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Review for Emed Exam 2 ACLS V-fib Cardiac Arrest: What do you do first? CPR Then what? Defib at 360j Then? 5 cycles of CPR Then? Shock and resume CPR Then? ACLS Then what meds? Vasopressor such as Epi or Vasopressin Then? Shock once Then? Antiarrhythmics such as amiodarone or lidocaine Then? 5 cycles CPR and repeat. When is magnesium used? torsades de pointes ACLS What is the first step in Asystole? CPR Vasopressor such as epi or vasopressin Then? Atropine Then? CPR Then? Repeat What about witnessed? ACLS What is the treatment of PEA? Same as asystole. Atropine if rate <60 only. Look for etiology including hypovolemia, hypoxia, hydrogen ion, hypo/hyper kalemia, hypoglycemia, hypothermia, toxins, tamponade, tension pneumo, PE, trauma ACLS Bradycardia Pulse <60 and symptomatic (signs of poor perfusion such as AMS, chest pain, hypotension, shock) Oxygen, IV access What is the management if poor perfusion? Atropine, epi or dopamine infusion ACLS Tachycardia What is patient is unstable? Synchronized cardioversion post IV access. Give sedation if conscious If stable and narrow QRS? IV, vagal maneuvers, adenosine. If does not convert? Might be a flutter, a tach or junctional tach so use diltiazem, b-blockers ACLS What about if wide QRS and regular? Amiodarone, Lidocaine or cardioversion. ACLS You are going to give a drug via ET, how is the dose adjusted? Give 2.5x the dose then dilute to 10cc Which medications are given via ET tube? LEAN- lidocaine, epinephrine, atropine, and narcan. PALS Know a little regarding the protocols utilized especially asystole, v-fib, PEA, bradycardia, shock. Heat Emergencies How is heat lost from the body? Conduction, convection, radiation, evaporation. Define heat cramps: Severe muscle cramps resulting from overexertion in heat. Occur after stopping the activity. Na deficiency. Define heat edema: Swollen feet and ankles. Vasodilation with vascular leak. Elevate extremity .Resolves after climate acclimatization. Heat Emergencies What is heat rash? How is this treated? Prickly heat. Blockage of sweat gland pores and can have staph infection. Pruritic vesicles Topical antibacterial cream What is heat syncope?How is this treated? LOC. Brain hypoperfusion due to hypotesnion due to peripheral vasodilation and vascular leak. Dehydration predisposes to this. Rehydrate. Heat Emergencies What is heat exhaustion? What is the clinical presentation? What is the management? Dehydration/ salt depletion. Sweating, weakness, fatigue, headache, n/v, dizziness. <104. Oral salt, IV rehydration What is heat stroke? Life threatening. >106. Loss of thermoregulation, tissue damage. Neurologic dysfunction and cerebral edema. Dehydrated with seizures, unconsciousness. Treatment Rehydration, rapid body cooling Cold Emergencies Define frostbite Vasoconstriction, extracellular ice crystals, intracellular dehydration, lysis. Leads to ischemia and tissue damage What are the clinical manifestations of frostbite? First degree: partial skin freezing. Erythema, edema, hyperemia, no blisters. Thrombing and aching Second degree: full thickness. Erythema, edema, vesicles with clear fluid Cold Emergencies Third degree: full thickness, subcutaneous. Hemorrhagic blisters, skin necrosis, blue gray color. First no sensation then shooting pains, burning, aching Fourth degree: full thickness, sub cutaneous, muscle, bone freezing: little edema, mottled deep red or cyanotic, to dry black mummified. Possible joint discomfort. What is the management? Re-warming in water of 107 degrees. Cold Emergencies What are the signs of moderate Hypothermia? Temp of 86-90f 30-32c. Clinical: stupor, no shivering, bradycardia, decreased respiratory rate, hypotension, afib. Cold Emergencies What about severe hypothermia? <86f <30c. Coma, pupils dilate, no corneal reflex, v-fib, apnea, asystole, areflexia, flat EEG What is the management? Supportive, rewarming, warm IV fluids. Metabolism slows so hypothermic patients tolerate long periods of hypoperfusion and anoxia. Do not pronounce until rewarmed. Abdominal Trauma Which abdominal organs are more susceptible to injury from blunt trauma? Spleen and liver. Spleen most frequently injured. What is kehr’s sign? Referred left shoulder pain (splenic rupture). Sign of liver trauma? Pain to right shoulder. Acute blood loss. Tachycardia, hypotension, acute abdominal tenderness. Abdominal Trauma Number one danger with hollow Visceral Injuries? Blood loss and peritoneal contamination What is the classic presentation of Pancreatic injury? Rapid deceleration. Pain radiates to back. Retroperitoneal abscess due to leakage of enzymes and bacteria. What about kidneys? Pain from flank to groin and hematuria. Diaphragmatic? Bowel sounds in thoracic cavity. Abdominal Trauma How is abdominal trauma diagnosed? Peritoneal lavage (DPL). FAST: focused assessment with sonography for trauma: Notes free fluid in dependent areas CT What is the management? ABC’s. Fluids isotonic, blood 0-, oxygen, What about eviscerated organs? Cover with sterile moist dressing prior to surgery Burns Categorized by size and depth. Burn size is rule of nines. Burns Burn depth What is the presentation of a superficial burn? Epidermis. Dry red, painful, blanches with pressure. What is the management? Antipruritics, lubricants, corticosteroids Superficial partial thickness burns: What is the etiology and clinical presentation? Scald. Epidermis and superficial dermis. Blisters, moist, red, weeping, blanches with pressure, pain to air and temperature. Management: debridement, topical antibiotics, dressings, analgesics Burns What about deep partial thickness burn? Scald, flame, oil. Involves epidermis and deep dermis. Presents as blisters, wet/ waxy, dry skin if sweat glands destroyed, patchy to cheesy white to red in color. Does not blanch with pressure. Perceive pressure not pain if nerves destroyed. What is the management? Cleaning, debridement, dressing and analgesics. Burns What about full thickness burn? Scald, flame, steam, oil. Epidermis, dermis and sub cutaneous layers. Nerve ending, blood vessels, hair follicles, sweat glands destroyed. How does this appear? Waxy white to leathery gray to charred and black. Skin dry, inelastic, does not blanch with pressure. No pain, deep pressure sensation only. What is a major complication? Contractures Burns Which burns should be treated at a burn center? burns to eyes, ears, genitalia, hands, feet, joints What is the parkland formula? 4 x kg x %BSA . Half in first 8 hours, remainder in next 16 hours. Burns What are the risks for smoke Inhalation? What is the presentation? Risk is fire in enclosed space. Facial burns, singed nasal hairs, soot in mouth or nose, hoarse, black sputum, wheezing What type of poisoning is suspected with smoke inhalation? CO poisoning. Arterial carboxyhemoglobin >10% is CO exposure. What is the management of smoke inhalation? Bronchodilators, hyperbaric O2 if Cohb >10% Burns What benefit is associated with acid burns? Coagulation necrosis limiting injury What is the complication of alkali burns? Liquefacation necrosis. Continues to penetrate deep into tissue. What is the presentation of low voltage AC electrical injury? Muscle tetany. V fib What is the presentation of high voltage AC/DC? single violent muscle contraction throwing individual. Asystole Burns What is the presentation of lightening injuries? AMS, amnesia, Headache, muscle pain, paresthesias, Tachycardia, hypertension, ruptured TM What type of radiation leads to the acute radiation syndrome? Ionizing Emerg of Eye, Ear, Nose, Oral What is the presentation of a Corneal Abrasion? Ocular pain, sensation of foreign body, blurred vision, photophobia, Conjunctival injection, visual acuity defects How is this diagnosed? Fluorescein staining, proparacaine, blue cobalt light. What is the management? Management: Anesthetics, cycloplegic eye drops, irrigation with NS, broad spectrum antibiotics. Oral analgesics Emerg of Eye, Ear, Nose, Oral What is a complication of Acute Angle closure glaucoma? Blindness due to optic nerve injury. What is the presentation? Sudden eye pain, blurred vision, headache, n/v, halos, visual acuity defects, conjunctival injection, cloudy cornea, midway positioned pupil, IOP elevated What is the management: Pilocarpine (miotic), laser, timolol (reduces IOP), mannitol. Emerg of Eye, Ear, Nose, Oral What is the classic presentation of Central Retinal Artery Occlusion? Painless vision loss. What is the appearance of the retina? Edematous gray with cherry red macula. Pupil does not constrict to direct light What is the management? Ocular massage, paracentesis. Emerg of Eye, Ear, Nose, Oral What is orbital cellulitis? Posterior to orbital septum within orbit. Little conjunctival injection, fever, edematous erythematous periorbital soft tissue, tenderness with EOM, elevated IOP, loss of vision. How is this diagnosed? CT Management? Broad spectrum antibiotics. Clindamycin, ceftazidime, admission, surgical drainage. Emerg of Eye, Ear, Nose, Oral What is the etiology and presentation of acute mastoiditis? S pneumoniae, s pyogenes, s aureus. Fever, pain, swelling and erythema at mastoid. What is the management? Admission, IV antibiotics What is the etiology and presentation of Otitis externa? Pseudomonas, staph, fungal Ear pain, itching, erthematous canal, pain with pinna movement, canal occluded Management: topical steroid, antibiotics (cortisporin otic) Emerg of Eye, Ear, Nose, Oral What is the etiology, presentation and management of Acute Otitis media? Etiology: s pneumonia, h flu TM erythematous, dull light reflex, limited motility, landmarks distorted Amoxicillin ten days, augmentin, ceftriaxone, analgesics What is the presentation and treatment of Perf TM? Pain, bleeding, decreased hearing No antibiotics unless infection. Emerg of Eye, Ear, Nose, Oral What is the management of anterior epistaxis? Posterior epistaxis? What is a complication of nasal fracture? septal hematoma Emerg of Eye, Ear, Nose, Oral What is dental extrusion? Tooth dislodged What is subluxation? Tooth loose without displacement What is dental avulsion? Tooth out. Root must be moist Emerg of Eye, Ear, Nose, Oral What is the presentation and management of periodontal abscess? Oral antibiotics, Analgesics, I/D, Dental referral Bites, Stings and Poisons Define an occlusion bite and location: Distal phalanges, ears, nose, genitalia Define Closed fist injury. What complication is associated with this? Clenched fist is lacerated against opponents teeth. High rate of infection. Concern is joint capsule integrity. Bites, Stings and Poisons What is the etiology of dog bites? Staph, strep, pasteurella multocida, pseudomonas, gram neg aerobes/anaerobes What is the etiology of cat bites? Pasteurella multocida (gram – anaerobic) What complication is associated with cat bites? Produces cellulitis, lymphangitis, lymphadenitis. Can cause cat scratch disease- lymphadenitis with ulcer (bartonella henselae) Bites, Stings and Poisons What is the etiology of human bites? Strep viridans, staph, eikenella corrodens What is the management of suspected rabies exposure? Soap and water HRIG up to 8 days post exposure. Half into wound, half IM, Vaccine 1 cc of HDCV IM on days 0,3,7,14,28. Bites, Stings and Poisons What is the care for uninfected bite wounds? Debridement, irrigation with normal saline. Suture if within 12 hours of occurrence. Recheck in 48 hours Don’t suture if signs of infection. No suturing high risk wounds such as punctures, cat, human bites of hand, CFI Tetanus or tetanus immunoglobulin. Bites, Stings and Poisons What antibiotics for dog bite? Augmentin (3-5 days), clindamycin and cipro What antibiotic for cat bites? Augmentin, cefuroxime, doxycycline What about human bites? Augmentin What about Cat bite with cellulitis caused by pasteurella multocida? Penicillin What is the treatment for infected dog bite? Penicillin, and Dicloxacillin What about infected human bite? IV antibiotics with cefoxitin and gentamycin, Augmentin, oxacillin and gentamycin Bites, Stings and Poisons Brown recluse spider bite. What is the presentation? Blister formation and tissue necrosis What is the management? Supportive, no antivenin, ice, surgically debride, administer antibiotics What is the presentation of the Black widow spider bite? Erythematous skin lesion, diffuse muscle cramps, severe abdominal pain, hypertension, resp failure, shock coma. Managed with Analgesics, benzo, antivenin, calcium gluconate Bites, Stings and Poisons What topical insecticides are used for lice? Permethrin, lindane, pyrethrin Scabies? Permethrin, crotamiton, lindane Bites, Stings and Poisons What is the presentation of Stingray sting? Venomous spine punctures skin causing painful local reaction. Also systemic symptoms such as n/v/d, weakness, paralysis, shock What is the MOA of jellyfish ting? Tentacles with stinging cells that release venom. Localized pain, erythema, urticaria Bites, Stings and Poisons What is the presentation of Tarantula sting? Flick barbed hairs, painful bite, erythema, edema and local joint stiffness. Tx analgesics, potho consult for barbed hairs What is the presentation of Scorpion sting? Burning, tachycardia, roving eye movements, excessive secretions, opisthotonos, fasiculations What is the management? Benzo, antivenin Bites, Stings and Poisons What are some delayed reactions to bites and stings? Serum sickness, fever, malaise, headache, urticaria, lymphadenopathy, polyarthritis What is the local management for bites and stings? Remove stinger, cleanse, RICE, debride ulcers, drain abscess, topical antipruritics Chest Trauma What is the MOA, clinical manifestations and management of a clavicle injury? Fall on shoulder or outstretched arm Pain, point tenderness, deformity Sling and swathe What is a complication of rib fracture? Underlying injury Which ribs are most commonly fx and why? Ribs 3-8 (thin/ poorly protected) What is the clinical presentation of a rib fx? Pain worse with movement, breathing, coughing, crepitus, splinting on respiration What are complications associated with a rib fracture? Atelectasis, ventilation perfusion mismatch. Chest Trauma What is a flail chest? Two or more adjacent ribs fx in two or more places producing free floating segment of chest wall What is the clinical presentation and management? Underlying pulmonary contusion. Paradoxical chest movements. Creptius Stabilize flail segment, high conc oxygen Chest Trauma What is the MOA of a sternal fx? Deceleration compression injury What are some complications? Myocardial or lung injury (Pneumothorax). Closed: air in pleural space. What is the management? Ventilation assistance, needle thoracostomy Chest Trauma What is the clinical presentation of a sucking chest wound Hypoventilation. SOB, pain, sucking sound, subcutaneous emphysema. Tachypnea, tachycardia, What is the management? Seal defect and secure on 3 sides to avoid pressure and tension pneumo What complication is associated with this? Tension pneumo Chest Trauma Define a tension pneumo Air in thoracic cavity cannot exit What are the clinical manifestations? Dyspnea, difficult ventilations, tracheal deviation, hypotension, JVD What is the management? Needle thoracostomy/ chest tube, Needle into 2nd intercostal space mid clavicular line Chest Trauma What complications are associated with hemothorax? What is the presentation? Associated with great vessel or cardiac injury, hypovolemia, hypoxemia, dull to percussion, JVD possible Tachypnea, dyspnea, cyanosis, narrowed pulse pressure What is the management? Fluids, ventilation support Chest Trauma What is the presentation of a pulmonary contusion? Tachypnea, tachycardia, cough, hemoptysis, respiratory distress, evidence of blunt trauma What is the management? Oxygen, ventilation if necessary, restrict IV fluids What is the MOA and etiology of traumatic asphyxia? Compression force to chest. Blood from right side of heart into veins of upper thorax, neck and face. Chest Trauma What is the presentation of traumatic asphyxia? Reddish, purple discoloration of face and neck, JVD, swelling to lips and tongue, swelling of head and neck, conjunctiva with petechiae, hypotension when pressure released. What is the presentation of Myocardial contusion? Chest pain, tachycardia, EKG changes, new murmur, pericardial friction rub, hypotension What is the management? Oxygen, antidysrhythmics, vasopressors. Chest Trauma What is becks triad? What does it represent? Narrowing pulse pressure, JVD, muffled heart sounds, cyanosis of head, neck, upper extremities, hypotension. Pericardial tamponade. What is the management? IV fluid challenge, pericardiocentesis Chest Trauma What is the management of aortic rupture? Upper extremity hypertension, absent femoral pulses Interscapular pain, harsh systolic murmur over pericardium, dyspnea, dysphagia, chest wall contusion, asymmetric pulses, fracture to rib 1 or scapula, widening mediastinum, aortogram. Urologic disease What is the presentation of Testicular torsion? Painful testes with high lie, hx of cryptorchidism, red swollen scrotum, negative prehn’s sign (relief of pain with elevation of scrotum). Need surgery What is the presentation of Epididymitis? Painful enlargement of epididymis, fever, scrotal swelling, erythematous scrotum, positive prehn’s sign What is the management? Antibiotics, UC, bed rest Urologic disease What is Orchitis? Inflammation of testes due to STD How does it present? Painful testes, tender and swollen, parotid swelling What is the management? Antibiotics What is a Hydrocele? Enlarged painless scrotum, transilluminating scrotal mass. What is the management? hydrocelectomy Urologic disease What is a Varicocele? Scrotal mass, infertility, bag of worms What is the management? Surgical ligation What is a Direct hernia Painless groin mass for years. Outside inguinal canal What is an Indirect hernia Painless scrotal mass. In inguinal canal Urologic disease What is the common etiology of Nephrolithiasis? Calcium, uric acid, cystine, struvite What is the presentation? Back pain, renal colic, pain radiates to groin, testicles, suprapubic, hematuria, dysuria, fever chills, CVAT, n/v What is the diagnosis/ management? CT without contrast, US, IVP, KUB >1cm do not pass spontaneously, less do Analgesics (morphine, Ketorolac, fluid hydration, antibiotics if UTI Bioterrorism Bioterrorist agents: Bacterial Bacillus anthracis- anthrax. Spores. Gram positive. Cutaneous(most common), GI, Inhaled. Pruritic macule, round ulcer, black eschar, lymphadenopathy. Sepsis, abdominal pain, tenderness, ascites, hemorrhagic diarrhea. IV ciprofloxacin, doxycycline. Inhalation: first stage: influenza prodrome, sudden fever, resp failure, shock. Widened mediastinum. Late is sepsis with high grade bacteremia, meningitis. Treat with ciprofloxacin 60 days if no vaccine. Bioterrorism Yersinia pestis- plague. Incubation 2-6 days. Pneumonic plaque- Acute pneumonia, bloody sputum, rapid respiratory distress, GI symptoms, sepsis. Treatment is streptomycin for 10 days, tetracyclines, vaccine. Bubonic plaque- 2-8 days incubation. Fever, chills, painful lymph node in groin, axilla, cervical region. Skin inoculation. Septicemia, DIC, purpura, gangrene Bioterrorism Viral Variola- small pox 12-14 days incubation. High fever, malaise, headache, severe abdominal pain, maculopapular rash starts on face, forearms spreads to trunk, legs, lesions on palms, and soles. Macules to vesicles to pustules. Treatment is vaccine and supportive. Bioterrorism Toxin Clostridium botulinum toxin- botulism. Cranial nerve abnormalities, descending progressive symmetrical weakness and paralysis, no sensory or central deficits, no fever. Need equine botulinum antitoxin, pentavalent toxoid.