SIM OSCE Emergent conditions

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Myocardial infarction

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- pain is described as diffuse, severe, "heavy" or "crushing"

- located centrally with radiation to the L-arm or jaw occurring rest

- associations: N/V, SOB, palpitations, weakness, dizziness & lightheadedness

- PE: obvious distress, diaphoretic, tachycardic, appear pale or gray, rale if HF

- Dx: EKG, cardiac biomarkers (CK, CK-MB, troponin), BMP, cardiac catheterization

Tx: "restore blood flow, limit remodeling"
- PCI w/in 90 minutes or thrombolytics w/in 12-hrs (alteplase 15 mg IV once, f/b 0.75 mg/kg over 30 min)
- O2 if <94%
- ASA: 325mg
- Ticagrelor: 180mg PO loading dose, f/b 90mg BID
- Atorvastatin 40mg PO
- NTG (unless hypotensive): 0.3 - 0.6 mg SL q5min, max: 3
- BB PO preferred (CI: HF, hypotensive, bradycardia) atenolol 50-100 mg PO or metoprolol tartrate 5mg IV q2min x3
- Heparin: 60 units/kg IV bolus, f/b 12 units/kg/hour infusion
- Morphine: 2-4 mg IV q5-15 for pain control

A3: ASA- 325, Atenolol- 50-100, Atorvastatin 40
H: Heparin 60 units/kg
M2: Morphine- 2-4mg IV q5-15min, Metoprolol- 5mg IV q2min x3
N: NTG- 0.3-0.6 mg SL q5min
O: oxygen- keep >94%
T: Ticagrelor 180mg PO

Thrombolytics CI:
- prior intracranial hemorrhage
- known malignant intracranial lesion or structural cerebral vascular lesion
- ischemic stroke in prev. 3 months
- suspected aortic dissection
- active bleeding
- significant head or facial trauma in the last 3-mo

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Terms in this set (20)

Myocardial infarction

Pulmonary embolism

- RF: cancer, trauma, major surgery, hospitalization, immobilization, pregnancy, OCP

- CM: CP, SOB, sense of apprehension, presyncope/syncope

Wells criteria: >4 PE likely
- 3: clinical signs of DVT, alt dx less likely than PE
- 1.5: previous PE or DVT, HR >100, surgery or immobilzation w/in 4-wks
- 1: hemoptysis, active cancer

PERC (PE rule out criteria)
- must meet all criteria
- <50, HR <100, O2 >94%, no unilateral leg swelling, no hemoptysis, no surgery or trauma w/in last 4-wks, no hx of DVT, no estrogen use

Order: CTPA, VQ (if allergic to contrast, severe renal failure, pregnancy, young pt), PT/INR, aPTT, BMP, CBC, D-dimer, pregnancy test, LE US, ECG

High risk
- >94%
- 500cc NS if SBP <90
- Norepi 0.1 mcg/kg/min if SBP <90
- heparin 80 units/kg IV bolus, f/b 18 units/kg/hr IV
- Warfarin 2-5mg once daily

Intermediate risk
- >94%
- Apixaban: 10mg PO BID x7 days, f/b 5mg BID

Pneumothorax

RF: smoking, FH, tall & slender, thoracic procedures, trauma, COPD/Asthma

Goal of tx: "remove air from the pleural space and decrease likelihood of recurrence"

Tension PTX:
- Needle decompression (2nd intercostal space midclavicular line or 4th/5th midaxillary), f/b chest tube
- at least 10L O2

Primary Spontaneous <2cm from lung margin to chest wall, <50yo & stable
- O2 10L/min for 4-6 hours

Primary spontaneous >2cm, symptomatic
- 10L O2 & needle decompression (2nd IC space mid-clav line)

Secondary spont. PTX (<1cm, no sx's)
- Supp. O2 & hospital admission

Secondary spnt. PTX (>2cm)
- O2, hospitalization
- Chest tube thoracostomy

Diabetic ketoacidosis

- CM: 3 P's, weight loss, N/V, dry mucus membranes, AMS, acetone breath

- Dx: glucose, ABG, beta-hydroxybutyrate, UA, CMP, CXR, ECG, CBC
*look for signs of preceding infection*

Management
- IVF: NS @ 1-1.5L/hr for 1st hour, when BS <200 switch to 5% dextrose w/ 0.45% NS at 150/hr
---monitor BMP q1-hr

- Regular insulin 0.14 units/kg/hr

- Add 20-30mEq K+ to each liter of IVF (3.3-5.3)
*STOP INSULIN if K <3.3, start when >3.3*

- pH <7.0, give Bicarb

Hyperosmolar hyperglycemic syndrome

Management
- NS 1-2L for the 1st hr
-- hypotension corrected, start NS 500mL/hr x4-hrs
--- then 250ml/hr x4-hrs

- IF K+ <3.3, give 20-30 mEq
- When K+ >3.3, add 20mEq to NS
- IF K+ >5.3, stop

- Insulin: K+ needs to be >3.3, bolus 0.1 units/kg, f/b 0.1 units/kg/hr