SAEM M4 Curriculum 2: Questions with Complete Solutions 2024, Exams of Nursing

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SAEM M4 Curriculum 2: Questions

with Complete Solutions 2024

PID cause - ANSWER - originates as a cervical infection with Neisseria gonorrheaand/or Chlamydia trachomatis, and becomes polymicrobial as it ascends into the uterus, fallopian tubes and ovaries. 3 sx PID - ANSWER - -lower abd pain -purulent vag d/c -vag bleed when getPID sx - ANSWER - Symptoms begin shortly after the start of the menstrual cycle, when there are fewer defenses by the cervical mucosal barrier to ascending infections. PID with gonnoccal - ANSWER - more likely to appear toxic (fever, N/V) dont forget one risk factor pid - ANSWER - -recent instrumentation of uterus common exam findings pid - ANSWER - -b/l adenexal tenderness -cervical d/c cervical motion tenderness -uterine tender -lower abd tenderness if pain is u/l think more - ANSWER - TOA if RUQ tender think - ANSWER - Fitz-Hugh Curtis (perihepatitis, inflamation of liver capsule) best test for gonorrohea and chlaymida - ANSWER - NAAT with PCR or DNA probes (either urine or cervical secretions) if suspect TOA get - ANSWER - US ruptured ovarian cyst shows - ANSWER - free fluid in pouch of douglas ovarian torsion shows - ANSWER - absence of blood flow to one ovary on pelvic ultrasound with doppler why US>CT - ANSWER - CT cannot eval for torsion bc there is no doppler

who gets abx for PID - ANSWER - -lower abdominal or pelvic pain coupled with adnexal, uterine or cervical motion tenderness on exam, in a patient at risk for STDs with no other discernible cause for the illness identified complications of pid - ANSWER - -chronic pelvic pain -infertility -ectopic -toa -fitz-hiugh curtis toa process - ANSWER - walled-off abscess that originates in the infected fallopian tube and extends to involve the ovary how confirm dx of Fitz hugh curtis - ANSWER - elevated liver fxn tests inpatient abx pid - ANSWER - -cefoxitin + doxy or -cefotentan + doxy or clinda+gentamy cin outpatient abx pid? add if 2 - ANSWER - -ceftriaxone -doxy -add metro if severe infection or hx of uterine instrumentation who getsa dmitted - ANSWER - -toa -fitz hugh curtis -septic -peritontiis -pre-pubertal kid -iud (which needs to be removed) -pregnant d/c with PID need what testing - ANSWER - test for other STD describe whats going on in ovarian torsion - ANSWER - ovary, and often the fallopian tube as well (adnexal torsion) become twisted around their vascular pedicle. progression of torsion - ANSWER - twisting initially obstructs venous flow, which causes engorgement and edema. The engorgement can progress until arterial flow is compromised, leading to ischemia and infarction risk factors for torsion - ANSWER - ovary with a mass or cyst is more prone to twisting by virtue of its asymmetry

classic present torsion - ANSWER - sudden onset of unilateral lower abdominal pain which is initially visceral in character (ie, vague and poorly localized) and may be accompanied by nausea and vomiting. It may radiate to the groin or flank. intermittent torsion - ANSWER - several episodes of pain over the course of hours, days, or even weeks, why does current pregnancy inc risk of torsion - ANSWER - corpus lutem cyst on ovary tests for torsion - ANSWER - There are no laboratory tests which are helpful in establishing the diagnosis of adnexal torsion best way to dx torsion - ANSWER - US careful with US: - ANSWER - important to note that the presence of Doppler blood flow does not exclude the diagnosis of torsion signs of torsion on US - ANSWER - -enlargement/edema of ovary -ovrian mass or cyst -free pelvic fluid what does CT torsion show - ANSWER - finding an enlarged ovary or ovarian mass -assocaited free fluid -thick fallopian tube -deviation of uterus to the affected side definitively dx torsion - ANSWER - OR tx torsion - ANSWER - or (try and salvage ovary but testicle just gets removed) torsion sotry often sounds like - ANSWER - kidney story testicular torsion is - ANSWER - twisting of the testis and spermatic cord within the scrotum, with resulting in occlusion of venous return and and edema which can progress to arterial occlusion and ischemia normal testicle anatomy and issue with torsion - ANSWER - anchored within the scrotum by the tunica vaginalis, which surrounds the testicle and attaches posteriorly to the scrotal wall and epididymis. The tunica vaginalis consists of a visceral and parietal layer with an interposed potential space. This potential space allows the testicle to rotate about the spermatic cord within the tunica vaginalis if a firm posterior scrotal attachment is lacking. bell clapper deformity - ANSWER - When the tunica vaginalis attaches higher up on the spermatic cord, the testicle can move and twist within the scrotum. inc risk of torsion

2 most common ages get torsion - ANSWER - 1st year of life and in puberty hx of testicular torsion - ANSWER - airly sudden, severe unilateral testicular pain, sometimes radiating into the abdomen, associated with nausea and vomiting -may have urgency, freuqency, dysuria which testicle most common - ANSWER - left weird cause of torsion - ANSWER - trauma exam - ANSWER - -testicle is tender and swollen -sits higher in sac -sits in transverse lie -loss of cremasteric reflex (rise hihgerthan .5cm) labs in torsion - ANSWER - usually not helpful best way to dx testicle torsion? what show2 - ANSWER - US: painful testicle is enlarged and hypeochoic as ocmpread to good side. can show absence of flow but this is alte finding torsion v. epididymitis - ANSWER - usually associated with increased blood flow to the testicle and the epididymis, as part of the body's inflammatory response. torsion of testicular appendage -age of pop -where is pain -timeline of paiin -creamsteric reflex -us shows -tx -outcome - ANSWER - -7-14yrs -upper pole of testicle -hrs-day -reflex is present -Body of testis similar to asymptomatic side with focal hypoechoic area -supportive -Infarction and resorption of appendage, no effect on fertility epididymis -timeline -2 sx -cremasteric reflex -exam shows -2 labs

-US shows -tx -outcome - ANSWER - -over days -fever, dysuria -present -Epididymal tenderness with or without testicular tenderness -wbc and nitrites -Body of testis similar to asymptomatic side with hypoechoic epididymis -abx -Possible scarring, possible impaired fertility definitive dx testicle torsion - ANSWER - OR if delay in getting to OR what do - ANSWER - manual detorsion (rotat eit way from midline at least 360) -know it owrked if dec pain within minutes how know twist right way - ANSWER - -if hard to untwist, try twisting the other way when susepct trauma is cause of torsion - ANSWER - testicular trauma who still has pain 1-2 hours after an injury. to US for torsion must - ANSWER - compare side to side when managing torsion - ANSWER - do not delay OR trip to use US as torison is mostly a clinical dx 4 types of intracranial hemorrhages - ANSWER - -epidural -subdural -subarachnoid -intracerebral sx of all intracrnial hemorrhages 4 - ANSWER - -headache -N/v -altered -seizure who is at risk for big bleed even with minor trauma - ANSWER - -old -alcohol -anticoagulated subarachnoid hemorrhage classic - ANSWER - -thunderclap ha -reach max intensity within sec sah sx - ANSWER - -loc -vomit

-neck stiff sentinel ha - ANSWER - -small headache=small bleed before a much larger bleed grading system for sah - ANSWER - hunt and hess most common cause sah - ANSWER - saccular aneurysms interestng risk factor for sah - ANSWER - recent exertion epidural hematoma patho - ANSWER - -trauma causes fracture of temporal bone to rupture middlemeningeal artery classic story of epidural. but really - ANSWER - -brief LOC after blow to head then lucid period than loc again -but most either dont hve loc or if they do, they dont get better subdural hematomas patho - ANSWER - bridging eins are sheared during acceler- decel of head timeline of subdural/ esp what pop, why - ANSWER - -can present late because the hematoma gros slow -esp delayed in those with brain atrophy bc there is more space in head for blood subdural in kid - ANSWER - think childabuse shaken baby syndrome 3 - ANSWER - -subdural -retinal hemorrhages -long bone fractures chronic subdural in 2 pops? 2 reasons why - ANSWER - -old and alcoolic bc most prone to atrophy and coaugloapthy cushings triad= - ANSWER - htn -brady -abnormal resp patterns signifcance of cushings - ANSWER - physiologic response to rapidly increasing intracranial pressure and imminent brain herniation colors of blood on ct by time - ANSWER - -white if acute -3-14d then same color as brain -after 2 weeks=hypodense diagnostic pathway of sah - ANSWER - -CT -then LP if after 6hrs of start of sx

subdural on ct - ANSWER - crescent sah on ct - ANSWER - starfish. fillls sulci epidural on ct - ANSWER - lens CSF of Sah - ANSWER - -absence or clearing of blood -xanthocromia blood in csf ddx 3 - ANSWER - -sah -infection -traumatic tap how know its traumatic tap - ANSWER - if fourth tube has almost no lbood in it if CT or LP pos in CAH next step - ANSWER - angiogprahy if unsure if should get head ct - ANSWER - -canadian ct rules what consider in hemorrhages - ANSWER - seizure prophylaxis control inc ICP 5 - ANSWER - -lower BP -elevate head of bed 30degrees -provide adequate sedation and analgesia -consider mannitol -or higer ventilation (goal CO2 around 30) 3 ways to have to stroke - ANSWER - -embolus -thrombosis -bleed (under 15%) aca stroke sx - ANSWER - -LE>UE (weak and sensory loss) mca stroke sx - ANSWER - -weak and sneosry loss of face and upper extremitiy with aphasia or neglect pca stroke sx - ANSWER - homonomynous hemianopsia vertebrobasilar syndromes - ANSWER - -c/l sensory and weakness -ipsilateral cn palsies -D signs: diplopia, dysarthria, dysphagia, droopy face, dysequelibrium, dusmetria, dec level fo conciosuness -N/V

what is lacunar infarct - ANSWER - cclusion of one of the deep perforating arteries which supplies the subcortical structures and brainstem. 5 diff presentations of lacunar syndromes - ANSWER - -pure motor hemipareiss -sensorimotor troke -ataxic hemiparesis -pure sensory -dysathria-clumsy hand syndrome most commmon ct findign in ishcmeic stroke= - ANSWER - normal bc cant see findigns for several hours earliest stroke finding on CT - ANSWER - hyperdensity representing acute thrombus or embolus in a major intracranial vessel. frank hypodensity on CT - ANSWER - indicative of completed stroke and may be a contraindication to thrombolytic therapy whst must rule out in all stroke people - ANSWER - hypoglycemia tpa - ANSWER - fibrinolytic agent that catalyzes the conversion of plasminogen to plasmin, the major enzyme responsible for clot breakdown tpa timeline - ANSWER - -best outcomes: witihn 90mi -max: 3-4.5h complication of TPA - ANSWER - intracranial hemorrhage tpa dispo - ANSWER - icu reasons to stop tpa and get head ct - ANSWER - -acute severe ha -acute sever ehtn -intractable n/v -ams -neuro deficits after TPA what must do - ANSWER - stricktly keep b p under 180/105 to prevent hemorrhage if not on TPA tx stroke BP control - ANSWER - under 220/ why aspirin within 48h of stroke - ANSWER - reduce the rate of early reucrrent stroke (dont give for at least 24hr after give tpa) exclusion criteria of tpa - ANSWER - -signficant head trauma or stroke in last 3 mo -sx suggest hemorrhage

-hx of previous intracrnail hemorrhage -structural issues in brain -recent surgery -BP>185/ -platelet under 100k -elevated PTT -INR>1. -PT? -CT shows multilobular infarction how get meningitis - ANSWER - pathogens often invade the host through the upper airway by infecting the mucosa, bloodstream, and ultimately crossing the blood-brain barrier 3 causes of meningitis - ANSWER - trauma, surgery, or a contiguous infection such as sinusitis or otitis media. 2 most common bacteria - ANSWER - -strep pneumo -n menigitis listeria - ANSWER - -over 50 -under 3 mo -immunocomproised -pregnany most commmon cause of encephalitis - ANSWER - virus when suspect encephalitis - ANSWER - -suspected CNS infxn with ams or FND triad meningitis - ANSWER - -fever -neck stiffness -ams common sx meningitis - ANSWER - seizure kernig - ANSWER - flexing the hip and extending knee to elicit pain in back and legs brudzinski - ANSWER - passive flexion of neck causes flexion oh hip when ct before lp 5 - ANSWER - -new seizures -immnocomrpsed -ams -fnd -papilledema try and do and b4 abx - ANSWER - -lp

-blood cultures CSF of bacterial meniningits -glucose -protein -wbc -percent neutrophils -opening pressure - ANSWER - -under 40 -over 200 -wbc over 1000 -80% or more -increased encephalitis csf - ANSWER - -inc wbc with llymhpcoccytic predominace -inc rbc why blood in csf 3 - ANSWER - -edema -hemorrhage -necrosis empiric abx under 1 mo-3mo - ANSWER - -amp and cefotaxime empiric abx over 3 mo-adult under 50 - ANSWER - -dexxamaethasone (maybe fore abx) -cefotaxime/ceftriazone -and vanco adult over 50 - ANSWER - -dexxamaethasone (maybe fore abx) -cefotaxime/ceftriazone -and vanco -and ampicillin tx hsv encephalitis - ANSWER - acyclovir tx other bugs that cause enhceplaitis - ANSWER - just supporive care why steroid - ANSWER - tarted before or concurrently with the first dose of antibiotics may decrease mortality and neurologic sequelae for some subsets of patients with bacterial meningitis. menigntiis triad prevlanece - ANSWER - only there under 50% of time order of tx and tests - ANSWER - Empiric antibiotics should not be delayed while waiting for a CT scan prior to an LP if meningitis is a likely diagnosis. When a CT scan is necessary, draw blood cultures and administer steroids and appropriate antibiotics before the LP.

CSF results if inconclusive - ANSWER - tx empriicall anyway,csf often doesnt yeild classic results types of seizures - ANSWER - simple v. complex focal. veneralized focal with secondary generalizaton most seizures last - ANSWER - 1-2min clues its seizure - ANSWER - -tongue trauma -urinary or bowel incontenince todds paralysis - ANSWER - fnd post seiure what 4 sx raise suspicion for what 3 causes of seizures - ANSWER - -tachy/diaphoresis/tremors/anixety -withdrawal -drug use -hypoglycemia 3 when do epileptics ahve breathru seizures - ANSWER - -med noncomplaince -sleep deprivation -emotional or physical stress causes of seizure - ANSWER - GAINCUCOHMW -low glucose -anatomic -infection -low or high Na -low calcuim -uremia -cocaine -low o -hepatic fail -low mag -withdrawal new onset first time seizure what tests - ANSWER - -chemistry panel -pregnacy test people with epilepsy test - ANSWER - get level of their drug when get CT - ANSWER - new onset seizure -chance in seizure pattern -more seizures latlet

-trauma -new neuro defitic -anyone in status when dc a seizure patient what need - ANSWER - mri as outpatient when get continuous eeg - ANSWER - in status alcohol withdraw sx - ANSWER - -anxiety -tremors -ams -tachy everything and htn does elevated alcohol blood level rule out withdrawal - ANSWER - no chrnoic alcoholics can seizre at any point worry about preg + seizure - ANSWER - eclampsia 4 when suspect ecalmpsia - ANSWER - -vision complaints -edema of face hands and feet -rpoteinuria on UA -htn tb med that can cause siezures - ANSWER - isonaidzid 2 trauma issues that can cause sieuzre - ANSWER - -intracraial hemorrhage -brain injury clues to pseudoseizure - ANSWER - -rhthymic, controlled shaking activity -ability to talk or follow commands during seizure -lack of postical status - ANSWER - continuous seizure or do not return to baselie in between seizures 1st line tx seizure secnd third - ANSWER - -benzo (lorazepam) -fosphenyton/phenobarbital/ valproate 3rd: versed/pentobarbital/propofol time of admin of seizure meds - ANSWER - every 2-5min tx eclampsia seizure - ANSWER - mag suflate tx isondiazid seizure - ANSWER - pyroxidine

patient with first-time, new-onset seizure who is back to baseline and has a normal exam needs - ANSWER - -chemistry panel -preg test -head CT most common cause of recurrent seizures - ANSWER - med noncomplaince when suspect suicide - ANSWER - -single vehicle traffic ollision -pedestrian struck by car -falls -shooting -stabbing imp to suicide eval - ANSWER - collateral hx pneumonic for psych assessment - ANSWER - MOMMAS2 M: Memory long and short term O: Orientation to person, place and time M: Mood (a symptom), "How do you feel?" "Happy," "Mad," "Sad?" M: Mentation Ask about hallucinations, delusions, paranoia A: Affect (a sign), How does the patient act? What are the eye contact, speech and demeanor? S: Speech Is it organized and logical or disorganized and tangential? S: Suicidality Is there a plan, intent, objective, preparation and/or rehearsal? reassuring signs in suidicde - ANSWER - -supportive home envionrment -reliable access to healthcare -younger female with hesitation cuts -nonlethal ingestions -strong wish to live men v women in suicide - ANSWER - -women more liekly to attempt men more likely co complete bc use more violent means SAD persosns - ANSWER - S = Sex (male) A = Age (<19 or >45) D = Depressive symptoms and hopelessness* P = Previous suicide attempt or psychiatric illness E= Excessive alcohol or drug use R= Rational thinking loss* S = Single, separated, divorced or widowed O = Organized or serious suicide attempt* N = No social support S = Stated future intent interpret score sad persons - ANSWER - 5 or below: low risk

9 or more high risk (in between get pych constul how score sad persons - ANSWER - -everything 1 except the following are 2 -depression/hopelessness -organzied or serious attempt -stated future attmept agitation is a sx of 3 - ANSWER - -delirium -dementia =psychosis always consdier - ANSWER - hypoglycemia and trauma (c collar) vitals og agitaiton - ANSWER - -tachycardia -HTN dementia - ANSWER - chronic progressive decline in intellectual ability, behavior and perosnality psyhcosis - ANSWER - -delusions -hallucinations0disorganized speech or bheavior ddx delirium - ANSWER - dimtops Drugs-intoxication, poisoning or withdrawal Infections-UTI, pneumonia, meningitis/encephalitis, and others Metabolic Disturbance-Glucose and other endocrine derangements as well as electrolyte disorders Trauma-Head injury Oxygen- Hypoxia Postictal State Space Occupying Lesion-Intracranial Tumor 2 meds often used in agitation - ANSWER - -benzo -antipsych (often give benztropine or diphenhydramine to prevent EPS sx) pathophys asthma 2 - ANSWER - -inc inflammation of airways -bronchospasm why chest tight in asthma - ANSWER - dec expiratory airflow most common resp trigger - ANSWER - uri when intubate asthm - ANSWER - -severe resp distress + one of the folllowing -albuterol or other tx not helping -hypoxia even with o

-too tired to breathe on their own imp asthma questions - ANSWER - -how many ed visitis -hospitalziaitons -icu -intubations -what are meds and are they complaint? astmha 2 tx - ANSWER - -o -beta block by nebulizer if albuterol not working waht do (onset) 3 - ANSWER - -steroids: onset in 4-6h -epi -terbutaline needs labs? - ANSWER - not in known asthmatic when get abg - ANSWER - -hypoxic after initiation of o expect abg to show - ANSWER - -resp aljalosis and hypoxia if severe abg shows - ANSWER - hypercpanea and acidosis pfts done when - ANSWER - -when present -after 1hr of tx how interepret pft - ANSWER - interpreted using standard tables listing the normal values expected based on the sex, age and height of the patient. grade the asthma exacerbation - ANSWER - ->70% of peak flow is mild -moder: 40- severe: under 40 albuterol onset of action and duration - ANSWER - -5 min -6hr 3 side effects albuterol - ANSWER - -tachy -tremor -hypok duoneb= - ANSWER - -albuterol + ipraotrpium iv or po steroids - ANSWER - equal efficacy pro of steroid - ANSWER - when used in acute setting it reduces number of recurrent attacks after an exacberation

how giev epi - ANSWER - IM in severe asthma can alaos try - ANSWER - mg sulfate what is heliox - ANSWER - -combo of heliu and o -used in severe exaberations why helium work - ANSWER - elium has a lower density compared to room air, which allows it to travel through narrow air passages in a more laminar fashion instead of causing turbulence. allows increased delivery of oxygen or bronchodilator medications to the alveoli, thereby decreasing the work of breathing. when dont use heliox - ANSWER - If a patient needs additional supplemental oxygen (thereby increasing the density of gas), the benefits of using heliox decrease and another method to deliver oxygen should be considered. non invasive PPV why work - ANSWER - rovides inspiratory assistance as well as PEEP. It enhances patient breathing in acute respiratory conditions by providing rest in patients with significant work of breathing NIPPV in - ANSWER - -chf -copd -not yet asthma concern with intbuat eand ventilate - ANSWER - patients can develop high lung pressures because they are unable to expire a full breathe. This may result in barotrauma, pneumothorax or hypotension from decreased venous return how decide asthma dispo - ANSWER - -not severitiy of intiial presentaion but their response to tx as measured by PEFR or FEV d/c asthma with - ANSWER - steroids and albuterol when admit asthma 4 - ANSWER - -perisstent severe sx -no/poor response to tx -persistent hypoxia despite 02 -PEFT or FEV1 under 40% when ICU asthma - ANSWER - -FEV! or PEFR <25% that improves by under 10% after tx other causes of copd - ANSWER - -air pollution -indoor cooking fires -alpha antitrypsin deficiency

causes of decomepnsation of copd - ANSWER - -infection -smoking -noncomplaince -ptx signs of inc wob - ANSWER - -accessory muscle -retractions -pursed lips -cyanosis why copd altered - ANSWER - -either hypoxia or hypercarbia cor pulmonate - ANSWER - -present as CHF sx with JVD, hepatomegaly nd leg edema how give o2 in copd - ANSWER - -venturi mask or nasal cannula. try to avoid nonrebreather bc in someone with chronic co2 retention, high flow o2 may cause resp depression copd ekg can show - ANSWER - multifocal atrial tachycardia common ekg features in copd - ANSWER - -low voltage -right anxis deviatio -p pulmonale: peakedp waves in 2, 3 , aVF -right atrial hypertrophy -tachycardia if wonder if its chf but neg xray - ANSWER - get bnp. sometimes xray has delayed findings ptx by us - ANSWER - -no bl lines -no lung sliding -barcode sign on m mode tx copd 3 - ANSWER - -broncholdilators -steroids -abx tx copd 4 steps - ANSWER - 1. oxygen 2.albuterol: multiple doses

3. ipratropium
4. steroids limits of how much albuterol you can use - ANSWER - tachycardia role for long acting beta agonist in acute exacerbation? - ANSWER - no

how give ipratropium v. albuterol - ANSWER - -ipra is given every 4 hrs, not in stacked or repeated doses like albuterol what steroids use? route? - ANSWER - iv methylprednisone oral prednisone asthma d/c with steroid instruction - ANSWER - 5 d pusle therapy copd d/c with steroid isntruciton 1 - ANSWER - 10-14days of prednisone that gets tapered off pros of steroid in copd - ANSWER - -reduce tx failure -reduce hospital stay -reduce need for additional tx when use abx on copd - ANSWER - -signs of infection -mod/severe exacerbations signs of infection in cpod - ANSWER - -fever -color change of sputum -inc vol of sputum what abx use in copd - ANSWER - -macrolide -quinilone -tetracycline -cephalopsorin when use PPV - ANSWER - -worsening CO2 retnetion and hypoxia despite standard tx or those with persistent inc wob how decide tidal vol - ANSWER - 4-5 ml/kg of ideal body weight (per height) intial mode of vent setting - ANSWER - -assist control with fied number oventilations want to avoid 2 things by use of 2 - ANSWER - -high peak and paleatus airway pressures -bronchodialtors and aggressive suctioning of secretions is copd on vent concern for how fix it - ANSWER - stacking phenomenon: it is an inc in peak pressure. relieved by disocnnecting the tube and then starting with a mroe prolonged expiraotry phase or dec minute ventilation good way to decide dispo for copd - ANSWER - ambulatory sat 2 indications icu - ANSWER - -PPV

-intubation most common bug cap - ANSWER - strep pneumo other cap bugs - ANSWER - -h flu -moraxella characteristics of atypical (bug itself) - ANSWER - -cannot be visualzied on gram stain and reqaure special culture mthods -not killed by beta lactams hcap criteria - ANSWER - -hospitalization for at least 2 days in last 90d -live in nursihn home -in past 30 days been to dilaysis, getting IV therapy, home wound care bugs of hcap - ANSWER - -pseudocmonas -e coli -klebisella hcap in hospital timeline - ANSWER - develop after 48 hrs in hospital when consdier aspiration pna - ANSWER - -dec mental stauts -conditions that may lead to dysphagia atypical pna sx - ANSWER - more protracted course beginning with upper respiratory symptoms, slowly worsening cough, malaise and fatigue. (but not sensitive or specific) strep pneumo sputum - ANSWER - blooody or rust colored chlamydia pna - ANSWER - -pharyngitis -laryngitis -sinusitis -associ with outbreaksi dorms/prisons legionella pna - ANSWER - -resp and gi sx aspiration pneumonitis (4 causes +athophys) - ANSWER - chemical injury from inhalation of gastric contents due to regurgitation that can occur with drug overdose, seizures, cerebrovascular accident, or use of anesthesia who is at risk for aspiration - ANSWER - -neuro disorder -nursing home -alcohol abuse bugs of aspiration pna - ANSWER - -enterobacteria -pseduomonas

-s aureus tx aspiration pna abx - ANSWER - -cephalosporin -quniolone -piperacillin tx PCP - ANSWER - bactrim factors that predict pna on cxr 5 (2 vs, 2 exam, 1 abset) - ANSWER - -fever -tachy > -no asthma -rales -locally dec breath sounds on auscultation one consoldiation=2 bugs - ANSWER - -s pneumo -klebsiella multi infiltarete = 2 bugs - ANSWER - -s aures -pseudomonas patchy infiltartates bugs - ANSWER - atypicals sens/spec of us for pna - ANSWER - -both over 85% why no blood cultures in cap (2) - ANSWER - false pos cultures lead to inc lenth of stay, inapporpraitely broad abx converage tx hap - ANSWER - -antipseudomonal plus pip/tazo tx aspiration pa - ANSWER - -amp/sulbactam -pip/tazo hap studies show that the most common bugs are - ANSWER - strep pneumo h flu kelbsiella risk startification tool for cap. how use - ANSWER - pneumonia severity index -class 4- hospitalize class 1-3 d/c home another, simpler tool cap - ANSWER - curb 65 score of 2 or more=admit curb 65 - ANSWER - confusion bun>= resp rate>=

systolic <90 age

=65 pathophys ptx - ANSWER - when the potential space between the parietal and visceral pleura of the lung fills with air and collapses the lung primary (spontaeous) ptx occurs in what pop - ANSWER - -thing young amle who smokes most common procedures to cause a ptx 7 - ANSWER - -central line -thoracentesis -pacemaker -tracheostomy -biopsy -cpr -ppv 2 clues its tension pneumo if intubated - ANSWER - -extreme difficulty in bagging or high airway pressures imp questions of pneumo - ANSWER - -onset and duration of sx -establish if there are any chronic disease that could produce a secondary ptx -any iatrogenic procedures deep sulcus sign= - ANSWER - anterior ptx another clue ptx - ANSWER - subq air how do needle thoracomoty - ANSWER - Place a 14-gauge angiocatheter into the 2nd intercostal space at the midclavicular lin utility of needle thoracomoty - ANSWER - convert tension pneumo to simple ptx then what do after needle - ANSWER - chest tube (The needle is a temproziing measure) 3 ways to manage a small ptx - ANSWER - -needle aspiration -small pigtail catheter -simple obs with repeat cxr post cpr patient on PPV begins to decompensate think - ANSWER - tension pneumo 3 kinds of forces in blunt abd trauma. define - ANSWER - -shearing forces that occur due to rapid deeleration causing tearing at fixed pots of attachment -crushing forces

-external compression: sudden and rapid rise in intraabd pressure leading to rupture of visocus organs why gunshot more mortality than stab - ANSWER - -hgiher energy of transfer -missile trajectory -bullet fragments most common blunt trauma injury? 2nd? - ANSWER - splenic rupture -second most: liver lac can occur with lbunt abd trauma? side? timeline - ANSWER - diaphragm rupture on left. can present weeks later gunshot wound where in abd - ANSWER - intestine stabwound where in abd - ANSWER - liver diagnostic peritoneal lavage when pos. what do if pos? - ANSWER - d positive if there is aspiration of 10 mL of gross blood or gastrointestinal contents, or the presence

100,000 RBC/mm3, >500 WBC/mm3, or vegetable matter in the liter of saline infused. -surgery 2 downsides of lavage - ANSWER - -does not eval retroperitoneum -can result in many unneeded lapraopotmies why need ua in trauma - ANSWER - -blood as sign of urogenital system injury permissive hypotension. goal? - ANSWER - favor of blood product resuscitation to a specific defined Mean Arterial Pressure (MAP) of 65. blunt abd trauma needs - ANSWER - abx why avoid tm fluids - ANSWER - -exacerbates lethal trauma tirad: coagulatopathy, acidosis, hypothermia whay lac grade needs surg - ANSWER - grade IV and above pelivc fracture with vessel injury needs - ANSWER - IR consult for emergent arterial embolization traumatic arrest due to penetration managed - ANSWER - ED thoracomoy followed by surg blunt injuries do NOT get - ANSWER - thoracotomy blunt trauma - ANSWER - refers to mechanisms casuing inc intrathoracic pressure

who gets thoractomy - ANSWER - -thoraco-abd penetrating trauma who experience a traumatic arrest manage tension pneumo in 3 steps - ANSWER - -us -needle decomrpession -tube what is open ptx - ANSWER - -sucking chest wall wound from penetrating injury presentation of open ptx - ANSWER - -present with chest pain, sob, sonorous breath sounds -sucking air from wound -shallow respirators tx open ptx - ANSWER - placement of a square dressing tape on three sides to create an escape valve -ultimately need a chest tube on same side as wound but at diff site of wound if dont tx open ptx what happens - ANSWER - becomes tension hemothorax exam - ANSWER - -dec breath sounds -dull to percussion dx hemothorax - ANSWER - us or xray tx heothorax - ANSWER - chest tube what if chest tube fails to tx it? - ANSWER - then video assisted thorascopic surgery is needed indications for emergent surgery for hemothorax - ANSWER - -greater than 1500mL of blood on itial chest tube placement -or if greater than 200ml/hr for 2-4hr consequence of flail chest - ANSWER - -pulm contusion clinidcal findngs of flail chest - ANSWER - -visible or palpable deformity -bruising -crepitus -paraodxical movement -splitning with secondary hypoventilation when intubate flail chest 3 - ANSWER - -old -multiple rib fractures -resp failure

tx goal of flail chest - ANSWER - -re expand lung with cpap or physiotherapy -avoid atelectasis pulm contusion= - ANSWER - leakage of blood and proteins into alveoli causing atelectasis that can lead to ARDS pulm contusion often present with - ANSWER - -sob -chest pain -hemoptyis -cough cxr timeline - ANSWER - xray may be normal in first 6-12hrs whats better to dx contusion - ANSWER - CT tx large pulm contusion - ANSWER - intubate tx small pulm contusion - ANSWER - -spirometry -pulm toilet -pain control -careful fluids in blutn chest trauma what part of heart is most affected - ANSWER - -right atrium and ventricle % of cardiac contusion develop - ANSWER - 40%; dec CO if cardiac contusion need - ANSWER - formal echo to measure ef -at least 24 hr telemetry bc at risk of dysrthmias and cadiogenic shock if reduced EF what need - ANSWER - dobutamine stress test tamponade common presentation vitals - ANSWER - -hypotension -pulsus paradoxus -narrowing of pulse pressre ekg tamponade - ANSWER - -electrical alterans but often dont see this in trauma cxr tampoande - ANSWER - enlarged card silhoeutte how tx if stable v. unstable - ANSWER - -periocardiocentesis if stable -if unstable go to OR if tmaponade loses vitals while in ed what do - ANSWER - thoractomy

mechanisms of blunt aortic injury - ANSWER - -over 30mph over 40ft fall where in aorta - ANSWER - proximal 3 categories of aortic injury - ANSWER - -dead at scene -hemodynamic unstable -stable what happened to those dead on scene - ANSWER - complete aortc transection on impact if unstable whati s injury - ANSWER - -full thickness transection with active hemorrhage from aora (nonsustained improvement in BP on fluid bolus) if hemodynamically stable - ANSWER - -partial thickness transection with possiiblity of pseduoanerysm how dx - ANSWER - cxr shows wide mediastinum -cta is diangostic tx unstable patient - ANSWER - surgery to cross clap aorta great vessel injury exam - ANSWER - -expanding hematoma -acute superior vena cava syndrome -hematoma compressing trachea if stable with great vessel injury - ANSWER - CTA if unstable great vessel - ANSWER - or traumatic arrest from penetrating chest injury role of cpr? what do - ANSWER - futile. instead intubate, b/l chest tubes, ed thoractomy penetrating trauma + PEA= - ANSWER - thoractomy tension ptx need xray? - ANSWER - no why is cervical spine most comonly injured part of the spine - ANSWER - bc of its mobility and exposure paraplegia occurs with - ANSWER - thoracic injury quadriplegia occurs with - ANSWER - cervical injury all must be trume to remove c collar 5 - ANSWER - -alert