asthma, bites, stroke Flashcards
simple, inexpensive ways of measuring the severity of airway obstruction in severe asthma exacerbation and are commonly used to monitor response to treatment in the ED
peak expiratory flow rate (PEFR) or FEV1
Severe asthma is defined as an FEV1 of less than 50% of predicted (typically less than 200 L/min in an adult) or one’s own personal best measurement
when to get ABG in asthma exacerbation
To determine degree of hypercapnea or assess degree of deterioration in tiring patient not yet sick enough to warrant endotracheal intubation
when to get CXR in asthma exacerbation
Temp +38°C Unexplained chest pain Leukocytosis Hypoxemia Comorbidities/alternative diagnosis
when to get EKG in asthma exacerbation
Persistent tachycardia
Comorbidities/alternative diagnosis
heliox in asthma? how does it work
produce a more laminar airflow and potentially deliver nebulized particles to more distal airways, but they have not been shown to consistently lead to improved ED outcomes, may be beneficial only in patients who present with severe asthma that is refractory to initial treatment
Oxygen should be provided to maintain a pulse oximetry reading of at least ? in adults and higher in whom?
90%
at least 95% in infants, pregnant women, and patients with coexisting heart disease
mainstay of asthma treatment
Albuterol
Typically 2.5 to 5 mg intermittently nebulized every 15 to 20 minutes for the first hour of therapy and then repeated every 30 minutes thereafter for 1 to 2 more hours
patients with severe obstruction or who cannot tolerate inhalation therapy (eg, children) are given
subQ administration of epi or terbutaline
Epi 0.3 to 0.5 mg subcutaneously every 20 minutes to a maximal combined total dose of 1 mg
Terbutaline is given 0.25 mg subcutaneously every 20 minutes up to a maximum of three doses. -preferable because of its beta-2 selectivity and fewer cardiac side effects
Levabuterol
typical dose for ipratropium bromide is ?
two puffs from a MDI with spacer device, or 0.5 mL of the 0.02% solution
when to use steroids in AE
Acute asthma in patients with moderate/severe asthma attack
Worsening asthma over many days (+3 days)
Mild asthma not responding to initial bronchodilator therapy or asthma that develops despite daily inhaled corticosteroid use
steroid dosing for AE
Oral administration of prednisone (dose 40-60 mg) is usually preferred to IV methylprednisolone (dose 125 mg), because it is less invasive and the effects are equivalent
alternatively: IM methylprednisolone, IV/oral dexamethasone, IV hydrocortisone
leukotriene antagonists and their role in asthma
zileuton (Zyflo Filmtab), zafirlukast (Accolate), and montelukast (Singulair)
only in the management of chronic asthma
what may benefit asthmatics with severe airway obstruction
magnesium sulfate given IV at dosages of 2 to 4 g
compete with Ca2+ for entry into smooth muscle, inhibit the release of Ca2+ from the SR, prevent acetylcholine release from nerve endings, and inhibit mast cell release of histamine
BiPAP in AE?
Severe asthmatics (defined as FEV1 less than 60% and RR +30) with impending respiratory failure should receive a trial of BiPAP prior to being intubated
Immediate rapid-sequence endotracheal intubation should be reserved for ?.
In an awake patient, an appropriate induction agent (eg, ?) and paralytic agent (eg, ?) should be used prior to intubation
unconscious or near-comatose patients with respiratory failure
ketamine
succinylcholine
why is ketamine the induction agent of choice?
it stimulates the release of catecholamines and causes relaxation of bronchial smooth muscle, leading to bronchodilation
IV infusion of 1 mg/kg, followed by a continuous infusion of 0.5 to 2 mg/kg/h
Once an asthmatic patient is intubated, the ventilator should be set to promote the goal of ?
permissive hypercapnea which aims at minimizing dynamic hyperinflation (ie, breath stacking or auto-PEEP) with low tidal volumes, and increased time for expiration, while limiting plateau pressures
Suggested initial settings for AE: Assist Control mode with what settings
respiratory rate of 8 to 10 breaths per minute, tidal volume 6 to 8 mL/kg, no extrinsic PEEP, inspiratory-to-expiratory (I/E) ratio of 1:4, and an inspiratory flow rate of 80 to 100 L/min. To prevent barotrauma, plateau pressures should not exceed 30 cm H2O
when can AE pts go home
An improvement of PEFR or FEV1 to greater than 70% predicted or personal best can also be used as a sign of objective improvement
Asthmatics who are discharged from the ED should receive ?
albuterol, an MDI spacer device, and a 5- to 10-day course of oral steroids
Glucagon has become an accepted antidote to ? poisoning because ?
beta-blocker
it stimulates cAMP synthesis independent of the beta-adrenergic receptor
use what to irrigate a wound
Sterile saline
povidone iodine, hydrogen peroxide, and detergents should be avoided because of their toxic effects on tissue
local anesthetic combos and uses (TAC and LET)
TAC (tetracaine, 0.25%-0.5%; adrenaline, 0.025%-0.05%; cocaine, 4%-11%) was commonly used initially, but was associated with seizure, arrhythmia, and cardiac arrest.
LET (lidocaine, 4%; epinephrine, 0.1%; tetracaine, 0.5%) is generally safer than TAC and is used for anesthesia of the face and scalp
avoid what LAs in large wounds and mucus membranes because of possibility for systemic absorption
lidocaine and tetracaine
repair of the scalp should be done with ?
repair of the forehead should be done with ?
4-0 monofilament suture of different color than the patient’s hair or staples removed after 7-10 days
6-0 nonabsorbable interrupted sutures, and removed after 5 days
Nasal septal trauma may lead to ?
hematoma formation, which can lead to necrosis of the septum or chronic obstruction of the nasal passageway
intraoral wounds are ? Therefore, give ?
dirty wounds and are at high risk for infection
prophylactic penicillin or clindamycin
look out for this in ear trauma
basilar skull fracture or tympanic membrane rupture
Patients with tetanus should receive ?
passive immunization with tetanus immunoglobulin (TIG) 3000 to 6000 units IM on the side opposite of the tetanus toxoid injection
PCN often given but questionable
tetanus dosing
http://casefiles.mhmedical.com/ViewLarge.aspx?figid=104716597&gbosContainerID=70&gbosid=218349
Postexposure prophylaxis for rabies
combination of immediate, passive (rabies IgG) immunization and active immunization (human diploid cell vaccine)
give tetanus vaccine should be administered if the patient has not received it within the last 5 years
what bites are left open?
puncture wounds, bites of the hand or foot, wounds more than 12 hours (or 6hrs?) old, and infected tissues
Oral flora in dogs and cats include
Staphylococcus aureus, Pasteurella spp, (P multocida most common org in cats) Capnocytophaga canimorsus, Streptococcus, and oral anaerobes
Humans usually have mixed flora, including
S aureus, Haemophilus influenzae, Eikenella corrodens and beta-lactamase-positive oral anaerobes
Good initial-choice antibiotics for cat/dog/human bites include
for how long?
amoxicillin-clavulanic acid (augmentin), ticarcillin-clavulanic acid (timentin), ampicillin-sulbactam (unasyn), or a second-generation cephalosporin
10 to 14 days and 3 to 5 days for prophylaxis
antivenom
Crotalidae polyvalent immune Fab CroFab
effects of poisonous snake bites
hematological: DIC, ecchymosis, and bleeding disorders
neuro: weakness, paresthesia, paralysis, confusion, and respiratory depression
stroke M and M?
third leading cause of death in the United States and the number one cause for disability
aphasia usually corresponds to a ? stroke; neglect generally indicates a ? stroke; crossed signs (eg, right-sided facial droop with left-sided extremity weakness) typically indicate ?
left hemispheric (dom) right hemispheric (nondom) brainstem involvement
dominant hemisphere stroke
Contralateral numbness and weakness, contralateral visual field cut, gaze preference, dysarthria, aphasia
nondominant hemisphere stroke
Contralateral numbness and weakness, visual field cut, contalateral neglect, dysarthria
anterior cerebral artery lesion
Contralateral weakness (leg more than arm); mild sensory deficits; dyspraxia
MCA lesion
Contralateral numbness and weakness (face, arm more than leg); aphasia (if dominant hemisphere)
PCA lesion
Lack of visual recognition; AMS with impaired memory; cortical blindness
vertebrobasilar syndrome
Dizziness, vertigo; diplopia; dysphagia; ataxia; ipsilateral cranial nerve palsies; contralateral weakness (crossed deficits)
basilar artery occlusion
Quadriplegia; coma; locked-in syndrome (paralysis except upward gaze)
lacunar infarct
Pure motor or sensory deficit
intracerebral hemorrhage
May be clinically indistinguishable from infarction; contralateral numbness and weakness; aphasia, neglect (depending on hemisphere); headache, vomiting, lethargy, marked HTN more common
cerebellar hemorrhage
Sudden onset of dizziness, vomiting, truncal instability, gaze palsies, stupor
NIH stroke scale measures
several aspects of brain function such as consciousness, vision, sensation, movement, speech, and language
NIH stroke scale
http://casefiles.mhmedical.com.mwu.idm.oclc.org/ViewLarge.aspx?figid=104716820&gbosContainerID=70&gbosid=218351
stroke protocol
physician evaluation within 10 minutes of arrival, specialist/neurologist notification within 15 minutes, CT of head within 25 minutes and CT interpretation within 45 minutes. For ischemic strokes, the guideline for the administration of rtPA (recombinant tissue-type plasminogen activator) in eligible patients is within 60 minutes
early CT findings in ischemic stroke
loss of the grey-white differentiation due to increased water concentration in ischemic tissues—leading to a loss of distinction among the basal ganglia nuclei, gyri swelling, and sulcal effacement
increased density within the occluded vessel, which represents the thrombus
how to administer tPA
rtPa is usually administered 0.9 mg/kg with a maximum dose of 90 mg, with 10% of the dose administered as an IV bolus and the remainder infused over 60 minutes
tx of elevated BP in ischemic stroke
generally left untx to promote CPP
if BP +220/120 mmHg tx with IV labetalol and nitrates
tx of hemorrhagic stroke
nimodipine, possibly reversing any anticoagulation with cryoprecipitate or platelets, and consultation with a hematologist and neurosurgeon
upper level of normal for the corrected QT interval is approximately ?
440 msec for men and 460 msec for women
look for medications, family history, and potential electrolyte imbalances
Prolonged QT syndrome is associated with sudden death
IV tPA guidelines
http://casefiles.mhmedical.com.mwu.idm.oclc.org/ViewLarge.aspx?figid=104716822&gbosContainerID=70&gbosid=218351
