Internal Medicine EOR: Critical Care (Smarty PANCE)

What is acute abdomen?

Sudden onset severe abdominal pain requiring urgent evaluation to determine need for surgical intervention

What are the classic signs of peritonitis in acute abdomen?

Rigidity (guarding), rebound tenderness, absent bowel sounds, pain with movement/percussion

What imaging is first-line for acute abdomen evaluation?

CT abdomen/pelvis with IV contrast (most sensitive for most causes); upright CXR if perforation suspected

What are the most common surgical causes of acute abdomen?

Appendicitis, cholecystitis, bowel obstruction, perforated viscus, ruptured AAA, ectopic pregnancy

What is the classic presentation of ruptured AAA?

Pulsatile abdominal mass, hypotension, severe tearing abdominal/back pain (triad) - surgical emergency

What lab findings suggest mesenteric ischemia?

Elevated lactate, leukocytosis, metabolic acidosis - pain out of proportion to exam findings

What is the initial management of acute abdomen?

NPO, IV fluids, analgesia (does NOT mask surgical findings), antibiotics if infection suspected, surgical consultation

What findings mandate immediate surgical consultation?

Free air on imaging, peritonitis, hemodynamic instability, ruptured AAA, unstable ectopic pregnancy

What is acute adrenal insufficiency (adrenal crisis)?

Life-threatening condition due to sudden cortisol deficiency causing hypotension, shock, and electrolyte abnormalities

What are the classic triggers for adrenal crisis?

Abrupt steroid withdrawal, infection/sepsis, surgery/trauma, adrenal hemorrhage, in patients with known or undiagnosed adrenal insufficiency

What are the classic laboratory findings in adrenal crisis?

Hyponatremia, hyperkalemia, hypoglycemia, elevated BUN/creatinine, metabolic acidosis

What is the classic presentation of adrenal crisis?

Hypotension refractory to fluids, abdominal pain, nausea/vomiting, weakness, altered mental status, fever

What is the immediate treatment for adrenal crisis?

Hydrocortisone 100mg IV bolus, then 50-100mg IV Q6-8H, aggressive IV fluid resuscitation (0.9% saline)

Should you wait for lab confirmation before treating adrenal crisis?

NO - treat immediately if suspected, draw cortisol and ACTH before first dose but do NOT delay treatment

What is the long-term prevention after adrenal crisis?

Stress dose steroids for illness/surgery, medical alert bracelet, patient education on doubling/tripling home dose when sick

What defines upper vs lower GI bleed?

Upper GI bleed: proximal to ligament of Treitz; Lower GI bleed: distal to ligament of Treitz

What are the most common causes of upper GI bleed?

Peptic ulcer disease (most common 50%), esophageal varices, Mallory-Weiss tear, gastritis/erosions

What are the most common causes of lower GI bleed?

Diverticulosis (most common), angiodysplasia, colorectal cancer, hemorrhoids, ischemic colitis

What is the initial management of acute GI bleed?

Two large-bore IVs, aggressive fluid resuscitation, type and crossmatch, correct coagulopathy, NPO status

What hemoglobin transfusion threshold is recommended in GI bleed?

Transfuse at Hgb <7 g/dL in stable patients; <8-9 g/dL in patients with cardiovascular disease

What medication should be given for suspected upper GI bleed?

IV proton pump inhibitor (pantoprazole 80mg bolus then 8mg/hr infusion) - reduces rebleeding

What is the definitive management for variceal bleeding?

Octreotide infusion, IV PPI, urgent endoscopy with band ligation, antibiotics (ceftriaxone), consider TIPS if refractory

What physical exam finding suggests variceal bleed?

Stigmata of chronic liver disease: ascites, spider angiomas, palmar erythema, jaundice, splenomegaly

What scoring system predicts need for intervention in upper GI bleed?

Glasgow-Blatchford Score (GBS) - score of 0-1 may allow outpatient management

What is acute angle-closure glaucoma?

Ophthalmologic emergency caused by sudden obstruction of aqueous humor outflow leading to rapidly elevated intraocular pressure

What is the classic triad of acute glaucoma?

Severe eye pain, blurred vision with halos around lights, headache/nausea/vomiting

What are the classic physical exam findings in acute glaucoma?

Mid-dilated non-reactive pupil, hazy/cloudy cornea, conjunctival injection, rock-hard eye on palpation

What is the normal intraocular pressure and what defines acute glaucoma?

Normal IOP: 10-21 mmHg; Acute glaucoma: IOP typically >30-40 mmHg (can exceed 60-80 mmHg)

What medications can precipitate acute angle-closure glaucoma?

Anticholinergics, antihistamines, decongestants, tricyclic antidepressants - anything causing pupillary dilation

What is the immediate medical treatment for acute glaucoma?

Topical beta-blocker (timolol), topical alpha-agonist (apraclonidine), topical pilocarpine, IV acetazolamide, IV mannitol

What is the definitive treatment for acute glaucoma?

Laser peripheral iridotomy - creates opening for aqueous humor drainage

What is ARDS?

Acute respiratory distress syndrome - diffuse inflammatory lung injury causing non-cardiogenic pulmonary edema and severe hypoxemia

What are the Berlin criteria for ARDS?

Acute onset (<1 week), bilateral infiltrates, PaO2/FiO2 ratio <300, not fully explained by heart failure

What is the severity classification of ARDS by P/F ratio?

Mild: 200-300, Moderate: 100-200, Severe: <100 (P/F ratio = PaO2/FiO2 x 100)

What are the most common causes of ARDS?

Sepsis (most common), pneumonia, aspiration, trauma, pancreatitis, massive transfusion

What is the cornerstone of ARDS management?

Lung-protective ventilation: low tidal volume (6 mL/kg ideal body weight), plateau pressure <30 cmH2O

What is the target oxygen saturation in ARDS?

88-95% (permissive hypoxemia acceptable to avoid ventilator-induced lung injury)

When should prone positioning be used in ARDS?

Severe ARDS (P/F ratio <150) - improves oxygenation and mortality

What is acute respiratory failure?

Inability to maintain adequate gas exchange - Type 1 (hypoxemic) or Type 2 (hypercapnic)

What defines Type 1 vs Type 2 respiratory failure?

Type 1: PaO2 <60 mmHg (hypoxemic); Type 2: PaCO2 >50 mmHg (hypercapnic)

What is unstable angina?

Acute coronary syndrome with chest pain at rest or with minimal exertion, no biomarker elevation, ST changes possible

What is the classic presentation of angina pectoris?

Substernal chest pressure/heaviness, radiating to left arm/jaw, triggered by exertion, relieved by rest or nitroglycerin (within 5 min)

What ECG changes are seen in demand ischemia/stable angina?

ST depressions, T wave inversions during pain (resolve with rest) - NO ST elevations, NO Q waves

What is the immediate treatment for acute angina?

Aspirin 324mg chewable, nitroglycerin 0.4mg SL Q5min x3, oxygen if hypoxic, morphine for pain

What is the HEART score used for?

Risk stratification in chest pain - predicts 6-week major adverse cardiac events (score 0-10)

What medications are used for long-term angina management?

Antiplatelet (aspirin), beta-blocker, statin, ACE inhibitor if indicated, long-acting nitrates or CCB

What are the reversible causes of cardiac arrest? Use mnemonic Hs and Ts

Hs: Hypovolemia, Hypoxia, H+ (acidosis), Hypo/hyperkalemia, Hypothermia; Ts: Tension pneumothorax, Tamponade, Toxins, Thrombosis (coronary/pulmonary)

What is the initial management sequence for cardiac arrest?

Call for help, start high-quality CPR immediately, attach defibrillator/monitor, identify rhythm

What are shockable vs non-shockable cardiac arrest rhythms?

Shockable: ventricular fibrillation (VF), pulseless ventricular tachycardia (pVT); Non-shockable: asystole, pulseless electrical activity (PEA)

What is high-quality CPR?

Compression rate 100-120/min, depth 2-2.4 inches, full recoil, minimize interruptions (<10 sec), switch compressors Q2min

What is the defibrillation energy for VF/pVT?

Biphasic: 120-200J initially, same or higher for subsequent shocks; Monophasic: 360J for all shocks

What medications are given during cardiac arrest and when?

Epinephrine 1mg IV Q3-5min (after 2nd shock in shockable, immediately in non-shockable); Amiodarone 300mg after 3rd shock

What is the post-cardiac arrest care bundle?

Targeted temperature management (32-36°C for 24hr), avoid hypotension (MAP >65), PCI if STEMI, avoid hyperoxia/hypoxia

What is the most common cause of sustained VT?

Prior myocardial infarction with scar tissue (structural heart disease) - creates reentry circuit

What is the emergency treatment for unstable VT with pulse?

Immediate synchronized cardioversion - 100J biphasic initially, increase if needed

What is the treatment for stable monomorphic VT?

Amiodarone 150mg IV over 10min, then 1mg/min x6hr, then 0.5mg/min; or procainamide; or cardioversion

What defines torsades de pointes and its treatment?

Polymorphic VT with prolonged QT interval - treat with magnesium sulfate 2g IV, correct electrolytes, increase heart rate

What is the acute treatment for atrial fibrillation with RVR?

Rate control: beta-blocker (metoprolol) or calcium channel blocker (diltiazem); cardioversion if unstable

What are the indications for immediate cardioversion in arrhythmias?

Hemodynamic instability (hypotension, chest pain, altered mental status, signs of shock) with any tachyarrhythmia

What is the rule for AV blocks requiring pacing?

Symptomatic bradycardia unresponsive to atropine, Mobitz II, third-degree (complete) heart block - need temporary pacing

What ECG finding distinguishes Mobitz I from Mobitz II?

Mobitz I (Wenckebach): progressive PR prolongation until dropped QRS; Mobitz II: constant PR with sudden dropped QRS

What is third-degree (complete) heart block?

Complete AV dissociation - atria and ventricles beat independently, requires pacemaker

What is acute decompensated heart failure?

Rapid onset or worsening of heart failure symptoms requiring urgent therapy

What are the two presentations of acute heart failure?

"Wet and warm" (volume overload, adequate perfusion) vs "Wet and cold" (volume overload with poor perfusion/shock)

What is the first-line treatment for acute pulmonary edema?

Oxygen, nitroglycerin (sublingual then IV), IV diuretics (furosemide 40-80mg IV), upright positioning

What medication should be avoided in acute pulmonary edema?

Morphine - associated with increased mortality in recent studies

What are the indications for non-invasive positive pressure ventilation in CHF?

Respiratory distress despite initial therapy, hypoxemia, work of breathing - use BiPAP or CPAP

When should inotropic support be considered in heart failure?

"Cold and wet" presentation with hypoperfusion despite diuretics - consider dobutamine or milrinone

What is cardiac tamponade?

Accumulation of pericardial fluid causing compression of cardiac chambers and impaired diastolic filling

What is Beck's triad of cardiac tamponade?

Hypotension, jugular venous distension (JVD), muffled heart sounds - classic but present in only 30% of cases

What is pulsus paradoxus and its significance?

Drop in systolic BP >10 mmHg during inspiration - sensitive sign of tamponade

What ECG finding suggests cardiac tamponade?

Low voltage QRS complexes, electrical alternans (beat-to-beat variation in QRS amplitude)

What is the diagnostic test of choice for cardiac tamponade?

Echocardiography - shows pericardial effusion with RA/RV diastolic collapse

What is the definitive treatment for cardiac tamponade?

Emergent pericardiocentesis - drainage of pericardial fluid

What is the immediate temporizing measure for tamponade?

Aggressive IV fluid bolus to increase preload while preparing for pericardiocentesis

What is coma?

State of prolonged unconsciousness with unarousable unresponsiveness - Glasgow Coma Scale ≤8

What are the most common causes of coma? Use mnemonic AEIOU TIPS

Alcohol, Epilepsy/Endocrine, Insulin, Overdose/Oxygen, Uremia, Trauma, Infection, Psychogenic, Stroke/Shock

What is the initial assessment approach to coma?

ABCs, check glucose immediately, assess pupils/brainstem reflexes, GCS score, identify reversible causes

What pupillary findings help determine coma etiology?

Pinpoint pupils (opioid overdose), unilateral dilated (herniation), mid-position fixed (brainstem lesion)

What is the emergency management of coma with unknown cause?

Thiamine 100mg IV (before glucose), Dextrose 50% 1 amp (D50) IV if hypoglycemic, Naloxone 0.4-2mg IV if opioid suspected

What imaging is essential in coma evaluation?

Non-contrast head CT immediately to rule out hemorrhage, mass effect, herniation

What is Cushing's triad and its significance?

Hypertension, bradycardia, irregular respirations - sign of increased intracranial pressure/herniation

What is diabetic ketoacidosis (DKA)?

Hyperglycemic crisis with ketoacidosis due to absolute insulin deficiency - glucose >250, pH <7.3, ketones present

What are the classic symptoms of DKA?

Polyuria, polydipsia, nausea/vomiting, abdominal pain, Kussmaul respirations (deep rapid breathing), fruity breath odor

What is the diagnostic triad of DKA?

Hyperglycemia (>250 mg/dL), anion gap metabolic acidosis (pH <7.3), ketonemia/ketonuria

What are the precipitating factors for DKA?

Infection (most common), insulin noncompliance, new-onset diabetes, MI, pancreatitis (5 I's: Infection, Insulin, Infarction, Intoxication, Inflammation)

What is the initial fluid management in DKA?

0.9% normal saline 1-2L bolus initially, then 250-500 mL/hr; switch to D5 0.45% NS when glucose <250 mg/dL

What is the insulin protocol for DKA?

Regular insulin 0.1 units/kg IV bolus, then 0.1 units/kg/hr continuous infusion; decrease rate when glucose <250

What electrolyte must be corrected before starting insulin?

Potassium - if K+ <3.3 mEq/L, hold insulin and replace potassium first (prevents life-threatening hypokalemia)

What is the most common cause of death in DKA?

Hypokalemia (from insulin therapy) and cerebral edema (in children) - monitor K+ closely

What defines resolution of DKA?

Glucose <200 mg/dL, anion gap <12, pH >7.3, bicarbonate >18 mEq/L

What is severe hypoglycemia?

Blood glucose <54 mg/dL (3.0 mmol/L) with altered mental status or requiring assistance

What is the treatment for severe hypoglycemia in unconscious patient?

Dextrose 50% (D50) 25-50mL (12.5-25g) IV push OR Glucagon 1mg IM/SC if no IV access

What is hypertensive crisis?

Severe elevation in BP (>180/120 mmHg) with or without end-organ damage

What distinguishes hypertensive emergency from urgency?

Emergency: elevated BP WITH acute end-organ damage; Urgency: elevated BP WITHOUT end-organ damage

What are the target organs affected in hypertensive emergency?

Brain (encephalopathy, stroke), Heart (MI, acute heart failure), Kidneys (acute kidney injury), Eyes (papilledema), Aorta (dissection)

What is the initial BP reduction goal in hypertensive emergency?

Reduce MAP by 10-20% in first hour, then to 160/100 mmHg over next 2-6 hours - avoid rapid drops

What IV medications are used for hypertensive emergency?

Nicardipine, labetalol, clevidipine, nitroprusside (avoid in pregnancy), esmolol, fenoldapine

What is the exception to gradual BP reduction in hypertensive emergency?

Aortic dissection - reduce SBP to <120 mmHg within 20 minutes with beta-blocker + vasodilator

How is hypertensive urgency managed?

Oral antihypertensives (resume home meds or start new agents), reduce BP over 24-48 hours, outpatient follow-up