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Emergency 1 Exam

Emergency Medicine: Intro, Pulmonary, Cardiac

ABCDE What does it stand for? Airway, Breathing, Circulation, Disability, Exposure/Environment control
Goal of ED: 3 parts 1) Treat 2) Identify 3) Stabilize
Physically moving air in and out of the lungs Ventilation
Loading oxygen molecules onto hemoglobin Oxygenation
Exchange of oxygen and carbon dioxide in the alveoli and other tissues Respiration
What's the problem with chest trauma, PE, and total pneumonia? Air and blood flow aren't at the same place at the same time (Ventilation and perfusion are mismatched)
Restlessness/irritability -> mental status changes, weak pulse, cyanosis Hypoxia (when tissues and cells don't receive enough oxygen)
What are the 3 elements of Primary Airway Survey? Inspection, Palpation, Auscultation
T/F: One of the most common mistakes with respiratory or cardiac arrest is to use advanced techniques too early. True
CONTRA to neck flexion. What do you do instead? potential C-Spine Injury. Instead use a "Jaw Thrust" where you lift the mandible w/o bending neck
Who should get an oropharyngeal (oral) airway? Someone who is unresponsive and has no gag reflex
A better tolerated artificial airway Nasopharyngeal (nasal) airway
Percentage of O2 w/ nasal cannula? What is it good for and what isn't it? 24-44%, Best for long-term therapy, ineffective w/apnea, hypoxia, mouth breathing
Indications and CONTRAs for non-rebreathing mask I: spontaneously breathing patients w/ trauma or CV event. C: apnea/poor respiratory effort
Technique for Bag-Mask Device (BVM) and what makes it difficult? Cup or make a C shape with your finger and thumb at the base of the mask. Harder w/ obesity, facial hair, neck/face trauma
What about patients who require more support than a bag-mask but don't require intubation? Laryngeal Mask Airway (LMA) establishes clear conduit from glottic opening by inflating and cutting of esophagus passage
Curved tube w/ ventilation ports between two inflatable cuffs King LT Airway (similar to LMA)
Only way to achieve definitive airway control? Indications for this? (2) Endotracheal intubation; 1) Inability to maintain/protect airway 2) Inability to ventilate/oxygenate
4 critical questions regarding intubation 1) How much time do we have? 2) How difficult will it be? 3) How might I harm this patient? 4) Comfort level with procedure?
What does LEMON stand for when assessing intubation? Look externally, Evaluate 3-3-2 (in fingers: mouth width, mandible length, hyoid bone to thyroid notch), Mallampati, Obstruction, Neck mobility
What is Mallampati scoring? Class I is an easy intubation where Class IV is a difficult one
Miller and Wisconsin blades; tip extends beneath epiglottis and lifts it up, good in small children but can damage teeth in adults Straight laryngoscope blade
Macintosh blade, tip placed in vallecula and indirectly lifts epiglotis to expose vocal cords Curved laryngoscope blade
Systematic protocol using sedatives and paralytics to increase chances of successful intubation and decrease the risk of aspiration indicated w/ air control or compromise, shock, head injury, or respiratory arrest. CONTRAs RSI (Rapid Sequence Intubation); C: physically obstructed airway; severe facial fractures or trauma
6 steps of RSI: 1) Prepare 2) Pre-Oxygenate 3) Pre-Treat 4) Paralysis 5) Pass the Tube 6) Position check
Creation of an opening in the __________ membrane for placement of a tracheal tube when oral intubation fails or is contraindicated. CONTRA: (4) Cricothyroid; Procedure: Cricothyroidotomy/Cricothyrotomy; CONTRA: distorted neck anatomy, infx, coagulopathy, children <10 yo
T/F: Cricothyroidotomy is a short term measure True, tracheostomy is the definitive intervention
No condensation indicates that endotracheal tube is: in the stomach
Only a limited amount of drugs can be emergently put through a ET. What are they? (5) NAVEL; Naloxone, Atropine, Versed, Epinephrine, Lidocaine
What are pediatric intubations more prone to? R-mainstem intubations (where tube goes into the right lung past the carina)
How do you assess breathing other than visual assessment? Pulse oximetry; IDs high risk patients an monitors them especially during intubation attempt or suctioning
CONTRAs to IOs (4) fracture, crush injury, osteoporosis, infx
T/F: Hypotension is synonymous with shock. FALSE, NO, it isn't! Shock is a pre-arrest state. A state of severe systemic reduction in tissue perfusion characterized by decreased cellular oxygen delivery and utilization as well as decreased removal of waste byproducts of metabolism.
Shock: Initial signs of end organ dysfunction (5) Tachycardia/pnea, metabolic acidosis (waste products can't be excreted), oliguria, cool and clammy skin
blood loss of significant magnitude to overcome the normal physiologic compensatory responses and compromise tissue perfusion. Baroreceptors sense fall in BP and release norepinephrine. (when we usually see pts come in) Hemorrhagic shock
Classify hemorrhagic shock by classes 1-4 1: 15% blood loss, tachycardia 2: 15-30%, loss of peripheral perfusion 3: 30-40%, loss of systolic BP, marked MS changes 4: >2 liters loss, obtunded, clammy marked hypotension, narrow PP
SIRS criteria for septic shock (4) 1) temp >38 or <36 degrees 2) HR> 90 bpm 3) RR> 20 4) WBC >12,000 or <4,000
Hot flushed skin (even hands and feet), hyperthermia or hypothermia, tachycardia, tachypnea, wide pulse pressure, mental status changes Septic shock
5 managements for septic shock 1) ABCs 2) Aggressive fluid administration 3) Empiric ABX 4) Pressors (norepinephrine first line) 5) Consider steroids
flushing, warmth, urticaria, pruritis, dyspnea, wheezing, angioedema, tachycardia, tachypnea, hypotension. Tx? Anaphylactic shock; 1) Epinephrine 2) H1/H2 blockers 3) Corticosteroids 4) Nebulized B2 agonist
flaccid paralysis, loss of DTR’s, loss of bladder tone, bradycardia, hypotension, hypothermia, skin warm & dry, but good urine output (no resistance). Tx? (4) Neurogenic shock; 1) Fluid replacement 2) Atropine 3) Phenylephrine 4) Methylprednisone
Acute MI is the main contributing cause of __________________. “Pump” failure can come from muscle damage directly from AMI or SIRS response following AMI. Tx? Cardiogenic shock; Tx: Pressors (dopamine at dose to be vasoconstrictive or nore/epi)
Quick assessment of Neuro status? (4) AVPU (Alert, Verbal, Painful stimuli, Unresponsive
The sensation of breathlessness or inadequate breathing, smothering Dyspnea
What part of the cervical spines innervates the diaphragm? C3-5
ED pulmonary diagnosis of exclusion? Anxiety
ED Mantra: (4 parts) ABC, IV, O2, monitor
Which hemoglobin: chocolate brown blood MetHgb
Which hemoglobin: cherry red blood COHgb
“expectoration of blood from the bronchopulmonary tree” Hemoptysis
What is considered a massive hemoptysis? >600 mL/24 hours, medical emergency
What does ROWL stand for? Rate, O2 sat, Words per sentence,Labored respiration?
What is important about assessing an EKG? Compare to an old EKG!
T/F: Normal ABGs exclude a cardiac/pulmonary diagnosis as cause of dyspnea. T/F: ABG more reliable than VBG FALSE, they sure don't; TRUE, ABG more reliable
inability of heart to maintain cardiac output equivalent to what the body requires Heart failure
Most common cause of right ventricle heart failure? left ventricle heart failure!
What does ADHF stand for and what does it mean? Acute Decompensated Heart Failure; sudden collapse of the body's ability to cope with disease
Inability to adequately squeeze blood forward from heart Systolic heart failure
abnormal ventricular filling or stiffness of heart Diastolic heart failure
SOB, night cough, PND (paroxymal nocturnal dyspnea), rales, fatigue (Blood/fluid build-up into the lungs due to impaired pulmonary venous return to the heart) Left sided heart failure
Edema of feet, legs and ankles. May affect the liver through backup of blood in the portal circulation. Can also have 3rd spacing into soft tissues, ascites, and pleural effusion Right sided heart failure
Air passing through narrowed (edematous) airways Wheezes
Occur from explosive opening of terminal endings Fine rales/crackles
Occur from air bubbling through fluid Coarse rales/crackles
Useful to differentiate CHF from COPD. Elevated in CHF – arises from the ventricles in response to high ventricular pressure from volume overload. Release during VENTRICULAR STRETCH BNP or B-natriuretic peptide
Almost all treatment modalities of CHF are geared towards reducing __________ or both) reducing preload or afterload
In general, how do we reduce preload? What is preload? Decrease venous return. Preload is amount of pressure stretching heart before contraction
In general, how do we reduce afterload? What is afterload? Decrease BP! Afterload is amount of pressure heart is pumping against
Medication that decreases both afterload and preload. Can be given sublinguallty, transdermally, intravenous drip, will cause precipitous drop in blood pressure Nitroglycerin
Continuous ‘force’ that keeps airways open. Idea is to overcome the pressure of the patient’s failing CO that is resulting in fluid leaking into the alveoli CPAP (Continuous Positive Airway Pressure)
Concept that positive pressure opens branches of collapsed alveoli. Allows more surface area of lung to open. Improves oxygenation. Recruitment
Difference between CPAP and BiPAP? CPAP is a fixed, one valve positive airflow where BiPAP helps those get air into lungs and get it out
5 Tx of pulmonary edema 1) O2 with non rebreather 2) Lasix 3) Reduction of hypertension (nitroglycerin IV, may use sublingual before line placed) 4) BiPAP 5) Intubate if no improvement
In healthy individuals, often occurs at rest and is associated with chest pain and SOB (thin tall male who is a smoker): Tx? Primary spontaneous pneumothorax; Usually self-resolving
Tracheal deviation to contralateral side, absent or decreased breath sounds, and distended neck veins. Tx? (2) Tension pneumothorax; 1) O2 2) CXR +/- needle decompression/emergent chest tube
T/F: Most PEs embolize from heart and lung sources FALSE, most embolize from DVTs in the periphery
venous stasis + endothelial damage + hypercoagulable state Virchow's Triad
Classic triad” (pleuritic CP, dyspnea, hemoptysis), tachycardia, dyspnea, T inversion in precordial leads Pulmonary Embolism presentation
Next step w/ low pre-test probability + negative D-Dimer? Discharge
opacity w/ rounded border pointing towards the hilum Hampton's Hump, CXR assessing PE
increased lucency from clot interrupting bloodflow Westermark's sign, CXR assessing PE
Advantages: 1) can use in pts who can’t have contrast 2) radiologists experienced in reading it. 3) catches smaller clots. Disadvantages: 1) CT better in pregnancy 2) less detail than CT 3) many times WISHY-WASHY RESULTS, especially if with an abnormal V/Q scan, GOLD STANDARD for PE evaluation. High probability? Good sensitivity and specificity
Advantages: 1) Detailed anatomical info 2) reveal alternative diagnoses 3) Can use in pregnancy (recent) 4) More useful if abnormal CXR. Disadvantages: 1) Must use IV contrast 2) May miss small PE’s. 3) Most radiologists experienced in reading them. Chest CT
The SUPER GOLD Standard for PE? Why isn't it used all the time?! Pulmonary Angiography...risky and invasive
Good prevention for PE in those that can't tolerate anti-coag therapy: IVC Filter
Nonreversible disease of gas exchange COPD
Reversible mechanical disease of inflammatory gunk in airways Asthma
Dyspnea, chronic productive cough, wt loss due to excessive caloric expenditure and poor intake. Barrel chest and pursed lips COPD
Dyspnea, chronic productive cough, wt loss due to excessive caloric expenditure and poor intake. Barrel chest and pursed lips. Peripheral edema COPD w/ right-sided heart failure
Dyspnea, chronic productive cough, wt loss due to excessive caloric expenditure and poor intake. Barrel chest and pursed lips. Fever, change in sputum COPD w/ pneumonia
T/F: Hypoxia is defined as PaO2 < 60mmHg FALSE, you're thinking of Hypoxemia!
Tx for COPD Albuterol (SABA)
Foundational Tx of Asthma (just as a reminder, not on exam:) Corticosteroids
For RSI (what does that stand for again), what is the induction agent? Paralytic agent? What's used for children? Rapid Sequence Intubation; I: Etomidate; P: Succinylcholine. Atropine used for children
What when used in ill patients w/ COPD exacerbations reduces risk of Tx failure and death? ABX!
Streptococcus pneumoniae, Haemophilus influenzae, Moraxella catarrhalis, Mycoplasma pneumoniae, and viruses These are often the culprits in COPD exacerbations!
severe, prolonged asthma attack that does not stop with conventional treatment Status asthmaticus
T/F: Patients with potentially fatal asthma often have severely compromised ventilation all the time True
Specific management of Asthma in ED in addition to normal (O2, IV access, peak flow assessment) (2) 1) Magnesium sulfate IV 2) Epinephrine SQ
What is the difference between Tx of mild Asthma and COPD in the ER initially? Nothing, give Beta agonists (albuterol) and Ipratropium
In Asthma: Increasing fatigue. Altered mental status. “Quiet chest” (nothing is moving, not even wheezing). Acidosis. Worsening hypoxia. Worsening hypercapnia. Next intervention? Pushes decision towards intubation
Dyspnea, chills, high fever, cough, foul smelling sputum, pleuritic chest pain Pneumonia
Viral or Bacterial Pneumonia: Younger than 5 yo, slow onset, rhinitis, wheezing, interstitial infiltrates bilaterally, fine rales, prodrome VIRAL
Viral or Bacterial Pneumonia: Adult w/ rapid onset, high fever, tachypnea, lobar alveolar infiltrates BACTERIAL
Pneumonia that can cause extrapulmonary manifestations Meningitis, encephalitis, pericarditis, hepatitis, hemolytic anemia. Tx? (3) Atypical pneumonia; 1) Macrolides (Z-pak) 2) Fluoroquinolones 3) Doxycycline
High mortality in young infants and elderly population, often from strep; cough, fever/chills, tachypnea/cardia, malaise, anorexia, myalgias, vomiting Bacterial pneumonia
Tx for CAP (choice of 4 ABX) MACROLIDES, Fluoroquinolone, Cephalosproin, Doxycycline
Tx for Aspiration Pneumonia (2) Cephalosporin AND Clindamycin
Fever, night sweats, cough, weight loss, HIV or travel TB
condition in which patients with non-thoracic injuries, massive transfusion, sepsis, aspiration and other conditions developed respiratory distress, alveolar atelectasis, decreased compliance, bilateral infiltrates and respiratory failure ARDS (Acute Respiratory Distress Syndrome)
Direct or Indirect ARDS? Aspiration, Pneumonia, near drowning, inhalation injury DIRECT; Intrapulmonary
Direct or Indirect ARDS? Sepsis, severe acute pancreatitis, DIC, shock, trauma INDIRECT; Extrapulmonary
What is the subtle difference in ARDS and ALI (acute lung injury)? PaO2/FiO2<300=ALI PaO2/FiO2<200=ARDS
Thick mucous causing obstruction due to autosomal recessive disease. Abx Tx? Cystic Fibrosis; Azithromycin
What does SASMR stand for? Systolic: Aortic Stenosis and Mitral Regurgitation
What does DARMS stand for? Diastolic: Aortic Regurgitation and Mitral Stenosis
What kind of heart generates a S4 gallop? Hypertrophied
Thickest wall to supply systemic circulation? Left ventricle
HR (heart rate) xSV (stroke volume)= CO (cardiac output)
Define Starling's Law The more the cardiac muscle is stretched, the stronger the contraction
Load against which the heart contracts to eject blood. How does this correspond to cardiac output? Afterload. Less afterload you have, the greater the cardiac output
stretching of the cardiomyocytes prior to contraction. How does this correspond to cardiac output? Preload. Stronger the preload, stronger the contraction
What is an ejection fraction? Amount of blood pumped out of ventricle over total amount of blood in ventricle.
Define automaticity (recall this question was on like every damn EKG and Cardio exam) the ability of the SA node (or highest level foci) to generate dominant pacemaking stimuli. And so on...SA -> Atrial Foci -> Junctional Foci-> Ventricular Foci
Define overdrive suppresion idea that the dominant foci suppresses all other foci since they have a slower inherent pacing rate
Beats per minute: SA, Atrial, Junctional, Ventricular foci? SA: 60-100 A: 60-80 J: 40-60 V: 20-40
6 steps on how you should assess an EKG EVERYTIME so you don't miss something 1) Rate 2) Rhythm 3) Axis 4) Intervals 5) Hypertrophy? 6) Ischemia, injury, infarction
Dyspnea, tachycardia, transient (or not) tachypnea; possible hypoxia (others: pleuritic chest pain, anxiety, rales, cough) Pulmonary Embolus (PE)
What is the Wells' criteria for? Scoring? Pulmonary Embolus (PE); >6 points: High probability, <2 points: low probability, 2-6: moderate
Test that assess the fibrin split product that has a 93-100% negative predictive value for PE. What are a few false positives (listing all, just know a few major ones)? D-dimer: Falses: Pregnant Patients, Post-partum < 1 week, Malignancy, Surgery within 1 week, Advanced age > 80 years, Sepsis, Hemorrhage, CVA, ACS, Collagen Vascular Diseases, Hepatic Impairment
Next step if HIGH or intermediate suspicion of PE? CT Angiography
Usually age 20s-40s, present with sudden onset dyspnea and pleuritic CP at rest, especially smokers w/ decreased/absent breath sounds and hyperresonance. Dx? Primary spontaneous pneumothorax. Usually can see it on CXR, look for pleural line
Sharp, "tearing" anterior or posterior chest/back pain. Sudden and severe onset. Often complicated by another disease process. Variations in pulses or BP more than 20mmHg between arms! Mediastinal widening on CXR Aortic Dissection
Spontaneous, after intense retching followed by severe chest and epigastric pain, tachypnea, dyspnea, fever, cyanosis, shock. CXR will show: Esophageal rupture. CXR shows mediastinal or free peritoneal air
greater than 10 mmHg drop in systolic BP during inspiration due to a fall in ventricular volume—DD: also with severe asthma Pulsus paradoxus
a paradoxical rise in JVD during inspiration, instead of down Kussmaul's sign
2/4 for Dx: 1) Chest pain 2) Friction rub leaning forward 3) ECG changes (wide ST elevation and PR depression 4) Pericardial effusion. Other supporing: Pulsus paradoxus and Kussmauls Pericarditis
Elevated intrapericardial pressure, restricting venous return and ventricular filling, pulsus paradoxus Cardiac Tamponade
worsening chest pain w/ exertion, rest/nocturnal pain, >20min duration Acute coronary syndrome
T/F: Normal EKG excludes Dx of Acute coronary syndrome FALSE, compare to previous EKG, look for hyperacute T waves
What do you order if you can't figure out between dissection, PE, MI? Contrast enhanced CT angiogram
What does the TIMI risk score assess? Risk for death, MI or recurrent ischemia with those w/ acute coronary syndrome w/in 14 days after hospitalization
T/F: Nitroglycerin doesn't improve outcome True, just Sx
CONTRA for PCI (percutaneous coronary intervention) in STEMI (2) Left main stenosis, diffusely diseased small artery
CONTRA to fibrinolytic use in STEMI (3) Prior intracranial hemorrhage, malignant intracranial neoplasm w/in 90 days, aortic dissection
hypotension, tachycardia, reduced urine output, mental confusion, diaphoresis, and cold extremities, Cardiogenic shock
Chest pain of MI subsides within 12 to 24 hours. Any residual or subsequent chest pain may represent pericarditis, pulmonary embolus, or other complications. Recurrent ischemia
Butterfly appearance not pathognomonic, but definitely helps w/ Hx and PE S3 gallop, rales, etc. (context) Pulmonary Edema
most often associated with an inferior-posterior infarct due to right coronary artery occlusion. It produces acute, severe mitral regurgitation characterized by a loud, apical murmur and thrill Rupture of papillary muscle
Sudden appearance of a loud systolic murmur and thrill medial to the apex along the left sternal border in the 3rd or 4th intercostal space, accompanied by hypotension with or without signs of LV failure, is characteristic Interventricular septum rupture
Increases in incidence with age and is more common in women. It is characterized by sudden loss of arterial pressure with momentary persistence of sinus rhythm and often by signs of cardiac tamponade. It is almost always fatal External rupture
Common with a large transmural infarct (most commonly anterior) and good residual myocardium Ventricular aneurysm
Sx of First degree and second degree heart block ASx
1) Acute myocardial infarction 2) Idiopathic fibrosis 3) Chagas disease 4) Infiltrative diseases 5) Lyme disease What can these 5 conditions cause? AV block
Series of cycles with progressively prolonged PR interval until an impulse is blocked Mobitz 1: Wenckebach
Constant long PR intervals prior to a blocked impulse – the ration of blocked P waves to conducted beats may vary: 2:1; 3:1; etc Mobitz 2 (second degree AV block type 2)
T/F: PVCs can occur w/ a narrow complex False, NEVER
T/F: PACs can occur w/ a wide complex True
Unique form of ventricular tachycardia Rate 250 – 350 beats / minute Changing axis and amplitude – QRS axis spirals around the baseline Torsades de Pointe
Precordial chest pain often at rest ST elevation on EKG Often women < 50 years Prinzmetal's Variant Angina (caused by a vascular artery spasm)
T/F: In the absence of encephalopathy or another catastrophic event, it is preferable to lower the BP over hours or longer, rather than minutes TRUE
see V1 and V2 with Right bundle branch block Brugada's Syndrome
Created by: crward88