Emergency Med & ICU Flashcards
Positive end-expiratory pressure (PEEP):
- refers to pressure in the airway at the end of passive expiration that exceeds atmospheric pressure
- PEEP is used to increase the functional residual capacity and stent open collapsable alveoli, thus reducing atelectatic trauma.
- The level of PEEP is usually set at 5 cmH2O and titrated based on the underlying condition and oxygenation needs.
Moderate or severe hyperkalemia + ECG changes →
→ administer 10 ml of 10% calcium chloride IV
OR
→ 30 ml of 10% calcium gluconate
The Glasgow-Blatchford scale is
- The Glasgow-Blatchford scale is used to assess the severity of bleeding and predict its course .
The Glasgow-Blatchford scale is used to assess the severity of bleeding
- what are the risk factors:
The following risk factors are assessed:
- blood urea concentration ,
- hemoglobin concentration ,
- systolic blood pressure ,
- heart rate ,
- presence of tarry stool ,
- loss of consciousness
- liver failure ,
- heart failure
- gastrointestinal bleeding
Management of regular tachycardia with narrow QRS complexes:
- VAGAL NERVE STIMULATION (carotid sinus massage and Valsalva maneuver),
- ADENOSINE in the scheme 6 mg → 12 mg → 12 mg.
- on the third attempt, the suggested dose was increased to 18 mg.
Sinus tachycardia often occurs as a physiological response to
- exercise and anxiety
or - secondary to pathological stimuli (e.g. fever, anemia) .
- Treatment should be CAUSAL .
acute radiation syndrome
tissues in order of decreasing sensitivity to ionizing radiation
following series:
- lymphatic tissue,
- testicular epithelium,
- bone marrow,
- gastrointestinal epithelium,
- ovaries,
- skin,
- connective tissue,
- bones,
- liver,
- pancreas,
- kidneys,
- nerves,
- brain
- muscles (ex: heart)
hemoptysis.
refers to coughing up blood from some part of the lungs (respiratory tract)
If blood loss exceeds 1/3 of the circulating blood volume (in an adult male weighing 70-80 kg it is approximately 1500 ml) leads to ?
- hypovolemic shock develops ,
- further loss exceeding 50% of the circulating blood volume leads to loss of consciousness.
Numerous doses of activated charcoal are most often used after an overdose of
- theophylline
- phenobarbital
- carbamazepine
- quinine
- barbiturates
- cardiac glycosides
If the seizure persists or further seizures occur, repeat administration of
- diazepam 10 mg IV
or - clonazepam 1 mg IV at 5-minute intervals and continue monitoring of vital signs
-
Diazepam may be continued up to a maximum dose of 50 mg
and - clonazepam up to a maximum dose of 5 mg
The golden hour for the use of hyperbaric oxygen (HBO) in severe CO poisoning is
6 hours
- 2.5 - 3.0 atmospheres for 90 minutes,
Symptoms of neurogenic shock include:
1) hypotension - results from loss of vascular tone .
2) bradycardia - results from the predominance of the action of the vagus nerve on the heart .
3) warm and well-circulated skin - the main feature that distinguishes this shock from others.
4
Intravenous antihypertensive drugs used in Poland:
– Urapidil
– Nitroglycerin
– Esmolol
– Furosemide
12
According to the table from [ Szczelik’s Internal Medicine ] presenting antihypertensive drugs used parenterally in the treatment of hypertension for urgent indications, the onset of action of individual drugs is as follows:
sodium nitroprusside - immediate effect
nicardipine - 5-15 min
clevidipine - 2-3 min
fenoldopam - 5-15 min
nitroglycerin - 1-5 min
enalaprilat - 5-15 min
labetalol - 5-10 min
esmolol - 1-2 min
metoprolol - 1-2 min
phentolamine - 1-2 min
urapidil - 3-5 min
conidine - 30 min
According to the table from [ Szczelik’s Internal Medicine ] presenting antihypertensive drugs used parenterally in the treatment of hypertension for urgent indications, the onset of action of individual drugs is as follows:
onset -immediate effect
Sodium nitroprusside -
According to the table from [ Szczelik’s Internal Medicine ] presenting antihypertensive drugs used parenterally in the treatment of hypertension for urgent indications, the onset of action of individual drugs is as follows:
name 3 drugs with onset of 5-15 min
nicardipine -
fenoldopam -
enalaprilat -
According to the table from [ Szczelik’s Internal Medicine ] presenting antihypertensive drugs used parenterally in the treatment of hypertension for urgent indications, the onset of action of individual drugs is as follows:
onset of - 2-3 min
clevidipine
According to the table from [ Szczelik’s Internal Medicine ] presenting antihypertensive drugs used parenterally in the treatment of hypertension for urgent indications, the onset of action of individual drugs is as follows:
Onset of action after: 1-2 min (4)
nitroglycerin -
esmolol -
metoprolol -
phentolamine -
According to the table from [ Szczelik’s Internal Medicine ] presenting antihypertensive drugs used parenterally in the treatment of hypertension for urgent indications, the onset of action of individual drugs is as follows:
onset of action after 3-5 min
urapidil -
According to the table from [ Szczelik’s Internal Medicine ] presenting antihypertensive drugs used parenterally in the treatment of hypertension for urgent indications, the onset of action of individual drugs is as follows:
onset of action after 30 min
conidine -
The advanced trauma life support course teaches that if only the patient’s carotid pulse is palpable, the systolic blood pressure is ?
(The lowest systolic blood pressure at which the carotid pulse is felt)
60 mmHg
if carotid and femoral pulses are palpable, the systolic blood pressure is
70-80 mm Hg
if the radial pulse is also palpable, the systolic blood pressure is more than
80 mm Hg
Hodgkin’s disease is the cause of
hypercalcemic crisis
Toxic megacolon - treatment
Short-term (<48h) intensive conservative treatment :
- insertion of a tube into the stomach and suction of the contents,
- total parenteral nutrition,
- intravenous broad-spectrum antibiotics and glucocorticoids,
- fluid therapy ( IV crystalloids )
Toxic megacolon - treatment
Indications for surgery :
- no improvement within 24-48 hours or deterioration of the patient’s condition despite conservative treatment,
- septic shock,
- massive hemorrhage,
- intestinal perforation and symptoms of diffuse peritonitis.
Toxic megacolon
The improvement in the condition is evidenced by:
- reducing abdominal circumference
-appearance of peristaltic sounds
The width of the colon should be monitored with repeated abdominal X-rays.
Indications for head CT before lumbar puncture
- Immune deficiencies .
- History of CNS disease .
- Seizure within the last week .
- Swelling of the optic disc .
- Disturbances of consciousness .
- Focal neurological symptoms (paresis, unresponsive pupil, etc.).
- The absence of the above risk factors allows for the exclusion of brain edema or tumor with a 97% effectiveness in adults with suspected CNS infection.
Mallampati scale:
Stage I - visible palatal rings, soft palate and uvula.
Grade II - soft palate and uvula visible.
Grade III - only the soft palate is visible.
Stage IV - soft palate invisible .
Shock
General rules of conduct
- Place the patient in the TRENDELENBURG position .
- Insertion of vascular cannulas :
- 2 LARGE DIAMETER cannulae into peripheral veins, ≤ 16 G (≥ 1.8 mm),
- radial artery catheter (for invasive measurement of blood pressure) ,
- central line.
Large-diameter peripheral venous cannulas (preferably ≥1.8 mm [ ≤16 G ]; insert 2 cannulas) are suitable for rapid transfusion of fluids and blood components , rather than conventional (standard) vena catheters.
If you cannot access peripheral veins for rapid transfusion of fluids and blood components, use a large-diameter central venous catheter (such as for renal replacement therapy or angiography, or endocavitary electrode [vascular sheath] insertion).
Wounds in direct contact with organs or functional structures of the body (e.g. joints) and wounds containing a foreign body are classified as
- a class III risk factor for wound infection and are an indication for the use of antibiotic therapy .
Clinical symptoms of hypokalemia result from its impact on
- the resting potential of myocytes and neurocytes.
- Hypokalemia causes hyperpolarization of the cell membrane and an increase in the excitability threshold for the action potential , which may lead to complete blocking of action potentials.
- This results in weakening of skeletal muscles and tendon reflexes .
- Hypokalemia occurs in 2.6-5.2% of hospitalized patients. It is associated with dangerous?
- heart rhythm disorders in the form of supraventricular and ventricular tachycardia. It increases heart failure and causes fainting.
- When potassium levels are below 2 mmol/l, respiratory muscles and tendon reflexes become weakened .
- In hypokalemia, nausea, vomiting, anorexia, and paralytic intestinal obstruction are also observed.
If you have diagnosed a tension pneumothorax, you need to act as soon as possible….3 facts are most important:
- it is supposed to be a *puncture *, not drainage
- the place is the *2nd intercostal space *(but don’t be fooled, if the answer was “over the 3rd rib “ it will also be correct)
- the injection should take place on the upper edge of the rib (if you aim the needle at the lower edge of the rib, you risk puncturing the neurovascular bundle)
Pneumothorax
symptoms in tension pneumothorax
1) Rapidly increasing shortness of breath.
2) Hypotension .
3) Symptoms of hypoxemia: cyanosis, tachypnea, tachycardia .
4) Widening of the jugular veins.
5) Cardiac arrest.
Pneumothorax
Treatment - life-threatening condition
Give me the oxygen!
1) Tension pneumothorax:
- through the 2nd intercostal space in the midclavicular line
(on the upper edge of the 3rd rib) immediately insert a cannula (such as for peripheral veins)
4–5 cm long and ∅ 2.0 mm (14 G ) or 1.7 mm (16 G )
and leave it on until the drain is inserted.
Classic triad of symptoms of pulmonary embolism,
occurring in 25% of patients, include:
1) shortness of breath - about 50% of patients,
2) chest pain - about 50% of patients, usually pleuritic in nature , coronary time,
3) cough – 20% of patients, usually dry,
Pleural pain
- The lung tissue and the visceral (lung) pleura do not have sensory innervation, so in pneumonia pain occurs only when the inflammation affects the parietal pleura .
- Suddenly appearing pleural pain, correlated with decreased or absent breath sounds on the side of pain, suggests suspicion of pneumothorax .
Pleural pain
Factors that intensify pain :
- deep inhalation, coughing, torso movements.
Pleural pain
- Factors that reduce the intensity of pain
- positioning on the side where the pain occurs.
Pleural pain- in Pulmonary embolism
- Character : sharp, prickly.
- Location : usually unilateral.
- Radiation : may radiate to the interscapular area. When the diaphragmatic pleura is involved, the pain radiates to the upper abdomen, most often the right one.
What is pseudohyponatremia?
This is a reduction in sodium concentration while maintaining normal plasma osmolality.
In cyanide poisoning, the antidote is:
- HYDROXYCOBALAMINA ,
- NITRITE – THIOSULFATE set .
diagnosis/antidote
Poisoning
Toxidromes - Cholinergic syndrome - Management
- Diagnosis:
- determination of AChE activity in blood cells or serum. - Decontamination and accelerated elimination, if indicated.
- Antidotes:
- ATROPINE - muscarinic receptor antagonist,
- PRALIDOXYME , OBIDOXYME in case of poisoning with ORGANIC PHOSPHORUS COMPOUNDS .
- Symptomatic treatment.
initial treatment,antidote
Poisoning
Drugs - β-blockers, calcium channel inhibitors and insulin .
- Initial treatment:
- ATROPINE ,
- fluid therapy.
- Decontamination and accelerated elimination, if indicated.
- Antidote: GLUCAGON .
Poisoning
Alcohols - Ethylene glycol - Procedure
- Decontamination is not recommended.
- Antidotes:
- ETHANOL ,
- FOMEPIZOLE .
- THIAMIN and PYRIDOXIN .
- Elimination: HEMODILYSIS (in case of severe poisoning and high glycol concentration in the blood) .
Poisoning
Toxidromes - Opioid-narcotic syndrome - Management
- Decontamination and accelerated elimination, if indicated.
- Antidote: NALOXONE .
3. Symptomatic treatment.
In severe acute pancreatitis, it is not recommended to use:
MORPHINE should not be administered to patients with AP due to its constricting effect on the sphincter of Oddi .
Acute Pancreatitis
AP - Treatment
1) Compensation for fluid deficiency and electrolyte disorders:
Ringer’s solution 250 –300 ml/h,
if > 250 mg/dl glucose – insulin,
if Hct < 25 % – RBC.
Indicator of adequate hydration: diuresis ≥ 0.5 ml/kg/h.
2) Painkillers:
Metamizole 1.0 g IV as needed ,
Tramadol 50 mg sc or iv every 6–8 h,
Buprenorphine 0.2–0.6 mg IV every 6 hours,
Pethidine 50 mg iv every 6–8 h,
possibly epidural blockade of Th4 - L1.
The basic daily fluid requirement for a child weighing 35 kg is:
Basic requirement in ml/24 h is calculated as follows:
up to 10 kg body weight – 100 for every kilogram.
10–20 kg body weight – 1000 ml + 50 ml for each kilogram over 10 kg.
>20 kg body weight – 1500 ml + 20 ml for each kilogram over 20 kg .
35 kg –> 1500 ml + ( 35kg-20kg ) x 20ml = 1500 ml + 15 x 20 ml = 1800 ml
Basics of traumatology
Triad of death
- Coagulopathy
- Hypothermia - reduces citrate metabolism, thus intensifying hypocalcemia. Additionally, hypothermia and hypocalcemia depress the myocardium,
- Metabolic acidosis - reduced cardiac output (caused by, among others, hypocalcemia) and hypotension worsen acidosis. Moreover, acidosis disturbs the functioning of the coagulation system)
Hypertension
Eclampsia - Treatment
1) Stopping a seizure and preventing its recurrence:
- MgSO4 at a dose of 4-6 g IV administered for 20 minutes,
- then a dose of 1-2 g/h for at least 24 hours.
2) Pharmacological control of blood pressure (as in hypertensive crisis).
Eclampsia - treatment
Workflow
- Place the mother in the recovery position, suck out the secretions from the oral cavity, administer oxygen 8–10 l/min, monitor blood oxygenation (pulse oximetry, possibly blood gases).
- Use anticonvulsant treatment → magnesium sulfate (Inj. Magnesii Sulfurici Polpharma) [Zuspan’s method], e.g. 6 g over 15–20 min, then 2 g/h in a continuous IV infusion for ≥24 h after delivery or after the last seizure. If magnesium sulfate is ineffective, → diazepam iv (Neorelium, Relanium) 10 mg or thiopental iv (Thiopental (i)) 50 mg.
- Maintain blood pressure at 140–160/90–110 mm Hg, using e.g. labetalol IV (Trandate(i)) 20–40 mg IV every 15 minutes as needed. Use diuretics only in case of pulmonary edema.
- In case of symptoms of fetal distress, the pregnancy should be terminated urgently by cesarean section after the mother’s condition has been stabilized. Otherwise, eclampsia is not an indication for a cesarean section and delivery may take place vaginally, after possible induction.
Zolpidem:
- is a hypnotic and anxiolytic drug from the imidazopyridine group,
- is a selective agonist of the omega-1 subunit of the GABA receptor,
- it is similar to benzodiazepines in terms of mechanism of action and side effects; overdose is treated in the same way - by administering flumazenil , which is a selective antagonist of benzodiazepine receptors.
The specific “antidote” for zolpidem poisoning is:
flumazenil
Poisoning
Toxidromes - Sedative-hypnotic syndrome - Management
- Decontamination and accelerated elimination, if indicated:
- ALKALIZATION of urine in PHENOBARBITAL poisoning .
- Antidotes:
- FLUMAZENIL in poisoning with BENZODIAZEPINES and “ZETKAS” .
3. Symptomatic treatment.
Hypertension
Treatment – Pharmacological – Antihypertensive treatment algorithm – Patients after stroke
- Hypertension in the acute phase of stroke should only be treated if CT exceeds 220/120 mm Hg .
- The drug of choice in such a situation is** labetalol **.
- The pressure should be lowered slowly to approximately 170–180/110 mm Hg .
- On the second day after stroke, HT treatment can be started if CT values exceed
180 and/or 120 mm Hg. - Fibrinolytic therapy may be used if CT values
are lower than 185/110 mm Hg .
Larynx diseases
Acute subglottic laryngitis -Clinical picture and diagnosis
- Then the airway patency is significantly impaired.
Characteristic symptoms:
- hoarseness ,
- inspiratory stridor ,
- barking “seal” cough,
- wheezing,
- shortness of breath.
Acute respiratory failure
Causes of ARDS (Acute Respiratory Distress Syndrome) - Pulmonary
1) Aspiration of gastric contents.
2) Pneumonia.
3) Chest injury and lung contusion.
4) Inhalation of smoke or toxins.
5) Chest irradiation.
6) Damage due to mechanical ventilation.
7) Flooding.
8) Pulmonary vasculitis.
Acute respiratory failure
Causes of ARDS - Extrapulmonary
1) Sepsis.
2) Shock.
3) Acute pancreatitis.
4) Multi-organ trauma - multiple fractures (fat embolism).
5) Extensive burns.
6) Head injury and increased intracranial pressure.
7) Massive transfusions of blood products (TRALI).
8) Pregnancy complications (eclampsia, amniotic fluid embolism).
9) Tumor lysis syndrome.
10) Condition after extracorporeal circulation.
11) Drug reactions and drug poisoning.
Shock
Hemorrhagic shock - Management
1) FFP ( Fresh Frozen Plasma ) , KKP (Platelet Concentrate) and cryoprecipitate :
– KKP, when the platelet count is < 50,000/µl,
– the recommended ratio of RBC: RBC: FFP is 1:1:1.
2) Tranexamic acid :
– loading dose 1 g iv for 10 min, then 1 g for 8 h.
Substances that can be eliminated by hemodialysis include:
- alcohols ( methanol , glycol , isopropanol, ethanol, acetone);
- lithium;
- salicylates;
- paracetamol;
- barbiturates;
- carbamazepine;
- tricyclic antidepressants;
- valproic acid;
- sotalol,
- procainamide.
Emergencies related to environmental factors
Hypothermia - Procedure - Differences in CPR
- Search for signs of life and pulse in the central arteries for 1 MINUTE .
- Defibrillation:
- WITH THE HIGHEST energy,
- after 3 FAILED defibrillation attempts
, another one after reaching core temperature ≥ 30 °C.
Electrolyte disturbances
Potassium - Hyperkalemia - Treatment
Myocardial protection :
- Myocardial protection :
- 10 ml of 10% CALCIUM CHLORIDE
solution or 30 ml of 10% calcium gluconolactobiate solution, - used in the presence of CHANGES IN THE ECG RECORDING .
- Shift of potassium ions into cells :
- 25 g GLUCOSE + 10 units of SHORT-ACTING INSULIN ,
- 10–20 mg SALBUTAMOL nebulized,
- 50 mmol NaHCO3 in case of acidosis.
- Accelerating the elimination of potassium from the body :
- 15–30 g of CALCIUM RESONIUM (polystyrene sulfonate) po or pr,
- 20–40 mg of FUROSEMIDE iv with 0.9% NaCl in patients with preserved diuresis,
- HEMODIALISIS .
Symptoms of a significant increase in intracranial pressure include the so-called
Cushing’s triad :
hypertension
bradycardia
irregular breathing
Intracranial hematomas
Symptoms of pressure on the brain stem
An expanding hematoma produces symptoms caused by pressure on centers in the brain stem:
1) Bradycardia and increase in blood pressure .
2) Slowing and shallow breathing.
3) Mydriasis on the side of the hematoma.
4) Deflection of the eyeballs that “look at the hematoma”.
5) Hemiparesis on the side opposite to the hematoma.
Such symptoms are an indication for urgent neurosurgical intervention -
intussusception begins!
Shock
Symptoms - Triad of symptoms
The classic triad of shock symptoms is:
- HYPOTENSION
- TACHYCARDIA
- Oliguria
Shock
Allgower Index
ALLGOWER INDEX
is the quotient of heart rate ( HR ) and systolic blood pressure ( SBP ).
ALLGOWER INDEX = HR / SBP
0.5 – healthy people
> 1 – SHOCK
Symptoms of superior mesenteric artery embolism :
- Sudden, severe abdominal pain, first located in the mid-abdomen, and then diffuse, initially paroxysmal and then continuous, often preceded by atrial fibrillation , sometimes embolisms of the cerebral arteries or lower limbs.
- The pain is accompanied by bloody diarrhea and sometimes bloody vomiting .
- Initially, intestinal peristaltic movements are increased, but later they disappear. Symptoms of peritonitis appear.
- As ischemia increases, blood pressure decreases, heart rate increases, and body temperature increases.
- High leukocytosis is usually observed
Cardiopulmonary resuscitation
BLS - Algorithm
- Use AED :
- ASAP ,
- turn on the AED → connect the electrodes → analyze the rhythm → as indicated: defibrillate / continue CPR,
- DO NOT TOUCH THE PATIENT DURING RHYTHM AND SHOCK ANALYSIS ,
- rhythm assessment every 2 minutes.
The antidote for benzodiazepine poisoning is:
flumazenil
Poisoning
Toxidromes - Sedative-hypnotic syndrome - Management
in poisoning with BENZODIAZEPINES and “ZETKAS” .
- Decontamination and accelerated elimination, if indicated:
- ALKALIZATION of urine in PHENOBARBITAL poisoning .
- Antidotes:
- FLUMAZENIL in poisoning with BENZODIAZEPINES and “ZETKAS” .
- Symptomatic treatment.
Emergencies related to environmental factors
Hypothermia - Procedure - Differences in CPR
- Search for signs of life and pulse in the central arteries for 1 MINUTE .
- Defibrillation:
- WITH THE HIGHEST energy,
- after 3 FAILED defibrillation attempts, another one after reaching core temperature ≥ 30 °C.
Procedure in the delivery room
Newborn resuscitation - Procedure
- If, despite proper ventilation for 30 seconds,
the heart rate remains < 60 beats/min or is undetectable, start chest compressions . - Compressions are performed in the rhythm of → 3 PRESSURES: 1 BREATH .
- Compressions are performed using the method of two thumbs in the lower 1/3 of the sternum, to a depth of 1/3 of the anterior-posterior dimension.
- For very small premature babies or for single-person resuscitation,
pressure is used with the index and middle fingers.
Indications for cardioversion include the following conditions:
- hemodynamically unstable ventricular tachycardia,
- ventricular tachycardia resistant to pharmacological treatment,
- reentrant supraventricular tachycardia,
- hemodynamically unstable, atrial tachycardia (AT) / fibrillation ( AF ) / atrial flutter (Afl) with low cardiac output syndrome and hemodynamic instability.
- However, it is worth remembering that the effectiveness of cardioversion in the case of these [last mentioned] arrhythmias is much lower, because tachyarrhythmias caused by the reentry wave mechanism are more susceptible to cardioversion treatment .
Kussmaul’s breath (“dead dog”) -
- rapid, deep breathing, with a frequency of 40-70/min in an adult,
- is most often a symptom of metabolic acidosis (e.g. as a result of salicylate or alcohol poisoning , uremia, liver failure).
- It may also occur with damage to the pons and midbrain.
- When damage occurs in the central part of the pontine tegmentum, it is called central neurogenic hyperventilation.
Crystalloids include:
1) Ringer’s lactate - crystalloid
2) 0.9% NaCl - crystalloid
3) glucose
solutions:
- Ringer
- Hartmann
4) multi-electrolyte fluids
colloids include:
gelatine
HES - hydroxyethyl starch
dextran
albumin
Anaphylaxis is rapid appearance of symptoms and its progression
respiratory disorder symptoms:
- swelling in the respiratory tract,
- hoarseness,
- laryngeal wheezing (stridor),
Anaphylaxis is rapid appearance of symptoms and its progression
respiratory system disorders:
- tachypnea,
- whistling and roaring,
- excessive breathing effort,
- hypoxemia ( respiratory failure ) and its consequences,
Anaphylaxis is rapid appearance of symptoms and its progression
circulatory system disorders: symptoms
- hypotension ,
- tachycardia,
- changes in hypoxia in the ECG,
- impaired tissue flow,
- dizziness and loss of consciousness (cerebral circulation disorders),
- sudden cardiac arrest,
Anaphylaxis is rapid appearance of symptoms and its progression
changes in the skin and mucous membranes (80% of reactions):
symptoms
itching
erythema
hives
angioedema
Anaphylaxis is rapid appearance of symptoms and its progression
gastrointestinal disorders: symptoms
crampy abdominal pain,
vomiting,
Anaphylaxis is rapid appearance of symptoms and its progression
disorders of the urogenital system: symptoms
pressure on the bladder,
urinary incontinence ,
uterine contractions.
Calcium and phosphate metabolism
Calcium - Hypercalcemia - Causes
1) 90% of hypercalcemia cases are caused by:
HYPERPARATHYROIDISM and CANCER (The causes are osteolytic metastases and PTHrP secretion)
2) VITAMIN D3 poisoning (Poisoning may occur with exogenous vitamins or those produced by granulomas (sarcoidosis, tuberculosis) and lymphomas)
3) LONG-TERM IMMOBILITY.
Calcium and phosphate metabolism
Calcium - Hypercalcemia - Symptoms (hypercalcemic syndrome)
“Stones, bones, abdominal groans, thrones and psychiatric overtones”.
1) Stones → Gallstones and kidney stones (The cause is increased excretion of calcium in urine and bile)
2) Bones → BONE PAIN .
3) Abdominal groans (abdominal groaning) → abdominal pain, nausea, vomiting.
4) Thrones → POLYURIA leading to DEHYDRATION (Calcium reduces the reactivity of collecting tubule cells to vasopressin (nephrogenic diabetes insipidus)), constipation.
5) Psychiatric overtones (psychiatric nuances) → DEPRESSION , orientation disorders, drowsiness, coma.
6) ULCER DISEASE of the stomach and duodenum(High levels of calcium stimulate the secretion of gastrin, which in turn stimulates parietal cells to secrete hydrochloric acid.)
7) PANCREATITIS (Calcium ions activate pancreatic trypsinogen into trypsin, which digests the gland parenchyma. The pancreatic ducts may also become blocked by calcium stones that precipitate in the pancreatic duct.
8) CONSTIPATION
9) HYPERTENSION
10) Decreased muscle strength
Electrolyte disturbances
Calcium - Hypercalcemia - Clinical picture
- Drowsiness , coma
- DEHYDRATION .
- HYPOTONIA .
The patient has cancer metastases to the bones , which are a common cause of hypercalcemia.
clinical picture of hypercalcemia
kidney dysfunction :
polyuria ,
hypercalciuria,
calcinosis,
kidney stones,
clinical picture of hypercalcemia
gastrointestinal disorders :
- lack of appetite,
- nausea and vomiting,
- constipation ,
- stomach or duodenal ulcer (may cause abdominal pain),
- pancreatitis (may cause abdominal pain),
- bile duct stones (the condition may wrap around the cause of abdominal pain) ,
clinical picture of hypercalcemia
cardiovascular symptoms :
- hypertension,
- tachycardia (palpitations),
- arrhythmia (palpitations),
- hypersensitivity to digitalis glycosides,
- neuromuscular symptoms:
- muscle weakness,
- weakened tendon reflexes,
- temporary paralysis of facial muscles,
clinical picture of hypercalcemia
cerebral symptoms :
headache,
depression,
orientation disorders,
somnolence,
coma,
Atropine is used to treat
bradycardia
Emergencies related to environmental factors
Hypothermia - Procedure - Differences in CPR
- Resuscitation is allowed WITH INTERRUPTIONS .
- Bradycardia in hypothermia is INSENSITIVE TO ATROPINE .
Cardiac pacing is only indicated if
symptoms of hemodynamic instability persist after rewarming the patient. - Hypothermia is an indication for EXTENDED RESUSCITATION
- resuscitation should be carried out until the core temperature reaches >35°C!
antidote
Acetylcysteine (antidote) is used in cases of
paracetamol poisoning
Pulseless ventricular tachycardia is an indication for
defibrillation , not cardioversion.
What is used only after successful resuscitation to support heart contractility. It can also be used for bradycardia when atropine is ineffective?
dopamine
- Management of regular tachycardia with narrow QRS complexes (in a stable patient) begins with:
- VAGAL NERVE STIMULATION (carotid sinus massage and Valsalva maneuver are effective in one quarter of cases of paroxysmal SVT.),
- ADENOSINE in the scheme 6 mg → 12 mg → 18 mg.
Capnometry
– measurement of the concentration or partial pressure of carbon dioxide in blood or exhaled air.
Capnography
– registration of the curve of changes in this parameter during breathing.
- CAPNOGRAPHY WITH CURVE RECORDING is the MOST SENSITIVE AND SPECIFIC way to confirm the position and continuously monitor the location of the endotracheal tube
in people with cardiac arrest.
In the course of acidosis……………. is excessively released from cells and its intracellular transport is impaired, resulting in…………….
potassium
hyperkalemia
Electrolyte disturbances
Potassium - Hyperkalemia - Causes
- INSULIN DEFICIENCY.
- Metabolic acidosis .
- Aldosterone or GCS deficiency (Gamma-glutamyl-cysteine synthetase)
name 5
The indication for the administration of *magnesium sulfate *is ventricular tachycardia caused by poisoning with?
- class IA and III antiarrhythmic drugs
- tricyclic antidepressants
- antihistamines
- neuroleptics
CURB-65 scale makes it easier to decide on further treatment of a patient with:
pneumonia
CURB-65 scale (acronym)
Confusion - confusion
Urea - urea concentration
Respiratory rate - frequency of breathing
Blood pressure - blood pressure
65 years and over
Remember - the CRB-65 scale is used outside hospitals, CURB-65 - in hospitals, due to the possibility of measuring urea concentration.
antidote
Ethylene glycol (poison) -
ethyl alcohol (antidote)
Symptoms of tamponade are known as Beck’s triad :
1) Hypotension (often accompanied by a threadlike pulse and a severe, unstable condition of the patient).
2) Muffled heart sounds (inaudible heartbeat).
3) Excessive filling of the external jugular vein (increase in central venous pressure).
Each minute of delay in delivering a defibrillator reduces the likelihood of survival to hospital discharge by
10–12%
THe difference between systolic and diastolic pressure is called the?
The correct amplitude is ?
- pressure amplitude (pulse amplitude).
- 30-50mmHg
Paroxysmal states
Epilepsy - Treatment
During an epileptic seizure you should:
- keep calm,
- move the patient to a safe place,
- place the patient in the safe side position,
- remove the patient’s glasses, remove foreign bodies from the mouth, put something soft under the patient’s head,
- secure the patient and stay with him until he regains consciousness.
You should not: stand, wake, hold, or put objects in the patient’s teeth or hands.
A 75-year-old patient with permanent atrial fibrillation suddenly developed right-sided paresis with aphasia. The patient is not taking anticoagulant treatment. First you need to:
determine glucose concentration.
- The patient described in the question most likely suffered an ischemic stroke .
- Failure to use anticoagulant therapy in the setting of persistent atrial fibrillation is an important risk factor for cerebrovascular occlusion by cardiac embolism.
- Additionally, the patient had typical focal symptoms - hemiparesis and speech disorders ( aphasia ).
- Glucose measurement is the first test (after assessing vital functions) in patients with suspected stroke, which can be performed in pre-hospital conditions .
- It allows you to exclude hypoglycemia , which can also lead to focal neurological symptoms or generalized disorders of the central nervous system.
Disturbances in consciousness up to loss of consciousness, slow and shallow breathing, apnea, narrow (pin-shaped) pupils are symptoms characteristic of?
A specific antidote for opioid poisoning is?
- opioid toxidrome .
- naloxone , especially indicated in patients with developing respiratory failure . Moreover, due to apnea and a significant drop in oxygen saturation, the patient should be intubated and oxygen ventilation should be started .
Chest pain (a possible symptom of myocardial ischemia) and a drop in blood pressure to 70/50 mmHg (a characteristic feature of shock) indicate of ?
TX?
- hemodynamic instability –> electrical cardioversion should be performed as soon as possible .
The classic triad of symptoms of a ruptured abdominal aortic aneurysm includes:
pain, hypotension, and a pulsating mass in the abdominal cavity.
The most popular interview pattern is the interview using the English mnemonic SAMPLE:
S ( symptoms + pain ) - symptoms + pain ;
A (allergy) - alergie;
M ( medications ) - medications taken;
P ( past illness ) - medical history;
L ( last oral intake ) - last meal;
E ( events leading up to the illness/injury ) - an event preceding the illness.
AT-MIST acronym used to transmit information from the Emergency Medical Services to the Emergency Department:
- A ( age ) - age of the injured party,
- T ( time ) - time since the injury occurred,
- M ( mechanism ) - mechanism of injury,
- I ( injury ) - injuries, degree of hypovolemic shock,
- S ( vital signs ) - basic respiratory and hemodynamic parameters:
Assessment according to the ABCD scheme:
A ( airways ) - airway patency,
B ( breathing ) - respiratory rate + saturation,
C ( circulation ) - heart rate + blood pressure,
D ( disability ) - assessment on the AVPU or GCS scale, - T ( treatment given ) - emergency medical procedures performed.
Usually, ETA ( estimated time of arrival ) is also added - the approximate time of arrival at the Emergency Department.
advance trauma life support
- if only the patient’s carotid pulse is palpable, the systolic blood pressure is __mm Hg
- if carotid and femoral pulses are palpable, the systolic blood pressure is ___ mm Hg
- if the radial pulse is also palpable, the systolic blood pressure is more than ____mm Hg .
- 60-70 mm Hg
- 70-80 mm Hg
- 80 mm Hg
Bone fractures
First aid
Pott’s Laws:
1) In the case of a fracture of a long bone , at least two adjacent joints should be immobilized.
2) In the case of a joint injury , all bones forming that joint should be immobilized .
Kramer’s splints can be used for temporary immobilization.
Hypothermia
- Diagnosis - Clinical classification
Hyperthyroidism
Hyperthyroidism
Thyroid crisis – Treatment
1) Cold compresses and paracetamol
Attention!
- Salicylates are contraindicated in thyroid crisis!
- Salicylates displace T4 from its binding to its carrier protein TBG, thereby increasing free T4 levels.
2) Phenobarbital if seizures occur.
- Additionally, it accelerates T4 metabolism in the liver.
algorithm:
treatment of acute pulmonary edema, the drugs used first
Procedure diagram
1) Termination of seizures and prevention of their recurrence:
1) Place the mother in the recovery position, suction the secretions from the oral cavity, administer oxygen at 8–10 l/min, monitor blood oxygenation (pulse oximetry, possibly gasometry).
2) Use anticonvulsant therapy → magnesium sulfate (Inj. Magnesii Sulfurici Polpharma ) [Zuspan Method], e.g. 6 g over 15–20 min, then 2 g/h by continuous iv infusion for ≥24 h after delivery or after last seizure. If magnesium sulfate is ineffective → diazepam iv ( Neorelium , Relanium ) 10 mg or thiopental iv ( Thiopental ) 50 mg.
3) Maintain blood pressure 140–160/90–110 mm Hg, e.g. labetalol iv ( Trandate ) 20–40 mg iv every 15 min as needed. Use diuretics only in case of pulmonary edema.
4) In the event of signs of fetal distress, the pregnancy should be terminated urgently by caesarean section after the mother’s condition has stabilized. Otherwise, eclampsia is not an indication for caesarean section and delivery can take place vaginally, after possible induction.
Arterial hypertension
Eclampsia – Treatment
1) Termination of seizures and prevention of their recurrence:
– MgSO4 in a dose of 4–6 g iv administered within 20 minutes (usually 4 g within 5–10 minutes),
– then a dose of 1–2 g/h for at least 24 hours . 2) Pharmacological control of blood pressure (as in hypertensive crisis).
Zolpidem:
- is a hypnotic and anxiolytic drug from the imidazopyridine group,
- is a selective agonist of the omega-1 subunit of the GABA receptor,
- It is similar to benzodiazepines in terms of its mechanism of action and side effects; overdose is treated in the same way - by administering** flumazenil ,** which is a selective antagonist of benzodiazepine receptors.
Poisoning
Toxidromes - Sedative-hypnotic syndrome - Management
- Decontamination and accelerated elimination if indicated:
- ALKALIZATION of urine in PHENOBARBITAL poisoning .
- Antidotes:
- FLUMAZENIL in poisoning with BENZODIAZEPINES and “ZETKAMI” drugs .
- Symptomatic treatment.
In patients with ischemic stroke treatement
Indications for the use of antihypertensive drugs:
- In ischemic stroke - systolic blood pressure >220 mm Hg or diastolic blood pressure >120 mm Hg.
- If the patient is to receive thrombolytic therapy (regardless of whether they will undergo thrombectomy or not), blood pressure cannot exceed 185/110 mm Hg (in the first 24 hours it should be maintained at <180/105 mm Hg, but it is not recommended to achieve systolic blood pressure of 130-140 mm Hg in the first 72 hours after the end of treatment).
- In order to lower blood pressure in these patients, iv urapidil or labetalol is most often used.
- In the first hours after stroke and during thrombolytic therapy, blood pressure must be carefully monitored and lowered if it increases.
Substances that can be eliminated by hemodialysis include:
- alcohols ( methanol , glycol , isopropanol, ethanol, acetone);
- lithium;
- salicylates;
- paracetamol;
- barbiturates;
- carbamazepine;
- tricyclic antidepressants;
- valproic acid;
- sotalol, procainamide.
Treatment of anaphylaxis - adrenaline (IM, if you are not experienced in IV administration) dose of adrenaline IM 1:1000 (repeat after 5 minutes if no improvement):
adults - 500 μg IM (0.5 ml) 0.1%;
children >12 years of age - 500 μg IM (0.5 ml) 0.1%;
children 6-12 years of age - 300 μg IM ( 0.3 ml ) 0.1% ;
children < 6 years of age - 150 μg IM (0.15 ml) 0.1%.
The CURB-65 scale is used to assess
- the severity of community-acquired pneumonia (CAP) in patients treated in hospital settings .
- The parameters included in this scale are:
- confusion ,
- urea - urea concentration (> 7 mmol/l),
- respiratory rate - respiratory rate (≥30 /min),
- blood pressure - arterial blood pressure (systolic <90 mmHg; diastolic ≤60 mmHg),
- ≥65 years.
- NOTE:
- CRB-65 scale is used outside hospitals ,
- CURB-65 in hospitals, due to the possibility of measuring urea concentration .
Poisoning
Treatment - Causal treatment - Antidotes
AT-MIST acronym used to transmit information from the Emergency Medical Services to the Emergency Department: Name
- A ( age ) - age of the injured party,
- T ( time ) - time since the injury occurred,
- M ( mechanism ) - mechanism of injury,
- I ( injury ) - injuries, degree of hypovolemic shock,
- S ( vital signs ) - basic respiratory and hemodynamic parameters:
- Assessment according to the ABCD scheme:
- A ( airways ) - airway patency,
- B ( breathing ) - respiratory rate + saturation,
- C ( circulation ) - heart rate + blood pressure,
- D ( disability ) - assessment on the AVPU or GCS scale,
- Assessment according to the ABCD scheme:
- T ( treatment given ) - emergency medical procedures performed.
Usually, ETA ( estimated time of arrival ) is also added - the approximate time of arrival at the Emergency Department.
Division of anemia according to its severity:
- mild – Hb 10–12.0 g/dl in women, 13.0 g/dl in men,
- moderate – Hb 8–9.9 g/dl,
- severe – Hb 6.5–7.9 g/dl,
- life-threatening – Hb <6.5 g/dl.
