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bad things Flashcards

1
Q

Toxic-metabolic coma

A

characterized by lack of focal physical examination findings.

pupils-small and reactive, but may be large in severe sedative poisoning as from barbiturates

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2
Q

structural coma

A

hemispheric (supratentorial) vs posterior (infratentorial) fossa

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3
Q

supratentorial comas

A

progressive hemiparesis or asymmetric muscle tone and reflexes

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4
Q

infratentorial lesions

A

may cause abrupt coma, abnormal extensor posturing,

loss of pupillary reflexes and extraocular movements, brainstem compression w/ loss of brainstem flexes may develop rapidly

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5
Q

coma neurologic exam

A
  • *cornerstone of assessment

* *reference point for serial assessment

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6
Q

breath associated with midbrain-hypothalamus issues

A

central-reflex hyperpnea

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7
Q

Lower pons problem

A

apneustic, cluster, ataxia

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8
Q

medulla

A

loss of automatic breathing

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9
Q

Goals in emergency coma

A

o Stabilize the airway, ventilation and circulation
o Identify and treat reversible causes, such as hypoglycemia and opioid toxicity.
o Consider empiric naloxone. Administer thiamine before glucose in hypoglycemic patients with a history of alcohol abuse or malnutrition.
o If elevated ICP is suspected, elevate the head to 30 degrees and keep at midline. Mannitol will help reduce ICP.

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10
Q

catatonia

A

CF: stupor, excitement, mutism (inability to speak), posturing.

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11
Q

conversion reactions

A

o Fairly rare– not!
o Oculocephalics may or may not be present
o The presence of nystagmus with cold water calorics indicates the patient is physiologically awake

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12
Q

allergic rxn, anaphylaxi

A

severe immediate hypersensitivity rxn

IgE mediated and anaphylactoid reactions- no previous sensitizing exposure

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13
Q

what is a ddx for anaphylaxis?

A

MI, gastroenteritis, asthma, carcinoid, epiglottis, herediatry angioedema, vasovagal rxn

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14
Q

what do you discharge a pt in anaphylaxis with?

A

antihistamin and prednisone

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15
Q

how do you treat hereditary angioedema

A

C1 esterase inhibitor replacement (may substitue FFP)

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16
Q

Acute Abdomen issues- PMHx?

A

surgery, MI, dysrhythmias, coagulopathies, vasculopathies, gynecologic

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17
Q

hearing high-pitched tinklin sounds in bowel?

A

may be SBO

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18
Q

Carnett sign

A

place hands on maximum point of tenderness and have the patient flex or do a sit up. . if pain got worse, muche more likely to be a MSK problem then an internal

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19
Q

where do you start when examining abdominal pain?

A

XR, then US, the CT scan

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20
Q

what are the most common types of burns?

A

**SCALD

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21
Q

Zones of coagulation

A

non viable area of tissue at the epicenter of the burn

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22
Q

zone of ishcemia or stasis

A

surrounding tissues (both deep and peripheral) to the coagulated areas, which are not deviatlized initially, but can progress irreversibly to necrosis over several days if not resuscitated properly

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23
Q

zone of hyperemia

A

peripheral tissues that undergo vasodilatory changes due to neighboring inflammaotry mediator relesease, but are no injured thermally and remain viable

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24
Q

burn depth classification

A

first to 4 th degree

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25
1st degree burn
superficial burns - epidermal only - caused by sun or minor flash - no blisters/edema - skin is pink or red and dry - hypersensitivity - rapid healing, 3-6 days
26
2cd degree
partial thickness - involves dermis - superficial or deep - healing time varies (2-3 wks)
27
superficial partial thickness
-caused by flame, scalding, chemicals -minimal damage to skin appendages -edema/blister formation (fluid filled) -skin is pink or red -blanches w/ pressure blister= 2cd or 3rd degree
28
depp partial thickness
- deeper dermis invloved some skin appendges - grease, flame, or chemcial - moderate edema, mixed w. pallor - skin pale or dry - thicker-walled blisters, many of which are ruptured - decreased sensation, healing takes greater than>21 days
29
3rd degree
``` full thickness -destruction of epidermal anddermal layers -exposure to prolonged heat -EDEMA, think pearly white or charred -painless this requires skin grafting, ```
30
"poking" or the rubbing test
poke the wound bed, if hte pt kicks you it is superficial partial thickness; if ask what are you doing, then deep or partial or 3rd degree
31
forth degree
burn reaching the muscle layer or bone | -extensive damage to nerves--> little to no sensation of pain
32
pre-hospital managment
- Stop the burning process o Remove clothing, irrigation of chemicals, etc. - Cool the burn surface – how? - Cover / protect burn wound o Prevent heat loss, keep clean - Do not put ice or cold water especially on larger burns as it carries a risk of hypothermia. Instead wrap in clean sheet of dry cloth or blanket before transferring to the ED.
33
Emergency managment
Focuse on pt!! not burn wound at first ABCDEF IV morphine and LR NS **need to put urinary catheter in to monitor resusciation efforts
34
base line labs?
ABG, CBC, hematocrit, BUN, creatinine, electrolytes, glucose, UA, CO level, EKG, carboxyhemoglobin
35
how to stop the buring process?
sterile water, but if chemical burn watch out bc water can activate it
36
Calculation of Burn area
"rule of 9" - % of 2nd and 3rd degree burns - Head is 9%, each arm is 9%, front of each leg is 9%, back of each leg is 9%, front of torso is 18%, back of torso is 18%, groin is 1% - Patient’s hand is approximately 1% TBSA - Modify for children - Lund–Browder charts, more accurate based on age and body part - First degree burns are not considered in surface area calculations. Extent of Burn
37
2cd degree burnts
>10% TBS | or any burns to face, hanges, feet, genitalia, perineum, major joings
38
3rd degree
any body part electric injury, chemical burns, inhalation inuries, burns accompanied by trauma
39
Fluid REsuscitation
SIRS, edema, decreasd CO, increased PVR, acture renal failure
40
Baxter/Parkland formula
total V of the first 24 hours of resuscitaiton with RL 4 ml/kg/%TBSA half volume given in the first 8 hours, while the remaining volume delivered over 16 hours
41
why do you need fluid resuscitation?
edema max in 2cd 24 hours post burn > decreased intravascular fluid> decreased CO > increased PVR (post void residual) > BURN SHOCK (distributive and hypoolemic) and then the hypoperfusion of tissues leads to acutre renal failure and possible brain damage **want to avoid burn shock!!!!
42
what is important to monitor during resuscitation?
Urine output!! * maintain 30-50 mL/hr in adults, and 1 ml/kg in children
43
Burn Wound Management
-Cleanse and Debride (greater than 2 cm) -topical abx Silver Sulfadiazine and Mafenide acetate -vaseline gauze
44
ABX for burns
most common pathogens are | S. Aureus and Pseudomonas
45
Silver Nitrate
applied as an occlusive dressing- but not eschar penetration
46
Siver Sulfadiazine
most commone, limited eschar penetration
47
Mafenide Acetate
good gram + and - coverage Penetrates eschar ** large amounts can block the cation of carbonic anhydrase and lead to metabolic acidosis EXTREMELY PAINFUL
48
Silver Products
antimicrobial activity - kills microbes on contact by poisoning microbe cellular respiration - speed of action directly correlated / sliver ion dose - silver resistance is not see - safe and non-
49
Silver Ion
- histologically decrases wound surface inflammation - decreases wound surface exces metalloproteinase by decreasing zinc, essential for metalloproteinase (MMP) activity - silver oxidized to sulfur bonds - increased wound Ca (pro epithelialization effect)
50
ABX
``` systemic ones not indicated unless: wound invasion (discoloration of the wound, erythema and induration at wound margin, fever >101.5), positive blood culutre, positive wound biopsy/culture ```
51
SIRS
systemic inflammatory response sydrome- common rexn to burns
52
surgical managment of burns
- Tangential excision and split thickness skin grafting (for 3rd degree burns and deep second degree) - Fascial excision w. split thickness skin grafting for some deep 3rd
53
when are deep dermal burns and full thickness burns excised?
about day 3, coverage is attained by neumerous methods, autography is best, but allographing can work other methods: epidermal cell culture, artifical skin, porcine xenograph
54
Complications of sever burns
inhalation injury, hypovolemic shock, neurogenic shock secondary to pain, renal failure, multiorgan system dysfunction, gastric/duodenal ulceration (Curling's ulcers) **most common- infection of the burn wound
55
Marjolin's Ulcer
chronic healing burn wounds that undergo malilgnant transformation in to a squatomus cell carcinoma
56
Eschartomy/Fasciotomy
assess need in circumferential burns of the extremities or anterior turnk--> compartment syndrome!!
57
Escharotomy
surgical incision into necrotic skin resulting from a sever burn; inelastic leathery dead skin cuases tourniquet like effect
58
Fasciotomy
surgical excision of fascia to relieve tension or pressure in muscle compartment - compartment syndrome - electrical burn w/ muscle injurty
59
the 5 Ps;- Indications for escharotomy / fasciotomy (5 Ps)
Pallor-cyanosis of distal unburned skin on limb Pain-unrelentin deep tissue pain Paraesthesia-progressive numbness paralysis- usually late finding Pulselessness- progressive decrease or absence of pulse
60
chest escharotomy
indicated to relieve respiratory distress
61
extremity escharotomy
o Circumferential full-thickness burns may impair circulation due to increase in edema o Procedure  Avoid major vessels, nerves, all tendons  Mid-medial or mid-lateral aspect  Extend down through eschar, to subcutaneous fat
62
Extremity compatment Syndrome
Edema w/in deep investing muscle fascia
63
what can cause compartment syndrome
high voltage electricity, massive IV fluid infusion, crush injury, delayed escharotomy
64
what pts have th highest risk of developing compartment syndrome?
those w/ circumferential burns
65
What is pressure is suggestion iv compartment syndrome
30 mmHg, but if they are in the 40s- need an emergency fasciotomy or eschartomy
66
Inhalation injury
CO poisoining--> injury above or below the glottis; 33% of pts admitted to burn centers
67
when to suspect inhalation injury?
enclosed space, facial burns, singed nasal and facial hair, carbonaceous deposits in oropharynx
68
what inhalation injuries cause?
smoke particles and toxins cause damage to airways that triggers inflammation, mucosal ulceration or necrosis of epithelium: c
69
complications of inhalation injuries
pulmonary edema, bronchospasma, PNA, ARDS **PNA is the most common cause of morbidity in smoke inhalation patients
70
Inhalation injury above the glottis
heat exchange capacity efficient; most heat damage occurs above the vocal cords
71
inhalation injury above the glottis complication
laryngeal edema!! can occur at any time (usually w/in 24 hours of the injury
72
Inhalation injury below the glottis
almost always chemical aldehydes, sulfur oxides, phosgenes adherent to sruface of smoke particles--> direct damage to epithemlium of large airways
73
how do you dx inhlation injury?
fiberoptic bronchoscopy: erythema, edema, mucosal ulceration or carbonaceous mater in
74
tx in inhalation injury
mostly supportive: humidified O2, pulmonary physiotherapy, mucolytic agents and bronchodilator 2-3 wks heal`
75
CO poisoining
Hg affinity 240 X that of O2 >7% carboxyhemoglobin
76
sx of CO poisoning
cherry red skin color, agitation and decreased LOC cyanosis and tachypnea unlikely bc CO2 removal unaffected
77
TX of CO
100% O2, hyperbaric O2 rarely needed

Urgent Care/Critical Care (inpt) (8 decks)

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