• Pres syndrome

Diagnosis of exclusion

Keep in your differential 

Treat for hypertension, consider MRI

• MS

3 associated conditions – INO, optic neuritis, dysautonomia

• Spinal cord syndromes

Anterior cord – hyperflexion

Central cord – hyperextension, elderly

Brown sequard – stab in the back classic

• Transverse myelitis

Bilateral, highly associated with MS

High dose steroids and plasma exchange 

• NMJ disorder

Botulism – presynaptic acetylcholine receptor

Myasthenia gravis – post synaptic acetylcholine receptor

Lambert Eaton -presynaptic ca channel

NIF is the negative inspiratory force, strength of inhale. 0- -20 is weak, needs intubation

• GBS

Steroids worsen mortality

Ascending weakness

Miller fisher variant 

Albuminocytologic disassociation 

• Bell’s palsy 

Peripheral cause of facial weakness

Does not spare the forehead

Steroids

Acyclovir if presents within time frame

Artificial tears

• Ramsey hunt syndrome 

Zoster

Vesicles of the ear

Steroids

Acyclovir

• Bilateral Bell’s palsy – Lyme disease

• Lumbar puncture 

Contraindications – Cellulitis, Fracture, Epidural abscess

Platelet must be atleast 50k

Head CT before LP , r/o increased icp 

L3-4 or l4-5

20 gauge is good, decreased spinal headache

Traumatic and larger needles have higher chance of LP headache

Lateral decubitus position (if you want pressure) versus sitting position 

• LP headache
  • need fluids
    • Worse with standing or position changes
      • Blood patch if refractory

• Multiple Sclerosis

Demyelinating CNS disease

INO

Optic neuritis – pulfrich test (feels something is coming at them when its not), red saturation test (changes to pink on affected eye)

MRI gold standard

Oligoclonal bands in CSF highy suggestive of MS

High dose steroids is treatment

• Posterior rib fractures in child should raise suspicion for fracture

• WPW

Short PR

Delta Wave

SVT is high yield test question, will need procaimaide If wider QRS

• Wellens Syndrome

Bipashic T wave in anterior leads

Chest pain usually resolved

Needs urgent catheterization

• Brugada

Needs AICD

Downsloping ST segment 

• AAA

Typically infrarenal 

When ruptured – need blood, but allow for permissive hypotension – call for your aorta team

• Heart blocks

Mobitz Type II and 3rd degree block need AICD/pacer

• SVT

Vagal maneuver —> Adenosine (6, 12, 12) if hemodynamically stable

If unstable, synchronized cardioversion

• Lefort fractures

3 types

Type III may have CSF rhinorrhea

Avoid NG tube placement

• Chest tube output for OR indication

1500cc of output right away (~20cc/kg)

200 cc an hour for 3 hours (~3 cc/kg)

• Boorhave syndrome

Hammans crunch

Massive vomiting or iatrogenic (most common)

Broad spectrum antibiotics

• Button battery needs emergent endoscopy if in esophagus

• Rectal prolapse

Slow, steady pressure

Sugar as pre treatment

Avoid if toxic appearing or nectroic appearing

• Trachinominate fistula

First attempt to overinflate the cuff

Next try manually compressing against the sternum through the trash

• PE

Most common sign is tachypnea

Most common symptom is dyspnea

Most common EKG finding is sinus tachycardia

Most specific finding on EKG Is S1Q3T3, T wave inversions in the anterior leads

• Status Epilepticus

Benzo first

Midazolam (can be given IM or intransal (great option for patient who doesn’t have access))

Lorazepam, Diazepam

Keppra (40-60 mg/kg IV. (Max dose of 4500 mg)), Fosphenytoin

Lacosamide or Valproic acid

Fosphenytoin and Valproic acid cannot be used together

Intubate with Propofol, Ketamine, or Versed as induction agents as these have anti-epileptic properties

Need continuous EEG to r/o subclinical seizures and further monitoring

GOODLUCK on ITE