TV Sonography and Pregnancy • Earliest finding is at ______

TV Sonography and Pregnancy
•
Earliest finding is _______________seen
at ___________ (sonolucent structure
surrounded by echogenic ring)
•
Next is _________at _____________
•
Next is __________at _____________
•
Next is ______________ at __________
TV Sonography and Pregnancy
•
Earliest finding is _______________seen
gestational sac
4 - 5 weeks (sonolucent structure
at ___________
surrounded by echogenic ring)
•
5 to 5.5 weeks
Next is _________at
_____________
yolk sac
•
5.5 to 6 weeks
Next is __________at
_____________
fetal pole
•
6 weeks
cardiac activity at __________
Next is ______________
1
2
3
4
Fetal demise
5
A frantic father brings his 5 month old to the ED
because the child had a seizure at home. The child
was treated symptomatically for a febrile illness 12
hours ago. Which of the following would leave you
to consider that this is NOT a benign febrile seizure?
•
•
•
•
The seizure lasted 5 minutes
The seizure was described as generalized tonicclonic
The short time between the febrile illness and the
child’s seizure
The child’s age
A frantic father brings his 5 month old to the ED
because the child had a seizure at home. The child
was treated symptomatically for a febrile illness 12
hours ago. Which of the following would leave you
to consider that this is NOT a benign febrile seizure?
•
•
•
•
The seizure lasted 5 minutes
The seizure was described as generalized tonicclonic
The short time between the febrile illness and the
child’s seizure
The child’s age
6
Febrile Seizures
•
HHV-6 infections (roseola) associated 18%
•
30% - 40% will have recurrence (high risk group
are those who had their FS < 1 year of age
•
2 types of Febrile seizures
Simple Febrile Seizures
-
6 mo – 6 yo (NIH 3m – 5yo)
Lasts < 15 minutes
Short post ictal period
Generalized tonic-clonic
(not focal)
No focal deficits
No previous neurologic
problems
Occurs once in 24 hours
Prior to seizure child was
fine
MCC of Sz in childhood
-
•
Simple Febrile seizures
-
•
Complex Febrile seizures
-
(3% - 5%)
Complex Febrile Seizures
- Anything that is not a
simple febrile seizure
and the child is back to
normal baseline
- Negative work-up
- Account for 65% - 90% of
all febrile sz
Febrile Seizures
•
History
•
•
•
•
•
Fever
Search for source
No meningismus
No focal findings
Return to normal neuro baseline
AAP recommendations for Febrile Seizures
•
Simple Febrile Seizure
•
•
•
•
•
Work-up the fever
Urinalysis (dip)
LP optional even in kids < 12 mo old
Nothing else if simple and kid back to baseline
Complex Febrile Seizure in kids > 6 mo
•
•
•
Glucose, lytes, (Ca++ not useful), U/A
? LP, ? EEG
No CT brain
7
Febrile Seizures – Management
•
•
Treat on-going seizure (complex by definition)
with Ativan 0.1mg/kg, then Dilantin, then
Keppra - ADMIT
For simple Febrile Seizures
•
•
•
Support parents and suggest child CPR course
NOT HELPFUL
• Prophylactic anti-convulsants (not helpful +
30% side effects)
• Antipyretic
Febrile Seizures – Complications
•
•
•
No long term damage from febrile seizures
1/3 will have a second one and 1/3 of those
will have more
Risk Factors for Recurrence
•
•
•
•
Age < 18 months at time of 1st seizure
Lower fever causing seizure
Shorter duration of fever before seizure (unless
high fever comes on suddenly)
Family hx of febrile seizure
DC home with safety instructions
A previously healthy 26 y.o. is involved in an
MVA. In the MVA he suffered multiple
injuries. His pulse is 110, his BP 110/96, his
respiratory rate 25, and is mildly anxious.
Based on ATLS principles his estimated blood
loss would be…
If it is a simple febrile seizure your job is to
find the source
For SFSx less is better
For CFSx more work-up, no Rx
a.
< 500 cc
b.
700 cc
c.
1500 cc
d.
2000 cc
e.
> 2500 cc
8
A previously healthy 26 y.o. is involved in an
MVA. In the MVA he suffered multiple
injuries. His pulse is 110, his BP 110/96, his
respiratory rate 25, and is mildly anxious.
Based on ATLS principles his estimated blood
loss would be…
a.
< 500 cc
b.
700 cc
c.
1500 cc
d.
2000 cc
e.
> 2500 cc
Class I
Blood loss
% blood
vol
Pulse
Class I
% blood
vol
Pulse
Class III
1500 –
2000
Up to 15% 15% - 30% 30% - 40%
< 100
> 100
> 120
> 140
Normal
Normal
Resp Rate
14 – 20
20 –30
30 – 40
> 35
Urine
> 30 cc/hr
20 – 30
5 – 15
cc/hr
Anxious
Negligeabl
e
Confused,
lethargic
+ Blood
+ Blood
Fluids; 3:1
cc/hr
> 120
> 140
Decreased Decreased Decreased
Normal
Resp Rate
14 – 20
20 –30
30 – 40
> 35
Urine
> 30 cc/hr
20 – 30
5 – 15
cc/hr
Anxious
Negligeabl
e
Confused,
lethargic
+ Blood
+ Blood
cc/hr
Slighlty
Mildly
anxious
anxious
Crystalloid Crystalloid
Decreased Decreased
> 40%
Decreased Decreased Decreased
Slighlty
Mildly
anxious
anxious
Crystalloid Crystalloid
> 100
> 40%
> 2000
Normal
CNS
< 100
> 2000
Class IV
Pulse
Press
BP
Output
1500 –
2000
Up to 15% 15% - 30% 30% - 40%
Normal
CNS
Class II
Up to 750 750 – 1500
Class IV
Normal
Output
Up to 750 750 – 1500
Class III
Pulse
Press
BP
Fluids; 3:1
Blood loss
Class II
Decreased Decreased
Volume loss
Pulse
Blood Pressure
CNS
Replacement
3:1
9
•
•
•
•
•
Maisonneuve Fracture
Associations
Proximal fibular fracture
Deltoid ligament disruption
and ankle joint instability
(stress views of the ankle)
Peroneal nerve injury
•
•
•
•
•
•
Motor: foot dorsiflexion
Sensory: dorsum of foot
With deep peroneal n injury
only: sensory dorsum between
big toe and second toes
May get Maisonneuve with
bad ankle sprain only so
must look for fibular fracture
A young male presents with exertional
syncope. His ECG is shown. One examination
you note a harsh systolic murmur heard best at
the lower left sternal border. His ECG is
shown. You expect that the murmur to increase
with…
a. Squatting
b. Isometric hand grip
c. Alpha agonists
d. Valsalva
e. Passive leg raising
10
A young male presents with exertional
syncope. His ECG is shown. One examination
you note a harsh systolic murmur heard best at
the lower left sternal border. You expect that
the murmur to increase with…
a.
b.
c.
d.
e.
Squatting
Isometric hand grip
Alpha agonists
Valsalva
Passive leg raising
HCM is cause of sudden death in young adults.
Increased LV Volume Decreased LV Volume
=
=
Decreased Murmur
Increased Murmur
Squatting
T-berg
Isometrics
Alpha agonists
Full
•
Cardiomyopathies
Hypertrophic Cardiomyopathy
•
•
Standing
Valsalva
Amyl nitrate
Beta agonists
•
•
Half Full
•
•
Click/m closer to S2 Click/m closer to S1
intensity/duration m intensity/duration m
Asymmetric thickening of the septum causing
•
Non compliant ventricles with diastolic filling
Dynamic obstruction of LV outflow (with mitral
valve leaflets blocking the outflow tract)
Clinically exertional dyspnea and sudden death,
cardiac ischemia, dysrhythmias
NO NO NO
Echo for diagnosis
- Digitalis
- inotropes
Avoid exertion
Beta-blockers, CaCh blockers slows down heart
more time to fill, helps improve diastolic fx
11
Murmur KEYCEPTS
Syncope – 4. Structural Problems
•
Hypertrophic Cardiomyopathy (HCM)
• Young with exertional syncope
•
HCM (hypertrophic cardiomyopathy)
•
•
Big thick septal wall on 2-D echo
RV
•
•
thick septum
LV
Goal:
•
•
Improve diastolic function (improve LV filling)
Beta blockers, CaCh blockers
Do not give meds that increase systemic
afterload (pheynylephrine)
Do not give meds that increase cardiac
contractility (e.g. dig, isoproteronol)
Do not give things that decrease preload (e.g.
lasix, vasodilators)
Rx: beta blockers
•
Murmur KEYCEPTS
IVDA
•
•
•
•
Tricuspid valve is affected
Less likely to hear murmur (pressure gradient
across tricuspid is lower)
Fever more likely
Pulmonary manifestations more common
•
•
•
•
1/3 have pleuritic chest pain
2/3 have CXR abnormalities
MCC is staph au – MRSA increasing
•
Upper sternal border
Carotids
For IVDA mortality is less than others who get
staph au endocarditis where mortality is 30% - 40%
The Apex
Axilla
Meningitis more common
12
•
Mitral regurgitation classically presents as a
•
•
•
•
•
•
•
•
harsh crescendo-decrescendo systolic murmur
heard best at the right second intercostal space that
radiates to the carotids and is
associated with an S4 gallop.
Ventricular septal defects have a characteristic
•
•
•
loud, harsh, blowing holosystolic murmur heard +/- thrill
best over the lower left sternal border (third or fourth intercostal
spaces)
when large, they can be accompanied by a displaced point of maximal
impulse and a palpable thrill.
Low pitched diastolic rumble radiates
S to apex, MCC Rh Hrt Dz
MC Sx exertional dyspnea
Straightening L heart border
Acute: cresc-desc mid systolic m radiates
S to base MCC ruptured chordae tend,
pap m dz 1 wk post MI MCSx dyspnea,
tachypnea, pulm edema, hypotension. Rx
with afterload reducer, inotropes, surgery
Chronic: high pitched holosystolic m
radiates S to axilla MCC Rh Hrt Dz more
common than acute better tolerated,
LAE, LVH Rx: treat CHF and A fib
High pitched cresc-desc systolic
murmur radiates N to
carotids/suprasternal notch
MCC: cong bicuspid valve < 65;
idiopathic calc/degen > 65
MCSx and 50% survival: Angina 5yr,
Syncope 3yr, Dyspnea (CHF) 2yr
Acute: soft short early mid diastolic m
radiates N MCC infective endocarditis,
prox aortic dissection, MC valvulopathy
chest trauma Rx surgery nitroprus, inotropes
Chronic: mid diastolic rumble radiates N
MCC Rh Hrt Dz, CHF funny names
Mitral stenosis classically presents with a
•
Aortic stenosis classically have a
•
•
blowing holosystolic murmur that radiates to the axilla.
best heard with the bell when the patient is in the left lateral decubitus
position.
Later narrow pulse pressure
Aortic Stenosis
75% stenosis required. Very
sensitive to preload and afterload
reducers, Low BP:inotropes, surg
Aortic Regurg
Wide pulse pressure
Mitral Stenosis
Pulm embolization, infection,
infarction, restrictive lung
dzAtrial fibrillation Rx:
manage complications
Mitral Regurg
•
loud S1 and an opening snap in early diastole (just after
S2), with a
low-pitched, mid-diastolic rumble apical murmur.
Aortic regurgitation is described as a
•
•
•
•
•
soft early diastolic, decrescendo murmur heard best at the
left upper sternal border with the patient leaning forward.
widened pulse pressure
rapidly rising and falling carotid pulse,
spontaneous nail bed pulsations, and a
to-and-fro murmur over the femoral artery.
Low pitched diastolic rumble radiates
S to apex, MCC Rh Hrt Dz
MC Sx exertional dyspnea
Straightening L heart border
Acute: cresc-desc mid systolic m radiates
S to base MCC ruptured chordae tend,
pap m dz 1 wk post MI MCSx dyspnea,
tachypnea, pulm edema, hypotension. Rx
with afterload reducer, inotropes, surgery
Chronic: high pitched holosystolic m
radiates S to axilla MCC Rh Hrt Dz more
common than acute better tolerated,
LAE, LVH Rx: treat CHF and A fib
High pitched cresc-desc systolic
murmur radiates N to
carotids/suprasternal notch
MCC: cong bicuspid valve < 65;
idiopathic calc/degen > 65
MCSx and 50% survival: Angina 5yr,
Syncope 3yr, Dyspnea (CHF) 2yr
Acute: soft short early mid diastolic m
radiates N MCC infective endocarditis,
prox aortic dissection, MC valvulopathy
chest trauma Rx surgery nitroprus, inotropes
Chronic: mid diastolic rumble radiates N
MCC Rh Hrt Dz, CHF funny names
Later narrow pulse pressure
Aortic Stenosis
75% stenosis required. Very
sensitive to preload and afterload
reducers, Low BP:inotropes, surg
Aortic Regurg
Wide pulse pressure
Mitral Stenosis
Pulm embolization, infection,
infarction, restrictive lung
dzAtrial fibrillation Rx:
manage complications
Mitral Regurg
2 Systolic M……...
2 Diastolic M…….
2 Radiate North….
2 Radiate South….
AS, MR
AR, MS
AS, AR
MS, MR
13
Cheyne-Stokes
torsades breathing
Ataxic/Cluster breathing
Cheyne-Stokes
Medulla
dysfunction
torsades breathing
Ataxic/Cluster breathing
Medulla
dysfunction
Irregular rate and
depth
Midbrain
dysfunction
Irregular rate and
depth
Midbrain
dysfunction
Apneustic
Pontine
dysfunction
Apneustic
Pontine
dysfunction
Slow gasping resps
Rapid breathing
(central neurogenic
hyperventilation)
Cerebral
dysfunction
Slow gasping resps
Rapid breathing
Cerebral
dysfunction
(central neurogenic
hyperventilation)
Toxidromes
AMS, Resp Alk,
Met Acid, tinnitus,
hyperpnea, diaphoresis
Agitation, mydriasis,
diphoresis, tachy, HTN,
hyperthermia, normal BS
CNS depression,
miosis, resp depression
AMS, incr muscle tone,
hypereflexia, hypertherm
Sal, Lacr, urination, N/V,
diaphoresis, diarrhea,
muscle fasciculation,
bronchorhea, weakness
AMS, mydriasis, dry mm
& skin, urinary retention,
BS, hyperthermia
Serotonin
toxidrome
Opioid toxidrome
Cholinergic
toxidrome
Sympathomimetic
toxidrome
Anticholinergic
toxidrome
Salicylate
toxidrome
14
Toxidromes
AMS, Resp Alk,
Met Acid, tinnitus,
hyperpnea, diaphoresis
Agitation, mydriasis,
diphoresis, tachy, HTN,
hyperthermia, normal BS
CNS depression,
miosis, resp depression
AMS, incr muscle tone,
hypereflexia, hypertherm
Sal, Lacr, urination, N/V,
diaphoresis, diarrhea,
muscle fasciculation,
bronchorhea, weakness
AMS, mydriasis, dry mm
& skin, urinary retention,
BS, hyperthermia
Serotonin
toxidrome
Opioid toxidrome
WET
DRY
Muscarinic Toxidrome
•
Diarrhea
Cholinergic
toxidrome
•
Urination
•
Miosis
Sympathomimetic
toxidrome
•
Bradycardia,
•
Bronchorrhea, Bronchospasm
Anticholinergic
toxidrome
•
Emesis
•
Lacrimation
Salicylate
toxidrome
•58
Salivation, sweating, Secretion
D
U
M
B
B
E
L
S
Nicotinic Toxidrome
MTWHFS (days of the week)
•
•
•
•
•
•
More severe toxicity:
Mydriasis
- seizures
Tachycardia
- respiratory depression
- hyperthermia
Weakness
Hypertension, Hyperglycemia
Fasciculation
No specific antidote
Supportive care
Seizures
Benzos
15
The most common findings on MRI in patients
with SCIWORA include all of the following
EXCEPT…
a.
b.
c.
d.
e.
•
•
•
The most common findings on MRI in patients
with SCIWORA include all of the following
EXCEPT…
Central disc herniation
Cord hemorrhage
Spinal stenosis
Cord edema
Cord contusion
SCIWORA
______ % of children with SCIWORA have
delayed onset of paralysis, sometimes up to 4
days
Many of these children have paresthesias,
numbness, or weakness at the time or shortly
after the injury
The most important factor in prognosis is
______________________
a.
b.
c.
d.
e.
•
•
•
Central disc herniation
Cord hemorrhage
Spinal stenosis
Cord edema
Cord contusion
SCIWORA
50 % of children with SCIWORA have
______
delayed onset of paralysis, sometimes up to 4
days
Many of these children have paresthesias,
numbness, or weakness at the time or shortly
after the injury
The most important factor in prognosis is
______________________
initial neurologic status
16
SCIWORA
SCIWORA in the Age of MRI
•
•
In the NEXUS study which included 34,000
patients of which 3,000 were children, all
SCIWORA (27 total) occurred in adults
THE POINT:
•
Anyone with initial neuro complaints regardless
of a normal X-ray and a normal CT is a
SCIWORA until proven otherwise by an MRI
(or seen by a neurosurgeon if no MRI)
You are taking care of a multiple trauma
patient. After taking care of airway, breathing
and IV access with volume resuscitation your
next best step is…
a.
b.
c.
d.
e.
To undress the patient
To assess for C-spine trauma
To assess Glascow coma score
To assess pelvic injury
To assess the need for splints
•
•
•
Hemorrhagic changes within the spinal cord
caused by MVC were accompanied by permanent
complete neuro deficits
Trauma patients with initial transient neurological
deficits whose MRI show no cord abnormality
have full recovery
In NEXUS the most common findings on MRI of
patients with SCIWORA were: central disc
herniation, spinal stenosis, cord edema, cord
contusion
You are taking care of a multiple trauma
patient. After taking care of airway, breathing
and IV access with volume resuscitation your
next best step is…
a.
b.
c.
d.
e.
To undress the patient
To assess for C-spine trauma
To assess Glascow coma score
To assess pelvic injury
To assess the need for splints
17
A trauma patient you are taking over for
another ED physician has this C-spine X-ray.
You know
a.
b.
c.
d.
e.
This is a ligamentous injury that can have
significant unstability associated with it
This is a bony injury that is stable but requires a
C-collar
This is a pseudo-subluxation and requires no
treatment
This is a unstable fracture requiring C-spine
immobilization
There is no injury seen on this film
A trauma patient you are taking over for
another ED physician has this C-spine X-ray.
You know
a.
b.
c.
d.
e.
This is a ligamentous injury that can have
significant unstability associated with it
This is a bony injury that is stable but requires a
C-collar
This is a pseudo-subluxation and requires no
treatment
This is a unstable fracture requiring C-spine
immobilization
There is no injury seen on this film
18
Unstable Cervical Spine Fractures – Jefferson
bit off a hangman’s thumb
The Stable Fractures
•
•
Jefferson
•
Bilateral facet dislocation
Stable spinal injuries are more common than
unstable ones and there are only a few
•
•
•
Odontoid II and III
•
Any fracture dislocation
•
Hangman’s
•
Tear drop fracture
Stable Fractures
- spinous fracture
- transverse process #
- wedge fracture
- unilateral facet dislocation
- vertebral burst fracture
(except Jefferson)
Alignment
3 X 7 = 21
3 mm predental space
7 mm at C 2
21 mm at C7
6 at 2
Predental
space in kids
can be up to
5 mm
Spinous
process
Line
Spino
laminar
Line
22 at 6
Posterior
Longitudinal
ligament
Line
Anterior
Longitudinal
ligament
Line
Soft
Tissue
Line
•
•
•
Wedge fractures
Process fractures (Spinous and Transverse)
Unilateral facet dislocations
Vertebral burst fractures excluding Jefferson’s
fracture (burst fracture of C1)
All other fractures are considered unstable or
potentially unstable
A 24 yo male alive at the scene, presents to the
ED after a head on collision where the car is
totally destroyed. He had to be extricated from
the car. On arrival to the ED his BP is not
recordable, P not palpable. The injury most
likely to be causing this patient’s demise is…
a. Massive head injury
b. Rupture of the great vessels
c. Pelvic fractures
d. C-spine injury with cord disruption
e. Airway obstruction
19
A 24 yo male alive at the scene, presents to the
ED after a head on collision where the car is
totally destroyed. He had to be extricated from
the car. On arrival to the ED his BP is not
recordable, P not palpable. The injury most
likely to be causing this patient’s demise is…
Die
a. Massive head injury
at the
b. Rupture of the great vessels
scene
c. Pelvic fractures
d. C-spine injury with cord disruption
e. Airway obstruction
3 Peak Times of Death in Trauma
•
•
•
•
•
•
•
•
•
•
•
b.
c.
d.
e.
3
6
9
11
13
Hemopneumothorax
Cardiac tamponade
Subdural or epidural hematomas
Injured spleen or liver
Pelvic fractures
Big time injuries with hypovolemia/shock
Peak 3: days to weeks later (20%)
Motor
•
•
a.
Massive head injury
Rupture of the great vessels
C-spine injury with cord disruption
Airway obstruction
Peak 2: the “golden hour” (minutes to hours) (30%
•
•
You are assessing an MVA patient who opens
his eyes to pain, he withdraws to painful
stimuli and when spoken to he only responds
with innapropriate comments. Based on this
information, you calculate his GCS to be…
Peak 1: first few minutes (50% of trauma deaths)
•
•
•
•
Obeys
Localizes
Withdraws
Flexion
Extension
None
6
5
4
3
2
1
20
Verbal
•
•
•
•
•
Eye Opening
Oriented
Confused
Inappropriate
Incomprehensible
None
5
4
3
2
1
•
•
•
•
GCS
6
5 4
3
motor Ob Lo W D
Or Co In
verbal
S V
eye opening
2
D
In
P
1
0
0
0
Motors have 6 cylinders
Spontaneous eye opening means that the
reticular activating system is functioning, but
does not imply awareness
Spontaneously
To speech
To pain
None
4
3
2
1
You are assessing an MVA patient who opens
his eyes to pain, he withdraws to painful
stimuli and when spoken to he only responds
with innapropriate comments. Based on this
information, you calculate his GCS to be…
•
a.
b.
c.
d.
e.
3
6
9
11
13
•
•
•
•
•
Obeys
Localizes
Withdraws
Flexion
Extension
None
•
•
•
•
6
5
4
3
2
1
•
•
•
•
•
Oriented
Confused
Inappropriate
Incomprehensible
None
Spontaneously
To speech
To pain
None
5
4
3
2
1
4
3
2
1
21
MC form of injury in
moderate to severe TBI
Bridging veins tear
Assoc with parietal or
temporal skull #
Classic: LOC lucid
LOC
Prolonged coma (weeks) death
from ICP 2nd to cerebral
edema. Indistinct grey/white
margins and no mass on CT
Crescent shaped lesion on CT
Older on coumadin, may
see nothing on CT
Lens shaped lesion on CT
Middle meningeal artery tear
TBIs
Initial CT neg MRI diffuse
white mater disruption
In 40% of coma producing TBI
Diffuse axonal
injury (DAI)
Subdural
Hematoma
Traumatic
subarachnoid
hemorrhage
Epidural
Hematoma
MC form of injury in
moderate to severe TBI
Bridging veins tear
Assoc with parietal or
temporal skull #
Classic: LOC lucid
LOC
Prolonged coma (weeks) death
from ICP 2nd to cerebral
edema. Indistinct grey/white
margins and no mass on CT
Crescent shaped lesion on CT
Older on coumadin, may
see nothing on CT
Lens shaped lesion on CT
Middle meningeal artery tear
TBIs
Initial CT neg MRI diffuse
white mater disruption
In 40% of coma producing TBI
Diffuse axonal
injury (DAI)
Subdural
Hematoma
Traumatic
subarachnoid
hemorrhage
Epidural
Hematoma
A 58 year old male with cough, fever and SOB for last few
days. CXR shows LLL infiltrate. BP 88/70, P 110, R 26, T
39C. ABGs show: pH 7.38, PaO2 80, PaCO2 22, HCO3 15,
on non-rebreather face mask. Which of the following does
the patient have?
a.
b.
c.
d.
Acute metabolic acidosis
Chronic metabolic acidosis secondary to
longstanding pneumonia
Mixed metabolic acidosis and respiratory
alkalosis
Metabolic acidosis secondary to hypoxia
22
A 58 year old male with cough, fever and SOB for last few
days. CXR shows LLL infiltrate. BP 88/70, P 110, R 26, T
39C. ABGs show: pH 7.38, PaO2 80, PaCO2 22, HCO3 15,
on non-rebreather face mask. Which of the following does
the patient have?
a.
b.
c.
d.
Acute metabolic acidosis
Chronic metabolic acidosis secondary to
longstanding pneumonia
Mixed metabolic acidosis and respiratory
alkalosis
Metabolic acidosis secondary to hypoxia
Primary
Metabolic
Acidosis
Metabolic
Alkalosis
Respiratory
Acidosis
HCO3
Response
Response
Mechanism
PCO2 Hyper-
ventilation
HCO3
PCO2 Hypoventilation
Renal
PCO2
HCO3
HCO3
Absorption
Respiratory
Renal
PCO2
HCO3
Acidosis
HCO3
Absorption
*********Both the 1o problem and the compensatory
response move in the same direction**************
Acid – Base
pH
HCO3
PCO2
AG
12 +- 2
7.40
24
40
7.35 – 7.45
22 – 26
35 – 45
•
Acidemia
=
low blood pH
•
Alkalemia
=
high blood pH
•
Acidosis
=
process that lowers pH
•
Alkalosis
=
process that raises pH
Four Steps to Solving Acid-Base Problems
1.
2.
Is it academia or alkalemia
Is the primary problem metabolic or
respiratory
1.
2.
3.
4.
If HCO3 is low the primary problem is
metabolic acidosis
If PCO2 is high the primary problem is
respiratory acidosis
Look for a mixed disorder
In metabolic acidosis look for an Anion Gap
23
Compensation for Respiratory
•
•
Respiratory Acidosis
•
•
•
Compensation for Metabolic
Acute:
Chronic:
PCO2 by 10 =
PCO2 by 10 =
HCO3 by 1
HCO3 by 3
Respiratory Alkalosis
•
•
Acute:
Chronic:
PCO2 by 10 =
PCO2 by 10 =
HCO3 by 2
HCO3 by 5
Metabolic Alkalosis
HCO3 by 1 = PCO2 by 0.7
Metabolic Acidosis
• Apply Rule of 15
• Take the HCO3 add 15 and that will
give you two important numbers
•
•
•
It takes 3 – 5 days for kidneys to compensate
So > 5 days would be chronic
The only numbers that change
Step 4 is for Metabolic Acidosis
•
•
•
The PCO2
+/- 2
The last two digits of the pH
Rule violation = mixed disorder
For Acid-Base Math Problems
Calculate the anion gap
Respiratory
acidosis
Respiratory
alkalosis
1.
2.
•
It is one or the other
•
NAGMA or AGMA
3.
Metabolic alkalosis
Metabolic
acidosis
24
History and Physical Clues to Acid Base
•
•
•
•
•
•
•
•
Vomiting......................... Metabolic alkalosis
Diabetes......................... Metabolic acidosis
Hx of smoking/COPD... Respiratory Acidosis
Hx of liver disease........ Respiratory Alkalosis
Recent binge drinking.... Metabolic acidosis
Diarrhea....................... Metabolic acidosis
Tachypnea................... Respiratory alkalosis
Hypotension................ Metabolic acidosis
Patient with asthma or emphysema Gm
–ve, aerobic, oxidase +ve diplococcus
Water diarrhea, relative brady, high temp
Elderly, post influenza, nursing home, cocci in
clusters, CXR: cavitation, pneumatocoeles
Young healthy male, 5 day prodome (URI),
resp failure ARDS
Young, bullous myringitis, CXR atypical
COPD, Gm-ve pleomorphic rods
Alcoholic, bulging fissures, currant js
Elderly, recent URI,winter, sudden prostratn
Rusty sputum, single shaking chill
Staccato cough, bird exposure
IVDA, fungal infection throat, CD4
Hunter, trapper, butcher, cook
Bird (parrot) owner, brady
Slaughterhouse worker, goat, sheep
Young, cough, fever, not toxic. CXR: LLL
infiltate and bilateral hilar adenopathy
Patient with asthma or emphysema Gm
–ve, aerobic, oxidase +ve diplococcus
Water diarrhea, relative brady, high temp
Elderly, post influenza, nursing home, cocci in
clusters, CXR: cavitation, pneumatocoeles
Young healthy male, 5 day prodome (URI),
resp failure ARDS
Young, bullous myringitis, CXR atypical
COPD, Gm-ve pleomorphic rods
Alcoholic, bulging fissures, currant js
Elderly, recent URI,winter, sudden prostratn
Rusty sputum, single shaking chill
Staccato cough, bird exposure
IVDA, fungal infection throat, CD4
Hunter, trapper, butcher, cook
Bird (parrot) owner, brady
Slaughterhouse worker, goat, sheep
Young, cough, fever, not toxic. CXR: LLL
infiltate and bilateral hilar adenopathy
Match - Pneumonia
•Hanta virus pulmonary syndr
•Chlamydophila Pn
•Klebsiella Pn
•Viral Pneumonia
•Hemophilus Infl Pn
•Strep Pneumonia (gm+ve lancet shaped)
•Q-fever Pn
•Psitticosis Pn
•PCP Pn
•Mycoplasma Pn
•Staphylococcal Pneumonia
•Legionella Pn
•Tuberculosis (also fungal)
•Tularemia (Gm+ve intracell)
•Moraxella catarrhalis
Patient with asthma or emphysema Gm
–ve, aerobic, oxidase +ve diplococcus
Water diarrhea, relative brady, high temp
Elderly, post influenza, nursing home, cocci in
clusters, CXR: cavitation, pneumatocoeles
Young healthy male, 5 day prodome (URI),
resp failure ARDS
Young, bullous myringitis, CXR atypical
COPD, Gm-ve pleomorphic rods
Alcoholic, bulging fissures, currant js
Elderly, recent URI,winter, sudden prostratn
Rusty sputum, single shaking chill
Staccato cough, bird exposure
IVDA, fungal infection throat, CD4
Hunter, trapper, butcher, cook
Bird (parrot) owner, brady
Slaughterhouse worker, goat, sheep
Young, cough, fever, not toxic. CXR: LLL
infiltate and bilateral hilar adenopathy
Match - Pneumonia
•Hanta virus pulmonary syndr
•Chlamydophila Pn
•Klebsiella Pn
•Viral Pneumonia
•Hemophilus Infl Pn
•Strep Pneumonia (gm+ve lancet shaped)
•Q-fever Pn
•Psitticosis Pn
•PCP Pn
•Mycoplasma Pn
•Staphylococcal Pneumonia
•Legionella Pn
•Tuberculosis (also fungal)
•Tularemia (Gm+ve intracell)
•Moraxella catarrhalis
Match - Pneumonia
•Hanta virus pulmonary syndr
•Chlamydophila Pn
•Klebsiella Pn
•Viral Pneumonia
•Hemophilus Infl Pn
•Strep Pneumonia (gm+ve lancet shaped)
•Q-fever Pn
•Psitticosis Pn
•PCP Pn
•Mycoplasma Pn
•Staphylococcal Pneumonia
•Legionella Pn
•Tuberculosis (also fungal)
•Tularemia (Gm+ve intracell)
•Moraxella catarrhalis
25
The Inconsolable Child
•
•
•
•
•
•
•
•
Strangulation: digit, penis, SVT (monitor)
Open diaper pin
Anal fissure
Battered
Infection (UTI, OM, meningitis)/Intussusception
Testicular torsion
Corneal abrasion
Hernia (incarcerated)
38 yo asian male with second syncopal episode in two
weeks. Now feels fine
A 35 yo male presents to the ED with syncopal
episode. He states that now he feels better. He tells
you he has fainted in the past. His EKG is shown.
Which of the following is the best course of action?
a.
b.
c.
d.
2D cardiac echo
Immediate cardiology consult for transfer
to cath lab
Cardiology consult
Acute coronary syndrome protocol (EKG,
CXR, cardiac enzymes, BMP, possibly stress test)
e.
Tilt table testing
A 35 yo male presents to the ED with syncopal
episode. He states that now he feels better. He tells
you he has fainted in the past. His EKG is shown.
Which of the following is the best course of action?
a.
b.
c.
d.
2D cardiac echo
Immediate cardiology consult for transfer
to cath lab
for electrophysiology
Cardiology consult lab and AICD placement
Acute coronary syndrome protocol (EKG,
CXR, cardiac enzymes, BMP, possibly stress test)
e.
Tilt table testing
26
Brugada Syndrome
•
EKG abnormalities in V1-V3
•
•
•
•
•
Brugada Syndrome
•
•
•
•
•
•
Syncope caused by polymorphic ventricular
tachycardia (Na+ channelopathy)
Accounts for 50% of idiopathic vent fib
cases in some Southeast Asian countries
(idiopathic V fib in the US accounts for 10%
- 20% of arrests)
Cardiac enzymes, Holter normal
30% 2 year mortality (4th or 5th decade)
RV outflow tract structural abnormality
Usually diagnosed at age 30 – 40 y.o.
incomplete RBBB pattern with ST elevation
usually in convex upward morphology but less
commonly can be concave upward morphology
(saddle type) (may be intermittent)
normally a RBBB will give you ST depression in
V1 – V2)
At risk for polymorphic or monomorphic V
tach and death (or syncope if self-terminating
Requires electophysiology studies and AICD
Without IACD the mortality is 10%/year
•
“Coved” ST
elevation, convex
morphology
•
“Saddle” ST
elevation, concave
morphology
Note that convex upward ST elevation is more sensitive and
more specific for Brugada
27
ABEM General
Three types of Brugada
A patient presents with a bug bite on his right
hand, he states this is what bit him. Which of
the following is correct:
a. The patient is likely to complain of severe
pain
b. Local tissue necrosis is the most common
finding
c. Abdominal pain is likely
d. It is unlikely to involve the joints
e. You must use antiserum
immediately
A patient presents with a bug bite on his right
hand, he states this is what bit him. Which of
the following is correct:
a. The patient is likely to complain of severe
pain
b. Local tissue necrosis is the most common
finding
c. Abdominal pain is likely
d. It is unlikely to involve the joints
e. You must use antiserum
immediately
28
Day 2
Day 4
Day 14
29
Black Widow - Lactrodectus
Brown Recluse - Loxoscelidae
Ventral hour glass
Dorsal violin
Aggressive
Passive
A 32 yo male involved in a roll-over MVA
presents with neck pain. Based on X-ray you
suspect…
Immediate pain – prick then quickly
extending to entire extremity
Delay in pain onset – 2 – 6 hours
later itching/aching
a.
Bite – circular erythematous
lesion – tiny fang marks
Bite – ischemic, clear avascular
center, later necrosis, volcano
b.
Potent neurotoxin; release of
acetylcholine and norepinephrine
Cytotoxin, hemolytic
Tremor, paresthesias, painful
muscle contractions, N/V, abd
pain mimic acute abdomen
Tissue necrosis around wound
may expand within 10 days
enough to require plastic repair
Benzodiazepine, Ca Gluconate
HBO, surgery
Antivenom available – rarely useful
No antivenom
Outhouses, woodpiles
Cellars, woodpiles
c.
d.
e.
A ligamentous disruption
An unstable fracture
A subluxation
A unilateral facet dislocation
A stable fracture
except in children w dysautonomia
A 32 yo male involved in a roll-over MVA
presents with neck pain. Based on X-ray you
suspect…
a.
b.
c.
d.
e.
A ligamentous disruption
An unstable fracture
A subluxation
A unilateral facet dislocation
A stable fracture
30
Axis Rings
Harris
Rings
Normal
Low Odontoid FX
Type III. ? II
Unstable
Overlap
structures
AXIS RING (HARRIS RING)
•
In the intubated patient,
loss of the continuous ring
may be the only indication
of fracture, because of
difficulty in assessing soft
tissue contours.
This “ring” should be continuous. Disruption indicates a
fracture at the base of the odontoid or upper C2 vertebral body.
(Unstable fracture)
31
A 5 yo male presents to the ED after falling
into a hay stack from 5 feet up. He complains
of neck pain. His X-ray is shown. You
suspect…
a.
b.
c.
d.
e.
Unilateral facet dislocation
Bilateral facet dislocation
Pseudosubluxation
Fracture/dislocation of C2
Axis fracture
A 5 yo male presents to the ED after falling
into a hay stack from 5 feet up. He complains
of neck pain. His X-ray is shown. You
suspect…
a.
b.
c.
d.
e.
Unilateral facet dislocation
Bilateral facet dislocation
Pseudosubluxation
Fracture/dislocation of C2
Axis fracture
Pediatric Pseudosubluxation
•Usually C2 on C3
•Sometimes C3 on C4
•Check the spinolaminar line
•(Swischuk line)
•The spinolaminar line connecting
the anterior portions of the spinous
processes of C1 and C3 is within 2
mm of the C2 spinous process
32
Alignment and Spaces
7 at 2
Predental
3 mm in adults
is pathologic
5 mm in kids is
pathologic
22 at 7
Spinous
process
Line
Spino
laminar
Line
Posterior
Longitudinal
ligament
Line
Anterior
Longitudinal
ligament
Line
A 28 yo male presents to the ED after being
involved in an altercation where he was hit in
the face and head. He denies any LOC. A CT
of his face was taken. With what you see on CT
you suspect on exam you will find…
a. Enophthalmos
b. Circumoral numbness
c. The patient will be unable to gaze down
and out
d. A hypopyon
e. The need to perform a lateral canthotomy
33
A 28 yo male presents to the ED after being
involved in an altercation where he was hit in
the face and head. He denies any LOC. A CT
of his face was taken. With what you see on CT
you suspect on exam you will find…
a. Enophthalmos
b. Circumoral numbness
c. The patient will be unable to gaze down
and out
d. A hypopeon
e. The need to perform a lateral canthotomy
Orbital Blowout Fracture
•
Orbital floor fracture:
•
•
•
•
•
•
•
Herniation of orbital contents through orbital floor
Retriction of eye mvt (upward gaze inhibited due to
inferior rectus m entrapped in orb floor), pain, diplopia
“tear drop” soft tissue mass in maxillary sinus
Infraorbital nerve involvement causes decreased
sensation of cheek and upper lip
Water’s view show maxillary opacity, teardrop soft
tissue mass
CT better than Water’s view
Consider blowout fracture of medial orbit wall
(thinnest of all orbital walls) if epistaxis without
nasal trauma
34
Alcohols KEYCEPS – Least toxic
to
Most toxic
Alcohols KEYCEPS – Least toxic
to
Most toxic
Ethanol
Isopropyl Alcohol
Ethylene Glycol
Methanol
Ethanol
Isopropyl Alcohol
Ethylene Glycol
No acidosis
Ketosis - NO acidosis
Profound acidosis
Bicarb near 0
No acidosis
Ketosis - NO acidosis
Profound acidosis
Bicarb near 0
Withdrawal:
- shakes: 6-8hrs with
visual hallucinations
Osmolar gap
Sweet taste
Osmolar gap
AGMA
Osmolar gap
Sweet taste
Osmolar gap
AGMA
Osmolar gap
Withdrawal:
- shakes: 6-8hrs with
visual hallucinations
Withdrawal:
Acetone
Oxalic acid
Formic acid
Withdrawal:
Acetone
Oxalic acid
Formic acid
Hemorrhagic gastritis
Severe hypotension
Pulmonary edema
Hypoglycemia
CNS depression
Intoxication without
smell of alcohol
Sx delayed 12– 18 hrs
N/V
Blindness
Hyperemic disc
Withdrawal:
Hemorrhagic gastritis
Severe hypotension
Pulmonary edema
Hypoglycemia
CNS depression
Intoxication without
smell of alcohol
Sx delayed 12– 18 hrs
N/V
Blindness
Hyperemic disc
Wernicke’s encephalopathy
- ophthalmoplegia: CrN6
palsy(lat rectus),
nystagmus,
- Ataxia
- Dementia – global
confusion
- Rx: thiamine 500 mg IV
> 50% metabolized to
acetone by liver w
renal and pulmonary
excretion
Renal failure
Hematuria
Hypocalcemia
Calcium oxalate
crystals in urine
Pancreatitis
Respiratory failure
Wernicke’s encephalopathy
- ophthalmoplegia: CrN6
palsy(lat rectus),
nystagmus,
- Ataxia
- Dementia – global
confusion
- Rx: thiamine 500 mg IV
> 50% metabolized to
acetone by liver w
renal and pulmonary
excretion
Renal failure
Hematuria
Hypocalcemia
Calcium oxalate
crystals in urine
Pancreatitis
Respiratory failure
Korsakoff psychosis
- Retrograde amnesia
- Confabulation
Rubbing alcohol
Antifreeze, paint,
solvents
Paint thinner, wood alcohol, gas
tank additive, window washer
solvent
Korsakoff psychosis
- Retrograde amnesia
- Confabulation
Rubbing alcohol
Antifreeze, paint,
solvents
Paint thinner, wood alcohol, gas
tank additive, window washer
solvent
-
ETOH withdrawal
seizures: 6-48hrs – Rx:
ativan not dilantin
Withdrawal:
-
Delirium tremens (DTs):
fever is a must,
confusion, HTN,
tachycardia 3rd or 4th day
of withdrawal, 5%
mortality from CV
collapse (MgSO4) –
Rx: fluids,
B1(thiamine), multivits,
folate, MgSO4, ativan
Osm Gap
Acidosis
Acetone
Urine
Crystals
Visual
+
+
-
+
+
+
+ +
+ - +
+ - -
-
-
ETOH withdrawal
seizures: 6-48hrs – Rx:
ativan not dilantin
Delirium tremens (DTs):
fever is a must,
confusion, HTN,
tachycardia 3rd or 4th day
of withdrawal, 5%
mortality from CV
collapse (MgSO4) –
Rx: fluids,
B1(thiamine), multivits,
folate, MgSO4, ativan
Methanol
Osmolar gap
A 16-year-old is brought in by ambulance after a
low-speed motor vehicle accident. The patient has
stable vital signs. In this patient, which ultrasound
window should be evaluated first?
a.
b.
c.
d.
Cardiac
Morrison’s pouch
Splenorenal space
Suprapubic
35
A 16-year-old is brought in by ambulance after a
low-speed motor vehicle accident. The patient has
stable vital signs. In this patient, which ultrasound
window should be evaluated first?
a.
b.
c.
d.
Cardiac
Morrison’s pouch
Splenorenal space
Suprapubic
-
-
•
With blunt trauma, FAST examination
begins in Morrison’s pouch.
Even though FAST examination begins in
the right upper quadrant with blunt
trauma, the most sensitive window is the
suprapubic view given its dependent
position.
The second most dependent area of the
abdomen is Morrison’s pouch, followed
by the splenorenal space.
In penetrating trauma, FAST examination
begins with the cardiac window.
The cardiac window can be evaluated
using the subxiphoid view or the
parasternal long axis view.
The Focused Assessment with Sonography in
Trauma (FAST) examination looks for free fluid
in 4 traditional windows:
• Right upper quadrant (RUQ)
•
•
•
•
Also called the hepatorenal view
This is the first view to look at in blunt trauma
This is the view that shows Morrison’s pouch which
is the second most dependent area of the abdomen
The probe marker is placed towards the head in the
mid-axillary line. The liver provides the acoustic
window.
FAST Exam and Extended FAST Exam
•
Looks for free fluid in 4 traditional windows:
•
•
•
•
hepatorenal view
____ , also known as _______________which
looks at
RUQ
_____________________________________
Morrison’s
pouch along inferior tip of liver
____ , also known as _______________which
looks at
splenorenal view
LUQ
_____________________________________
free
fluid above and below the diaphragm and around
___________
the
spleen
Suprapubic
__________(image most likely to show fluid (gravity)
Cardiac
________.
•
The Extended-FAST (E-FAST) evaluates the
_______________________
bilateral anterior pleura.
•
The Focused Assessment with Sonography in Trauma
(FAST) examination looks for free fluid in 4 traditional
windows:
•
Left upper quadrant (LUQ)
•
•
•
•
•
Also called the splenorenal view
Looks at fluid above and below the diaphragm and
around the spleen
This is the third most dependent area of the
abdomen
In the LUQ view the probe marker is placed
towards the head in the posterior axillary line with
knuckles on the gurney.
The probe needs to be placed more superior and
posterior for this window as the spleen is more
posterior and superior than the liver.
36
•
The Focused Assessment with Sonography in
Trauma (FAST) examination looks for free fluid
in 4 traditional windows:
3. Suprapubic
1.
4.
•
The Focused Assessment with Sonography in Trauma (FAST)
examination looks for free fluid in 4 traditional windows:
4.
Cardiac. Parasternal long axis:
•
most sensitive window given its dependent
position
•
Cardiac.
• In penetrating trauma to the chest of an acutely
unstable patient, FAST examination begins with the
cardiac window to quickly ascertain the presence of
pericardial bleeding, which determines need for
cardiothoracic surgical intervention.
• The cardiac window can be evaluated using the
subxiphoid view or the parasternal long axis view
Four traditional windows of FAST
1. RUQ view (hepatorenal view)
• Probe marker towards head
• Mid axillary line
• Liver provides acoustic
window
• Looks at Morrison’s pouch
2. LUQ view (splenorenal view)
• Probe marker towards head
• Posterior axillary line
(knuckles on gurney –
spleen is more superior and
posterior than the liver)
3. Cardiac view
1. Probe marker towards head
to right
2. Epigastric L subcostal
4. Suprapubic
•
Probe is placed on the anterior chest wall at the 4th
intercostal space, lateral to the sternum at the level of the
nipples.
In this view, a pericardial effusion is likely to be seen
furthest from the probe, anterior to the hyperechoic line
representing the pericardium.
Locating the descending thoracic aorta may help differentiate
pleural fluid and pericardial fluid.
• fluid anterior to (or above) the descending aorta, is
pericardial fluid, (pericardial fluid will also be posterior to the L
ventricle)
•
1.
2.
3.
4.
5.
fluid posterior to (or below) the descending aorta, is
pleural fluid.
Next best step scenario
Position of probe scenario
Pleural vs pericardial fluid question
Next best image scenario (blunt vs penetrating trauma
Trauma, shoulder pain, next best step scenario
RSI, Give blood, CT scan, DPL,O.R., ABCDEs
37
58 yo alcoholic with epigastric pain. WBC
17.4, LDH 400, BS 250, AST 300, Lipase 400.
Admit to ICU
Admit to floor
Admit to observation
Discharge home with early follow up
a.
b.
c.
d.
Pancreatitis – Ranson Criteria
Initial
48 hours
Age > 55
↓ in Hct > 10%
WBC > 16,000
↑ BUN > 5
Glucose > 200
Calcium < 8.0 mg/dl
AST > 250
pO2 < 60
LDH > 350
BE > 4
Fluid sequestration > 6 liters
Pancreatitis – Ranson Criteria
Number of Signs
Mortality
•
0 – 3 signs…………… 0 – 3%
•
3 – 4 signs…………… 11% - 15%
•
5 – 6 signs…………… 40%
•
>/= 7 signs…………… 100%
38