5's (combined from lectures) Flashcards
Approach to the Emergency Patient: “ABCDE/NGT, Opening Gambit, and FIVE vital signs”
“How do they look?” e.g. Sick, Not Sick, CPR in progress, etc
- Airway–is the patient alert, speaking, coughing, moving air? Stridor, hoarseness, gurgling?
- Breathing–any distress? Do you hear bilateral breath sounds?
- Circulation–do they have bilateral radial pulses? Do they look well perfused?
- Disability (Neuro)–are they alert and appropriate? ALTERED MENTAL STATUS? Think ”NGT!”
- Exposure/Environment–patient in a gown or trauma patient naked. Skin cold/hot, wet/dry?
“The OPENING GAMBIT” for any patient who has an emergency or appears unstable
- O2
- O2 Sats
- IV access
- ECG monitoring
- 12-lead EKG, +/- portable CXR
“There are FIVE vital signs” -Dr. Slovis
- HR
- BP
- RR
- O2 sat
- Temperature
What is “NGT”?
In patients with altered mental status, think of “NGT” before moving on:
Narcan: opiate reversal. for the obtunded patient with pinpoint pupils, apnea or slow RR, stigmata of narcotic use.
0.4mg IV to reverse iatrogenic opiates
2mg IV to reverse heroin user off the street (typical dose)
10mg IV to reverse certain special overdoses (see “ROC-LAVA-X”)
Glucose: CHECK FINGER STICK ON EVERY PATIENT WITH ALTERED MENTATION, SEIZURE, TIA/CVA, OR GENERALIZED WEAKNESS! (in grams/100ccs) – with glucose 1 amp = 50 ccs
One amp D50- adult. This is 25 grams of glucose in 50cc of water. Should raise glucose by ~200 within a few minutes
D25 at 4cc/kg- child.
D10 at 10cc/kg- infant.
Thiamine: (usually 100 mg) there are 5 types of patient who need thiamine if they are altered– 1. The cachectic calorie malnourished; 2. disheveled alcoholic; 3. malabsorption syndromes (short gut, gastric bypass, etc); 4. hyperemesis gravidarum; 5. anorexia nervosa
Causes of pinpoint pupils: narcotics, cholinergic overdose, pontine bleed
Causes of big pupils: benzos, barbiturates, global CNS hypoxia, anticholinergics
Narcan Dosing and Indications
opiate reversal. for the obtunded patient with pinpoint pupils, apnea or slow RR, stigmata of narcotic use.
0.4mg IV to reverse iatrogenic opiates
2mg IV to reverse heroin user off the street (typical dose)
10mg IV to reverse certain special overdoses (see “ROC-LAVA-X”)
High-dose Narcan (10mg IV) is the antidote for…
"ROC-LAVA-X" Reserpine (antipsychotic); Opiates; Clonidine; Lomotil (anti-diarrheal); ACE inhibitor/ARB overdose; Valproate; Aldomet (methyldopa); Xanaflex. There are many others.
Glucose Dosing
Glucose: CHECK FINGER STICK ON EVERY PATIENT WITH ALTERED MENTATION, SEIZURE, TIA/CVA, OR GENERALIZED WEAKNESS! (in grams/100ccs) – with glucose 1 amp = 50 ccs
One amp D50- adult. This is 25 grams of glucose in 50cc of water. Should raise glucose by ~200 within a few minutes
D25 at 4cc/kg- child.
D10 at 10cc/kg- infant.
Who needs thiamine?
Dose: usually 100 mg
There are 5 types of patient who need thiamine if they are altered–
- The cachectic calorie malnourished;
- disheveled alcoholic;
- malabsorption syndromes (short gut, gastric bypass, etc);
- hyperemesis gravidarum;
- anorexia nervosa
Causes of Hypoglycemia
Causes of Hypoglycemia “Re-ExPLAAAINeD”
Renal failure (insulin metabolism occurs in the kidneys); EXogenous insulin or oral hypoglycemics; Pituitary insufficiency; Liver disease; Adrenal failure; Alcohol ingestion (esp in children); Aspirin toxicity; Infection (esp sepsis in children); NEoplasm (insulinoma); Drugs Other hypoglycemia pearls: OCTREOTIDE can treat Sulfonylurea overdose by suppressing endogenous insulin secretion. GLUCAGON can stimulate glycogenolysis and gluconeogenesis but causes bad nausea and vomiting. Watch for POTASSIUM shifts when treating hyper and hypoglycemia!
3 Causes of pinpoint pupils (Miosis)
narcotics
cholinergic overdose
pontine bleed
4 Causes of big pupils (midriasis)
benzos
barbiturates
global CNS hypoxia
anticholinergics
5 causes of altered mental status:
- Vital sign abnormalities–hypoxia, shock, hypertensive encephalopathy, heat stroke (Open the gambit!)
- Toxic/Metabolic–particularly Hypoglycemia, Hypo/hypernatremia, (NGT, get labs!)
- Structural lesion–mass, bleed, stroke, demyelination, edema, (Get imaging!)
- CNS infection–encephalitis/meningitis (Get cultures, give abx, do an LP!)
- Psychiatric or Non-convulsive Status Epilepticus (Get a neuro consult for EEG, possibly psych consult!)
5 Causes of Seizure
- vital sign abnormalities–hypoxia, febrile sz
- toxic/metabolic–hypoglycemia, hyponatremia, alcohol withdrawal, INH toxicity, cocaine
- structural–bleed, mass
- CNS infection–herpes encephalitis
- Epilepsy
The FIVE treatments for status seizures
- ABC/NGT/GAMBIT–Roll on their side to protect airway from vomit, give O2, check O2 sats, CHECK GLUCOSE!
- Begin a Benzo–Ativan1-2mg IV, repeat as necessary
(What if I can’t get an IV? Ativan 2mg IM, Versed 5mg IM or 0.5mg/kg Intranasal, Valium 10mg rectal) - Consider Specific Antidotes (see below)
- Keppra 1000mg IV loading dose, or Fosphenytoin 1000mg IV over 20 min
- Barbiturates or Propofol ONLY IF you can manage the airway
The FIVE causes of seizure that need a true ANTIDOTE
- Hypoxia –> oxygen
- Hypoglycemia –> D50
- Hyponatremia –> 3% hypertonic saline
- INH toxicity –> Vitamin B6
- Eclampsia –> Magnesium and delivery of fetus
The DDX for Agitated Delirium/Hyperthermic and Altered
Sympathomimetic intoxication Anticholinergic toxidrome Sepsis Aspirin toxicity Heat stroke (T>40) Thyroid storm NMS (stiff) Serotonin Syndrome (clonus) Malignant Hyperthermia (stiff) Subarachnoid hemorrhage Malaria
The Five treatments of heat stroke
Heat stroke dx = Temp >105 + altered mental status + appropriate context
- Wet & Windy–spray and fan. NO ice water immersion (can’t monitor, will overshoot). Slow down when temp reaches 102
- Benzos for shivering (shivering keeps core temp high)
- IV fluids but be cautious. Replace their urine output. Need 2 IVs, a foley, and a rectal probe.
- Search for COMORBID CONDITION– occult infection or HONK in the elderly; CO poisoning, hypoglycemia, or sodium imbalance in the marathon runner
- Admit to ICU for support of multisystem organ failure (ARDS, liver failure, kidney failure, DIC)
The Five treatments of HYPOthermia
Only Rewarming will help the heart
1. Rewarm from the core–>out. Heating blankets, warm fluids, gut lavage, etc. NO immersion!
What is “Cold Diuresis”? When the pt gets cold, blood is shunted to the core, so renal perfusion increases and the kidneys pee off fluids that they should be holding onto. Hypothermic patients are thus usually hypovolemic.
Why not immerse in the hot tub? Lactate, potassium, and toxic metabolites are trapped in cold extremities and skin-warming will vasodilate, causing dumping of these toxins into the core causing hypotension
2. Consider NGT. Is this a malnourished drunk/drug user who passed out in the cold?
3. Consider Cx and antibiotics. Is this an elderly person who is septic and immobilized without heat?
4. Consider steroids. Is this pituitary/adrenal failure?
5. Consider synthroid. Is this hypothyroid myxedema coma?
Hypothermia: 5 EKG findings
(1) J/Osborne wave—risk of re-warming arrhythmia;
(2) Sinus brady;
(3) Slow A-fib;
(4) long QT; (prolonged PR, QRS too)
(5) V-fib that doesn’t respond to drugs or shocks.
Approach to a TIA/CVA
- ABC–protect airway by keeping HOB at 30 degrees, keep NPO
- NGT– CHECK FINGER STICK
- Activate stroke team
- Stat head CT without contrast to look for bleed
- Thrombolytics within 3-4.5h from sx onset)
(tPA = 30% more likely to have “minimal disability”; 5% will bleed [10-fold increase]; NO change in mortality)
Tests to order for TIA (3-5)
MRI of brain;
CTA or MRA of head and neck (or carotid duplex ultrasound);
+/- TEE for atrial thrombus
Meds to prescribe for TIA:
Aspirin. If on aspirin, consider plavix. If on plavix, consider heparin/coumadin.
Risk of stroke after TIA
10% of TIA patients will have CVA within 3 months, half of these within the first 48 hours (5%)!Do not miss this dx!
5 indications for intubation
- Failure to maintain airway—altered LOC, no gag, stridor, aspiration
- Failure to oxygenate (sats dropping) or ventilate (PCO2 rising)
- Multisystem instability—severe shock, poor physiologic reserve
- Projected Clinical Course—e.g. airway swelling after burn resuscitation, neck abscess/hematoma
- Need for transport/definitive tests—combative, harmful to self, safety in ambulance or helicopter
Troubleshooting Problem with ventilator
DOPES
Displacement of tube
Obstruction of tube,
PTX (also: PE, pulmonary edema, collapse),
Equipment failure
‘Stacked breaths’ (bronchospasm, ventilator settings)
Vignette: “Patient on a ventilator goes into PEA.” Think….
Think HYPOVOLEMIA or PNEUMOTHORAX. High intrathoracic pressure is occluding venous return.
Tx = disconnect vent, allow exhalation, bag ventilate, give bolus, consider needle decompression
Vignette: “Patient in status asthmaticus is getting better, then goes into PEA”: think
Think BREATH STACKING or PNEUMOTHORAX. High intrathoracic pressure is occluding venous return.
Tx = disconnect vent, allow long exhalation, give bolus, consider needle decompression.
The 5 reversible causes of Cardiac Tamponade
(1) Trauma
(2) Uremia
(3) Infection/TB
(4) malignant effusion—breast CA or lymphoma
(5) Rheumatic effusion—RA/SLE
The 5 phases of Alcohol Withdrawal:
(1) Tremulous/tachycardic/anxious in 6-8 hours
(2) Seizures in 24 hours
(3) hallucinosis in 24-48 hours
(4) Delirium Tremens = acting wild/all vitals elevated/need to be restrained in 3-5 days
(5) post-abstinence personality changes
Treatment of acute alcohol withdrawal (2)
- Benzos. Give Ativan or Valium. Titrate to effect, not a fixed dose.
2. Fluids/Lytes/Supplements. A Banana Bag is: 1L of D5NS at 200cc/hour, containing 1 amp multivitamin, 100 mg thiamine, 20-40 mEq K 2g Mg
Treatment for acute THYROTOXICOSIS: in order— (4)
(1) Dexamethasone;
(2) Propranolol;
(3) PTU;
(4) Oral potassium-iodide
The 5 causes of Anaphylaxis:
- Food
- Stings /hymenoptera
- Drugs (sulf, NSAIDs)
- Contrast
- Blood Transfusion
The 5 treatments for Anaphylaxis
- EPI 0.3 mg 1:1000 IM injection for adult, (0.1 for cardiac dose,
Peds dose 0.01 mg/kg) - Benadryl 25mg IV (as effective as 50mg, with less side effects)
- H2 blocker of choice (20mg pepsid)
- Solumedrol 125mg IV
- IV Fluids 20 cc/kg
+/- epi drip (= 1mg epi in 1L NS at 240cc per hour = 4 mics/min)
Can also give albuterol and glucagon if on beta blocker (with zofran)
The 5 causes of Hyperkalemia; next step
1) NOT (hemolyzed)
2) CRF/renal failure;
3) Acidosis(RF made worse by…acidosis);
4) Cell Death (burns, Rhabdo, Post-Ictal, Tumor Lysis;
5) Drugs (NSAIDS, ACE-I/ARB, succ, dig, tmp/smx)
“Next step for Hyperkalemia” = EKG! And repeat the lab sample
The 5 EKG findings of HyperK, in order of appearance:
(1) Peaked T—5.5;
(2) prolonged PR—6.5;
(3) Flat P wave—6.5;
(4) QRS widens—7.0-8.0;
(5) Sine wave
The 5 causes of Sine Wave on EKG:
1) HyperK;
2) TCA overdose;
3) Beta-blocker overdose;
4) CaChannel blocker overdose;
5) Severe Acidosis
If you see a sine wave, assume hyperK, go down that pathway
The 5 treatments for Hyperkalemia: (K should fall about 1-1.5/hr if you do this)
3 stages:
- reverse electrical (EKG) effects: CaCl
- Drive K into cells (I+G, albuterol)
- get it out of body (Kayexelate)
- Ca Chloride 10cc (1 amp), max 2 amps. for wide QRS, stabilizes membranes
- Regular Insulin 10U IV + 2 amps D50
- Albuterol or other Beta-Agonist
- Bicarb ONLY IF acidotic
- IV Fluids in DKA, rhabdo, tumor lysis, adrenal insufficiency
What you need to know about bicarb: 1 amp is 50mL (1mEq per mL), will raise pH acutely by 0.10. Has intrinsic pH of 8.0, tons of sodium, osmolality of 2000.
Treatment for Rhabdomyolysis (3)
Myoglobin dissociates into sticky ferrous/heme component and clogs renal tubules under acidic/low-flow conditions.
- IV fluids to obtain urine output of 1.5-2 cc/kg/hr or 200cc/hr
- NaBicarb to alkalinize urine (may use acetazolamide)
- Mannitol, ONCE EUVOLEMIC, to increase urine output
The 5 EKG findings of Hypokalemia
(1) Flat T;
(2) U wave;
(3) LONG QT;
(4) Non specific ST/T Wave changes;
(5) V-tach or Torsades
The 5 things that drive K into a cell:
(1) Insulin
(2) beta agonist
(3) rising pH
(4) Sodium
(5) Magnesium
The 5 causes of HypOKALemia:
(1) Cellular shifts—Alkalosis, Albuterol, Insulin
(2) Renal—diuretics (lasix, HCTZ), hyperaldosteronism; RTA 1&2,
(4) GI—vomiting, diarrhea, fistula, pancreatic/biliary losses;
(5) Starvation state, alcoholism
(6) HypOMagnesemia (hypokalemia is a better indicator than the actual Mg level!)
Treating HypoK
100mEq will raise serum K by 0.3. (takes forever, so replenish until 3, and eat K rich foods)
Supplement 500mg/hr of Magnesium.
8 Life Threatening Causes of Chest Pain
ACS Aortic Dissection Cardiac Tamponade Myocarditis PE PTX PNA Esophageal Rupture (Boerhaave's)
- ACS—STEMI, NSTEMI/UA: Ask sharp? Pleuritic or reproducible? No heart dz? (“yes” to these three makes ACS 1% likely.) get CXR, CBC, BMP, Coags, Cardiac Enzymes, repeat ECG
- Aortic Dissection: Ask Maximal at onset? Tearing/ripping to the back? Migratory pain source? (“no” to all three questions = low likelihood). Get both arm BP, CBC, BMP, Coags, Type+Cross, CXR, spiral CT of chest or TEE, esmolol for BP control
- Tamponade: Muffled heart, clear lungs on CXR, JVD, hypotension. Get ECG and ECHO
- Myocarditis: fever, positional chest pain, troponin leak, heart failure, effusion
- Esophageal rupture/Boerhaaves: h/o scope procedure or wretching. Ask “hurts to swallow and move neck?” CBC, BMP, blood cultures, Get CXR, CT, Gastrograffin Swallow Study, antibiotics, call CT surgery
- Pulm embolism
- Pneumothorax
- Pneumonia
Who do we get ABG’s on? (5)
- on ventilator
- pts in shock
- very bad asthmatic (can’t tell if sleepy or hypercarbic)
- significantly sick
- significant lung disease (COPD, more)
What 5 tests are routine for eval a toxic/metab camuse of AMS?
Glucose BMP Calcium (hyper and hypo) Urine drug screen Alcohol
What 5 tests are routine if an overdose is suspected?
ECG (TCA OD shows RSR' complex in V1) Aspirin Level Tylenol level Blood alcohol level UDS (6) pregnancy test
The 5 causes of DKA (the 5 I’s):
(1) Insulin lack;
(2) Indiscretion with sugar (eating badly)
(3) Infection;
(4) Ischemia–brain, heart, bowel;
(5) Infant on board (pregnancy)
The 5 treatments for DKA, and any pearls?
Glucose will drop about 100/hr.
- IVF: IL bolus, then 250-500cc/hr for next 4 hours
- Insulin: load 0.1 unit/kg IV -then- maintain 0.1 unit/kg/hr IV until gap is closed
- Potassium 10-20mEq in each liter of fluid
- Consider Bicarb if pH <6.9 to 7.0 (Risk of cerebral edema!)
- Phosphate supplement
When blood glucose drops to about ~250, SLOW the insulin, ADD DEXTROSE to fluids (D10 or D5)
** NO FLUID BOLUS in CHILDREN unless hypoperfusion… (Risk of cerebral edema!)
DKA pearls:
- The killer in children is CEREBRAL EDEMA. To avoid this, avoid large fluid boluses, avoid bicarb, and don’t load with insulin—just start a gentle drip.
- Cerebral edema = obtunded. Treatment is 3% hypertonic saline
- If the gap closes but the pH and HCO3 are still low, it’s probably HYPERCHLOREMIA. Switch your fluids to half-normal saline or LR.
- The most common cause of death in DKA is arrhythmia due to iatrogenic hypOkalemia
What are the 5 BMP rules?
- Check the #s (are the high/low?, check K)
- Check the gap
- Apply the rule of 15 (to determine additional resp process, HCO3- + 15 = what should be the pCO2, pH after decimal. If actual pCO2 higher or lower, separate resp. process)
- apply delta 1:1 rule (Difference between AG-14 should be same diff. b/w [24 - current HCO3]. If actual HCO3 is higher, addl. met. alk. If lower, addl. met. acid.
- Unexplained acidosis? Figure out cause by doing osmolar gap.
5 Red flags for Back pain
- Age <20, >55 (less likely to be benign pain)
- Severe systemic disease
- Non-MSK complaints (fevers, rashes, etc.)
- Non-MSK pain (i.e. moving around for kidney stones)
- ANY new Neurologic symptoms (like urinary retention, new numbness, weakness)
5 Acid-Base Rules
- Check the numbers; is there a low or high bicarb?
- Check the Anion Gap, even if the bicarb is normal
- Rule of 15: uncovers respiratory compensation
a. if there is perfect respiratory compensation for a metabolic acidosis, then:
Bicarb + 15 = expected PCO2 = expected last two digits of the pH
b. A PCO2 higher than expected means additional primary respiratory acidosis.
c. A PCO2 lower than expected means additional primary respiratory alkalosis.
d. The PCO2 bottoms out at 15—maximal hyperventilation.
A Bicarb of 5CO2 15pH 7.12; Bicarb of 2.5CO2 15pH 6.88
- Delta Gap: compare the (gap – 14) to the (bicarb – 24). Should be equal and in opposite direction for a single metabolic disturbance. If the delta is larger than 3-4, there is an additional metabolic disturbance.
- Check Osmolar Gap: compare estimated Osm = (Na x 2) + (BUN/2.8) + (Gluc/18) + (EtOH/4.6) to lab serum osmoles. Osmolar Gap > 10 or so suggests alcohols as cause of anion gap acidosis
a. As glucose goes up by 100, the minimum fall in sodium is 2 `