Term
| Hyperventilation is assoc with what on physical exam? |
|
Definition
| Chovstek sign: tap on masseter muscle and get nose or lips twitch) |
|
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Term
| Hyperventilation causes..... |
|
Definition
respiratory alkalosis
blowing off CO2 so more oxygen |
|
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Term
| atrial flutter is usually assoc with what diseases? |
|
Definition
most common: ischemic heart disease
less common: COPD and CHF |
|
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Term
|
Definition
|
1. Synchrononized cardioversion (100-200 J)
2. 2)stabilized pts with AF for longer than 48 hrs should be anticoagulated with heparin 80 units/kg IV followed by an infusion of 18 units/kg/hr IV) before cardioversion Transesophageal echocardiogram should be considered to rule out atrial thrombus before cardioversion
3. Rate control with diltiazem 20 mg IV over 2 mionutes
4. If impaired cardiac function include amiodarone 150 mg IV over 10 minutes or digoxin
If AF for shorter than 48 hrs- can be considered for chemical or electrical cardioversion in the ED. Pts with normal cardiac function can be electrically or chemically cardioverted with amiodarone, ibultilide, procainamide, flecainide, or prpafenone. Pts with impaired cardiac function may be electrically or chemically cardioverted with amiodarone.
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Term
| What's the difference between spontaneous pneumo and tension pneumothorax? |
|
Definition
spontaneous: on chest xray: media stinal shift to affected side
tension pneumo: shift of trachea AWAY from side of pneumo |
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Term
| How do you treat 90% of cases of atrial flutter? |
|
Definition
| Low-energy cardioversion (25 to 50 J) is very successful in converting more than 90 percent of cases of AF into sinus rhythm. Energies weaker than 10 J should be avoided, because they are more likely to convert AF into atrial fibrillation than into sinus rhythm. |
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Term
| what do u do if cardioversion is contraindicated for atrial flutter? |
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Definition
| If cardioversion is contraindicated, control of ventricular rate can be achieved with digoxin, verapamil, diltiazem, esmolol, or propranolol |
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Term
| What's the difference between first, second and third degree heart block? |
|
Definition
First-degree AV block : a delay in AV conduction manifest by a prolonged P-R interval.
Second-degree AV block: intermittent AV conduction: some atrial impulses reach the ventricles and others are blocked.
Third-degree AV block: complete interruption of AV conduction. |
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Term
What is this:
each atrial impulse is conducted into the ventricles, but more slowly than normal. This is recognized by a P-R interval longer than 0.20 s The AV node is usually the site of conduction delay, although this block may occur at any infranodal level. |
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Definition
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Term
What is this:
progressive prolongation of AV conduction (and the P-R interval) until an atrial impulse is completely blocked. This property of a gradually increasing block until it is complete is a normal property of cardiac tissue. In the face of disease, this property occurs at a much slower rate. In the EP laboratory, a Wenckebach type of block is frequently seen when atrial pacing occurs at fast rates to uncover an accessory pathway. Conduction ratios are used to indicate the ratio of atrial to ventricular depolarizations: 3:2 indicates that two of three atrial impulses are conducted into the ventricles. Usually, one atrial impulse is blocked. After the dropped beat, the AV conduction returns to normal, and the cycle usually repeats itself with the same conduction ratio (fixed ratio) or a different conduction ratio (variable ratio). This type of block almost always occurs at the level of the AV node and is often due to reversible depression of AV nodal conduction.
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Definition
| Second degree heart block, mobitz 1 |
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Term
What is this:
In this block, the P-R interval remains constant before and after the nonconducted atrial beats. One or more beats may be nonconducted at one time. Mobitz II blocks usually occur in the infranodal conducting system, often with coexistent fascicular or bundle branch blocks, and the QRS complexes therefore are usually wide. Even if the QRS complexes are narrow, the block is generally in the infranodal system.
When second-degree AV block occurs with a fixed conduction ratio of 2:1, it is not possible to differentiate between a Mobitz type I (Wenckebach) or Mobitz type II block. If the QRS complex is narrow, then the block is in the AV node or infranodal system with about equal incidence. If the QRS complex is wide, the block is more likely to be in the infranodal system.
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Definition
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Term
What is this:
there is no AV conduction. An escape pacemaker at a rate slower than the atrial rate paces the ventricles. Third-degree AV block can occur at nodal or infranodal levels. |
|
Definition
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|
Term
What can cause first degree heart block?
Do you treat? |
|
Definition
vagal tone (any cause), digoxin toxicity, acute inferior MI, and myocarditis.
Don't usually need to treat |
|
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Term
| How do you treat second degree mobitz I? |
|
Definition
Atropine 0.5 mg IV is the initial treatment of choice, repeated every 5 min as necessary, titrated to the desired effect, or until the total dose reaches 2.0 mg. Almost all patients will respond to atropine. The need for an increased rate and, one hopes, increased perfusion must be consistently balanced with the increased myocardial O2 consumption in the ischemic patient.
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Term
What type of heart block implies structural damage to the infranodal conducting system, are usually permanent, and may progress suddenly to complete heart block, especially in the setting of an acute MI.
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|
Definition
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Term
| What should be used for second degree heart block? |
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Definition
| Emergent treatment is required when slow ventricular rates produce symptoms of hypoperfusion. Atropine should be the first drug used, and up to 60 percent of patients will respond. Isoproterenol is effective in up to 50 percent of cases but is potentially hazardous in the setting of acute MI or digoxin toxicity, and its use should be avoided. |
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Term
| How do you treat third degree heart block? |
|
Definition
| Nodal third-degree AV blocks should be treated like second-degree Mobitz I AV blocks with atropine or ventricular demand pacemaker, as required. |
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Term
| What defines a complete BBB? |
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Definition
| Complete BBB is present when the QRS complex is > 0.12 s (or three small boxes on the ECG). Look at leads I, V1, and V6. Degenerative changes and ischemic heart disease are the most common causes. |
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Term
|
Definition
The RSR pattern seen in V1, V2, or both. Also a wide S in leads I and V6
Clinical signficicance: Healthy persons; diseases affecting the right side of the heart (pulmonary hypertension, ASD, ischemia); sudden onset associated with PE and acute exacerbation of COPD
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Term
|
Definition
RR' in leads I, V6, or both. QRS complex may be more slurred than double-peaked as in RBBB. A wide S wave is seen in V1
Clinical Signficance: Organic heart disease (hypertensive, valvular, and ischemic), severe aortic stenosis. New LBBB after AMI can be an indication for inserting a temporary cardiac pacemaker. Consider new LBBB MI until proven otherwise. |
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Term
|
Definition
1. Synchronized cardioversion 25-50J) should be done in any unstable patient (ie. Hypotension, pulmonary edma or severe chest pain)
2. Stable pts,the first intervention should be vagal maneuvers, inclsing: carotid sinus massage, diving reflex (immerse face in cold water or apply bag of ice water to face for 6 to 7 seconds—very effective in infants), valsalva maneuver (while in supine position, ask the pt to strain for at least 10 seconds. The legs may be lifted to increase venous return and augment the reflex.
3. Adenosine 6 mg as a rapid IV bolus followed by a 20 mL normal saline rapid flush
4. If narrow complex and normal cardiac function, cardioversion can be achieved with
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Term
| How do you treat pt with premature beats? |
|
Definition
1. Stable pts require no treatment.
2. Pts with acute coronary syndromes and frequent PVCs should receive adequate Beta adrenergic blockade to suppress ectopic rhythm generation with metoprolol
For hemodynamically unstable pts with PVCs, consider lidocaine, amiodarone or procainamide |
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Term
|
Definition
a) Pulseless VT should be defibrillated with unsynchronixed cardioversion started at 200 J. Unstable pts whoa re not pulseless shuld be treated with synchronized crdioversion (200-360 J)
Hemodynamically stable pts with normal cardiac function can be treated with amiodarone followed by an infusion at 1 mg/min |
|
|
Term
fine to coardse zigzag pattern without discernible P waves or QRS complex
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Definition
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|
Term
What is this:
a) Wide WRS complex
b) Rate faster than 100 beats.min
c) Regular rhythm, although there may be some beat to beat variation
d) Constant QRS axis
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|
Definition
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Term
|
Definition
a) Immed electrical defibrillation start 200 J, If VF persists, defib should be repeated immed, with 200 to 300 J and increased to 360 J at the third attempt.
b) If initial 3 attempts at defib are unsuccessful, CPR and intubation should be intiated
c) Epi 1 mg IV push or vasopressin 40 units IV push (1 time only) should be followed by a 20 mL normal saline flush and a repeat countershock at 360 J
d) Epi 1 mg IV push may be repeated every 3 to 5 min, followed by a repeat countershock at 360 J, If this is not successful, high dose epi (.1 mg/kg) may be considered
e) Btw successibe countershocks, antidyshytmics should then be administered, Preferred agents, in order of current ACLS recommendations, are amiodarone 300 mg IV push, procainamide 100 mg IV bolus every 5 min and lidocaine 1.5 mg/kg IV
Magnesium sulfate 2 g IV can be given in cases of presumed hypomagnesemia |
|
|
Term
Tachycardia with a wide monomorphic QRS complex
Ventricular rate may be very rapid (300 bpm)
Sine wave appearance with regular large oscillations
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|
Definition
|
|
Term
| Vflutter is treated as.... |
|
Definition
1) Ventricular flutter is treated as ventricular tachycardia.
2) Ventricular flutter usually leads to ventricular fibrillation if not promptly corrected with antiarrhythmic medications or electrical cardioversion.
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Term
|
Definition
1) 100% O2 by face mask
2) If hypoxia despite O2 theapy, continuous positive airways pressue or biphasic positive airways pressure should be applied via face mask
3) Immediate intubation is indicated for unconscious or visibly tiring patients
4) Nitro .4 mg admin sublingually or topical paste in; alternative is nesiritide
Potent IV diuretic such as furosemide 40 to 80 mg IV, electrolyte should be monitored, especially serum K |
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Term
| What are three main classifications of infective endocardiits? |
|
Definition
1) Native valve endocarditis: most common involves aortic valve; predisposing facots: congential heart defects, valve pathology, indewelling lines, poor dentition, or HIV; common organisms: streptococci, staphylococci, enterococci
2) IV drug use; Tricuspid valve: assoc with staph aureus
3) Prosthetic valve: early and late; eary assoc with staph epidermidtis—high mortality AND late disease- similar bacteriology as native valve endocarditis
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Term
What is the most common complication of infective endocarditis?
What is the second most common complication |
|
Definition
#1: CHF
#2: Arterial embolization of valve vegetation fragments
|
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Term
| What's management plan for patient with infective endocarditis? |
|
Definition
First priority in care of pts with IE is stabilization of respiratory and cardiac symptoms:
1. For pts with mental status changes and hypoxia or compromised airway- oral intubation
2. Acute rupture of the mitral or aortic valve should be stabilized with after load reducers such as sodium nitroprusside and insertion of a Swanz ganz catheter for monitoring therapy ASAP; if rupture suspected-emergency surgery indicated
3. Second priority: draw blood cultures from two different sites and then start empiric therapy
4. Prophylaxis against endocardidits should be performed before invascvie procedures.
Dental procedures: amox /ampicillin/ or clinda
GU interventions: add gentamicin
I&D of affected tissue: admin cefazolin or Cephalexin |
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Term
| What is tx for pericardial tamponade? |
|
Definition
1) Initial treatment of tamponade is emergency pericardiocentesis
2) immediate surgical intervention will be required to control the bleeding. An intravenous bolus of fluid to transiently increase the pressure filling the right atrium is helpful to increase cardiac output for a minute or two.
3) If surgery cannot be performed immediately, a cannula can be placed within the pericardial sac for serial aspirations as surgical preparations are being made. Aspiration of only 5 to 10 mL of fluid can substantially improve cardiac performance—again a consequence of the rigidity of the pericardium.
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|
Term
| What is treatment for hypovolvemic shock? |
|
Definition
1) airway control- endotracheal intubation is indicated
2) supplemental high flow O2; neuromuscular blocking agents to decrease lactic acidosis from muscle fatigue and increased oxygen consumption
3) early surgical consultation for internal bleeding; external hemorrhage can be controlled with direct compression
4) Istonic crystalloid IV fluids (ie. .9$ NacLa, ringer lactate) in initial resuscitation; infuse 3x the estimated blood loss
5) Blood: when possible, cross matched blood is preferred.- use type O
6) vasopressors used after approp volume resuscitation and still persistent hypotension
guide:
dobutamine: systolic >100 mmHg
dopamine: systolic >70 to 100 mmHg
NE systolic >70 mmHg
7) early surgical or medical consultation for admission or transfer is indicated. |
|
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Term
| How do you treat hypertensive emergencies? |
|
Definition
1) HTN encephalopathy: use sodium nitroprusside IV
2) Labetalol second line agent for hypertensive encephalopathy.
3) Fenoldopam: new selective postsynaptic doaminergic receptor for hypertensive emergencies
4)HTN assoc with pregnancy: hydralizine
5) HTN urgency: oral labetalol, oral captopril, sublingual nitroglycerin
6)non-emergent HTN: choce of oral agent should be based on coexisting condition; diuretics such as HTZ, |
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|
Term
| Where do you insert a chest tube in pt with pneumothorax? |
|
Definition
| large bore needle in the second or third intercostal space in the '[=midclavicular line |
|
|
Term
What time of day might asthma symptoms be worse?
why? |
|
Definition
| worse at night due to circadian variations in bronchomotor tone and bronchial reactivity reach their nadir btw 3 AM and 4 AM, increasing ssxs of bronchoconstriction |
|
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Term
What type of infections are COPD pts most susceptible to? Bacteria or viral?
What abx do u want to use? |
|
Definition
BACTERIAL
Choices:
First line inexpensive:
amoxicillin, cefaclor, and bactrim
Second-line expensive: azithromycin, clarithromycin, fluoroquinolones
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Term
| What distinguished a mild asthma attack from a severe one? |
|
Definition
Mild attack if FEV >50%
Severe attach if FEV <50% |
|
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Term
| What are normal peak flow rate readings? |
|
Definition
women: 350-500 L/min
Men: 450-650 L/min |
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|
Term
| What type of medication do you want to avoid in asthmatics? |
|
Definition
|
|
Term
| What maneuver should be used in conscious and unconscious patient if foreign body is obstructing airway? |
|
Definition
conscious: heimlich
unconscous: finger swipe |
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Term
| You suspect strep throat. What are abx? |
|
Definition
PenV,amoxicillin, erythromycin,azithromycin
–cephalosporins; clindamycin
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Term
| How do you differentiate strep from viral pharyngitis? |
|
Definition
strep sudden onset of •fever, exudative pharyntitis, tender anterior cervical lymphadenitis, absent cough/nasal congestion
Virus:
Adenovirus
–associated with triad of conjunctivitis, pharyngitis and preauricular lymphadenopathy
•conjunctivitis typically produces little exudate and begins unilaterally
•symptomatic relief is sufficient therapy
EBV:
–PE reveals fever, exudative tonsillopharyngitis, posterior cervical lymphadenopathy, splenomegaly
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Term
What are pathogens involved with external otitis media?
What discharge is assoc? |
|
Definition
•copious green exudate- pseudomonas
•yellow crusting - staph aureus
•scaling, cracked, weeping skin - eczema
•fluffy, breadlike mold - fungal |
|
|
Term
When you read boggy, pale mucosa...what should you think?
|
|
Definition
|
|
Term
| What are tx options for sinusitis? |
|
Definition
nasal decongestants: ie. oxymetazoline or phenylephrine (no longer than 3 days)
oral abx for 10-14 days
ampicillin, bactrim, clarithromycin, cefdinir, cefprozil, or augmentin |
|
|
Term
| Most cases of bronchitis are due to what organism? |
|
Definition
viral
influenzae B and A
parainfluenza
|
|
|
Term
| How do you treat acute bronchitis? |
|
Definition
abx are rarely used
albuterol by metered dose inhaler, 2 puffs every 4 to 6 hrs |
|
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Term
| How do you differentiate viral bronchitis from bacterial bronchitis? |
|
Definition
· Low grade fever, predominate mucous membrane involvement, malaise, aches and pains tends to be more suggestive of a virus or mycoplasma
· High fever, productive mucopurulent cough, chest pain, in a patient who smokes or has chronic lung disease suspect H. influenzae
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Term
| What are risk factors for developing pneumonia? |
|
Definition
Recent or concurrent URI
Extremes of age
Chronic illness or immunocompromise
Smokers/ COPD/ CHF
Cancer/ Chemotherapy/AIDS
S/P splenectomy
Alcoholism
Chronic steroid use
|
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|
Term
What are the CAP organisms for pneumonia?
How do you differentiate? |
|
Definition
Community –acquired (CAP)
S. pneumoniae (pneumococcal)
Most common cause
Gram positive diplococci
Typically follows URI
Seen in persons with chronic cardiopulmonary disease
H. influenzae
Gram negative coccobacilli
Typically follows URI
Usually associated with patients with COPD, heart disease
M. catarrhalis
Usually seen in the elderly, patients with COPD or on immunosuppressive therapy
Gram negative diplococci
Anaerobes
Mixed oral flora
Associated with periodontal disease and aspiration
causes both CAP and hospital acquired pneumonia
|
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Term
| What are some characteristics of atypical pneumonia? |
|
Definition
Onset insidious
Classic prodrome of H/A, myalgia, arthralgia, malaise, photophobia
Typically follows URI
Low grade fever
Cough with scanty mucus production
Minimal dyspnea
Rare pleuritic chest pain
CXR with patchy infiltrates
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Term
| What are abx to use for pneumonia in hospitalized and non hospitalized pt? |
|
Definition
Non hospitalized
Macrolides
Doxycycline
Fluoroquinolones (comorbidities/>50)
Hospitalized
Dependent on pt on general ward or ICU
May require multiple drugs |
|
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Term
|
Definition
|
|
Term
| if between typical and atypical pneumonia? |
|
Definition
| atypical- generally gradual onset; diffuse infiltrates on chest xray, dry cough, chills are uncommon |
|
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Term
| Whats tx for anaphylaxis? |
|
Definition
.5 epi in 1:1000 solution
ranitidine
diphenydramine
prednisone |
|
|
Term
| What's tx for infective endocarditis? |
|
Definition
uncomplicated hx: ceftriaxone or nafcillin + gentamycin
IV drug use: nafcillin + gentamicin + vancomycin
Prostethic heart valve: vanco + gentamycin + rifampin |
|
|
Term
Beck's triad is assoc with what?
what is beck's triad? |
|
Definition
JVD
muffled heart sounds
hypotension
Assoc with cardiac tamponade |
|
|
Term
What's tx for acute pericarditis?
what is usual pathogen? |
|
Definition
NSAIDS are mainstay of tx
usually due to virus |
|
|
Term
| When may you heard a pericardial friction rub? |
|
Definition
|
|
Term
Darvon
Percodan
Pepto Bismol
what do they all have in common? |
|
Definition
|
|
Term
|
Definition
MVI (riboflavin)
mag
folate
thiamine |
|
|
Term
| painless vaginal bleeding in third trimester. what could it be? how do u detect? |
|
Definition
placenta previa
ultrasound |
|
|
Term
what drugs do u use in preg woman w bp pver 140/90
what is this called? |
|
Definition
use methyldo[a or labetalol
preclampsia
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|
Term
what drugs do u use in preg woman w bp pver 140/90
what is this called?
when do women typically start tx? |
|
Definition
use methyldo[a or labetalol
preclampsia
systolic blood pressure exceeds 160 mm Hg or the diastolic blood pressure exceeds 100 mm Hg
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|
Term
| What do u give preg ladies in acute hypertensive crisis? |
|
Definition
| IV hydralizine or IV labetalol |
|
|
Term
When a woman beyond 20 weeks of gestation develops seizures in the setting of hypertension, edema, and proteinuria
What is this called? |
|
Definition
|
|
Term
If a preg lady has a seizure at presents to ER.
What do u do?
What is definitive therapy for eclampsia? |
|
Definition
consult neuro and obstetrician
Magnesium sulfate has been used and works
definitive therapy: deliver baby |
|
|
Term
What makes an ovarian cyst rupture unique from other types of abdominal pain?
how do u treat?
|
|
Definition
no leukocytosis
no fever
no abdominal pain
tx: analgesics; ultrasound to confirm |
|
|
Term
| When are ovarian ruptures most common in menstrual cycle? |
|
Definition
|
|
Term
| What is standard first line therapy for gout? |
|
Definition
|
|
Term
| Calcium pyrophosphate is what? |
|
Definition
pseudogout
rhomboid shape crystal and yellow |
|
|
Term
| What are prophylactic drugs for gout? |
|
Definition
| probenacid and colchicine |
|
|
Term
| What is the action of the achilles tendon? |
|
Definition
| allows for plantar flexion |
|
|
Term
| How do you manage achilles tendon rupture? |
|
Definition
| plinted in neutral position with a Robert Jones splint, with prompt referral to an orthopedist. Crutches will be needed for ambulation |
|
|
Term
| When the achilles tendon pulls, what two muscles contract? |
|
Definition
| soleus and gastrocnemius muscles contract |
|
|
Term
| What are two ways to test integrity of achilles tendon? |
|
Definition
thompson test- grasp calf muscle and pt should plantar flex (this is normal)
or ask pt to walk on toes |
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|
Term
pain along the radial side of the wrist and localized tenderness in the anatomic snuffbox
what could it be? |
|
Definition
|
|
Term
| How do you manage scaphoid fracture? |
|
Definition
thumb spica splint
Splinting in dorsiflexion and radial deviation helps to compress the fracture fragments. Patients with unstable fractures should be placed in a long-arm thumb spica splint and should be seen promptly by an orthopedic surgeon for definitive treatment |
|
|
Term
| What is usual tx for cellulitis? |
|
Definition
|
|
Term
| What are the four stages of decubitus ulcers? |
|
Definition
| Stage one ulcers are characterized by an area of nonblanchable erythema over intact skin. A stage two pressure sore appears as a shallow, open sore with a pink wound base. When the wound is full thickness with no muscle, tendon, or bone exposed, it is defined as a stage three ulcer. If muscle, tendon, or bone is exposed it is described as stage four |
|
|
Term
| What are three types of treatments for decubitus ulcers? |
|
Definition
| hydrocolloid dressings, Silvadene, or vacuum-assisted closing (VAC) sponges |
|
|
Term
| What's the tx for a Ellis II tooth fracture? |
|
Definition
| cover the exposed dentin to decrease pulpal contamination. This is best achieved using a glass ionomer dental cement that is easily mixed according to the manufacturer's instructions and carefully applied to the dried exposed dentin |
|
|
Term
| What is tx for Ellis III dental fracture? |
|
Definition
| placing a glass ionomer or calcium hydroxide base is adequate until dental evaluation within 24 h |
|
|
Term
| How do you treat otitis externa in the ED? |
|
Definition
mild: Mild OE can be treated with cleaning and acidifying agents alone. Acetic acid eardrops are the easiest and least expensive way to eliminate the infecting agent. A 2% solution is effective and available commercially in aqueous (Otic Domeboro) or alcohol-based (VoSoL or Orlex) solutions. These drops should be used three to four times a day for at least 1 week
Moderate tx: Antibiotic preparations containing neomycin and polymixing B |
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|
Term
Abrupt onset o f of a focal neurologic deficit that worsens steadily over 30 to 90 min.
Alt level of consciousness, stupor, coma.
H/A, vomiting |
|
Definition
Intracranial hemorrhage
Mannitol |
|
|
Term
| What is the most common cause of SAH? |
|
Definition
|
|
Term
| What is clinical feature of SAH? |
|
Definition
worse headache in the absence of focal neuroo sxs
sudden, transietn loss of consciousness |
|
|
Term
|
Definition
|
|
Term
| What's tx for cluster headache? |
|
Definition
high flow O2
DHE
NSAIDS
sumatriptan |
|
|
Term
| What is common management of seizure? |
|
Definition
IV, O2, Monitor
Dextrose if indicated, thiamine for alcoholic or malnourished
Lorazepam or Phenytoin or phenobarbitol |
|
|
Term
| if you have acute hydrocephalus..you may need |
|
Definition
|
|
