ER deck 2 Flashcards
When not to use succinylcholine for int
ubation
Succinylcholine raises potassium. Do not use it in a crush injury or burns or in patients with massive muscle denervation due to spinal injury as hyper Kalemia may be severe and cause ischemia and or myocardial infarction. Immobilization may also cause hyperkalemia so no succinylcholine for people with casts.
Also don’t use it in lithium, lithium increases onset time and duration of sedation with succinylcholine
Rocuronium dose
0.8 to 1.2 µg per kilogram. Usually 100 µg for the average adult. rocuronium comes in 50 µg ampules. If you’re intubating, make sure you have 220 gauge IV s in the antecubital and flush after the Rocuronium
Average dose of morphine and Zofran?
4 mg of each you can repeated every 15 minutes until you reach the max for morphine
PVC vs PAC
PVCs have WIDE QRSs. PVCs themselves have no P waves.
-BiGeminy - every other normal
QRS there is a PVC
- Trigeminy: Every 2nd normal
QRS there is a PVC
- Check K+, Ca++ and Mg++
and correct any derangements
PACs are narrow but just out of order. It may just look like an irregular sinus rhythm. There will be P waves for each QRS
HypoKalemia
below 3.5 [3.5 - 5 is normal]
presents usually as weakness, fatigue and exercise intolerance
give a bolus to restore but you’ll need to give Mg++ also as they run together and its hard to raise K+ if Mg++ is low. Go ahead and check Ca++ too.
Hypomagnesemia
Weakness
Tetany
Fatigue
Wide QRS to Torsades
Give MgSO4 and K+
Altered Mental Status DDX?
Alcohol/Drugs
Hypoglycemia
UTI (elderly)
Hypoxia
Hyponatremia
Head Trauma
Postictal period
Sepsis (usually other signs more
impressive than AMS)Vistaril
Hydroxyzine
Antihistamine for Anxiety and insomnia
H1 blocker
very old school but it works
Budesonide
Inhaled Steroid
Straight up it is PULMICORT
if mixed with Formoterol, a Long Acting Beta Agonist (LABA) it is SYMBICORT.
Ipatropium Bromide
Inhaled Anticholinergic
It decreases contractility of smooth muscle in the bronchioles by inhibiting ACh at muscarinic receptors. This prevents them from constricting in an asthma attack.
MDI or Nebulized
Straight up it is ATROVENT
Together with Albuterol in a NEBULIZATION it is DUONEB
Together with Salumetrol in an MDI it is COMBIVENT
It is more effective than albuterol alone
Liquid PREDNISONE dose in Asthma
0.5mg - 1mg / Kg in a divided dose
Treat early but in short bursts
I’ve read 3pm - 5 pm may be the best time of day to give the 2nd dose as it gives time for the steroid to calm the inflammation before bed.
DuoNeb
Ipatropium Bromide: Reduces
bronchial smooth
muscle contractility
anticholinergic
\+
Albuterol: Short Beta 2 Agonist
Only by nebulizer. The combo is more effective than either alone.
Combivent
Ipatropium Bromide: Reduces
bronchial smooth muscle
contractility
+
Salumetrol: Long Acting Beta 2
Agonist
Only by MDI.
Mainly for COPD
Asthmatics usually use DUONEB for severe rescue - that’s where they usually encounter Ipatropium. Its in the ED and on the Rigs.
Otherwise they use SYMBICORT for maintenance: a steroid + a LA Beta Agonist instead of COMBIVENT because the don’t usually need the Ipatropium.
Monteleukast
Singulair 10 mg/day
For allergic Asthma
Don’t Use Nitrofurantoin in…
past the 38th week of pregnancy and up to 1 Month Infancy. Causes Hemolysis.
in G6PD Deficiency (also don’t use Bactrim or Cipro in G6PD). Causes Hemolysis.
The Elderly in general. BEERS says no d/t:
It also causes Pulmonary Fibrosis and Inflammation at high levels so you don’t want to give it to folks with poor kidney function as high levels will result since it is renally cleared.
In the elderly, use Cefalexin (Keflex), also a good choice in G6PD, pregnancy and infancy
UTI Rx:
Nitrofurantoin 100mg BID X 7 days for Adults with good kidney function and no hemolysis risk (neonate, late pregnancy and G6PD). Risk of pulmonary fibrosis/inflammation in which case you STOP and SWITCH
Keflex (Cephalexin) 1st gen cephalosporin still kills e.coli
Use it when you can’t use Nitrofurantoin. Use it in elderly people.
Bactrim: 20% of e.Coli strains are resistant. Don’t use Bactrim or Cipro empirically
Ceftriaxone empirically if you can’t use Nitrofurantoin or Keflex. Then be sure to do a culture and switch if necessary.
G6PD Deficiency: Hemolysis. Heinz Bodies on a RBC Smear. Coombs test negative.
Don’t use Nitrofurantioin, Bactrim, Cipro
Mediterranean, African, Middle Eastern
Dk Urine (positive for RBCs or Hemoglobin) SOB, TACHY - because RBCs are stressed by hemolysis
Doesn’t present until a stressor (medication usually: Bactrim, Cipro, Nitrofur, Primiquine…)
Gastric vs Duodenal Ulcer sxs
DUODENAL: MOST COMMON ULCER
-Wakes Patient
-Pain relieved by food and comes back
after food has passed the duodenum in 1-2 hrs after eating
- H. Pylori
GASTRIC ULCERs: 2nd most common cause of GI Bleed
- Pain immediately on eating
- Early Satiety (weight loss...)
- NSAIDS
BOTH mainly caused by H. Pylori 70+ %
So… get a urea breath test before starting PPIs… otherwise you have to wait 14 days to get a reliable urea breath test result for PUD
Hydrogen breath test is for lactose intolerance.
Atrovent
Ipatropium, straight up
mix it with Salumetrol (a LABA) in MDI & you have COMBIVENT
mix it with albuterol in a neb & you have DUONEB
Bend, Lift, Twist….. (what gets hurt?)
DISC!!!
This is classic MOI for the slipped disc. CT the guy and send him off to PCP with a few days of valium. PCP can make the switch to Flexoril and send him to PT, order an MRI if he feels its necessary.
Ortho doesn’t do spines- Neurology does - let the PCP decide who to send him to. He’s going to need a work note.
Narcotics really won’t help. Heat and valium.
Document these parameters of intoxication always:
slurred speech,
nystagmus,
ataxia, and
somnolence
(+) slurred speech, (+) ataxia and (+) somnolence/stupor(-) nystagmus Put the negative last in your note
Establish the NEED for a drug/alcohol/tox screen in your note
Also go ahead and document :
Agitation
Aggression
Poor Insight
If you are ETOH, DRUG or TOX screening a competent not intoxicated patient, obtain verbal and, where possible, written consent.
The BIG CLUE in Salicylate Toxicity?
TINNITUS
Tinnitus with a significant anion gap acidosis is classic. Aspirin is, after all, an acid.
Agitated Delerium, Tachycardia Tachynea and Elevated temp as well but Tinnitus is the red flag.
Salicylate screening is part of the required MH Tox screen at CMC but not necessarily part of the alcohol screening
Add “Any recent ringing in your ears” to your ROS for altered mental status or just plain sick people.
Max time to administer Mucomyst orally in suspected Acetaminofen toxicity
8 - 10 hrs.
You draw the blood for testing at 4 hrs, if you know when it was ingested. Then you give the rescue loading dose, which is weight based.
If you don’t know the time of ingestion or it is beyond 8 hrs. take the blood then Just give the loading dose, adjust it when the levels come back
First dose is meant to be oral. Activated charcoal the pt if ingestion is within 1 hr of arriving at ED. Gastric Lavage as well. If Over two hrs, you may be out of luck for physically removing the acetaminophen.
n-acetylcystine
Mucomyst
Tylenol overdose
