EM Surg StepUp Flashcards
1st degree burn
epidermis only
2nd degree burn
partial thickness dermal
3rd degree burn
full thickness dermal and maybe deeper
4th degree burn
additional involvement muscle and or bone
electrical shock burn classification
4th degree becuase likely involve mm and bones
when do you need inpatient Tx fo rburns
2nd degree with >10% body surface
3rd degree> 2% body surface
which burns require airway managment
2nd or 3rd with >25% body or involving face
formula for IV fluid resuscitation for burns
LR 4mL x Kg x % body surface burned
half volume in initial 8 hours with remaining half over 16 hours
burn surface area of adult
9% head, each leg, back, trunk
4.5% each arm
1% genitals
what antibiotic is used for burn dressing
topical sulver sulfadiazine or bacitracin
also give tetanus toxoid
infections with burns
pseudomonas, stress ulcers- curlings
complications burns
infection stress ulcers apspiration dehydration ileus renal insufficiency from rhabdomyolysis compartment syndrome epithelial contractures
age group highest risk of drowning
children
what happens with drowning to lungs
decreased compliance, V/P mismatch
shunting
cerebral hypoxia
freshwater drowning
hypotonic fluid absorbed causeing decreased electrolyte concentrations and RBC lysis
salt water drowning
hypertonic fluid draws water from pulm capillaries into alveoli causing pulmonary edema and increased serum electrolyte concentrations
Tx drowning vitim
secure airway resuscitation supp O2 nasogastric tube placement maintenance of body temp
complications drowning
depends on degree and length of hypoxemia and hypothermia
Tx foreign body aspiration
rigid bronchoscopy
comlications of choking
atelectasis, penumonia, lung abscess, hypoxemia
risk factors hypothermia
alcohol
elderly
signs of hypothermia
lethargy, weakness, severe shivering, confusion, dec temp, arrhythmias, hypotension
EKG
J waves, possible vtach or vfib
Tx hypothermia
warm externally
internally warm IV fluids
treat arrythmias
why do patients with severe hypothermia feel really hot before they die
increased blood viscosity
heat exhaustion
weakness HA and sustantial sweating
need hydration
heat stroke
confusion, blurred vision, nausea
little sweating
labs in heat stroke
inc WBC BUN and Cr
Tx for heat stroke
evaporative cooling
benzos for seizures
Tx for snake bite
immobilize and cleanse
need antivenom
signs scorpion bite
severe pain and swelling at site
increased sweating
vomiting
diarrhea
Tx scorpion bite
antivenin, atropine phenobarbital
complications scorpion bite
acute pancreatitis, myocardial toxicity, respiratory paralysis
signs of black widow spider bite
muscle pain and spasms
localized diaphoresis
abdominal pain
autnomic stimulation
Tx black widow spider bite
local wound care, benzos and antivenin
complications black widow spider bite
ileus, CV collapse
hemolytic anemia, DIC, rhabdo
signs of brown recluse bite
increasing pain and possible ulceration and necrosis
Tx brown recluse bite
local wound care and dapsone to prevent necrosis
Tx mammalian bite
saline irrgation, debridement, tetanus and rabies proph
Tx human bite
saline, broad coverage Antibiotic, debridement
how does charcoal work for ingestion
blocks absorption of poisons
repeat every few hours
Tx acetominophen toxicity
N acetylcysteine
Tx for anticholinergic OD
physostigmine
Tx benzo OD
flumenazil
Tx beta blocker OD
glucagon, Ca and insulin
dextrose
Tx CCB OD
glucagon, Ca, insulin and dextrose
Tx cocaine OD
supportive
Tx cyanide toxicityq
nitrates and hydroxocobalamine
Tx dig toxicity
Dig antibodies
Tx heparin toxicity
protamine sulfate
Tx isoniazid neuropathy
vit b6
Tx isopropyl alcohol OD
supportive
Tx methanol OD
ethanol, fomepizole and dialysis
Tx opioid OD
naloxone
pinpoint pupils
Opiate OD
Tx salicylate toxicity
charcoal, dialysis and NaHCO3
Tx sulfonylurea toxicity
octreotide and dextrose
Tx TCA OD
NaHCO3 and diazepam
Tx warfarin toxicity
Vit K and FFP
Tx of acids or alkali
copious irrigation
activated charcoal
Tx ethylene glycol ingestion
ethanol and dialysis
Sx ethylene glycol ingestion
ataxia
hallucination
seizures
sweat breath
Tx of organophosphate (insecticide) poisoning
atropine
pralidoxime
supportive care
Tx iron overload
deferoxamine
Tx lead poisoning
succimer, dimercaprol
EDTA
Tx mercury poisoning
dimercaprol
signs CO poisoning
HA, dizziness, nausea, myalgias
cherry red lips
mental status changes, hypotension
Tx CO poisoning
100% O2
hyperbaric O2
Tx Vfib and Vtach
alternating attempts at electrical and Rx cardioversion
pulseless electrical activity
detectable cardiac conduction with absense of CO
asystole
no cardiac activity
if come upon unresponsive patient with no pulse, next step
CPR 30:2
if come upon unresponsive patient with pulse
next step
1 breath Q 5-6 sec
intubate and ventilate
recheck pulse Q 2 min
order of pharmacology to use in Vfib or pulseless Vtach
epinephrine 1 mg
amiodarone 300mg IV bolus, second is 150 mg
or lidocarine 1-1.5 up to 3 mg/kg
Tx torsades
Mg 1-2 g IV or IO loading dose
protocol for PEA and asystole
CPR 30:2
epinephrine 1 mg Q 3-5 min
consider vasopressin 40 units
common causes of pulseless electrical activity
Hs and Ts Hypovolemia Hypoxia Hyper K hypo K hypothermia hydrogen ions tamponde tension pneumo thrombosis tablets toxin drugs
what gets injured in acceleration decceleration injuries
aortic arch and mesentery
Trauma assessment
ABCs
evaluation head trauma
LOC assessment sensation, motor bowel and bladder pupil responsiveness to light presence skull fracture ICP
image for head trauma
CT
Tx head trauma
maintain perfrusion
decrease high ICP
IV mannitol
hyperventilation
HTN with bradycardia
increased intracranial P
cushing phenomenon
spinal cord trauma
neuro exam
imaging to assess spinal cord trauma
CT and MRI if normal CT with abnormal neurologic exam findings
Tx spinal cord trauma
stabilized, give IV corticosteroids for 24 hours if presenting in initial 8 hours
imaging for neck trauma
cervical XR, CT, carotid doppler US
esophagoduodenoscopy
angiography
bronchoscopy
where is zone 3 in neck trauma
above mandible
where is zone 2 in neck truma
mandible to bottom cricoid
where is zone 1 in neck trauma
below cricoid to clavicles
Tx penetrating abdominal trauma
ex lap
Tx retroperitoneal hematomas
upper abdomen need laparotomy
lower need angiography embolization
high riding prostate on rectal exam
urethral injury
how to determine renal pelvis injury
IV pyelogram IVP
differences of trauma during pregnancy than non pregnant
low CO from IVC compression
decreased risk GI low injury from superior placement of bowel by uterus
trauma during pregnancy increases what
risk of placental abruption
what position to examine trauma pregnant women
left lateral decubitus
bleeding pregnant women from trauma
need to give what after stabilized
RhoGAM
when doing exam for sexual assault
make sure chaperone is present
collect oral vaginal and penile cultures
swan ganz catheter
P right atrium and pulm artery
pulm capillary wedge P
can measure CO and mixed venous O2 saturation and SVR
nonhemolytic febrile transfusion reaction
most common
cytokines generated by cells in transfused blood while in storage
1-6 hours post transfusion get fevers, chills, rigors, malaise
Tx with acetominophen
acute hemolytic blood transfusion reaction
ABO incompatibility
onset during transfusion with fever, chills, nausea flushin, tachy, hypotension, hemolysis of donor RBCs
need aggressive supportive care
delayed hemolytic transfusion reaction
Ab to Kidd or D (Rh) Ag
2-10 days post transfusion
slight fever, falling H/H
mild inc in uncong bili
Anaphylactic blood transfusion reaction
anti IgA IgG ab in those with IgA deficiency
cause mast cell degranulation
need epinephrine, volume maintenance and airway control
urticaria from transfusion
from plasma in donor blood
Tx with benadryl
post blood transfusion purpura
thrombocytopenia 5-10 days post transfusion
usually in women sensitized by pregnancy
Tx with IVIG and plasmapheresis
when to give FFP
warfarin OD
clotting factor deficiency
DIC
TTP
when to give cryoprecipitate
smaller volume FFP
when to give packed RBCs
low Hct from blood loss or anemia
when is whole blood used
massive transfusions for severe blood loss
what is given in transfusion reactions to prevent hemolytic debris from clogging vessels
mannitol or bicarb
Vasopresors used in EM for
cases shock and insufficient CO
indication to give phenylephrine
sepsis or shock need to increase BP
when to give norepi
shock, causes vasoconstriction and increased contractility
when to give epi
anaphylactic shoc
septic shock
post bypass hypotension
causes increased contractility, vasodilation at low dose and vasoconstriction at high dose
when to give dopamine
shock
increased HR and contractility
causes vasoconstricion at high dose
when to give dobutamine
CHF and cardiogenic shock
effects dobutamine
increased HR and contractility
mild reflex vasodilation
when to give isoproterenol
contractility stimulant for arrest
wheredoes isoporternol work
B1 and 2 agonist
when to give vasopressin
resistent septic shock
causes vasoconstriction
when should one stop smoking before surgery
8 weeks out
COPD with crackles needs surgery
give preop antibiotics
when to order preop CXR
> 50 years old
Hx pulmonary disease
anticipated surgical time >3 hours
patient with renal insufficiency needs surgery with contrast
give N acetylcysteine to prevent damage
when to stop warfarin before surgery
3-4 days out with INR kept
which meds decrease risk postop thromboembolism
warfarin, heparin and LMWH
epidural catheter, when do you start LMWH
more than 2 hours after removal of epidural catheter
fever on postop day 3
pneumonia or UTI
fever on post op day 5-8
wound or IV catheter infection
any postop fever should be evaluated with
CXR, CBC, UA
post op fevers
Wind Water Wound Walking Wonder drugs
is atelectasis a cause of postop fever
not anymore
clean contaminated wound
GI or respiratory entry
contaminated wound
gross contact of wound with GI or GU contents
dirty wound
established infection before incision
continued infection following procedure including debridement
secondary infection
wound left open and allowed to heal through epithelialization
delayed primary closure
left open for a few days then cleaned again before closed
how long do closed wounds require dressings
48 hours after closure
what can inhibit wound healing
malnutrition corticosteroids smoking hepatic or renal failure DM
abdominal pain out of proportion to exam
mesenteric ischemia
what can induce malingnat hyperthermia
halothane or succinylcholine
Sx of malignant hyperthermia
rigidity
cyanosis
tachycardia
rising body temp
uncontrolled hyperthermia can cause
arrhythmias, DIC, acidosis, cerebral dysfunction and electrolyte abnormalities
labs of malignant hyperthermia
mixed acidosis acutely
abnormal increase in muscle conraction
Tx for malignant hyperthermia
evaporative cooling cold inhaled O2 cold GI lavage cool IV fluids dantrolene stop offending agent
most common organ transplant
renal
HLA Ag matching is most important for what transplants
kidney and pancreas
when to do bone marrow transplant
aplastic anemia induction chemo leukemia lymphoma hematopoietic disorders
when to do heart transplant
severe heart disease with estimated death within 2 year
Contraindication to heart transplant
pulm HTN and smoking in prior 6 mo
renal insufficiency
COPD
>70 years old
when to do lung transplant
COPD, primary pulm HTN, CF
CI to lung transplant
smoking in prior 6 mo
poor cardaic function
renal or hepatic insufficiency
terminal illness
when to do liver transplant
chronic hep B or C
PBC PSC, biliary atresia, wilsons
when to do renal transplant
ESRD requiring dialysis
when to do pancreatic transplant
DM I with renal failure
CI to pancreatic transplant
age >60 CAD PVD obesity DM II
hyperacute transplant rejection
initial 24 hours
caused by antidonor Ab in recipient
how to avoid hyperacute transplant rejection
crossmatching blood
acute transplant rejection
6 days to 1 year
from antidonor T cell proliferation in recipient
Tx acute transplant rejection
immunosuppressive agents
chronic transplant rejection
over a year later
develop multiple cellular and humoral immune reactions to donor tissue
what meds are used in early transplant rejection
murmonab-D3 which inhibits T cell function and depletes population
antithymocyt globulin which depletes T cell population
what drugs are used in chronic graft vs host
hydroxychloroquine
thalidomide
how dose hydroxychloroquine work and adverse effect
inhibits Ag processing
cause visual disturbances
how dose thalidomide work and adverse effect
inhibit T cell function and migration
sedation, constipation and teratogenic
how does cyclosporine work and adverse effect
helper T cel inhibition
can cause nephrotoxicity and HTN
how does azathioprine work and adverse effect
inhibits T cell proliferation
can cause leukopenia
how does tacrolimus work and adverse effect
inhibits T cell function
can cause nephrotoxicity and neurotoxicity
what is graft vs host
reaction donor immune cells to host cells
risk factors for graft vs host
HLA Ag mismatch
old age
donor-host gender disparity
immunosuppresion
signs graft vs host
maculopapular rash, abdominal pain, n/v/d
recurrent infections and easy bleeding
labs in GVH
inc LFTs
dec Ig
dec plaelets
Tx GVH
corticosteroids, tacrolimus, nycophenolate to decrease graft response
thalidomide and hydroxychloroquine for chronic
