Emergency Department Study Guide

What is SVT?

SVT is a fast heart rhythm origination above the ventricles; HR >150

What’s the initial treatment to stabilize SVT?

Vagal maneuvers (bearing down, blowing through a straw) is used as the initial treatment to stabilize SVT

What is the medication of choice for SVT?

Adenosine is the medication of choice for the acute termination of SVT (6mg IVP —> followed by a second dose of 12mg if necessary) + crash cart ready

(temporarily blocks conduction through the AV node)

What are the 3 key symptoms of a STEMI (ST-Elevation Myocardial Infarction)?

The three key symptoms of a STEMI are:

1) chest pain or discomfort

2) shortness of breath

3) radiating chest pain to jaw, neck, or arm pain.

What is the first priority upon arrival for a STEMI (ST-Elevation Myocardial Infarction) patient?

12-Lead EKG within 10 minutes is the first priority upon arrival of a STEMI patient

What are the interventions for a STEMI (ST-Elevation Myocardial Infarction) patient?

MONA: Morphine, Oxygen, Nitrates, Aspirin

+

Notify MD for cath lab

What is the first screening tool for CVA (Stroke) patients?

The first screening tool for CVA (Stroke) patients is the National Institutes of Health Stroke Scale (NIHSS), which assesses the severity of stroke symptoms

FAST: face drooping, arm weakness, speech changes, & time

What is the priority intervention for a CVA (Stroke) patient?

STAT non-contrast head CT to rule out bleed

is the priority intervention for a CVA (Stroke) patient

What is the treatment for ischemic stroke & within what timeframe?

The treatment for ischemic stroke is

tPA within 3-4.5 hours from symptom onset

What are the sepsis criteria?

The sepsis criteria include symptoms such as

1) suspected infection: fever, ↑heart rate, ↑respiratory rate, ↓blood pressure, & altered mental status

&

2) 2+ SIRS signs: T>38.3C or <36C, HR>90, RR>22, WBC↑/↓

What is included in the sepsis bundle when considering first interventions?

1) Lactate levels

2) Blood cultures

3) IV Broad-Spectrum Antibiotics

4) IV Fluids (30mL/kg)

5) Vasopressors if MAP<65 after fluids

What are the 4 red flag signs for sepsis?

1) Hypotension

2) Altered LOC

3) Mottled skin (bluish-red, lace-like pattern under the skin)

4) Oliguria (low urine output)

What’s your priority for a pregnant patient with abdominal pain or bleeding?

The first priority for a pregnant patient with abdominal pain or bleeding is to

assume it’s ectopic until ruled out… then get:

1) LMP (last menstrual period)

2) Rh (Rhesus factor)

3) hCG (Human Chorionic Gonadotropin)

3) FHT (Fetal Heart Tones)

What position is the safest to keep the patient on during OB Emergencies? Why?

The safest position for OB emergencies is the Left Lateral because it avoids vena cava compression

How is Emergency Severity Index (ESI) Triage Level 1 (ESI-1) described?

Immediate life-saving intervention

How is Emergency Severity Index (ESI) Triage Level 2 (ESI-2) described?

High risk, confused/lethargic/disoriented, or severe pain/distress

How is Emergency Severity Index (ESI) Triage Level 5 (ESI-3) described?

Needs multiple resources, but stable

How is Emergency Severity Index (ESI) Triage Level 4 (ESI-4) described?

Needs one resource

How is Emergency Severity Index (ESI) Triage Level 5 (ESI-5) described?

Needs no resources

On the Emergency Severity Index (ESI) Triage Level, what level is this condition: Code Blue?

ESI-1

On the Emergency Severity Index (ESI) Triage Level, what level is this condition: Severe Respiratory Distress?

ESI-1

On the Emergency Severity Index (ESI) Triage Level, what level is this condition: Chest Pain?

ESI-2

On the Emergency Severity Index (ESI) Triage Level, what level is this condition: Stroke?

ESI-2

On the Emergency Severity Index (ESI) Triage Level, what level is this condition: Suicidal?

ESI-2

On the Emergency Severity Index (ESI) Triage Level, what level is this condition: Abdominal pain needing labs?

ESI-3

On the Emergency Severity Index (ESI) Triage Level, what level is this condition: CT, labs, imaging?

ESI-3

On the Emergency Severity Index (ESI) Triage Level, what level is this condition: Simple Fracture?

ESI-4

On the Emergency Severity Index (ESI) Triage Level, what level is this condition: Laceration?

ESI-4

On the Emergency Severity Index (ESI) Triage Level, what level is this condition: Medication Refill?

ESI-5

On the Emergency Severity Index (ESI) Triage Level, what level is this condition: Suture removal?

ESI-5

What does Emergency Severity Index (ESI) Triage Level 1 signify?

Dying

What does Emergency Severity Index (ESI) Triage Level 2 signify?

Shouldn’t wait

What does Emergency Severity Index (ESI) Triage Level 3 signify?

Needs tests

What does Emergency Severity Index (ESI) Triage Levels 4-5 signify?

Simple

What is the pathophysiology of STEMI (ST-Elevation MI)?

Complete coronary artery occlusion

—> ↓perfusion to myocardium

—> myocardial death (if untreated)

Clinical Scenario:

A 58-year old male presents with chest pain radiating to jaw, diaphoretic, BP 160/90

What do you do in order? What do you expect the diagnosis to be?

1) Apply O2 is SpO2 <90%

2) Get EKG within 10 minutes

3) Place IV, draw labs (troponin, CBC, CMP, PT/INR)

4) Administer MONA

5) Notify MD for cath lab activation

6) Monitor rhythm for VT/VF

= STEMI patient

What are the critical meds for STEMI? (5 meds)

1) Aspirin 325mg: antiplatelet, chewable for faster absorption

2) Nitroglycerin: vasodilator (watch BP!)

3) Morphine: pain & vasodilation (use after nitro)

4) Heparin or anticoagulants: prevents clot propagation

5) Beta-blockers: ↓myocardial oxygen demand (if no contraindications)

What is the pathophysiology of CVA (stroke)?

Ischemic (blockage) vs hemorrhagic (bleed)

—> ↓brain perfusion

—> rapid neuro changes

What are the critical meds for CVA (stroke)? (3 meds)

1) tPA (alteplase): clot buster (ischemic stroke only; time-sensitive!)

2) Labetalol or Nicardipine: for BP control

3) Antiplatelets/anticoagulants: only after CT confirms no bleed

Clinical Scenario:

A 72-year old female with slurred speech, right arm weakness, & facial droop comes in. Last seen normal 1 hour ago.

What do you do in order? What do you expect the diagnosis to be?

1) Active Stroke Code

2) NIH Stroke Scale + Full Neuro Exam

3) CT non-contrast head STAT

4) Establish last known well time

5) If ischemic & within 3-4.5 hrs —> prep for tPA

6) Monitor BP, neuro, & signs of bleeding

= CVA (stroke) patient

What is the pathophysiology of sepsis?

Systemic infection

—> inflammatory response

—> vasodilation + capillary leak

—> hypotension & organ dysfunction

What are the critical meds for CVA (stroke)? (4 meds)

1) Broad-spectrum antibiotics (e.g. ceftriaxone, zosyn): IV within 1 hour

2) IV fluids: 30 mL/kg of NS or LR

3) Vasopressors (norepinephrine): if fluids fail to raise MAP > 65

4) Acetaminophen: for fever

Clinical Scenario:

An 85-year-old with UTI symptoms, confusion, hypotension (BP 85/40), & fever comes in.

What do you do in order? What do you expect the diagnosis to be?

1) Assess vitals & LOC

2) Lactate, blood cultures, & urinalysis

3) Start IV fluids + antibiotics

4) Place foley, monitor UOP

5) Start norepinephrine drip (if hypotension persists)

6) Watch for MODS (Multiple Organ Dysfunction Syndrome)

What is the pathophysiology of SVT?

Re-entry electrical circuit in atria

—> rapid HR

—> ↓cardiac output if prolonged

What are the critical meds for SVT? (3 meds)

1) Adenosine: causes transient AV node block (6mg, then 12mg)

2) Beta-blockers or Ca-channel blockers (if recurrent SVT)

3) Cardioversion: if unstable

Clinical Scenario:

A 24-year-old female with palpitations, HR 180, alert, BP 110/72

What do you do in order? What do you expect the diagnosis to be?

1) Apply O2

2) Attempt vagal maneuvers (bear down, blow intro syringe)

3) Prepare for adenosine push

4) Educate patient on transient side effects of Adenosine (flushing, chest pressure)

5) Monitor rhythm post-intervention

= SVT patient

What is the pathophysiology of Gunshot Wound?

High/low velocity trauma

—> tissue disruption, internal bleeding, & infection risk

What are the critical meds for Gunshot Wound? (3 meds)

1) IV fluids: for hypotension

2) Blood products: if hemorrhagic shock

3) Antibiotics: broad-spectrum to prevent infection

4) Tetanus prophylaxis: if outdated or unknown status

5) Analgesia (e.g. morphine): for pain

Clinical Scenario:

A 30-year-old male GSW to abdomen. BP 90/60, HR 125, pale, guarding abdomen.

What do you do in order?

1) ABC assessment

2) Apply O2, place 2 large-bore IVs

3) Initiate massive transfusion protocol (MTP)

4) Draw labs: type & screen, CBC, CMP, & coags

5) Apply pressure if external bleed

6) Notify trauma team, prep for OR

7) DO NOT remove impaled object

(ALWAYS consider internal bleeding even if external bleeding is minimal)

What is the pathophysiology of OB Emergency?

Ectopic pregnancy, placental abruption, miscarriage

—> life-threatening bleeding

What are the critical meds for OB Emergency? (4 meds)

1) Rhogam if Rh-

2) Misoprostol or oxytocin for incomplete miscarriage

3) IV fluids for volume support

4) Pain meds

Clinical Scenario:

A 28-year-old, 9 weeks pregnant, vaginal bleeding, severe lower abdominal pain

What do you do in order?

1) Place in left lateral

2) Ask for LMP, Rh status, & pregnancy history

3) Obtain quant hCG, CBC, type & screen

4) Get bedside ultrasound

5) Keep NPO in case of OR

6) Reassure, monitor vitals, & fetal heart tones if > 20 weeks

What are the 5 hallmark signs of anaphylaxis?

1) Hypotension

2) Respiratory distress

3) Rash

4) Swelling (angioedema)

5) Stridor (high-pitched, noisy sound produced during breathing, indicating a narrowed or obstructed upper airway)

What is the first-line medication for anaphylaxis?

What are 5 additional treatments?

Epinephrine IM (0.3 - 0.5mg)

Additional treatments:

1) Antihistamines (diphenhydramine)

2) Corticosteroids

3) Albuterol

4) Oxygen

5) IV fluids

What are 5 signs of a Pulmonary Embolism (PE)?

1) Sudden SOB

2) Chest pain

3) Tachycardia

4) Low O2

5) Possible hemoptysis (coughing blood)

What are the 3 diagnostic tests for Pulmonary Embolism (PE)?

1) CT angiogram

2) D-dimer

3) V/Q scan

What are the 3 treatments for Pulmonary Embolism (PE)?

1) Anticoagulants (heparin)

2) Oxygen

3) Thrombolytics: for massive PE

What is 6 classic presentation signs of Diabetic Ketoacidosis (DKA)?

1) Polyuria

2) Polydipsia

3) Dehydration

4) Kussmaul breathing

5) Fruity breath

6) AMS

What are 3 first-line treatments for Diabetic Ketoacidosis (DKA)?

1) IV fluids

2) Insulin drip

3) Correct potassium before insulin if K+ is <3.3

What defines Status Epilepticus?

Seizure lasting >5 mins or recurrent seizures without return to baseline

What are 2 first-line meds for Status Epilepticus?

1) Lorazepam (Ativan) IV

2) Fosphenytoin or Levetiracetam (Keppra)

What are 4 common signs of Opioid Overdose?

1) Pinpoint pupils

2) Bradypnea

3) Unconsciousness

4) Low O2 sats

What is the antidote for Opioid Overdose?

Naloxone (Narcan) 0.4 - 2mg IV/IM/IN, repeat as needed

After giving Naloxone (Narcan) to an Opioid Overdose patient, what do you monitor?

Respiratory effort, potential re-sedation, & withdrawal symptoms