Fellowship Flashcards
What documents are printed out for a transfer to a correctional facility?
ED/inpatient summary Current visit notes Nursing documentation AVS Face sheet
- What are the sepsis/SIRS criteria? (Must meet 2)
2. What are the severe sepsis/septic shock criteria? (Must meet one in addition to 2 of above)
- HR >90
- RR >20
- Temp >38.3 or <36.0
- WBC’s >12,000 OR <4,000
- AMS
Severe/sepsis:
- lactic >2.0
- creatinine >2 or double baseline
- oliguria (<0.5/ml/kg/hr for >2hrs
- Platelets <100k
- SBP <90, MAP <65
- Bilirubin >2mg/dl
- INR >1.5 or PTT >60 sec
After the ABCDE primary assessment, what is involved in the secondary assessment?
F: full set of vitals
G: giving comfort
H: history and head to toe assessment
I: inspecting posterior surfaces
What effect does an increase or decrease in stroke volume have in pulse pressure?
Increase in stroke volume: widened pulse pressure
Decrease in stroke volume: narrowed pulse pressure
What are pediatric contraindications for taking a rectal temp?
Less than 1 month
Recent rectal surgery
Diarrhea or rectal lesions
Taking chemotherapy
What is the circulatory state of an obstetric patient?
Hyperdynamic, hypervolemic, hypercoagulable
Allodynia
Pain caused by a stimulus that does not normally cause pain
Damaged tissue releases which powerful pain mediators?
bradykinins
leukotrienes
serotonin
histamines
What is “LET” and what is in it?
When should it not be used?
A topical mixture of lidocaine, epinephrine, and tetracaine. Often used for pediatric patients prior to venipuncture.
Do not use in areas with decreased circulation such as fingertips, toes, or penis.
Normal bicarbonate (HCO3)
Venous
Arterial
Venous: 22-26
Arterial: 22-26
Normal PaO2
Venous:
Arterial:
Venous: 38-42
Arterial: 80-100
Normal base excess
No difference between arterial or venous
2.0
Flow range for simple mask?
Less than 5lpm can cause CO2 retention.
Range is 5-10lpm
Hiflo NC fitment considerations
Prongs should occlude no more than 50% of each nare
Max pressure for suctioning et tubes?
150
Standard RSI pre-oxygenation
15 LPM NRB
+
6 LPM NC
X 3 minutes
When is etomidate contraindicated?
Sepsis
Post RSI considerations/tasks
Pain control
Additional sedation
HOB at 30 degrees
X-ray tube placement confirmation
Hemoccult test process
- Apply sample and wait 3-5 minutes.
- Apply developing drops on back side - 2 drops per side plus 1 drop for control
- wait 60 seconds to read results - blue is positive
How do you pull RSI meds for a patient not in the Pyxis?
Flu vaccine, employee Redmond
What is normal anion gap?
8-16
High anion gap = acidosis such as DKA
What are the 3 primary types of obstructive shock?
Tension Pneumothorax
Pericardial tamponade
Massive PE
Dobutamine
Catecholamine (vasopressor) used in the treatment of shock.
Difference between epi and nor-epi?
Epi has less A1 effects and more B1 effects thereby having less effect on BP and more on HR.
What is considered a prolonged QT?
0.44 seconds
or
Greater than 50% of the R to R interval
What EKG change might be seen in hemorrhagic stroke?
T-wave inversion
I’m addition to troponin, what are 2 other cardiac markers that can indicate cardiac tissue damage?
CK - creatinine kinase
or
Myoglobin
Onset, peak, and return to baseline timeframes for cardiac bio markers:
- Troponin I
- Troponin T
- 4-6 hours, 14-18 hours, 5-7 days
2. 3-4 hours, 4-6 hours, 2-3 weeks
What type of drug is clopidigrel?
Plavix - P2Y12 receptor blocker
Anti-coagulant (reduces platelet aggregation
What is normal lactate?
0.5-2.2 (variable depending on facility)
What does a base deficit indicate? What are levels for: Mild Moderate Severe
Indicates tissue ischemia (shock)
Mild: 2-5
Moderate: 6-14
Severe: >15
How recent must a blood glucose be to be used in Endo tool?
20 minutes
What is the definitive diagnosis for temporal arteritis?
Biopsy.
Consider temporal arteritis for any patient over 50 who presents with new headache or vision changes.
What’s the first and second steps (charting) in a massive transfusion?
- Order set -> massive transfusion
2. Release 4 RBC’s and 2 plasma
What’s a consideration with pediatric DKA fluid administration?
Cerebral edema can occur if fluids are administered too quickly.
Recent studies recommend 20ml/kg over the first hour for initial fluid resuscitation
Pediatric DKA
- After initial fluid resuscitation of 20ml/kg NS, what is the determining criteria for whether or not to start an insulin drip?
- If potassium is greater than 5.5 what maintenance fluid should be used?
- What maintenance fluid if potassium is 3.5-5.5?
- What maintenance fluid if potassium is less than 3.5
- Start insulin drip at 0.1 units/kg/hr only if potassium is greater than 3.5
- D5NS
- D5NS w/40k
- NS w40k
Never give insulin bolus
What is the “last seen normal” or “onset of symptoms” inclusion criteria for ischemic stroke fibrinolytic therapy?
Less than 4.5 hours
Stroke Fibrinolytic exclusion criteria?
- Significant head trauma or prior stroke within previous 3 months
- Arterial puncture at non-compressible site in previous 7 days
- Hx of previous intracranial hemorrhage.
- Intracranial neoplasm or aneurysm
- HTN >185/110
- Platelets less than 100k
- Heparin received in the last 48hrs resulting in a high aPTT
rTPA dose and
How to administer
0.9 mg/kg
Max dose of 90mg
1. 10% of dose bolus over 1 minute
2. Remaining 90% over 1 hour
What is endovascular coiling?
inserted through the groin and then inserted and coiled full of thin wires into the aneurysm around which clots form so that blood can no longer circulate into the weakened structure.
What precautions for suspected bacterial meningitis?
Droplet for first 24hours of antibiotic therapy.
What is myasthenia gravis?
Autoimmune disorder that damages nicotinic acetylcholine receptors.
Because these sites cannot be activated, muscle weakness occurs. May present with drooping eyelid(s)
Nexus criteria
- No midline cervical tenderness
- No focal neuro deficits
- Normal alertness (no AMS)
- No intoxication
- No distracting injuries
Atypical antipsychotics such as haldol and droperidol can cause what type of adverse reaction?
Dystonic reactions such as tardive dyskinesia or torticollis (painful neck rotation)
Mechanism of barbiturates and 1 example of a barbiturate.
Enhances activity of GABA
Phenobarbital
What class of drug is phenytoin?
Anti-seizure
Hydantoin class
Milk and antacids can reduce absorption
What is the reversal agent for benzos
Flumazenil
What type of drug is valproic acid?
Anti-seizure
LEAPS neuro assessment
L- LOC E- eyes, pupils, gaze A- Arm & leg strength P- Pat’s other symptoms S- Swallow screen
Post TNK administration vitals/neuro assessment timeline
Q15 for 2 hours
Q30 for next 4 hours
Q hour after that until discharge
When should a swallow screen occur?
Within 1 hour of ED arrival for all Ischemic, hemorrhagic, or TIA patients.
Hemorrhagic stroke or subarachnoid bleed goal BP
140 SBP
Goal BP for ischemic strokes who have received TNK?
180 SBP
TNK qualification criteria
Symptom onset <4.5 hours
NIH > 4 or life altering deficit
No contraindications present
Drug/alcohol and suicide screenings are mandatory for what age?
12 or older
Fetal heart tones should be performed on what gestational age?
12 weeks or greater (if applicable to chief complaint)
Blood cultures:
- Min/max volume for Adult tubes?
- Min/max volume for pediatric tubes?
- What color tubes for no abx?
- What color tubes if pt is on abx?
- What must be done before putting blood into culture tubes?
- 8ml/10ml
- 0.5ml/4ml
- Blue and Red
- Green and Red
- Wipe top with alcohol
Cath lab door to balloon time goal?
<90 minutes
ART lines:
- Pressure bag set to?
- Phlebostatic access point?
- 300
2. 4th intercostal, mid-axillary
ART line contraindications?
- Failed Allen’s test (no ulnar circulation after holding pressure)
- Uncontrolled coagulopathies or DIC
All sexual assault victims should be triaged at what level?
2
Which physician does not like when nurses put any orders in?
Bouska
Lab requirements to meet criteria for DKA?
Anion Gap >15
Bicarb <18
What is anion gap?
Sodium - (Chloride + HCO3)
What is the ideal hourly blood glucose decrease in a DKA or HHS patient?
30-100
Facts about GHB
*Gamma-hydroxybutyrate
*Metabolite of GABA
*Depressant
*Used as a “date rape” drug
*Abrupt onset and rapid recovery
Not detected on routine drug screenings
Bath Salts facts
- chemically similar to methamphetamines
- can be inhaled, injected, or taken orally
- can cause paranoia, hallucinations, violent behavior, euphoria
Ecstasy facts
- increases activity of dopamine, norepinephrine, and serotonin
- Usually lasts 3-6 hours
- Complications can include hypertension, hyperthermia, and tachycardia
What drug, that might be used to treat alcohol withdrawal behavior issues, should be used with caution as it can lower the seizure threshold?
Haldol
What is the incubation period for chickenpox?
10-20 days after exposure
What is the timeframe for reversing testicular torsion?
If detorsion is performed within 12 hours, the testicular salvage rate is 80%
What does HELLP stand for in regards to a pregnancy complication?
HELLP syndrome is a life threatening form of preeclampsia which presents with N/V, RUQ pain, and jaundice
Hemolysis
Elevated liver function tests
Low platelet count
How to fit crutches
2-3 inches below axilla. Advise pt not to rest body weight on axillary padding as it could cause nerve compression.
Is a cane used on the injured side or non-injured side?
Non-injured
How long should LET be left on?
At least 20 minutes
Procedural Sedation Equipment checklist:
SOAPME
Suction Oxygen Airway - airway adjuncts and bvm, intubation supplies if needed Pharmacy - meds Monitors Equipment - code cart
Sedation Meds that must be pushed by MD
Ketamine (ok for RN to push for RSI)
Propofol
Methohexital
Etomidate
Vitals frequency for moderate sedation?
Vitals frequency for deep sedation?
Moderate: Q15
Deep: Q5
Also Within 5 minutes of any medication administration
How long must a patient be monitored after procedural sedation?
At least 60 minutes from last med administration
AND
At least 30 minutes from end of procedure
If reversal agents are used - 120 minutes of monitoring is required.
