EMED 2 Flashcards
Define Mental Status
Define Delerium
Clinical state of emotional and intellectual function
Transient disorder of impaired attention and cognition w/ difficulty shifting/maintaining attention
Define Dementia
Define Coma
Failure of content portion of consciousness w/ preserved alerting functions
Failure of arousal and content functions
Define the pathophysiologies for delirium
Wide neuron/transmitter dysfunction due to:
Priary intracranial dz (bleed mass stroke)
Systemic dz (pyelonephritis UTI sepsis)
Exogenous toxin (drug poison)
Withdrawal (DTs opiates)
What are the two etiologies of dementia
What causes a stroke?
Idiopathic- Alzheimer’s
Vascular- cerebrovascular dz w/ multiple/repeat infarction
Deficiency of glucose/O2 supply
What are the different coma etiology categories?
Uncal: medial lobe pushes on brain stem/CN3= ipsilateral pupil dilation, hemiparesis
Central herniaion: cerebral edema of increased ICP causing LoC, loss of brain stem reflexes, decorticate posture, irregular RR
Inc ICP- >15mmHg decreases perfusion leading to ischemia
Define Kellie-Monroe doctrine
What is the equation
Increase of one fluid within the brain should cause reciprocal decrease of the other two pressures
CPP= MAP - ICP
How long does it take for delirium to develop?
How does it present
Hours to days
Altered thinking, memory and perception
Outbursts Hallucinations HTN Asterexis Tachy Sweat Somnolence/Sun downing
How long does it take for dementia to develop?
Define the characteristic Alzheimer’s onset
Slow and insidious onset of hallucinations, repetitive behavior, delusion/depression
Impaired memory/orientation w/ preserved speech/motor ability
What are the two categories of dementia?
How does each present
Idiopathic, forgetfulness of-
Early: items, names
Mid: direction reading social
Sev: personality self-care disorientation
Vascular:
Gait abnormality
Extremity weakness
DTRs exaggerated/asymmetric
What are the 3 causes of comas
Diffuse- toxic/metabolic
Small reactive pupils, no PE findings
Focal- structural coma
Supratentorial (uncle)- HTN, bradycardia, WPP
Infratentorial- abrupt coma, extensor posture, no pupil reflex/EOMs
Pseudo- faker won’t look at you
+nystagmus w/ caloric test
How is delirium Dx
What labs are ordered
What rads are ordered
Hx PE Medication consolidaiton
CBC LP UA E+ HR function
CXR Head CT
How is dementia Dx?
What labs are ordered?
What rads are ordered?
Hx PE
LCC STUB CHEF
CT MRI
How is GCS measured
How does opiate syndrome coma present
Motor: FLWFEN
Verbal: OCIIN
Eye: SCPN
Hypoventilation
Small pupils
How does cholinergic syndrome coma present?
Asymmetric PE findings in coma PTs means?
Extensor/flexor posturing indicates?
Miosis Lacrimation Seizure
Focal CNS lesion
CNS dysfunction
What is the imaging modality of choice for AMS?
How is delirium PTs managed?
Non-contrast CT
Tx underlying issue
Haldol/Benzo w/ capnography
B52- Benadryl, Ativan, Haldol
What is the disposition for delirium, dementia, coma?
What are the causes of delirium in elderly PTs
Reversible can be d/c
Admit all others
Pneumonia UTI Sepsis Skin infxn Metabolic/toxin Drugs Infection Neuro Cardiopulm
What are the DDx for coma
Alcohol Acidosis Arrhythmia Endocrine E+ Encephalopathy Infection O2 OD Opiates Uremia Trauma Temp Thiamine Insulin Poison Psych Stroke Seizure Space lesion Shunt malfunction
DDx for delirium
DDx for dementia
Non-convulsive/complex partial status epilepticus
Hypothyroid UTI CHF- mild but functional dementia
PT w/ seizure Hx hasn’t woken up after 30min since seizure stopped needs to have ? DDx considered
What is the 5th MC Sx seen in the ED?
Non-convulsive status epilepticus
HAs
Primary HAs include?
Secondary HAs include?
Migraine Cluster
Tumor Meningitis SAH
HA onset during exertion needs to have ? two Dxs considered
HA associated w/ valsalva indicates ? issue?
SAH
Arterial dissection of carotid or vertebrobasilar circulation
Intracranial abnormality
? PT population w/ new or worsening HA is high risk
Why is this risk present?
> 50y/o w/ new or worsening HAs
Migraine, cluster, and tension HAs decrease w/ age
PTs on what three classes of meds are at increase risk for hemorrhage and automatically get CT scan?
Anticoagulants
Antiplatelets
ABX
Define Reversible Cerebral Vasoconstriction Syndrome
Why does this occur
Coke/Meth/Amphetamine use increases risk for hemorrhage
Vasospasm and ischemia affects smooth muscles
? renal dz causes PTs to be at risk for intracranial aneurysm
What PE finding indicates an infection or brain hemorrhage?
What PE exam needs to be done?
PolyKDz
Meningismus
ENT for OM and sinusitis
? eye issues can present as HA?
Intraocular pressure above ? is abnormal
Scleritis
Enophthalmitis
Acute ACG
> 21
If PT is high risk, what labs are drawn for HAs?
What form of imaging is done for these PTs
BMP ESR
CBC Coags Culture CSF
NCHCT regardless of Sxs
MRI- arterial dz
What can be diagnostic and therapeutic for HAs?
What part of this is critical?
LP
Opening pressure
When can an LP be down w/out prior imaging?
When do HA PTs need to be d/c w/ follow up plans
No ImmSupp,
No focal neuro deficit and,
Normal sensorium
High risk- GCA, IIHTN
Chronic HAs
What is the classic presentation of meningitis
When can the head CT be delayed until after LP for these PTs
HA (MC) + Triad: fever (2nd MC) AMS stiff neck
Awake/alert
No papilledema, focal neuro deficit, ImmComp or new onset seizure
What are the common pathogens of bacterial meningitis
Where are these pathogens found?
Strep pneumo GBS N meningitidis H influenza L monocytogenes
SP: penetrating head trauma NM: dorm, barracks HI: unvaccinated LM: alcoholics Staph A/Strep: post-craniotomy
How is bacterial meningitis Tx
ABCs, labs, cultures Empiric ABX w/ Dexameth during 1st dose Non contrast CT LP Admit w/ droplet isolation
Why are SAHs so dangerous?
75% of SAHs are caused by ?
50% have 30 day survival rate
Ruptured aneurysm
What are the SAH RFs in the AD/Ret population
What is the first step for suspected SAHs
FamHx Alcohol Smoking HTN
Non contrast CT
Sens best after Sx onset
Spec best 6-12hrs later
What is the next step for suspected SAH if CT is negative?
Why is this next step so important?
LP for RBCs or xanthochromia
Normal CT, no xanthochromia/RBCs= SAH exclusion
When are SAH PTs at the highest risk for re-bleeds?
How is this risk window reduced?
What meds need to be avoided?
First 24hrs
BP control- Labetalol/Nicardipine
Nitroprusside
Nitroglycerine
How are all SAH PTs managed?
What PT populations are at risk for non-traumatic intracranial hemorrhage?
Neurosurgery consult
Admit to ICU
Elderly
Alcoholic/drug abuse
Anti-platelet/coagulant
PTs presenting w/ ? Sx duo have cerebellar hemorrhage until proven otherwise?
How do brain tumors cause HAs
Acute HA
Vestibular Sxs- vertigo/ataxia
CSF flow obstruction
Intracranial HTN
What PE findings suggest brain tumor
What is the preferred imaging modality?
Abnormal neuro exam Worse w/ valsalva Mental status change Awakes from sleep Recent Ca Dx Seizures
MRI w/out gadolinium
Non contrast CT is used, but misses small mass
Cerebral venous thrombosis is suspected when PTs present w/ HA and ? Sxs
If PT has abnormal CT, focal neuro deficit or AMS, what is the definitive way to Dx cerebral venous thrombosis
Female
Hypercoagulable
Peripartum
Recent SurgHx
MR venography
What PE finding should prompt suspicion of cerebral venous thrombosis
How does Posterior Reversible Encephalopathy
Syndrome present?
Who does this occur more often in?
Inc opening LP pressure
Severe HA
Visual changes
Seizure
Encephalopathy
ImmSupp
Chemo PTs
ESRenal Dz
What is the imaging modality for Posterior Reversible Encephalopathy
Syndrome
How is it Tx
When is this Dx considered
MRI
CT will be normal
BP management
Thunderclap HA and SAH is r/o
What is the characteristic of Posterior Reversible Encephalopathy
Syndrome etiology?
How do PTs w/ GCA present
What needs to be measured and r/o
Cerebral vasospasm from cocaine/amphetamines
>50y/o Fatigue Fever Proximal muscle weakness Jaw claudication Transient vision loss
IOP to r/o glaucoma
How is Temporal Arteritis Dx
How is Temporal Arteritis Tx
3 of: \+50y/o New HA Abnormal artery/biopsy ESR >50mm
Prednisone 60mg PO
Consult w/ Rheum/Ophthal
What are the MC auras to occur w/ migraines
What med is used as first line abortive therapy?
How are these initially Tx?
Scotoma- light headed
Scintillations- vision changes
Triptans
IV hydration NSAIDs anti-emetic/histamine
Steroids to reduce re-occurrence after d/c
What meds can and cannot be used for migraine Tx during pregnancy
Triptans, Ergotamines (caffeine/isometheptene combo)- c/i
Acetaminophen, Opioids, CCS Metoclopramide- ok
NSAIDs until 3rd-T
What needs to be given to migraine PTs upon d/c?
II-HTN is AKA and is MC in ?
Abortive meds
Pseudotumor Cerebri
Obese women 20-44y/o
What are the prominent Sxs of II-HTN?
Why does this Dx need to be ID’d fast?
HA
Transient visual obscurations
Back pain
Pulsatile tinnitus
Permanent visual impairment
What is the Dx criteria for II-HTN
What is necessary to complete/confirm Dx
Papilledema w/ normal neuro exam
Inc opening pressure on LP (>25mm)
Normal CSF, images
LP- can be Dx and Thx
How is II-HTN Dx if there is no papilledema or abducens palsy?
What medication can be used to help lower ICP for these PTs?
Need 3 of: Empty sella Flat posterior globe Distended perioptic subarachnoid space Transverse venous sinus stenosis
Acetazolamide
What criteria needs to be met in order to Dx cluster HAs
What is the first line Tx for cluster HAs?
5 attacks that are:
Severe Unilateral 15-180min and Circadian w/ one ipsilateral:
Ptosis Edema Miosis Congestion Injection Lacrimatoin
100% O2 12L/min NRB
Sumatriptan
Define Stroke
What are the 3 categories and types of stroke
Dz process that interrupts blood/substrate flow
Injury causing edema/mass effects to brain
Ischemic- thrombotic hypoperfusion embolic
Hemorrhagic- intracerebral subarachnoid
What is the mechanism of thrombotic strokes?
What are these a common cause of?
Narrowing of damaged lumen by in situ process (clot formation)
Gradual waxing/waning Sxs
Common cause of TIAs
What is the mechanism of embolic strokes?
How do these present and what do they account for?
Obstruction of normal lumen by material from remote source
Sudden onset, 20% of ischemic strokes
What is the mechanism of hypoperfusion strokes?
How do these present
Low blood flow
Injury to water shed areas w/ wax/wane Sxs
What is the mechanism of hemorrhagic strokes?
Where are these more common?
Intraparenchymal hemorrhage from weakened arterioles
Inc ICP causes damage, constriction changes perfusion
Asians/Africans
What is the mechanism of non-traumatic subarachnoid strokes?
How are these types of strokes foreshadowed?
Hemorrhage into subarachnoid space
Preceded by sentinal HA (warning leak)
What are the general Sxs of strokes?
What is used to grade the PTs Sxs
General: Facial droop Arm drift Abnormal speech
Subtle: weak, light headed, vague sensory changes
Cincinnati pre-hospital scale
Traditional stroke Sx women present with?
Non-traditional Sx they present w/ ?
What is an odd non-traditional Sx
AMS
General weakness
Hiccups
Embolic/hemorrhagic strokes present as?
Thrombotic/hypoperfusion strokes present as ?
? type of stroke is suspected when HA w/ valsalva or lifting?
Sudden onset Sxs
Wax/wane Sxs
Stuttering
Cerebral aneurysm rupture
? type of injury can present after neck trauma or manipulation?
RFs for thrombus stroke and how it will be seen on PE
Cervical artery dissection
HTN DM Atherosclerosis
Transient neuro deficits in SAME vascular distribution
RFs for embolus stroke and what will be seen on PE
When are stroke Sx onset calculated?
A-fib
Valve replacement
Recent MI
Transient neuro deficits in DIFFERENT vascular distributions
Time of last known baseline/normal
Inclusion criteria for rtPA during strokes?
Measureable Dx: >22 poor
Sx onset <3hrs
18 or older
Exclusion criteria for rtPA use during strokes?
Head trauma/stroke <3mon SAH Sxs Arterial puncture <7days Hx ICH Intracranial Ca/AV-mal/aneurysm Cranial/spine surgery recent Active internal bleeds Platelets <100K Heparin use <48hrs and prolonged aPTT INR >1.7 PTT >15s Current direct thrombin inhibitor/Factor Xa use Glucose <50 CT shows multi-lobular infarct
What is done during a PE for stroke
How many categories are in NIHSS scale and what is the score range
ABCs
Confirm/exclude immitators
ID comorbidity
Evaluate cardiac/vascular dzs
11 categories 0-42pts <4= minor 5-15= mod 16-20= mod to sev \+21= sev stroke
What vessel is MC involved in ischemic strokes?
How do these strokes present?
Mid cerebral artery infarction
Hemiparesis
Facial plegia (Face>LE)
Contralateral sensory loss
What is the difference in MCA infarctions if it affects dominant or non-dominant side?
What will be seen regardless of hemisphere involvement?
Dom: aphasia
Non-dom: neglect apraxia dysarthria inattention
Homonymous hemianopsia and gaze preference TOWARD infarcted side
How do posterior cerebral artery infarct present?
What are common presenting sxs?
Classic: ataxia nystagmus AMS and vertigo
Ipsilateral CN deficits
Contralateral motor weakness
Dizzy HA Dysarthria Visual field deficit Unilateral limb weakness Gait ataxia CN7 signs Lethargy Sensory deficit
What PE finding is specific for distal posterior circulation stroke?
What other Sxs may be seen?
Contralateral homonymous hemianopsia and unilateral cortical blindness
CN3 palsy
Hemiballismus
How do basilar artery infarcts present
Unilateral limb weakness Dizzy Dysarthria Diplopia HA
MC: Unilateral limb weakness CN7 Sxs Dysarthria Babinski
What unique PE finding can be seen in basilar artery infarction?
Why is this finding dangerous?
Locked in syndrome from bilateral pontine ischemia
High risk of death
Define Lacunar infarction
What can cause these?
Why would this type of stroke be preferred?
Pure motor/sensory deficit from infarction of small arteries
Chronic HTN
Inc age
More favorable prognosis
What are the RFs for carotid/vertebral artery dissection
What is the first presenting Sx?
If PT has new onset HA/neck pain of unclear etiology, what imaging is ordered?
Judy chop
Chiropractor
Unilateral HA in frontotemporal region
CT angiogram of neck vessels
What PE finding may be seen if PT has carotid artery dissection
What type of HA is localized to occipital area
Partial Horner’s
Vertebral artery dissection
What imaging modalities are preferred for carotid/vertebral artery dissections
What types of strokes have higher MnM
CT angiography followed by MRA
Intracerebral
What Sxs usually precede neurological deficits during intracerebral hemorrhages?
What imaging is used to differentiate between hemorrhage and ischemic strokes?
HA, N/V
NCHCT
How are cerebellar hemorrhages Dx on images?
How what are the S/Sxs of SAH strokes
NCHCT but has low sensitivity
MRI w/ diffusion weighted images
Occipital/nuchal HA w/ recent onset of max intensity HA
What is the time frame from presentation to imaging and Tx decision for stroke PTs
How is a stroke Dx?
Image: <20min
Dx/Tx: 60min from PTs arrival
EMS Code team H/P Inclusion/exclusion criteria CT
When are stroke CTs interpreted?
What is the only imaging study necessary prior to giving rtPA?
W/in 45min of arrival by radiologist>neurologist or ASAP after completion
NCHCT
How are ischemic strokes Tx
If PT is not candidate for thrombolytics or reperfusion, how are they managed?
Fluids
Maintain SPo2 >94%
IV acetaminophen
Maintain glucose 140-180
Permissive HTN, don’t lower unless:
BP >220/>120
Condition reqs lower BP
Reduce x 10-20% in first 24hrs
What is the BP goal for stroke PTs that are reperfusion candidates?
What if this goal can’t be met?
<185/110
No longer candidate for rtPA therapy
? metabolic condition is common in acute strokes?
NIHSS score of ? is commonly used as criteria for rtPA therapy
Hyperglycemia from release of cortisol/NorEpi
4-22
? lab result is required prior to administering rtPA?
Why are TIAs such a big deal?
Glucose
1/3 of PTs will have stroke in 30 days
How are TIA Dx scored
ABCD2 Age 60+ BP >140/90 Clinical features Duration DM
How are TIAs Tx
What is the MC cause of ischemic stroke in kids
How is this MC cause Tx
ASA
ASA + Dipyridamole
Warfarin if no Afib
Sickle cell
O2
When are pregnant PTs at highest risk for all types of strokes?
Can you use rtPA during pregnancy?
6wk post-partum
Yes, doesn’t cross placenta
What is the MC precipitating factor to a seizure?
What presenting PE findings suggest a previously unwitness/unrecognized seizure
Missed dose of anti-epileptic
Unexplained injury
Nocturnal tongue biting
Enuresis
Seizure PT w/ persistent/severe HA suggests?
What does a PE for suspected seizure include?
What are 3 common post-seizure sequelaes?
Intracranial pathology
VS
POC glucose
Head/spine assessment
Post shoulder dislocation
Tongue lac/dental fx/pulmonary aspiration
Define Todd’s Paralysis
What needs to be monitored closely in PTs post-seizure?
Transient focal deficit, usually unilateral, following simple/complex focal seizures
Resolve in 48hrs
Loc/mentation to avoid missing non-convulsant status epilepticus
Most seizures are followed by period of postictal confusion or lethargy except for ?
Syncope presents w/ ? prodome Sx
Simple absence
Simple partial seizure
Light headed
Diaphoresis
Nausea
Tunnel vision
? form of syncope has no prodrome?
What are the characteristic movements of pseudoseizures?
What are two uncommon events
Cardiac
Side to side head thrash
Rhythmic pelvic thrusts
Clonic extremity motions that alternate
Incontinence
Injury
What lab result proves pseudoseizure and an actual seizure was less likely?
What are the only two labs needed to be drawn for a PT w/ known epilepsy Hx
What labs are drawn for a first seizure
No lactic acidosis
No elevated prolactin
Glucose
Anti-convulsant med levels
Glucose BMP Lactate Ca+ Mg hCG Toxicology
Seizures can cause the body to acquire ? metabolic state?
What is the first imaging ordered for first time seizure?
What other images may be considered?
Lactate driven wide anion gap metabolic acidosis
CT to r/o structural lesion
Head/neck CT
CXR
Shoulder x-rays
When would an LP be ordered for a seizure PT
If the rare/odd PT needs an EEG in the ER, what is the f/u fate of this PT?
Febrile
ImmComp
SAH suspected w/ normal NCHCT
Admit w/ neuro consult
What steps are taken for PT protection during seizure?
What is the time limit of concern?
Protect
Roll on side
> 5min= more interventions
Considered status epilepticus
How are PTs managed after their first unprovoked seizure?
How are PTs managed after provoked seizure d/t an identifiable underlying cause?
As long as PT returns to baseline, do not:
Admit
Initiate anticonvulsant meds
Safe to d/c
Admit and medicated
How are HIV PTs that have a seizure managed?
NCHCT shows now lesions,
No evidence of inc ICP,
do LP
No explanations= contrast CT/MRI
When are pregnancy related seizures Dx as eclampsia?
How are these seizures Tx?
> 20wks w/ HTN, edema, proteinuria
MgSulfate
How are alcohol withdrawal seizures managed?
What is the criteria for Status Epilepticus
Benzos
Single seizure lasting 5m or more
2 or more seizures w/out recovery of consciousness
What short acting paralytic is used to intubate these PTs and which one is avoided?
What type of fluid is used and what anti-epileptic drug is d/t this fluid administration
Succinylcholine
Not Rocuronium
NS
Phenytoin, not compatible w/ glucose solutions
What serial monitoring occurs in Status Epilepticus Pts afte paralytic agents are administered?
What Dx lab test is avoided in status epilepticus PTs
What transient lab result may be seen?
EEG
LPs
Peripheral leuckocytosis
Mild CSF pleocytosis
What drugs are most often used during status epilepticus
What two drugs may be given by neurologist for d/c PTs
IV Lorazepam- first choice
Fos/Phenytoin
Levetiracetam
Lacosamide
What is the criteria for refractory status epilepticus
What 3 drugs may be pushed at this time?
Persistent seizure activity despite two antiepileptic agents and
Exceeds 60min
1st: Propofol
2nd: Midazolam
3rd: Barbitals, Ketamine
Define Syncope
This can be due to lack of circulation supplying ? parts of the brain?
Brief LoC w/ inability to maintain postural tone that spontaneously resolves w/out medical intervention
Cerebral cortices
Brainstem
How are cerebral perfusion and consciousness restored after a syncope?
What is the MC cause
Supine
Autonomic autoregulation
Perfusing cardiac rhythm
Vasovagal (reflex mediated)
Of all the causes of syncope, what is the only one that has no increased risk of death when compared to GenPop?
What 4 cardiac conditions can lead to cardiac syncope?
Vasovagal
Hypertrophic myopathy- MC
Aortic stenosis
PE
MI
When do situational syncope tend to occur?
How does carotid sinus hypersensitivity present?
Micturition
Coughing
Defecation
Swallowing
Brady or HOTN
MC- abdominal vagal response causing brady and asystole >3seconds
Less common- vasodepressor response- BP dec >50mm
When is carotid sinus hypersensitivity considered as a Dx?
What two psych d/os are associated w/ psychiatric syncope?
Older PTs w/ recurrent syncope and negative cardiac evals
General anxiety
MDD
Define Subclavian Steal Syndrome
What will be seen on PE?
Abnormal narrowing of subclavian artery proximal to vertebral artery origin, MC on L side
Dec pulse volume/BP on affected arm
What medications are the MC cause of orthostasis?
What meds have pro-arrhythmic properties?
BBs/CCBs- dec HR response
Diuretics- deplete volume
Anti fungal
Anti emetics
ABX
What type of syncope prodrome Sxs are concerns for immediate life threatening Dx
What type of presentation indicates cardiac dysrhythmia or structural lesion?
Chest pain
HA
Abd pain
Palpitations
Sudden w/out warning
Associated w/ exertion
SAH
What Dx is the MC event mistake as a syncope
? type of PT presentation indicates a sudden event w/out warning?
Seizure
Trauma w/out defensive injuries
Post-syncope PE needs to focus on what two thing?
What assessment must be done for these PTs?
Cardio
Neuro
BP on both arms
What steps are done to Dx orthostatic HOTN
What two EKG findings are linked w/ higher morbidity?
Dec of SBP >20mm
SBP <90 w/ Sxs
New LBBB
Non-sinus rhythms
What is the only lab needed to be ordered for syncope?
What lab result is predictive for PTs w/ higher risk of morbidity
hCG
BNP
When are CT/MRI images not needed in syncope PTs
What is the disposition for PTs that had cardiac/neurological syncope?
ASx w/ isolate event w/out head trauma
Admit
What are the first Dxs considered in pregnant women w/ syncope?
DKA usually occurs in ? types
Ectopic pregnancy
PE
DMT-1
Newly Dx DMT-2 AfAm/Hispanics
What is the process leading to DKA?
What hormones are involved in this process?
Cellular starvation due to insulin deficiency and counter-regulatory response
Glucagon GH
Catecholamines Cortisol
What metabolic issues develop during DKA
Clinical manifestations of DKA are directly related to ?
Hyperglycemia Osmotic diuresis Prerenal azotemia Ketones Wide gap acidosis
Hyperglycemia
Acidosis
Volume depleion
What are the 3 Ps of DKA
Why do these PTs experience N/V?
Polydipsia Polyuria Polyphagia
Prostaglandins
Why do DKA PTs have AMS?
? PE finding correlates to the level of acidosis?
Inc serum osmolality
Abd pain/tenderness
How is DKA Dx
DDx for DKA
pH <7.3 Ketonuria/emia BiCarb <15 Anion gap >10 Glucose >250
Renal failure Alcholic ketoacidosis Ingestion (salicylate ethylene methanol) Lactic acidosis Starvation
What labs are ordered for DKA PTs
What is the goal and sequence of Tx
Glucose VBG CBC CMP Anion gap ABG if critical
Fluid repletion w/ NS, 20mL/kg/hr for first hr
Correct K+
Insulin
What serial monitoring occurs on DKA PTs during treatment effort?
What are the criteria for a DKA PT to be ‘treated’?
MS Out/INs VS E
Glucose <200 and 2:
BiCarb 18 or higher
pH >7.3
Normal anion gap
When is Dextrose added to DKA Tx regime
What adverse outcome can develop if too much fluid is pushed too quickly in these PTs?
250mg, 5%D in 0.45%NS
ARDS
Cerebral edema
What is the most life threatening part of DKA?
Severe HypoK
Tx sequence for DKA if K is >3.3-<5.2
Tx sequence if K+ is <3.3
Tx sequence if K+ is >5.2
Fluids, K+, Insulin
Fluid K, no insulin
Fluid, no K, insulin
What is the disposition for DKA PTs
DKA is the leading cause of death in ?
ICU if critical
Gen/Med surg if AG <25/glucose <600 and no comorbidity
Fetus
What is unique about DKA in pregnancy?
What two Sxs can precede and episode of DKA?
Triggered at lower sugar levels
Vomit/UTI
What is used for prognostic indicator in PTs w/ sepsis?
What has this traditionally bee attributed to
Serum lactate
Failure to red x 10% in first hrs, higher mortality
Anaerobic metabolism secondary to tissue hypoperfusion
What are the two events that occur during sepsis
What series of Sxs are hints for sepsis
Abnormal inflammatory response
Imbalanced pro/anticoagulants= DIC
Fever HOTN and/or tachy
What type of shock is sepsis
What sequelae injury is common during sepsis
What findings hint towards this issue
Distributive
Acute lung injury- ARDS
AKI- azotemia, a/oliguria
Refractory hypoxemia
Non-compliant lungs w/ mechanical ventilation
CXR showing bilateral infiltrates
What is the MC live abnormality to occur due to sepsis
What is the MC GI manifestation of sepsis
Cholestatic jaundice
Ileus
What can develop as a result of DIC in sepsis
What skin presentation can indicate sepsis
Thrombocytopenia
Erysipelas
How is sepsis Dx in ER?
What is the only accurate method to get temp in septic PT?
SBP <90 after fluids
Evidenced poor perfusion
Rectal Temps
What is the last Sx to present in Peds w/ sepsis
What are the 3 cornerstones of sepsis Tx
HOTN
Early recognition
Reversal of hemodynamics
Early infection control
Sepsis rescuscitation efforts are based on ? 3 things
The goals of Tx are to improve ? 3 things
Fluids
Adjunct therapies
Response
Preload
Perfusion
O2 delivery
How is sepsis Tx
What is the next step if PTs are not responding to this first Tx step
What is added to Tx w/in ?time frame
Cyrstalloid bolus 20mg/kg
NorEpi/Epi
Vasopressin
ABX w/in 1hr or 3hrs of triage
Anaphylaxis is a ? dependent process
Anaphylaxis is a more severe/end result of ?
IgE
Hypersensitivity
What are the MC provoking factors of anaphylaxis reactions
Anaphylaxis starts with the activation of ?
What substances are released
Foods
Meds
Stings
Injections
Mast cells, Basophils
Histamine
Tryptase
Carboxy A
Proteoglycans
What is the sequence of events during an anaphylaxis reaction
Allergen igE forms IgE and mast cells link Release of THCP Dilation/inc permeability Inc HR, contraction, glandular secretion
Classic presentation of anaphylaxis includes ? 3
What presenting Sx is indicator of life threatening issue
Pruritis Urticaria Flushing
Lump in throat
Hoarseness
How fast do anaphylaxis Sxs present
When are these PTs at risk for recurrence?
<60min
Faster Sxs= worse reaction
3-4hrs later, peaks 8-11hrs later
How is anaphylaxis Tx
What is used in PTs on BBs and have anaphylaxis?
ABCs
IV access w/ crystalloids
O2 therapy
IM Epi q5-10min
Glucagon reverses BB
What are the 5 second line therapies for anaphylaxis Tx
What are PTs dispositions after Tx
CCS Antihistamine- Diphen/Ranitidine Vasopressors Glucagon B2 bronchodilators
ASx x 6hrs= d/c
Bees/wasps belong to ? group
What is the MC response to one of these stings?
Hymenoptera
Transient local reaction, spontaneously resolves from 15m-6hrs
What is the important principle of Hymenoptera stings
What meds can be used for Sx relief
Immediate removal
Wash w/ soap and water
CCS
Antihistamines
NSAIDs
How is Hymenoptera anaphylaxis Tx
What are these PTs d/c home w/?
Antihistamines/CCS
Crystalloids
Epi
Steroid Antihistamine
Epi Pen
How do Loxoscele bites present
What med is used for Tx
What follow on Tx is needed
Recluse- red white blue sign
Dapsone
Skin grafts after necrosis heals into schar
Black Widows belong to ? class
What is the most active component of it’s venom and what does this component cause to be released
Lactrodectus
A-lactrotoxin-
Ach- neuromuscular manifestations
NorEpi- cardiac manifestation
What is the difference between the brown recluse and black widow bite
How are BW bites Tx
Brown- painless
Black- pinprick, abdominal wall cramping, HTN, tachy
IV Ca+
Opioids/benzos
Antivenom
What type of scorpion can cause systemic toxicity
What happens in the body if stung?
C sculpturatus- Bark scorpion
Opens Na channels= prolong/excessive depolarization= seizure-like activty
What would be seen on PE of a scorpion sting
When do these PTs need to be admitted?
Hypersalivation
CN5 7 9 dysfunction
Eye, pharyngeal, tongue control issues
Systemic Sxs
CN impairment
Crotalinae includes ?
What does their venom cause
What would be the early indications of poisoning since 25% are dry bites
Rattle snakes
Tissue/hematological toxins by fibrinogen/platelet consumption
N/V
Weak
PO numbness/tingles
Local swelling
What are the systemic effects of a Crotalinae bite
How is a snake bite Dx
How is snake envenomation Dx
How is a dry bite Dx
Tachy Tachy HOTN
Fang marks and Hx
Fang marks and tissue injury
ASx x 8-12hrs
What is the mainstay of Crotalinae therapy?
Difference between Coral and Milk snake
FabAntivenom- IV/IO
Do not give IM if finger bite
Red on yellow- kills fellow
Red on black, venom lacks
How are coral snake bites Tx
What group do they belong to
3-5 vials of Antivenin IV or IO
Elapid
