Author: Zack (Page 3 of 8)

NBME Shelf Review (Part 9) – Cardiopulmonary

Pulmonary Embolism
  • Three types of pulmonary embolism
    • “Massive”
      • Hypotension or severe bradycardia
        • Treat with tPA or thrombectomy
    • “Submassive”
      • Normotensive but with Right Heart Strain
      • S1Q3T3 on EKG
      • Elevated BNP
      • Elevated troponin
      • Dilation of RV on ultrasound
        • Treat with heparin/lovenox and admit
    • “Low Risk”
      • Treat with anticoagulation
      • Outpatient vs inpatient treatment
  • Testing
    • CTA of the Chest
      • If severe contrast allergy or other contraindication
        • Ventilation/Perfusion (V/Q) Scan
Inferior STEMI
  • EKG shows ST elevation in 2, 3, aVF
  • Can involve AV node (bradycardia)
    • Avoid beta blockers
    • Treat with atropine
  • Can involve RV (preload dependent)
    • Avoid nitroglycerine
    • Treat with fluids
Common to Nitroglycerine
  • Hypotension
  • Current sildenafil usage
Aortic Dissection
  • Type A (ascending) Dissection
    • Surgical emergency
  • Type B (descending) Dissection
    • Medical management
  • Testing
    • CTA of the chest
    • Chest X-Ray SOMETIMES shows a widened mediastinum
  • Treatment
    • Esmolol (decrease heart rate)
    • Labetelol (decrease blood pressure)
  • PEARL: Aortic dissection can cause STEMI
Heart Failure
  • Treatment
    • Diuresis
    • Nitroglycerin
    • BiPAP
  • If patient needs fluids
    • Decrease size of fluid bolus
COPD
  • Treatments
    • Albuterol/Ipratropium
    • Antibiotics
    • Steroids
    • BiPAP
Pneumonia
  • If alcoholic/homeless/dementia/parkinson’s
    • Treat for aspiration (anaerobes)
  • If recent hospitalization/ventilator
    • Treat for pseudomonas and MRSA
  • If pneumonia PLUS atypical symptoms
    • Treat for legionella
  • If recent influenza
    • Treat for MRSA
Additional Reading

NBME Shelf Review (Part 8) – Abdominal Pain

Acute Mesenteric Ischemia
  • History of atrial fibrillation
  • “Pain out of proportion to exam”
Bowel Obstruction
  • History
    • Abdominal pain
    • Bloating/Distention
    • Vomiting
    • Decrease stool/flatus
  • Exam
    • Abdominal tenderness and distention
    • If guarding/rigidity/rebound tenderness (aka peritonitis)
      • Consider perforated bowel
  • Testing
    • Obtain CT abdomen with IV contrast
  • Treatment
    • Fluids
    • NPO
    • NG Tube
Acute Diverticulitis
  • NOTE: DiverticulOSIS is what causes GI bleeding
  • History/Exam
    • Fever
    • Left lower quadrant pain/tenderness
  • Testing/Treatment
    • CT abdomen with IV contrast
    • Liquid diet
    • Antibiotics
  • Complications
    • Abscess
    • Stricture
    • Fistula
    • Perforation
    • Obstructions

Abdominal Aortic Aneurysm

  • If suspected, perform bedside ultrasound of the abdomen
    • Aortic diameter >3 cm
Spontaneous Bacterial Peritonitis
  • Diagnose by performing a paracentesis
    • Look for >250 white blood cells
  • Treat with ceftriaxone

Kidney Stones

  • CT without contrast
  • If the stone is <5mm
    • Treat with analgesics and tamsulosin
  • If the stone is >5mm
    • Consult urology
Common Indications for Emergency Dialysis
  • Mnemonic: AEIOU
    • Acidosis (pH <7.1)
    • Electrolytes (K > 6.5)
    • Intoxication
      • Lithium
      • Ethylene Glycol
      • Methanol
      • Aspirin
    • Overload of volume resistant to diuresis
    • Uremia that is symptomatic
      • Altered mental status
      • Pericarditis
Ectopic Pregnancy
  • Testing
    • BhCG QUANTITATIVE
    • Type and screen for Rh Status
    • Pelvic ultrasound
      • IUP = Gestational sac PLUS a Yolk sac
      • Beware “heterotopic” pregnancy in fertility treatment patients (IVF)
    • Treatment
      • If no IUP visualized, ectopic pregnancy is a possibility, and management depends on hCG
        • If <1500
          • Consider sending stable patients home and repeat hCG in 48 hours
        • If >1500
          • Ectopic until proven otherwise, consult OBGYN
      • Rh- needs RhoGAM
        • Prevents complications in future pregnancies
Additional Reading

NBME Shelf Review (Part 7) – Abdominal Pain

Hernia
  • 3 classifications for hernia
    • Reducible
      • Able to be reduced (placed back into the abdomen) at bedside
    • Incarcerated
      • Cannot be reduced but not severely tender or erythematous
      • Can occasionally cause bowel obstructions
    • Strangulated
      • Cannot be reduced but LOSING BLOOD SUPPLY
      • Extremely tender and abnormal exam
      • Needs emergent surgical consult
Esophageal Varices
  • Classic presentation
    • Hematemesis/Melena
    • Chronic liver disease (hepatitis, alcoholics)
  • Treatment
    • Fluid bolus if hypotensive
    • Octreotide
    • Ceftriaxone
    • Transfuse blood as needed
      • If hemoglobin <7 transfuse
      • If patient actively bleeding and level <8 transfuse
  • Consult GI for endoscopy
Hepatic Encephalopathy
  • Common findings
    • Altered mental status
    • Asterixis
    • Elevated ammonia level
  • Treat with lactulose or rifamixin
Peptic Ulcer Disease
  • History
    • Hematemesis or Melena
    • Epigastric abdominal pain
    • Chronic NSAIDS or steroids
  • Treatment
    • PPI (such as pantoprazole)
      • Works better than an H2 blocker
Cholecystitis
  • RUQ ultrasound
    • Thickened gallbladder wall
    • Distended gallbladder
    • Pericholecystic fluid
    • Obvious impacted stone
  • HIDA scan
    • Inject radioactive material
    • Absorbed by hepatocytes
    • Secreted into biliary tree into small intestine
      • If gallbladder not visualized
        • Cystic duct obstruction
      • If common bile duct cannot be visualized
        • Choledocolithiasis
Ascending Cholangitis
  • Charcots Triad
    • Fever
    • RUQ Pain
    • Jaundice
  • Patient requires ERCP (gastroenterology consult)
  • Give antibiotics
Acute Pancreatitis
  • Diagnosis
    • Classic description
      • Epigastric pain radiating to back
      • Severe vomiting
    • Lipase
      • >3x upper limit of normal is diagnostic
    • CT scan to look for complications of pancreatitis
Additional Reading

NBME Shelf Review (Part 6) – Common Arrhythmias

“Unstable” Arrhythmias
  • Arrhythmias that cause
    • Hypotension
    • Pulmonary Edema
    • Chest Pain
    • Altered Mental Status
Supraventricular Tachycardia (SVT)
  • Stable
    • Vagal maneuver
    • Adenosine
    • Beta blocker or calcium channel blocker
  • Unstable
    • SYNCHRONIZED cardioversion
Monomorphic Ventricular Tachycardia (VT)
  • Stable
    • Amiodarone
    • Procainamide
    • Lidocaine
  • Unstable
    • SYNCHRONIZED cardioversion
  • Pulseless
    • Defibrillation

Polymorphic Ventricular Tachycardia (aka Torsades de Pointes)

  • Known complication of prolonged QTc
    • Side effect of multiple medications
      • Antipsychotics
      • Methadone
      • Ondansetron
  • Give Magnesium Sulfate
High yield EKG patterns
  • Long QTc
  • Wolf Parkinson White (WPW)
  • Brugada Pattern
Atrial Fibrillation
  • Stable
    • Patient presents immediately after onset (<24-48 hours)
      • Synchronized cardioversion
      • Rhythm control medications
        • Amiodarone
        • Procainamide
        • Flecanide
  • Patient does not present immediately (or unknown onset)
    • Rate control
      • Beta blockers
        • Metoprolol
      • Calcium channel blocker
        • Diltiazem
    • Anticoagulation (heparin)
  • Unstable
    • Synchronized cardioversion
  • Atrial fibrillation with extremely fast rate (200+) is common in WPW
  • Atrial fibrillation with slow rate is common with Digoxin toxicity
Bradycardia
  • AV Blocks
    • 1st Degree
    • 2nd degree (type 1)
    • 2nd degree (type 2)
    • 3rd degree
  • If symptomatic and stable…
    • Atropine
  • If they become unstable…
    • Transcutaneous or transvenous pacing
Additional Reading

NBME Shelf Review (Part 5) – Ophthalmology and Toxicology

Corneal Abrasion
  • Stain the eye with fluorescein and use woods lamp
    • Look for fixed staining (“uptake”) on the cornea
Acute Angle Closure Glaucoma
  • Symptoms
    • Eye Pain
    • Headache
  • Check for intraocular pressure greater than 20
  • Commonly precipitants
    • OTC cough/cold medicine (anticholinergic effect)
    • Dark environment (such as movie theater)
  • Treatment
    • Timolol
    • Pilocarpine
    • Acetazolamide
    • Apraclonidine
Giant Cell Arteritis
  • Common features
    • Severe headache
    • Tenderness of the Temporal Arteries
    • Jaw claudication
    • Elevated ESR (“sed rate”)
  • Treat with steroids
Anterior Uveitis
  • Painful red eye
  • Cell and flair on slit lamp examination
UV Keratitis (“snow blindness”)
  • Common in skiers/snowboarders
  • Diagnose with fluorescein and use woods lamp
    • Punctate lesions on the cornea
Common Poisons/Antidotes
  • Digoxin toxicity
    • Digibind
  • Acetaminophen toxicity
    • N-Acetylcysteine (NAC)
  • Ethylene glycol or methanol toxicity
    • Fomepizole
  • Jimson weed (anticholinergic toxicity)
    • Physostigmine
  • Organophosphate toxicity
    • Atropine
      • Treat until airway secretions have stopped
    • Pralidoxime
  • Opiate toxicity
    • Naloxone
  • Benzodiazepine
    • Flumazenil (falling out of favor)
  • Cocaine toxicity
    • DON’T give beta blockers
      • Unopposed alpha effect
      • Very little data to support this but commonly believed
  • Iron toxicity
    • Deferoxamine
  • Salicylate overdose
    • Sodium bicarbonate
    • Dialysis
  • Tricyclic antidepressent
    • Sodium bicarbonate
  • Beta blocker overdose
    • Glucagon
    • Calcium channel blocker overdose
    • Glucagon
    • IV Calcium
    • High dose euglycemic insulin therapy
  • Sulfonylurea overdose
    • Octreotide
    • Dextrose
  • Heparin reversal
    • Protamine sulfate
  • Cyanide toxicity (common in house fires)
    • Hydroxocobalamin
    • Sodium Nitrite
  • Carbon monoxide toxicity
    • Oxygen oxygen oxygen
    • Hyperbaric oxygen
      • BEWARE: pulse oximetry will be normal
  • Valproic acid toxicity
    • L-carnitine
Additional Reading

NBME Shelf Review (Part 4) – Environmental

General Bite Wound Management
  • Irrigate thoroughly
  • Update tetanus
  • LOW RISK bites get sutured
    • High risk bites to cosmetic areas (face) get sutured AND antibiotics
    • High risk bites to non-cosmetic areas are left open AND get antibiotics
Rabies
  • Give vaccine if…
    • ANY suspicion for bat bite (bat in room, cave, etc)
    • Bite by wild animal that can’t be monitored
    • Bite by domestic animal that develops symptoms during observation
Black widow spider
  • Painful bite
  • Symptoms
    • Abdominal pain
    • Diaphoresis
    • Myalgias
    • Muscle spasms/cramping
  • Supportive care
Pit Viper Bite
  • Causes Coagulopathy/DIC
  • Swelling around bite site
  • Treat with CroFab antivenin
Brown Recluse Bite
  • Painless bite
  • Ulceration/necrosis around bite site
Altitude Illnesses
  • Acute Mountain Sickness (AMS)
    • Headache
    • Nausea and vomiting
    • Treat with acetazolamide or decent
  • High Altitude Pulmonary Edema (HAPE)
    • Shortness of breath
    • Treat with supplemental oxygen and immediate decent
    • Consider nifedipine or sildefenil
  • High Altitude Cerebral Edema
    • Ataxia
    • Confusion
    • Cushings reflex
      • Bradycardia
      • Hypertension
      • Cheyne-Stokes respirations
    • Treat with supplemental oxygen and immediate decent
    • Consider dexamethasone
Digit Amputation
  • Wrap in saline soaked gauze
  • Put in plastic bag
  • Place on ice
  • Send to surgeon
Tooth avulsion
  • Reimplant tooth in socket
  • Place in glass of milk
Frostbite
  • Remove wet clothing
  • Rewarm at body temperature
Additional Reading

NBME Shelf Review (Part 3) – Pediatrics

Febrile Seizures
  • Simple (All features must be present)
    • Age 6 months – 5 years
    • Febrile
    • Lasts less than 15 minutes
    • Only one seizure in 24 hour period
    • No focal neuro deficits on exam
    • Generalized seizure (must have LOC)
      • Treat with acetaminophen and reassurance
  • Complex
    • Does not meet ALL of the criteria for a simple febrile seizure
      • Consider full workup including lumbar puncture
Pediatric Abdominal Pain
  • Intussusception
    • Classic history
      • Severe emesis
      • INTERMITTENT severe abdominal pain
    • Common causes
      • Meckles diverticulum
      • Henoch-Schonlein purpura
    • Diagnose with abdominal ultrasound
      • Look for target sign
    • Treat with air enema
  • Malrotation with Volvulus
    • Classic symptoms
      • Bilious emesis
      • Projectile
      • CONSTANT severe abdominal pain
      • Peritonitic abdominal exam
    • Common tests (if stable)
      • Upper GI Series
        • Corkscrew sign
        • Coffee-bean sign
  • Necrotizing Enterocolitis
    • Classic symptoms
      • Premature neonate
      • Bloody stool
    • X-Ray shows pneumotosis intestinalis
      • (Air in the bowel wall)
  • Hirschsprungs Disease
    • Delayed passage of meconium
    • Diagnosis
      • Contrast enema (not typically done in ED)
        • Look for distal transition point
      • Rectal suction biopsy (DEFINITELY not done in the ED)
        • Gold standard for diagnosis
Bronchiolitis
  • Commonly caused by RSV
  • Initial fever and URI
    • Progresses to respiratory distress
Croup (laryngotrachealbronchitis)
  • Commonly caused by parainfluenza
  • Initial fever and URI
    • Progresses to stridor
    • Barky cough
  • Neck xray will show “steeple sign” (subglottic narrowing)
  • Treatment
    • Steroids
    • Nebulized epinephrine
Epiglottitis
  • Commonly caused by Haemophilus influenzae 
  • Classic symptoms
    • Fever
    • Sore throat
    • Drooling
    • Muffled voice
  • Treatment
    • Keep the child calm
    • Intubation in a controlled environment
    • Antibiotics
Additional Reading

NBME Shelf Review (Part 2) – Trauma

Penetrating Abdominal Trauma
  • Anything below the 4th intercostal space (nipple) is potentially an abdominal injury
    • Gunshot wounds to the abdomen
      • Needs immediate exploratory laparotomy
    • Stab wounds to the abdomen
      • Needs immediate exploratory laparotomy IF…
        • Hemodynamically unstable
        • Peritonitis on exam (rebound, rigidity, guarding)
        • Organs hanging out of abdomen
Blunt Abdominal Trauma
  • If the patient is unstable
    • Perform FAST exam
  • If the patient is stable
    • CT scan of the abdomen/pelvis with contrast
Basilar Skull Fracture
  • Bilateral post-auricular ecchymosis (Battle’s Sign)
  • Raccoon eyes
  • Hemotympanum
  • Otorrhea/Rhinorrhea
Tension Pneumothorax
  • Classic findings
    • Hypotension
    • Obstructive shock
    • Absent breath sounds
    • Jugular vein distension (JVD)
  • Treatment
    • Needle decompression
      • 2nd intercostal space
      • Mid-clavicular line
    • Tube thoracostomy
Hemothorax
  • Hypotension
    • Hemorrhagic shock
  • Absent breath sounds
  • NO jugular vein distension
Cardiac Tamponade
  • Beck’s Triad
    • Hypotension
      • Obstructive shock
    • Jugular vein distension
    • Muffled heart sounds
  • Perform bedside ultrasound
    • Diastolic collapse of right ventricle (RV)
  • EKG
    • Electrical alterans
Traumatic Aortic Rupture
  • Rapid deceleration injuries
  • Tears at ligamentum arteriosum
  • Widened mediastinum on chest X-Ray
Pulmonary Contusion
  • Blunt chest trauma
  • Respiratory distress
    • NO paradoxical chest movement with breathing
  • Chest X-Ray
    • Shows non-lobar infiltrates
    • Located near location of injury
Additional Reading

NBME Shelf Review (Part 1) – General Concepts

General Approach to a Test Question
  • Read the last sentence of the question
  • Read the answer choices
  • THEN read the vignette
Common Scenarios with Quick Answers
  • Hypotensive patients
    • Give a fluid bolus
  • Altered mental status
    • Check a blood glucose
  • Hypoglycemia
    • Orange juice if can swallow safely
    • D50 if patient cannot swallow and mildly altered
    • IM glucagon if unresponsive
  • Patient with altered mental status and possible drug overdose
    • Give empiric naloxone
  • Female patients of childbearing age
    • Get a pregnancy test
  • If you need to give contrast for a CT scan (example CTA for pulmonary embolism)
    • Need renal function
Hyperkalemia
  • Common scenarios
    • Crush injury
    • Severe burns
    • End stage renal disease
    • Especially if missed dialysis
    • Leukemia on chemotherapy
  • Remember: Don’t give succinylcholine to a patient with hyperkalemia
  • Common EKG findings on test
    • Hyperacute T waves
    • Sinusoidal waves
  • Treatment
    • Stabilizes cardiac cell membranes
      • Calcium
    • Shifts potassium into the cells
      • Insulin/Glucose
      • Albuterol
      • Sodium Bicarbonate
    • Removes potassium
      • Furosemide
      • Dialysis
      • Kayexalate
Hypokalemia
  • EKG findings
    • Flattened T waves
    • QTC prolongation
    • U waves
  • At risk for ventricular arrhythmias
  • Treatment
    • Oral potassium replacement
    • IV potassium replacement
    • Consider magnesium replacement
Hyponatremia
  • Hypertonic saline IF
    • Comatose
    • Actively seizing
  • Otherwise treat with normal saline
  • Pseuohyponatremia
    • Correct the sodium if patient has severe hyperglycemia
    • Add 1.6 to sodium for every 100 glucose above normal limit
Hypercalcemia
  • Symptoms
    • “Stones, bones, groans, psychiatric overtones”
  • Treatment
    • IV fluids (promotes excretion) FIRST
    • Then calcitonin/bisphosphates
Torsade de Pointes
  • Common in patients with prolonged QTc
    • Hypokalemia
    • Hypocalcemia
  • Treat with magnesium
Additional Reading

When to Stop CPR

Why is this Important?
  • It is a poor stewardship of resources to continue a resuscitation when the prognosis is clearly dismal.
  • Hospitals need to steward their resources to distribute equitable care between its patients
When is it Appropriate to Stop CPR on a Pulseless Patient?
  • Patient shows signs of irreversible death
    • Rigor mortis
    • Decapitation
    • Rotting/decaying
  • Patient has dismal prognosis (3 studies discuss this)
    • Implementation of the universal BLS termination of resuscitation rule in a rural EMS system
      • Non-EMS witnessed arrest
      • No return of spontaneous circulation prior to transport
      • Only non-shockable rhythms present
    • Early identification of patients with out-of-hospital cardiac arrest with no chance of survival and consideration for organ donation
      • Non-EM witnessed arrest
      • Non-shockable INITIAL rhythm
      • No ROSC despite 3 doses of epinepherine
  • Duration of pre-hospital CPR and favorable neurologic outcomes for pediatric out-of-hospital cardiac arrests. A nationwide, population based cohort study
    • Less than 1% chance of recovery after 46 minutes of resuscitation
Additional Reading
  • Jordan MR, O’keefe MF, Weiss D, Cubberley CW, Maclean CD, Wolfson DL. Implementation of the universal BLS termination of resuscitation rule in a rural EMS system. Resuscitation. 2017;118:75-81.
  • Jabre P, Bougouin W, Dumas F, et al. Early Identification of Patients With Out-of-Hospital Cardiac Arrest With No Chance of Survival and Consideration for Organ Donation. Ann Intern Med. 2016;165(11):770-778.
  • Goto Y, Funada A, Goto Y. Duration of Prehospital Cardiopulmonary Resuscitation and Favorable Neurological Outcomes for Pediatric Out-of-Hospital Cardiac Arrests: A Nationwide, Population-Based Cohort Study. Circulation. 2016;134(25):2046-2059.

Abdominal Aortic Aneurysm

Kidney Stones are a Diagnosis of Exclusion!!!

History
  • Risk factors
    • Age >60
    • Tobacco use
  • Classic presentations
    • Stable with sudden flank/back/abdominal pain or syncope
    • Unstable with pallor, hypotension, and ill appearance
Exam
  • Pulsatile abdominal mass
  • Unstable vitals
Testing Plan
  • Labs
    • TYPE AND SCREEN
    • CBC
    • Electrolytes
    • Coagulation studies
    • Lactic acid
  • Imaging
    • Bedside ultrasound (optimal)
      • Aorta protocol
        • Look for aorta >3cm
      • RUSH protocol
        • Mnemonic: HI-MAP
        • Heart
        • IVC
        • Morrisons Pouch (RUQ)
        • Aorta
        • Pulmonary
    • CT scan with IV contrast (less optimal)
Treatment Plan
  • 2 Large bore IVs (16G)
  • Massive transfusion protocol
    • PRBCs
    • Platelets
    • Fresh Frozen Plasma
  • Blood pressure management
    • Goal Systolic ~100
    • Goal MAP ~60-65
Clerkship Pearls
  • Put AAA in your differential during your presentation for all older patients with back/flank pain
  • Attempt to perform a bedside ultrasound of the aorta OR find recent CT of the abdomen with normal sized aorta
Additional Reading

Testicular Torsion

Kidney Stones are a Diagnosis of Exclusion!!!

Introduction
  • Testicular torsion is a time sensitive diagnosis (risk of infertility, etc)
  • Commonly mimics kidney stones
History
  • Sudden onset pain
    • Epididymitis tends to be slower in onset
  • Flank/lower abdomen/scrotal pain
  • Frequently causes vomiting
  • Uncommon in geriatric patients
Exam
  • Perform a GU exam and look for
    • Unequal/horizontal “lie”
    • Testicular tenderness
    • Swelling
    • Absent cremasteric reflex
Testing Plan
  • Testicular/Scrotal Ultrasound
  • Urinalysis
Treatment Plan
  • Consult urology when suspected (even if ultrasound hasn’t returned yet)
  • Manual detorsion
    • “Open the Book”
    • Twist medial to lateral
      • Switch directions if no pain relief
Additional Reading

Flank Pain and Kidney Stones

Kidney Stones are a Diagnosis of Exclusion!!!

Step 1: Consider the Differential Diagnosis for Flank Pain
  • Appendicitis
  • Abdominal Aortic Aneurysm
  • Ectopic Pregnancy
  • Testicular/Ovarian Torsion
  • Kidney Stone
Step 2: Diagnose the Kidney Stone
  • Option 1- Renal Ultrasound
    • Findings consistent with kidney stone diagnosis
      • Hydronephrosis
      • Lack of ureteral jets (in bladder)
      • Kidney stones (poor sensitivity for this)
    • Benefits
      • Can be performed at bedside
      • No radiation
  • Option 2- Non-contrast CT scan
    • Great for identifying alternative diagnoses
Step 3: Rule Out Infection
  • Fevers
  • Urinalysis with nitrites or bacteria
    • If present, patient needs antibiotics
Step 4: Control Symptoms
  • Analgesics
    • NSAIDS (such as ketorolac)
    • Opiates
  • Antiemetics
    • Zofran
Step 5: Rule Out Kidney Injury
  • Elevated creatinine
  • Solitary kidney
Admission Criteria for Kidney Stones
  • Coexisting Urinary Tract Infection
  • Unable to Control Symptoms
  • Renal Injury/Solitary Kidney
Additional Reading

Ventilator Basics

Step 1: Start Patient on Volume Assist-Control Ventilation
  • The most basic mode of ventilation
    • Provides a FIXED VOLUME at a FIXED RATE
  • If the patient over-breaths…
    • The ventilator will give another FULL breath
      • Can cause breath stacking and be uncomfortable in patients who are poorly sedated
      • This is not a problem in the ED because patients are typically deeply sedated
Step 2: Know your oxygenation and ventilation goals
  • Oxygenation (getting oxygen in)
    • Try to keep O2 saturation >92%
  • Ventilation (getting CO2 out)
    • Try to keep pCO2 <40
Step 3: Know the 4 Most Important Settings on a Ventilator
  • FiO2
    • The concentration of oxygen
      • Room air is 21% oxygen (or 0.21 on the vent)
      • Maximum is 100% oxygen (or 1.0 on the vent)
  • PEEP
    • The pressure applied during exhalation
      • Typical starting point is 5 (but can be increased significantly)
    • “Recruits” and opens alveoli
  • Tidal Volume
    • The volume of air moved during each cycle of the vent
  • Respiratory Rate
    • How fast the ventilator cycles/breaths for the patient
Step 4: Improving the patient’s OXYGENATION
  • FiO2
    • Increases the amount of oxygen present for exchange in non-damaged alveoli
  • PEEP
    • Increases the number of alveoli available to exchange oxygen
Step 5: Improving the patient’s VENTILATION
  • FORMULA: Minute Ventilation (MV) = Tidal Volume (Vt) x Respiratory Rate (RR)
  • Increasing either of these will improve ventilation
BONUS
  • Patients with COPD/asthma
    • Have tendency to not get full breath out (“breath stacking”)
      • “Plateau pressures” will increase above 30
        • Can damage alveoli
        • Can cause pneumothorax
    • Treat by increasing the I:E ratio
      • Quick inhalation
      • Longggggggggggggg exhalation
Additional Reading

Rabies Prophylaxis

Introduction

  • What is rabies?
    • A very rare and aggressive encephalitis
    • Global impact with exception of UK/Australia
  • Animals whose bites/scratches may require prophylaxis
    • Bats
    • Dogs, Cats, Ferrits
    • Other carnivorous animals
    • Foxes, Coyotes, Skunks, Raccoons
  • Post exposure prophylaxis
    • Both Rabies vaccine and immunoglobulin

When Do You Give Rabies Prophylaxis?

  • Step 1: Bitten or scratched by domesticated pet?
    • Immunization status of pet does not matter
    • Animal must be monitored
    • Give prophylaxis if animal develops encephalitis
  • Step 2: Bitten or scratched by wild animal?
    • If animal is captured it can be sacrificed and tested
    • Give prophylaxis the animal is not captured and is a potential carrier
  • Step 3: Possible bat scratch/bite?
    • Give prophylaxis if the patient (or baby) cannot confidently say “NO, I DID NOT GET BITTEN OR SCRATCHED BY THE BAT”
  • Step 4: Do NOT give prophylaxis if the animal is not a carrier of rabies (check local guidance)
    • Reptiles
    • Birds
    • Small rodents
    • Rabbits/Hares
    • Livestock
  • Step 5: How to give prophylaxis
    • Only contraindication is severe egg allergy
    • Can be given to babies/pregnant women/etc
    • Rabies immunoglobulin
      • Give ONCE in the department
      • Inject as much as possible around wound
    • Rabies vaccine
      • Give first day
      • Have patient come back for more doses on day 3, 7, 14 (and SOMETIMES 28)

Pearls

  • It doesn’t matter if the bite/scratch was provoked or unprovoked
  • It doesn’t matter where on the body the patient received the bite/scratch
  • It’s a universally fatal disease
  • No rabies in small rodents, reptiles, birds, squirrels, hamsters, rats, or rabits
  • The NNT is >300,000 (but we still do it)

Additional Reading

Occupational Exposures

The only chief complaint that you are guaranteed to eventually have to manage in a colleague

Respiratory Exposures

  • Meningococcus​ (meningococcemia, meningitis, etc)
    • Give prophylaxis (ceftriaxone) if…
      • Intubated a pt without a mask
      • Suctioned a pt without a mask
      • Performed mouth to mouth resuscitation
  • Tuberculosis​ 
    • CDC recommends testing if exposed
      • Treat if positive
    • CDC recommends prophylaxis in..
      • Little children, HIV positive, immunosuppressed

Cutaneous Exposures (Broken Skin, Mucous Membranes, Needle Stick)

  • Hepatitis B​
    • Test source patient
      • If positive, 1-30% risk of transmission with needle stick exposure
        • (Mucous membrane/broken skin exposures are much lower risk)
    • Test exposed colleague for anti-HepB surface antibody level
    • If source patient is positive and coworker is not fully immunized…
      • Treatment
        • Hep B Vaccine
        • Hep B Immunoglobulin
  • Hepatitis C​
    • Test source patient
      • If positive, 2% risk of transmission with needle stick exposure
        • (Mucous membrane/broken skin exposures are much lower risk)
    • Get baseline hepatic function labs (LFTs) in coworker
    • Follow-up on outpatient basis, no prophylaxis available
  • HIV​
    • Test source patient with rapid HIV test
      • If positive, 1/300 risk of transmission with needle stick exposure
        • Transmission risk increases if: bloody exposure, large needle bore
        • (Mucous membrane/broken skin exposures are much lower risk)
    • Generally recommend prophylaxis if source is positive
      • Prophylaxis is potentially curative if given at exposure
      • Counsel on safe sex practices
      • Counsel on common treatment side effects
        • GI symptoms, headaches, fatigue

Additional Reading HIV Occupational Exposure Guidelines (US Public Health Service)

Breast Complaints

All breast complaints are cancer until proven otherwise!!!

History

  • Increased risk of breast cancer
    • Family history of breast cancer (especially 1st degree)
    • Delayed childbearing (no children until after 30)
    • Age >50
  • Associated with menstrual cycle

Exam

  • Asymmetric appearance of breasts
  • Palpable mass
    • Red Flags
      • Non-mobile
      • Overlying skin changes
      • Lymphadenopathy
      • Located in upper/outer quadrant of breast

Differential Diagnoses

  • Red/inflamed/painful breast
    • Postpartum engorgement
      • Treat with warm compresses, continue breastfeeding/pumping, massage
    • Infection (“Mastitis”)
      • Treat with antibiotics and continue breastfeeding
    • Abscess
      • Treat with needle aspiration
      • Refer to breast surgeon
  • Non-inflamed breast pain
    • Fibrocystic changes
      • Associated with menses
      • Treat with supportive bra
  • Breast mass
    • Fibroadenoma
      • Slippery/mobile
    • Fibrocystic changes
  • Nipple discharge
    • Red flags
      • Unilateral discharge
      • Bloody discharge

Additional Reading

  • Breast Cancer Screening Guidelines (CDC)

Neonatal Conjunctivitis

The 3 Worst Causes of Neonatal Conjunctivitis

  • Gonorrhea
    • Causes corneal ulcers and sepsis
    • Red flags
      • 1st week of life
      • Copious purulent drainage
    • Diagnose with cultures
    • Treatment
      • Cefotaxime (3rd generation cephalosporin)
      • Admit
  • Chlamydia
    • Occurs in 1st month of life
    • Treat with PO erythromycin
  • HSV
    • Can disseminate to the brain
    • Red flags
      • Mother tested positive (or had active lesions)
      • Vesicles on baby
    • Treatment
      • IV acyclovir
      • Admit

Other Causes of Conjunctivitis

  • Viral/other bacterial
    • Treat with erythromycin ointment
  • Chemical conjunctivitis
    • Caused by eye drops given after birth
  • Dacryostenosis (closed eye ducts)
    • Watery eyes from tears not draining

Additional Reading

  • Neonatal Conjunctivitis (CDC)

Subarachnoid Hemorrhage

History

  • Sudden and maximal in onset
  • Compared to previous headaches
  • Family history of aneurysm
  • Associated Symptoms
    • Photophobia
    • Visual Changes
    • Neck Stiffness

Exam

  • Full neuro examination
    • Cranial nerves
    • Visual fields
    • Speech
    • Cerebellar (finger-nose)
    • Motor
    • Sensation
    • Gait

Testing Plan

  • Non-contrast head CT
    • Excellent sensitivity <6 hours from onset
  • Lumbar puncture
    • >100 RBCs in tube 4
      • Can be difficult to interpret after a traumatic lumbar puncture
    • Xanthochromia

Treatment Plan

  • Prevent rebleeding
    • Keep SBP <140
      • Nicardipine
    • Reverse any anticoagulants
      • Vitamin K
      • Prothrombin complex concentrate
      • Fresh frozen plasma
  • Prevent vasospasm
    • Nimodipine PO
  • Prevent delayed ischemia
    • Avoid hyperthermia
    • Avoid hyper/hypoglycemia
  • Prevent seizures
    • Levetiracetam (aka Keppra)

Additional Reading

Blood in the Diaper

The 4 Most Common Causes of Blood in Diaper

  • Urinary crystals
    • Will be guaiac negative
    • Common in first few weeks of life
  • Vaginal bleeding
    • Common in newborn females as they withdraw from maternal estrogen
  • Maternal blood
    • Swallowed during birthing process
    • Breastfeeding with cracked/bleeding nipples
  • Anal fissures
    • Common and will improve on its own

Basic Approach

  • Step 1: Check if guaiac positive
    • If negative, it’s not blood
    • Urinary crystals, food coloring, etc
  • Step 2: Consider vaginal bleeding
  • Step 3: Perform apt test
    • Diagnoses maternal blood
  • Step 4: Check for anal fissure
    • Self resolve
  • Step 5: Expand the differential diagnosis
    • Necrotizing enterocolitis
    • Intussusception
    • Cow’s milk allergy
    • Colitis
    • Red Food Dye

Additional Reading

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