Class 4: intra-articular fracture of epiphysis, metaphysics, and epiphyseal plate
-Class 5: crush injury
What is compartment syndrome?
-Pressure in a compartment exceeds the arterial perfusion pressure
-MC in the lower extremity
-Risk factors: crush injuries, burns, casts, hemorrhage, edema
pain out of proportion to the injury, pain with passive flexion, decreased 2 point sensory discrimination, paresthesia or hypesthesia, tenderness. Late-pallor, absence of pulses, cold extremity
-Diagnosis: measuring compartment pressure with manometer
-Tx: removing constricting devices, fasciotomy for pressures for > 30 mmHg
What is AVN of the hip?
-Etiology: arteries in the medial and lateral circumflex become occluded d/t sickle cell disease or during immbolication
-Frequently a complication following a fracture of the neck of the femur
-Symptoms: aching of the joint early on, difficulty sitting for prolonged periods of time, weakness of hip, limp
-Diagnosis: x-rays may not show signs of the disease until more advanced
-Tx: less severe=PT, more severe=total hip arthroplasty
What is adrenal crisis (acute adrenal insufficiency)?
-Acute life-threatening emergency that occurs 2/2 to cortisol and aldosterone insufficiency
-Etiology: autoimmune, infections, metastatic cancer, adrenal hemorrhage (trauma, burns, sepsis, coagulopathy), drugs,
withdrawal of steroid therapy
-Symptoms: shock, anorexia, N/V, abdominal pain, fatigue, confusion/coma, fever
low serum cortisol level and inadequate serum cortisol response (30-60 mins after ACTH stimulation test)
, hyperkalemia, hyponatreia, CT may show hemorrhage in the adrenals, calcification of the adrenals (seen with TB), or metastasis.
-Tx: aggressive fluid resuscitation, steroid replacement with dexamethasone, treat underlying cause, long-term glucocorticoid replacement
What is DKA?
-State of absolute or relative insulin deficiency and counter regulatory excess resulting in hyperglycemia, dehydration, acidosis, and ketosis
-Etiology: infection, d/c of insulin, new onset DM
-Hyperglycemia --> osmotic diuresis and depletion of Na, K, and phosphorus
-Symptoms: polyuria, polydipsia, nocturia, weakness, N/V, confusion, coma, dehydration signs (hypotensive and tachycardia), kussmaul respiration (slow deep breaths),
fruity odor on breath
hyperglycemia, hyperketonemia, metabolic acidosis
-Tx: aggressive IV fluids, insulin infusion at 0.1 U/kg/h, correction of hypokalemia (it will be normal initially, but K moves intracellular with correction of acidosis)
What is hyperosmolar hyperglycemic state (HHS)?
-AKA nonketotic hyperosmolar coma
-Syndrome of marked hyperglycemia without ketoacidosis and metabolic acidosis (different from DKA)
-Insulin is inadequate to prevent hyperglycemia
-Etiology: infection, MI, stroke, GI bleed, pancreatitis, uremia, drugs (steroids, thiazide diuretics)
-Symptoms: hyperglycemia and pronounced osmotic diuresis, szs, coma, decreased skin turgor, more pronounced electrolyte losses (potassium, magnesium, and phosphorus)
-Tx: replace fluid losses with NS, insulin may be less but similar to 0.1 U/kg/h, tx precipitating factor. We don't want to correct too quickly bc it may result in cerebral edema
What is hyperparathyroid?
-Etiology: parathyroid adenoma, hyperplasia, and carcinoma
-Symptoms: same as hypercalcemia:
"stones, bones, abdominal groans, and psychic moans"
-Tx: volume expansion with saline followed by
loop diuretics to induce urinary Ca loss
What is thyroid storm?
-Life-threatening hyper metabolic state resulting from hyperthyroidism
-Mortality is high (20-50%)
-Etiology: infection, trauma, major surgery, DKA, MI, stroke, PE, withdrawal of anti hyperthyroid meds, iodine administration, idiopathic
-Symptoms: over activated sympathetic nervous system-
fever > 101, tachycardia, high output CHF and volume depletion, exhaustion, diarrhea, abdominal pain, agitation, confusion
-Tx: ABCs, IV hydration,
beta-blocker therapy (propranolol) to block adrenergic effects, acetaminophen for fever,
PTU or methomazole*, iodine to decrease release of preformed thyroid hormone, but wait 90 mins after getting PTU
What is myxedema coma?
-Life-threatening complication of hypothyroidism with profound lethargy or coma
-High mortality (20-50%)
-Etiology: sepsis, prolonged exposure to cold weather, CNS depressants, trauma or surgery
-Symptoms: profound lethargy (or coma), hypothermia, bradycardia, delayed relaxation phase of DTR
-Diagnosis: clinical, hx of hypothyroidism, blood and urine cultures, BUN, Cr, urine toxicology
-Tx: airway management with mechanical ventilation, active rewarming, ICU monitoring, IV levothyroxine, IV hydration
What is diabetes insipidus?
-Central: production of vasopressin from posterior pituitary d/t tumor, pituitary surgery, basilar skull fracture
-Nephrogenic: renal response to vasopressin d/t chronic renal disease, sickle cell, lithium, or colchicine
polyuria, polydipsia, dehydration, hypotension
low urine-specific gravity (< 1.005), hypernatremia, hyperosmolality. Positive challenge test for central DI
-Tx: treat underlying cause, central=DDAVP and nephorgenic=thiazides
What is lice?
-Phthirus wapitis mite lives on scalp and lays egg (nits) on hair shafts
-Location: scalp and neck (capitits) and pubic (pubic hair)
-Symptoms: severe itch
-Tx: 1% permethrin rinse and wash after 10 minutes and again after 5 days, fine tooth comb
What is scabies?
-"Itch mites" burrows into the skin and lays its eggs
-Location: flexural creases, hand, feet
-Symptoms: intense itch and mild burning, excoriation and pruritic red papules
-Tx: put on 5% permethrin and wash after 8 hours
What is impetigo?
-Bacterial superinfection of epidermis from broken skin
and nonbullous group A beta-strep
-Location: usually the face, but can be anywhere
-Age group: preschool children with predisposing atopic dermatitis
slow evolving pustules and the initial lesion is a erythematous papule or thin-roofed vesicle that ruptures easily and forms a "honey-colored" crust
, pruritic but not painful, enlarged lymph nodes, contagious
-Tx: remove crusts by soaking in warm water, antibacterial washes, topical abx
if limited, oral abx if not limited
erythromycin or first gen cephalosporin
What is pilonidal disease?
-Acute or chronic recurring abscess or chronic draining sinus over the sacrococcygeal or perianal area
-MC in white males 16-20 years
-Symptoms: pain, tenderness, purulent drainage, induration, midline pits or abscesses on or off the midline near the coccyx or sacrum
-Tx: I&D under local anesthesia
-An acute onset of superficial spreading cellulitis arising in inconspicuous breaks in skin involving the dermis and epidermis
-Location: leg (MC) but can affect any area
-Age group: very young or very old
an erythematous, shiny area of warm and tender skin with a well-demarcated and indurated advancing border
-Tx: same as cellulitis, elevated, IV abx (
pencillin G or amoxicillin
), if involves the eyes-consult optho
What is lyme disease?
-Caused by Borrelia Burgdorferi
-Common in atlantic and NE states
-Usually affects groin, popliteal folds, axillary folds, and earlobes
-Symptoms: fever, malaise, h/a, erythema migrans ("target lesion"), neuro symptoms (Bell's palsy)
-Tx: Doxy 100mg BID x 21 days
What s rocky mountain spotted fever?
-Location: wrists and ankles
-Age: 5-10 yo
-Common in the Western hemisphere
-Symptoms: maculopapular lesions that become petechial (ankles/wrists --> trunk), sudden onset of
, severe h/a, rigors, N, photophobia
-Diagnosis: clinical, indirect fluorescent antibody
-Tx: Doxy 100mg BID x 7 days
What is varicella zoster aka shingles?
-An acute dermtomal viral infection caused by reactivation of latent varicella zoster virus that has remained dormant in a sensory root ganglion
-Risk factors: age, malignancy, immunosuppression, and radiation
-Symptoms: pain, burning, itching, parenthesis in affected dermatome, fever, h/a, malaise, maculopapular rash that quickly transitions to become a vesicular eruption along a dermatome
-Tx: moist and cool compresses to affected dermatome, oral acyclovir, valacyclovir or famciclovir, analgesics
What is a drug reaction/eruption?
-An immunologic reaction that results in mast-cell degranulation of histamine. Histamine also causes vasodilation giving localized erythema and classic wheal appearance
-MCC by allopurinol, beta-lactam abx, sulf meds, anti-convulsants, ACEi, NSAIDs, thiazides, oral hypoglycemic meds
-Symptoms: wheals-abrupt development of transient, edematous, pink papules and plaques that may be localized or generalized and are usually pruritic
-Tx: benadryl (H1 antihistamine) and pepcid (H2 blocker) SQ epi if anaphylactic, PO/IV corticosteroids, observation
What is bullous pemphigoid?
-Autoimmune disorder with immunoglobulin G (IgG) antibodies to the dermoepidermal junction giving vesicles and bull that lyse and yield erosions
anywhere including oral mucosa
-Age group: elderly
-Symptoms: occasional pruritus and tenderness/burning sensation, large, erythematous urticarial plaques may precede bull by months, multiple, intact, tense bull crusted after ruptuing, primarily located on flexural areas of axilla, groin, medical thighs, forearms and lower legs
-Diagnosis: oral/IV steroids, consult term
-Tx: methotrexate, consult derm
What is eczema?
-Loss of epidermal lipids by excessive washing or decrease in production (elderly) causing flaking and cracking
-Location: flexor surfaces on adults and extensor surfaces on children
-Symptoms: red, blistery, oozy, thickened in acute, lichenified, and pigmented in chronic
-Tx: decrease frequency of washing or use moisturizer after each washing
What are drug eruptions?
-Erthema multiforme rxns-->immune complex mediated (IgM, C3) vasculitis of blood vessels at derma-epidermal junction that give rise to multiple pink-red target-snapped bullae and papules of varying sizes
-Age: MC in 20-40 yo
-Symptoms: lesions itch and burn, target lesions
-Tx: withdrawal agent, antihistamines for itch, wet to dry dressing with topical bacitracin for erosions
What is stevens-johnson syndrome?
-The bulls variant of erythema multiforme 2/2 to meds
sulfa drugs, barbiturates, phenytoin, carbamazepine, thiazides, penicillins
-Symptoms: viral prodrome precedes skin and mucosal lesions, lesions are
, burning, red-pink, target-shaped bull,
lesions are < 10% of the body
-Tx: hospital admission, antihistamines for the itch, IV corticosteroids, remove offending med
What is toxic epidermal necrolysis?
-Erythema multiforme variant that is a true emergency of the epidermis at the dermal junction
-Location: everywhere and
-Symptoms: prodrome of
and influenza symptoms, pruritus, pain, tenderness, and burning.
Initial target lesions become confluent, erythematous, and tender with bulls formation and subsequent loss of epidermis.
Sloughing may become generalized
Positive Nikolsky sign (sloughing of epidermis with light pressure over lesion)
-Tx: hopsital admission, wounds are treated as second degree burns
What are decubitus ulcers?
-Any pressure-induced ulcer that occurs 2/2 to external compression the skin, resulting in ischemic tissue necrosis
-Etiology: usually polymicrobial-staph aureus, street, pseudomonas, enterococcus, clostridium, proteus,
-Location: over bony prominences (sacrum, ischial tuberosities,iliac crests, greater trochanters, heels, elbows, knees, occiput)
-Tx: prophylaxis=mobilize patients, reposition patient, pressure reducing devices, nutrition. Local wound care=proper cleansing mild agents, moisturization, polyurethane, hydrocolloid, or absorptive dressiness, topical abx. Surgical debridement for necrotic tissue.
What are the different anesthesia options?
Ketamine: sedation-good for anxious children
. 4 mg/kg IM or 2 mg/kg IV. Need to be fasting for 4 hours from solids, 2 hours from liquids.
Midazolam (Versad): benzo. Good for sedation and amnesia but does not have analgesia
. Onset is 1-2 minutes and lasts for 30-45 mins.
Fentanyl: opioid that provides analgesia
. Good when combined with a bento (midazolam). Onset is 1-3 mins and lasts for 30-60 mins.
Ketamine (Ketelar): dissociative hypnotic-allows painful procedures performed while maintaining sedation
. Onset is 30-60 secs, duration is 15 mins.
Propofol: sedation and anesthesia, not analgesia
. 1 mg/kg IV loading dose followed by 0.5 mg/kg dosing every 2-5 minutes until desired effect. Onset is 40 secs and lasts 3-5 mins. Causes hypotension
-Etomidate: nonbarbituate hypnotic. Anesthesia not analgesia. Onset is within 60 secs and duration is 3-5 mins
-Nitrous oxide: administed inhalation
-Naloxone: opiate receptor antagonist 0.2-2.0 mg IV and onset is 30-90 secs
What are the upper extremity splints?
Reverse sugar tong: forearm or colles fracture
Boxer splint: 4th and 5th metacarpal fracture
Long arm ulnar gutter splint: supracondylar factor, elbow sprain, radial head fracture
Cock-up splint: wrist sprain, carpal tunnel
Thumb spica: scaphoid fracture, thumb dislocation, UCL sprain, thumb proximal phalanx fracture
What are lower extremity splints?
Posterior leg (ankle) splint: distal tibia and fibula fracture, ankle sprain, achilles tendon tear
Ankle stirrup: ankle strain/sprain, shin splint, hairline fracture
Long leg splint: femoral fracture
Knee imbolizer: knee sprain, post-op knee surgery
What are the different suturing material?
-Absorbable: gut (mucosa only), chromic gut (intramural) dexon (SQ sutures), vicryl, polydioxanone
-Nonabsorable: silk (not used on face), nylon (ethilon or dermal), polypropylene (prolene), polyester (mersilene) is good for facial wounds, plybutester
What sutures are used for different locations of lacerations?
-Pinna: 5-0 vicryl
-Eyebrow: 4-0 or 5-0 vicryl
-Eyelid: 6-0 nylon
-Lip: 4-0 vicryl
-Oral: 4-0 vicryl
-Face: 6-0 nylon or 5-0 vicryl
-Trunk: 4-0 vicryl or 4-0/5-0 nylon
-Extremity: 3-0 or 4-0 cicryl or 4-0/5-0 nylon
-Hands/feet: 4-0 or 5-0 nylon
-Nail bed: 5-0 vircyl
How long should sutures be in place?
-Face, eyelid, ear, nose: 3-5 days
-Neck: 5-7 days
-Scalp, trunk: 7-12 days
-Arm, hand: 8-12 days
-Leg, foot, extensor surfaces: 10-14 days
What is a cholinergic OD?
-Seen in organophosphates and carbamates
-Works on both muscarinic and nicotinic receptors
SLUDGE (salivation, lacrimation, urination, defecation, GI upset, emesis)
What is anticholinergic OD?
-Scopolamine, muscaria, MAOIs, think of the four groups of drugs (antidepressants, antihistamines, antipsychotics, antiparkinsonian)
AMS, mydriasis, flushed skin, hyperthermia, dry
-Tx: benzos, cooling measures, physostigmine
What is a sympathomimetic OD?
-Direct stimulation of alpha and beta adrenergic receptors. Amphetamines stimulate release of NE into synapse. Cocaine/TCAs prevent reuptake of NE from synapse. MAOIs inhibit breakdown of NE
-Symptoms: Agitation, mydriasis, tachycardia, HTN, hyperthermia, Resembles anticholinergic except they have diaphoresis and hypoactive BS (they're wet)
-Tx: supportive (benzos, hydration, cooling)
What is an opioid OD?
-Heroin, morphine, propoxyphene, meperidine, codeine, fentanyl
decreased level of consciousness, respiratory depression, and pinpoint pupils
-Tx: respiratory support,
(competitive opiate receptor antagonist). Start small < 0.4 mg to less likely precipitate withdrawal.
What is an acetaminophen OD?
-MC reported potential toxic ingestion
-Meds: tylenol, cold and flu preparations, percocet and norco
-Metabolism in OD: sulfating and glucuronidation pathways become saturated, P450 processes more APAP generating more NAPQI. NAPQI is toxic.
-Symptoms: asymptomatic, RUQ pain 24-48 hours later
What is an ASA OD?
-Meds: ASA, pepto-bismol, alia-seltzer, ben-gay, tiger balm
-Symptoms: delayed gastric emptying, tachypnea/hyperpnea, tinnitus, h/a, cerebral edema/coma
-Diagnosis: ferric chloride spot test
-Tx: respiratory support (intubate if necessary), IV fluids, activated charcoal, make urine alkalized with bicarbonate drip, consider hemodialysis if ASA > 100 mg/dL
What is an iron OD?
-Iron is absorbed by intestinal mucosa and stored as ferritin and elimination is primarily via sloughing of intestinal mucosa. In OD, the ingested iron overwhelms the proteins carriers and enters via passive diffusion. Iron is corrosive to GI mucosa and enters circulation directly.
-Symptoms: abdominal pain, N/V/D, shock, metabolic acidosis
-Diagnosis: serum level
-Tx: supportive, decontamination with deferoxamine
What is an alcohol OD?
-Toxic alcohol level: osmol gap=alochol level / molecular weight/10 --> elevation=toxic, but normal level does not rule out toxic ingestion
Most commonly used and abused intoxicant in the U.S
-CNS depressant cross reacts with other depressant (bento, barbiturates)
-Majority is metabolized by the liver
-Majority is absorbed in the proximal small bowel
slurred speech, nystagmus, disinhibition, CNS depression
-Tx: supportive (
thiamine, folate, IV fluids
) or a
"banana bag" (D5NS with 100mg thiamine, 1mg folate, and 1 amp MV)
-Alcoholic ketoacidosis=anion gap acidosis in heavy alcohol user who has temporarily stopped drinking and eating. Tx with IVF, IV glucose, and thiamine.
What is a cocaine OD?
-Blocks presynaptic reuptake of biogenic amine transmitters (DA, serotonin, and NE)
-Local anesthetic effect by blocking fast Na channels
-Initial euphoria is 2/2 to release of biogenic amine, subsequent dysphoria 2/2 to depletion of DA
-Symptoms: euphoria followed by dysphoria, HTN, tachycardia, chest pain (coronary vasoconstriction), szs, infarction, hemorrhage, rhabdomyolysis, hyperthermia
-Tx: supportive with sedation and cooling measures, decontamination (charcoal), benzos for tachycardia, HTN, and szs, aggressive IVF, ASA/nitrites for ischemia
What is carbon monoxide toxicity?
-Either from fires, vehicle exhaust, or home generators
-CO binds to hemoglobin with 250 x greater affinity than oxygen
-History: multiple victims, initial flulike symptoms, exposure to products of combustion
-Symptoms: mild=h/a, N/V, moderate=chest pain, concussion, tachycardia, tachypnea, taxia, severe=palpitations, disorientation, szs, coma
-Tx: hyperbaric oxygen to enhance pulmonary elimination when patient shows end-organ ischemia (syncope, coma, sz, focal neuro deficits, MI, dysrhythmias), CO-Hgb > 25%, severe metabolic acidosis, pulmonary edema (unable to oxygenate)
What is acute mountain sickness?
-Syndrome of several constitutional complaints related to hypobaric hypoxemia and its physiologic consequences
-Risk factors: children, rapid ascent, higher sleeping altitudes, COPD, decreased vital capacity, cold, heavy exertion, sickle cell disease
-Symptoms: hangover symptoms (anorexia, h/a, N/V), then oliguria, peripheral edema, retinal hemorrhage, and in late high-altitude cerebral edema
, oxygen (low flow), acetazolamide (decreases the formation of bicarbonate by inhibiting the enzyme carbonic anhydrase. Diuretic action counters the fluid retention of AMS. Decrease bicarbonate absorption in the kidney resulting in a metabolic acidosis that stimulates hyperventilation), hyper barbaric oxygen, NSAIDs for h/a, prochlorperazine for N/V
What is high-pressure dysbarism?
-Barotrauma associated with descent or dive into body that cannot equalize pressure
-Symptoms: middle barotitis media (eustachian tube dysfunction, ear fullness/pain, nausea and vertigo), external barotitis media (bloody otto rhea), sinus pressure, hemoptysis, SOB, PE
-Tx: equilibrate spaces (remove foreign body, use decongestants, give abx for sinus symptoms, otitis external, TM rupture)
How do you treat people who got stung by a "stinger" in the ocean (stingrays, starfish, scorpion fish, catfish, lion fish)?
-Immerse wound in non scalding hot water for 90 minutes (or until pain is gone) to break down venom
-X-ray to find and remove stings
-Aggressive cleaning, abx
How do you treat nematocysts?
-Corals, fire corals, anemones, sea wasps, jellyfish
-Tx: ABCs and inactivate nematocysts by immersing in them in vinegar, immobilize limb, IV access and fluid, antivenin, antihistamines/epi/steroids for anaphylaxis, pain control, tetanus
How do you treat snake bites?
-Avoid harmful interventions (cutting, sucking, tourniquets)
-Antivenom 4-6 vials IV immediately
What are brown recluse spiders?
-Found in the midwest, mid-Atlantic, and southern states
-Inhabits warm, dry places
-Symptoms: narcosis at bite site, mild red lesion, may be bluish/ischemic, fever, chills, N, sz, myalgias, hemolysis, renal failure
-Tx: monitor ABCs, daily wound care, tetanus, analgesia, abx if becomes infected
What is a black widow spider bite?
-Found throughout the continental U.S
-Inhabits warm, dry, protected places (cellars, barns, under rocks, etc.)
-Symptoms: local pinprick sensation, red, swollen. HTN, coma, shock, respiratory failure.
-Tx: symptoms will resolve on their own. Pain control and muscle relaxants, tetanus. Antivenin for severe.
How do you treat dog wounds?
-Etiology: MC is *capnocytophaga canimorus? aerobes like streptococcus, staph aureus, pasteurella, staph intermdeius. Anaerobes like bactericides, actinomyces, fusobacterium, peptostreptococcus.
-Tx: ABCs, aggressive irrigation, debridement, repair lac, but consider loose suture or leave open for delayed primary closure of hand lacerations. Tetanus prophylaxis. Augmentin for immunocompromised and frail prophylaxis. If infection < 24 hours: penicillin (tetracycline or erythromycin for allergies). If infection > 24 hours: cephalexin
How do you treat a cat bite?
-Tx: don't close them! Abx is the same as dogs, but always give them in cats. Cats are dirty ew!
How do you treat human bites?
-Clenched-fist injuries from punches in the face have higher rates of poor wound healing and complications
-Human oral flora is usually polymicrobial (aerobes and anaerobes)
-Tx: if clenched fist injury, copious irrigation, debridement, tetanus, penicillin, and 2nd generation cephalosporin for staph coverage. DM should get an amino glycoside. Immobilize, daily dressing changes, and elevate extremity.
What are burns?
-First degree=superficial burn, epidermis only
-Second degree=superficial partial thickness; epidermis and dermis
-Third degree=full thickness; epidermis, dermis, and SQ fat
-Fourth degree=skin, fat, muscle, bone
-Use the rule of nines
-Tx: transport to nearest burn hospital, oxygen, fluid resuscitation according to parkland formula (don't want to do too much=excessive pulmonary and peripheral edema), foley catheter to monitor fluid output, "put out the fire" with cool water within 30 minutes and always cover with clean, sterile, saline-soaked dressings to small areas, escharotomy for full thickness or circumferential burns, morphine for pain, leave blisters intact, no role for abx
-When to intubate: known smoke inhalation, respiratory distress, hypoxia, hoarse voiced, singed hairs, carbonaceous sputum
What is a lightning injury?
-Direct=lightning vs. person
-Contact=lightning vs. object person is touching
-Side flash=lightning vs. object near person
-Ground current: lightning vs. ground near person
-Symptoms: fernlike pattern to skin, ruptured TMs, unconscious, cardiac arrhythmias
-Tx: ABCs, secure airway, immobilize in c-spine, tetanus, EKG, u/a, CBC, CK, CK-MB, lytes, BUN, admit for observation
What is heat exhaustion?s
-Syndrome of vague constitutional symptoms associated with salt and water depletion and heat exposure or heavy exertion
-Symptoms: dizziness or fatigue, N/A, h/a, syncope, mildly elevated temp, diaphoresis, prickly heat rash, heat cramp
-Tx: remove from heat, rest, IV hydration with NS, oral hydration with sports drinks, check and correct electrolytes, observe
What is heat stroke?
-Rapid rise in core temp (>40.5 C or 104.9 F) associated with AMS, anhidrosis, loss of temperature regulation
-Symptoms: CNS abnormalities (ataxia, combativeness, hallucination, sz, posturing, hemiplegia, coma), renal failure, coagulation (increased bleeding times), liver failure, hypotension, death
-Tx: r/o sepsis, thyrotoxicosis, meningitis, remove from heat source, ABCs, use cooling techniques, correct bytes, check CBC< u/a, CPK, PTT, BUN/CR, and EKG. Benzos for shivering. Tylenol is helpful
--Evaporation: water mist and blowing fans (most practical in the ED)
--Immersion: tub of water and ice (impratical)
--Ice packing: ice bags to groin and axillae (poorly tolerated)
--Gastric cool lavage: via NG tube (poorly tolerated)
--Peritoneal: via peritoneal catheter (questionable sterility, but rapid)
What are chilblains?
-Local injury from dry cold at nonfreezing temperatures
-Symptoms: local edema, nodules or blisters, erythema or cyanosis
-Tx: reversible with gentle rewarming, avoid cold
What is trench foot?
-Nonfreezing injury from wet cold
-D/t prolonged immersion in standing water
-Symptoms: numbness/tingling, pallor, lack of pulses
-Tx: rest, elevation, local skin care, avoid cold
What is frostbite?
-Freezing injury when skin temperature fall below 0 degrees celsius
-Symptoms: there is tissue loss, throbbing, shooting pain in joints, numbness, tingling, edema, blisters, eschars
-Tx: active rewarming in warm water (104-108), tetanus, aspirate clear blisters, limb elevation, topical aloe vera
What is hypothermia?
-Core temperature < 35 degrees celsius
-Usually d/t prolonged overwhelming cold exposure
-Risks: extremes of ages, alcohol, homeless, AMS, trauma victims, underlying chronic illness, hypoglycemia, sepsis
-Symptoms: mild=shivering excitation, tachypnea, tachycardia, apathy, ataxia. Moderate=shivering ceases, stupor, bradycardia, dysrhythmias, dilate pupils. Severe=coma, hypotension, decreased CO, decreased RR, dysrhythmias
-Diagnosis: rectal temperature,
Osborn (J) wave
-Tx: remove wet clothing, mild=passive rewarming with blankets, moderate-severe=active rearming, cardiac monitoring, treat cardiac dysrhythmias per ACLS protocol
--Mechanical warming blanket
--Warmed IV fluids
--Warmed gastric lavage
--Warmed peritoneal irrigation
--Warmed cardiopulmonary bypass
--Warmed pleural cavity
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