Inservice review 2006High yield facts

Steven T. Dorsey, MDDepartment of Emergency Medicine

The Cleveland Clinic FoundationMetroHealth Medical Center

General exam tips Formulate your answer before you scan the choices Lean towards aggression Keep moving – later questions may clarify your confusion No penalty for guessing

Study hard, do your best

Study hard, do your best

But if you bomb, you’ll break my heart, Fredo

And not just my heart

DKAEstimated fluid deficit is 4 to 6 liters in adults, 10% in kidsMajor complication is cerebral edema, usually from too-rapid rehydration with hypotonic fluidsInsulin rate is 0.1 units/kg/hr Remember precipitants like AMI/acute ischemia

GCS Eyes

4 Open3 Voice2 Pain1 No response

GCS Verbal

5 Oriented4 Confused3 Inappropriate2 Sounds1 None

GCS Motor

6 Follows commands5 Localizes4 Withdraw3 Decorticate2 Decerebrate1 None

GCS example18 year old motorcycle accident,only opens eyes when told to, says “F- you” when asked his name, and won’t follow commands to wiggle toes, but rather swings with his right arm toward the nurse putting in his left antecubital line

GCS = Eyes = 3, to voiceVerbal = 3, inappropriateMotor = 5, localizes= 11

tPA for stroke – NINDS inclusion criteria

> 18 years Symptoms under three hours Normal PT/PTT

tPA dosing, acute strokeDOSES LIKELY NOT ON EXAM, JUST GOOD TO KNOW*

0.9 mg/kg, max 90 mg* 10% given as bolus, rest over one hour

Thrombolytics for AMI – indications (AHA/ACC 2004) Class I STEMI patients presenting to a facility without the capability for expert,

prompt intervention with primary PCI within 90 minutes of first medical contact should undergo fibrinolysis unless contraindicated. (Level of Evidence: A)

Class I1. In the absence of contraindications, fibrinolytic therapy should be administered to STEMI patients with symptom onset within the prior 12 hours and ST elevation greater than 0.1 mV in at least 2 contiguous precordial leads or at least 2 adjacent limb leads. (Level of Evidence: A)

2. In the absence of contraindications, fibrinolytic therapy should be administered to STEMI patients with symptom onset within the prior 12 hours and new or presumably new LBBB. (Level of Evidence: A)

Thrombolytics for AMI – indications (AHA/ACC 2004)Class IIa

1. In the absence of contraindications, it is reasonable to administer fibrinolytic therapy to STEMI patients with symptom onset within the prior 12 hours and 12-lead ECG findings consistent with a true posterior MI. (Level of Evidence: C)

2. In the absence of contraindications, it is reasonable to administer fibrinolytic therapy to patients with symptoms of STEMI beginning within the prior 12 to 24 hours who have continuing ischemic symptoms and ST elevation greater than 0.1 mV in at least 2 contiguous precordial leads or at least 2 adjacent limb leads. (Level of Evidence: B)

Contraindications to thrombolysis (AHA/ACC 2004)

Fair game

Intussusception 3:1 male 5 – 9 months Ileocolic junction Sausage-shaped mass Currant jelly stools Plain films (U/S), hydrate, NGT, barium enema

Pyloric stenosis 5:1 male 3 to 6 weeks Projectile vomiting Palpable olive

Charcoal doesn’t absorb . . . Lithium Acids Alkali Potassium

Iron Pesticides Hydrocarbons Alcohols

Hemodialysis/hemoperfusion may work for . . .*

Lithium Salicylates Theophylline Isopropyl alcohol Ethylene glycol

*all of these have low molecular wt, low protein binding, small volume of

distribution

Ingestion Activated charcoal

1 – 2 grams/kilogram*Multiple dose may work for theophylline, phenobarbital, tegretol, dilantin, digoxin

Gastric lavageConsider for large ingestion, if less than one hour, opiates*, anticholinergics*Risks include aspiration, perforation

*slow motility

Iron ingestion < 40 mg/kg elemental not likely to be toxic Ferrous sulfate is 20% elemental Treat with deferoxamine if

symptomatic AND level > 350 mcg/dl -OR- level of 500 mcg/dl

Iron toxicity – Four stages GIQuiescentLiver failure/metabolic derangement/acidosisChronic GI effects

Acetominophen Toxic dose is 140 mg/kg

-OR-7.5 grams

-OR-Level > 140 at 4 hours by nomogram

N-acetylcysteine dosing is 140 mg/kg, then 70 mg/kg q 4 hours X 17 doses*

Don’t wait for levels

Intravenous N-acetylcysteineAKA Acetadote150 mg/kg IV, then 6.25 mg/kg/hr for 16 hours*

Osmolality 2 Na + glucose + BUN + ETOH

Normal 285 – 295

Some agents that increase osmolal gap: methanol, ethylene glycol, isopropanol, ETOH, mannitol

18 2.8 4.6

AlcoholsMethanol formaldehyde(toxic)

formic acid CO2, H2O

(toxic)

Dialysis always an option for methanol and ethylene glycol

ADH

folateETOH and 4MP

saturate

Isopropyl alcoholIsopropanol acetone ketonuria

exhaled

Does not cause acidosis Twice as intoxicating as ETOH Irritating to gastric mucosa; hematemesis

Myasthenic crisisWeakness

Ptosis, diplopia, dysarthria, head droopingWorsens with repetitionWorse with heat, better with coldTensilon test

Test dose of 1 mg with monitoring then 8 mg IV

• Better = myasthenic crisis• Worse = cholinergic crisis from their meds (look for SLUDGE

that you missed)

Cholinergic insecticides Inhibit acetylcholine esterase Organophosphates Carbamates

Bind reversibly, don’t penetrate CNSEdrophonium, physostigmine are carbamates

Acetylcholine is the neurotransmitter at motor end plates, all preganglionic autonomic synapses, post-ganglionic parasympathetic synapses, and some CNS synapses

Cholinergic insecticidesThus overstimulates the autonomic nervous system, somatic musculature, and CNSClinically, SLUDGE (muscarinic symptoms) + nicotinic symptoms (cramps, weakness) + altered mental statusTreatment

Boatloads of atropine2-PAM only for organophosphates, only works within 24-48 hours, and only on nicotinic symptoms

Electrical injuries AC

Causes tetany, can precipitate ventricular fibrillation

DC Causes single muscle spasm, often throws victim Asystole

Lightning is like a massive brief DC current, death often due to respiratory arrest inducing a secondary cardiac arrest

Hemorrhage Class I

Up to 15% blood volumeMinimal symptoms

Class II15 to 30% loss, or 750 to 1000 ccTachycardia, tachypnea, narrowed pulse pressure

Hemorrhage Class III

30 to 40%, approx. 2000 ccTachycardia, tachypnea, altered mental status, drop in systolic pressure

Class IV > 40% lossImmediately life threateningDecreased urine output

Rule of 9s

Rule of 9’s

Rule of 9’s Head = 9 Each arm = 9 Each leg = 18 Trunk front = 18 Trunk back = 18

Rule of 9’s Head = 9 Each arm = 9 Each leg = 18 Trunk front = 18 Trunk back = 18

9 9

9

1

18 x 2

1818

Parkland formula 4cc/kg/%TBSA

½ over the first eight hours, rest over 16 hours

Pediatric burn formula*Maintenance plus 3cc/kg/%TBSA

Diagnostic peritoneal lavage Indications

Altered sensoriumEquivocal examYour ultrasound is broken*

ContraindicationsAbsolute - need for laparatomyRelative – previous abd surgery, morbid obesity, advanced cirrhosis, coagulapathy

Foley and NGT first

DPL - Positives Blunt trauma

gross blood feces dinner> 100,000 RBC/cc > 500 WBC/cc (+) gram stain

Penetrating trauma 5,000 – 10,000 RBC/cc

Apgar score

0 1 2HR absent < 100 > 100

RESP absent slow/irreg good/cryingTONE limp some flexion active

IRRITABILITY none grimace cough/cryCOLOR blue/pale mixed pink

Neonatal resuscitation 3 : 1 ratio of compressions to breaths Medications indicated if HR < 60 despite adequate ventilation with 100% O2 and chest compressions Narcan dose 0.1 mg/kg

Neonatal resuscitationHR > 100 and pink

BVM*

BVM*

Chest compressions

Epinephrine

Supportive care

Apnea or HR < 100

HR > 60HR < 60

HR < 60

*Or intubation

PALS BLS

30:2 ratio for lay rescuers of children, health care providers can do 15:2 ratio, 100 compressions/minute

SVT Adenosine 0.1 mg/kg, max 6 mg/kg Cardioversion 0.5 – 1 J/kg

PALS – Bradycardia/Pulseless arrest

Epinephrine IV/IO .01 mg/kg OR 0.1 cc/kg of 1:10,000 (ET dose 0.1 cc/kg of 1:1000)

Atropine .02 mg/kg Minimum 0.1 mg Max 0.5 mg child, 1 mg adolescent

PALS VF/VT Defibrillate 2 J/kg, 2-4 J/kg, 4 J/kg

Epinephrine Amiodarone 5 mg/kg IV/IO* Lidocaine 1mg/kg IV/IO*

“Drug-shock”

Adult BLS 2005– vent/comp ratio

Ratio is 30:2 for one or two rescuers UNTIL definitive airway is established, rate of 100 compressions/minute, compression depth 1.5 to 2 inches

Aortic dissection Stanford classification

A = ascending B = descending / distal to left subclavian artery

Debakey classification I = A + B II = A III = B

AB

Adrenal insufficiency Symptoms

Weakness, anorexia, hyperpigmentation (primary AI only,) weight loss, abd pain, nausea, vomiting

TherapyIVFHydrocortisone 100 – 200 mg IV* OR decadron IV (doesn’t mess up Cosyntropin stim test)

Thyroid storm - management Antipyretics Propranolol PTU Iodine (one hour after PTU) Hydrocortisone 100 mg IV*

Inhibits peripheral conversion of T4 to active T3

Drugs that precipitate heat stroke Amphetamines Cocaine Anticholinergics Phenothiazines Anti-hypertensives

Hypothermia

Mild 33 - 35 C maximal shivering, slurred speech

Moderate 29 - 32 C altered mental status, incoordination, rigidity

Severe < 28 C mydriasis, Osborn waves, bradycardia

Tumor lysis syndrome Symptoms

Renal failure from hyperuricemia, arrhythmia, hyperkalemia, hypocalcemia

Management IVF, allopurinol, alkalinize urine, dialysis

Kanavel’s signs of tenosynovitis Pain with passive extension Sausage/circumferential swelling Finger held flexed Tender to palpation along sheath

Carbon monoxide Room air half-life = 320 minutes 100% NRB = 80 minutes 3 ATM hyperbaric = 23 minutesConsider hyperbaric for comatose/sick victims of carbon monoxideBeware the whole family with headaches and gastroenteritis

Cyanide – Lilly kit

Methemoglobin

Nitrite + hemoglobin

CN- CN-MetHgb

Sodium thiosulfate thiocyanate Renal excretion

Pregnancy-induced hypertensionaka Pre-eclampsia

Moderate – hypertension > 140/90, proteinuria Severe – thrombocytopenia, hypertension > 160/110, elevated liver transaminases HELLP – Hemolytic anemia, Elevated Liver enzymes, Low Platelets

Hemolytic-uremic syndromeUsually < 5 yearsNephropathy, microangiopathic hemolytic anemia, thrombocytopeniaAssociated with E.coli 0157:H7, Salmonella, and Shigella gastroenteritisIntussusception, hypertension, CNS effectsPallor, petechiae, purpura

Thrombotic thrombocytopenic purpura

Altered mental status Thrombocytopenia Renal failure Microangiopathic hemolytic anemia Fever

Von willebrand’s disease Most common inherited bleeding disorder Autosomal dominant Increases PTT and bleeding time, NOT PT/INRTherapy – cryoprecipitate, DDAVP

Hemophilia A X-linked recessive Increases the PTT Major bleeds require 50 units/kg of Factor VIII*Cryoprecipitate and DDAVP also helpful

Hemophilia B (Christmas disease)

For major bleeds, 50 units/kg of Factor IX* or large doses of FFP

Cryoprecipitate not helpful

Food-related squirtsBacillus cereus – fried riceClostridium perfringens – cooked poultry or meat that is not refrigerated promptly

Most common bug in food-related illnessStaphlycoccal – starts within one to six hours of ingestion, heavy vomiting, resolves in six to eight hoursScromboid – whitefish, histamine-like symptoms, especially flushing and cramps

Adult anaphylaxisMild symptoms (not hypotensive per PEER VI question)

.3 - .5 cc 1:1000 SQ or IM Ill/hypotensive

1 ml of 1:10,000 slow IVP (3 to 5 minutes) with caution (PEER VI) Alternate drip: 1 ml of 1:1000 in 250 ml D5W (or NS) makes 4 mcg/ml , run at 1 to 4 mcg/min

Peds anaphylaxis.01 cc/kg 1:1000 SQ/IM up to .5 ml

Flexion “teardrop” fractureVery unstableDiving injuries

Extension mechanism can cause same injury, often in elderly who fall on their chin

“Clay shoveler’s” fractureStableC7>C6>T1Hyperflexion, interspinous ligament avulses part of spinous process

Bilateral facet dislocationVery unstableBest seen on oblique views

“Hangman’s fracture”UnstableTraumatic spondylolyis of C2

Atlanto-occipital dislocationUnstableAlmost always fatalTearing of all ligamentous connections between C1 and occiput

Jefferson FractureUnstable Four part burst fracture of C1Associated with axial load / diving Lateral masses shifted laterally on odontoid view

Odontoid fracture Type IStableTip of dens avulsed

Odontoid fracture Type IIUnstableMost common Transverse fracture at base of odontoid

Odontoid fracture Type IIIPotentially unstableFracture through body of C2 involving both articular facets

Compartment SyndromePallor, paresthesias, paralysis, pulselessness, and painNormal pressures 0 to 8 mm Hg>30 mm Hg requires fasciotomy

HIV drug side effectsCrixivan (Indinavir)AZT (Zidovudine)ddI (Didanosine)FoscarnetEpivir (Lamuvidin)

Renal stonesVomitingPancreatitisNephrotoxicitycough

Other drugs that should make you suspicious . . .

PhenothiazinesWarfarinPhenytoinSulfonylureas

Antihistamines-AzolesStatinsSulfas (including celocoxib, furosemide)

Presentations that should make you suspicious for drug reactions

RashesBleedsSyncopeArrhythmiaHypoglycemia

RubellaProdrome low grade fever, sorethroat, headache, malaisePink or red maculopapularFace, then neck, then trunk and extemitiesMay be coalescentSuboccipital and retroauricular nodes

Fifth Disease4 to 10 year oldsErythema infectiosumParvovirus B-19Slapped cheek (spares eyelids, chin, perioral area)Then discrete “lacy” trunk and extremity rash

Rubeola (measles)Fever, cough, rhinorrhea, conjunctivitis, photophobiaDay 2 - Koplik’s spots (bright red, blue-white centers)Rash appears on day 3 to 5, erythematous, maculopapular, starts on back of neck and forehead hairline, then goes south

RoseolaSix months to three yearsHHV 6Exanthem subitum3 to 4 days of high feverThen defervescense and 1 to 2 day maculopapular rash (trunk to extremities)

Rocky Mountain Spotted FeverRickettsia RickettsiAbrupt fever, myalgias, fatigueStarts on palms, soles, wrists, anklesThen goes centralBecomes palpable and red, then petechial within 3 daysChloramphenicol and tetracycline

Kawasaki’s diseaseFever (usually > 40C) for five days PLUS at least FOUR of the following:

Conjunctival injection Mucous membrane findings (strawberry tongue, fissuring/cracking of lip, hyperemic pharynx) Palm/sole edema and erythema (later desquamation) Rash Cervical adenopathy, with one node > 1.5 cm

Kawasaki’s disease - treatmentIVIGAspirinEcho (serially)

Henoch-Schonlein purpuraPeaks at 4 – 5 years, winter/springSkin – palpable purpura, gravity dependentNephropathy (may cause lasting damage)GI – vomiting, bleeding, intussusception Joint swelling, extremity and facial edemaTreatment: supportive, steroids (efficacy not proven)

Central cord syndromeOld person fall and go boomArm > leg involvementHyperextensionLigamentum flavum

Two RSI drugs that increase ICPKetamineSuccinylcholine

Seizures not responding to standard therapy

Think TCAs Avoid IA anti-arrhythmics Sodium bicarbonate

Or Isoniazid Pyridoxime

Euvolemic hyponatremiaSIADH = inappropriately [urine]Psychogenic polydipsia = dilute urine

Steroids in meningitisDexamethasone 10 mg IV* before or as first dose of antibiotics is givenPediatric dose : 0.15 mg/kg* Give Q 6 hours until causative organism is known

Acute mountain sicknessSymptoms include headache plus at least one of the following:

Anorexia Nausea Vomiting Dizziness Insomnia Lassitude

Acute mountain sickness - management

Mild Descend 500 m, or hold current altitude and rest/acclimate, acetazolamide, anti-emetics, NSAIDS

Severe Descend or hyperbaric Acetazolamide Dexamethasone

HACESymptoms of acute mountain sickness plus altered mental statusManagement:

Immediate descent (or hyperbaric) Dexamethasone O2 Acetazolamide

HAPEImmediate descent or hyperbaricO2 (reduces PA pressure 30 – 50 %)

Nifedipine lowers PA pressure also, but does not increase partial pressure of arterial O2

Croatalid evenomationsNo Envenomation: No local or systemic manifestations.Minimal Envenomation: Local swelling and other local changes; no systemic manifestations; normal laboratory findings.Moderate Envenomation: Swelling progressing beyond the site of bite and one or more systemic manifestations; abnormal laboratory findings, for example, a fall in hematocrit or platelets.Severe Envenomation: Marked local response, severe systemic manifestations and significant alteration in laboratory findings Dose

Moderate - 2 to 4 vials antiveninSevere – 10, 20, up to 40 vials

CroFab vs. Antivenin PolyvalentAnaphylaxis risk/prepare!

Elapidae evenomationsChompers (cobra family)Venin blocks acetylcholine

Slurred speech Ptosis Midriasis Paralysis Respiratory failure

Few/no local reactionsEquine Antivenin

Micrurus fulvius

Visual stimuli

Visual stimuli

Visual stimuli

Visual stimuli

Dr. Horner

Visual stimuli

Visual stimuli

Visual stimuli

Visual stimuli

Kid’s butt with purple spots – easy,

right?

Visual stimuli

Visual stimuli

Your blind date from Connecticut . . .

Visual stimuli

Your blind date from hell

Your blind date from Connecticut . . .

Visual stimuli

Visual stimuli

Visual stimuli

Visual stimuli

Visual stimuli

Visual stimuli

Visual stimuli

Yellow on black – friend of Jack

Black on yellow – kill a fellow

Visual stimuli

Visual stimuli

Visual stimuli – Name the trisomy

Visual stimuli – Name the trisomy

Visual stimuli – Google search Queen, John

John Lewis Queen

And finally . . .What band lead the Gallup poll as most popular for 1977, had the highest grossing tour of 1996, AND has more Gold records than the Beatles?

The ABEM philosophy?

Keep

It

Simple,

Stupid