Watch – peds rashes, back do, vag bleed, upper abd

CARDIO

 Systolic – EF < 45% and low CO

o Cause – MI, ischemia, dilated cardiomyopathy
 Diastolic – impaired relax bc strong/stiff so LV fills less and pulmonary congestion, can lead to
systolic dysfunction
o Cause – ischemia, hypertrophy/HTN
 L sided HF
o LV doesn’t pump well so lungs back up and capillary leakage (rales), WOB inc
o Dx – CXR cardiomegaly, pulmonary edema
 R sided HF
o Most common
o Sx – JVD, liver enlarged, peripheral edema
 Decompensated
o BNP from ventricles due to stress = <100 good, 100-300 present, 300+ mild, 600+ mod,
900+ severe
o Tx – O2, nitrates quick 200-400 mcg/min
 Myocarditis
o Sx – flu-like, sinus tachy, CHF, fever
o Dx – elev troponin, ESR, CRP, cardiac MRI, EKG diffuse T wave inversion/ST/saddle
shaped ST elev
 Angina
o Sx - >20 min, some EKG changes
 STEMI tx – NTG (caution inferior (II, III, avF), posterior (ST dep V1-V4), aortic stenosis), BB and
statin within 24 hrs, plavix 300 mg loading, LMWH/heparin, morphine ADR?
o EKG change – 2mm men, 1.5mm F V2-V3, 1mm contiguous others, new LBBB? Deep
broad S V1-V2 & broad R I/avL/V5-V6 lateral leads, QRS > .12, ST dep and T wave inv
lateral leads, ST elev and T peak V1-V3
o RBBB – V1/V2 rSR’, V5/V6 broad deep S
o PCI 90 min, thrombolytic 30 min
o Anterior – V3, V4 (V1, V2 septal), I/aVL/V5/V6 - lateral
o Inferior – RCA, II/III/avF, Q III/avF, recipricol I and avL
o Lateral – L circumflex – I avL
o Posterior – ST dep V1-V4, tall R V1 and V2, ST elev V7-V9 posterior, looks like anterior MI
if flipped vertically
o LAD – all else
o Tx – thrombolytic >30 min < 12 hrs – hold if INR > 1.7 and on anticoag
 Arrhythymias
o 1st AV block – PR > 0.2 sec (1 big box), normal athletes/inf MI/low K or Mg,
antiarrhythmic drugs
o 2nd AV block
 Type 1 wenckebach lengthen. Cause – drugs (BB, CBB), ischemia
  Type 2 QRS sudden drop, worse, c/s cards, tx maybe pacer bc can go to 3 rd
degree
o 3rd AV block – acute ischemia, drugs BB/CBB/amio/dig, tx with pacer
o PAC – start above AV node, P wave diff shape then mild pause and maybe change QRS,
no tx bc benign
o SVT – unstable synch cardio 50-100J,6 then 12mg adenosine or CCB (verapamil,
diltiazem)
o A flutter – narrow QRS atrial rate 300, cause ETOH/CHF/HTN/hyperthyroid/mitral
valve/CAD post MI, Tx cardiovert if unstable, stable then CCB (verapamil, diltiazem)/BB
2nd line (amio best)
o Afib - >48 hrs then anticoag before cardiovert (low threshold TEE prior r/o clot
o MAT – irreg irreg narrow complexes, HR > 100 but <100 then wandering atrial
pacemaker, Cause COPD/theophylline, Dx 3 diff P waves/variable PR interval
o WPW – short PR, delta wave (slurred early QRS), wrong pathway not thru AV node
 Tx: narrow then tx like reg SVT, wide then BAD unstable tx like vtach (cardiovert,
procainamide) or stable then adenosine
 Afib + WPW – NO AV BLOCKERS! Tx cardiovert or procainamide
o PVC – premature below AV node, wide, benign unless multifocal 3+ -> Vtach
o Vtach – can become hypotn or Vfib. Stable c/s with lido or amio, unstable cardiovert,
pulseless vfib defib!
o Torsades – tx bicarb acidotic, 2-4gm IV Mg, cause antidepressant OD or drugs QT
prolong
o Brugada – sudden death vfib young healthy, tx defibrillator. Cause
ETOH/stress/BB/vagal stimuli, Dx type 1 most common V1 St coved, type 2 saddle, type
3 raised J point (after QRS)

ENDOCRINE

 Acid/Base
o DKA – Is – infection, infarct, infant, ischemia, illegal drugs, iatrogenic steroids, idiopathic
 Metabolic acidosis – low pH, low bicarb
 Elev anion gap
 Check potassium, CXR, lipase (pancreatitis?)
 Corrected sodium – hyperglycemia causes sodium fall = sodium + [(glucose
-100/100)] x 1.6
 Tx – NS 1-2L, can change to ½, kids 10ml/kg children concern cerebral edema,
start insulin 0.1u/kg/hr when you know K (insulin lowers K wait until 3.3-5) until
<250 then D5NS (hypertonic, move fluid out cell into circulation) or D51/2NS
o HHS – DM2, no ketosis
 Tx – rehydrate NS or 1/2NS 1L/hr, watch K – can give 10mEq//hr, insulin
o Hypoglycemia – usually admit
 Tx – LOC 1mg glucagon SQ or IM. Tx oral sugar or 10-25g aka 20-50cc D50W 1-
3min (D25W children) q15-30min, if continuing from SU then IV octreotide
100mcg SQ and repeat 50-100 mcq q6 hrs usually 1-3 doses or 50-125 mcg/hr
infusion
 o Hyperthyroid – check TSH new afib
 Tx – IV with dextrose, APAP, BB (propranolol 80-120 PO or esmolol 50-
100mcg/kg/min if IV needed), Methimazole 1st line then iodine later, PTU black
box bc liver
o Myxedema crisis – stressors, inc CPK, check cortisol, hypoglycemia!
 Tx – pan cx r/o sepsis, rewarm if cold, hydrocortisone 1 st (100mg or 5-10mg/hr)
then IV 500-800mcg levothyroxine ASAP after, low glucose and Na
o Acid/Base
 R Acidosis – pCO2 >42
 Tx – inc ventilation
 R Alkalosis – pCO2 < 38
 M Acidosis – HCO3 <24
 Elev anion gap
o CMUDPILES = CN/CO tox, uremia, DKA, paraldehyde,
Iron/INH/ibu, lactic acidosis, ethanol (gas)/ethylene glycol
(antifreeze), salicylates/starve
 Normal anion gap = 8-16ish
o Dr. FiSHPUCS = diarrhea, RTA, pancreatic fistulae,
hyperparthyroid, saline, parental nutrition, ureteroenteric
conduits, CA inhibitors, spironolactone
 M Alkalosis – HCO3 > 28
 High pH = hyperaldosteronism, iatrogenic diuretics, gastric losses,
hypercortisol/hypercarbia chronic, potassium deplete, high calcium
 Acid < 7.38, alka > 7.42
 Respiratory quick min-hrs, metabolic hrs to days
 Base excess +3 – M alka, <3 = M acid
 Electrolytes
o Hypernatremia - >145, severe >160
 Cause – lack water, usually fluid loss or deprived
 Sx – twitch, hyperreflexia, ataxia, tremor, onset quick worse
 Tx – PO H20, unstable then IV NS no more than 0.5-1mEq/L, calc total body
water deficit
o Hyponatremia - <135, severe <125
 Cause – CHF/liver/renal/PNA/diuretics, kids
 Sx – altered LOC, seizures <115 bc brain edema
 Check volume status, duration, severity
 Tx – fluid restriction, severe then 0.5-1 mEq/hr gently slow to >125
symptoms resolve, emergent then hypertonic saline inc 4-6 mEq (3%
0.5cc/kg/hr check Na q1-q4 moderate or severe like seizure/coma then
150cc IV drip 10 min x 2 prn)
 Pseudohyponatremia – elev sugar and lipids dilute sodium so recalc!
o Hyperkalemia - >5.5
 Sx – arrhythmia
 Cause – renal failure usually, DKA leak, ACE/K spare
  Tx – Ca 1st line if > 6.5 5-10ml CaCl (3x more Ca then gluconate) over 2-5 min,
onset 5 min, last 30-60 min. repeat if EKG no improved. If only peaked T waves
then okay to not treat.
 Can also do glucose + insulin, bicarb (best if acidotic H+), albuterol
(lower 0.5-1.5 esp if renal failure), kayexalate slow 2-12 hrs (poor, risk
colonic necrosis bc binding resin), veltassa (new and $$)
 CaCl can cause hypercalcemia or tissue necrosis and dysrhythmia so can
do 15-30mL of 10% gluconate instead
o Hypokalemia - <3.5mEq/L
 Cause – gI and renal losses, poor diet, diuretics
 Sx – palpitations, polyuria. Severe <2.5 PAC, PVC, hypotn, brady/tachy, dec DTR,
ileus
 Usually low Mg!
o Hypercalcemia - >10.5 (40% protein bound, 50% ionized and active)
 Cause – CA, hyperparathyoidiism
 Bad >14
 Low protein can dec Ca total but ionized normal
 Sx – lethargy, vomit, constipation, altered LOC, HA, polyuria (dehydrated inc
BUN), polydipsia, HTN, bradycardia, dec DTR
 Bones stones groans and moans
 Dx – EKG shortened QT (or ST), Osborn waves (J wave)
 Tx – rehydrated NS then loop diuretics like Lasix to excrete, severe then salmon
calcitonin (inhibit osteoclasts and can excrete within few hrs 4-8u/kg SC or IM
q12 hours) and later bisphosphonates from PCP
o Hypocalcemia - <9
 Cause – renal failure, parathyroid deficiency, low or high Mg, Vit D
 CATS GO NUMB – convusion, arrhythmia, tetany, numb/paresthesia, carpal
spasm, hyperreflex, hypoTN
 Trousseau, chvostek sign
 Check albumin to calc corrected Ca
 Tx – acute then IV ca gluconate (90mg 1-2 amps 10mL over 10 minutes) then
drip 0.5mg/kg/hr, chronic then prob don’t treat
o Hypomagnesemia - <1.7
 Cause – starve, alchys, GI/renal loss
 Mg and K similar
 Tx – 2-4 tabs/day mild, 6-8 severe Mg-Ox or Mg tabs or 50mEq slow IV 8-24 hrs
if low K too, arrest then 1-2g MgSO4 IV push
 Check for low Ca
o Hypermagnesemia - > .5
 Cause – renal failure
 Sx – vomit, skin flush, weak, lightheaded
 Inc K and Ca common
 Tx – dilute + loop
EYE

 WATCH - Slit lamp tutorial hyperlink, tonopen how to use

 Reg IOP = 8-21mm Hg, ph 7-7.4
 Eye drill/grind/hammer – Xray/CT consider, check Seidel sign
 Iritis – pain worse with light, no relief topical anesthetic, red mostly limbus, cell & flare slit lamp
– consult opthalmo!
 Acute angle closure glaucoma – cloudy corneo, dec vision, halos, ha, eye pain, vomit, poor
reactive pupil. Usually IOP > 30 – tx BB, pilocarpine (cholinergic – constrict pupil), apraclonidine
(alpha adrenergic – red aq humor), or acetazolamide 500mg IV (dec aq prod), consult opthalmo

GYN

 Vaginal Bleeding
o DUB
 OCP 35 mcg ethinyl estradiol BID until stop bleeding/7 days then 1x/day for 10
days (withdrawal bleeding 3-5 days after stopping)
 Medroxyprogesterone 10 mg qd x 10 days
 HcG doubles ever 2 days. HcG over 1500 empty uterus +ectopic or free pelvic
fluid/adnexal mass/no IUP
 2-3rd trimester NO vaginal exam until no placentia previa on U/S

NEURO

 Stroke – EKG, head CT without contrast unless better then do MRI instead, rapid glucose, lower
20% BP ONLY if >180/220, ASA only if CT neg bleed, discuss heparin if cardio source, TPA 3-4.5
hours of onset/last normal. Dose 0.9 mg/kg max 90mg over 1 hr, 10% bolus 1 minute
 NO TPA - >80 yo, severe stroke NIH > 25, oral anticoagulant, hx DM + prior ischemic stroke.
Discuss risk IC bleed. MCA – most common, contralateral arms > legs, NO forehead,
contralateral hemianopsia (eyes look toward blocked artery), aphasia, unaware of symptoms
 Anterior – contralateral weakness legs > arms
 Posterior – visual, contralateral homonymous hemianopsia, visual agnosia, not rly motor
 Vertebrobasilar – vertigo, n/v, ataxia, h/a, nystagmus, CN issues, variable motor/sensory
 Lacunar – motor only, ?TPA helps
 TIA – start ASA, CT head/neck, ECHO, inc rate 60 days stroke, consider admit further workup
o NOT TIA – LOC, dizzy, gen wea
 knees, confused, loss vision, incontinent
 Head Trauma
o 3 coma, <=8 intubate Glasgow scale
o Linear nondepressed fx – no treatment
o Stellate, complex – babuse?
o Open/depressed = abx + neuro
o Temporal, occipital – r/o bleed
 o Basilar skull fx – CSF otorrhea/rhinorrhea, bleed ear, CN defects (V, VI, VII, VIII HL,
nystagmus, ataxia), ring test (halo clear beyond blood tinged fluid), raccoon eyes and
battle sign
o Major head trauma – ICP manage (mannitol, hypertonic saline), antiseizure meds,
antiplatelets or rev anticoag
 Etomidate reduce ICP or cause adrenal suppression? Ketamine good too to
intubate -> succ or roc
o Epidural hematoma – btwn skull and dura, LOC then lucid, dilated ipsilateral pupil,
biconcave lens CT
o Subdural – btwn dura and arachnoid, elderly and ETOH, acute 24 hrs white vs subacute
1-14 days vs chronic 2+weeks dark, CT crescent
o Intracerebral hematoma
o Herniation – coma, fixed dilated pupil (uncal – HOB up), hemiplegia
o Concussion – CT usually normal, MRI subtle abnormality
o Canadian CT - <15 2 hours after GCS, open/dep skull fx, basilar skull fx signs, vomit 2+,
65+
o PT – warfarin, PT and PTT – Xa or thrombin inhibitors
 H/A
o Fundus exam
o Check eye (visual acuity, fundus, r/o glaucoma), neuro
o Document fever, eye pain, trauma, past h/a, change position
o Worse supine = mass lesion
o Cluster h/a – pain in/around 1 eye, know time/trigger. 30-90 min, mult h/a/weeks.
Runny eyes, sweat 1 eye injected, tearing, red face. ETOH, NTG, histamine cause. Tx
100% O2, lidocaine 4% nasal drops
o Tension h/a – b/l band. NO n/v, photophobia, focal deficits, not worse activity
o Toxic metabolic h/a – fever, CO, hypoxia, ETOH
o 1 dose of narcotic okay
o Tx – TCA, BB, CCB, methysergide
 Abortive – dihydroergotamine 45 (NOT CAD PVD HTN preg macrolides), triptans
(no CAD, HTN, ergotamine), Compazine > reglan
o Idiopathic IC HTN (7-15 normal) – young ovese F irreg periods, N/V/H/A/eye issues, elv
CSF pressure, CT slit like ventricles or normal, eye lost venous pulsation, LP high
pressure, tx shunt/drain repeat LP/acetazolamide

PULM

 Asthma
o measure FEV1, PEF
o epie 1:1000 (1mg/mL) – 0.3-0.5 mg q 20 min x 3 doses, terbutaline SQ
o severe – Mg 2g IV over 20 min
o heliox
o d/c if FEV1 or PFTs >70% baseline
  COPD
o Review GOLD therapy
o FEV<FVC < 0.7
o RHF – cyanosis, peripheral edema/blue bloater
o Without RHF – pink puffer, hyperinflated lungs
o ABG – low pH and high PaCO2 = CO2 retention
 BIPAP
o Start low in 8-12cm H20, ex 3-5, then inc in 10-20, o2 sats > 90
o CPAP 5-8, inc up to 20
o ABG q1-2 then prn

SKIN INFECTIONS/SEPSIS

 SOFA score
 U/S – cobblestone = cellulitis, hypoechoic -= abscess
 IVDU – update Tetanus
 Cx only if severe, systemic, high risk, poor response prior, lots outbreaks
 ABX only iff high risk, mult, age, celluilts, face/handsgenitals, fail drain
 Sepsis – Abx 1 hour, fluid bolus 30ml/kg over 3 hrs (LR, balanced crystalloids)
o Straight leg raise – sit up 45 degrees, then lie down and raise leg 45 degrees, check CO
after 1 minute – BP no change then DO NOT add more abx – consider pressors
o Pressors
 1st line – norepinephrine
 2nd line – vasopressin (0.03u/min – raise BP, NO effect heart like for afib RVR or
VT) or epi (low CO)
 Dopamine – low risk tachy/bradycardia
 Dobutamine – if persisting despite fluids and other pressors
 Vasopressor refractory – IV hydrocortisone 200mg/day
 Transfuse Hgb < 7.0 if NO MI, acute hemorrhage, or acute hypoxia
o