acute care common problems Flashcards
What are the 3 steps of pain management: WHO Ladder of Pain Management
Step 1: acetaminophen, NSAIDS, adjuvants- non traditional ex. amitriptyline (non-narcotics)
Step 2: add oral narcotics
Step 3: add IV narcotics
what kind of dressing should be applied to pressure wound with high amounts of slough or drainage?
hydrocolloid dressing
what are causes of post-op fever?
atelectasis- reduce with incentive spirometer
increased basal metabolic rate
dehydration
drug reactions
what is a tension headache?
most common type of headache
s/s: tight, band sensation around head, generalized, no focal neurological symptoms, lasts several hours
Management: OTC pain meds, relaxation
describe migraine headaches: w/wo aura
class migraine- with aura, common migraine- without aura
lasts 2-72 hours
onset- adolescence, early adulthood, familial relation, females > males
triggers: emotional or physical stress, lack or excess sleep, missed meals, specific foods, alcohol, menstruation, OCP, nitrate containing foods, changes in weather
s/s: unilateral throbbing, building up gradually, possible neurological disturbances, visual disturbances; field defects, luminous visual hallucinations, aphasia, numbness, tingling, clumsiness or weakness, nausea, vomiting, photophobia, phonophobia.
if new migraine- rule out other causes of the symptoms; no new migraines in 50+ people
diagnostic w/u for other causes: CBC, BMP, venereal disease research laboratory test (syphilis), ESR, CT head
Pharm management: amitriptyline, divalproex, propranolol, imipramine, clonidine, verapamil, topiramate, gabapentin, methysergide, magnesium
describe cluster headaches
very painful, middle aged men common
cause/ incidence: alcohol, not familial. occurs at night, awaken from sleep, last less than 2 hours, severe unilateral periorbital pain daily for several weeks, ipsilateral nasal congestion, rhinorrhea and eye redness.
management: oral drugs don’t help. 100% supplemental oxygen can help, sumatriptan SQ, ergotamine tartrate aerosol inhalation
what electrolyte abnormalities are associated with refeeding syndrome?
hypophosphatemia hypokalemia hypomagnesemia hypocalcemia thiamine deficiency
–> all low in these electrolytes: calcium, magnesium, potassium, phosphorus
should cat bite/dog bite wounds of hands/ lower extremities be open or closed?
leave the bite wounds open
what should antibiotic coverage look like for human and animal bites?
prophylaxis: staphylococci and anaerobes
on gram stain, what do gram positive and gram negative bacteria look like?
gram positive- pink/ purple: retain the stain
gram negative- (do not retain the stain)
which antibiotics have MRSA coverage?
ceftaroline (5th gen), clindamycin, daptomycin, linezolid, tedizolid, TMP/SMX (bactrim), vancomycin
what is anti-rejection triple therapy ?`
- corticosteroid: methylprednisolone, prednisone
- antimetabolite: Imuran, cellcept, myfortic, cytoxan- azathioprine, mycophenolate mofetil, mycophenolate sodium, cyclophosphamide
- calcineurin inhibitor (Tacrolimus, cyclosporine) or mammalian target of rapamycin inhibitor (mTOR): sirolimus, temsirolimus, everolimus
what is the treatment for herpes zoster (singles)?
acyclovir, famciclovir, valacyclovir
if shingles impacts the eye, what should you do?
urgent referral to ophthalmologist
who should get shingrix?
all adults > 50 years, regardless of previous shingles vaccine; two dose regimen, 2nd dose given 2-6 months after initial dose
describe squamous cell carcinoma
comes from actinic keratoses
firm irregular papule or nodule
develops over a few months- 3-7% metastasis
prolonged sun exposed in fair skin people
tx: biopsy, surgical excision
seborrheic keratoses
benign, not painful. beige brown or black plaques
“stuck on”, 3-20mm in diameter
tx. liquid nitrogen, or no tx
basal cell carcinoma
most common skin cancer slow growing 1-2cm after years waxy pearly appearance, shiny or red central depression or rolled edge, telangiectatic vessels tx: shave biopsy, surgical excision
how to detect skin cancer: abcdee
asymmetry, border irregularity, color variation, diameter > 6cm, elevation, enlargement
malignant melanoma
highest mortality rate of all skin cancers
median age of diagnosis = 40
may metastasize to any organ
when are gastric lavage or activated charcoal indicated?
within 1st hour of ingestion
often used with Sorbitol as well
acetaminophen intoxication
delayed symptoms- 24-48 hours- hepatotoxicity: jaundice, LFTs elevated, PT prolonged, AMS, RUQ pain
Tx of tylenol overdose
N-acetylcysteine (mucomyst)
Salicylate Intoxication (ASA)
tinnitis, dizziness, n/v, respiratory distress, LFTs
tx activated charcoal, sodium bicarb for severe acidosis
Organophosphate (insecticide) poisoning
blurred vision, bradycardia, AMS
wash skin, if ingested- activated charcoal
atropine- drug of choice
antidepressant toxicity
s/s- AMS, urinary retension, hemodynamic instability, seizures– need ICU admission
activated charcoal
sodium bicarb- dysrhythmias and maintain pH
serotonin syndrome management
Dantrolene sodium (dantrium), clonazepam - rigor, cooling blankets
opioid toxicity
narcan
activated charcoal
emetics contraindicated
pupillary effects: opioids vs cocaine
pinpoint: miosis: opioids
dilated: mydriasis: cocaine
Benzodiazepine overdose
flumazenil IV
activated charcoal
respiratory/ BP support
beta blocker overdose
hypotension, SB, bronchospasm
tx: charcoal, glucagon***, atropine for SB, airway stabilization
Ethylene Glycol (antifreeze) overdose
Fomepizole (antizol)
Ethanol (if fomepizole not available)
Stages of ethylene glycol overdose
1st stage (30 min-12 hours): loss of coordination, headache, slurred speech 2nd stage (12-24 hrs): irregular HR, shallow breathing, BP changes 3rd stage 24-72 hrs: kidney failure
Burns: Rule of 9s- what are the body percentages?
each arm- 9% each leg- 18% thorax- 18% front, 18% back head-9% perineum/ genitalia- 1%
what is Parkland’s formula? for burns
4ml/kgx TBSA % burned = fluid resuscitation goal in 1st 24 hours. 1/2 of fluid goal in first 8 hours, 1/2 in the remaining 16 hours
crystalloids** no colloids
monitor for metabolic acidosis, - presents in early resucitaiton phase
hyperkalemia in first 24-48 hours, then hypokalemia after that- - fluid shifts
Burn mangement pearls
maintain normal temperature
sterile saline for treatment, wrap in sterile towels
pain management IV narcotics, conscious sedation
definition of AIDs
HIV + and
CD4< 200 cells/uL and/ or presence of opportunistic infection
what is ELISA test?
enzyme-linked immunosorbent assay (ELISA) is an immunological assay commonly used to measure antibodies, antigens, proteins and glycoproteins in biological samples.
HIV testing
HIV 1/2 antigen/ antibody combination immunoassay; if positive, then do HIV 1/2 antibody differentiation immunoassay
PCR: viral load- high numbers correlate to progression of HIV- should be zero or undetectable with AART
pneumocystis jirovecii
pneumonia that is an opportunistic infection in HIV
patients need prophylaxis for this with Bactrim
AART
active antiretroviral therapy:
take as soon as HIV+ diagnosis occurs.
danger of drug resistance- adherence is extremely important
PrEP
indicated for HIV negative people that are at risk:
have sex with HIV + person, IV drug uses that share needles
PEP
post-exposure prophylaxis:
Truvada (emtricitabine/tenofovir disoproxil fumarate)- prevent HIV for all people at risk
Descovy (emtricitabine/tenofovir alafenamide)- not studied in people with receptive vaginal sex
Descovy- improved renal and bone safety- 90% decrease in plasma levels, more intracellular concentrations- smaller doses needed.
Truvada- can cause significant renal and bone density effects due to high plasma concentration
osteoarthritis vs rheumatoid arthritis
OA: asymmetrical, older, better in morning, worse at the end of the day, Xray- narrowing of joint space,
RA: symmetrical, younger onset, worse in morning, better as day progresses, warm joints, ESR elevaed, synovial aspirate- WBCs, joint swelling
Heberden’s nodes
distal interphalangeal joints
finger tips
Bouchard’s nodes
proximal interphalangeal joints
mid finger knuckles
osteoporosis
osteoarthritis medication management
ASA, acetaminophen, NSAIDS, celebrex (but likely avoid in cardiac patients)
Rheumatoid arthritis pharmacological management
high dose ASA, NSAIDs,
disease modifying antirheumatic drugs; corticosteroids, methotrexate, antimalarials (hydro chloroquine), gold salt injections
define avulsion
bone fragment pulled off by attached ligaments and tendons
define subluxation
incomplete dislocation- often for vertebrae
how to objectively assess for compartment syndrome?
Stryker tonometer- intra-compartmental pressure > 30 mm Hg- needs fasciotomy
What is delta pressure?
for compartment syndrome
delta pressure = diastolic blood pressure- intra-compartmental pressure
if < 30 mmHg, fasciotomy needed
systemic lupus erythematous s/s
butterfly rash, fever, malaise, weight loss, splinter hemorrhages, alopecia, joint symptoms, vasculitis, nephritis, ocular manifestations, pericardial and pulmonary manifestations, abdominal pain
**so many impacted areas; multisystem inflammatory autoimmune disorder
SLE diagnostics
ANA + in 95% of patients
antiphospholipid antibodies
anemia, leukopenia, thrombocytopenia; CBC
SLE pharmacological management
NSAIDs, hydroxychloroquine, glucocorticoids
Many medications can create lupus-like syndrome
cardiac meds, psych meds, antibiotics, cholesterol meds, seizure meds, OCPs,
amiodarone, atenolol, buproprion, diltiazem, gemfibrozil, hydralazine, lithium, macrobid, OCPs, phenytoin, rifampin, tetracycline
Giant cell arteritis
temporal arteritis -inflammation of temporal artery,
age 50+, can lead to permanent blindness
s/s: fever of unknown origin, headache, scalp tender, visual complaints, temporal artery tender
giant cell arteritis diagnostics and treatment
ESR very high, normal WBC,
temporal artery biopsy- gold standard
Prednisone, referral needed
diabetic retinopathy eye exam findings
microaneurysms, ruptured is late finding- retinal hemorrhages- cotton-wool spots- deep layers of retina or superficial- flame- shaped hemorrhages
AV nicking on eye exam
sign of chronic hypertension
arcus senilis
cloudy appearance of cornea with gray/white arc or circle- due to deposition of lipid material - no visual impairment
bacterial conjunctivitis antibiotics:
drops: levofloxacin, ciprofloxacin, tobramycin, gentamycin
gonococcal conjunctivitis treatment
ophthalmic emergency- copious, purulent discharge
ceftriaxone 250 mg IM and azithromycin
same treatment for chlamydial conjunctivitis
open vs closed angle glaucoma
open: chronic, asymptomatic, elevated IOP, cupping of disc, constriction of visual fields, prostaglandin analogs: latanoprost, travoprost, alpha 2 adrenergic agonists- brimonidine
beta-adrenergic blockers- timolol
miotic agents- pilocarpine
Closed: acute, extreme pain, blurred vision, halos, pupil dilated or fixed; carbonic anhydrase inhibitors- acetazolamide IV (diamox), osmotic diuretics- mannitol, surgery to relive humoral pressure
