Iran Specialty Board - Emergency Medicine cheat sheet

Adult cardiac arrest: high-quality CPR at 100-120/min, depth 5-6 cm, full recoil, interruptions <10 s; compression fraction target >60% (ideally >80%).

Shock index = heart rate / systolic blood pressure; normal 0.5-0.7; >0.9 suggests occult hemorrhage or decompensation in adults.

MAP = DBP + (SBP - DBP)/3; septic shock initial target MAP >=65 mmHg with norepinephrine first-line when fluids insufficient.

Anaphylaxis: IM epinephrine 0.3-0.5 mg (1 mg/mL) into anterolateral thigh, repeat every 5-15 min; IV epinephrine reserved for refractory shock with infusion titration.

Pulseless VT/VF: defibrillate biphasic 120-200 J (manufacturer) or 360 J monophasic, resume compressions immediately, epinephrine 1 mg every 3-5 min after second shock.

Non-shockable rhythms (asystole/PEA): epinephrine 1 mg every 3-5 min as early as feasible; no atropine in current adult cardiac arrest algorithms.

Hemorrhagic shock: permissive hypotension (SBP 80-90 mmHg) until hemorrhage control in penetrating trauma without TBI; balanced transfusion 1:1:1 over crystalloid.

Post-ROSC: target SpO2 92-98% and PaCO2 35-45 mmHg, avoid hyperoxia and hyperventilation; targeted temperature management 32-37.5 C for comatose survivors.

Fluid responsiveness: passive leg raise or 250-500 mL crystalloid challenge; a >10-15% stroke volume or pulse pressure rise suggests preload responsiveness.

STEMI: ST elevation >=1 mm in two contiguous limb leads or >=2 mm in V2-V3 (men >=40 y), new LBBB with ischemic symptoms, or posterior MI (V1-V3 depression with tall R).

Acute coronary syndrome: obtain ECG within 10 min of arrival; door-to-balloon <=90 min at PCI center, or fibrinolysis within 30 min if PCI unavailable and symptom onset <12 h.

Aortic dissection: sudden tearing chest/back pain, pulse or BP differential >20 mmHg; CT angiography is diagnostic; give IV beta-blocker to HR 60 and SBP 100-120 before vasodilator.

Acute pulmonary embolism: Wells score, age-adjusted D-dimer, and CTPA; high-risk PE with hypotension gets systemic thrombolysis or embolectomy, not just anticoagulation.

Atrial fibrillation with rapid ventricular response: rate control with IV beta-blocker or diltiazem if EF preserved; avoid diltiazem in decompensated heart failure or pre-excitation (WPW).

Hypertensive emergency: end-organ damage (encephalopathy, aortic dissection, pulmonary edema, ACS) requires controlled BP reduction, typically <=25% in first hour.

Acute decompensated heart failure: IV loop diuretic plus noninvasive ventilation for pulmonary edema; nitroglycerin if SBP >110 mmHg; avoid beta-blockers in acute cardiogenic shock.

Tachycardia with pulse and instability: synchronized cardioversion; narrow regular SVT 50-100 J, narrow irregular 120-200 J, wide regular 100 J, wide irregular defibrillation dose.

Primary survey: catastrophic hemorrhage control, airway with cervical spine protection, breathing, circulation, disability, exposure; reassess after each intervention.

Massive transfusion: give plasma and platelets early; calcium replacement when citrate exposure is high; TXA 1 g within 3 h of injury then 1 g over 8 h.

Tension pneumothorax is a clinical diagnosis: needle decompression (5th intercostal space anterior axillary line, or 2nd ICS midclavicular in adults) followed by tube thoracostomy.

FAST exam detects free fluid in pericardial, perihepatic, perisplenic, and pelvic windows; sensitivity is lower for retroperitoneal and hollow viscus injury.

Blunt abdominal trauma with hypotension and positive FAST: operative exploration; hemodynamically stable patients get CT with IV contrast.

Traumatic brain injury: prevent hypoxia (SpO2 >94%) and hypotension (SBP >=110 mmHg for adults 15-49 or >70 years, >=100 for 50-69); hypertonic saline or mannitol for herniation.

Pelvic fracture with hemodynamic instability: pelvic binder at greater trochanters, avoid repeated pelvic exams, and consider preperitoneal packing or angioembolization.

Burns: Parkland formula 4 mL/kg/%TBSA lactated Ringer over 24 h (half in first 8 h); use Lund-Browder for children; escharotomy for circumferential full-thickness burns with compromised perfusion.

Compartment syndrome: pain out of proportion, pain with passive stretch, tense compartment; pressure >30 mmHg or delta <30 mmHg from diastolic warrants fasciotomy.

Toxidrome recognition: anticholinergic (dry, hot, flushed, mydriasis, delirium), cholinergic (SLUDGE/ DUMBELS), opioid (miosis, respiratory depression), sympathomimetic, sedative-hypnotic.

Acetaminophen: Rumack-Matthew nomogram at 4 h post-ingestion; N-acetylcysteine is most effective within 8 h; treat if level above treatment line or unknown time with hepatic injury.

Salicylate toxicity: mixed respiratory alkalosis and metabolic acidosis, tinnitus; urinary alkalinization with sodium bicarbonate targets urine pH 7.5-8.0; hemodialysis for severe cases.

Opioid overdose: naloxone 0.04-0.4 mg IV titrated to respirations, or 4 mg intranasal; repeat dosing because naloxone half-life is shorter than most opioids.

Tricyclic overdose: sodium channel blockade with wide QRS; sodium bicarbonate 1-2 mEq/kg for QRS >100 ms or ventricular arrhythmia; avoid class IA/IC antiarrhythmics.

Carbon monoxide: measure carboxyhemoglobin; 100% oxygen; hyperbaric oxygen for severe poisoning (syncope, neurologic deficit, COHb >25%, pregnancy with COHb >15-20%).

Organophosphate poisoning: atropine titrated to dry secretions plus pralidoxime; avoid succinylcholine due to prolonged paralysis.

Heat stroke: core temperature >40 C with CNS dysfunction; rapid cooling (ice immersion, evaporative) to target <39 C within 30 min; avoid antipyretics like acetaminophen.

Beta-blocker and calcium channel blocker overdose: high-dose insulin euglycemia therapy, calcium, glucagon; vasopressors and pacing for refractory bradycardia.

Acute ischemic stroke: IV alteplase 0.9 mg/kg (max 90 mg, 10% bolus) within 4.5 h of onset; tenecteplase 0.25 mg/kg is an alternative; thrombectomy up to 24 h with selected imaging.

NIHSS quantifies deficit; glucose must be checked before thrombolysis; BP must be <185/110 mmHg before thrombolysis and <180/105 after.

ICH: reverse anticoagulation (vitamin K + PCC for warfarin; idarucizumab for dabigatran; andexanet or PCC for factor Xa inhibitors), BP target SBP 130-150 mmHg.

Status epilepticus: benzodiazepine first-line (lorazepam 0.1 mg/kg or midazolam IM), then fosphenytoin/valproate/levetiracetam, then intubation with continuous infusion.

Bacterial meningitis: dexamethasone before or with first antibiotic dose, then ceftriaxone plus vancomycin; add ampicillin for Listeria in >50 years or immunocompromised.

Subarachnoid hemorrhage: thunderclap headache, CT within 6 h highly sensitive; if CT negative and suspicion persists, LP for xanthochromia after 12 h.

Headache red flags: sudden onset, fever with neck stiffness, focal deficit, papilledema, age >50 with new headache, pregnancy/postpartum, immunocompromise, and cancer history.

Spinal epidural abscess: fever, back pain, and neurologic deficit triad; urgent MRI and neurosurgical consultation; do not delay antibiotics for imaging in unstable patients.

ARDS Berlin criteria: onset within 1 week, bilateral opacities, not fully explained by cardiac failure, P/F ratio <=300 on PEEP >=5; lung-protective ventilation 6 mL/kg predicted body weight.

Mechanical ventilation: plateau pressure <=30 cmH2O, driving pressure <=15 cmH2O, permissive hypercapnia; target pH >7.20 for severe ARDS.

Asthma severe exacerbation: continuous inhaled beta-agonist, ipratropium, systemic corticosteroids, magnesium sulfate 2 g IV over 20 min; avoid routine antibiotics.

COPD exacerbation: controlled oxygen to SpO2 88-92%, short-acting bronchodilators, systemic steroids, antibiotics if increased sputum purulence or ventilatory support needed.

Noninvasive ventilation indications: COPD exacerbation with respiratory acidosis (pH 7.25-7.35), acute cardiogenic pulmonary edema; contraindicated with altered mental status or inability to protect airway.

Post-intubation hypotension: consider sedation, hypovolemia, auto-PEEP, pneumothorax, and adrenal insufficiency; check for esophageal intubation with waveform capnography.

Sepsis-3: suspected infection plus SOFA increase >=2; qSOFA (RR >=22, altered mentation, SBP <=100) is a screening tool, not diagnostic.

Ventilator-associated pneumonia: new infiltrate plus fever, purulent secretions, leukocytosis after 48 h of ventilation; obtain cultures before antibiotics.

Pediatric assessment triangle: appearance, work of breathing, circulation to skin; abnormal appearance is the most sensitive predictor of serious illness.

Weight estimate: (age in years x 2) + 8 kg for children 1-10 years; use length-based tape for resuscitation dosing when available.

Fluid bolus in children: 10-20 mL/kg isotonic crystalloid, reassess after each bolus; in septic shock, 40-60 mL/kg may be needed but reassess for hepatomegaly and rales.

Epinephrine for pediatric cardiac arrest: 0.01 mg/kg IV/IO (0.1 mL/kg of 1:10,000) every 3-5 min; defibrillation 2 J/kg first, then 4 J/kg.

Bronchiolitis: supportive care with oxygen and hydration; no routine bronchodilators, corticosteroids, or antibiotics; high-flow nasal cannula for moderate distress.

Croup: single dose dexamethasone 0.15-0.6 mg/kg; nebulized epinephrine 1:1000 (5 mL) for stridor at rest or severe distress.

Kawasaki disease: fever >=5 days plus 4 of 5 criteria (rash, conjunctivitis, mucosal changes, extremity changes, lymphadenopathy); IVIG 2 g/kg plus aspirin.

Pediatric sepsis: tachycardia and tachypnea may be the earliest signs; hypotension is a late finding in children.

Postpartum hemorrhage: uterine atony is the most common cause; give oxytocin, then methylergonovine, carboprost, or misoprostol; tranexamic acid 1 g IV within 3 h.

Ectopic pregnancy: check beta-hCG and transvaginal ultrasound; free fluid with hypotension requires urgent operative management; methotrexate for stable, small, unruptured cases.

Preeclampsia with severe features: BP >=160/110 mmHg or symptoms (headache, visual changes, RUQ pain) plus proteinuria or end-organ dysfunction; give magnesium sulfate and labetalol or hydralazine.

Magnesium sulfate dosing: 4-6 g IV loading over 20 min, then 1-2 g/h; monitor reflexes, respiratory rate, urine output; calcium gluconate for toxicity.

HELLP syndrome: hemolysis, elevated liver enzymes, low platelets; delivery is definitive treatment.

Placental abruption: painful vaginal bleeding, uterine tenderness, fetal distress; avoid digital cervical exam; resuscitate and deliver.

Ovarian torsion: sudden unilateral pelvic pain with nausea; ultrasound may show enlarged ovary with decreased Doppler flow; surgical detorsion is definitive.

Shoulder dystocia: McRoberts maneuver plus suprapubic pressure first; then internal rotational maneuvers; avoid fundal pressure.

FAST windows: subxiphoid (pericardial), right upper quadrant (Morison pouch), left upper quadrant (splenorenal), and suprapubic; a negative FAST does not exclude injury.

Focused cardiac ultrasound: parasternal long axis, apical four-chamber, subxiphoid; assess pericardial effusion, LV function, and RV dilation suggesting PE.

Lung ultrasound: B-lines suggest interstitial edema; absence of lung sliding plus A-lines suggests pneumothorax; lung point is specific.

Central venous access: use ultrasound guidance and confirm with manometry or ultrasound; complications include pneumothorax, arterial puncture, and infection.

Arterial line: radial first; perform Allen test (limited evidence but commonly used); avoid in inadequate collateral flow.

Lumbar puncture: opening pressure in lateral decubitus; avoid in suspected increased ICP with focal deficit or coagulopathy; CT before LP only if red flags present.

Cricothyrotomy: vertical skin incision, horizontal stab through cricothyroid membrane, bougie-assisted tube; used in cannot-intubate, cannot-oxygenate situations.

Chest tube: safe triangle at 4th-5th intercostal space, midaxillary line; avoid intercostal nerve injury by entering over the superior rib margin.

Response time benchmarks: cardiac arrest response and defibrillation within 8 min in urban settings; trauma scene time <=10 min for priority patients.

Triage in mass casualty incidents: START for adults (RPM: respirations, perfusion, mental status) and JumpSTART for children.

Prehospital airway: bag-valve-mask is first-line; supraglottic airway preferred over endotracheal intubation when providers lack experience; capnography confirms placement.

12-lead ECG acquisition in the field reduces reperfusion time when prehospital activation transmits to PCI centers.

Spinal motion restriction: apply only for suspected spinal injury; avoid routine backboards, which increase pressure ulcers and pain.

Destination protocols: trauma center criteria (anatomic, physiologic, mechanism), stroke center for thrombolysis candidates, STEMI center for primary PCI.

Handoff: use SBAR or MIST (mechanism, injuries, signs, treatment) to standardize communication and reduce errors.

Medical direction: offline protocols for standing orders and online medical control for deviations; document all deviations and refusals.

Disaster triage categories: immediate (red), delayed (yellow), minor (green), expectant (black/gray); reassess frequently as resources change.

Incident command system: unified command, operations, planning, logistics, and finance/administration; span of control is typically 3-7 subordinates.

Surge capacity: staff, stuff, space, and systems; crisis standards of care may be activated when resources are overwhelmed.

Hazardous materials: hot zone (only trained responders in PPE), warm zone (decontamination), cold zone (safe); decontaminate before transport.

Blast injury phases: primary (barotrauma), secondary (fragments), tertiary (displacement), quaternary (burns, inhalation); primary lung injury may present with delayed respiratory failure.

Chemical exposures: nerve agents treated with atropine and pralidoxime; cyanide with hydroxocobalamin; chlorine requires removal from exposure and supportive care.

Radiation: time, distance, shielding; acute radiation syndrome occurs with whole-body doses >1 Gy; decontaminate externally and monitor for marrow suppression.

Crisis communication: use plain language, avoid speculation, provide regular updates, and coordinate with public health authorities.

Informed consent requires capacity, disclosure, understanding, and voluntariness; emergency exception applies when immediate treatment is needed and no surrogate is available.

EMTALA: provide medical screening exam and stabilizing treatment regardless of insurance; transfer only after stabilization or with physician certification of benefit.

Capacity assessment: patient communicates a choice, understands information, appreciates consequences, and reasons; capacity is decision-specific.

Mandatory reporting: suspected child abuse, elder abuse, certain communicable diseases, and gunshot wounds (jurisdiction-dependent) to designated authorities.

Confidentiality: HIPAA permits disclosure for treatment, payment, and operations; minimum necessary standard applies; breaches require notification.

Advance directives: honor living wills and durable power of attorney for healthcare; in emergencies, provide treatment unless a valid directive is immediately available.

Documentation: record time of arrival, vital signs, interventions, reassessments, and disposition; late entries should be clearly labeled as addenda.

Conflict of interest and gifts: disclose relationships with industry; avoid gifts that could influence clinical decisions; follow institutional policy.

Sensitivity = TP/(TP+FN); specificity = TN/(TN+FP); positive predictive value depends on prevalence and equals TP/(TP+FP).

Number needed to treat = 1/absolute risk reduction; absolute risk reduction = control event rate minus treatment event rate.

Likelihood ratios: positive LR = sensitivity/(1-specificity); negative LR = (1-sensitivity)/specificity; LR >10 or <0.1 are clinically strong.

Levels of evidence: systematic reviews/meta-analyses of RCTs highest; case reports and expert opinion lowest; GRADE separates quality from strength of recommendation.

Randomized controlled trials reduce confounding by randomization; intention-to-treat analysis preserves randomization benefits.

Confidence intervals describe range of plausible values; a CI that includes 1 for relative risk or odds ratio is not statistically significant at that alpha.

Quality improvement: PDSA cycles (plan-do-study-act); measure structure, process, and outcome; use run charts and statistical process control.

Publication bias and conflict of interest should be assessed when appraising studies; check for trial registration and prespecified outcomes.