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Emergency Medicine Board Review: Insights on Critical Conditions

This board review provides detailed insights on various critical conditions commonly encountered in emergency medicine practice. Topics covered include thoracic and respiratory issues, pneumothorax, pneumonia, lung abscess, DVT/PE, toxicology, and management of different toxic syndromes. Essential information on diagnosis, treatment, and key considerations is presented in a concise and informative manner.

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Emergency Medicine Board Review: Insights on Critical Conditions

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  1. Department of Emergency Medicine University of Pennsylvania Health System Board / Inservice Review Part 3 • Angela M. Mills, MD

  2. Thoracic/ • Respiratory • 8%

  3. A-a Gradient • Alveolar-arterial gradient (RA) • 150 – pCO2 / 0.8 = pAO2 • pAO2 – paO2 = A-a gradient • normally <10 mmHg • Pure hypoventilation does not cause increased A-a gradient • Ventilation perfusion mismatching most common cause of increased A-a gradient • Shunt cannot be corrected by supplemental O2

  4. Hypoxemia • Hypoventilation • Right to left shunt • Ventilation-perfusion mismatch • Diffusion impairment • Low inspired oxygen

  5. Epiglottitis • Mean age higher • Strep pyogenes & Staph aureus • Subtle presentation • Stridor may not be present • Severe sore throat • Normal exam

  6. Epiglottitis

  7. Tracheostomy Complications • Accidental decannulation • Tube obstruction • Infection • Bleeding tracheo-innominate fistula • Tracheal stenosis

  8. Pleural Effusion • Transudate = plasma (2 A’s) • ultrafiltrate of plasma with ↓ protein • hydrostatic pressure or ↓ oncotic pressure • most common  CHF • Exudate  high protein • pleural inflammation • most common  infection

  9. Pneumomediastinum • Spontaneous • Valsalva, drugs • Mediastinal crepitation  Hamman’s crunch • 50-80%

  10. Pneumomediastinum

  11. Pneumothorax • Tall, thin male smoker • Acute pleuritic CP  95% • SOB  85% • Decreased BS  85%

  12. Pneumothorax • 1¼ % intrapleural air absorbed / day • Not all need CT in 1º PTX • 20% or greater need CT • 2 º PTX need CT • COPD, TB, CA • Traumatic PTX needs CT

  13. Pneumothorax

  14. Tension PTX • Large bore needle over catheter • 2nd intercostal space MCL • CXR NEVER right answer

  15. Tension PTX

  16. ARDS • Rapid labored breathing • Exclude CHF • CXR  diffuse infiltrates, normal-size  • Sepsis, shock, trauma, aspiration, drugs • ABGs

  17. Hemoptysis • Differentiate from hematemesis • Chronic bronchitis, neoplasm • ICU, bronchoscopy • Massive hemoptysis  surgery • Bleeding side down • ABCs

  18. Asthma • All that wheezes is not asthma • CHF, FB, COPD, upper airway obst • PEF • B-agonists, corticosteroids • Epinephrine  life threatening dz

  19. COPD • Smoking • Exertional dyspnea • Chronic productive cough • Avoid mech vent if poss • B-agonist, corticosteroids • Low dose O2

  20. Pneumonia • CAP  pneumococcus, Mycoplasma, Legionella, H.flu, viral • Legionella  high fever, dry cough, abd pain, n/v/d • Chlamydia  mild, subacute • Mycoplasma  “walking” PNA • PNA + bullous myringitis + rash + arthralgia • Pregnancy  think Varicella

  21. Pneumonia • < 60 yo  macrolide OR doxy OR 3rd gen fluoroquinolone • > 60 yo and/or comorbid  3rd gen fluoroquinolone, macrolide + 2nd gen cephalosporin

  22. Pneumococcus • Fever, rigors, rusty sputum, pleurisy • Lobar infiltrate • ↑ PCN resistant (4-5%) • 3rd generation fluoroquinolone

  23. Pneumonia

  24. Lung Abscess • Suppuration/ necrosis  cavity AFL • Risk factors  ETOH abuse, 90% have periodontal disease • Clindamycin

  25. Lung Abscess

  26. Tuberculosis • Mycobacterium  aerobic rod • Multiple drug resistance • 4 drug therapy • Most common sx  fever • Night sweats, mild cough, fever, malaise • Cavitary lesions in upper lobes • Parenchymal infiltrates, hilar and mediastinal nodes, pleural effusion

  27. DVT / PE • Virchow’s triad • venous stasis + trauma to vasc endothelium + hypercoaguable state • Risk factors • trauma, immob, surg, CA, prior DVT/PE • Dyspnea, chest pain • Tachypnea, tachycardia • VQ scan • High pre-test + high prob = 96% PPV • Low pre-test + low prob = 96% NPV • all others need more studies

  28. PE

  29. Toxicology • 4%

  30. Toxicology • Know your toxidromes! • ABC’s + resuscitation / supportive • Coma cocktail  • O2 + naloxone + D50 + thiamine • Hypotension responsive to IVF + Trendelenberg in most cases • Gastric emptying/lavage  limited use

  31. Toxicology • Activated charcoal does not bind  • iron, lithium, hydrocarbons, solvents, pesticides, acid, alkalis, alcohols • first dose with sorbitol • Hemodialysis  I STUMBLE • isopropyl alcohol, salicylates, theophylline, uremia, methanol, barbiturates, lithium, ethylene glycol • Whole bowel irrigation  SLIM • sustained release, stuffers, lithium, iron, metals (heavy)

  32. Opioids • ↓CNS (coma), ↓pupils (miosis) • ↓HR, ↓RR, pulmonary edema • Supportive, ventilate • Naloxone • Opiate T ½ > naloxone T ½

  33. Sympathomimetics • Agitation, diaphoresis • ↑ T, ↑HR, ↑BP, ↑pupils (mydriasis) • Seizures, MI, rhabdo • Cocaine, amphetamines • RX  sedation, cooling • avoid B-blocker  unopposed alpha

  34. Cholinergic • “Wet”  Salivation, lacrimation, diaphoresis, n/v, bronchorrhea • SLUDGE • Bradycardia, fasciculations • Insecticides, organophosphates • RX  airway, atropine, pralidoxime (2-PAM)

  35. Anticholinergic • Mad as hatter, blind as bat, dry as bone….. • AMS, mydriasis, dry flushed skin, urinary retention, ↑T, ↑HR, ↓BS, rhabdo • OTC cold/sleep-aid meds, jimsonweed, amanita mushrooms • RX  supportive • Physostigmine  resistant hallucinations, seizures, muscle rigidity, symptomatic tachycardia

  36. Salicylates • AMS, ↑T, ↑HR, ↑RR, diaphoresis, tinnitus, AG met acidosis • mixed early resp alkalosis, late met acidosis adults • ASA, oil of wintergreen • RX  mult dose AC, alkalinize urine, HD

  37. Hypoglycemia • AMS, diaphoresis, seizure, bizarre behavior, ↑HR, ↑BP • Insulin, sufonylureas • RX  D50, glucagon

  38. Methanol • ↓CNS, visual disturbance, abd pain • visual loss with nonreactive pupils & disc hyperemia • “snowstorm” • Drunk w/o breath odor • AG acidosis, osmolar gap • RX  ETOH, fomepizole, folate

  39. Ethylene Glycol • CNS (drunk) + cardiac failure (CHF, ↓ BP) + renal • Hypocalcemia • Calcium oxalate crystals • AG acidosis, osmolar gap • RX  ETOH, fomepizole

  40. Iron • GI bleeding • KUB • 5 stages • 1-6 hrs  n/v, gib • 6-24 hrs  sx resolve • 1-2 days  shock, acidosis, MOF • 2-5 days  hepatic failure • 4-6 weeks  gastric outlet obstruction • RX  deferoxamine

  41. Digitalis • Dysrhythmias • Yellow-green halo visual finding • Treat hyperkalemia • ECG  PAT with block, regular afib, high –grade AV block • RX  Fab fragments • 10 vials if amt ingested unknown

  42. TCA • Anticholinergic + CNS + Cardiac • ECG  ST, wide QRS, prolonged QT, terminal R wave in aVr • Benzos for agitation or sz • RX  alkalinize serum • ↓ BP, wide QRS, vent dysrhythmias • Admit ↓CNS, QRS>100, tachyarrhythmias

  43. Acetaminophen • Sx’s / hepatotoxicity delayed • Toxic dose  7.5 gm (140 mg/kg) • Toxic level  140 mcg/ml at 4 hours • RX N-acetylcystein (NAC, Mucomyst) • Fully protective 8-10 hrs • Partially protective 24 hours • 140 mg/kg PO  70 mg/kg x 17 doses

  44. Antidotes • Arsenic BAL • Lead  BAL, EDTA • Cyanide amyl nitrite pearl  Na nitrite  Na thiosulfate • Methanol  ETOH, fomepizole • Ethylene glycol  ETOH, fomepizole • Iron  deferoxamine

  45. Antidotes • Organophosphates  atropine, 2PAM • INH pyridoxine (B6) • intractable seizures + met acidosis • Digoxin  Fab fragments (Digibind) • CO  high flow O2, HBO • CCB  calcium, glucagon • B-blocker  glucagon • Acetaminophen  NAC

  46. Alkalinize • Serum  TCA • Urine  salicylates, barbiturates, chlorpropamide

  47. OB/GYN • 4%

  48. GYN • Females childbearing age  pregnant until proven otherwise • First trimester bleeding  ectopic until proven otherwise

  49. Infections • Cervicitis, salpingitis, PID • Gonorrhea, chlamydia • Fitz-Hugh-Curtis syndrome • PID + RUQ pain + jaundice • Vulvovaginitis • Trichomonas, Gardnerella, Candida • Treat asymptomatic bacteruria in pregnancy • Macrodantin  1st & 2nd trimester • Ampicillin  3rd trimester

  50. P&B / P&C • Identify IUP  w/u over • Identify ectopic  w/u over • ß-hcg >2000 w/o US IUP  ectopic until proven otherwise

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