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Reversible causes of Cardiac arrest	H's: hypovolemia, hypoxia, hydrogen, hypo/hyper K, hypothermia T's: Tension, tamponade, thrombosis, toxic,
Well's criteria	3 - suspect PE 3 - clinical signs of DVT 1.5 - bedridden 1.5 - HR > 100 1.5 - hx of DVT/PE 1 - malignancy 1 - hemoptysis
Wells score interpretation	Score > 7 Score > 2-6 Score < 2.0
Perc criteria	HAD CLOTS: hormone therapy, age > 50, DVT hx, Cough, LE swelling, hypoxia, Tachycardia, surgery/trauma
LEMONS	Look, evaluate, mallampati, obstruction/obesity, neck
MOANS	mask seal, obst/obesity, age > 50, no teeth, stiff lungs
epi for anaphylaxis	Epinephrine: •IM 1:1000 IM near the reaction site •Adult: 0.3-0.5 mL q5 min, titrated to effects •Peds: 0.01 mL/kg, q5 min, titrated to effects •EpiPen 0.3 mL or EpiPen Jr 0.15 mL in anterolateral thigh
epi IV for anaphylaxis	IV 1:100,000 at 1 ml per minute titrated to effects •To make 1 mL of 1:1000 in 1L bag of NS)
other meds for anaphylaxis	Albuterol 2.5mg/Atrovent 0.5 Nebulizer •Diphenhydramine 50 mg (Peds 1 mg/kg) IV/PO •Ranitidine: 50 mg IV (150 mg PO) (Peds 1 mg/kg IV/PO) •Methylprednisolone 125-250 mg IV (Peds 1-2 mg/kg/IV)
Hyperkalemia Differential Diagnosis: (SLEEP)	Shift: acidosis, burns, insulin deficiency, succinylcholine, digoxin, beta-blockers •Load: supplements, hemolysis, GI bleed, rhabdomyolysis, transfusions, chemotherapy •↓ Excretion: renal failure, ACE inhibitor, hypoaldosteronism, spironolactone •Pseudo: hemolysis, tourniquets
Hyperkalemia tx: kayexalate doseage	Kayexalate 15-30 g PO, or 50 g PR (ped: 1 g/kg) with sorbitol
hypothermia temp ranges	Severe: (28°C/82°F) Moderate: (32°C/90°F) Mild: (35°C/95°F)
hypothermia warming goal	>35C
hypothermia: don't declare until	Don’t declare until 35°C/95°F and dead.
status asthmaticus 1st treatment	Ativan 0.1 mg/kg IV/IM (at 2mg/min); repeat q5min x4 (↑ duration) •OR Valium 0.2 mg/kg IV (at 5 mg/min); rpt q5min x4 (faster onset)
Status asthmaticus 2nd line	•Second Line Treatment: •Fosphenytoin 20 (15-20) PE/kg IV/IM load at 150 PE/min OR •Phenytoin 20 (15-30) mg/kg IV load at 50mg/min •Give over 20 minutes usually (Propylene glycol diluent causes ↓ BP, dysrhythmias if rapidly infused. •9 mg/kg load if already on Dilantin •May give simultaneous with benzos •But not in same line & no glucose in line (precipitates) •Phenobarbital 20 (10-20) mg/kg IV at 50 mg/min.
ACS tx:	NTG 0.4mg q5 x 3 sprays lovenox 1mg/kg sq or heparin 60U/kg bolus then 12U/kg heparin Emergent PCI if available (90 minutes of arrival) •Thrombolytic (If no PCI in 90 minutes):
CVA t-PA dose	Dose: 0.9mg/kg (max 90mg)- give 10% as bolus dose followed by an infusion lasting 60 minutes. •If not a tPA candidate and no ICH, then give ASA 325.
hemorraghic CVA anti HTN e	Nicardipine gtt, start at 5mg/h, titrate •Labetalol 10-20mg IV push q20min to max 150mg5
RSI status asthmaticus	lidocaine 1.5mg/kg 3mins prior ketamine 1-2mg/kg IV succ Propofol gtt 0.1-0.2 mg/kg/min + Fentanyl gtt 0.5-1.5mcg/kg/min
rsi peak flow rate	•Peak Flow •<70% abnormal (Av adult ♂ <450, ♀ <325) •<40% severe (Av adult ♂ <260, ♀ < 180) •PaO2, SaO2 (<90% severe), EtCO2
HTN encephalopathy tx	Labetolol 20mg IV, double dose q10 min until goal achieved (max 300mg). Consider infusion 1-2mg/min
aortic dissection tx	Esmolol 500mcg/kg IV ovr 1 min, then 50mcg/kg/min gtt. Target HR 60-80 AND •Nitroprusside: 0.25-10 mcg/kg/min OR Target is SBP <120 •Alternatively, use Labetalol as single-agent therapy. 5-20 mg bolus 20-40 mg q10-15 min
Immediate Action Items: Increased Intracranial Pressure	2.Mannitol 1gm/kg, followed by 0.25gm/kg q6 H (hold for serum osmolality >320) 3.Hypertonic saline 3% 250ml bolus
First 15 Minutes: AMS, tx for menigitisw	Get LP & Treat For Menigitis: •Dexamethasone 10 mg IV •Rocephine 2 gm IV •Vancomycin 1 gm IV •Acyclovir 10 mg/kg IV •Consider Flumazenil 0.2 mg IV q1 min, only for known ingestion
NAC treatment for APAP tox	NAC: PO or IV PO: 140mg/kg, then 70mg/kg q4h x17 doses IV: 150mg/kg IV over 30min, then 50mg/kg over 4h followed by 100mg/kg over 16h Stop when APAP <10ug/ml and normal LFTs and INR
ASA tox dose	Acute Toxic Dose: single ingestion of >150mg/kg •150-300 mg/kg – Mild •300-500 mg/kg – Moderate •>500 mg/kg – Likely Fatal
ASA tox indications for dialysis	Level >100mg/dL in acute intoxication •Level >50mg/dL in chronic intoxication
TCA tox tx.	Treatment (Based on QRS >100msec): 1.Consider 1 dose activated charcoal 1g/kg if mental status 2.NaHCO3: (dysrhythmias or hypotension): 1-2 amps IV push (1mEq/kg for peds) pH goals: 7.45-7.55 3.Pressors: Dopamine or norepi for refractory ↓ BP 4.Treat altered mental status with early elective intubation, as acidosis worsens the condition.
CO tox tx: Hyperbaric O2 indications:	Age >50yrs •COHgb >25% •Loss of consciousness •Syncope •Cerebellar or Focal Neuro Findings •Cardiovascular Depression or Ischemia •Metabolic Acidosis •Pregnancy
benzo tox tx	3.Flumazenil 0.2 mg IV over 30 sec, wait 3 min for response → 0.3 mg over 30 sec, wait 3 min → 0.5 mg over 30 sec then q1min to (max of 3 mg) → 0.5 mg q1 min (max of 5 mg)
anticholin tox pathophys	Inhibits acetylcholinesterase → ↓ destruction of acetylcholine
anticholin tox sx:	dumbbels diarrhea/diaphoresis, urination, miosis, bradycardia, bronchospasm, emesis, lacrimation, salivation
anticholin tox tx	atropine: Start with 1-2 mg and double q5 minutes 2-pam: 1-2gm in NS IV over 30min benzo for seizure
Antidotes: Lead	•BAL= Dimercaprol 4mg/kg IM q4h
Antidotes: Iron	•Deferoxamine: •1 gm IM
Antidotes: Toxic Alcohols	Ethylene Glycol or Methanol •EtOH gtt (Goal EtOH level is 100 mg/dL): •10% mixed in D5W •Load 7-10 mL/kg •Then maintenance at 1-1.5mL/kg/hr) •Fomepizole: •Load 15mg/kg •Then 10 mg/kg IV q12 x 4
BB tox tx	Glucagon: •2-5 mg IV q10 min •May require large doses, intubate early PRN.
Ca blocker tox tx	Goal is to drive Ca to 14 mg/dl. •Ca-gluconate 20-60 mL of 10% solution IV q15 min x 4 •CaCl2 (if central line) 10-20 mL of 10% solution q15 min x 4 •Consider IV infusion (0.5 meq/kg/hr) •Glucagon 2-5 mg IV •Insulin 0.1 – 10 U/kg/hr IV with D50 1-3 amps/hr or D5 or D10 to maintain euglycemia
cyanide tox tx	Hydroxocobalimine/Cyano-kit 5 gm
Antidotes: Methemaglobinemia	Methylene blue 1mg/kg IV of 1% solution •Reduces the iron from a 3+ state to a 2+ state. •Avoid in G6PD patients as it can cause hemolysis.
Toxidrome: Opiate Withdrawal	YAWNED Yawning Agitation Wet – Sweating Nausea/Vomiting/Diarrhea pilo-Erection Don’t sleep
Toxidrome: Ethanol Withdrawal	SSSSHHT Sweaty Sweaty Shakes - Tremors Seizures HTN Hallucinations Tachycardia
Toxidrome: TCA	Tachycardia Hypotension Widened-QRS Anti-Cholinergic Symptoms Seizures
Norepinephrine (doses and indications	Start 2-4 mcg/min (0.025 – 0.05 mcg/kg/min) •Indications: Distributive (septic), Obstructive, or Cardiogenic shock
Phenylephrine (doses and indications)	0.1 – 0.5 mg IV q 15 min
Epinephrine (doses and indications)	Start 2-4 mcg/min (0.025 – 0.05 mcg/kg/min) •Indications: Cardiac arrest, anaphylactic shock, severe bronchospasm or larygospasm
Vasopressin (doses and indications)	Start 0.1-0.4 U/min •Indications: As an adjuvant therapy with NE or dopamine in treatment of septic and other forms of shock
Nitroprusside (doses and indications)	Start 0.25-10 mcg/kg/min, and titrate to MAP •Indications: Acute afterload reduction in aortic dissection, acute decompensated CHF, renal failure, and other hypertensive emergencies
Nitroglycerin (doses and indications	Start 40-60mcg/min (0.5 – 0.75mcg/kg/min) and titrate to desired MAP •Indications: Acute decompensated CHF, unstable angina, or acute MI
Esmolol (doses and indications	0.5 mg/kg IV over 1 min •Then followed by 0.05 mg/kg/min gtt
Labetalol (doses and indications	Aortic Dissection: •5-20 mg bolus •Then up to 20-40 mg q10-15 min Hypertensive Emergencies: •Load 20 mg IV over 2 minutes every 10 minutes •Then 40-80 mg IV every 10 minutes to max of 300 mg OR •Drip at 1-2 mg/min
proprofol doseage	Induction •Peds: 2.5-3.5 mg/kg IV •<55 yo: 2-2.5 mg/kg IV •>55 yo: 1-1.5 mg/kg IV •Maintenance •Peds: 0.125-0.3 mg/kg/min IV •<55 yo: 0.1-0.2 mg/kg/min IV •>55 yo: 0.05-0.1 mg/kg/min IV
ketamine dosage	Induction •1-4.5 mg/kg IV •6.5-13 mg/kg IM •Sedation •1-2 mg/kg IV •Chronic Pain •0.1-0.4 mg/kg IV
versed doses and indications	•Induction: •0.3 mg/kg IV •Sedation of Intubated Patients: •0.1-0.5 mg/kg IV q10-15 min PRN
Succinylcholine (dose, onset & duration)	1.5 mg/kg IV 30-60 seconds 2-10 minutes
1 (0.6-1.2) mg/kg IV 1-2 minutes 30-60 minutes	Rocuronium (dose, onset & duration)
Vecuronium (dose, onset & duration)	0.1 mg/kg IV 3-5 minutes (unless premed) 20-35 minutes
Morphine (doses and indications	Sedation of Intubated Patient: •0.1 mg/kg IV •Pain Control •Adults: 0.05-0.1 mg/kg IV load then 0.8-10 per hr IV (↓ dose for elderly)
Fentanyl (doses and indications)	Sedation of Intubated Patient: •1 mcg/kg IV •Sedation of Intubated Patient: •1 mcg/kg IV •Pain Control •Adults: 50-100 mcg/kg q 1-2 hrsPain Control •Adults: 50-100 mcg/kg q 1-2 hrs
Ativan (doses and indications)	•Sedation of Intubated Patient: •0.05 (0.02-0.06) mg/kg IV q6° PRN •Status Epilepticus •Adult: 4 mg IV •Peds: 0.05-0.1 mg/kg IV
Precedex (doses and indications)	•Sedation of Intubated Patient: •Load 1 mcg/kg IV •Maintiance 0.2-0.7 mcg/kg/hr IV
RSI Premedications	LOAD Lidocaine 1.5mg/kg IV Opioid =Fentanyl 3mcg/kg IV Atropine (Peds or rebolus sux): 0.02mg/kg IV Defasiculating medications: 10% dose Rocuronium 0.1mg/kg Vecuronium 0.01mg/kg Sux 0.15mg/kg IV
There are 3 key fractures: to see on shoulder dislocation	Hill-Sachs lesion → humeral head is damaged by the sharp anterior rim of the glenoid. 2. Bankart fracture → a fracture of the inferior glenoid rim from impaction of the dislocated humeral head. 3. The most common is a fracture of the greater tuberosity of the humerus.
types of shoulder reduction	stimson traction-countertraction scapular rotation external rotation
types of posterior elbow reduction	traditional traction method minford and beattie (186)
transvaginal ultrasound goal	Transvaginal 1.Find cornual flare (uterus-fallopian tube junction), ovaries are lateral. 2.Scan left to right. 3.Transverse- same orientation as CT scan 4.Longitudinal- scan left to right 5.Empty bladder helps
gestational age and US works to see	4: gest sac: 1500 HCG 5: yolk sac 6: fetal pole
aorta and iliac diameters	STANDARD FINDINGS – Measure from outer wall to outer wall. To include luminal clot. PATHOLOGY 1.Aorta >3 cm 2.Iliac Arteries >1.5 cm 3.Abdominal Free Fluid
SIRS criteria	SIRS Criteria: • Temp >38.3 or <36 • HR >90 • RR >20 or PaCO2 <32 • WBC >12,000 or <4000 or >10% bands
types of sepsis	SIRS Criteria: • Temp >38.3 or <36 • HR >90 • RR >20 or PaCO2 <32 • WBC >12,000 or <4000 or >10% bands Sepsis: SIRS and a presumed or documented focus of infection Severe Sepsis: Sepsis complicated by organ dysfunction, hypotension before fluid challenge, or lactate ‚4 mmol/L Septic Shock: Sepsis with persistent hypotension, despite 2-3 L of fluid IV, this is where Early Goal Directed Therapy is best.
correct for serum sodium in hyperglycemia	Serum Sodium Correction: Add 1.6 mEq/L Na+ for each 100 mg/dL Glucose >100
Discuss the management of difficult vaginal delivery due to shoulder dystocia:	HELP: Call for OB, peds, anesthesia 2.Episiotomy: Cut large episiotomy 3.Lithotomy position: McRobert’s maneuver 4.Pressure over the suprapubic area 5.Enter the vagina 6.Rubin’s maneuver: push most accessible shoulder toward fetal chest 7.Wood’s maneuver: Grasp axilla or fetal hips and corkscrew fetus to rotate shoulder under symphysis pubis 8.Remove posterior arm: 9.Splint, sweep, grasp, and pull arm to extension through the vagina across the face
Discuss the management of difficult vaginal delivery due to breech presentation:	Breech: 1.Generous episiotomy 2.Knee flexion and sweep out legs 3.Pull out 10-15cm of umbilical cord after umbilicus clears the perineum (allows for more room to work) 4.Support the infant by the bony pelvis 5.Keep face and abdomen away from the symphysis pubis, and rotate if necessary to deliver the most accessible arm 6.Mauriceau maneuver: insert fingers into the fetal mouth to flex the neck and draw in the chin. This avoids fetal head extension which can cause spinal cord injuries.
Discuss the management of difficult vaginal delivery due to multiple gestation:	Multiple Gestation: 1.Determine the lie of each twin. 2.Twin A is non-vertex or breech – C section for both. 3.Twin A is vertex and twin B is non-vertex - manipulate the 2nd twin to vertex. 4.If twin B not come within minutes of twin A, then assess twin B with ultrasound to determine presentation and cardiotocographic monitoring.
neonatal resuscitation	review
Discuss the indications and tools needed for newborn intubation:	Meconium suctioning in NON-vigorous baby 2. Diaphragmatic hernia 3. Prolonged PPV Laryngoscope Sizes: Blade Age No. 1 Full Term No. 0 Preterm No. 00 Extreme Preterm Newborn Intubation: Tube Weight Age 2.5 mm <1 kg <28 wks 3.0 mm 1-2 kg 28-34 wk 3.5 mm 2-3 kg 35-38 wk 4.0 mm >3 kg >38 wks
neonate fever organism to consider	Organsims to consider → GBS, Listeria, E. Coli
neonate fever abx	Emperic Antibiotics: •Amp 25 mg/kg IV plus either •Gent 2.5 mg/kg or Cefotaxime 50 mg/kg IV •Add Vancomycin if NICU baby •Acyclovir 20 mg/kg if risks exist
Describe the evaluation of a fever in a infant 1-3 months of age:	29-90 Days: (Fever is >38.0°C or >100.4°F) •Septic workup → CBC, UA, Urine, Blood, (LP optional, but must perform if antibiotics will be given) •Emperic Antibiotics: •Amp 25 mg/kg IV plus either •Ceftriaxone 100 mg/kg IV (Meningitis dosing) •Add Vancomycin if GBS resistance is common •If toxic or positive findings on septic workup → Emperic Amtobiotics & Admission •If non-toxic and negative septic workup → 24 hour outpatient follow up with ±IM Ceftriaxone
Indications for Thoracotomy:	Operating Room: Initial chest tube output of >1500 ml Chest tube output > 200 mL/hr x 6 hr Hemopericardium with vital signs Severe tracheobronchial injury
Hard Signs of vascular injury (need immediate OR)	Hard Signs of vascular injury (need immediate OR) •Neurological deficit •Shock •Pulsatile bleeding •Expanding hematoma +/- airway compromise •Bruits or thrills •Loss or diminished distal pulse •Hemothorax
penetrating neck zones	Zone 3: above angle of mandible Zone 2: cricoid to angle of mandible Zone 1: base of neck to cricoid
intervention per zones	Zone 3: •Aniography is procedure of choice to rule out vascular injury, both diagnostic and therapeutic. •Zone 2: •Platysma violated go to the OR for exploration. •Otherwise, color-flow Doppler, positive take to OR or angiography. •CT scan of neck if clinically stable and airway secured with ETT. •Zone 1: •Angiography &/or Doppler to r/ocarotid injury •Direct laryngoscopy to rule out tracheal or laryngeal injuries (soft tissue neck or CT scan if stable and airway already secured with ETT) •Esophagram with gastrograffin (1st) followed by barium if negative, or CT scan of chest (equally sensitive) •Esophagoscopy (rigid) for any concerns of upper esophageal injury.
Retropharyngeal space:	Retropharyngeal space: •7mm at C2  •22mm at C7
Atlanto-Dens Space:	Atlanto-Dens Space: •3mm adult, 5mm child
Describe the common C-spine injury patterns (6 items) and neurological exam findings of a C-spine injury (4 items):	Clay shoveler’s fx = lower spinous process fx •Hangman’s fx = spondylolisthesis C2/C3 •Flexion teardrop fx = ant/inf VB fx •Extension teardrop fx = Avulsion C2 •Jefferson burst fx = C1 arch fx •Hyperextension injury = no fx, soft tissue edema only Common Neurological Exam Findings: •C4 Neck/spontaneous breathing •C5 Shoulder and arm/shrug shoulders •C6 Thumb/elbow flexion •C7 Third digit/elbow extension
In the lateral ankle view below name the bones and describe how to find and use Bohler’s angle:	Bohler’s angle range: 25°-40° Suspect fracture if <25° Obtain CT at that point
In the AP mortis ankle view below name the bones and describe the anatomic relationships:	Tibiofibular Clear Space <5 mm Tibio-Fibular Overlap ≥10 mm Lateral Malleolar Fractures below the tibiotalar joint (Weber A) usually only require casting & follow up. Above it should have Ortho consult.
For which ankle fractures is orthopedic consultation in the ED recommended?	unimalleolar fx with displacement and/or ligament rupture All bimalleolar fractures All trimalleolar fractures All intra-articular fractures with step deformity All open fractures All pilon (comminuted fracture of the distal tibia) fractures
lis franc fx	Dx Lis Franc Injury: 1)Plantar bruises in area. 2)>1 mm between 1st & 2nd metatarsal heads 3)Avulsion fx at the base of the 2nd metatarsal on the medial side.
jones fx	5th metatarsal fx distal to the joint between the proximal 4th & 5th metatarsals (i.e. Jones fx) needs to be non weight bearing with ortho f/u in ~2 days for surgical eval
elbow fx xr	1. Hourglass Sign/Figure Of 8 2. Anterior Fat Pad (Sail Sign) •Sail Sign + Trauma = Intraarticular Fracture. •No Trauma = Inflammatory Intraarticular Fluid 3. Posterior Fat Pad – always abnl, implies fx 4. Anterior Humeral Line – middle ⅓ of capitellum 5. Radio-capitellar Line – middle ⅓ of capitellum 6. Inspection Of The Radial Head 7. Distal Humerus Examination 8. Olecranon & Ulnar Examination
Describe the types of supracondylar elbow fractures and which need surgery:	Classification: •Type I: non-displaced frx; splint with follow up 24°-48°, do the same for tenderness without discernable fracture. •Type II: displaced with intact posterior cortex, may need surgery •Type III: displaced with no cortical contact, in ED ortho consult , likely surgical
bones in the wrist	S Scaphoid L Lunate Tq Triquetrum P Pisiform Tm Trapezium Tz Trapezoid C Capitate H Hamate
ECG intervals	Intervals •PR 120-200ms (3-5 sm box) •QRS < 120ms (3 sm box) •QTc prolonged >450 ♂, >470
•Low voltage criteria on ecg	Amplitude of QRS: <5mm (1large box) in all limb leads OR <10mm in all precordial leads
LBBB criteria on ECG	Broad, monomorphic S waves in V1. Broad, monomorphic R waves in I and V6, with no Q waves.
RBBB criteria on ECG	QRS wide (≥ 0.12 sec) •If all criteria are met except QRS <0.12 then incomplete RBBB •rSR’ in V1 or wide R wave or a qR pattern •Bunny ear pattern. •Wide, slurred S wave in lateral leads (I, aVL, V5, V6)
1st degree av block	PR > 0.20 sec
QRS wide (≥ 0.12 sec) •If all criteria are met except QRS <0.12 then incomplete RBBB •rSR’ in V1 or wide R wave or a qR pattern •Bunny ear pattern. •Wide, slurred S wave in lateral leads (I, aVL, V5, V6)	This continues until on of the P waves reaches the node at a point when it is will not conduct the impulse so it drops a beat.
Second-Degree (Mobitz II) Heart Block	In it the PR interval remains constant, but there are still intermittent dropped QRS complexes.

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