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*Review TD 2020 > Acute Care > Flashcards

Acute Care Flashcards

1
Q

Indications for Intubation?

When to call anesthesia?

A
  • Airway patency
  • Airway protection
  • Respiratory distress/failure/arrest
  • Cardiac dysfunction
  • Procedures

– Upper airway obstruction
– Mediastinal mass
– Known/anticipated difficult airway

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2
Q

Ventilator: how to improve oxygenation?

- assessment

A

Increase FiO2
Increase PEEP

O2 saturation

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3
Q

Ventilator: how to clear CO2?

- assessment

A

Increase RR
Increase PIP

  • pH, CO2
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4
Q

O2 dissociation curve: left shift?

  • what is happening to O2
  • causes
A

Loading

increased pH
decreased DPG
deceased temp

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5
Q

O2 dissociation curve: right shift?

  • what is happening to O2
  • causes
A

Releases

decreased pH
increased DPG
increased temp

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6
Q

High flow nasal canal

how does it work

A
  • Upper + lower airway distending pressures
  • Dead space washout
  • Secretion clearance
  • More tolerable
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7
Q

What type of shock is anaphylaxis?

A

distributive

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8
Q

Oxygen delivery formula

A

CaO2 = (Hb xSat x1.34) + (PaO2 x 0.003)

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9
Q
  • Shockable rhythms?
  • PALS order of shock/epi
  • dose of epi?
A

VT
Vfib

shock - shock - epi
CPR ongoing q 2min shock

Epinephrine 0.01mg/kg

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10
Q

PALS
CPR instructions
rate

ratio

A

– Rate 100 – 120 compressions / minute
– Minimize interruptions
– Allow full chest recoil
– Push 1/3 diameter

Single rescuer 30 : 2
Two or more rescuers 15 : 2
Advanced airway (ETT or LMA) = continuous compressions, 10 breaths/min

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11
Q

Defibrillation dose

A

2 J/kg then 4 J/kg

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12
Q

Status Epilepticus Algorithm

A

1) Benzodiazepine (IV preferred)
2) Repeat Benzodiazepine (IV preferred)
3) Fos/Phenytoin or Phenobarbital load
– Typically Fos/Phenytoin for > 1y, phenobarb < 1y
4) Other agent not given in #3
5) Midazolam infusion (other options also possible…)

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13
Q

When do you hyperventilate in TBI

A

If herniating

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14
Q

What do you want to avoid in TBI/increased ICP?

A 
Hypotension
hypoxia
hyperthermia
hyponatremia
hypo/hypercapnia
hypo/hypergylcemia
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15
Q

Management of TBI

A

• Increase venous drainage
– HOB to 30 degrees
– Head midline
– C-collar not too tight

• Osmotic Therapies
– Hypertonic saline (preferred agent 2-5mL/kg IV over 10-20 mins)
– Mannitol

• Control ICP surge stimuli (may require intubation)
– Analgesia, sedation, anti-seizure, anti-pyretic
– Neuromuscular blockade in severe cases

• CSF removal (especially if hydrocephalus present)
– Extraventricular drainage

• Space-occupying mass removal
– Hematoma

• Reduce Cerebral Blood Volume * (in setting of herniation)
– Hyperventilation (PCO2 20 – 30 mmHgàtitrate to pupillary/vital sign
improvement)

• Increase Intracranial Space
– Decompressive Craniectomy

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16
Q

Brain death?
Newborn <30d and ≥36wga
Infant 1-12m
Children ≥ 1yo

A

Newborns: < 30 days and ≥ 36 wks gestation
– 2 full exams w apnea tests w ≥ 24h interval between exam
– ≥ 48h after birth
– Exam must include oculocephalic & suck reflexes
– Minimum body temp is 36 C

Infants: 30 days ≥ and ≤ 1 year
– Full, separate exams must be performed, but no fixed interval – Exam must include oculocephalic reflex

Children ≥ 1 year old to adults
– Still need two physicians, but can perform exam, including apnea testing, concurrently
– If examined separately, apnea test must be repeated

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17
Q

Apnea test criteria

A

Final PaCO2 ≥ 60 mmHg
Final PaCO2 ≥ 20 mmHg above pre-test baseline
Final pH ≤ 7.28
Absence of respiratory effort during test duration

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18
Q

Most effective prevention strategy for submersion injury

A

a four-sided self-closing fence with a self-locking gate

at least 4ft high

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19
Q

Risk factors for submersion injury

A
  • Leaving children unattended
  • Alcohol or drug abuse (50% of adult drownings) Limited swimming ability
  • Underlying medical conditions(?):
    Seizure disorder, toxin, prolonged QT, syncope
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20
Q

what minimum temp for discontinuing resus

A

35

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21
Q

What are good prognostic indicators for submersion injury?

A

1: Immediate bystander CPR

Other:

  • Return of spontaneous circulation in < 10 min
  • Submersion < 5 min
  • Pupils equal and reactive at scene
  • Normal sinus rhythm at scene
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22
Q

What are poor prognostic indicators for submersion injury?

A
  • Delayed CPR
  • Return of spontaneous circulation > 25 min
  • Submersion > 10 min
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23
Q

What are complications of submersion injury?

A 
ARDS
Pulmonary edema
Pneumonia
Cerebral edema leading to increased ICP 
Trauma
Hypothermia
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24
Q

Temp of hypothermia?
Temp when shivering stops?
Association?

A

<35
32
Pancreatitis
hypoglycemia, hypocalcemia, hypokalemia, metabolic acidosis

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25
Q

ECG at <28 deg C

A

Osborn waves

Marked sinus bradycardia
First degree AV block
Osborn or J waves
Associated with prolonged QT and bradycardia

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26
Q

When do you start passive and active rewarming?

A

< 34 deg C - passive rewarming

< 30 deg C - active rewarming

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27
Q

How many times can you defibrillate if T < 30?

A

3 times

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28
Q

Heat stroke

A 
Core T > 40 C with CNS dysfunction Headache
Disorientation
Dizziness
Weakness
Gait disturbance
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29
Q

Complications of heat stroke

A 
Hyponatremia
Seizure
Rhabdomyolysis
DIC
Multi-system organ failure
30
Q

Burns - SA

A

Age > 9: Rule of 9’s
Age < 9: Child’s palm = 1% BSA (not superficial)

Parkland
= 4 cc/kg/BSA over 24 hours (1st half in 8 hours, 2nd half in 16 hours)

ADD TO MAINTENANCE

31
Q

Burns - bugs?

Antibiotics?

A

No prophylactic Abx

Early infection: Staph aureus, GAS
Late infection: Pseudomonas, Bacteroides

32
Q

Signs of smoke inhalation?

A
  • Singed nasal hairs
  • Soot in the airway
  • Hoarseness
  • Drooling
33
Q

Cholinergic drugs

A 
Pesticides
organophosphates + carbamates
DUMBELLS
Diaphoresis
Urination
Miosis
Bronchorhea and bradycardia
Emesis
Lacrimation
Lethargy
Salicavation

Tx:
Atropine
Pralidoxime

34
Q

Anticholinergic drugs

A

Jimson weed, TCA, atropine, Benadryl, gravel, neuroleptics, etc

Tachycardia
Confused
hyperthermia
Dry skin
Flushed
Mydriasis
Urinary retention
Absent bowel sounds

Activated charcoal
Physostigmine only if PURE anticholinergic ingestion

35
Q

Sympathomometic

A

Cocaine
Methamphetamine
Ectasy/MDMA
Ephedrine

Mydriasis 
Diaphoresis 
Hypertension 
Tachycardia 
Seizures 
Hyperthermia
Psychosis 
Severe agitation

Activated charcoal
Supportive

36
Q

Difference between anticholinergic toxidrome and sympathomometic

A

sympathomometic has diaphoresis

37
Q

PCP

A

nystagmus

38
Q

What can’t you use activated charcoal for?

A

shiny things

Potassium
Hydrocarbons
Alcohols
Iron
Lithium
Solvents
39
Q

Serotonin syndrome

A

Altered LOC
Autonomic instability
Neuromuscular hyperactivity

40
Q

Opioid ingestion

A 
Bradycardia 
Hypotension 
Respiratory depression 
Miosis
Coma

TX: naloxone

41
Q

Neuroleptic Malignant syndrome

A

Antipsychotics

Fever
muscle rigidity
Altered LOC
Autonomic dysfunction

42
Q

How to tx seizure after Anesthetic

A

Benzo

Intralipid

43
Q

Hydrocarbons - biggest risk

A

Aspiration pneumonitis

44
Q

Acetaminophen

  • toxic dose
  • complications
  • tx
A

150 mg/kg (7.5 grams in adult)

Anion gap metabolic acidosis
Acute tubular necrosis
Fulminant liver failure

NAC
draw levels 4 hours after ingestion if timing unknown

if timing unknown draw levels and start NAC right away

45
Q

Radio opaque drugs

A 
Chloral hydrate
Opioid packets (latex)
Iron and other heavy metals
Neuroleptics (early)
Sustained-release tablets / Salicylates (early)
46
Q

isopropyl alcohol

A

ketosis w/o acidosis

47
Q

methanol

A

tx w fomepizole if not yet metabolized (IE OSM GAP PRESENT)

48
Q

TCA

A

Inhibit norepinephrine and serotonin reuptake Block cardiac fast Na channels → wide QRS
Block muscarinic receptors → weakly anticholinergic Block histamine receptors → sedation
Block alpha receptors → hypotension
Block GABA receptors → seizure

Activated charcoal
Frequently require intubation because obtunded
NaHCO3 for QRS > 100 
Norepinephrine infusion if hypotensive 
**Physostigmine contraindicated
49
Q

Calcium Channel Blockers

A

Bradycardia and hypotension
Normal LOC

High dose insulin euglycemic therapy (positive inotropic effects)
Atropine Q2-3 minutes
Calcium gluconate bolus or infusion
Glucagon but causes severe N/V
Insulin infusion plus IV D10W
50
Q

When should you X-ray an ankle?

A 
Tenderness at:
- posterior or tip of medial malleolus
- posterior or tip of lateral malleolus
- base of 5th metatarsal
- navicular
Or inability to bear weight immediately and now in ED
51
Q

How best to assess pain in a child >8yo post op

A

Visual pain analog

52
Q

Reasons a brain dead person would not be candidate for organ donation?

A

Severe untreated systemic sepsis
Acquired immunodeficiency syndrome
Active viral hepatitis B or C, CMV
Viral encephalitis
Active extra cranial malignancy
Risk of rare viral or prion protein illnesses (Creutzfeldt-Jakob dz)
Recipient of cadaver human pituitary growth hormone
Undiagnosed acute or progressive neurological d/o w or w/o dementia
Active West Nile Virus or Rabies
Active disseminated TB

53
Q

Xray findings of RPA

A

Widening of retropharyngeal space

Reversal of the normal cervical spine curvature

54
Q

Who do you treat w abx for bite?

What abx?

A 
moderate and severe wounds; 
all cat bites; 
patients who have diabetes mellitus
immunocompromised, 
face and hand involvement, 
have deep puncture wounds.

The recommended course is 3 to 5 days.
The antimicrobial agents recommended for prophylaxis include:
penicillin V potassium, amoxicillin, a first-generation cephalosporin in penicillin-allergic patients, and erythromycin in patients allergic to penicillin and cephalosporin.

55
Q

Staph Scalded Skin Syndrome tx

A

Cloxacillin

56
Q

Child in house fire with soot coating his nostrils and mouth. Alert and oriented. Next step?

A

Intubate

57
Q

Initial vent settings after intubation?
PEEP
PIP
VT

A

PEEP typically 5
PIP: 15-25, targeted based on gas CO2
VT: 7-10mL/kg for healthy lungs

58
Q

TCA overdose treatment

A

Activated charcoal
Intubation if obtunded
NaHCO3 for QRS > 100
Norepinephrine infusion if hypotensive **Physostigmine contraindicated

59
Q

Pulled elbow

A

hyperpronation

supination - flexion

60
Q

Epi dose for

  • Shock
  • anaphylaxis
A
  • Shock: 0.01mg/kg

- anaphylaxis: 0.1mg/kg

61
Q

Antidote for benzo overdoer

A

Flumazenil

62
Q

How long should you observe after drowning?

A

6-8 hours

63
Q

Signs of inhalational injury?

A 
Singed nasal hairs
Carbonaceous sputum
Stridor/wheeze
Facial burns
hoarseness
stridor
64
Q

How to treat dehydration?

  • Mild
  • Mod
  • Severe
A
  • Mild: ORT 50ml/kg over 4 hours + replace ongoing loses
  • Mod: ORT 100ml/kg over 4 hours + replace ongoing loses
  • Severe: IVF 20-40ml/kg over 1 hour
    repeat if necessary
    ORT when possible
65
Q

Left shoulder pain in trauma?

A

splenic rupture

66
Q

Indications for admission with a burn?

A

burns affecting >15% of body surface area
Full thickness (3rd degree burns)
electrical burns 2ary high tension wires or lightning
chemical burns
inhalation injury, regardless of amount of BSA burned
inadequate home or social environment
suspected child abuse or neglect
burns to: face, hands, feet, perineum, genitals, major joints
burns in patients with preexisting medical conditions that may complicate acute recovery phase
associated injuries (fractures)
pregnancy

67
Q

Necrotizing fasciitis
Bug
Mgmt

A

Strep pyogenes (GAS)

IV penicillin + clinda and surgery consult

68
Q

MVC with abdominal wall bruising, unable to urinate or move legs

A

Chance fracture L1/L2

69
Q

Child given suppositories
Vomiting, recurrent tonic spasms, conscious, mouth open most of the time

What is this
How do you treat

A

Acute Dystonic Reaction

Benadryl

70
Q

What kind of meds are gravol and Benadryl;?

A

Anticholinergic

71
Q

Abdo trauma - investigations?

A

CT if stable

FAST if unstable

72
Q

RPA - abx

A

Clindamycin

*Review TD 2020 (16 decks)

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