ABEM ACCM cheat sheet

Reperfusion timing in STEMI: primary PCI within 90 minutes of first medical contact at a PCI-capable facility; fibrinolysis within 30 minutes when PCI is unavailable and symptom onset is under 12 hours without contraindication.

Aortic dissection: initiate intravenous beta-blockade to achieve heart rate near 60 bpm before adding a vasodilator, then titrate to systolic pressure of 100-120 mmHg; type A dissection is a surgical emergency.

Cardiac tamponade: Beck triad, pulsus paradoxus above 10 mmHg, and electrical alternans; positive-pressure ventilation can precipitate collapse, so drainage precedes or accompanies induction when feasible.

ACLS ventricular fibrillation or pulseless VT: biphasic defibrillation at 120-200 J, epinephrine 1 mg every 3-5 minutes after the second shock, amiodarone 300 mg bolus then 150 mg.

Unstable bradycardia: atropine 1 mg every 3-5 minutes to a maximum of 3 mg, then transcutaneous pacing, then epinephrine infusion 2-10 mcg/min or dopamine 5-20 mcg/kg/min.

Hypertensive emergency without aortic dissection: reduce mean arterial pressure by no more than 10-25 percent in the first hour; nicardipine, labetalol, or clevidipine are first-line infusions.

High-risk pulmonary embolism with hypotension: systemic thrombolysis (alteplase 100 mg over 2 hours), catheter-directed therapy, or surgical embolectomy; heparin alone is insufficient.

Acute cardiogenic pulmonary edema: noninvasive ventilation plus nitroglycerin for hypertensive patients; withhold nitrates in right ventricular infarction, severe aortic stenosis, or systolic pressure below 90 mmHg.

Berlin ARDS criteria: onset within 1 week of a known insult, bilateral opacities, respiratory failure not fully explained by cardiac failure, and PaO2/FiO2 ratio below 300 on PEEP of at least 5 cm H2O.

Lung-protective ventilation: tidal volume 6 mL/kg predicted body weight, plateau pressure below 30 cm H2O, permissive hypercapnia, and PEEP titration guided by oxygenation and compliance.

Tension pneumothorax: needle decompression at the second intercostal space midclavicular line or fifth intercostal space anterior axillary line, followed by tube thoracostomy without waiting for imaging.

Massive hemoptysis: secure the airway with a large-bore or double-lumen tube, position the bleeding side dependent, and proceed to bronchoscopy for localization and tamponade.

COPD exacerbation: titrate oxygen to SpO2 88-92 percent, give short-acting bronchodilators, systemic corticosteroids, antibiotics when sputum purulence increases, and noninvasive ventilation for hypercapnic acidosis.

Severe asthma: inhaled anticholinergics plus albuterol, systemic corticosteroids, magnesium sulfate 2 g intravenously over 20 minutes, and early noninvasive or invasive ventilation if fatigue develops.

Light criteria for exudative pleural fluid: pleural protein to serum protein ratio above 0.5, pleural LDH to serum LDH ratio above 0.6, or pleural LDH above two-thirds the upper limit of normal serum LDH.

Acute upper gastrointestinal bleeding: intravenous proton pump inhibitor bolus and infusion, endoscopy within 24 hours, and a restrictive transfusion threshold of hemoglobin 7 g/dL unless ongoing massive hemorrhage or ischemia.

Suspected variceal hemorrhage: octreotide 50 mcg bolus then 50 mcg/h plus ceftriaxone 1 g daily, restrictive resuscitation, and band ligation within 12 hours of presentation.

Spontaneous bacterial peritonitis: ascitic polymorphonuclear count of at least 250 cells/mcL; treat with cefotaxime and add albumin 1.5 g/kg on day 1 and 1 g/kg on day 3 when creatinine exceeds 1 mg/dL or bilirubin exceeds 4 mg/dL.

Acute pancreatitis: goal-directed lactated Ringer at 5-10 mL/kg/h, multimodal analgesia, early enteral feeding within 24-48 hours, and no prophylactic antibiotics in the absence of infection.

Acute mesenteric ischemia: pain out of proportion to examination, CT angiography is the diagnostic study of choice, then systemic heparin and urgent revascularization or laparotomy for peritoneal signs.

Boerhaave syndrome: transmural esophageal rupture presenting with chest pain, subcutaneous emphysema, and left pleural effusion; treat with broad-spectrum antibiotics, drainage, and surgical repair.

Toxic megacolon: nonobstructive colonic dilation above 6 cm with systemic toxicity; stop antimotility and opioid agents, resuscitate, and consult surgery for perforation, bleeding, or deterioration.

Acute ischemic stroke thrombolysis: alteplase 0.9 mg/kg (maximum 90 mg) with 10 percent as a bolus within 4.5 hours; blood pressure must be below 185/110 mmHg before and below 180/105 mmHg for 24 hours after.

Mechanical thrombectomy is offered up to 24 hours from last known well in large-vessel occlusion selected by advanced imaging, independent of thrombolysis eligibility.

Intracerebral hemorrhage: reverse anticoagulation immediately, target systolic pressure 130-150 mmHg, and obtain neurosurgical consultation for cerebellar hemorrhage above 3 cm or hydrocephalus.

Status epilepticus: benzodiazepine first (lorazepam 0.1 mg/kg or 4 mg), then levetiracetam 60 mg/kg, fosphenytoin 20 phenytoin equivalents/kg, or valproate 40 mg/kg; refractory cases require intubation and continuous anesthetic infusion.

Elevated intracranial pressure: head of bed 30 degrees, midline head position, brief hyperventilation to PaCO2 30-35 mmHg, and hypertonic saline or mannitol 0.5-1 g/kg; corticosteroids are indicated only for vasogenic edema from tumors.

Bacterial meningitis: give dexamethasone 0.15 mg/kg with or just before the first antibiotic dose when pneumococcal disease is suspected; antibiotics must not be delayed for lumbar puncture in unstable patients.

Subarachnoid hemorrhage: noncontrast CT within 6 hours is highly sensitive; if negative and suspicion persists, perform lumbar puncture for xanthochromia and start nimodipine 60 mg every 4 hours.

Spinal epidural abscess: fever, focal back pain, and progressive neurologic deficit warrant contrast-enhanced MRI and urgent surgical decompression with antibiotics.

Hemorrhagic shock: permissive hypotension with systolic pressure 80-90 mmHg until hemorrhage control, except in traumatic brain injury or pregnancy where higher pressures are maintained.

Massive transfusion: balanced 1:1:1 ratio of plasma, platelets, and packed red cells, tranexamic acid 1 g over 10 minutes within 3 hours of injury, calcium repletion, and active warming.

Traumatic brain injury: avoid systolic pressure below 110 mmHg and SpO2 below 90 percent; reverse anticoagulants and treat elevated intracranial pressure with hyperosmolar therapy.

FAST examination in unstable blunt trauma identifies pericardial and intraperitoneal free fluid; positive findings mandate operative intervention rather than further imaging.

Burn resuscitation: lactated Ringer 2-4 mL/kg per percent total body surface area in the first 24 hours, half given in the first 8 hours from the time of injury; use the rule of nines for extent.

Succinylcholine is avoided beyond 24-48 hours after major burns, denervation injury, or prolonged immobility because upregulated acetylcholine receptors cause life-threatening hyperkalemia.

Trauma in pregnancy: left lateral tilt or manual uterine displacement, resuscitate the mother first, and perform perimortem cesarean delivery within 4-5 minutes of maternal arrest.

Acetaminophen overdose: N-acetylcysteine is most effective within 8 hours; risk is assessed with the Rumack-Matthew nomogram using a level drawn at least 4 hours after a single acute ingestion.

Salicylate toxicity: sodium bicarbonate to alkalinize serum and urine (urine pH 7.5-8, serum pH 7.45-7.55), correct potassium, and initiate hemodialysis for seizures, coma, pulmonary edema, or renal failure.

Tricyclic antidepressant overdose: sodium bicarbonate 1-2 mEq/kg for QRS above 100 ms, ventricular arrhythmia, or hypotension; avoid class IA and IC antiarrhythmics and flumazenil.

Beta-blocker toxicity: glucagon 3-5 mg bolus then infusion, high-dose insulin with euglycemia, intravenous calcium, and vasopressors; calcium channel blocker toxicity follows the same approach with calcium first.

Digoxin toxicity: digoxin-specific antibody fragments for life-threatening arrhythmia or hyperkalemia; calcium salts are traditionally avoided and potassium is corrected cautiously.

Organophosphate poisoning: decontaminate, give escalating atropine until secretions clear and bronchospasm resolves, and add pralidoxime early; nicotinic weakness does not respond to atropine.

Carbon monoxide poisoning: 100 percent oxygen for all patients; hyperbaric oxygen is considered for loss of consciousness, neurologic deficit, cardiac ischemia, or pregnancy with elevated carboxyhemoglobin.

Methanol or ethylene glycol ingestion: fomepizole to block alcohol dehydrogenase, treat metabolic acidosis with bicarbonate, and dialyze for severe acidosis, visual or renal involvement, or high toxin levels.

Heat stroke: core temperature above 40 Celsius with central nervous system dysfunction requires immediate cold-water immersion; antipyretics are ineffective because the hypothalamic set point remains normal.

Severe hypothermia with cardiac arrest: continue resuscitation during active internal rewarming and consider extracorporeal membrane oxygenation; pronounce death only after rewarming fails.

Frostbite: rapid rewarming in water at 37-39 Celsius, no rubbing or early débridement, analgesia with ibuprofen, and thrombolysis for severe deep injury presenting early.

Drowning: hypoxia is the primary insult, so begin rescue breathing and chest compressions promptly; routine cervical spine immobilization and attempts to drain aspirated water are not indicated.

High-altitude illness: descend for altitude sickness; dexamethasone 8 mg then 4 mg every 6 hours for cerebral edema, and nifedipine plus descent and oxygen for high-altitude pulmonary edema.

Decompression illness: 100 percent oxygen, supine positioning, and urgent hyperbaric recompression for neurologic, pulmonary, or cardiac symptoms after diving.

Electrical injury: cardiac monitoring for high-voltage exposure or loss of consciousness, aggressive fluid resuscitation for deep tissue injury, and evaluation for rhabdomyolysis and compartment syndrome.

Compartment syndrome: pain with passive stretch is the earliest reliable sign; delta pressure (diastolic pressure minus compartment pressure) below 30 mmHg justifies fasciotomy, and palpable pulses are usually preserved.

Necrotizing fasciitis: surgical debridement is the definitive treatment and must not be delayed for imaging; add clindamycin for toxin suppression and consider intravenous immunoglobulin in streptococcal toxic shock.

Open fracture: prophylactic antibiotics within 1 hour (cefazolin, with an aminoglycoside for gross contamination), tetanus prophylaxis, and prompt irrigation and debridement.

Rhabdomyolysis: early aggressive isotonic fluids targeting urine output 200-300 mL/h, serial potassium and creatine kinase monitoring, and avoidance of nephrotoxins; bicarbonate is optional.

Septic arthritis: arthrocentesis before antibiotics with synovial white count, Gram stain, and culture; empiric vancomycin plus ceftriaxone covers staphylococci and gonococci in adults.

Gas gangrene from Clostridium perfringens: high-dose penicillin plus clindamycin, urgent radical debridement, and hyperbaric oxygen as an adjunct.

Septic shock bundle: measure lactate, obtain blood cultures, give broad-spectrum antibiotics within 1 hour, infuse 30 mL/kg crystalloid, and start norepinephrine for persistent hypotension with a mean arterial pressure target of 65 mmHg.

Vasopressor sequencing in septic shock: norepinephrine first, add vasopressin 0.03 units/min, then epinephrine; consider hydrocortisone 200 mg/day for shock refractory to vasopressors.

Anaphylaxis: intramuscular epinephrine 0.3-0.5 mg of the 1 mg/mL solution in the lateral thigh, repeated every 5-15 minutes; antihistamines and corticosteroids do not treat airway or vascular collapse.

Febrile neutropenia: antipseudomonal beta-lactam within 60 minutes of presentation; avoid rectal temperatures and lumbar puncture in hemodynamically unstable patients.

Toxic shock syndrome: source control, clindamycin plus vancomycin or penicillin for streptococcal disease, and intravenous immunoglobulin for refractory or severe streptococcal cases.

ACE inhibitor angioedema is bradykinin mediated and responds poorly to epinephrine; treat airway compromise with fresh frozen plasma, icatibant, or C1 esterase inhibitor concentrate.

Stevens-Johnson syndrome and toxic epidermal necrolysis: stop the culprit drug, transfer to a burn or intensive care unit, provide fluid and temperature support, and avoid prophylactic antibiotics unless infection is documented.

Diabetic ketoacidosis: isotonic fluid resuscitation, insulin infusion 0.1 units/kg/h, potassium replacement once serum potassium is below 5.2 mEq/L and urine output is adequate, and dextrose added when glucose reaches 200-250 mg/dL.

Hyperosmolar hyperglycemic state: profound free water deficit, modest insulin dosing after fluids, and attention to a corrected sodium that may be high despite dilutional hyponatremia.

Adrenal crisis: hydrocortisone 100 mg intravenously then 50 mg every 6 hours; use dexamethasone if a cosyntropin stimulation test is planned, and give saline with dextrose for hypoglycemia.

Thyroid storm: propylthiouracil or methimazole first, then iodine at least 1 hour later, plus beta-blockade, corticosteroids, aggressive cooling, and treatment of the precipitating illness.

Hyperkalemia with ECG changes: intravenous calcium for membrane stabilization, insulin with glucose and nebulized albuterol for intracellular shift, and hemodialysis for refractory or renal failure cases.

Dialysis indications summarized as AEIOU: acidosis, electrolyte disturbance (refractory hyperkalemia), intoxication (dialyzable toxin), fluid overload, and uremia with encephalopathy or pericarditis.

Thrombotic thrombocytopenic purpura: urgent plasma exchange for microangiopathic hemolytic anemia with thrombocytopenia and organ dysfunction; avoid platelet transfusion unless bleeding is life-threatening.

Serotonin syndrome: stop serotonergic agents, give benzodiazepines and supportive care, and use cyproheptadine for refractory neuromuscular hyperactivity; neuroleptic malignant syndrome instead responds to dantrolene and bromocriptine.

Sickle cell acute chest syndrome: antibiotics, incentive spirometry, transfusion, and exchange transfusion for severe hypoxemia or rapid progression; avoid overhydration and opioid-induced hypoventilation.