Ch. 10 All Other Systems Flashcards
Carotid Stenosis
* Definition
* Causes
* Symptoms
* Treatent of high risk vs low risk
- Narrowing of the carotid artery
- Often caused by plaque build up
- Present with TIAs, visual changes, memory loss, vertigo, syncope, bruit or thrill
- Antiplatelet aggregation (aspiriin or plavix), BP control <130/80, Statin therapy slows progression, Carotid endarterectomy for high risk patients, carotid stending, balloon agioplasty for low risk patients (minimally invasive procedure to widen narrowed artery/vein)
Carotid Endarterectomy
* What to monitor for postop
* Cranial Nerve VII
* CN IX/X
* CN XI
* CNXII
- Monitor for bleeding/hematoma, airway assessment d/t swelling (assess for difficulty breathing and swallowing), Neuro assessment for stroke risk
- Smile
- Swallow, gag, speech
- Shrug shoulders against resistance
- Stick out tongue midline
Stroke
* 2 types
* Is this common
* Etiology
* Pre-op Risk Factors (2)
- Ischemic/Embolic vs Hemorrhagic
- Not common ~ 4% after cardiac surgery
- Aortic debris, post op afib, air embolism, cerebral hypoperfusion
- Hypertension, Atrial fibrillation, Diabetes, Prior stroke, >65 y.o.
Diagnosis with stroke like symptoms
1. first
2. second
3. third
4. fourth
- CT scan without dye (many are micro-emboli or watershed territory)
- MRI often preferred
- Assess Glucose
- Other considerations: baseline 12 lead, tropes, coags, platelet count
What is a watershed terroritory stroke
- A watershed stroke, also known as a border zone infarct, is a type of ischemic stroke that occurs when blood flow to the brain’s border zones (furthest away from blood supply) is severely reduced
What does LOE Class 1 Level BR mean?
The american heart association has developed a system of rating the strength of their medical recommendations and quality of evidence. The highest level of recommendation is Class 1, Level A
https://cpr.heart.org/en/resuscitation-science/cpr-and-ecc-guidelines/tables/applying-class-of-recommendation-and-level-of-evidence
NIH stroke scale NIHSS
* What does it do
* Score range
- Grades severity of stroke but does not diagnose the stroke
- Score range from 0 to 42, no deficits to devastating
Initial priorities in BP management in stroke
* how fast should we lower the BP
* what medications
* Treat hyperglycemia to what range
* Highest cause of epsilepsy in the elderly
- slowly
- nicardipine 5mg/hr up to 15 mg/hr max
- Clevidipine IV
- Hydralazine IV
- 70-180 is normal
- Acute ischemic stroke (there is some risk for seizure)
Endovascular therapies for ischemic stroke
* tPA vs. tPA + Thrombectomy
* What is the window for thrombectomy
- Should receive tPA regardless
- Mechanical thrombectomy if they present within 6-16 hours of last known state of wellness and have an anterior circulation large vessel occlusion. May also be reasonable in patients with a contraindication to IV fibronolysis
3 Hallmark Signs of Delirium
PADIS guideline
* Definition
* Which is more common, Hyperactive or Hypoactive
- Inattention
- Confusion
- Disorganized thinking
* This is a guideline for the order of treatment in delirium. Pain, Agitation, Delirium, Immobility, Sleep disruption
* Hypoactive delirium is most common, increased mortality 3x
Highest Risk factors for developing AKI
* Gender, age, what kind of surgery,
* Baseline renal function
* Hx of what
- Female, >65, Cardiac surgery
- Baseline renal dysfunction
- Liver dysfunction, Stroke, smoking, Long CPB time, Strong abx
- What does proteinuria mean
- Casts in the urine
- Normal urine electrolytes
- Normal Urine to BUN ratio
- Proteinuria means kidney dysfunction because only a small amount of protein is normal
- Casts mean tubular cell death
- Urine Na 40-100 mEq/L
- 10:1 - 15:1
- BUN 6 - 24, Creat .6 - 1.2
Prerenal AKI
* Def
* Cause
* Is the kidney permanently damaged
* Urine Na
- Cause of injury to kidneys occurs befor the blood reaches kidney
- Caused by hypoperfusion
- Kidney structure and function is preserved
- Urine Na+ <40 mEq/Li
ATN
* Def
* Signs
* Treatment
- Injury occurs at the nephron; there is structural damage to the kidney
- BUN/creat ratio normal but they’re both elevated, BUN >25, Creat >1.2
- Dialysis if indicated, Prevent acidosis, electrolyte imbalance and uiremia, stop nephrotoxic medications
ATN Acute Tubular Necrosis
* 2 types
* what type of damage
* Recovery time
- Toxic ATN caused by drugs or bacteria (vanco, gent, aminoglycosides, antivirals). This causes widespread damage but is reversible with recovery <8 days
- Ischemic ATN causes irregular damage along tubular membranes. Tubular cell damage and cast formation. Poor prognosis with recovery time >8 days
Most Nephrotoxic medications
(5)
- Amphotericin B
- Contrast Dye
- Nsaids
- Vancomycin
- Ciprofloxacin
*What are the kidneys supposed to do?
ATN Phase 1
* Def
* Symptoms
* Na, Uring specific gravity
* treatment
- retain sodium and excrete other electrolytes
*Oliguric phase - Inability to excrete fluids and wastes, Sig increase in BUN and creat, fluid overload, metabolic acidosis because urine not releasing acid,
- NA low but urine specific gravity elevated > 1.01,
- often required dialysis
ATN Phase 2
* Def
* Symptoms
* what to watch for
- This is the Diuretic phase
- Gradual improvement in renal function, increase in GFR and often develop polyuria,
- Kidney can often clear volume but not solute or waste so watch electrolytes closely, monitor for fluid deficit
ATN Phase 3
* Def
* can progress to
* GFR usually returns to
* What % will recover
- Recovery phase
- Can progress to CKD
- GFR usually returns to <80% within 2 years
- 33% will have chronic renal insufficiency, 60% recover
Indications for Dialysis
* Abbreviation
- AEIOU
- Acid/base imbalance
- Electrolyte imbalance
- Intoxications (ODs/toxins)
- Overload (fluid)
- Uremic symptoms
What drug prevents contrast induced nephropathy
Acetyl Cysteine
Uremic Syndrome
* Def
* Symptoms
- This is elevated Blood Urea Nitrogen
- Lethargy, Fatigue, Coma, Hyperkalemia, Fluid overload, Anemia, Pulm edema, effusions, pleuritis, decreased appetite, N/V, ascites
SLED
Disequilibrium syndrome
Advantage of CRRT
- Slow Low Efficiency Dialysis
- Dialysis disequilibrium syndrome is the collection of neurological signs and symptoms, attributed to cerebral edema, during or following shortly after intermittent hemodialysis or CRRT
- Can use in pts with hemodynamic instability
Meds Removed by Dialysis
- B LIST MED
- Barbituates, Lithium, Isoniazid, Salicylates, Theophylline, methanol, ethylene glycol, depakote
- Hold BP meds until after dialysis
LABORATORY NORMS
* BUN
* Creat
* Urine specific Gravity
* Osmolality
* Urine Sodium
* Urine Protein
* 6-20 mg/dL
* 0.6 - 1.2
* 1.010 - 1.020
* 500 - 800 mOsm/L
* 40 - 100 mEq/24h
* 30 - 150 mg/24h
Postrenal AKI
* Def
* S/S
- also known as obstructive nephropathy, occurs when waste builds up in the kidneys due to an obstruction in the urinary tract below the kidneys
- High urine Na, BUN to creat ratio normal but both elevated
Electrolytes associated with Acidosis
Electrolytes associated with Alkalosis
- Hyperkalemia, Hypermagnesemia, Hyperchloremia, Hypercalcemia, Hyperphosphatemia
- Hypokalemia, hypomagnesemia, Hypochloremia, hypocalcemia, Hypophosphatemia
What does potassium do to myocardial tissue
Causes a change in the resting action potential of the cell
In the Presence of what, potassium is excreted by the renal tubules
Aldosterone (RAAS - Ace inhibitor will cause potassium build up)
Cardiac Symptoms Related to
* Hyperkalemia / hypermagnesemia
* Hypokalemia / hypomagnesemia
*Cardiac stability
* Tall tented T waves, wide QRS, prolonged PR, Wide p waves, progressing to asystole or VFfib, N/V, diarrhea, numbness in hands and feet, flaccid paralysis, apathy, confusion
* Ventricular ectopy, Depressed ST segment, prolonged QT, muscle cramping and spasms, Cardiac irritability, U wave, can potentiate Dig toxicity
Hyperkalemia protocol
* contains
- Insulin
- Sodium Bicarb
- Albuterol, Dialysis
- Loop diuretici
- Lokelma potassium binder
- Kayexalate potassium binder
Chvostek’s sign
* Indicates
* Defintion
- Hypocalcemia
- Cheek twitching
Trousseau’s Sign
* Indicates what
* Def
- Hyperphosphatemia and Hypocalcemia
- Italian pinching type of spasm
Hypocalcemia
Hypercalcemia
Calcium is also needed to
Which one lasts longer
*This is stability plus the two hypocalcemia signs
* Prolonged QT, hypotension, Low CO, Ventricular ectopy, Chvostek’s and Trousseau’s signs, PRBC transfusions
* N/V, bone and muscle weakness, muscle cramping, lethargy, depression,
* Calcium is needed to clot, Calcium gluconate lasts longer
Hypophosphatemia
Hyperphosphatemia
Which electrolytes have an inverse relationship to eachother?
- Acute confusion, muscle weakness, incoordination, speech difficulty, numbness, tingling, seizures, coma
- N/V, anorexia, muscle weakness, hyperreflexia, tetany, tachycardia
- Phosphate and calcium have an inverse relationship to each otheri
Hyperchloremia
Hypochloremia
* Metabolic acidosis, excessive sodium chloride administration, decreased renal perfusion leading to kidney injury
* Metabolic alkalosis, hypochloremia = volume depleted patient,
