Category: NBME Shelf Review

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Think A-B-C-P (Airway, Breathing, Circulation, Pregnancy Test) in ALL Women of Child-Bearing Age!

• It changes the differential diagnosis
• It changes the medications you can give
• It changes the tests you can order

Vaginal Bleeding Pearls

• Non-pregnant vaginal bleeding
  • Order a pelvic ultrasound (for structural causes)
  • Order a CBC and coagulation panel (for anemia and coagulopathy)
• Pregnant vaginal bleeding
  • If sick…
    • Think ectopic pregnancy (early pregnancy)
    • Think uterine rupture (late established pregnancy)
    • Think placental abruption (recent trauma or cocaine)
  • Don’t forget to order a type and screen
    • Rh- mothers will need RhoGam
  • If patient is unstable and you can’t wait for blood type…
    • Transfuse type O negative blood
• Postpartum vaginal bleeding
  • Most common cause is retained products of conception
    • Order an ultrasound
  • Consider endometritis if patient also has fever
    • Treat with clindamycin and gentamycin

Vaginal Discharge Pearls

• Cervical motion tenderness?
  • Pelvic Inflammatory Disease (PID)
• Thin, grey, and smells like fish?
  • Bacterial vaginosis (BV)
    • Treat with metronidazole
    • Warn patient not to mix metronidazole with alcohol
• Thick like cottage cheese?
  • Vulvovaginal candidiasis
    • Diagnosis with KOH prep
      • Look for yeast and pseudohyphae
    • Treat with fluconazole
• Thin Yellow/Green and “frothy”?
  • Trichomoniasis
    • Diagnose with wet prep
    • Look for mobile organisms
    • Treat with metronidazole
    • Partners should be checked and treated too

Ovarian Torsion

Additional Reading

• Approach to Non-Pregnant Vaginal Bleeding (EM Clerkship)
• Approach to 1st Trimester Vaginal Bleeding (EM Clerkship)

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Stroke

• Most appropriate initial tests
  • Blood Glucose
    • Hypoglycemia is a common stroke mimic
  • CT Head without contrast
    • Rules out HEMORRHAGIC strokes

Subarachnoid Hemorrhage

• Classic description
  • “Worst headache of life”
  • “Sudden and maximal in onset”
  • “Thunderclap”
• Testing
  • CT Head without contrast
  • (If negative CT) Lumbar puncture
    • Xanthochromia (yellowish fluid)
• Treatment
  • Nimodipine (Given orally)
    • Prevents vasospasm

Causes of Stroke in Young People

• Cervical artery dissection
• Vasospasm
• Vasculitis
• Sickle Cell Disease

Meningitis

• Treatment
  • Vancomycin, Ceftriaxone
  • Add ampicillin (covers listeria) in very young/old
  • Rifampin prophylaxis for close contacts (if patient has petechial rash)
    • Neisseria Meningitidis

HSV Encephalitis

• Classic symptoms
  • Fevers
  • Headache
  • Altered Mental Status
  • Seizures
• Treat with acyclovir

Altered Mental Status

Fat embolism

• Trauma PLUS petechial rash
• Common with long bone fracture

Schaphoid Fracture

• Exam shows tenderness over anatomic “snuffbox”
• Notorious for being missed on X-ray
  • High risk of osteonecrosis
• If suspicious, place patient in thumb spica splint regardless of X-ray findings
  • Outpatient followup 1-2 weeks for repeat xray

Pericarditis

• Patient complains of chest pain that is…
  • Sharp
  • Positional
  • Worse when laying flat
• Friction rub on exam
• EKG Findings
  • Diffuse ST segment elevation
  • Diffuse PR depression
• Treat with NSAIDS

Kawasaki’s Disease

• Mnemonic: CRASH and Burn
  • Conjunctivitis
  • Rash
  • Adenopathy
  • Strawberry Tongue
  • Hands/Feet Swelling
  • Burn = Fever for 5 days
• Treat with aspirin

Burns

• Parkland formula
  • Weight (kg) x BSA (%) x 4 = Volume of fluid needed in first 24 hours
  • Give half over first 8 hours
• Rule of 9s
  • Estimates % Body surface area burned

Vascular Injury

• Hard Signs
  • If present patient needs OR
  • Mnemonic: ABCDE
    • Active pulsatile hemorrhage
    • Bruit
    • Cerebral ischemia
    • Diminished Distal pulses
    • Expanding Hematoma

Infectious Disease Pearls

• Gram positive cocci in CLUSTERS
  • Staphylococcus Aureus
• Gram positive cocci in CHAINS
  • Streptococcus Pneumoniae

Additional Reading

• Basic approach to altered mental status (EM Clerkship)
• Basic approach to neck trauma (EM Clerkship)

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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

• Pulmonary Embolism Basics (EM Clerkship)
• Pulmonary Embolism Severity (PubMed)

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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

• Ectopic Pregnancy (EM Clerkship)
• Abdominal Aortic Aneurysm (EM Clerkship)

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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

• RUQ Abdominal Pain (EM Clerkship)
• Biliary Diseases and Pancreatitis (EM Clerkship)

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“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

• Life in the Fast Lane EKG Library (LITFL)
• Tachycardias (EM Clerkship)
• Bradycardias (EM Clerkship)

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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

• Approach to Eye Complaints (EM Clerkship)
• Acetaminophen Overdose (EM Clerkship)
• Salicylate Overdose (EM Clerkship)

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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

• Rabies Prophylaxis (EM Clerkship)

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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

• Pediatric Abdominal Pain (EM Clerkship)
• Peds O – Oxygen, Airway, and Respiratory Disorders (EM Clerkship)

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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

• Abdominal Trauma (EM Clerkship)
• Head Trauma (EM Clerkship)
• Thoracic Trauma (EM Clerkship)

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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

• Hyperkalemia (EM Clerkship)