Chapter 9: Misc stuff Flashcards
What clinical manifestations of alcohol poisoning?
1) Diminished gag reflex and resp depression
2) AMS (But GCS is not classically affected till pthas min blood level of 200mg%.
3) Wernicke’s encephalopathy
- Ataxia
- Ophthalmoplegia(horizontal nystagmus/lateral gaze palsy)
- Confusion(look for depression, apathy)
4) Alcohol Withdrawal syndrome
What is the supportive care instituted in suspected alcoholics/drunken pt?
1) ABC
-Maintain airway and C-spine evaluation
-OPA/NPA depending on gag reflex
-Suctioning equip
-C-collar if trauma is suspected
-IV access
2) IV crystalloids (IV D5W 500ml)
3) Use physical restraints
4) Measure body temp
5) Invg
Bloods: CBG, FBC, U/E/Cr(Anion gap), +-ABG, +-Blood ethanol levels, +-Amylase, +-LFT, +-Tox screen, Serum Osmolality
Imaging: +-Trauma series X rays, Head CT(if evidence of head trauma w LOC, mental state is inconsistent with the blood alcohol level and worsening neuro status)
Others:+-Urinalysis(for ketones, blood, sugar), ECG
5) Drug RX:
-IV Thiamine 100mg
-IV D50W 40ml in hypogly
-Haloperidol in agitated pt
-Naloxone 2mg IV if narcotic use
What is the Rx of Alcohol withdrawal syndrome(AWS)?
1) Supportive Rx:
-ABC, IV D5W, correct electrolytes
2) Invg:
Focal seziure: Head CT
Febrile seizure: LP, Head Ct, antibiotics
Status seizure: Head CT+Metabolic screen
3) Drug Rx:
1) Thiamine IV and MgSO4 prophylactically
2) BZD: IV diazepam 5mg
3) Haloperidol Im 5-10mg
+- B-blockers(if multiple BZD doses used)
What is anaphylaxis?
A severe, systemic allergic reaction to an antigen ppt by abrupt release of mediators in a prev sensitized pt and is IgE mediated.
2 or more of the following occur:
1) Involvement of skin/mucosal tissue
2) Resp compromise
3) GI symptoms
4) Hypotension/related symp
What are some early signs of impending anaphylaxis?
1) Nasal itching
2) A lump in the throat
3) Giddiness/syncope
4) CP, SOB, Tachypnoea
5) Warmth and tingling of the face
6) N/V, Diarrhea w tenesmus, crampy abdo pain
Full-Blown anaphylaxis:
1) Angioedema(Stridor)
2) AMS
3) Cyanosis
4) Cardiopulmonary arrest
What is the definitive mgmnt of anaphylaxis?
1) ABC
- Supp O2
- Be prepared for intubation(awake)/cricothyroidotomy
- ENT consult
- IV Fluid resus 2L N/S
2) Consider use of vasopressors
3) Allergen removal
- Stop all blood trnx
- Flick out the insect stinger
- If allergen was ingested, consider charcoal, lavage
Drug Rx:
- Adrenaline: If Hypotensive pt(0.1mg of a 1: 10 000 solution IV over 5 mins) If normotensive pt (0.01ml/kg of a 1:1000 solution by IM injection) CI: IHD, Severe HTN, Pregnancy, Pt on B Blockers
- Glucagon IV 1-5mg over 5mins followed by 5-15ug/min infusion
- Diphenhydramine 25mg IM/IV
- Nebulized Bronchodilators(Salbutamol) 2:2 via nebulizer
- Hydrocortisone 200-300mg IV bolus
What is cellulitis?
Acute, subacute, chronic infection of dermis and subcut tissue characterized by edema, erythema and pain. Most often at the legs and near sites of trauma/surgical wounds usually in DM/Immunocompromised pts
What is the mgmnt of cellulitis?
1) Demarcate area of redness
2) Invg:
-Bloods: FBC, U/E/Cr, CRP, +-Blood cultures
3) Rx:
PO Augmentin, Amoxicillin, Erythromycin
If serious: IV Cefazolin
What is Nec fasc?
Group of rapidly progressive bact infections of soft tissues causing extensive tissue necrosis. Organisms-Group A Step, Staph aureus, Polymicrobial
What are the clinical features suggestive of Nec Fasc?
1) Tenderness out of proportion to clinical picture
2) Hemorrhagic blisters/bullae
3) Subcut emphysema
4) Toxic, febrile and hypotensive
What is the LRINEC scoring system?
1) WBC
2) Hb
3) CRP
4) Sodium
5) Creatinine
6) Glucose
Score>6 and above is suggestive of Nec Fasc
What invg would you order in Nec Fasc and what is the definitive mgmnt?
Bloods: FBC, U/E/Cr, CBG, CRP, Blood Cultures, GXM, PT/PTT
Imaging: Xray of affected limb
Antibiotics: IV Penicillin, Clindamycin, Ceftazidime STAT
Refer to Ortho
What is dengue fever?
it is an acute febrile infectious disease spread by female Aedes Aegypti mosquitoes causing an abrupt increase in capillary permeability, leakage of plasma, hemoconcentration and non-hemorrhagic hypovolemic shock.
What is the incubation period and duration of the DF?
4-7 days and it may last up to 2 weeks. It should come to the mind of the doc when fever persists beyond 3 days.
What are the 2 features suggestive of an impending shock?
Abdominal pain and hemoconcentration
What are the usual clinical features of DF?
1) Fever
2) Headache
3) Retro-orbital pain
4) Marked muscle and joint fever(break-bone fever)
5) Non-specific petechial rash(islands of sparing)
6) N/V, diarrhea
7) URTI symptoms
8) Hemorrhagic manifestations (bleeding gums, menorrhagia)
DF pts will have marked constitutional symptoms as opposed to normal viral fevers.
What is DHF and DSS and the clinical criteria?
Dengue Hemorrhagic Fever most serious manifestation of dengue virus infections and a/w circ failure and shock.
4 features by WHO criteria are:
1) Fever lasting 2-7 days
2) Thrombocytopenia20% increase in Hct/ascites/Pleural effusion
4) Hemorrhagic tendency(positive tourniquet test) or spontaneous bleeding
DSS is the 4 criteria + shock
What are the RFs for the devt of DHF?
1) Extremes of age
2) Good nutritional status (as malnourished pts have poor cellular immune response)
3) Viral genotypes with increased pathogenicity
4) Repeat dengue infections
What are the clinical indicators of impending DSS?
1) Severe abdo pain
2) Hepatomegaly
3) Change from fever to hypothermia
4) Sweating
5) Restlessness/lethargy
6) Persistent vomitting
Some notable atypical presentations of DF?
1) Myocarditis
2) ARDS
3) Hepatitis
4) Myositis
5) Encephalitis
6) Acute Pancreatitis
7) Febrile diarrhea
What is the mgmnt of pts with DF?
1) ABC
- Establish 2 peripheral IV lines
2) Aggressive Fluid Resus with 1-2 L of crystalloids
3) Invg:
- FBC( in all pts with pers high fever with no abvious focus of infxn)
- U/E/Cr(dehydration and AKI, Hyponat)
- LFT(AST)
- PT/PTT
- Dengue Tests
- Serology(IgM levels if fever>5 days)
- Dengue viral PCR(if fever 2-3 days)
4) Anti-pyretic(Paracet) Don’t use NSAIDS.
5) Transfusions
- Platelet tranx only indicated if sig bleeding occurs
- PCT/Whole blood only indicated if blood loss>10% or hemorrhagic shock not responding to fluid rx
What other infections are ddx for thrombocytopenia?
Measles Rubella Meningococcemia Malaria SARS
What is neutropenia?
Abnormally low levels of neutrophils
What invg and mgmnt should be instituted in neutropenic fever?
1) ABC
2) Look for source of infection(abdo, chest, urine, skin)
3) Invg:
-FBC
-U/E/Cr
-LFT
-Blood culture X2 sets
-CXR
-Urine dipstick and culture
4) Antibiotics:
Iv cefepime 2g
5) No PR exam
6) Isolation bed with positive pressure
What are the indications of whole blood transfusion?
1) Acute hemorrhage(despite normal Hb/Hct)
- Following blood loss, the 2 parameters may remain normal for >1hr. Loss of 20% blood vol can be safely corrected with crystalloids
2) Blood Loss>25%
3) At risk pts
- CAD, Valvular Hrt dz, CCF, Hx of TIA, thrombotic strokes developing signs and symptoms such as syncope, SOB, postural hypotension, tachycardia, angina, TIA
What are the indications of RBC PCT Tnsx?
1) Slow continuous blood loss
2) Acute and chronic leukemia
3) Chronic anemia due to bone marrow failure, uremia, severe symptomatic Iron def
-Whole CI in chronic anemia because of risk of overload
1 unit of RBC—raise non-bleeding adult’s Hb by 1 g/dL
Indications for FFP transx?
It contains all clotting factors
1) Replacement of single clotting def when specific or combined conc not available
2) Immediate reversal of warfarin effect in pts with life threat hemorrhage
What is cryoprecip?
1) Factor 8
2) Fibrinogen
3) vWF
What are some cx of blood transfusion?
1) Acute hemolytic reaction
- pt complains of burning in the IV site and with fever, chill, low back pain and joint pain.
- Give IV hydrocort and fluid rx
2) Febrile non-hemolytic reaction
3) Blood-borne Bacterial infection
4) Anaphylaxis
5) TRALI
6) Cardiac overload
What kinds of lab abnormalities do you find in DF?
1) Thrombocytopenia50%
4) U/E/Cr -hyponat
5) LFT-abnormal liver enzymes
6) PT/PTT
