common problems in acute care Flashcards
Name three individuals in your family who have loved and supported you throughout grad school
This should be easy.
What type of pain last longer than 6 months, may be episodic?
chronic pain
What type is on the skin?
cutaneous
How do you describe soft tissue pain?
somatic
What is the three step process associated with the treatment of cancer pain?
step 1: begin with non-opoid (NSAID, tylenol), +/- adjuvanct (antidepressants etc)
step 2: maintain step one + mild narcotid (codeine, oxycontin)
step 3: add hydromorphone, fentanyl
Per Barkely, what type of medication can be used for round the clock breakthrough pain?
narcotic patch (fentanyl patch)
What’s normal body temperature?
37 Celcius
What are causes of fever they don’t require antibiotics?
SLE
MI
thrombus
neurogenic fever
hyperthyroidism
seratonin syndrome
neuroleptic malignant syndrome
malignant hyperthermia
non-infectious post op fever
What degree celcius defines fever?
38.3
What woul you consider in the differential of a patient taking antipsychotics (aka neuroleptic drugs) who presents to the ER with fever, muscle cramps, muscle rigidity, and elevated creatinine phosphokinase?
neuroleptic malignant syndrome
What are causes of non-infectious post-op fever?
atelectasis
dehydration
medications/drug reactions
A shift to the left results in bandemia which means:
high young neutrophil count, implies infection
If your WBC is extremely high, like >40, what should you consider in the differential?
leukemia
transplant patient
In the abscence of source of infection, the first line treatment for post-op fever should be:
hydration (to treat dehyration)
lung expansion (to treat atelectasis)
A post op patient has a fever for three days, WBC elevated, eosinophils 9%, and negative blood cultures. What is your most likely cause?
drug fever (high eosinophils imply allergic reaction)
What is the medication treatment for malignant hyperthermia?
dantrolene
Cluster headache are characterized by:
unilateral peri orbital pain
sinus congestion
awakens patient at night
Vice like headache pain describes what type of common HA?
tension HA
Are classic migraines with or without aura?
Classic migraines are with aura
Are the most common migraines with or without aura?
The most common migraines are without aura
What are some triggers for migraines?
emotional/physical stress
changes in weather
nitrate containing foods
too much/lack of sleep
What are differentials for patient presenting with HA and focal neuro deficits?
neurosyphilis (test with VDRL venereal disease research lab)
tumor
migraine
What medications can be given for migraine prophylaxis?
amitriptyline (antidepressant)
propranolol
topamax (topiramate)
What medication can be given for treatment of acute migraine?
sumatriptan (causes vasoconstriction)
100% O2
What are normal albumin levels?
3.5-5
What two labs gives an indication of malnutrition?
prealbumin (early indicator)
albumin
Why are women’s H and H values lower than mens?
because testosterone stimulates erythropoietin production
According to Society of Critical Care medicine, what it the H & H threshold for blood transfusion?
hgb 8/ hct 24
If you give a patient one unit PRBC, how much do you expect their H & H to change?
hgb increase by 1, hct increase by 3
You would consider a PEG tube in a patient who needs enteral nutrition support for longer than _____ weeks.
6
What percent dextrose content requires a central line?
>10% dextrose content requires a central line
What are complications of enteral feedings?
aspiration
dehydration
What are complications of parenteral nutrition?
catheter related complications (infection, pneumo)
What is the most common electrolyte abnormality?
hyponatremia
How do you determine if hyponatremia has a renal or non-renal cause?
look at the urine sodium
if the urine sodium is <10 the problem is outside the kidney
if the urine sodium is >20 the problem is with the kidney
Normal urine sodium is 10-20
What are causes and treatments of a pseudohyponatremia AKA isotonic hyponatremia?
extreme hyperlipidemia
hyperproteniemia
treatment: cut down on the fat in the diet
*the patient is asymptomatic
What are some causes of hypoosmolar hypovolemic hyponatremia and what is the treatment?
diarrhea (c. dif)
vomiting/prolonged NG tube suctioning
diuretics
ace inhibitors
treatment: NS (replaces the Na+ and volume)
What are three causes of hypoosmolar hypervolemic hyponatremia and what is the treatment?
heart failure
cirrhosis
advanced renal failure
treatment: fluid restriction, diuretics if needed
What is a common cause of hyperosmolar hyponatremia?
elevated BG
HHNK
What are signs/symptoms of hypokalemia?
decreased amplitute, broad t-waves, multifocal PVCs, u-waves on EKG
muscle weakness/muscle cramps
<2.5 tetany, hyporeflexia, rhabdo
What are two differentials for a patient with new multifocal PVCs?
hypokalemia
MI
How does alkalosis influence serum potassium levels?
high pH –>>> low K+
What are causes and signs of of hyperkalemia?
chronic NSAID use
renal failure
signs: peaked T waves
How do you treat hyperkalemia?
(What do you do when you “C BIG K” on the labs?)
C BIG K
calcium
bicarb
insulin
dextrose (“glucose”)
kayexalate
Calcium levels need to be interpretted in relationship to albumin levels because calcium binds to albumin. Which calcium levels do not change with albumin levels, serum or ionized?
ionized calcium levels don’t fluctuate with albumin levels and therefore should be treated in critically ill patients
What are causes of hypocalcemia?
pancreatitis
hypoparathyroidism
low magnesium
renal failure
severe trauma
multiple blood transfusions
What are signs of hypocalcemia?
*(remember signs of hypocalcemia are “opposite/high”)
INCREASED DTRs
chvosteks (sustained cheek blink)
trousseau’s (carpal tunnel spasm)
QTc prolongation
What are causes of hypercalcemia?
hyperthyroidism
hyperparathryoidism
vitamin D intoxication
prolonged immobility
the use of thiazide diuretics
What are symptoms of hypercalcemia?
(remember it is opposite, everything is slow)
sluggish
fatigue
muscle weakness
N/V
constipation
What is the drug treatment for hypercalcemia?
calcitonin, it pushes calcium back into the bone
consider NS and lasix
How do you calculate an anion gap and why is it useful?
Na - bicarb - chloride
Normal 8-16ish
Anion gap is helpful to identify the cause of a metabolic acidosis.
What are causes of non-anion gap metabolic acidosis?
(HARDUP)
Hyperchloraemia,
Acetazolamide, Addison’s disease
Renal tubular acidosis
Diarrhoea, ileostomies, fistulae
Ureteroenterostomies, uretosigmoid fistula
Pancreatoenterostomies, parenteral saline
What are causes of anion gap metabolic acidosis?
(MUDPILES)
Methanol
Uremia
DKA
Paraldehyde
INH, iron
Lactic acidosis
Ethylene glyol
Salycilates
The higher the anion gap the more ______ the patient.
acidotic and acutely ill
What are causes of metabolic alkalosis and what drug can be used to treat metabolic alkalosis?
vomiting
prolonged NG suctioning
Manegement: acetazolamide/diamox forces the kidneys to excrete bicarbonate, the conjugate base of carbonic acid. By increasing the amount of bicarbonate excreted in the urine, the blood becomes more acidic
What differentiates 1st and 2nd degree burns?
2nd degree has blistering and 1st degree doesn’t
A burn that goes down to the muscle or bone is classified as what degree?
3rd degree
According to the rule of 9s in burn injury, each arm is worth what percent?
9%
According to the rule of 9s in burn injury, each leg is worth what percent?
18%
According to the rule of 9s in burn injury, the front of the chest is worth what percent?
18%
According to the rule of 9s in burn injury, the back of the chest is worth what percent?
18%
According to the rule of 9s in burn injury, any burn to the head is worth what percent?
9%
How do you calculate fluid requirements for a burn patient using the Parkland formula?
4ml/kg x TBSA burned = volume needed over 24 hours
1/2 given in the first 8 hours, the other 1/2 given in the next 16 hours.
the time begins at the time of injury, not at the time of arrival to the hospital
If a 220 pound man had a 60% burn, how much fluid would he need in the first 24 hours?
4ml x 100kg x 60 = 24,000ml in the first 24 hours
12,000ml in the first 8 hours
12,000ml over the next 16 hours
In the first three days of the burn the potassium will be ________. Three days post burn the potassium will be ____.
In the first three days of the burn the potassium will be high. Three days post burn the potassium will be low.
What type of medication cream is used for the treatment of burns?
silvadene
What type of bites are the dirtiest? human dog or cat?
human
Generally speaking, how many hours do you have to close a wound?
less than 6 hours from the time of injury
What antibiotic covers staph and anaerobes very well and can be given PO for 3-7 days for the treatment of bites?
augmentin
What are the two major types of bacteria do we consider covering in outpatient cellulitis?
staph and strep
How would you manage community associated MRSA without systemic symptoms?
Without systemic signs: I&D and culture, return in three days if not feeling better
How would you manage community associated MRSA with systemic symptoms?
options: bactrim, doxyminocycline, clindamycin
Clindamycin is sensitive to BOTH staph and _____. So it is a good single agent treatment for cellulitis
strep.
What is the reversal agent for benzodiazapine overdose?
flumazenil
What drug is used in the overdose of tylenol?
N-acetylcycsteine/mucomyst
What type of overdose causes anion gap metabolic acidosis, tinnitus, hyperthiermia, elevated LFTs, and can be treated with dialysis?
ASA overdose
Severe acidosis defined by ACLS is less than___.
7.1
Acidosis and fever cause the oxyhemoglobin dissociation curve to shift to the_____.
right
A shift to the right in the oxyhemaglobin dissociation curve can be caused by:
acidosis
fever
MiOsis is seen in downers (heroin, synthetic opiates). Miosis is:
pupilary cOnstriction
MydriAsis is seen in patients using uppers. Mydriasis means:
pupillary dilAtion
Malignant hyperthermia and seratonin syndrome can both be treated with what drug?
dantrolene
What are signs of organ transplant rejection?
flu-like prodrome and immediate failure of the organ
What do you do if you suspect organ transplant rejection?
treat as transplant rejection until proven otherwise
call transplant service
biopsy the organ
Varicilla (chicken pox) is a live vaccine so patients with _____ cannot get a varicella vaccine.
HIV
Zostavax is a vaccine used for _____.
shingles prophylaxis
If a patient has shingles on the side of the face, it is an emergency because the patient can:
go blind
Two drugs used for the treatment of post herpatic neuralgia pain:
pregabalin (lyrica)
gabapentin
*both cause sleepiness and weight gain
A typical presentation of herpes zoster looks like:
an erruption of vesicles with non-purulant exudate and errythema
This type of keratosis is typically found on sun exposed areas of the body, including inside the ear, on top of the head, rough raised areas, and they are premalignant to squamous cell cancer.
actinic keratosis
This type of carcinoma comes from actinic keratosis so they are usually in sun exposed places, they are firm, irregular papules or nodules, they bleed easily when scratched.
squamous cell cancer
This type of keratosis is NOT premalignant, found on sun exposed and not sunexposed areas of the body, the have a stuck on appearance, brown/black plaques. Require no treatment. You can freeze them off if you want.
suborrheic keratosis
The most common skin cancer. It is slow growing. It has a classic valcano lesion: spider veins, waxy shiny read, central depression.
basal cell carcinoma
highest mortality rate of all skin cancers, can spread anywhere, ABCDE mnemonic applies
malignant melanoma
What is the ABCDE(F) mnemonic for malignant melanoma?
Asymmetry
Boarders, irregular boarders
Color variation
Diameter >6mm
Enlargement
(F)riend (your friend points it out because it may be in a place you don’t see)
Is EEG required for brain death diagnosis?
No, you do not need EEG for braindeath diagnosis
Clinical indicators of brain death:
abscent reflexes
no cranial nerve involvement
apnea
“You aren’t dead until you are warm and dead.”
Brain death means you are dead both functionally and legally.
In end of life care, scopolamine is indicated for____.
management of secretions
In end of life care, morphine is indicated for _________.
tachypnea and respiratory distress
