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NRS 251 D: Emergency, Surgery, Geriatrics, Peds, OB > Emergency Med > Flashcards

Emergency Med Flashcards

1
Q

Definitions: Sepsis, Systemic Inflammatory Response Syndrome, Septic Shock

A
  • Sepsis:
    • life-threatening organ dysfunction secondary to dysregulated host response to infection
      • condition
  • Systemic Inflammatory Response Syndrome (SIRS):
    • an exaggerated defense response of the body to a stressor (infx, trauma, surgery, acute inflammation, ischemia, etc). meant to localize and then eliminate the source of the insult
  • Septic Shock:
    • a subset of sepsis in which particularly profound circulatory, cellular, and metabolic abnormalities are associated with a greater risk of mortality than with sepsis alone.
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2
Q

SIRS Criteria

A

Systemic Inflammatory Response Syndrome is defined as presence of 3+ of the following”

  • fever > 38C (100.4F) or hypothermia <36F (96.8F)
  • Tachypnea (RR > 24)
  • Tachycardia (HR > 90/min)
  • Leukocytosis (>12K), Leukopenia (<4K), or >10% bands
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3
Q

Sepsis vs Severe Sepsis

A
  • Sepsis:
    • at least 3 SIRS criteria AND a confirmed or suspected infection
  • Severe Sepsis:
    • sepsis WITH evidence of end-organ damage due to the tissues not getting adequate perfusion
      • hypotension
      • serum lactate levels (≥ 4.0mmol/L)
      • pre-renal azotemia and transaminitis (elevated ALT/AST)
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4
Q

Hour-1 Sepsis Bundle

A
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5
Q

Exam findings of Septic Shock

A
  • Compensated:
    • tachycardia
    • dynamic (heaving) precordium
    • bounding peripheral pulses
    • reduced cap refill
    • skin = warm or hot to touch (WARM shock)
  • Decompensated Septic Shock:
    • peripheral pulses become weak/thready
    • hypotension worsens
    • skin becomes cold/pale/clammy (COLD shock)
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6
Q

Management of Septic Shock

A
  • fluid resuscitation with Crystalloid (NS or albumin) and colloid (blood products) up to 80ml/kg
  • 1st line vasoactive agents for fluid refractory shock:
    • Norepi in Warm shock (compensated)
    • Epi in Cold Shock (decompensated)
  • add vasopressin if refractory to vasopressors
  • Restore MAP to ≥ 65 mmHG
  • Restore Central venous pressure (CVP) to 8-12mmHg
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7
Q

How to Calculate MAP

A

Mean Arterial Pressure

  • MAP = [(Diastolic BP x 2) + Systolic BP] / 3
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8
Q

ABA Burn Center Referral Criteria

A
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9
Q

Burn Treatment

A
  • Keep the patient warm, prevent hypothermia
  • < 15% BSA burns
    • moist sterile dressing
  • >15% BSA burns
    • cover with dry sterile dressing
      • decreases risk of hypothermia
  • for bigger areas → use a clean dry sheet
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10
Q

Parkland Formula for fluid resuscitation in a burn patient

A
  • IV fluid of choice = Ringer’s Lactate
  • 1st 24 hours:
    • 4mL x kg x % BSA burned
    • 1st 8 hours: give ½ of total fluid
    • next 16 hours: give rest of fluid (½ of total fluid)
  • Inhalation Burn: 6ml x kg x % BSA
  • Electrical Burn: 7ml x kg x % BSA
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11
Q

Airway & Breathing Tx for Burn Patients

A
  • >15% BSA burns: give 100% oxygen even if pulse ox is normal
  • Be prepared to support ventilation
    • may require an advanced airway for inhalation burns
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12
Q

Rule of 9s

A
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13
Q

Superficial vs Partial Thickness vs Full Thickness

A
  • Superficial:
    • epidermis only
    • pain & erythema
    • heals in a few days
      • topical aloe vera
      • injured epidermal cells peel away
  • Superficial Partial Thickness:
    • entire epidermal & superficial (papillary) dermis
    • erythematous & skin may blister
      • may be moist, weepy, or shiny
      • painful & hypersensitive to touch
    • blanches with pressure
      • does not extend into capillary bed so it can heal better b/c basement membrane is intact
    • usually heals on its own in 2-3 weeks
  • Deep Partial Thickness:
    • extends into deep (reticular) dermis
    • Blood filled blisters
    • usually Mottled pink to white in color
    • Does NOT blanch
    • healing time = 3+ weeks
      • may require excision and skin grafting
  • Full thickness:
    • total loss of dermis & epidermis
    • Skin appears dry, leathery, peeling
      • may be white, yellow, tan/brown, or charred
      • hair follicles removed easily
    • often not painful
    • may require escharotomy or fasciotomy
    • heals by contracture & epithelial ingrowth or skin grafting
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14
Q

Categories of Shock Table

A
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15
Q

Stages of Shock

A
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16
Q

T or F : a normal BP rules out shock

A

FALSE, a normal BP does NOT rule out shock

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17
Q

What are 3 identifiable and treatable immediately life-threatening causes of shock?

A
  • Bleeding
  • Tension Pneumothorax
  • Pericardial Tamponade
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18
Q

What would you use tranexamic acid for?

A

it is an antifibrinolytic

helps to stabilize the clotting system during hemorrhagic shock

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19
Q

what is the MCC of cardiogenic shock?

A

Acute MI

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20
Q

Tx of Cardiogenic Shock

A
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21
Q

Types of Distributive Shock

A
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22
Q

Neurogenic Shock Overview

A
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23
Q

Anaphylactic Shock

A
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24
Q

Obstructive Shock Overview

25
Q

EMTALA

A

Emergency Medical Treatment & Labor act of 1986

requires hospital EDs to medically screen all pats who present requesting care for an emergency medical condition

CANNOT be screened by a triage RN

26
Q

Advantages and Limitations of Transfers via Private Car, Wheelchair/Gurney Van, BLS, ALS, and CCT

27
Q

Advantages and Limitations of Transfers via Specialty Teams, Heli, Fixed Wing

28
Q

Hypothermia Body Temps

A

Body Core Temp < 35C (95F)

  • Mild Hypothermia: 32-35C (90-95F)
    • shivering, increased metabolic rate, conscious to mildly AMS, ability to self rewarm
  • Moderate Hypothermia: 28-32C (83-90F)
    • AMS, ECG changes (J wave–right after QRS complex) loss of shivering at 30C (86F) losing ability to self-rewarm
  • Severe Hypothermia: <28C (83F)
    • decreased metabolic rate by 50%, not shivering, unconscious, lowered threshold for dysrhythmias (VF/VT), incapable of self-warming
29
Q

Afterdrop and Hypothermia

A
  • Occurs after the cooling process has been stopped
  • when heat from the core gets conducted to the circulation and the periphery
  • expect the body temperature to drop an additional 1.3-6.4C
    • patient may get worse before they get better after being removed from the cold
30
Q

General Tx of the Hypothermic Patient

A
  • remove pt from cold
  • administer oxygen (warmed and humidified)
  • assess for other injuries & illnesses
  • check blood sugar
  • hand gently – avoid rough and excessive movement
  • anticipate afterdrop
31
Q

Tx of Mild Hypothermia

A
  • Assess LOC and gag reflex
  • provide warmed oral fluids with calories
    • no caffeine, alcohol, or nicotine
  • passive rewarming
  • external heat (if possible)
  • may not require further treatment
32
Q

Tx of Moderate Hypothermia

A
  • Assess for pulse & respirations for at least 60-120sec
    • if respirations or cardiac electrical activity are present, assume cardiac output, even if a pulse is not present
    • U/S can be used to detect cardiac activity
  • active external rewarming
  • IV/IO access:
    • fluid bolus with warmed NS (40-42C [104-107F])
33
Q

Cardiac Arrest in Hypothermia

A
  • If VT/VF is present or AED advises shock, defibrillate once at max output
  • start CPR
  • ventilate with warmed oxygen
  • hypothermic heart does not respond well to ACLS meds as drug metabolism will be reduced
    • withold ACLS meds for core temps < 30C (86F)
34
Q

Active vs Passive Rewarming of Hypothermic Patients

A
  • no shivering in a hypothermic pt?
    • active rewarming recommending
      • large heat packs/hot water bottles
      • forced warm air
      • invasive/extracorporeal warming (ECMO, bypass machine, etc)
35
Q

Define & Tx Heat Exhaustion

A
  • Definition:
    • Flu-like sxs:
      • malaise, HA, weakness, pale skin, loss of appetite, nausea & vomiting
    • tachycardia, orthostatic hypotension
    • temp usually around 38-39C (100.4 - 102.2F)
    • sweating
    • normal mental status
  • Tx:
    • cooling measures
    • oral fluids
      • dilute sports drinks (½-⅓ strength)
      • cooler fluids are more easily absorbed
    • Oxygen as necessary
    • they may be able to self-evacuate after cooling and rehydration
36
Q

Define & Tx Heat Stroke

A
  • Definition:
    • Body temp us usually 104F (>40C)
    • AMS = most important!
      • confusion, bizarre behavior, loss of balance, seizures, coma
    • hypotensive, tachypnic, tachycardia
    • flushed, red skin
    • sweating +/-
  • Tx:
    • aggressive cooling measures
      • wet clothing/sheets, fans, ice water baths, ice/cold packs on armpits, neck and groin
    • Protect the airway
    • Monitor body core temp
37
Q

Exercise Associated Hyponatremia

A
  • athletes who exercise in hot weather
  • consume excess amounts of water or hypotonic fluids
    • dilution hyponatremia (usually <125 mmol/L)
    • weight gain
  • Neuro sxs
  • Rapid serum Na+ measurement is crucial
  • Tx is sodium repletion (IV 3% NaCl)
38
Q

Snake Bites: Local Rxn, Systemic Rxns, Tx

A
  • Local Reaction:
    • Pain, swelling, discoloration, numbness, paresthesias, hemorrhagic blebs
  • Systemic Rxns:
    • diaphoresis, chills, weakness, metallic/minty taste
    • neurologic sxs:
      • paresthesias of tongue, mouth or feet
      • fasciculations in face, back and neck
    • Anaphylaxis
  • Tx:
    • Calm victim, remove constricting clothing/rings/etc, assess for signs of bite, measure and mark swelling
    • cleanse area around bite with soap and water
    • immobilize at heart level
    • establish IV access (2 lines: 1 for antivenom, 1 for fluids
    • Draw labs:
      • CBC, PT, PTT, fibrinogen, D-Dimer, CMP, CK, troponin-I, UA, type and screen
    • Give Antivenom
    • All pts should be observed for 18-24 hours
      • generally require ICU admission
39
Q

Tick Paralysis: s/sxs & Tx

A
  • presents similarly to guillain barre
    • progressive, ascending, symmetric, flaccid paralysis with loss of DTRs
      • caused by a neurotoxin transmitted by the bite of a female Dermacentor tick
        • sxs usually begin 5-6 days after tick has initially attached
  • Tx:
    • tick removal, supportive care, ventilatory support until the sxs resolve
    • no antivenom available
40
Q

Major Risk Factors for Falls

A
  • female gender
  • older age
  • hx of previous fall(s)
  • extremity weakness
  • psychotropic med use
  • co-morbidities (Parkinsons, cardiac disease, infection)
41
Q

Canadian CT Head Rules

A
  • Do any of the following apply?
    • GCS < 15 at 2 hours after injury
    • Suspected open or depressed skull fracture
    • vomiting ≥ 2 episodes
    • Age ≥ 65 years
    • Pre-impact amnesia ≥ 30 minutes
    • Dangerous mechanism
  • If yes to any -→ CT required!!
42
Q

New Orleans Head Trauma Rule

A
  • Do any of the following apply?
    • HA
    • Vomiting
    • Age > 60 years
    • Alcohol or drug intox
    • Persistent anterograde amnesia
    • visible trauma above the clavicles
    • seizure
  • if yes to any → CT is indicated
43
Q

The Disaster Cycle

A
  • Planning
  • Preparedness
  • The Disaster Event
  • Response
  • Recovery/mitigation
  • Planning (Again)
44
Q

What does START stand for in disasters?

A

Simple Triage and Rapid Treatment

45
Q

ACLS Medications

46
Q

Respiratory Failure vs. Respiratory Arrest

47
Q

Anaphylaxis Criteria

48
Q

Tx of Anaphylaxis

49
Q

Tx of Anaphylactic Shock

A
  • Volume resuscitation (2-7 L) for persistent hypotension
    • NS > LR
  • Epi infusion
  • Dopamine/Dobutamine for refractory shock
  • Glucagon for pts on beta-blockers → to reverse the beta blockade
  • endotracheal intubation and mechanical ventilation
50
Q

Biphasic Anaphylaxis

A
  • Anaphylactic rxns are typically uniphasic and resolve in an hour
    • some episodes may last hours - days
  • up to 23% may experience return of sxs in hours to days (biphasic rxn)
    • typically less severe than initial rxn
    • almost all cases are not clinically significant and there are no fatalities
51
Q

Anaphylaxis: Observation, Discharge and Pt Ed

A
  • Mild - moderate anaphylaxis with complete resolution of sxs:
    • observation recommended for 4-8 hours
    • if pt remains asymptomatic, consider a short outpt course of H1/H2 blockers and glucocorticoid therapy
    • all pts need to be discharged with an epi pen
  • All pts without complete resolution of sxs or requiring an infusion of meds should be admitted for further observation
52
Q

Correction Factor for Sodium in DKA

A
  • Add 1.6mEq Na for every 100mg/dL the glucose is above normal
53
Q

High Anion Gap Metabolic Acidosis

54
Q

Tx of DKA

A
  • ABCs
  • IV Fluids:
    • 20-30cc/kg of crystalloid
    • LR is best b/c it is closer to physiologic solution and does not cause hyperchloremic metabolic acidosis
  • Electrolyte Correction:
    • Potassium = most important lab
      • Oral: KCl 40mEq q hour
      • IV: KCl 10-40 mEq in each liter of fluid
      • Insulin will push potassium intracellularly so watch it!!
      • hypokalemia = hypomagnesemia → replace Mg → 1-2 gm MgSO4 IV
    • Sodium: dilutional hyponatremia will correct on its own
  • Insulin:
    • insulin should NOT be started until K+ level is known
      • Regular (Humalog/Novalog) Insulin infusion 0.1-0.4 units/kg/hr
      • do NOT bolus, can be harmful
  • Bicarb:
    • only if pH < 7.1
      • pt needs to be able to blow off CO2 → ventilatory rate must be artificially increased
      • watch out for: hypokalemia, delay in improvement of ketosis
55
Q

Tooth Anatomy

56
Q

Local Analgesics for Dental Pain

57
Q

Pediatric Assessment Triangle

A

Appearance

Breathing

Circulation

58
Q

When to refer to ophtho

59
Q

When to refer to ENT with epistaxis

NRS 251 D: Emergency, Surgery, Geriatrics, Peds, OB (9 decks)

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