asthma, bites, stroke Flashcards

1
Q

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

A

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

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
2
Q

when to get ABG in asthma exacerbation

A

To determine degree of hypercapnea or assess degree of deterioration in tiring patient not yet sick enough to warrant endotracheal intubation

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
3
Q

when to get CXR in asthma exacerbation

A
Temp +38°C
Unexplained chest pain
Leukocytosis
Hypoxemia
Comorbidities/alternative diagnosis
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
4
Q

when to get EKG in asthma exacerbation

A

Persistent tachycardia

Comorbidities/alternative diagnosis

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
5
Q

heliox in asthma? how does it work

A

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

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
6
Q

Oxygen should be provided to maintain a pulse oximetry reading of at least ? in adults and higher in whom?

A

90%

at least 95% in infants, pregnant women, and patients with coexisting heart disease

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
7
Q

mainstay of asthma treatment

A

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

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
8
Q

patients with severe obstruction or who cannot tolerate inhalation therapy (eg, children) are given

A

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

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
9
Q

typical dose for ipratropium bromide is ?

A

two puffs from a MDI with spacer device, or 0.5 mL of the 0.02% solution

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
10
Q

when to use steroids in AE

A

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

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
11
Q

steroid dosing for AE

A

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

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
12
Q

leukotriene antagonists and their role in asthma

A

zileuton (Zyflo Filmtab), zafirlukast (Accolate), and montelukast (Singulair)
only in the management of chronic asthma

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
13
Q

what may benefit asthmatics with severe airway obstruction

A

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

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
14
Q

BiPAP in AE?

A

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

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
15
Q

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

A

unconscious or near-comatose patients with respiratory failure
ketamine
succinylcholine

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
16
Q

why is ketamine the induction agent of choice?

A

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

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
17
Q

Once an asthmatic patient is intubated, the ventilator should be set to promote the goal of ?

A

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

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
18
Q

Suggested initial settings for AE: Assist Control mode with what settings

A

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

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
19
Q

when can AE pts go home

A

An improvement of PEFR or FEV1 to greater than 70% predicted or personal best can also be used as a sign of objective improvement

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
20
Q

Asthmatics who are discharged from the ED should receive ?

A

albuterol, an MDI spacer device, and a 5- to 10-day course of oral steroids

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
21
Q

Glucagon has become an accepted antidote to ? poisoning because ?

A

beta-blocker

it stimulates cAMP synthesis independent of the beta-adrenergic receptor

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
22
Q

use what to irrigate a wound

A

Sterile saline

povidone iodine, hydrogen peroxide, and detergents should be avoided because of their toxic effects on tissue

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
23
Q

local anesthetic combos and uses (TAC and LET)

A

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

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
24
Q

avoid what LAs in large wounds and mucus membranes because of possibility for systemic absorption

A

lidocaine and tetracaine

25
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
26
Nasal septal trauma may lead to ?
hematoma formation, which can lead to necrosis of the septum or chronic obstruction of the nasal passageway
27
intraoral wounds are ? Therefore, give ?
dirty wounds and are at high risk for infection | prophylactic penicillin or clindamycin
28
look out for this in ear trauma
basilar skull fracture or tympanic membrane rupture
29
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
30
tetanus dosing
http://casefiles.mhmedical.com/ViewLarge.aspx?figid=104716597&gbosContainerID=70&gbosid=218349
31
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
32
what bites are left open?
puncture wounds, bites of the hand or foot, wounds more than 12 hours (or 6hrs?) old, and infected tissues
33
Oral flora in dogs and cats include
Staphylococcus aureus, Pasteurella spp, (P multocida most common org in cats) Capnocytophaga canimorsus, Streptococcus, and oral anaerobes
34
Humans usually have mixed flora, including
S aureus, Haemophilus influenzae, Eikenella corrodens and beta-lactamase-positive oral anaerobes
35
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
36
antivenom
Crotalidae polyvalent immune Fab CroFab
37
effects of poisonous snake bites
hematological: DIC, ecchymosis, and bleeding disorders neuro: weakness, paresthesia, paralysis, confusion, and respiratory depression
38
stroke M and M?
third leading cause of death in the United States and the number one cause for disability
39
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 ```
40
dominant hemisphere stroke
Contralateral numbness and weakness, contralateral visual field cut, gaze preference, dysarthria, aphasia
41
nondominant hemisphere stroke
Contralateral numbness and weakness, visual field cut, contalateral neglect, dysarthria
42
anterior cerebral artery lesion
Contralateral weakness (leg more than arm); mild sensory deficits; dyspraxia
43
MCA lesion
Contralateral numbness and weakness (face, arm more than leg); aphasia (if dominant hemisphere)
44
PCA lesion
Lack of visual recognition; AMS with impaired memory; cortical blindness
45
vertebrobasilar syndrome
Dizziness, vertigo; diplopia; dysphagia; ataxia; ipsilateral cranial nerve palsies; contralateral weakness (crossed deficits)
46
basilar artery occlusion
Quadriplegia; coma; locked-in syndrome (paralysis except upward gaze)
47
lacunar infarct
Pure motor or sensory deficit
48
intracerebral hemorrhage
May be clinically indistinguishable from infarction; contralateral numbness and weakness; aphasia, neglect (depending on hemisphere); headache, vomiting, lethargy, marked HTN more common
49
cerebellar hemorrhage
Sudden onset of dizziness, vomiting, truncal instability, gaze palsies, stupor
50
NIH stroke scale measures
several aspects of brain function such as consciousness, vision, sensation, movement, speech, and language
51
NIH stroke scale
http://casefiles.mhmedical.com.mwu.idm.oclc.org/ViewLarge.aspx?figid=104716820&gbosContainerID=70&gbosid=218351
52
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
53
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
54
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
55
tx of elevated BP in ischemic stroke
generally left untx to promote CPP | if BP +220/120 mmHg tx with IV labetalol and nitrates
56
tx of hemorrhagic stroke
nimodipine, possibly reversing any anticoagulation with cryoprecipitate or platelets, and consultation with a hematologist and neurosurgeon
57
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
58
IV tPA guidelines
http://casefiles.mhmedical.com.mwu.idm.oclc.org/ViewLarge.aspx?figid=104716822&gbosContainerID=70&gbosid=218351