Acute Care Flashcards
Indications for Intubation?
When to call anesthesia?
- Airway patency
- Airway protection
- Respiratory distress/failure/arrest
- Cardiac dysfunction
- Procedures
– Upper airway obstruction
– Mediastinal mass
– Known/anticipated difficult airway
Ventilator: how to improve oxygenation?
- assessment
Increase FiO2
Increase PEEP
O2 saturation
Ventilator: how to clear CO2?
- assessment
Increase RR
Increase PIP
- pH, CO2
O2 dissociation curve: left shift?
- what is happening to O2
- causes
Loading
increased pH
decreased DPG
deceased temp
O2 dissociation curve: right shift?
- what is happening to O2
- causes
Releases
decreased pH
increased DPG
increased temp
High flow nasal canal
how does it work
- Upper + lower airway distending pressures
- Dead space washout
- Secretion clearance
- More tolerable
What type of shock is anaphylaxis?
distributive
Oxygen delivery formula
CaO2 = (Hb xSat x1.34) + (PaO2 x 0.003)
- Shockable rhythms?
- PALS order of shock/epi
- dose of epi?
VT
Vfib
shock - shock - epi
CPR ongoing q 2min shock
Epinephrine 0.01mg/kg
PALS
CPR instructions
rate
ratio
– 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
Defibrillation dose
2 J/kg then 4 J/kg
Status Epilepticus Algorithm
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…)
When do you hyperventilate in TBI
If herniating
What do you want to avoid in TBI/increased ICP?
Hypotension hypoxia hyperthermia hyponatremia hypo/hypercapnia hypo/hypergylcemia
Management of TBI
• 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
Brain death?
Newborn <30d and ≥36wga
Infant 1-12m
Children ≥ 1yo
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
Apnea test criteria
Final PaCO2 ≥ 60 mmHg
Final PaCO2 ≥ 20 mmHg above pre-test baseline
Final pH ≤ 7.28
Absence of respiratory effort during test duration
Most effective prevention strategy for submersion injury
a four-sided self-closing fence with a self-locking gate
at least 4ft high
Risk factors for submersion injury
- Leaving children unattended
- Alcohol or drug abuse (50% of adult drownings) Limited swimming ability
- Underlying medical conditions(?):
Seizure disorder, toxin, prolonged QT, syncope
what minimum temp for discontinuing resus
35
What are good prognostic indicators for submersion injury?
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
What are poor prognostic indicators for submersion injury?
- Delayed CPR
- Return of spontaneous circulation > 25 min
- Submersion > 10 min
What are complications of submersion injury?
ARDS Pulmonary edema Pneumonia Cerebral edema leading to increased ICP Trauma Hypothermia
Temp of hypothermia?
Temp when shivering stops?
Association?
<35
32
Pancreatitis
hypoglycemia, hypocalcemia, hypokalemia, metabolic acidosis
ECG at <28 deg C
Osborn waves
Marked sinus bradycardia
First degree AV block
Osborn or J waves
Associated with prolonged QT and bradycardia
When do you start passive and active rewarming?
< 34 deg C - passive rewarming
< 30 deg C - active rewarming
How many times can you defibrillate if T < 30?
3 times
Heat stroke
Core T > 40 C with CNS dysfunction Headache Disorientation Dizziness Weakness Gait disturbance
Complications of heat stroke
Hyponatremia Seizure Rhabdomyolysis DIC Multi-system organ failure
Burns - SA
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
Burns - bugs?
Antibiotics?
No prophylactic Abx
Early infection: Staph aureus, GAS
Late infection: Pseudomonas, Bacteroides
Signs of smoke inhalation?
- Singed nasal hairs
- Soot in the airway
- Hoarseness
- Drooling
Cholinergic drugs
Pesticides organophosphates + carbamates DUMBELLS Diaphoresis Urination Miosis Bronchorhea and bradycardia Emesis Lacrimation Lethargy Salicavation
Tx:
Atropine
Pralidoxime
Anticholinergic drugs
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
Sympathomometic
Cocaine
Methamphetamine
Ectasy/MDMA
Ephedrine
Mydriasis Diaphoresis Hypertension Tachycardia Seizures Hyperthermia Psychosis Severe agitation
Activated charcoal
Supportive
Difference between anticholinergic toxidrome and sympathomometic
sympathomometic has diaphoresis
PCP
nystagmus
What can’t you use activated charcoal for?
shiny things
Potassium Hydrocarbons Alcohols Iron Lithium Solvents
Serotonin syndrome
Altered LOC
Autonomic instability
Neuromuscular hyperactivity
Opioid ingestion
Bradycardia Hypotension Respiratory depression Miosis Coma
TX: naloxone
Neuroleptic Malignant syndrome
Antipsychotics
Fever
muscle rigidity
Altered LOC
Autonomic dysfunction
How to tx seizure after Anesthetic
Benzo
Intralipid
Hydrocarbons - biggest risk
Aspiration pneumonitis
Acetaminophen
- toxic dose
- complications
- tx
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
Radio opaque drugs
Chloral hydrate Opioid packets (latex) Iron and other heavy metals Neuroleptics (early) Sustained-release tablets / Salicylates (early)
isopropyl alcohol
ketosis w/o acidosis
methanol
tx w fomepizole if not yet metabolized (IE OSM GAP PRESENT)
TCA
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
Calcium Channel Blockers
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
When should you X-ray an ankle?
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
How best to assess pain in a child >8yo post op
Visual pain analog
Reasons a brain dead person would not be candidate for organ donation?
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
Xray findings of RPA
Widening of retropharyngeal space
Reversal of the normal cervical spine curvature
Who do you treat w abx for bite?
What abx?
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.
Staph Scalded Skin Syndrome tx
Cloxacillin
Child in house fire with soot coating his nostrils and mouth. Alert and oriented. Next step?
Intubate
Initial vent settings after intubation?
PEEP
PIP
VT
PEEP typically 5
PIP: 15-25, targeted based on gas CO2
VT: 7-10mL/kg for healthy lungs
TCA overdose treatment
Activated charcoal
Intubation if obtunded
NaHCO3 for QRS > 100
Norepinephrine infusion if hypotensive **Physostigmine contraindicated
Pulled elbow
hyperpronation
supination - flexion
Epi dose for
- Shock
- anaphylaxis
- Shock: 0.01mg/kg
- anaphylaxis: 0.1mg/kg
Antidote for benzo overdoer
Flumazenil
How long should you observe after drowning?
6-8 hours
Signs of inhalational injury?
Singed nasal hairs Carbonaceous sputum Stridor/wheeze Facial burns hoarseness stridor
How to treat dehydration?
- Mild
- Mod
- Severe
- 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
Left shoulder pain in trauma?
splenic rupture
Indications for admission with a burn?
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
Necrotizing fasciitis
Bug
Mgmt
Strep pyogenes (GAS)
IV penicillin + clinda and surgery consult
MVC with abdominal wall bruising, unable to urinate or move legs
Chance fracture L1/L2
Child given suppositories
Vomiting, recurrent tonic spasms, conscious, mouth open most of the time
What is this
How do you treat
Acute Dystonic Reaction
Benadryl
What kind of meds are gravol and Benadryl;?
Anticholinergic
Abdo trauma - investigations?
CT if stable
FAST if unstable
RPA - abx
Clindamycin
