Last Minute Board Review
Cardiovascular
EKG Measurements
Paper speed
25mm/sec
Horizontal
1 big box = .2 sec (2ms)
1 small box (5 per big box) = 0.04 sec (.4ms)
Vertical
1 big box = 5mm or 0.5 mV
P wave
<0.10 seconds wide and < 3mm
PR interval
0.12-0.20 seconds
Q wave
< .04 seconds wide and <3mm deep or < 1/3 of the QRS complex
QRS complex
.06- 0.10 seconds (some use 0.120 seconds though in toxicology the
QRS should be < 0.10)
R wave
< or = 7.5mm
QT Interval
<440 ms in Males and <450mS in females
T wave
<5mm in limb leads and <10mm in V leads
Pacemaker Codes
1st Letter- chamber paced (Ventricle, Atrium, Dual, O (None))
2nd Letter- chamber sensed (Ventricle, Atrium, Dual, O (none))
3rd Letter- response to sensed electrical activity (Triggers, Inhibits, Dual, O (none))
4th Letter- program functions
5th Letter- anti-tachydysrthythmia function
Serum Markers In MI
Marker
Rises
Myoglobin
2-3 hrs
CK-MB
4-10 hrs
Troponin
6 hrs
Peaks
4-24hrs
20 hrs
12-18 hrs
Congestive Heart Failure Radiographic Staging
Stage
Finding
Remains Elevated
<1 day
<2 days
7-10 days
1
2
3
Cephalization
Interstitial edema
Alveolar edema
Pulmonary Artery Wedge
Pressure
12-18mmHg
18-25mm Hg
>25mm Hg
Aortic Dissection
Stanford
Type A
Type A
Type B
Debakey
Type II
Type I
Type III
Lesion
Ascending aorta only
Ascending + descending
Descending only
Murmur Maneuvers
Maneuver
Decrease LV volume
(valsalva, sudden
standing)
Increase LV volume
(squat, passive leg raise,
hand grip)
Mitral Valve Prolapse
HOCM
Longer murmur, click
Increases murmur
moves closer to S1 (earlier
and greater prolapse
Shorter murmur and
Decreases murmur
delayed click (decrease in
prolapse)
Jones Criteria (For Rheumatic Fever)
Need 2 major (or 1 major + 2 minor) plus evidence of preceding GABH infection
Major (CASES)- Carditis, Arthritis, Sydenham Chorea, Erythema Marginatum,
Subcutaneous Nodules)
Minor- fever, arthralgia, history of rheumatic fever, lab findings (elevated WBC, ESR,
CRP, or long PR interval)
Reperfusion Times for STEMI (symptoms less than 12 hours)
Door To Balloon (PCI) < 90 minutes
Door To Needle (Fibrinolysis) <30 minutes
Fibrinolytic Contraindications
Absolute
 Any prior intracranial hemorrhage
 Known structural cerebral vascular lesion
 Known malignant intracranial neoplasm
 Ischemic stroke within 3 months (if they have had stroke symptoms
for less than 3 hours though you’re in the clear)
 Suspected aortic dissection
 Active bleeding or bleeding diathesis (excluding menses)
 Significant closed head or facial trauma within 3 months
Relative
 Hx of chronic, severe, or poorly controlled HTN
 Severe uncontrolled HTN on presentation (>180 SBP or >110 DBP)
 History of prior ischemic stroke >3 months, dementia, or known
intracranial pathology not covered in contraindications
 Traumatic or prolonged (>10 min) CPR
 Major surgery <3 weeks
 Recent (within 2-4 weeks) internal bleeding
 Noncompressible vascular punctures
 For streptokinase/anistreplase: prior exposure (>5 days ago) or prior
allergic reaction to these agents
 Pregnancy
 Active peptic ulcer
 Current use of anticoagulants (the higher the INR, the higher the
bleeding risk)
Hypertension
Stage
Pre-HTN
Stage I
Stage II
SBP
120-140
140-160
>160
DBP
80-90
90-100
>100
Treatment
Lifestyle change
1-2 meds
Start 2 meds
Pulmonary
A-a Gradient = 150-[PO2 + (PCO2/.08)]
normal is 10-12
Wells for DVT (1 point each)
 Active cancer
 Recent immobilization/paralysis
 Bedridden for >3 days or major surgery within 4 weeks
 Localized tenderness along deep vein system
 Entire leg swollen
 Calf swelling >3cm compared to opposite leg
 Pitting edema
 Collateral superficial veins evident
 “Alternate diagnosis”= if you really think its something else then subtract 2
0 = low risk (<10%)
1-2 moderate risk (10-65%)
3 = high risk (>65%)
Wells Criteria for PE
Suspected DVT
3 points
“Alternative Diagnosis” so if you think it is a PE
3 points
Pulse >100 bum
1.5 points
Immobilization (or surgery) within 4 weeks
1.5 points
Hx of previous DVT/PE
1.5 points
Hx of hemoptysis
1 point
Hx of malignancy
1 point
<2 = low pretest prob (3.6% risk) 2-6= mod prob (20.5%) >6 high prob (66.7%)
PCP Pneumonia
CD4 count usually <200
Treat with steroids if pO2 <70 or A-a gradient is >35mmHg
Pleural Effusions
Exudate if
 Pleural fluid protein/serum protein >0.5
 Pleural fluid LDH > 200
 Pleural fluid LDH/serum LDH >0.6
 Pleural fluid cholesterol >60 mg/dL
Pneumothorax
Reabsorb 1% per day without oxygen and 5% a day with 100% oxygen
ARDS
PFTs
PaO2:FiO2 <200
Obstructive Pathology = FEV1/FVC of <80%
Massive hemoptysis= 50mL blood in one expectorant or >600mL/day
Gastrointestinal
Esophageal FB levels
C6- cricopharyngeus (most common site of FB in kids)
T4- aortic arch
T10-11 = lower esophageal sphincter (most common site in adults)
Hepatitis Incubation Periods
Hepatitis A = 15-50 days
Hepatitis B = 45-160 days
Hepatitis C = 15-150 days
Ranson’s Criteria (Remember “Georgia Law” GA LAW) at 24 hours
Glucose > 200
AST > 250
LDH >350
Age >55
Leukocytosis >16,000
Peritoneal Fluid Analysis
Serum Albumin- peritoneal fluid albumin= SAAG
SAAG >1.1 g/dL is portal hypertension
Spontaneous Bacterial Peritonitis
WBC >500 cells/uL
WBC >250 cells/uL with 50% neutrophils (more conservative)
Orthopedics
Compartment Pressure > 30mmHG = fasciotomy
Synovial Fluid Analysis
Normal
WBC
<250 WBC/mm3
Neutrophils <25% of WBC
Glucose
95-100% serum
glucose
Traumatic
200-2000
<25%
95-100%
Inflammatory
2,000-50,000
50-75%
75%
Septic
5,000->50,000
>75%
<50%
Trauma
Hemorrhagic Shock Classification
Class I
Volume Loss %
0-15%
Volume Loss (mL) 0-750mL
Heart Rate
<100
Pulse Pressure
Normal
Blood Pressure
Normal
Mental Status
Slightly
anxious
Urine Output
>30ml/hr
Fluid Replacement Crystalloid
Class II
15-30%
750-1500mL
>100
Decreased
Normal
Mildly anxious
20-30 ml/hr
Crystalloid
Class III
30-40%
1500-2000mL
>120
Decreased
Decreased
Anxious,
confused
5-15 ml/hr
Add blood
Class IV
>40%
>2000mL
>140
Decreased
Decreased
Confused,
lethargic
Negligible
Add blood
Indications for Thoracotomy with Hemothorax
 Initial output of >1500mL of blood
 50% hemothorax
 >200ml/hr for the first 2-4 hours
 Persistent decompensation or need for transfusions
Diagnostic Peritoneal Lavage
Positive DPL
>10mL of gross blood
>100,000 RBC for blunt trauma
>100,000 RBC for most stab wounds
>5,000 RBC for gunshot wounds (and “low chest” stab wounds)
Cervical Spine Injuries in Children
Children <8 years old have mostly high C-spine injuries
Children >12 years old are like adults and have low C-spine injuries
Spinal Injuries
Extension Type
Hangman’s (C2 fx)
Extension teardrop
Posterior atlanto-axial dislocation
Neural Arch fracture (of C1)
All of the rest are flexion (except for burst which is compression)
Spinal Cord Injuries
Central Cord (Hyperextension)- arm greater than leg weakness
Anterior Cord (Hyperflexion)- paralysis and decreased sensation
Brown Sequard (hemisection)- ipsilateral hemiplegia with contralateral
sensory deficits
Glasgow Coma Scale (best response)
Score
Eye Opening
6
X
5
X
4
3
Spontaneous
To voice
2
To pain
Verbal
X
Oriented,
conversant
Confused
Inappropriate
words
Moaning
1
None
none
Motor
Obeys commands
Localize to pain
Withdraws
Abnormal flexion
(decorticate)
Extension
(decerebrate)
None
Obstetrics/Gynecology
Pre-Eclampsia
Blood Pressure
Protein
Mild
SBP >140 DBP >90
0.3gm/24 hour
Urology/Nephrology
Urine Sodium- Low = <20, High = > 40
FENa <1 is pre-renal
Urine osmolality >500 is concentrated and <300 is dilute
Urine culture results- Positive if:
>100,000 (105)/mL
>100 (102)/mL if symptomatic
Pediatrics
Shock
Blood 10ml/Kg
Fluid 20ml/kg
Severe
SBP >160 DBP>110
>5gm/24 hour
Maintenance fluids
4ml/kg for the first 10kg
2ml/kg for the next 10kg
1ml/kg for each kg after this
ET tube diameter= (Age in years/4) + 4
Cardioversion
Synchronized = 0.5J/kg
Defibrillating= 2J/kg
APGAR Score
Activity (tone)
Pulse
Grimace (to
irritation)
Appearance
Respirations
0
Limp
Absent
None
1
Minimal flexion
<100
Some motion
2
Good flexion
>100
Cry
Blue
Body pink/ ext
blue
Slow/irreg
Pink
Absent
Good, crying
Causes of death
Birth-1month = infection
1month- 1year = SIDS
>1 year = trauma
Kawasaki Disease
Fever for 5 days plus 4 out of the following:
 Changes of the lips/oral cavity (strawberry tongue, redness
 Bilateral nonsuppurative conjunctivitis
 Extremity features (palmar/plantar erythema, induration)
 Rash- lacey erythematous on the trunk
 Cervical lymphadenopathy (usually unilateral)
Cyanotic Heart Lesions (remember the hand mnemonic)
1. Truncus arteriosis
2. Transposition of the great vessels
3. Tricuspid atresia
4. Tetralogy of Fallot
5. Total Anomalous pulmonary venous return
Metabolic/Allergic
Serum Osmolality:
2(Na) + Glucose/18 + BUN/2.8 + Ethanol/4.6
Anion Gap
Na- (HCO3 + Cl)
Winter’s Formula
Expected PCO2 (+/- 2)= 1.5 x HCO3 +8
Allergic/Hypersensitivity Reactions
Type I: Immediate, IgE, bee stings, PCN allergy
Type II: Cytotoxic/compliment mediated, ITP, Blood transfusion rxn
Type III: Immune Complex ,(IgE with antigen clump up), serum sickness
Type IV: Delayed, T-cell mediated, TB test or poison ivy
Toxicology
Activated Charcoal: 1g/kg or 10:1 charcoal to toxin
Lithium
0.6-1.2 mEq/L therapeutic
Dialysis for
 Clinical signs of mod to severe poisoning
 Worsening of clinical condition despite falling levels
 Dysrhythmias
 Decreasing urine output or renal failure
 Serum level >4 mEQ/L
Salicylates (draw levels at 4-6 hrs then every 4 hours)
Dialysis for
 Serum ASA >90-100mg/dL
 Neurologic signs/symptoms (confusion, coma, sz)
 Renal failure
 Pulmonary edema
 Severe cardiac toxicity
 Severe acid-base imbalance
 Rising ASA levels despite urinary alkylinization
Acetaminophen
Phase
Time
1
0-24hr
2
24-72hr
3
3-4 days
4
4days2week
Symptoms
N/V, anorexia
Increasing hepatic enzymes but may be quiescent
Hepatic failure and encephalopathy
If survive stage III then will have complete resolution of
hepatic dysfunction
Iron
Potential toxicity at 40-70mg/kg
Blood levels and toxicity
Mild: 150-300
Moderate 300-500
Severe >500
Iron Concentrations (Feels So Good as you go down)
Ferrous Fumarate = 30% elemental iron
Ferrous Sulfate = 20% elemental iron
Ferrous Gluconate = 10% elemental iron
Stages (very much like APAP)
Stage Time
Manifestations
1
0-6hr
V/D, abdominal pain, GI bleeding
2
4-12 hrs
Improvement in symptoms (developing acidosis)
3
6-72 hrs
Coma, shock, sz, coagulopathy
4
12-96hr
Hepatic failure, hypoglycemia
5
2-4 wks
Pyloric scarring and bowl obstructions
Hydrocarbons
Badness= low viscosity and high volatility
Amanita Poisoning (again, a lot like APAP)
Phase Time
Manifestations
1
6-10hr
N/V/d
2
24-48hr
Symptoms resolve but LFT rise
3
1-6days
Hepatic failure, renal failure, encephalopathy, death
With mushrooms you would always rather vomit immediately then have delayed
vomiting (the bad mushrooms cause delayed vomiting)
Taylor Cyanide Kit
Amyl/Sodium nitrite- induce Methemoglobinemia (don’t use in a fire victim)
Sodium thiosulfate- sulfur donor
Carbon Monoxide (suggested hyperbaric therapy- very controversial)
 CoHb level >25%
 COHb level >10% and pregnant
 Any neuro symptom other than HA (including brief syncope)
 Coma
 MI
 Worsening symptoms with oxygen therapy
Electrolytes/Fluids
Total Body Water= 60mL/kg male and 50ml/kg in female
Total Blood Volume in adults 70ml/kg (7% body weight)
Total Blood Volume in children 90ml/kG (9% body weight)
3:1 rule- for every 3 L of crystalloid you infuse, only 1L stays intravascular
Neurology
Strokes made simple
MCA-contralateral upper more than lower weakness/sensation, aphasia/agnosia
ACA- contralateral lower more than upper weakness/sensation, no frontal lobe
PCA- Ipsilateral CN III palsy, contralateral homonymous hemianopsia, memory loss
All vertebral/brainstem lesions have crossing/mixed signs
VA- ipsilateral cranial nerve palsy, contralateral sensory defect, cerebellar signs
Wallenberg Syndrome (Lateral Medullary Plate)- Horner’s, vertigo, ipsilateral facial
numbness
Basilar- bilateral signs, Locked-in
Lacunar- small, focal, isolated motor or sensory
Tetanus mimic? = Strychnine
Physostigmine crosses the blood brain barrier
Lower CO2 to between 30-35mmHg for acute ICP increase
Uncal herniation- Ipsilateral pupil dilation and fixation
Central herniation- sudden respiratory changes and posturing
Cerebellar tonsillar herniation- pinpoint pupils, apnea
Fibrinolytics in Stroke (must be >18 YO, <3 hrs since normal, and measurable defect
Absolute Contraindications
 Evidence of intracranial bleeding (clinical or on head CT)
 Multilobar infarct (greater than 1/3 the cerebrum)
 History of any intracranial hemorrhage
 Known AVM, neoplasm, aneurysm
 Witnessed seizure at stroke onset
 SBP >185 or DBP >110 after treatment
 Active internal bleeding or trauma
 Bleeding diathesis (Plt <100,000, Heparin in 48 hrs, INR >1.7)
 Within 3 months of intracranial surgery, spinal surgery, prior stroke
 Arterial puncture at non-compressible site in past 7 days
Relative Contraindications






Only minor or rapidly improving symptoms
Within 14 days of major trauma or surgery
Recent GI or GU hemorrhage (21 days)
Recent MI (in 3 months)
Post MI pericarditis
Blood glucose <50 or >200
Environmental
Burn Transfer Criteria
 Second- or third-degree burns greater than 10% total body surface area
(TBSA) in patients younger than 10 years or older than 50 years
 Second- or third-degree burns greater than 20% TBSA in persons of other
age groups
 Second- or third-degree burns that involve the face, hands, feet, genitalia,
perineum, or major joints
 Third-degree burns greater than 5% TBSA in persons of any age group
 Electrical burns, including lightening injury
 Chemical burns
 Inhalational injury
 Burn injury in patients with preexisting medical disorders that could
complicate management, prolong recovery, or affect mortality
 Any patients with burns or concomitant trauma
 A lack of qualified personnel or equipment for the care of children (transfer
to facility with these qualities)
Parkland Formula (only includes 2nd and 3rd degree burns >20%)
4ml/kg X BSA- give LR and give half in the first 8 hours (AFTER THE BURN
NOT AFTER PRESENTATION TO THE ER)
Brooke Formula uses 2ml/kg
Add maintenance fluids for children
High Voltage is >1,000 volts
AC effects are usually worse than DC effects b/c you can’t let go
Voltage= current x resistance
Hypothermia
Temperature
34-36 C
30-34 C
Type
Mild
Moderate
<30 C
Severe
Rewarming
Passive external
Active external
(noninvasive active
internal)
Invasive Active internal
Moderate altitude = 8,000-10,000 ft
High altitude is 10,000-18,000 ft
High Altitude Pulmonary Edema is uncommon below 10,000 ft
High Altitude Cerebral Edema is uncommon below 12,000 ft
Radiation Doses
Mild dose (n/v/d)= 75-125 rads
Moderate dose (Acute radiation syndrome)= 100-200 rads
Severe (massive fluid loss, sepsis)= 500 rads
Absolute Lymphocyte count at 48 hours
>1200/mm3= good prognosis
300-1200/mm3= fair prognosis
<300/mm3= poor prognosis
Hematologic/Oncologic
Factor Replacement in Hemophilia
Severity
Examples
Severe
Head injury, major trauma, intra-abdominal
Moderate
Oral lacerations, dental extractions, late
hemarthrosis
Mild
Early hemarthrosis, hematuria, deep
laceration
Factor Replacement
50 units/kg
26 units/kg
18 units/kg
Cyanosis requires 5mg/dL of deoxygenated hemoglobin
EMS/Legal
Negligence (must have the 4 components)
1. Duty to treat- they belong to you
2. Breach of duty- you didn’t follow standard of care
3. Causation- you caused an injury and this could be foreseen
4. Damages- the result is actually a problem
Laws you might have to know
 Highway Safety Act of 1966- established DOT and EMS
 EMS Act of 1973- development of EMS standards of care
ER planning
12-14 parking spaces per 20,000 annual patient visits
1 patient space per 2000 annual visits
Minimum Staffing levels
30,000 annual patient visits = 5 full time docs with double coverage during
peak hours
40,000 annual patient visits = 6 full time docs with double coverage during
peak hours