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Emergencies > Final deck > Flashcards

Final deck Flashcards

1
Q

AFIB vs A flutter pathophysiology

A

In atrial fibrillation, the atria beat irregularly. In atrial flutter, the atria beat regularly, but faster than usual and more often than the ventricles. (re-entrant circuirt around the tricuspid valve.)

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2
Q

T/F supraventericular arrythmias have a regular QRS complex

A

T

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3
Q

T/F Ventricular arrythmias (which are a type of tachyarrythmia) have wide QRS

A

T

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4
Q

Types of bradyarrythmias due to the atria

A

Respiratory sinus: RR shortens during inspiration, lenghtens during expiration
Sinus bradycardia: physiological, sick sinus sx, BB, CCB
Sinus pause/arrest: CVD. Absent P wave + escape rhythm
Tachycardia/bradycardia sx: Abnormal supraventricular impulse generation and conduction

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5
Q

Types of bradyarrythmias due to the AV node

A

AV block

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6
Q

Types of supraventricular arrythmias of atrial origin

A

Premature beats: electrolyte imbalance (abnormal/absent P waves)
Sinus tachycardia (max rate is 180, narrow QRS)
Atrial flutter: re-entrant rhythms within the atria
A fib: mechanism unknown
Atrial tachycardia: wither focal atrial tachycardia (regular) or multifocal atrial tachycardia (irregular)

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7
Q

Types of supraventricular arrythmias of AV node entry

A

AVRT: due to an accessory pathway. Abrupt onset. Regular.
AVNRT
Junctional tachycardia (AV node takes over the pacemaker function. can occur in Digitalis toxicity, MI, myocarditis)

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8
Q

Ventricular arrythmias

A

Premature ventricular beats (hypoxia, hyperthyroidism, electrolyte abnormalities)
V Tach (CAD, MI)
Torsades de pointes (long QT, hypokalemia)
V-fib: MI

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9
Q

Cinchonism:

A

headache, hearing/vision loss, tinnitus, psychosis and cognitive impairment, associated with quinidine use

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10
Q

Most common causes of extrinsic SA node dysfunction

A

Drugs, ANS influence.
Hypothyroidism, hypothermia, hypoxia, bezolf-jarish reflex, ICP (Cushings response), hyperkalemia/magnesemia

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11
Q

Bezold Jarish reflex

A

increased vagal tone due to ischemia

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12
Q

TX of arrythmia

A

1- TX underlying cause
2- If can’t treat cause:

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13
Q

What factors contribute to the severity of a burn

A

Depth and surface area involved

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14
Q

How do you decide if the pt is on the right amount of fluids

A

Based on the urine output and clincial stability

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15
Q

Labs needed for DX/MX of burns

A

Pulse oximetry, ABG, electrolyte and creatinine levels

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16
Q

Most common cause of death after burns are

A

shock, sepsis, respiratory failure

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17
Q

Common pathogens that infect burns

A

mrsa, pseudomonas, klebsiella, acinetobacter, candida

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18
Q

Lun-Browder charts to evaluate the surface area of burn involved, the palm rule, wallace’s rule of nines

A

Lun-Browder: age specific
Palm rule: palm is 1% of body area
Wllace’s rule of nines: for adults

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19
Q

Clinical features of burn patient

A

Shock (hypotension, anuria) ARDS
Compartement syndrome (if in abd then JVD, tachycarida, hypotension)
Acute limb ischemia

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20
Q

What triggers a change in respiration?

A

PaCO2 levels

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21
Q

Normal Pa02 calculation

A

109 - 0.4 (age of pt)

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22
Q

ARDS has what

A

bilateral involvemetn and diffuse distribution

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23
Q

Calculate the anion gap (must be corrected for albumin - as there is an increase
the anion gap by 2.5 mEq/L for every 1 g/dL reduction in serum albumin.)

A

[Na] - [Cl + HCO3]
[137] - [104 + 24] mEq/L
10 +/- 2 is normal
If its elevated you are in metabolic acidosis
If low anion gap: wasting issues (diarrhea, renal tubular acidosis) (hypoalbuminemia, hyperkalemia)
If high anion gap: sepsis or liver dx, intoxication, drugs

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24
Q

Effects of acidosis

A

Lungs: hyperventiation (kussmall), shift of ocyHb surve to right (bohr effect)
CV: tachycardia, peripheral vasodilation
increased bone resorption, hyperkalemia, reduced lactate clearance

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25
Q

Where does a CVC go?

A

Enters through subcalvian vein, or interior jugular vein. lies at border with right atrium

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26
Q

What three values influence oxygen delivery to tissues

A

Hb concentration
O2 bound to Hb
Pumping of blood by the heart to the tissues
O2 delivery (ml/min) = 1.34 (ml/g) x SaO2 (fraction) x Hb (g/dL) x CO (dL/min)

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27
Q

Possible methods to increase O2 delivery

A

blood transfusion
O2
crystalloids

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28
Q

How todecrease the pts consumption of O2

A

correct fever
no exercise
treat increased breathing effort (ventilator)
sedate

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29
Q

Cardiac arrest manifests as

A

Apnea, pulselessness, loss of consciousness

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30
Q

Most common cuases of cardiac arrest in adults v children

A

Adults : CAD, hypothermia
Kids: hypoxia (airway obstruction)

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31
Q

Reversible causes of cardiac arrest (H’s and T’s)

A

Hs: hypoxia, hypovolemia, hydrogen ions (acidosis), hypo/hyperkalemia, hypothermia
- Ts: toxins, thrombosis (coronary and pulmonary), tamponade, tension pneumothorax

ALSO: hypoglycemia, hypocalcemia, hypomagnesemia, anaphylaxis, asthma

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32
Q

compression rate

A

100-120 per minute
5-6 cm deep
allow full chest recoil between compression
restart CPR immediately after shock delivery
30 compression 2 breaths

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33
Q

PEA can be due to

A

cardiac tamponade
pulmonary embolism
tension pneumothorax
hypovolemic shock

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34
Q

Causes of asystole

A

hypoxia
hyperkalemia

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35
Q

Define shock

A

a life-threatening, generalized form of acute
circulatory failure associated with inadequate oxygen utilization by the cells

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36
Q

circulation evaluation

A

Several clinical parameters must be integrated to obtain information about patient’
circulation, including heart rate (60-90bpm), blood pressure (90-120mmHg), capillary
refill time/CRT, color and temperature of the skin, urine output and edema.

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37
Q

fluid challenge

A

It consists in administering small
boluses of fluids (4ml per kg/ 250 mL of crystalloids) over 15 minutes, while vital parameters are checked.
A positive fluid challenge test is defined as an increase in cardiac output in response to the increased blood volume (increased pre-load).

38
Q

When is the only time you use colloidal solutions

A

Rarely in severely low oncotic pressure

38
Q

When is the only time you use colloidal solutions

A

Rarely in severely low oncotic pressure.
They increase Intravascular volume wayyy more than crystalloids do

39
Q

what are the three types of fluids

A

crystalloids (minerals, dextrose)
colloids (albumin, starch)
balances IV fluid solutions (the aboce which dont alter homestasis of ECC)

40
Q

Osmolarity vs osmolarity vs tonicity

A

Osmolality: the concentration of dissolved particles per unit mass of solution (mOsm/kg); preferred term to describe the osmotic pressure of biological systems

Osmolarity: the concentration of solutes per unit volume of solvent (mOsm/L); often used interchangeably with osmolality in clinical practice Preferred term to describe the osmotic pressure of parenteral fluids

Tonicity: the capacity of an ECF to create an osmotic gradient that will cause water to move into or out of the ICC; cannot be measured and has no unit (dep on Na, K)

41
Q

The best solution for IV fluid resus is

A

isotonic crystalloids (are normal saline or ringers lactate)

42
Q

T/F IO (intraosseous) access is preferred to CV access for resus

A

T
But the best is peripheral IV

43
Q

Why perform fluid challenge?

A

to differentiate between hypovolemia and euvolemia

44
Q

Define critical illness

A

A critical illness is any disease process which causes physiological instability leading to disability
or death within minutes or hours. Generally, the perturbation of the neurological and
cardiorespiratory systems has the most immediate life-threatening effects.

45
Q

Five parameters for critical illness dx then 5 others after

A

Level of consciousness
RR
HR
BP
urine output

Others: age, comorbidities, current drug regime, magnitude of change from baseline

46
Q

What issues are present with breathing

A

asthma
pulmonary edema
tension pneumothorax
hemothorax

47
Q

OPACS for B (breathing) assessment

A

Observation of the thorax during the respiratory process (moving symmetrically or asymmetrically, e.g due to an obstruction in one bronchus)
Palpation (assess if there is a subcutaneous emphysema)
Auscultation: crackles can be heard in case of congestion of the alveoli by fluid as in case of pulmonary edema or pneumonia, while wheezing can appear in case of an asthmatic crises. The obtusity at the bases of the lungs can signal a pleural effusion or a
pneumothorax.
* Count (respiratory rate): measure it accurately because it is a very important sign in case of critically ill patient.
* Saturimetry (normally >96%, in COPD patients the target should be 88-92%).

48
Q

What is the Early warning score?

A

Takes into consideration the vital parameters and all the deviations from the normality give us a score. The higher is the score the more the patient is critical. This is a very useful tool for the
communication among health care professionals.
Includes: HR, SPO2, TEMP, SBP, RR, STATE OF CONSCIOUSNESS, O2
0-4: low risk, 7+ high risk

49
Q

What are the three peaks of dying risk after trauma

A

1: Immediately after (aortic laceration, CNS)
2: 3-4 hours (due to hemorrhages)
3: due to sepsis and multiple organ failure

50
Q

What are the new resuscitatino targets?

A

damage control surgery
permissive hypotension (keep SBP at 80mmHG until major bleed has been stopped)
hemostatis resuscitation (restore normal tissue perfusion, preserving clotting)

51
Q

three most important factors causing TIC

A

acidosis
hypothermia
blood dilution

52
Q

T/F fibrinogen is the first coagulation factor that reaches critically low values in TIC.

A

T

53
Q

Steps of hemostatis resuscitation

A

correct hypothermia
correct acidosis
correct hypocalcemia (to >1mmol/L)
blood componenets
tx of coagulopathy

54
Q

what is PCC (a factor concentrate)

A

It is a powder for dissolution containing pro- and anti-coagulant factors (II – VI – IX – X – PC – PS)
and heparin. It is sold in vials of 500 IU or 1000 IU vials. It can be stored at room temperature and
quickly dissolved in sterile water. It is the first choice for warfarin reversal.

55
Q

massive transfusion prediction scores

A

ABC score: it doesn’t require any lab exam, very easy to use, can be used with pre-hospital
information. Takes 4 things: presence of penetrating trauma, positive FAST sca, SBP<90, HR>120
Score of <2: unlikely need for massive transfusion.
Score of >2: massive transfusion program will likely be necessary.
* TASH score: requires lab tests (Hb);
1, SBP; 2, Hb; 3, intra-abdominal fluid; 4, complex long bone and/or pelvic fractures; 5, HR; 6, base excess; and 7, gender.
Score of >24: positive, massive transfusion program will likely be necessary

56
Q

Goals of damage control surgery

A

rapidly control bleeding
containing abdominal contamination
restrogin patient physiology
achieving temporary abdo wall closure

57
Q

When to perfrom emergency thoracotomy

A

In case of thoracic penetrating trauma with PEA

58
Q

AMS can manifest as

A

hyperalertness
Somnolence
lethargy
obtundation
stupor

59
Q

Four mechanisms of hypoxia

A

hypoventilazione
Bradypnea (<12)
V/Q mismatch (COPD, emphysema, p. embolism)
Shunt (pneumonia, atelectasia, lung tumor, CHF, ARDS)
Diffusion abnormality

60
Q

Define shock

A

circulatory disorder leads to inadequate organ perfusion, tissue hypoxia and microcirculation disturbance that eventually results in irreversable organ damage

61
Q

What 3 things can help distinguish between the types of shock

A

Pulmonary capillary wedge pressure
CO
Systemic vascular resistance

62
Q

what is the shock index?

A

HR/SBP

63
Q

Parameters of hypovolemic shock and tx options

A

low CVP
LOW Pulmonary capillary wedge pressure
LOW CO
HIGH SVR
HIGH HR
TX: fluid resus, blood transfusion, hemostatic control

64
Q

Parameters of cardiogenic shock, causes and tx options

A

cardiac ischemia, arrythmias, valvulopathy, toxic substances
HIGH CVP, HIGH PCWP, LOW CO, HIGH SVR, DISTEDED JVP
TX: IV fluids if fluid responsive, inotropic support, vasopressors, diuretics

65
Q

Parameters of obstructive shock, causes and tx options

A

cardiac tamponade (causes impaired filling of right ventricle), tension pneumothorax (obstructs venous return), massive PE (increases ventricular afterload)
HIGH CVP, LOW CO, HIGH SVR, HIGH HR
TX: fluid resus, relieve obstructions

66
Q

Types of disdributive shock

A

septic
neurogenic
anaphylactic

67
Q

Parameters of septic shock and tx options

A

flushed skin!!
TX: fluid resus, vasopressors, antibiotics, infections source control (abscess, drainage, surgery)

68
Q

Parameters of anaphylactic shock and tx options

A

epinephrine
fluid resus

69
Q

Parameters of neurogenic shock and tx options

A

due to CNS injury
Has bradycardia unlike other shocks
TX: fluid resus, vasopressors, atropine if severely bradycardic

70
Q

How many phases does shock have

A

3

71
Q

Routine investigations for shock

A

high lactate
ABG
renal function, liver function, coagulation panel if in sispected stage 3

72
Q

Base deficit in shock pts

A

if BD> or equal to 10 pt has severe hemorrhagic shock

73
Q

Septic shock management

A

1 hour bundle:
crystalloids 30ml/kg/hr
antibiotics
vasopressors (start with norepi, if doesnt work add vasopressin)

74
Q

Anaphylactic shock management

A

epinepphrin IM 1:1000
fluids
add anti histamines and corticosteroids only after initial tx

75
Q

tx for refractory shock

A

corticosteroids (hydrocortisone)
bicarbonate
mechanical circulatory support (ECMO for ARDS)

76
Q

ACS includes

A

STEMI
NSTEMI
Unstable angina (myocardial ischemia at rest or minimal exertion in absence of cardiomyocyte necrosis)

77
Q

Most common sources of sepsis infection

A

pneumonia
abdominal infections
UTI

78
Q

SOFA score (range from 0-24, 0 is normal)

A

The SOFA score assesses the proper functioning or the failure of 6 organs through the results of in-hospital readily available tests:
- Lungs (respiration) → PaO2/FiO2 and need for support (oxygenation)
- Platelets (coagulation) → platelet count
- Liver → total bilirubin concentration
- Cardiovascular system (circulation) → ABP (MAP) and need for support (drugs)
- Brain → Glasgow Coma Scale
- Kidney → creatinine concentration

79
Q

qSOFA score

A

considers 3 variables that reflect the function of 3 organs only:
- Lungs (respiration) → respiratory rate ≥ 22
- Cardiovascular system (circulation) → systolic blood pressure ≤ 100 mmHg
- Brain → mental status: altered cognition (if GCS < 15 or if AVPU is not A)
If ≥ 2 of these signs are present, the patient should be considered at risk of having an organ dysfunction/sepsis and thus referred to the hospital

80
Q

what three things determine if an antibiotic is correct

A

timing
penetration into infected tissue
pharmacodynamic/pharmacokinetic properties

81
Q

septic shock antibiotics should be given

A

w/in the first hour

82
Q

dont use linezolid for MRSA in septic shock bc?

A

it is bacteriostatic

83
Q

screen for MDR pathogens

A

rectal swab for carbapenen reisitant K pneumonia
Nasal swab for MRSA
cutaneous swab for MDR Acinetobacter baumanii

84
Q

A person is at risk of ESBL-producing microorganism infection if at least one among the following risk factors is present:

A

Previous therapy with a quinolone or a cephalosporin in the last 3 months
▪ 4 cycles of antibiotic therapy in the last year (especially cephalosporins and quinolones)
▪ Previous isolation of ESBL producing organisms
Stay in long term care facilities (LTCF)

85
Q

Define a hypertensive crisis

A

acute increases in blood pressure (generally defined as ≥ 180/120 mm Hg) that cause or increase the risk of end-organ damage, i.e., damage to the brain (e.g., encephalopathy, stroke), eyes (e.g., retinopathy), cardiovascular system (e.g., ACS, pulmonary edema, aortic dissection), and/or kidneys (e.g., acute kidney injury).

86
Q

define malignant hypertension

A

severe hypertension with retinopathy (flame hemorrhages, papilledema)

87
Q

which drugs exacerbate hypertenison

A

MAOi (consuming wine/choc/cheese/cured meat)
TCA
NSAIDS
cocaine
amphetamines
ecstasy
stimuant diet pills

88
Q

Hypertensive emergency management

A

first hour: reduce BP by 25%
For non specific sx: rapid acting oral antiHTN (clonidine, labetalol, prazosin)
Aortic dissection: esmolol 500-1000mcg/Kg IV bolus in 1 min then 50mcg IV infusion (follow with vasodilators nitroprusside 0.3-0.5 mcg/kg)
P. edema: nitroglycerin 5 mcg/min infusion
ACS: nitroglycerin, esmolol
AKI: nicardipine 5mg/hour
catecholamine excess: benzo 5mg IV bolus

89
Q

if GCS <8 then pt is in a coma so

A

need to be put ona ventilator

90
Q

The most commonly involved nerve in TBI is

A

the facial nerve, 7th

Emergencies (10 decks)

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