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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

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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
EMTALA
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
Advantages and Limitations of Transfers via Private Car, Wheelchair/Gurney Van, BLS, ALS, and CCT
27
Advantages and Limitations of Transfers via Specialty Teams, Heli, Fixed Wing
28
Hypothermia Body Temps
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
Afterdrop and Hypothermia
* 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
General Tx of the Hypothermic Patient
* 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
Tx of Mild Hypothermia
* 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
Tx of Moderate Hypothermia
* 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
Cardiac Arrest in Hypothermia
* 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
Active vs Passive Rewarming of Hypothermic Patients
* 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
Define & Tx Heat Exhaustion
* 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
Define & Tx Heat Stroke
* _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
Exercise Associated Hyponatremia
* 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
Snake Bites: Local Rxn, Systemic Rxns, Tx
* _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
Tick Paralysis: s/sxs & Tx
* 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
Major Risk Factors for Falls
* female gender * older age * hx of previous fall(s) * extremity weakness * psychotropic med use * co-morbidities (Parkinsons, cardiac disease, infection)
41
Canadian CT Head Rules
* 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
New Orleans Head Trauma Rule
* 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
The Disaster Cycle
* Planning * Preparedness * The Disaster Event * Response * Recovery/mitigation * Planning (Again)
44
What does START stand for in disasters?
Simple Triage and Rapid Treatment
45
ACLS Medications
46
Respiratory Failure vs. Respiratory Arrest
47
Anaphylaxis Criteria
48
Tx of Anaphylaxis
49
Tx of Anaphylactic Shock
* 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
Biphasic Anaphylaxis
* 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
Anaphylaxis: Observation, Discharge and Pt Ed
* 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
Correction Factor for Sodium in DKA
* Add 1.6mEq Na for every 100mg/dL the glucose is above normal
53
High Anion Gap Metabolic Acidosis
54
Tx of DKA
* _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
Tooth Anatomy
56
Local Analgesics for Dental Pain
57
Pediatric Assessment Triangle
Appearance Breathing Circulation
58
When to refer to ophtho
59
When to refer to ENT with epistaxis

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

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