Board / Inservice Review Part 1 Angela M. Mills, MD Department of Emergency Medicine University of Pennsylvania Health System

Board / Inservice ReviewPart 1

Angela M. Mills, MD

Department of Emergency Department of Emergency MedicineMedicine

University of Pennsylvania Health University of Pennsylvania Health SystemSystem

The TestThe Test

305 questions in 6.5 hours305 questions in 6.5 hours 10-15% pictorial10-15% pictorial 75% required to pass75% required to pass 90% pass rate - EM residency trained90% pass rate - EM residency trained Practice lots of questionsPractice lots of questions

Taking the TestTaking the Test

76 seconds per question76 seconds per question Fill in answer sheet as you goFill in answer sheet as you go Mark difficult questions you wish to Mark difficult questions you wish to

later reconsiderlater reconsider Write in the bookletWrite in the booklet


If you anticipate an answer as you If you anticipate an answer as you read the question, you’re prob rightread the question, you’re prob right

1/3 of test not scored1/3 of test not scored 3 types of questions3 types of questions

– you know the answeryou know the answer– you know part of the answeryou know part of the answer– you have no idea what they’re talking aboutyou have no idea what they’re talking about


Answers which state “always” or Answers which state “always” or “never” are usually not correct“never” are usually not correct

If two answers are close, one is If two answers are close, one is probably correctprobably correct

If two answers are direct If two answers are direct opposites, one is usually correctopposites, one is usually correct

You frequently won’t need the You frequently won’t need the picture to answer the questionpicture to answer the question

Abdominal / Abdominal / GastrointestinalGastrointestinal

9%9%

Sudden PainSudden Pain

Mesenteric embolus leading to Mesenteric embolus leading to ischemia / infarctionischemia / infarction

Ruptured AAARuptured AAA Perforated viscusPerforated viscus Renal colicRenal colic Cecal volvulus Cecal volvulus

– sigmoid volvulus more gradualsigmoid volvulus more gradual

Lethal Causes of PainLethal Causes of Pain

Mesenteric ischemia / infarctionMesenteric ischemia / infarction Ruptured or leaking AAARuptured or leaking AAA Perforated viscusPerforated viscus Acute pancreatitisAcute pancreatitis Bowel obstructionBowel obstruction

Abdominal Pain that is….Abdominal Pain that is….

diffuse, severe, colicky = diffuse, severe, colicky = bowel obstructionbowel obstruction

out of proportion to examination = out of proportion to examination = mesenteric ischemiamesenteric ischemia

radiating from epigastrium straight radiating from epigastrium straight through to midback = through to midback = pancreatitispancreatitis

Gastrointestinal BleedGastrointestinal Bleed

Hematemesis: bright red or coffee-groundHematemesis: bright red or coffee-ground Melena: black tarry stoolMelena: black tarry stool

– requires 150-200 cc blood in GI tract for minimum of requires 150-200 cc blood in GI tract for minimum of 8 hours to turn black8 hours to turn black

Hematochezia: bloody stoolsHematochezia: bloody stools– 5cc of hemorrhoid blood can turn toilet water bright red5cc of hemorrhoid blood can turn toilet water bright red

Nausea and VomitingNausea and Vomiting

Medications - most common cause Medications - most common cause in adultsin adults

Acute gastroenteritis - most Acute gastroenteritis - most common GI disease in UScommon GI disease in US

Vomiting….Vomiting….

……of bile rules out gastric outlet of bile rules out gastric outlet obstructionobstruction

……of feculent material suggests distal of feculent material suggests distal obstructionobstruction

……in morning suggests pregnancy, in morning suggests pregnancy, uremia, or uremia, or ICP ICP

……of food > 12 hours old of food > 12 hours old pathognomonic for outlet obstructionpathognomonic for outlet obstruction

Diarrhea….Diarrhea….

……which is mucoid bloody + high fever which is mucoid bloody + high fever + febrile seizure in infant = + febrile seizure in infant = ShigellaShigella

……in pt with pet turtle or iguana = in pt with pet turtle or iguana = SalmonellaSalmonella

……in pt w/o spleen or with Sickle Cell = in pt w/o spleen or with Sickle Cell = SalmonellaSalmonella

……and pseudoappendicitis = and pseudoappendicitis = YersiniaYersinia


……and fecal WBCs after poultry or and fecal WBCs after poultry or eggs = eggs = Salmonella or CampylobacterSalmonella or Campylobacter

……after poultry or meat, NO fecal after poultry or meat, NO fecal WBCs = WBCs = Clostridium perfringensClostridium perfringens

……profuse and watery after antibiotic = profuse and watery after antibiotic = Clostridium difficileClostridium difficile

……after potato salad or mayonnaise = after potato salad or mayonnaise = Staphylococcus aureusStaphylococcus aureus


……after fried rice = after fried rice = Bacillus cereusBacillus cereus ……after raw oysters = after raw oysters = Vibrio choleraVibrio cholera ……after drinking from mountain stream after drinking from mountain stream

= = Giardia lambliaGiardia lamblia ……in AIDS pt = in AIDS pt = isospora or isospora or

cryptosporidiumcryptosporidium ……and Hemolytic Uremic Syndrome or and Hemolytic Uremic Syndrome or

TTP = TTP = E. coliE. coli 0157:H7 0157:H7

Foreign BodiesForeign Bodies

80% in children80% in children Most common object in kids = coinMost common object in kids = coin Most common object in adults = foodMost common object in adults = food ““Café coronary”: unchewed meat Café coronary”: unchewed meat

lodged in upper esophaguslodged in upper esophagusairway airway obstruction obstruction sudden cyanosis sudden cyanosis collapse collapse deathdeath

Foreign BodiesForeign Bodies

““Steakhouse syndrome”: distal Steakhouse syndrome”: distal esophageal obstructionesophageal obstruction– glucagon + effervescent agent relieves glucagon + effervescent agent relieves

acute lower esophageal obstruction acute lower esophageal obstruction 75% of pts75% of pts

– proteolytic enzymes contraindicatedproteolytic enzymes contraindicated Suspected perforation: water-soluble Suspected perforation: water-soluble

contrast material (gastrograffin®)contrast material (gastrograffin®)

Swallowing DysfunctionSwallowing Dysfunction

Most common upper causeMost common upper cause– neuromuscular (e.g. stroke)neuromuscular (e.g. stroke)

Most common lower causeMost common lower cause– intrinsic motility disorderintrinsic motility disorder

• (e.g. achalasia, spasm)(e.g. achalasia, spasm)

Tear vs RuptureTear vs Rupture

Mallory-Weiss: vomiting Mallory-Weiss: vomiting esophageal tear and bleedingesophageal tear and bleeding

Boerhaave syndrome: vomiting Boerhaave syndrome: vomiting esophageal rupture esophageal rupture (left posterior (left posterior

distal)distal)mediastinitismediastinitis– consider in alcoholic with vomiting + chest pain consider in alcoholic with vomiting + chest pain

OR chest pain + left pleural effusionOR chest pain + left pleural effusion

Upper GI BleedUpper GI Bleed

Most common causes UGI bleed: Most common causes UGI bleed: Peptic ulcer disease > erosive Peptic ulcer disease > erosive gastritis > varices > Mallory-Weiss gastritis > varices > Mallory-Weiss > esophagitis> esophagitis

EndoscopyEndoscopy Surgery only in severe, unrelenting Surgery only in severe, unrelenting

hemorrhagehemorrhage

Peptic Ulcer DiseasePeptic Ulcer Disease

Duodenal ulcer more common: Duodenal ulcer more common: pain between mealspain between meals

Gastric ulcer: pain immediately Gastric ulcer: pain immediately after eatingafter eating

Remember H. pyloriRemember H. pylori

Biliary DiseaseBiliary Disease

Bilirubin 2.0 - 2.5 Bilirubin 2.0 - 2.5 jaundice jaundice Pre-hepatic: hemolyticPre-hepatic: hemolytic Hepatic: hepatocellularHepatic: hepatocellular Post-hepatic: obstructivePost-hepatic: obstructive Cholecystitis = cholelithiasisCholecystitis = cholelithiasis

– acalculous in 5-10%acalculous in 5-10%

Murphy sign 97% sensitiveMurphy sign 97% sensitive– pain during subcostal palpation on pain during subcostal palpation on

inspirationinspiration

GallstonesGallstones

Ultrasound Ultrasound – 94% sensitive, 78% specific94% sensitive, 78% specific

Radioisotope study (HIDA) Radioisotope study (HIDA) – 97% sensitive, 90% specific97% sensitive, 90% specific

Charcot triad: fever + jaundice + Charcot triad: fever + jaundice + right upper quadrant pain = right upper quadrant pain = ascending cholangitisascending cholangitis

Acute CholecystitisAcute Cholecystitis

Liver DiseaseLiver Disease

Hepatitis A: short incubation, usually Hepatitis A: short incubation, usually benign, fecal/oral spreadbenign, fecal/oral spread

Hepatitis B: percutaneous, STDHepatitis B: percutaneous, STD– carrier, chronic, fulminant diseasecarrier, chronic, fulminant disease– vaccinevaccine

Hepatitis C: percutaneous, STDHepatitis C: percutaneous, STD– carrier, chronic, fulminant diseasecarrier, chronic, fulminant disease

Most common US blood borne Most common US blood borne infection = infection = Hepatitis CHepatitis C

PancreatitisPancreatitis

Gallstones Gallstones 45% 45% Alcohol Alcohol 35% 35% Lipase and amylase most usefulLipase and amylase most useful

– but both normal in up to 25%but both normal in up to 25%– mild elevations not specificmild elevations not specific– very specific if levels > 5 x normalvery specific if levels > 5 x normal

2 or more Ranson criteria 2 or more Ranson criteria ICU ICU– on admission: age > 55, WBC > 16,000, fasting on admission: age > 55, WBC > 16,000, fasting

glucose > 200, AST/SGOT > 250, LDH > 350glucose > 200, AST/SGOT > 250, LDH > 350– AWFALAWFAL

Small Bowel ObstructionSmall Bowel Obstruction

Most common cause = adhesions from Most common cause = adhesions from prior surgery > 50%prior surgery > 50%

No prior surgery = hernias & neoplasms No prior surgery = hernias & neoplasms 15% each 15% each

Diagnosis: air-fluid levels on xray Diagnosis: air-fluid levels on xray

Intestinal IschemiaIntestinal Ischemia

Most common: arterial embolus >50%Most common: arterial embolus >50%– arterial thrombosis arterial thrombosis 15% 15%– venous thrombosis venous thrombosis 15% 15%– nonocclusive vascular disease nonocclusive vascular disease 20% 20%

Mesenteric IschemiaMesenteric Ischemia

Pain out of proportion to examPain out of proportion to exam High mortality rate High mortality rate Heme-positive stoolHeme-positive stool serum lactate may helpserum lactate may help Study of choice: Study of choice: AngiographyAngiography

AppendicitisAppendicitis

Most common surgical emergencyMost common surgical emergency Classic appendicitis still a clinical Classic appendicitis still a clinical

diagnosisdiagnosis CBC, c-reactive protein, plain xrays CBC, c-reactive protein, plain xrays

not helpfulnot helpful If equivocal: CT scan, ultrasoundIf equivocal: CT scan, ultrasound

GastroenteritisGastroenteritis

Symptoms within 2-4 hours of eating Symptoms within 2-4 hours of eating Staphylococcus Staphylococcus (mostly vomiting)(mostly vomiting) or or Bacillus cereusBacillus cereus– others take longerothers take longer

Enterotoxigenic Enterotoxigenic E. ColiE. Coli 50% of 50% of traveler’s diarrheatraveler’s diarrhea– daily prophylaxis prevents daily prophylaxis prevents 90% 90%

Diverticular DiseaseDiverticular Disease

Uncommon < 40 yearsUncommon < 40 years Diverticulitis Diverticulitis LLQ tenderness, LLQ tenderness,

distension, normal bowel soundsdistension, normal bowel sounds CT equivalent to barium enema for CT equivalent to barium enema for

diagnostic accuracydiagnostic accuracy Diverticulosis Diverticulosis most frequent cause most frequent cause

of significant lower GI bleedof significant lower GI bleed

Bowel DiseaseBowel Disease

Most common cause of large bowel Most common cause of large bowel obstruction obstruction tumors and diverticular tumors and diverticular diseasedisease

Crohn’s diseaseCrohn’s disease ALL layers of ALL layers of bowel wall, spares rectum, fistulas bowel wall, spares rectum, fistulas and abscesses, “skip” lesionsand abscesses, “skip” lesions

Ulcerative colitisUlcerative colitis mucosal disease, mucosal disease, involves rectum in 90%involves rectum in 90%

Bowel DiseaseBowel Disease

Sigmoid volvulusSigmoid volvulus– elderly, debilitated, sigmoidoscopyelderly, debilitated, sigmoidoscopy

Cecal volvulus (15 - 20%)Cecal volvulus (15 - 20%)– young (35 - 55), requires surgeryyoung (35 - 55), requires surgery

Sigmoid VolvulusSigmoid Volvulus

CutaneousCutaneous 2%2%

Nikolsky’s SignNikolsky’s Sign

Minor rubbing Minor rubbing desquamation of desquamation of underlying skin, including pigmentunderlying skin, including pigment

Positive in Toxic Epidermal Positive in Toxic Epidermal Necrolysis, Staph scalded skin Necrolysis, Staph scalded skin syndrome syndrome (Tintinalli - yes, Rosen - no),(Tintinalli - yes, Rosen - no), Pemphigus vulgaris Pemphigus vulgaris (NOT bullous (NOT bullous pemphigoid)pemphigoid)

DermatologyDermatology

Steven Johnson Syndrome Steven Johnson Syndrome – AKA Erythema Multiforme MajorAKA Erythema Multiforme Major– erythema multiforme with mucous erythema multiforme with mucous

membrane and visceral involvementmembrane and visceral involvement

Toxic Epidermal NecrolysisToxic Epidermal Necrolysis– sloughing of epidermissloughing of epidermis– children children Staph Staph– adults adults drugs drugs


MeningococcemiaMeningococcemia– young pt, generalized rash, gun-metal gray young pt, generalized rash, gun-metal gray

patches of purpurapatches of purpura

GonococcemiaGonococcemia– young pt, arthralgia, rashyoung pt, arthralgia, rash– erythematous papules with central purpuraerythematous papules with central purpura

Rocky Mountain Spotted FeverRocky Mountain Spotted Fever– pink-red macules that start on wrists, ankles, and pink-red macules that start on wrists, ankles, and

forearm spreads to involve the soles with feverforearm spreads to involve the soles with fever

RMSFRMSF


Lyme DiseaseLyme Disease– erythema chronicum migrans starts as a erythema chronicum migrans starts as a

red macule that expands to form a ring red macule that expands to form a ring with raised border and central clearingwith raised border and central clearing

MeaslesMeasles– Koplik spots = bluish dots on oral Koplik spots = bluish dots on oral

mucosa 24-48 hours before rashmucosa 24-48 hours before rash

PurpuraPurpura– palpable = vasculitis (HSP)palpable = vasculitis (HSP)– non-palpable = thrombocytopenia, TTP, non-palpable = thrombocytopenia, TTP,

von Willebrand’svon Willebrand’s

ECMECM

Koplik spotsKoplik spots

CardiovascularCardiovascular 11%11%

Hypertrophic CardiomyopathyHypertrophic Cardiomyopathy

Most common symptom = Most common symptom = dyspneadyspnea

Syncope in 20 - 30%Syncope in 20 - 30% Harsh crescendo-decrescendo Harsh crescendo-decrescendo

murmur <> at left sternal bordermurmur <> at left sternal border with valsava or standingwith valsava or standing with squatting or hand gripwith squatting or hand grip

Mitral StenosisMitral Stenosis

Most common symptoms = Most common symptoms = exertional dyspnea, hemoptysisexertional dyspnea, hemoptysis

Most common cause = Most common cause = rheumatic heart diseaserheumatic heart disease

Most patients develop A fibMost patients develop A fib Mid-diastolic rumble into S2Mid-diastolic rumble into S2

Aortic StenosisAortic Stenosis

Dyspnea, chest pain, syncopeDyspnea, chest pain, syncope Congenital #1 causeCongenital #1 cause Rheumatic heart disease #2 causeRheumatic heart disease #2 cause Harsh systolic ejection murmurHarsh systolic ejection murmur Sudden arrhythmic death in Sudden arrhythmic death in 25% 25% ECG ECG LVH LVH

Valvular DiseaseValvular Disease

Aortic and mitral regurgitationAortic and mitral regurgitation– reduce afterload reduce afterload

• nitroglycerin and nitroprussidenitroglycerin and nitroprusside

– control rate of atrial fibrillationcontrol rate of atrial fibrillation– balloon pump contraindicated in balloon pump contraindicated in

wide-open aortic regurgitationwide-open aortic regurgitation

Infective EndocarditisInfective Endocarditis

Most common = left sidedMost common = left sided– Mitral >> aortic > tricuspid > pulmonicMitral >> aortic > tricuspid > pulmonic– Streptococcus viridansStreptococcus viridans, staph, enterococcus, staph, enterococcus– Sepsis Sepsis ++ heart failure heart failure– Neurologic symptoms in 1/3Neurologic symptoms in 1/3– Subacute: murmur of AI, MRSubacute: murmur of AI, MR

Oxacillin and aminoglycosideOxacillin and aminoglycoside


Roth spotsRoth spots– retinal hemorrhage with central clearingretinal hemorrhage with central clearing

Osler nodesOsler nodes– tender nodules on fingers and toestender nodules on fingers and toes

Janeway lesionsJaneway lesions– plaques on palms and solesplaques on palms and soles

Splinter hemorrhagesSplinter hemorrhages

Osler NodesOsler Nodes

Splinter HemorrhageSplinter Hemorrhage


Right sided: intravenous drug useRight sided: intravenous drug use– Staphylococcus aureus, Streptococcus pneumoniaeStaphylococcus aureus, Streptococcus pneumoniae

Usually acuteUsually acute– fever, cough, chest pain, dyspnea, hemoptysisfever, cough, chest pain, dyspnea, hemoptysis– murmur much less commonmurmur much less common

Diagnosis: Echo, blood culturesDiagnosis: Echo, blood cultures Penicillinase-resistant penicillin or Penicillinase-resistant penicillin or

vancomycin + aminoglycosidevancomycin + aminoglycoside– possible emergent surgerypossible emergent surgery

ThrombolysisThrombolysis

Symptoms of myocardial Symptoms of myocardial infarction within prior 12 hours + infarction within prior 12 hours + >1mm ST >1mm ST in 2 limb leads or in 2 limb leads or >2mm ST >2mm ST in chest leads or new in chest leads or new LBBB and no contraindicationsLBBB and no contraindications

Antero-Lat MIAntero-Lat MI

Inferior MIInferior MI

Postero-Lat MIPostero-Lat MI

CardiologyCardiology

Cocaine chest painCocaine chest pain– all usual treatments except beta-all usual treatments except beta-

blockers blockers unopposed alpha unopposed alpha Cardiac tamponadeCardiac tamponade

– Beck’s triadBeck’s triad• JVD, hypotension, muffled heart soundsJVD, hypotension, muffled heart sounds

– Electrical alternansElectrical alternans

Electrical AlternansElectrical Alternans

DysrhythmiasDysrhythmias

Patient stability dictates actionPatient stability dictates action Regular vs irregularRegular vs irregular Slow vs fastSlow vs fast Relation of P to QRSRelation of P to QRS Supraventricular vs ventricularSupraventricular vs ventricular Wide vs narrowWide vs narrow Treat as VT if not sure if SVT w/ aberrancyTreat as VT if not sure if SVT w/ aberrancy

Multifocal Atrial TachycardiaMultifocal Atrial Tachycardia

Irregularly irregular (100 – 180)Irregularly irregular (100 – 180) P waves multiple shapes, PR variesP waves multiple shapes, PR varies Treat underlying problem (COPD)Treat underlying problem (COPD) MagnesiumMagnesium

MATMAT

Atrial FlutterAtrial Flutter

Regular (rate 300) Regular (rate 300) – unless variable block 2:1, 3:1unless variable block 2:1, 3:1

““Sawtooth” flutter wavesSawtooth” flutter waves AV conduction usually 2:1 AV conduction usually 2:1

– ventricular rate 150ventricular rate 150

Rate control B-blocker or CCBRate control B-blocker or CCB Synch cardioversion 25 – 50 JSynch cardioversion 25 – 50 J

Atrial FlutterAtrial Flutter

Atrial FibrillationAtrial Fibrillation

Irregularly irregularIrregularly irregular Untreated vent response <100 implies Untreated vent response <100 implies

AV node diseaseAV node disease NO P wavesNO P waves Narrow QRS (unless aberrant)Narrow QRS (unless aberrant) Slow vent rate with diltiazem, ibutilideSlow vent rate with diltiazem, ibutilide Synch cardioversion 100 JSynch cardioversion 100 J

Atrial FibrillationAtrial Fibrillation

Supraventricular TachycardiaSupraventricular Tachycardia

Regular, rate 160 – 200Regular, rate 160 – 200 P waves may not be visibleP waves may not be visible QRS narrow (unless aberrant)QRS narrow (unless aberrant) AdenosineAdenosine drug of choice drug of choice Synch cardiovert 50 – 100 JSynch cardiovert 50 – 100 J Most common non-arrest Most common non-arrest

tachydysrhythmia in infants / childrentachydysrhythmia in infants / children PAT with blockPAT with block = classic digitalis toxic = classic digitalis toxic

Ventricular TachycardiaVentricular Tachycardia

Regular, 3 or more consecutive beatsRegular, 3 or more consecutive beats Wide complexWide complex Stable: Amiodarone, lido, procainamideStable: Amiodarone, lido, procainamide Unstable: CardiovertUnstable: Cardiovert

V TachV Tach

Ventricular FibrillationVentricular Fibrillation

Pulseless, apneic patientPulseless, apneic patient Grossly disorganized patternGrossly disorganized pattern Defibrillate 200 JDefibrillate 200 J Amiodarone, lidocaineAmiodarone, lidocaine

V FibV Fib

DysrhythmiasDysrhythmias

Pulseless electrical activity (PEA)Pulseless electrical activity (PEA)– hypovolemia, hypothermia, hypoxia, hypovolemia, hypothermia, hypoxia,

tamponade, tension pneumothoraxtamponade, tension pneumothorax Torsade de PointesTorsade de Pointes

– magnesium or overdrive pacingmagnesium or overdrive pacing

Torsade de PointesTorsade de Pointes

AV BlocksAV Blocks

11stst deg – prolonged PR >200 msec deg – prolonged PR >200 msec 22ndnd deg – Mobitz I deg – Mobitz I Wenckebach Wenckebach

– progressive PR prolongation, RR decreased progressive PR prolongation, RR decreased until dropped QRS until dropped QRS no Rx no Rx

22ndnd deg – Mobitz II deg – Mobitz II– constant PR, RR constant, drop QRS constant PR, RR constant, drop QRS pacer pacer

33rdrd deg – deg – – independent atrial / vent contractions independent atrial / vent contractions pacer pacer

22ndnd Degree - Mobitz I Degree - Mobitz I

22ndnd Degree – Mobitz II Degree – Mobitz II

33rdrd Degree AV Block Degree AV Block

Wolff Parkinson WhiteWolff Parkinson White

Short PRShort PR Delta waveDelta wave PSVT 40 - 80%PSVT 40 - 80% Atrial fibrillation 10 - 20%Atrial fibrillation 10 - 20% Atrial flutter Atrial flutter 5% 5% Procainamide, flecanide, cardiovertProcainamide, flecanide, cardiovert

WPWWPW

Hypertensive EmergencyHypertensive Emergency

Hypertensive encephalopathy: Hypertensive encephalopathy: nitroprusside, labetalolnitroprusside, labetalol

Stroke: labetalolStroke: labetalol Pulm edema: nitroglycerin, nitroprussidePulm edema: nitroglycerin, nitroprusside Myocardial ischemia: nitroglycerinMyocardial ischemia: nitroglycerin Thoracic dissection: nitroprusside + Thoracic dissection: nitroprusside +

beta-blockerbeta-blocker Pheochromocytoma: phentolaminePheochromocytoma: phentolamine Eclampsia: hydralazineEclampsia: hydralazine

Acute PericarditisAcute Pericarditis

Friction rub increased by leaning forwardFriction rub increased by leaning forward

Diffuse PR depression, ST elevationDiffuse PR depression, ST elevation

Aortic DissectionAortic Dissection

>50 years, hypertension, connective >50 years, hypertension, connective tissue disease (Marfan), pregnancytissue disease (Marfan), pregnancy

90% abrupt tearing back pain90% abrupt tearing back pain MI / CVA / spinal cord sx’s all possible MI / CVA / spinal cord sx’s all possible

presentationspresentations Asymmetric BP’s, aortic regurgAsymmetric BP’s, aortic regurg Type A : ascending, surgeryType A : ascending, surgery Type B : descending, medicalType B : descending, medical Nitroprusside + beta-blockerNitroprusside + beta-blocker

AAAAAA

Beware the elderly man with hematuria Beware the elderly man with hematuria and sudden back painand sudden back pain

Commonly misdiagnosed as renal colicCommonly misdiagnosed as renal colic Decreased lower ext pulsesDecreased lower ext pulses AAA may not be palpableAAA may not be palpable

AAAAAA

Endocrine / Endocrine / MetabolicMetabolic

5%5%

Acid - BaseAcid - Base

Respiratory alkalosis Respiratory alkalosis hyperventilation hyperventilation Respiratory acidosis Respiratory acidosis hypoventilation hypoventilation Metabolic alkalosis Metabolic alkalosis volume and volume and

potassium depletion potassium depletion Anion gap = NaAnion gap = Na++ – (Cl – (Cl-- + HCO + HCO33

--) ) – normal 12 normal 12 ++ 3 mEq/L 3 mEq/L

Acute alkalosis Acute alkalosis HCO HCO33-- 2 mEq/L for 2 mEq/L for

each 10mmHg each 10mmHg in PaCO in PaCO22

Acid - BaseAcid - Base

Winter’s formula:Winter’s formula:– pCOpCO22 = 1.5 (HCO = 1.5 (HCO33) + 8 ) + 8 ++ 2 2– If pCOIf pCO22 not in this range not in this range superimposed superimposed

primary respiratory processprimary respiratory process Metabolic acidosis caused by:Metabolic acidosis caused by:

acid production, acid production, acid excretion (renal), acid excretion (renal), loss of alkaliloss of alkali

Most common mixed disturbance: Most common mixed disturbance: primary metabolic acidosis + primary primary metabolic acidosis + primary respiratory alkalosisrespiratory alkalosis

Anion Gap AcidosisAnion Gap Acidosis

CCarbon monoxide / arbon monoxide / CCyanide exposureyanide exposure

AAlcoholic ketoacidosis / lcoholic ketoacidosis / AAcute alcohol cute alcohol intoxicationintoxication

TToluene exposureoluene exposure MMethanol intoxicationethanol intoxication UUremiaremia DDiabetic ketoacidosisiabetic ketoacidosis

PParaldehyde ingestionaraldehyde ingestion IIsoniazid / soniazid / IIron ron

intoxicationintoxication LLactic acidosisactic acidosis EEthylene glycol thylene glycol

intoxicationintoxication SSalicylate intoxicationalicylate intoxication

Metabolic acidosisMetabolic acidosis

Non-anion gap acidosis implies loss Non-anion gap acidosis implies loss of HCOof HCO33

– GI loss GI loss diarrhea, enterostomy diarrhea, enterostomy– Renal loss Renal loss renal tubular acidosis, renal tubular acidosis,

acetazolamideacetazolamide– HyperalimentationHyperalimentation

ElectrolytesElectrolytes

Consider laboratory error as part Consider laboratory error as part of differentialof differential

Primary responsibility Primary responsibility restore restore intravascular volume and tissue intravascular volume and tissue perfusionperfusion

Correct electrolyte abnormalities Correct electrolyte abnormalities at rate they occurredat rate they occurred

HypernatremiaHypernatremia

Excess free water lossExcess free water loss– Diabetes insipidus, hyperglycemiaDiabetes insipidus, hyperglycemia

Inadequate free water intakeInadequate free water intake– Poor oral intakePoor oral intake

Excess sodium gainExcess sodium gain– Iatrogenic, hyperaldosteronism, Cushing’s Iatrogenic, hyperaldosteronism, Cushing’s

syndromesyndrome If volume depleted, give If volume depleted, give IV NSSIV NSS Correct too fast Correct too fast brain edema, seizures brain edema, seizures

HyponatremiaHyponatremia

HypovolemicHypovolemic– Renal loss, vomiting, burns Renal loss, vomiting, burns IV NSS IV NSS

EuvolemicEuvolemic– SIADH, glucocorticoid deficiency SIADH, glucocorticoid deficiency

furosemide + IV NSSfurosemide + IV NSS HypervolemicHypervolemic

– CHF, renal failure CHF, renal failure water restriction + water restriction + furosemide, consider Na replacementfurosemide, consider Na replacement

HyperkalemiaHyperkalemia

Renal failure, acidosis, tissue Renal failure, acidosis, tissue necrosis, hemolysis, transfusions, necrosis, hemolysis, transfusions, GI bleed, drugsGI bleed, drugs

ECG findings: peaked T waves, ECG findings: peaked T waves, widened QRS, “sine wave”, V fib, widened QRS, “sine wave”, V fib, asystoleasystole

Protect heart Protect heart calcium chloride calcium chloride or gluconateor gluconate


Shift KShift K++ into cell into cell insulin, albuterol insulin, albuterol Block KBlock K++ reabsorption reabsorption furosemide furosemide Bind KBind K++ for excretion for excretion sodium sodium

polystyrene (Kayexalate®)polystyrene (Kayexalate®) Prevent hypoglycemia Prevent hypoglycemia dextrose dextrose


HypokalemiaHypokalemia

pH 0.1 pH 0.1 serum Kserum K++ 0.5 0.5 ++ 0.2mEq/L 0.2mEq/L RedistributionRedistribution alkalosis, insulin, beta- alkalosis, insulin, beta-

agonistsagonists Renal lossRenal loss diuretics, excess diuretics, excess

glucocorticoidglucocorticoid GI lossGI loss vomiting, diarrhea vomiting, diarrhea Oral KOral K++ better absorbed, safer better absorbed, safer MagnesiumMagnesium

HypokalemiaHypokalemia

HypercalcemiaHypercalcemia

Most common outpt cause: Most common outpt cause: primary hyperparathyroidismprimary hyperparathyroidism

Most common inpt cause: Most common inpt cause: malignancymalignancy Most common paraneoplastic syndMost common paraneoplastic synd Signs & sx’s variable and nonspecificSigns & sx’s variable and nonspecific Restore intravascular volume (Restore intravascular volume (NSSNSS)) Enhance renal elimination Enhance renal elimination loop diuretic loop diuretic

– Thiazides can make worseThiazides can make worse

HypocalcemiaHypocalcemia

Neuromuscular hyperexcitability, Neuromuscular hyperexcitability, Perioral paresthesias, muscle Perioral paresthesias, muscle cramps, tetanycramps, tetany

Chvostek’s signChvostek’s sign: tap facial nerve : tap facial nerve ipsilateral facial muscles twitchipsilateral facial muscles twitch

Trousseau’s signTrousseau’s sign: inflate arm blood : inflate arm blood pressure cuff pressure cuff carpal spasm carpal spasm

Hyperglycemia - DKAHyperglycemia - DKA

Lack of insulin, the only anabolic Lack of insulin, the only anabolic hormonehormone

MOST important treatmentMOST important treatment IV NSSIV NSS Half-life IV regular insulin 3-10 mins Half-life IV regular insulin 3-10 mins

continuous dripcontinuous drip Replace KReplace K++ early early

– phosphate not needed phosphate not needed – bicarb controversial (generally not needed)bicarb controversial (generally not needed)

Hyperglycemia - HHNCHyperglycemia - HHNC

Hyperglycemic hyperosmolar Hyperglycemic hyperosmolar nonketotic comanonketotic coma– Prodrome longer than DKAProdrome longer than DKA– Infection commonInfection common– Higher glucose, deeper coma, greater volume lossHigher glucose, deeper coma, greater volume loss– Focal neurologic findings commonFocal neurologic findings common

– 85% with underlying renal or cardiac impairment85% with underlying renal or cardiac impairment Rapid IV fluid most important (NSS)Rapid IV fluid most important (NSS)

– Phenytoin contraindicated, impairs endogenous Phenytoin contraindicated, impairs endogenous insulin releaseinsulin release

HypoglycemiaHypoglycemia

Symptoms at 40 – 50 mg/dlSymptoms at 40 – 50 mg/dl Bedside tests essential, accurateBedside tests essential, accurate 1 amp D50 raises 40 – 350 mg/dl1 amp D50 raises 40 – 350 mg/dl Glucagon 1 mg IM similarGlucagon 1 mg IM similar

– takes 10 – 20 minutestakes 10 – 20 minutes– not in alcoholics not in alcoholics no glycogen no glycogen

If refractory If refractory consider cortisone consider cortisone– adrenal insufficiencyadrenal insufficiency

Alcoholic KetoacidosisAlcoholic Ketoacidosis

Binge drinking followed by Binge drinking followed by poor intake, vomitingpoor intake, vomiting

Blood glucose usually < 250 mg/dlBlood glucose usually < 250 mg/dl Beta-hydroxybutyrate >> acetoacetateBeta-hydroxybutyrate >> acetoacetate

– urine may dip negative for ketonesurine may dip negative for ketones Use D5NSS, replace KUse D5NSS, replace K++

HyperthyroidHyperthyroid

Graves’ diseaseGraves’ disease most common most common cause of stormcause of storm

AmiodaroneAmiodarone 25% of pts 25% of pts develop thyrotoxicosisdevelop thyrotoxicosis

SignsSigns: : T, T, HR, AMS, goiter, heart HR, AMS, goiter, heart failure, ophthalmopathyfailure, ophthalmopathy

SymptomsSymptoms: agitation, weight loss, : agitation, weight loss, nervousness, palpitationsnervousness, palpitations

HyperthyroidHyperthyroid

Block peripheral effects:Block peripheral effects: beta-blockade (propranolol)beta-blockade (propranolol)

Inhibit hormone synthesis:Inhibit hormone synthesis: PTU (propylthiouracil), methimazolePTU (propylthiouracil), methimazole

Block hormone release:Block hormone release: iodine, lithiumiodine, lithium

Prevent peripheral conversion of Prevent peripheral conversion of T4 to T3:T4 to T3: dexamethasone dexamethasone

HypothyroidHypothyroid Women >> men ; hypothermia Women >> men ; hypothermia 80% 80% Altered sensorium: COAltered sensorium: CO22 narcosis narcosis Most sensitive test: TSHMost sensitive test: TSH CXR: pleural, pericardial effusionCXR: pleural, pericardial effusion Replace thyroid immediately: Replace thyroid immediately:

– Thyroxine (T4)Thyroxine (T4) Treat precipitating factorsTreat precipitating factors

– most common: CHF, pneumoniamost common: CHF, pneumonia

Correct metabolic abnormalitiesCorrect metabolic abnormalities COCO22, , glu, glu, NaNa

HypoadrenalHypoadrenal Inadequate glucocorticoids, primarily cortisolInadequate glucocorticoids, primarily cortisol Most common cause: Most common cause:

– exogenous steroid therapyexogenous steroid therapy

Anorexia, vomiting, abd pain, Anorexia, vomiting, abd pain, BP, BP, circulatory collapse, circulatory collapse, glu, glu, Na, Na, KK

Unconfirmed diagnosis Unconfirmed diagnosis dexamethasonedexamethasone does not interfere with ACTH stim testdoes not interfere with ACTH stim test

Known adrenal failure Known adrenal failure hydrocortisonehydrocortisone

EnvironmentalEnvironmental 3%3%

Spider BitesSpider Bites Brown recluse spiderBrown recluse spider: painless bite: painless bite

– Often not recognizedOften not recognized– Necrotic lesionNecrotic lesion– Rx: Dapsone, consider HBORx: Dapsone, consider HBO– Loxoscelism: fever, vomiting, myalgias, Loxoscelism: fever, vomiting, myalgias,

hemolysis, DIChemolysis, DIC Black widowBlack widow: painful bite: painful bite

– Severe muscle cramps (acute abd)Severe muscle cramps (acute abd)– Rx: analgesics, benzodiazepinesRx: analgesics, benzodiazepines– Antivenin if severe, very young or oldAntivenin if severe, very young or old

Black WidowBlack Widow

Marine EnvenomationsMarine Envenomations

Jellyfish, Man-o’-war Jellyfish, Man-o’-war VinegarVinegar Starfish, sea urchin, lionfish Starfish, sea urchin, lionfish

remove spines, hot water (45remove spines, hot water (45°)°) Ocean infections Ocean infections VibrioVibrio

– TMP/SMZ, doxycycline, fluoroquinoloneTMP/SMZ, doxycycline, fluoroquinolone

Most common envenomation Most common envenomation stingraystingray

SnakesSnakes

Rattlesnake: crotalid biteRattlesnake: crotalid bite– 4 – 6 vials or more of antivenin4 – 6 vials or more of antivenin

Coral snakesCoral snakes– admit for 24 – 48 hour observationadmit for 24 – 48 hour observation

Red on yellow Red on yellow Kill a fellow Kill a fellow Red on black Red on black Venom lack Venom lack

Coral SnakeCoral Snake

High AltitudeHigh Altitude

Acute Mountain SicknessAcute Mountain Sickness– headache, nausea, fatigue, insomniaheadache, nausea, fatigue, insomnia

– Acetazolamide, descent, OAcetazolamide, descent, O22

High Altitude Cerebral EdemaHigh Altitude Cerebral Edema – increased ICP, cerebral edemaincreased ICP, cerebral edema– ataxia, vomiting, confusion, seizures, comaataxia, vomiting, confusion, seizures, coma

– descent, Odescent, O22, steroids, HBO, steroids, HBO

High Altitude Pulmonary EdemaHigh Altitude Pulmonary Edema – dyspnea at rest, tachypnea, tachycardiadyspnea at rest, tachypnea, tachycardia

– descent, Odescent, O22, nifedipine, HBO, nifedipine, HBO

HypothermiaHypothermia

Core temperature < 35Core temperature < 35°° OsborneOsborne (“J”) waves (“J”) waves Ignore dysrhythmias except V fibIgnore dysrhythmias except V fib

– sinus bradycardia / slow A fib most freqsinus bradycardia / slow A fib most freq Rewarm (passive / active)Rewarm (passive / active) Frostbite – impossible to predict extent Frostbite – impossible to predict extent

of damage from initial examof damage from initial exam– rapid thawing 42rapid thawing 42° water bath° water bath

Osborne wavesOsborne waves

HyperthermiaHyperthermia

Heat exhaustion Heat exhaustion volume volume depletion, nausea, vomitingdepletion, nausea, vomiting

Heat stroke Heat stroke CNS dysfunction CNS dysfunction– altered mental status + feveraltered mental status + fever

Rapid cooling: mist and fansRapid cooling: mist and fans

Electrical InjuriesElectrical Injuries

AC burns more destructive than DCAC burns more destructive than DC– burns worse than they appearburns worse than they appear– beware posterior shoulder dislocation, c-spine injury, beware posterior shoulder dislocation, c-spine injury,

severe rhabdomyolysis severe rhabdomyolysis acute renal failure acute renal failure

Lightning causes asystoleLightning causes asystole AC electricity causes V fibAC electricity causes V fib Respiratory arrest commonRespiratory arrest common Feathery burns (Lichtenburg), tympanic Feathery burns (Lichtenburg), tympanic

membrane injury = membrane injury = LightningLightning

LichtenburgLichtenburg

Hydrofluoric Acid BurnsHydrofluoric Acid Burns

Glass etching, rust removersGlass etching, rust removers Rx Rx Ca gluconate gelCa gluconate gel

– SQ or intradermal Ca gluconateSQ or intradermal Ca gluconate– Intraarterial Ca gluconateIntraarterial Ca gluconate

Ongoing pain = need for more Ongoing pain = need for more treatmenttreatment

RadiationRadiation

Rapid onset of sx’s poor prognosisRapid onset of sx’s poor prognosis Nausea, vomiting, diarrhea, anemiaNausea, vomiting, diarrhea, anemia Absolute lymphocyte countAbsolute lymphocyte count (ALC) (ALC)

at 24 hours = best predictorat 24 hours = best predictor– > 1200 not lethal> 1200 not lethal– 1200 – 300 serious1200 – 300 serious– < 300 lethal< 300 lethal

Documents

Board / Inservice Review Part 1 Angela M. Mills, MD Department of Emergency Medicine University of Pennsylvania Health System