CEN study notes as questions Flashcards
What type of antibodies are produced during an allergic reaction
IgE antibodies
Scientific name of hives
Urticaria
Scientific name of species of bees, wasps, etc
Hymenoptera
Scientific name for itchiness
Urticaria
What is the standard dose of epinephrine IM for allergic reaction?
Epinephrine 1:1000 1mg/1mL 0.2 to 0.5mg IM
What factor missing from a person with Hemopheilia A?
Classic Factor VIII
What factor is missing from a person with Hemophilia B?
Factor IX
What kind of genetics is Hemophilia?
Recessive genes, sex-linked
Hemophilia A and B only occur in…
Males
What is the most common type of hemophilia that occurs in women, but can also occur in men?
Von Willebrand
What is the scientific name for bleeding in the joint cavity?
Hemarthrosis
What is something that you want to be aware of if you have a hemophiliac patient who hit their head?
They have decreased LOC, but easy to bleed in the brain
What kind of blood transfusions would you give a hemophiliac?
- Clotting factors specific to their type of hemophilia
- Cryoprecipitate (plasma that is rich in clotting factors)
- FFP
Treatment for hemophiliac patient with a laceration?
Topical thrombin and observe for 4 hours post suturing.
What do you need to be aware of for IVs and IM’s for hemophiliac patients?
No IM
Hold pressure over IV site for 5 mins after pulling out IV
What medications should hemophiliacs never receive?
No blood thinners including aspirin. No NSAIDs
What are the main causes of DIC?
- Trauma
- Sepsis
- Pancreatitis
- HELLP syndrome in OB
What blood work would you expect in a patient with DIC?
Prolonged PT/PTT times
Elevated D-dimer
Fibrin degradation products
Low H/H and platelets
Low fibrinogen
How can you tell from bloodwork if DIC treatment is working?
Platelets will be increasing
What is Idiopathic Thrombocytopenia Purpura (ITP)?
ITP is an autoimmune condition that seen after a viral infection in children 2-4 years old. It usually spontaneously resolves or it becomes chronic in adults. It causes low platelet count with normal bone marrow function which leads to excessive bleeding.
What are causes of anemia?
Blood loss, low iron, low vitamin B12, or low folic acid
What are side effects of oral iron?
Dark stools and constipation
What is Polycythemia?
Excess blood cells that increases blood viscosity
What causes secondary polycythemia?
The increased RBC’s are made from high altitudes or the hypoxia seen in COPD patients
What is polycythemia Vera?
It is a cancer that causes overactive bone marrow results in increase in RBC, WBC, and platelets.
What are some issues in the body caused by polycythemia Vera?
Hematocrit will be over 55%. Hepatosplenomegaly (enlarged liver and spleen), increased blood viscosity
What is treatment for secondary polycythemia?
Aspirin for clotting risk
What is treatment for polycythemia vera?
Phlebotomy to remove whole blood and infuse NS, chemotherapy to decrease blood cell production
What home medication helps with Sickle Cell Disease and how?
Hydroxyurea - decrease sickling and produce more Hgb.
Genetically, who does the Sickle Cell Disease come from, mother or father?
Gene must come from both parents.
What level of ESI triage should a Sickle Cell patient be and why?
Triage level 2 due to risk of acute chest syndrome, and Vaso-occlusive crisis.
What are some possible complications of Sickle Cell Crisis
- Acute Chest Syndrome - blood vessels in heart and lungs are blocked by sickle cells (immediately life threatening!)
- Vaso-occlusive crisis - most common - blood vessels in tissue is blocked by sickle cells (immediately life threatening!)
- Splenic ischemia
What are some triggers for Sickle Cell Crisis?
Low oxygen saturation, infection, dehydration, exposure to cold
What are diagnostics for Sickle Cell Crisis?
CBC to detect infection; reticulocyte count
What is the ultimate treatment goal for Sickle Cell Crisis patients?
Early stem cell transplantation
What level triage should you put someone who is neutropenic?
Triage level 2
What is leukemia?
Leukemia is a cancer that causes the bone marrow to produce leukemic (abnormal), immature WBC’s that do not function properly or provide adequate protection from infection.
What low lab value, presented with a low grade fever indicates a form of neutropenia?
Low neutrophil count presented with a low grade fever
What meds may help neutropenic patients?
Bone marrow stimulants (Filgrastim and Neupogen)
What are the standard fluid resuscitation amounts for adults, peds, and neonates?
Adults - 1-2L
Peds - 20mL/kg
Neonates - 10mL/kg
What can cause hyperkalemia?
Renal failure
Burns
Crush injuries
ACE inhibitors
Rhabdomyolysis
What EKG changes would you see with a patient who has hyperkalemia?
(Early; 5 - 6.5mEq) Peaked T waves
(Progressed) Widening of QRS, loss of P waves
(Advanced; >8mEq) Sine wave
What are medications used to treat hyperkalemia?
- Calcium gluconate 10% - 10mL IV over 10 mins (cardiac stabilizer)
- Beta agonists such as Salbutamol nebulizer or Sodium Bicarb (intracellular shift)
- Insulin 10units and D50W
- Kayexalate (K+ Removal for patients with chronic renal failure who can’t take lasix)
- Diuretics (K+ Removal via urinary system)
What are some causes of hypokalemia?
Metabolic Alkalosis
Overuse of diuretics
Acute alcoholism
Cirrhosis
Intestinal tract diseases (malabsorption)
Signs and symptoms of hypokalemia?
PARALYTIC ILEUS
FLAT T WAVES
POSSIBLE U WAVES
weakness, mental depression, leg cramps
Treatment for hypokalemia?
Correct K+, alkalosis, and hypomagnesemia
What is the normal range of calcium?
8.5-10.5mg/dL
What are some causes of hypercalcemia?
Renal disease
Prolonged immobility
hyperparathyroidism
How does alcoholism affect a person’s BGL and electrolytes?
It causes hypoglycemia and low electrolytes
What electrolyte imbalance can be caused by binge alcohol consumption?
Hypokalemia
What medical problem can be caused by the hypokalemia in binge alcohol consumption?
Rhabdomyolysis
Parathyroid gland controls which electrolytes in the blood?
Calcium and phosphorus
Signs of magnesium toxicity?
Beginning signs: Dizzy, flushed, somnolence, weakness, prolonged PR, QRS, QT intervals, bradycardia, loss of patellar reflexes
Advanced signs: hypotensive (refractive to pressors), resp paralysis, cardiac arrest
What medication should be given for magnesium toxicity?
Calcium Gluconate
What are two most common medications for bipolar disorder?
Lithium and Carbamazepine (Tegretol)
What are the signs of lithium toxicity?
SAD LITH
Seizures
Ataxia - impaired balance
Dystonia - muscle contractions
Lethargy/Leukocytosis - increase WBC’s
Insipidus (DI)
Tremors
Hypothyroidism
Two most common treatments for psychosis?
Haldol and Geodon
What are some adverse/side effects of Haldol?
Risk of neuroleptic malignant hyperthermia; prolonged QT interval; dystonic reactions
What is a side effect of Geodon?
It can cause prolonged QT interval
What medications are concerning for extrapyramidal symptoms?
Neuroleptic medications such as Haldol and Chlorpromazine (both can cause dystonic reactions)
What is the treatment for extrapyramidal symptoms and how do you know when it has worked?
Benadryl, Benztropine (Cogentin), and Trihexyphenidyl (Artane). It has worked when muscles relaxed.
What is Neuroleptic Malignant Syndrome?
A life-threatening condition that can be caused by antipsychotic medications, manifested by hyperthermia, muscle rigidity, and autonomic instability (fluctuations in BP)
What is the treatment for hyperthermia from neuroleptic malignant syndrome?
ABC’s and reduce temperature with cooling blankets and icepacks. Give Dantrolene (usually 35 vials)
What treatment is used when someone ingests an overdose of long-acting or enteric coated medications?
Activated charcoal with sorbitol (cathartic) every 4-6 hours for 12-24 hours (often used for acetaminophen overdose)
When would Gastric Lavage be used?
For toxic, symptomatic patients with recent ingestion (<1hr)
What is a risk of gastric lavage?
Risk of esophageal perforation
What is treatment for body packers (cocaine packs)?
Whole bowel irritation with Go-lytely or MiraLAX.
What are the signs and symptoms or iron overdose?
N/V, abdominal pain, hematemesis
What is treatment for iron overdose?
No charcoal (iron does NOT bind to charcoal). Desferal (Deferoxamine) - chelating agent that binds to free iron and it is excreted renally (rust, pink, or “vin rose” urine color expected).
What is the time frame for using activated charcoal?
Ideally within 1 hour of ingestion, but within 4 hours may be appropriate for people who take opioids (slows bowel motility) or who took EC medication.
What are diagnostic tests that would be ordered after an overdose of Tylenol?
Quantitative level at 4 hours from ingestion, monitor LFT’s
What are the best treatment options for Acetaminophen overdose?
Gastric Lavage and activated charcoal, N-acetylcysteine (Acetadote) within 8 hours for best response.
What are signs and symptoms of salicylate overdose?
Tachypnea to compensate for metabolic acidosis, N/V, abdominal pain, tinnitus, hypoglycemia.
What medications are considered salicylates?
Aspirin and Magnesium salicylate (OTC med for pain and inflammation)
What is the treatment for salicylate toxicity?
Sodium bicarb for urine alkalization
Dextrose for hypoglycemia
Hemodialysis
What are some tricyclic antidepressants?
Elavil
Tofranil
Amitriptyline
Trimipramine
Nortriptyline
What are some symptoms of tricyclic antidepressant overdose?
3 C’s
Coma (altered LOC)
Cardiac dysrhythmias (ventricular tachycardia)
Convulsions (seizures)
+ metabolic acidosis
What is the treatment for tricyclic antidepressant overdose?
Cardiac monitoring, intubation, sodium bicarbonate for urine alkalization, lidocaine, and magnesium sulfate if polymorphic tachycardia develops.
What is the antidote for acetaminophen?
N-Acetylcysteine (Acetadote)
What is the antidote for Tryicyclics (TCA’s)?
Sodium Bicarbonate
What is the antidote for Calcium Channel Blockers?
Calcium, Glucagon, Insulin
What is the antidote for beta blockers?
Glucagon, insulin
What is the antidote for organophosphates (insecticides and nerve gas)?
Atropine/2-PAM
What is the antidote for Ethylene glycol (found in antifreeze)?
Fomepizole (Antizol)
What is the antidote for Iron?
Deferoxamine
What is the antidote for Sulfonylureas (a class of meds that are used to lower BGL in diabetics by stimulating the pancreas - glipizide, tolbutamide)
Dextrose, Octreotide (Sandostatin)
What are some symptoms of hypercalcemia?
Lethargy, decreased deep tendon reflexes, constipation, “metallic taste”, risk of kidney stones
What is the treatment for hypercalcemia?
IVF’s, furosemide, glucocorticoids to decrease GI absorption of Ca+, dialysis
What causes hypocalcemia?
Pancreatitis, hypoparathyroidism, low albumin, burns, malignancy, and hyperventilation
What are some signs and symptoms of hypocalcemia?
Chvostek’s sign - spasm of lip and cheek, Trousseau’s sign - carpopedal spasms
Tetany
Confusion
Prolonged QTI - risk of Torsades VT (polymorphic VT)
What is the treatment for hypocalcemia?
Replace calcium, vitamin D, parathyroid hormone (as needed)
What are two types of causes of hypernatremia and their causes?
- Excess water and sodium (renal failure)
- Hypovolemic hypernatremia (DKA, HHS, DI)
What are symptoms of hypernatremia?
Thirst, dry membranes, orthostatic hypotension
What is the treatment for hypernatremia?
Correct slowly with D5W or 0.45NS to prevent cerebral edema; sodium restriction; vasopressin (ADH) for diabetes insipidus; diuretics and dialysis for renal failure.
What are the two types of hyponatremia and their causes?
- Hypovolemia (with hyponatremia) - vomiting diarrhea, or burns
- Hypervolemic hyponatremia - fluid overload, SIADH, excessive water ingestion
Symptoms of hyponatremia?
Fatigue, diarrhea, risk of seizures
What is the treatment for hyponatremia?
Hypertonic saline (or just NS if from n/v/d or burns)
Water restriction
What is the normal range of magnesium in blood?
1.5-2.5 mEq/L
What causes hypermagnesemia?
Renal failure and laxative abuse
What are symptoms of hypermagenesemia?
Respiratory depression, bradycardia, hypotension, decreased DTR’s
What is the treatment for hypermagnesemia?
Stop magnesium if infusing, furosemide, calcium gluconate 10% 10mL over 10 minutes, dialysis.
What causes hypomagnesemia?
Acute and chronic alcoholism (most common), malnutrition, malabsorption, thiazide diuretics (HCTZ) and loop diuretics (Lasix)
Signs and symptoms of hypomagnesemia?
Ventricular dysrhythmias like (Torsades de Pointes), agitation, hyperreflexia
What is the treatment for hypomagnesemia?
Give magnesium sulfate - 1-2 grams IV (rapid if emergency, over 2 hours if non-emergent) or IM depending on severity (monitor for respiratory depression, hypotension, and decreased DTR)
Hypomagnesemia can cause what other electrolyte imbalance
Hypomagnesemia can cause hypokalemia because hypomagnesemia can increase renal K+ loss and impair K+ reabsorption.
How do you calculate cerebral perfusion pressure?
MAP - ICP = cerebral perfusion pressure
What is normal ICP?
Normal ICP <15mmHg
Abnormal >20mmHg sustained
What is the Monroe-Kellie doctrine?
Monro-Kellie doctrine - an increase in one element must be accompanied by a corresponding decrease in one of the other elements, Brain 80%, CSF 10%, Blood 10%.
What is the GCS scores r/t severity of head injuries?
Minor head injury: 13-15
Moderate head injury: 9-12
Severe head injury: 8 or < (secure airway)
What score is most helpful for checking neuro status on vented patients?
FOUR score (Full outline unresponsiveness score) - includes reflexes and respiratory pattern
What vitamin (+dose) should be given to deficient patients to prevent Wernicke’s encephalopathy?
Thiamine (Vitamin B1) 50-100mg
What are the symptoms of Wernicke’s encephalopathy?
Confusion
Confabulation (creating false memories)
Ataxia
Nystagmus
What causes pinpoint pupils?
Opioids
OP pesticides
chemical warfare agent (CWA)
What causes nystagmus?
Drugs, tumor
Decorticate posturing signals that what part of the brain is injured?
Cerebrum
Decerebrate posturing signals that what part of the brain is injured?
Brainstem
What is it called when CSF leaks from the ear?
otorrhea
What is it called when CSF leaks from the nose?
rhinorrhea
What interventions for CSF leakage from nose or ears
Do NOT pack, just let it drain, place sterile nasal drip pad to prevent infection, not to prevent drainage. Instruct patient to not blow nose. Do NOT insert an NG tube.
How do you confirm whether clear drainage from ears or nose is mucus or CSF?
Check glucose. CSF should be 66% of glucose.
What clinical symptoms should you look for if you see blood from ears or nose to determine if it is a neurological injury?
bloody drainage - look for halo
What is Babinski reflex?
Fanning of toes, abnormal in adults
What is the name of the “Doll’s eyes” reflex and what does it signal?
Oculocephalic reflex - eyes look to opposite side that head is being rotated to;
No movement of eyes= brain death
What is the name of the “cold caloric” reflex?
Oculovestibular reflex - eyes look toward ear irrigated;
No response in brain death
What are cranial nerves 2-6 used for?
II - vision
III - assess extraocular movement
IV - assess extraocular movement
V - sensory to nerves of face and neck
VI - assess extraocular movement
What problem is caused by damage to cranial nerve 3?
Leads to limited upward gaze
What medical condition is associated with cranial nerve V?
Trigeminal neuralgia
What medical condition is associated with cranial nerve VII?
Bell’s palsy
What causes Multiple Sclerosis?
Demyelination of axons
What are the symptoms of Multiple Sclerosis?
weakness, unsteady gait, altered sensation in extremities and face
What is the treatment for Multiple Sclerosis?
Treated with steroids and immunosuppressants (interferon)
What is Myasthenia Gravis and what symptoms does it cause?
An autoimmune condition affecting women 20-30; affects acetylcholine binding sites leading to muscle fatigue, ptosis (drooping eyelids), dysphagia, and respiratory paralysis.
What is the test used to diagnose Myasthenia Gravis?
Tensilon test
What is treatment for cholinergic crisis in someone with Myasthenia Gravis?
Atropine (have at bedside; also give if excessive Neostigmine taken)
What is treatment medication for Myasthenia Gravis?
Neostigmine
What are s/s of Parkinson’s?
tremor at rest
facial “mask”
“Cogwheel” rigidity
Bradykinesia
What is Lou Gehrig Disease?
Lou Gehrig Disease (Amyotrophic lateral sclerosis) - genetic disorder that leads to progressive loss of voluntary muscle control (grip strength) but retains intelligence and personality.
Temporal Arteritis
- definition
- population
- s/s
- Dx
-Tx
- inflamed temporal artery (palpable cord-like)
- age >50 years
- throbbing headache in temporal area, fever, temporary unilateral vision loss
- Dx: ESR and C-reactive protein increased
- Tx: corticosteroids
Tension headache s/s and interventions?
Band-like pain across forehead; teach relaxation techniques
What are Migraine symptoms
Unilateral pulsating pain, photophobia and phonophobia, n/v, possible aura
Symptoms of Cluster headache?
excruciating, unilateral, episodic (multiple per day; short-lived), excessive tearing (lacrimation), and nasal congestion on affected side.
Initial treatment of cluster headaches?
Treat with oxygen initially
What is the most common bacterial source of meningitis?
Group B streptococcus
What is the name of the signs of when a person with meningitis legs pull up when head is bent?
Kernig’s and Brudzinski’s sign
What are symptoms of meningitis in infants?
Bulging fontanelles, opisthotonos (backward arch), and high-pitched cry
What is the most common bacteria that causes meningococcemia, but can also cause meningitis?
Neisseria Meningitides
What is key symptoms of meningococcemia?
Non-blanching petechial rash on torso/legs
What is first intervention for a stable patient who has meningococcemia?
Don PPE and place under droplet precautions
What are interventions for a patient with meningitis?
Tx: assume it is bacterial, institute isolation immediately, antibiotics STAT, assist with LP (side lying position preferred)
What does bacterial CSF look like?
High pressure, cloudy, low glucose
Status Epilepticus results from a sequelae of what 3 things?
hypoxia, acidosis, hypoglycemia
What is the protocol for giving Dilantin?
Mix Dilantin in NS only and infuse no faster than 50mg/minute, monitor closely for infiltration. Cardiac, BP, and RR monitoring during and 20 mins post infusion.
Nursing teaching for seizure medication
Cause drowsiness and avoid alcohol.
Differential diagnosis for strokes?
hypoglycemia, atypical migraines, Bell Palsy, Lyme disease facail paralysis
Paralysis will be on which side of the clot in an ischemic stroke patient?
Paralysis will be on opposite side of the clot
What is scientific name of slurred speech?
Dysarthria
Definition of homonymous hemianopsia
The loss of half of your visual field in one or both eyes. If the injury is to the RIGHT side of the brain, then there will be a loss of vision to the LEFT side of each eye.
Time for rTPA?
3-4.5 hours
Dose for TPA?
0.9mg/kg (maximum 90mg), bolus 10% of dose over 1 minute, remainder as a drip over the next hour. Flush with NS at same rate once infusion is complete
What is exclusion criteria for TPA?
Tumor, head trauma, AV malformation, current internal bleeding, platelets <1000,000mm2
Blood pressure parameters for giving TPA?
SBP<185mmHg
DBP <110mmHg
Timeline for TIA?
usually resolve within 10-20 minutes, defined as resolving within 24 hours
What is a cerebral infarct that lasts >24 hours, but <72 hours
Reversible ischemic neurologic deficit (RIND)
what is a sign that may help distinguish a hemorrhagic stroke and an ischemic stroke?
Hemorrhagic stroke will often have focal deficits
Medications given to hemorrhagic stroke patient to help stop the bleed
- Vitamin K, FFP, and/or TXA
- Anticoag reversal agents as needed
– Coumadin - Kcentra and vitamin K
– Xarelto or Eliquis - Andexxa
Symptoms of Subarachnoid hemorrhage
explosive or “worst HA of my life”, altered LOC, N/V, photophobia, focal deficits, and nuchal rigidity
What is the most common cause of subarachnoid hemorrhage?
Aneurysm or AV malformation
What medication is best used to control BP in a patient with subarachnoid hemorrhage?
Calcium channel blockers (such as Nimodipine)
What is the difference between primary and secondary brain injuries?
Primary brain injury is caused by trauma such as car accident, fall, sports, etc.
Secondary brain injury is caused by cerebral edema from hypotension, hypoxia, or hypercarbia
What are the degrees of brain injury?
Mild - GCS 13-15 with LOC <30 mins and no deficits
Moderate - GCS 9-12 with LOC and focal deficits
Severe - GCS of 8 or less with significant LOC, abnormal pupils, and posturing
Special consideration for scalp lacerations?
Very vascular so apply direct pressure
What is a concussion?
Short period of impaired neurological function that resolves spontaneously (GCS 13-15)
What are possible symptoms of concussion?
headache, dizziness, retrograde amnesia, vomiting, answers questions slowly
What are head injury precautions?
acetaminophen for pain only; no narcotics, no caffeine to stimulate the brain; cognitive brain rest and graduated return to play.
What happens if people return to physical play too quickly after a concussion?
Secondary impact syndrome (may lead to death)
When does the patient know that they can return to active play after a concussion?
They must be medically cleared by a physician
What are two complications after a concussion?
Secondary impact syndrome and post concussive syndrome
What are symptoms of post concussive syndrome?
cognitive impairment, slowed reaction time, and memory difficulties
What is a Diffuse Axonal Injury?
A severe, diffuse TBI
What are symptoms of diffuse axonal injury?
Widespread microscopic hemorrhage (no focal lesion) leads to immediate and prolonged coma (reticular activating system affected), hypertension, hyperthermia, excessive sweating, and abnormal posturing.
Symptoms of Basilar Skull Fractures
Altered LOC, combative behavior, headache, and vomiting, possible CSF leakage
How do you determine if bloody drainage from nose/eyes has CSF in it? What about clear drainage?
Bloody Drainage: Halo test
Clear Drainage: Glucose test (CSF BGL is 50-80)
What is the scientific name for “loss of smell”
Anosmia
What are the symptoms of an anterior fossa fracture?
“racoon eyes”, rhinorrhea, anosmia
What are the symptoms of Middle fossa fracture?
“battle sign”, otorrhea, ruptured tympanic membrane
What are some interventions for CSF drainage form ears or nose?
Place sterile drip pad under nose and over ears to prevent infection, do not pack ears and nose, let it drain, no NG tube
What is an epidural hematoma?
A rapidly forming hematoma between the skull and dura because of a temporal bone impact and laceration or tear of the middle meningeal artery.
How often does a patient with epidural hematoma present with the classical symptoms?
75% of the time
What is the classical presentation of an epidural hematoma?
Period of unconsciousness, followed by lucid period with severe headache, then second loss of consciousness; ipsilateral pupil dilation with contralateral weakness or paralysis. Appears as lens-shape on CT scan.
What are the time parameters for an acute, subacute, or chronic subdural hematoma?
Acute: <48 hours
Subacute: 48hr - 2 weeks
Chronic: >2 weeks
What is a subdural hematoma and who is it most often seen in?
A collection of blood between the dura and subarachnoid layer due to tearing of the bridging veins seen most in older patients (anticoagulants) and in chronic alcohol abuse (fall often).
What is shaken impact syndrome?
Triad of subdural hematoma, fractured (posterior) ribs, retinal hemorrhage seen more in infants and young children, and in interpersonal violence.
What are key points of an epidural hematoma?
- Arterial bleed
*Sudden loss of consciousness - Short period of unconsciousness followed by lucid period and subsequent deterioration
- Dilated, nonreactive pupil on ipsilateral side
- Younger population
What are the key points of subdural hematoma?
- Venous bleed
- Progressively decreasing LOC
- Elderly or alcoholic
- Shaken impact syndrome
What are interventions for increased ICP?
Monitor ICP and keep <20mmHg
Elevate HOB to 30-45, neutral alignment, avoid hip flexion
Maintain SBP 100 or higher to encourage cerebral perfusion CPP 50-70mmHg
Mannitol 1g/kg bolus or hypertonic saline (effective if urine output increases)
Avoid hypotonic fluids
Monitor sodium and serum osmolality closely, especially if administering Mannitol
Keep Hgb up (RBC’s deliver oxygen) using 1:1:1; give meds to stop bleeding
Avoid venous compression of neck (remove rigid cervical collar)
Maintain normothermia by treating fever aggressively
Low stimulus environment
Control agitation with benzos and short-acting opioids so you can assess frequently
What is NEXUS criteria?
NEXUS Criteria is a guide to determine which trauma patients don’t need spinal imaging. (Use NSAID mnemonic)
Neuro deficit
Spinal tenderness
Altered mental status
Intoxication
Distracting injury
What is SCIWORA and what should be ordered for these patients?
Spinal cord injury without radiographic injury seen in children under age 8. MRI to assess edema.
What is a “Chance” fracture?
Fracture of T12-L2 seen in hyperflexion “lap belt” injuries with concurrent hollow organ bowel or stomach injuries
What is Cauda equina syndrome?
Cord compression of L5-S1 “horse-tail” from fall onto coccyx. (All of nerves in the lower back suddenly become severely compressed)
What are symptoms of cauda equina syndrome?
“saddle anesthesia” (tingling and numbness in saddle area); sciatica-type back pain; bowel, bladder, and sexual dysfunction
What are the symptoms of a complete spinal cord injury?
Loss of all motor/sensory function and reflexes below level of injury
Loss of bowel and bladder function
Loss of proprioception
Priapism
Poikilothermic (difficulty regulating body temperature)
Spinal or neurogenic shock
Interventions for a patient with complete spinal cord injury
Protect airways and monitor breathing effectiveness
Keep pt warm
Remove backboard early to protect skin early
Insert gastric tube to prevent ileus
Insert urinary catheter if not contraindicated
What is the result of a cervical fracture?
Cervical - tetraplegia or quadriplegia when all four limbs are involved
C1-C4 - Requires 24 hour-a-day care, may be able to use powered wheelchair
C5-C6 - May be able to breath on their own and speak normally, needs assistance with ADL’s. Little or no control of bowel or bladder
What is the result of thoracic fracture?
Thoracic - Paraplegia, can use a manual wheelchair, learn to drive a modified car, stand in standing frame
What is the result of a lumbar fracture?
Lumbar - may walk with braces, no control of bowel and bladder
What is the result of a sacral fracture?
Most able to walk, no control of bowel and bladder
What is sacral sparing?
The patient maintains voluntary anal sphincter tone from an incomplete cords injuries
What are the four types of Incomplete Cord Injuries?
Anterior cord injury
Brown-Sequard Syndrome
Central cord injury
Posterior cord injury
What are the symptoms of an anterior cord injury?
Loss of motor function
Loss of sensory of pain, crude touch, and temperature
Retains proprioception
What are symptoms of a Brown-Sequard Syndrome from a incomplete cord injury?
Transverse hemisection (stab or GSW)
Loss of motor function on side of injury (ipsilateral)
Loss of pain and temperature on opposite side of injury (contralateral)
What are the symptoms of an incomplete central cord injury?
Loss of motor and sensory function, more pronounced in arms than legs (can walk to table, but can’t eat)
What are the symptoms of an incomplete posterior cord injury?
Loss of proprioception, vibration, fine touch, and fine pressure
Intact motor function
What is the basic patho of neurogenic shock?
An injury at T6 or above that causes loss of sympathetic nervous system innervation leaving unopposed parasympathetic nervous stimulation. This prevents the compensatory mechanisms that would increase HR to combat hypotension.
What are the symptoms of neurogenic shock?
Warm, flushed skin with full pulses, hypotension, and bradycardia (or lack of expected tachycardia), temperature instability (poikilothermia)
What are interventions for neurogenic shock?
Spinal motion restriction; support airway and breathing; augment vascular tone with IV fluids, vasopressors, and positive inotropes.
What type of shock is neurogenic shock?
Distributive shock (maldistribution of blood)
What is spinal shock?
Spinal shock is not actual shock. It can happen form an injury at any level. It causes:
* Loss of motion and sensation below level of injury
*Transient episodes of hypotension
*Flaccid paralysis
*Loss of reflexes.
What is a possible complication of a spinal cord injury above T6?
Autonomic Dysreflexia
What is autonomic dysreflexia?
Noxious stimulus in a patient with a fracture above T6 that leads to massive sympathetic nervous system response
What are symptoms of autonomic dysreflexia?
Sudden onset of severe HTN, pounding headache, nausea, nasal congestion, anxiety, flushed face, sweating with piloerection (goose bumps)
What is the treatment for autonomic dysreflexia?
Identify and treat cause (ex: over-distended bladder, bowel impaction, skin pressure, infection, ingrown toenail)
Lower blood pressure
What is utilitarianism?
benefit of the majority (disaster triage)
How to preserve a deceased patient’s eyes for corneal donation
Elevate HOB to 20-30 degrees, instill artificial tears and tape eyelids shut with paper tape, apply ice over eyes
What are some things to be careful of for forensic evidence collection?
Do NOT cut through any clothing tears, rips, holes or stains.
Place evidence in paper bags, fold top of bags, tape across, do NOT staple.
Do not remove bullet with metal instrument, used gloved fingers or rubber tip hemostats.
Do not label wounds as entrance and exit wounds, label them as wound 1 and wound 2.
What kind of documentation must accompany evidence for court?
Documentation that demonstrates the item’s location and responsible party to prove integrity of evidence
Types of pain scales and population they are used for:
N-PASS or NIPS - neonates
FLACC - children who are too young to used face scale (<7yrs) (can be used for adults too)
Wong-Baker Faces - children >7yr
PAIN-AD - dementia
What is Ricin?
made from castor bean; latent 8 hours; then flu-like symptoms
What are some pathogens used for biological weapons?
Ricin, Anthrax, Viral hemorrhagic fever (Ebola), Nerve agents, Botulism
What are 2 types of nerve agents?
Sarin or VX agents
What is the treatment for nerve agents?
Decontaminate, atropine with bronchial secretions dry, 2-PAM, benzodiazepine.
What are symptoms fo botulism
Ptosis, flaccid paralysis, blurred vision
What should nurse do before black-tagging a child in a mass casualty situation?
The nurse should provide 5 rescue breaths, then if no response, black tag the child
What is the decontamination flow in a large group of people?
Patient flow is in opposite direction.
Hot zone - HAZMAT gear to provide life-saving treatment only
Warm zone - decontamination
Cold zone - where patient care happens
How do you know if treatment has been effective for extrapyramidal reactions?
Decrease in muscle spasms
How do you know if treatment has been effective for STEMI/Prinzmetal’s/Pericarditis?
decrease in pain and ST elevation
How do you know if treatment has been effective for CHF/PE/Pneumo
Increase in breathing effectiveness
How do you know if treatment has been effective for shock/adrenal crisis/tamponade?
Increase in BP
How do you know if treatment has been effective for asthma?
increase in PEFR
How do you know if treatment has been effective for carbon monoxide poisoning?
Decrease in COHb to <10
How do you know if treatment has been effective for cirrhosis?
increase in LOC after lactulose
How do you know if treatment has been effective for thyroid storm?
decrease in pulse
How do you know if treatment has been effective for diabetes insipidus?
Decreased urine output
How do you know if treatment has been effective for SIADH?
Increase in sodium level
How do you know if treatment has been effective for cholinergic syndrome (Organophosphate Poisoning)
decrease in bronchial secreations
How do you know if treatment has been effective for acute angle glaucoma?
decrease in IOP <20
What is the formula for TPA dose for ischemic stroke?
0.9mg/kg with 10% over 1 minute followed by 90% as infusion over 60 minutes
Max dose: 90mg/kg
What is the most common cause of central cord injury?
Whiplash
Out of the incomplete spinal injuries, which one has the worst prognosis and which one is the best prognosis?
Best Prognosis - Brown-Sequard
Worst Prognosis - Anterior Cord injury
What are the 6 P’s of neurovascular assessment?
Pain
Paresthesia
Pallor
Pressure
Paralysis
Pulselessness
How should a nurse check the radial nerve?
Motor: extend wrist or thumb (thumbs up)
Sensory: sensation to thumb
How should a nurse check the median nerve to the hand?
Motor: oppose thumb to fingers
Sensory: Sensation to index finger
How should a nurse check the ulnar nerve?
Motor: abduct (fan) fingers
Sensory: sensation to 4th and 5th fingers
When is it appropriate to give tetanus toxoid (active immunity) vs tetanus immunoglobulin?
Tetanus toxoid - revaccinate q10 years for minimal contamination or q5years for grossly contaminated.
Tetanus immunoglobulin - no or unsure of initial vaccination with gross contamination
What are symptoms of tetanus?
Trismus, lock jaw
How should a splint be placed on a patient?
Splint the injury as it lies on the padded splint, immobilize above and below the joint
What are some considerations when fitting a patient with crutches?
- The crutches should be adjusted for the hieight of the patient with their shows on.
- Elbow at 30 degrees
- Keep crutches 6 inches to side
- good leg up; bad leg down
Dressing for abrasion?
Non-adherent dressing
What is an avulsion?
Peeling of skin from underlying tissue
What is a degloving injury?
Degloving injury is avulsion where skin is pulled away from the scalp, hands, digits, foot, and toes.
What is the preferred dressing for an avulsion?
Non-adherent dressing
For a wound with foreign bodies in it, what would the xray show?
Xray would show tempered glass.
What is plan of care for a patient with vegetative material in a wound (such as a thorn)?
Remove vegetative material ASAP, do not soak otherwise it will swell; tetanus, antibiotics; MRI is ordered for vegetative material in wounds
Which areas of the body should not have xylocaine with epinephrine and why?
Ears, nose, fingers, toes, and penis - decreased circulation to distal areas increases risk of infection
When a patient has a wound to the face, what should not be shaved?
Eyebrows - loss of landmarks or uneven/no regrowth
How long should adhesive tapes (butterfly tape) over a laceration be left on?
Until they fall off (usually 7-10 days)
When placing adhesive tapes (butterfly tape) over a laceration, what should not be put on skin?
Petroleum ointments (weakens glue)
What should be done for a scalp laceration?
Staple scalp (should be removed in 10-14 days)
What are nurse interventions for when wound bonding agents (skin glue) is used for a wound?
Leave a waterproof bandage over area; educate patient that the glue with slough off in 5-10 days and to avoid petroleum ointments as they weaken glue.
What are the times for suture removal for:
Face
Scalp/Trunks
Arm/Leg
Over joint
Face 3-5 days
Scalp/Trunks 7-10 days
Arm/Leg 10-14 days
Over joint 14 days
With a traumatic amputation, what are some factors contributing to poor outcomes?
Crush injuries, contamination, comorbidities, age, poor nutrition
How should a nurse prepare a patient with a traumatic amputation to go to another facility?
- Lightly brush off gross materials
2.Rinse gently with sterile saline (avoid iodine) - Wrap amputated part in sealable plastic bag, label with patient info
- Place bag with amputation on a separate bag of ice; avoid direct contact between amputated part and ice
What is compartment syndrome?
Excessive pressure develops within a body cavity enclosed by fascia; as pressure increases circulation decreases, and edema increases; leading to ischemia and necrosis
Where is compartment syndrome most common?
Lower leg and forearm
When is there irreversible damage from compartment syndrome?
After 4-6 hours of ischemia
What are some common causes of compartment syndrome?
fractures, external compression from circumferential burns, casts, splints, ace bandages, edema, soft tissue, or vascular injury (crush injury, bleeding, hemarthrosis, recent surgery)
What are the early and late signs of compartment syndrome?
Early - severe pain disproportionate to injury, unrelieved by narcotics
Late - pulselessness (permanent damage)
How is compartment syndrome diagnosed?
Measure compartment pressure with compartmental pressure monitoring device:
Normal: <10mmHg
High: 20-30mmHg
What is the treatment for compartment syndrome?
Elevate area to the level of the heart and in a neutral position
Remove any external compression
Surgical decompression (fasciotomy at >30mmHg)
What are the risks/interventions in an open fracture?
Risk is hemorrhage and infection, so irrigate with NS and administer antibiotics
What are the risks in a closed fracture?
Risk is compartment syndrome
What should be assessed when a patient has a clavicular fracture (fracture of scapula is rare)?
Assess for axillary nerve as well as damage to subclavian or axial artery
Assess for signs of pneumothorax/hemothorax or great vessel injury
What is the treatment for clavicular fracture?
Ice, sling & swath, figure 8 brace
What should the nurse assess for with a fracture to the humerus?
Assess for brachial nerve injury
What is the treatment for a fracture of the humerus?
Proximal fracture - sling & swath
Mid-shaft humeral fracture - sugar tong splint
Distal fracture - surgery
What is the most common cause of a forearm fracture?
Fall on outstretched hand (FOOSH)
What is a Colles fracture?
A fracture of the distal radius
What is the presentation of a patient with a Colles fracture?
“Silver fork deformity”
What is the name of a fracture of the distal radius?
Colles fracture
What is the name for a dislocation of radius and fracture of the ulna?
Monteggia’s fracture
What is a smith’s fracture?
Smith’s Fracture is a fracture of the distal end of the radius caused by a fall on the back of the hand (flexed), resulting in a volar displacement of the fractured fragment. It is also known as a reverse Colles fracture.
What are interventions for forearm fracture?
Assess for median nerve damage, splint with elbow flexed 90 degrees, use sling to support arm
What is the name of a fracture of the carpal bone below the thumb
Scaphoid fracture
Where is the scaphoid bone?
A bone in the carpal bones below the thumb
Where will the pain be located with a scaphoid fracture?
“Anatomic snuff box”
What is the treatment for a scaphoid fracture?
Splint with thumb abduction
What is a Boxer’s Fracture?
Fracture of the 4th or 5th metacarpal fracture
What are the s/s of and treatment for a boxer’s fracture?
S/S: depression of knuckles
Treatment: posterior ulnar splint
What is the difference between a stable and unstable pelvic fracture?
Stable - one point broken (often fall)
Unstable - multiple points broken (MVC)
How should one safely assess for a pelvic fracture?
If there is no obvious injury, gently compress inward and down over symphysis pubis (only do once so as to not dislodge clots)
What are some risk factors related to a pelvic fracture?
Hypovolemic shock, associated urethral damage, bladder rupture
What is the immediate treatment for a pelvic fracture?
- Apply pelvic binder over greater trochanter ASAP for pelvic ring fractures (any fracture around the pelvic ring)
- Massive transfusion protocol (10 units of PRBC’s plus plasma and platelets)
- Permissive hypotension
- Prepare for embolization (REBOA) or surgery
What is a high-risk post-op of pelvic repair?
DVT/PE/Fat emboli
What is the most common situation that causes femoral head fractures?
Elderly patients who fall (especially with osteoporosis)
What is the most common situation that causes femoral shaft fractures?
High energy forces (such as in an MVA)
What are symptoms of femur fracture?
Shortened leg, external rotation, swollen thigh
What is the treatment for a mid-shaft femur fractures?
Apply traction splint to align and reduce blood loss and pain
What is the treatment for femoral head fracture?
Open reduction and Internal Fixation surgery (ORIF) - only used for severe fractures
What is a major concern with femur fractures?
Fat emboli! (12-48 hours after injury)
What are the common causes of patella fracture?
Fall on knee, knee into dashboard
What is the treatment for a patella fracture?
Surgery, long leg splint/cast