Untitled Flashcards Set
PULMONARY
SVO2: 60-80%, higher the SVO2 worse pt doing, 90% -bad, 50%- good
ARDS:
Ideal body weight: 6-8ml/kg
Ideal body weight(ARDS): 4-6ml/kg
Horowitz index= P/F ratio
Horowitz index is a ratio of the partial pressure of oxygen in the blood (PaO2) to the fraction of inspired oxygen (FiO2).
P/F ratio, is between 350 and 450 normal
ARDS: A Horowitz index of 200 or less
Berlin definition: based on hypoxemia
-300 indicates mild lung injury
-200 indicates moderately severe lung injury,
-below 100 indicates severe lung injury.
Vent
AC- preset TV, preset rate if pt breathes extra will get preset TV
SIMV: extra breath will be their own TV
CPAP: 6/14 cm H2O, avg 10/5, continuous pressure
PEEP: Expiration
PS: Inspiration- pressure support
Pulmonary shunting- atelectasis, alveolar collapsing- fixed with peep
BIPAP- positive pressure ventilation with two pressure settings- used for COPD and CHF
· IPAP – Inhalation
· EPAP- Exhalation reduced setting
Intubation- start at 100%, Bring down to 60% within 1 hour, Then 40% and hold
· Rate of 12,
· TV- 6-8ml/kg of IBW
· Peep +5
· Draw gas/ adjust vent
Oxygenation problem increased Fio2/peep
Ventilation problem adjust TV/rate
Pleural Effusions: Exudate, Transudate, Hemorrhagic, Empyema(pus)
Exudate: creamy Pleural fluid ratio higher than serum
• Protein ratio> 0.5
• LDH ratio> 0.6
• LDH greater than 2/3 the upper limit of normal serum LDH
Transudate: clear, transudate have none of the above
PFT’s:
Obstructive diseases: asthma, chronic bronchitis, emphysema have low flow rates and normal or large lung volumes
Airflow rates: FVC, FEV1, FEV 25-27, PEFR
· FVC (Forced Vital Capacity): Represents the total amount of air a person can forcefully exhale after taking a deep breath.
· FEV1 (Forced Expiratory Volume in 1 second):volume of air exhaled in the first second of a forced expiration, considered a key indicator of airflow obstruction. 80% or higher of the predicted value.
o FEV1/FVC ratio considered to be above 0.7, indicating good lung function.
· FEV 25-75 (Forced Expiratory Flow between 25% and 75% of FVC): average airflow rate during the middle portion of a forced exhalation, helpful in detecting early signs of small airway disease.
· PEFR (Peak Expiratory Flow Rate): fastest rate of air exhaled during a forced breath, often used to monitor asthma severity.
Restrictive disease: morbid obesity, sarcoidosis, Pulmonary fibrosis have low volumes and low expiratory flow rate.
Volumes: TLC, FRC, RV: 80% and 120% of the predicted value.
· Total lung capacity (TLC): The amount of air in the lungs after inhaling as much as possible
· Functional residual capacity (FRC): The amount of air remaining in the lungs after exhaling normally
· Residual volume (RV): The amount of air remaining in the lungs after exhaling as much as possible
. Pneumonia:
· Strep pneumoniae
· Gram neg: H. influenza, Moraxella catarrhalis, Klebsiella
· Gram + Staph aureus
· S/S anorexia, poor appetite, tachypnea, SOB, fever, productive cough, confusion, change in mental status of elderly
· Elderly may not present with classis signs
CXR:
· Bacterial – bronchopneumonia, lobular, other locations
· Viral- bil interstitial infiltrates
· Aspiration: right middle lobe or diffuse
PEARLS (partnership, empathy, acknowledgement/apology, respect, legitimation, support) in elderly
GERO’S
Pulm :
· Decrease VC (amt of air forcibly exhaled) b/o increased residual capacity( amt of air left in lung after max exp
· Increase ant/post diameter
· Lungs and chest wall stiffens
· Alveoli collapses easily
· Cilia diminish
· Increased number of mucous cells
· Diminish cough reflex
PRACTICE ISSUE: PART 1
Healthy people 2030
Health literacy – degree to which people have the capacity to obtain, process and understand basic health info and necessary to make health care decisions-how much do they understand
At risk: elderly, minorities, poor population, underserved
1. Average adult reads at 8th grade level
2. Written info 6- less than 8th grade
Legislative and regulatory: Accreditation by Joint Commission
1. JC also lays National patient safety goals areas of concern for HCP
2. Goals for inpatient (acute /critical care):
· Proper ID
· Communication
· Medication safety
· Alarms- response
· Infection prevention(hand hygiene, resistant bugs, central lines, surgery, UTI-catheters)
· Surgical sites and time out
Institutional Bylaws: follow institutional guidelines
Rules laid down by institution may provide further qualification and restriction of health care staff
Economics: Resource utilization
· How consumers use healthcare resources and services
· Patient interaction with HCP
· Special concerns for acute care
o Length of stay
o Top diagnosis
o Preventable hosp
o LTC
o Emergency and primary care clinic utilization
Multidisciplinary Teams: MRT
· Multidisciplinary team
· RRT/code blue teams (provider, Nurse, RT, and others) no guilt, no shame
· Institutional disaster preparedness (pandemic, train crash, terrorist/ mass shooting, natural disaster, chemical exposure, fire explosion)
E.g.: Increase funding for RRT- to get more money, show hosp how they can save or make money
Future Mass causality – pre-enroll to help with disaster program like RED CROSS, then can help without having privileges
USEFUL ASSESSMENT TOOLS:
1.Alcohol/ drug abuse: CAGE or CAGE- AID/ AUDIT
2. Pain:
· Wong- Baker FACES – pediatric scale, self-assessment with faces
· Critical Care observation tool (CPOT)- assess 4 behavior changes - categories
1. Facial expression
2. Body movement
3. Muscle tension
4. Compliance with vent or vocalization
Each category is 0, 1, 2. “O” is pain free, Total is 0-8
3. Delirium: Confusion assessment CAM ICU- delirium, disorganized thinking, altered mental status. Should be conducted every day shift with patient
Four features:
1. Acute onset mental status changes or fluctuating course
2. Inattention
3. Disorganized thinking
4. Altered LOC
ANEMIA: reduction below normal erythrocytes, Hgb, or volume of RBC’s
Hgb: main protein that combines with O2. Normal 4-18 male, 12-16 females
Hct: amt of RBC to plasma Normal 40-54 males, 37-47 females
TIBC: total iron binding capacity 250-450
Serum Iron: 50-150
MCV- avg volume and size of RBC- 80-100
· Macrocytic: >100, Normocytic 80-100, Microcytic <80
MCH: avg weight/ amount of Hgb in RBC 26-34
MCHC: avg hgb conc or proportion of RBC by hgb percentage more accurate than MCH 32-36
· Hypochromic: <32, Normochromic32-36, Hyperchromic>36
Low MVC: Iron deficiency and Thalassemia
Normocytic: anemia of chronic disease, SS disease, renal failure, blood loss, hemolysis
High MCV: B-12 or folate deficiency (megaloblastic anemia), alcoholism, liver failure, drug effects
IRON DEFICIENCY ANEMIA: •Microcytic (low MCV<80), Hypochromic (<32), overall deficiency of iron
· Most common anemia
· Iron loss exceeds stores, decrease in iron avail for RBC formation
· Blood loss (vaginal bleeding), inadequate iron intake, impaired iron absorption
· Slow onset, few symptoms if HCT >30
· HCT falls- PICA, dyspnea, fatigue, weakness, pos hypotension, headache pallor
· Low: hgb, hct, mcv, mchc, rbc, serum iron store, low serum ferritin (iron stores)
· High: TIBC (iron binding capacity), RDW
· Take with OJ (increase absorption), avoid antacid, (decrease absorption)
· GI upset, flatus, constipation
· High iron foods: green leafy veg, raisins, red meat, citrus, iron fortified bread and cereal
· Ferrous sulfate 300-325 mg 1-2 hours after meals( food decreases absorption by 50%
THALASSEMIA: Microcytic/ Hypochromic
· Inherited disorder
· Abnormal Hgb production, Microcytic
· Mediterranean, African, middle eastern, Indian, Asian
· Symptoms unremarkable, unless severe
· Beta Thalassemia: most familiar type
· Decreased prod of normal adult Hgb A
· Hgb A has 4 chains, alpha chains are same, beta chains are same but diff than alpha
Beta thalassemia is the most common type of Thalassemia
Thalassemia Minor:
· Beta chains are reduced
· Thalassemia minor(adults) have one beta gene and one normal- heterozygous for beta
· Mild anemia
· Mimic iron deficiency
Thalassemia Major (Cooley’s anemia)- major problem-children do not survive
· 2 genes for beta and no normal chains
· Deficiency in beat chain production and production of Hgb A
· Normal presentation at birth
· Anemia gets worse over months and years
· **Neurological signs present
· Children with failure to thrive, feeding diff due to fatigue and low oxygen, fever, diarrhea, hepatosplenomegaly, jaundice, maxillary enlargement
· Low Hgb, low MCV (microcytic), MCHC(hypochromic), decreased alpha and beta chains
· Normal TIBC, normal Ferritin,
FOLIC ACID DEFICIENCY: Macrocytic /Normochromic
· Folic acid deficiency
· Inadequate or malabsorption of folic acid needed for RBC production
· Glossitis (big beefy tongue), Aphthous (ulcers in mouth), fatigue, DOE, pallor, headache, tachycardia, anorexia
· No neuro signs
· Low HCT&RBC serum folate decreases, RBC folate<100
· High MCV (macrocytic), MCHC normal(normochromic)
· Seen in ETOH, homeless, anorexia/bulimia
· Folate 1mg daily
· High folate foods: bananas, PB, fish, green leafy veg, iron fortified bread and cereal
PERNICIOUS ANEMIA: Macrocytic/ Normochromic
· Decrease intrinsic factor which results in malabsorption of B-12
· Weaknesses, glossitis, anorexia
· Neuro findings- paresthesia, loss of vibratory sense/ fine motor control, +Romberg, +Babinski, dizziness
· Low: hgb, hct, RBC, serum B-12 <200,
· Anti intrinsic factor (IF) and Anti-parietal test
· Lifelong replacement
· B-12 (cyanocobalamin) 100mg IM daily x1 week
ANEMIA OF CHRONIC DISEASE: chronic Normocytic /Normochromic
· Second most common anemia
· Associated with chronic inflammation, infection, RF, malignancy
· Decrease erythrocyte life span
· Fatigue, weakness, DOE, anorexia
· Low H/H, iron, TIBC
· Normal MCV (normocytic), MCHC(normochromic)
· Serum ferritin high >100
· Treat associated disease
· Nutritional support
· Epogen
· PPI- check CBC
SICKLE CELL DISEASE: chronic hemolytic anemia genetically transmitted – sicle cell red blood cells
· Acute period exacerbation RBC’s become sickle shaped and cause vessel obstruction
· African Americans/ Mediterranean
· Cellular hypoxia results in acidosis and tissue ischemia
· Pain from tissue hypoxemia and blood hyperviscosity
· Caused by hypoxia, high altitudes, dehydration, physical/emotional stress, surgery, blood loss, acidosis
· August thru September
· Develops in infancy and childhood
· Delayed growth and development, and high susceptibility to infection
· Crisis: sudden onset of severe pain in extremities, chest back and abdomen, aching joints, weakness, joints, dyspnea
· Decreased hgb
· Peripheral smear- distorted sickle shaped RBC’s
· Treatment: acute and chronic complications of disease
· Acute: fluids for dehydration, analgesia for pain(dilaudid), oxygen for hypoxemia
VON WILLEBRAND DISEASE: Genetic disorder reduced ability to clot blood, mutation of deficiency in Von Willebrand factor and clotting factor VIII(8)
· Easy bruising
· Frequent, prolonged or severe bleeding
· Desmopressin, recombinant von Willebrand factor(vWF/ factor VIII(8) concentrate
LEUKEMIA: Neoplasms arising from hematopoietic factors in Bone Marrow
· No direct cause
· More frequent in males
Ø Acute Myelogenous Leukemia(AML):
· **Auer rods
· 80% acute leukemia in adults
· Remission rate 50-80%
· Long term survival about 40%
· Chemo/BM transplant
Ø Acute Lymphocytic Leukemia(ALL)
· More difficult to cure in adults than children(90% remission in children)
· Pancytopenia with circulation blasts (hallmark of disease) Everything is low**
Ø Chronic Lymphocytic Leukemia (CLL)
· **Lymphocytosis (hallmark)
· **Most common leukemia
· Occur in middle and old age
· Avg survival 10 years
Ø Chronic Myelogenous Leukemia (CML)
· 40 or older, Survival – 65% survive about 5 years.
· **Philadelphia chromosome in leukemic cells (Hall mark)
LYMPHOMAS: Lymphocytic malignancy
Diagnosis/staging: Diagnosed by Bx enlarged Lymph node.
Staging:
o Stage 1 localized to single lymph node or group.
o Stage 2 more than 1 lymph node group, confined to one side of the diaphragm (under rib cage)
o Stage 3 Lymph nodes or the spleen involved occur both side of diaphragm
o Stage 4 Live or bone marrow involvement
Lymphoma Types:
Ø Non-Hodgkins:
· lymphadenopathy
· Cause unknown, viral?
· Often present with , Increase in 50’s
· Less predictable pattern that Hodkins
· Advanced stage apparent
Ø Hodgkins
· **Reed Sternberg cells -which differentiate it from non-Hodgkins
· Unknown cause, Common in males about 32 years
· Presents with cervical adenopathy, spread in a predictable fashion along lymph node group
· Painless swelling of lymph nodes, fatigue, fever, night sweats, and unexplained weight loss
· CT, Xray, ultrasound, MRI used to locate and stage.
· Biopsy/ histopathologic examination confirms diagnosis.
· Radiation, chemo, BM transplant
IDIOPATHIC THROMBOCYTOPENIA PURPURA (ITP): thrombocytopenia resulting from autoimmune destruction of platelets with or without suppression of thrombopoiesis.
· Usually chronic, causing mild to moderate thrombocytopenia maybe asymptomatic for long intervals
· Only occ develop bleeding that requires hospitalization
· More women than men 3:1
· BM analysis
· Low platelet count with other causes of thrombocytopenia ruled out/ hx of bruising/bleeding
· Management not needed until Platelets < 20,000
· High dose steroids help raise within 2-3 days
· IVIG produces responses in 2-3 days
· Gamma globulin preferred steroids in HIV- related ITP
· Occ platelet transfusion helps.
· Thrombocytopenia precautions: avoid constipation, no flossin, no shaving, hold pressure for 5 mins or more for cuts, line insertions
· Heparin induced thrombocytopenia (HIT)
o 4 T score
§ Thrombocytopenia: Evaluates the magnitude of the platelet count fall.
§ Timing: Assesses the timing of the platelet count fall relative to heparin exposure.
§ Thrombosis: Considers the presence of thrombosis or other sequelae of HIT.
§ Other causes of Thrombocytopenia: Examines the likelihood of other causes of thrombocytopenia.
o Stop heparin
o Agatroban, Lepirudin
o To differentiate between ITP and SLE- both have thrombocytopenia, -BM aspiration
DISSEMINATED INTRAVASCULAR COAGULATION(DIC)
acquired coagulation disorder resulting from intravascular activation of both coagulation and fibrinolytic systems (thrombin and plasma are activated) causing simultaneous thrombosis and hemorrhage, mortality 50-85%
Associated conditions: Malignant neoplasm, Infection /sepsis, Liver disease, massive trauma, Extensive burns, shock, ob complications, acute leukemia
· Thrombin causes fibrinogen to turn to fibrin producing fibrin clots
· Coagulation factors (fibrinogen, proththrombin, platelets, factors V and VIII) are reduced
· Circulating plasma activates the fibrinolytic system which lyses fibrin clots into fibrin degrading products (FDP’s).
· ***hemorrhage results from anticoagulation activity of FDPS and the depletion of coagulation factors***
· DIC varies each patient, bleeding vs thrombosis. Disturbances in hemostasis, oozing petechiae, ecchymosis.
· Thrombocytopenia platelets<150,000, Hypo fibrinogen (fibrinogen<170, (increase FDP’s)
· Decrease RBC, Increased FDP >45 or present at >1:100 dilution
· Prolonged PT>19, PTT>42, D. Dimer (at >1:8) simulation activation of thrombin and plasmin.
· Increased FDP 96% accuracy DIC
· Goal: treat underlying condition, control bleeding
· For sever bleeding: Platelet transfusion - thrombocytopenia, FFP – replace clotting, Cryo – to maintain FDP levels
· Use of heparin controversial
· Therapy goal: aimed at cessation of bleeding, increasing plasma fibrinogen and platelet count, decreasing FDP’s
· Hgb : Hct ratio, 1:3, 1-U PRBC- increase 1-Hgb, 3- Hct
COMMON PROBS IN ACUTE CARE
PAIN:
Acute: short<6 months- tissue damage
Chronic: continuous/ episodic >6 combination therapy is needed
Cutaneous: on skin
Visceral: poorly localized, internal organs (GB, peptic ulcer)
Somatic: no localized – muscles, bone, nerves, blood vessels, supporting tissues (subluxation shoulder)
Neuropathic: tumors, nerve pathway damage or compression (sciatic nerve)
· Pt self-reporting most reliable description
· WHO- 3 step -start with ASA, Tylenol, or nonsteroidal anti-inflammatory(NSAIDS, continue with adding narcotics while maintaining initial ASA, Tylenol, NSAIDS.
· Mild- no opioid + adjuvant - amtriptilline
· Moderate- weak opioid Tyelnol #3
· Severe: - non opioid + adjuvant - strong opioid
· Adjuvants: nontraditional therapy
· Breakthrough Cancer pain- fentanyl patch
· Met bone pain: Bisphosphonates (osteoporosis meds x5 years) - prevent cancer induced bone lesions
· Management conservative but liberal
PRESSURE INJURY:
Stage 1: intact skin- no blanching
Stage 2: Partial thickness loss of skin epidermis exposed
Stage 3: full thickness – adipose tissue is exposed
Stage 4: full thickness – fascia, muscle, tendon, ligament, bone
Unstageable: obscured full thickness skin and tissue loss
DTPI: persistent non blanchable deep red, marron, purple
Consideration:
Normal albumin (3.5-5.0), hypoalbuminemia problem
Wound care consult
Dressings: hydrocolloid
Worse outcomes: Death, bone infection- osteo, sepsis
FEVER: increased body temp above 37 Celsius (98.6) degrees, 37.7 (100.4) fever
Causes:
· Bacteria, viral, rickettsia, fungal or parasites- only one needs antibiotics
· Autoimmune (SLE, arteritis)
· CNS- (cerebral hemorrhage, brain tumor, MS)- interference with regulatory system
· Malignant neoplastic disease (primary and liver mets)
· Hematologic disease (lymphoma, leukemia)
· CV disease (MI, phlebitis, PE)
· GI (IBD, alcoholic hep)
· Endocrine (hyperthyroid, pheochromocytoma)
· Misc: familial Mediterranean fever, hematoma
· Neuroleptic syndrome:
o Antipsychotic syndrome (toxic on their antidepressant)- Haldol
o SSRI- 4-6 weeks relief from depression/ serotonin syndrome- high fever toxic to their SSRI
o Succinylcholine (SUX): relaxes laryngeal muscles, complication MH-
§ Do not use hyperkalemia or electrolyte imbalance
Staph epi, staph and aureus most common cultured organisms on cultures
Make sure cultures are done even before Tylenol, - need most robust response, body’s max immune response
POST-OP FEVER: INFECTIOUS/ NONINFECTIOUS
Concern sudden spike in fever
Noninfectious fever- causes
· Atelectasis
· Increased basal response (stress response),
· Cancer , pheochromocytoma,
· Dehydration, I/O, lymphoma/leukemia,
· Drug reaction(fever): amphotericin B, trimethoprim- sulfamethoxazole, beta lactams, procainamide, INH, alpha-methyldopa- insidious and stays up- linger
· MI, phlebitis, PE
· Neuroleptic Malignant syndrome: toxic on antidepressant/antipsychotic
· Serotonin syndrome: high fever from SSRI
· MH- succinylcholine reaction- check for hyperkalemia
· Staph epi and stap aureus most common cultured organisms
Infectious fever: causes
· Sudden spike
· Increase in WBCs with shift to left – Bandemia “left shift," increase in the number of immature white blood cells (specifically, band neutrophils) in the blood, often indicating an infection or inflammatory process.
· WBC elevation > 30,000 not usually infection-? Heme/leukemia
· Surgical incisions, IV sites, POC- catheter: culture, UTI, Lungs, Sinusitis- Ngt, Abscess -intra- abdominal
Initial response:
· Hydration/ Tylenol
· Lung expansion- atelectasis/ CXR?
· Infections -culture all invasive lines/catheters- sinusitis?
NUTRITIONAL SUPPORT
· Albumin 3.5-4.5 think protein malnutrition, EDEMA if Alb<2.7,
· Low alb(protein malnutrition) increases drug toxicity- and drug to drug interaction
· Prealbumin- earliest indicator of protein malnutrition
· Mg 1.7-2.2, - be careful of Malox, Mylanta
· Hgb- lack of iron and O2 perfusion women<12, men <13.5- testosterone stimulates erythrocyte production
· Clinical sign of healthy nutrition: Clear nail beds, pink moist mucous membranes, hair in good condition
Type of Nutritional support:
· Use GI tract first
· If >6 weeks use GI Ngt, if >6 weeks G-tubes (peg/gtube)
· Aspiration? Yes.>6 weeks duodenal tube (ND tube small bore beyond stomach), No asp -Ngt
· If cannot use GI tract, use PPN if need support more than 2 weeks then Central line
· Most common solution used is Dextrose 20%- need central line use TPN- do Accu-Check’s q6
· Peripherals cannot have more than D10%- sclerosis vein
Complications Enteral support
· Has to do with solution
· Diarrhea, emesis, bleeding, hypernatremia, dehydration
· Refeeding syndrome: hypophosphatemia, hypokalemia, hypomagnesemia, hypocalcemia, low Thiamine
Management of diarrhea:
1. Solution- too strong- try diluting
2. Rate Too fast-
3. Stop bolus – do continuous
Complication of parenteral support has to do with mode of delivery
Central lines: pneumo, air embolism, catheter sepsis, hemothorax, hyperglycemia- finger sticks
OVERDOSE: / DRUG POISONING:
1. Most treated symptomatically
2. GI decontamination:
a. Gastric lavage
b. Activated charcoal 1-2mg/kg usually first hour of ingestion
c. Cathartics: not routinely indicated with activated charcoal – sorbitol – usually given with first dose of activated charcoal
d. Antidotes of available
Acetaminophen OD: Tylenol, Anacin-3, Panadol
· Asymptomatic early phase, 1st 24 hour,
· 24-48 hours Nausea vomiting, RUQ pain, hepatotoxicity: jaundice, elevated LFT’s, PT, alt mental status, delirium
· Get Tylenol level
· Activated charcoal
· N-Acetylcysteine(mycomyst) with loading dose as needed
Salicylate OD: Aspirin
· Nausea/vomiting, increase temp, Tinnitus, dizziness, headache, dehydration, hyperthermia, apnea, cyanosis, metabolic acidosis, elevated LFT’s
· Activated charcoal
· bicarb drip to correct acidosis <7.1
Organophosphate(insecticide) poisoning: malathion, parathion
· N/V, cramping, diarrhea, excessive salvation, headache,
· **Blurred vision and Miosis(constriction)
· ** Bradycardia, mental confusion, slurred speech, coma
· Wash-skin thoroughly
· If insecticide- uses activated charcoal
Antidepressant (psych -like): Amitriptyline, Fluoxetine, Impramine, Nortriptyline, Bupropion
· Confusion, hallucinations, blurred vision, urinary retention-> hypotension, tachycardia, dysrhythmias, hypothermia, seizures
· ICU, if CNS or cardiac tox evident
· Activated charcoal, IV bicarb to counter dysrhythmias and maintain PH
· **Benzo for seizures (Valium)
· **Serotonin Syndrome (Dantrolene, Klonopin -rigors, cooling blankets- manage temp)
Opioid OD: Heroin, Codeine, Morphine, Opium
· Relaxed Euphoria
· Drowsiness, hypothermia, resp depression, shallow breathing, Miosos (pinpoint)
· Narcan, No Emetics, activated charcoal,
Benzodiazepine OD: “Pams”, Diazepam, Clonazepam, Lorazepam
· Drowsiness, confusion, slurred speech, resp depression, hyporeflexia
· Flumazenil, Resp/BP support, activated charcoal
BB OD: “lol” Metoprolol, Propranolol
· Bradycardia, hypotension, delirium, coma, bronchospasm
· Glucagon, Atropine, airway, Charcoal
Ethylene Glycol(antifreeze) OD
· 1st stage: (30-120mins) Loss of coordination, headache, n/v, slurred speech
· 2nd stage: (12-24) change in VS, irreg heartbeat, shallow breathing, change in BP(shocky)
· 3rd stage: (24-72)- kidney failure
· Fomepizole (Antizol), Ethanol- if Fomepizole not available
Compartment syndrome: increased interstitial pressure within a closed fascial compartment(skin-> fascia-> bone)
· Hemorrhage, edema, sustained pressure (cast, dressing) ?unconscious pt with swollen limb
· 24-hour post-op
· severe ischemic pain, Paresthesia
· tensely swollen, normal skin/arterial perfusion, passive stretch of muscle painful, progressive loss of sensory/ motor function, need frequent monitoring for development
· diagnosed with Stryker tonometer
· release constricting appliances(cast), fasciotomy- effective only if done within a few hours
Compartment Pressure: Stryker tonometer
· Normal compartment pressure: 0-8mmhg
· Intra-compartmental pressure >30mmhg Compartment syndrome- Need Fasciotomy
· Intra-compartmental pressure increases within 10-30 DBP: inadequate perfusion/ ischemia in extremity
· Delta Pressure: perfusion pressure of compartment: Delta pressure= DBP-ICP
· Delta pressure< 30 needs fasciotomy
Dog/Cat/ Human Bites:
· High pressure irrigation with NS
· Animal bites- rabies
· X-ray? head, Plastics
· Wounds to hands or lower extremities should be left open
· ANY wound older than 6 hours should be left open to heal with secondary intention
· Antibiotics: ? humans but def for animal staph and anaerobes coverage: 3-7 days prophylactic
Managing infections: “PSSP”
Presence of infection: increased WBC’s, fever, infiltrates-CXR, erythema, pus, secretions
Severity: age, immune status, comorbidity
Site: resp, skin, blood, IV urine
Pathogen: based on site /patient factors
DESCRIBING/CLASSIFY BACTERIA:
Gram Positive: thick wall, retain purple color after staining
· **Staphylococcus- most common
· Streptococci
· Enterococci
· Corynebacterium
Gram negative: thin walls- no stain
· **Escherichia Coli- most common
· Klebsiella
· Pseudomonas
· Proteus Mirabilis
· Moraxella catarrhalis
· Serratia Marcescens
· Acinetobacter
· Enterobacter
EMPIRIC THERAPY:
Otitis Media/Sinusitis: “itis” probs:
· Strep Pneumoniae: “itis” sinusitis, bronchitis, otitis, meningitis, CAP
· H. Influenzae, Moraxella catarrhalis
· Amoxicillin, amox clavulanate, cefuroxime, trimethoprim- sulfamethoxazole (TMP-SMZ)
Endocarditis: fever on unknown origin/heart murmur
· Acute: Staph Aureus, Vanco
· Subacute: Viridian Strep, enterococci, Penicillin +gentamycin OR Ceftriaxone
GI:
Peritonitis: ruptured viscus:
· Coliform, Bacteroides fragilis
· Metronidazole+ Cehplosporin (Cefepime or Cefotaxime) OR Piperacillin/Tazobactam OR Meropenem/Doripenem/ Imipenem
Intrabdominal:
· E. coli, Klebsiella/Bacteroides fragilis, Enterococci
· Cefazolin OR Cefuroxime OR Ceftriaxone OR Ciprofloxacin OR Levofloxacin(fluoroquinolones) + metronidazole OR piperacillin/tazobactam
Cellulitis: use least expensive/invasive
· Staph A, group A staph
· 1st generation cephalosporin (cefazolin, Cephalexin), Vanco IV, Clindamycin, Linezolid, Daptomycin, Doxycycline, TPM-SMX
Sepsis: Any bacteria
· Vancomycin + Cephalosporin (3rd or 4th generation) OR Piperacillin/Tazobactam or Imipenem OR Meropenem
Antibiotic Prophalaxis:
· Staph, strep, enteric- gram neg rods- Cefazolin if MRSA- Vancomycin
· Colorectal, appendectomy(non-perforated): gram- neg rods, anaerobes- Cefoxitin, Cefotetan, OR Cefazolin +Metronidazole
Red Man Syndrome/Vanco Flushing Syndrome (VFS)
· Stop vancomycin, H1 Blockers (Diphenhydramine) , H2 Blockers(Famotidine)
· For moderate reactions: restart at 1/2 original rate 10mg/hr
· Severe reactions run over 4 hrs- premedicate with antihistamine before each dose
Steven Johnson Syndrome: skin peeling off body
· Discontinue offending agent
· Start steroids
· IVIG
TRANSPLANT CONSIDERATION:
· All are immunosuppressed months before
· Acute Rejection
o Immediate failure of that organ
o Flu- like symptoms/Prodrome (fever, chills, malaise)
o Immediate Biopsy of transplanted organ
Tx: with 3 immunosuppressants
1.Corticosteroids: Methylprednisolone or prednisone (Deltasone, Orasone, Meticorn)
2.Antimetabolites: antiproliferative agents: maintenance immunosuppressants (Azathioprine (Imuran)ormycophenolate Mofetil (Cellcept), mycophenolate sodium (Myfortic) or cyclophosphamide(Cytoxan))
3. Calcineurin inhibitor: Tacrolimus (Prograf), or Cyclosporine (Sandimmune, Neoral, Gengraf)OR
Mammalian target of Rapamycin(mTOR) inhibitor: Sirolimus, (Rapamune), Temsirolimus (Torisel), Everolimus (Afinitor)
HERPES ZOSTER (SHINGLES)
· Acute vesicular eruption, varicella-zoster virus, life threatening in immunocompromised.
· Pain along dermatomal distribution- usually trunk
· **Grouped vesicles erythema exudate along dermal pathway
· if Ocular involvement- ophthalmology consult- medical emergency
· Regional lymphadenopathy
· Use “VIR” – Acyclovir, Famciclovir, Valacyclovir
· Post Herpetic Neuralgia: Gabapentin, (Neurontin): pregabalin (Lyrica)- FDA approved
· Shingrix: all adults >50, regardless of previous shingle vac. 2shots 2nd given 2-6 months after 1st
· Significant arm soreness,
· Crusty not contagious/ oozing contagious
KERATOSIS/ SKIN CANCER:
Actinic Keratoses:
· Small patches on sun exposed skin, maybe tender, rough, flesh colored, pink or hyperpigmented
· Premalignant- advance to Squamous Cell Cancer
· TX: Liquid Nitrogen
Squamous Cell Carcinoma:
· **Arises from Actinic Keratoses
· Dev over few months, 3%-7% metastasis
· Firm irregular papule or nodule, Prolonged skin exposed areas in fair skin
· Keratotic- scaly Bleeding
· Tx: Biopsy and surgical excision (Mohs procedure- deep chunk check edges to make sure its out)
Seborrheic Keratosis:
· Benign painful lesions
· Beige, brown, black plaques, stuck on, 3-20mm diameter
· Tx: none or liquid nitrogen
Basal Cell Carcinoma:
· Waxy, Shinny, pearly appearance, with red center and spider veins
· Most common cancer, slow growing (1-2cm after years)
· Central depression or rolled edges
· Telangiectatic vessels
· Tx: shave/ punch Bx and surgical excision
Malignant Melanoma:
· Highest mortality rate of all cancer
· Median age 40
· May metastasize to any organ
· Asymmetry, Border irregularity, Color variation, Diameter>6mm Elevation, Enlargement
(if 2 yes-melanoma)
· Tx: biopsy and excision
Brain death Consideration:
· Criteria: No cranial nerve function, Normothermia(37o)
· Family education: brain death =death(functionally/legally)
Terminal extubation:
· Family education: prep, education, support
· Morphine or other Opioid tachypnea and Resp distress (lungs ventilation no perfusion, lungs fluid
· Scopolamine patch – behind ear or sublingual atropine otic drops under tongue- reduce excess secretions
HEADACHES:
· Chronology is important- how did it start?
· Location, duration and quality, activity- sleeping, exertion, tension, relaxation, timing of headache- menstrual? assoc symptoms, triggers?
Tension: most common
· Vice-like, tight grip, generalized, lasts hours
· Intense around neck and back of headache
· No focal neuro symptoms
· No labs
· Tx: OTC meds, relaxation
Migraine: 2 categories
· Classic-aura(deja-vue), Common -without aura
· Dilatation and excessive pulsation of branches of external carotid artery
· Last 2-72hours and follow Trigeminal nerve pathway
· Triggers: menstrual, emotional or physical stress, lack or excess sleep, missed meals, specific foods, alcohol, oral contraceptives, nitrates, change in weather
· Adolescence or early adult, family history, females
· Unilateral, lateralizing throbbing headache occurs episodically
· Dull or throbbing
· Gradual and last hours to days
· ** positive neuro disturbances- aphasia, weakness, photophobia, phonophobia, tingling
· **Visual disturbances: Field defects luminous hallucinations (stars, sparks, zigzag)
· Normal appearing with neuro deficits or appearing ill
· Careful neuro exam to focal deficits r/o organic causes such as tumors.
· New migraines – through diagnostics (CBC, BMP, VDRL-r/o syphilis, ESR, CTH,
· Tx: avoid trigger foods, relaxation/stress techniques
· Prophylactic treatment: If occurring >2-3x a month-
o Anticonvulsant: Topiramate, Valproic acid
o BB: “Lol” atenolol, metoprolol, nadolol, propranolol, timolol
o Botulism toxin: inject tiny amounts around face/scalp q3 months, only approved for at least 15 headaches/month
o Tricyclic antidepressants (TCA)- “triptyline” Amitriptyline or Nortriptyline
o Calcitonin gene related peptide (CGRP) inhibitors “Mabs”: Eptinezumab, Erenumab, Fremanezumab, Galcanezumab
o NSAIDS- and triptans: helpful with menstrual cycle migraines
o Acute attack: quiet dark room, simple analgesic- right way, Sumatriptan 6mg sq at onset, repeat 1 hr (total 3x/day)
o Sumatriptan 25mg orally
Cluster Headaches:
· Very painful syndrome, middle aged men
· Severe unilateral peri-orbital pain occurring daily for weeks
· Physical exam normal: Ipsilateral nasal congestion, rhinorrhea, eye redness
· No fam hx, precipitated by alcohol, at night- awaken, lasts 2 hours, pain-free between attacks
· Tx: oral drugs don’t help, 100%O2, Sumatriptan 6mg sq may help
ELECTROLYTES:
Hyponatremia:
1. Urine Na (10-20 meq/L)
2. Serum osmolality usually 2x Na (275-285) 280
3. Isotonic hyponatremia: serum osmo 284-295
4. Hypotonic hyponatremia: serum osmolality<280mOSm water retention
5. Hypertonic hyponatremia urine serum osmo>290( maple syrup) water loss
6. Clinical status
Urine Na >20- renal salt wasting (prob with kidneys)
Urine Na<10- renal retention-extra renal losses (prob outside kidneys)
Isotonic Hyponatremia: Pseudohyponatremia secondary to hyperlipidemia or hyper proteinemia
· False elevation serum osmo 284-295
· Body water normal, asymptomatic
· Tx: cut down fat, do not fluid restrict
Hypotonic Hyponatremia: (serum osmolality<280mOSm)- body retaining water, water excess diluting all body fluid
Is it Hypovolemic or Hypervolemic Hyponatremia?
-Hypovolemic Hypotonic Hyponatremia.
Is Hyponatremia due to excess salt losses (Na >20)or renal salt wasting(Na<10).
· Hypovolemic with urine Na >20 : low volume kidneys cannot conserve Na( salt wasting)
Causes: Diuretics, ace inhibitors, mineralocorticoid deficiency (adrenal insufficiency)
· Hypovolemic with urine Na <10 : extra renal losses
Causes: vomiting, diarrhea-c.diff. vomiting
- Hypervolemic Hypotonic Hyponatremia (need to restrict fluid)
· Causes: edematous states, CHF, liver disease, advanced renal failure
Hypertonic Hyponatremia: urine serum osmo>290( maple syrup) not a true deficit of sodium, presence of a substance that draws water into the extracellular space, diluting sodium levels.
· Causes: hyperglycemia from HHS/ high blood sugar , osmolality is high and Na is low
· Tx: treatment based on cause
· Hypovolemia: give fluids NS
· Urine Na>20 – hold diuretics, ace inhibitors, or mineral corticosteroids
· Hypervolemic- water restriction
· Symptomatic give NS with loop diuretic
· CNS symptoms- 3% Na with loop diuretic (slow and calculated)
Hypernatremia: due to excess water loss, always indicates hyperosmolality (deficiency of water)
· Tx: Severe hypernatremia with hypovolemia: NS IV followed by ½ NS.
· Hypernatremia with Euvolemia – D5W
· Hypernatremia with hypervolemia – free water and loop diuretics(D5W + Lasix- watch K+) , may need dialysis.
Hypokalemia:
· Chronic use diuretics, GI losses, extra renal causes, alkalosis, Trauma pts- due to elevated serum epinephrine
· Muscle weakness, fatigue, muscle cramps, Constipation/ileus due to smooth muscle involvement
· If severe <2.5 may see flaccid paralysis, tetany, hyporeflexia, and rhabdomyolysis
· Check creatine kinase, urine myoglobin
· Decrease amp on ECG, Broad T waves, Prominent u waves, PVC’s, Vtach, vfib
· Tx: Oral replacement - if>2.5 and no ECG changes
· If<2.5 or symptomatic, may give 40meq/l/hr, check labs q 4 and continuous ECG
· ***Correct Mag, if low, K+ will not correct.
Hyperkalemia:
· excess intake, Renal failure, drugs (NSAIDS), hypoaldosteronism, and cell death.
· Acidosis- Intracellular K+ to extracellular
· K+ increases 0.7 with each 0.1 drop in potential hydrogen(pH)
· Weakness flaccid paralysis, abdominal distention, diarrhea
· ECG not sensitive even with K>6.5, Tall peaked T waves
· Exchange resin (sodium zirconium cyclosilicate -Lokelma)
· If >6.5, cardiac toxicity, muscle paralysis: urgent management: 10units insulin +D50%
(pushes K+ back into cells)
CALCIUM:
· mediator of neuromuscular and cardiac function
· Total Ca: 2.2-2.6mmol/L (8.5-10.5mg/dl)
· Ionized Ca: 1.1-1.4mmol/L(4.5-5.5mg/dl)
· Ionized Ca: does not vary with albumin levels (useful when albumin not in range)
· Ionized Ca: Acidemia -increase, Alkalosis-decreases
· 50% of calcium is bound to albumin
· Normal Ca with low alb -> Hypercalcemia
Hypocalcemia: Hyper Sign
· Hypoparathyroidism, hypomagnesemia, pancreatitis, renal failure, sever trauma, multiple blood transfusion
· Increased DTR’s, muscle cramps, prolonged QT, Convulsions
· Trousseau sign/carpopedal spasm- BP cuff leaves spasm
· Chvostek’s sign (cheek twitching after touching)
· Check ph- look for alkalosis
· Acute: IV CA gluconate
· Chronic: vit D, oral supplements, aluminum hydroxide
Hypercalcemia:
· Malignancy, hyperparathyroidism, hyperthyroidism, Vit D intox, prolonged immobilization (pelvic fx), rarely thiazide
· Fatigue, muscle weakness, depression, anorexia, n/v, constipation, severe- coma/death
· Tx: Calcitonin (pushes Calcium into bones) if impaired cardio/renal
· NS with loop diuretics
· Dialysis- if severe
ACID BASE: ROME
Resp Acidosis: hypoventilation
· pH <7.35, CO2>45mmhg
· decrease in alveolar ventilation
· acute resp failure: sharp rise in CO2 with only small rise in plasma bicarb
· somnolence, confusion, coma, myoclonus (involuntary jerking) with asterixis(flapping tremors)
· low pH<7.35, PCO2>45mmhg
· Tx: Narcan- if no obvious cause. 0.04to 2mg
· Increased rate on ventilator
Resp Alkalosis: hyperventilation
· Decrease arterial pCO2 and increase pH
· Decrease in cerebral blood flow
· Lightheadedness, anxiety, paresthesia, stocking/ glove tingling (feeling of wearing tight clothing)
· Tetany if severe
· Increase pH>7.45, low pCO2, low serum HCO3- if chronic
· Tx: underlying cause, hyperventilation breath into paper bag, decrease vent rate, sedate, rapid correction can cause resp acidosis.
Metabolic acidosis: low serum bicarb, high pH
· Measure anion Gap- will lead to cause and treatment
· Anion gap = (Na+K)-(HCO3+CL)
· Increased bicarb – more acute/sicker patient
· Increased Bicarb: MUD PILES
o Methanol, Uremia, Diabetes, Paraldehyde, Iron/INH, Lactate, Ethylene glycol, Salicylate
· Normal bicarb: diarrhea, ileostomy, renal tubular acidosis/RTA, recovery from DKA
· Treat underlying cause/fluid resuscitation
Metabolic Alkalosis: high pH and high bicarb
· High ph>3.45, HCO3>26
· compensatory PCO2 rarely exceed 55mmhg, if PCO2>55mmhg then resp acidosis is likely too(mixed venous
· Saline responsive – volume contraction/ contraction alkalosis
· Post hypercapnia alkalosis, Ngt suction, vomiting, diuretics
· Tx: saline responsive: correct with NS and potassium
· d/c diuretics
· H2 blockers with GI loss
· Acetazolamide (Diamox) 250-500 mg IV q 4-6 if volume replacement is contraindicated
ENDOCRINE:
Diabetes: inability to produce or utilize insulin causing hyperglycemia
DM1:
· antibodies again glutamic acid decarboxylase (GAD-65)
· ketones development, insult from infection/environmental toxin insult to pancreatic B cells
· develop “poly’s”: polyuria, polydipsia, polyphagia, nocturnal enuresis, weight loss, weakness/fatigue
· serum fasting at least 8 hour BS>126 more than once OR
o random BS >200 with the poly’s OR
o BS > after 2 hr glucose tolerance test OR
o Hgb AIC >6.5
· Management individualized
· Insulin regimen: basal + mealtime boluses of rapid or short acting insulin
· Basal insulin: once or 2xdaily of intermediate (NPH) or long acting (Detemir) or continuous insulin – pump using rapid acting (Lispro)
· Mealtime boluses + additional insulin to correct add hyperglycemia
Complications: DKA
Early morning hyperglycemia: DK1
· Somogyi effect(rebound)- nocturnal hypoglycemia stimulating counter regulatory hormones to raise BS. Hypoglycemia at 0300 but rebounds by 7.
Tx: check sugar at 0300 and reduce or omit bedtime insulin
· Dawn phenomenon: rising with dawn .desensitization of tissue to insulin at night, BS rises all night and hyperglycemia at 0700. Tx: add or increase bedtime insulin
Complication DKA:
· Acute complication of DKA
· Intracellular dehydration because of high blood sugar
· Kussmaul’s breathing- blow off ketones, fruity breath
· Poly’s, N/V, orthostatic hypotension, tachycardia, poor skin
· Hyperglycemia: BS >250 and >350
· Ketonemia/ Ketonuria, marked glycosuria,
· Metabolic acidosis ph<7.30
· Low bicarb (HCO3), lowPCO2,
· Hyperkalemia, Hyperosmolality:2(Na+K)+glucose +BUN/2.8
· Leukocytosis, High Hct, BUN, Create
· Tx:
o Isotonic fluids: NS in first hour then 500mls/hr
o If BS>500 use 1/2NS after 1st hr (water deficit exceeds Na loss)
o When BS<250 change to D51/2NS to prevent hypoglycemia
o Reg insulin bolus 0.1units/kg IV then
o Regular insulin drip 0.1units/kg/hr
o If glucose levels do not fall by at 10% after 1st hr then rebolus
o Correct severe acidosis(ph<7.1) with bicarb drip (44-48) meq in 900 ml in ½ NS until ph >7.1
o Do not treat initial hyperkalemia
o Hourly urine
DM 2: most common
· Enough insulin to prevent ketosis but not enough to meet needs
· Tissue insensitivity or insulin secretory defect causing resistance and or impaired insulin production
· Obesity syndrome: HTN abnormal lipids (low HDL) and high triglycerides
· Metabolic syndrome: (require 3/5) high risk for DM and cardioembolic death
o Waist circumference >40in (men), >35 in women (2.54cm)
o BP> 130/85
o Triglycerides>150
o FBG>100
o HDH<40 in men and <50women
· Insidious, get poly’s, recurrent vaginitis, peripheral neuropathy, blurred vision, chronic skin infections, pruritus
· Labs same as DM, theses have no ketones in blood or urine
· Tx: baseline data, weight control, diet, exercise
o Biguanides (Metformin) starter drug- absorbs glucose and hepatic glycogenesis, wt loss, Stop 1-2 days before contrast, BB: Lactic acidosis/muscle cramps
o GLP-1(Victoza/Trulicity): Oral/Sq, use with metformin, endogenous incretin GLP-1 , stimulate insulin release reduce glucagon, slow gastric emptying mimic BB: thyroid cancer, REMS: pancreatitis.
o SGLT2(Farxiga) Oral, use with metformin lowers renal glucose threshold leading to increased urinary glucose secretion. Canagliflozin/Invokana: renal dose adjustment. BB: high risk for foot and leg amputation.
Complication Hyperosmolar Hyperglycemic State (HHS)
· Elevated BS, hyperosmolarity, sever intracellular dehydration without ketone production.
· Not enough insulin is produced to prevent hyperglycemia, osmotic diuresis and extracellular fluid depletion
· Poly’s, weakness, change loc, hypotension, tachycardia, poor skin hydration, dehydration
· BS>600 commonly>1000
· Hyperosmolarity>310
· Elevated BUN/create, relatively normal pH, normal anion gap
· Tx:
o Isotonic fluids: NS in first hour then 500mls/hr
o If BS>500 use 1/2NS after 1st hr (water deficit exceeds Na loss)
o When BS<250 change to D51/2NS to prevent hypoglycemia
o Reg insulin bolus 0.1units/kg IV then
o Regular insulin drip 0.1units/kg/hr
o If glucose levels do not fall by at 10% after 1st hr then rebolus
o Correct severe acidosis(ph<7.1) with bicarb drip (44-48) meq in 900 ml in ½ NS until ph >7.1
o Do not treat initial hyperkalemia
o Hourly urine
Hyperthyroidism:
· Most common in women (8:1), 20-40
· **Graves’ disease, other causes of toxic adenoma, subacute thyroiditis, TSH secreting tumor and high dose amiodarone
· Nervousness, anxiety, sweating, fatigue, emotional liability, fine tremors, hyperreflexia- DTR’s, increased appetite, weight loss, smooth warm velvety skin, thin hair, exophthalmos, lid lag, tachycardia, heat intolerance, increased afib
· TSH assay most sensitive is low, ** T3 elevate (80-230) TSH low- normal/ T3 high
· ANA high- without lupus or other autoimmune
· Thyroid radioactive iodine uptake and scan to establish etiology of hypothyroidism-
· High uptake consistent with Graves, low uptake -thyroiditis
· MRI orbits preferred for visualizing graves ophthalmology
· Specialist as needed
· Propranolol for symptom management 10mg go up to 80mg daily
· Thiourea drugs for mild cases, small goiters or fear of isotopes
o Methimazole (Tapazole) 30-60mg daily in divided doses
o Propylthiouracil (PTU) 300-600mg daily divided doses
o Radioactive iodine to destroy goiter
o Thyroid surgery- must be euthyroid pre-op
o Lugol’s solution 2-3 gtts daily x10 days to reduce vascularity
o Subacute thyroiditis- use propranolol for symptom management
3 Labs 3.5-5.0
1. Potassium 3.5-5.0
2. Albumin 3.5-5.0
3. Phosphorus 3.5-5.0
4. Magnesium: 1.7-2.0
5. Hgb: Normal 4-18 male, 12-16 females
6. Hct: Normal 40-54 males, 37-47 females
7. TIBC: 250-450
8. Serum Iron: 50-150
9. MCV- avg volume and size of RBC- 80-100
a. Macrocytic: >100, Normocytic 80-100, Microcytic <80
10. MCH: avg weight/ amount of Hgb in RBC 26-34
11. MCHC: avg hgb conc or proportion of RBC by hgb percentage more accurate than MCH 32-36
a. Hypochromic: <32, Normochromic32-36, Hyperchromic>36
12. Low MVC: Iron deficiency and Thalassemia
13. Normocytic: anemia of chronic disease, SS disease, renal failure, blood loss, hemolysis
14. High MCV: B-12 or folate deficiency (megaloblastic anemia), alcoholism, liver failure, drug effects
15. TPN- D20%
16. PPN- D10%
17. Acetaminophen OD: N-Acetylcysteine(mycomyst)
18. Salicylate OD: Activated charcoal, bicarb drip if ph<7.1
19. Organophosphate(insecticide) poisoning- psych -like: Atropine- brady cardia -activated charcoal if insecticide
20. Antidepressant (psych -like)- Activated charcoal, IV bicarb to counter dysrhythmias and maintain ph
a. Benzo for seizures (Ativan, valium), Serotonin Syndrome (Dantrolene, Klonipin -rigors, cooling blankets- manage temp)
21. Opioids: Narcan(heroin, codeine, morphine, opium, fentanyl)
22. Benzo- “pams” Fluconazole
23. BB OD- Glucagon/atropine bradycardia
24. Ethylene Glycol(antifreeze)- Fomepizole (Antizol)
25. Compartment pressure 0-30mmhg, >30 -fasciotomy
26. Delta Pressure: perfusion pressure of compartment: DBP-ICP /< 30- need fasciotomy
27. Vanco- MRSA
28. Fluoroquinolones- kill kidneys
29. Miosis- constriction/pinpoint(organophosphate/opioid)
30. Mydriasis- dilated pupils (crack/cocaine/ methametapines)
31. ABI >1.3- calcification, <0.5 critical limb ischemia
32. Urine Na (10-20 meq/L)
33. Urine Na >20- renal salt wasting (prob with kidneys)
34. Urine Na<10- renal retention-extra renal losses (prob outside kidneys)
35. Serum osmolality usually 2x Na (275-285) 280
36. Isotonic hyponatremia: serum osmo 284-295
37. Hypotonic hyponatremia: serum osmolality<280mOSm water retention
38. Hypertonic hyponatremia urine serum osmo>290( maple syrup) water loss
39. Hypokalemia: Decrease amp on ECG, Broad T waves, Prominent u waves, PVC’s, Vtach, vfib
40. Hyperkalemia: tall peaked T waves
41. Total Calcium: 8.5-10.5mg/dl/ 2.2-2.6mmol/L
42. Ionized Ca: 4.5-5.5mg/dl, 1.1-1.4 mmol/L
43. Hypocalcemia: Trousseau sign/carpopedal spasm- BP cuff leaves spasm,- Ca Gluconate IV
44. Hypocalcemia: Chvostek’s sign (cheek twitching after touching) - Ca Gluconate IV
45. Hypercalcemia: Calcitonin- pushes Calcium into bones
46. Acute: short<6 months- tissue damage
47. Chronic: continuous/ episodic >6 combination therapy is needed
48. Cutaneous: on skin
49. Visceral: poorly localized, internal organs (GB, peptic ulcer)
50. Somatic: no localized – muscles, bone, nerves, blood vessels, supporting tissues (subluxation shoulder)
51. Neuropathic: tumors, nerve pathway damage or compression (sciatic nerve)
52. Anion gap = (Na+K) -(HCO3+CL)-Metabolic acidosis/ high anion gap
53. MUD PILES: Methanol, Uremia, Diabetes, Paraldehyde, Iron/INH, Lactate, Ethylene glycol, Salicylate- Metabolic acidosis with high anion gap
54. Transgender: patient how would you like me to address you
55. Cisgender: identify as birth gender
56. Nonbinary; not relate to birth gender
57. Reliability- reliable overtime
58. Validity
59. Somogyi effect(rebound)- nocturnal hypoglycemia stimulating counter regulatory hormones to raise BS. Hypoglycemia at 0300 but rebounds by 7. Tx: check sugar at 0300 and reduce or omit bedtime insulin
60. Dawn phenomenon: desensitization of tissue to insulin at night, BS rises all night and hyperglycemia at 0700.
Tx: add or increase bedtime insulin
61. Inch=2.54cm
62. Hyperthyroidism: TSH low- normal/ T3 high
63. Hypothyroidism: TSH high/T4 low or normal