Clin Lab - EM Diagnostics Flashcards
1
Q
What is the workup as needed for Trauma?
A
Imaging:
- US: eFAST exam
–> Bedside US – checks for blood where it tends to gather in abd/pelvis as well as pneumothorax/hemothorax
–> Blood = dark
2
Q
What are the areas evaluated for trauma?
A
- RUQ – around liver/ Morrison’s pouch
- LUQ – around spleen b/t spleen & L kidney
- Pelvic – around bladder
- Pericardial
- Hemothorax
3
Q
What is assessed via US the RUQ?
A
around liver/Morrison’s pouch
4
Q
What is assessed via US in the LUQ?
A
- around spleen
- b/t spleen & L kidney
5
Q
Describe location of Morrison’s pouch.
A
b/t liver & right kidney
6
Q
Where would you more likely find blood in the LUQ
A
more around the spleen rather than b/t spleen & L kidney
7
Q
Typical order eFAST probe positions?
A
- RUQ / RIH
- Subxiphoid
- Parasternal
- LUQ/LIH
- Suprapubic
- Anterior thoracic L/R
8
Q
Which side of the pt should you stand on during the eFAST exam?
A
right side
9
Q
What does the e stand for in the eFAST?
A
looking for the lung stuff
10
Q
Describe the subxiphoid view & what we’re looking for
A
- Dig into patient’s abdomen
- Looking a pericardial sac for blood around heart
11
Q
Describe parasternal view.
A
- Upper left of chest
- Probe faces right shoulder
12
Q
Describe LUQ/LIH view.
A
Knuckles should be hitting the table
13
Q
What is being assessed in the suprapubic view?
A
Assessing the bladder, sagittal & transverse views
14
Q
What is being assessed in the anterior thoracic L/R view?
A
Assessing the pleural sliding
15
Q
What does a pneumothorax look like on US?
A
“Barcode” sign & no movement
16
Q
If indicated, what X-ray imaging is used for trauma?
A
- Spine imaging
- Extremities imaging
- Head/neck imaging
17
Q
If indicated, what CT/CTA imaging is used for trauma?
A
- Facial
- Cervical spine
- Chest/abdominopelvic
18
Q
Labs ordered get during a trauma?
A
- Type & screen
- CBC (anemia)
- CMP (kidney/liver issues)
- UA (blood)
- PT/INR, PTT / clotting
19
Q
Labs ordered as indicated during a trauma?
A
- EtOH / UDS
- pregnancy test
- EKG
- bedside glucose
20
Q
What is trauma associated with?
A
significant hemorrhage
21
Q
__% of trauma pts can develop ___ w/ resultant ____.
A
- 30%
- coagulopathy
- massive hemorrhage
22
Q
If coagulopathy occurs, how does this affect mortality?
A
increases by 3-4x
23
Q
Causes of coagulopathy
A
- Acidosis from poor perfusion
- Consumption of clotting factors (disseminated intravascular coagulation)
- Hemodilution from fluids (resuscitation associated coagulopathy)
- Trauma-induced coagulopathy
24
Q
In traumatic situations, why would acidosis from poor perfusion cause coagulopathy?
A
- Can change the ability to clot
- PROs (clotting factors) denature
25
Describe a trauma transfusion.
1:1:1
- plasma, prbcs, plts vs targeted transfusion vs whole blood
26
Describe Thromboelastography (TEG) & rotational thromboelastometry (RoTEM).
- Bedside, real time evaluation of clotting
- Evaluates clot formation time, clot strength & degree of fibrinolysis
- Protocols being developed to use TEG &/or RoTEM info to guide what to transfuse next
27
Meds that can cause Poisonings / ODs/Exposures.
- Analgesics – acetaminophen, salicylic acid, NSAIDS
- Opioids
- Cardiac meds (BBs, etc)
- Insulin & oral DM meds
- Anticoags
- Antiepileptics
- Antidepressants – serotonin syndrome
- Antipsychotics – neuroleptic malignant syndrome
- Anticholinergics –”red as a beet…”
- Vitamins/herbals
28
Illicit drugs that can cause Poisonings / ODs/Exposures.
- Cocaine
- Heroin
- Marijuana
- LSD
- Methamphetamine
29
Industrial toxins that can cause Poisonings / ODs/Exposures.
- Asbestos
- Silicone
- Pesticides - cholinergics
- Hydrocarbons, including toluene
30
Heavy metals that can cause Poisonings / ODs/Exposures.
mercury & lead
31
Metabolic disruptors that can cause Poisonings/ ODs/Exposures.
Carbon monoxide & cyanide
32
NOTE
alcohol, methanol & ethanol can cause Poisonings/ODs/Exposures
33
Serotonin Syndrome S/Sx
- more abrupt
- myoclonus/tremor
- mydriasis
- incr reflexes
- rapidly resolves
34
Neuroleptic malignant syndrome
- more prolonged
- tachycardia
- AMS
- diffuse muscle rigidity
- diaphoresis
- decr reflexes
35
Anticholinergic ODs S/Sx
- tachycardia
- urinary retention
- mydriasis
- agitation
36
Aspirin OD
resp alkalosis that turns into metabolic acidosis
37
What diagnostics are needed for a suspected poisonings/ODs?
- Pregnancy test
- Glucose
- CMP
- ABG
- UA
- UDS
- EKG
38
For suspected poisonings/ODs, what are we looking for on CMP?
- renal & liver function
- electrolyte abnormalities
39
For suspected poisonings/ODs, what are we looking for on ABG?
- Will give carboxyhemoglobin & methemoglobin levels
- Carboxyhemoglobin-->CO
Methemoglobin--> industrial solvents, nitrates
- Many poisonings will cause a metabolic acidosis
40
If acidosis is severe what can be given for treatment?
IV sodium bicarb
41
For suspected poisonings/ODs, what are we looking for on UA?
- Evidence of rhabdomyolysis
- Crystals (ex – ethylene glycol = Ca+ oxalate crystals)
42
What will show up on UA for Rhabdomyolysis?
- myoglobin
- blood
- no RBC
43
For suspected poisonings/ODs, what are we looking for on UDS?
- Opioids
- Barbiturates
- Cocaine
- Methamphetamine, etc
44
What opioids are not measure on standard UDS?
- Fentanyl
- Methadone
- Tramadol
45
For suspected poisonings/ODs, what are we looking for on EKG?
QT prolongation
46
Why do we get a serum osmolality & osmol gap for suspected poisonings/OD?
Most helpful if pt is obtunded & it is not clear if there was an OD
47
What is an osmol gap?
difference b/t measured osmolality & calculated osmolality
48
Calculated osm formula?
(2*Na) + (glucose / 18) + (BUN / 2.8) + (ethanol/4.6)
49
Describe the results when comparing the calc osm vs measured osm.
If measured osm – calculated osm is > 10, there is another substance increasing the osmolality
50
Why would there be an elevate osmol gap?
- methanol
- isopropyl alcohol
- ethylene glycol, etc.
51
Why do we get a lactate for suspected poisonings/OD?
Indicator of perfusion
- usually elevated
52
Why do we get x-rays for suspected poisonings/OD?
- Abdominal--> drug packets
- Chest--> pneumonitis, pulm edema; ground glass opacities
53
What drug levels can be tested w/ suspected poisonings/OD?
- Acetaminophen *
- Salicylic acid *
- Lithium
- Dilantin
- Valproic acid
- Carbamazepine
54
Acetaminophen: measured when? Initial management? Tx?
- Measure levels 4hrs after ingestion if unsure go ahead & order
- Initial management: suction, activated charcoal
- Tx: call poison control
55
What metal levels can be tested w/ suspected poisonings/OD?
Lead & mercury
56
What other drug can be tested w/ suspected poisonings/OD?
Toluene
57
Bio/Chemical terrorism NOTE
Rare & unlikely, but need to recognize the possibility
58
What is used in bioterrorism?
microorganisms
59
Describe what happens if someone is affected w/ bioterrorism?
- Sx develop over days/wks
- May or may not know about exposure
60
Describe what happens if someone is affected w/ bioterrorism?
- Sx develop acutely, often after gaseous exposure
61
Which Sx develops faster, bioterrorism or chemoterrorism?
chemoterrorism
62
What are the diagnostics for Bioterrorism?
- CBC, CMP
- Swabs & samples – get guidance from the experts! **CDC**
--> Swabs – nasal, skin
--> Samples – sputum, blood, stool, urine, CSF, BAL
63
Bioterrorism: Category A
- Arenaviruses (Lassa, Junin)
- Bacillus anthracis (Anthrax)
- Clostridium botulinum toxin (botulism)
- Filoviruses (Ebola, Marburg)
- Francisella tularensis (tularemia)
- Variola Major (smallpox)
- Yersinia pestis (plague)
64
Bioterrorism: Category B
- alphaviruses
- B. pseudomallei (melioidosis )
- Brucella spp. (brucellosis)
- Burkholderia mallei (glanders)
- Chlamydia psittaci (psittacosis)
- Cryptosporidium parvum
- Coxiella burnetii (Q fever)
- E. coli (O157:H7)
- Epsilon toxin of C. perfringens
- Ricin toxin
- Rickettsia prowazekii (typhus fever)
- Salmonella spp.
- Shigella dysenteriae
- Staph enterotoxin B
- Vibrio cholerae
65
Bioterrorism: Category C
- Hantaviruses
- Nipah virus
- Multidrug-resistant TB
- Tickborne encephalitis viruses
- Tickborne hemorrhagic fever viruses
- Yellow Fever
66
What are the categories of chemical terrorism?
- Pulmonary
- blood
- nerve
- vesicant
- incapacitating
67
Examples of chemical terrorism?
- Sarin
- "tear gas"
- mustard gas
- BZ
- VX
68
What is included in the diagnostic evaluation for chemical terrorism?
- Clinical toxidrome
- Supportive testing
--> ABG
--> CXR
--> CBC (daily)
--> CMP
- Specific tests – not readily available & results aren’t timely
69
What is required when collecting forensic evidence for sexual assault occurs?
- informed consent & is not mandatory
- Separate providers in separate areas if both victim & suspect are evaluated
70
What is collected from the sexual assault victim?
- Clothing
- Any materials used in transport (sheet, blanket, etc)
- Swabs from cheek, vagina, rectum, areas identified by UV light
- Combings from scalp & pubic hair
- Hair samples (pulled)
- Fingernail clippings & scrapings
- Blood
- Saliva
71
What is collected from the sexual assault suspect?
- Hair combings
- Swabs – wounds, hands, penis
- Fingernail scrapings/clippings
- Blood for HIV/Hep B
72
What further diagnostics are needed for sexual assault victim?
- Trauma imaging
- Screening for HIV, hep B, syphilis, gonorrhea, chlamydia, trichomonas
- Pregnancy test (depending on timing)
- Presence of drugs: flunitrazem (Rohypnol), gamma hydroxybutyrate (GHB), etc…
73
A physical abuse workup depends on ___.
suspected or evident trauma as well as age of victim
74
What should be done/order when suspect physical abuse in adult/adolescents?
Hx/PE guides workup
- X-rays or CT
- CBC, CMP
- Pregnancy test
- If obtunded – CT head
75
What is evidence of abuse?
- Bruising
- Fractures
- Burns
- Any unexplained visceral or intracranial injury
76
What does the evaluation of child abuse include?
- Bruising w/ petechiae
- Only frax, low suspicion for abuse
- Visceral injury
- Neurologic impairment
- Skeletal survey
- Retinal evaluation
77
What needs to be evaluated when bruising w/ petechiae is seen? What do you order?
evaluate for bleeding disorder:
- CBC,
- PT/INR, PTT
78
What needs to be evaluated when Only frax, low suspicion for abuse is seen ? What do you order?
evaluate for bone disorder: Calcium, PTH, phosphorus vitamin D
79
What needs to be evaluated when visceral injury is seen? What do you order?
LFTs
- Lipase
- Abdo imaging (CT w/ contrast)
80
What needs to be evaluated when neurologic impairment is seen? What do you order?
CT or MRI
81
What a skeletal survey?
21 separate xrays to assess frax; mostly used w/ younger children or those w/ developmental or communication issues
