Trauma Patient Assessment:
ABCDEAirwayBreathingCirculationDisabilityExposure
AMPLE history?
AllergiesMedicationsPast Medical HistoryLast MealEvents surrounding injury
Glascow coma scale
< 8 must be intubated!
What test must be done on all women aged 11-60 in the ER?
Pregnancy test
Pericarditis Presentation/ Diagnosis? Treatment?
Sharp burning pain when breathing (worse with inspiration)Worse when laying down & improved sitting & leaning forwardFriction rub with auscultation EKG: Diffuse ST elevation Tx= NSAIDs + Colchicine
Cardiac Tamponade Presentation/Diagnosis? Treatment?
SOB, chest pain, tachycardia, tachypneaBeck's Triad= Distant/ muffled heart sounds + Increased JVP + HypotensionPulsus paradoxus: >10 decrease in SBP with inspirationEKG: Signs of effusion low voltage QRS & electrical alternansEcho: Effusion & diastolic collapseTx= Pericardiocentesis
Risk factors for aortic dissection?
HypertensionGenetics: Marfans, Ehlers- Danlos TraumaBicuspid aortic valve
Type A vs Type B aortic dissection?
Type A= Ascending aorta involvedType B= Only descending aorta involved
Presentation/ diagnosis of aortic dissection? Tx?
Sudden, severe sharp/tearing chest pain radiating to the back Unequal blood pressures in both arms (>20 change)CXR: widened mediastinum CTA Tx= Control BP & HR ➜ IV beta blockersCan use IV morphine for painType A ➜ emergent surgical repairType B ➜ manage w/ meds & stent
Risk factors for Abdominal Aortic Aneurysm
SmokingMales> 50 years oldAtherosclerosis
Presentation/ Diagnosis of Abdominal aortic aneurysm rupture? Tx?
Sudden & intense pain in abdomen, back or chestAbdominal bruitHypotensionFlank ecchymosis (Gray Turner Sign)SyncopeContrast CT/ CTAUltrasound Tx= Immediate surgical repair
What is hypovolemic shock?
Loss of blood or fluid volume due to either hemorrhage or fluid loss Inadequate tissue perfusion & oxygenation
Presentation/ diagnosis of hypovolemic shock? Tx?
Pale, cool mottled skinAMSTachycardiaHypotensionDecrease urine output Weak/ absent pulses Tx= Control source of bleeding2 large bore IVs of crystalloids (NS or LR)Give Blood if needed
Acute decompensated heart failure presentation/ diagnosis?
Progressive dyspneaVarious others: peripheral edema, increased fatigue, N/V, confusion, unintentional weight lossEKGCXR: "Butterly" pleural effusion, kerley B lines, cardiomegaly *compare to past CXREchoElevated BNP
Treating Acute decompensated heart failure?
Oxygen & keep patient in up position (sitting)Continuous cardiac monitoring Diuretic therapy: IV LasixMonitor urine outputVasodilators ➜ Nitro if (HTN, regurg)
Presentation/ diagnosis of cardiogenic shock? Tx?
Hypotension (SBP <90)Cold, clammy skinTachypneaAMS *Decreased COEKG, Echo, CXR Troponin, lactate, BNPTx= Treat cause normally MI Oxygen Dopamine, Norepinephrine or Dobutamine *SMALL fluid given
Presentation of acute coronary syndrome?
Retrosternal chest pain at rest "squeezing, tightness, pressure" Elephant sitting on chest sensation Radiation of pain to many areas (lower jaw, left arm, back, shoulders)Levine sign Anxiety, sweating, tachycardia Women/ diabetics atypical: abdominal pain, epigastric pain, jaw pain, SOB without chest pain, N/V, fatigue
Work up for acute coronary syndrome?
EKG & troponin! *troponin change takes 3 hrsOthers CBC, BMP, Drug screen, CXR
Management of NSTEMI/ Unstable Angina
Nitrates (Nitroglycerin)AspirinHeparin/ClopidogrelBeta blockers Rest Consider angiography revascularization based on mortality risk
Anterior wall STEMI leads?
V1, V2, V3, V4Left anterior descending artery
Inferior wall STEMI leads?
II, III, aVFRight coronary artery
Lateral wall STEMI leads?
I, aVL, V5, V6Left circumflex artery
Management of STEMI?
MONA O2+ Nitro+ ASA (325 mg) + Morphine *No morphine in inferior MI Heparin/Clopidogrel Percutaneous coronary intervention (PCI) within 90 minsLong term= BB, statin, aspirin, anticoag, ACE
Presentation/diagnosis of ectopic pregnancy/ rupture? Tx?
Young female with severe abdominal painN/V Vaginal bleeding/ spotting + b-hCG test Transvaginal ultrasoundTx= Not ruptured➜ Methotrexate Ruptured/ unstable ➜ laparoscopic salpingostomy or salpingectomyRhoGAM given to Rh- women
Patient vomiting bright red blood... what should you do?
CBC, BMP, liver tests, lipase & coagulation studiesUnstable ➜ Resuscitation & continue with stable measures Stable ➜ IV PPI (protonix) +/- octreotide & upper endoscopy to identify source of bleeding*If patient has portal HTN/ esophageal varices they should be given Abx (ceftriaxone)
Presentation/ diagnosis of volvulus? Tx?
Normally 1st month of lifeAbdominal pain & distensionBilious emesis Blood or mucus in stoolTachycardicAbdomen xrayUpper GI series w/ contrast *if stable!Tx= Nasogastric tube placement & IV fluids NPO ➜ Surgical correction Abx
In what patients should you suspect spontaneous bacterial peritonitis?
Patient with ascites & cirrhosis with any:Abdominal pain/ tendernessAltered mental statusFever, chillsOccasional vomiting
Workup/ diagnosis for spontaneous bacterial peritonitis? Tx?
Sepsis workup: Blood cultures, lactate, procalcitonin, CBC, LFTs, UAParacentesis ➜PMNs >250 & culture Tx= CeftriaxoneLong term Prophylaxis= Cipro/metronidazole or Piperacillin/tazobactam (Zosyn)
Presentation/ diagnosis of diverticulitis? Tx?
LLQ abdominal pain & tendernessLow grade feverMay have N/V, bowel changesLeukocytosis NO colonoscopy or barium enema if suspected diverticulitis instead CT scanTx= Metronidazole + Cipro/ Levo or ZosynIf severe➜ surgery & make sure no sign of sepsis
Presentation/ diagnosis of mesenteric ischemia? Tx?
Acute onset of severe abdominal pain The pain is not proportionate with physical exam ➜ PE doesn't show peritoneal sign & is not usually localized Pain is worst after eating HypertensionLeukocytosis, lactic acidosis, ↑ hematocrit, ↑ amylase CT angiography Tx= Surgery & anticoagulation in patients with Afib
Presentation/ diagnosis of small bowel obstruction?
Crampy abdominal painAbdominal distensionVomiting ConstipationHigh pitched tinkles on auscultation Abdominal Xray: multiple air fluid levels "step ladder" appearance & dilated bowel loops
Presentation/ diagnosis of cholecystitis? Tx?
RUQ/ epigastric pain with + rebound tendernessN/V Fever +Murphy's sign ↑ WBCs, ↑ bilirubin,↑ alk phos, ↑ LFTsDx= Ultrasound or HIDA scan Tx= NPO, IV fluids, antibiotics (ceftriaxone +metro) followed by cholecystectomy
Presentation/ diagnosis of pancreatitis? Tx?
Acute severe epigastric abdominal pain that may radiate to back Pain is worse laying down & after meals Fever & N/V ↑ amylase & lipase Dx= Abdominal CT Tx= Mild ➜ Rest & support (NPO, IV fluids)Severe ➜ ICU admission & antibiotics maybe
Presentation/ diagnosis of appendicitis? Tx?m
Periumbilical/ epigastric pain that shifts to RUQ pain with + rebound tendernessLoss of appetiteN/V + Mcburney's point tenderness,+ RovsingAdults ➜ CT scan Children/ Pregnant ➜ ultrasound Tx= Appendectomy
Presentation/ diagnosis of pelvic inflammatory disease (PID)? Tx?
Acute lower abdomen pain FeverPain with urination Purulent discharge & cervical motion tenderness *chandelier sign"N/V ↑WBC WBC on wet prep Tx= Ceftriaxone + doxy or azithromycin
When should imaging be done for concussion?
Red flags ➜Severe headache Loss of consciousness > 30 secMental status impairment Repeated vomiting SeizureWeakness/ tingling in arms/legs
How to treat cold urticaria?
Antihistamine (Benadryl)
What are chilblains (pernio)? Tx?
Painful, red/purple pruritic lesion from the cold Most commonly on hands & feet Tx= Keep the area warm & avoid cold & NO smokingCould try topical corticosteroids or nifedipine
What is an immersion injury (trench foot)?
Injury to the soft tissue, nerves & vasculature of foot or other extremities due to prolonged exposure to cold wet conditions *Commonly seen in homeless individuals Stages exist: Pale foot with loss of sensation & pulselessness ➜ mottled blue skin & numb, weak pulse with rewarming Hours after rewarming ➜ red swollen & painful, delayed capillary refill but bounding pulse Chronic pain is common with cold exposure
Treating immersion injury (trench foot)?
Gradual rewarming with bed rest & leg elevation NSAIDs or Narcotic for pain
Progression of frostbite?
Frostnip (numbness, white skin with erythema)↓Vesicles/ blebs with surrounding edema ↓Hemorrhagic blister bulla ↓Necrotic tissue involving muscles, tendons, bones*Last 2 phases bad signs for recovery!
How to manage frostbite?
Do not rewarm frostbitten tissue until you can guarantee it will stay warm Remove wet clothing & keep out of elements Treat hypothermia first Rewarm with warm water & rest frozen extremitiesMonitor swelling *risk of compartment syndrome Use ibuprofen to limit inflammation
Symptoms progression of Hypothermia?
Shivering (no longer when <82°). Confusion/ lethargy, Tachycardia, Hypertension↓Altered mental status, dilated pupils, Bradycardia↓Unresponsive/ coma, hypotension, cardiac arrhythmias, acidemia
Management of Hypothermia?
Rectal temp & Cardiac monitoring with EKG & watch electrolytes! Mild (90-95°) ➜ slow external rewarming (remove from cold, remove wet clothes, blankets)Moderate (82-90°) ➜ active external rewarming (warm water immersion, heating blankets, heated lamps, warm air) Severe (< 82°) ➜ active core rewarming (warm IV fluids, warm humidified oxygen, warm lavage, hemodialysis)
EKG hypothermia findings
Initial Tachycardia ➜ Bradycardia Osborn wave "hypothermic bump"Potential Atrial & ventricular arrhythmias *Atrial often resolve, ventricular must be defibrillated
Presentation of heat rash? Treatment?
Pruritic, maculopapular, and erythematous rash due to the heatTx= Light loose clothing & avoiding sweating
Presentation of heat cramps? Treatment?
Painful, involuntary, spasmodic contractions of skeletal muscles usually due to hyponatremia & hyperkalemiaTx= Oral rehydration with electrolyte containing fluids
Presentation of heat edema? Treatment?
Mild swelling of the feet, ankles, and hands that appears with exposure to a hot environment due to cutaneous vasodilatation and orthostatic pooling Tx= Extremity elevation & oral rehydration; diuretics do not help!
Presentation/ diagnosis of heat exhaustion/stress? Treatment?
Sweating, Headache, N./V, malaise, dizziness, and muscle cramps, goosebumps Rectal temp >100° but <104°Get CMP to check electrolytes!Tx= Rest, oral rehydration, and cooling with fans/ice packs & continue to monitor IV fluids if patient is not alert or has severe N/v
Presentation/ diagnosis of heat stroke? Treatment?
Altered mental status, tachycardia, tachypnea, no sweating, oliguria, CNS dysfunctionRectal temp >104°Tx=This is life threatening! IV fluids & rapid cooling! Ice packs, cooling fans, cool water immersion
Presentation of Acute Mountain Sickness? Tx?
Patient ascenting develops a headache with related symptoms:Loss of appetite, N/V, fatigue, weakness, dizziness, light-headedness, fluid retention, difficulty sleepingTx= Stop ascension & if symptoms do not improve within 24 hours descend! Monitor for HAPE/ HACERest, NSAIDs, Antiemetics, Oxygen Avoid alcohol, narcotics & smoking Acetazolamide can be taken as prophylaxis
Presentation/ diagnosis of High Altitude Cerebral Edema? Tx?
Headache, ataxia, papilledema, altered mental status Tx= Immediate descent & do not attempt ascent! 2-4 L Oxygen & high dose dexamethasoneGamow bag (portable hyperbaric chamber) can be used if descent not possible
Presentation/ diagnosis of High Altitude Pulmonary Edema? Tx?
Dyspnea at rest, cough, weakness, decreased performance, chest tightness, tachypnea, & tachycardia Could have AMS Rales on auscultation Tx= Immediate descent! Rest & 2-4L Oxygen Garnow bag 2-6 hrs Mild case >93% O2 with supplemental O2 can resume ascent once asymptomatic Severe must seek hospital! Nifedipine used if descent not possible!
First aid for drowning?
Ventilation! Give 2 initial rescue breath & check pulse for >1 min before starting chest compressionsNO back thrust or heimlich Always suspect hypothermia & associated trauma especially if jumping was involved (immobilize cervical spine)DO NOT stop basic life support until core temp is 90°
Symptoms of drowning?
Respiratory difficulty (dyspnea, cough, wheezing, apnea)Chest pain, arrhythmia, hypotension, cyanosis, Hypothermia (from cold water or prolonged submersion).
How do you manage symptomatic & asymptomatic drowning victim?
Symptomatic ➜ electrolytes, creatinine kinase, cardiac monitoring, EKG, O2 monitoringAsymptomatic ➜observed for 8 hours for possible risk of deterioration
When is arterial gas embolism suspected? Treatment?
Loss of consciousness upon surfacing after diving or Stroke like symptoms after resurfacing Tx= ACLS & oxygen! Immediate recompression/hyperbaric oxygen
When is decompression sickness suspected? Treatment?
When "The bends", "The staggers" & "The chokes" appear 1-6 hrs post diving The bends: joint & muscle pain, skin rashThe staggers: nausea, back pain, headache, other CNSThe chokes: dyspnea, chest pain, coughTx= Oxygen followed by hyperbaric oxygen
First aid for snake bites?
Keep patient calm & stillRemove jewelry/ shoes before swelling startsNo NSAIDs or ASANo tourniquet
Work up for snake bites?
Call poison controlCBC, CMP, Fibrinogen, PT/INR/PTT, CKMark skin at bite site to monitor
Crotaline snake bite presentation? Tx?
Abnormal tastePain & swelling at bite site & necrosisN/VHypotension & tachycardiaTx= Tetanus & wound careAbx if cellulitisAntivenom "CroFAB" if worsening or lab abnormalities
Elapidae snake bite presentation? Tx?
PtosisSlurred speechLoss of facial expressionNumbness & weakness of extremity *descendingRespiratory depressionNO pain or swelling at siteTx= Tetanus & wound careIntubate if neeeded
How would a person with a bark scorpion sting present? Tx?
*ArizonaImmediate pain & numbness around site of sting but no visible woundFollowed by CN deficits, N/V, tachycardia, agitation, spastic muscles , possible pancreatitis Tx= Ice to affected area + tetanus +Analgesics & benzosCould use antivenom but high risk of anaphylaxis
What must be done for assessment in all toxicity/ overdose patients?
Cardiac monitoring & EKGIV fluidsPoint of care glucoseCall Poison Control Labs:CMP, Salicylate & acetaminophen level, Blood alcohol, Urine drug screen, Serum osmolarity, ABG, Urine pregnancy, Specific drug levelsCould try activated charcoal *not in sleepy ptsAntidotes
Presentation of sympathomimetic toxidrome? Tx?*Meth, cocaine, PCP, Bath salts, Ecstasy & Molly
Mydriasis (very dilated pupil)Hypertension, tachycardia, tachypnea, hyperthermia, sweatingHallucination, agitation, anxiety Tx= IV fluids + Benzos + cooling*No restraints could cause rhabdo *No beta blockers
How would someone with an opioid/opiate overdose present? Tx?
Respiratory distress, bradypneaMiosis (very constricted pupil)Altered mental status Slurred speech & sedated appearance Tx= Oxygen/ airway/ need ventilation assistance + Narcan (naloxone) *watch for 3 hrs post narcan
How would someone with an opioid/opiate withdrawal present? Tx?
Mydriasis Sweating, lacrimation RhinorrheaN/V, diarrhea (GI upset)YawningPiloerection "goosebumps" Restlessness, anxietyTx= Symptom control ➜ antiemetics, antidiarrheals, Bentyl for cramps, NSAIDsOpioid replacement (Methadone, Suboxone)Narcan kit with discharge
What occurs with anticholinergic toxicity? Tx?*Antihistamines, Atropine, Scopolamine other motion sickness meds, TCAs, cyclobenzaprines
Tachycardia Flushing "red as a beet"Anhidrosis "dry as a bone"Hyperthermia "hot as a hare"Blurry vision & mydriasis "blind as a bat"Delirium/ hallucinations "mad as a hatter"Urinary retentionTx= IV fluids + benzos + cooling Antidote= Physostigmine "phyxes the bat" If TCA no physostigmine ➜ sodium bicarbonate
What occurs with cholinergic toxicity? Tx?
Opposite of anticholinergic SalvationLacrimation UrinationDefecationFasciculationsTx= skin decontamination/ showerAtropine 2-PAM (pralidoxime) if neurologic symptoms If intubation NO suc!
What occurs with sedative/hypnotic toxicity/overdose? Tx?*Alcohol, Barbiturates, Benzos, Propfol
CNS depression/ altered mental statusAtaxiaSlurred speechVery similar to opioid user but normal vitalsTx= IV fluidsBanana bag➜ NS, thiamine, folic acids, multivitamin and vit K
What are alcohol withdrawal symptoms?
High BPTachycardiaAnxiety/ agitation Tremor N/V, sweatingHeadache Can advance ➜ hallucinations, tactile disturbances, seizures *Use CIWA to diagnose severity
How to treat alcohol withdrawal?
1st line= Benzos (could do librium taper)Bentyl, Antiemetics, NSAIDs, Clonidine
What occurs with benzodiazepine overdose? Tx?"Pams
CNS depression/ AMSAtaxia Slurred speechRespiratory depressionCan advance to comaTx= Flumazenil - only for overdose in a non-habitual user
What occurs with aspirin/salicylate toxicity? Tx?
Tinnitus Hyperventilation, Fever, TachycardiaAMS, lethargic AgitatedAcid/base disturbances, ↑ lactateTx= Activated charcoal in first 2 hrs + IV fluids Correct acidosis with IV sodium bicarbDo NOT intubate if at all possibleIf severe Salicylate >100 ➜ hemodialysis
What occurs with tylenol toxicity? *Remember >4,000 mg/day
Initially (first 24 hrs) N/V, malaise, RUQ pain24-48 hrs: Asymptomatic, ↑ LFTs49-96 hrs: hepatic failure, encephalopathy, coagulopathy
Management of tylenol toxicity?
Get levels right away & at 4 hrs post ingestionUse Rumack- Matthew Nomogram for acute ingestionTx= Activated charcoal within first 2 hrsN- Acetylcysteine (NAC) if indicated by Rumack or liver failure
Presentation of methanol toxicity?*Moonshine
Ataxia, N/V, headacheSnowstorm blindness/ blurred visionAnion gap Metabolic acidosis*Always get point of care glucose
Presentation of ethylene glycol toxicity?*Anti-freeze
AtaxiaFlank pain, hematuria ➜ kidney damageTachycardia, tachypnea, hypertensionCalcium oxalate in UA Anion gap Metabolic acidosis *Always get point of care glucose
Treating methanol & ethylene glycol toxicity?
(4-MP) Fomepizole + IV Ethanol HemodialysisSodium bicarb
Presentation of isopropyl toxicity? Tx?*Rubbing alcohol
Fruity breath odorHematemesisPulmonary edemaHypoglycemiaTx= IV fluids & supportivehemodialysis if needed
How does a beta blocker/ Ca channel blocker overdose present? Tx?
HypotensionBradycardia EKG: bradycardia, PR elongation, or possible heart block *This is history dependent no lab test available Tx= IV fluids followed by: •High dose insulin and dextrose (1U/kg bolus)•Epinephrine•Atropine•Calcium salts•Glucagon•lipid emulsion therapy
What is serotonin syndrome? How does it present? Tx?
Increased serotonergic activity in the CNS due to overdose of antidepressants/antipsychotics Tachycardia, Fever, flushed skin, diaphoresis, dry mucous membranesOcular clonus, Tremor, myoclonus/akathisia, hyperreflexia, lower and upper ataxiaAMS, AgitationTx= Stop offending drugSupportive care: Charcoal + Benzos Cyproheptadine (serotonin antagonist)
When should you suspect carbon monoxide poisoning? Symptoms? Diagnosis? Tx?
History of smoke inhalationOther people living in same house have the same problemsHeadache, Nausea, Dizziness, MalaiseConfusion, LOC, Cheat pain, pulmonary edema, red skin Dx= COHgb level (should be <3% if smoker <10%)Pulse ox not useful Tx= High flow O2 via non-rebreather to ALL patientHyperbaric oxygen in severe cases (>25%, metabolic acidosis, EKG changes, AMS)
When should you suspect cyanide toxicity? Symptoms? Diagnosis? Tx?
House fire/ smoke inhalation & CO poisoningWorking with industrial productsSOB, tachycardia, agitation, headache, dizziness, vomiting ➜ progresses to seizure, hypotension, coma, cardiac arrest Dx= History, cyanide levels, metabolic lactic acidosis Tx= Hydroxycobalamin
With smoke inhalation injuries what signs indicate need for intubation?
HoarsenessStridorFacial burnsOropharyngeal burns/edemaRespiratory distressPoor oxygenation/ventilation
Rule's of 9 for burns
0
How are thermal burns classified?
Superficial (epidermis) *NO blister, blanch Superficial partial thickness (epidermis & dermis) *Blister, blanchDeep partial thickness (epidermis/dermis & hair follicles) *Painful only to pressure, blister, NO blanchFull thickness (into subq) *NOT painful, leathery, NO blanch4th degree (muscle & bone)
How to treat thermal burns?
IV fluids, keep patient warm, wet gauze, tetanus Consult burn center
When to refer patient to burn center?
> 10% total BSA in pts < 10 and > 50> 20% of total BSAFull-thickness burn > 5% of total BSASignificant burns to hands, feet, genitalia, perineum, or major jointsSignificant electrical/chemical injurySignificant inhalation injury, concomitant mechanical trauma, preexisting disordersPsychosocial or rehabilitative care needs
Presentation of acid/alkali ingestion? Work up? Tx?
Acid➜ eschar formationStridor, horsenessDrooling, Unable to swallow/ painful swallowingChest pain Vomiting DETERMINE if substance was acid or alkali & amount*Endoscopy within 12-24 hrs if symptomatic! CXR if respiratory symptoms may have edema Tx= Airway management, IV fluids, Pain control If asymptomatic monitor & refer to GI
Treatment for chemical burns?
Contact poison control!Irrigate with lots of waterAlkaline burns ➜ 5% acetic acid (vinegar)Large surface area ➜ IV hydrationTopical antibiotics (if non-superficial)If in the eye ➜ remove contact, saline irrigation with morgan lens until pH neutralized & refer to ophthalmology*If Oxalic acid or Hydrofluoric acid monitor for hypocalcemia
Electrical injury workup? Tx?
Skin damage does not correlate with the degree of injuryEKG & evaluate for any associated traumaCBC, CMP, LFTs, CK, UA, Troponin, Xray for fractures*Be concerned for compartment syndrome, rhabdomyolysis, acute kidney injury, arrhythmias & fracturesTx= IV fluids & monitor electrolytesTopical antibiotics
Workup for lightning strike victims? Tx?
EKG (common to have Vfib)Full trauma assessment CT of brain alwaysSame labs for electrical burnsTx= Aggressive resuscitation & ventilatory supportBurn care & tetanus
Presentation/diagnosis of epidural hematoma? Tx?
Associated skull fracture Headache, confusion, drowsiness, Seizures, Focal deficits Non- Contrast Head CT: Lens shaped hematomaTx= Rapid neurosurgical intervention for evacuation
Presentation/diagnosis of subdural hematoma? Tx?
Recent head injury or fall in elderly (esp if on blood thinners)Acute: focal deficitsChronic: headache, lightheadedness, cognitive impairment, ataxia Non- Contrast Head CT: Banana shaped hematoma & midline shiftTx= Dependent on severity of symptoms and size of bleedNeed neurosurgical consult & evacuation if large
When should. you be suspicious of meningitis? Work up?
Red flag for meningitis: Headache, fever, AMS & stiff neck +Kernig's, +Brudzinski, + Jolt accentuation headache CBC, BMP, Lactate, Blood cultures x2Head CT followed by lumbar puncture
What is it?Appearance= TurbidOpening Pressure= ↑WBC= ↑ (esp neutrophils)Protein= ↑Glucose= ↓Chloride= ↓
Bacterial Meningitis
What is it?Appearance= ClearOpening Pressure= Normal/mild ↑WBC= ↑ (not as much as bacterial)Protein= Normal/mild ↑Glucose= NormalChloride= Normal
Viral meningitis
Treating bacterial meningitis?
Vancomycin + Ceftriaxone +Dexamethasone (if strep pneumo)
Initial management of stroke in ER?
Emergent noncontrast head CT (stroke perfusion series)Order basic labsPage stroke / neurology teamFollow neuro recommendations+/- MRI / MRAControl BP, supportive cares, reverse anticoagulation if needed, etc.
Treatment for stroke?
ABCWithin 3hrs of symptoms onset= TPA if eligible>3-4.5 hrs = Aspirin + long term managementLong term management= antiplatelet + statin
Contraindications to TPA?
BP >185/ 110Glucose >400 or < 50Minor/rapidly improving strokeINR >1.7 Platelet <100,000Seizure at onset of stroke Current brain bleed/ hx of brain bleedInternal bleedingHx or current intracranial hemorrhagePost MI pericarditisIntracranial surgery, head trauma, or stroke w/ last 3 mos
When should you suspect a subarachnoid hemorrhage? Work up? Tx?
Worst headache or my life"Thunderclap headache Noncontrast head CT If negative CT but high suspicion get Lumbar puncture:Xanthochromia (yellow color to CSF)Tx= Treated with conservative & supportive measuresManage hypertensionManagement of cerebral edema (mannitol & corticosteroids)
When should you have high concern for cauda equina? Work up? Tx?
Severe low back pain Saddle anesthesia Recent onset of bladder/bowel incontinenceMotor impairment or diminished sensation in the legsMRITx= Emergent decompression
When should you have high concern for spinal epidural abscess? Work up? Tx?
IV drug user or immunocompromised, recent surgeryFever, back pain and neurologic deficits (motor weakness, radiculopathy, and bowel/bladder dysfunction)↑ ESR & CRP MRITx= Immediate surgical decompression and drainage + antibiotics (vancomycin + ceftriaxone for 4-8 weeks)
Ventilation/ Perfusion ration (V/Q) normal? What causes it to rise? Drop?
V/Q = 1 is perfectNormal = 0.8 Reduced ventilation ➜ dropsReduced perfusion ➜ elevates
Intubation medications?
Sedation ➜ Etomidate, ketamine, propofol, fentanylParalysis ➜ Suc, Roc, Vec
When to suspect pneumothorax & tension? PE findings? Workup? Tx?
Trauma, Hx of asthma, COPD, but can also be spontaneousAcute onset of unilateral chest pain (pleuritic) and dyspneaLabored breathingAbsent breath sounds, unilateral chest expansion, TachycardiaTension➜ hypotension tracheal deviation, neck vein distension Dx= Lung ultrasound, CXR, CT *Not for tension no timeTx= Chest tube (5th intercostal space @ midaxillary line)Tension➜ needle decompression 2nd intercostal space @ midclavicular line) followed by tube
What is flail chest? Signs?
3 or more adjacent ribs fractured in 2 placesParadoxical inward movement of the involved chest wall segment during spontaneous inspiration and outward movement during expiration
When to suspect pulmonary embolism? Workup? Tx?
Patient with cancer, recent trip, estrogen therapy or prior DVT, or clotting disorders presenting with:Pleuritic chest painSOBSyncopeTachycardiaD-dimer (-) rules out but (+) doesn't rule in If (+)➜ Chest CT with contrastV/Q scan Tx= Heparin, coumadin, NOAC's & can be sent home if stable vitalsIf saddle or large ➜ TPA or thrombectomy
Presentation of COPD exacerbations? Workup? Tx?
Acute onset or worsening of respiratory symptoms:Dyspnea, cough, and/or sputum production, over several hours to daysPE findings may include wheezing and tachypnea, use of accessory muscles, profound sweating Workup: Pulse ox, CXR, CBC, BMP, ABG (if respiratory acidosis suspected)Tx= OxygenAlbuterol- Ipratropium Prednisone 2 weeksAntibiotic based on sputum culture (Zpack)CPAP/ BiPAP
Presentation of asthma exacerbations? Workup? Tx?
Acute onset of tachypnea, tachycardia, sweating, SOB, wheezing Workup: ABG Tx= Oxygen Albuterol-Ipratropium Prednisone or methylprednisolone IV magnesium Epinephrine if not responding to above
Presentation of pneumonia? Workup? Tx?
Fever, shaking chillsTachypnea, Tachycardia Pleuritic chest painPossible sputum production with cough Lung crackles, tactile fremitus CXR: consolidations Tx= Use CURB- 65 to determine inpatient vs outpatientUncomplicated= Zpack or Doxy
Presentation of epiglottis? Workup? Tx?
Acute onset high fever, sore throatPatient appears very sick: drooling, tripoding, muffled voice, respiratory distressLateral neck Xray: thumbprint sign Tx= IntubationAntibiotics (ceftriaxone or cefotaxime)
What is delirium classified as? Workup? Tx?
A state in which patients become acutely agitated, disoriented, and are unable to sustain attention - not explained better by preexisting or established neurocognitive disorderPresumed etiology: Medications, drugs, withdrawal, neurologic condition, infectionLook for all possible causes! Run many labs & screenings! Head CT & CXR , EKGTx= treat underlying causeAntipsychotics if needed to control symptoms (Olanzapine, Haloperidol) or can use Lorazepam if can't use antipsychoticsAvoid restraints if possible!
What is psychosis classified as? Workup? Tx?
Impaired thinking and behavior causing delusions, hallucinations, and disorganization (confusion, mood change)Look for all possible causes! Run many labs & screenings! Head CT & CXR , EKGTx= Mental health evaluationAntipsychotics if needed to control symptoms (Olanzapine, Haloperidol) or can use Lorazepam if can't use antipsychoticsAvoid restraints if possible!
Management of suicidality?
SAFE- T assessment SAD PERSONS Score*Any patient contemplating or actively planning suicide requires hospitalizations, voluntary or involuntary