Exam 4 Flashcards
Most commonly involved drugs in adult poisoning
- analgesics
– sedatives/hypnotics/antipsychotics
– antidepressants
Approach to patient with unknown overdose
- contact Poison Control Center
- obtain H&P and PMH, although may not be possible
- assess underlying conditions, chronic illnesses, suicidal or not?
- MATTERS acronym
MATTERS acronym
- Medication/substance ingested
- Amount ingested
- Time of ingestion
- Toxicology of the drug
- Emesis/presence of pill fragments
- Reasons for ingestion
- Signs and symptoms
Rapid first look: toxidrome oriented physical exam
- vital signs – hypo or hypertensive, brady or tachycardic
- alert, responsive to voice, responsive to pain, or unresponsive
– pupil size, position, nystagmus - mucous Membranes
- skin temperature and moisture
– presence/absence of bowel sounds
– motor tone
General toxicology Diagnostics
- 12 lead EKG
– plain film radiographs; not much benefit unless packing or drug is radiopaque, or looking for aspiration - toxicology screens: acetaminophen, salicylates, “drugs of abuse” immunoassay, comprehensive urine drug screen
- CMP, K, calcium, glucose, liver enzymes, kidney function, CBC, lactate, ABG
ICU admission criteria for toxicology
- hemodynamic instability: hypotension, non-sinus rhythm, hypothermia, hypoxia
- signs of end organ damage: GCS < 13, unable to protect airway, confusion requiring monitoring for respiratory depression, renal failure, hypertensive emergency, heart block (other than first-degree), life-threatening electrolyte imbalances, rhabdomyolysis, DIC, seizures
- if none of the above are present, they can go to a general medical floor
Be aware of post admission delayed toxic effects
- Late toxic effects: sustained release drugs or problems with absorption
– acetaminophen peaks 24 hours post ingestion
– oral hypoglycemics, insulin, TCAs - methanol, Ethylene glycol, isopropyl alcohol peaks over six hours post ingestion
- ingested drug packets
Geriatric considerations for poisoning/toxicology
- Polypharmacy can lead to unintentional overdose; but do NOT rule out intentional overdose
- May have atypical presenting symptoms
– decline in GFR and creatinine clearance
Pathophysiology of acetaminophen toxicity
Small amount is metabolized to a highly toxic reactive intermediate called NAPQI. NAPQI is normally detoxified by glutathione, but when you take too much acetaminophen, the liver runs out of glutathione leaving a build up of the toxic byproduct NAPQI
acetaminophen toxicity presentation
- often asymptomatic or have mild G.I. symptoms at initial presentation
- can cause varying degree of liver injury over the next four days
- Time sensitive: people treated within eight hours of ingestion rarely have hepatotoxicity; hepatotoxicity can occur with ingestion of over 10 g in 24 hours
Four phases of acetaminophen poisoning
- phase 1: <24 hours; anorexia, malaise, pallor, n/v, diaphoresis
- phase 2: 24-48 hours; RUQ pain, abnormal LFTs
- phase 3: 48 to 96 hours; encephalopathy, coagulopathy, hypoglycemia, LFT peaks, rare – pancreatitis, ARF, MI
- phase 4: >96 hours; decreased LFTs, liver transplant, death, or recovery
Diagnostics for acetaminophen toxicity
- plasma acetaminophen level: must be 4+ hours after ingestion to be accurate/have utility
- baseline AST, AL T, PT/INR, creatinine, serum lactate
- toxicology screen
- Rumack-Matthew monogram: used to decide whether to treat with n-acetylcysteine (Mucomyst) or not
G.I.decontamination for acetaminophen overdose
- emesis and gastric lavage are not recommended
– activated charcoal can be considered if presenting within two hours of ingestion - give anti-emetics (especially if giving acetylcysteine orally)
Antidote for acetaminophen overdose
- Acetylcysteine
- if given within 8 HOURS of ingestion, serious hepatotoxicity and death are uncommon (do not delay giving waiting for the 4 hour level and Rumack Matthew nomogram)
Indications for acetylcysteine administration
- suspected single ingestion of > 150 mg/kg and patient with unavailable concentration
- patient with unknown ingestion time and serum level > 10 µg/milliliter
- patient with history of APAP ingestion and evidence of any liver injury
- patient with delayed presentation (>24 hours) with lab evidence of liver injury
Acetylcysteine dosing
20 hour IV protocol
- initial loading dose of 150 mg/kg IV over 15-60 minutes
- then administer a 4 hour infusion at 50 mg/kg at 12.5 mg/kg/hr IV
- finally administer 16 hour infusion at 100 mg/kg at 6.25 mg/kg/hr IV
72 hour PO protocol
- loading dose of 140 mg/kg PO then 70 mg/kg PO q4h for a total of 17 doses for 72 hours
Kings college criteria
- developed to determine which patients with fulminant hepatic failure should be referred for liver transplant
- PH < 7.3, PT < 100, Cr 3.4 mg/dL with grade 3 or 4 encephalopathy
Diagnostics for alcohol and glycol poisoning
- blood ethanol, methanol, ethylene glycol
- serum osmolality
- CMP
- ABG
Ethanol toxidrome
- CNS depression
- ataxia
- dyarthria
- odor of ethanol
Ethanol metabolism
- Gets broken down by liver enzymes to acetaldehyde and then to acetate
- acetaldehyde is toxic to the liver
- this process also creates free radicals which cause more damage
Ethanol management
- IV fluids
- thiamine (B1) deficiency is common in etoh dependence
— Wernicke’s encephalopathy is under-diagnosed and under-treated - if CNS depression: intubate, gastric lavage if < 1 hour
- charcoal NOT helpful
- observe and hold until sober or etoh is < 100 mg/dL
- watch for delirium tremens
- always assess for intent
Isopropyl management
- examples: rubbing alcohol, solvents for cosmetics
- can cause CNS depression: 2x more potent than ethanol and duration of action is 2-4x times longer than ethanol
- lavage and charcoal if within one hour of ingestion
- IV fluids
- if hypotensive despite treatment, HD to remove acetone
Isopropyl metabolism
Broken down by the liver to acetone
Examples of methanol
Found in wood alcohol, paint thinners, fuel additives
Methanol metabolism
Methanol gets broken down by the liver into formaldehyde and then into formic acid which causes metabolic acidosis and tissue injury
- formic acid is the toxic metabolite
Unique methanol symptoms
- takes 12 to 24 hours for methanol to become toxic due to metabolism timeframe
- Visual changes: non-reactive mydriasis, photophobia, papilledema
Methanol management
- lavage if within one hour of ingestion
- folinic acid: facilitates the breakdown of formic acid into CO2 and H2O
- IV NaHCO3 for severe acidosis
- HD for MeOH > 50 ml/dL, severe acidosis, renal failure, or visual symptoms
- antidote: Fomepizole
Fomepizole indications
- anion gap metabolic acidosis, visual disturbances, oxalate crystals in the urine, methanol concentration > 20 mg/dL
- stop the infusion when MeOH < 20 mg/dL or undetectable, normal pH, and is asymptomatic
Ethylene glycol metabolism
Gets broken down into glycoaldehyde and further into glycolic acid (glycolate) which is the toxic metabolite
Presentation of ethylene glycol poisoning
- timing can vary, stages can overlap, multiple organ systems are affected
- neurologic stage: 30 minutes - 12 hours
— glycol acid and calcium oxalate crystals – cerebral edema, seizures, infarction, meningolencephalitis - cardiopulmonary stage: 12-24 hours
— most deaths occur at this stage
— tachycardia, tachypnea, HTN, HF, acute lung injury
— Hypocalcemia: EKG changes are QT prolongation, myocardial depression, arrhythmias - renal stage: 24-72 hours
— due to calcium oxalate crystals deposition in proximal tubules, the most common major complication
— May need short term HD, can take kidneys weeks to months recover
Management of ethylene glycol poisoning
- charcoal and lavage if < 1 hour since ingestion
- correct acidosis with NaHCO3 of pH < 7.2 (used more in methanol poisoning)
- Fomepizole (same dose as MeOH)
- pyridoxine and thiamine IV
- HD for severe cases: glycol level > 50 mg/dL, pH < 7.3, hemodynamically unstable
Assessment findings of opioid overdose
- toxidrome: miosis (constricted pupils), respiratory depression, CNS depression, hypothermia, bradycardia, euphoria to coma
- IF MIOSIS AND RESPIRATORY DEPRESSION, ALWAYS CONSIDER OPIOID OVERDOSE
- non-cardiogenic pulmonary edema especially with heroin
- GI: Decreased bowel sounds and motility, ileus, nausea and vomiting
Opioid overdose management
- G.I. decontamination: no charcoal, no emesis, whole bowel irrigation for body packers (contraindicated if packages are leaking or bowel perforation)
- HD
- Surgery for a bowel obstruction or necrotic bowel syndrome
- antidote: naloxone
— goal is not a normal LOC, but adequate ventilation and spontaneous respirations
— 0.2-1 mg for apneic, minimum 2mg for cardiopulmonary arrest
Examples of cholinergics
- Direct cholinergic receptor stimulus: bethanechol (urecholine), pilocarpine
- acetylcholinesterase inhibitors: insecticides, organophosphates, neostigmine
Cholinergic toxidrome
Salvation, lacrimation, diaphoresis, vomiting, urination, defecation, bronchorrhea, muscle fasciculations, weakness, bradycardia, seizures
Management of cholinergic overdose
- aggressive dermal and G.I. decontamination: charcoal and lavage if < 1 hour of exposure
- treat seizures with benzos: lorazepam and diazepam
- antidotes
— atropine 2mg followed by double doses every 5 minutes until secretions are controlled
— 2-PAM can be given in severe cases
Anticholinergic overdose toxidrome
- Altered mental status, dry flushed skin, urinary retention, decreased bowel sounds, dry mucous membranes
- dry as a bone, red as a beat, hot as a hare, blind as a bat, mad as a Hatter, stuffed as a pipe
- can’t see, can’t pee, can’t sit, can’t shit
Anticholinergic overdose management
- observation, monitoring, supportive care
- Control agitation: benzos, phyostigmine
Beta blocker overdose assessment and findings
- cardiac: bradycardia, brady-dysrhythmias, conduction abnormalities, hypotension
- pulmonary: bronchospasm/constriction
- CNS: depressed LOC, seizures, coma
Beta blocker overdose diagnostics
12-lead EKG: progressively worsening sinus bradycardia, increased PR intervals, loss of atrial activity, AV junctional rhythm, widening QRS complex, AV block, idioventricular rhythm, asystole
Beta blocker overdose management
- hypotension: 20 ml/kg IVF, Trendelenburg positioning
- Inotropes: dopamine, milrinone (effect contractility)
- chronotropes: atropine, epinephrine (effect heart rate)
- HD, temporary pacemaker, CPR
Calcium channel blocker overdose assessment and findings
- CNS: Drowsiness, seizures, altered LOC
- cardiac: bradycardia, tachycardia, hypotension
- GI: Enteric dysmotility, bowel perforation
Calcium channel blocker overdose diagnostics
EKG: Bradycardia, tachycardia (reflects secondary to vasodilation), AV blocks, BBB, ST-T-wave changes
Calcium channel blocker overdose management
- G.I. decontamination: charcoal if < 1 hour since ingestion, gastric lavage, whole bowel irrigation
- hypotension: 1L boluses NS or LR
Digitalis overdose assessment and findings
- CNS: drowsiness, lethargy, headache, hallucinations
- cardiac: palpitations, dyspnea, bradycardia
- Visual: photophobia, yellow halo around lights, snowy vision
- GI: Anorexia, nausea, vomiting, abdominal pain
Digitalis overdose diagnostics
- SERUM DIGOXIN LEVEL: toxic = > 0.2 mg/dL
Digitalis overdose management
- G.I. decontamination: charcoal if within 6-8 hours of ingestion
- correct electrolyte imbalances
- antidote: digoxin immune fab (Digiband)
Salicylate overdose assessment and findings
- TINNITUS, TACHYPNEA, FEVER
- Altered mental status, tachycardia, diaphoresis
Salicylate overdose diagnostics
- serum salicylate level is symptomatic at 40 mg/dL, severe intoxication at > 70 mg/dL
Salicylate overdose management
- G.I.decontamination with activated charcoal
- urine excretion or alkalization
— LR or NS 10-20 ml/kg/hr until urine output of 1-1.5 ml/kg/hr is established
— IF > 40 mg/dL: 100 mEq NaHCO3 in 1L D5W - HD if serum level > 120 mg/dL, pulmonary edema, or volume overload
Benzodiazepine overdose toxidrome
CNS depression, ataxia, dysarthria, bradycardia, respiratory depression, dizziness, hypotension
Benzodiazepine overdose antidote
- Naloxone: 0.05 mg initially, increase PRN
- Flumazenil: begin at 0.2 mg IV
Antidepressant overdose assessment and findings
- CNS: altered LOC, delirium, seizures, psychotic behavior, hallucinations, stupor, coma
- cardiac: hypotension, dysrhythmias, tachycardia, torsades
- pulmonary: acute lung injury, hypo ventilation, aspiration pneumonitis secondary to CNS depression, ARDS
- anticholinergic: hypothermia, dry skin and mucous membranes, decreased gastric motility, urinary retention
Antidepressant overdose diagnostics
- 12-lead EKG: QTc prolongation, QRS prolongation
Antidepressant overdose management
- Dysrhythmias: give sodium bicarb until pH is 7.45-7.55 (do not give procainamide, beta blockers, or calcium channel blockers)
- hypotension: isotonic IVF, NaHCO3
- convulsions: benzodiazepines
- G.I. decontamination: activated charcoal
General information about trauma
- top etiologies: MVC’s, falls, violence, being struck by/against an object
- # 1 under recognized public health problem in the United States
Golden hour
- patient has 60 minutes from time of injury to receive definitive care after which morbidity and mortality increase significantly
- historically has been a tri-modal distribution of death but now is bi-modal
Advanced trauma life support underlying concepts and basic principles
Underlying concepts
- treat the greatest threat to life first
- never allow the lack of definitive diagnosis to impede the application of indicated treatment
- a detailed history is not essential to begin the evaluation of a patient with acute injuries
Basic principles
- injury kills in a certain reproducible timeframe: ABCDE approach
- Rapid initial assessment & primary treatment
ATLS Basics
Primary survey – very rapid initial assessment, seconds to minutes
Adjuncts to primary survey - additional tools/diagnostics/interventions we have at our disposal
Secondary survey - more detailed head to toe approach
Initiate definitive care – usually happening simultaneously
Tertiary survey - more complete head to toe
Hospital phase - preparing for arrival
- resuscitation area/trauma room/bay with functional airway support, monitoring equipment, protocol to summon additional assistance, warm IV crystalloids, transfer agreements when appropriate, standard precautions
- EFFECTIVE COMMUNICATION
The big six deadly problems
- airway obstruction – tension pneumothorax – open pneumothorax – flail chest – cardiac tamponade – massive external or internal hemorrhage
ATLS primary survey - A
Airway with restriction of cervical spine motion
Assess patency of airway plus simultaneous C-spine immobilization
Gag reflex, pooling or copious secretions/bleeding
Suction
Airway management
Airway maintenance
Drug assisted intubation agents a.k.a. rapid sequence intubation
ATLS – primary survey: airway management
- oxygen, anticipate vomiting, plan for a, B, and C
- predict a difficult airway: LEMON (Look externally (facial trauma, large incisors, beard, large tongue), Evaluate the 3-3-2 rule, Mallampati score, Obstruction, Neck mobility)
- +/- drug assisted intubation (DAI)
ATLS – primary survey: airway maintenance and definitive airways
- Chin lift, jaw thrust, nasal pharyngeal airway, oral pharyngeal airway, extraglottic/superaglottic devices
- definitive airways: oral endotracheal intubation, nasotracheal intubation, surgical airways breakaway cricothyroidotomy, tracheostomy
- indications for a definitive airway: inability to maintain patent airway by other means, inability to maintain adequate oxygenation, obtundation or combativeness resulting in hypotension, GCS < 8
ATLS – primary survey: drug assisted intubation agents
- Etomidate: Little hypotension, no analgesic affect
- ketamine: provides analgesia in addition to analgesic and sedative effect
- midazolam: amnesic properties, can result in hypotension, no analgesic effect
- propofol: dose-related hypotension, no analgesic effect
ATLS – primary survey: Breathing & ventilation
- expose neck and chest
– inspect and determine rate/depth/quality of respirations - auscultate, quick and dirty, do they have bilateral breath sounds?
- breathing management
ATLS – primary survey: Breathing & ventilation - breathing management
- oxygen: nasal cannula, facemask, bag mask ventilation, mechanical ventilation
- SPO2
- chest decompression: moving away from needle decompression and going towards finger thoracostomy
- ventilatory support
- analgesics, careful anxiolytics
ATLS – primary survey: Circulation
- assess level of consciousness and skin perfusion
- pulse (central): feeling pulses doesn’t necessarily mean that you have adequate perfusion
- blood pressure (manual first!)
- identify sources of external bleeding and potential sources of internal bleeding
- circulatory management
ATLS Management: circulation - circulatory management
- cardiac monitor
- source control: Direct pressure, reduce/stabilize long bone injuries, pelvic binder, splint/reduce/traction extremities, definitive control (surgery)
- IV access: at least an 18G
- resuscitation: replace volume loss with warmed IVF and blood products
- surgical consultation, IR consultation
- remember that vasopressors are contraindicated in trauma patients except for very specific circumstances only
ATLS Management: circulation - types of responders
- rapid: respond to a bolus, no signs of perfusion issues
- transient: respond at first and then deteriorate, may need more, low threshold for blood products
- minimal/none: look for source of bleeding
ATLS Management: Disability/neurologic status
- GCS, pupil size/reaction
- ID lateralizing gaze: Unequal pupils, deviation, facial symmetry, unilateral reflex
- management: prevent secondary injury!, Transfer to neuro center, consult neurosurgery PRN
ATLS Management: expose and environment
- completely undress the patient
– trauma 4 Person logroll: look at the back! - environment management: warm trauma room/bay, warm blankets, external warming devices PRN, warmed IVF/blood products
Hemorrhagic shock
- recognize presence of shock ➡️ ID probable cause ➡️ treat
- any trauma patient who is cool to touch and tachycardic is in shock until proven otherwise
- classes of hemorrhagic shock
Four classes of hemorrhagic shock
- class 1: up to 750 mL, < 15%, usually no VS changes, normal compensatory mechanisms will restore blood volume in 24 hours
- class 2: uncomplicated hemorrhage, 750-1500 mL, 15-30%, crystalloid resuscitation required, most are rapid responders, subtle CNS changes, subtle VS changes
- class 3: complicated hemorrhage, 1500-2000 mL, 31-40%, crystalloid resuscitation with blood products, classic signs of inadequate perfusion
- class 4: 2000+ mL, >40%, pre-terminal event unless aggressive measures taken, huge change in VS, massive transfusion protocol and surgery
Review of other types of shock
- Cardiogenic: could come from blunt cardiac injury, cardiac tamponade, air embolus from long bone fracture, MI; suspect particularly if blunt trauma to chest
- cardiac tamponade: comes from penetrating or blunt trauma; muffled heart sounds, JVD, hypotension
- tension pneumothorax: absent breath sounds
- neurogenic shock: classic here is hypotension without tachycardia, don’t respond to fluids,”warm shock”
- septic: not likely unless it’s a delayed presentation
Special considerations with hemorrhagic shock
- geriatric: decreased sympathetic activity, decreased cardiac compliance, vascular occlusive changes, pre-existing volume depletion, meds, reduced physiologic reserve
- athletes: blood volume increased 15-20%, lower resting heart rate
- pregnancy: normal hypervolemia, physiologic anemia of pregnancy, hypocapnia late in pregnancy
- pacemakers/ICD’s: unable to respond to blood loss as expected
- meds: beta blockers, CCB, long-term diuretics, NSAIDS
ATLS Management: adjuncts to primary survey
- can’t happen simultaneously with primary survey as long as they don’t distract from the primary survey
- monitoring: ECG, cardiac, respirations, pulse ox, capnography +/-ABG
- tubes: IV access, urinary, gastric
- labs: CBC, type in screen, lactate, metabolic panels, coags, UA, toxicology screens, hCG
- x-ray and diagnostic studies: CXR, pelvis, DPL, FAST/eFAST
- consider the need to transfer early!
Trauma triad of death
- these are the leading causes of death patient and they feed into each other
- hypothermia, coagulopathy, metabolic acidosis
Thoracic trauma: primary survey problems
- airway: obstruction, tracheobronchial tree injury
- breathing problems
— tension pneumo: immediate decompression with finger thoracostomy
— open pneumo: 3-sided occlusive dressing
— massive hemothorax: midline trachea, immediate decompression with finger thoracostomy - circulation problems
— massive hemothorax
— cardiac tamponade: hypotension, muffled heart sounds, JVD; FAST exam to help diagnose; pericardiocentesis or sternotomy
— traumatic cardiac arrest: most common rhythm is PEA
Thoracic trauma: secondary survey problems
- Single/multiple rib fractures
- simple pneumothorax: if >35 mm, will need a chest tube
- Hemothorax: if large enough to be seen on x-ray, needs a chest tube
- flail chest: 2+ ribs in 2+ places
- pulmonary contusion: common with rib fractures, “ blossoms”, gets worse before they get better
- Blunt cardiac injury: can cause arrhythmias on ECG monitoring; TTE; troponins are worthless
- traumatic aortic disruption: CT, beta blockage, MAP’s should be 60-70
- traumatic diaphragmatic injury: surgical repair required
- Blunt esophageal rupture
Abdominal and pelvic trauma: blunt injury
Seatbelts, lower rims of handlebars, doors, falling into an object, steering columns
Indications for a laparotomy
- Blunt abdominal trauma with hypotension, +FAST, clinical evidence of intraperitoneal bleeding
- hypotension with abdominal wound that penetrates anterior facia
- GSW that transverses abdominal cavity
- bleeding from stomach, rectum, GU tract following penetrating trauma
- contrast CT demonstrating rupture of G.I. tract
- blunt or penetrating trauma with aspiration of G.I. contents
Diaphragmatic injury
- Blunt tear, left is more common
– may see luring of hemidiaphragm on CXR or obvious G.I. contents in left chest - CTF stable
– laparotomy, thoracotomy, laparoscopy
Duodenum injury
- classic in unrestrained driver and frontal impact collision and direct blow to abdomen; also handlebar injuries
- CT is diagnostic, suspect if NG/OG tube has blood coming out or see retroperitoneal air on image
- urgent/emergent laparotomy
GU injuries
- contusion, hematomas, ecchymosis of flank/back are markers of underlying renal injuries
- Gross hematuria and microscopic hematuria
- CT scan usually is diagnostic
- usually non-operative for renal injury
Pancreatic injury
- Direct epigastric blow that compresses the pancreas against vertebral column; handlebar injuries
- EARLY normal and amylase does not exclude
- CT may not identify immediately post-injury (up to eight hours), likely needs repeat imaging
- May need surgical intervention
Hollow viscus injuries
- often delayed finding in blunt trauma
- Low threshold to Lap
Solid organ injuries
- liver, kidney, spleen
- hemodynamically normal: admit and observe
– hemodynamically unstable: emergent surgery - all solid organs have a grading scale
Pelvic fractures
- lateral compression: 60-70%, constellation of sacral fractures and rami fractures
- vertical sheer: 5-15%, disrupted symphysis, sacral fractures
- windswept pelvis: AP compression on one side and lateral compression on the other, pelvis is “scrunched”
- AP compression: 15-20%, widened pubic symphysis, widened SI joints
- management: resuscitation, pelvic binder/sheet, no repeat exams, IR for embolization, ortho consult
Head trauma
- PRIMARY GOAL: prevent secondary injuries
- CT scanning should NEVER delay transfer to definitive care
Classification of head trauma injuries
- based on severity: mild (GCS 13-15), moderate (GCS 9-12), severe (GCS = 8)
- based on morphology: skull fracture (vault or basilar) or intracranial lesions
Types of focal intracranial lesions
- epidural hematoma
- subdural hematoma
- subarachnoid hematoma
- Intraparenchymal hemorrhage
- contusions
Epidural hematoma
- relatively uncommon
– classic is lucid interval then deterioration - 2.4-4% of cases with overall mortality of 10%
- cranial fractures are present in 70-90% of cases
- CT scan characteristic: appears as a lemon shape against the skull
Subdural hematoma
- more common
– damage underlying acute subdural hematoma is typically more severe than epidural hematoma due to presence of concomitant parenchymal injury - acute subdural hematoma is seen in 12-29% of severe TBIs and has a mortality rate of 40-60%
- CT scan characteristic: thin layer against the skull, non-lemon shaped
Subarachnoid hemorrhage
- most frequent traumatic brain lesion
- traumatic subarachnoid hemorrhage occurs in roughly 35% of TBI‘s
- results from rupture of corticomeningeal vessels and from hemorrhagic contusions of the brain
- usually it is diffuse and does not exert localized pressure
- blood is diluted by CSF and does not clot unless it is massive
Intraparenchymal hemorrhage
- these are tough because you cannot evacuate these
Examples of diffuse intracranial lesions
- concussions, multiple contusions, hypoxic/ischemic injuries, axonal injury
General management for mild and moderate brain injury
- mild: don’t need neurosurgery consultation, can even discharge from the ER, if GCS is 13 or 14 do a CT with serial exams until GCS is 15
- moderate: neurosurgery consultation, focused neuro exams, CT scan always with follow-up CT scan in 12-24 hours or if any changes occur
General management for severe brain injury
- neurosurgery consultation with frequent neuro exams
- serial CT scans: typically at 6, 12, and 24 hours (do not send unstable patient to CT scan, go to OR first)
- SBP <100 (ages 50-69) or <110 pages 15-49, 70+)
- mannitol?: PRN for increased ICP normal (ICP is 7-15 mmHg)
- hypertonic saline: PRN for increased ICP
- Antiepileptics: typically a 7 day course
- AVOID HYPOXIA AND HYPOTENSION
Facial fractures- LeFort fractures
- suspect facial trauma with any head and neck trauma
- Pay special attention to VISUAL ACUITY AND OCULAR EXAM
- occlusion, look for interior open bite and midfacial mobility
- carefully inspect dentition, remove any dental fragments from the mouth
- look at bony symmetry in palpate step offs at nasal dorsum, inferior orbital rims, zygomaticofrontal suture area, and zygomatic arch
- cranial nerve V2sensation
- scored as a level 1-3; level 3 means they essentially have a floating mid face
- Will need plastics/OMF depending on facility
Spine and spinal cord injury
- IF spine is protected: okay to defer evaluation/exclusion of injury
- 4 people to log roll safely
- Levophed is preferred vasopressor for hypotension in spinal cord injuries because it acts on both alpha and beta receptors
Neurogenic shock vs. spinal shock
- neurogenic shock: loss of vasomotor tone and sympathetic innervation of the heart, typically T6 and above, need fluids, “warm shock“
- spinal shock: flaccidity and loss of reflexes that occurs immediately after a spinal cord injury
Spinal cord syndromes
- Central cord: disproportionate loss of motor in upper extremities, typically after hyperflexion injury with pre-existing spinal canal stenosis, some recovery with aggressive rehab
- Anterior cord: injury to motor in sensory pathways with paraplegia and bilateral loss of pain and temperature sensation; sensation is intact to position, vibration, deep pressures; poorest prognosis for recovery
- Brown-Sequard: how many section of cord, penetrating, ipsilateral motor loss and loss of position sense, associated with contralateral loss of pain and temperature beginning 1-2 levels below injury, some recovery usually achieved
C-spine fractures
- Atlantooccipital dislocation: severe flex/distraction injury, most die but can survive if properly resuscitated at the scene
- Atlas (C1) fracture: multiple types, need rigid C-collar
- Axis (C2) fracture: largest cervical vertebrae, most unusual shape, (odontoid) is specific part of C2 that is susceptible to fracture, c-collar vs. surgical repair
- C5-5: AREA OF GREATEST FLEXION/EXTENSION LEADING = MOST VULNERABLE AREA, C5 fracture is most common
- BLUNT TRAUMA TO NECK CAN RESULT IN CAROTID AND VERTEBRAL ARTERY INJURIES: Early recognition and treatment is needed to prevent strokes, CTA indicated
Thoracic spine fractures
- anterior wedge fracture: compression
– chance fracture: transverse fracture through vertebral body
– fracture/dislocation: relatively uncommon, can be caused by extreme flexion/severe blunt trauma, commonly results in complete injuries to spinal column due to narrow canal through here - NOTE: T11-L1 at thoracolumbar junction are almost always unstable due to immobility of thoracic spine compared to lumbar spine, falls from height and restrained drivers are at risk
Lumbar spine fractures
- injury patterns similar to thoracic types
- cauda equina is involved
- probability of complete neurodeficit much lower with lumbar injuries
Spinal fracture rules of thumb
- restrict spine motion
- ABCDE
– consult spine
– transfer
Musculoskeletal trauma - limb threatening injury
- always x-ray above and below the fracture
- crush injuries: aggressive resuscitation
- Open fracture and open joints
- vascular injuries
- compartment syndrome
- neurologic injury secondary to fracture/dislocation
Vascular injury management
- need a CTA
- concerning findings: pulsatile bleeding, arterial thrill on palpation, bruit, signs of distal ischemia, visible expanding hematoma
Compartment syndrome - the 6 P’s
- pain
- poikilothermia
- pallor
- pulselessness
- paralysis
- paresthesia
Geriatric trauma considerations
- pre-existing conditions: I.e., cirrhosis, coagulopathy, COPD, ischemic heart disease, DM, etc.
- normal physiologic changes of age
- palliative/goals of care conversations early on!
Trauma in pregnancy considerations
- considered an intra-pelvic organ until 12 weeks gestation
- HR increases to 10-15 over baseline by third trimester
- eclampsia of later pregnancy can mimic TBI
- displace to left: vena cava compression can impede venous return
- Rh negative patients should receive Rh immunoglobulin unless injury remote from uterus
Transfer to definitive care for trauma patients
- if definitive care cannot be provided at local hospital, transfer to closest appropriate hospital that has resources and capabilities
- do NOT delay transfer to obtain imaging
- become familiar with local/system/community protocols
- when in doubt, call trauma surgeon on call
Goals of palliative care
- prevent or relieve suffering
- support the best possible quality of life for patients and their families
- make sure therapies are in accordance with their values and preferences
Differences between palliative and hospice: palliative care
- location: home, facility, clinic, hospital
– team: palliative MD or APRN, palliative care social worker, chaplain
– patient goals: disease modifying treatment, re-hospitalization when declining
– provider goals: continuation of treatment if treatment meets patient goals, symptom management to accommodate - Who to call for acute medical needs: 911, ED, or PCP
Difference between palliative and hospice: hospice
- location: home, facility, inpatient hospice
– team: hospice RN typically visits 2-3x/week, hospice MD or APRN visits & 24/7 availability, bath aids 2-3x/week, volunteers, hospice social workers - patient goals: comfort and peace through natural end of life, no rehospitalization, < 6 month life expectancy
- provider goals: optimal symptom control, spiritual calm, social interaction, achieving “bucket list“ goals
– who to call for acute medical needs: hospice nurse who will advise/visit and collaborate with hospice physician
Benefits of palliative care
- increased symptom control, patient/family involvement, coordination of care between specialties
- Advanced care planning and education about chronic disease stages
Determining next of kin if there is no medical POA documentation
Patient spouse unless legally separated ➡️ adult child of patient ➡️ domestic partner ➡️ siblings ➡️ close friend ➡️ attending position with ethics committee consult
Symptom management: dyspnea
- opioids are the drugs of choice at the EOL as well as dyspnea refractory to the treatment of the underlying cause
- majority of data is on morphine, effect on the dyspnea felt to be a “class effect“
- non-pharm options: positioning, increasing air movement with a fan, relaxation techniques, acutely dying (D/C fluids, no reason to go beyond 4-6 L O2, do not titrate to 02 saturation)
Dysphasia: artificial nutrition and hydration in dementia
- PEG tubes do not prevent aspiration and may increase risk if reflux occurs
- tube feeding has not shown benefits in preventing aspiration pneumonia, prolonging survival, preventing pressure ulcers, improving functional status, or increasing patient comfort
Patient assessment and documentation near EOL
Nutrition, activity levels, comfort (not indicated by vital signs), breathing pattern, depressed LOC, decreased urine output, temperature fluctuations, comfort medications (opioids for dyspnea, benzo’s for anxiety/restlessness), tasks after death
SPIKES Protocol
- goal is 4 objectives: gather info from patient/family, deliver medical info, support for patient/family, and create a team of provider/patient/family to develop a plan of care for the future
- Setting up the interview, assessing patient’s Perception, obtain Information, giving Knowledge and info, addressing patient’s Emotions, Strategy & Summary
What is empathy?
- taking the perspective of another by seeing the situation from their point of view
- turning into and understanding another’s feelings
Ectopic pregnancy
- implantation of a fertilized ovum in tissue other than the endometrium
- risk factors: PID, STD’s, hx of endometriosis, smoking, adhesions, prior ectopic pregnancy, age > 35, CONCEPTION WITH IUD
- patient presentation: MISSED/DELAYED MENSES, VAGINAL BLEEDING, ABDOMINAL PAIN/DISCOMFORT (USUALLY UNILATERAL)
- physical exam findings: shock s/s, fever, Cullen sign (ecchymosis around umbilicus), palpation of adnexal mass, abdominal and/or adnexal tenderness
- diagnostics: ABSENCE OF INTRAUTERINE GESTATIONAL SAC WITH HCG LEVEL > 1500 via ULTRASOUND
Ectopic pregnancy management
Surgical approach: usually reserved for the unstable patient
- LAPAROTOMY IS TX OF CHOICE FOR HEMODYNAMICALLY UNSTABLE PATIENT
- possible salpingectomy
Medication approach: usually reserved for the stable patient
- METHOTREXATE (folic acid antagonist)
- CONSIDER CONTRAINDICATIONS: HEMODYNAMICALLY UNSTABLE, RUPTURED TUBE, UNABLE TO COMPLY WITH FOLLOW UP, HEPATIC OR RENAL DISEASE
- CHECK CBC, CREATININE, LFTs PRIOR TO METHOTREXATE ADMINISTRATION
PERIPARTUM CARDIOMYOPATHY
- dilated cardiomyopathy with no other cause
- onset usually within the last month of pregnancy or within five months postpartum (but can happen at any stage of gestation)
- treatment is the same as CHF (vasodilators, diuretics, sodium restriction)
AMNIOTIC FLUID EMBOLISM (AFE)
- risks: prolonged labor, increased maternal age, multiparity, oxytocin
- presentation: rapid decline in maternal and/or fetal status intrapartum or maternal status postpartum, hypotension with respiratory symptoms, coagulopathy, and cardiac arrest
- PLACE THE WOMAN IN LEFT LATERAL DECUBITUS POSITION TO MINIMIZE VENA CAVA COMPRESSION
VENOUS THROMBOEMBOLISM
- due to increased levels of clotting factors, increased platelet and fibrin activation, and decreased fibrinolytic activity
- management usually includes 3-6 months LWMH
- NO COUMADIN!!
Cardiac disease in pregnancy
- increased blood volume, CO rises, and SVR decreases
- pulmonary edema is most common complication in late pregnancy or immediately after delivery
Hypertensive disorders of pregnancy
- chronic hypertension – gestational hypertension – preeclampsia - HELLP – hypertensive crisis – eclampsia
Chronic hypertension
- before 20 weeks gestation
Gestational hypertension
- SBP >140 and or DBP > 90 documented on 2 separate readings that are at least four weeks apart WITH NO PROTEINURIA OR FEATURES OF PREECLAMPSIA
- after 20 weeks gestation
– most cases resolve postpartum - FIRST LINE ANTIHYPERTENSIVE FOR MODERATE HTN ARE ORAL ALPHA METHYLDOPA AND ORAL LABETALOL
Preeclampsia
- BP > 140/90 WITH PROTEINURIA > 300 mg FOR 24 HOURS (or other end-organ damage)
- after 20 weeks gestation in previously normotensive patient
- May have headache, rapid weight gain, edema
- MAG SULFATE GIVEN FOR SEIZURE PROPHYLAXIS
- NICARDIPINE AND LABETALOL ARE FIRST LINE AGENTS FOR HTN
HELLP
- HEMOLYSIS, ELEVATED LIVER ENZYMES, LOW PLATELET COUNT
- Often misdiagnosed
- RUQ PAIN IS CHARACTERISTIC
- DELIVER BABY IF > 34 WEEKS; IF < 34 WEEKS, GIVE STEROIDS
HYPERTENSIVE CRISIS
- maintain perfusion, reduce hypotension risk
- GOAL BP < 160/110
- LABETALOL OR HYDRALAZINE, NIFEDIPINE
- NO NITROPRUSSIDE DUE TO CONCERN FOR CYANIDE AND THIOCYANATE TOXICITY IN MOM AND FETUS
ECLAMPSIA
- EMERGENCY: DELIVER BABY!
- BP CONTROL
- SEIZURE MANAGEMENT WITH MAG SULFATE IS MAINSTAY
Infectious diseases of pregnancy
- PATHOGENS: RUBELLA, CMV, HSV, LISTERIOSIS
- can cause congenital malformations and disease
- LISTERIOSIS CAN CAUSE FETAL NEONATAL INFECTIONS: CAUSES WIDESPREAD ABSCESSES IN BABY AND/OR GRANULOMAS IN INTERNAL ORGANS
- USUAL PRESENTATION IN 2nd OR 3rd TRIMESTER WITH FLU-LIKE SYMPTOMS RESULTING IN MASSIVE UTERINE BACTEREMIA
- PREVENTION AND EDUCATION IS IMPERATIVE: PASTEURIZATION AND THOROUGH COOKING
Pulmonary diseases of pregnancy
- shortness of breath is common because of pressure on diaphragm and structures: NORMAL IN PREGNANCY (The biggest thing is to know when the SOB is abnormal)
- asthma: the most common medical complication in the US
- pneumothorax: primary spontaneous pneumothorax, usually so small that they require only observation
Renal disease of pregnancy
- Nephrolithiasis not uncommon
- do not delay in starting treatment for pyelonephritis!
Endocrine disorders of pregnancy
- diabetes mellitus
– gestational diabetes mellitus
– thyroid abnormalities in pregnancy
Diabetes mellitus in pregnancy
INSULIN REQUIREMENTS DECREASE BY 10-20% IN 1ST TRIMESTER D/T INCREASED INSULIN SENSITIVITY - HIGH LIKELIHOOD OF HYPOGLYCEMIA
Gestational diabetes mellitus
- metformin or glyburide often initiated if lifestyle and diet alterations do not work
- higher risk for type two diabetes mellitus
Thyroid abnormalities during pregnancy
- POSTPARTUM THYROIDITIS MAY OCCUR UP TO 12 MONTHS AFTER DELIVERY
- BRIEF HYPERTHYROID PHASE FOLLOWED BY HYPOTHYROID PHASE
- MAY NEED PROPRANOLOL IF SYMPTOMATIC
- MAY NEED LEVOTHYROXINE DURING HYPOTHYROID PHASE IF SYMPTOMATIC
- PRE-EXISTING HYPOTHYROIDISM PATIENTS SHOULD HAVE DOSE OF LEVOTHYROXINE INCREASED BY 30% IN EARLY PREGNANCY
Depression and pregnancy
- to medicate or not?
– Watch and wait approach: supportive treatment and psychotherapy may be enough
– SSRIs (fluoxetine, sertraline, citalopram, etc.) AND SNRIs (venlafaxine and duloxetine) - tools: phone apps, screening tools
– know red flags: blues, depression, psychosis
Neurocritical care in pregnancy
- always suspect and rule out a VENOUS SINUS THROMBOSIS in a pregnant patient presenting with acute neurologic symptoms
- CEREBRAL SINUS THROMBOSIS IS ONE OF THE MOST COMMON FORMS OF STROKE IN PREGNANCY
- OBTAIN DETAILED HISTORY: Often present with subacute and progressive headache and then stroke-like signs
- DETAILED NEURO EXAM
- BRAIN IMAGING (LIKELY CT)
- EEG AND/OR TRANSCRANIAL DOPPLER ULTRASOUND MAY BE NEEDED
- SEIZURE MANAGEMENT, BP MANAGEMENT, AND REDUCTION OF ICP IS IMPERATIVE
- SEEK EXPERT HELP ON TX FOR WELFARE OF MOM AND FETUS
Causes of bleeding in second half of pregnancy
- abruptio placentae
- placenta previa
- premature labor
Abruptio Placentae
- placenta detaches from uterine wall
- present with PAINFUL vaginal bleeding, abdominal pain, and uterine tenderness after 20th week of pregnancy
- ASK ABOUT TRAUMA, SMOKING HX, HTN DX, AND COCAINE USE
- stabilization of mother and delivery of baby is needed if there is distress or instability
Placenta previa
- placenta extends near or partially over the internal cervical os
- DO NOT DO A DIGITAL EXAM
- ULTRASOUND TO CONFIRM
Premature labor
- less than 37 weeks
- steroids and antibiotics given
Postpartum fever
- greater than 38.0°C on any 2 of the first 10 days postpartum exclusive of the first 24 hours
- ENDOMETRITIS IS MOST
ADNEXAL TORSION
- surgical emergency
– prompt diagnosis is critical for preserving ovarian function: ISCHEMIC EVENT - ULTRASOUND WITH AND WITHOUT COLOR FLOW DOPPLER IS THE IMAGING MODALITY OF CHOICE
- PROMPT REFERRAL TO SURGEON MINIMIZES TRAUMA AND ISCHEMIA
OVARIAN CYST
- complex, painful, massive blood flow
- most asymptomatic masses (< 10 cm) can be managed conservatively, repeat ultrasounds
FDA Medication categories
A - Studies in pregnant women have not demonstrated any risk, safe to use in pregnancy
B - no known specific risk, controlled human studies are lacking
C - no studies or studies on animals show adverse affects; most new drugs fall here; only to be given if potential benefit outweighs potential risk to fetus
D - drugs show definite risk but may be necessary during pregnancy, risk benefit assessment should be done
E - drugs shall definite risk, use is contra indicated because risks to fetus outweighs the benefits
Indications for thoracentesis
- diagnostic to establish cause pleural effusion
- to drain large effusions that lead to respiratory compromise
Insertion site for a thoracentesis
5-10 cm lateral to the spine and at least 1 to 2 intercostal spaces below top of the infusion
Complications of thoracentesis
- pneumothorax: rare, rarely requires chest tube placement
- hemothorax, intra-abdominal organ injury, air embolism
- post expansion pulmonary edema (never remove more than 1500 ml)
- indications for CXR: air aspirated during procedure, patient is critically ill or mechanically ventilated, or patient experiences chest pain/dyspnea/hypoxemia
Indications for paracentesis
- diagnostic procedure for establishing etiology of new-onset ascites
- rule out spontaneous peritonitis in patients with pre-existing ascites
- to alleviate discomfort or respiratory compromise in patients with tense or refractory ascites
Insertion site for paracentesis
- 2 cm below umbilicus midline and either left or right lower quadrant lateral to the rectus sheath
Serum ascites albumin gradient (SAAG)
- SAAG = serum albumin - ascites albumin
- SAAG > 1.1 = portal HTN
- SAAG < 1.1 = cancer, infection, pancreatitis
Lights criteria - transudative
- serum protein < 0.5, serum LDH < 0.6, pleural fluid LDH < 2/3 upper limit of normal
- main causes: heart failure, cirrhosis, nephrotic syndrome, pulmonary embolism
Lights criteria - exudative
- serum protein > 0.5, serum LDH > 0.6, pleural fluid LDH > 2/3 upper limit of normal
- main causes: malignancy, bacterial/viral pneumonia, tuberculosis, pancreatitis, pulmonary embolism
Complications of paracentesis
- post paracentesis circulatory dysfunction: May occur after a large volume paracentesis and may lead to hypertension, hyponatremia, renal failure (giving albumin is recommended if > 5L of fluid are removed)
- hemorrhage, intra-abdominal organ injury, artery puncture
Indications for central venous catheterization
Monitoring of CVP, delivery of caustic or critical medications, emergency resuscitation, HD, pulmonary artery catheterization
Location of insertion for IJ central line placement
Apex of the triangle formed by the sternal and clavicular heads of the sternocleidomastoid muscle, just lateral to the carotid artery
Indications for a lumbar puncture
- spinal or epidural anesthesia
- infectious (meningitis, encephalitis, myelitis)
- inflammatory, oncologic
- therapeutic (meningitis, SAH, hydrocephalus, drug administration)
Insertion site for a lumbar puncture
- draw a line between the superior aspect of the iliac crests and intersects the midline at the L4 spinous process
- insert the needle in the inter-space of the L3 and L4 or L4 and L5
