EM Notes

High risk = 3 or more

AF is best managed by tx the underlying cause rather than the rhythm

itself
Chronic low levels of tachycardia lead to global cardiomyopathy

NonsustainedVTisbydefinitionaselfterminatingevent,andthereforeusually
nospecifictreatmentisindicated.

Inuptoonequarterofpatients,DKAistheinitialpresentationoftypeIdiabetes,
solackofadiabetichistorycannotexcludethediagnosis
Acidosis,dehydration,hyperosmolality,andinsulindeficiencycanleadto
potassiumshiftsintotheextracellularspace,sopatientsmayhavesignificant
serumhyperkalemiaatpresentation,evenwithmassivetotalbodydeficitsof
potassium
Diagnosisisbasedonthetriadofhyperglycemia,ketosis,andmetabolic
acidosis.
majordifferentialdiagnosisishyperosmolarhyperglycemicstate(HHS),which
canpresentwithveryhighglucosebutslightornoacidosis.

Thecombinationofrehydrationandinsulinwillcommonlylowertheserum
glucosemuchfasterthanketonesarecleared.Regardless,insulininfusionshould

continueuntiltheaniongaphasreturnedtonormal.Dextroseshouldbeadded
totheIVinfusionwhentheserumglucosefallsto200to300mg/dL(11.116.7
mmol/L)topreventhypoglycemia
insulindoseof0.1U/kg/h(510U/hintheadult)isadequateforalmostallclinical
situations
Ifthepotassiumiselevatedinitially,lookforandtreatanyhyperkalemicchanges
ontheECG.GivefluidswithoutpotassiumuntiltheserumKreachesthenormal
range,andthenaddpotassiumtotheIVinfusion.IftheinitialserumKisnormal
orlow,potassiumreplacementcanbestartedimmediately.Magnesium
supplementationmaybenecessarytohelpthepatientretainpotassium.
SYSTEMICINFLAMMATORYRESPONSESYNDROME(SIRS):Atleast
twoofthefollowing:
.

Temperature>38Cor<36C

Heartrate>90beatsperminute

Tachypneaorhyperventilation(respiratoryrate>20breathsperminuteorPaco <32mm
Hg)

Whitebloodcellcount>12,000cells/mLor<4000cells/mL,or>10%bands

insepsisapatientsglucosegoalsshouldbebetween140and180mg/dL.

Shockisdividedintothreestages:Compensated,progressive,and
irreversible.
Withinseconds,baroreceptorsandchemoreceptorselicitpowerfulsympathetic
stimulationthatvasoconstrictsarteriolesandincreasesheartrateandcardiac
contractility.Afterminutestohours,angiotensinconstrictstheperipheralarteries
whilevasopressinconstrictstheveinstomaintainarterialpressuresandimprove
bloodreturntotheheart
Thenormalmanifestationsofshockdonotapplytopregnantwomen,athletes,
andindividualswithalteredautonomicnervoussystems(olderpatients,those
takingblockers).

7.2 - Based on 5L blood vol.

Blood pressure at rest does NOT decrease until CLASS III
hemorrhagic shock, ~ 1500-2000mL (30-40% of blood vol) is
lost.

ClassIIshock,associatedwith750to1500mLEBL,isassociatedwith
tachycardiabutnormalbloodpressureatrest,andlowurineoutput.
Five sites to check for bleeding in hemorrhagic shock:
Four and on the floor
1. Thorax
2. Peritoneal cavity
3. Pelvis/retroperitoneum
4. Soft tissue (long bone fractures)
a. Tibia or humeral Fx: ~750mL blood loss
b. Femur Fx: ~ 1500mL
5. External sites (lacerations) - on the floor

Withtheongoingmetabolicacidosisofhemorrhagicshock,anincreasedbase
deficitandlactatelevelwillbeseen.Bothlactateandbasedeficitlevelsare
laboratoryvaluesthatindicatesystemicacidosis,notlocaltissueischemia.They
areglobalindicesoftissueperfusionandnormalvaluesmaymaskareasofunder
perfusionasaconsequenceofnormalbloodflowtotheremainderofthebody.
Normalizationofbasedeficitandserumlactatewithin24hoursafterresuscitation
isagoodprognosticindicatorofsurvival.Ofnote,giventhatlactateishepatically
metabolized,itisnotareliablevalueinpatientswithliverdysfunction.

mostcommonandeasilyavailablefluidreplacementsareisotoniccrystalloid
solutionssuchasnormalsalineorlactatedRingersolution.Foreachliterofthese
solutionsthatisinfused,approximately300mLstaysintheintravascularspace
whiletheremainderleaksintotheinterstitialspace.Thisdistributionhasledto
theguidelineof3mLcrystalloidreplacementforeach1mLofbloodloss.A
bloodtransfusionisindicatedifthepatientpersistsinshockdespitetherapid
infusionof2to3Lofcrystalloidsolution,orifthepatienthashadsuchsevere
bloodlossthatcardiovascularcollapseisimminent

Inpermissivehypotension,thepatientsbloodpressureisnotresuscitatedtotheir
normalbloodpressure,ortowhatphysiciansconsideranormalbloodpressure.
Instead,thebloodpressureisallowedtoremainlow(meanarterialpressuresof
6070mmHgorasystolicbloodpressureof8090mmHg).
Patientsinwhompermissivehypotensionshouldnotbepracticedare:patients
withtraumaticbraininjurieswhorequiremaintenanceoftheircerebralperfusion
pressure;patientswithahistoryofhypertension,congestiveheartfailure,or
coronaryarterydisease,inwhomhypotensionwillbepoorlytoleratedandmay
produceothermedicalproblemssuchasstrokesormyocardialinfarctions.
DPLandFASTcannotruleoutretroperitonealinjuryoridentifythespecificsiteof
injury,buttheycanbeperformedquicklyatbedsideonunstabletraumapatients.
Tofindthespecificsiteofinjuryandruleoutretroperitonealinjury,aCTscancan
bedone;

uprightchestxray(CXR)hasadequatesensitivitytoevaluateforpneumo
thoraxandhemothorax.Obtaininganendexpiratoryfilmmayincreasethelikeli
hoodofdetectingasmallpneumothorax.
Compressionoftheanteriorcordcanproducecompletemotorparalysis,lossof
painandtemperatureperceptions.
Posteriorcordsyndrome(BrownSequard)causesparalysislossofvibratory
sensationandproprioceptionipsilaterallyandlossofpainandtemperature
sensationscontralaterally.

Centralcordsyndromeisproducedbyinjuriestothecorticospinaltract,which
producesgreatupperextremitiesweaknessincomparisontothelowerextremities.