Medical Emergencies Flashcards
What are some hematologic emergencies?
Sickle Cell Anemia
Hemophilia
Disseminated Intravascular Coagulation
Describe sickle cell anemia
Sickle cell anemia is a genetic disease that affects one in 500 African-Americans. It is also found in those of Mediterranean, East Indian, and Middle Eastern dissent.
2 genes are necessary for the disease to be present. If the individual has one gene, they have sickle cell trait.
Pathophysiology = development of HbS instead of HbA which creates red blood cells that are incapable of transversing the microcirculation.
What are some complications of sickle cell anemia?
Hepatomegaly Hepatic infarctions Jaundice Pulmonary emboli Core pulmonale Chronic skin ulcers Hemolytic anemia Cholelithiasis Cholecystitis Aseptic necrosis of bones Osteoporosis Priapism Cardiomegaly CHF Tachycardia Mesenteric infarcts Abdominal vessel infarcts CVAs
Where do the main types of sickle cell crisis occur?
Bone
Chest
Abdominal
Joints
What is acute chest syndrome?
Pulmonary micro-infarctions which can be complicated by infection.
Leading cause of mortality/morbidity in sickle cell patients.
What is the treatment for sickle cell crisis?
Hydration – normal saline (Be sure to watch for overload)
Analgesia (Do not use Demerol can be neurotoxic)
Oxygen
Partial exchange transfusion if PO2 < 60 mm Hg
Anti-emetics
Blood transfusions
Antibiotics
Folic acid supplements for aplastic crisis
Anti-inflammatories
Hydroxyurea - creates fetal hemoglobin
What are precipitating events that cause sickle cell crisis?
Infections Dehydration Hypoxemia Depression Fever Acidosis Anxiety Exposure to cold Travel in nonpressurized aircraft Sudden change in altitude
What chromosome carries the gene for Hemophilia?
X-recessive gene
Describe hemophilia A:
Lack of Factor VIII Occurs in males Minor bleeding episodes can lead to major sequelae. Arthritis. Treatment: FFP Cryoprecipitate Factor VIII DDAVP (D-Desaminoarginine) - stimulates the release of Factor VIII
Describe Hemophilia B:
Lack of Factor IX. Occurs in Males. Minor bleeding episodes can lead to major sequelae. Arthritis. Treatment: Antibody purified Factor IX FFP
Describe Von Willebrand’s Disease:
Occurs in women. Lack of Factor VIII Defective platelet adherence. Muco-cutaneous bleeding and heavy menstrual flow can be bad. Treatment: FFP Cryoprecipitate Factor VIII DDAVP Factor complex
Describe the pathophysiology of Disseminated Intravascular Coagulation:
Accelerated clotting triggers thrombosis which accelerates fibrinolysis causing platelets, fibrinogen, and clotting factors to be consumed faster than they can be replaced. The end result is simultaneous clotting and bleeding.
What are the manifestations of the thrombosis part of Disseminated Intravascular Coagulation?
Dysrhythmias Acrocyanosis Absent/unequal pulses Hypoxia Respiratory Distress Decreased Breath sounds Aphasia Unequal pupils Decreased Urine output Decreased bowel sounds Necrosis of extremities
What are the manifestations of the bleeding part of Disseminated Intravascular Coagulation:
Tachycardia Hypotension Bloody sputum Decreased breath sounds Decreased LOC Convulsions Dilated pupils Hematuria Enlarged kidneys Guaiac positive stools/emesis Abdominal hemorrhage Oozing from sites Ecchymosis
What are the lab values for disseminated intravascular coagulation?
PT/PTT - normal or decreased
Fibrinogen levels - decreased
Platelet levels - decreased
Fibrin Split products - increased
What is the treatment for Disseminated Intravascular Coagulation?
Heparin
Used when there is evidence of organ damage or loss of life/limb is imminent.
Blocks microthrombi formation.
Not recommended for CNS injury, Liver failure, Obstetrical events.
Antidote is Protamine Sulfate (can not give if have a fish allergy).
Treat underlying cause.
FFP - replace clotting factors.
Platelets
PRBC
Factor VIII
Cryoprecipitate
Relative vs. Absolute depletion of available insulin:
Relative: infection illness pregnancy stressors Absolute: non-compliant patient illness - fails to take insulin
Hyperglycemia causes both _____ and _____ _____ by osmosis. _______ are created from the use of fats and muscle proteins as a means to produce energy.
1) intracellular
2) extra cellular dehydration
3) Ketones
4 major problems with Diabetic ketoacidosis:
1) hyperglycemia
2) dehydration
3) Electrolyte Disturbances
4) Metabolic Acidosis
Lab Values for Diabetic Ketoacidosis:
Glucose - >300mg/dL UA - + glucose and Ketones pH - Acidotic Bicarbonate - decreased (<22) Acetone - Increased NaCl - decreased K - normal or elevated PCO2 - decreased BUN - Increased Creatinine - Increased Hgb - increased Hct - increased WBC - increased if infection present
Manifestations of Diabetic Ketoacidosis:
Lethargy Flushed skin Thirst Abdominal pain Hyporeflexia Anorexia Acetone breath Vomiting Blurred vision Orthostatic Hypotension Kussmaul respirations Fever Hypotension Tachycardia Poor skin turgor Weakness Dysrhythmias Polyuria History infection/illness Dry mucus membranes Mental status changes
Treatment of Diabetic Ketoacidosis:
Dehydration - fluid replacement When glucose is 250 switch to D5NS. Hyperglycemia - regular insulin Correct gradually Reduce glucose 75-100 per hour or can develop headache and cerebral edema. Electrolyte replacement: Hypokalemia can develop rapidly with treatment. Fluid replacement also depletes. Potassium replacements Acidosis: Bicarbonate if pH <7.0 - 7.1 Can cause rebound alkalosis can add to IV fluids
What is Hypersmolar Hyperglycemic Syndrome?
Hyperglycemic reaction in a non-insulin dependent diabetic.
What are some precipitating events for the development of hypersmolar hyperglycemic syndrome?
Pneumonia, G.I. bleed, MI, acute viral illness, subdural hematoma, pancreatitis, heat stroke, tube feedings without enough water, recent cardiac surgery, severe diarrhea/vomiting, UTI, sepsis, uremia, pulmonary embolism, CVA, burns, hyper alimentation, dialysis,
Medications: Thiazide diuretics, steroids, phenytoin, propanolol, Cimetidine, immunosuppressives.
What are the three major problems with hyperosmolar hyperglycemic syndrome?
Hyperglycemia
Dehydration
Hyperosmolality
Why are the presence of Ketones not noted with hyperosmolar hyperglycemic syndrome?
There is enough circulating insulin in order to avoid ketones.
What lab values are associated with hyperosmolar hyperglycemic syndrome?
Glucose – usually > 600, often > 1000
UA – Positive for glucose; negative for ketones
pH - normal (may be slightly acidotic)
PO2 - normal unless underlying respiratory problem.
WBC - increased if underlying problem infection.
Na - Normal or increased depending on dehydration.
K - normal or increased depending on dehydration.
Osmolality - increased.
Manifestations of hyperosmolar hyperglycemic syndrome:
Vague abdominal pain Polyuria Headache Seizures Shallow respirations Elevated T waves Anorexia Polydipsia Blurred vision Coma Tachycardia Dysrhythmias Confusion Nausea/vomiting
What is the treatment for hyperosmolar hyperglycemic syndrome?
Rehydrate
Oxygen
Foley
Potassium supplements to prevent hypokalemia from hemodilution and insulin therapy.
Cardiac monitor
Insulin drip not as important but is often used.
Heparin or Lovenox for blood viscosity.
What are some contributing factors to hypoglycemia?
Lack of intake. Increased physical stress. Liver disease Changes in medication. Pregnancy Alcohol ingestion Drugs - NSAIDs, phenytoin, thyroid, propanolol. Increased insulin intake Certain drugs – Salicylates / sulfonamides influence the metabolism of oral hypoglycemics
What is the pathophysiology of hypoglycemia?
When a decrease in glucose is sensed, the body releases glucagon and epinephrine. The glucagon releases stored glucose, but it cannot be utilized fast enough. The epinephrine decreases the utilization of existing glucose and may be the cause of the symptomatology that occurs.
Manifestations of hypoglycemia:
Confusion Seizures Slurred speech Cool & clammy Palpitations Shakiness Hunger Pale Competitiveness Coma Staggering gate Tachycardia Diaphoresis Dilated pupils Death
Treatment for hypoglycemia:
Glucose Oral - 10 to 15 g of carbohydrate followed by a meal. 4 to 6 ounces of orange juice 5 to 6 Lifesavers 1/2 to 3/4 cup of nondiet soda 6 ounces of milk 2 to 3 glucose tablets D50 Glucagon - IM (this will not work for a cirrhosis patient) Insulin Pump — turn off
What are the time frames for standard insulin peaks?
NovoLog, Apidra, Numalog = 30 to 90 minutes.
Humulin R, Novolin R = 2 to 4 hours.
Humulin N, Novolin N = eight hours.
Levimir, Lantus = no peak.
What is thyroid storm and what is the mortality rate?
Thyroid storm occurs in hyper thyroid patients who may either be undiagnosed or stop taking their medication. Mortality rate is 20 to 60%
What are some causes of hyper thyroidism?
Overactive thyroid – Grave’s disease.
Thyrotoxicosis - increased hormone release.
Drug induced - Iodine containing agents (amiodarone/lithium).
What are some manifestations of a thyroid storm?
Hyperthermia Tachycardia Tremors Exophthalmus Cardiac failure Hyperglycemia Hypertension Agitation Diaphoresis Mental status changes Pulmonary edema Hypercalcemia Metabolic acidosis Flushed skin
What is the treatment for thyroid storm?
General treatment:
Treat fever - no salicylates (causes more thyroid hormone to be released from binding sites).
Fluid replacement (hyperthermia/vomiting/diarrhea).
Anti-emetics
Antidiarrheals
Oxygen
Monitor/treat dysrhythmias
Do not allow shivering.
Treatment to slow release of hormone:
 Propanolol (large doses needed for tachycardia. Blocks conversion of T4 to T3).
Guanethidine/ Reserpine - depletes stores/blocks release.
Iodine (Give one hour after use of meds to block synthesis.)
Treatment to Block Synthesis of Hormone:
Propylthiouracil
Methimazole
Glucocorticosteroids/Diuretics
What is a myxedema coma?
Myxedema coma is a complication of hypothyroidism with a mortality rate of 50% (stated to be as high as 80%). It is a progressive disease process with respiratory failure as the usual cause of death.
What are the Etiologies of myxedema coma?
Autoimmune thyroiditis
Ablation therapy
Iodine deficiency
Tumor
Drugs (lithium, amiodarone, anticonvulsants)
Secondary hypothyroidism - pituitary dysfunction.
Tertiary hypothyroidism - hypothalamic dysfunction.
What are some precipitating factors of myxedema coma?
Infections General anesthesia Sedatives Antidepressants Trauma CHF Surgery Narcotics Cold temperatures Stress
How to tell the difference between hyperthyroid and hypothyroid:
Hyperthyroid = low TSH Hypothyroid = increased TSH
What are some manifestations of myxedema coma?
Hypothermia Decreased activity tolerance Weight gain Confusion Altered mental status Hypo ventilation Hyponatremia Decreased cardiac output Depressed T waves Myxedema madness Pronounced fatigue Dyspnea Tongue swelling Slow answers Coma Hypercarbia Decreased renal blood flow Peripheral vasoconstriction prolonged QT interval Dry, pale, cold skin
What is the treatment for myxedema coma?
ABC’s
Hormone replacement – T4 or T3
Glucocorticoids to prevent adrenal crisis in patients with compromised adrenal systems.
Passive warming.
What are the Etiologies for Addisonian Crisis (adrenal crisis)?
Disease state
Discontinuation of steroids
What are the Hallmark findings of Addisonian Crisis?
Hyponatremia
Hypoglycemia
Hyperkalemia
What are the manifestations of Addisonian Crisis?
N/P Amenorrhea Fever Irritability Abdominal cramps Hypovolemic shock Weakness Fatigue headache Tachycardia
What are some clues to a diagnosis of Addison’s disease?
Hyper pigmentation
Moon face
Truncal obesity
What is the treatment for Addisonian Crisis?
Fluids – used D5NS (Patient is hyponatremic and hypoglycemic).
Hydrocortisone
Mineralocorticoids (dexamethasone)
Treat for hyperkalemia - D50 and insulin but may resolve with fluids and glucocorticoids.
Cardiac monitoring
What are the five types of hepatitis?
Hepatitis A Hepatitis B Hepatitis C Hepatitis D Hepatitis E
What is the route for infection of hepatitis A?
Fecal – oral
What are the routes of infection for hepatitis B?
Percutaneous, sexual, Bile, perinatal
What are the routes of infection for hepatitis C?
Percutaneous, sexual, perinatal
What are the routes for hepatitis D?
*Occurs in combination with hep-B
Percutaneous, sexual, bile, perinatal
What is the route of infection for hepatitis E?
Fecal - oral.
*occurs in Underdeveloped countries
What are some manifestations of hepatitis?
Fever Anorexia Dark urine Jaundice Malaise N/V Abdominal pain Rash occurs with type B
What can chronic hepatitis C progress to?
Cirrhosis or carcinoma
Vaccines are available for which types of hepatitis?
Hepatitis A and hepatitis B
What is the postexposure prophylaxis for exposure to hepatitis?
Immune globulin
What is tuberculosis?
A pulmonary disease caused by Mycobacterium tuberculosis.
Usually pulmonary in nature but can also affect other organs.
Incubation period is 4 to 12 weeks.
A TB test is positive is 10 mm induration (5mm if HIV +).
What are some manifestations of tuberculosis?
Night sweats Coffee Anorexia Weight loss Bloody sputum
What is the treatment for tuberculosis?
INH Rifampin Myambutal Streptomycin Pyrazinamycin Need baseline liver studies Isolation Controlled airflow rooms Identify at triage if possible Treat symptoms
What are the symptoms of rubeola for adults and pediatrics?
Fever Headache Macular rash (head to toe is typical; extremities to central is atypical). Koplick’s sign (mucosal lesions) Photophobia Arthralgia
What is the mode of transmission for rubeola?
Droplet (nasopharyngeal)
What are some complications associated with rubeola?
Pneumonia
Encephalitis
Otitis media
What is the treatment for rubeola?
Treatment of symptoms.
Exposed family members should be vaccinated within 72 hours.
What is the incubation period for rubeola?
10 to 14 days
What are the symptoms of rubella in adults?
Rash Low-grade fever Malaise Conjunctivitis Sore throat
What are the symptoms of Rebella in a pediatric patient?
Pink, popular rash (face/neck to extremities)
What is the mode of transmission for Rebella?
Droplets (nasopharyngeal)
What are some complications associated with rubella?
Arthralgia
Arthritis
Fetal injuries (deafness, mental retardation, cataracts, heart defects)
What is the treatment for Rebella?
Treat the symptoms
What is the incubation period for rubella?
14 to 21 days
What are the adult and pediatric symptoms of varicella (chickenpox)?
Low-grade fever
Lesions in stages (macules - papules - vesicles - crusted)
What is the route of transmission for Varicella (chickenpox)?
Direct contact with the vesicular discharge or mucus membranes
What are Complications associated with varicella (chickenpox)?
Encephalitis
Pneumonia
What is the treatment for varicella (chickenpox)?
Anti-histamines
Varicella immunoglobulin within 96 hours of exposure.
May use acyclovir
Symptomatic treatment
What is the incubation period for varicella (chickenpox)?
10 to 21 days
What are the Symptoms of mumps in an adult?
Epididymitis
Orchitis
Testicular atrophy
Meningitis
What are the symptoms of mumps in a pediatric patient?
Low-grade fever Headache Vomiting sore throat Unilateral/bilateral parotid swelling
What is the Mode of transmission for mumps?
Droplet oral contact with saliva or contaminated articles
What are some complications associated with mumps infection?
Sterility
Meningitis
What is the treatment for mumps?
Symptomatic treatment
Bedrest for adult males
Analgesics
What is the incubation period for mumps?
14 to 21 days
What are the symptoms of tetanus in an adult or pediatric patient?
History of injury Malaise Muscle rigidity Fever Headache Trismus (lockjaw) Dysphasia Distorted facial muscles Sardonic grin (risus sardonicus) Opisthotonos Respiratory arrest Seizures
What is the mode of transmission for tetanus?
Contact of open wound with spores.
What are some complications associated with tetanus?
Respiratory failure
Death
What is the treatment for tetanus?
Tetanus immunoglobulin. Benzodiazepines (spasms) Neuromuscular blocking agents Supportive care Dark room with low stimulation Fluid/electrolyte balance Anabiotic‘s Wound excision/debridement Horse serum antitoxin Nitroprusside (hypertension) Propranolol (dysrhythmias)
What is the incubation period for tetanus?
Two hours to seven days.
What are the adult and pediatric symptoms of pertussis?
Persistent cough (greater than seven days)
“Whoop” sound to cough
Paroxysmal cough
What is the route of transmission for pertussis?
Respiratory secretions
What are some complications associated with pertussis?
Pneumonia
Seizures
Cranial nerve abnormalities
What is the treatment for pertussis?
Erythromycin
Supportive
Possible intubation
What is the incubation period for pertussis?
7 to 13 days
What are the adult and pediatric symptoms of mononucleosis?
Fatigue Fever Sore throat Lymphadenopathy Splenomegaly Hepatomegaly
What is the Route of transmission for mononucleosis?
 droplet cross infection
What are complications associated with mononucleosis?
Splenic rupture (avoid sports and aspirin products for up to eight weeks)
What is the treatment for mononucleosis?
Supportive
What are the adult and pediatric symptoms of meningitis?
N/V Headache Fever Nuchal rigidity Decrease LOC Petechiae Purpuric rash Hypertension Seizures Sepsis
What is the route of transmission for meningitis?
Droplet (nasopharyngeal)
What are complications associated with meningitis?
Meningococcemia DIC Death Loss of Limbs Increased ICP
What is the treatment for meningitis?
Anabiotic‘s Volume replacement Strict isolation Anticonvulsants Airway management
What are the adult and pediatric symptoms of diphtheria?
Sore throat Dysphasia Headache Fever (really > 103) Nausea Malaise Respiratory distress Tachycardia Tachypnea Decreased mental status Cervical lymphadenopathy Dirty, gray white rubbery membrane covering structures of the pharynx (removal causes bleeding) Paralysis of soft palate and posterior pharynx Aspiration
What is the mode of transmission for diphtheria?
Respiratory droplets
Direct contact with secretions or skin lesion exudates
What are complications associated with diphtheria?
Widespread organ damage Myocarditis Thrombocytopenia Vocal cord paralysis Acute tubular necrosis Ascending paralysis Death from asphyxia or cardiac complications
What is the treatment for diphtheria?
Airway management Diphtheria antitoxin (horse serum)
What is the incubation period for diphtheria?
2 to 5 days
What are the adult and pediatric symptoms of tuberculosis?
Call for three weeks or longer Hemoptysis Weakness or fatigue Weight loss Anorexia Chills and fever Night sweats
What is the route of transmission for tuberculosis?
Airborne and droplet.
Negative pressure room needed.
What complications are associated with tuberculosis?
Can affect other organs (extra pulmonary)
Can have multiple drug resistant TB
What is the treatment for tuberculosis?
INH
Rifampin
Hospitalization for severe disease.
What is the incubation period for tuberculosis?
2 to 10 weeks
What are the adult and pediatric symptoms for Ebola?
Hemorrhage
Fever
Vomiting/diarrhea
What is the root of transmission for Ebola?
Droplet/contact
Negative pressure room
What is the treatment for Ebola?
Supportive care
What complications associated with Ebola?
Death
What is the incubation period for Ebola?
2 to 21 days
What is Reye’s syndrome?
Rarely seen now because of education of the general public.
Etiology is unknown, but it is seen with use of salicylates in viral illnesses in children.
Find encephalopathy with fatty liver and fatty infiltrates in the heart.
Manifestations of Reye’s syndrome:
Vomiting Hepatomegaly Altered mental status G.I. bleeding Lethargy Coma
Lab tests associated with Reye’s syndrome:
Increased ammonia Decreased glucose Acidosis Increased liver enzymes Increased PT/PTT Increased skeletal and cardiac enzymes
Treatment for Reye’s syndrome:
Supportive
May need mechanical ventilation
Categories of causes of renal failure:
Pre-renal
Intra-renal
Post-renal
Examples of pre-renal causes of renal failure:
Hypokalemia
Decreased cardiac output
Decreased peripheral resistance
Renal vascular obstruction
Examples of intra-renal causes of renal failure:
Drugs X-ray contrast Transfusion reactions Chemicals Pyelonephritis Toxemia Lupus
Examples of post-renal causes of renal failure:
Calculi Prostatic hyperplasia Prostate cancer Bladder cancer Trauma Strictures Spinal cord disease
Cardiovascular manifestations of renal failure:
Hypertension CHF Pericarditis Cardiomyopathy Pericardial effusion
Hematologic manifestations of renal failure:
Anemia
Infections
Integumentary manifestations of renal failure:
Pallor Pigmentation Pruritis Ecchymosis Excoriations Uremic frost
Gastrointestinal manifestations of renal failure:
Nausea/vomiting Uremic Fetor (urine odor to breath) Bleeding Ulcers Stomatitis Gastritis
Reproductive manifestations of renal failure:
Amenorrhea
Infertility
Sexual dysfunction
Azoospermia
Ocular manifestation of renal failure:
Retinopathy
Endocrine manifestation of renal failure:
Thyroid abnormalities
Neurologic manifestations of renal failure:
Fatigue Headaches Sleep disturbances Muscle irritability Seizures Confusion Coma Peripheral paresthesias
Pulmonary manifestations of renal failure:
Pulmonary edema Pleuritis Dyspnea Pneumonia Depressed cough reflex
Treatment for renal failure,
Dialysis
Peritoneal
Vascular (hemo)
What are some fluid electrolyte in balance is associated with renal failure?
Hyperkalemia Hyponatremia Hypocalcemia Hyperphosphatemia Volume overload
What are the Manifestations of hyperkalemia?
Cardiac dysrhythmias N/V/D Twitching Seizures Paresthesias Paralysis Peaked T-waves Prolonged P-R intervals Widened QRS
What is the treatment for hyperkalemia?
IV calcium chloride or calcium gluconate (reduce cardiotoxicity)
IV Glucose and IV insulin (to take potassium back in the cells)
Loop/osmotic diuretics
Renal dialysis
Kayexalate
Continuous cardiac monitoring
Albuterol treatment
What are the manifestations of hypokalemia?
Arrhythmias Depressed T-wave Postural hypotension Anorexia N/V Paralytic ileus Constipation Hyporeflexia Muscle weakness Paresthesias
What is the treatment for hypokalemia?
IV potassium chloride (must use infusion pump)
Cardiac monitoring
Oral potassium chloride
What are the manifestations of Hypernatremia?
Irritability Apprehension Confusion Hypotension Tachycardia N/V Dry mucous membranes Tremors seizures Appears dehydrated Hyperthermia
What is the treatment for Hypernatremia?
Fluid replacement (dilute sodium – if pure water loss - treat with hypotonic solutions - no D5W - causes increased ICP) Slow correction to avoid cerebral edema.
What are the manifestations for Hyponatremia?
Lethargy Postural hypotension Tremors Headache Edema Confusion Seizures Coma
What is the treatment for Hyponatremia?
If severe (< 110) give hypertonic saline solutions *be cautious!) Only give until symptoms go away, don’t wait for numbers to go down
