Anesthesiology Flashcards
Bone immobilization should always follow the?
* Pott’s rule:*
-If a long bone is broken, the immobilizing dressing should involve the given bone and two adjacent joints
-If a joint is damaged, the immobilizing dressing should involve the given joint and both bones forming it
Antipyretics MOA
cause the hypothalamus to override a prostaglandin-induced increase in temperature.
Antipyretics: example
-salicylates (eg, sodium salicylate and acetylsalicylic acid),
-ibuprofen, nonsteroidal anti-inflammatory drugs (NSAIDs),
-para-aminophenol derivative acetaminophen
Hypovolemic shock is a
generalized state of ischemia in the body when the body’s cells do not receive enough oxygen as a result of blood loss or transfer to other cavities in the body.
Hypovolemic shock resulting from blood loss is called
hemorrhagic shock
An orthostatic drop in blood pressure of _____mmHg and a concomitant increase in heart rate of ______ indicates what ?
An orthostatic drop in blood pressure of** ≥10 mmHg** and a concomitant increase in heart rate of** ≥20/min** indicates hypovolemia.
Loss of blood up to ____ is usually accompanied by ___.
Loss of blood up to 1500 ml is usually accompanied by** anxiety.**
The loss of half of total blood volume (_______ml) is associated with _______ disturbances of _______.
** (2000–2500 ml)** is associated with quantitative disturbances of** consciousness.**
Assuming an adult’s blood volume of 5 liters, the loss of **750ml of blood **is ____% of the circulating blood
Assuming an adult’s blood volume of 5 liters, the loss of **750ml of blood **is **15% **of the circulating bloodv
ATLS guidelines that break down the shock according to the percentage of
Class 1 shock loss of less than 15% of blood
- no symptoms
ATLS guidelines that break down the shock according to the percentage of
Class 2 shock loss of 15%-30% of blood
- increase in heart rate
ATLS guidelines that break down the shock according to the percentage of
Class 3 shock loss of 31%-40% of blood
- increase in heart rate and decrease in pressure, moderate increase in respiratory rate and decrease in diuresis.
ATLS guidelines that break down the shock according to the percentage of
Class 4 shock loss of more than 40% of blood
- a significant increase in heart rate and a decrease in pressure, an increase in respiratory rate, a significant decrease in diuresis.
Hypothermia is a condition in which the internal body temperature falls below ___ ° C.
**35 ° C. **
Classification of hypothermia distinguishes 5 stages of this condition
1 ° - mild hypothermia -
32-35 ° C
Classification of hypothermia distinguishes 5 stages of this condition
2 ° - Moderate hypothermia -
28-32 ° C
Classification of hypothermia distinguishes 5 stages of this condition
3 ° - Severe hypothermia -
24-28 ° C
Classification of hypothermia distinguishes 5 stages of this condition
4 ° - Cardiac arrest or hypoperfusion state
<24 ° C
Classification of hypothermia distinguishes 5 stages of this condition
5 ° - Death due to irreversible cooling of the body
<13.7 ° C
Cooling the body reduces ?
Oxygen demand (6% for every 1 ° drop in core body temperature).
Hypothermia reduces ?
body’s sensitivity to medication .
in case of hypothermia are warming the patient and performing chest compressions in a ratio of 30: 2. After reaching the body temperature of ____ ____, we start to administer drugs, remembering?
30 degrees, we start to administer drugs, -remembering that the time interval between two doses should be doubled
**Ventricular Tachycardia **
The ECG shows broad QRS tachycardia of ventricular origin.
The ECG record shows wide QRS complexes and the absence of a P wave.
Tachycardia is the result of the activity of the ventricular ectopic focus triggering high-frequency beats or is formed in the reentry mechanism.
** assystolia** - no electrical activity of the heart and no contractile activity of the heart. It should be distinguished from pseudo-asystole, which is caused by technical problems of the ECG recording equipment, poor adhesion of electrodes to the skin or errors in the examination technique, there is a systolic function of the heart.
**atrial fibrillation **- fast and irregular stimulation and contractions of individual bundles and fibers of the atrial muscle.
It arises most likely as a result of sending excitations through numerous ectopic foci or chaotic circulation of reentry waves over several circuits.
torsade de pointes - a rare form of ventricular tachycardia with variable direction and different shapes of QRS complexes.
ventricular fibrillation - fast and uncoordinated work of the heart’s ventricles (heart stimulation during relative refraction).
The ECG of the QRS complex is an irregular sine wave. If the sine wave is regular in shape and the heart rate is 200-300 beats per minute, it is called ventricular flutter.
causes of acute epigastric pain include:
-peptic ulcer of the stomach and duodenum, ulcer perforation
-acute hepatitis
-intestinal ischemia
-abdominal aortic aneurysm
causes of epigastric pain include:
acute hepatitis
abdominal aortic aneurysm
bile duct diseases
drug-induced mucosal damage of the stomach and duodenum
functional dyspepsia
gastroesophageal reflux disease (GERD)
gastroenteritis
intestinal ischemia
malignant tumors
myocardial infarction
peptic ulcer of the stomach and duodenum, ulcer perforation
pancreatitis or pancreatic pseudocysts
The potentially reversible causes of cardiac arrest (so-called ‘four H’s) Include?
- hypoxia
- hypovolemia
- hypokalemia or hyperkalemia, metabolic disorders (hypoglycemia, hypocalcaemia, acidosis)
- hypothermia
4T’s:
- pneumothorax
- cardiac tamponade
- toxic causes of sudden cardiac arrest
- venous thromboembolism (pulmonary embolism, myocardial infarction)
Vitamin K antagonists (VKAs)
-have been the mainstay of anticoagulation therapy -VKAs are mainly used for the* prevention of stroke in patients with atrial fibrillation (AF) and the treatment*
-secondary prevention of venous thromboembolism
Name 3 tissues with a rapid cell turnover
bone marrow - aplasia
gastrointestinal tract - diarrhea, mucus in the stool, nausea and vomiting, abdominal pain, urgent pressure on the stool, persistent wind and flatulence, bleeding from the lower gastrointestinal tract
skin - moderate or severe erythema; mottled moist exfoliation, usually limited to folds and folds of the skin
CNS - although neurons rarely divide, there are many other cells in the brain outside of them. Radiation causes apoptosis of mature oligodendrocytes, and also** disrupts the function of astrocytes** and microglial cells. Ionizing radiation in cases of strong exposure may also directly affect synaptic conductivity.
Haemophilia A (Factor 8)
- is a congenital hemorrhagic diathesis caused by a decrease in the activity of factor VIII which causes increased bleeding.
- Most often, hemophilia A occurs as an inherited disease with the X chromosome but sometimes occurs as a result of de novo mutation. Therefore, most of the patients are males;
- In the majority of cases it is inherited as an X-linked recessive trait, though there are cases which arise from spontaneous mutations.
define
Hyperosmolar hyperglycemic state
- is one of the acute disturbances of water-electrolyte balance and is most common in people with type II diabetes, especially in the elderly. -Diagnosis is established on the basis of laboratory values:
Hyperosmolar hyperglycemic state
Diagnosis is established on the basis of laboratory values:
-plasma glucose concentration> 600 mg / dl
-pH> 7.3
-bicarbonate concentration> 15 mmol / l
-sodium concentration> 150 mmol / l (in 50% of patients)
-absence of ketone bodies in the urine
-serum osmolality> 320 mOsm / kh H2O
-disturbances of consciousness, coma
Diabetes insipidus does not
affect the plasma glucose level.
Adrenal crisis is characterized by
hyperkalemia,
hyponatremia,
hypoglycemia.
Acute lithium poisoning manifests itself as symptoms:
on the part of the nervous system:
quantitative and qualitative disturbances of consciousness, psychomotor slowness, headaches, visual disturbances, impaired coordination of eye movements, dysarthria, cerebellar ataxia, coarse and fine wave tremors, dystonias, muscle stiffness, seizures
Acute lithium poisoning manifests itself as symptoms:
on the part of the digestive tract:
nausea, vomiting, diarrhea, abdominal pain
Acute lithium poisoning manifests itself as symptoms:
on the part of the kidneys:
acute prerenal and renal failure - incl. acute tubular necrosis
Acute lithium poisoning manifests itself as symptoms:
on the part of the circulatory system:
arrhythmias, changes in the ECG recording, tachyarrhythmias, bradyarrhythmias, widening of the QRS complexes, disturbances in intraventricular conduction, heart blocks, bundle branch blocks, prolongation of the QTc interval, T wave inversion, non-specific ST-T changes
Acute lithium poisoning manifests itself as symptoms:
on the part of the respiratory system:
acute respiratory distress syndrome (ARDS).
activated charcoal is widely used, however, it is not effective in the treatment of poisoning caused by:
alcohols
solvents
acids and caustics
metals (iron and lithium)
It should be remembered that the most effective method of treating acute lithium poisoning is ?
hemodialysis
Adrenaline dosage varies with the age of the child:
Age Dose
<6 months
150 µg (0,15 ml)
Adrenaline dosage varies with the age of the child:
6 months to 6 years
150 µg (0,15 ml)
Adrenaline dosage varies with the age of the child:
6 years to 12 years
300 µg (0,3 ml)
Adrenaline dosage varies with the age of the child:
> 12 years
300–500 µg (0,3–0,5 ml)
the tidal volume characteristic of an adult
the tidal volume is 500 ml
The tidal volume of an infant can be calculated by knowing the child’s
** body weight** and is: 7-9 ml x kg.
Pediatric Basic Life Support
Indicate the 3 immediate emergency care factors regarding PBLS:
- breath assessment should take 10 seconds - same as for adult resuscitation, breath assessment is based on 3 senses:
hearing (the patient’s audible breathing)
touch (feeling the patient exhale)
eyesight (lifting the chest)
2, while performing CPR on an infant you should compress the chest at a rate of at least 100/min;
- chest compressions to breaths ratio is 15:2 - true, the altered breathing-to-compression ratio in favor of rescue breaths is due to the fact that in children, respiratory arrest usually precedes cardiac arrest. More specifically, we start with 5 rescue breaths, then continue with chest compressions and breaths at a ratio of 15:2.
Using ALS - advanced life support after defibrillation, we perform the assessment of the heart rhythm:
- after 2 minutes of CPR
- after signs of return to vital signs
- when there is a sharp increase in the partial pressure of carbon dioxide in the end expiratory air (ETCO2
An antidote for benzodiazepine intoxication is
Flumazenil -> BZD receptor antagonist, is used in BZD poisoning.
Naloxone is used in
opioid overdose.
Hypothermia is defined as a decrease in body core temperature
<35 ° C.
Body core temperature can be measured in the
rectum,
esophagus
tympanic membrane.
Degrees of hypothermia according to the Swiss Classification of Hypother
HT1 - core temperature
32-35 ° C - conscious patient with shivering
Degrees of hypothermia according to the Swiss Classification of Hypother
HT2 - core temperature
28-32 ° C -* impaired consciousness *without shivering
Degrees of hypothermia according to the Swiss Classification of Hypother
HT3 - core temperature
24-28 ° C - unconscious, vitals signs present
Degrees of hypothermia according to the Swiss Classification of Hypother
HT4 - core temperature
<24 ° C - no vitals signs
Degrees of hypothermia according to the Swiss Classification of Hypother
HT5 -
death
reversible causes of SCA
4-H’s
hypoxia,
hypokalaemia/hyperkalaemia,
hypothermia/hyperthermia,
hypovolaemia
reversible causes of SCA
4-T’s
tension pneumothorax,
tamponade,
thrombosis,
toxins
It is a pathophysiological reaction to extensive bodily injury that usua
“Ach”…. triad of death:
acidosis
coagulopathy
hypothermia
Which of the following is not used in patients with severe respiratory failure caused by status asthmaticus?
Adenosine can cause bronchospasm, which is highly undesirable in people with asthma.
is used in case of paracetamol poisoning.
N-acetylcysteine
is used in Organophosphate poisoning
Atropine
1
used in Cyanide poisoning
Amyl nitrate
2
used in Cyanide poisoning
Hydroxocobalamin
used in Opioid poisining
Naloxone
Antidote that can reverse benzodiazepine intoxication
Flumazenil
We evaluate the depth in terms of the degree of burn, and thus:
I ° -
*covers only the epidermis *- the patient feels a burning sensation, redness and a slight swelling appear, healing takes about 1 week, does not leave a scar.
We evaluate the depth in terms of the degree of burn
II ° a -
covers the epidermis and part of the dermis - the patient experiences severe pain, redness and swelling appear, blisters filled with light yellow liquid, healing takes about 2 weeks, leaves discoloration.
We evaluate the depth in terms of the degree of burn
II ° b -
covers the epidermis and the entire dermis - the skin takes a white color, and as a result of damage to the sensory nerves, the burn does not hurt. Healing takes up to a few weeks and leaves a permanent scar.
We evaluate the depth in terms of the degree of burn
III ° -
covers the entire thickness of the skin - the patient does not feel pain because the sensory receptors are damaged, the skin is hard, dry, white-grayish, the necrosis forms a scab, which, when it falls off, will fill with granulation tissue and large deep wounds will appear.
We evaluate the depth in terms of the degree of burn
IV ° -
covers the tissues deeper - muscles, tendons, internal organs - necrosis and charring appear.
Parkland rule
Parkland rule
Discusses the amount of fluids that we have to infuse the patient during the first 24 hours after burns.
-Fluid quantity = 2-4 ml x patient weight x percent burned body surface area.
-50% in 8 hours, 50% in the remaining 16 hours.
Example: A patient weighing 50 kg has two upper limbs burned.
2-4 x 50 x (9 + 9) = 1800 - 3600 ml. Half of them within the first 8 hours.
name 5
Advanced Life Support (ALS):
- Assess whether the patient is responding or breathing
- Call the resuscitation team
- Perform CPR 30 compressions up to 2 rescue breaths
- RATE THE RHYTHM
- Perform CPR for 2 minutes until your next rhythm analysis.
name 2
DEFIBRILLATION RHYTHM -
ventricular fibrillation (VF)
or
pulseless ventricular tachycardia (VT)
Prepare intravenous access. After 3 failed shocks, give
-
amiodarone 300 mg in 20 ml 5% glucose and adrenaline 1 mg.
-Subsequent doses of drugs - adrenaline 1 mg every 3 - 5 minutes,
-amiodarone after 5 unsuccessful defibrillation 150 mg.
Remember: adrenaline is _______ dependent
“time-dependent”, we give it every 3 - 5 minutes
amiodarone is “_______-dependent”, we give it after ______
“defibrillator-dependent”, we give it after** 3 and 5 failed defibrillation.**
When amiodarone is not available, it is recommended to administer?
** lidocaine **3 mg / kg. within an hour.
NON-DEFIBRILLATION RHYTHM = ASSYSTOLY AND PEA OR ELECTRICAL ACTIVITY OF
NON-DEFIBRILLATION RHYTHM = ASSYSTOLY AND PEA OR ELECTRICAL ACTIVITY OF THE HEART WITHOUT A PULSE
- Provide intravenous access as soon as possible and give 1 mg of adrenaline.
- Repeat dose every 3-5 minutes, on average every other CPR cycle.
- The guidelines for resuscitation state that “survival from an asystole or PEA cardiac arrest is unlikely if a potential cause is not identified and treated.” Therefore, actively seek 4H / 4T.
shockable rhythm -
-defibrillate as quickly as possible,
-after 3 unsuccessful shock deliveries give amiodarone and adrenaline
non-shockable rhythm -
-cardiac massage,
-adrenaline administered as quickly as possible, 3 - 5 minutes apart.
torsade de pointes
(polymorphic ventricular tachycardia)
In the event of persistence:
- ventricular fibrillation or ventricular tachycardia after 3 ineffective electrical shocks and suspected hypomagnesaemia,
- torsade de pointes (polymorphic ventricular tachycardia)
-> use magnesium in the form of** magnesium sulphate**
-dose of 1-2 g i.v., if necessary,
-repeat after 10-15 minutes.
Symptoms of PE:
A classic triad of symptoms in pulmonary embolism, occurring in 25% of patients, includes:
- sudden onset, 80% reports dyspnea
- Pluric chest pain
- hemoptysis.
-In studies: tachycardia, tachypnea, increase in the volume pulmonary component of the 2nd tone and tricuspid regurgitation (right ventricular dilation) murmur.v
Pulmonary embolism (PE) is
a narrowing or closure of the pulmonary artery or its branches by an embolus (embolic material).
Examples of emboli:
- thrombi - most often from the deep veins of the lower limbs
- amniotic fluid
- air
- adipose tissue - when a long bone is broken
- tumor masses
- foreign bodies
Pathophysiology of embolism:
- When the embolic material closes the pulmonary artery, the ventilation to perfusion ratio decreases, and hypoxemia develops.
- As a result of the embolism, blood from the right side of the heart must overcome more resistance.
- This leads to right ventricular dilatation and a reduction in the amount of blood that goes to the left heart.
- The minute capacity decreases and shock develops.
- In addition, as a result of impaired perfusion, symptoms of myocardial ischemia may appear.
- The clinical picture depends on the size of the embolus and the general condition of the patient.
- A young, healthy patient may have only minor symptoms.
- In an elderly patient with numerous chronic diseases, even a small embolism can lead to shock.
Risk factors:
Pulmonary embolism
age >40 years old
obesity
varicose veins of the lower extremities
multi-organ injuries
fractures of the pelvis and femur
operations and associated long-term immobilization
long >4 hour flight
cancer
pregnancy and puerperium (first 6 wks postpartum)
HRT and contraception
Pulmonary embolism
Supplementary tests: PE
-D-dimers - have a negative predictive value - that is, increased D-dimer levels do not allow the diagnosis of PE, but when they are normal (i.e. <500 in people <50 years of age, 10 for each year of life in people >50 years old) this allows you to exclude PE
-ECG - right axis deviation, RBBB - right bundle branch block, “SIQIIITIII” syndrome
--Angio-CT - remember to include information about suspicion of PE on the referral
-CUS - compression ultrasound examination of lower limb veins
Levine’s symptom
when the patient points to the source of pain by placing a clenched fist or an open hand on the chest.
name 5
Features and characteristics of chest pain:
angina pectoris - retrosternal, can radiate to the left jaw, left shoulder, epigastrium, crushing, burning, intensifying during physical exertion
unstable angina or myocardial infarction - the same characteristics as above and does not subside after stopping exercise and taking nitroglycerin, lasting> 20/30 minutes
pericarditis - sharp, stinging, variable intensity, decreases in a sitting position with a forward lean, pericardial friction present
pleural pain - one-sided, sharp, stinging, it decreases when you lie on your side where the pain occurs
aortic dissection - sudden, severe, excruciating, covers the anterior chest wall.
In the event of electrocardiographic features of** hyperkalemia or arrhythmias** you should administer problems.
30 ml of a 10% solution of calcium gluconolactobionate
or
10 ml of a 10% solution of calcium chloride .
-This procedure does not cure hyperkalemia itself !
These drugs are cardioprotective and should always be given if you have heart rhythm
In order to move potassium into the cells, give
20-40 ml of 40% glucose solution + 4-8 units of short-acting insulin (1 unit of insulin for 3 g of given glucose).
If you have acidosis, give
50 ml of 8.4% NaHCO3 (Sodium bicarbonate) solution.
treatment that removes excessive potassium from the body - options:
*loop diuretic in patients with preserved diuresis , eg furosemide 20-40 mg iv, the dose can be repeated after 6-8 h. Loss of fluids due to increased diuresis is compensated with 0.9% NaCl infusion.
cationic exchangers binding potassium in the gastrointestinal tract - polystyrene sulphonate p.o. or p.r. 30 g in 150 ml of water or 10% glucose solution; a 0.5-1.0 mmol / l reduction of kalemia occurs within 4-6 hours
hemodialysis (rarely peritoneal dialysis) - in the case of life-threatening hyperkalemia and in patients with severe renal insufficiency.
Spurious hyponatremia occurs secondary to:
Hyperglycemia
Hyponatraemia is a serum sodium concentration of
<135 mmol / L.
We can divide hyponatraemia according to the degree of severity:
mild
moderate
severe
and due to the duration:
acute - lasts
chronic - lasts
mild 130 - 134 mmol / l
moderate 125 - 129 mmol / l
severe <125 mmol / l,
duration:
acute - lasts <48 hours
chronic - > 48 h and any undocumented hyponatremia.
hypotonic with hypovolemia -
high loss of fluids and Na, e.g. in diarrhea.
hypotonic with isovolemia -
a decrease in Na concentration causes the passage of water into the extracellular space, causing edema. The most common form of hyponatraemia. It occurs in patients with inadequate secretion of vasopressin.
isotonic or hypertonic -
-it occurs when there are a lot of osmolally active substances in the plasma.
-They cause fluid to pass from the cells into the blood. Plasma is diluted.
-Depending on the concentration of these substances, the plasma osmolality is normal or increased.
hypotonic with hypervolaemia -
may occur when there is an excessive supply of electrolyte-free fluids, with AKI or CKD.
A tourniquet is a type of dressing used to?
name specific situations: name 4
Placement ?
-provide first aid.
-This band helps to stop severe bleeding that threatens life by pushing the artery to the bone and completely closing its light . According to the latest guidelines of the European Resuscitation Council, we only use the tourniquet in specific situations:
- mass accident,
- amputation,
- crushing,
- when the direct compression does not block the bleeding
-It is placed about* 5 centimeters above the source of hemorrhage* , but never below the elbow or knee,
“It is good to remember the following important facts:
the radial pulse can be checked at a systolic pressure of about ____
80 mmHg,
“It is good to remember the following important facts:
the femoral artery can be checked at systolic pressure of ___
70 mmHg
“It is good to remember the following important facts:
The carotid artery systolic pressure can be checked at
60 mmHg.
name 10 from top -> bottom
We test the heart rate on the artery:
jugular
subclavian
axillary
brachial
radial
ulnar
femoral
knee-length
posterior tibia
dorsal foot.
Hypothermia reduces the body’s sensitivity to
medication
patient with irregular tachycardia with narrow QRS, no symptoms of circulatory failure is considered ?
-
stable. **
-the most common symptoms are* atrial fibrillation with an uncontrolled ventricular response* or *atrial flutter with variable AV block. *
-We do not stimulate the vagus nerve in such patients**
-We** do** it in patients with regular tachycardia in order to release the conductivity in the atrioventricular node.
Management of a patient with pulse tachycardia: Point 1- 3 of 4
Management of a patient with pulse tachycardia:
Point 1-3
- Examine the patient according to the ABCDE scheme
- Obtain intravenous access, perform an ECG, and administer oxygen when indicated
- Recognize and treat a reversible cause
Management of a patient with pulse tachycardia: Point 4 of 4
Management of a patient with pulse tachycardia:
Point 4
- Assess whether the patient is stable, whether there are any disturbing symptoms such as shock, fainting, myocardial ischemia or heart failure
Management of a patient with pulse tachycardia: Point 4 of 4
Management of a patient with pulse tachycardia:
Point 4a
-If the patient is unstable, we should perform cardioversion up to 3 attempts, then give amiodarone 300 mg IV. within 20 minutes
Management of a patient with pulse tachycardia: Point 4 of 4
Management of a patient with pulse tachycardia:
Point 4b
-If the patient is stable, we need to evaluate the QRS
-When they are narrow <120 ms and regular, we should stimulate the vagus nerve and administer adenosine in the 6-12-18 mg regimen
-When they are narrow and irregular, it is most likely atrial fibrillation that requires appropriate treatment.
-Included here: pharmacological ventricular rhythm control - A with B-blocker or diltiazem.
-Moderation with medication - pharmacological cardioversion or electrical cardioversion.
-In such patients, treatment to prevent complications should also be started.
-When the duration of the arrhythmia is greater than 48 hours or unknown, in order to perform cardioversion, we must administer antiplatelet drugs for 3 weeks before the procedure and 4 weeks after the procedure.
-If the patient requires immediate moderation, we must perform a transesophageal ECHO in order to exclude a thrombus in the left atrial appendage.
Cardioversion is a medical procedure that
-uses quick, low-energy shocks to restore a regular heart rhythm. It’s a treatment for certain types of irregular heartbeats (arrhythmias), including atrial fibrillation (A-fib).
-Sometimes cardioversion is done using medications
in order
Management of recurrent ventricular tachycardia is as follows:
cardioversion
overdrive electrostimulation
amiodarone
lidocaine
adenosine in the case of
tachycardia with pulse with narrow and regular QRS.
Sudden Cardiac arrest
What is used in the case of SCA
We use defibrillation and adrenaline in the case of SCA
-Heart attack is when blood flow to the heart is blocked.
-heart attack is a “circulation” problem
-Sudden cardiac arrest is when the heart malfunctions and suddenly stops beating.
-sudden cardiac arrest is an “electrical” problem.
it should be noted that if a patient is not in cardiac arrest therefore we do not perform ___
it should be noted that the patient is** not in cardiac arrest **and therefore we do not perform CPR.
percutaneous ablation
-an experienced interventional radiologist places a needle through the skin in the back and into the tumor.
-This is done under CT scan or ultrasound guidance.
-The ablation machine is then turned on and the tumor is destroyed.
the use of* intravenous lidocaine* to treat recurrent sVT or VF is considered in the event of unresponsive treatment with?
β-blocker or amiodarone therapy
formulas to calculate the QTc.
Bazett formula is most commonly used.
Bazett formula =
QT interval (s) / √ RR interval (s)
QT prolongation is confirmed occurs when QTc is:
≥0.45s in males
≥0.46s in females
The cause of prolongation QT is
hypokalemia
hypocalcemia
hypervagotonia
In the case of acute pulmonary edema, the following medications are used:
- loop diuretics: furosemide, torasemide
- oxygen
- **opioids: ** morphine - this group of drugs is considered, in the case of strong agitation, anxiety, they also reduce the feeling of shortness of breath
depending on the systolic pressure
In the case of acute pulmonary edema, the following medications are used:
a) SBP <85 mmHg
b) SBP <110 mmHg
- depending on the systolic pressure
a) SBP <85 mmHg - **positive inotropic drugs: **dopamine, dobutamine, milrinone, levosimendan, noradrenaline, adrenaline
b) SBP <110 mmHg - vasodilators: nitroglycerin, sodium nitroprusside
digoxin - it also belongs to ___ ___ drugs, but we only use it if ?
-belongs to positive inotropic drugs
-but we only use it if ?
the pulmonary edema was caused by a tachyarrhythmia, (eg atrial fibrillation).
-It is not recommended if pulmonary edema was caused by a myocardial infarction - it works arrhythmogenically.
What is ARDS?
It is an acute respiratory distress syndrome (ARDS).
What is cardioversion?
It is a procedure to restore the normal heart rhythm by simultaneous appearance of the R wave in the ECG and discharge of the short-term current of high voltage, resulting in partial depolarization of the myocardium.
The indications for cardioversion are:
- Urgent: supraventricular and ventricular tachyarrhythmias inducing hemodynamic disturbances.
- Elective cardioversion: tachyarrythmiaa (predominantly atrial fibrillation and atrial flutter) that do not cause hemodynamic disturbance, persisting despite pharmacological treatment or when it is not possible to use drugs.
A racing heart rate is known as ___. If it is fast and an arrhythmia, it is called ___
tachycardia
tachyarrhythmia
Elective cardioversion indication in :
tachyarrythmiaa (predominantly atrial fibrillation and atrial flutter)
Atrial fibrillation is a
-supraventricular tachyarrhythmia,
-heart disorder that is an indication for electrical cardioversion.
VF / pVT are
-cardiac arrhythmias synonymous with cardiac arrest
-requiring CPR and defibrillation
Asystole and PEA as well as
VF / pVT are rhythms identical to cardiac arrest, but they do not require defibrillation.
name 4
rhythms identical to cardiac arrest, but they do not require defibrillation:
Asystole
PEA
VF / pVT
name 6
Antihypertensives used parenterally for the treatment of hypertension with urgent indications are:
A - dilating vessels:
- sodium nitroprusside - onset of action: immediate
- nicardipine - onset of action: 5-10 min
- fenoldopam - onset of action: <5 min
- nitroglycerin - onset of action: 2-5 min
- enalaprilat - onset of action: 15-30 min
- dihydralazine - onset of action: 10-20 min
name 4
Antihypertensives used parenterally for the treatment of hypertension with urgent indications are:
B - betablockers:
- labetalol - onset of action: 5-10 min
- esmolol - onset of action: 1-2 min
- phentolamine - onset of action: 1-2 min
- urapidyl - onset of action: 1-5 min
The CURB-65 scale is .
a medical scoring scale that allows you to assess the severity of pneumonia and determine the place of treatment of the patient
CURB-65
The name of the scale is an acronym of the risk factors taken into account when calculating the score:
-consciousness disorders and ( **C **onfusion)
-urea level ( U rea) greater than 7 mmol / l (BUN> 19)
-respiratory rate ( R ) equal to or greater than 30 / minute
-blood pressure ( B ) equal to or lower than 90/60 mmHg
- age over 65.
You can get 1 point for each answer
0-1 = outpatient
2 - recommended admission to the hospital
3-5 - obligatory hospitalization, possible treatment in ICU
Infusion fluids can be divided into two groups: crystalloids and colloid
Crystalloids - these are
.
-water solutions:
-mineral salts such as sodium chloride, potassium chloride, calcium chloride, magnesium chloride,
-salts of organic acids, e.g. sodium acetate, sodium lactate, sodium citrate, low molecular weight carbohydrates.
They are cheap, easily available, do not cause allergic reactions.
Crystalloids after intravenous infusion quickly pass into the extravascular space, only briefly replenishing the plasma volume.
The crystalloids include:
- 0.9% NaCl
- Polyelectrolyte fluid
- Ringer’s lactate and lactate-free Ringer
Colloids - these are
-aqueous solutions of macromolecular substances, most commonly polymers of glucose or derivatives of gelatine.
In contrast to crystalloids, colloids stay longer in the plasma without going quickly to the tissues.
-They better supplement plasma loss.
-Colloidal solutions are more expensive than crystalloids.
-All of them may cause allergic reactions (especially dextranes and to a lesser extent gelatine) with anaphylactic shock,
.
Colloids include:
- Hydroxyethylated starch - HES (HAES)
- modified gelatin
- dextrans
- albumin.
- Plasma is also a colloid, although it is not a typical infusion fluid
ischemic stroke - S/D bp of
systolic blood pressure > 220 mm Hg
or
diastolic> 120 mm Hg
if the patient is to receive thrombolytic therapy, the blood pressure must not exceed 185/110 mm Hg;
- are used to reduce BP ?
185/110 mm Hg;
- Labetalol and urapidil are used to reduce BP
symptoms of increased intracranial pressure:
somnolence,
double vision
abnormal reaction of the pupils to light,
optic disc swelling → remember, however, that this is a late symptom,v
symptoms of brain intussusception:
bradycardia
irregular breathing
high blood pressure
A 36-year-old patient weighing 80 kg was taken to the ED because of burns from boiling water. Thorough examination revealed the burns to both legs and the right upper limb.
What amount of fluids should be infused in this patient during the first 8 hours after the trauma?
Name the Rule’s used to calculate ?
- First, calculate the area of the patient’s burn.
-According to Wallace’s rule, we count it as follows:
- 2 x lower limb (18%) = 36
- 1 x upper limb (9%)
In total, we obtain a result of 45%
- Then, the demand for crystalloids within 24 hours should be calculated, according to the Parkland rule, using the formula:
x = 4 ml x body weight x area burns (%) = 4 ml x 80 kg x 45% = 14400 ml
- The obtained result should be divided in half.
- We will then get a demand for the first 8 hours, and the other half should be distributed over the remaining 16 hours, i.e.
14440 ml / 2 = 7200 ml - this is the amount to be given within 8 hours and the remaining volume within the next 16 hours
A patient with diabetes mellitus is suffering from an acute complication known as ____ which is an acute syndrome of?
ketoacidosis
carbohydrate, lipid, protein, water-electrolyte and acid-base disorders.
The latest ERC 2021 Guideline recommends Targeted Temperature Management (TTM) control in any adult patient following cardiac arrest who does not regain consciousness after ROSC. Target temperature should be
-between** 32°C and 36°C for min. 24 h, **
-in addition, in these patients, an increase in temperature> 37.7°C should be avoided for at least 72 h.
Antidote for carbon monoxide:
OXYGEN
Hyperbaric oxygen therapy is used in pregnant women with a COHb concentration __, regardless of the clinical condition, and if the concentration of COHb ___ - when neurological and / or cardiac disorders persist.
> 25%
15% (a <25%)
What is a normal ABG level?
pH
PaO2
PaCO2
pH (7.35-7.45)
PaO2 (75-100 mmHg)
PaCO2 (35-45 mmHg)
A patient with diarrhoea symptoms lasting several days was admitted to the hospital. Arterial blood gas test showed pH = 7.2, PaCO2 = 28 mmHg. Which acid-base imbalance should be diagnosed in the patient?
metabolic acidosis
The correct pH of human blood is: 7.35 - 7.45
Based on this, we can diagnose acidosis in the patient .
Now you need to determine which type of acidosis it is.
Diarrhea is given in patient history. As a result, the patient loses bicarbonate ions, i.e. anions of an alkaline nature, which meets the definition of metabolic acidosis. In the ABG test we will have a reduced HCO3- concentration.
name 8
The characteristic fractures in Battered Child Syndrome include
- sternum
- shoulder blade,
- ribs (especially the back section),
- spinous processes and vertebral bodies,
- collarbone,
- tibia and thigh in infants (shaft),
- bones of fingers in children who do not walk yet
- epiphyseal, metaphyseal and intra-articular fractures
Pulmonary embolism is a disorder involving
the occlusion or narrowing of the pulmonary artery or its branches by embolic material, which may be: thrombus - from deep veins of the lower limbs or pelvis, amniotic fluid, air, adipose tissue, tumor masses, foreign bodie
Symptoms of Pulmonary embolism include
sudden dyspnoea (in 80% of patients),
chest pain of pleural origin,
less frequently coronary (in 50% of patients),
cough (in 20% of patients),
moreover fainting, collapse, hemoptysis.
Physical examination of Pulmonary embolism shows
tachypnoea, tachycardia,
sometimes distension of the jugular veins,
louder pulmonary compound of the S2 sound,
sometimes murmur of tricuspid regurgitation,
hypotension and symptoms of shock
The correct respiratory rate at rest is
12-15 / min.
One of the pathological cycles and breathing paths is the deepened and accelerated breath, so-called
Kussmaul breathing
Kussmaul breathing - occurrs in
metabolic acidosis
name 6
Kussmaul breathing - occurring in metabolic acidosis, to which the following can lead:
- diabetic ketoacidosis (sudden insulin deficiency),
- lactic acidosis,
- acidosis caused by the supply of acid precursors (eg. poisoning with ethanol, methanol, ethylene glycol, salicylates),
- impaired regeneration of bicarbonates by the kidneys - acidosis in acute or chronic renal failure - it may occur in the case of metformin overdose;
- loss of the bases by kidneys - proximal and distal tubular acidosis;
- through the digestive tract - diarrhea, biliary fistulas, pancreatic, intestinal fistulas.
causes of Kussmaul breathing, you can use the following acronym:
“KUSMAUL”
“K” Ketosis
“U” Uremia
“SS” Salicylate poisoning
“M” Methanol poisoning
“A” Ethylene poisoning (earlier spelt Aethylene)
“U” Uremia
“L” Lactic Acidosis
Epiglottitis is a rare form of___ ?
Aetiology
** laryngitis** that occurs more often in children than in adults (usually from 2 to 6 years of age)
-The most common aetiological factor is Haemophilus influenzae type B
The disease begins suddenly with pain in the upper part of the larynx, when swallowing, the pain intensifies to such an extent that the patient avoids it. This results in abundant salivation. From the onset of the disease there is high temperature and rapidly increasing dyspnoea (with stimulation of the sympathetic system and subsequent tachycardia)
Epiglottitis is a rare form of laryngitis that begins
- begins suddenly with pain in the upper part of the larynx, when swallowing, the pain intensifies to such an extent that the patient avoids it. –This results in abundant salivation.
- From the onset of the disease there is high temperature and rapidly increasing dyspnoea (with stimulation of the sympathetic system and subsequent tachycardia)
The Parkland formula is the basic protocol for
-replacement of fluids in burned patients
-4-5 ml × mass (kg) × burn area (%) *
- calculated on the basis of Wallace rule of nines
Near-drowning
is the survival (at least temporarily) of an incident associated with being submerged in water.
Drowning
is death due to asphyxiation caused by being submerged in water.
Sudden immersion syndrome
is a sudden death caused by immersion in very cold water.
Drowning leads to ->
Drowning → hypoxia → laryngospasm → no aspiration of water to the respiratory tract.
Wet drowning
where water is aspirated into the lungs.
Hypokalemia is defined as
a decrease in serum potassium **<3.8 mmol / l **.
Acidosis is most often associated with
hyperkalemia.
name & provide the amount
Antidote used intravenously in paracetamol intoxication amounts to:
(coma, severe lactic acidosis) massive drug overdoses (75-100 g).
N-acetylcysteine (NAC)
300 mg/kg m.c.
NAC dosing regimen (3 doses in 21h):
I dose - 150 mg/kg
II dose - 50 mg/kg
III dose - 100 mg/kg
Summing up all 3 doses, the total dose is 300 mg/kg
Mallampati classification or Mallampati score - is used
-four-level classification used in anaesthesiology, -defining the degree of difficulty of tracheal intubation determined by the anatomical structure of the oral cavity.
The classification is as follows:
visible soft palate, uvula, fauces and pillars
visible soft palate and uvula
visible soft palate and the base of uvula
one cannot see the soft palate
name 4
Convulsions may occur in the following electrolyte and metabolic disorders:
hyponatremia
hypocalcaemia
hypomagnesemia
hypoglycemia
In Poland, septic shock is most often caused by ____ ____ infections, followed by ___-___ infections, which are the most common cause of severe sepsis treated in ICUs.
respiratory tract infections
intra-abdominal infections
Normocapnia or normocarbia is a state of
normal arterial carbon dioxide pressure (32 - 45 mmHg)
Proceeding in ICU after ROSC (return of spontaneous circulation)
-Temperature control: constant temperature 32 - 36 ℃ for ≥ 24h; prevent fever for 72 hours.
-Keep normocapnia (32 - 45 mmHg) and **normoxia (75 - 100 mmHg); lung-saving ventilation
-Optimalization of hemodynamic parameters** (MAP, lactates, ScvO2, CO / Cl, diuresis)
-echocardiography
-Maintain normoglycemia
-Diagnose / treat convulsions (EEG, sedation, anticonvulsants)
-Delay assessment of prognosis for at least 72h
present symptoms characteristic of hypercalcemia:
-impaired renal function - polyuria, calcinosis and kidney stones
-gastrointestinal disorders - lack of appetite, nausea, vomiting, constipation, gastric and duodenal ulcer disease, cholecystolithiasis - these conditions usually occur with abdominal pain
-dysfunction of the cardiovascular system - hypertension, tachycardia, arrhythmia
-neuromuscular symptoms - muscle weakness, facial muscle paralysis
-neurological symptoms - headache, depression, drowsiness
dehydration
note; metastasis to the bones are very often associated with hypercalcaemia.
Thyroid (or hypermetabolic) storm
- is a life-threatening condition associated with an increased concentration of thyroid hormones in the blood serum and the inability of the body to adapt to this situation.
- It can occur in patients with any form of hyperthyroidism.
-Mortality in the course of thyroid storm is up to 30% .
Thyroid (or hypermetabolic) storm main symptoms
hyperthermia,
disturbances of consciousness,
tachycardia,
arrhythmia (supraventricular arrhythmias, atrial fibrillation)
in Thyroid (or hypermetabolic) storm
Inhibition of thyroid hormone synthesis:
Thiamazole - iv 40-80 mg
*Iodine *- over an hour after the administration of thyrostatine - 4-5 drops; possibly Lugol’s iodine or iohexol
Thyroid (or hypermetabolic) storm
Blockade of ß-adrenergic receptors:
Propranolol orally 40-80 mg or iv 2 mg very slowly (also inhibits peripheral conversion of T4 to T3)
Esmolol iv 0.25 - 0.5 mg / kg very slowly (selective ß1-blocker)
Inhibition of peripheral conversion of T4 to T3:
β-blocker , e.g. propranolol
Hydrocortisone iv 50-100 mg (also acts as anti-shock)
Body temperature equalization:
Cold compresses
Paracetamol, less frequently NSAIDs (salicylates, eg acetylsalicylic acid are CONTRAINDICATED! They remove thyroid hormones from complexes with proteins.)
Normalization of fluid and electrolyte disturbances:
Hydration of the patient iv about 2-3 l / day
Electrolyte and 10% glucose supply
Anaphylaxis
is a severe, generalized or systemic hypersensitivity reaction which is potentially life-threatening.
Anaphylactic shock
-is an anaphylactic reaction in which there is a life-threatening reduction in blood pressure.
-It reduces tissue perfusion and cell damage.
Urticaria
hives
electric cardioversion can be started with energy of 50J in the following conditions
-supraventricular tachycardia (SVT),
-stable ventricular tachycardia
-atrial flutter (AFI)
Cardioversion with the energy of 100J, 200J, 300J, and 360J are applied to
atrial fibrillation (AF),
unstable ventricular tachycardia (VT)
Electric cardioversion is a procedure used to?
differs from defibrillation ?
- normalize tachyarrhythmias hemodynamically unstable but without circulatory arrest.
- It differs from defibrillation in that the electric impulse is synchronized with R-waves.
The conductivity of tissues is determined by
- electrolyte ions (Na +, K +, Ca ++, Cl-).
- These tissues, which are rich in electrolytes, will therefore have the lowest resistance.
Central venous catheters with large diameter are used in situations where it is
impossible to gain access to peripheral veins.
Spironolactone
-is a medication that is primarily used to treat fluid build-up due to heart failure, liver scarring, or kidney disease
-also used in the treatment of high blood pressure, low blood potassium that does not improve with supplementation, early puberty in boys, acne and excessive hair growth in women, and as a part of transgender hormone therapy in transfeminine people
START
( Simple Triage and Rapid Transport ) protocol is one of the protocols enabling the initial selection of the patients according to their condition and priority of providing assistance at the time of a mass event.
name and describe
-We distinguish four categories in it, marked with colors:
BLACK - Victims considered dead .
RED - Injured people requiring immediate assistance - the priority of evacuation.
YELLOW - Injured, whose condition does not require immediate intervention - evacuated in the second place.
GREEN - Victims walking.
__ __ The chest compressions in newborns should be started if the heart rate is slower than 60 beats per minute despite adequate ventilation.
The chest compressions in newborns should be started if the heart rate is slower than 60 beats per minute despite adequate ventilation.
- two thumbs on the lower 1/3 of the sternum, with the remaining fingers embracing the chest and back of the child.
- compressed to 1/3 of the anterior-posterior dimension of the chest
- frequency with which resuscitation should be performed is 120/minute, maintaining the ratio of compressions to breaths 3:1,
- Within a minute, therefore, 90 compressions and 30 breaths should be performed
- The re-evaluation of heart rate should occur after about 30 seconds, then it should be checked periodically.
- Chest compressions should be discontinued if the spontaneous heart rate exceeds 60 beats per minute.
define and name each
ABCDE
- short assessment that should be performed at the site of the event for the initial assessment of the patient’s condition.
**A - airway **- it should be managed by tilting the head back and pointing the mandible upwards, or by just jaw-thrust. The oral cavity should also be assessed to reveal items that could potentially cause airway obstruction
B - breathing - after airway patency is confirmed, breathing is assessed for 10 seconds using three senses - sight, hearing, touch. If breathing occurs, its speed, depth and character are assessed
C - circulation - indirectly by assessing the breath (in the absence of circulation, the breath will also stop), directly assessing the heart rate of the carotid artery
D - disability - the AVPU scale is used most often, in which the A - alert - V - verbal response - P - response for pain - U - unconscious. You can also use a more accurate Glasgow scale.
E - expose and examine - eg a quick trauma assessment.
Aortic dissection (AD)
-occurs when an injury to the innermost layer of the aorta allows blood to flow between the layers of the aortic wall, forcing the layers apart.
-Symptoms:
1. associated with a sudden onset of strong, tearing chest pain radiating to the back, often leading to fainting.
2. You may experience symptoms of shock, neurological symptoms, and heart attack symptoms. The preferred diagnostic method is angio-CT.
3. vomiting, sweating, and lightheadedness may occur
4. Other symptoms may result from decreased blood supply to other organs, such as stroke, lower extremity ischemia, or mesenteric ischemia.
- Aortic dissection can quickly lead to death from insufficient blood flow to the heart or complete rupture of the aorta
name 2- define
aortic dissection Classification
Standford classification:
type A - dissection includes the ascending aorta regardless of the place of origin
type B - dissection does not include the ascending aorta
DeBakey classification:
type I - dissection starts in the proximal part of the aorta and travels to the descending part
type II - dissection limited to the ascending aorta
*type III *- dissection is located distally to the branching of the left subclavian artery
III a) only thoracic aorta
III b) Aorta below the diaphragm
A massive haemorrhage is a loss of at least
20% of the circulating blood in a short time, which is about 1000 ml.
General principles of transfusion of packed RBC:
- Before commencing the transfusion of packed cells, the patient’s blood should be collected for a crossmatch.
- If there is time for this, the patient’s blood type should be marked and a type -compatible pack should be ordered. If the patient is in a life-threatening condition, universal packs are transfused, in the case of packed RBS it will be blood type 0 RhD (-)
- Transfusion speed should be planned - in the case of massive hemorrhages it is possible that packed cells will have to be transfused at high speed, e.g. 1 unit in 5-10 minutes
- The patient’s* body temperature, blood pressure and heart rate* should be measured before connecting the blood component. Measurements should be repeated 15 minutes after the start of transfusion.
Supraventricular tachycardia (SVT)
-is every rhythm with a frequency of> 100 ud / min, which is formed in the bundle of His or above it.
-In the ECG record, it will be characterized by narrow QRS complexes.
Supraventricular tachycardia (SVT)
We distinguish the following types of SVT:
name 3
- *AV nodal reentrant tachycardia *- AVNRT - arises as a result of the circulation of the excitation wave in the AV node through the fast path with longer refraction and the slow path with shorter refraction.
- *atrioventricular reentrant tachycardia *- AVRT
- atrial tachycardia - AT - paroxysmal or continual tachycardia that arises in the atrium outside the sinus node
Supraventricular tachycardia symptoms
- Symptoms usually include palpitations, fatigue, dizziness, shortness of breath, fainting or loss of consciousness.
- Most often it is paroxysmal.
- Supraventricular tachycardia usually occurs in patients without any organic heart disease.
treatment of supraventricular arrhythmias, the following are used:
-
treatments that increase the tension of the vagus nerve :
**Valsalva maneuver **- an attempt to make a forced exhalation with a closed epiglottis. The modified Valsalva maneuver ends with a patient lying down with raised legs
a. provoking vomiting
b. dipping the face in cold water
c. cervical sinus massage -
Anti-arrhythmic drugs - depending on the type of SVT:
a. adenosine
b. Beta-blocker
c. Ca-blocker ( Werapamil, Diltiazem )
d. amiodarone
3.Electrotherapy - in states of hemodynamic instability - electric cardioversion
4. Percutaneous and surgical ablation - in recurrent and persistent tachycardias
Atropine
- is an anticholinergic drug
- used principally to treat bradycardia
- selective antagonist of the M1 and M2 cholinergic receptors.
- It lowers the effects of acetylcholine
- serves as an antidote for poisoning with organophosphorus compounds, AChE inhibitors and digitalis.
specific antidote in the intoxication with zolpidem
flumazenil
a selective benzodiazepine receptor antagonist
Zolpidem
- is a drug from the group of non-benzodiazepine hypnotics.
- It is a selective agonist of the GABAa receptor omega-1 subunit, which modulates the chloride channel function.
- has a rapid hypnotic effect, thanks to which it facilitates falling asleep
- ensures the occurrence of deep sleep phases.
- dose of 10 mg just before going to bed.
- Treatment: short time due to the high addictive potential - a maximum of 4 weeks.
- Discontinuation: gradually with dose reduction.
in the case of overdose of Zolpidem: the following procedure is done
-gastric lavage should be used,
-supply of activated charcoal,
-monitoring of vital signs.
-When severe symptoms like respiratory depression occur, the supply of flumazenil, which is a selective benzodiazepine receptor antagonist, may be considered .
Sodium bicarbonate antidote used for intoxication with
cyclic antidepressant drugs
Glucagon
- is used in the case of beta-blockers and Ca-blockers poisoning -
- it accelerates heart activity,
- increases the strength of myocardial contraction
- facilitates conduction in the atrioventricular node by acting on specific receptors for glucagon located in the myocardium.
Acute pancreatitis
- is a condition associated with the premature activation of pancreatic proenzymes and their destructive effects on surrounding tissues.
- The most common causes: diseases of the gallbladder and bile ducts and alcohol.
Acute pancreatitis
Symptonms
sudden, severe abdominal pain
nausea
vomiting that do not bring relief
fever
Acute pancreatitis
laboratory tests
- an increase in serum amylase activity
- increase in lipase activity
- leukocytosis
- increase in CRP and procalcitonin
Treatment in uncomplicated form of Acute pancreatitis (AP)
is conservative treatment:
1.* Intensive fluid therapy, alleviation of electrolyte and glycemic disorders*
-
Combating pain
a. Metamizol ad hoc 1 g
b. Tramadol 50 mg every 6 - 8h
c. Buprenorphine 0.2 - 0.6 mg every 6 hours
d. Pethidine 50 mg every 6 - 8h
e. Continuous epidural blocking with bupivacaine - Nutritional treatment - initially diet “0”
- Antibiotic therapy as a treatment for pancreatic necrosis
Morphine is not recommended for use in the AP due to its potential
-contraction effect on the Oddi sphincter - if the cause of AP is the stones of this area, - morphine may exacerbate symptoms.
The indications for the use of temporary electrostimulation of the heart are:
- Symptomatic bradycardia or bradyarrhythmias, resistant to anticholinergic drugs and other treatments
- Symptomatic type II second degree atrio-ventricular block (Mobitz II)
- Third degree atrioventricular block (also asymptomatic)
- Asystole with P waves in the ECG
Myosis is accompanied by poisoning with the following substances:
-opioids
-barbiturates
-Horner syndrome (unilateral myosis)
-damage to the pons
Wide pupils (mydriasis) can be observed in poisoning with:
-Anticholinergic substances:
a. Atropine
b. TCAs
-cannabinoids
- LSD
- sympathomimetics:
a. Amphetamine
b. derivatives
Name group of opioid drugs which cause narrowed (myosis)- pin-like pupils
Tramadol
Morphine
Fentanyl
Codeine
symptoms of toxemia
- fever, tachycardia, anemia
Young scale =
Young Mania Rating Scale (YMRS) - defines the presence and severity of clinical symptoms and manic states occurring in the course of bipolar disorder.
Tile classification
- refers to the classification of pelvic fractures:
a. stable fractures (Type A),
b. vertically unstable fractures and vertically stable fractures (Type B)
c. vertically and rotationally unstable fractures (type C) are distinguished.
Cormack-Lehane system
- classifies the conditions prevailing in the area of entry to the larynx assessed by means of direct laryngoscopy. There are 4 levels on this scale:
Grade I - entry into the glottis completely visible
Grade II - visible back of the glottis
Grade III - only the epiglottis visible
Grade IV - only the soft palate is visible
Key and Conwell classification
is a classification of pelvic fractures.
ERC 2015 guidelines allow administration of medications during the resuscitation of a neonate right after the birth. When the heart rate remains below 60/min the administration of which one below should be considered?
adrenaline
-in the *initial dose of 10 μg / kg *. administered intravenously.
-Subsequent doses can be increased up to 30 μg / kg
Charcot triad, which consists of:
pain in the right hypochondrium
fever and chills
mechanical jaundice
This triad refers to acute cholangitis,
define
acute cholangitis
- or simply cholangitis, is inflammation of the bile duct, usually caused by bacteria ascending from its junction with the duodenum (first part of the small intestine).
- It tends to occur if the bile duct is already partially obstructed by gallstones.
acute cholangitis
can be observed in laboratory tests
Leukocytosis,
high CRP and conjugated bilirubin ,
possible increase in activity of ALT, AST , GGTP, ALP.
In imaging studies - widening of the bile ducts.
Treatment of acute cholangitis
-Emergent ERCP
-consists of fluid replacement,
-supply of diastolic drugs, strict diet
- broad-spectrum antibiotics: ciprofloxacin with metronidazole.
The indications for electrical cardioversion are:
- Urgent indications
ventricular and supraventricular tachyarrhythmia causing haemodynamic disturbances - Scheduled indications
ventricular and supraventricular tachyarrhythmias that do not cause hemodynamic disturbances, which do not pass despite pharmacological treatment or when it is not possible to use it
Ventricular tachycardia without pulse is, of course, an indication for
defibrillation
The normal respiration rate for an adult at rest is
12 to 20 breaths per minute
young pregnant woman, 34hbd. Symptoms: headache, nausea, vomiting, edema, blurred vision. On exam: tachycardia, tachypnea, high blood pressure. Seizures have occurred. The patient presents the symptoms of eclampsia. The main drug used in eclampsia is
magnesium sulfate administered intravenously at a dose of 4-6 g .
adenosine is a drug that is administered in
tachycardia with a pulse, with narrow regular QRS. At a dose of 6mg-12mg-12mg.
crepitation audible over the lungs, the patient has edema and crackling that may suggest pulmonary edema.
What drug can be used in this patien condition of eclampsia with pulmonary edem?
furosemide is a drug used also for pulmonary edema.
relanium is diazepam, a
benzodiazepine drug that has anxiolytic, sedative, anticonvulsant, hypnotic and miorelaxant effects.
Category D.
Arterial hypertension in a pregnant woman can be divided into:
Chronic HTN -
diagnosed before pregnancy or before 20 hbd and persisting for more than 6 weeks after delivery
Arterial hypertension in a pregnant woman can be divided into:
Gestational HTN -
identified after 20 hbd, without proteinuria; we divide them into 1. transient - disappears up to 12 weeks after delivery and 2. chronic - persisting 12 weeks after delivery
Arterial hypertension in a pregnant woman can be divided into:
preeclampsia -
increased blood pressure> 140/90 after 20 hbd and proteinuria> 300mg / day; or no proteinuria but there present: thrombocytopenia PLT <100,000 / ul, Alat / Aspt> 2 x upper limit, creatinine> 1.1mg / dl, pulmonary edema , CNS problems, visual impairment
Arterial hypertension in a pregnant woman can be divided into:
eclampsia - .
the appearance of tonic-clonic seizures in the course of preeclampsia
eclampsia: prevention
rest
stress reduction
physical activity
acetylsalicylic acid 100mg from 16 hbd
low molecular weight hepari
Eclampsia Treatment:
Ending pregnancy before 40 hbd
Magnesium sulfate iv 4-6 g in 20 minutes, then 1-2g / h for 24h = Zuspan method.
Control reflexes and breathing when administering magnesium!
Pressure control - nifedipine, urapidil, dihydralazine, labotalol
Oxygen 8-10l / minute.
A 44-year-old male complains of severe abdominal pain and hematemesis. On examination: respiratory rate - 24/min, normal respiratory sounds over the lungs, SpO - weak signal, heart rate - 130/min, no pulse on the distal arteries, blood pressure - 75/50 mmHg, the skin is pale and sweaty, on the ECG - a regular rhythm with narrow QRS complexes. Which of the following should be performed?
Causal treatment -** LIQUID THERAPY** - 500 ml crystalloids within <15 minutes; within 30 minutes 1000 ml of crystalloids or 300-500 ml of colloids. After the transfusion of 2000 ml, further portions of fluid are administered depending on the patient’s condition, 200-500 ml.
A 44-year-old male complains of severe abdominal pain and hematemesis. On examination: respiratory rate - 24/min, normal respiratory sounds over the lungs, SpO - weak signal, heart rate - 130/min, no pulse on the distal arteries, blood pressure - 75/50 mmHg, the skin is pale and sweaty, on the ECG - a regular rhythm with narrow QRS complexes. Which of the following should be performed?
provide explination
Data from the question: abdominal pain, bloody vomiting - bleeding into the upper gastrointestinal tract, tachycardia 130 / minute, tachypnoe, lack of pulse on distal arteries and a weak pulse oximeter signal suggests centralization of circulation, pressure 75/50, Allgover index 1.7 .
Patient pale and sweaty.
Symptoms suggest hypovolemic shock due to upper gastrointestinal bleeding.
Allgover index = heart rate / systolic pressure
0.6 - 1 - norm
~ 1 - developing shock
> 1.4 - heavy shock.
According to 2015 guidelines, in a patient with tachycardia we should proceed as follows:
- Examine the patient according to the ABCDE scheme
- Get intravenous access, do ECG, give oxygen when indicated
- Diagnose and treat a reversible causes !!
- Assess whether the patient is stable or has disturbing symptoms such as shock, syncope, myocardial ischaemia or heart failure.
- If so, we should perform cardioversion up to 3 times, then give amiodarone 300mg iv. within 20 minutes
- If the patient is stable, we must assess QRS
- When they are narrow <120 ms and regular (as in our patient’s) we should perform vagal maneuver and give adenosine in the 6-12-12 mg approach.
- When they are narrow and irregular, it is probably atrial fibrillation that requires appropriate treatment.
hyperosmolarity.
- It is a condition in which the blood has a high concentration of salt (sodium), glucose, and other substances.
- This draws the water out of the body’s other organs, including the brain. Risk factors include: A stressful event such as infection, heart attack, stroke, or recent surgery
What causes Hyperosmolarity?
Symptoms and Causes
Hyperosmolar Hyperglycaemic State (HHS) occurs when the blood sugar of a person with diabetes becomes too high (hyperglycemia) for a long time.
The extra sugar is passed into the urine, which causes the person to urinate frequently.
As a result, he or she loses a lot of fluid, which can lead to severe dehydration (extreme thirst).
There are 4 major acute diabetes complications.
Ketoacidosis - the most common, especially in patients with type 1 diabetes.
*Lactic acidosis *- the least common.
HHS, i.e. Hyperglycemic-Hyperosmolar Syndrome - common in people with type 2 diabetes.
Drug-induced hypoglycaemia.
HHS is characterized by
high hyperglycemia, high plasma osmolality and often prerenal AKI (due t
Criteria for diagnosing HHS:
Glucose> 600mg / dl
pH> 7.3
Serum bicarbonate> 15 mmol / l
Na serum> 150 mmol / l
Plasma osmolality> 320 mOsm / kg h20
Ketone bodies in urine - NONE!
Criteria for diagnosing HHS:
Glucose> 600mg / dl
pH> 7.3
Serum bicarbonate> 15 mmol / l
Na serum> 150 mmol / l
Plasma osmolality> 320 mOsm / kg h20
Ketone bodies in urine - NONE!
Treatment: of HHS (Hyperglycemic-Hyperosmolar Syndrome
- Hydrate 0.45% or 0.9% NaCl Within 1 hour - 1000 ml During the next 4 - 6 hours - 500 ml per hour Until the shortage is compensated - 250 ml per hour.
- Reduce hyperglycemia - short-acting insulin Bolus - 0.1j / kg bw Start continuous infusion 2-4j / h
- Correct potassium deficiencies
- Look for the reason.
Remember that a patient with ZHH has a higher risk of
*rhabdomyolysis *
venous thromboembolism.
causes
torasemide -
-a loop diuretic that has no potassium-sparing effect.
-when using such diuretics, i.e.* furosemide, torasemide*, we expect HYPOkalemia.
medications that can cause hyperkalaemia:
ARB
potassium supplements
heparin
digoxin.
ramipril - ACEi -
-angiotensin converting enzyme inhibitors - blocking this enzyme prevents the change of angiotensin I to angiotensin II.
-Angiotensin II is a potent hormone. It compresses vessels, accelerates the formation of compounds with the same effect, stimulates the formation of aldosterone. In short, aldosterone works to cause HYPERnatremia and HYPOkalemia.
-If we use a drug blocking this pathway, we will get the opposite effect, i.e. **HYPERkalemia. **
-Other side effects of ACEi are kidney damage, cough and angioedema.
ketoprofen -
-NSAIDs - when it comes to potassium, they reduce the concentration of renin and aldosterone.
-Thus, the effect of aldosterone is reduced, which can lead to HYPERkalemia.
propranolol -
B-blocker - competitive β1 and β2 adrenoceptor antagonist.
-By blocking β2 adrenergic receptors, potassium transport into cells is impaired.
-Thus, HYPERkalemia will be a side-effect .
trimethoprim -
an antibiotic - it works by inhibiting dihydrofolic acid reductase.
-It is used in the case of urinary tract infection, upper respiratory tract infection or diarrhea.
-Has many side effects: pruritus, gastrointestinal disorders, kidney and bone marrow toxicity, HYPERkalemia.
Principles of chest compressions in adults:
compressions in the middle of the chest, in the lower half of the sternu
BLS in adults:
-Check if the patient responds: “Can you hear me?”
-Open the airway and check if the patient is breathing - I look, listen, feel. Take a maximum of 10 seconds ( 1 minute in hypothermia)
-Call the Emergency Medical Team
-30 chest compressions - in the middle of the chest. in the lower half of the sternum, compression depth 5 cm, not more than 6 cm, with a frequency of 100-120 per minute
-2 breaths - open the airway, breathe in normally, surround the patient’s mouth, make sure there is no leakage, slowly blow the air for 1 second, checking if the chest rises.
—Repeat.
To make 2 breaths, stop compressing the chest for no more than 10 seconds.
When available, connect AED.
- assessment of whether the patient is breathing - 10 seconds, hypothermia - 1 minute
inhale - 1 second - ventilation pause - 10 seconds
- cardiac rhythm assessment - every 2 minutes
- Adrenaline supply - every 3-5 minutes t, in hypothermia - extended 2x until reaching over 35 ° C
- change of rescuers oppressing KLP - every 2 minutes
- recommended time till defibrillation since unconsciousness starts- 3 minutes
for children, after 5 rescue breaths, perform CPR for 1 minute before you look for help.
- suspect cardiac arrest (SCA)* should always be suspected in people with
seizures!
- check breathing and rule out cardiac arrest!!
values - symptoms
Hyperkalemia -
- K + > 5.5 mmol / l.
symptoms:
weakness
flaccid paralysis
paraesthesia
weakness of deep reflexes
bradycardia
cardiac arrest.
values & synmptoms
Severe hyperkalemia -
concentration K> 6.5 mmol / l.
ECG changes: (guidelines state that ECG changes will occur when K+ is ?
K +> 6.7 mmol / l)**
1st degree block (PQ interval> 200ms)
flattening or lack of P wave
high, pointed T wave
lowering of the ST segment
QRS widening> 120ms.
When* hyperkalemia is mild (5.5-5.9 mmol / l)*, we want to remove potassium from the body. We use
*Calcium resonium 15-30g ion *exchange resin.
We give it orally or rectally. It binds potassium ions in the intestine and is removed with the stool.
When hyperkalemia is moderate (6.0-6.4 mmol / l), we give ion exchange resins for the same purpose. However, we also want to move K + ions to the cell. We use ? nebulization.
10 units of short-acting insulin and 25 g of glucose or salbutamol 10-20 mg in
When the hyperkalaemia is* moderate* but there are ECG changes or the hyperkalaemia is severe> 6.5 mmol / L, in addition to the treatment described above, we also use myocardial protection. For this purpose we use ?
10 ml 10% calcium chloride iv.
in the case of acidosis, we can give ___ ___ ___ mmol in a quick bolus. Reducing acidosis will reduce ___ levels.
-sodium bicarbonate 50
-K +
In summary, in the treatment of hyperkalemia, we use drugs that are designed to reduce the amount of potassium in the body. These are:
- ion exchange resins
- short-acting insulin
- salbutamol
- furosemide / torasemide
- sodium bicarbonate
We also use __ __, which is designed to protect the heart from high potassium levels and protect the patient from sudden cardiac arrest. __ does not cause a decrease in K + in the blood -
-calcium chloride
The maintenance fluid requirement in a child weighing 35 kg amounts to:
- Holliday and Segar method *
Our patient weighs 35 kg (20 kg +15 kg).
1500 ml + (20 ml x 15 ) = 1800 ml
Indicate the true statement concerning capnography (ETCO2) used during chest compressions in the course of CPR:
ETCO2 monitoring allows:
Confirmation of the location of the endotracheal tube in the trachea
Monitoring the frequency of ventilation during CPR
Monitoring the quality of chest compressions - the deeper the greater the cardiac output, so ETCO2 also increases
Prognosis during CPR - when we cannot get a value greater than 10mm Hg for 20 minutes, this is associated with poor prognosis for the patient
Diagnosis of ROSC - ETCO2 increase.
PEEP -
-positive end-expiratory pressure- this is the pressure that is present in the lungs after normal exhalation.
-In a person breathing spontaneously, it is about 2-3 cm H2O.
-During ventilation, we also set this pressure, but it is higher,* in standard circumstances it is about 5-8 cm H2O.*
Advantages of PEEP:
-alveoli do not collapse and it is easier to take another breath (“open it and keep them open”)
-allows reduction of FiO2 in the gas mixture, thanks to which we eliminate the negative effects of oxygen treatment
-it also causes the inclusion of dead areas in the gas exchange.
Adversity that high PEEP can carry:
-chest pressure increases, so venous return to the heart and cardiac output decrease
-the phenomenon of auto-PEEP - can occur in patients with obstruction, where as a result of an air trap there is air retention and a decrease in cardiac output.
Characteristics of opioid toxidrome:
& Antidote
Naloxone - a non-selective antagonist of all classes of opioid receptors, is mainly used to improve breathing, not to restore consciousness.
pinpoint pupils (like poppy seeds)
drowsiness or coma (CNS depression)
breathing disorders - shallow, irregular breathing, can lead to apnea (respiratory depression)
bradycardia
hypotension
paralysis of intestinal motility
urinary retention
nausea, vomiting
pallor of the skin
dizziness.
Provide Antidote
Active substance
Methanol :
Ethanol, Fomepizol, folinic acid
Provide Antidote
Active substance
Ethylene glycol
Ethanol, Fomepizol
Provide Antidote
Active substance
benzodiazepines
flumazenil
Provide Antidote
Active substance
cyanide
hydroxocobalamin
Provide Antidote
Active substance
Digoxin
Fab fragments of digoxin binding antibodies
Provide Antidote
Active substance
paracetamol (acetaminophen)
N-acetylcysteine
Provide Antidote
Active substance
Carbon monoxide
Oxygen
Provide Antidote
Active substance
Anticholinergic syndrome
physostigmine
Provide Antidote
Active substance
Cholinergic syndrome
Atropine, Pralidoxime
Provide Antidote
Active Substance
Opioids
naloxone
Activated charcoal - 0.5-1.0 g / kg It binds to a poisonous substance and prevents its further absorption. Do not use in case of poisoning with alcohol, metals, cyanide. These substances are poorly absorbed by charcoal. Do not administer when there is an antidote to be given orally, suspected bleeding to the upper GI tract or obstruction.
Management of acute poisoning:
WHat is administered in management of acute pisoning ?
It binds to a poisonous substance and prevents its further absorption.
Do not use in case of poisoning with __,__,__.
These substances are poorly absorbed by charcoal.
Do not administer when there is an antidote to be given orally, suspected bleeding to the upper GI tract or obstruction.
Activated charcoal - 0.5-1.0 g / kg
Do not use in case of poisoning with* alcohol, metals, cyanide. *
Hemodialysis - can use it in case of ?
-poisoning with substances easily soluble in water, weakly binding to proteins. -
-Examples of these substances are: ethanol, methanol, glycol, paracetamol, lithium (may lead to renal and prerenal/renal AKI), salicylates.
Hemodialysis - can use it in case of ?
-poisoning with substances easily soluble in water, weakly binding to proteins. -
-Examples of these substances are: ethanol, methanol, glycol, paracetamol, lithium (may lead to renal and prerenal/renal AKI), salicylates.
Hyperthermia -
deep body temperature > 40 ° C due to increased heat production or impaired heat loss mechanisms.
Toxidrome -
a set of symptoms that occur after poisoning with a specific substance.
Neuroleptic Malignant Syndrome (NMS) -
-an acute state in psychiatry, it is caused by a blockage of dopaminergic conduction, most often as a result of ingesting typical and atypical antipsychotic drugs, combination of these drugs with e.g. metoclopramide, or as a result of sudden withdrawal of antipsychotic drugs.
-Symptoms: muscle stiffness (often the first symptom), “cogwheel” rigidity, muscle tremor, dystonia and dyskinesias, tachycardia, variable blood pressure, tachypnoe, HYPERthermia, extensive sweating.
-We use benzodiazepines and dantrolene for treatment .
systemic inflammatory response syndrome
(SIRS) criteria:
> = 2 of the following 4:
- body temperature > 38 ° C or <36 ° C
- heart rate > 90 / minute
- breaths > 20 / minute or PaCO2 <32 mm Hg
- leukocytes > 12,000 / ul or <4000 / ul, or > 10% of immature forms of neutrophils.
Maneuvers that increase the tone of the vagal nerve (e.g. Valsalva maneuver) are frequently effective in the emergency treatment of:
Maneuvers that increase the tone of the vagal nerve (e.g. Valsalva maneuver) are frequently effective in the emergency treatment of:
ventricular tachycardia with narrow QRS complexes
-fast cardiac rhythms (generally more than 100 beats/min) with a QRS duration of 100 ms or less.
-Differential diagnosis of tachycardia with narrow QRS complex (shorter than 0.12 second).
-Although rarely life-threatening, these arrhythmias are a common source of morbidity.
Valsalva maneuver →
-this is the act of making a forced exhalation with the glottis closed.
-This leads to increased chest pressure and pressure on the heart along with large blood vessels.
-At the moment of exhalation, the baroreceptors are excited and the vagus nerve stimulation increases
As a result Valsalva maneuver the following occur:
- inhibiting the frequency of sinus node depolarization
- inhibition of conduction velocity in bundle of His
- breakdown of the wave of recurrent stimulation that causes tachyarrhythmia
Tachycardia with narrow QRS complexes → (__ms) non-pharmacological methods of interruption of tachycardia are effective, i.e.
<120 ms
- Valsalva maneuver
- carotid sinus massage
- other methods of stimulating the vagus nerve :
(e.g. a sip of cold fluid, provoking vomiting, immersing the face in cold water)
provide values/ cause
Hypercalcemic crisis is a life-threatening condition that can occur in severe hypercalcaemia, usually
> 3.75 mmol / L.
**Hodgkin’s disease **
Hodgkin’s disease →
The most common causes of hypercalcaemia (> 3.75 mmol / L) .(90%) are *hyperparathyroidism and cancer. *
-Tumors can directly infiltrate bones, leading to the release of calcium (hypercalcaemia) or indirectly lead to an increase in calcium levels in the blood by secreting hormones similar to PTH.
Glasgow-Blatchford Score,
assesess the risk of gastrointestinal bleeding before performing an endoscopic examination.
According to the applicable Resuscitation Guidelines, a capnography graph is used to
-confirm the *position of the endotracheal tube and monitor the frequency of ventilation. *
-Capnometry *registers the carbon dioxide content of exhaled air *and allows you to determine the effectiveness of ventilation in a non-invasive way.
-It also makes it possible to recognize the return of spontaneous breathing.
Diazepam is a
-benzodiazepine drug with anticonvulsant, hypnotic and sedative effects.
-It shows an addictive effect both physically and mentally.
-Indications for use of diazepam include
anxiety, panic attacks
conditions with increased muscle tone
increased agitation
insomnia
epileptic seizures
febrile seizures
The maximal daily dose of diazepam used in the treatment of status epilepticus in adults amounts to:
50mg
The dosage of the diazepam depends on the indication.
For the treatment of seizures in adults, __ __ should be used, doses can be repeated to a maximum dose of __
-2 to 10mg 2-4x / d should be used
-maximum dose of 50 mg.
Zolpidem
- brand name Ambien
- medication primarily used for the short-term treatment of sleeping problems
- Guidelines recommend that it be used only after cognitive behavioral therapy for insomnia and behavioral changes, such as sleep hygiene, have been tried
- It decreases the time to sleep onset by about fifteen minutes and at larger doses helps people stay asleep longe
- It is taken by mouth and is available in conventional tablets, sublingual tablets, or oral spray
Antidote for
Zolpidem
Flumazenil
a specific benzodiazepine antagonist, is useful in reversing the sedation and respiratory depression that often occur when benzodiazepines are administered to patients undergoing anesthesia or when patients have taken an intentional benzodiazepine overdose.
NOTE: antidote for benzodiazepines, such as diazepam (Valium®), lorazepam (Ativan®), and midazolam (Versed®), and must be administered intravenously.
SLAC- slacker has wide pupils
Wide pupils (mydriasis) can be observed in poisoning with:
“SLAC”
S- sympathomimetics:
Amphetamine and derivatives
(Adderall, Concerta, Dexedrine, Focalin, Metadate, Methylin, Ritalin)
L- LSD
A- Anticholinergic substances
Atropine
TCAs
C- cannabinoids
belong to the group of opioid drugs,
causing “Myosis”
“TFCM”
Tramadol
Fentanyl
Codeine
Morphine
belong to the group of opioid drugs, hence they will cause narrowed, sometimes pin-like pupils “myosis”
The extension of Charcot’s triad is __ __ which includes symptoms of?
-Reynolds pentad
- septic shock and disturbances of consciousness.
Charcot triad
consists of:
pain in the right hypochondrium
fever and chills
mechanical jaundice
Systemic Inflammatory Response Syndrome
(SIRS)
Systemic inflammatory response syndrome (SIRS) is an exaggerated defense response of the body to a noxious stressor (infection, trauma, surgery, acute inflammation, ischemia (lack of blood supply to a part of the body)
or reperfusion,
or malignancy
or certain conditions, such as an autoimmune disorder
or pancreatitis
define/ indications/ dosage
Diazepam
is a benzodiazepine drug with anticonvulsant, hypnotic and sedative effects. It shows an addictive effect both physically and mentally. Indications for use of diazepam include
anxiety, panic attacks
conditions with increased muscle tone
increased agitation
insomnia
epileptic seizures
febrile seizures
The dosage of the drug depends on the indication.
For the treatment of seizures in adults, 2 to 10mg 2-4x / d should be used, doses can be repeated to a maximum dose of 50 mg.
The *polymorphic ventricular tachycardia *occurred in a patient intoxicated with tricyclic antidepressants.
The treatment should include the administration of:
rapid intravenous infusion of
*magnesium sulfate *
at a dose of 2 g (1 amp. 10 ml MgSO4 20%)
A characteristic symptom of cyanide poisoning is the
smell of almonds in the breath.
The antidote for cyanide poisoning is
- hydroxocobalamin* (5 g iv infusion over 15 min).
A toxic concentration of *methanol *in the serum is considered to be __mg / dl. Antidotes (mainly ___) and ____ can be used to treat methanol poisoning. __ __ is not recommended, nor is the use of __ __.
> 20 mg/dl..
ethanol (antidote) and hemodialysis
Gastric lavage is not recommended, nor is the use of activated charcoal.
- Neurogenic shock arises from
Arises from spinal cord injury, intracranial hemorrhage, or brain injury.
Neurogenic shock is a type of *distribution shock *in the course of which blood __ __, and thus__ and __ ___ skin occurs and there is a decrease in __ __. This leads to relative __ and __ __ with ___ cardiac output and ___ peripheral blood flow.
vessels dilate, and thus redness and warming of the skin occurs and there is a decrease in vascular resistance.
-This leads to relative hypovolemia and hyperkinetic circulation with increased cardiac output and reduced peripheral blood flow.
Neurogenic shock is a type of *distribution shock *in the course of which blood __ __, and thus__ and __ ___ skin occurs and there is a decrease in __ __. This leads to relative __ and __ __ with ___ cardiac output and ___ peripheral blood flow.
vessels dilate, and thus redness and warming of the skin occurs and there is a decrease in vascular resistance.
-This leads to relative hypovolemia and hyperkinetic circulation with increased cardiac output and reduced peripheral blood flow.
Image caption shows a ___ ___ with a pulse. In case of haemodynamic instability, we use
supraventricular tachycardia with a pulse
electrical cardioversion, 70-120J
hypothermia it inhibits the
coagulation cascade, which in turn leads to coagulopathy, which is the second element of the death triad
coagulopathy
is responsible for the appearance of symptoms of a
-hemorrhagic diathesis.
-In addition, the presence of coagulopathies promotes further blood loss and the development of symptoms of hypovolemia.
-Hypovolemia reduces the supply of oxygen to tissues.
-This in turn implies a gradual change in metabolism to anaerobic.
-Under these conditions, the cells produce lactic acid and ketone bodies, which are responsible for the last element of the death triad, i.e. acidosis.
metabolic acidosis significantly reduces
- reduces myocardial efficiency, it also leads to ↓ peripheral perfusion, which in turn aggravates hypothermia.
Doloplus-2
pain assessment: an effective tool in patients over 85 years with advanced dementia and persistent pain
DOLOPLUS consists in an observation form consisting of 10 items divided into 3 sub-groups proportionally to the observed frequency (5 somatic items, 2 psychomotor items and 3 psychosocial items).
antidote for carbamazepine poisoning
Multiple doses of *activated charcoal *
Repeated administration of *activated charcoal *is also known as?
The method consists in administering 12.5 g of activated charcoal every hour or equivalent doses at greater intervals until the patient’s clinical condition or toxicological parameters improve.
- “enteric dialysis”/MDAC (multi-dose activated charcoal).
-administering *12.5 g of activated charcoal every hour *or equivalent doses at greater intervals until the patient’s clinical condition or toxicological parameters improve.
Which of the following lowers the pressure in the portal venous system in patients bleeding from esophageal varices?
terlipressin
It causes constriction of visceral vessels and a reduction in blood flow to the portal vein - it lowers the portal pressure and causes a decrease in pressure in esophageal varices.
Terlipressin is usually used as an adjunct to endoscopic haemostasis.
Propranolol -
-a non-selective B-blocker used in the primary and secondary prophylaxis of bleeding from esophageal varices in patients with cirrhosis of the liver at high risk of bleeding.
-Non-selective B-blockers lower the pressure in the portal vein, which reduces the risk of bleeding.
a non-selective B-blocker used in the primary and secondary prophylaxis
Sodium nitroprusside -
-a drug which strongly and immediately lowers blood pressure.
-It is used PRN in emergencies.
-Due to the toxicity of the metabolites, sodium nitroprusside is used for a short time, usually up to 48 hours, and one of the contraindications to its administration is liver failure.
Urapidil -
α1 adrenergic receptor blocker used PRN to rapidly reduce blood pressure
Glucagon -
-according to some reports, glucagon may increase blood flow and pressure in the portal vein, which would be detrimental to bleeding esophageal varices.
-Glucagon is used in hypoglycemia, diagnostics of gastrointestinal motility disorders and intoxication with B-Blockers
In children up to 8 years of age, we usually use endotracheal tubes without a cuff. Depending on the child’s age, we choose the size as follows:
premature newborns →
term newborns →
children 1-2 years of age →
children> 2 years of age →____ (knowledge of this formula is most often useful in LEK)
premature newborns → age in weeks / 10
term newborns → 3.5
children 1-2 years of age → 4.0 - 4.5
children> 2 years of age →* age/4 + 4* (knowledge of this formula is most often useful in LEK)
Skin infection with rapidly spreading connective tissue infection, purulent discharge from the wound, general symptoms and the formation of distant abscesses, is characteristic of wounds caused by:
“Pasteurella multocida”
-clinical picture corresponds to pasteurellosis.
-The bacterium that causes the disease lives in the upper respiratory tract of various animals, both wild and domestic), but most often (about 60-80% of cases) the cause of the disease is caused by cat bites (long, thin canines → deep penetration of bacteria
Differences in Infant CPR
- Head in neutral position (may need to be slightly tilted by placing a rolled up towel under the baby’s shoulder blades).
- In infants, we include (if possible) both the mouth and nose - the so-called mouth-nose ventilation.
- We make 5 initial rescue inhalations.
- For infants, the recommended chest compressions technique depends on the number of rescuers:
a. with the tips of two fingers - if there is one rescuer,
b. two thumbs wrapped around the chest - if there are two rescuers. - Compression of the chest to a depth of 1/3 of the chest dimension or to a depth of 4 cm in an infant.
- When there is one rescuer, he or she should conduct CPR for about 1 minute before seeking help.
Nitroglycerin
- if the patient suffers from coronary artery disease and takes the drug on an emergency basis, he should take 1 dose of nitroglycerin sublingually.
- If the pain persists within 5 minutes → call an ambulance.
- Possible administration of subsequent doses under the supervision of medical personnel (a total of 3 sl doses of 0.4 mg every 5 minutes, then continuation iv). -Contraindications: systolic blood pressure <90 mmHg, tachycardia> 100 / min, suspected right ventricular infarction, taking a phosphodiesterase inhibitor within 24h or 48h in the case of tadalafil.
Oxygen -
we give each patient with symptoms of hypoxia, SpO 2 <90% - our patient does not have dyspnea and hypoxemia.
Morphine -
-the drug of choice for pain management in STEMI. -
-We use doses of 4-8 mg iv, subsequent doses of 2 mg every 5-15 minutes until the pain subsides (in some cases the total dose reaches 2 mg / kg and is well tolerated).
Antiplatelet treatment:
-ASA immediately 150-500 mg p.o. (150-300 mg when PCI is planned) or 250 mg IV (80-150 mg IV when PCI is planned) and
-Ticagrelor (B) / prasugrel / clopidogrel
-GP IIb / IIIa blocker - abciximab / eptifibatide / tirofiban for emergency indications or if there is evidence of no-return of blood flow or a thrombotic complication. Do not administer before the procedure.
Beta-blockers
-use in patients without contraindications, especially with tachyarrhythmia or elevated blood pressure (metoprolol 50 mg x 2/day, then 100 mg x 2/day)
-In case of contraindications, a calcium channel blocker (diltiazem / verapamil) can be used - provided that there is no left ventricular systolic dysfunction or AV block.
ACEI
- use as early as on day 1 of a heart attack, provided that there are no contraindications, especially LVEF ≤40% or with symptoms of heart failure in the early stage of STEMI.
- Use ARB in case of ACEI intolerance.
Lipid-lowering drugs
- we use a statin in all patients, regardless of the concentration of cholesterol in the plasma (unless there are contraindications).
- Target LDL cholesterol 1,4 mmol/l (<55 mg/dl) or a decrease of ≥50% from baseline. –Use ezetimibe if patient does not tolerate statins.
Anticoagulants
- choice and dosage depends on the STEMI treatment method. Independent indications apply when using heparin:
a. extensive myocardial infarction, anterior wall infarction, atrial fibrillation, left ventricular thrombus or cardiogenic shock → low molecular weight heparin (D, enoxyparin is a type of LMWH) sc or unfractionated heparin (UFH) (C) iv if we plan CABG in the next 24 h → UFH
b. prophylaxis of VTE → heparin in a prophylactic dose until the patient is fully mobilized.
Use of diuretics - patients intensively treated with diuretics may develop
-metabolic alkalosis associated with *hypokalaemia *and increased elimination of hydrogen ions
Diarrhea - can lead to
metabolic acidosis due to the loss of alkalis through the gastrointestinal tract (bile, pancreatic juice and intestinal juices contain HCO3− in high concentration)
Alcohol poisoning - excessive consumption of alcohols, especially alcohol not meant for consumption, leads to
**metabolic acidosis associated with the formation of acids and aldehydes during the metabolism of the consumed substances in the liver
Metformin overdose
- Lactic acidosis associated with overdose of metformin is known as MILA - Metformin- Induced Lactic Acidosis.
- The mechanism of this phenomenon is not fully understood, but is probably related to the inhibition of gluconeogenesis by blocking pyruvate carboxylase by the drug
slow rhythm - about __ bpm
40 beats per minute (to approximate the heart rate at 25mm / s writing speed, divide 300 by the number of 5mm squares between successive R-waves.
-In the above case it will be 300 / 7.3 ≈ 41
no P waves …no impulses from the sinoatrial node excludes
sinus bradycardia and sinus rhythm
regularity (excludes) , what’s more, the characteristic f-wave is not visible )
atrial fibrillation
name type of rhythm
-the nodal rhythm (now more commonly referred to as the AV junction rhythm).
-It is characterized by a frequency of about 40-60 / min,
-no P waves or P waves of extra-sinus origin (negative P in II, III, aVF, positive in aVR)
-and most often morphologically normal QRS waves.
Enoxaparin -
“parin”
in patients with a high or intermediate clinical probability of pulmonary embolism, it is recommended that *anticoagulant treatment with low molecular weight heparin *should be started immediately during the diagnostic procedure.
Apixaban is a direct
** factor Xa inhibitor (api X aban) from the new generation of anticoagulant drugs (NOACs), which is currently the preferred choice for the prevention of recurrence of VTE.**
Indicate body organs that are ranked from the
shortest to longest time of tolerance to hypoxia
cerebral cortex
brainstem
cardiac muscle
kidneys
liver
name 7
Primary medications used in CPR:
adrenaline (epinephrine)
amiodarone
lidocainre
sodium bicarbonate
magnesium sulfate
calcium chloride
alteplaza
benzodiazepines, zolpidem →
flumazenil
opioids, opiates →
naloxone
methyl alcohol →
ethyl alcohol
beta-blockers →
glucagon
ethylene glycol →
ethyl alcohol
paracetamol →
N-acetylcysteine
organophosphorus compounds →
pralidoxime, obidoxime, atropine
pulse pressure is usually __-__mmHg. A fall in blood pressure suggests?
-pulse pressure is usually 35-45 mmHg.
-A fall in blood pressure suggests arterial spasm, which may be caused by cardiogenic, hypovolemic or tachyarrhythmic shock.
This is because arterial contraction causes diastolic blood pressure to increase more than systolic blood pressure, resulting in a decrease in the difference between systolic and diastolic pressure.
Diuretics are the mainstay of treatment in patients with AHF and the associated symptoms of fluid overload and concomitant stasis
Diuretics are the mainstay of treatment in patients with AHF and the associated symptoms of fluid overload and concomitant stasis
The rate pressure product is a?
provide formula ?
-parameter used in cardiology to determine the load on the heart muscle.
-The formula for calculating it is the product of heart rate and systolic blood pressure
(HR x SBP)
Thanks to this indicator, we can see how high the heart’s need for oxygen is.
The parameter is given on a 5-point scale:
Carbon monoxide is a
-colourless, non-irritating and odourless gas.
-Carbon monoxide molecules are lighter than air and have size that allows it easily pass through wall porosity and diffuse throughout the room.
-Carbon monoxide binds to hemoglobin 250 times easier than oxygen forming carboxyhaemoglobin (COHb), which is not able to carry oxygen and leads to hypoxia.
define
“postictal sleep”
-After the seizure patient may develop so-called “postictal sleep”, you should put the patient in the recovery position and do not wake him up.
-In the postictal phase nervous system is regenerated and the patient should not be woken up.
Management in the patients with seizures:
- you should stabilize the patient’s head and maintain patent airways
- protect the patient from injuries (e.g. put something soft under the patient’s head)
- check glucose level, basic parameters - ABCD, provide intravenous catheter
- measure oxygen saturation and BP
- diazepam or clonazepam can be given
- during the seizures you should not put any material objects between patient’s teeth or pour water over his face
Aphasia
is a language disorder caused by damage in a specific area of the brain that controls language expression and comprehension
What are the 3 types of aphasia?
The three most common types of aphasia are:
Broca’s aphasia.
Wernicke’s aphasia.
Global aphasia1.
A 40-year-old male patient has lost consciousness.The patient is unconscious at the time of arrival of an RRT (Rapid Response Team), takes 6 breaths per minute, and occasionally falls into apnea, pulse 120/min, saturation 78%, the pupils are constricted. What do you need to do first?
-* start to ventilate the patient with oxygen, intubate the patient, administer naloxon*e.
-The correct number of respirations in adults is 12-20 per minute, the value of 6/min with 78% saturation indicates acute respiratory failure, which may be caused, among others, by overdosing of certain medications.
-Narrow pupils and symptoms of respiratory depression indicate the possibility of poisoning with opiates.
-As hypoxia may be one of the causes of sudden cardiac arrest, start oxygen ventilation immediately and intubate the patient.
-A specific antidote used in the treatment of opiate intoxication is naloxone at a dose of 0.4-2.0 mg.
