EMS 3 QUIZ
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Questions and Answers

Which of the following conditions is NOT associated with increased platelet destruction, leading to thrombocytopenia?

  • Hemolytic-uremic syndrome
  • Vitamin B12 and/or folate deficiency (correct)
  • Thrombotic thrombocytopenic purpura
  • Immune thrombocytopenia

    • A patient presents with thrombocytopenia and a history of recent heparin administration. What is the most likely diagnosis?

  • Immune thrombocytopenia
  • Thrombotic thrombocytopenic purpura
  • Disseminated intravascular coagulation
  • Heparin-induced thrombocytopenia (correct)

    • A patient presents with a platelet count of 30,000/microl. What is the most concerning risk associated with this level?

  • Increased risk of spontaneous bleeding (correct)
  • Increased risk of surgical bleeding
  • Increased risk of blood clots
  • Increased risk of infection

    • Which of the following laboratory tests is essential in the evaluation of thrombocytopenia?

    <p>Complete blood count (CBC) (C)</p> Signup and view all the answers

    A patient with thrombocytopenia is found to have a high reticulated platelet count. Which of the following is the most likely mechanism of thrombocytopenia?

    <p>Increased platelet destruction (D)</p> Signup and view all the answers

    Which of the following clinical presentations would raise suspicion for thrombocytopenia in a patient?

    <p>Easy bruising and petechiae (A)</p> Signup and view all the answers

    What is the significance of a platelet count below 50,000/microl?

    <p>It increases the risk of surgical bleeding (D)</p> Signup and view all the answers

    What is the primary survey in the approach to thrombocytopenia?

    <p>Assessment of airway, breathing, and circulation (ABCs) (B)</p> Signup and view all the answers

    Why is a peripheral blood smear considered a key diagnostic tool in thrombocytopenia?

    <p>It helps identify the type of platelet deficiency (D)</p> Signup and view all the answers

    Which condition is specifically characterized by warm, flushed extremities and a wide pulse pressure?

    <p>Early septic shock (A)</p> Signup and view all the answers

    What is the formula to estimate Mean Arterial Pressure (MAP) using systolic and diastolic blood pressure?

    <p>MAP = 1/3(SBP) + 2/3(DBP) (C)</p> Signup and view all the answers

    In which type of shock is increased cardiac output typically observed?

    <p>Warm septic shock (C)</p> Signup and view all the answers

    What is a key sign of end-organ hypoperfusion?

    <p>Cyanotic extremities (D)</p> Signup and view all the answers

    Which type of shock is primarily caused by inadequate blood volume?

    <p>Hypovolemic shock (B)</p> Signup and view all the answers

    A patient presents to the ER with an altered mental status (AMS). What step should be taken first to stabilize the patient?

    <p>Check the patient's blood glucose level. (D)</p> Signup and view all the answers

    A patient presents to the ER with a 160/110 blood pressure. What should be the next step?

    <p>Conduct a detailed history and physical exam, especially if the patient is an athlete. (C)</p> Signup and view all the answers

    A patient arrives in the ER with shortness of breath and chest pain. What is the most important consideration for the initial assessment?

    <p>Assess airway, breathing, and circulation (ABCs). (D)</p> Signup and view all the answers

    The concept of 'revaluation and reprioritization' in ER patient management refers to:

    <p>Re-assessing the patient's condition after initial treatment to determine if further interventions are needed. (A)</p> Signup and view all the answers

    Which of the following scenarios best represents the concept of “ED patients ‘don’t read the textbook’”?

    <p>A patient with a history of heart failure presents with chest pain, but it turns out to be a pneumothorax. (D)</p> Signup and view all the answers

    Which of the following aspects is not considered during the primary survey of an ER patient?

    <p>History of present illness and past medical history. (A)</p> Signup and view all the answers

    Which of the following scenarios best illustrates an 'emergent' triage level?

    <p>A patient with a laceration on their arm that is bleeding profusely. (C)</p> Signup and view all the answers

    Which laboratory finding suggests a diagnosis of TTP in the context of a patient who appears sick?

    <p>MCV levels &lt; 90 fL (C)</p> Signup and view all the answers

    Which of the following statements about Hemolytic Uremic Syndrome (HUS) is incorrect?

    <p>HUS primarily presents with neurological symptoms. (D)</p> Signup and view all the answers

    In the treatment of TTP, what should be initiated promptly regardless of ADAMTS13 activity levels?

    <p>Plasma exchange (plasmapheresis) (C)</p> Signup and view all the answers

    Which symptom is most characteristic of HUS as opposed to TTP?

    <p>Abdominal pain (D)</p> Signup and view all the answers

    What does not support a diagnosis of Thrombotic Thrombocytopenic Purpura (TTP)?

    <p>Creatinine &lt; 2.0 mg/dL (C)</p> Signup and view all the answers

    What is a priority in the management of severe cases of HUS?

    <p>Dialysis for severe kidney involvement (A)</p> Signup and view all the answers

    What laboratory findings are expected in a patient with HUS?

    <p>Elevated unconjugated bilirubin (D)</p> Signup and view all the answers

    Which is an essential consideration during the treatment of TTP by glucocorticoids?

    <p>Intravenous administration of methylprednisolone (B)</p> Signup and view all the answers

    Which clinical manifestation does NOT typically occur in TTP?

    <p>Diarrhea (B)</p> Signup and view all the answers

    What is the risk associated with platelet transfusion in TTP?

    <p>Increased risk of exacerbating thrombocytopenia (D)</p> Signup and view all the answers

    What is the primary pathological change in Disseminated Intravascular Coagulation (DIC)?

    <p>Uncontrolled fibrin production (D)</p> Signup and view all the answers

    What clinical sign is NOT typically associated with DIC?

    <p>Delayed wound healing (C)</p> Signup and view all the answers

    Which laboratory finding would best indicate Thrombocytopenia in the context of DIC?

    <p>Platelet count &lt; 50 x 10⁹/L (B)</p> Signup and view all the answers

    Which statement about the ISTH DIC Scoring System is accurate?

    <p>A platelet count of 50–100 x 10⁹/L scores 1 point. (B)</p> Signup and view all the answers

    What is a potential complication of using antibiotics in the treatment of Hemolytic Uremic Syndrome (HUS)?

    <p>Release of more toxins worsening the condition (C)</p> Signup and view all the answers

    What symptom is most commonly seen in critically ill patients suffering from DIC?

    <p>Hypotension (HOTN) (C)</p> Signup and view all the answers

    Which laboratory test finding would most suggest DIC?

    <p>Prolonged PT/PTT (A)</p> Signup and view all the answers

    In the context of DIC, what does the presence of fragmented RBCs (schistocytes) indicate?

    <p>Microangiopathic hemolytic anemia (D)</p> Signup and view all the answers

    What is a common consequence of the consumption of platelets in DIC?

    <p>Thrombocytopenia (A)</p> Signup and view all the answers

    Which condition is least likely to be a trigger for the development of DIC?

    <p>Renal failure (B)</p> Signup and view all the answers

    Flashcards

    Triage

    The process of determining the priority of patients' treatments based on the severity of their condition.

    Primary Survey

    The immediate assessment of a patient's vital functions: ABCDE (Airway, Breathing, Circulation, Disability, Exposures).

    Secondary Survey

    A detailed assessment to identify potential serious causes of symptoms after the primary survey.

    Revaluation

    The process of reassessing a patient's condition using new information like labs or imaging.

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    Disposition

    Deciding whether a patient should be admitted to the hospital or discharged home after evaluation.

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    Hematologic Emergencies

    Acute conditions affecting blood (e.g., ITP, TTP, HUS, HIT, DIC) requiring immediate attention.

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    Sepsis

    A life-threatening response to infection causing systemic inflammation and organ dysfunction.

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    Thrombocytopenia

    A condition characterized by a low platelet count, defined as < 150,000/microliter.

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    Types of Thrombocytopenia

    Includes ITP, TTP, HUS, DIC, and HIT.

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    Decreased Platelet Production

    Reduced creation of platelets due to factors like marrow infiltration, infections, and vitamin deficiencies.

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    Increased Platelet Destruction

    Conditions leading to higher destruction include immune thrombocytopenia and thrombotic thrombocytopenic purpura.

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    Splenic Sequestration

    Condition where platelets are trapped in the spleen, leading to low circulation levels, common in sickle cell disease and cirrhosis.

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    Primary Survey for Thrombocytopenia

    Initial assessment focusing on vital signs and urgent issues (XABC's).

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    Clinical Signs of Thrombocytopenia

    Includes symptoms like petechiae, bruising, and mucosal bleeding.

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    Lab Tests for Thrombocytopenia

    Key tests include CBC, peripheral blood smear, and coagulation panel to assess platelet count.

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    Severe Thrombocytopenia Risk

    Platelet count < 50,000 increases surgical bleed risk; < 20,000 poses spontaneous bleed risk.

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    Hematology Consultation Criteria

    Consult hematology if patient appears sick with severe thrombocytopenia and specific lab findings.

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    Severe Thrombocytopenia

    Defined as a platelet count less than 2mg/dL.

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    TTP Diagnosis Probability

    Probability levels: 6-7 = high, 5 = intermediate, 0-4 = low for TTP diagnosis.

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    TTP Treatment

    Immediate plasma exchange; do not wait for ADAMTS13 confirmation.

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    Glucocorticoid in TTP

    Methylprednisolone IV is used as a treatment.

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    HUS Classic Triad Symptoms

    Hemolytic anemia, thrombocytopenia, acute renal failure.

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    HUS Diagnostic Tests

    CBC, CMP show anemia, elevated creatinine, and fragmented RBCs in HUS.

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    E.coli in HUS

    HUS often caused by Shiga-toxin from E.coli O157:H7.

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    Symptoms of HUS in Kids

    Kids with diarrhea prodrome often present with HUS.

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    Supportive Care for HUS

    Includes fluids, electrolytes, and dialysis when needed.

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    Antihypertensives

    Medications used to manage high blood pressure.

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    HUS and Antibiotics

    Antibiotic use in Hemolytic Uremic Syndrome is controversial due to potential toxin release.

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    Disseminated Intravascular Coagulation (DIC)

    Pathological activation of coagulation leading to uncontrolled clotting and bleeding.

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    DIC Symptoms

    Signs of DIC include tachycardia, abnormal bleeding, and organ ischemia.

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    DIC Diagnosing CBC

    CBC in DIC shows anemia, thrombocytopenia, and possible leukopenia.

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    DIC Coag Panel

    Coagulation panel reveals prolonged PT/PTT and low fibrinogen in DIC.

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    ISTH DIC Scoring

    Scoring system assessing platelet counts to indicate DIC severity.

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    Clinical Signs of DIC

    DIC can result in abdominal pain, jaundice, and skin complications.

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    D-Dimer Test

    A test that is elevated in DIC, indicating fibrin breakdown.

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    Shock

    A state of circulatory insufficiency leading to tissue hypoperfusion and organ dysfunction.

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    Types of Shock

    The 5 main types are Hypovolemic, Cardiogenic, Anaphylactic, Septic, and Neurogenic shock.

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    Mean Arterial Pressure (MAP)

    MAP is calculated as CO x SVR; minimum of 65 mmHg is needed for tissue perfusion.

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    Septic Shock Symptoms

    Early septic shock shows warmth and hyperdynamic profile; late septic shows cold and hypodynamic profile.

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    Signs of End-Organ Dysfunction

    Altered mental status, oliguria, or anuria indicate hypoperfusion effects on organs.

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    Study Notes

    Heme/ID Emergencies

    • This presentation covers emergencies in hematology and infectious diseases.
    • ESM 11 focuses on the approach to Emergency Room patients including triage, primary survey, secondary survey, re-evaluation, discharge vs. admit, and disposition.
    • ESM 12 focuses on identifying and treating hematologic emergencies (ITP, TTP, HUS, HIT, DIC) and sepsis/septic shock.
    • ER patients often present with complex issues, not straightforward textbook cases.
    • A team approach is important in the ER, with providers and nurses working simultaneously.

    ER Overview

    • The main ER concern is ruling in or out life-threatening conditions.
    • ER patients often don't present as expected; recognition of patterns is crucial.
    • Key actions in the primary survey are performed simultaneously by different roles (providers and nurses)
    • ABCs (airway, breathing, circulation) are assessed and managed first.

    Approach to ER patients

    • Triage involves assessing if the patient is immediately life-threatening.
    • Recognizing possible life-threatening patterns in the patient's presentation is key.
    • Primary survey (XABCDE's) is used to prioritize actions. Severe external bleeding (X) is a high priority. Next comes Airway (A), Breathing (B), Circulation (C), Disability (D), and Exposures (E).
    • Nurses obtain vital signs while providers assess the ABCs. Access to IV & O2 is also important.

    Triage Scoring

    • A triage system is shown using different colors for different urgency levels (red, orange, yellow, green).
    • The system provides parameters to assess urgency based on vital signs and airway status.

    Normal vs Abnormal Vital Signs

    • Normal ranges for heart rate (HR), blood pressure (BP), respiratory rate (RR), oxygen saturation (O2), and temperature (T) are provided
    • Abnormal values (less than/more than the listed ranges) indicate potential issues, and need for further evaluation (bradycardia, tachycardia, hypotension, hypertension, hyperventilation, hypoventilation, hypoxemia, hypothermia, fever)

    Approach to Thrombocytopenia

    • Primary and secondary survey are needed.
    • High yield history includes recent hospitalizations, drug use, infections, bleeding risk factors, pregnancy, and medications.
    • Physical assessment includes checking for petechiae, purpura, bruising, lymphadenopathy, hematuria, and mucosal bleeding.
    • Lab work is essential for platelet levels, coagulation panel, CBC, peripheral blood smear, CMP, UA, and HCG(female).

    Thrombocytopenia Disposition

    • Consult specialists like hematology.
    • Discharge may happen if chronic, but careful monitoring and follow up for bleeding or worsening symptoms are required
    • Admit for acute, severe conditions (<20,000 platelets) with concern of bleeding, TTP/HUS, DIC, or HIT.

    Immune Thrombocytopenia (ITP)

    • It is an autoimmune disorder (autoantibodies attack platelets).
    • Patients are typically young to middle-aged women.
    • Clinical signs may include petechiae on mucosal areas or lower limbs, mucosal bleeding, hemorrhagic mouth blisters, bruising, and possible splenomegaly.
    • Diagnosis is via blood tests, looking at excluding other causes.
    • Treatment includes steroids, IVIG, and potential platelet transfusions if bleeding is severe and platelets are low.

    Thrombotic Thrombocytopenic Purpura (TTP)

    • A life-threatening condition caused by a lack of the von Willebrand factor-cleaving protease ADAMTS13.
    • Symptoms include: thrombocytopenia, microangiopathic hemolytic anemia, organ damage, and potentially a fever(but not always.)
    • Diagnosis often considers clinical presentation (a classic pentad, but often less than all symptoms are seen) as well as blood tests
    • The 4 T's score often is used as well as clinical assessment, history
    • Immediate treatment is required through plasma exchange (plasmapheresis) as well as hematology consultation.
    • Platelet transfusions are only used for severe/life-threatening bleeding.

    Hemolytic Uremic Syndrome (HUS)

    • Usually caused by bacteria(often E. coli) and Shiga-toxin.
    • Symptoms often similar to TTP, but with greater kidney (renal) involvement.
    • Diagnosis assesses for classic triad: hemolytic anemia (low H/H, or hemoglobin), thrombocytopenia and acute renal failure (kidney failure).
    • Treatment is supportive care, including fluids and possibly dialysis.

    Disseminated Intravascular Coagulation (DIC)

    • DIC is a consequence of severe underlying illnesses (sepsis, trauma, burns, obstetric problems, malignancies).
    • Characterized by abnormal activation of the coagulation system and consumption of clotting factors resulting in widespread microthrombi clotting, organ ischemia and diffuse bleeding from thrombocytopenia (low platelets).
    • Signs include: tachycardia, hypotension (low blood pressure), hypoxia, bleeding from orifices, and potential skin changes. Clinically, think of 'sick patient.' The presence of DIC may necessitate lab evaluation of clotting factors (PT/PTT, D-dimer).
    • Treatment focusses on addressing the underlying cause and providing supportive care like fluids, early antibiotics,source control(if indicated)

    Sepsis

    • Sepsis is a life-threatening condition caused by the body's response to infection.
    • Criteria include suspected or proven infection plus organ dysfunction
    • qSOFA & SOFA score are used, clinically, to assess end-organ dysfunction.
    • Treatment includes supportive care (fluids, antibiotics, source control, organ support), directed at reversing the infection and managing end-organ complications.

    Septic Shock

    • Septic shock is a severe form of sepsis characterized by persistent hypotension despite adequate fluid resuscitation.
    • Criteria for septic shock include sepsis combined with hypotension despite adequate fluids and elevated lactate values.
    • Treatment requires aggressive fluids, source control and antibiotics, and often the use of Vasopressors to help maintain blood pressure (MAP≥65)

    Shock

    • Shock is a state of circulatory insufficiency resulting in end-organ hypoperfusion.
    • Signs of shock include altered mental status, oliguria, warm shock, and cold shock.
    • There are five main types of shock (Hypovolemic, Cardiogenic, Anaphylactic, Septic, Neurogenic)
    • Treating shock involves identifying and addressing the underlying cause and providing supportive care.

    Optimization of Circulation

    • Central venous access is required for monitoring and vasopressor therapy (often in the ICU or similarly critical settings)
    • The choice of vasopressor therapy is dictated by the patient's situation.
    • Addressing end organ hypo-perfusion and the signs of end organ damage is important.

    Vasopressors in Septic shock

    • Common vasopressors used include norepinephrine, vasopressin, epinephrine.
    • The choice of agent is often dependent on the cause of the shock, but usually norepinephrine as a first-line for most

    End Points of Resuscitation for Vasopressors

    • Optimal end-points for titration include maintenance of mean arterial pressure (>65), heart rate(80-120) and urine output (>0.5mL.kg.hr) as well as observing for skin mottling.

    Disposition Consideration in Critical Illnesses

    • Disposition for patients with sepsis and septic shock generally (but not always) requires admission to the ICU

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    Heme/ID Emergencies ESM I Spring 2025 PDF

    Description

    Explore the critical aspects of managing emergencies in the Emergency Room with a focus on hematologic complications and sepsis. This quiz delves into triage strategies, patient assessment protocols, and the team approach necessary to handle complex ER cases effectively. Test your knowledge on identifying and treating life-threatening conditions.

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