Muscarinic Toxidrome

01/29/2014

Lyte Notes Diagnoses Associations Causes Book of Commons Basic Training Killer Foils Complications

Paul de Saint Victor M.D., F.A.C.E.P., M.H.A., C.P.E., F.I.M. Associate Director, Emergency Medicine Residency Program St Vincent Mercy Medical Center Assistant Clinical Professor Department of Surgery University of Toledo, College of Medicine Toledo, Ohio Friday, February 7

Muscarinic Toxidrome Excess acetylcholine (ACh) at muscarinic parasympathetic end organ receptors • Diarrhea D • Urination U • Miosis M • Bradycardia, B • Bronchorrhea, Bronchospasm B E • Emesis L • Lacrimation S •2 Salivation, sweating, Secretion

Nicotinic Toxidrome Excess ACh at central autonomic receptors Can be mixed sympathetic and parasympathetic presentation MTWHFS (days of the week)

• Mydriasis More severe toxicity: - seizures • Tachycardia - respiratory depression • Weakness - hyperthermia • Hypertension, Hyperglycemia • Fasciculation No specific antidote Supportive care • Seizures Benzos

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www.ohacep.org/emrlectures

Trauma in Pregnancy and Fetal Death

• The most common cause of fetal death in trauma is maternal shock and death.

• When the mother survives, abruption is the next leading cause of fetal mortality followed by uterine rupture

Match the following red eyes with the diagnosis •EKC (epidemic keratoconjunctivitis) With preauricularHerpes Zoster adenopathy Ophthalmicus With discharge and a cough •Uveitis Painful with mild mucoserous •Herpes simplex infection discharge for 5 d then spread •UV keratitis With cobblestone papillae under •Pseudomonas upper lid •Glaucoma With hypopeon in contact wearer •Iritis After eye surgery •Endophthalmitis With diffuse punctate keratopathy •Viral conjunctivitis With cup:disc ratioHutchinson > 1:2 sign •Allergic conjuncitivitis Dendridic pattern (dumbells) •Chlamydia Cells in the vitreous cavity Ciliary flush, flare in anterior chamber, •GC consensual photophobia

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AMS, Resp Alk, Toxidromes Serotonin Met Acid, tinnitus, hyperpnea, diaphoresis toxidrome Agitation, mydriasis, diphoresis, tachy, HTN, Opioid toxidrome hyperthermia, normal BS CNS depression, Cholinergic miosis, resp depression toxidrome AMS, incr muscle tone, hypereflexia, hypertherm Sympathomimetic Sal, Lacr, urination, N/V, WET/BS+ toxidrome diaphoresis, diarrhea, DRY/no BS muscle fasciculation, Anticholinergic bronchorhea, weakness toxidrome AMS, mydriasis, dry mm & skin, urinary retention, Salicylate BS, hyperthermia toxidrome

Sudden Loss of Vision Associ ations Pale retina, cherry • Central retinal artery occlusion red spot squashed tomatoes • Central retinal vein occlusion Blood and thunder Sand dunes, flashes of light, floaters , • Retinal detachment lowering curtain, visual field defect 3Fs

• Temporal arteritis Polymyalgia rheumatica, 50, CRP, prednisone, blindness, jaw claudication

• Multiple sclerosis Optic neuritis, Bilateral internuclear ophthalmoplegia, red desaturation test • Diabetic with visual floaters, loss of red Vitreous hemorrhage reflex, with/without retinal detachment

• Amaurosis Fugax Ocular TIA

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Because the optic nerve is sensitive to red, when it is damaged, the affected eye sees red colors as washed out pink-orange color.

Posterior Vitreous Detachment

• Very common problem in the elderly (75% of patients > 65 yo) • Floaters, Flashes of light, cobwebs • May be difficult to differentiate from retinal detachment • Occasionally associated with vitreous hemorrhage (significant visual impairment) which usually resolves spontaneously • Rarely PVD is associated with retinal tears with subsequent retinal detachment

A well appearing 38 yo male presents with a 5 day history of diarrhea. PMHx: HTN, smoker. Which of the following is the management of choice? a. IV fluids, laboratory tests, empiric antibiotics b. Oral rehydration, laboratory tests, empiric antibiotics c. IV fluids, imaging, empiric antibiotics d. Oral rehydration and symptomatic outpatient therapy e. Oral rehydration, ultrasound evaluation, stool cultures

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Pseudomembranous colitis Seizing pt w diarrhea Toxin producing C diff Fever, toxic, profuse diarrhea Diarrhea w anxiety and Stop Abx, No antidiarrheal heat intolerance Vanco, Metronidazole Diarrhea w paresthesias Legionella Pneumonia and reverse temperature sensation Shigellosis, Theo Tox Elderly pt with bloody diarrhea and abd POOP Arsenic Poisoning Diarrhea, pet turtle or eggs, Sickle cell pts get septic Ciguatera Diarrhea , crampy abd pain, fever, antecedent Salmonella Hx of Abiotic use Diarrhea c Pneumonia Thyrotoxicosis Cholera like diarrhea Mesenteric ischemia

All of the following are intrinsic (Contact Activation Pathway) factors of the clotting cascade EXCEPT: • Factor 8

• Factor 9

• Factor 10

• Factor 11

• Factor 12

The Clotting Cascade How it works (in a minute)

Tissue Activation Contact Activation Pathway Pathway Extrinsic IN trinsic On 9/11 we Warfarin, INR (PT) were Contacted Heparin , PTT Vit K by outsiders Protamine zinc VII 8-9-11 -12

3, 4, 6 are out 1, 2, 5, 10, 13 Common pathway

Vit K dependent factors: II, VII, IX, X

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Hematology: Match the Following a. Factors I, II, V, 1. CAP Factors (intrinsic) X, XII 2. Common pathway b. II, VII, IX, X factors c. Factors 9-11 and 3. TAP factors (extrinsic) 8 and 12 4. Vitamin K d. Factors VII dependent factors

2 – 7yo appears ill, dysphagia Sore Throat drooling , distress, muffled Retropharyngeal voice, PE findings except for high fever normal, pain hyoid abscess 6 mo – 3 yo, URI that Bacterial worsens, worse at night, mildly ill, barky cough, Tracheitis stridor, dyspnea, subglottic inflammation, viral Peritonsilar Severe croup pt not abscess responding to racemic epi, pus from ET tube Croup 6mo – 3yo (<4yo) severe airway obstruction, retropharyngeal lymph nodes, dysphagia, ill appearing tripod, muffled voice Epiglottitis > 8 yo, dysphagia, Peds: systemic trouble swallowing, OR for direct exam trismus, deviated uvula Adult: localized

Diarrheal disease: Match ’em Looks like appendicitis Vibrio • RLQ pain, little diarrhea Vulnificus • Camper, gay, flatulence Invasive dz of terminal ileum • Shellfish, alcoholic incr Yersinia and cecum – morbidity mortality MC in children Scombroid • Liver cysts

• Tuna, (looks like allergic Rx ), Amebiasis peppery taste, facial flushing, palp, abd cramps Giardia

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Peritonsillar Abscess • Polymicrobial infections are the rule • Fusopbacterium • GABH strep • Streptococcus • Staphylococcus • Numerous anaerobes • Rx • Needle aspiration + antibiotics

Withdrawal Syndrome

• Clinical Presentation • Mydriasis • Tachycardia looks sympathomimetic • Hypertension • Diarrhea these indicate withdrawal • Hallucinations Alcoholics drink cheap • Piloerection D-CHEaPLY • Lacrimation • Crampy abdominal pain • Yawning • Seizures – only EtOH, BZ, barb, propoxyphene

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Since the radius and ulna have adjacent joints at both ends, a fracture of the shaft of one with significant angulation implies fracture or dislocation of the other. This X-ray depicts which type of fracture?

a. Fitch's b. Galeazzi c. Smith's d. Monteggia's e. Colle's

Galeazzi - Montaggia - radius fracture • Galeazzi: -distal radio-ulnar joint disruption -distal deformity GR OUND -ulnar nerve ? injury

• Monteggia - ulnar fracture -proximal radial head dislocation -elbow deformity -radial nerve ? injury

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Monteggia fracture

• Apex of ulnar fracture points in direction of radial head dislocation (often missed on x- ray interp) • ORIF required • Galiazzi (reverse Montegia): fracture distal third of radius (G-closer to the Ground) associated with a distal radioulnar joint dislocation

Galeazzi - GR ound Ulnar dislocation easily missed

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A 28yo male playing soccer suffers this injury during the game. Your next best step is… a. Order an X-ray of the other ankle b. Order an MRI of the same side knee c. Consult orthopedics d. Discharge the patient home in weight bearing posterior splint and crutches

A 28yo male playing soccer suffers this injury during the game. Your next best step is…

a. Order an X-ray of the other ankle b. Order an X-rayMRI of the same side knee c. Consult orthopedics d. Discharge the patient home in weight bearing posterior splint and crutches

Stress X-rays of the ankle is an important step because Maisonneuve fracture puts the ankle mortise joint at extreme risk of instability

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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

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a. Cord injury b. Cardiac tamponade c. Pelvic vessel rupture d. Long bone fracture bleeding e. Acute myocardial infarction

A 47yo male involved in MVA. He presents to your ED, severely hypotensive, tachycardic. His GCS is 13. His C-spine, CXR and pelvis X-rays are all negative. His monitor strip is shown. The most likely cause of his hypotension is… a. Cord injury b. Cardiac tamponade c. Pelvic vessel rupture d. Long bone fracture bleeding e. Acute myocardial infarction Persistent hypotension in a multiple trauma patient with normal pelvis and chest X-rays is most likely due to intraperitoneal hemorrhage or cardiac tamponade.

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A 47yo male involved in MVA presents hypotensive to the ED. As you are doing the FAST exam, he looses consciousness. The ultrasound you immediately obtain is shown. Your next best step is…

a. Intubate the patient b. Insert US guided internal jugular catheter c. Start CPR d. Perform immediate thoracotomy e. Perform pericardiocentesis

SamePericardial scenario Window: Pericardial Tamponade

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A 47yo male involved in MVA presents hypotensive to the ED. As you are doing the FAST exam, he loses consciousness. The ultrasound you immediately obtain is shown. Your next best step is… a. Intubate the patient b. Insert US guided internal jugular catheter c. Start CPR d. Perform immediate thoracotomy e. Perform pericardiocentesis US guided

Beck’s triad…

• Hypotension • Muffled heart sounds • JVD

Removal of ______20 - 30 cc may result in immediate improvement

SamePericardial scenario Window: Pericardial Tamponade Pericardial fluid

L ventricle

Identify what arrows point to Rt Ventricular collapse consistent with tamponade

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Tricuspid v Liver

Mitral v

All of the following are potential causes of the following ECG EXCEPT…

a. Congestive heart failure b. Cardiomyopathy c. End-stage COPD d. Morbid obesity e. Pericardial effusion

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All of the following are potential causes of the following ECG EXCEPT…

a. Congestive heart failure b. Cardiomyopathy c. End-stage COPD d. Morbid obesity e. Pericardial effusion

Low voltage ECG

< 5 mV < 10 mV

Pericardial effusion End stage COPD Morbid obesity Myocarditis Cardiomyopathies Severe hypothyroidism

AMI Associations Lower grade Blocks Hypotension Inferior AMI CHF/Shock Ruptures Anterior AMI Better prognosis R V AMI Fluid Load Missed Posterior Bad bradycardias AMI Associated w RV and inferior AMI Assoc w Inferior MI

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A 32 yo male involved in a roll-over MVA presents with neck pain. Based on X-ray you suspect… a. A ligamentous disruption b. An unstable fracture c. A subluxation d. A unilateral facet dislocation e. A stable fracture

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Axis Rings Harris Rings

Normal

Overlap structures

Low Odontoid FX

Type III . ? II

Unstable

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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)

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Most Common Most unstable

Unstable Cervical Spine Fractures – Jefferson bit off a hangman’s thumb

• Jefferson

• Bilateral facet dislocation

• Odontoid II and III Stable Fractures • Any fracture dislocation - spinous fracture - transverse process # • Hangman’s - wedge fracture - unilateral facet dislocation • Tear drop fracture - vertebral burst fracture (except Jefferson)

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. Unilateral facet dislocation b. Bilateral facet dislocation c. Pseudosubluxation d. Fracture/dislocation of C2 e. Axis fracture

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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. Unilateral facet dislocation b. Bilateral facet dislocation c. Pseudosubluxation d. Fracture/dislocation of C2 e. 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

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Alignment and Spaces

6 at 2

22 at 6

Posterior Anterior Spinous Spino Longitudinal Longitudinal process laminar ligament ligament Line Line Line Line

Predental 3 mm in adults is pathologic 5 mm in kids is pathologic

a. Liver b. Kidneys c. Bladder d. Spleen e. Diaphragm

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A 27 yo male is involved in an MVA. He has no obvious fractures, head, neck, chest or pelvic injuries, but is hypotensive and tachycardic. His FAST scan is shown. The most likely cause for his hypotension is injury to the… Spleen is MC organ injured, a. Liver followed by: b. Kidneys - liver - kidney c. Bladder - small bowel d. Spleen - bladder - colon e. Diaphragm - diaphragm - pancreas - retroperitoneal duodenum

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LIVER HEAD KIDNEY

SPINE DIAPHRAGM

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Disseminated GC

Muliforme (erythema)

Kawasaki

Rocky Mountain Spotted Fever

Secondary syphilis

Meningococcal Meningitis Scabies

hand Foot and mouth

Norwegian scabies

diSSeminated GC

Rash palms and soles – RKMSF

• Rocky Mountain Spotted Fever

• Kawasaki (sloughing)

• Multiforme (erythema), Meningococcal Meningitis (petichiae)

• Scabies, Syphilis, diSSeminated GC

• Foot: hand foot and mouth disease

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Associate the bugs with the wound

• Cat bite…………………... Pasteurella multocida 50% usually early infection after cat bite • PW through tennis shoe.…Staph, Strep

• Osteo from above ……… Pseudomonas Aeruginosa Staph, Strep MC Alpha hemolytic strep, eik • Dog bite…………………. corr pasteurella multocida • Human bite……………….Staph, Strep MC Bacteroides MC anaerobe Also consider: Hep B &C, Syph, TB, HIV Eikenella corrodens (chronic/abscess ) 25% • Bat bite……………………Rabies

• Rat urine……………………Leptospirosis

Associate the bugs with the wound

• Salt water abrasion infection….. Vibrio Vulnificus

• Fish tank granuloma.… Mycobacterium marinum (skin lesions going up arm) • Rose thorn injury ………(Fungus) Sporothrix schenckii

• Reptile bites and exposures. Salmonella (non typhi)

• Fish monger’s hand……. Erysipelothrix rhusiopathae Buboes in arm pit with • Cat-scratch fever………………Bortonella henselae large lymph nodes

Which of the following vasopressors have been shown to improve mortality in the setting of shock (excluding anaphylaxis)?

a. Dobutamine b. Vasopressin c. Norepinephrine d. Epinephrine e. None of the above Dose of norepinephrine: 1 – 20 mcg/min

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What is the most common mode of completed suicide?

a. Medication overdose

b. Hanging

c. Firearms

d. Wrist slashing

e. Carbon monoxide

Completed Suicide • Most common method is firearms and presence of firearms in the home is a independent risk factor for completed suicide and patients should be asked about presence of firearms in their home • Medication is most MC of suicide attempt • Hanging is 2 nd MC method of completed suicide in men • Women attempt more, men succeed more • Wrist slash and CO uncommon

Suicide

• Nearly half a million visits per year • 9th leading cause of death • 3rd leading cause of death in 10 - 24 yo • Attempt to complete ratio 40:1 • Majority of attempts: drug OD

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In Interest S Sleep S Sex: male > female A Appetite D Depression Age < 19 or > 45 C Concentration Plan A A Affect Means G Guilt Family Hx E Energy completed D Depression S&S S Suicide

P Previous attempt or psych E ETOH or drug Excess R Rational thought loss S Separated/divorces/widow/single O Organized attempt > 8 High N No social support 6 – 8 Intermediate S Stated future intent < 6 Low

Diarrhea - Chinese Campylobacter restaurant or fried rice ETEC Secretory diarrhea in kids E-coli is MC 6mo – 2yo in winter 2nd MC is shigella 3rd viral/protozoa Froathy foul smelling Cryptosporidium Travellers’ diarrhea Bacillus Cereus Diarrhea: then HUS Most common cause Vibrio cholera of bacterial diarrhea Most common cause of Giardia chronic diarrhea in AIDS Rotavirus Rice water stool Diarrhea assoc with E-coli 0157:H7 No antibiotics Guillain-Barre Synd MCC of HUS which is also Reiter’s, HUS MCC of ARF in kids

A 32 y.o. obese female patient presents with abdominal pain. Her US is depicted. What is your next step? a. Office visit to her OB-GYN b. Start an IV, call her OB-GYN c. Start IV antibiotics d. Admit for D&C in the morning e. Discharge home with radiotherapy appointment for tomorrow

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Ectopic Pregnancy – Keycepts

• Second leading cause of death of maternal death • 50% missed diagnosis first office visit • 36% missed diagnosis first ED visit • Risk Factors: previous ectopic (7x), PID (6x), IUD, recent elective abortion, older age, infertility treatment, smoker • Unilateral adnexal tenderness +/-

Ectopic Pregnancy - Keycepts

• Syncope = rupture (also BP, tachycardia) • No blood on culdocentesis is non diagnostic • B-hCG should double every 1 – 3 days (first 6 wks) • B-hCG discriminatory zone for US (1500 TV, 6500 TA) • Methotrexate treatment for stable patient with unruptured ectopic < 4cm; can present one week later with pelvic pain – but could be ectopic progression • Laparoscopy for definitive diagnosis

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The CDC states that all major criteria and one minor criteria be present if the diagnosis of PID is to be established. All of the following are major criteria for the diagnosis of PID EXCEPT…

a. Abdominal pain

b. Vaginal discharge

c. Adnexal tenderness

d. Cervical motion tenderness

Diagnosis of PID based on major and minor criteria. All major criteria must be present and at least on minor criteria The most common • Minimal Criteria clear cut risk for • Abdominal (pelvic) pain ectopic pregnancy • Uterine/adnexal tenderness • Cervical motion tenderness >25% of patients • Additional Criteria admitted for PID • Temp > 100 F will develop TOA • Abnormal cervical/vaginal discharge • Elevated ESR/CRP • Positive cervical cultures for N gon or C. trachomatis, anearobes

Risk Factors for PID

• Young women (15 – 25) • Multiple sex partners • Smoking • Bacterial vaginosis

Peak time is within 1 st week of menses

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Who gets admitted

• Adnexal mass • Pregnant • IUD • Peritonitis • Immunocompromised • OP Failure • Unable to tolerate PO • Concerns about future fertility

Treatment of PID • Inpatient: • Cefoxitin 2 gm QID or Cefotetan 2 gm IV BID + Doxy 100 mg BID or • Clindamycin 900 mg IV Q8H + Gentamycin • Augmentin 3 gms IV Q6H + Doxy • Outpatient: • Ceftriaxone 250 mg IM x 1 • + Doxy 100 BID for 14 days • +/- Flagyl 500 mg BID x 14 d • NO quinolones – too much resistance

PID Morbidity

• Ectopic pregnancy is 6 times more likely in women who have had PID

• Infertility 8 % with first episode

• Chronic pelvic pain in up to 18% of women after PID had resolved

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What about IUDs in patients with PID

• The risk of PID assoc with IUD is confined to the first 3 weeks after insertion and uncommon thereafter. No evidence suggests that IUD should be removed in women diagnosed with acute PID, but close follow up is mandatory

Fitz-Hugh-Curtis Patient with PID RUQ pain worse with deep breathing or cough Radiation to Right Shoulder Perihepatitis (LFT: N or minimally elevated) “Violin string ” adhesions on laparoscope Occurs in 4% - 14% of patients with PID, more common in adolescents with PID

MCC is…..………...... Chlamydia >>> GC

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A patient presents with this injury after a fall down some stairs. You should suspect…

a. Occult malignancy

b. Radial nerve injury

c. Associated wrist injury

d. Associated elbow injury

e. Seizure

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A patient presents with this injury after a fall down some stairs. You should suspect…

a. Occult malignancy

b. AxillaryRadial nerve injury

c. Associated wrist injury

d. Associated elbow injury

e. Seizure

> 6 mm

Glenoid fossa faces anteriorly and laterally Post dislocated head of humerus rests against posterior rim giving appearance of increased space between humeral head and anterior rim

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The lightbulb sign

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Posterior Dislocation - Clinically

• Occurs with violent force: seizure, electrocution… • Cannot abduct or externally rotate humerus • Less likely to have neurovascular injury than anterior dislocation due to anterior position of neurovascular bundle

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Causes of Eosinophilia

• N Neoplasm

• A Allergy

• A Addison ’s

• C Chlamydia

• P Parasites

A 66 y.o. previously healthy female presents to the ED with sudden onset of severe vertigo , and vomiting. Her Sx dramatically worsen when she opens her eyes and so the physical exam is limited. The neuro exam was grossly normal except for truncal ataxia , the patient follows commands and has no focal weaknesses. She was given lorazepam IV and now has a headache . You should… a. Add diazepam and acetaminophen to your Rx b. Perform an Epley maneuver on the patient c. Add meclazine (Antivert)to your Rx d. Give IV corticosteroids e. Order a CT scan

Vertigo Peripheral Central

Acute onset Gradual onset (going on for a while) Intense illusion of motion Milder illusion of motion Worse with movement Mildly worse with movement Nystagmus fatigues Nystagmus does not fatigue Nystagmus latency period Nystagmus has no latency Nystagmus inhibited by Nystagmus not inhibited by fixation fixation Nystagmus vertical

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Illusion of motion

Vestibular System 85% 15% Peripheral System Central System

BPPV Cerebellar (infarct, infection, hem) CNS infection

Labyrinthitis Brainstem (infarct, hem, tumor) Vestibular neuronitis Multiple sclerosis Vertebrobasilar dz Meuniere ’s ETOHic cerebellar degeneration

Cerebellar hemorrhage

• Neurosurgical emergency Consider CT/MRI in any: • Headache - Unable to ambulate - Associated H/A • Acute vertigo - Physical findings suggestive of • Vomiting central cause - abn VS • Marked truncal ataxia - Cr N findings • Inability to walk - Truncal ataxia • Gaze palsies (6 th Cr.N.), • Increasing stupor. Romberg +ve.

II, III ,IV

VI Brainstem Fx: VII VIII RAS Vital signs IX, X,XI, XII Cranial nerve

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Cerebellar hemorrhage

It’s all about the 4 th ventricle

• All patients with cerebellar hemorrhage may deteriorate rapidly due to obstructive

hydrocephalus (4 th ventricle becomes compressed) or progressive brainstem compression – both of which require emergent operative intervention

It’s all about the 4 th ventricle

• Cerebellar infarcts can also progress to impingement on the 4 th ventricle with subsequent hydrocephalus requiring operative intervention and should all be admitted to the ICU. • Patients with vertebrobasilar insufficiency (TIA) should be admitted because of potential 4 th ventricle compromise

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Steroids and Cerebellar infarct

• Although corticosteroids help reduce vasogenic edema associated with tumors they do not help in the cytotoxic edema associated with infarction

With hemorrhage or edema from infarction, fourth ventricle gets compressed causing obstructive hydrocephalus which requires immediate neurosurgical interventionn

A 26 yo fell of his bicycle when he hit a lamp post. You are about to clear his C-spine. All of the following must be met prior to clearing the C-spine (NEXUS) EXCEPT:

a. No drugs or alcohol b. NoNo midline neck tenderness neck tenderness c. No neurologic findings

d. No distracting injury

e. Clear sensorium

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Clearance of C-Spine • Clinical • No neck pain • No neck tenderness(midline) - * • No neurologic signs/ symptoms - * • Reliable • Clear sensorium - * • No drugs/ ETOH - * • No distracting injury - * • Age > 4 years • Lack of mechanism * = NEXUS

All of the following are true about heat stroke EXCEPT: 1. Classic heat stroke is associated with temperature > 40.5 C 2. Classic heat stroke is associated with sweating 3. The hallmark of heat stroke is altered mental status 4. Classic heat stroke may be associated with coagulopathy 5. Classic heat stroke may be associated with mild lactic acidosis

Heat Stroke – requires CNS dysfunction Classic Heat Stroke Exertional Heat Stroke

• Elderly , debilitated • Young healthy • Sedentary • Extreme exertion • Associated with heat • Occurrence sporadic waves • Sweating preserved • Anhidrosis common • Hypoglycemia • Normal glucose • Severe coagulopathy • Mild coagulopathy /DIC • CK mildly increased • Rhabdo myolysis • Oliguria • Acute renal failure • Mild lactic acidosis • Severe lactic acidosis

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Spectrum of Illness

Heat Cramps

Heat Edema

Heat Syncope

Heat Exhaustion

Heat Stroke

Faint due to volume depletion, postural hypotension Heat edema painful, involuntary contractions calves, in Prickly heat people who previously sweat profusely Pruritic maculopapular Heat cramps rash due to inflammation blocked sweat ducts Heat tetany hyperpyrexia (> 40C, CNS dysfunction , ataxia, later anhydrosis, and +ve LFTs Heat syncope Paresthesias m cramps due to hyperventilation Heat exhaustion ankles, feet and hands swollen severe volume depletion, Heat stroke weak malaise, fatigue, orthostatic drop in BP

Heat related illness

• The most common ECG finding in patients with heat related illness is ______QT prolongation which is also a common ECG finding in hypothermia • Although bradycardia is common in hypothermia it is not in heat related illness

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A 17 yo male presents to the ED after a temporary and brief interruption of neurologic function after hitting the goal post with his head while playing soccer. He is feeling fine in your ED. All of the following are true regarding this condition EXCEPT… a. Patients may be amnesic for the event b. Patients may have insomnia after the event c. Patients may have difficulty concentrating after the event d. Patients may have transient ataxia after the event e. Patients may have headaches after the event

Which of the following regarding concussion is correct? a. It does not necessarily require a loss of consciousness b. Retrograde amnesia is more common than and longer in duration than antegrade amnesia c. Otherwise well patients may not be able to recall their name or date of birth malingering d. Skull fractures is a strong predictor of brain hemorrhage e. Postconcussion syndrome (headache, dizziness, memory problems, neuropsych complaints) is common in young children

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Head Trauma: Post Concussive Syndrome

• Headache: For weeks to years • Dizziness • Insomnia • Anxiety • Decreased concentration • Any change in mental function No ataxia, no focal neurologic signs

2011 Concussion Guidelines

• 1. Rest until asymptomatic ( physical, mental) • 2. Light aerobic exercise ( exercise bike) • 3. Sport- specific exercise • 4. Non-contact training drills ( wt lifting or sleds) • 5. Full contact training (after medical clearance) • 6. Return to competition( game play) Each stage can be 24 hrs or longer and return to stage one if symptoms re-occur

What we are trying to avoid

• Second impact syndrome : The sudden death that may result with a second concussion before complete recovery from the first one.

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Head injury in kids – Who avoids a CT brain

• < 2yrs old • > 2yrs old • Normal neuro exam • Normal mental • No scalp hematoma status except frontal • Normal neuro exam • No LOC or LOC < 5 • No LOC seconds • No severe headache • Consider mechanism • No vomiting • No palpable skull • No signs of basilar fracture skull fracture • Acting normally • Consider mechanism

Bottom line for concussion guidelines in children and adolescents

• No comprehensive return-to-play guidelines have been adapted for the young athlete, and the majority of current and past studies were performed with older athletes.

This patient front seat passenger involved in MVA, suffered this injury which is most likely… a. Anterior hip dislocation b. Femur neck fracture c. Open book pelvis fracture d. Posterior hip dislocation e. Achilles tendon rupture

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Shortened Internal rotation of hip Adducted Flexed

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Posterior Hip Dislocation

• Posterior hip dislocation is most common 90%: ______shortened/lengthened leg, internal/external______rotation of hip, abducted/adducted______and slightly ______flexed/extended • 27% get osteoarthritis • 8% - 30% get avascular necrosis of femoral head • Must be reduced within 6 hours

Hip Injuries

Abd Add Int R Ext R Posterior Hip disl

Anterior Hip disl

Femoral neck #

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75 yoAortic male with Dissection abdominal pain

Upper extremity pulse deficit is the most specific physical exam finding but its sensitivity is < 15% 50% do not survive to make it to the ED – of those who do mortality increases 1% per minute

2 lumens in aorta. Suspect dissection, you might see it by scanning abdominal aorta.

Belly

SMA Celiac

Aorta Heart Feet

Back

Acute Thoracic Aortic Dissection • Widened mediastinum is the most common abnormal finding • 12% of patients have normal CXR • 21% of patients have a normal mediastinum and aortic contour • Non specific findings may be very subtle and not typically picked up by the ED physician • Abnormal aortic contour in 50% • Abnormal cardiac contour in 25% • Pleural effusion in 19% • Displacement or abnormal calcification of aorta in 14%

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There has been a radiation accident at your local nuclear power plant. A patient present at the site at the time of the accident presents to your ED with complaints of nausea and vomiting. She is now, 48 hours after the event, worried about this exposure. Her absolute lymphocyte count is 1600/mcL. You should explain to her that… a. That her exposure will require intensive and aggressive therapy for her to survive b. That her lab value suggests that she has a 50:50 chance of survival c. That she requires no treatment and is expected to recover from her exposure without significant complications d. That it is to early to tell and that her ALC will have to be re-taken in 24 hours e. That she has likely suffered a lethal dose of radiation

Absolute lymphocyte counts at 48 hours after exposure as a prognostic factor

• > 1200/mcL means it is unlikely that the patient has received a clinically significant dose of radiation • 500 – 1200/mcL serial counts especially if symptomatic • 100 - 500 /mcL possibility of exposure to a lethal dose of radiation should be suspected

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All of the following are true regarding radiation exposure EXCEPT:

a. Alpha rays are the most penetrating b. GI syndrome (N/V/D) occurs at 1 Gy (gray) c. Survival is unlikely with a exposure of greater than 800 rads d. The GI tract is one of the tissues most affected by radiation e. The absolute lymphocyte count (ALC) at 48 hours of 1200 indicates a 50% mortality

Types of Radiation

Paper Plastic Lead Concrete 444 ++++++ 222α Alpha ? need alpha counter

000 −−− −1−1−1 βββ Beta Skin burns Geiger counter 0 0γ Gamma and X-rays Primary cause of acute radiation syndrome 1 0n Neutron Stopped neutrons are captured and cause previously stable atoms to become radioactive – source of radioactive fallout

A 28 y.o. male presents to the ED with throbbing headache, palpitations and abdominal pain after eating at the Golden Lobster, where he states they put too much pepper on their fish. You note marked facial and neck flushing, conjunctival injection and scattered urticaria on his trunk. His BP 150/100, P 110, R 24, T N. What is the most likely cause? a. Ciguatoxin b. Scombroid fish poisoning c. Bacillus cereus d. Cyclospora cayentnenensis e. E-coli 0157:H7

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Scombroid • Multiple patients with ‘allergic reaction ’ – due to excessive histamine levels in the fish due to inadequate refrigeration • Tuna, mackerel, mahi-mahi • Peppery taste • Sx occur within minutes of eating the fish • Facial flushingflushing, throbbing H/A, abd cramps, diarrhea, palpitations, burning sensation in the mouth, pruritus • Rx: antihistamines, H-2 blockers

38 y.o. female presents to ED with acute onset of N/V, watery diarrhea, diaphoresis and cramping abdominal pain that woke her up from sleep. Also c/o tingling tongue and around mouth. She refused a cold drink of water saying if felt like hot water. She had dinner at the “Fish House ” 5 hours earlier. The most likely cause is: a. Ciguatoxin b. Scombroid fish poisoning c. Bacillus cereus d. Cyclospora cayentnenensis e. E-coli 0157:H7

Ciguatera Fish Poisoning: neurotoxin

• Common cause of fish poisoning diarrhea • Ciguatoxin produced by marine dinoflagellate – Gambierdiscus toxicus; mostly in South Pacific • Fish: grouper, barracuda, sea bass, red snapper • Odorless and tasteless • Incubation: 2 – 6 hrs; Duration: 12 – 30 hrs • GI and neuro Sx • Rx: symptomatic, ? Mannitol

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Fish Poisoning Ciguatera Scombroid

- Produced by marine - Inadequate refrigeration dinoflagylate (excess histamine) - Perioral paresthesia “loose teeth” - Peppery taste - Hot cold reversal - Facial flushing - Ataxia, weakness, vertigo - Multiple patients – - Sx worse with ETOH allergic reaction - Rx: Supportive, manitol (neuro Sx) - Red meat fish - Antihistamines, H2-bl - Rx: Antihistamines, H-1, - May be permanent H2-blockers, beta-2 agonists for bronchospasm

Parvovirus B -19 • In pregnant patients • Hydrops faetalis (due to severe fetal anemia) leading to miscarriage or stillbirth • Risk of fetal loss is 10% if contracted before 20 wks gestation but minimal after that • Patients with hemolytic anemias (incl SCDz) • Can cause aplastic crisis • In AIDS patient • Can trigger an inflammatory reaction on patients started on antiretroviral therapy • Causes chronic anemia – frequently overlooked • Adults • Seronegative arthritis , resolves by 1- 3 wks • In kids • Erythema infectiosum – slapped cheek syndrome

Ciguatera Poisoning

• Perioral paresthesiaparesthesia,, feels like loose painful teeth,teeth, burning hands/feet • Hot cold reversal • Ataxia,Ataxia , weakness, vertigovertigo,, visual hallucinations • Abdominal pain,pain , vomiting, profuse diarrhea (occur earlier) • Fish eat dinoflagellates that contain toxins • Sxtic treatment, lasts 1 – 2 wks (50% Sx at 8 wks) • Sx may get worse with ETOH • Sx may be permanent

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All of the following are true regarding pancreatic injuries EXCEPT… a. They are more common in penetrating trauma b. Although the pancreatic injury itself in blunt trauma may be subtle, pancreatic injuries usually occur in more severely injured patients c. Classically,Classically the physical physical exam exam improves initially worsens initially and over the first 6 hours the patient looks and and then worsens over the first six hours feels better d. Serum amylase is elevated in only 27% of penetrating injuries to the pancreas e. Release of pancreatic enzymes more commonly cause mild tenderness to palpation (rather than peritoneal signs)

All of the following are more consistent with delirium than dementia EXCEPT…

a. Onset is acute (days to weeks)

b. It is usually reversible

c. Hallucinations

d. Consciousness is clear

e. Fluctuating course

Features Delirium Dementia Onset Acute Insidious Course Fluctuating Progressive Duration Days to weeks Months to years Consciousness Altered LOC Clear – awake/alert Attention Poor attention Pays attention Reversibility Usually Rarely Hallucinations Yes No Delusions Fleeting delusions None until very late Additional Info Disorganized thought 50% of pts > 85 Flight of ideas Alzheimer’s accounts for Global disorder of cognition and attention 70% of dementia pts Sleep/wake cycle disturb Impaired memory and meds, lytes, infection, liver fail judgment ‘Sundowning’ Mortality 20% - 30%

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Treatable Causes of Dementia

Drugs Electrolytes Metabolic Emotional Nutritional/Normal pressure hydrocephalus Trauma/Tumor Inflammation (SLE,/infection) Alcohol

Keycepts: Dementia

• Before diagnosing dementia R/O treatable Dz: • Normal Pressure Hydrocephalus: • dementia, ataxia , incontinence • Wernicke-Korsakoff Syndrome: • ataxia, ocular abn, confusion • Pseudodimentia (depression): • severely depressed patient • Disturbed sleep pattern • Sudden onset ppted by emotional event • Mental status improves with encouragement • Medical problem: drugs, lytes , metabolic dz

Delirium

Frequency: 10-15% of admissions to hospitals (but usually not primary diagnosis) Mortality: 20-30% Race: more common in Caucasians Age: elderly, (20-40 ’s think toxic/withdrawal) Sex: female > male

PSYCHO-BEHAVIORAL 165

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Dementia

• Incidence: 50% over 85 • Alzheimer ’s accounts for 70% • Vascular dementia is 10-20% • Earlier stages are subtle and may be concealed by the pt. • Stuttering course points to multi-infarct

166

Transient Global Amnesia • Patient working in garage all of a sudden gets confused as to where he is, and does not know how to get home from where he is. • Restricted memory loss • Only 5% relapse • What it is not: • Not a stroke • Not delirium

Terms

• Gray (Gy) is the international unit of absorbed radiation dose of ionizing radiation (IR) defined as absorption of one joule of IR by 1Kg of matter • Seivert is an international unit of equivalent dose which for X-rays is numerically equal to a Gy • One Rad (old term) = 0.01Gy (1Gy = 100 rad) • Roentgen equivalent man ( REM ) = 1 rad

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A patient presents to the ED with the following injury. You tell him he has… a. A fractured triquetrum b. A perilunate dislocation c. A Smith fracture d. A Rolando fracture e. A lunate dislocation

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A patient presents to the ED with the following injury. You tell him he has…

a. A fractured triquetrum

b. A lunate dislocation

c. A Smith fracture

d. A Rolando fracture

e. A perilunate dislocation

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“““KEEP THE LUNATE IN LINE ”””

Lunate Capitate

Ask yourself: Which bone is more out of line with the radius?

Piece of Spilled Pie tea cup Triagular of appearance lunate of lunate

Lunate Dislocation

No big tilt Although some gap

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Ortho

Renal Ca

A patient presents with this lesion. The most likely cause of this lesion is…

a. Syphilis b. Human papilloma virus c. Venereal warts d. Hemorrhoids (bad ones) Condylomata Acuminata e. LGV (lymphogranuloma venereum) The most common anorectal STD May turn malignant in HIV patients If indurated consider squamous cell CA

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Condylomata acuminata Human papilloma virus Pedunculated papules Develop into cauliflower like masses Dry, keratinized surface Rx: Cryotherapy

From secondary syphilis Flat weeping warts on genitalia Emits foul odor Look also for diffuse maculo papular rash all over body including palm and soles Loss of lateral 1/3 of eyebrow Patchy alopecia Benz pen 2.4 if greater than 1 yr give weekly for 3 weeks

A patient presents to the ED after he fell 20feet to the ground off a scaffolding landing on his feet. He comes in with the injury seen on this X-ray. His contrasted CT shows a non enhanced kidney on the left side. The most likely diagnosis is…

a. Acute traumatic hydronephrosis b. Renal artery thrombosis c. Acute renal contusion d. Acute renal rupture e. Patient only has one kidney

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A patient presents to the ED after he fell 15 feet to the ground off a scaffolding. He comes in with the injury seen on this X-ray. His contrasted CT shows a non enhanced kidney on the left side. The most likely diagnosis is…

a. Acute traumatic hydronephrosis

b. Renal artery thrombosis

c. Acute renal contusion

d. Acute renal rupture

e. Patient only has one kidney

Apex of Apex of anterior posterior process facet

34 15 o

Posterior calcaneal tuberosity

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Ortho Boehler ’s angle

Bilateral

Dorsolumbar compression fractures

Tibial plateau fracture

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Boehler ’s angle and calcaneus fracture associated injuries • Falls from heights onto feet and MVCs are the most common mechanisms of injury for a calcaneus fracture • Boehler ’s angle: can be measured and should be 20 to 40 degrees • Associated injuries include: • Lumbosacral fracture (10%) • Other calcaneus (10%) • Tibial plateau fracture • Other extremity injuries (26%) • GU and renal injuries (left pedicle injuries more common than right cuz right is well locked in)

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AAA Definition > 3cm 90% begin below renal arte ries 4 – 5 cm 50% are palpable 5cm are palpable, but pulsatile abdominal mass is felt in < 50% Grow at 4mm per year > 5cm requires vascular surgeon Audible bruit is rare

A 43yo male presents to the ED with altered mental status. His wife says he just got over a “bad sore throat” a few days ago. VS BP 90/60, P 110, RR 24, T 39C. On exam you note a anisocoria (R >L), a drooping L eyelid. You also note some tongue deviation. Which of the following is the most likely diagnosis? a. Peritonsillar abscess b. Epiglottitis c. Ludwig’s angina d. Parapharyngeal abscess e. Tracheitis

Parapharyngeal Abscess leading to sepsis

• These patients typically present after resolution of sore throat • Can encroach of adjacent tissues: • Cervical sympathetic chain (Horner’s) • Carotid artery and jugular vein (causing sepsis) • Patients with this complication will present in severe sepsis • Organ hypoperfusion (AMS in this case) • Two of the following 4 (for dx of SIRS) • Fever > 38 or < 36 • Pulse rate > 90 • RR > 20 or PCO2 < 32 • WBC count > 12,000 or > 4,000 or > 10% bands

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Match the following regarding lightning injuries Current transferred through the ground Direct strike Current travels over surface of skin Side flash May injure multiple victims at once Contact strike Current strikes object victim is holding Ground current Causes most serious injuries Upward streamer Not connected to the completed lightning Flashover channel

Lightning (in a minute) • Lightning is high voltage DC electrical discharge • Pregnant patients have ______fetal50% mortality • 70%______- 90% of persons struck by lightning survive – >______70% of survivors have permanent sequelae • Tympanic membrane perforation occurs in ______> 50% • Asystole is the MCC of death in lightning victims; spont cardiac activity may resume spontaneously; resp arrest may persist with resultant hypoxia which sometimes causes V.fib ( go to them first ) • Rhabdo and myoglobinuria in <___% 6 • Burns and myoglobinuric renal failure are uncommon in the setting of lightning strikes

Lightning • Flashover : lightning traveling over the surface of the body (more likely with wet skin) this protects internal organs from injury – get fern like skin pattern but no burns • Direct strike produce the most serious injuries • Side flash : nearby object struck and current travels through the air ( multiple victims at once) • Triage priorities reversed in high voltage injuries, go to patients without signs of life first – do CPR until pt starts to breathe spontaneously

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Keraunoparalysis

• Caused by lightning strike • Typically occurs in the lower extremities • Characterized by: • Transient paralysis • Mottled, cool, blue, pulseless extremities • Typically resolves on its own within minutes to hours

AC/DC (in a minute) • AC > danger than DC • AC causes tetany once “let go current ” is exceeded • Impossible to predict degree of underlying damage by looking at extent of cutaneous burn • …….< 10 % of patients who suffer low voltage injury have cardiac dysrhythmia and most common is ………………………..ventricular fibrillation • High-voltage electrical injuries (>1000V) = increased risk of spinal injuries (immobilize) • ECG changes or LOC requires 24 hrs monitoring.

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A 24 yo male presents with this injury after falling off his motor cycle. You know… a. This is an extension injury b. The patient is likely to have significant motor paralysis c. The patient should receive methylprednisolone 1 gm IV now and 30 mg/kg/hr for the next 24 hours d. May require open reduction e. This is a pseudosubluxation in a patient with connective tissue disease

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Unilateral Facet Dislocation

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Anterior Subluxation Injury

Hyperflexion Sprain

Delayed instability

Forced flexion disrupts posterior ligaments

Often missed

Flexion Injury

Hyperflexion Bilateral Facet

NOT perched One facet in front of the other

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Bilateral Facet Dislocation

• Severe Flexion with distraction and disruption of posterior ligaments • Both inferior facets jump over the corresponding superior facets • > 50% subluxation of vert. body width • Cord injury very common • HIGHLY UNSTABLE

bilateralperched

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Bilateral Facet

• “doubly locked = misnomer ” • Implication of stability could not be further from the truth • Use of the word locked is pathologically inaccurate and clinically misleading and should be avoided

• The Radiology of Acute Cervical Spine Trauma third edition

Bilateral Facet Dislocation

Which of the following is most likely to help prevent secondary brain injury in the trauma patient?

a. Treat hypertension aggressively b. Treat hypothermia aggressively c. Treat hypoxia aggressively d. Use blood transfusions and blood products aggressively e. Treat metabolic disturbances aggressively

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A 35 y.o. male presents after he miss- stepped off a curb. He complains of severe left knee pain. His X-ray is depicted. The most likely diagnosis is… a. Tibial plateau fracture b. Patellar extensor tendon disruption c. Quadriceps tendon rupture d. Maisonneuve fracture e. Anterior cruciate tear

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Insall and Salvati Method

Greatest diagonal B length B/A =1 measured Lower pole of < 1 = patella alta patella to A tibial tubercle

Greatest B diagonal length B measured

A A

A/B < 0.8 B/A =1 Blackburn < 1 = patella alta

Insall and Salvati Method

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High riding patella – Patella Alta

• 80% of knee extensor disruptions in < 40 y.o. will be patellar extensor tendon that will be affected • 80% of knee extensor disruptions in > 40 y.o. will be the quadriceps tendon that will be affected

• No trauma then chronic patella alta (not expected at ABEM General)

A patient presents in coma after minor traumatic event. You inject cold water into the patient ’s left ear and the eyes slowly move to the left. This means

a. His cerebral cortex is intact b. His brainstem is not functioning c. His brainstem and cerebral cortex are not functioning d. His brainstem is functioning e. His brainstem and cerebral cortex is intact

Cold calorics (Oculovestibular reflex)

• If you inject cold water into the left ear and the eyes slowly move towards the left ear, this means the brainstem is intact • If then the eyes move with fast movement (nystagmus) towards the opposite ear this means the cerebral cortex is intact • If both of the above occur, the patient is faking it • If there is no movement then nothing is working Corneal stimulation will cause eye to blink if Cr V and VII are intact which is another way to check brainstem function

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Doll ’s eyes (oculocephalic reflex)

• When you turn a doll ’s head to one side, the eyes follow slowly after the head is turned • When you do this to a comatose patient (not a trauma pt) and his eyes lag behind (as if the patient is maintaining fixation on a single point in space). The eyes thus appear to be moving relative to the head in the direction opposite to the head movement (this means normal functioning brainstem). • The absence of this reflex suggests brainstem dysfunction in a comatose patient. • This reflex is suppressed in the conscious patient but is normal in the unconscious patient without brainstem injury

A 74 yo male known diabetic and hypertensive presents to the ED with sudden onset of left eye pain. He also complains of blurred vision, headache, abdominal pain and nausea. His VA is 20/200 OS and 20/40 OD. Exam of the eye shows conjunctival injection and pupil is mid position and non reactive to light. Funduscopic exam is shown. Your next best step a. Order a sedimentation rate

b. Give prednisone 60 mg

c. Perform tonometry

d. Order a CTA brain

e. Order an ultrasound of L eye

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Glaucoma: Associations

• Red painful eye • Risks: • ‘Steamy cornea ’ • Hypertension • Blurred vision • Vascular disease • Nausea/headache • Familial • Abdominal pain • IOP • Mid dilated pupil • Diabetes mellitus poorly reactive • Cup/disc > 1:2

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Glaucoma

• Glaucoma = increased IOP

Disc cup

Ratio = 0.8 Cup/disk should < 0.5 Glaucoma = > 0.5 Caution other DZ High Myopes

Treatment and Why?

Patient supine….. Gravity pulls lens away from iris Timolol 0.5% (Timoptic) suppress aqueous humor 1 gtte Q-15-min…… production

Pilocarpine 1% 1 drop Q- facilitates drainage of 15-min X 1 hour, then Q-30-min…… aqueous humor

Topical steroids (pred-forte) Decreases aqueous humor

Treatment and Why?

Mannitol 20 gms I.V….. osmotically drains eye reduce vitreous volume

Acetazolamide 500 mg I.V…… Decreases AH production

Ophtho consult…. peripheral iridectomy

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Which of the following is true regarding fetal exposure to radiation a. A single CXR in a women who is 6 weeks pregnant could increase the risk of fetal malformation by 20% b. A CT of the abdomen of a 20 week pregnant female gives more radiation to the fetus that is considered a safe level of radiation exposure to any fetus c. During the nine months in utero the fetus is exposed to an average of 50 – 100 mrads d. The highest risk of radiation to the fetus occurs at fetal age 8 to 16 weeks

Fetal exposure to radiation

• ______< 5 rads is considered to be safe • During the 9 months in utero the fetus is exposed to ______50 – 100 mrads • >10______rads increases the risk of childhood cancer but does not increase the risk of: • Fetal malformation • Spontaneous abortion • Growth retardation

Fetal exposure to radiation

• Maternal plain films of the head, C-spine, T- spine, extremities or CXR exposes the fetus to ______< 5 mrads (1000 times less than safe threshold) • X-rays of the LS spine, hips or pelvis expose the fetus to ______> 5 mrads • CT of the abdomen exposes the fetus to 2.5______rads

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Fetal exposure to radiation

• Maternal abdominal lead shielding decreases radiation to the fetus by 50% • The highest risk of radiation to the fetus is ______2 – 7 weeks gestation organogenesis

53yo male presents to the ED with sudden SOB. He is a smoker and has COPD and has renal insufficiency. His dimer is +ve. A CXR shows evidence of COPD but no PTX. What is the most appropriate diagnostic test? a. Alveolar dead space determination b. PET Scan c. VQ scan d. Spiral CT scan e. Pulmonary angiography

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A 66 yo diabetic hypertensive is brought in by his daugther. His CT is shown. Which of the following findings are you more likely to find a. Tongue deviation to the left with R sided hemiparesis b. L sided oculomotor paralysis with R hemisensory loss c. L sided facial sensory loss R sided paralysis d. R sided facial droop with L sided sensory loss e. Rotatory nystagmus with L sided facial droop

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II, III ,IV

VI Pontomedullary Brainstem Fx: VII VIII junction RAS Vital signs IX, X,XI, XII Cranial nerve

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Coma, miosis, apneustic ’ breathing, only up eye mvt Match em Vertigo, N/V, nystagmus, drop Brainstem stroke ataxia, (fatal gastroenteritis) Contralateral paralysis: Leg > Arm, Pontine stroke distal weakness > prox weakness, perseverates, responds slowly, abulia Vertibrobasilar stroke Vertigo, dysarthria, syncope, diplopia, ipsilateral CN Cerebellar infarct deficits, contralat motor dfts Significant edema Contralateral paralysis: , Anterior cerebral Face/Arm > Leg, homonoms hemianopsia, conj gaze impair stroke Circumoral paresthesia, ipsi Posterior cerebral Cr N contra hemi-loss, HTN Homonomous hemianopsia, stroke visual agnosia, memory loss, cortical blindness, minimal Middle cerebral motor involvment, ipsi CN 3 artery stroke

KEYCEPT

• The hallmark of a brainstem stroke is crossed findings • Think about this diagnosis in patients with perioral paresthesia • Ipsilateral cranial nerve findings with contralateral hemi – findings (paresis or sensory loss

Associate K-stones Gout rd 2/3 of all Kstones Calcium Ammonia-phosphate Hyperparathyroid Sarcoidosis Struvite Radioluscent Least common Uric Acid 1/5 th of all Kstones Stones Inborn error of Cystine metabolism Stones Laxative abuse, IBS UTI: proteus, klebsiella, pseudomonas

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Associate K-stones 2/3 rd of all Kstones Gout Calcium Asthma Ammonia-phosphate Hyperparathyroid Struvite Sarcoidosis Radioluscent Uric Acid Least common Stones 1/5 th of all Kstones Cystine Inborn error of metabolism Stones Laxative abuse, IBS UTI: proteus, klebsiella, pseudomonas

Associate S&S seizures Roseola Infantum Generalized lymphadenopathy Rubeola Koplik spots Measles Rash after fever subsides Rubella German Measles Post cervical lymphadenopathy Erythema K infectiosum Slapped cheek Sudden fever

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1 in 5 sexually active adults Associate Multiple genital ulcerations with tender inguinal lymphadenitis HSV-2 Painless primary genital lesion – ignored Painless chancre Syphilis MCC of ulcerative vulvar and vaginal lesions Tender unilateral lymphadenopathy Chancroid Lymphadenopathy is unilateral and occurs in 50% of patients LGV Chronic painless genital ulcerations Primary infections more Granuloma severe than recurrent infections Inguinale Bubos

Associate 1 in 5 sexually active adults Multiple genital ulcerations with tender inguinal HSV-2 lymphadenitis Painless primary genital lesion – ignored Syphilis Painless chancre MCC of ulcerative vulvar and vaginal lesions Tender unilateral Chancroid lymphadenopathy Lymphadenopathy is unilateral and occurs in LGV 50% of patients Chronic painless genital ulcerations Granuloma Primary infections more severe than recurrent Inguinale infections Bubos

STDs - Match em

Painless indurated Granuloma genital ulcer with tender inguinale inguinal adenopathy Small painless shallow Haemophilus anal or perianal ulcers with significant tender ducreyi inguinal adenopathy that Gm –ve bacillus evolves into painful inguinal buboes Painless genital ulcers Lymphogranuloma often mistaken for syphilis venereum - LGV Painful nonindurated irregular genial ulcers and solitary tender unilateral Treponema Palladium lymph node (could be bilateral inguinal adenopathy) Syphilis

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Associate GC Primay cause of osteomyelitis in healthy host MCC of Salmonella osteomyelitis in SCDz patients

Predominant cause of septic arthritis in Staph SCDz patients Aureus

MCC of septic arthritis in young sexually active adults

Associate Osteoarthritis MCP joints (OA) PIP joints

First Carpometacarpal joint Rheumatoid DIP joints Arthritis (RA)

Best Antibiotic to use Trimethoprim- Most cases of invasive sulfamethoxazole bacterial diarrhea Campylobacter diarrhea Metronidazole Yersinia diarrhea Doxycycline C.difficile Macrolides ETEC Vibrio diarrhea Ciprofloxacin Giardia

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Clinical Spectrum Infectious agents Drug Exposure

Target lesions Mucosa Symmetical Exfoliative Benign dz involved face/trunk rash mucocutaneous from host limited to Sore throat disorder – life hypersensititivit oral cavity Mucosal threatening involvement Purulent y Painful eating, conjunctivitis 50% of cases urinating, Tender diffuse are idiopathic profuse diarrhea erythematous HSV is MC Photophobia, lesions infectious agent decreased vision Blistered inflammed mm

Vacor (RH-787) Odors Salicylates Acetone Arsenic Garlic Chroral hydrate Organosphosphates Almonds Paraldehyde Peanuts Phosgene Pear like odor Toluene Laetrile Rotten eggs Zinc Ketosis Fishy odor Ricin Smell of Glue HS, mercaptan Castor bean Cyanide processing Ethanol Newly mown hay Isopropyl alcohol Selenium

Peripheral Associate neuropathy PAN – Recurrent oral and polyarteritis genital ulcerations nodosa Asthma Takayasu’s dz Coronary ischemia Behcet’s dz Mesenteric ischemia Wegener’s Recurrent hypopeon Agranulomatosis Glomerulonephritis Pregnancy, DM, Churg-Strauss hyperthyroidism, RA Syndrome Sinusitis, otitis, Carpal Tunnel nasal congestion syndrome Cutaneous findings

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Young adult Associate Acute onset Disorientation Medical Auditory cause of hallucinations Psychosis Abnormal VS Older patient Gradual onset Psychiatric Flat affect cause of Psychosis Aphasia, ataxia Impaired consciousness Visual hallucinations

You are working in Nome, Alaska. A 15 yo fell 7 feet and hit his head. He was initially unconscious then woke up for a while and now is unconscious again and while you are attending to him his R pupil dilates and he no longer moves his L side and then crashes.Your next best step is… a. Hyperventilate, manitol, call neurosurgeon in Fairbanks for transfer b. Elevated head of bed, manitol, decadron c. Burr hole on the R if unsuccessful, burr hole on L d. Burr hole on the L if unsuccessful bur hole on R e. Call the neurosurgeon in Fairbanks

Epidural • Classic: Brief LOC , then lucid interval , then LOC • Decrease LOC, ipsilateral pupillary dilatation (due to compression of CN III and its superficial parasympathetic fibers), contralateral hemiparesis (due to compression of ipsilateral cerebral peduncle – motor fibers cross below this level) • Lenticular (football) shape lesion on CT • Mortality rate 0% - 20% • Middle meningeal artery injury

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Parasympathetic fibers

3rd nerve arachnoid

dura corticospinal tracts

Uncal portion of temporal lobe pushes through tentorium , causes 3rd nerve compression on edge of tentorium, causing injury to the superficial parasympathetic nerves causing unopposed sympathetic stimulation thus ipsilateral dilated pupil. In addition corticospinal tract fibers in midbrain become compressed causing contralateral paralysis

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Transtentorial (Uncal) herniation syndrome

• In 20% of cases hematoma compresses opposite side of midbrain against tentorium edge resulting in contralat pupil dilatation and ipsilateral paralysis • This is why bilateral burr holes is necessary in ipsilateral burr hole does not work

Collection of blood below inner table of dura but external to the brain (between cortex and venous sinuses – dissects the arachnoid away from the dura) Occurs in 33% of patients with severe head injury

Subdural Below inner layer of dura External to arachnoid • H/A • Decreased LOC subacute • Bridging veins • 25% are bilateral • Crescent shape lesion on CT • 30% - 60% mortality acute • Acute, subacute (isodense, coumadin), chronic 6X more common than epidural

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Types of brain herniation 11)Uncal 2) Central 3) Cingulate 4) Transcalvarial 5) Upward 6) Tonsillar

An 87 yo male fell a week ago, hit head but not knocked out. On admission to the ED his LOC is depressed. His CT brain is shown. Of the following which is most likely a. He is likely to have urinary incontinence and some dementia b. He has a history of atrial fibrillation c. He has a family history of brain cancer d. This is probably physical elderly abuse e. Most patients with this injury have a cycle of loss of consciousness, awake period and return to loss of consciousness over hours

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An 87 yo male fell a week ago, hit head but not knocked out. On admission to the ED his LOC is depressed. His CT brain is shown. Of the following which is most likely a. His LOC has been disturbed for at least 2 weeks b. He has a history of atrial fibrillation c. He has a family history of brain cancer d. This is probably physical elderly abuse e. Most patients with this injury have a cycle of loss of consciousness, awake period and return to loss of consciousness over hours

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You are working in Nome, Alaska. A 15 yo fell 7 feet and hit his head. He is unconscious and while you are attending to him his R pupil dilates and he no longer moves his L side and then crashes.Your next best step is…

a. Hyperventilate, manitol, call neurosurgeon in Fairbanks for transfer b. Elevated head of bed, manitol, decadron c. Burr hole on the R if unsuccessful, burr hole on L d. Burr hole on the L if unsuccessful bur hole on R e. Call the neurosurgeon in Fairbanks

Transtentorial (Uncal) herniation syndrome

Match the following red eyes with the diagnosis •EKC (epidemic keratoconjunctivitis) With preauricular adenopathy With discharge and a cough •Uveitis Painful with mild mucoserous •Herpes simplex infection discharge for 5 d then spread •UV keratitis With cobblestone papillae under •Pseudomonas upper lid •Glaucoma With hypopeon in contact wearer •Iritis After eye surgery •Endophthalmitis With diffuse punctate keratopathy •Viral conjunctivitis With cup:disc ratio > 1:2 •Allergic conjuncitivitis Dendridic pattern (dumbells) •Chlamydia Cells in the vitreous cavity Ciliary flush, flare in anterior chamber, •GC consensual photophobia