IN-SERVICE EXAM REVIEW 2009 EMERGENCY MEDICINE

David Lee Pierce, M.D

Assistant Professor of Clinical Emergency Medicine University at Buffalo

Objectives
Review High Yield Material Pass the exam ****Gives me the chance to study and stay one step ahead of interns

Mesenteric Ischemia/Infarction
Elderly Atrial fibrillation Excruciating Abd Pain Abdominal Exam Relatively Benign (pain out of proportion to exam) Lactate Elevated Phosphate Elevated Leukocytosis > 15,000 Metabolic acidosis

 Diarrhea (no blood) Hiking

Giardia

Crampy abdominal pain Frothy awful smelling stool Flatulence Stool Ova/Parasites Most common cause of parasitic disease in US Rx
Flagyl

Diarrhea
1. 2. 3. 4. 5. 6. 7. 8. Shigella Salmonella E.coli 0157:H7 Campylobacter Yersinia enterocolitis C. Diff Staph Bacillus cereus 1. 2. 3. 4. 5. 6. 7. 8. Explosive diarrhea, seizures Eggs, poultry HUS,TTP, (beef or unpast. milk) #1 bacterial enteritis (Adults) Profuse watery diarrhea RLQ pain Hx of antibiotics #1 Food Poison, ham, mayo Fried rice

Diarrhea
1. Vibrio cholera 2. Vibrio parahemolyt. 3. Scombroid 4. 5. 6. 7. Ciguatera Entamoeba histolyica Giardia Cryptosporidium 1. Rice water diarrhea 2. Raw seafood 3. Histamine reaction, metallic, bitter or peppery taste 4. Hot/cold reversal, neuro findings 5. Liver abscess (Only 1/3 diarrhea) 6. Backpackers diarrhea 7. #1 chronic diarrhea AIDs

Ultrasound of Cholecystitis
Confirmatory Test? HIDA

Wall thickening > 3 mm

Stone

Sludge

Splenic injury
20 yo F s/p MVC 11th rib Fx on left LUQ Pain Left shoulder pain

Kehrs sign (Phrenic Nerve)

Most common organ injured in blunt abdominal trauma

Intussusception
1 mo male Soft tissue mass Colon cut-off Cyclical severe abdominal pain Vomiting Bloody stools (Current jelly) Dx/RX: Contrast Enema Most common cause of bowel obstruction in first 2 years

Colonic Cut-Off

Gastrointestinal Pearls
1. Level Cricopharyng. Muscle 2. #1 Level FB Child 3. Level Esophagus Terminates 4. #1 Level FB Adult 5. Globus hystricus 1. C6 2. C6 3. T11 4. T11 5. FB sensation throat

Gastrointestinal Pearls
1. Odynophagia 2. Dysphagia 3. Medication for Food Impaction 4. Size of Objects Require Removal? 1. PAIN with swallowing 2. DIFFICULTY swallowing 3. Glucagon (1mg IV2mg IV) 4. -5cm LONG -2cm WIDE -SHARP

Best Method Esophogeal FB Removal?

Button Batteries
1. Asymptomatic in stomach 2. In Esophagus 1. Observe/ Repeat Xray

2. Emergent Endoscopy (Perforation in 4-6 h) 3. Stop eating button batteries!!

3. D/C Summary Instructions

Foreign Body!!!
Whos your consultant? GI Esophageal FB

FB Throat
ENT Trachea GI Esophagus

Boerhaaves Syndrome
45 yo male Choking Vomits large piece steak Severe Chest Pain Unstable Stabilize Surgery

NG TUBE

Mallory-Weiss Tear
45 yo male ETOH Hiatal hernia Mult. Dry Heaves Mild hematemesis Vitals stable Rx:
Antiemetics PPI

Sigmoid Volvulus
Elderly schizophrenic Chronic severe constipation Abdominal Distention Bent Inner-Tube
Loop out of the left side of the pelvis and its superior aspect projects upward

Rx: NGT, Surgery

Cecal Volvulus
30 year old male Marathon runner Prior abdominal surgeries Sudden onset abdominal pain
COFFEE BEAN shape Several distended small bowel loops Rx: NGT, Surgery

Midgut Volvulus
Newborn Emesis Abdominal Distention Shock Birds Beak

Lower GI Bleeding
1. Elderly Lower GIB 1. Diverticulosis/ Angiodysplasia 2. Meckels Diverticulum 3. Esophageal Varices (Large volume) 4. Aortoenteric Fistula

2. #1 Congenital LGIB

3. Cirrhotic 4. AAA Repair then LGIB

SBO
50 yo female Hx 20 surgeries Hx Multiple Hernias Rx: ? NPO NGT Surgery Consult

Most Common Obstructions

1. Small Bowel Adhesions Hernias Neoplasm Inflammation (Crohns) Cancer Diverticulitis Volvulus

2. Large Bowel

Free Air Peritoneum Perforation PUD

Cardiac-Acute Coronary Syndromes EKG 101

Einhovens Triangle

Anterior/Septal STEMI

*
*
Note Reciprocal Changes (ST depression)

Anterior/Septal STEMI

Anterior V1-V4 Septal V1-V2 Left Anterior Descending (LAD)

Thrombus

Lateral Wall STEMI

Lateral Wall STEMI

(aVL, I, V5, V6) Circumflex Artery (Cx)

Lateral on Einhovens Triangle!

Wheres the Thrombus?

LAD + Cirx = Left Main (WIDOW MAKER) or 2 critical lesions

Inferior Wall STEMI

*Reciprocal Changes

Inferior Wall STEMI

(II,III,aVF) Right Coronary Artery

Inferior on Einhovens Triangle!

Posterior Wall STEMI

Posterior Wall STEMI V1 Large R (> S wave) ST Depression (Equivalent to STEMI)

Treatment: Same ACS Fluids (Gentle on NTG) Often Accompanies an Inferior Wall MI

Heart Block and ACS

1. Heart Block-Inferior MI 1. Second Degree Type 1 (Wenckebach)

2.

Heart Block-Anterior MI

1. 2.

2nd Degree Type 2 High Grade AV Block (Get Pacer Ready)

Aortic Pathology 101

Dissection Intimal tear Blood leaks into media Aneurysm (True Aneurysm) All 3 layers arterial wall Ruptured Aneurysm (Leaking Aneurysm)

Thoracic Aortic Dissection

60 yo smoker HTN Sudden tearing CP Crack Cocaine Radiates to his back

Cold Pulseless Arm DIASTOLIC Murmur EKG STEMI (Inferior) CTA Chest

Thoracic Dissection
Debakey Treatment Ascending Medical!! Surgical! Descending Medical!!

BBNitroprusside Stanford or Labetolol

(Prevent reflex tachycardia)

Ruptured AAA
80 yo Smoker HTN PVD Flank Pain Scrotal swelling Anesthesia Medial Thigh Pulsatile Mass Unequal pulses Hypotensive Airway IV T&C 10 Units Surgery

Hypertensive Emergencies
1. 2. 3. 4. HTN Encephalopathy HTN Aortic Dissection HTN Hemorrhagic CVA HTN with SAH 1. 2. 3. 4. BBNitroprusside or (Labetolol) BBNitroprusside or (Labetolol) Labetolol/ BB CCB (Nimodipine)

Hypertensive Emergencies
1. 2. 3. 4. HTN with ACS HTN Pulmonary Edema HTN Eclampsia Pheochromocytoma/MAOI 1. NTG, BB 2. NTG, Lasix, Morphine, CPAP 3. Magnesium, Hydralazine, BB 4. Phentolamine BB (No BB 1st-Unopposed alpha )

5.

HTN Cocaine Intoxication

5. BZD, IVF (Labetolol)

Hypothermia
Osborne (J) wave

Bidirectional VTach

Dig toxicity

Digoxin Toxicity
Yellow Halos Nausea/ vomiting

Dig bind criteria

1. 2. 3. 4. 5. K+ > 5.5 Cardiovascular collapse Blocks (Mobitz II , 3rd Degree) Ventricular Dysrhythmia Dig level >10

 Dig Toxic + Hyperkalemic

What medication contraindicated?

Calcium Gluconate/Chloride!!
Worsens intracellular Calcium derangement

WPW

SHORT PR

DELTA WAVE

Cardiac-Pacemaker

Pace Sense Trigger Program Shock

Cardiac-Pacemakers
Effect of magnet on: 1. Pacemaker 1. Resets to Fixed Rate

2. AICD

2. Turns it Off

Cardiac-AICD
#1 Electrolyte Abnormlality AICD Dsyrhythmias? Hypomagnesemia

Paddle over AICD during code?

Dont place close to the AICD generator

Most Specific Troponin

Trop I most specific (~100%)

Ventricular Dysrhythmias
Ventricular Fibriallation Arrest 1st Thing you do?

Shock

Torsades What now?

Magnesium IV Overdrive Pacing Isoproterenol

Multifocal Atrial Tachycardia

Multiple P Waves (Multiple Atrial Foci) P1 P2 P3

Pulmonary Disease (COPD)

Treatment: Treat Underlying Pathology (COPD)

Atrial Flutter

Saw-Tooth F-Waves

Supraventricular Tachycardia
Rhythm Breaks

SVT

NSR

PAC

PAC

Atrial Tachycardia
Stable SVT (AVNRT)
Vagal Maneuvers Adenosine 6mg 12mg 12mg CCB/BB

Stable AFib/ Aflutter

CCB/BB Amiodarone Ibitilide Anticoagulate Cardioversion

Unstable

Cardiomyopathy
1. Hypertrophic CM 1. Beta Blocker

2.

Restrictive CM

2.

Diuretics/ Digoxin

3.

Idiopathic Dilated CM

3.

Diuretics/ Digoxin/ Vasodilators

Tamponade
Becks Triad Hypotension Muffled Heart Sounds JVD Diff Dx Tension PTX Massive PE Acute Pulm Edema Severe Asthma

1. 2.

Disorder Pericarditis Tamponade (Stable Vitals) Hypotensive

Pericardial Disorders
Treatment ASA, NSAIDs IVF, Surgery Urgently (Window)

IVF, Inotropes, Pericardiocentesis, Surgery Emergently

Penetrating Chest Trauma ER Thoracotomy (No Vitals)

Electrical Alternans Tamponade/ Large Pericardial Effusion

Pneumococcal Pneumonia
Cough productive of rusty colored sputum Fever Single shaking chill
Lobar Infiltrate

Staph Pneumonia
Cough Fever Hemoptysis Recent Influenza Toxic appearance

Air Fluid Level

Legionella Pneumonia
Non-Productive cough Elevated AST/ALT Hyponatriema Gram stain with PMNs but no organisms
Relative Bradycardia (Despite Fever) Diarrhea (GI Symptoms)***

Mycoplasma Pneumonia
Non productive cough Clinically well appearing with awful CXR

Rx: Macrolide

Atypical Pneumonias
1. Legionella (Macrolide) 2. Mycoplasma (Macrolide) 3. Chlamydia (Tetracyclines/Macrolide)

Klebsiella Pneumonia
Alcoholic Cough Black/maroon sputum Abscess/ Empyema Gram (-) bacilli in pairs Rx:
Cephalosporin + AG

Weight loss SOB Cough Hypoxic

PCP Pneumonia

Bilateral Interstitial Infiltrates LDH Elevated Rx:

Bactrim Pentamidine Steroids if PaO2 < 70

Pneumonia with Abscess

1. Staph 2. Klebsiella 3. Pseudomonas

Upper lobe infiltrate? Think.

1. Aspiration 2. TB 3. Klebsiella

Peritonsillar Abscess
Sore throat Drooling Muffled Voice Organism? Polymicrobial (GABHS) Rx: Aspiration Abx (PCN, Clinda)

MEDIAL TO CAROTID!!

Ludwigs Angina
Sore throat Drooling Muffled Voice Swelling floor mouth Chest Pain Organism? Polymicrobial (aerobic-anaerobic) Rx: Airway! Airway! Airway! ENT ABX (clinda, unasyn)

Retropharyngeal/Prevertebral Abscess
Sore throat Drooling Muffled Voice Neck Stiff Extension more comfortable ENT IV ABX (clinda/ unasyn) Admit ICU
Greater than 6 mm prevert. tissue

ENT Trauma
Injury 1. 2. Nasal Septal Hematoma Ethmoid Fx (Cribiform Plate) Complication 1. 2. Avascular Necrosis CSF Rhinorrhea/ Meningitis

3.

Hematoma Auricle

3.

Cauliflower Ear

Septal Hematoma
Complication?
Septal Necrosis (cartilage death within 24 hours) Saddle nose deformity

Rx:
Surgical drainage, packing and antibiotics

Epistaxis
Frequent cause?

Epistaxis
Treatment 1. Blow Nose** 2. Topical Anesthetic (Lidocaine/Cocaine) 3. Vasoconstrictor (Neosynephrine) 4. Pressure 5. Evaluate

Anterior (90%) Murocele Rapid Rhino Cautery has high incidence return visits

Posterior (10%) Epistat ENT

Sinusitis
1. Most common site 1. 2.

Maxillary

2.

Cavernous Sinus thrombosis

Sphenoid (Ethmoid)

3.

Potts Puffy Tumor

3.

Frontal

4.

Periorbital/Orbital cellulitis

4.

Ethmoid

Angioedema Acute onset. Diagnosis?

Which is the most common medication that causes angioedema?

ACE inhibitors

Facial Fractures

Tripod Fracture
Punched in cheek Zygomaticofrontal Suture Zygomatic Arch

Flat cheek Infraorbital Foramen Periorbital swelling Diplopia Anesthesia of the cheek, upper teeth, lip and gums

Five clinical signs of basilar skull fracture

1. Periorbital ecchymosis (Raccoon eyes) 2. Retroauricular ecchymosis (battles sign) 3. CSF Otorrhea or rhinorrhea 4. Hemotympanum 5. CN I, II, VII, or VIII deficits

Ellis Type III Dental Fracture

Broken tooth Blood on tooth (pulp involved)

Rx? Calcium Hydroxide Paste

Seat Belt Injuries

Rectus Sheath Hematoma Chance Fx

Intestinal Perforation

Trauma Pearls
1. 2. 3. 4. 5. 6. You see Blunt Abd. Trauma Penetrating Abd. Trauma Ustable after MCV/ Fall Sternal Fracture Pelvic Fracture Lap Belt Mark 1. 2. 3. 4. 5. 6. Think Spleen Laceration Liver Laceration Traumatic Aortic Rupt Myocardial Contusion Bladder Injury Jejunal/Mesenteric Lac.

Painful ulcer Chancroid

Friable Jagged edges Inguinal Bubos Etiology
H. Ducrei

Rx?
Azithro 1 gram or CTX 250 mg IM

Molar pregnancy
10 week preg Hyperemesis HTN (Preeclampic Sx) Uterus is larger than expected B-HCG is higher than expected Ultrasound = snowstorm appearance

Abruptio Placenta
Painful bleeding during 3rd trimester Severe Abdominal Pain Hypotensive Smoked Crack

OB Deliver

Pre-Eclampsia
3 rd Trimester Hypertension Proteinuria Edema Hypertriglyceridemia Treatment
Hydralazine Labetalol MgSO4 (eclampsia)

Trichomonas Vaginitis
Strawberry cervix Profuse, yellow-green discharge Rx:
Flagyl

STD
1. Strawberry cervix 1. Trichomonas

2.

Painful necrotic ulcer

2.

Chancroid

3.

Painless indurated ulcer 3.

Primary Syphilis

1.

Beefy-red, velvety ulcers 4.

Granuloma Inguinale

Toxicology - Antidotes
1. 2. 3. 4. 5. 6. 7. 8. Acetaminophen Beta blockers Bromides CCB Carbon monoxide Cholinergics Cyanide Digoxin 1. 2. 3. 4. 5. 6. 7. 8. NAC Glucagon Chloride (NSS) Calcium, glucagon O2 Atropine, pralidoxime Nitrate, thiosulfate Digibind

Toxicology - Antidotes
1. Methanol 2. Ethylene glycol 3. Iron 4. Isoniazid 5. Lead 6. Arsenic 7. Mercury 8. Nitrites 9. Opiates 10. TCA 11. Warfarin 1. ETOH, 5MP, dialysis 2. ETOH, 5MP, dialysis 3. Defuroxime 4. Pyridoxine, Vit B6 5. BAL 6. BAL 7. BAL 8. Methylene Blue 9. Narcan 10. Sodium Bicarbonate 11. Vit K, FFP

Drugs that are Radioopaque

CHIPES
C = Chloro Hydrate H = Heavy Metals I = Iron P = Phenothiazines E = Enteric Coated S = Solvents

Drugs that are Dialyzable

BLIST MED 1. 2. 3. 4. 5. 6. 7. 8. Barbituates Lithium Isoniazide/Iron Salicylates Theophyline Methanol Ethylene Glycol Depakote

Charcoal
Useless
Lithium Alkali/Acids Heavy Metals Iron

Toxic Overdoses
1. Phenytoin 2. Iron 3. Lithium 4. NMS 5. Wernickes 1. Folate deficiency, osteomalacia, lupus like syndrome 2. Abdominal pain, hematemesis, coma and shock 3. Tremors, hyperreflexia, seizures, N/V/D 4. Altered MS, muscular rigidity, hyperthermia, rhabdo 5. Oculomotor deficits, ataxia, AMS

Caustics
Acid Ingestion Coagulation Necrosis Alkali Ingestion Liquefaction Necrosis (Worse/Deeper Burn)

Tylenol Toxicity (APAP)

1. 2. 3. 4. 5. Time 1st level Charcoal/Cathartic? Phases Poisoning? Toxic Metabolite APAP? Treatment? 1. 2. 3. 4. 5. 4 Hours After Ingestion Yes (<1 Hour) 4 Phases NAPQI NAC

Indication for Dialysis

A E I O U Acidosis Electolytes Ingestions (Toxins) Overload (Fluid) Uremic Symptoms

Rotator Cuff Tears

Subscapularis Supraspinatus Infraspinatus Teres minor Most Commonly Injured?
Supraspinatus*

Nerve Injury with Fractures

1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. Humeral Shaft Elbow Fx Shoulder Dislocation Colles/Smiths Fx Sacral Fx Acetabular Fx Posterior Hip Dislocation Anterior Hip Dislocation Femoral Shaft Fx Knee Dislocation Lateral Tibial Plat. Fx

Fracture

Nerve Injured

1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11.

Radial Median/Ulnar Axillary Median Cauda Equina Sciatic Sciatic Femoral Peroneal Peroneal/ Tibial Peroneal

You See 1. Scapular Fx 2. Supracondylar Fx 3. High-Pressure Injection (grease/paint gun)

Think 1. Associated Injuries 2. Volkmanns Ischmic Contracture 3. Consult ortho immediately despite benign exam initially (amputation!!!)

4. Ortho Consult (OR 4. Flexor Tendon Injury repair) Finger (FDP)

Compartment Syndrome
Pain out of proportion to injury (earliest sign) Paralysis Parasthesia Pulselessness Poikilothermia Pallor

Normal Pressure = 10 mmHg Abnormal >30 mmHg

Lisfrank Fracture
Fracture dislocation at the base of the 2nd metatarsal
Unstable fracture Keystone of Midfoot Requires ORIF

Jones Fracture
Fx 5th Metatarsal High incidence of delayed/nonunion

Amputated Digits
Wrap Sterile Gauze moistened with NS Place in water-tight container Place container in ice water

Dont Submerge in Ice Water!!

Anterior Hip Dislocations (10%)

ABducted Externally rotated Flexed Complication: Femoral Vein/Artery thrombosis Pulm Embolus

Posterior Hip Dislocation (90%)

Flexed Knee strikes dashboard Short ADDucted Internally rotated Flexed Avascular necrosis Femoral Head

Scaphoid Fracture
Proximal or Distal Worse? Proximal (Blood supply is distal)

Complication?
Avascular Necrosis

Thumb spica if unsure!

Bucket Handle Fracture

R/O Child Abuse!

Galeazzi Fracture

Distal Radioulnar dislocation

Distal Radial Shaft ORIF

Monteggias Fracture
Fracture Proximal 1/3 Ulna Dislocation radial head Draw line radial shaft Should interect the capitellum ORIF

Colles Fracture

Maisonneuve Fracture

Consult or send home with splint? Consult! (High energy injury)

Maisonneuve Fracture

Felon
Staph Aureus I&D ABX

Flexor Tenosynovitis
Organism? Rx?

Staph/Strep

Hospitalization Ortho IV ABX (PCN/Cephalo)

Bells Palsy (CN 7 lesions)

Peripheral Unable to wrinkle forehead on same side Rx? Steroid burst Acyclovir Eye patch Central Able to move forehead on same side Dx? Brain Imaging (MRI) Bilateral Bells Palsy Caused by? Lyme Disease

Jeffersons Fracture (C1 Blowout Fracture)

Hangmans Fracture (C2)

Bilateral C2 Pedicle Fractures Mechanism--Ext/Flex?
Hyperextension!

Anterior Cord syndrome

Motor paralysis distal to the lesion Loss of pain and temperature Retention of posterior cord function
Vibration Proprioception

Flexion Injury

Central Cord Syndrome Paralysis

Extension Injury
Upper > Lower Extremities

Distal > Proximal Clumsy Hands

Brown Sequard Syndrome

Penetrating injury Ipsilateral loss of motor, position, vibration, touch Contralateral loss of pain and temperature

Cauda Equina Syndrome

Lower back pain Hyporeflexia Asymmetric finding Saddle anesthesia Decreased rectal tone MRI Neurosurgery

In what situation is an MRI the emergent study of choice for back pain?
Cauda Equina Spinal Epidural Abscess

Trigeminal neuralgia
Facial pain (right side more common) Electrical shock like Lancinating pain Treat: Tegretol

Pontine hemorrhage
Pinpoint pupils Occipital Headache Hyperventilating Coma Decerebrate posturing

Anterior Cerebral Artery Infarct

Contralateral Paralysis
Legs >> arms

Gait disturbance

Middle Cerebral Artery

Contralateral paralysis Arms >> legs Expressive aphasia #1 CVA

Subdural
HA Decreased LOC Crescent shape on CT Airway! Neurosurgery Reverse Anticoagulation

Epidural
Head Trauma Brief LOC HA Lenticular shape lesion Temporal/Parietal skull fx Airway! Manage BP Neurosurgery Reverse Anticoagulation

Temporal arteritis
> 50 yrs old Eye pain Temporal HA Malaise Blood Test: ESR What is the most common complication? Blindness Management? Prednisone/Biopsy

Associated with Dz:

Polymyalgia rheumatica

Multiple Sclerosis
Optic neuritis Sensory symptoms that dont follow a pattern Female in 30s with bizarre neuro findings

Double vision on lateral gaze

Kidney Stones
<4 mm will pass 95% 4-6 mm will pass 50% >6 mm will pass 10%

Fourniers Gangrene
Immunocompromised Diabetic Polymicrobial (anaerobes)

Treatment:
IVF Broad spectrum antibiotics Surgical debridement

Erythema Multiforme (Minor)

Mycoplasma Malignancy Drugs (SOAP)
S = Sulfa O = Oral hypoglycemic A = Anticonvulsants P = PCN

Stage I Lyme Disease

Annular erythematous lesion Spares palms and soles Associated with arthritis Erythema chronicum migrans Rx? Doxycycline

Retinal Artery Occlusion

Sudden painless monocular loss of vision Marcus-Gunn pupil Cherry red spot Rx: Digital massage Cycloplegics Acetazolamide Ophtho
Dilated pupil unreactive to direct, reactive to indirect light

Diagnosis?

Papilloedema

 Localized whitish corneal infiltrate Organism?

Pseudomonas

Corneal Ulcer

Rx:
Ophtho consult Antibiotics (Cipro) No contact lenes

Pterygium

Diagnosis?
Hypopyon

Normal IOP

10- 21 mm hg

Retinal Detachment
Painless loss vision Flashes of light Floaters Lowering of a curtain

Associated with: Myopia Trauma Marfans

Horners Syndrome
Ptosis Miosis Anhydrosis Facial flushing Iris Heterochromia

Eye findings in a PCP Overdose?

Rotary nystagmus

Ramsey-Hunt Syndrome
Vesicular rash Ear/ TM Bells palsy Loss of taste Caused by?
Herpes Zoster

Electrical Shock
AC (Alternating) Vfib
Household and commercial Explosive exit wounds Worse effects with equivalent voltage

DC (Direct) Asystole
Industrial, batteries, welding supplies Produces discrete exit wounds