Oral Boards:
Have a system/flow/approach, use the grid layout if that helps
Remember to go through AMPLEFRIENDS
Make sure to let the patient know what you’re doing/why.

Cardiac Tamponade:
200-400cc of fluid usually necessary to cause tamponade, faster accumulation more likely to cause tamponade.
Cardiac path (CA, trauma, etc) -> pericardiac filling -> cycle of heart failure to pump against building pressure
Signs: SOA, CP, fatigue, dizziness, elevated JVD, hypotension, narrow pulse pressure, possible cardiomegaly
-Beck’s triad only 10% of the time
EKG: sinus tach or alternans
Dx: clinically, can use US +/- CXR, EKG
Tx: 1L IVF, pericardiocentesis, window

AAA:
50% increase in normal diameter (normal ~3cm)
Infrarenal is most common location (classified by where it starts/location of most superior aspect)
Smoking and Age are biggest RFs, also fluorquinolones (don’t use em)
Asymptomatic Signs: pulsatile abdominal mass
Symptomatic non-rupture: abd pain, back pain, flank pain, limb ischemia
Symptomatic ruptured: pain, hypotension, pulsatile mass. Pain radiating to back.
Dx: Stable gets CTA (non-con CT for those who can’t do contrast). Unstable gets OR (CT surg or vascular) if known AAA, if unknown then US.
Tx: crossmatch 6U, pain control, esmalol/labetalol/nitroprusside (permissive hypotension 80-100 SBP if conscious), get them to OR
Complications: aortoenteric fistula, aortocaval fistula, limb ischemia, graft infection, inflammatory AAA, endoleak
Beware of thrombolytics since it can break up mural thrombus and send emboli

Aortic Dissection:
Tear in aortic intima. Type A involves ascending aorta, Type B doesn’t
Hypertension is #1 RF, also some sort of prior cardiac path, connective tissue disorders, inflammatory vasculitities
Hx: sudden onset chest pain most common, look for pulse deficit
Paraplegia if it involves the vertebral arteries
Mitral valve complications if involvement of aortic root
Horner’s syndrome if dissection compresses superior cervical ganglion
Dx: BP in both arms, CTA chest
Tx: control HR and BP, as well as pain
-Esmolol (quick on/quick off, good for HR control, titrate to HR 60-70), add cardene if BP still too high once HR controlled (SBP goal 100-110)
-Fentanyl for pain
Surgery for Type A, Type B can be medically managed
Complications: MI, Tamponade, rupture

Air embolism:
Iatrogenic is common, occurs due to pressure gradient (low pressure in venous system allows air from central line to easily enter system)
Central line air embolism 1 in 772
RFs: patient sitting upright, hypovolemic, negative intrathoracic pressure
Lethal dose thought to be 200-300cc of air (3ml/kg)
Signs and symptoms: sudden CNS/Resp/cardiac symptoms with central line placement
-looks like PE with CP, SOB, cough, tachy, syncope, anxiety, possible cardiac arrest, mental status change
Tx: prevent further air, reduce air volume, 100%FiO2, fluids, ionotropic support, hyperbaric oxygen (less so with CVC related), ECMO, L lateral decub positioning (takes embolus out of RV outflow track), and trandelenburg (unless arterial then avoid for cerebral complications)
Prevention: flush lumens and cap hubs prior to placement, adequately hydrate patient, keep insertion site below the heart

SHOCK:
Hypotension doesn’t mean hypoperfusion
Stressor->body compensates->decompensates->end-organ dysfunction->Death
-goal is to treat the stressor
diastolic is good indicator for PVR, systolic is good indicator for the strength of the heart
Shock index: HR/SBP, normal is 0.5-0.7 (HR goes up before BP)
Lactate up in times of lack of blood flow/oxygenation, but also depends on sympathetic nervous system and B-blockade can lead to lower lactate despite how sick patient is
Shock types: Obstructive, cardiogenic, hypovolemic, distributive
Obstructive: decreased CO, increased CVP, increased SVP (trying to shunt blood to heart), cool extremities (from shunting)
-PE, tension pneumo, tamponade, restrictive pericarditis, abdominal compartment syndrome, dissection
Cardiogenic: decreased CO, increased CVP, increased SVR, cool extremities
-MI, arrhythmia, cardiomyopathy, valve disease
-Ionotropes: dobutamine, milrinone, dopamine, epi (below 5-10mcg/kg/min)
-Milrinone solely renal clearance and better in chronic B-blockade, dobutamine is fast on/fast off. Make sure properly fluid resuscitated prior to starting these meds
Hypovolemic: CO normal or decreased, decreased CVP, increased SVR (trying to get blood back to heart), cool extremities (elderly might be a little warm due to slowed response)
-Fluid loss (GI/kidney/skin/DKA/3^rd space) or hemorrhage
-Permissive hypotension (MAP 65-70) has mortality benefit in trauma
-Balanced resuscitation (whole blood, keeping prbcs:ffp:plts 1:1:1)
-Calcium will be low because all the product are in citrate which will bind Ca so make sure to replete
Distributive: Septic, anaphylactic, neurogenic
Anaphylactic: consider delayed sequence intubation, need IM epinephrine (slowly diffuses over hours), consider glucagon if chronically B-Blockade
Neurogenic: Dx of exclusion, MAP>85

Narcan 1hr rule
-Safe to discharge patient 1hr after Narcan administration if provider feels comfortable and if has not needed further Narcan in the department and meets 6 criteria:
1. Able to walk
2. Temp >36C and <38C
3. RR 10-20
4. Sats 95%
5. HR 60-100
6. GCS 15

Fluid Comparison
-Across multiple studies Balanced Fluids (example LR) is non-inferior to NS and Odds Ratio would suggest possible superiority in terms of decreasing rate of AKI and reducing mortality.
-NS also associated with hyperchloremic metabolic acidosis, with balanced fluids leading to higher pH, lower chloride, and higher bicarb levels
-Balanced fluids more costly than NS (LR ~25% more expensive than NS)

NightShift Pro-Tips
-Phase delay scheduling is better than Phase advance (better to go morning shift then evening shift then night shift then morning shift, etc)
-Nap prior to shift, and nap on shift if possible (short 20min nap is best)
-Use Bright Lights (prior to 4am) to help keep you awake
-Caffeine early in shift and avoid big meals. Aim for snacks high in protein and fat and low in carbs (avoid big sugar swings)
-Minimize bright lights after shift and on drive home (sunglasses can help)
-Consider Melatonin 30min prior to sleep (shown to help fall asleep faster and stay asleep longer)
-Sleep in dark, cool room (blackout curtains and/or facemasks can help, and body needs cool temps to aid in sleep
-Try to avoid >3 night shifts in a row, but avoid 1 solo night shift (messes up your rhythm)

Neurogenic shock v spinal shock/stun

Spinal stun/shock: After spinal cord injury can have transient loss of function below the injury (loss of continence, anesthesia, paralysis). Can last hours to weeks.
-Can see priapism in males. (especially C-spine injury)
-Thought to be due to loss of K and thus reduced axonal transmission, with return of some if not all movement once K re-equilibrates
-Do Bulbocarvenosus Reflex checks to determine when distal spinal function has returned and gives idea of prognosis

Neurogenic shock: true shock from TBI/spinal cord injury. Interruption of autonomic pathways –> decreased SVR and alters vagal tone.            
-MAP goal 85, need to resuscitate with fluids in case there’s hypovolemic/hemorrhagic component to the trauma, otherwise need pressors (NE first line)

Lyme Disease Review

Lyme rarely transmitted in first 48hrs, ~25% chance in first 72hrs
Prophylactic ABx only if they meet all criteria:
-36hrs or more with tick attached, PPx started within 72hrs of removal, no contraindication to doxy (<8yrs old, pregnant, lactating), only if ixodes, inf disease society of America doesn’t recommend PPx unless in state with >20% lyme rate in ticks (which doesn’t count Kentucky, TN, IN, IL. Only surrounding state is WV)

-After removal (tweezers/foreceps, don’t crush or twist, just steady straight pull), clean and then have patient observe x30days for EM
-Observing for EM better plan of action than PPX ABx, serologic testing not recommended (don’t develop markers early in course)

If you believe they have early stage 1 lyme then doxy 100mg BID x10-14days
Stage 2/early disseminated (carditis/meningitis/bells): Doxy 100mg x14-28 days (14 days appropriate, will need ID f/u anyway) (Ceftriaxone if need IV)
Stage 3: severe arthritis 14-28days of doxy 100mg BID PO (again 14days shown to be appropriate, will need ID f/u), encephalitis x14-28days of ceftriaxone IV initially and Doxy PO when able
If contraindication to doxy then amox is second line

Serotonin Syndrome
autonomic hyperactivity, mental status changes, neuromuscular abnormalities

Mental status change (anxiety/restless/agitated delirium), autonomic (tachy, hyperthermic, diaphoretic, htn, vom, diarrhea), NM (clonus, rigidity, hyper-reflexive, tremor)
Fentanyl can cause serotonin release because 5-HT1A receptor agonist
Tx: stop offending agent, support, sedate with benzos PRN, cyproheptidine (12mg initial dose)

SCAPE

Increased afterload –> to pulm edema –> stress response with epi/NE/etc –> vasoconstriction –> afterload increase and the cycle continues

Workup: basic labs (including BNP), ekg, cxr, can do US/echo (can be normal or reduced EF)
-Concern if BNP >500
Treatment: BIPAP/CPAP for PPV, nitro drip (start at 100mcg/min and titrate from there, can give sublingual in the meantime while setting up drip)
-most are fluid down so don’t diurese (i.e. no Lasix right away, confirm fluid status first)
-Can wean BIPAP/CPAP once pt’s BP is at their normal and nitro <50mcg/min. Wean PEEP by 2 q10min, if patient doesn’t tolerate then turn back up. Once below PEEP 5 then can attempt switch to NC
-Can start ACE-I (enalapril/captopril) as patient improves
-Morphine can make some more comfortable but poor support for it overall

WPW and SVT

SVT: AVNRT and AVRT
AVNRT: abnormal circuit going round and round in the AV node, goes down septum so narrow
AVRT: doesn’t use AV node but rather accessory pathway (WPW), so often wide

WPW: 2 conduction pathways (AV node and accessory pathway), accessory pathway doesn’t have the pause that AV node provides thus PR is shortened and QRS broadens (can be wide, usuall 110s) and sloping upstroke (delta wave).
-Orthodromic and Antidromic
-Orthodromic has the impulse come back up the accessory pathway and going back into AV node. Antidromic is the opposite.
-Orthodromic is narrow because conducting through the AV node and bundle of His (looks like normal AVNRT)
-Antidromic is wide because it conducts through the ventricle, looks like VTach
-WPW+AFib: accessory pathway allows a lot of the atrial impulses to go down that are normally blocked by AV node. Looks like AFib with aberrancy but rate between some beats can be up to 300bpm. Also get some variation beat to beat in QRS structure, some will be narrow and some will be wide, overall different QRS morphologies of the different beats.

Adenosine blocks AV node, CCB and amiodarone slow AV node conduction. So Adenosine will return orthodromic WPW tachycardia to normal WPW ekg/rhythm. If antidromic then shock if unstable or procainamide because procainamide blocks the accessory pathway. Also, use procainamide or shock if WPW and AFib.

Pharmacy Pressor Lecture (A=alpha, B=Beta, doses in mcg/kg/min unless specified)

Vasopressors: vasopressin and phenylephrine (increase SVR)
Ionotropines: dobutamin, milrinone, isoproterenol (increase CO)
Inopressors: NE, epi, dopa (SVR and CO increase)
Beta-1 increases myocardial contractility and chronicity
Alpha-1 is arterial smooth muscle contracture

Vasopressin acts on V1 (vasoconstrict) and V2 (fluid resorption in kidney, slower) receptors
Dose is 0.3U/min, no more, no less. NE sparing effect. Can cause tissue ischemia and other ischemia at higher doses.

Dopamine: 0.5-5mcg/kg/min primarily hits dopamine receptors, but as you increase it hits B-1 (5-10mcg), and at 10-20 you hit A receptors. More arrhythmia than NE. Usually start around 5mcg/kg/min, max 20mcg/kg/min.

NE: strong A with some B. Start at 0.02mcg/kg/min (can start 0.1 or 0.2 if really needing it) and max 0.8mcg/kg/min. Too high can cause peripheral and GI ischemia.
-Safe to give up to 24hrs peripherally

Epi: mainly B activity below 0.05, then above you get more A activity. Starting dose 0.02, max 0.8

Phenylephrine: strong A only, start 0.5mcg/kg/min, max at 3. Reflex bradycardia and tachyphlaxis are possible adverse reaction.

Dobutamine (Do-beta-mine): Almost all Beta (1>2), start 2.5, max 20, used for HF and symptomatic brady, does increase myocardial demand

Milrinone: PDE-3 inhibitor, Start 0.125, max 0.75. Increases contractility and improves relaxation. Vasodilation leading to hypotension is adverse effect

Weight-based dosing: ideal BW for the morbid obesity. Can always titrate.
If extravasation: Stop infusion, aspirate as much fluid as possible, warm compresses for 30mn q4hrs for 24hrs, give phentolamin (5-10mg diluated in 10ml NS) injected in affected site

Cardiogenic shock: first line is NE, if low output can consider adding Epi
Hypovolemic shock: Stop the bleed and replace volume, pressors not recommended, adequately resuscitate before any pressor
Neurogenic shock: MAP goal >85, NE phenylephrine or dopa (>10mcg) but NE #1
Septic shock: NE then add vaso if needed. If refractory to pressors -> hydrocortisone 50 q6hrs

Push-dose pressors: Phenylephrine and epi
-Phenylephrine: concentration 100mcg/ml, giving 0.5-2ml q2-5min, onset 1min, lasts 10-20min. Good for patients who are hypotensive and tachy
Our code phenylephrine sticks are 1mg/10ml which are the correct concentration
-Epi: 10mcg/ml, dose 0.5-2ml every 2-5min.
Our code epi sticks are 1mg/ml, to make the push dose concentration mix 1ml from code epi into 9ml of NS and you get appropriate concentration.

Arrhythmias:
Think IV, O2, monitor, then look at rhythm strip: fast or slow, narrow or wide, regular or irregular, P waves present? Is patient stable?
Fast and unstable gets shocked, Slow and unstable gets paced

Bradycardia: wide is less responsive to meds and block is below AV node, narrow is normally faster and more responsive to Atropine

Sinus(narrow) Brady DDx think “DIE”
Drugs: BB/CCB OD, med SE
Ischemia: RCA supplies SA node, sick sinus syndrome
Electrolyte abnormality: Hyperkalemia causes no response to pacer or meds due to inability to repolarize

Wide, Fast, Regular: VTach, WPW antidromic, SVT with aberrancy
Tx: Amio, Procainamide, synchronized cardioversion

Wide, Fast, Irregular: AFib w/BBB, polymorphic VTach, AFib with WPW, Torsades
Tx: Cardioversion or Block AV node depending on stability, (Torsades gets Magnesium)

Fast, Narrow, Regular: SVT, orthodromic WPW, AFlutter, Narrow complex VTach
Tx: unstable gets cardioverted, stable gets adenosine, dilt, verapamil, or metoprolol depending on rhythm

Nursing Update:
-Broselow tape in the top drawer of the Peds code carts
-2+ SIRS with suspected infection -> within 3hrs needs lactate, blood culuture, broad spectrum ABx, 30cc/kg if lactate >4.
-Monotherapy ABx in sepsis that meet bundle criteria: Ceftriaxone for PNA or urinary (Cefepime if pseudomonas concern), Zosyn, Unasyn. (Just Vanc doesn’t cut it)

(Pediatric emergency medicine playbook is good podcast for Peds EM education)
Peds congenital heart disease (CHD):
Normal baby caloric intake is 100kcal/kg/day, CHD babies can need closer to 150
QTc cutoff in peds 460
Most common CHD in bicuspid aortic valve, most common cyanotic lesion is Tetrology.
CHD is leading cause of death in babies
Risk Factors: prematurity, 1st degree relative with CHD, genetic syndrome, maternal DM, HTN, obesity, thyroid d/o, epilepsy, in-utero infection (TORCH)

Ductal Dependent Lesions:
-Ductus Arteriosus closes around 42wks gestation (~2wks old)
-Left->Right shunting seen around 6-8weeks with sweating with feeds, tachypnea/cardia, FTT
-If reliant on duct for pulmonary flow: severe cyanosis and shock when it closes (critical pulm stenosis or pulm atresia, tetralogy)
-If reliant on duct for systemic flow: tachypnea, cardiogenic shock, lactic acidosis (hypoplastic L heart, critical aortic stenosis)

CHD signs and symptoms: HR >160, ASD causes fixed S2 splitting, extra heart sounds, pathologic murmur, decreased pulses, cyanosis/pallor, sweating with feeds, tachypnic, decreased activity, increased irritability, weight loss/FTT, hepatomegaly

Workup: PE (want BP and pulse ox in all 4 extrem), CXR, EKG, CBC, CMP, iCal, Mg, vbg, consider hyperoxia test to r/o pulm cause (100%, PaO2 should be >150 if pulm path), Echo stat
Tx: Control airway PRN (likely needed), Cyanotic 75-85% is okay (over oxygenating causes vasodilation and that can cause issues and more R-side shunting) (goal is 85% if you don’t know what’s going on), ABx for r/o sepsis, PGE-1 0.05-0.1mcg/kg/min (start high and wean down, titrate to palpable femoral pulses and SpO2 improves. This can cause apnea so make sure to be ready for airway)

CXR findings: Boot-shaped heart in tetrology, Eggs on a string in Transposition (see below)

Tet Spell: AMS, LOC, and death from cyanosis
Tx: knees to chest (increase SVR to push blood to R-side of heart), 100% O2 (vasodilate pulm to push blood to R-side), Morphine .1mg/kg IM or IV (helps relax the kid), 5-10cc/kg NS bolus, phenylephrine.5-5mcg/kg/min (same effect as knees to chest), propranolol (if needed, decrease HR and increase ventricle filling), RSI with ketamine 1-2mg/kg (if needed)

Hypoplastic L Heart Emergency: Needs fluids (clot if dehydrated), heparin (break up and prevent clotting), consider pressors, Call CV-surg ASAP, ECMO

Infective Endocarditis:
Dx with Duke Criteria: diagnostic if 2 major, 1 major and 3 minor, or all 5 minor
-Major criteria: Both BCx’s positive, Endocardial involvement (vegetation, abscess, prosthetic valve dehiscence, new valve regurg)
-Minor criteria: Fever, predisposing heart condition or IVDU, Vascular Phenomena (Major arterial emboli, septic pulmonary infarcts, mycotic aneurysm, intracranial hemorrhage, conjunctival hemorrhages, and Janeway’s lesions), Immunologic Phenomena (Glomerulonephritis, Osler’s nodes, Roth’s spots, and rheumatoid factor), Blood culture + but not meeting major criteria

Growing more common in elderly with increase in valves and stents (higher risk of subacute). L-sided more common since mitral and aortic valve issues more common in older individuals.

Acute decompensated Heart failure is #1 COD (think valve rupture, need CV surg ASAP, can consider nitroprusside or dobutamine in the interim)

Valve Ring Abscess: needs CV surg repair or will recur and destroy heart. Also surgery for recurrent septic emboli or metastatic infection.

Increased risk in first 3months post-surgery because that’s how long endothelialization takes

STEMI Mimics:
Read “Dr Smith’s ECG blog”!!!!!! and OMI manifesto
STEMI mimics: hyperacute T waves, posterior MI, LCMA occlusion, DeWinters, wellens, sgarbossa and smith
Hyperacute T waves: occur early in MI
Posterior MI: look for ST depression in V1-V4
LMCA occlusion: aVR ST elevation predicts left main involvements
DeWinter: hyperacute T wave with broad base and low J-point/ST depression
Sgarbossa: use with BBB or paced rhythm or PVCs
Wellens: biphasic T wave (up and then down), not stemi equivalent, it represents reperfusion T waves, can be spontaneous or after cath. Has poor R wave progression

A FAQ by many in the department, whether it be out loud or kept silently in our hearts, is “How much pain meds can I/should I give the patient?” I came across this question frequently last month on my teaching elective. Whether from an intern who doesn’t understand their MD powers yet, from an upper level second-guessing or verifying their decision, or from myself second-guessing my own decisions, how much pain meds to give is a common question. Hydrocodone/Norco and Oxycodone/Percocet come in 5, 7.5, and 10mg (+/- the 325mg acetaminophen). But how much should one give? And when can one give dilaudid? Or Morphine? And how much? The simple answer is: it depends. It depends on what they normally take at home. It depends on the injury and your assessment of the patient’s pain. It depends on their allergies. It depends on so many factors. Can they take PO or do they need IV? With all these questions and variables, it’s good to break it down into levels or treatment.

Basic non-narcotics (these are your simple household names everyone knows and loves): Ibuprofen 400-600mg, Tylenol 500-625mg (Chronic liver disease patients can take tylenol, Max 3g per day. Just don’t give it in acute liver failure). Can also give tylenol IV and rectal. IV gets bad rap for being “super expensive.” While it is expensive compared to PO, it is not the >$1K some med schools generally teach people (closer to $40, expensive compared to PO which is <<$1). Thus totally okay for a dose if needed.

Next Level non-narcotics and adjuncts: Toradol 15-30mg IV or IM (studies suggest 10-15mg is plenty and above that doesn’t add much more than side effects. No need for the 60mg order in Cerner), Cyclobenzaprine 10mg (don’t order 5mg, nurses will hunt you down and make you split the pills yourself because they only come in 10mg tabs), other muscle relaxers (there’s plenty to choose from, great in those car accident patients with sore neck/back/muscles). There’s also Gabapentin as well as other less common options, but for now let’s stick to more of the basics.

Narcotics: PO you have a few options but staples are Oxycodone/Percocet and Hydrocodone/Norco. There is MS contin but just give that to people already on it (Onc patients). When deciding how much to give, if patient is taking it at home it is appropriate to give their home dose. You can always give more later, looks bad if you have to give Narcan because you gave too much. Just watch out for the amount of Acetaminophen given. It’s more than appropriate to give someone 2 Norco 5mg tablets to get 10mg hydrocodone and full dose of 650mg Acetaminophen, just dont give more Norco if they need further meds, consider Oxycodone or hydrocodone alone. If they aren’t on narcotic meds at home, always appropriate to start low and increase from there. Again, can always give more, harder to take it away.

In terms of IV, go-to options are morphine, dilaudid, and Fentanyl. Morphine 2mg or 4mg are generally safe starting dose, 2mg better for the older and narcotic-naive patients needing something a little extra. Dilaudid 0.5mg is generally lowest dose but can do 0.25mg if you really want to. If patient appears in a lot of pain (broken bone, appendicitis, diverticulitis, etc) then 1-2mg is appropriate. This is all at the physician’s discretion, but again, can always give more, so safer to start with 0.5-1mg and can give more from there. Fentanyl dosage is generally 50-100mcg, it is fast on, fast off, great for room 9 when you want something fast to help with pain. Can always then give something like dilaudid that lasts longer but takes a little longer to kick in.

Other Option: Ketamine 0.3mg/kg (generally 20-30mg) IV is a great pain dose, just don’t give too much and sedate em.

When considering how much to give of each and/or when switching between drugs, it is important to remember their strengths compared to one another. Refer to the tables below. But in general, 0.5mg dialudid IV is about 4-5mg of morphine IV. Oxy PO is 1.5x the strength of hydrocodone PO (only in 2nd chart). 5mg of Oxy PO is about 3.75mg morphine IV (assuming their gut is working…). One common thing people do is they give 2-4mg morphine IV and it doesn’t do enough for the pain so they give 1mg dilaudid next. That’s basically giving the patient greater than or equal to 2x the original dose, would be better to simply repeat first dose or switch to equivalent dilaudid dose (4mg morphine -> 0.5mg dilaudid). Lastly, remember Fentanyl is in micrograms, it is generally the only pain med we deal with that isn’t described as in milligrams.