ASM readings Flashcards
t/f hypoglycemia is a common SE of metformin
FALSE
rare to get it, but possible
only common in the -ides
s/s of hypoglycemia
weating, shakiness, anxiety, nausea, dizziness, palpitations, slurred speech, blurred vision, headache, seizure, focal neurologic deficits, and altered mental status rang- ing from confusion to coma.
Why do you have an anion gap metabolic acidosis in DKA?
ketone body formation
why might a nitroprusside test for serume or urine ketones be falsely low or negative in DKA?
it only detects acetoacetate, not β-hydroxybutyrate
acetoacetate is often converted to β-hydroxybutyrate in DKA
when trying to get rid of glucose during DKA, your body will try to pee it out - but what electrolyte problems result from this?
loss of things that follow water
NaCl
Ca2+
PO4 3-
Mg2+
k+ loss from vommiting OR high from acidosis and insulin def (as insulin drives K+ into cells)
psedohyponatermia is common
Mng of K+ abnormalities in DKA
> 5.2 = IV insulin
3.3-5.2 and urine o/p = K+ and insulin (K-rider)
<3.3 = K+ until > 3.3 then follow above
2 dosing options for insulin
0.1 U/kg bolus, then 0.1 U/kg/hr
0.14 U/kg/hr without a bolus
need to know this
A patient is acidotic and has normal k+, what is there totaly body k+
LOW
when do you give bicarbonate for DKA
pH <6.9 until pH > 7.0
goal for DKA
glucose
bicarb
pH
electrolytes
glucose < 200 (75 mg/dL/hr every hour - check this)
bicarb >17.99
pH >7.3
electrolytes every 2 hours
what is a complication of DKA treatment and the fix?
cerebral edema
fixed with mannitol
Avoiding rapid correction of sodium, glucose, and hypovolemia may reduce risk.
disposition for DKA
ALL get admitted
MC stroke
iscehmic
presents with motor deficits MC, but can be sensory, balance, AMS,
what exactly is a TIA?
transient episode of neurological dysfunction caused by ischemia but WITHOUT an acute infarc- tion of brain tissue.
TIA episodes typically lasts less than 1 to 2 hours
1 historical piece of information is
last known normal
let’s you know if they can get rTPA
anterior cerebral artery stroke
con- tralateral leg weakness and sensory change
Middle cerebral artery stroke
contralateral hemiparesis (arm > leg), facial plegia, and sensory lo
what signs can a baisalr artery stroke lead to?
oculomotor
Horner’s
locked-in (basic)
MC symptoms of an internal carotid dissection?
Vertebral artery dis- sections?
unilateral head pain (68% #1), neck pain (39%), or face pain (10%)
vertebral = neck pain #1 aslo HA
SAH symptoms
thunderclap HA
RF for SAH
excessive alcohol consumption, polycystic kidney disease, family history of SAH, Marfan’s syndrome, and Ehlers–Danlos syndrome
If you are considering thrombyltic therapy for stroke, what do you use?
Calculate a National Institutes of Health Stroke Scale (NIHSS) score if thrombolytic therapy may be considered.
Imaging for stroke
emergent NON-contrasted CT scan of the brain (best interpreted by a neuroradiologist) is essential to determine whether hemorrhage or a stroke mimic is present. Most acute ischemic strokes will not be visualized on a CT scan in the early hours of a stroke.
when are SAH best seen on CT
6 hours of symptom onset
w/up for SAH w/ negative CT
LP to look for blood
or CTA (actually better)
initial management for stroke or SAH
- O2 > 94%
- non-contrast CT (w/in 25 min) and coag studies
- NPO
- Supine unless CI
- Tylenol if fever
- Reverse anticoag if hemmoragic
when should you get HEAD CT? begin thrmobyltic therapy by? admitted to a stroke center?
25 minutes (will be normal in ischemic stroke or white in hemmoragic)
60 min
3 hours
BP goals for intracerebral hemorage
140-160
If BP is > 220, then aggressive reduction
labetolol, nicardipine, clevidipine
mng for acute ischemic stroke who is NOT a thrombyltic candidate
permissive hypertension with max of 220/120 or signs of end organ damage
reduce 15% in first 24 hours if outside of this range
inclusion criteria for rtPA
- 18+
- onset of symptoms < 4.5 hours ago
- NIHSS score > 23 or diagnosed with ischemic stroke
mng for acute ischemic stroke who IS a thrombyltic candidate
185/110 with labetolol or nicardipine followed by the thrombylitic 60 min infusion with informed consent
-neuro checks
-keep BP <180/105 after rTPA
-admit to stroke unit or ICU
aspirin at 24-48 hours after rTPA
after thrombyltic therapy with rTPA for stroke, what CANNOT be taken
aspirin or heparin within 24 hour window (aspirin is taken AFTER this though)
when do you get endovascular thrombectomy for stroke
Alternative if rt-PA is CI or ineffective in a patient with a persistent potentially disabling neuro deficit (NIHSS ≥6)
Indication: large artery occlusion in the anterior circulation (dx by CTA or MRA) with small infarct core and no hemorrhage (dx by MRI)
Treatment must occur within 24 hours of symptom onset and performed at a stroke center with surgeons experienced in procedure
what is the management of TIA?
aspirin or clopidogrel or aspirin plus extended-release dipyridamole
admit if ABCD >= 4
subacute stroke on CT
>50% ipsilateral stenosis
infarct on MRI
Recent TIA with/in past mouth
Other conditoins warranting admission
Acute cardiac process/arrythmia
Barriers to rapid OP follow up
management of SAH and goal BP
<140 MAP with
labetolol
nicardipine
nimodpine and ICU admission for neurosurgery
reverse any coag issues
what environmental changes can help with delirium?
adequate lighting and emo- tional support may help patient condition
what type of dementia may have exaggerated or asym- metric deep tendon reflexes, gait abnormalities, or extremity weakness
vascular
fix HTN
Dementia-like symptoms with increased motor tone and other extrapyramidal signs may suggest
Parkinson’s disease
Consider _____ if urinary incontinence and gait disturbance are noted
normal pressure hydrocephalus
confirm with CT
What is the Cushing reflex and when is it sometimes seen?
hypertension and bradycardia
seen in coma
Coma from ______may be abrupt in onset, with abnormal extensor posturing and loss of pupillary reflexes and extraocular movements
posterior fossa or infratento- rial lesions
you are in a coma and have pinpoint pupils, what might be the cause
Pontine hemorrhage
way to detect psedo/psychogenic coma
manual eye opening (there should be little or no resistance in an unrespon- sive patient)
imaging for a coma patient
head CT 1st line, below are if it is not diagnostic:
LP if non-dx and SAH or infection is plausible
MRI for baisalr artery thrombosis (common after non-dx CT)
EEG if seizure history
mangement of ICP during coma
- elevate bed 30 degrees
- mannitol
- dexamethasone if brain edema associated with a tumor
discharge management for coma
Discharge patients with readily reversible causes of coma if home care and follow-up care are adequate and a clear cause of the episode is found and reversed. Admit all other patients for further evaluation and management.
