admissions and GIB Flashcards
1
Q
types of admissions
A
- planned
- emergency
- direct
2
Q
planned admission
A
- no immediate threat
- planned elective procedure i.e. hip replacement
3
Q
emergency admission
A
- unplanned
- most likely through ER
- have been stabilized in ED
4
Q
direct admission
A
- usually from PCP
- avoids ER
- n/v, neutropenic fever
5
Q
reasons for admission
A
- clinical course with significant potential for deterioration
- urgent surgery or invasive procedures
- short term IV drugs or transfusions needed
- inability to care for themself at home
- unstable pt who needs critical care
6
Q
what are the two most common causes for admission
A
- circulatory disorders
- respiratory disorders
7
Q
sepsis
A
- life threatening inflammatory disorder
- high mortality rates with septic shock
- common sites of infection= respiratory, GU, GI, SST
8
Q
SIRS
A
- 2 or more of the following:
- temp > 38 or < 36
- HR >90
- RR > 20, PaCO2 <32
- WBC > 12 or <4
- not as bad as sepsis
9
Q
what does ADCVANDIMALS stand for
A
- admit
- diagnosis
- condition and code status
- vitals
- activity
- nursing
- diet
- iv fluids
- medications
- allergies
- labs
- special
10
Q
what type of GI bleed is most common?
A
- upper GI bleed
- 4X more common
11
Q
where do UGIB occur?
A
- proximal to ligament of treitz
12
Q
what lab changes suggest bleed?
A
- drop in H&H
13
Q
causes of UGIB
A
- peptic ulcer*
- esophagitis, gastritis, duodenitis
- gastroduodenal erosions
- mallory weiss tears
- variceal bleeds
- tumor
- angiodysplasia, telangiectasias
- vascular ectasias
14
Q
treatment for UGIB
A
- stabilize pt*, fluid resuscitation, type/screen blood
- NEED to ID source of bleed
- monitorl BP, HR, urine output
- contact GI ASAP
- high dose IV PPI- reduces rebleed risk for peptic ulcers
- keep NPO
- NGT not routinely done
15
Q
what is oliguria
A
- urine output < 30 cc/hour
16
Q
what is the goal Hgb when replacing blood
A
- Hgb between 7-9%
- keep HCT > 30% in elderly
17
Q
when would someone get platelets
A
- if < 50K and active bleed
18
Q
what are signs of fluid overload
A
- raised JVP
- pulmonary edema
- peripheral edema
19
Q
triple therapy for H pylori
A
- PPI + 2 abx
- clarithromycin
- amoxicillin
- flagyl
20
Q
risk factors for UGIB
A
- previous bleed
- alcohol/ liver disease
- steroids
- anticoags, NSAIDs
- severe vomiting
- aortic surgery- aortoenteric fistulas
21
Q
factors that influence outcome of UGIB
A
- CV compromise
- age > 65
- coexisting cardio-respiratory disease
- Hgb < 10
- hematemesis and melena
22
Q
high risk UGIB pts
A
- hematemesis or BRB on NGT aspiration
- shock
- hemodynamic compromise even with IVF
- serious comorbidities
- advanced liver disease
- admit to ICU
- after resuscitation, endoscopy should be performed in 2-24 hours
23
Q
endoscopy therapeutic options
A
- should be performed immed after intubation, hemodynamic stabilization
- mechanical clip +/- adrenaline
- thermal coagulation with adrenaline
- fibrin or thrombin with adrenaline
24
Q
angiography for UGIB
A
- may be useful in UGIB if bleeding persists and endoscopy does not ID bleed site
- done by interventional radiology
- pt needs to be stable
25
variceal bleed mortality
- 50% mortality rate on average
- 50% rebleed in 10 days
- 30-50% cirrhosis pts have variceal bleeds
- 33% survive 3 years post bleed
- generally very poor prognosis
26
what is the goal pressure for the portal system?
- < 12 mmHg
27
treatment for variceal bleeds
- endoscopy- banding or sclerotherapy
- octreotide +/- vasopressin
- tamponade
- TIPSS surgery
28
general treatment plan for variceal bleeds
- resuscitation and early endoscopy
- banding +/- sclerotherapy
- if still bleeding repeat in 5-7 days
- if you fail- vasoconstrictor +/- tamponade
- if endoscopy fails X2 then TIPSS procedure
29
prevention of variceal bleeds
- propranolol
- reduces risk of bleed by lowering sheer force of pressure on vessels
- prophylactic banding in pts with cirrhosis
- long acting nitrates
- soft foods
30
TIPSS procedure
- shunts blood from portal vein to hepatic vein
| - usually a bridge to transplant
31
what is TIPSS procedure used for
- refractory bleeding
- refractory ascites
- budd chiari
32
complications of TIPSS procedure
- restenosis, occlusion, thromboembolism
- hepatic encephalopathy
- hemorrhage
- cholangitis
- stent migration
- HF
- liver failure
- infection
33
causes of LGIB
- diverticulosis*
- angioectasias
- hemorrhoids
- colitis- IBD, infectious, ischemic
- neoplasm
- post-polypectomy
- dieulafoy's lesions
34
predictors of severe LGIB
- HR > 100
- SBP < 115
- syncope
- nontender abd exam
- bleeding during first 4 hours of eval
- ASA use
- > 2 active comorbid conditions
- > 3 present= 80% risk
35
management of LGIB
- 80% spontaneously resolve
- lack of standardized approach
- traditional= elective colonoscopy after bleeding stops, angiography for massive or unstable bleed
36
urgent colonoscopy
- done usu within 6-12 hours of presentation
- requires rapid purge prep with 5-6 L of go lytely
- colonoscopy within 1 hour of clear stools
- not good for unstable pts
- can ID hemorrhage and perform therapy
37
radiographic studies for LGIB
- tagged RBC scan
| - angiography
38
tagged RBC scan
- medicine taggs RBCs
- IDs area of leaking/ bleeding vessels
- non-invasive and highly sensitive
- good if bleed is not brisk" 0.05-0.1 ml/min
- NOT therapeutic
39
angiography for LGIB
- good choice for brisk bleed who cant be stabilized or prepped for colonoscopy
- detects bleeds at 0.5-1 ml/min
- also therapeutic
40
APAP toxicity pathophys
- APAP overwhelms glutathione
- NAPQI (toxic intermediate) accumulates
- causes hepatic necrosis and liver damage
41
when are peak plasma levels after APAP OD?
- 4 hours
42
factors predicting hepatotoxicity after APAP OD
- total amount ingested
- time from ingestion to presentation
- age of pt
- alcoholism
- other enzyme inducing medications
43
complications of APAP toxicity
- jaundice
- renal failure- hepatic renal syndrome
- hyperlatatemia
- metabolic acidosis
- hypophosphatemia
- hypo/hyperglycemia
- cardiac arrhythmias
- pancreatitis
- GIB
- cerebral edema
44
phase 1 APAP poisoning
- 30 min - 4 hours
- anorexia
- nausea
- pallor
- vomiting
- diaphroesis
45
phase 2 APAP poisoning
- 24-48 hours
- less severe
- RUQ pain d/t hepatic damage
- elevated LFTs
- prothrombin may be prolonged
- renal funciton may deteriorate
46
phase 3 APAP poisoning
- 3-5 days
- hepatic necrosis
- jaundice
- renal failure
- coag defects
- hepatic encephalopathy
- death due to hepatic failure
47
phase 4 APAP poisoning
- 4 days to 2 weeks
| - complete resolution or death
48
management of APAP OD
- GI decontamination in first 1-2 hours with ipecac
- activated charcoal
- cathartics
- dialysis not effective
- four hours post ingestion get levels, plot on rumack-matthews nomogram
- admin NAC
49
labs to monitor with APAP toxicity
- baseline cbc
- cr, BUN
- sugar
- electrolytes
- tox screen
- prothrombin time
- AST/ALT
50
what is NAC
- antidote for APAP toxicity
- given PO or IV
- must finish treatment once started
- 72 hour protocol: loading dose then maint dose q 4 hours X 17 doses
- if emesis within one hour of dose then repeat dose
