ABEM:
LLSA 2004:
1. new TB: mid- lower lobe inf, hilar nodes
2. adjunct for hyoglycemia: ocreotide
3. triathelete: diamox
4. 52 DM cough and fever, 92% sat: social circumstances, NH resident.
5. lactic acidosis from metformin (Glucophage): decreases liver production and
intestinal glucose absorption, enhances insulin sensitivity.
6. beta agonist, mild to moderate asthma: albuterol inhaler.
7. heatstroke: monitor K+
8. knee: MCL gone, what else? PCL: posterior cruciate. With foot planted, tibia
posterior against femur:
9: most adverse: meds
10: 23 F ingestion Benadryl ingestion: charcoal.
11: Status after TB meds: pyridoxine for INH
12: 30 YO LBP from bending: NSAIDs
13: 68 R knee: fel, weeks, medial meniscus
14: AMS: ataxia
15: Subraglottic FB, needs ventilation: jet
16: Hep vaccine for non-highrisk exposure
17: Radiation burns: delayed.
18: Severe acute asthma: oral prednisone
19: 30 YO F sickle cell: good paper: acute chest syndrome, best is blood for oxygenation
20: 35 F 2 gray of whole body: intestinal most susceptible
21: most likely cocaine EKG: nonspecific changes! 6% rulein rate.
22: best indication of distracting injury: clinical judgment.
23: in EM, most successful: RSI.
24: viral hepatitis: hep B vaccine safe for pregnant women
25: 24-hour onsite attending for residents: avoiding tech error.
26: acute chest syndrome organisms: Chlamydia instead of pneumococcal.
27: which of the following inccreases insulin secration: sulfonylureas
28: best for internal radiation: KI
29: PE presentation: CT
30: 10 YO with ITP with petechiae definitive treatment: splenectomy. Target
    50,000, prednisone if needed.
31: Pneumonia Specific Severity Index: severity of illness.
32: Mite: scrub typhus
33: predictor in chest syndrome: thrombocytopenia
34: common complication for GI decontamination: aspiration
35: false negative D-dimer: more than 7 days.
36: IV/IM malaria drugs: > 4% of RBCs with falciparum
37: which fracture: Salter III
38: NH pneumonia: FQ + antipseudomonal (NB: COPD)
39: swolen knee, no end joint with Lachman: ACL
40: most serious from ITP, Plats < 20K: ICH.

LLSA 2005:
 - Decadron for bacterial meningitis: give BEFORE giving antibiotics; only
 works in sick (GCS <=11) and with pneumococcal meningitis; no reduction in
 hearing loss. May lower penetration of vanco into CSF.

 - CT head before LP in adults with suspected meningitis: ? if clinical
 features to tell who needs CT. Focal and Mass effect; CT before LP if > 60,
 immunocompromised, history of CNS disease, stroke within a week, or focal
 signs on neuro exam. Only 3% of those with no hi-risk findings had abnormal
 CT. Give antibiotics, get CT, get LP... in that order.

 - Treatment of acute ischemic stroke: glucose is fuel for lactic acidosis.
 Ischemic peneumbra. BP dependent, electrically silent, may last for 6-8
 hours. Streptokinas no good. ECASS: tPA for stroke. Minimal difference at 6
 hours. NINDS: functional 11>13% increase (24-25% relative) function back to
 normal. Mortality changes not significant. tPA > 3 hours no benefit. ASA:
 benefit. No benefit from hperain, LMWH, neuroprotective. Intra-arterial:
 shows benefit; can go up to 6-8 hours. 5% have seizures, 30% will have
 headache. Maximal at onset. NIH Stroke Scale.
 0-1 normal, near normal
 1-4: minor (except global aphasia
 5-15:L moderate
 15-20: moderately severe
 > 20: severe
 Differential: wide. TIA? 80 gone in 7-10 minutes, 30% 5-year risk of CVA.
 2-25% risk of cardiovascular complications within 5 years.
 CVA sensitivity of CT: 3 hrs - 30%, 24 hours 60%, 7 days 100%
 effacement of sulci, effacement of gray-white border, mass effect,
 hypodensitiy (hypodensity of >33%, Hyperdense MCA, predictive of acute CVA).
 AHA: treat if SBP > 220, or MAP > 130
 tPA: get to 180/115 at time of thrombolysis (not ineligible, just control
 BP!)
 Don't give ASA, but having had ASA prehospital or at home not
 contraindication.

 - Minor pediatric head injury: low-risk criteria include alerg, no
 extenuating history. Obtain CT if GCS < 1, focal neuro deficit, depressed or
 basilar skull fracture. Consider CT if LOC, seizure, amensia, HA, persistent
 vomiting, irribatilyut or behavior change. If < 2 years, any sx get CT, scalp
 hematomas nonfrontal=CT. < 3 months if MOT more thantrivial or scalp
 hematoma. Skull radiographs only in alert infants with scalp hematoma.

 - Febrile seizures: most common cause of seizures in child < 5 years old,
   is febrile, no hx of prior seizure. 2-4%; FH of febrile sz important. Same
   with twins. Certain viral infections and vaccinations more likely.
   Recurrence: more if younger, lower temp at presentation, short duration,
   complex seizure. Slightly increased reisk of epilepsy slightly higher.
   Prehosp: check glucose. Treat if > 5 minutes. In ED: look for trauma, child
   abuse, serious bacterial illness: same incidence of SBI as those without a
   sz and with a fever. ? partially treated meningitis. ? developmental delay
   > likely epilepsy. Testing: 2YO with febrile seizure and obvious URI, no
   testing (per article/test). If doesn't perk up, may need SBI workup. Do LP
   if < 18 months and look sick. CT not routine: consider if ^ ICP, trauma.
   EEG not routine, not predictive of going on to epilepsy, only if focal sz
   or developmental delay. Dispo: home, guidance, recurrenc risk, ? if fever
   control helps. Followup with PCP. If complex, maybe admit, at least
   outpatient workup. Prophylaxis works but more side effects, not worthwhile:
   don't.

 - Pharm of pain and conscious sedation: opiods: no ceiling.
   Agonist-antagonists:
   Don't get tolerant to constipation.
   Fentanyl: give 1/3 dose to infants.
   COX-2 inhibitors. N2O: N/V 15%. Can distend any air pockets, balloon tip
   catheters
   Other agents:
    Steroids: for some inflammation
    TCAs: for neuropathic
    Anticonvulsants: for neuropathics
    Caffeine: maybe
    Calcitonin: helps with compression fractures. (Miacalcin): helps pain.
    Sedation: depressed LOC, airway reflexes intact. Recent food OK, short
    acting. not chloral hydrate or DPT.
    Midazolam: pregnancy Cat D, may cause hypotension,
    Methohexital (brevital): drops BP, myocardial depression, vasodilation
    Ketamine: emergence more common in adults. Myoclonus. 1.5-2 mg/kb IV, 4-5
    IM.
    Propofol: fast, goes away fast, drops BP. Slight apneic. Not analgesic.

 - Fomepizol for methanol: osmolal gap. Formic acid is the bad stuff. Blocks
   alcohol dehydrogenase. Less erratic than alcohol. Hemodialysis if high
   levels to avoid long admit. If any visual symptoms, or if levels not
   dropping. Study didn't compare with ethanol.

 - Ethanol abuse: CAGE questionnaire: list of questions for chronic alcohol
   abuse. Withdrawal: stop the substance, treat withdrawal with subsitute. May
   DC from hospital if CIWA scale OK. Dilantin doesn't help. EtPH peaks 2-3
   days, benzos 7-10 days. Use slow benzos as lower chance of abuse. Can use
   phenobarb, haldol, beta blockers, clonidine, depakote, tegretol, Tegretol
   has less relapse, more sx. Opiate: 36-72 hours. Piloerection. Clnidine:
   .1-.2 Q4H, taper in 3 days. Stimulant withdrawal: treat as dpressed.
   Amantadine, Ritalin (methylphenidate).

 - GHB: gorked, resp depression, vomiting. Schedule I: for narcolepsy. Raves,
 date rape. Body building. Anecodotal physostigmine: no, just supportive care.
 GBL and other prodrugs: not illegal. Can get GHB withdrawal if using all the
 time.

 - Ingestion of toxics by kids: Medications:cocaine, TCAs, iron. Ipecac in
 first hour if tox call, no contraindications; not in ED. Lavage: no benefit.
 Charcoal: 1 g/kg, NG if needed. multiple doses for theo, pehonbarb, tegretol.
 No cathartics. Whole bowel irrigation: iron, lithium maybe. May observe if
 mild or hours since ingestion.

 - Vertigo and dizziness. Peripheral: worse,sudden, intense, worse with
 motion, fatigues, +/- hearing loss, no CNS signs; lateral nystagmus. Central
 constand, not motional, vertical nystagmus. BPPV: Women in 50's. Perilymph
 fistula: infection, trauma: puff of air makes worse. Vestibular neuronitis:
 post-viral, Suddenly, days: if hearing loss too, call it labyrinthitis. Drugs
 cause ototoxicity. Usually bilateral, oscillopsia: can't mantain visual
 fixation when moving. Benzos can make chronic worse. 8th nerver lesion,
 Cerebellopontine area lesions: peripheral.
 Post-traumatic vertigo: immediately after injury, lasts for weeks. Not
 post-concussive. Central: CVA, bleed, Wallenbert: lateral medullary infarct:
 ipsilateral facial finding. VB insufficienc: rotating head worsens. Basilar
 migraine: occipital HA siwht >= 2 of laundry list. of finding.

 - Syncope: vagal most common, 34% unknown. arrhythmia 14%. IF have structural
 disease, admit: CAD, IHSS, CHF, valvular HD, congenital HD, or abnormal EKG.
 Predictive for death. Can diagnose 45% of time. EKG diagnose 5%. Ambulatory
 monitoring: no benefit for 72 hours. EP study: if has EKG changes or
 structural HD, 21% VT. If structural disease uncertain OR exercise-related,
 needs stress and echo. No SD or EKG findings: neurally mediated. If
 recurrent, may need carotid massage, tilt table. Single episode, normal EKG,
 no structural HD: stop workup, send home. If sturcural HD, other symptoms,
 abnormal EKG: admit.

 - Angioplasty: Transfer vs. tPA? All three endpoints reduced by angioplasty.
 Results depend on number of PTCAs done by center.

 - Natrecor study: nesiritide: AHA says only use if everything else fails.
 Recombinant BNP: venodilator, decreases preload, afterload, increases GFR.
 Study with decompensated CHF by Swan. Compared to NTG, had more effect on
 PCWP than NTG. But people the same, overall function, same with both agents.
 Hypotension lasts longer with Natrecor.

 - EKG in MI: Inferior MI: RV infarct: 1 mm elevation in V4R with upright T
 wave. LAD: if aVL elevation: proximal LAD lesion. LBBB: if concordance with
 QRS, conclude acute MI: Best marker for resolution of acute infarct is STs go
 down. Rescue angioplasty for failed tPA.

 -WNV: mostly asymptomatic. Less than 1% get severe disease: flaccidity, CN
 palsies, sz, fatalaty rate 4-18%, worse with age. Comorbidity with DM,
 immunocompromised, MS. May get permanent neuro. CT an dMRI usually normal.
 Detection of IgM ab in serum or CSF by serum test. Supportive. No vacccine.

 - Community-acquired peds pneumonia: WHO: clinical signs and RR. This: fever
   or URI and infiltrate. 35% of RSV culture out pneumococcus, but they don't
   need treatment. Immunization works, H. Flu gone now. Rhinorrhea, ill
   contacts, myalgias: no difference. Mycoplasma has variable infiltrates.
   patchy scattered are viral and loba are bacteral. CRP and absolute
   neutrophils maybe useful. Age, epidem, CXR.
   3wks-3months: C. traromatak, Brodatella PErtussis.
   3 months-3 years:
   sicker, nonretrosternal chest pain > more likely bacterial.
   Wheezing: viral
   Conj < 3 months: chlamydia.
   0-3 weeks: amp + gent. +/- claforan.
   3 wks-3 onths: macrolide, +/- clagoran
   4 mo-40 years; hidose amox for home, inpatient: viral, none
   5-15: macrolide
   + if lobar:

 - Ottowa knee rule in kids: 100 in adults,
  _isolated_ pateller tender
  nonisolated head of fibula tender
  can't flex more than 90 degrees
  can't walk 4 steps home AND in ED
  Don't use if distracting painful injury, o imperfecta,
  Should not use < 5, > 55

 - Lacerations, US:

LLSA 2007:
1. Appendicitis:
 - appy most common emergency surgery
 - CBC and temp unreliable
 - higher mortality if have appy with normal appendix
 - WBC: +LR 1.59, -LR 0.46, ROC .72
 - Temp: worse. +LR 1.3, -LR 0.82 ROC .59

2. Clinical Decision Making
 - Pattern Recognition
 - Rule Using: must be on right pathway
 - Hypothetico-deductive
 - Naturalistic: ATLS approach

 - Medical Inquiry errors:
  - attitudinal error: missing bad stuff in frequent flyer
  - anchoring

3. Adverse Drug Reactions in the Elderly
 - Unintended consequences in appropriate use e.g. opioids > somnolence
 - More common in elderly, detection rate 5-15%
 - Severe: hospitalized
 - Mild: no change in Rx

4. Clinical Policy: Early Pregnancy
 - Ectopic: 4.5 > 19.7/1000
 - IVF big risk
 - Level C: TV US MAY detect IUP/Ectopic below HCG=1000
 - Serial Quant: reliably detects nonviable IUP (12.5% will have abnormal
   rise)
 - HCG > 2000 and empty uterus on TV US:
 - Sono signs like fluid and HCG >1500: probably Ectopic
 - No IUP on TV US and HCG > 2000: probably
 - MTX
  - do NOT assume n/v/abd after MTX is from MTX and not from ectopic!

5. Clinical Dehydration:
 - 98% sensitive: severe orthoststic dizziness
 - NH resident: orthostatics and cap refill not reliable. Clinical signs if combined maybe OK.

6. CHF:
 - Wheezing makes it less likely
 - CXR good: interstitial edema or vascular congestion, not cardiomegaly
 - <250 BNP reliably excludes
 - high BNP doesn't always mean CHF, other reasons for it
 - Gestalt: good, +LR 9.9
 - Historical not very good
 - S3 good +LR 57, JVD +LR 4.3, but leg edema and rales not that good

7. Attempted Suicide
 - completers: older men, living alone, physically ill, tend to use
firearms
 - attempt is risk for completion
 - ED visits higher for females, but males complete more

8. Alcohol counseling in the ED
 - 

9. 35 year old physician with opiod dependence
 - self-treatment is a risk
 - EM and anaesthesia at risk
 - arrange for drug test if suspect colleague
 - 

10. Schizophrenia
 - Late adolescence or early adulthood
 - positive: hallucinations or delusions
 - can't pay attention, loss of pleasure, will
 - congnitive dysfunction, short term verbal and nonverbal
 - 10% risk of suicide lifelong
 - too much dopamine in basal ganglia
 - genetics: multiple chromosomes

First Gen: 
 - haldol, etc.: 20% complete cure, 30% better but relapse
 - Extrapyramidal: 
 - Prolonged QT
Second Gen
 - Clozapine: agranulocytosis
 - less relapse, less extrapyramidal, but weight gain
 - good for negative symptoms
 - 

11. Generalized anxiety disorder
 - #2 psychiatic depression
 - comes on before age 25; but if > 35, likely from a medical condition
 - anxious more days than not for 6 months
 - 25% have panic disorder
 - 3 of following: 
   restlessness
   easy fatigue
   difficulty concentrating
   irritability
   muscle tension
   sleep disturbance
 - longterm: antidepressants, e.g., half-dose tricyclics or Buspar
 - benzos only shortterm
 - SSRIs: cause insomnia
 - benzos: no good in 1st or 3rd trimester

12. Domestic Violence
 - pregnancy a risk factor
 - vague, nonspecific complaints early on

13. Acute Coronary Syndrome
 - Risk Stratification:
  - chest or L arm pain
  - similar to previous CAD
  - CAD
  - male, >70, DM
  - tachy, brady, MR, sweaty, acute CHF or hypotension
  - EKG changes with pain
  lower:P cocaine, T in leads with
  atypical: elderly: SOB or weakness
  normal EKG: 6% rulein
  ST depression: 50% rule in
  new BBB with clinical c/w chest pain: high risk
  check repeat EKGs

nitrates, beta blockers; if still hypertensive, give ACE inhibitor
ASA, Plavix for unstable angina (IC: controversial)
GP inhibitor: if going to cath lab
LMWH: might be superior to UFH; don't give LMWH if CABG to be done within 24 hours

14. Who sets standards?

15. Nesiritide:
 - kills people, retraction of prior article

16: blood cultures for cellulitis?
no

17: MRSA
 - 2 DS Bactrim BID

18. renal transplant patient in the ED
 - macrolides (all) may interfere with P450 and increase levels of
   immunosupressive drugs and cause toxicity
 - seizure drugs dilantin, phenobarb, Tegretol, rifampin, INH may
   induce P450 and decrease transplant drugs and cause rejection
 - fever and allograft tenderness suggests rejection
 - if suspect rejection, check levels of cyclosporine etc.
 - Consider ultrasound to look for hydro, fluid around graft, doppler of
   vascular structures
 - WBC in UA may be recention
 - Same pathogens as in non-transplant patients
 - Avoid nephrotoxic aminoglycosides
 - occlusion of renal artery or vein > oliguria, renal failure (#1
   cause)
 - First year: infectious including CMV common, fever, ^ LFTs,
   leukopenia, anemia, thrombocytopenia
 - after first year: weaned down on meds, mostly community-acquired
   infections
 - increased cardiovascular disease 
 - increased HTN: can use any standard drugs
 - Pneumonia: highest risk for opportunistic in first 1-6 months,
   consider admission
 - HA serious, always CT and LP
 - consider stress dose steroids as on chronic steroids

19. US for peripheral IV access
 - fewer punctures: 1.7 vs. 3.7