Emergency Medicine

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  1. Pathophysiology of Tylenol overdose:
    Acetaminophen is conjugated in the liver to glucuronide and sulfate metabolites.  

    In an overdose, this pathway gets overwhelmed and the cytochrome P450 system directs conversion of excess acetaminophen to N-acetyl-p-benzoquinone imine (NAPQI) which is conjugated with glutathione to form a nontoxic mercapturate metabolite

    Once glutathione stores are exhausted in the liver, the excess NAPQI combines with proteins within hepatic cells causing hepatic cell death.
  2. Tylenol overdose treatment:
    • N-acetylcysteine
    • helps restore hepatic glutathione stores an provides sulfhydryl groups that bind toxic metabolites

    Dosing: Loading dose = 140mg/kg followed by 17 doses of 70mg/kg given Q4h

    Most effective if started within 8hrs of ingestion, but still beneficial if started within 24hrs.
  3. Tylenol overdoes prognosis predictors:
    • Poor prognosis is associated with:
    • - elevated serum lactate >3.5
    • - acidemia (pH < 7.3)
    • - renal failure
    • - coagulopathy

    • Evaluate using Rumack-Matthew nomogram:
    • Image Upload 1
  4. Ottawa Ankle Rules:
    Obtain ankle radiographs if:

    Pain in malleolar zone AND

    • Bone tenderness along the distal 6cm of the posterior edge of:
    •       tibia/tip of medial malleolus OR
    •       fibula/tip of lateral malleolus
    • OR
    • Inability to bear weight immediately and in ED for 4 steps
  5. Ottawa Foot Rules:
    Obtain foot series radiographs if:

    Pain in midfoot zone AND

    • Bone tenderness at the base of the:
    •       5th metatarsal
    •       navicular bone
    • OR
    • Inability to bear weight immediately and in ED for 4 steps
  6. Most common cause of fever in geriatric patients is:

    First step in work up is:
    80% are due to respiratory, urinary or skin infections.

    CXR, Urinalysis
  7. Medical treatment of achalasia:
    • Diltiazem
    • Nifedipine
  8. Transfer dysphagia =
    • difficulty with starting to swallow associated with multiple sclerosis
    • liquids are more difficult than solids
  9. Aortic dissection initial treatment:
    • 1.  Beta blocker to decrease shear force (directly related to left ventricular pressure) by decreasing cardiac contractility & to prevent reflex tachycardia
    •      Esmolol - short acting & easily titrated
    •      Metoprolol
    •      Labetalol
    • Goal HR = 60bpm, SBP = 100-120, MAP = 60

    2.  Vasodilator to decrease blood pressure
  10. Phases of acute radiation syndrome (ARS):
    • 1.  Prodromal - anorexia, nausea, vomiting
    • 2.  Latent - symptom free for hours to weeks
    • 3.  Manifest illness (depends on rad dose)
    •      - Hematopoietic syndrome = rapid decline in lymphocytes (ALC), followed by granulocytes and platelets --> pancytopenia
    •      - Gastrointestinal syndrome = severe vomiting, diarrhea, abdominal pain --> volume loss, electrolyte abnormalities, fulminant enterocolitis (fatal)
    •      - Cardiovascular & CNS syndrome = above + refractory hypotension, AMS, lethargy, ataxia, tremors, convulsions
    • 4.  Recovery/death
  11. Best predictor of ARS prognosis:
    Absolute lymphocyte count (ALC) measured at 24 & 48hrs postexposure

    • @24h:
    • ALC >1200/mcL - good prognosis, no clinical support required
    • ALC <500/mcL - poor prognosis

    • @48h:
    • ALC >1200/mcL - good prognosis
    • ALC <300/mcL - predictive of death
  12. Otitis externa treatment:
    Cortisporin otic suspension= combo neomycin, polymixin B, & hydrocortisone

    Suspension from less ototoxic than solution preparation.

    Use ear wicks to administer if ear canal is swollen shut
  13. Scleroderma diagnostic criteria:
    • One major and two minor:
    • Major
    •   - proximal thickening
    •   - tightening
    •   - induration of skin of fingers & toes

    • Minor
    •   - sclerodactyly
    •   - digital pitting scars of the finger pads
    •   - bibasilar pulmonary fibrosis
  14. Scleroderma treatment:
    Initial - gentle warming and topical/oral calcium channel blocker or nitrates
  15. Features associated with Cauda equina syndrome:
    • Urinary retention
    • Low back pain
    • Saddle/perineal anesthesia (dermatomal)
    • Hyporeflexia (its a lower motor neuron lesion)
    • Lumbosacral radiculopathies
  16. Features associated with Conus Medullaris Syndrome:
    • Upper motor/mix upper & lower motor neuron lesions
    • Spinal cord compression symptoms
    • Nondermatomal sensory loss
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Emergency Medicine
Emergency Medicine
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