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Board / Inservice ReviewPart 1
Angela M. Mills, MD
Department of Emergency Department of Emergency MedicineMedicine
University of Pennsylvania Health University of Pennsylvania Health SystemSystem
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The TestThe Test
305 questions in 6.5 hours305 questions in 6.5 hours 10-15% pictorial10-15% pictorial 75% required to pass75% required to pass 90% pass rate - EM residency trained90% pass rate - EM residency trained Practice lots of questionsPractice lots of questions
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Taking the TestTaking the Test
76 seconds per question76 seconds per question Fill in answer sheet as you goFill in answer sheet as you go Mark difficult questions you wish to Mark difficult questions you wish to
later reconsiderlater reconsider Write in the bookletWrite in the booklet
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Taking the TestTaking the Test
If you anticipate an answer as you If you anticipate an answer as you read the question, you’re prob rightread the question, you’re prob right
1/3 of test not scored1/3 of test not scored 3 types of questions3 types of questions
– you know the answeryou know the answer– you know part of the answeryou know part of the answer– you have no idea what they’re talking aboutyou have no idea what they’re talking about
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Taking the TestTaking the Test
Answers which state “always” or Answers which state “always” or “never” are usually not correct“never” are usually not correct
If two answers are close, one is If two answers are close, one is probably correctprobably correct
If two answers are direct If two answers are direct opposites, one is usually correctopposites, one is usually correct
You frequently won’t need the You frequently won’t need the picture to answer the questionpicture to answer the question
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Abdominal / Abdominal / GastrointestinalGastrointestinal
9%9%
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Sudden PainSudden Pain
Mesenteric embolus leading to Mesenteric embolus leading to ischemia / infarctionischemia / infarction
Ruptured AAARuptured AAA Perforated viscusPerforated viscus Renal colicRenal colic Cecal volvulus Cecal volvulus
– sigmoid volvulus more gradualsigmoid volvulus more gradual
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Lethal Causes of PainLethal Causes of Pain
Mesenteric ischemia / infarctionMesenteric ischemia / infarction Ruptured or leaking AAARuptured or leaking AAA Perforated viscusPerforated viscus Acute pancreatitisAcute pancreatitis Bowel obstructionBowel obstruction
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Abdominal Pain that is….Abdominal Pain that is….
diffuse, severe, colicky = diffuse, severe, colicky = bowel obstructionbowel obstruction
out of proportion to examination = out of proportion to examination = mesenteric ischemiamesenteric ischemia
radiating from epigastrium straight radiating from epigastrium straight through to midback = through to midback = pancreatitispancreatitis
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Gastrointestinal BleedGastrointestinal Bleed
Hematemesis: bright red or coffee-groundHematemesis: bright red or coffee-ground Melena: black tarry stoolMelena: black tarry stool
– requires 150-200 cc blood in GI tract for minimum of requires 150-200 cc blood in GI tract for minimum of 8 hours to turn black8 hours to turn black
Hematochezia: bloody stoolsHematochezia: bloody stools– 5cc of hemorrhoid blood can turn toilet water bright red5cc of hemorrhoid blood can turn toilet water bright red
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Nausea and VomitingNausea and Vomiting
Medications - most common cause Medications - most common cause in adultsin adults
Acute gastroenteritis - most Acute gastroenteritis - most common GI disease in UScommon GI disease in US
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Vomiting….Vomiting….
……of bile rules out gastric outlet of bile rules out gastric outlet obstructionobstruction
……of feculent material suggests distal of feculent material suggests distal obstructionobstruction
……in morning suggests pregnancy, in morning suggests pregnancy, uremia, or uremia, or ICP ICP
……of food > 12 hours old of food > 12 hours old pathognomonic for outlet obstructionpathognomonic for outlet obstruction
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Diarrhea….Diarrhea….
……which is mucoid bloody + high fever which is mucoid bloody + high fever + febrile seizure in infant = + febrile seizure in infant = ShigellaShigella
……in pt with pet turtle or iguana = in pt with pet turtle or iguana = SalmonellaSalmonella
……in pt w/o spleen or with Sickle Cell = in pt w/o spleen or with Sickle Cell = SalmonellaSalmonella
……and pseudoappendicitis = and pseudoappendicitis = YersiniaYersinia
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Diarrhea….Diarrhea….
……and fecal WBCs after poultry or and fecal WBCs after poultry or eggs = eggs = Salmonella or CampylobacterSalmonella or Campylobacter
……after poultry or meat, NO fecal after poultry or meat, NO fecal WBCs = WBCs = Clostridium perfringensClostridium perfringens
……profuse and watery after antibiotic = profuse and watery after antibiotic = Clostridium difficileClostridium difficile
……after potato salad or mayonnaise = after potato salad or mayonnaise = Staphylococcus aureusStaphylococcus aureus
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Diarrhea….Diarrhea….
……after fried rice = after fried rice = Bacillus cereusBacillus cereus ……after raw oysters = after raw oysters = Vibrio choleraVibrio cholera ……after drinking from mountain stream after drinking from mountain stream
= = Giardia lambliaGiardia lamblia ……in AIDS pt = in AIDS pt = isospora or isospora or
cryptosporidiumcryptosporidium ……and Hemolytic Uremic Syndrome or and Hemolytic Uremic Syndrome or
TTP = TTP = E. coliE. coli 0157:H7 0157:H7
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Foreign BodiesForeign Bodies
80% in children80% in children Most common object in kids = coinMost common object in kids = coin Most common object in adults = foodMost common object in adults = food ““Café coronary”: unchewed meat Café coronary”: unchewed meat
lodged in upper esophaguslodged in upper esophagusairway airway obstruction obstruction sudden cyanosis sudden cyanosis collapse collapse deathdeath
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Foreign BodiesForeign Bodies
““Steakhouse syndrome”: distal Steakhouse syndrome”: distal esophageal obstructionesophageal obstruction– glucagon + effervescent agent relieves glucagon + effervescent agent relieves
acute lower esophageal obstruction acute lower esophageal obstruction 75% of pts75% of pts
– proteolytic enzymes contraindicatedproteolytic enzymes contraindicated Suspected perforation: water-soluble Suspected perforation: water-soluble
contrast material (gastrograffin®)contrast material (gastrograffin®)
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Swallowing DysfunctionSwallowing Dysfunction
Most common upper causeMost common upper cause– neuromuscular (e.g. stroke)neuromuscular (e.g. stroke)
Most common lower causeMost common lower cause– intrinsic motility disorderintrinsic motility disorder
• (e.g. achalasia, spasm)(e.g. achalasia, spasm)
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Tear vs RuptureTear vs Rupture
Mallory-Weiss: vomiting Mallory-Weiss: vomiting esophageal tear and bleedingesophageal tear and bleeding
Boerhaave syndrome: vomiting Boerhaave syndrome: vomiting esophageal rupture esophageal rupture (left posterior (left posterior
distal)distal)mediastinitismediastinitis– consider in alcoholic with vomiting + chest pain consider in alcoholic with vomiting + chest pain
OR chest pain + left pleural effusionOR chest pain + left pleural effusion
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Upper GI BleedUpper GI Bleed
Most common causes UGI bleed: Most common causes UGI bleed: Peptic ulcer disease > erosive Peptic ulcer disease > erosive gastritis > varices > Mallory-Weiss gastritis > varices > Mallory-Weiss > esophagitis> esophagitis
EndoscopyEndoscopy Surgery only in severe, unrelenting Surgery only in severe, unrelenting
hemorrhagehemorrhage
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Peptic Ulcer DiseasePeptic Ulcer Disease
Duodenal ulcer more common: Duodenal ulcer more common: pain between mealspain between meals
Gastric ulcer: pain immediately Gastric ulcer: pain immediately after eatingafter eating
Remember H. pyloriRemember H. pylori
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Biliary DiseaseBiliary Disease
Bilirubin 2.0 - 2.5 Bilirubin 2.0 - 2.5 jaundice jaundice Pre-hepatic: hemolyticPre-hepatic: hemolytic Hepatic: hepatocellularHepatic: hepatocellular Post-hepatic: obstructivePost-hepatic: obstructive Cholecystitis = cholelithiasisCholecystitis = cholelithiasis
– acalculous in 5-10%acalculous in 5-10%
Murphy sign 97% sensitiveMurphy sign 97% sensitive– pain during subcostal palpation on pain during subcostal palpation on
inspirationinspiration
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GallstonesGallstones
Ultrasound Ultrasound – 94% sensitive, 78% specific94% sensitive, 78% specific
Radioisotope study (HIDA) Radioisotope study (HIDA) – 97% sensitive, 90% specific97% sensitive, 90% specific
Charcot triad: fever + jaundice + Charcot triad: fever + jaundice + right upper quadrant pain = right upper quadrant pain = ascending cholangitisascending cholangitis
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Acute CholecystitisAcute Cholecystitis
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Liver DiseaseLiver Disease
Hepatitis A: short incubation, usually Hepatitis A: short incubation, usually benign, fecal/oral spreadbenign, fecal/oral spread
Hepatitis B: percutaneous, STDHepatitis B: percutaneous, STD– carrier, chronic, fulminant diseasecarrier, chronic, fulminant disease– vaccinevaccine
Hepatitis C: percutaneous, STDHepatitis C: percutaneous, STD– carrier, chronic, fulminant diseasecarrier, chronic, fulminant disease
Most common US blood borne Most common US blood borne infection = infection = Hepatitis CHepatitis C
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PancreatitisPancreatitis
Gallstones Gallstones 45% 45% Alcohol Alcohol 35% 35% Lipase and amylase most usefulLipase and amylase most useful
– but both normal in up to 25%but both normal in up to 25%– mild elevations not specificmild elevations not specific– very specific if levels > 5 x normalvery specific if levels > 5 x normal
2 or more Ranson criteria 2 or more Ranson criteria ICU ICU– on admission: age > 55, WBC > 16,000, fasting on admission: age > 55, WBC > 16,000, fasting
glucose > 200, AST/SGOT > 250, LDH > 350glucose > 200, AST/SGOT > 250, LDH > 350– AWFALAWFAL
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Small Bowel ObstructionSmall Bowel Obstruction
Most common cause = adhesions from Most common cause = adhesions from prior surgery > 50%prior surgery > 50%
No prior surgery = hernias & neoplasms No prior surgery = hernias & neoplasms 15% each 15% each
Diagnosis: air-fluid levels on xray Diagnosis: air-fluid levels on xray
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Intestinal IschemiaIntestinal Ischemia
Most common: arterial embolus >50%Most common: arterial embolus >50%– arterial thrombosis arterial thrombosis 15% 15%– venous thrombosis venous thrombosis 15% 15%– nonocclusive vascular disease nonocclusive vascular disease 20% 20%
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Mesenteric IschemiaMesenteric Ischemia
Pain out of proportion to examPain out of proportion to exam High mortality rate High mortality rate Heme-positive stoolHeme-positive stool serum lactate may helpserum lactate may help Study of choice: Study of choice: AngiographyAngiography
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AppendicitisAppendicitis
Most common surgical emergencyMost common surgical emergency Classic appendicitis still a clinical Classic appendicitis still a clinical
diagnosisdiagnosis CBC, c-reactive protein, plain xrays CBC, c-reactive protein, plain xrays
not helpfulnot helpful If equivocal: CT scan, ultrasoundIf equivocal: CT scan, ultrasound
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GastroenteritisGastroenteritis
Symptoms within 2-4 hours of eating Symptoms within 2-4 hours of eating Staphylococcus Staphylococcus (mostly vomiting)(mostly vomiting) or or Bacillus cereusBacillus cereus– others take longerothers take longer
Enterotoxigenic Enterotoxigenic E. ColiE. Coli 50% of 50% of traveler’s diarrheatraveler’s diarrhea– daily prophylaxis prevents daily prophylaxis prevents 90% 90%
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Diverticular DiseaseDiverticular Disease
Uncommon < 40 yearsUncommon < 40 years Diverticulitis Diverticulitis LLQ tenderness, LLQ tenderness,
distension, normal bowel soundsdistension, normal bowel sounds CT equivalent to barium enema for CT equivalent to barium enema for
diagnostic accuracydiagnostic accuracy Diverticulosis Diverticulosis most frequent cause most frequent cause
of significant lower GI bleedof significant lower GI bleed
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Bowel DiseaseBowel Disease
Most common cause of large bowel Most common cause of large bowel obstruction obstruction tumors and diverticular tumors and diverticular diseasedisease
Crohn’s diseaseCrohn’s disease ALL layers of ALL layers of bowel wall, spares rectum, fistulas bowel wall, spares rectum, fistulas and abscesses, “skip” lesionsand abscesses, “skip” lesions
Ulcerative colitisUlcerative colitis mucosal disease, mucosal disease, involves rectum in 90%involves rectum in 90%
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Bowel DiseaseBowel Disease
Sigmoid volvulusSigmoid volvulus– elderly, debilitated, sigmoidoscopyelderly, debilitated, sigmoidoscopy
Cecal volvulus (15 - 20%)Cecal volvulus (15 - 20%)– young (35 - 55), requires surgeryyoung (35 - 55), requires surgery
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Sigmoid VolvulusSigmoid Volvulus
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CutaneousCutaneous 2%2%
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Nikolsky’s SignNikolsky’s Sign
Minor rubbing Minor rubbing desquamation of desquamation of underlying skin, including pigmentunderlying skin, including pigment
Positive in Toxic Epidermal Positive in Toxic Epidermal Necrolysis, Staph scalded skin Necrolysis, Staph scalded skin syndrome syndrome (Tintinalli - yes, Rosen - no),(Tintinalli - yes, Rosen - no), Pemphigus vulgaris Pemphigus vulgaris (NOT bullous (NOT bullous pemphigoid)pemphigoid)
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DermatologyDermatology
Steven Johnson Syndrome Steven Johnson Syndrome – AKA Erythema Multiforme MajorAKA Erythema Multiforme Major– erythema multiforme with mucous erythema multiforme with mucous
membrane and visceral involvementmembrane and visceral involvement
Toxic Epidermal NecrolysisToxic Epidermal Necrolysis– sloughing of epidermissloughing of epidermis– children children Staph Staph– adults adults drugs drugs
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DermatologyDermatology
MeningococcemiaMeningococcemia– young pt, generalized rash, gun-metal gray young pt, generalized rash, gun-metal gray
patches of purpurapatches of purpura
GonococcemiaGonococcemia– young pt, arthralgia, rashyoung pt, arthralgia, rash– erythematous papules with central purpuraerythematous papules with central purpura
Rocky Mountain Spotted FeverRocky Mountain Spotted Fever– pink-red macules that start on wrists, ankles, and pink-red macules that start on wrists, ankles, and
forearm spreads to involve the soles with feverforearm spreads to involve the soles with fever
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RMSFRMSF
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DermatologyDermatology
Lyme DiseaseLyme Disease– erythema chronicum migrans starts as a erythema chronicum migrans starts as a
red macule that expands to form a ring red macule that expands to form a ring with raised border and central clearingwith raised border and central clearing
MeaslesMeasles– Koplik spots = bluish dots on oral Koplik spots = bluish dots on oral
mucosa 24-48 hours before rashmucosa 24-48 hours before rash
PurpuraPurpura– palpable = vasculitis (HSP)palpable = vasculitis (HSP)– non-palpable = thrombocytopenia, TTP, non-palpable = thrombocytopenia, TTP,
von Willebrand’svon Willebrand’s
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ECMECM
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Koplik spotsKoplik spots
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CardiovascularCardiovascular 11%11%
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Hypertrophic CardiomyopathyHypertrophic Cardiomyopathy
Most common symptom = Most common symptom = dyspneadyspnea
Syncope in 20 - 30%Syncope in 20 - 30% Harsh crescendo-decrescendo Harsh crescendo-decrescendo
murmur <> at left sternal bordermurmur <> at left sternal border with valsava or standingwith valsava or standing with squatting or hand gripwith squatting or hand grip
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Mitral StenosisMitral Stenosis
Most common symptoms = Most common symptoms = exertional dyspnea, hemoptysisexertional dyspnea, hemoptysis
Most common cause = Most common cause = rheumatic heart diseaserheumatic heart disease
Most patients develop A fibMost patients develop A fib Mid-diastolic rumble into S2Mid-diastolic rumble into S2
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Aortic StenosisAortic Stenosis
Dyspnea, chest pain, syncopeDyspnea, chest pain, syncope Congenital #1 causeCongenital #1 cause Rheumatic heart disease #2 causeRheumatic heart disease #2 cause Harsh systolic ejection murmurHarsh systolic ejection murmur Sudden arrhythmic death in Sudden arrhythmic death in 25% 25% ECG ECG LVH LVH
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Valvular DiseaseValvular Disease
Aortic and mitral regurgitationAortic and mitral regurgitation– reduce afterload reduce afterload
• nitroglycerin and nitroprussidenitroglycerin and nitroprusside
– control rate of atrial fibrillationcontrol rate of atrial fibrillation– balloon pump contraindicated in balloon pump contraindicated in
wide-open aortic regurgitationwide-open aortic regurgitation
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Infective EndocarditisInfective Endocarditis
Most common = left sidedMost common = left sided– Mitral >> aortic > tricuspid > pulmonicMitral >> aortic > tricuspid > pulmonic– Streptococcus viridansStreptococcus viridans, staph, enterococcus, staph, enterococcus– Sepsis Sepsis ++ heart failure heart failure– Neurologic symptoms in 1/3Neurologic symptoms in 1/3– Subacute: murmur of AI, MRSubacute: murmur of AI, MR
Oxacillin and aminoglycosideOxacillin and aminoglycoside
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Infective EndocarditisInfective Endocarditis
Roth spotsRoth spots– retinal hemorrhage with central clearingretinal hemorrhage with central clearing
Osler nodesOsler nodes– tender nodules on fingers and toestender nodules on fingers and toes
Janeway lesionsJaneway lesions– plaques on palms and solesplaques on palms and soles
Splinter hemorrhagesSplinter hemorrhages
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Osler NodesOsler Nodes
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Splinter HemorrhageSplinter Hemorrhage
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Infective EndocarditisInfective Endocarditis
Right sided: intravenous drug useRight sided: intravenous drug use– Staphylococcus aureus, Streptococcus pneumoniaeStaphylococcus aureus, Streptococcus pneumoniae
Usually acuteUsually acute– fever, cough, chest pain, dyspnea, hemoptysisfever, cough, chest pain, dyspnea, hemoptysis– murmur much less commonmurmur much less common
Diagnosis: Echo, blood culturesDiagnosis: Echo, blood cultures Penicillinase-resistant penicillin or Penicillinase-resistant penicillin or
vancomycin + aminoglycosidevancomycin + aminoglycoside– possible emergent surgerypossible emergent surgery
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ThrombolysisThrombolysis
Symptoms of myocardial Symptoms of myocardial infarction within prior 12 hours + infarction within prior 12 hours + >1mm ST >1mm ST in 2 limb leads or in 2 limb leads or >2mm ST >2mm ST in chest leads or new in chest leads or new LBBB and no contraindicationsLBBB and no contraindications
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Antero-Lat MIAntero-Lat MI
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Inferior MIInferior MI
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Postero-Lat MIPostero-Lat MI
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CardiologyCardiology
Cocaine chest painCocaine chest pain– all usual treatments except beta-all usual treatments except beta-
blockers blockers unopposed alpha unopposed alpha Cardiac tamponadeCardiac tamponade
– Beck’s triadBeck’s triad• JVD, hypotension, muffled heart soundsJVD, hypotension, muffled heart sounds
– Electrical alternansElectrical alternans
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Electrical AlternansElectrical Alternans
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DysrhythmiasDysrhythmias
Patient stability dictates actionPatient stability dictates action Regular vs irregularRegular vs irregular Slow vs fastSlow vs fast Relation of P to QRSRelation of P to QRS Supraventricular vs ventricularSupraventricular vs ventricular Wide vs narrowWide vs narrow Treat as VT if not sure if SVT w/ aberrancyTreat as VT if not sure if SVT w/ aberrancy
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Multifocal Atrial TachycardiaMultifocal Atrial Tachycardia
Irregularly irregular (100 – 180)Irregularly irregular (100 – 180) P waves multiple shapes, PR variesP waves multiple shapes, PR varies Treat underlying problem (COPD)Treat underlying problem (COPD) MagnesiumMagnesium
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MATMAT
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Atrial FlutterAtrial Flutter
Regular (rate 300) Regular (rate 300) – unless variable block 2:1, 3:1unless variable block 2:1, 3:1
““Sawtooth” flutter wavesSawtooth” flutter waves AV conduction usually 2:1 AV conduction usually 2:1
– ventricular rate 150ventricular rate 150
Rate control B-blocker or CCBRate control B-blocker or CCB Synch cardioversion 25 – 50 JSynch cardioversion 25 – 50 J
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Atrial FlutterAtrial Flutter
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Atrial FibrillationAtrial Fibrillation
Irregularly irregularIrregularly irregular Untreated vent response <100 implies Untreated vent response <100 implies
AV node diseaseAV node disease NO P wavesNO P waves Narrow QRS (unless aberrant)Narrow QRS (unless aberrant) Slow vent rate with diltiazem, ibutilideSlow vent rate with diltiazem, ibutilide Synch cardioversion 100 JSynch cardioversion 100 J
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Atrial FibrillationAtrial Fibrillation
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Supraventricular TachycardiaSupraventricular Tachycardia
Regular, rate 160 – 200Regular, rate 160 – 200 P waves may not be visibleP waves may not be visible QRS narrow (unless aberrant)QRS narrow (unless aberrant) AdenosineAdenosine drug of choice drug of choice Synch cardiovert 50 – 100 JSynch cardiovert 50 – 100 J Most common non-arrest Most common non-arrest
tachydysrhythmia in infants / childrentachydysrhythmia in infants / children PAT with blockPAT with block = classic digitalis toxic = classic digitalis toxic
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Ventricular TachycardiaVentricular Tachycardia
Regular, 3 or more consecutive beatsRegular, 3 or more consecutive beats Wide complexWide complex Stable: Amiodarone, lido, procainamideStable: Amiodarone, lido, procainamide Unstable: CardiovertUnstable: Cardiovert
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V TachV Tach
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Ventricular FibrillationVentricular Fibrillation
Pulseless, apneic patientPulseless, apneic patient Grossly disorganized patternGrossly disorganized pattern Defibrillate 200 JDefibrillate 200 J Amiodarone, lidocaineAmiodarone, lidocaine
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V FibV Fib
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DysrhythmiasDysrhythmias
Pulseless electrical activity (PEA)Pulseless electrical activity (PEA)– hypovolemia, hypothermia, hypoxia, hypovolemia, hypothermia, hypoxia,
tamponade, tension pneumothoraxtamponade, tension pneumothorax Torsade de PointesTorsade de Pointes
– magnesium or overdrive pacingmagnesium or overdrive pacing
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Torsade de PointesTorsade de Pointes
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AV BlocksAV Blocks
11stst deg – prolonged PR >200 msec deg – prolonged PR >200 msec 22ndnd deg – Mobitz I deg – Mobitz I Wenckebach Wenckebach
– progressive PR prolongation, RR decreased progressive PR prolongation, RR decreased until dropped QRS until dropped QRS no Rx no Rx
22ndnd deg – Mobitz II deg – Mobitz II– constant PR, RR constant, drop QRS constant PR, RR constant, drop QRS pacer pacer
33rdrd deg – deg – – independent atrial / vent contractions independent atrial / vent contractions pacer pacer
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22ndnd Degree - Mobitz I Degree - Mobitz I
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22ndnd Degree – Mobitz II Degree – Mobitz II
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33rdrd Degree AV Block Degree AV Block
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Wolff Parkinson WhiteWolff Parkinson White
Short PRShort PR Delta waveDelta wave PSVT 40 - 80%PSVT 40 - 80% Atrial fibrillation 10 - 20%Atrial fibrillation 10 - 20% Atrial flutter Atrial flutter 5% 5% Procainamide, flecanide, cardiovertProcainamide, flecanide, cardiovert
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WPWWPW
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Hypertensive EmergencyHypertensive Emergency
Hypertensive encephalopathy: Hypertensive encephalopathy: nitroprusside, labetalolnitroprusside, labetalol
Stroke: labetalolStroke: labetalol Pulm edema: nitroglycerin, nitroprussidePulm edema: nitroglycerin, nitroprusside Myocardial ischemia: nitroglycerinMyocardial ischemia: nitroglycerin Thoracic dissection: nitroprusside + Thoracic dissection: nitroprusside +
beta-blockerbeta-blocker Pheochromocytoma: phentolaminePheochromocytoma: phentolamine Eclampsia: hydralazineEclampsia: hydralazine
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Acute PericarditisAcute Pericarditis
Friction rub increased by leaning forwardFriction rub increased by leaning forward
Diffuse PR depression, ST elevationDiffuse PR depression, ST elevation
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Aortic DissectionAortic Dissection
>50 years, hypertension, connective >50 years, hypertension, connective tissue disease (Marfan), pregnancytissue disease (Marfan), pregnancy
90% abrupt tearing back pain90% abrupt tearing back pain MI / CVA / spinal cord sx’s all possible MI / CVA / spinal cord sx’s all possible
presentationspresentations Asymmetric BP’s, aortic regurgAsymmetric BP’s, aortic regurg Type A : ascending, surgeryType A : ascending, surgery Type B : descending, medicalType B : descending, medical Nitroprusside + beta-blockerNitroprusside + beta-blocker
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AAAAAA
Beware the elderly man with hematuria Beware the elderly man with hematuria and sudden back painand sudden back pain
Commonly misdiagnosed as renal colicCommonly misdiagnosed as renal colic Decreased lower ext pulsesDecreased lower ext pulses AAA may not be palpableAAA may not be palpable
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AAAAAA
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Endocrine / Endocrine / MetabolicMetabolic
5%5%
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Acid - BaseAcid - Base
Respiratory alkalosis Respiratory alkalosis hyperventilation hyperventilation Respiratory acidosis Respiratory acidosis hypoventilation hypoventilation Metabolic alkalosis Metabolic alkalosis volume and volume and
potassium depletion potassium depletion Anion gap = NaAnion gap = Na++ – (Cl – (Cl-- + HCO + HCO33
--) ) – normal 12 normal 12 ++ 3 mEq/L 3 mEq/L
Acute alkalosis Acute alkalosis HCO HCO33-- 2 mEq/L for 2 mEq/L for
each 10mmHg each 10mmHg in PaCO in PaCO22
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Acid - BaseAcid - Base
Winter’s formula:Winter’s formula:– pCOpCO22 = 1.5 (HCO = 1.5 (HCO33) + 8 ) + 8 ++ 2 2– If pCOIf pCO22 not in this range not in this range superimposed superimposed
primary respiratory processprimary respiratory process Metabolic acidosis caused by:Metabolic acidosis caused by:
acid production, acid production, acid excretion (renal), acid excretion (renal), loss of alkaliloss of alkali
Most common mixed disturbance: Most common mixed disturbance: primary metabolic acidosis + primary primary metabolic acidosis + primary respiratory alkalosisrespiratory alkalosis
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Anion Gap AcidosisAnion Gap Acidosis
CCarbon monoxide / arbon monoxide / CCyanide exposureyanide exposure
AAlcoholic ketoacidosis / lcoholic ketoacidosis / AAcute alcohol cute alcohol intoxicationintoxication
TToluene exposureoluene exposure MMethanol intoxicationethanol intoxication UUremiaremia DDiabetic ketoacidosisiabetic ketoacidosis
PParaldehyde ingestionaraldehyde ingestion IIsoniazid / soniazid / IIron ron
intoxicationintoxication LLactic acidosisactic acidosis EEthylene glycol thylene glycol
intoxicationintoxication SSalicylate intoxicationalicylate intoxication
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Metabolic acidosisMetabolic acidosis
Non-anion gap acidosis implies loss Non-anion gap acidosis implies loss of HCOof HCO33
– GI loss GI loss diarrhea, enterostomy diarrhea, enterostomy– Renal loss Renal loss renal tubular acidosis, renal tubular acidosis,
acetazolamideacetazolamide– HyperalimentationHyperalimentation
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ElectrolytesElectrolytes
Consider laboratory error as part Consider laboratory error as part of differentialof differential
Primary responsibility Primary responsibility restore restore intravascular volume and tissue intravascular volume and tissue perfusionperfusion
Correct electrolyte abnormalities Correct electrolyte abnormalities at rate they occurredat rate they occurred
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HypernatremiaHypernatremia
Excess free water lossExcess free water loss– Diabetes insipidus, hyperglycemiaDiabetes insipidus, hyperglycemia
Inadequate free water intakeInadequate free water intake– Poor oral intakePoor oral intake
Excess sodium gainExcess sodium gain– Iatrogenic, hyperaldosteronism, Cushing’s Iatrogenic, hyperaldosteronism, Cushing’s
syndromesyndrome If volume depleted, give If volume depleted, give IV NSSIV NSS Correct too fast Correct too fast brain edema, seizures brain edema, seizures
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HyponatremiaHyponatremia
HypovolemicHypovolemic– Renal loss, vomiting, burns Renal loss, vomiting, burns IV NSS IV NSS
EuvolemicEuvolemic– SIADH, glucocorticoid deficiency SIADH, glucocorticoid deficiency
furosemide + IV NSSfurosemide + IV NSS HypervolemicHypervolemic
– CHF, renal failure CHF, renal failure water restriction + water restriction + furosemide, consider Na replacementfurosemide, consider Na replacement
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HyperkalemiaHyperkalemia
Renal failure, acidosis, tissue Renal failure, acidosis, tissue necrosis, hemolysis, transfusions, necrosis, hemolysis, transfusions, GI bleed, drugsGI bleed, drugs
ECG findings: peaked T waves, ECG findings: peaked T waves, widened QRS, “sine wave”, V fib, widened QRS, “sine wave”, V fib, asystoleasystole
Protect heart Protect heart calcium chloride calcium chloride or gluconateor gluconate
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HyperkalemiaHyperkalemia
Shift KShift K++ into cell into cell insulin, albuterol insulin, albuterol Block KBlock K++ reabsorption reabsorption furosemide furosemide Bind KBind K++ for excretion for excretion sodium sodium
polystyrene (Kayexalate®)polystyrene (Kayexalate®) Prevent hypoglycemia Prevent hypoglycemia dextrose dextrose
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HyperkalemiaHyperkalemia
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HypokalemiaHypokalemia
pH 0.1 pH 0.1 serum Kserum K++ 0.5 0.5 ++ 0.2mEq/L 0.2mEq/L RedistributionRedistribution alkalosis, insulin, beta- alkalosis, insulin, beta-
agonistsagonists Renal lossRenal loss diuretics, excess diuretics, excess
glucocorticoidglucocorticoid GI lossGI loss vomiting, diarrhea vomiting, diarrhea Oral KOral K++ better absorbed, safer better absorbed, safer MagnesiumMagnesium
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HypokalemiaHypokalemia
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HypercalcemiaHypercalcemia
Most common outpt cause: Most common outpt cause: primary hyperparathyroidismprimary hyperparathyroidism
Most common inpt cause: Most common inpt cause: malignancymalignancy Most common paraneoplastic syndMost common paraneoplastic synd Signs & sx’s variable and nonspecificSigns & sx’s variable and nonspecific Restore intravascular volume (Restore intravascular volume (NSSNSS)) Enhance renal elimination Enhance renal elimination loop diuretic loop diuretic
– Thiazides can make worseThiazides can make worse
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HypocalcemiaHypocalcemia
Neuromuscular hyperexcitability, Neuromuscular hyperexcitability, Perioral paresthesias, muscle Perioral paresthesias, muscle cramps, tetanycramps, tetany
Chvostek’s signChvostek’s sign: tap facial nerve : tap facial nerve ipsilateral facial muscles twitchipsilateral facial muscles twitch
Trousseau’s signTrousseau’s sign: inflate arm blood : inflate arm blood pressure cuff pressure cuff carpal spasm carpal spasm
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Hyperglycemia - DKAHyperglycemia - DKA
Lack of insulin, the only anabolic Lack of insulin, the only anabolic hormonehormone
MOST important treatmentMOST important treatment IV NSSIV NSS Half-life IV regular insulin 3-10 mins Half-life IV regular insulin 3-10 mins
continuous dripcontinuous drip Replace KReplace K++ early early
– phosphate not needed phosphate not needed – bicarb controversial (generally not needed)bicarb controversial (generally not needed)
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Hyperglycemia - HHNCHyperglycemia - HHNC
Hyperglycemic hyperosmolar Hyperglycemic hyperosmolar nonketotic comanonketotic coma– Prodrome longer than DKAProdrome longer than DKA– Infection commonInfection common– Higher glucose, deeper coma, greater volume lossHigher glucose, deeper coma, greater volume loss– Focal neurologic findings commonFocal neurologic findings common
– 85% with underlying renal or cardiac impairment85% with underlying renal or cardiac impairment Rapid IV fluid most important (NSS)Rapid IV fluid most important (NSS)
– Phenytoin contraindicated, impairs endogenous Phenytoin contraindicated, impairs endogenous insulin releaseinsulin release
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HypoglycemiaHypoglycemia
Symptoms at 40 – 50 mg/dlSymptoms at 40 – 50 mg/dl Bedside tests essential, accurateBedside tests essential, accurate 1 amp D50 raises 40 – 350 mg/dl1 amp D50 raises 40 – 350 mg/dl Glucagon 1 mg IM similarGlucagon 1 mg IM similar
– takes 10 – 20 minutestakes 10 – 20 minutes– not in alcoholics not in alcoholics no glycogen no glycogen
If refractory If refractory consider cortisone consider cortisone– adrenal insufficiencyadrenal insufficiency
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Alcoholic KetoacidosisAlcoholic Ketoacidosis
Binge drinking followed by Binge drinking followed by poor intake, vomitingpoor intake, vomiting
Blood glucose usually < 250 mg/dlBlood glucose usually < 250 mg/dl Beta-hydroxybutyrate >> acetoacetateBeta-hydroxybutyrate >> acetoacetate
– urine may dip negative for ketonesurine may dip negative for ketones Use D5NSS, replace KUse D5NSS, replace K++
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HyperthyroidHyperthyroid
Graves’ diseaseGraves’ disease most common most common cause of stormcause of storm
AmiodaroneAmiodarone 25% of pts 25% of pts develop thyrotoxicosisdevelop thyrotoxicosis
SignsSigns: : T, T, HR, AMS, goiter, heart HR, AMS, goiter, heart failure, ophthalmopathyfailure, ophthalmopathy
SymptomsSymptoms: agitation, weight loss, : agitation, weight loss, nervousness, palpitationsnervousness, palpitations
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HyperthyroidHyperthyroid
Block peripheral effects:Block peripheral effects: beta-blockade (propranolol)beta-blockade (propranolol)
Inhibit hormone synthesis:Inhibit hormone synthesis: PTU (propylthiouracil), methimazolePTU (propylthiouracil), methimazole
Block hormone release:Block hormone release: iodine, lithiumiodine, lithium
Prevent peripheral conversion of Prevent peripheral conversion of T4 to T3:T4 to T3: dexamethasone dexamethasone
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HypothyroidHypothyroid Women >> men ; hypothermia Women >> men ; hypothermia 80% 80% Altered sensorium: COAltered sensorium: CO22 narcosis narcosis Most sensitive test: TSHMost sensitive test: TSH CXR: pleural, pericardial effusionCXR: pleural, pericardial effusion Replace thyroid immediately: Replace thyroid immediately:
– Thyroxine (T4)Thyroxine (T4) Treat precipitating factorsTreat precipitating factors
– most common: CHF, pneumoniamost common: CHF, pneumonia
Correct metabolic abnormalitiesCorrect metabolic abnormalities COCO22, , glu, glu, NaNa
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HypoadrenalHypoadrenal Inadequate glucocorticoids, primarily cortisolInadequate glucocorticoids, primarily cortisol Most common cause: Most common cause:
– exogenous steroid therapyexogenous steroid therapy
Anorexia, vomiting, abd pain, Anorexia, vomiting, abd pain, BP, BP, circulatory collapse, circulatory collapse, glu, glu, Na, Na, KK
Unconfirmed diagnosis Unconfirmed diagnosis dexamethasonedexamethasone does not interfere with ACTH stim testdoes not interfere with ACTH stim test
Known adrenal failure Known adrenal failure hydrocortisonehydrocortisone
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EnvironmentalEnvironmental 3%3%
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Spider BitesSpider Bites Brown recluse spiderBrown recluse spider: painless bite: painless bite
– Often not recognizedOften not recognized– Necrotic lesionNecrotic lesion– Rx: Dapsone, consider HBORx: Dapsone, consider HBO– Loxoscelism: fever, vomiting, myalgias, Loxoscelism: fever, vomiting, myalgias,
hemolysis, DIChemolysis, DIC Black widowBlack widow: painful bite: painful bite
– Severe muscle cramps (acute abd)Severe muscle cramps (acute abd)– Rx: analgesics, benzodiazepinesRx: analgesics, benzodiazepines– Antivenin if severe, very young or oldAntivenin if severe, very young or old
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Black WidowBlack Widow
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Marine EnvenomationsMarine Envenomations
Jellyfish, Man-o’-war Jellyfish, Man-o’-war VinegarVinegar Starfish, sea urchin, lionfish Starfish, sea urchin, lionfish
remove spines, hot water (45remove spines, hot water (45°)°) Ocean infections Ocean infections VibrioVibrio
– TMP/SMZ, doxycycline, fluoroquinoloneTMP/SMZ, doxycycline, fluoroquinolone
Most common envenomation Most common envenomation stingraystingray
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SnakesSnakes
Rattlesnake: crotalid biteRattlesnake: crotalid bite– 4 – 6 vials or more of antivenin4 – 6 vials or more of antivenin
Coral snakesCoral snakes– admit for 24 – 48 hour observationadmit for 24 – 48 hour observation
Red on yellow Red on yellow Kill a fellow Kill a fellow Red on black Red on black Venom lack Venom lack
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Coral SnakeCoral Snake
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High AltitudeHigh Altitude
Acute Mountain SicknessAcute Mountain Sickness– headache, nausea, fatigue, insomniaheadache, nausea, fatigue, insomnia
– Acetazolamide, descent, OAcetazolamide, descent, O22
High Altitude Cerebral EdemaHigh Altitude Cerebral Edema – increased ICP, cerebral edemaincreased ICP, cerebral edema– ataxia, vomiting, confusion, seizures, comaataxia, vomiting, confusion, seizures, coma
– descent, Odescent, O22, steroids, HBO, steroids, HBO
High Altitude Pulmonary EdemaHigh Altitude Pulmonary Edema – dyspnea at rest, tachypnea, tachycardiadyspnea at rest, tachypnea, tachycardia
– descent, Odescent, O22, nifedipine, HBO, nifedipine, HBO
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HypothermiaHypothermia
Core temperature < 35Core temperature < 35°° OsborneOsborne (“J”) waves (“J”) waves Ignore dysrhythmias except V fibIgnore dysrhythmias except V fib
– sinus bradycardia / slow A fib most freqsinus bradycardia / slow A fib most freq Rewarm (passive / active)Rewarm (passive / active) Frostbite – impossible to predict extent Frostbite – impossible to predict extent
of damage from initial examof damage from initial exam– rapid thawing 42rapid thawing 42° water bath° water bath
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Osborne wavesOsborne waves
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HyperthermiaHyperthermia
Heat exhaustion Heat exhaustion volume volume depletion, nausea, vomitingdepletion, nausea, vomiting
Heat stroke Heat stroke CNS dysfunction CNS dysfunction– altered mental status + feveraltered mental status + fever
Rapid cooling: mist and fansRapid cooling: mist and fans
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Electrical InjuriesElectrical Injuries
AC burns more destructive than DCAC burns more destructive than DC– burns worse than they appearburns worse than they appear– beware posterior shoulder dislocation, c-spine injury, beware posterior shoulder dislocation, c-spine injury,
severe rhabdomyolysis severe rhabdomyolysis acute renal failure acute renal failure
Lightning causes asystoleLightning causes asystole AC electricity causes V fibAC electricity causes V fib Respiratory arrest commonRespiratory arrest common Feathery burns (Lichtenburg), tympanic Feathery burns (Lichtenburg), tympanic
membrane injury = membrane injury = LightningLightning
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LichtenburgLichtenburg
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Hydrofluoric Acid BurnsHydrofluoric Acid Burns
Glass etching, rust removersGlass etching, rust removers Rx Rx Ca gluconate gelCa gluconate gel
– SQ or intradermal Ca gluconateSQ or intradermal Ca gluconate– Intraarterial Ca gluconateIntraarterial Ca gluconate
Ongoing pain = need for more Ongoing pain = need for more treatmenttreatment
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RadiationRadiation
Rapid onset of sx’s poor prognosisRapid onset of sx’s poor prognosis Nausea, vomiting, diarrhea, anemiaNausea, vomiting, diarrhea, anemia Absolute lymphocyte countAbsolute lymphocyte count (ALC) (ALC)
at 24 hours = best predictorat 24 hours = best predictor– > 1200 not lethal> 1200 not lethal– 1200 – 300 serious1200 – 300 serious– < 300 lethal< 300 lethal