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Emergency Medicine aaoaoooaoaaaaaoaoSaoaooaooaaaoaooaaaaoaaaaaooooaaaaaoaa Dr. Donald Sefcik Donald J. Sefcik is the Associate Dean at the Chicago College of Osteopathic Medicine (CCOM), Midwestern University (N[WU), in Downers Grove, IL. He is a tenured professor and board certified in both Emergency Medicine and Family Medicine. From June 1997 through May 2000, Dr. Sefcik served as Medical Director for the Physician Assistant Program, Coliege of Health Sciences (CHS), at MWU. Dr. Sefcik's lectures are based upon his experiences as a clinician and preceptor, tenure as a medical school faculty member, and his student assessrnent research. Dr. Sefcik has practiced with physician assistants since 1988 and been involved in the clinical training of physician assistants since 1990. Prior to joining Midwestem University's faculty, Dr. Sefcik was a faculty member in the Pharmacology Department at Butler University and in the Nursing Department at Marian College, both in Indianapolis, Indiana. Dr. Sefcik has a Bachelor of Science in Pharmacy (1981), a Master of Science in Pharmacology (1994), both from Butler University, ffid an MBA (May 2004) from Purdue University. CME Resources Certification & Recertification Exam Review

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Emergency Medicine


Page 1: PANRE and PANCE Review Emergency Medicine

Emergency Medicine


Dr. Donald Sefcik

Donald J. Sefcik is the Associate Dean at the Chicago College ofOsteopathic Medicine (CCOM), Midwestern University (N[WU), inDowners Grove, IL. He is a tenured professor and board certified in bothEmergency Medicine and Family Medicine. From June 1997 through May2000, Dr. Sefcik served as Medical Director for the Physician AssistantProgram, Coliege of Health Sciences (CHS), at MWU. Dr. Sefcik's lecturesare based upon his experiences as a clinician and preceptor, tenure as amedical school faculty member, and his student assessrnent research.

Dr. Sefcik has practiced with physician assistants since 1988 and beeninvolved in the clinical training of physician assistants since 1990. Prior tojoining Midwestem University's faculty, Dr. Sefcik was a faculty member inthe Pharmacology Department at Butler University and in the NursingDepartment at Marian College, both in Indianapolis, Indiana. Dr. Sefcik hasa Bachelor of Science in Pharmacy (1981), a Master of Science inPharmacology (1994), both from Butler University, ffid an MBA (May2004) from Purdue University.

CME ResourcesCertification & Recertification Exam Review

Page 2: PANRE and PANCE Review Emergency Medicine

Cerffication & RecertiJication Exam ReviewCME Resources


Emergency Medicine TopicsDonald J. Sefoik, D.O., FACOEP

Learning Objectives

Upon completion of flris portion of the review course, the participant should be able to:

1. Discuss the basic principles of toxicolory.2. Describe colnmon toxidromes and their management.3. Differentiate the three common causes of primary headaches.4. Discuss cofirmon secondary headaches.5. Describe the evaluation/management of common ophthahnologic fraumatic injuries.6. Discuss hyperkalemia - its presentation and management.7. Discuss cerebrovascular accidents and traumatic brain injuries.8. List and describe corrmon abnormal findings in urine specimens.9. List and describe common physical examination "signs" and findings.

Page 3: PANRE and PANCE Review Emergency Medicine

Overdose Sfafes

ldentifu the Druq

A, History

Who was there ?

What did they find out ?

Are there any bottles ?

Abiliiy to 'quantity'the ingestion ?Pafient's medical history ?' Time since ingestion ?

B. Physical Data

S - SalivaiionL. LacrimaiionU - UrinationD - DefecationG - Gl DistressE - Emesis

Flo'ir:; , sG'rr'r'u-u

opiates (- ftr'\.rxo^e-\IVliosis - Iin;.t\ p.ry',r(BradycardiaHypotensionHypoveniilationReduced LOC


Heart Rate 1Respiratory Rate-----r ,Z-.1 gz Signs-Biood Pressure / Toxidrome \Temperature -1 \- / (-symptoms.

* Level of consciousness, Pupil size, Breath..,.etc.



..Nff)-. VI- Chssic Toxidromes

LhS''- q)9..d\.WL Cholinergic Aqents


Acute, One-time lnqestions

y *Acetarninophen - Rumack-Matthew

,-+ AnTih"sIr rer,AGS\

nnticno[nerqic AHyperemia (Red as a Beet)Dry Skin (Dry as a Bone)Dilated Pupils (Blind as a Bat)Delirium (Mad as a Hatter)Tachycardia




Y1I* Aspirin - Done ( b e".,e \

ncr\v:.ig-^ )

Page 4: PANRE and PANCE Review Emergency Medicine

(G eneralizations - Common F eatures)


Age of Onset





Time of Onsa

Associated Featura

Anu&x"cr--ff\C^u\C4 tt'O''ASl

Aggravatkg Factors(Precipitdingfaaors)

Clinical Appestance



Childhood-< 3OyoF>M

l-4 /.month



Unilateral (65%)

Variable (often AIv!

AA{A/ (75o/o)

Phono/photophobia70% Fam.IIxC/assic - auraCommon - no aura


Withdrawal fromactivify

Prescription RxAbortiveProphylactic


Eariy Adulthood


30 min - weelcs



Later in day

AnorexiaMuscle tendemess


Mild disability


CLUSTER LIt".u" Lln s)20-40 yo \M>>F (,f .. t 1Cyclic,(Muitipie/day)

10-120 mi:r




Bed time

IpsilateralAI,IS Dvsfxn





02Many Rxs

* hsgrp"d','.\ h nls*-:t<;;Ae rale,

Page 5: PANRE and PANCE Review Emergency Medicine

S elect S econdarv Ileadaches


Sudden Onset & SeverityUsually innamanial areurysm (beny) rupture

50%(+; with Altered LOCAverage age = 50yq,..: .

"Sentinel" Headache Hx in 30%75% Neck Stifiness - ,f s,315% New-onset Seizures

V.f e e-,),,n5

CT Scan Misses 10-20% (False Negative)If CT Scan is negative and suspicion is high, DO A LUMBAR PLINCTTIRE

a, Hemo6hagrt fup (False Positive) a i;t-) a;t $Rr-'! ,\ isl'\ '' ltuf ii$e-b. Cerebral Aagiography is the "GOLD" standard for diagnosis/aneurysm location



Dull, deep aching, nondescript, progressiveOften worse on awakeningUsually worsened by valsalva maneuver or exerlionMay have nausea/vomiting or focal furdingsVomiting that precedes headache- think posterior fossa fimorcrscans$S+t,


Usualiy involves entire headOften associated with feverivomitingOften associated with Nuchal signs

Kcrnig's SignBrudzinski's sign

Diagnosis requires high index of suspicion and a lumbar pulcture


Usually a throbbing, occipital headacheMost often a morning headache \4.Usually does not occur until the diqslolic biood pressure ir o:gi-]{mmHg'Often overdia€nosed cause of headachesTreafinent- Antihypertensives

Disease of patients over 50yo/ESR> 50Women with 4:1 predorninanceUnilaterai, jabbing pain/worse at night \iArtery tender/pulseless- Biopsy=DiagnosisHigh dose rry to prevent biindness

L TEMPORAL ARTERITIS + Pa1*-*^g.r,. Rh"o*.";!z^ Lfncrc\Infiln'ation of Temporal Artery with lymphocytes, plasma cells and multinucleate giant cells


LUI<a { c:hcui'}

\e154\?,0 pt7 sui''i'h i*Y '*?t'* 'r',

Page 6: PANRE and PANCE Review Emergency Medicine

Ophthalmologic Trauma


L Contusion ("Black Eye")a, RIO Other Injury

2, Orb it al Wall' Fr hittn' e' 1;' bi o,w o ut Fr ac fiir e " )a. Flydraulic forces tbroughout the globe; rupture of medial wall and floor,

fapping faVmuscle and occasionally injuring nerve

b, Findings:

$ - Diplopia on upward gaze- Enophthalmos' Infraorbital anesthesia- Subcutaneous emphysema

)r ;'glsuding" of Maxillary Sinus

c. Treatrnent- Consult


-1.. Chemical Init;a:iest Do NOT Delay Treannent !!!

a. Alkali Bums- Liquefaction Nemosis- Irrigate (sometimes 24 hrs+)

Check pH with litnus paper-Refer/ConsultNOW !

b. Acid Burns- Coagulation Necrosis- hrigate & Consult

I'3. Radiation Butns (Iieratitis)($T Vrr,* beqn sK'rq\ 1 s*'b'<th'n1 *A

a.IJV radiation causes comeal epithelial sweliing; pain & blunedvision, hours afterthe exposure

,s ut4-b. Findings Jce r,vr k

Multiple Punctate a^reas on fluorescein staining \}) RiSn r

b, Trearnent ()- p*,{Jt {*TfD,.Ly. bdY

- Mydriatic agent \:2/ g(i\6b Lorrta

- Systemic Analgesic- Follow-up

Page 7: PANRE and PANCE Review Emergency Medicine

4. Corneal Abrasions

a. Complaint of foreign body "feeling"

b. Findings

- Foreign Body (+l)s Check Lid in eversion

- "Ice Rink Sign" with fluorescein

c. Treatnent

- Cycloplegic Agent- Antibiotic topically- Follow-up in 24-48 hrs

5 . Sub conj mctiv al Hemorchagea. Bright Red blood overlying scierab. Be sure no bleeding diathesis existsc. Blood Stops at limbusd. Should NOT affect visione. No specific therapy


l. Traumatic Hyphemaa. Blood in anterior charrber due to ciliary body or iris vessel disruptionb. Best seen with patient sitting upright with slit lampc. Must R/O other iqiuriesd. Findings

- MaY be ary':nPtomatic- PainlPhotophobia.tslured Vision- May cause N & V

e. Consult OphthaLnologist- Place a FOX Eye shield- Keep patient quiet @ 30-45 degree angle- Risk of secondary glaucoma

2. Lens Dislocationa. Marked VA Decreaseb. May be seen in Marfan's Syndromec. Consult your OphthaLnologist

3 . Tr^aumatic Mydriasisa.lmpairrrent of PSNS functionb. Referffsualiy temporary

Page 8: PANRE and PANCE Review Emergency Medicine

^ ^ t"rl

F{I?ERLATEMLA q R /o L.,\rrnue\\u;\er .

1. Definition - An elevated plasma potassium level (usually > 5.0 mEq/I-)

2. Pathophysiology

Hod\4/hy does it happen ?

Etiology -

L lncreased Potassium Load

Hemolysis (of sp ecimen) ; Leuko cytosis ; Thromb o cyto sis ; Phiebotomy

a, Exogenous - Excess intake; Dietary; Suppiemental, .,t\,8

b, Endogenous -Xedun'ibution )ll .r \r'so"o*htq\rb'^Y. 1, . C'-t

Kt t 'T ufAcidosis: Hemolysis; lnsulin deirciency; Exercise

C .KAJ 6r G], \2. Decreased Excrerion - T Kr Lh.,ire kt" \

Renal Failure; Rx Effect: NSAIDs; ACE inhibitors; K-Sparing Diuretics

3. Factitious -


Cardiac - Peaked T-wavesFiat P-wavesWidened QRS


V entricuiar fi brillation

Neuromusc- Paresthesias. Weakness


3. Differential Diagnosis -


^ni\** /JWII.

HypocalcemiaNeuromuscular disorderEKG abnormalities from other cause

4. Treatment Plan -

a, Rx - Sodi'hpolystlrene s{Y:}G\GXALATE) orally or rectaiiy

More sevet'e cases (Cardiac arrhythnzias, etc) may require:Dextrose & Insulin fV - temporizing measure/shifts potassium intracellularS o dium B i carb onate - temp orizin g measure/shifts potas sium intraceilularCalcium Giuconate - cardioprotective/potassium antagonist*\u_le"ut "{X s.

c, Other - Hemodialysis

Page 9: PANRE and PANCE Review Emergency Medicine

Cerebrovascular Accidents (CVAs)


A. lncidence @ 730,000 per year

B. Risk Factors


a. Advancing {ge- 2/3 occur in patients > 65 yo feach decade after 55 yo doubles the risk......]

b. Gender:Verr t Women

c. Family History: CVA or TIA

d. Diabetes mellitus: - 2 - 3 times the risk


a. Hypertension: - 4- 6 tirnes the riskA contributing factor in up to 70 olo of all CVAs

b, Atrial Fibrillaiion: - up to 6 iimes the riskA contribuiing factor in up to 15 % of all CVAs

,c, Transient lschemic Attack (TlA)Risk of a CVA is - 35 % wiihin 5 years

d. Cigarette smoking: -2-3 times the risk

e. Prior CVAMales: 42 o/o risk of a second CVA within 5 yearsFemales: 24 % risk of a second CVA within S years

f, Others: Myocardial lnfarction, Hypercholesterolemia, Sleep apnea


A. Transient lschemic Attack (TlA) + rF- transient neurologic deficii, ihat by definition, lasts less than 24 hours 't- - 90 % last less than 60 minutes (many < 15 minutes)- Amaurosis fugax - transient, partial or complete monocular blindness- Rule of 1/3sr' 1/3 will have a CVA in the future \f l4l ,,r.,.1*",.trJ ../ 1/3 will have a second TIA

\r,/ 1/3 will have no sequelae

B, Lacunar lnfarct (Deep Subcortical/"Whiie Matter" Area Changes; rD^ lz.i fr. ir,l{ -LC

- Contralateral PURE Motor Deficit (lnternal capsule) lj'T N) pt- Contralateral PURE Sensory Deficii (Thalamus)

- Clumsy Hand - Dysarthria (Pons or lnternal capsule)

Page 10: PANRE and PANCE Review Emergency Medicine

Intracranial l{emorrhagic Events Cerebral Ischemic Evenl.sIrrlr'acranial Hemorrhage Snbarachnoitl llemorrhage l'hrombotic CYAs Ernbolic CVAs

Onset/Progressiou Ol-ten actiye at onsetRapid progression

May be active/nonactiveVariable course

? 50% comatose atpresentation)

Nonacl.ive at onset- 60 % during sleepGradual progl'ession

Active at onsetRapicl onset

Etiology Aneurysm (berry)

Itisk(s) IlypertensionBleeding Diathesis

Associated with polycystickidney disease aud aorticcoarctation

fuleriosclerosis[IypeftensiorrDiabetes Mellitus

I-Ieart (Valvular) Disease

furatomic Locatiott Middle cerebralartery(comnon)

History Severe Cephalgia Severe CephalgiaStiff neckMay be lristory of alteredlevel ofconsciousness

tlsually no CephalgiaOften history of TtAs

Usually no Cephalgia

Physical Exanr Focal Neurological Signs Nonfocal examNuchal rigidity

Focal Neurological Signshrteural Carotid Bruit(s)

Focal Neurological Signs

Page 11: PANRE and PANCE Review Emergency Medicine

Arteny'Site of Involvernent Character-istic Feature(s) of CYA

lnternal Carotid Artery Ipsilateml Monocular Blindness (Anaurosis Fugax)Contmlateral HerniparesisContralateral l{emianesthesia/Hemianalgesia

Auterior Cerebral Artery Contralateral Lower Extremity paresis; aneslhesia,./analgesiaMinirnal Contralateral Upper ExtremityNo Face Clnnges

Middle Cerebral Artery Contralateral Upper Extrcmities paresis; anesthesia/analgesiaContralateral Lower Face droop (Tongue cleviates to sicle opposite of lesion; no fasiculal.ions)Minimal/No Lower Extrernify ChangesAphasia (if dorninant hemisphere is involved)

Posterior Cerebral Artery Contralateral l{omonymous Hemianopsia (rvith macu|ar sparing)Ipsilateral Cranial Nerve III PalsyMemory deficits (if hippocarnpus is involved)

Vertebrobasilar Artely Diplopia (PPRF or CN ltr, fV, VDWatch for CN dysftrnctionAtaxia / Vertigo (cerebellar signs)Bilateral Motor/Sensory Changes

Lacunar CVA Purc Motor (basilar pons or internal capsule) conlralateral to lesionPure Sensory (thalalnus) contralateral to lesionClurnsy I-Iand-Dysaltlu ia

Page 12: PANRE and PANCE Review Emergency Medicine

Traumatic Brain Iniuries


A. lncidence

a. - 2 million Americans with Head Trauma annuallyb, - 500,000 are admitted to the hospitalc, - 100,000 deaths per year (- 60 % occur before arrivalto the ED)d, Aicohol consumpiion is involved in - 25 - 50 % of cases

B. Classificaiions (arrival to ED)

a. Mild Head lniury

.ay GCS=14-15

n ^. erra$1^*J

- 80 % of rniuries

.. h{'-1 -( ' d9.n v-.<v"' b, Moderate Head lniurv

d'n*>Z ecs=9-13oof' -1o%oflnjuries\ -ze%die

c. Severe head lniury

GCS=Eorless- 10 % of lnjuries-40%die

C. Tvpes of Brain lniurv

Primary Injury



NeuralTissue lniuru

ContusionLacerationDifiuse Axonal lnjury

Secondary lnjuryHypotensionHypoxemiaHypovolemialncreased lntracranial Pressure

Cerebral V ascul ar I niury

lntraparenchymal HemorrhageEpidural HematomaSubdural HematomaSubarachnoid Hemorrhage

00 ms)




EYE Ooeninq4 Spontaneous3 To soeech2 To Pain1 No response

VERBAL Response5 Alert & Oriented4 Disoriented3 Nonsensical soeakino2 Moans/Unintelliqible sounds1 No response

MOTOR Response6 Follows commands

Localizes pain

4 Withdrawals from oain5 Decorticate posturinqI Decerebrate posturinq1 No response

Page 13: PANRE and PANCE Review Emergency Medicine


cLosED " rec #hcrL,'.a'h


{-Eng-aryAl Lesions i

- Epidurai Hematota * SKr\ Rnr\.nc, I me''"5 r'rdrrrS

,/ - 1 % of all traumatic brain injuries (- 12 % die)./ - 80 - 90 % associated wiih a skull fracture (often tears a meningeal artery)\/ Only - 20 % have classic: lnjury - LOC - Lucid lnterval - Deterioration

Up to 60 % have no loss of consciousness'/ Underlying brain injury is generally not severe./ 60 % occur in patients < 20 yor' < 10 % occur in patients > 50 yo

Subdural Hematorna'/ - 35 % of severe traumatic brain injuries

'v\.{a. rrtsvln'r' a' '/ Most occur in patients > 60 yo-i*).,n *W"Y \ * Atrophic brains (elderly and alcoholics) are at greatest risk

qJ- \

. . ^. yd vn,,X i Hffiliil3.tffii$;,ti:1?H,ltiJlla...r.,"tion mechanisms

t i,",*.r '/ Underlying brain injury is generally more severe'v '- J * Simple (no associated parenchymal injury - - 20 % die)* Complicated (associated brain injury - - 50 % die)

- Subarachnoid Bleed (Hemorrhage)

b. lntra-axial Lesions

- Cerebral Coniusions & Lacerations* Concussions

- Diffuse Axonal lnjuries (Axonal Shearing)

lncreased lntracranial Pressure

- Herniation Syndromes

Cn^ it:ru'cr{t,t\

ill6$ff:l''}jr" l'F[6sc- - Ariem.,t


cYc [c'-

t . Cushing Response (hyperiension; bradycardia; irregular respirations)

OPENa. Penetrating lnjuries

Page 14: PANRE and PANCE Review Emergency Medicine

ot,' .-

/-'"'''tqtut ' t


lmmobilize cervical spine(GCS < 6 = 14 % have C1 or C2 fracture)

E lev ated Inttucranial PressureHyperventiiationMannitolPentobarbiotai


A. CausesMotor Vehicle Accidents (MVA) - 45 o/o (cause - 60 % of deaths)Falls - 15 % (cause - 12 0/o of deaths)Assaulis - 14 o/o (Firearms - 14 o/o of deaths - approximately 75 o/o occur at the scene)OccupationalAccidents - 10 %RecreationalAccidents - 10 %

B. Preventiona. Safety (Seat) Belts and Air Bagsb. Helmetsc. Firearm Legislation


A, Salvage brain tissue not already irreversibly injured

B. ldeniifyicorrect eniiiies that may cause secondary injury

Operative Lesion

Epidural HematomaSubdural hematomalntracranial Hemorrhage with shiftDepressed Skull Fracture


lVsMonitorsFrequent Serial Examinations (NEURO)Secondary SurveyMonitor for ETTiHyperventilaiion need

Non-Operative Lesion

Non-Depressed Skull FractureContusionSubarachnoid Hemorrhage


lntubate (ETT)HyperventilatelVsMonitorsResuscitateSedation/ParalysisSecondary Survey(Life Threats....,)







Page 15: PANRE and PANCE Review Emergency Medicine

Considerations at Presentation:

a. Low-risk lniuries

- Not likely to deteriorate- Normal neurologic examination

* Asymptomatic; Subjective complaints: Headache, Dizzy... .,.

- Minor injury:* Scalp wound - Hematoma, Abrasion, Laceration....

*"* Approximately 0,3 - 3 % will deteriorate

b. Moderate -risk lniuries

- Difficult group to ass.ign a prognosis- Neurologic Signs & Symptoms of unclear significance

" Brief LOC; Vomiting; Post-traumatic amnesia.....* Progressive headache; Child age < 2 yo..

- lnjury (?):

" Arduous Assessment to make (Work-up ???)

*** Approximately 40 % will have an abnormal CT scan** Approximately I % will need a neurosurgical procedure*n Approximately 10 % will deteriorate

c. Hiqh-risk lniuries

- Criteria-defined neurosurgical emergencies- Neurolog ic Assessment dem onstrates si gnificant findings

* Depressed LOC (not explained by drugs, EIOH...)* Focal Neurologic signs" Decreasing LOC* Skull Penetration or Depressed Fracture

- lnjury: Suspect Primdry or Secondary Brain lnjury

*** Approximately 25 % will need a neurosurgical procedure


Manual of Neurology; McGraw-Hill 2002 (0-07-137351-9)

Handbook of Neurosurgery; Thieme New York; 2001 (0-865Z7-909-0)

Emergency Medicine ReporlsDecember 3, 2001: Head Trauma: Emergency Management and lmagingDecember 17,20Q1: Head Trauma: Severe, Moderate and Minor Head TraumaMay 11, 1998: Traumatic Brain lnjury: State-of-the-Art Proiocols