common problems in acute care Flashcards
acute vs chronic pain
plus or minus 6 months
cutaneous pain
skin
visceral
poorly localized in the organs
somatic
in muscle or soft tissue
neuropathic
nerve pain
step one pain control
asa, tylenol, nsaids, + adjuvants
step two pain control
insitial nsaid plus codeine, oxy or hydro, tramadol (not with asa or tylenol)
step three pain control,
nsaid plus morphene, dilaudid, methadone, fent
break through cancer pain
fent patches
causes of fever non bacterial
autoimmune disease, cns, neoplasm, blood disease, mi, gi disease, endocrine, nms
38.3 =
101.5
nms
antipsychotics, high fever, treat with fluids
treatment of fever
abx when microbe is present, tylenol, treat underlying cause
sux
not used with hyperkalemia
post op fever (non infecitous) leading cause
post op atelectesis, increased metabolic rate, dehydration, drug reactions,
infectious causes of post op fever
- leftshift, band formation lots of immature bands
2. wbc over 30K usually not infection
treatment of post op fever
in abcence of infection, expand lungs and hydrate
headache
chronology is most important history item
tension
most comon, vice like, tx withtylenol, no focal neuro symptoms
migrane
classic with aura- common without aura, related to diation and pulsation of external carotid, female > male, family history often present,
migrane symptoms
unilateral pain, dull or throbbing, lasts for hours, + focal neuro disturbances,
migrane tx
asa + sumatryptan iv or po- 6mg sq and up to three per day vs 25 po
albumin <3.5
malnutrition
albumin <2.7
edema
hgb repletion levels
8/24
need nutritional support for > 6 weeks <6weeks
peg tube ND nasoduedeanl tube if at risk of aspiration
need nutrition but cant use gi tract,
2 weeks or more or dex >10% central line, 2 weeks or less picc
Hyponatremia most common e abnormality determine and treat the cause eval includes
Urine NA- normal is 10-20
serum osmo 2xNA
Clinical status
hyponatremia urine
> 20 renal salt wasting ie a kidney problem
< 10 outside kidney
isotonic or psuedo hyponatremia
284-295 hiigh lipids, no symptoms, cut fat
fluid volume ranges
<280 is dry, 280-294 normal >290 is overloaded
hypernatremia cause and management
low volume
euvolemic
wet
145+ excess water loss,
dry- nss and 1/2 nss
nromal - free water
wet - free water and loop diuretics, may need HD
low K
cause
> 3.5 chronic use of diuretics, alkalosis , gi or renal loss
Low K sx
muscle weakness, constipation or illeus,
flacid paralysis if <2.5 tetany hyperrelfexia and rhabdo
Low K on diagnostics
broad T, low amplitude EKG, prominent U waves, PVC, vtach or fib
Low K treatment
oral if >2.5
IV at 10meq/hr if cant do po
if <2.5 or with sx give 40 IV, check q3, fix the mag. (1.7-2.2)
High K >5 causes
renal failure, nsaids, excess intake, low aldosterone, cell death, acidosis
High K acidosis
ph drops .1 K increase 0.7
High K S and S
weak, facid paralysis
ab distention
diarrhea
labs K>5
peaked T but not all
K>5 management
kayexalate
insulin 10uiv and and 1amp dex if >6.5
normal total ca
2.2-2.6mmol/L or 8.5-10.5mg/dl
normal ionized CA
1.1-1.4mmol/L or 4.5-5.5 mg/dl
if albumin is jacked up
use i calc cause it does not vary with serum albumin 3.4-5.4
50% of ca is bound to albumin so normal ca (2.2-2.6mmol/L or 8.5-10.5mg/dl) with low albumin <3.4
means that ca is high
ca <2.2 or 8.5 causes
hypoparathyroidism low mag >1.7, kidney failure, severe trauma, blood transfusion
management of ca .2.2 or <8.5
check ph looking for alkalosis
if acute IV calcium gluconate
if chronic - vitamin D, oral supplements, aluminum hydroxide,
CA >2.6 or 10.5 causes
hyper thyroid, vitamin D intox, prolonged immobilizaiton, rare with thiazide diuretics.
CA >2.6 or 10.5 S and S
fatigue, muscle weak, depression, aorxia, nausea, and emisis, sever >12 can lead to death. and is a medical emergency
CA >2.6 or 10.5 tx
calcitonin if poor cardiac or renal funciton
HD
if >12 loop diuretics and ns infusion
ca is opposite ie
low ca is up symptoms trusods - sustained carpal pedal spasm, cvostics wink or cheek, hi ca and ur sleepy
Resp acidosis
PH <7.35 and Pco2 >45
ph <7.35 and Pc02 >45 symptoms
sleepy, asteriskis myoclonus, increased csf pressure
Ph <7.35 and Pco2 >45 tx
narcan for pts with no obvious cause, 0.04 to 2mg, intubate or improve ventilation, up vent rate.
Resp alkalosis PH, >7.45 and pco2 <35
anxious, tingling, tetany if severe parastesia
resp alkalosis ph >7.45 and pco2 <35
serum bicarb is low if chronic, renal system wont kick in for a while
tx resp alkalosis,
retain more co2
metabolic acidosis hallmark sign is Bicarb below 22
yup
AG vs NAGM
NA + K - (bicarb+CL)
AG metabolic acidosis
DKA, alcoholic keto, lactic acidosis, drug or chemical reaction
Non anion gap acidosis
diarrhea, illy, renal tubular acidosis, dka recovery
AG metabolic acidosis treatment
fluid restriction, no bicarb repletion for hypoxia or dka, yes bicarb if significant hyperkalemia is present
non gap acidosis tx
common with chronic conditions like renal failure, treat with bicitral 10-30 with meals and hs
metabolic acidosis, high plasma hco3 >26 and Pc02 rarely above 55 (compensatinng) causes
post hypercapnea alkalosis,
ng suction
vomiting and diuretics
metabolic acidosis tx if salene responsive
correct volume deficit with nacl and kcl, discontinue diureticis, h2 blockers for nausea,
metabolic acodisis if cant replete with fluidis
acetazolamide 250-500mg IV every 4-6h
burns categories
1 dry no blisters epidermis only
2 moist blisters beyond epidermis
3 dry, black, down to fat or bone.
measuring extent of burn arm leg thorax front thorax back head perineum genitals
arm 9 leg each 18 thorax front 18 thorax back 18 head 9 perineum genitals 1
lund and broward chart for burns
most common, takes into account total body surface area according to age and area burned.
burns fluid recussitation calc
4ml/kg x tbsa during first 24 hours
burn fluid recussitation general rule
1/2 of all the fluid req during the first 24 hours, should go in within the first 8 hours, then 1/4 and 1/4 over the next 16
burns metabolic acidosis
seen early
burns and potasium
early is high, late is low and can happen up to three days out
burns and when to tube
face burns, singed eyes, dark soot in nares or mouth - indication is laryngeal edema
emergent burn managemnt,
submerge in water, no ice or lotion, wrap in clean dry towel, maintain normal temp 37-37.5 c, pain managemnt, fent and morphen, silvadine is used for abx
refer to burn center if
partial thickness over >10%of surface area, electrical or chemical burns, inhalation injury , third degree in any group.
cellulitus most commmon cause outpatient
group a strep strep pyogenes most common
staph a
other strepg group
abx for bite
augmentin ammox and clavulanate po 3-7days
cellulitis most comon inpatent
gram negs- ecoli, klebs, psudomonas, enterobacter
staph(mrsa)
strep
community associated mrsa
no fever - staph on foot, I&D culture and come backin 3
boil + fever bactrim, doxy or clinda
group a strep
bactrim + beta lactam (pcn, ammox, or keflex)
or doxy/minocycline + ocn, ammox, keflex
clinda works alone,
solid ingestions
syrup of ipacac
gastric lavage in poisoing
lavge to clear then bind with charcole and sorbital to poop it out
ipicac never use
corrosivs, or detergents, emisis will erode esophogaus or lead to
benzo od
use flamozolil
aceytlcystine or acetaminophin or anacin-3 or panadol tox
asymptomatic early
RUQ pain
24hrs in nausea and emisis
hepatotoxiity
acetaminophen intox- tx
emisis for recent vs lavag and charcole
N-acetylcystine or mucomyst with a loading dose po prn
asa tox s and s
nausea, tinnitis, dehydration, hyperthermia, apnea, met acodosis, elevated LFT
asa tox tx
emiss for recent vs levage and activated charcoe
sodium bicarb to correct severe acodosis
insecticide tox (malathion, parathion
blurred vision and miosis
bradycardia
nausea emisis, cramps diarrhea salivation headache confusion
management of insecticide tox (ions)
wash skin charcole, atropine for organophosphate tox
antidepressant tox s and s
confusion, hallicunation, blurred vision, urinary retention,
hypotension, brady, dysrythmias, hypothermia, seizures
antidepressant tox managemtn
admit to ICU is cns or cardiac sx
gastric lavage and activated charcole
sodium bicarb to tx dysrythmias and hold ph
benzo for seizures
serotonin syndrome treatment
dantrium (dantrolene sodium) clonopin to treat rigor, cooling blankets for hyperthermia.
cocain pupils
big
heroin pupils
small
opiate od
narcan, emetics are contirindicated, lavage and charcole,, butorphanol
benzo od s and s
hyporeflexia and sleepy
benzo tx
Flumazenil (romazicon) IV breathing and bp support, gastric levage and activated charcole
BB od s and s
bronchospasm, hypo and brady delerium
BB od
charcole, glucagon, atropine, airway watch
transplant acute rejection
flu like prodrome plus immediate failure of the organ
transplant rejection first priority
call in expert for immediate biopsy of the organ
transplant meds classes
calcineurin inhibitor -tacrolimus or cyclosporine
antimetabolite- azathioprine Imuran or mycohenolate
steroids- prednisone
shingles
erythema and exudate alonge the dermatomal path grouped vesicles,
shingles tx
the ovirs, if eyes involved consult opthomolagist,
post herpetic neuralgia:
gaba, lyrica or neurontin,
actinic keratoses
small patches on sun exposed skin
premalignant- can progress to squamus cell
rough, flesh colored, hyperpigmented
freeze offf
squamous celll
arise out of AK, firm irregular pap or nodule, develop oer a few months
keratotic, scaly bleeeding
tx biopsy and mohs
seborrhec keratoses
benign
not painful
stuck on beigh brown or black
3-20mm in diameter
teatment maye none or liq nitrogen
basal cell ca
most common skin cancer slow growing 1-2cm after years waxy pearly or shiny red centrel depression or rolled edge may have telangietatic vessels
shave punch and surgical excision
malignant melanoma
highest mortality rate
median age at diagnosis is 40
may metastize to any organ
A B C D E
Asymmetyr Border irregulairty Color variation Diameter >6mm Elevation or enlargement
NMS cause, sypmtoms, priority treatment
antipsytotics, crazy high fever, fluids
best earlist lab sign of mal nutrition
pre- albumin 15 to 36 milligrams per deciliter (mg/dL) or 150 to 360 milligrams per liter (mg/L)
prolonged QT electrolyte imbalance
HYPO calcemia
