In-service Exam Review 2009 Emergency Medicine
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![Page 1: In-service Exam Review 2009 Emergency Medicine](https://reader034.fdocuments.in/reader034/viewer/2022050801/5537def3550346bf308b4650/html5/thumbnails/1.jpg)
IN-SERVICE EXAMREVIEW 2009
EMERGENCY MEDICINEDavid Lee Pierce, M.D
Assistant Professor of Clinical Emergency MedicineUniversity at Buffalo
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Objectives
• Review High Yield Material• Pass the exam
• ****Gives me the chance to study and stay one step ahead of interns
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Mesenteric Ischemia/Infarction• Elderly• Atrial fibrillation• Excruciating Abd Pain• Abdominal Exam
Relatively Benign• (pain out of
proportion to exam)• Lactate Elevated• Phosphate Elevated• Leukocytosis > 15,000• Metabolic acidosis
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Giardia• Diarrhea (no blood)• Hiking
• Crampy abdominal pain• Frothy awful smelling stool• Flatulence
• Stool Ova/Parasites
• Most common cause of parasitic disease in US
• Rx – Flagyl
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Diarrhea1. Shigella2. Salmonella3. E.coli 0157:H74. Campylobacter5. Yersinia enterocolitis6. C. Diff7. Staph8. Bacillus cereus
1. Explosive diarrhea, seizures2. Eggs, poultry3. HUS,TTP, (beef or unpast. milk)4. #1 bacterial enteritis (Adults)5. Profuse watery diarrhea RLQ pain6. Hx of antibiotics 7. #1 Food Poison, ham, mayo 8. Fried rice
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Diarrhea1. Vibrio cholera2. Vibrio parahemolyt.3. Scombroid
4. Ciguatera5. Entamoeba histolyica6. Giardia7. Cryptosporidium
1. Rice water diarrhea2. Raw seafood3. Histamine reaction, metallic,
bitter or peppery taste4. Hot/cold reversal, neuro findings5. Liver abscess (Only 1/3 diarrhea)6. Backpackers diarrhea 7. #1 chronic diarrhea AIDs
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Wall thickening> 3 mm
Stone
Ultrasound of Cholecystitis
Sludge
Confirmatory Test? HIDA
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Splenic injury• 20 yo F s/p MVC
• 11th rib Fx on left
• LUQ Pain
• Left shoulder pain• Kehr’s sign
(Phrenic Nerve)
• Most common organ injured in blunt abdominal trauma
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Intussusception• 1 mo male
• Soft tissue mass• Colon cut-off
• Cyclical severe abdominal pain• Vomiting• Bloody stools (Current jelly)
• Dx/RX:– Contrast Enema
• Most common cause of bowel obstruction in first 2 years
Colonic Cut-Off
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Gastrointestinal Pearls1. Level Cricopharyng. Muscle
2. #1 Level FB Child
3. Level Esophagus Terminates
4. #1 Level FB Adult
5. Globus hystricus
1. C6
2. C6
3. T11
4. T11
5. FB sensation throat
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Gastrointestinal Pearls
1. Odynophagia
2. Dysphagia
3. Medication for Food Impaction
4. Size of Objects Require Removal?
1. PAIN with swallowing
2. DIFFICULTY swallowing
3. Glucagon (1mg IV2mg IV)
4. -5cm LONG -2cm WIDE -SHARP
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Best Method Esophogeal FB Removal?
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Button Batteries
1. Asymptomatic in stomach
2. In Esophagus
3. D/C Summary Instructions
1. Observe/ Repeat Xray
2. Emergent Endoscopy (Perforation in 4-6 h)
3. Stop eating button batteries!!
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Foreign Body!!!
• Who’s your consultant?
• GI
• Esophageal FB
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FB “Throat”
ENTTrachea
GIEsophagus
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Boerhaave’s Syndrome• 45 yo male • Choking• Vomits large piece steak
• Severe Chest Pain• Unstable
• Stabilize• Surgery
NG TUBE
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Mallory-Weiss Tear• 45 yo male • ETOH• Hiatal hernia
• Mult. Dry Heaves• Mild hematemesis• Vitals stable
• Rx: – Antiemetics– PPI
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Sigmoid Volvulus• Elderly schizophrenic
• Chronic severe constipation
• Abdominal Distention
• “Bent Inner-Tube”– Loop out of the left side of the
pelvis and its superior aspect projects upward
• Rx: NGT, Surgery
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Cecal Volvulus• 30 year old male• Marathon runner • Prior abdominal surgeries
• Sudden onset abdominal pain
– COFFEE BEAN shape– Several distended small bowel
loops
– Rx: NGT, Surgery
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Midgut Volvulus• Newborn• Emesis• Abdominal Distention• Shock• “Birds Beak”
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Lower GI Bleeding1. Elderly Lower GIB
2. #1 Congenital LGIB
3. Cirrhotic
4. AAA Repair then LGIB
1. Diverticulosis/ Angiodysplasia
2. Meckels Diverticulum
3. Esophageal Varices (Large volume)
4. Aortoenteric Fistula
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SBO
• 50 yo female• Hx 20 surgeries• Hx Multiple Hernias
• Rx: ?• NPO• NGT• Surgery Consult
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Most Common Obstructions
1. Small Bowel
2. Large Bowel
• Adhesions• Hernias• Neoplasm• Inflammation
(Crohn’s)
• Cancer• Diverticulitis• Volvulus
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Free Air PeritoneumPerforation PUD
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Cardiac-Acute Coronary Syndromes EKG 101
Einhoven’s Triangle
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Anterior/Septal STEMI
*
Note Reciprocal Changes (ST depression)
*
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Anterior/Septal STEMI
Anterior V1-V4 Septal V1-V2Left Anterior Descending (LAD)
Thrombus
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Lateral Wall STEMI
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Lateral Wall STEMI(aVL, I, V5, V6)
Circumflex Artery (Cx)
Lateral on Einhoven’s Triangle!
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Where’s the Thrombus?LAD + Cirx = Left Main (WIDOW MAKER) or 2 critical lesions
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Inferior Wall STEMI
*Reciprocal Changes
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Inferior Wall STEMI
(II,III,aVF)Right Coronary Artery
Inferior on Einhoven’s Triangle!
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Posterior Wall STEMI
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Posterior Wall STEMI
• Treatment: • Same ACS • Fluids (Gentle on NTG)
• Often Accompanies an Inferior Wall MI
V1• Large R (> S wave) • ST Depression
(Equivalent to STEMI)
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Heart Block and ACS
1. Heart Block-Inferior MI
2. Heart Block-Anterior MI
1. Second Degree Type 1 (Wenckebach)
1. 2nd Degree Type 22. High Grade AV Block
(Get Pacer Ready)
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Aortic Pathology 101
Dissection• Intimal tear• Blood leaks into media
Aneurysm (True Aneurysm)• All 3 layers arterial wall
Ruptured Aneurysm (Leaking Aneurysm)
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Thoracic Aortic Dissection
• 60 yo smoker • HTN• Sudden tearing CP• Crack Cocaine• Radiates to his back
• Cold Pulseless Arm• DIASTOLIC Murmur
• EKG STEMI (Inferior)
• CTA Chest
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Thoracic Dissection
Debakey
Stanford
Treatment
Ascending DescendingMedical!! Medical!!Surgical!
• BBNitroprusside (Prevent reflex tachycardia)
or• Labetolol
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Ruptured AAA• 80 yo Smoker HTN PVD
• Flank Pain• Scrotal swelling • Anesthesia Medial Thigh
• Pulsatile Mass• Unequal pulses• Hypotensive
• Airway• IV• T&C 10 Units• Surgery
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Hypertensive Emergencies
1. HTN Encephalopathy
2. HTN Aortic Dissection
3. HTN Hemorrhagic CVA
4. HTN with SAH
1. BBNitroprusside or (Labetolol)
2. BBNitroprusside or (Labetolol)
3. Labetolol/ BB
4. CCB (Nimodipine)
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Hypertensive Emergencies1. HTN with ACS
2. HTN Pulmonary Edema
3. HTN Eclampsia
4. Pheochromocytoma/MAOI
5. HTN Cocaine Intoxication
1. NTG, BB
2. NTG, Lasix, Morphine, CPAP
3. Magnesium, Hydralazine, BB
4. Phentolamine BB (No BB 1st-Unopposed alpha )
5. BZD, IVF (Labetolol)
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Hypothermia
• Osborne (J) wave
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Bidirectional VTach
Dig toxicity
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Digoxin Toxicity
• Yellow Halos
• Nausea/ vomiting
Dig bind criteria1. K+ > 5.5
2. Cardiovascular collapse
3. Blocks (Mobitz II , 3rd Degree)
4. Ventricular Dysrhythmia
5. Dig level >10
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• Dig Toxic + Hyperkalemic
• What medication contraindicated?
• Calcium Gluconate/Chloride!!– Worsens intracellular Calcium derangement
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WPW
SHORT PR
DELTA WAVE
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Cardiac-Pacemaker
Pace Sense Trigger Program Shock
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Cardiac-Pacemakers
Effect of magnet on:
1. Pacemaker
2. AICD
1. Resets to Fixed Rate
2. Turns it Off
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Cardiac-AICD
• #1 Electrolyte Abnormlality AICD Dsyrhythmias?
• Paddle over AICD during code?
• Hypomagnesemia
• Don’t place close to the AICD generator
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Most Specific Troponin
Trop I most specific (~100%)
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Ventricular Dysrhythmias
Ventricular Fibriallation Arrest
• 1st Thing you do?
Torsades
• What now?
• Shock
• Magnesium IV• Overdrive Pacing• Isoproterenol
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Multifocal Atrial Tachycardia
Pulmonary Disease (COPD)
Treatment: Treat Underlying Pathology (COPD)
Multiple P Waves (Multiple Atrial Foci)
P1 P2 P3
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Atrial Flutter
Saw-Tooth F-Waves
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Supraventricular TachycardiaRhythm Breaks
PACSVT NSR PAC
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Atrial Tachycardia
• Stable SVT (AVNRT)
• Stable AFib/ Aflutter
• Unstable
• Vagal Maneuvers • Adenosine 6mg 12mg 12mg• CCB/BB
• CCB/BB• Amiodarone• Ibitilide• Anticoagulate
• Cardioversion
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Cardiomyopathy
1. Hypertrophic CM
2. Restrictive CM
3. Idiopathic Dilated CM
1. Beta Blocker
2. Diuretics/ Digoxin
3. Diuretics/ Digoxin/ Vasodilators
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Tamponade
Beck’s Triad• Hypotension• Muffled Heart Sounds• JVD
Diff Dx• Tension PTX• Massive PE• Acute Pulm Edema• Severe Asthma
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Pericardial DisordersDisorder
1. Pericarditis
2. Tamponade• (Stable Vitals)
• Hypotensive
• Penetrating Chest Trauma (No Vitals)
Treatment• ASA, NSAIDs
• IVF, Surgery Urgently (Window)
• IVF, Inotropes, Pericardiocentesis, Surgery Emergently
• ER Thoracotomy
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Electrical Alternans Tamponade/ Large Pericardial Effusion
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Pneumococcal Pneumonia
• Cough productive of rusty colored sputum
• Fever
• Single shaking chill
Lobar Infiltrate
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Staph Pneumonia
• Cough• Fever• Hemoptysis
• Recent Influenza• Toxic appearance
Air Fluid Level
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Legionella Pneumonia
• Non-Productive cough
• Elevated AST/ALT
• Hyponatriema
• Gram stain with PMN’s but no organisms
– Relative Bradycardia (Despite Fever)
– Diarrhea (GI Symptoms)***
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Mycoplasma Pneumonia
• Non productive cough
• Clinically well appearing with awful CXR
• Rx: Macrolide
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Atypical Pneumonias
1. Legionella (Macrolide)2. Mycoplasma (Macrolide)3. Chlamydia (Tetracyclines/Macrolide)
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Klebsiella Pneumonia• Alcoholic
• Cough
• Black/maroon sputum
• Abscess/ Empyema
• Gram (-) bacilli in pairs
• Rx:– Cephalosporin + AG
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PCP Pneumonia• Weight loss
• SOB
• Cough
• Hypoxic
• Bilateral Interstitial Infiltrates
• LDH Elevated
• Rx:– Bactrim
– Pentamidine
– Steroids if PaO2 < 70
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Pneumonia with Abscess
1. Staph2. Klebsiella3. Pseudomonas
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Upper lobe infiltrate? Think….
1. Aspiration
2. TB
3. Klebsiella
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Peritonsillar Abscess
• MEDIAL TO CAROTID!!
• Sore throat• Drooling • Muffled Voice
• Organism?– Polymicrobial (GABHS)
• Rx:– Aspiration– Abx (PCN, Clinda)
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Ludwigs Angina• Sore throat• Drooling • Muffled Voice• Swelling floor mouth• Chest Pain
• Organism?– Polymicrobial
(aerobic-anaerobic)
• Rx:– Airway! Airway! Airway!– ENT– ABX (clinda, unasyn)
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Retropharyngeal/Prevertebral Abscess
• Sore throat• Drooling • Muffled Voice
• Neck Stiff• Extension more comfortable
• ENT• IV ABX (clinda/ unasyn)• Admit ICU
Greater than 6 mm prevert. tissue
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ENT Trauma
Injury
1. Nasal Septal Hematoma
2. Ethmoid Fx (Cribiform Plate)
3. Hematoma Auricle
Complication
1. Avascular Necrosis
2. CSF Rhinorrhea/ Meningitis
3. Cauliflower Ear
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Septal Hematoma• Complication?
– Septal Necrosis (cartilage death within 24 hours)– Saddle nose deformity
• Rx:– Surgical drainage, packing and antibiotics
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Epistaxis
• Frequent cause?
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Epistaxis
Anterior (90%)• Murocele • Rapid Rhino• Cautery has high
incidence return visits
Posterior (10%)• Epistat• ENT
Treatment1. Blow Nose**
2. Topical Anesthetic (Lidocaine/Cocaine)3. Vasoconstrictor (Neosynephrine)
4. Pressure5. Evaluate
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Sinusitis1. Most common site
2. Cavernous Sinus thrombosis
3. Pott’s Puffy Tumor
4. Periorbital/Orbital cellulitis
1. Maxillary
2. Sphenoid (Ethmoid)
3. Frontal
4. Ethmoid
![Page 77: In-service Exam Review 2009 Emergency Medicine](https://reader034.fdocuments.in/reader034/viewer/2022050801/5537def3550346bf308b4650/html5/thumbnails/77.jpg)
Acute onset. Diagnosis?
Angioedema
Which is the most common medication that causes angioedema?
ACE inhibitors
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Facial Fractures
![Page 79: In-service Exam Review 2009 Emergency Medicine](https://reader034.fdocuments.in/reader034/viewer/2022050801/5537def3550346bf308b4650/html5/thumbnails/79.jpg)
Tripod Fracture
• Zygomaticofrontal Suture
• Zygomatic Arch
• Infraorbital Foramen
• Punched in cheek
Flat cheekPeriorbital swellingDiplopiaAnesthesia of the cheek, upper teeth, lip and gums
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Five clinical signs of basilar skull fracture
1. Periorbital ecchymosis (Raccoon eyes)
2. Retroauricular ecchymosis (battle’s sign)
3. CSF Otorrhea or rhinorrhea
4. Hemotympanum
5. CN I, II, VII, or VIII deficits
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Ellis Type III Dental Fracture• Broken tooth • Blood on tooth (pulp involved)
• Rx?• Calcium Hydroxide Paste
![Page 82: In-service Exam Review 2009 Emergency Medicine](https://reader034.fdocuments.in/reader034/viewer/2022050801/5537def3550346bf308b4650/html5/thumbnails/82.jpg)
Seat Belt Injuries
Chance Fx
Rectus Sheath Hematoma
Intestinal Perforation
![Page 83: In-service Exam Review 2009 Emergency Medicine](https://reader034.fdocuments.in/reader034/viewer/2022050801/5537def3550346bf308b4650/html5/thumbnails/83.jpg)
Trauma Pearls
You see…
1. Blunt Abd. Trauma
2. Penetrating Abd. Trauma
3. Ustable after MCV/ Fall
4. Sternal Fracture
5. Pelvic Fracture
6. Lap Belt Mark
Think…
1. Spleen Laceration
2. Liver Laceration
3. Traumatic Aortic Rupt
4. Myocardial Contusion
5. Bladder Injury
6. Jejunal/Mesenteric Lac.
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Painful ulcer
• Friable
• Jagged edges
• Inguinal Bubos
• Etiology– H. Ducrei
• Rx?– Azithro 1 gram or CTX 250 mg IM
Chancroid
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Molar pregnancy• 10 week preg
• Hyperemesis
• HTN (Preeclampic Sx)
• Uterus is larger than expected
• B-HCG is higher than expected
• Ultrasound = snowstorm appearance
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Abruptio Placenta• Painful bleeding during 3rd trimester• Severe Abdominal Pain• Hypotensive• Smoked Crack
• OB• Deliver
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Pre-Eclampsia
• 3 rd Trimester Hypertension
• Proteinuria
• Edema
• Hypertriglyceridemia
• Treatment– Hydralazine
– Labetalol
– MgSO4 (eclampsia)
![Page 88: In-service Exam Review 2009 Emergency Medicine](https://reader034.fdocuments.in/reader034/viewer/2022050801/5537def3550346bf308b4650/html5/thumbnails/88.jpg)
Trichomonas Vaginitis
• Strawberry cervix
• Profuse, yellow-green discharge
• Rx: – Flagyl
![Page 89: In-service Exam Review 2009 Emergency Medicine](https://reader034.fdocuments.in/reader034/viewer/2022050801/5537def3550346bf308b4650/html5/thumbnails/89.jpg)
STD1. Strawberry cervix
2. Painful necrotic ulcer
3. Painless indurated ulcer
1. Beefy-red, velvety ulcers
1. Trichomonas
2. Chancroid
3. Primary Syphilis
4. Granuloma Inguinale
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Toxicology - Antidotes1. Acetaminophen2. Beta blockers3. Bromides4. CCB5. Carbon monoxide6. Cholinergics7. Cyanide8. Digoxin
1. NAC2. Glucagon3. Chloride (NSS)4. Calcium, glucagon5. O26. Atropine, pralidoxime7. Nitrate, thiosulfate8. Digibind
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Toxicology - Antidotes1. Methanol2. Ethylene glycol3. Iron4. Isoniazid5. Lead6. Arsenic7. Mercury8. Nitrites9. Opiates10. TCA11. Warfarin
1. ETOH, 5MP, dialysis2. ETOH, 5MP, dialysis3. Defuroxime4. Pyridoxine, Vit B65. BAL6. BAL7. BAL8. Methylene Blue9. Narcan10. Sodium Bicarbonate11. Vit K, FFP
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Drugs that are Radioopaque
CHIPESC = Chloro Hydrate
H = Heavy Metals
I = Iron
P = Phenothiazines
E = Enteric Coated
S = Solvents
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Drugs that are Dialyzable
BLIST MED1. Barbituates2. Lithium3. Isoniazide/Iron4. Salicylates5. Theophyline6. Methanol7. Ethylene Glycol8. Depakote
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Charcoal
Useless• Lithium
• Alkali/Acids
• Heavy Metals
• Iron
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Toxic Overdoses
1. Phenytoin
2. Iron
3. Lithium
4. NMS
5. Wernicke’s
1. Folate deficiency, osteomalacia, lupus like syndrome
2. Abdominal pain, hematemesis, coma and shock
3. Tremors, hyperreflexia, seizures, N/V/D
4. Altered MS, muscular rigidity, hyperthermia, rhabdo
5. Oculomotor deficits, ataxia, AMS
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Caustics
Acid Ingestion• Coagulation Necrosis
Alkali Ingestion• Liquefaction Necrosis
(Worse/Deeper Burn)
![Page 97: In-service Exam Review 2009 Emergency Medicine](https://reader034.fdocuments.in/reader034/viewer/2022050801/5537def3550346bf308b4650/html5/thumbnails/97.jpg)
Tylenol Toxicity (APAP)
1. Time 1st level
2. Charcoal/Cathartic?
3. Phases Poisoning?
4. Toxic Metabolite APAP?
5. Treatment?
1. 4 Hours After Ingestion
2. Yes (<1 Hour)
3. 4 Phases
4. NAPQI
5. NAC
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Indication for Dialysis
• Acidosis
• Electolytes
• Ingestions (Toxins)
• Overload (Fluid)
• Uremic Symptoms
• A
• E
• I
• O
• U
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Rotator Cuff Tears
• Subscapularis• Supraspinatus• Infraspinatus• Teres minor
• Most Commonly Injured?– Supraspinatus*
![Page 100: In-service Exam Review 2009 Emergency Medicine](https://reader034.fdocuments.in/reader034/viewer/2022050801/5537def3550346bf308b4650/html5/thumbnails/100.jpg)
Nerve Injury with FracturesFracture
1. Humeral Shaft2. Elbow Fx3. Shoulder Dislocation4. Colles’/Smith’s Fx5. Sacral Fx6. Acetabular Fx7. Posterior Hip Dislocation8. Anterior Hip Dislocation9. Femoral Shaft Fx10. Knee Dislocation11. Lateral Tibial Plat. Fx
Nerve Injured
1. Radial2. Median/Ulnar3. Axillary4. Median 5. Cauda Equina6. Sciatic7. Sciatic8. Femoral9. Peroneal10. Peroneal/ Tibial11. Peroneal
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You See…1. Scapular Fx
2. Supracondylar Fx
3. High-Pressure Injection (grease/paint gun)
4. Flexor Tendon Injury Finger (FDP)
Think…1. Associated Injuries
2. Volkmann’s Ischmic Contracture
3. Consult ortho immediately despite benign exam initially (amputation!!!)
4. Ortho Consult (OR repair)
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Compartment Syndrome
• Pain out of proportion to injury (earliest sign)• Paralysis• Parasthesia• Pulselessness• Poikilothermia• Pallor
Normal Pressure = 10 mmHgAbnormal >30 mmHg
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Lisfrank Fracture
• Fracture dislocation at the base of the 2nd metatarsal
•Unstable fracture•Keystone of Midfoot•Requires ORIF
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Jones Fracture
• Fx 5th Metatarsal• High incidence of
delayed/nonunion
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Amputated Digits
• Wrap Sterile Gauze moistened with NS
• Place in water-tight container
• Place container in ice water
Don’t Submerge in Ice Water!!
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Anterior Hip Dislocations (10%)
• ABducted• Externally rotated• Flexed
Complication:• Femoral Vein/Artery
thrombosis Pulm Embolus
![Page 107: In-service Exam Review 2009 Emergency Medicine](https://reader034.fdocuments.in/reader034/viewer/2022050801/5537def3550346bf308b4650/html5/thumbnails/107.jpg)
Posterior Hip Dislocation (90%)
• Flexed Knee strikes dashboard
• Short• ADDucted• Internally rotated• Flexed
• Avascular necrosis Femoral Head
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Scaphoid Fracture
• Proximal or Distal Worse?– Proximal– (Blood supply is
distal)
• Complication?– Avascular Necrosis
• Thumb spica if unsure!
![Page 109: In-service Exam Review 2009 Emergency Medicine](https://reader034.fdocuments.in/reader034/viewer/2022050801/5537def3550346bf308b4650/html5/thumbnails/109.jpg)
Bucket Handle Fracture
• R/O Child Abuse!
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Galeazzi Fracture
• Distal Radioulnar dislocation
• Distal Radial Shaft
• ORIF
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Monteggia’s Fracture
• Fracture Proximal 1/3 Ulna
• Dislocation radial head
• Draw line radial shaft• Should interect the
capitellum
• ORIF
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Colle’s Fracture
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Maisonneuve Fracture
•Consult or send home with splint?•Consult! (High energy injury)
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Maisonneuve Fracture
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Felon
• Staph Aureus• I&D• ABX
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Flexor Tenosynovitis
• Organism?– Staph/Strep
• Rx?– Hospitalization– Ortho– IV ABX
(PCN/Cephalo)
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Bell’s Palsy (CN 7 lesions)Peripheral• Unable to wrinkle forehead on same side
• Rx?
– Steroid burst
– Acyclovir
– Eye patch
Central• Able to move forehead on same side
• Dx?
– Brain Imaging (MRI)
Bilateral Bell’s Palsy Caused by?Lyme Disease
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Jefferson’s Fracture (C1 Blowout Fracture)
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Hangman’s Fracture (C2)• Bilateral C2 Pedicle Fractures
• Mechanism--Ext/Flex?– Hyperextension!
![Page 120: In-service Exam Review 2009 Emergency Medicine](https://reader034.fdocuments.in/reader034/viewer/2022050801/5537def3550346bf308b4650/html5/thumbnails/120.jpg)
Anterior Cord syndrome
• Motor paralysis distal to the lesion
• Loss of pain and temperature
• Retention of posterior cord function – Vibration– Proprioception
• Flexion Injury
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Central Cord Syndrome
• Paralysis – Upper > Lower Extremities
• Distal > Proximal
• Clumsy Hands
• Extension Injury
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Brown Sequard Syndrome
• Penetrating injury
• Ipsilateral loss of motor, position, vibration, touch
• Contralateral loss of pain and temperature
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Cauda Equina Syndrome
• Lower back pain
• Hyporeflexia
• Asymmetric finding
• Saddle anesthesia
• Decreased rectal tone
• MRI• Neurosurgery
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In what situation is an MRI the emergent study of choice for back pain?
• Cauda Equina
• Spinal Epidural Abscess
![Page 125: In-service Exam Review 2009 Emergency Medicine](https://reader034.fdocuments.in/reader034/viewer/2022050801/5537def3550346bf308b4650/html5/thumbnails/125.jpg)
Trigeminal neuralgia
• Facial pain (right side more common)
• Electrical shock like
• Lancinating pain
Treat: • Tegretol
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Pontine hemorrhage
• Pinpoint pupils• Occipital Headache
• Hyperventilating
• Coma
• Decerebrate posturing
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Anterior Cerebral Artery Infarct
• Contralateral Paralysis– Legs >> arms
• Gait disturbance
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Middle Cerebral Artery
• Contralateral paralysis– Arms >> legs
• Expressive aphasia
• #1 CVA
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Subdural
• HA
• Decreased LOC
• Crescent shape on CT
• Airway!
• Neurosurgery
• Reverse Anticoagulation
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Epidural
• Head Trauma• Brief LOC• HA• Lenticular shape lesion• Temporal/Parietal skull fx
• Airway!• Manage BP• Neurosurgery• Reverse Anticoagulation
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Temporal arteritis
• > 50 yrs old
• Eye pain
• Temporal HA
• Malaise
• Associated with Dz:– Polymyalgia rheumatica
Blood Test:• ESR
What is the most common complication?
• Blindness
Management?• Prednisone/Biopsy
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Multiple Sclerosis
• Optic neuritis• Sensory symptoms that don’t follow a pattern• Female in 30’s with bizarre neuro findings
Double vision on lateral gaze
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Kidney Stones
• <4 mm will pass
• 4-6 mm will pass
• >6 mm will pass
• 95%
• 50%
• 10%
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Fournier’s Gangrene
• Immunocompromised• Diabetic• Polymicrobial (anaerobes)
• Treatment:– IVF– Broad spectrum antibiotics– Surgical debridement
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Erythema Multiforme (Minor)
• Mycoplasma
• Malignancy
• Drugs (SOAP)– S = Sulfa
– O = Oral hypoglycemic
– A = Anticonvulsants
– P = PCN
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Stage I Lyme Disease
• Annular erythematous lesion
• Spares palms and soles
• Associated with arthritis
• Erythema chronicum migrans
• Rx?
• Doxycycline
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Retinal Artery Occlusion• Sudden painless monocular loss of vision
• Marcus-Gunn pupil – Dilated pupil unreactive to direct, reactive to indirect light
• Cherry red spot
Rx: • Digital massage• Cycloplegics• Acetazolamide• Ophtho
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Diagnosis?
Papilloedema
![Page 139: In-service Exam Review 2009 Emergency Medicine](https://reader034.fdocuments.in/reader034/viewer/2022050801/5537def3550346bf308b4650/html5/thumbnails/139.jpg)
Corneal Ulcer• Localized whitish
corneal infiltrate
• Organism?– Pseudomonas
• Rx: – Ophtho consult
– Antibiotics (Cipro)
– No contact lenes
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Pterygium
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Diagnosis?Hypopyon
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Normal IOP
10- 21 mm hg
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Retinal Detachment
• Painless loss vision
• Flashes of light
• Floaters
• Lowering of a curtain
Associated with:
• Myopia
• Trauma
• Marfan’s
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Horner’s Syndrome
• Ptosis
• Miosis
• Anhydrosis
• Facial flushing
• Iris Heterochromia
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Rotary nystagmus
Eye findings in a PCP Overdose?
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Ramsey-Hunt Syndrome
• Vesicular rash Ear/ TM
• Bell’s palsy
• Loss of taste
• Caused by?– Herpes Zoster
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Electrical Shock
• AC (Alternating)• Vfib
– Household and commercial
– Explosive exit wounds
– Worse effects with equivalent voltage
• DC (Direct)• Asystole
– Industrial, batteries, welding supplies
– Produces discrete exit wounds