The Clerkship Directors in Emergency Medicine (CDEM) Solution Study guide 2022.

The Clerkship Directors in Emergency Medicine (CDEM) Solution Study guide 2022. 1. primary survey 2. pregnancy test for women of childbearing age 3. order blood products in unstable patients suspected of hemorrhage 4. bedside imaging if concern for pneumoperitoneum or hemoperitoneum 5. Order abx if concern for sepsis peritonitis or perforation 6. analgesia 7. surgical consult for hemodynamic instability or rigid abdomen (Answer)- initial actions for patient with abdominal pain (7) Those using infertility drugs or assisted reproductive technologies (in normal pt positive intrauterine pregnancy means ectopic stastistically improbable) (Answer)- population in which an introuterine pregnancy seen on TVUS does NOT rule out ectopic pregnancy 4.5-5 weeks (double decidual sack) (Answer)- duration of pregnancy at which the earliest sign can be seen on TVUS culdocentesis (rarely used since advent of ultrasound) (Answer)- procedure in which needle is advanced through posterior vaginal wall into peritoneal space, wiht greater than 2ml of nonclotting blood suggestive of hemoperitoneum and ruptured ectopic pregnancy (point at which TVUS SHOULD show intrauterine pregnancy) (Answer)- discrimatory zone of bHCG Outpatient serial US exams and bHCG levels (less than doubling of bHCG levels every 2 days worrisome for ectopic) Return precautions: return to ER immediately if worsening pain, vaginal bleeding, dizziness, syncope, or weakness (Answer)- management of stable patients with suspected ectopic pregnancy but the diagnosis is in doubt due to inconclusive ultrasound findings Diamater 7mm and non compressible Increased Wall thickness Fecalithh Increased Vascularity on doppler (Answer)- ultrasound findings of appendicitis IV fluid resusc Pain management with opioids and morphine Anti-emetics IV Abx (unasyn or metro+cipro) Surgical COnsult (Answer)- management of appendicitis in the ED once diagnosis confirmed testicles! (Answer)- think someone has a ruptured appy due to acute RLQ pain, be sure to check the [blank]! CBC BMP UA (rule out pyelo) US vs CT ABD with contrast (Answer)- basic workup for appendicitis CBC (anemia could indicate aortoenteric fistula) Coags (look for potentially reversible bleeding disorders) CMP and Lipase (look for alternative causes of undifferentiated abdominal pain) ABD Ultrasound (Answer)- workup for suspected ruptured AAA Ruptured Triple AAA (Answer)- [blank] should be in the differential of anyone over 50 with abd, back or flank pain too aggressive resusc can worsen hemorrhage (dislodging clots) not enough causes underperfusion (Answer)- reason for a target of 90-100 systolic in ruptured triple AAA during resusc CBC with diff Liver Function if Fitz hugh suspected gonorrhea and chlamydia PCR testing (cervical or urine secretions, more sensitive than culture and faster) Gram stain of cervical secretions TVUS (can show TOA, or evaluate for alternatives such as ovarian torsion or cyst) Also check HIV, hep panel, and RPR (Answer)- workup for pelvic inflammatory disease Cefotetan 2 grams IV q12 hours with Doxycycline 100mg PO or IV q 12 hours (oral preferred because doxy can be caustic to vessels) (If allergic to cephalosporins can use Unasyn with doxy or Clindamycin+gentamycin) (Answer)- inpatient treatment for PID Ceftriaxone 250mg IM and Doxycycline 100mg BID X 14 days +/- flagyl 500mg BID X 14days (if severe or uterine instrumentation in last 3 weeks) (Answer)- outpatient treatment for PID Pregnant IUD Fitz hugh Curtis TOA Peritonitis Prepubertal children (nulliparous patients should be strongly considered to preserve fertility) (Answer)- indications for admission of PID patients avoid sexual contact refer partners for treatment follow up in 72 hours unless symptoms worsen then return to ER (Answer)- discharge instructions for outpatient PID patients 6mm in adults (8mm in elderly) (Answer)- threshold for common bile duct dilation 5mm (Answer)- threshold for GB wall thickening lack of visualization of the GB within 4 hours (Answer)- criteria for a positive HIDA scan study Pancreatitis Perforation of the GI tract Dye reactions Bleeding (Answer)- risks of ERCP Female 40 Obesity Multiparity Rapid weight loss Heme disorders (Answer)- risk factors for gallstones ABCs Symptom control with fluids, antiemetics, and analgesics Cipro+Flagyl Surgical Consult (delayed cholecystectomy for both, possible immedaite decompresesion, cholecystostomy, and ERCP for stone removal in cholangitis if that is the cause) (Answer)- management of cholecystitis/cholangitis outpatient surgery f/u Return precautions: 6 hour symptoms, fever 100.4, or jaundice (Answer)- dispo for biliary colic generally admit to surgery to avoid developing complications (Answer)- disposition for choledocholithiasis rectal exam to test for gross blood or hemoccult positive stools (suggests strangulation or malignancy) genital exam (look for hernia as cause of obstruction) (Answer)- reason to include rectal exams and genital exams in patients with suspected bowel obstruction Upright CXR (look for free air) Upright abdominal film (look for air fluid levels) supine abdominal film (look for distended loops of bowel) (Answer)- initial imaging for suspected small bowel obstruction CT scan with PO and IV contrast (used to be small bowel follow through) (Answer)- definitive imaging for bowel obstruction A serrated beak Bowel wall thickening Pneumatosis Portal venous gas (Answer)- CT findings of bowel strangulation celiac (followed by SMA) (Answer)- most common artery involved in mesenteric artery thrombosis distal portions of SMA (Answer)- most common artery involved in mesenteric artery embolus embolectomy and bowel visualization for signs of necrosis (percutaneous tPA alternative for non operative candidates) (Answer)- treatment of choice for mesenteric artery embolus Heparin as soon as diagnosis made + thrombectomy and bowel visualization (Answer)- treatment of choice of mesenteric artery throbosis thrombectomy or distal bypass + anticoagulation to prevent recurrence (Answer)- treatment of choice for mesenteric vein thrombosis Fluid resusc ABX PPx Papervine (reduces mesenteric vasoconstriction) Definitive care based on cause of ischemia (arterial emboli vs thrombus vs venous thrombus vs hypotension) (Answer)- general management of mesenteric ischemia Artery embolus: Arrythmia Post MI mural thrombi Valvular Heart Disease Structural Heart Disease Artery thrombosis: Atherosclerotic Disease Old Age Vein Thrombosis: inherited hypercoagulable state recent surgery malignancy cirrhosis Non occlusive ischemia: any cause of hypotension (Answer)- risk factors for mesenteric ischemiaa Loss of cremasteric reflex (storking ipsilateral thigh leads to elevation of testicle) High Riding Testicle Lack of pain relief with elevation (pain relief with elevation + prehn sign, finding of epididymitis, not reliable) (Answer)- physical exam signs of testicular torsion Fluids Only consider labs if working up possible epididymitis (gonorrhea,clamydia, UA, CBC) Doppler Ultrasound Urology Consult While waiting try to detorse manually (most torsions occur towards midline, so first try rotating away from midline) (Answer)- management of testicular torsion AEIOUTIPS Alcohol Epilepsy, Electrolytes, and Encephalopathy (hepatic) Insulin (hypoglycemia) Opiates and Oxygen Uremia Trauma and Temperature Infection Poisons and Psychogenics Shock, STroke, Subarachnoid Hemoorhage, Space Occupying Lesion (Answer)- pneumonic for AMS differential Delerium Dementia Psychosis (Answer)- 3 broad categories of AMS Delerium = visual Psychosis = auditory (can be visual too) (Answer)- type of hallucinations associated with delirum vs psychosis confusion assessment method 1. Different than baseline prehospital mental status? 2. patient with fluctuating mental status in past 24 hours by LOC? 3. Inattention test (squeeze hand when letter A is said, say "Casablanca" 2 errors is + 4. RASS not 0 (alert and calm) 5. Disorganized thinking (1 error in question and commands) 6. RASS -3? Must have 5 of 6 (Answer)- simple screening tool for delerium Metabolic 1. Rapid blood glucose 2. electrolytes 3. VBG 4. Bun/Cr 5. Thyroid function tests 6. Ammonia level 7. serum cortisol level 8. medication levels 9. UDS 10. alcohol levevl Infection 11. CBC with diff 12. UA with culture 13. blood cultures 14. CXR 15. LP Neurologic 16. CT non con head 17. EEG if non convulsive status suspected hemodynamic instability 18. ECG 19. Tropoins 20. Echo 21. Carotid/vertebral artery US (Answer)- full workup for undifferentiated AMS 14-16 angiogatheter (Answer)- device used for needle decompression in a tension pneumothorax CXR pelvic Xray FAST (Answer)- adjunct tests to the primary survey in trauma SAMPLE Survey (head to toe exam) Allergies Medications PMHx Last Ins/Outs Events/environment/mechanism (Answer)- components of secondary survey in trauma supraglottic pathology (Answer)- inspiratory stridor after trauma suggests [blank] subglottic pathology (Answer)- expiratory stridor after trauma suggests [blank] Alert, not intoxicated No Neck pain No midline neck tenderness No distracting Injury No sensory or motor deficits (Answer)- criteria for clearing cervical spine in trauma 1 hour (Answer)- processing time for type and crossmatched blood 10 minutes (Answer)- processing time for type and screen (tests ABO and Rh and indirect coombs test) Type and cross CBC (check Hgb, hct and platelets) Chem Panel ABG and Lactate to screen for shock UA EtOH (Answer)- general lab tests for trauma patients AP chest and AP pelvis (adjunct to primary) Cervical C spine 3 view (Answer)- standard trauma x rays You scream out "ABC's, IV, O2, Monitor!" as you tend to the patient's primary survey. A: Is Airway intact? No, patient needs to be intubated with inline stabilization as he is altered and combative B: Is Breathing intact? No, gurgling breath sounds with increased respiratory rate and tracheal deviation. This patient needs a needle decompression followed by a chest tube. C: Are there signs of shock? Yes, tachycardia and hypotension with altered mental status. These resolved when you placed the chest tube. D: What is the GCS? Eyes closed (1), withdraws only to pain (4), makes incomprehensible sounds (2)=total of 7. Less than 8, intubate! E: Upon exposure you see a cold, blue right foot. You reduce the foot to regain pulses. Next you perform a Secondary Survey HEENT: large boggy right parietal scalp, the pupils are sluggish and there's hemotympanum on the right side. You note no facial trauma. The trachea is also deviated to the left. Chest: absent breath sounds on right Heart: tachy Abdomen: soft, no guarding or obvious tenderness Extremities: Left ankle open, dislocated cold, no pulse Neck/Back: normal You begin to resuscitate with 2 liters IV Normal Saline, order Type and cross, cbc, chem 7, u/a, and coags. Noting the tracheal deviation to the left and decreased breath sounds on the right, you quickly perform a needle decompression and place a chest tube. They come to shoot your chest x-ray and you now note a resolving R sided simple PTX. Pelvis xray is negative. FAST is negative. You order Antibiotics, tetanus booster and call ortho. When the patient is stablized you move to CT scan where the following scans are obtained: CT of the Head, C spine, Chest , Abdomen and Pelvis. The rest of his scans reveal the resolved pneumothorax and chest tube you placed, several broken ribs on the right, no visceral injuries and no pelvic trauma. He is taken emergently to the OR for treatment of his epidural hematoma as well as washout of his open ankle fracture/dislocation. He spends several days in the SICU with an excellent hospital course, is extubated, and has normal neurological function. His chest tube is pulled and he is discharged home in excellent condition. (Answer)- 47 year old male unrestrained driver, ejected 15 ft from car then arrives via EMS, Vital Signs: 100/40, RR 28, HR110. Initially combative at the scene, but now difficult to arouse. He does not open his eyes, withdrawals only to pain, and makes gurgling sounds. EMS placed a C-collar and Backboard, but could not start an IV. As you move the patient over to the gurney, you notice tracheal deviation, paradoxical chest movement, and a large boggy right parietal scalp hematoma. You realize you have to move quickly using what you've learned! What do you do first? Irrigate canal wit warm water, gently past the object (don't use with seeds or beans, or TM perforation) If unable to remove safely on an uncooperative infant may require referal to ENT for removal under general anesthesia (lidocaine is ok, suction is reasonable, grasping live insect leg firmly also ok) (Answer)- management for a child with 2 days of left ear pain with foreign body in ear canal on exam Sharp Objects Long rigid objects width 2cm Failure to pass after 24 hours (Answer)- indications for endoscopic or surgical internvetion of swallowed foreign body bartholin cyst Drainage and placement of word catheter (Answer)- diagnosis and management cormmack lehane 1 = fully visualized 4 = not visualized at all (Answer)- scale which allows ccommunication of relative ease of visualization of vocal cords during direct laryngoscopy ketamine (activates sympathetic system, and has bronchodilatory effect) (Answer)- sedative agent of choice for intubation in patient with reactive airway disease presenting with impending respiratory failure propafol (Answer)- induction agent that should not be used in patients with soy or egg allergies MoMMAS2 Memory: short and long Orientation: person, place and time Mood: how do you feel? Mentation: hallucinations, delusions, paranoia? Affect: eye contact, speech, and demeanor? Speech: disorganized or tangential? Suicidality: plan, intent, prep, rehearsal? (Answer)- Mnemonic for a focused psychiatric assessment SAD PERSONS S = sex Age 19 or 45 Depression and hopelessness (2 points) ************************CONTINUES...............