CDEM M4 Curriculum Comprehensive Review Exams_ Answered 2022/2023.

CDEM M4 Curriculum Comprehensive Review Exams_ Answered 2022/2023. how many pts with aortic dissection have normal CXR? - 40% initial actions in abdominal pain patients? - UPT, blood products for hemorrhage, abx, bedside ultrasound, immediate surgical consult if unstable or rigid abdomen, analgesia hemodynamic instability and abdominal pain should alert you to... - possible AAA, hemorrhage, sepsis, perforated viscus, necrotic bowel - think bowel edema or fluid placing pressure on IVC and splinting breathing hemodynamic instability and abdominal pain immediate actions... - consult surgery, 2 PIV large bores, NS bolus, O2, monitors, type and cross (give type O if needed) differential for life/organ threatening abdominal pain: - Infectious: sepsis GI: biliary, appendicitis, SBO, perforated bowel, mesenteric ischemia, pancreatitis, diverticulitis GU: PID, tubo-ovarian abscess, testicular/ovarian torsion, ectopic pregnancy CV: AAA, dissection, schemia, CAS initial actions in patient presenting with AMS? - ABCDE-G: - airway: visual check, pulse O2, O2 prn - breathing - RR (i.e. narcan?), ventilation (BVM?) - circulation - rhythm monitor vs EKG, BP, pulses, fluids, PIV access - disability - GCS, neuro deficits, pupils, trauma, pain (imaging?) - exposure - undress, trauma, patches, PIC or dialysis access, petechiae, bruising - GLUCOSE AMS differential for: Primary CNS/Structural - - tumors: primary vs mets - hemorrahge: spontaneous vs trauma - edema: HTN, hydrocephalus, tumor - seizure: post-ictal vs todd paralysis - dementia: degenerative vs vascular AMS differential for: Metabolic/autoregulatory - - high/low: glucose, sodium, calcium, thyroid, temperature - hypercarbia - poor ventilation? - hypoxemia AMS differential for: pharm/toxic - - Meds: HTN, anti/pro-epileptics, overdose, sedatives, opiods, TCA, anticholinergics, polypharmacy, steroids, sleep aids, tylenol - Toxins: ETOH, methanol (WWF) vs ethylene glycol (antifreeze) - Illicit drug use - Withdrawal: benzos, cocaine, ETOH, opiods AMS differential for: infectious - CNS: meningitis, encephalitis, abscess (viral vs bacterial...) Other: UTI, pneumonia, cellulitis, GI, AMS differential for: CV - hemorrhagic, cardiogenic, hypovolemic, distributive, anaphylaxis AMS differential for: psych - migraine, psych dx, psychosis, psychosomatic mnemonic for AMS - AEIOU TIPS A: alcohol E: ethylene glycol, epilepsy, encephalopathy I: insulin O: opiates, O2 U: uremia T: temp, TCA, trauma I: infecious P: poisons, psychogenic S: sex (TSS vs PID), stroke, subarachnoid, space lesions petechiae differential; labs? - low plts, meninococcemia, emesis, ITP, HTP, HSP, DRESS Rocky Mountain spotted fever, Labs: CBC with diff, retic count, smear, Ig levels, HIV, Hep C, H. pylori, LFTs, antiphospholipid Abs, SLE serology, Diagnostic testing to consider for AMS - No shotgun orders unless absolutely necessary: - Met/Endo - fingerstick glucose, BMP (Na, Ca, BUN, Cr), ABG/VGB, TSH, T4, ammonia, cortisol - Meds/toxins - serum osmolality, ETOH, drug screen, drug levels (i.e. antiepileptics) - CBC w/ diff, UA, UC, BC, LP - CXR, CT head/spine, MRI, EEG - Cardiac: ECG, trops, cardiac echo, carotid/vertebral US vasogenic edema from CNS lesions. give - glucocorticoids what are the goals of BLS primary survey? - support or restore early oxygenation, ventilation, and circulation until you get a return of spontaneous circulation or until ACLS can be initiated T/F patients with shockable rhythm and in desperate need for intubation should be intubated first - F: pts with shockable rhythm should be defibrillated without delay What consists ABC of ACLS? - Airway - jaw thrust, oropharyngeal or nasopharyngeal airways, or intubation Breathing - auscultation of lung sounds, ETCO2, CZR, etc. Circulation - IV/IO access What drugs are safe for ET administration? What dosage shuold be used? - NAVEL Naloxone, atropine, vasopressin, epinephrine, lidocaine 2-2.5 times the IV route dosage ACLS recommends that compressions should be interrupted for... - ventilation, rhythm checks, and shock delivery after how many minutes of resuscitation with BLS and ACLS is it okay to cesate? - 20 minutes of unsuccessful rescucustation - studies have shown that resuscitation efforts are unlikely to be successful what are the two shockable rhythms? - V fib and V-tach you see a patient with cardiac arrest. what should you do first? - 1) shout for help, activate emergency response 2) start CPR 3) give O2, attack monitors and defibrillator 4) determine whether rhythm is shockable (VF/VT) or not (asystole or PEA) you see a patient with cardiac arrest, initiate CPR, and determine has shockable rhythm. What are the next few steps? - 1) shock immediately w/o delay 2) Give CPR 2 minutes while you obtain IO/IV access 3) determine rhythm again 4) repeat if still shockable rhythm starting epinephrine 1 mg q3-5m IV/IO, consider advanced airway 5)continue algorithm until develops ROSC or non-shockable rhythm you see patient with shockable rhythm, received CPR, 3x defibrillations, and epinephrine q2-q5m, and got LMA and continues to have a shockable rhythm. What additional step do you take? - - Continue CPR, shocks, and epineprhine q2-5m - Add antiarrhythmics: amiodarone 300 mg bolus, 150 every 2 shocks until no longer has shockable rhythm, or lidocaine 1-1.5 mg/kg bolus, then 0.5-0.75 mg/kg q5-10m you see a pt in cardiac arrest, obtain help, start CPR and determine they have a non-shockable rhythm. What are your next steps? - - Continue CPR - Establish IV/IO access - Administer Epinephrine 1 mg q2-5m - Consider advanced airway - Check if they have shockable rhythm - Treat reversible causes you see a pt in cardiac arrest, start CPR, and determine they have shockable rhythm. You initiate the algorithm and determine they V-tach developed into Torsades de Pointes. In addition to the normal shockable algorithm. What medication can you administer? - Magnesium 1-2 g (in 10 mL of D5W) bolus, then 0.5-1 g/hr in ACLS, what mediation can you substitute once for epinephrine - 40 U of vasopressin you see a pt in cardiac arrest without shockable rhythm, start CPR, and epinephrine q2-5m. In addition to aforementioned a`lgorithm, what medication should you consider in PEA or asytole? - 1 mg atropine IV/IO q3-5m x3 doses What precautionary steps should you take in patients with chest pain, regardless of how sick they look? - 2 large bore PIV, O2 NC, monitor, defibrillator pads. A patient can present with acute pulmonary edema or cardiac arrhythmias at any moment. when do you see peaked T-waves in MI? - hyperacute - within minutes when do you see ST elevation in MI? - within minutes to hours when do you begin to form the Q-wave in MI? what also occurs during this period? - within hours to days. also loose R-wave when does the T-wave begin inverting in MI? - within days when do you only see q-waves in MI? - weeks to months post-infarct. T waves have normalized worst case scenarior differential for chest pain? - ACS, PE, thoracic aortic dissection, tension pneumo, esophageal rupture, pericarditis, pericardial tamponade what are unique physical exam features of PE? - tachycardia, hypoxia that corrects w/ O2, clear lungs, no infectious symptoms, and unilateral leg swelling sudden onset severe chest pain should rule out... - tension pneumo vs thoracic aneurysm distended neck veins, muffled heart sound, and hypotension.... what is on your differential - think pericarditis and/or tamponade; JVD could also be MI, PE, or other clinical decision rules for PE? - Well's criteria what does the TIMI score tell you? - all cause mortality, new or recurrent MI, or ischemia requiring revascularization in MI -like patient what doe sthe WElls criteria tell you? - risk straitification of patient with PE what is the anatomical marker that divides upper and lower GI bleeds? where is it located - Ligament of treitz - located at the duodenal/jejunal junciton what is an option for severe UGIB that cannot be controlled and no option for emergent endocoscopy? - esophageal tamponade - tube inserted into esophagus with a balloon dilated in stomach and second in esophagus Immediate labs that should be taken in acute GI bleed? - CBC, BMP, PT, PTT, type and cross - STAT what blood should be considered if type and cross not completed? - blood type O negative indications for blood transfusion - - hemorrhagic shock non-responsive to IV fluids - 1000 ccs, 3 g/dL over 2-4 hours w/ active bleed - subacute bleed Hbg 7 - symptomatic anemia 8/9 reversal agent for warfarin - FFP or cryoprecipitate reversal agent for clopidogrel or ASA - platelets reversal agent for dibigatran, rivaroxaban, apixaban - PCC - prothrombin complex concentrate Idarucimab for dabigatran patients with cirrhosis and severe variceal bleed consider - - octreotide (aka somatostatin) - FFP or clotting factor replacement - SBP ppx: ceftriaxone (1st line), or ciprofloxacin (2nd line) what med should be given in all hospital patients until the source of GI bleeding is found? - IV PPI BID patients with cirrhosis and any GI bleed should receive? - ceftriaxone (1st line) or ciprofloxacin (2nd line) - shown to reduce mortality by 20% blood streaked emesis and mild anemia - presumably mallory weiss tear dispo for patietns with GI bleed - mild bleed - home, with PPI, serial Hbg, GI follow up for endoscopy or colonoscopy moderate to severe - admission emergent - GI consult and emergent endoscopy or OR Upper GI bleed differential - gastric vs duodenal ulcers, gastritis, esophagitis, varices, mallory weiss tear, aortoenteric fistula, malignancy Lower GI bleed ddx - diverticulosis, meckel's diverticulum, angiodysplasia, malignancy, IBD, ischemic or infectious colitis, hemorrhoids or fissures patients with new headaches with others in the household with similar symptoms in the winter may suggest.. - carbon monoxide poisoning patients with headache and minimally reactive mid-dilated pupils w/ ciliary flush may suggest - acute angle closure glaucoma patients with headache and papilledema suggests - increased ICP. Might also see loss of spontanous venous pulsations. Think possible pseudotumor (ICH) vs hydro vs bleed vs tumor etc patients with headache and temporal tenderness suggests - temporal arteritis (giant cell arteritis) this is the one that can cause transient or eventual permanent vision loss 2/2 ocular ischemia Common causes of headaches - tension, migraines, fever, sinusitis, TMJ, cluster headaches, trigeminal neuralgia *************************CONTINUED