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7/24/2019 ED Study Guide

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CARDIOLOGY

AV Block

Type Signs & Symptoms/Info/Wok!p "#n#gement $%G

ist 'egee -Asymptomatic

-EKG showing lengthened PR interval

-Determine site of block using EKG

findings atropine e!ercise or vagal

maneuvers

-"reat reversible

causes such as

ischemia increased

vagal tone or meds

-Pacemaker usually not

recommended

Secon'

'egee

Wencke(#c)

*"o(it+ type

I,

-"ypically asymptomatic

-EKG shows progressive PR prolongation

for several beats prior to nonconducted P

wave

-#eats classically occur in ratios of $%& '%$

or (%'

-)an be a result of inferior *+

-"reat reversible

causes such as

ischemia increased

vagal tone or meds

-Pacemaker if there is

symptomatic

bradycardia

"o(it+ type II -*ay be asymptomatic or have signs of

hypoperfusion or ,

-PR interval remains unchanged prior to anonconducted P wave

-"reat reversible

causes such as

ischemia increasedvagal tone or meds

-*ost patients will

re.uire a pacemaker

T)i' 'egee -*ay have di//iness presyncope syncope

v-tach v-fib worsening , or angina

-P waves don0t correlate to 1R2-Escape rhythm takes over for 1R2

34unctional or ventricular5

Ventic!l# T#c)yc#'i#

1


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Tos#'es 'e pointes is a

polymorphic form of 6"

Ventic!l# fl!tte is a rapid 3&'7-

&875 unstable form of 6" that can

deteriorate to 6

C#!ses

-Electrolyte imbalances

-Acid9base abnormalities-,ypo!emia

-*+

-Drugs

Signs & Symptoms

-)an remain alert and stable with

short runs

-Prolonged runshypotension

myocardial ischemia syncope

chest pain dyspnea

-2udden cardiac death

"#n#gement

-"orsades% remove offending med use

anti-arrhythmics

-"reat if : $7 s with antiarrhythmics

3amiodarone lidocaine procainamide5

-)ardioversion if pt remains unstable

Ventic!l# i(ill#tionC#!ses

-;nderlying ischemia or


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Signs & symptoms

-2udden onset chest pain

nausea vomiting diaphoresis

2=#

-@aw neck scapular throat or

arm pain

-D=E

-)hest pain : $7 min not

responsive to G

-,ypovolemia-," or hypotension

-"achy or bradycardia

-2$ or 2'

-2igns of ),

-2ystolic murmurs

-riction rub if day & or later

-)hange from stable angina to

A)2 B angina at rest new onset

angina that markedly limits

activity more fre.uent angina

long duration angina or angina

occurring with less e!ertion than

previous

-Remember that women theelderly and diabetics may have

atypical presentations

Wok!p

-=btain C& lead within C7 min of arrival

and repeat every C7 minutes if initial EKG

is not diagnostic 3CstEKG is negative '7

of the time5

- ?7 or resp

distress5

-Aspirin G

-*orphine for continued chest pain

despite G

-"reat , if present with G furosemide

-Give L-blocker if , is not present in

order to reduce myocardial o!ygen

demand-#egin 87 mg atorvastatin for pts not

already on

-Echo to determine cardiac function

A''ition#l ST$"I Te#tment

-Antiplatelet and anticoagulant therapy

for all patients 3in addition to aspirin5

-Emergent stent if > $ hours from

symptom onset

-Alternative is lytic therapy if not

contraindicated symptoms > C& hours

and P)+ unavailable within ?7-C&7

minutes

-)A#G rarely performed during acute *+

A''ition#l .ST$"I Te#tment

-Antiplatelet therapy for all patients 3in

addition to aspirinF clopidogrel

ticagrelor etcI5

-Anticoagulant therapy for all patients

3heparin5

-+nvasive intervention based on presence

of high risk factors 3recurrent angina at

rest elevated troponin 2" depression

high risk stress test result E > '7

hemodynamic instability sustained 6"

recent P)+ prior )A#G "+*+ score5-Glycoprotein ++A9+++# inhibitor in

addition to all other meds for a subset of

select pts who will undergo early P)+

Te#tment of Coc#ineRel#te' ACS

-#en/os every C( minutes PR

-D=0" give L-blockers

0ostACS Te#tment

-)ontinue drugs used during hospitali/ation% L-blocker statin A2A 2 C 3salt

conserving indicating a

functioning kidney with

normal physiologic response

to volume depletion5

6ariable usually normal i f

in4ury is acute and there is still

tubular functioning

: C if oliguric > C -6ariable

Urine #smolalit : (77 > '77 &(7-$77 6ariable 6ariable

Urinar Se!iment -#enign or hyaline cast s -;sually normal

-*ay see R#)s O#)s or

crystals

-*uddy br

own casts renal tubular casts

-Ohite cells white cell casts

S eosinophils

-Red cells dysmorphic red

cells and red cell casts

1et)itis Diffeenti#l-Oith dischargethink gonorrhea or chlamydia first others includeMycoplasma, &reaplasma, 'richomonas

-Reactive arthritis with associated urethritis

-;rethral carcinoma

-*en% balanitis

-Oomen% candidiasis cystitis

O2#i#n CystsDiffeenti#l;ruptured ectopic mittelschmer/ ovarian torsion degenerating leiomyoma P+D acute endometritis

!nction#l Cysts *0)ysiologic O2#i#n Cysts, .on!nction#l Cysts-)aused by e!aggerations of normal

menstrual cycle rather than true

neoplasms

-+ncreased risk with smoking

Types

-ollicular cyst% continued growth of

follicle despite failed ovulation

-)orpus luteum cyst% failure of

involution with enlargement after

ovulation and continued progesterone

secretion

-"heca lutein cyst% a result of abnormalpregnancy uncommon

Signs & Symptoms

-)an be asymptomatic

-Pelvic pain and

dyspareunia if large

-ollicular% pelvic pain if

rupture

-)orpus luteum% adne!al

enlargement one-sided

pain missed menses

-"orsioned or ruptured

cyst will cause acute

abdominal pain rebound

tenderness

Wok!p

-*ust be differentiated from malignancy 3benign B mobile cystic

unilateral smooth > C7 cm minimal septations5F get pelvic ;2

"#n#gement

-Oill usually regress spontaneously

-"reatment only if recurrent or symptomatic 3=)Ps etc5

-Ruptured cyst% e!pectant management if uncomplicated 3no

hypotension tachycardia fever leukocytosis signs of acute abdomen

or ;2 suspicious for malignancy5 surgical management if

complicated

0ognosis-Risk of torsion if large or penduculated

-ot associated with

ovulation

Types

-Dermoid cysts 3teratomas5%

contains developmentally

mature skin and sometimes

hair bone nails teeth

other tissue

-Endometrioma 3chocolate

cyst5% related to

endometriosis

-2erous or mucinouscystadenomas

Signs & Symptoms

-)an be

asymptomatic

-Adne!al tenderness

"#n#gement

-2urgical e!cision

Ce2icitis

$tiologies

-+nfectious% chlamydia gonorrhea ,26 ,P6 trichomoniasis

Mycoplasma genitalium )*6 #6

-oninfectious% cervical cap pessary or diaphragm use

chemical or late! allergy cervical trauma

Signs & symptoms

-Postcoital spotting

-+ntermenstrual spotting

-Dyspareunia

-;nusual vaginal discharge

-+f chroniccervical stenosis leukorrhea granular redness

erythema vulvar irritation

-2alpingitis

-Edematous or friable cervi!

Wok!p

-2"+ testing

-Oet prep

-Pap M pelvic

Te#tment

-)hlamydiasingle a/ithromycin dose or do!ycycline

-Gonorrheaceftria!one +* or single cefi!ime oral dose

-,26acyclovir

29


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-"richomoniasissingle metronida/ole

0el2ic Infl#mm#toy Dise#se

-+nflammation of the uterus fallopian

tubes and9or ovaries and possibly

surrounding pelvic organs

-;sually polymicrobial with 2"+s

endogenous organisms

Risk #ctos

-*ultiple se! partners

-Douching

-2moking

Signs & Symptoms

-Pelvic or abdominal pain

-Painful defecation

-Abnormal vaginal bleeding

-Dyspareunia

-;terine adne!al or cervical motion

tenderness

-R;1 pain 3from perihepatitis5

-2igns of 2"+ infection

Wok!p

-"esting for G)

hlamydia ,+6 hep #

syphilis

-)ervical cultures

-h)G

-Pelvic ;2 if concern for

abscess

-)#)

-;A

"#n#gement

-+f no other cause of pelvic or abdominal pain can be found in a se!ually active

woman at risk for 2"+s always treat for P+D

-#egin antibiotic before cultures come back

-Admit for inpatient management if there is pregnancy nonresponse to oral

antibiotics inability to take P= severe illness or tubo-ovarian abscess

-=utpatient treatment of mild-mod P+D% ceftria!one +* do!ycycline

-+npatient treatment of severe or complicated P+D% +6 cefo!itin P=

do!ycycline

-"reat partners

0ognosis

-Risk for infertility increases with each episode

O2#i#n Tosion

-A gynecologic emergency caused by ovarian

ischemia as a result of complete or partial

rotation of the ovary on its ligamentous

supports

-allopian tube may also be torsioned

Risk #ctos

-=varian mass

-=vulation induction for infertility

Signs & Symptoms

-Acute pelvic pain 3although rarely can be

chronic pelvic pain5

-9v

-


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-#uilding collapse

-"rapped in machinery

-atural disasters

-*6)s

-Prolonged duration of wearing antishock garment

-+nability to move away from hard surface 3)6A )=

hypoglycemia fall etc5

paresthesias paralysis

"#n#gement

-A#)s

-)ardiac monitoring

-luid resuscitation

-Pain management

-*annitol% a non-osmotic diuretic to help wash myoglobin

out of renal tubules to protect kidneys

-)ompartment syndrome% fasciotomy hyperbaric o!ygen

0ognosis

-Degree of physiologic dysfunction is not related to time

elapsed before e!trication

#ct!es

0e'i#tic #ct!es Types of #ct!es Gene#l Infom#tion

31


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-#owing and greenstick f! are uni.ue to kids due to

their skeletal immaturity

-Growth plate f! are classified by 2alter-,arris

-*ost f! only re.uire closed reduction

-Kids heal faster due to more active periosteum and

higher cartilage

#ct!es Associ#te' 8it) C)il' A(!se

-*etaphyseal corner f!% child abuse until proven

otherwise

-Posterior rib f!% child abuse until proven otherwise-Any fracture in a child under C

9-


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Ankle #ct!e -+nvolves lateral medial or posterior

malleolus

-*=+% eversion or lateral rotation on the

talus

-"enderness in these areas suggests fracture vs strain

or sprain 3=ttawa ankle rules5

-=ttawa ankle rules help determine

need for !-ray

-2tandard AP and lateral views on

!-ray 3plus AP view with C(Z

internal rotation if suspecting ankle

fracture5

-Elevation and ice

-2hort leg cast

oot #ct!e -+nvolves talus calcaneus metatarsals or

phalanges

%nee #ct!es

#ct!e Type Infom#tion Signs & Symptoms Wok!p "#n#gement & 0ognosis

0#tell# #ct!e -*=+% direct blow -Knee pain difficulty walking

-2welling and bruising

-Aspiration will show hemarthrosis

with fat globules

-Point tenderness

-


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-*ortality &7-$( in the first year

-*a4ority will re.uire corrective surgery

#ct!e

Type

Infom#tion Signs & Symptoms Wok!p "#n#gement & 0ognosis

$6t#c#ps!l

#

-Does not affect blood supply to

femoral head B complications of

nonunion are rare

-2table vs unstable 3detached fragment

of lesser trochanter5

-,9o fall or trauma

-


35/59

the body

-!me#l

S)#ft

-"ypically from trauma in the elderly -E!tensive bruising of upper arm

-Orist drop from radial nerve damage

-Orist splinting and casting over site of

break

S!p#con'yl#

#ct!e

-Pediatric fracture

-;sually involves distal humerus

-


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Colles

#ct!e of

Dist#l R#'i!s

-*=+% ==2,posterior

displacement of wrist 3Tdinner fork

deformityU5

-)asting alone if nondisplaced

-)losed reduction followed by casting if

slightly displaced

-=R+ M short arm cast if displaced

Smit)

#ct!e of

Dist#l R#'i!s

-*=+% opposite )olles B fall on back

of hand

-=R+ M short arm cast

C)#!ffe!


37/59

Bo6et)

"et#c#p#l

-*=+% blow of closed fist againstanother ob4ect

-2plinting vs percutaneous pinning

Common #ct!es of t)e SpineSpon'ylolysis -2tress f! of pars

interarticularis usually


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Diffeenti#l

-*uscle strain

-=steoarthritis

-,erniated disc

-2pinal stenosis

-2ciatica

-2acroillitis

-Rheumatoid

arthritis

-*etastatic cancer

-)ompressionfracture

-=steomyelitis or

epidural abscess

-)auda e.uina

tumor

-+schial bursitis

-Piriformis

syndrome

-ibromyalgia

-Aortic aneurysm

-Duodenal ulcer

-Kidney stones

-Pyelonephritis-Pancreatitis

-Prostatitis

-,ip osteoarthritis

Re' l#gs fo Seio!s

$tiology

-"rauma

-;ne!plained weight loss

-Age : (7 or h9o

osteoporosis or prolonged

corticosteroids

-;ne!plained fever

-,istory of urinary or other

infections

-+mmunosuppression or D*-,9o cancer

-+6 drug use

-Age : J7

-ocal neuro deficits or

progressive or disabling

symptoms

-Duration : H weeks

-Prior surgery

-ighttime pain

-#ladder dysfunction

-2addle pattern anesthesia

0)ysic#l $6#m-+nspect gait and spinal

motion

-2pinal palpation

-2traight leg raise test

-Peripheral pulses

-ocused neuro e!am

-"esting of


39/59

Stoke-An acute neurological deficit of vascular etiology with symptoms lasting : &' hours-*ore prevalent in the Tstroke beltU in 2E ;2

Diffeenti#l; transverse myelitis #ell0s palsy Gullain-#arre myasthenia gravis "+A

Types of Stoke

-emo)#gic Isc)emicAccounts for C(-&7 of strokes

0#enc)ym#l IC-

-#leeding within the brain itself-Primary if due to spontaneousrupture of small vessels damaged

by chronic ," or amyloidangiopathy

-2econdary if due to traumavascular abnormalities tumorsimpaired coagulation or vasculitis

-Presentation will be severe ,"bad ,A n9v focal neuro deficits

-+f in thalamus or basal ganglia

contralateral motor and sensorydeficit aphasia language or spatial neglect depressed


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-An acute focal neurologic deficit as a result of

ischemia that resolves within &' hours

-)an be caused by brain spinal cord or retinal

ischemia

Diffeenti#l

-2ei/ure

-*igraine with aura

-2yncope

-,ypoglycemia

-Encephalopathy-*ultiple sclerosis

Wok!p

-)#) #*P to r9o metabolic causes

-


41/59

-Represents an infection of the arachnoid mater and )2 Signs & Symptoms

-#acterial% fever nuchal rigidity A*2 severe ,A

-


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-Represents an infection

of the brain itself

-*ay be primary or

postinfectious

Diffeenti#l

-*eningitis

-*eningoencephalitis

-2troke

Agents

-,26

-Rabies virus

-O6

Signs & Symptoms

-ever

-,eadache

-


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$pi'!#l -em#tom#-Due to tearing of middle meningeal

artery

-Rarely seen in kids > & and in the

elderly as the dura is firmly attached in

these ages

Signs & Symptoms

-,A vomiting confusion9lethargy

aphasia sei/ures hemiparesis

-;nconsciousness abnormal pupil

reactions to light or abnormal posturing

due to compression of ) by hematoma

-;sually coe!ists with a skull fracture

Wok!p

-oncontrast head )" shows hematoma that

does not cross suture lines brain parenchyma

may be compressed to the midline

"#n#gement

-;sually re.uires craniotomy with evacuation of bleed

St#t!s $pileptic!s

-2ingle unremitting sei/ure with duration : (-C7 minutes or fre.uent sei/ures w9o interictal

return to baseline clinical state

C#!ses

-oncompliance with antiepileptic drug regimen

-Drug or Et=, withdrawal

-Acute brain in4ury or infection

-*etabolic disturbances

Wok!p

-2imultaneous assessment M treatment

-)areful neuro e!am for any focal deficits

-EEG

"#n#gement-


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-ormal physical activity does not aggravate

Oith tension and migraine headaches watch for signs of hemicrania continua 3daily unilateral headache with miosis ptosis eyelid edema lacrimation nasal congestion rhinorrhea5 which can

transform from migraine or tension headaches and is prompted by medication overuseF responds only to indomethacin

"ig#ine -e#'#c)e

-,ighest prevalence in &(-'( year olds with decreased

incidence during childbearing years-*ay have genetic component incurring

hypercoagulability

-,igh incidence of comorbid depression

-Precipitators% stress hormones hunger sleep

deprivation odors smoke alcohol meds high

tyramine foods

-,igh incidence of P= with migraines with aura

Signs & symptoms

-*ay have prodrome of sensitivity to touch or

0)#m#cologic T)e#py

A(oti2e .onopioi's% 2A+Ds acetaminophen rectal indomethacin +* ketorolac E!cedrin migraine

Tipt#ns;constrict intracranial bood vessels interrupt pain transmission centrally

-ever use during an aura due to risk of stroke

-2umatriptan /olmitriptan 3wafer avail5 etcI

-AEs% parestesias di//iness flushing somnolence rebound ,A with overuse

$gots% direct smooth muscle vasoconstrictors non-selective (-,"C-R agonists

-Ergotamine

-Dihidyroergotamine% available as in4ection nasal rectal 2

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