Stable Angina

Causes: reduction in O2 supply or increase in myocardial O2 demand with atheroscolerosis

Sx: precipitated by activity, stress, or anger - chest pressure/tightness/squeezing/burning/choking/aching. Last <20 min

Risk factors: family hx CAD, male, dyslipidemia, DM, HTN, physical inactivity, excess alcohol, smoking, obesity

EKG: NL, maybe old MI

Labs for lipids, DM, HTN

CXR: LVH, aneurysm, HF

Stress test to confirm dx

Tx:

- Keep in hospital for observation and serial troponins

- SL Nitro

- Nitrates - oral, patch, ointment

- BBs

- Asprin daily

- Plavix

- RIsk reduction

- Consider need for revascularization

angina or equivalent ischemic discomfort with and least one:

- rest angina (worse if >10 min)

- New-onset that causes marked limitations of physical activity

- increasing angina in severity, frequency, duration, lower threshold of precipitation

EKG: ST depression, transient ST elevation, T-wave inversion, no changes

CK-MB: Rises 4-6 hrs, peaks at 24 hours, remains elevated 36-48 hrs

Troponin: gold standard for dx - only rises in INFARCTION - not in ischemia, rises 4-8 hr, may remain elevated for 2 weeks

UA: No elevation in enzymes

NSTEMI: elevated enzymes without EKG changes

STEMI: elevated enzymes with EKG changes

1. monitoring, observation, repeat EKG/enzymes after 6-12 hrs, stress test after discharge

2. MI: admit for catheterization or PCI within **90 MIN**

3. anti-ischemics: sublingual nitro, morphine, BB, CCB, ACE

4. anti-platelet: aspirin, clopidegrel

5. anti-coagulation: LMWH (enoxaparin, dalteparin)

MONA-BAH:morphine, O2, nitrogen, asprin, BB, ACE/ARB, Heparin

BP: <140/90 or <130/80 if DM/CKD

- BB and ACE are best

LIpids: LDL<100; Tg<200

- Statins

Glucose: A1C < 7%

PVCs

tx: BB, catheter ablation

VFIB

tx: DEFIB - 200 biphasic, 360 monophasic

1. sustained

2. unsustained

3. tx: BB, implantable defibrillator, ACLS protocol

Shock

CPR 2 min

Shock

CPR

Epi

CPR

Shock

CPR

Amiodarone

CPR

Shock

CPR

Epi

CPR

NON-SHOCKABLE RHYTHM

CPR

EPI

CPR

EPI

H's and T's:
Hypothermia

Hypovolumea

Hypoxia

Hydrogen ions (acidosis)

Hypo/hyperkalemia

Tension pneumo

Tamponade

Toxins

Thrombosis

A flutter

***tx: ventricular rate control - convert to sinus rhtyhm with Class III antiarrhtyhmic (amiodarone) or electrical conversion

Afib

***tx:

1. slow ventricular rate: CCB (verapamil, diltiazem) or dig

2. 2nd: determine CHADS score (CHF, HTN, Age, DM, Prior stroke)

3. Anticoagulation - aspirin, warfarin, coumadin (depending on CHADS)

4. Cardioversion

5. Consider ablation, implantable defibrillator, pacemaker

PSVT

**Tx: Vagal/valsalva

- adenosine IV, CCB, esmolol

- cardiversion if hemodynamically unstable

- may need catheter ablation

nursemaid's elbow (slipped radial head)

tx: reduction

Radiology: posterior fat pad sign or sail sign

Supracondylar fracture: most common. due to fall on outstretched arm

complications: median nerve damage, brachial artery damage leading to volkmann's contracture

** labs: hyperglycemia >250, acidosis, serum bicarb <15, serum positive ketones, hyperkalemia, hyponatremia

** sx: usually preceded by a day or more of polyuria/polydipsia with marked fatigue, n/v, mental stupor, coma

** PE: dehydration (hypotension/tachy), rapid deep breathing, fruity breath/acetone odor, abd pain

Tx: Intubation if coma, NS to GB of 250 - then switch to D5W, insulin, potassium, bicarb, phosphate

Sx: deep retroorbital pain, lacrimation, conjunctival injection, rhinorrhea, nasal congestion, ptosis. need to move about, pace.

tx:

1. acute: 100% O2 for 15-20 min, sumatriptan

2. preventative: 10 day course of prednisone, ergotamine, lithium, verapamil

1. alcoholism: disulfuram (makes you puke), naltrexone (pleasurable effects), acamprosate (reduces cravings). diet high in thiamine, pyridoxine, folic acid, ascorbic acid

2. Withdrawal: CNS depressants (benzos - lorazepam), carbamazepime, atenolol, clonidine

carb-deficient transferrin

GGT >30

MCV >95 (men), or >100 (women)

High HDL

1. limited to subarachnoid space

2. classic triad: HA, Fever, neck stiffness

3. workup:

- + brudzinski's and kernig's

- CT if neuro defects, papilledema, AMS, nerve palsies, posturing, otherwise move straight to LP

- LP: Glucose <40 in bacterial (bc bacteria are eating it), protein >150, WBC, PMNs,

- blood cultures, CBC, chemistry

4. tx: abx, steroids

Meningicoccal meningitis

tx: ceftriaxone, dexamethasone

listeria monocytogenes

tx: ampicillin x 3 weeks

strep pneumonia

tx: ceftriaxone

NEXUS criteria = NSAID: neuro deficit, spinal tenderness, AMS, intoxication, distracting injury

NEXUS score

PE: examine genitals for priapism, decreased rectal sphincter tone, perineal sensation, neuro exam with glasgow coma scale,

- dorsal column: vibration, light touch

- ventral column: pain, temperature

- brainstem reflexes (nystagmus, hypoventilation)

- spinal reflexes (DTR, babinski)

imaging: CT of head is best

1. Brown-sequard

2. central cord syndrome

3. anterior cord syndrome

4. cauda equina syndrome

5. spinal cord injury without radiological abnormalities

1. causes: MI, exacerbation of CHF, acute volume overload, mitral stenosis, high ICP, opioids, DIC, sock

2. ** Sx: dyspnea, productive cough, diaphoresis, pink/frothy sputum, cyanosis

3. ** PE: rales in ALL lung fields, wheezing, rhonchi, low O2 sat

4. xray: BUTTERFLY PATTERN, increased interstitial markings, enlarged heart

5. **tx: sit with legs over side of beds, O2, morphine, diuretics, nitrates, SABA

sx:

1. acute: hypotension, tachycardia, hypokalemia, seizures, arrhythmia

2. chronic: n/v, abd cramps, tremor, anxiety, arrhythmia, seizures

tx: obtain serial levels

GI decontam: activated charcoal if dose ingested w/in 1 hr of arrival

Diazepam/phenobarb for seizures

IV fluids for hypotension

Antiarrhythmics

Demodialysis

OD at >150-200 mg/kg or 8-10 g in adult, lower if alcoholic or on INH

sx: n/v at first - asymptomatic for 24-48 hours - then fulminant hepatic necrosis with jaundice, hepatic encephalopathy, CKD, death

dx: serum acetaminophen level

**tx: activated charcoal within 1-2 hours of ingestion

N-acetylcysteine no matter how long after ingestion

sx:euphoria, drowsiness, constricted pupils, hypotension, bradycardia, hypothermia, coma, resp arrest

tx: activated charcoal if recent ingestion, Naloxone (narcan)

age >55

isolated patellar tenderness

fibular head tenderness

inability to flex to 90 deg

inability to walk 4 steps

MOI: falls, forceful contraction of quads

sx: pain, tenderness, joint effusion, palpable defect

tx: immobilize, ortho consult

MOI: hyperflexion - almost always displaces laterally

sx: tenderness, deformity, effusion, patellar apprehension

tx: sedate pt and reduce patella then immobilize, crutches, ortho refurral

MOI: varus or valgus stress

high risk for compartment syndrome

sx: pain, tenderness, hemarthrosis, associated ligamentous injury

tx: ortho

MOI: direct anterior/posteroir force, rotational force

Test: lachman, anterior drawer

tx: immobilization, crutches, non-WB, ortho

MOI: rotational force applied to knee while foot is planted

MCL more commonly affected

Sx: may say they heard a pop, joint line tenderness, feeling of knee locking,

Tests: McMurray, Apley

Tx: immobilization, crutches, pain control, ortho

1. anterior talofibular ligament

2. anterior drawer or talar tilt test

L3-4 (L4 nerve root): weakness in anterior tib, numbness in shin, pain in thigh, asymmetric knee reflex

L4-5 (L5 nerve root): weakness in great toe extensor (extensor hallucis longus), numbness top of foot and first web space, pain in posterolateral thigh and calf

L5-S1 (S1 nerve root): weakness in great toe flexor and gastroc/soleus, inability to toe walk, numbness in lateral foot, pain and ache in posterior calf, assymetric ankle reflex

NSAIDs

Neurontin

abstain from nicotine

narcotics for 7 days or less

Limit sitting and prolonged standing walking/standing

** Epidural steroid injections (3 in 6 mos) - NOT if pt has neuro deficit

Surgical disckectomy

1. causes: H. pylori, NSAIDs, ZE syndrome

2. most common complication: UGI hemorhage (10%)

3. most deadly: Perforation (7%)

4. Sx: occur periodically - epigastric dyspepsia relieved by antacids or food, abd distention, belching, flatulence, halitosis, epigastric tenderness

5. workup: H. pylori test (endoscopic culture gold standard), urea breath test

Triple: PPI qd, amoxicillin 1 g BID, clarithromycin 500 mg  BID x 14 days

Quadruple: bismuth QID, Flagyl 500mg TID, TCN 500mg QID, PPI BID x 14 days

1. 98% are tubal

2. most common cause of 1st trimester maternal death

3. sx: lower abd pain - sudden, stabbing, intermittent; abn menstruation; pelvic mass; abd distention; mild paralytic ileus

4. workup: positive hCG (lower than normal pregnancy), US shows empty uterus, CBC: anemia, leukocytosis

5. Tx:

***- stable: methotrexate 50 mg IM --> NEVER if unstable

- Surgery is definitive

Epiglottitis

Tx: intubation

pH: 7.35-7.45

pCO2: 35-45

HCO3: 21-28

pO2: 80-100

O2 sat: 95-100%

Base Excess: 0 +/- 2 mEq/L

Respiratory Acidosis:

pH: low

pCO2: high (>45)

HCO3: normal (rises to compensate)

Metabolic Acidosis:

pH: low

pCO2: normal (falls to compensate)

HCO3: low (<22)

Respiratory alkalosis:

pH: high

pCO2: low (<35)

HCO3: normal (falls to compensate)

Metabolic alkalosis:

pH: high

pCO2: normal (rises to compensate)

HCO3: high (>26)

evaluation:

1. pH - acidosis or alkalosis?

2. Is CO2 or HCO3 off? Which one makes sense with the pH? Low pH = high PCO2 or low HCO3. This tells you respiratory or metabolic

3. Is the other value (pCO2 or HCO3) off also? This tells you if it's compensated.

Resp acidosis: respiratory depression, pulmonary disease

Resp alkalosis: hyperventilation

Metabolic acidosis: DM, shock, CKD, intestinal fistula

Metabolic alkalosis: HCO3 overdose, prolonged vomiting, NG drainage

Initially NS - 2L or 2 hr

Then 300-400 ml NS/hr

Switch to D5W when glucose gets <250 mg/dl to prevent hypoglycemia and reduce chance of cerebral edema

subdural hematoma

from tear in tethered bridging veins

Tx:

1. ABCs, intubate if necessary

2. CT

3. Elevated head of bed to 30 deg

4. Surgery if focal neuro deficit, >1 cm bleed, midline displacement >5 mm, increased ICP

Epidural hematoma - tear in middle meningeal artery

tx: surgery

subarachnoid hemorrhage

tx: O2, maintain BP, CCB to prevent vasospasm, surgical coil/clipping/embolization

head injury w/ skull penetration

any alteration in consciousness

hx of LOC w/ memory deficit

focal neuro deficit

seizures

recurrent vomiting

increased HA

1. Bronchodilators: SABA + ipratroprium - nebulizer is best

2. ABX (most common organisms - s. pneumo, h. flu, m. catarrhalis, m. pneumo, chlamydia pneumo)

3. glucocorticoids - hyperglycemia is common

4. O2

5. mechanical ventilator

1. Causes: MOVE STUPID - metabolic, O2, vascular, electrolytes/endocrine, seizure, trauma/tumor/toxins/temp, uremia, psych, infection, drugs

2. Give thiamine (for alcoholic/Wernicke's encephalopathy), D5W, and narcan ASAP

3. assessment: MMSE, Glasgow coma scale

Eyes:

1. does not open eyes

2. opens eyes in response to pain

3. opens eyes in response to voice

4. opens eyes spontaneously

Verbal:

1. makes no sounds

2. incomprehensible sounds

3. utters inappropriate words

4. confused, disoriented

5. oriented, converses normally

Motor:

1. makes no movements

2. extension to painful stimli (decerebrate)

3. abnormal flexion to painful stimuli (decorticate)

4. flexion/withdrawal to pain

5. Localizes painful stimuli

6. Obey's commands

Risk factors: HTN, DM, hyperlipidemia, smoking, heart disease, AIDS, recreational drugs, alcoholism, fm hx

sx: sudden onset neuro deficit

evaluation: always listent to heart and carotids

Tx:

1. **thrombolytics (TPA) w/in 4.5 hrs

2. elevate head of bed

3. mannitol (osmotic agent)

4. ** DO NOT lower BP - keeps perfusion to brain adequate

5. anticoagulation

1. def: focal ischemic neuro deficit <24 hr

2. sx: abrupt onset and quick recovery - sx depend on area of ischemia

3. dx studies: CT/MRI, carotid US, angiography, check for HTn, heart diesease, lipids, PVD, holter monitor

4. Hospitalization if w/in 48 hr of onset, crescendo atacks, sx lasting >1 hr, symptomatic carotid stenosis, known cardiac source or hypercoagulability

- carotid endarterectomy

stop smoking!

anticoagulants if cardiac source

ASA + clopidegrel if non-cardiac

Head and neck: 9%

Anterior trunk: 18%

Posterior trunk: 18%

Arms: 9% each

Legs: 18% each

Genitals: 1%

Depth:

1st degree - red/grey w/ good capillary refill. no blistering

2nd degree superficial: blistering, blanches

2nd degree deep: red/white, blistering, bloody, less blanching. may have contractures

3rd degree: stiff, white/brown, painless

1. ABCs

2. Fluids - ** Parkland formula **: 4 ml/kg LR (Crystalloid) x % body burned = total for 24 hrs.

- Half over first 8 hours, half over second 16 hours

- Use colloids (blood/plasma) - for pulmonary injury

3. Surgery - escharotomy, fasciotomy, debridgement

common pathogens: Staph, VRE, pseudomonas

** face: 3-5 days **

Scalp: 5-9 days

Neck: 5-7 days

Trunk: 10-14 days

Arm: 10-14 days

Leg: 10-28 days

Sx: hematemesis, melena, hematochezia

Causes: PUD (Most common), erosive gastritis/esophagitis (EtOH), salicylates, NSAIDs, varices, Mallory-Weiss tears

Workup: NG tube, endoscopy is best, Angiography

- monitor for rebleed: NG tube, stool, H&H q 4

sx: hematochezia, melena

2. Causes: Upper GI bleed (most common cause of LGI bleed), hemorrhoids (most common true LGI bleed), diverticulosis, angiodysplasia, carcinoma, IBD, infection, Meckel's diverticulum

3. workup: colonoscopy, anoscopy, angiography, bleeding scan

Sx: weakness varies in severity w/ proximal emphasis and systemic distribution - legs--> arms --> face; distal paresthesias, neuropathic pain, autonomic disturbances (tachy, hypo/hypertension, cardiac irregularities, facial flushing)

labs:

- CSF: high protein, NL cell count

- EMG: demyelination

Tx:

- ** NOT PREDNISONE **

- Plasmapheresis, IVIG

Definition: extreme thyrotoxicosis that may be triggered by stressful illness, thyroid surgery, or RAI administration

Sx: marked delirium, tachycardia, vomiting, dehydration, very high fever, tremors, death

Tx: 5 drug regimen: thiourea (PTU), ipodate sodium, iodine, propanolol, hydrocortizone

- ** AVOID ASPIRIN **

cause: twisting of spermatic cord. often due to bell clapper deformity

sx: severe pain, absent cremasteric reflex, high elevation of testicle in scrotum, blue dot sign (twisted testicular appendage)

tx: surgery in 4-6 hr or will lose testis

Coma: deep sleeplike state from which pt cannot be aroused

Stupor: pt can be aroused with vigorous stimuli

Drowsiness: light sleep, easily arousable

Ddx: SAH, intoxication, shock, post-seizure, concussion, infection, sub/epidural hemorrhage

tx:

1. ABCs

2. Check: BP, BG, electrolytes, O2 sat, temp

3. Drugs: Naloxone, D5W, thiamine, thrombolytics (after hemorrhage r/o), phyostigmine (anticholinergic od)

pathophysiology: stimulates sympathetic ns - increases HR and BP --> coronary spasm

tx: nitrates, CCB, anti-platelet, benzos

SABA

Oral corticosteroids (3-10 days)

Ipratroprium

Mag Sulfate

Intubation

1. always think PE
2. atelectasis, bronchospasm, pnuemonia, upper airway obstruction, pleural effusion

3. atelectasis tx: CPAP

4. PE: iv fluids, vasopressor, anticoagulation, thrombolysis, inf vena cava filter

Asystole or PEA

CPR w/ rhythm checks every 2 min

1 mg epi q 3-5 min

Vtach and Vfib

shock 200J biphasic/360 J monophasic

2 min CPR

assess - SHOCK

2 min CPR

1 mg epi

Assess - SHOCK

2 min CPR

1 mg epi

Assess - SHOCK

2 min CPR

1 mg epi

Assess - SHOCK

2 min CPR

300 mg Amiodarone

Assess - SHOCK

2 min CPR

150 Amiodarone

Hypovolemia, Hypoxemia, Hydrogen ions (acidosis), Hypo/hyperkalemia, Hypothermia

Tension pneumo, Tamponade, Toxins, Thrombosis

Vtach

tx: amiodarone, procainamide, lidocaine, shock

cardioversion if anticoagulated - cardizem or adenosine or electrical

rhythm control - amiodarone

rate control - dig, BB, CCB

anticoagulation

AV node ablation

Aflutter

tx: same as Afib - cardioversion (cardizem, adenosine, electrical), amiodarone, rate control (BB, CCB, dig)

II, III, aVF: inferior - RCA

V1-V4 (often add V5-6, I, and aVL): anterior - LAD

V5-6, I, aVL: Lateral - Left circumflex

Depression in V1-2: posterior: Left circumflex or RCA

4.5 hrs

** CI: stroke/head trauma w/in 3 mos, hx IC hemorrhage, recent surgery, GI bleed within 3 weeks, MI in last 3 mos

- if 3-4.5 hours, CI include: >80 y/o, evidence of hemorrhage, high INR

PE: palpable cord, calf/thigh pain, edema with increased calf diameter, warm, erythema

Tests: *** Compression US, D-dimer

Tx: Lovenox

** UNINTENTIONAL INJURY (including MVA)

homicide

suicide

malignancy

heart dz

Grade I: no LOC, sx <15 min - checked every 5 min - can RTP in 15 min

Grade II: Sx > 15 min, no LOC - RTP in 1 week

Grade III: LOC

- IIIA: LOC seconds - RTP 1 mon

- IIIB: LOC minutes - RTP 6 months

Cause: stroke (>50%), metabolic abn, trauma, alcohol/drugs, neoplasm, infx

sx: confusion, ams, memory problems

workup: CBC, CMP, UA, ca, mg, tox screen, LP if febrile, abg if resp compromise, CT/MRI, EEG

Tx:

- treat cause if known

- AED (anti-epileptic drug) for epilepsy

Motor: tonic/clonic

Head movement: to one side

Clonus/limb jerks: bilateral, synchronous

Purposeful movements: absent
Biting: tongue
Babinski: present
Micturation: frequent
Eyes: open
Pupils: dilated or hippus
Color: cyanotic or grey
Pulse: rapid, strong
Duration: 1-5 min
ONset: sudden
Termination: spontaneous
Injury: Frequent
Post-ictal: tired, confused, sleepy

Motor: tonic, flailing, thrashing

Head: side to side

Clonus: asynchronus

Purposeful mvements: present avoidance

Biting: lips, arms, other people

Babinski: absent

Micturation: rare

Eyes: closed
Pupils: Normal

Color: rubor or normal

Duration: 5-60 min

Termination: variable

Injury: rare

Post-ictal: alert, emotional

Motor: atonic

Clonus: bilaterally synchronous

Purposeful movements: absent

Biting: rare

Babinskis: absent

Micturation: occasional

Eyes: open
Pupils: dilated

Color: pale

Pulse: slow

duration: 1-2 min

Onset: gradual

Termination: rapid

Injury: depends on situation

Post-ictal: alert but tired

Causes: impaired excretion (acute or chronic kidney dz, d/o of renin-angiotensin-aldosterone, drugs), redistributive (hyperglycemia)

Always check for hemolysis during blood draw

Sx: muscle weakness, paralysis, arrhythmias (K > 7)

EKG: peaked T waves

**Tx: C BIG K + Albuterol

Calcium

Bicarb

Insulin

Glucose

Kexylate

Albuterol

Also - loop/thiazide diuretics

Always ask about tetanus status

Organisms: eikenella corrodens (corrosive teeth), group A strep, staph

Abx: Augmentin or Doxy if allergic - for hand, ear, tendon, joint

1. Most common: pasturella

2. Abx: augmentin

3. Cat scratch fever (bartonella henselae)

pasteurella

augmentin for moderate to severe injuries

Compression of cardiac chambers due to increased pericardial pressure. Chambers become smaller and are unable to completely fill. Venous return falls, chambers shrink, CO and BP fall

Causes: rupture of heart or aorta, neoplasm, hypovolemia, uremia, surgery

Sx: CP, tachypnea, dyspnea, high JVP, venous distention, hypotension, cyanosis, decreased urine

Subacute: dyspna, chest discomfort, peripheral edema, fatigue, narrow pulse pressure, hypotension

PE:
*** BECK'S TRIAD: hypotension, JVD, muffled heart sounds **

- tachy, pulseus paradoxus, pericardial rub

EKG: tachy, electrical alternans

CXR: elarged heart w/ clear lungs

Echo: chamber collapse, resp variations in flow, IVC plethora (dilation of IVC during inspiration)

CT/MRI: rarely used

FAST scan

Tx: Catheter pericardiocentesis, surgery, supportive care

1. decide if it's ischemic or hemorrhagic

2. In ischemic stroke, only tx if >220/>120, if active ischemic coronary dz, HF, aortic dissection, or acute renal failure

- Needs to be <185/110 for lytic therapy

3. drug of choice: labetolol

Sx: CNS depression w/ nl vitals, slurred speech, ataxia, AMS

tests: glucose, acetaminophen and salicylate levels, EKG, pregnancy test, EtOH

Tx: ABCs

** Antidote: flumazenil

Sx: severe, sharp, tearing chest/back pain + syncope, CVA, MI, CF, pulse dificit, hx HTN

Hallmark: widened mediastinum, variation in pulse or BP

EKG: nonspecific

Cholangitis

RUQ pain, fever, jaundice

tx: cipro, ERCP, surgery

Primary: absence of underlying lung dz

Secondary: presence of lung disease

Traumatic: chest injury

Tension: Positive pressure in skinny males

- needle to 2nd ICS then chest tube