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NUR: 746 > Exam 4 > Flashcards

Exam 4 Flashcards

1
Q

Most commonly involved drugs in adult poisoning

A
  • analgesics
    – sedatives/hypnotics/antipsychotics
    – antidepressants
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2
Q

Approach to patient with unknown overdose

A
  • contact Poison Control Center
  • obtain H&P and PMH, although may not be possible
  • assess underlying conditions, chronic illnesses, suicidal or not?
  • MATTERS acronym
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3
Q

MATTERS acronym

A
  • Medication/substance ingested
  • Amount ingested
  • Time of ingestion
  • Toxicology of the drug
  • Emesis/presence of pill fragments
  • Reasons for ingestion
  • Signs and symptoms
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4
Q

Rapid first look: toxidrome oriented physical exam

A
  • 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
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5
Q

General toxicology Diagnostics

A
  • 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
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6
Q

ICU admission criteria for toxicology

A
  • 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
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7
Q

Be aware of post admission delayed toxic effects

A
  • 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
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8
Q

Geriatric considerations for poisoning/toxicology

A
  • Polypharmacy can lead to unintentional overdose; but do NOT rule out intentional overdose
  • May have atypical presenting symptoms
    – decline in GFR and creatinine clearance
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9
Q

Pathophysiology of acetaminophen toxicity

A

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

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10
Q

acetaminophen toxicity presentation

A
  • 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
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11
Q

Four phases of acetaminophen poisoning

A
  • 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
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12
Q

Diagnostics for acetaminophen toxicity

A
  • 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
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13
Q

G.I.decontamination for acetaminophen overdose

A
  • 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)
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14
Q

Antidote for acetaminophen overdose

A
  • 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)
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15
Q

Indications for acetylcysteine administration

A
  • 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
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16
Q

Acetylcysteine dosing

A

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

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17
Q

Kings college criteria

A
  • 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
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18
Q

Diagnostics for alcohol and glycol poisoning

A
  • blood ethanol, methanol, ethylene glycol
  • serum osmolality
  • CMP
  • ABG
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19
Q

Ethanol toxidrome

A
  • CNS depression
  • ataxia
  • dyarthria
  • odor of ethanol
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20
Q

Ethanol metabolism

A
  • 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
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21
Q

Ethanol management

A
  • 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
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22
Q

Isopropyl management

A
  • 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
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23
Q

Isopropyl metabolism

A

Broken down by the liver to acetone

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24
Q

Examples of methanol

A

Found in wood alcohol, paint thinners, fuel additives

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25
Q

Methanol metabolism

A

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

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26
Q

Unique methanol symptoms

A
  • takes 12 to 24 hours for methanol to become toxic due to metabolism timeframe
  • Visual changes: non-reactive mydriasis, photophobia, papilledema
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27
Q

Methanol management

A
  • 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
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28
Q

Fomepizole indications

A
  • 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
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29
Q

Ethylene glycol metabolism

A

Gets broken down into glycoaldehyde and further into glycolic acid (glycolate) which is the toxic metabolite

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30
Q

Presentation of ethylene glycol poisoning

A
  • 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
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31
Q

Management of ethylene glycol poisoning

A
  • 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
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32
Q

Assessment findings of opioid overdose

A
  • 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
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33
Q

Opioid overdose management

A
  • 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
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34
Q

Examples of cholinergics

A
  • Direct cholinergic receptor stimulus: bethanechol (urecholine), pilocarpine
  • acetylcholinesterase inhibitors: insecticides, organophosphates, neostigmine
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35
Q

Cholinergic toxidrome

A

Salvation, lacrimation, diaphoresis, vomiting, urination, defecation, bronchorrhea, muscle fasciculations, weakness, bradycardia, seizures

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36
Q

Management of cholinergic overdose

A
  • 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
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37
Q

Anticholinergic overdose toxidrome

A
  • 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
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38
Q

Anticholinergic overdose management

A
  • observation, monitoring, supportive care

- Control agitation: benzos, phyostigmine

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39
Q

Beta blocker overdose assessment and findings

A
  • cardiac: bradycardia, brady-dysrhythmias, conduction abnormalities, hypotension
  • pulmonary: bronchospasm/constriction
  • CNS: depressed LOC, seizures, coma
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40
Q

Beta blocker overdose diagnostics

A

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

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41
Q

Beta blocker overdose management

A
  • hypotension: 20 ml/kg IVF, Trendelenburg positioning
  • Inotropes: dopamine, milrinone (effect contractility)
  • chronotropes: atropine, epinephrine (effect heart rate)
  • HD, temporary pacemaker, CPR
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42
Q

Calcium channel blocker overdose assessment and findings

A
  • CNS: Drowsiness, seizures, altered LOC
  • cardiac: bradycardia, tachycardia, hypotension
  • GI: Enteric dysmotility, bowel perforation
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43
Q

Calcium channel blocker overdose diagnostics

A

EKG: Bradycardia, tachycardia (reflects secondary to vasodilation), AV blocks, BBB, ST-T-wave changes

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44
Q

Calcium channel blocker overdose management

A
  • G.I. decontamination: charcoal if < 1 hour since ingestion, gastric lavage, whole bowel irrigation
  • hypotension: 1L boluses NS or LR
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45
Q

Digitalis overdose assessment and findings

A
  • CNS: drowsiness, lethargy, headache, hallucinations
  • cardiac: palpitations, dyspnea, bradycardia
  • Visual: photophobia, yellow halo around lights, snowy vision
  • GI: Anorexia, nausea, vomiting, abdominal pain
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46
Q

Digitalis overdose diagnostics

A
  • SERUM DIGOXIN LEVEL: toxic = > 0.2 mg/dL
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47
Q

Digitalis overdose management

A
  • G.I. decontamination: charcoal if within 6-8 hours of ingestion
  • correct electrolyte imbalances
  • antidote: digoxin immune fab (Digiband)
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48
Q

Salicylate overdose assessment and findings

A
  • TINNITUS, TACHYPNEA, FEVER

- Altered mental status, tachycardia, diaphoresis

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49
Q

Salicylate overdose diagnostics

A
  • serum salicylate level is symptomatic at 40 mg/dL, severe intoxication at > 70 mg/dL
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50
Q

Salicylate overdose management

A
  • 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
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51
Q

Benzodiazepine overdose toxidrome

A

CNS depression, ataxia, dysarthria, bradycardia, respiratory depression, dizziness, hypotension

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52
Q

Benzodiazepine overdose antidote

A
  • Naloxone: 0.05 mg initially, increase PRN

- Flumazenil: begin at 0.2 mg IV

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53
Q

Antidepressant overdose assessment and findings

A
  • 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
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54
Q

Antidepressant overdose diagnostics

A
  • 12-lead EKG: QTc prolongation, QRS prolongation
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55
Q

Antidepressant overdose management

A
  • 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
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56
Q

General information about trauma

A
  • top etiologies: MVC’s, falls, violence, being struck by/against an object
  • # 1 under recognized public health problem in the United States
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57
Q

Golden hour

A
  • 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
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58
Q

Advanced trauma life support underlying concepts and basic principles

A

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

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59
Q

ATLS Basics

A

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

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60
Q

Hospital phase - preparing for arrival

A
  • 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
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61
Q

The big six deadly problems

A 
- airway obstruction
– tension pneumothorax
– open pneumothorax
– flail chest
– cardiac tamponade
– massive external or internal hemorrhage
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62
Q

ATLS primary survey - A

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

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63
Q

ATLS – primary survey: airway management

A
  • 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)
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64
Q

ATLS – primary survey: airway maintenance and definitive airways

A
  • 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
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65
Q

ATLS – primary survey: drug assisted intubation agents

A
  • 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
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66
Q

ATLS – primary survey: Breathing & ventilation

A
  • expose neck and chest
    – inspect and determine rate/depth/quality of respirations
  • auscultate, quick and dirty, do they have bilateral breath sounds?
  • breathing management
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67
Q

ATLS – primary survey: Breathing & ventilation - breathing management

A
  • 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
68
Q

ATLS – primary survey: Circulation

A
  • 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
69
Q

ATLS Management: circulation - circulatory management

A
  • 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
70
Q

ATLS Management: circulation - types of responders

A
  • 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
71
Q

ATLS Management: Disability/neurologic status

A
  • 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
72
Q

ATLS Management: expose and environment

A
  • 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
73
Q

Hemorrhagic shock

A
  • 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
74
Q

Four classes of hemorrhagic shock

A
  • 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
75
Q

Review of other types of shock

A
  • 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
76
Q

Special considerations with hemorrhagic shock

A
  • 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
77
Q

ATLS Management: adjuncts to primary survey

A
  • 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!
78
Q

Trauma triad of death

A
  • these are the leading causes of death patient and they feed into each other
  • hypothermia, coagulopathy, metabolic acidosis
79
Q

Thoracic trauma: primary survey problems

A
  • 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
80
Q

Thoracic trauma: secondary survey problems

A
  • 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
81
Q

Abdominal and pelvic trauma: blunt injury

A

Seatbelts, lower rims of handlebars, doors, falling into an object, steering columns

82
Q

Indications for a laparotomy

A
  • 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
83
Q

Diaphragmatic injury

A
  • 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
84
Q

Duodenum injury

A
  • 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
85
Q

GU injuries

A
  • 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
86
Q

Pancreatic injury

A
  • 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
87
Q

Hollow viscus injuries

A
  • often delayed finding in blunt trauma

- Low threshold to Lap

88
Q

Solid organ injuries

A
  • liver, kidney, spleen
  • hemodynamically normal: admit and observe
    – hemodynamically unstable: emergent surgery
  • all solid organs have a grading scale
89
Q

Pelvic fractures

A
  • 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
90
Q

Head trauma

A
  • PRIMARY GOAL: prevent secondary injuries

- CT scanning should NEVER delay transfer to definitive care

91
Q

Classification of head trauma injuries

A
  • 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
92
Q

Types of focal intracranial lesions

A
  • epidural hematoma
  • subdural hematoma
  • subarachnoid hematoma
  • Intraparenchymal hemorrhage
  • contusions
93
Q

Epidural hematoma

A
  • 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
94
Q

Subdural hematoma

A
  • 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
95
Q

Subarachnoid hemorrhage

A
  • 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
96
Q

Intraparenchymal hemorrhage

A
  • these are tough because you cannot evacuate these
97
Q

Examples of diffuse intracranial lesions

A
  • concussions, multiple contusions, hypoxic/ischemic injuries, axonal injury
98
Q

General management for mild and moderate brain injury

A
  • 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
99
Q

General management for severe brain injury

A
  • 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
100
Q

Facial fractures- LeFort fractures

A
  • 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
101
Q

Spine and spinal cord injury

A
  • 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
102
Q

Neurogenic shock vs. spinal shock

A
  • 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
103
Q

Spinal cord syndromes

A
  • 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
104
Q

C-spine fractures

A
  • 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
105
Q

Thoracic spine fractures

A
  • 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
106
Q

Lumbar spine fractures

A
  • injury patterns similar to thoracic types
  • cauda equina is involved
  • probability of complete neurodeficit much lower with lumbar injuries
107
Q

Spinal fracture rules of thumb

A
  • restrict spine motion
  • ABCDE
    – consult spine
    – transfer
108
Q

Musculoskeletal trauma - limb threatening injury

A
  • 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
109
Q

Vascular injury management

A
  • need a CTA
  • concerning findings: pulsatile bleeding, arterial thrill on palpation, bruit, signs of distal ischemia, visible expanding hematoma
110
Q

Compartment syndrome - the 6 P’s

A
  • pain
  • poikilothermia
  • pallor
  • pulselessness
  • paralysis
  • paresthesia
111
Q

Geriatric trauma considerations

A
  • 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!
112
Q

Trauma in pregnancy considerations

A
  • 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
113
Q

Transfer to definitive care for trauma patients

A
  • 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
114
Q

Goals of palliative care

A
  • 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
115
Q

Differences between palliative and hospice: palliative care

A
  • 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
116
Q

Difference between palliative and hospice: hospice

A
  • 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
117
Q

Benefits of palliative care

A
  • increased symptom control, patient/family involvement, coordination of care between specialties
  • Advanced care planning and education about chronic disease stages
118
Q

Determining next of kin if there is no medical POA documentation

A

Patient spouse unless legally separated ➡️ adult child of patient ➡️ domestic partner ➡️ siblings ➡️ close friend ➡️ attending position with ethics committee consult

119
Q

Symptom management: dyspnea

A
  • 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)
120
Q

Dysphasia: artificial nutrition and hydration in dementia

A
  • 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
121
Q

Patient assessment and documentation near EOL

A

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

122
Q

SPIKES Protocol

A
  • 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
123
Q

What is empathy?

A
  • taking the perspective of another by seeing the situation from their point of view
  • turning into and understanding another’s feelings
124
Q

Ectopic pregnancy

A
  • 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
125
Q

Ectopic pregnancy management

A

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

126
Q

PERIPARTUM CARDIOMYOPATHY

A
  • 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)
127
Q

AMNIOTIC FLUID EMBOLISM (AFE)

A
  • 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
128
Q

VENOUS THROMBOEMBOLISM

A
  • 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!!
129
Q

Cardiac disease in pregnancy

A
  • increased blood volume, CO rises, and SVR decreases

- pulmonary edema is most common complication in late pregnancy or immediately after delivery

130
Q

Hypertensive disorders of pregnancy

A 
- chronic hypertension
– gestational hypertension
– preeclampsia
- HELLP
– hypertensive crisis
– eclampsia
131
Q

Chronic hypertension

A
  • before 20 weeks gestation
132
Q

Gestational hypertension

A
  • 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
133
Q

Preeclampsia

A
  • 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
134
Q

HELLP

A
  • HEMOLYSIS, ELEVATED LIVER ENZYMES, LOW PLATELET COUNT
  • Often misdiagnosed
  • RUQ PAIN IS CHARACTERISTIC
  • DELIVER BABY IF > 34 WEEKS; IF < 34 WEEKS, GIVE STEROIDS
135
Q

HYPERTENSIVE CRISIS

A
  • 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
136
Q

ECLAMPSIA

A
  • EMERGENCY: DELIVER BABY!
  • BP CONTROL
  • SEIZURE MANAGEMENT WITH MAG SULFATE IS MAINSTAY
137
Q

Infectious diseases of pregnancy

A
  • 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
138
Q

Pulmonary diseases of pregnancy

A
  • 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
139
Q

Renal disease of pregnancy

A
  • Nephrolithiasis not uncommon

- do not delay in starting treatment for pyelonephritis!

140
Q

Endocrine disorders of pregnancy

A
  • diabetes mellitus
    – gestational diabetes mellitus
    – thyroid abnormalities in pregnancy
141
Q

Diabetes mellitus in pregnancy

A

INSULIN REQUIREMENTS DECREASE BY 10-20% IN 1ST TRIMESTER D/T INCREASED INSULIN SENSITIVITY - HIGH LIKELIHOOD OF HYPOGLYCEMIA

142
Q

Gestational diabetes mellitus

A
  • metformin or glyburide often initiated if lifestyle and diet alterations do not work
  • higher risk for type two diabetes mellitus
143
Q

Thyroid abnormalities during pregnancy

A
  • 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
144
Q

Depression and pregnancy

A
  • 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
145
Q

Neurocritical care in pregnancy

A
  • 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
146
Q

Causes of bleeding in second half of pregnancy

A
  • abruptio placentae
  • placenta previa
  • premature labor
147
Q

Abruptio Placentae

A
  • 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
148
Q

Placenta previa

A
  • placenta extends near or partially over the internal cervical os
  • DO NOT DO A DIGITAL EXAM
  • ULTRASOUND TO CONFIRM
149
Q

Premature labor

A
  • less than 37 weeks

- steroids and antibiotics given

150
Q

Postpartum fever

A
  • greater than 38.0°C on any 2 of the first 10 days postpartum exclusive of the first 24 hours
  • ENDOMETRITIS IS MOST
151
Q

ADNEXAL TORSION

A
  • 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
152
Q

OVARIAN CYST

A
  • complex, painful, massive blood flow

- most asymptomatic masses (< 10 cm) can be managed conservatively, repeat ultrasounds

153
Q

FDA Medication categories

A

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

154
Q

Indications for thoracentesis

A
  • diagnostic to establish cause pleural effusion

- to drain large effusions that lead to respiratory compromise

155
Q

Insertion site for a thoracentesis

A

5-10 cm lateral to the spine and at least 1 to 2 intercostal spaces below top of the infusion

156
Q

Complications of thoracentesis

A
  • 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
157
Q

Indications for paracentesis

A
  • 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
158
Q

Insertion site for paracentesis

A
  • 2 cm below umbilicus midline and either left or right lower quadrant lateral to the rectus sheath
159
Q

Serum ascites albumin gradient (SAAG)

A
  • SAAG = serum albumin - ascites albumin
  • SAAG > 1.1 = portal HTN
  • SAAG < 1.1 = cancer, infection, pancreatitis
160
Q

Lights criteria - transudative

A
  • 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
161
Q

Lights criteria - exudative

A
  • 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
162
Q

Complications of paracentesis

A
  • 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
163
Q

Indications for central venous catheterization

A

Monitoring of CVP, delivery of caustic or critical medications, emergency resuscitation, HD, pulmonary artery catheterization

164
Q

Location of insertion for IJ central line placement

A

Apex of the triangle formed by the sternal and clavicular heads of the sternocleidomastoid muscle, just lateral to the carotid artery

165
Q

Indications for a lumbar puncture

A
  • spinal or epidural anesthesia
  • infectious (meningitis, encephalitis, myelitis)
  • inflammatory, oncologic
  • therapeutic (meningitis, SAH, hydrocephalus, drug administration)
166
Q

Insertion site for a lumbar puncture

A
  • 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

NUR: 746 (3 decks)

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