Emergency Medicine: Intro, Pulmonary, Cardiac
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| ABCDE What does it stand for? | Airway, Breathing, Circulation, Disability, Exposure/Environment control
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| Goal of ED: 3 parts | 1) Treat 2) Identify 3) Stabilize
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| Physically moving air in and out of the lungs | Ventilation
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| Loading oxygen molecules onto hemoglobin | Oxygenation
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| Exchange of oxygen and carbon dioxide in the alveoli and other tissues | Respiration
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| 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)
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| Restlessness/irritability -> mental status changes, weak pulse, cyanosis | Hypoxia (when tissues and cells don't receive enough oxygen)
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| What are the 3 elements of Primary Airway Survey? | Inspection, Palpation, Auscultation
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| T/F: One of the most common mistakes with respiratory or cardiac arrest is to use advanced techniques too early. | True
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| 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
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| Who should get an oropharyngeal (oral) airway? | Someone who is unresponsive and has no gag reflex
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| A better tolerated artificial airway | Nasopharyngeal (nasal) airway
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| 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
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| Indications and CONTRAs for non-rebreathing mask | I: spontaneously breathing patients w/ trauma or CV event. C: apnea/poor respiratory effort
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| 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
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| 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
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| Curved tube w/ ventilation ports between two inflatable cuffs | King LT Airway (similar to LMA)
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| Only way to achieve definitive airway control? Indications for this? (2) | Endotracheal intubation; 1) Inability to maintain/protect airway 2) Inability to ventilate/oxygenate
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| 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?
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| 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
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| What is Mallampati scoring? | Class I is an easy intubation where Class IV is a difficult one
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| 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
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| Macintosh blade, tip placed in vallecula and indirectly lifts epiglotis to expose vocal cords | Curved laryngoscope blade
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| 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
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| 6 steps of RSI: | 1) Prepare 2) Pre-Oxygenate 3) Pre-Treat 4) Paralysis 5) Pass the Tube 6) Position check
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| 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
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| T/F: Cricothyroidotomy is a short term measure | True, tracheostomy is the definitive intervention
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| No condensation indicates that endotracheal tube is: | in the stomach
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| Only a limited amount of drugs can be emergently put through a ET. What are they? (5) | NAVEL; Naloxone, Atropine, Versed, Epinephrine, Lidocaine
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| What are pediatric intubations more prone to? | R-mainstem intubations (where tube goes into the right lung past the carina)
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| How do you assess breathing other than visual assessment? | Pulse oximetry; IDs high risk patients an monitors them especially during intubation attempt or suctioning
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| CONTRAs to IOs (4) | fracture, crush injury, osteoporosis, infx
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| 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.
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| Shock: Initial signs of end organ dysfunction (5) | Tachycardia/pnea, metabolic acidosis (waste products can't be excreted), oliguria, cool and clammy skin
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| 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
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| 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
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| 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
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| Hot flushed skin (even hands and feet), hyperthermia or hypothermia, tachycardia, tachypnea, wide pulse pressure, mental status changes | Septic shock
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| 5 managements for septic shock | 1) ABCs 2) Aggressive fluid administration 3) Empiric ABX 4) Pressors (norepinephrine first line) 5) Consider steroids
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| 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
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| 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
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| 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)
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| Quick assessment of Neuro status? (4) | AVPU (Alert, Verbal, Painful stimuli, Unresponsive
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| The sensation of breathlessness or inadequate breathing, smothering | Dyspnea
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| What part of the cervical spines innervates the diaphragm? | C3-5
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| ED pulmonary diagnosis of exclusion? | Anxiety
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| ED Mantra: (4 parts) | ABC, IV, O2, monitor
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| Which hemoglobin: chocolate brown blood | MetHgb
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| Which hemoglobin: cherry red blood | COHgb
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| “expectoration of blood from the bronchopulmonary tree” | Hemoptysis
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| What is considered a massive hemoptysis? | >600 mL/24 hours, medical emergency
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| What does ROWL stand for? | Rate, O2 sat, Words per sentence,Labored respiration?
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| What is important about assessing an EKG? | Compare to an old EKG!
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| 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
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| inability of heart to maintain cardiac output equivalent to what the body requires | Heart failure
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| Most common cause of right ventricle heart failure? | left ventricle heart failure!
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| 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
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| Inability to adequately squeeze blood forward from heart | Systolic heart failure
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| abnormal ventricular filling or stiffness of heart | Diastolic heart failure
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| 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
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| 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
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| Air passing through narrowed (edematous) airways | Wheezes
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| Occur from explosive opening of terminal endings | Fine rales/crackles
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| Occur from air bubbling through fluid | Coarse rales/crackles
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| 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
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| Almost all treatment modalities of CHF are geared towards reducing __________ or both) | reducing preload or afterload
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| In general, how do we reduce preload? What is preload? | Decrease venous return. Preload is amount of pressure stretching heart before contraction
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| In general, how do we reduce afterload? What is afterload? | Decrease BP! Afterload is amount of pressure heart is pumping against
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| Medication that decreases both afterload and preload. Can be given sublinguallty, transdermally, intravenous drip, will cause precipitous drop in blood pressure | Nitroglycerin
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| 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)
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| Concept that positive pressure opens branches of collapsed alveoli. Allows more surface area of lung to open. Improves oxygenation. | Recruitment
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| 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
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| 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
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| 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
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| 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
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| T/F: Most PEs embolize from heart and lung sources | FALSE, most embolize from DVTs in the periphery
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| venous stasis + endothelial damage + hypercoagulable state | Virchow's Triad
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| Classic triad” (pleuritic CP, dyspnea, hemoptysis), tachycardia, dyspnea, T inversion in precordial leads | Pulmonary Embolism presentation
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| Next step w/ low pre-test probability + negative D-Dimer? | Discharge
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| opacity w/ rounded border pointing towards the hilum | Hampton's Hump, CXR assessing PE
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| increased lucency from clot interrupting bloodflow | Westermark's sign, CXR assessing PE
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| 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
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| 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
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| The SUPER GOLD Standard for PE? Why isn't it used all the time?! | Pulmonary Angiography...risky and invasive
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| Good prevention for PE in those that can't tolerate anti-coag therapy: | IVC Filter
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| Nonreversible disease of gas exchange | COPD
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| Reversible mechanical disease of inflammatory gunk in airways | Asthma
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| Dyspnea, chronic productive cough, wt loss due to excessive caloric expenditure and poor intake. Barrel chest and pursed lips | COPD
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| 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
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| 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
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| T/F: Hypoxia is defined as PaO2 < 60mmHg | FALSE, you're thinking of Hypoxemia!
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| Tx for COPD | Albuterol (SABA)
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| Foundational Tx of Asthma (just as a reminder, not on exam:) | Corticosteroids
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| 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
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| What when used in ill patients w/ COPD exacerbations reduces risk of Tx failure and death? | ABX!
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| Streptococcus pneumoniae, Haemophilus influenzae, Moraxella catarrhalis, Mycoplasma pneumoniae, and viruses | These are often the culprits in COPD exacerbations!
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| severe, prolonged asthma attack that does not stop with conventional treatment | Status asthmaticus
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| T/F: Patients with potentially fatal asthma often have severely compromised ventilation all the time | True
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| Specific management of Asthma in ED in addition to normal (O2, IV access, peak flow assessment) (2) | 1) Magnesium sulfate IV 2) Epinephrine SQ
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| What is the difference between Tx of mild Asthma and COPD in the ER initially? | Nothing, give Beta agonists (albuterol) and Ipratropium
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| 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
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| Dyspnea, chills, high fever, cough, foul smelling sputum, pleuritic chest pain | Pneumonia
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| Viral or Bacterial Pneumonia: Younger than 5 yo, slow onset, rhinitis, wheezing, interstitial infiltrates bilaterally, fine rales, prodrome | VIRAL
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| Viral or Bacterial Pneumonia: Adult w/ rapid onset, high fever, tachypnea, lobar alveolar infiltrates | BACTERIAL
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| Pneumonia that can cause extrapulmonary manifestations Meningitis, encephalitis, pericarditis, hepatitis, hemolytic anemia. Tx? (3) | Atypical pneumonia; 1) Macrolides (Z-pak) 2) Fluoroquinolones 3) Doxycycline
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| High mortality in young infants and elderly population, often from strep; cough, fever/chills, tachypnea/cardia, malaise, anorexia, myalgias, vomiting | Bacterial pneumonia
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| Tx for CAP (choice of 4 ABX) | MACROLIDES, Fluoroquinolone, Cephalosproin, Doxycycline
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| Tx for Aspiration Pneumonia (2) | Cephalosporin AND Clindamycin
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| Fever, night sweats, cough, weight loss, HIV or travel | TB
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| 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)
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| Direct or Indirect ARDS? Aspiration, Pneumonia, near drowning, inhalation injury | DIRECT; Intrapulmonary
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| Direct or Indirect ARDS? Sepsis, severe acute pancreatitis, DIC, shock, trauma | INDIRECT; Extrapulmonary
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| What is the subtle difference in ARDS and ALI (acute lung injury)? | PaO2/FiO2<300=ALI
PaO2/FiO2<200=ARDS
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| Thick mucous causing obstruction due to autosomal recessive disease. Abx Tx? | Cystic Fibrosis; Azithromycin
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| What does SASMR stand for? | Systolic: Aortic Stenosis and Mitral Regurgitation
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| What does DARMS stand for? | Diastolic: Aortic Regurgitation and Mitral Stenosis
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| What kind of heart generates a S4 gallop? | Hypertrophied
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| Thickest wall to supply systemic circulation? | Left ventricle
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| HR (heart rate) xSV (stroke volume)= | CO (cardiac output)
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| Define Starling's Law | The more the cardiac muscle is stretched, the stronger the contraction
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| 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
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| stretching of the cardiomyocytes prior to contraction. How does this correspond to cardiac output? | Preload. Stronger the preload, stronger the contraction
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| What is an ejection fraction? | Amount of blood pumped out of ventricle over total amount of blood in ventricle.
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| 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
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| Define overdrive suppresion | idea that the dominant foci suppresses all other foci since they have a slower inherent pacing rate
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| Beats per minute: SA, Atrial, Junctional, Ventricular foci? | SA: 60-100 A: 60-80 J: 40-60 V: 20-40
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| 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
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| Dyspnea, tachycardia, transient (or not) tachypnea; possible hypoxia (others: pleuritic chest pain, anxiety, rales, cough) | Pulmonary Embolus (PE)
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| What is the Wells' criteria for? Scoring? | Pulmonary Embolus (PE); >6 points: High probability, <2 points: low probability, 2-6: moderate
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| 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
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| Next step if HIGH or intermediate suspicion of PE? | CT Angiography
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| 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
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| 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
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| 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
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| greater than 10 mmHg drop in systolic BP during inspiration due to a fall in ventricular volume—DD: also with severe asthma | Pulsus paradoxus
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| a paradoxical rise in JVD during inspiration, instead of down | Kussmaul's sign
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| 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
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| Elevated intrapericardial pressure, restricting venous return and ventricular filling, pulsus paradoxus | Cardiac Tamponade
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| worsening chest pain w/ exertion, rest/nocturnal pain, >20min duration | Acute coronary syndrome
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| T/F: Normal EKG excludes Dx of Acute coronary syndrome | FALSE, compare to previous EKG, look for hyperacute T waves
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| What do you order if you can't figure out between dissection, PE, MI? | Contrast enhanced CT angiogram
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| 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
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| T/F: Nitroglycerin doesn't improve outcome | True, just Sx
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| CONTRA for PCI (percutaneous coronary intervention) in STEMI (2) | Left main stenosis, diffusely diseased small artery
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| CONTRA to fibrinolytic use in STEMI (3) | Prior intracranial hemorrhage, malignant intracranial neoplasm w/in 90 days, aortic dissection
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| hypotension, tachycardia, reduced urine output, mental confusion, diaphoresis, and cold extremities, | Cardiogenic shock
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| 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
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| Butterfly appearance not pathognomonic, but definitely helps w/ Hx and PE S3 gallop, rales, etc. (context) | Pulmonary Edema
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| 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
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| 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
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| 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
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| Common with a large transmural infarct (most commonly anterior) and good residual myocardium | Ventricular aneurysm
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| Sx of First degree and second degree heart block | ASx
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| 1) Acute myocardial infarction 2) Idiopathic fibrosis 3) Chagas disease 4) Infiltrative diseases 5) Lyme disease What can these 5 conditions cause? | AV block
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| Series of cycles with progressively prolonged PR interval until an impulse is blocked | Mobitz 1: Wenckebach
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| 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)
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| T/F: PVCs can occur w/ a narrow complex | False, NEVER
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| T/F: PACs can occur w/ a wide complex | True
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| Unique form of ventricular tachycardia Rate 250 – 350 beats / minute Changing axis and amplitude – QRS axis spirals around the baseline | Torsades de Pointe
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| Precordial chest pain often at rest ST elevation on EKG Often women < 50 years | Prinzmetal's Variant Angina (caused by a vascular artery spasm)
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| 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
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| see V1 and V2 with Right bundle branch block | Brugada's Syndrome
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