Acute Care Flashcards
Indications for Intubation
GCS < 8
Hemodynamic instability
Airway
Respiratory failure
Muscle weakness
Secretions
EET Size
Age/4 + 4
Causes of hypoxemia
low FiO2
Hypoventilation
V/Q mismatch
Shunt
Impaired gas exchange
PRAM Score
Oxygen saturations 0-2
Suprasternal retractions 0-2
Scalene retractions 0-2
Air entry 0-3
Wheezing 0-3
Mild 0-3
Moderate 4-7
Severe 8-12
Discharge criteria for asthma
Sats > 94% on RA
Ventolin > q4hr
Mild exacerbation
Observed in ED for 2 hours without tx
PARDS
NIPPV:
CPAP/BiPAP > 5cm H2o
PF < 300
SF < 264
IPV:
mild OI 4-8
mod OI 8-16
sev OI > 16
OI
(MAP x FiO2 x 100) / PaO2
High risk bronchiolitis
GA < 35 weeks
< 3 months age at presentation
Hemodynamically significant cardioresp disease
Immunodeficiency
Bronchiolitis criteria for admission
severe resp distress (WOB, RR > 70)
O2 to keep sats > 90
dehydration/poor intake
cyanosis/apnea
high risk infants
family unable to cope
Oxygen Delivery
DO = CaO2 x CO
CaO2 (carrying capacity of oxygen)
CaO2 = 1.34 x Hgb x Saturation (+ dissolved O2 - negligible)
H’s & T’s (reversible causes of cardiac arrest)
Hypovolemia
Hypoxia
Hypoglycemia
Hydrogen ion (acidosis)
Hypo/hyperkalemia
Hypothermia
Tension PTX
Tamponade
Toxins
Thrombosis (coronary, pulmonary)
Declaration of Brain Death requirements
2 exams by qualified positions
deep unresponsive coma with a clear etiology and lack of cofounders (unresuscitated shock, severe metabolic disorders, hypothermia < 34, peripheral neuropathy, drug effects)
Exam: no motor response, gag, cough, corneal reflex, vestibulo-ocular response, pupillary response + apnea test
*may have spinal reflexes
Timing of brain death declaration
Newborn: > 24 hours between exams, < 48 hours after birth, minimum temp 36 degrees, need oculocephalic reflex
Infant: full, separate exams, no interval, need oculocephalic reflex
Child: two physicians, can do concurrent exams + apnea test
*Needs for be > 24 hours after a significant event
Apnea test
MUST MEET ALL CRITERIA
PaCO2 >/= 60
PaCO2 >/= 20 above baseline
pH </= 7.28
No respiratory effort during entire test
GCS
Prognostic Indicators in Drowning
Good:
- immediate bystander CPR (most important!)
- ROSC in < 10 mins
- submersion time < 5 minutes
- PERL at scene
- Normal Sinus Rhythm at scene
Bad:
- delayed CPR
- ROSC > 25 minutes
- submersion > 10 min
Burn classification
- Superficial - epidermis only, redness/pain/no blisters
- Superficial partial thickness - epidermis + 1/2 dermis, red/pain/blisters
- Deep partial thickness - epidermis + > 1/2 dermis, pale/dry/speckled/less tender/non-blanching
- Full thickness - subcutaneous tissue, pale/charred/leathery/non-tender/non-blanching
Fluid management in Burns
Parkland: 4ml/kg/BSA in 24 hours
- 1st half in 8 hours, 2nd half over 16 hours
- ADD maintenance fluids
Admission criteria for burns
- suspected NAT
- > 10% partial thickness
- > 2% full thickness
- hands, feet, face, perineum
- circumferential burn
- enclosed space fire or evidence of inhalational injury
- electrical injury (risk of rhabdo)
- associated trauma
Most common cause of morbidity and mortality in burn patients
infection
Cholinergic toxidrome
DUMBELLS
- diaphoresis
- urination
- miosis
- bronchorrhea/bradycardia
- emesis
- lacrimation
- lethargy
- salivation
Treatment of cholinergic ingestion
Organophosphates/carbamates
- oxygen
- REMOVE CLOTHING
- atropine
- atrovent
- pralidoxime
- intubate early (NO SUCC)
Anticholinergic toxidrome
Mad as a hatter, blind as a bat…
- Mydriasis
- Hyperthermia
- Confused, grabbing invisible stuff
- dry mouth
- urinary retention
- tachycardia
- flushed
- absent bowel sounds
Treatment of anticholinergic ingestions
TCAS, anti-histmines, jimson weed, neuroleptics, atropine
- NaHCO3 (TCAs) for prolonged QRS
- benzos for agitation
- cool
- +/- activated charcoal
- +/- physostigmine if pure (not with TCAs or cardiac involvement)
Sympathomimetic toxidrome
cocaine, amphetamines, ecstasy
- mydriasis
- diaphoresis
- HTN
- tachycardia
- seizures
- hyperthermia
- psychosis
- severe agitation
- hyperreflexia
Management of sympathomimetic ingestions
- benzos
- fluid restriction or 3% NS (SIADH)
- activated charcoal if 1 hour
- cooling
Toxidrome of Hallucinogens
- mydriasis (LSD) / miosis (PCP)
- HTN
- tachycardia
- diaphoresis
- hyperreflexia
- hallucinations (LSD)
- nystagmus while awake (PCP)
- LSD usually not fatal compared to PCP
Opiate toxidrome
- miosis
- bradypnea
- decreased bowel sounds
- somnolence
- hypotension
- hypothermia
Treatment of opioid ingestion
Naloxone IN or IV
CXR findings of hydrocarbon ingestion
pneumatoceles
peri-hilar infiltrates
Hypothermia CPR
Be-Low 30?
Just push, no Do (pamine, or epi)
Rewarming with a pulse
34-36
- passive rewarming (dry)
30-34
- passive and active external warming (electric blanket, overhead warmer, hot water bottles, heating pads)
<30
- active external and internal rewarming (warmed IV fluid, warmed O2, peritoneal lavage, ECMO)
Upward deflections on ECG with hypothermia?
Osborn waves
Stages of Iron Overdose
- Stage 1: nausea, vomiting, diarrhea (30min - 6 hours)
- Stage 2: quiet (6-12 hours)
- Stage 3: metabolic acidosis –> shock, GI hemorrhage, coagulopathy, respiratory failure (12-24 hours)
- Stage 4: ARDS, liver failure (2-3 days)
- Stage 5: GI strictures at gastric outlet (3-4 weeks)
Treatment of iron overdose
- fluid resuscitation
- WBI if seen on X-ray within 6 hours
- IV deferoxamine
Radio-Opaque drugs (COINS)
- chloral hydrate
- opioid packets (latex)
- iron and heavy metals
- neuroleptics
- sustained release/salicylates
COINS
Isopropyl Alcohol
ketosis without acidosis
methanol ingestion
- profound AG acidosis presents late
- osmolar gap
- causes retinal injury (blindness)
- treat with fomepizole
- dialysis if already acidotic
ethylene glycol
- metabolic acidosis leads to cardiac decompensation
- hypocalcemia leads to prolonged QTc
- oxalate crystals appear late
- fomepizole
CATCH CT Head Rule
Anyone with minor head injury (GCS 13-15) and one of the following:
HIGH RISK
- GCS < 15 2 hours post
- suspected open or depressed skull fracture
- irritabilty on exam < 2 yo
- worsening headache
LOW RISK
- basal skull fracture
- boggy hematoma (> 2 yo, if < 2 yo, do skull X-ray first)
- dangerous mechanisms (MVC<, fall > 3ft or down 5 stairs, fall from bike without helmet)
Absolute and relative indications for CT in head injury
ABSOLUTE
- focal neurologic deficit
- clinically suspected open/depressed skull #
- wideded of diastatic skull # on X-ray
RELATIVE
- GCS < 14 after initial assessment or < 15 2 hours post
- clinical deterioration over 4-6 hours
- signs of basal skull #
- boggy hematoma
- mechanism of injury
- seizure at time of event or later
- known coagulopathy
Poor prognostic indicators in acute head trauma
- GCS < 5
- increased ICP
- pre-injury ADHD
- low SES
- injuries to other body sites
Diagnosis of Pericarditis
2/4
- pericardial chest pain (sharp, pleuritic, improved by sitting up and leaning forward)
- pericardial rub
- widespread ST elevation or PR depression on ECG
- pericardial effusion
Supportive
- elevated inflammatory markers
- imaging with pericardial inflammation
ECG changes in myocarditis and pericarditis
Pericarditis
- concave ST elevated and PR depression in most limb leads
- reciprocal ST depression and PR elevation in aVR
- sinus tachycardia
Myocarditis
- PACs/PVCs or SVT/VT, intraventricular conduction delay, abnormal q waves, low voltages
- AV node conduction delay
- ST segment and T wave changes
- prolonged QRS
- QT prolongation
- diffuse T wave inversion
Treatment of pericarditis
- Ibuprofen
- Colchicine
No role for steroids or IVIG
What is the toxic dose of acetaminophen?
150mg/kg (7.5g in adult)
