Medical Emergencies Flashcards
to study for ME exams
- (Lou Gehrig’s Disease) a muscular dystrophy caused by degeneration of motor neurons of the spinal cord
- Management - support ventilations; assure airway and oxygenation; remain aware of patient’s LOC (compassion is essential)
Amyotrophic lateral sclerosis (ALS)
- A disease characterized by muscular weakness and fatigue improved by rest
- Management - support ventilations; assure airway and oxygenation; remain aware of patient’s LOC (compassion is essential)
Myasthenia gravis
- A disease of unknown etiology, characterized by pain and weakness beginning in the distal extremities and progressing to involve entire limbs and possibly the trunk
- Management - support ventilations; assure airway and oxygenation; remain aware of patient’s LOC (compassion is essential)
Guillain-Barre’s syndrome
- A severe, prolonged attack that cannot be broken by beta bronchodilators (albuterol, levalbuterol, metaproterenol, epinephrine, terbutaline)
- Greatly diminished breath sounds
- Respiratory arrest imminent - aggressively manage airway and breathing; transport immediately
- Pharmacologic interventions
a. Oxygen - moderate to high flow
b. Beta sympathomimetics - albuterol, levalbuterol, metaproterenol, epinephrine, terbutaline
c. Anticholinergics - ipratropium
d. Anti-inflammatory - methylprednisolone
e. Bronchodilators - magnesium sulfate - Physical interventions
a. CPAP
b. Intubation - as needed to improve ventilation; pharmacologically assisted/rapid sequence
c. Instill saline down endotracheal tube or use albuterol bullets
d. Chest percussion
Status asthmaticus
- A wasting disease of the muscles
- Management - support ventilations; assure airway and oxygenation; remain aware of patient’s LOC (compassion is essential)
Muscular dystrophy
- Causes - acidosis, beta-adrenergic agonist, bronchial asthma, cardiovascular disorder, CNS infection, CHF, drugs, fever, hepatic failure, high altitude, hypotension, hypoxia, interstitial pneumonitis, metabolic disorders, methyxanthine derivatives, pain, pneumonia, pregnancy, progesterone, psychogenic or anxiety, pulmonary disease, pulmonary emboli, salicylates
- Assessment
a. Focused history and physical exam - SAMPLE and OPQRST
b. Fatigue, nervousness, dizziness, dyspnea, chest pain; numbness and tingling in hands, mouth, and feet
c. Presence of tachypnea and tachycardia
d. Spasms of the fingers and feet
e. Dyspnea, chest pain, other symptoms based on etiology, carpopedal spasm, rapid breath with high minute volume, varying depending on cause of syndrome - Management
a. Depends on cause
b. Airway and ventilation
c. Oxygen - based on symptoms and pulse oximetry
d. If anxiety hyperventilation - coached ventilation/rebreathing technique
Hyperventilation syndrome
- Chronic infection
a. Clinically, productive cough - three months/year for two or more consecutive years - Increased number of goblet cells
a. Over production of mucus - Usually the result of heavy smoking history
- Pathophysiology
a. Results from increase in mucus-secreting cells in respiratory tree
b. Alveoli relatively unaffected
c. Decreased alveolar ventilation - Assessment
a. History - frequent respiratory infections; productive cough
b. Develop pulmonary hypertension causing RHF (cor pulmonale)
c. Gas exchange decreased from lower alveolar ventilation (hypoxia and hypercarbia) - Physical exam
a. Often overweight, rhonchi present on auscultation, jugular vein distention, ankle edema, hepatic congestion, “blue bloaters”
Chronic bronchitis
- Common causes - tongue, foreign matter, trauma, burns, allergic reaction, infection
- Assessment - differentiate cause
- Management
a. Conscious patient - if the patient is able to speak, encourage coughing; if the patient is unable to speak, perform abdominal thrusts
b. Unconscious patient - full CPR (inspect mouth before ventilation); visualize the airway with the laryngoscope (remove foreign body with Magil forceps)
Upper airway obstruction
- Headache, congestion, tenderness over the sinuses, worsening of pain with leaning forward, yellow nasal discharge, pressure behind the nose
- Management
a. Typically no intervention required
b. Oxygen administration
c. Supportive care - antipyretics, analgesics
d. Remain cautious when symptoms seem extremely severe (meningitis)
e. Avoid evaluating the airway in a patient with epiglottis
f. Remain alert for complications in patients with asthma or COPD (prepare to use bronchodilators and corticosteroids)
Sinusitis
- Infection of the lungs (immune-suppressed patients)
- Pathophysiology
a. Bacterial and viral infections - hospital-acquired vs. community-acquired
b. Infection can spread throughout lungs
c. Alveoli may collapse, resulting in a ventilation disorder - Risk factors - cigarette smoking, alcoholism, exposure to cold, extremes of age (old or young)
- Assessment
a. Focused history and physical exam - SAMPLE and OPQRST (recent fever, chills, weakness, and malaise; deep, productive cough with associated pain)
b. Tachypnea and tachycardia may be present
c. Breath sounds: presence of rales/crackles in affected lung segments; decreased air movement in affected lung - Management
a. Maintain the airway
b. Support breathing - high flow O2 or assisted ventilation as indicated
c. Monitor vital signs; establish IV access (avoid fluid overload)
d. Medications - antibiotics, antipyretics, beta-agonists
Pneumonia
- Not a disease but a pathophysiological condition
a. High pressure (cardiogenic) - acute MI, chronic HTN, myocarditis
b. High permeability (non-cardiogenic) - acute hypoxemia, near-drowning, post-cardiac arrest, post shock, high altitude exposure, inhalation of pulmonary irritants, ARDS - Assessment
a. Hypoxic episode - shock (hypovolemic, septic, or neurogenic) dyspnea, orthopnea, fatigue, cough, frothy sputum, pulmonary rales - Management
a. Airway and ventilation - intubation as necessary; assisted ventilation (PEEP), high flow O2
b. Avoid fluid excess; diuretics - not usually appropriate in high permeability edema; corticosteroid
Pulmonary edema
- Odorless, colorless gas
a. Results from combustion of carbon-containing compounds
b. Often builds up to dangerous levels in confined spaces such as mines, autos, and poorly ventilated homes - Pathophysiology
a. Binds to hemoglobin; prevents oxygen from binding and creates hypoxia at cellular level - Assessment
a. Determine source and length of exposure
b. Symptoms: headache, confusion, agitation, lack of coordination, loss of consciousness, seizures - Management
a. Ensure scene safety - remove the patient from the toxic environment
b. Maintain the airway
c. Support breathing - high flow O2 or assisted ventilations as indicated
d. Establish IV access; transport to hyperbaric therapy
CO inhalation
- Pathophysiology
a. A variety of bacteria and virus; 20-30% are group A streptococci; 50% of pharyngitis have no demonstrated bacterial or viral cause; most are self-limiting diseases - Assessment findings
a. Chief complaints - sore throat, fever, chills, headache
b. Physical findings - erythematous pharynx, positive throat culture - Management
a. Typically no intervention required
b. Oxygen administration
c. Supportive care - antipyretics, analgesics
d. Remain cautious when symptoms seem extremely severe (meningitis)
e. Avoid evaluating the airway in a patient with epiglottis
f. Remain alert for complications in patients with asthma or COPD (prepare to use bronchodilators and corticosteroids)
Upper respiratory infection
- Pathophysiology
a. Includes inhalation of heated air, chemical irritants, steam
b. Airway obstruction due to edema and laryngospasm due to thermal/chemical burns - Assessment
a. Determine nature of substance; length of exposure/loss of consciousness - Management
a. Consider Haz-Mat
b. Maintain airway - early, aggressive management may be indicated
c. Support breathing; establish IV access; transport promptly to appropriate facility
Toxic inhalation
- Pathophysiology
a. Obstruction of a pulmonary artery - may be of air, fat, amniotic fluid, foreign bodies - Risk factors - recent surgery, long-bone fractures, pregnancy or postpartum, atrial fibrillation, oral contraceptive use, tobacco use, long term immobilization
- Assessment - presence of risk factors, sudden onset of severe dyspnea and pain, cough (often blood-tinged)
- Physical Exam - signs of heart failure including JVD and hypotension; warm, swollen extremities
- Management
a. Maintain airway
b. Support breathing - high flow O2 or assisted ventilations as indicated; intubation may be indicated
c. Establish IV access; monitor closely; transport to appropriate facility
Pulmonary embolism
- Pathophysiology
a. Significant variety in cell types/growth rates
b. Signs and symptoms vary according to location of tumor
c. Signs of severe distress - altered mentation, 1-2 syllable dyspnea, severe or uncontrollable hemoptysis, dysphagia - Management - supportive care
a. Airway and ventilation; intubation if required; assisted ventilation if necessary; oxygen (flow rate based on symptoms and pulse ox); honor scope of DNR (palliative care may be indicated)
Pulmonary neoplasms
- Pathophysiology - chronic inflammatory disorder
a. Results in widespread but variable air flow obstruction
b. The airway becomes hyperresponsive
c. Induced by a trigger, which can vary by individual
d. Trigger causes release of histamine, causing bronchoconstriction and bronchial edema
e. 6-8 hours later, immune system cells invade the bronchial muscosa and cause additional edema - Initial presenting signs on physical exam
a. Dyspnea, wheezing (not present in all asthmatics), cough - Secondary (worsening) symptoms on physical exam
a. 1-2 word dyspnea, lengthened expiratory periods,
hyperinflation of the chest, accessory muscle use, tachycardia, pulsus paradoxus - Management
a. Treatment goals - correct hypoxia, reverse bronchospasm, reduce inflammation
b. Maintain the airway
c. Support breathing - High flow O2 or assisted ventilations as indicated - Pharmacologic interventions
a. Oxygen - moderate to high flow
b. Beta sympathomimetics - albuterol, levalbuterol, metaproterenol, epinephrine, terbutaline
c. Anticholinergics - ipratropium
d. Anti-inflammatory - methylprednisolone
e. Bronchodilators - magnesium sulfate - Physical interventions
a. CPAP
b. Intubation - as needed to improve ventilation; pharmacologically assisted/rapid sequence
c. Instill saline down endotracheal tube or use albuterol bullets
d. Chest percussion
Asthma
- Pathophysiology - exposure to noxious substances
a. Exposure results in destruction of walls of alveoli
b. Weakens walls of small bronchioles/results in increase residual volume - Often develop pulmonary hypertension, leading to right heart failure (cor pulmonale); polycythemia causing elevated hematocrit; increased risk of infection and dysrhythmia
- Live with condition every day (compensated); when infection sets in, or stress in present (decompensated)
- Assessment
a. History: recent weight loss, dyspnea with exertion; cigarette and tobacco usage; diseases usually start after 20 pack/years
b. Lack of cough - Physical exam
a. Barrel chest, prolonged expiration/rapid rest phase, thin, pink skin due to extra red cell production, hypertrophy of accessory muscles, pursed lips - “pink puffers”
Pulmonary emphysema
- Respiratory syndrome characterized by respiratory insufficiency and hypoxia
- Pathophysiology
a. High mortality, multiple organ failure, affects interstitial fluid (disrupts diffusion and perfusion) - Causes - sepsis, aspiration, pneumonia, pulmonary injury, burns/inhalation injury, oxygen toxicity, drugs, high altitude, hypothermia, near-drowning syndrome, head injury, pulmonary emboli, tumor destruction, pancreatitis, invasive procedures (bypass, hemodialysis), hypoxia, hypotension, cardiac arrest
- Findings - SOB, rapid breathing, inadequate oxygenation, decreased lung compliance
- Management
a. Provide supplemental oxygen
b. Support respiratory effort - provide positive pressure ventilation if respiratory failure is imminent
c. PEEP; suction
d. Manage the underlying condition
e. Consider medications - beta adrenergic, corticosteroids
Adult respiratory distress syndrome (ARDS)
- Rhinorrhea, nasal congestion, sneezing
- Management
a. Typically no intervention required
b. Oxygen administration
c. Supportive care - antipyretics, analgesics
d. Remain cautious when symptoms seem extremely severe (meningitis)
e. Avoid evaluating the airway in a patient with epiglottis
f. Remain alert for complications in patients with asthma or COPD (prepare to use bronchodilators and corticosteroids)
Rhinitis
- Sore throat, difficulty swallowing, erythmatous pharynx, tonsil enlargement, pus on tonsils, cervical lymph node enlargement
- Management
a. Typically no intervention required
b. Oxygen administration
c. Supportive care - antipyretics, analgesics
d. Remain cautious when symptoms seem extremely severe (meningitis)
e. Avoid evaluating the airway in a patient with epiglottis
f. Remain alert for complications in patients with asthma or COPD (prepare to use bronchodilators and corticosteroids)
Pharyngitis
- Sore throat, drooling, ill appearing, upright position
- Avoid evaluating the airway
Epiglottitis
- Sore throat, hoarseness, pain on speaking, red pharynx, hoarse quality to voice, cervical lymph node enlargement
- Management
a. Typically no intervention required
b. Oxygen administration
c. Supportive care - antipyretics, analgesics
d. Remain cautious when symptoms seem extremely severe (meningitis)
e. Avoid evaluating the airway in a patient with epiglottis
f. Remain alert for complications in patients with asthma or COPD (prepare to use bronchodilators and corticosteroids)
Laryngitis
- Sudden pneumothorax without trauma
- Risk factors - males, younger age, smokers, thin body mass, hx of COPD
- Assessment
a. SOB, chest pain (sudden onset), pallor, diaphoresis, tachypnea
b. Severe - altered mentation, cyanosis, tachycardia, decreased breath sounds, local hyperresonance to percussion, subcutaneous emphysema - Management - supportive
a. Airway and ventilation - intubation as required; assisted ventilation if necessary; oxygen - administration levels based on symptoms and pulse ox - Tension pneumothorax? - needle decompression
Spontaneous pneumothorax
Inflammation of the lining of shealth that surround a tendon
Tenosynovitis
One of the big 5 higher-order personality traits that causes the pt to be prone to moodiness. The pt will respond worse to stressors and experiences; anxiety, fear, frustration, anger, envy, depression.
Neuroticism
unusual and stressful situation that is encountered in every call. This is the paramedic’s most challenging role.
Emotional crisis
The origin of abnormal behaviors caused/ related by structural changes or disease processes. Eg metabolic disease, infection, head trauma
Biological/ organic
The origin of abnormal behaviors caused/ related to the pt’s personality style, unresolved conflict, or crisis management methods
Psychosocial
The origin of abnormal behaviors caused by the pt’s actions and interactions with society such as environmental violence/ cultural norms.
Sociocultural
General management of behavioral emergencies pt
-SS/BSI
- supportive + calm environment
- treat any existing medical conditions
- do not allow SI pt to be alone
-do not confront/ argue with pt
- provide realistic reassurance
- IDENTITY cause (medical or psychological)
- if psychological build trust, use interviewing skills, and talk down pt
-inquire mental warrant if applicable
Chemical restraint medication options
- benzodiazepines
- haloperidol
- droperedol
-ziprasidone - paralytics (RARE)
Produces a rapid onset of unconsciousness, seizures, and widening of the QRS complexes. This is a type of overdose
Tricyclic Antidepressants (TCA)
what drug should TCA overdoses be treated with?
1 mEq/kg Sodium Bicarbonate
the eating disorder when the pt consumes non-food items
pica
The lack of maintenance of a healthy body weight and obsessive fear of gaining weight. The pt may refuse to gain weight. The unrealistic perception or non-recognition of the seriousness of weight
Anorexia nervosa
Recurrent binge eating, followed by compensatory behaviors such as purging. Pt presents with
- self induced vomiting
- eating to the point of vomiting
-excessive use of laxatives/ diuretics
excessive exercise
Bulimia nervosa
neutralization
disarms
- contagious respiratory infection
- three types (A,B,C)
- constant change or antigenic drift
- mild to severe illness, frequently fatal
- spread through airborne secretions
- sudden onset of : fever, headache, fatigue, dry cough, sore throat, runny nose, muscle aches, GI complications
Influenza
general signs and symptoms for hepatitis
-fever and weakness being first to appear
- anorexia, nausea, and abdominal pain
- guarding to upper right quadrant
- jaundice, with dark yellow urine
- light stool
- inflammation of the lining of brain and spinal cord
- viral, bacterial, or fungal
- often follows trauma or sinus infectious
- airborne or direct contact with respiratory secretions
- S/S include irregular fever, headache, nausea, STIFF NECK
- presents with brudzinskis neck sign ( with supine pt, lift head. Knees should rise)
- eventually vomiting, rash, anorexia, constipation, noise, light intolerance, and decreased mentation will occur
- treatment includes supportive, control seizures, maintain airway and ventilations, IV fluids
Meningitis
Syndrome, not disease
- developed from HIV
- began in homosexual men and IV drug abusers- since spread to general population
- spread through direct contact with human fluid
- S/S include fever, cough, reddish lesions (kaposi’s sarcoma), night sweats, and weight loss
- may develop encephalopathy
- pneumonia from pneumocystis carinii parasite
cause of death: pneumonia and suicide
AIDS
Gram positive spore-forming bacterium
- normal flora of colon
- remains/ flourishes after antibiotic treatment
- outbreaks follow accidental ingestion of spores
- releases toxins that cause: bloating, diarrhea, abd pain, causes psuedomebranous colitis, may be life threatening
to manage:
- maintain hydration
- antibiotics
- control nausea/ emesis
- stool transplant
Latent bacteria can be killed by bleach solutions
Clostridium Difficile (C-Diff)
Conjunctival condition
- raised, wedge shaped growth of conjunctiva
- non-cancerous
- common in people who have increased outdoor exposure to sun, wind , and dust.
Pterygium
Clouding of lens of eye
-associated with; aging, breakdown of proteins within lens
risk factors: diabetes, eye injury, radiation exposure, smoking, exposure to ultraviolet light
Presents with:
decreased vision, cloudy / fuzzy vision, light sensitivity, diplopia, loss of color intensity, halos around lights
treatment is prevention and surgical removal
Cataract
Separation of retina from supporting structures:
causes: trauma, diabetes, unknown
presents as: bright flashes in peripheral vision, floaters in eye, shadow/ blindness in part of visual field
Retinal detachment
Infection/ inflammation of sinuses
- bacterial, viral, allergies
symptoms: facial pressure, headaches, sore throat, posterior nasal drip, cough, bad breath, loss of smell, malaise, fever
treatment
-antibiotics, decongestants, antihistamines, corticosteroids
Sinusitis
Viral infection/ drainage from upper airway/sinus infection
- causes; allergies, bacterial infections, injury, chemical exposures, germ, pneumonia
S/S include: fever, hoarseness, loss of voice
Laryngitis
Chronic autoimmune disease that affects skin, joints, kidneys, and other organs
- runs in families but common in women
- joint pain/ swelling with some developing arthritis
- fingers, wrists, knees are affected
S/S include: chest pain, fatigue, fever, malaise, skin rash, swollen Lymph nodes
- diagnosed through laboratory testing/ physical exam
- treatment is symptomatic
Systemic lupus erythematous (SLE)
Pediatric condition of painful swelling of the anterior tibial tubercle
- bump on upper tibia below knee
- repetitive injuries before growth complete
-treatment is rest, ice, NSAID medications
Osgood-schlatter disease
The informal term that refers to a pattern of antisocial behavior and attitudes. This is most closely represented by antisocial personality disorder. Lack empathy but HAS conscience.
Sociopathy
Categorized under antisocial personality disorder. Lacks empathy but DOES NOT have a conscience
Psychopath
Functional mental disorders that involve chronic distress but is absent of delusion/ hallucinations. This term is no longer used by the psychiatric community. Pt still has a touch of reality and is not a fundamental personality trait.
Neurosis
RAPID ONSET of widepread, disorganized thought.
- inattention
- memory impairment
- disorientation
- clouding of consciousness
- vivid visual hallucinations
Delirium
GRADUAL development of memory impairment and cognitive disturbances.
-aphasia, apraxia, agnosia
- abstract thinking/ judgment
Dementia
The behavioral disorder that presents with gross distortions of reality
- withdrawal from social interaction
- disorganized thought, perception and emotion
assessment will present with
-delusions
-hallucinations
- disorganized speech
- high risk SI/ HI
Schizophrenia
the worry of future events
Anxiety
the fear of CURRENT events regarding behavioral disorders
fear
Recurrent attacks of sudden anxiety. May present with 4 symptoms peaking within 10 minutes, including but not limited to
- palpitations
- sweating
- SOB
-trembling
-CP
-nausea
- parethesia
- dizziness
Panic disorders
Exaggerated, sometimes disabling, frequently inexplicable fear. May be unreasonable for the average person.
Phobias
Anxiety reaction to a severe psychosocial event. Usually from a life threatening event. There will be repetition of intrusive memories. Findings will include:
- depression/ nightmares
- survivor guilt
- frequent and complicated substance abuse
PTSD
One of the most prevalent major psychiatric conditions. Affects 10-15% of population. This condition is episodic with periods of remission. There may be gradual or rapid onset with clusters of episodes. This is a major cause of suicide.
Depression
Depressed mood lasting all day, nearly every day
- diminished interest in pleasure and dainty activities
- significant weight change
- insomnia or hypersomnia
- psychomotor agitation
- recurrent thoughts of death
Major depressive episodes
Requires 5 or more symptoms during the same 14 day period and depression cannot be accounted for by other events. ( ISAD CAGES)
-interest
- sleep
-appetite
- depressed mood
- concentration
- activity
-guilt
- energy
- suicide
Major depressive disorder (MDD)
What should be noted during documentation of a suicidal pt?
-Document observations about the scene that may be valuable to mental health professionals
- notes, plans, or statements from pt
- treat trauma/ medical complaints
described as alternating periods of depression with manic behavior. Depressive periods are greater than manic episodes. Irritation, gregarious, and quickly becomes argumentative and hostile if thwarted
Bipolar
OD of this drug produces extrapyramidal reactions (shakes, dyskinesia)
Phenathiazines
what drug should be used in treatment of an OD of phenathiazines?
25 mg of Diphenhydramine
The feigning of the symptoms of a disease or injury in order to undergo diagnostic tests, hospitalization, or medical/ surgical treatment.
Munchausen’s syndrome
The eating disorder involving the regurgitation of food
rumination disorder
Eating disorder presenting with the lack of interest of food
Avoidant/ restrictive food intake disorder
Preoccupation that one’s own body is too small, too skinny, insufficiently muscular or lean. Eats to bulk up and build muscle. Mostly affects males
muscle dysmorphia
Grazing on large quantities of food rather than binging
Compulsive overeating
Aberrant eating disorders of children in foster care
Food maintenance
obsession with pure diet
orthorexia nervosa
restricting food to save food calories for alcohol calories
drunkorexia
Obsessive focus on fine foods, following frontal lobe injury
Gourmand syndrome
Odd/eccentric cluster of personality disorders
includes:
-paranoia
- schiziod
- schizotypical
common features include social awkwardness, social withdrawal, and dominated by distorted thinking
Cluster A
Pervasive social detachment/ restricted range of emotional expression. “Loners”
Schiziod personality disorder
Pervasive pattern of social/ interpersonal limitations.
- experience acute discomfort in social settting
- reduced capacity for close relationships
- notices flashes of light no one else can see
- think they can read thoughts/ others steeling theirs
schizotypal personality disorder
Cluster of personality disorders that share problems with impulse control, emotion, and regulation.
- borderline personality disorder
- narcissistic personality disorder
- histrionic personality disorder
- antisocial personality disorder
Cluster B
Pervasive pattern of disregard for the rights of others. Often manifesting as hostility or aggression
- may first appear in childhood
- do not experience genuine guilt
- take little to no responsibility for their actions
antisocial personality disorder
pattern of excessive emotionality and attention seeking
- drama queens
- emotional expression is vague/ shallow but has manners that draw attention to oneself
Histrionic personality disorder
Significant problems with the sense of self worth stemming from a powerful sense of entitlement.
- they believe they deserve special treatment, assume the are uniquely talented
- can fundamentally disregard/ disrespect worth of those around them
narcissistic personality disorder
Most widely studied personality disorder that is characterized by intense/ unstable emotions/ moods that can shift fairly
- generally have a hard time calming down once upset.
- angry outbursts
- engage in impulsive behaviors
- see world as black and white
- unstable sense of self
borderline personality disorder
Cluster of personality disorders that share a high level of anxiety
- avoidant personality disorder
- dependent personality disorder
- OCD
Cluster C
Characterized by
- pervasive pattern of social inhibition
- feelings of inadequacy
- hypersensitivity to negative evaluation
people with this disorder are afraid others will ridicule, reject, and criticize them.
Avoidant personality disorder
Characterized by:
- strong need to be cared for
- fear of losing support of others
- fear of losing relationship makes them vulnerable to manipulation/ abuse
dependent personality disorder
Characterized by:
-preoccupied with rules, regulations, orderliness
- great makers of list/ schedules
- devoted to work- often neglect social relationships
- unable to delegate bc “ it wont be done right”
obsessive compulsive personality disorder
Development disorder characterized by troubles with social interaction/ communication
- restricted/ repetitive behavior
- usually seen within first 2-3 years of life
Autism
- Unicellular, microorganism
- visible under light microscopy
- plant-like without photosynthetic capabilities
- reproduce through binary fission
- treated with antibiotics
Bacteria
- Extremely small, non-living, microorganism
- not visible under light microscopy
- obligate, intercellular
- depend on host for nutrition
Virus
- unicellular organism
- motile
- lack cell walls
- capture food through phagocytosis
-malaria, giardiasis, amebic dysentery
Protozoa/ protozoan diseases
- cellular organisms which live off of organic matter
- size varies
- found in decaying tissues, and damp, warm environments
- athletes foot, yeast infections
fungi/ fungal infection
- recently recognized infections agent
- normal protein, mutated
- smaller than viruses
- kuru, creutzfeld-Jakob disease, bovine spongiform encephalitis
prions/ prion diseases
A foreign substance, usually protein, may be anything (dust, pollen, drug, food)
Antigens
-immunoglobulin proteins
- each specific antibody is developed in response to specific antigen
Antibodies
What is the most short lived immunoglobulin protein that is formed in almost every immune response following contact of B-lymphocyte with its specific antigen.
IgM (gamma M)
The most abundant immunoglobulin protein that compromises 75 % of normal persons antibodies. Important in producing immunity in fetus prior to birth
IgG (gamma G)
Principle immunoglobulin protein in exocrine secretions that PROTECTS MUCOUS MEMBRANES
IgA (gamma A)
antibody responsible for allergic effects. Allergies can be from the overproduction of this
IgE (gamma E)
Present in very small amounts in human serum. Kickstarts immune system, least abundant immunoglobulin protein.
IgD (gamma D)
Agglutination
grab+ clump, bear hug cells
Precipitation
makes liquid to solid
Lysis
destruction of antigen
- white blood cells
- travels circulatory system
- Destroy invading substances
- 7000 per milliliter
Leukocytes
- another circulatory system
- contains lymph nodes, lymphocytes
- spleen is key factor
lymphatic system
Staph that is resistant to beta-lactum antibiotics such as penicillins, and cephalosporins (CEF drugs)
- presents with skin infection such as pimple or boil
- can lead to more serious infections such as pneumonia, sepsis, surgical wound infections.
methicillin-resistant staphylococcus aureus (MRSA)
- airborne or direct contact disease
- infectious for 4 days before and 5 days following a rash
- S/S include: fever, cough, conjunctivitis, photosensitivity, rash to face, neck, and may spread to entire trunk/ extremities
- treatment is supportive but look out for complications such as Ottis media, bronchopneumonia, and encephalitis
measles (rubeola)
- viral infection
- transmitted through salvia
- infectious 2 days before swelling of parotid gland until symptoms subside
- S/S include fever, fatigue, sore throat, dysphasia, testicular swelling
- treatment is supportive, apply ice to swollen areas, look for complications such as orchitis, pancreatitis, and meningoencephalitis.
Mumps (epidemic parotitis)
- “general measles”
- transmitted through airborne droplet, urine/ feces on skin
- virus teratogenic/ crosses placenta
- stops cells from developing- destroys the fetus
- S/S include rash (face, spread to trunk/ limbs) that fades in THREE DAYS, low grade fever, swollen lymph nodes, joint pain, headache, conjunctivitis
Rubella
- herpes varicella zoster virus
- airborne/ direct contact with respiratory secretions
- infectious 1 days before swelling before symptoms until all lesions have scabbed over
- S/S fever + vomiting early, headache and chills, general fatigue, itchy skin eruptions begin on chest and may cover the entire body.
- treatment is supportive, lotions and cream may ease itching, virus may become active in later years as shingles
Chicken pox
-from bacterium clostridium tetani
- infection puncture or deep wound
- muscle spams development in jaw “lock jaw”
- S/S include spasms in jaw, chest, neck, and abd
- back muscle spasms can cause arching (opisthotonos)
- spasms may affect intercostal muscles
- drooling, sweating, fever, irritability, uncontrolled urination/ defecation may be present as well.
Tetanus
- caused by bacteria bordetella pertussis
- spread by coughing or sneezing while in close contact with others
- infants contract from parents, older siblings, or other caregivers
- S/S include starting like a common cold (runny nose/ congestion, sneezing, mild cough, fever)
- after 1-2 weeks severe coughing begins
- violent and rapid cough until air is gone from lungs, forcing and inhale
- infants can have a minimal/ absent cough but may present with a life threatening apnea.
Pertussus (whooping cough)
- bacterial infection
- usually involves the lungs
- can spread to kidneys, pericardium, bone and meninges
- airborne; contact with respiratory secretions
- S/S include fever, productive cough (hemoptysis), night sweats, weight loss, fatigue
tuberculosis
Infection of the liver that is the most common form.
- formally called infectious hepatitis
- fecal-oral transmission
- approximately 30 day incubation period
- once infected- immune for life
Hepatitis A
Infection of liver that is commonly called serum hepatitis
- serious risk to healthcare workers
- transmitted through body fluids, primarily blood
- approximately 50-day incubation period
- carrier state possible
Hepatitis B
Infection of the liver that is bloodborne and is a major cause of post-transfusion hepatitis
- incidences declining
- approximately 50-day incubation period
- carrier state exists
hepatitis C
Infection of the liver that is called delta hepatitis
- a defective virus ( must have another virus to exist)
- exaggerated symptoms with Co-infection
- can lead to fatal cirrhosis
hepatitis D
Infection of the liver with a fecal-oral transmission
- rare in the US
- approximately 40 day incubation period
- chronic states do not appear to exist
Hepatitis E
disease from palladium bacteria
- transmitted through direct sexual contact
- infectious during active periods
- several stages, may be dormant for long periods
-Primary stage: 2-4 weeks after exposure, chancre (painless genital ulcer) that will disappear untreated and pt becomes asymptomatic
- Stage 2: 6-8 weeks post chancre, headache, malaise, anorexia, fever, sore throat, reddish rash on palms and soles but may cover whole body, will end untreated
- Tertiary stage: months to years later, bacteria invades vessels and CNS, tabes dorsalis (wide gait, slapping feet, ataxia), psychosis, potentially fatal (usually from ruptured aorta)
syphilis
Bacterial disease from direct sexual contact
- females remain asymptomatic for extended periods while transmitting disease
- may be symptomless in oropharynx and rectums
- painful and frequent urination, constant purulent discharge from urethra/ vagina.
- lower abd pain in women
Gonorrhea
Bacterial disease transmitted from vaginal, anal, or oral sex
- can pass from infected mother to baby during vaginal childbirth
- S/S in women asymptomatic in 50-70% of women, unusual vaginal bleeding/ discharge, abd pain, painful intercourse, fever, urinary complications
- S/S in men, urethritis, painful/ burning urination, purulent discharge from penis (lighter color than gonorrhea), swollen/ tender testicles, fever
chlamydia
Chronic viral infection
- infectious anytime lesions are present
- can reoccur anytime
- S/S include fever, swollen lymph nodes, ulcerated lesions, thin white discharge from ulcer until encrusted
Herpes
Itch mite infestation through direct contact
s/s include red/ elevated skin lesions, itching, dermatitis
scabies
Ectoparasite
- small sting insect
- transmitters of epidemic typhus and other diseases
- transmitted through direct contact
-S/S include itching, small white speck resembling dandruff, secondary injury is burns
Lice
bacterial infection disease from the borrelia family, tick borne from infected ticks belong to species genus Ixodes.
S/S include early fever, headache, fatigue, depression, character circular skin rash, erythema migrans (EM).
Later symptoms involve joints, heart, and CNS
Lyme disease
warm blooded animals
- zoonotic (can be transmitted from one species to another)
- early S/S include malaise, headache, fever
- progression to acute pain, violent movements/ uncontrolled excitement, depression, hydrophobia
- finally, mania and lethargy, coma
- death is usually in 2-10 days mostly from respiratory insufficiency
Rabies
Viral infection that affects the respiratory system
coronavirus is a cause for infection
- first reported in Asia in 2003
- spread through airborne droplets or by touching contaminated surface
S/S include: high fever, headache, body aches/chills, malaise, dry cough, pneumonia, diarrhea.
Good prognosis if caught early
Sudden Acute Respiratory Syndrome (SARS)
Viral infection from central and west Africa, coming to the US in 2003
- transmitted by respiratory droplets or contact with bodily fluids
- S/S include fever, headache, muscle aches, backache, lymph nodes swell, fatigue, rash for 1-3 days after fever.
- rash develops into raised bumps, fluid starting on face, spreads to other parts of the body, bumps go through several stages before they get crusty, scab over, and fall off
- illness usually lasts for 2-4 weeks
Monkey pox
Variola virus that is extremely contagious and fatal
- no cure
- vaccine has been extremely successful
- S/S include fever malaise, headache and body ache, emesis, fever, prodrome phase lasting 2-4 days.
- rash emerges as small red spots on tongue/ mouth
- spots develop into sores and break open, spreading large mounts of virus into mouth/ throat.
- rash appears on skin (face, arms, legs, body, over 24 hours)
- fever usually falls and the person may start to feel better
- by 4th day, bumps fill with thick/ opaque fluid, often have depression in the center that looks like a bellybutton
- fever will often rise again and remain high until scabs form over the bumps
- remained contagious until scabs fall off
Small pox
Viral infection spread by mosquitoes feeding on infected birds
- only 20% of those infected will develop symptoms
- S/S include fever, headache, body aches, skin rash on trunk, swollen lymph glands.
- severe S/S include neck stiffness, stupor, disorientation, coma, tremors, convulsions, muscle weakness, paralysis
West Nile virus
Bacterial infection, yersinia pestis, spread by fleas on rats and other vectors
- responsible for millions of deaths from multiple epidemics in china, Europe, and africa
- currently still present in many countries
There are 3 types with 3 different sets of symptoms
- bubonic: swollen lymph nodes, fever, chills, weakness
- septicemic: fever, chills, weakness, septic shock, DIC
- pneumonic: dyspnea, hemoptysis, cheat pain, weakness, fever, headache
Plague
Virus spread by rodent urine, feces, and saliva
- symptoms, following 1-5 week incubation
early: fatigue, fever, muscle aches, headaches, dizziness, chills,
abd problems
late: cough, chest pain, dyspnea, pulmonary edema
Hantavirus
Viral hemorrhagic fever
- death rate of up to 90%
- symptoms are flu like: fever, intensive weakness, muscle pain, headache, sore throat, vomiting, diarrhea, rash, impaired kidney/liver function, internal/ external bleeding
- symptoms appear from 2-21 days after exposure
Ebola
What alert should be called based on the following criteria ?
Suspected infection + 2 (or more) of the following:
- AMS
- RR >/= 20
- HR > 90
- SBP </= 100
- ETCO2 </= 25
- Temp > 100.4/38 or <95/35
Sepsis
Infection of the eyelid- external hordeolum
- blockage of oil glands associated with eyelash
- located at lash line with a small pustule/lump
- resolves when gland blockage is relieved
Stye
Internal hordeolum
- inflammation/infection
- blockage of the meibomian glands (produces the fluid tha lubirvstes the eyes)
- red, tender lump in eyelid/ margin
chalazion
Infection/inflammation of the conjunctiva
Bacterial cause:
-pinkeye
- cornea is clear
- redness/ itching
- more tears than normal
-topical antibiotics can be used for treatment
viral cause:
-similar to bacterial but cause is viral
- treatment is symptomatic
Allergic cause:
-redness, watery discharge, itching, swelling
- tends to be seasonal
- oral/ topical ocular antihistamines for treatment
Conjunctivitis
Swelling/ irritation in the middle layer of the eye
- common in pt with autoimmune diseases
- anterior is the inflammation in the front of the eye
- posterior is the back part (choroiditis)
- can effect one or both eyes
causes: blurred vision, eye pain, erythema, photosensitivity, floaters
treatment: protection from light, analgesia, corticosteroid eye drops
Iritis / Uveitis
Infection/ inflammation of the cornea
- frequent cause of corneal transplantation
- pain
-photophobia
- blurry vision
- tearing
- erythema
Herpes simplex virus (HSV) keratitis
Shingles that affects eye
- virus spreads along first division of trigeminal nerve
- damage can result to eye itself
- ulcer/ similar lesion on cornea
Herpes Zoster Ophthalmicus
Infection of cornea that breaks through the epithelial of cornea
- serious/ sight-threatening infection
- painful red eye, tearing, photophobia
- Evaluation by ophthalmologist essential
Corneal ulcers
Soft tissues surrounding eye infected
- sight-threatening/ life threatening condition
- edematous, erythematous, warm eyelids/ surrounding tissues
- eye itself not involved
Cellulitis
Type of cellulitis that is usually bacterial
- risk for children
- presents w/ pain, conjunctivitis, blurred vision, increased tear production
- treated with potent antibiotics + hospital admission
Periorbital cellulitis (preseptal)
ype of cellulitis that infects the structures behind the orbital septum
- common in winter
-S/S include fever, headache, malaise, eyelid edema, runny nose, protrusion of eye, inability to move eye, decreased vision
- true emergency
orbital cellulitis (postseptal)
Collection of blood in the anterior chamber of eye
From
- trauma
- sickle cell disease
-diabetes
- tumors of eyes
sight threatening
Hyphema
Group of eye sight threatening eye conditions
- increased pressure with eye IOP
- damages optic nerve
- blockage of flow of aqueous humor from anterior chamber
Glaucoma
Most common type of glaucoma
-IOP increases slowly over time
- no symptoms other than begin to lose vision
- places pressure on optic nerve/ retina
open-angle glaucoma
Type of glaucoma that is an outflow of aqueous humor suddenly blocked
- rapid and severe increased on IOP
- severe eye pain
- decreased, cloudy vision
- red/ swollen
- rainbow/ halo like effects around lights
treatment is to reduce IOP, medicate, and perform surgery
Angle closure glaucoma
Inflammation of the optic nerve
result of:
autoimmune diseases, infections, drug toxicity, multiple sclerosis
-presents as loss of vision in single eye in hour, loss of color vision, changes in pupillary reaction to light, pain with eye movement
vision returns to normal within 2-3 weeks without treatment
-corticosteroids used
- ophthalmology evaluation essential
Optic neuritis
Swelling of optic disc secondary to increased intracranial pressure
caused by: trauma, infections within the brain, stroke, tumors, hydrocephalus
can be a retinal artery or vein occlusion
papilledema
Ear disease that has:
-earache
-ear plugging
- tinnitus
- hearing loss
Plug may be removed by mineral/ baby oil, drops, detergents, hydrogen peroxide
Impacted cerumen
Inflammation of the external auditory canal
- S/S include pain, drainage, itching ear/ canal, hearing loss,
- treatment is analgesia, topical otic antibiotics, anti inflammatory drugs
Otitis external
Ear infection that spreads to bones/ cartilage at the base of the skull
- caused by difficult to treat bacterial infections
- difficult swallowing, loss of voice, facial weakness
- treatment includes hospitalization and antibiotic therapy
malignant otitis external
Blockage of eustachian
- increased fluid pressure within middle ear
- bacterial/ viral infection
- S/S include earache, fullness, pressure, general malaise, hearing loss, fever, vomiting/ diarrhea
- chronic middle ear infection
management includes antibiotics, placement of tympanostomy tubes to decompress the middle ear
otitis media
Delicate structure that separates the external ear from the middle ear
- membrane is easily ruptured/ perforated
- trauma
- foreign objects
- infections
symptoms begin acutely and include: decreased hearing, earache, drainage of blood/ pus, noise/ buzzing
perforated tympanic membrane
Infection that spreads from the middle ear to the mastoid
- primarily affects children
- symptoms include ear pain, drainage, hearing loss, erythema/ tenderness over mastoid bone, headache, fever
management includes antibiotics, surgery
Mastoiditis
Swelling/ irritation of the inner ear
- occurs following a middle ear infection/ upper respiratory infection
symptoms: vertigo, involuntary eye movement, dizziness, loss of balance, nausea/ vomiting, hearing loss, tinnitus
treatment is supportive
labrynthitis
Labyrinths within inner ear are swollen
S/S include begin acutely, vertigo/ dizziness, severe nausea. Hearing loss unilateral
no known cure
meniere disease
Nosebleed
Epistaxis
inflammation of the nose
- upper respiratory infection
- allergies
- similar condition
in infants: treat with humidification of air, saline nose drops, and bulb suctioning
in adults: treat with decongestants, antihistamines, nasal corticosteroids
rhinitis
- red/ swollen throat
- pus
- enlargement/ tenderness of anterior nodes
- head/neck pain
- nausea/ vomiting
viral- symptomatic treatment
bacterial- antibiotics
pharyngitis/ tonsillitis
Fungal (yeast) infection of the mouth
- found in infants, diabetics with poor BGL control, AIDS pts, side effect to antibiotics.
- presents with white/ cream colored deposits inside mouth
- oral mucosa red/swollen
treatment is to correct cause, anti-fungal agents
oral candidiasis (thrush)
Collection of pus around the tonsils
- complication of tonsillitis
- swollen tissues block airway
- life threatening
symptoms include: flu like, difficulty opening mouth, swallowing, drooling, facial swelling, muffled voice, tender glands of jaw/ throat.
Peritonsillar Abscess
Lack of preventive dental care, restorative care, and trauma can be causes
- non-life-threatening
- S/S include: dental pain, exterior of tooth broken down, allowing sensitive interior structures (nerve) to be exposed
to Manage: alleviate pain, treat infection, dental care
dentalgia/ dental abscess
Oral bacterial cellulitis (floor of mouth, under tongue)
-occurs after infection of dental abscess, mouth injury
- develops quickly swelling can occlude airway, can be life threatening
S/S include difficulty breathing, confusion/ AMS, fever, neck pain, redness/ swelling of neck, weakness, fatigue, excess tiredness, difficulty swallowing, drooling, earache, speech that sounds like person has “hot potato” in mouth.
-Management: in severe cases, cricothyrotomy, cured with proper protection of airways + appropriate antibiotics
Ludwig’s angina
Inflammation/ infection of the epiglottis
- can be life threatening emergency
- S/S include fever, sore throat, drooling, stridor, hoarseness, difficulty breathing, cyanosis
-Management is to protect airway, antibiotics
epiglottis
Bacterial infection in the airway/ respiratory system component
- S/S include: deep cough, dyspnea, fever, stridor, pt may be hypoxic
- management is to prevent airway obstruction, ventilate the pt
Tracheitis
Problems with the joint between temporal bone/ mandible
- malocclusion of teeth
- orthodontic appliances
- difficulty/ pain in biting/ chewing/ clicking/ popping, of joint, dull facial pain, earache, jaw pain, headache
Temporomandibular Joint (TMJ)
Central herniated disc, compressing nerve roots
- pain radiating down one/ both legs
- weakness of legs
- lack of feeling in genitalia
- bladder/ bowel disturbance/ no urge/ inconsistency
treatment is supportive/ symptomatic, pain management, application of cold/ heat packs
cauda equina syndrome
Inflammation of tendon
- tennis elbow: inflammation of the extensor tendon on the lateral aspect of the elbow
- golfer’s elbow: inflammation of the tendinous sheath that inserts into the medial epicondyle
tendinitis
Inflammation of the bursae in elbow, knee, and hip
bursitis
Painful condition of various/ unknown causes during
lifting
moving
turning
chronic myalgia
Caused by pressure on median nerve in wrist
- S/S include tingling, numbness, weakness, pain felt in fingers/ hand
carpal tunnel syndrome
Disturbance in normal functioning of affected tissues/ organs systems
due to age/ wear/ tear
can affect virtually any body system
what type of condition ?
Degenerative conditions
Degenerative joint disease
- wear/ tear on joints
associated with aging- runs in families
exacerbated by obesity
can result from medical disorders (hemophilia, avascular necrosis, arthritic disorder)
S/S pain/ stiffness on arising in morning, becomes worse over time, may be swelling/ crackling of joints
routine movement/ activities painful
-chronic condition but improves with medications/ physical therapy
Osteoarthritis (OA)
Common form of bone disease
thinning of bone tissue
loss of bone density occurs over time
- body fails to produce enough new bone to replace bone being reobsorbed/ used
- calcium/ phosphate substances essential for normal bone formation
- primary causes is loss of estrogen in women during menopause
- drop in testosterone levels in men
- Increased risk groups: women over 50, men over 70, chronic arthritis, pts taking corticosteroids, hyperparathyriodism, vitamin D deficiency, bedridden pts
AS condition progresses, pts may present with:
- bone pain, tenderness, fx with little/ no trauma
- pt may lose body height
- prone to low back pain/ neck pain
- women tend to develop increased kyphosis of spine Treatment Includes pain control, medications/therapies, to reduce bone loss/ promote bone development, preventive strategies to minimize falls/ injuries. Calcium replacement, hormonal therapy, and exercise is often used
osteoporosis
Age- related changes in spinal discs
- discs dehydrate/ become stiff
- function less effectively as shock absorbers
- outer layer cracks causing disc to bulge/ rupture
- herniated portion of disc places pressure on spinal nerves, causing pain/ weakness
- does not have blood supply
- pain often worsened with movement
degenerative disc disease
Chronic disease that leads to the inflammation/ injury to joints/ surrounding tissues
- autoimmune disease
- women more often affected
S/S include: painful/ swollen joints, fatigue, low-grade fever, malaise, weakness
- chronic condition that has no cure although surgery can restore damaged joints to fairly normal level
rheumatoid arthritis (RA)
Inflammatory arthritis of the spine
- extremely fragile and subject to fx with spinal cord injury
- important to pad underneath the head, neck, upper back, with sheets/ pillows.
- manage airway with techniques that do not extend neck
ankylosing spondylitis (AS)
inflammatory arthritis with uric acid accumulation in joints
- although not every pt with elevated uric acid will develop
- tends to occur in families
- symptoms include: severe pain, swelling, erythema
- treatment is medication for pain/ inflammation, dietary restrictions to help keep uric acid levels at a minimum.
Gout
Flesh eating disease
- bacterial infection that rapidly destroys skin, muscles, surrounding tissues
- causes widespread tissue damage
- bacteria resistant to potent antibiotics
- critically ill
Necrotizing fasciitis (NF)
Death of a tissue in part of body
- blood supply in affected tissue interrupted
- from: peripheral vascular diseases, diabetes, immunosuppressed, post-surgical procedures
gangrene
Widespread cause of pain in the body with an unknown cause
fibromyalgia
- wear/ tear on joints
associated with aging- runs in families
exacerbated by obesity
can result from medical disorders (hemophilia, avascular necrosis, arthritic disorder)
S/S pain/ stiffness on arising in morning, becomes worse over time, may be swelling/ crackling of joints
routine movement/ activities painful
-chronic condition but improves with medications/ physical therapy
Degenerative joint disease
- Not a medical condition; symptom of ALL conditions gone bad; requires in-depth assessment to find cause
A. Alcohol, epilepsy, infection, overdose, uremia, trauma, insulin, pregnancy, poisoning, stroke, shock - Assessment
A. Perform detailed history (pt, family, and by-standers); perform detailed physical exam; attempt to determine cause - Management
A. Treat specific cause if known; manage airway, breathing, and circulation; transport in lateral recumbent position if no trauma
B. Appropriate use of pharmacology
- Do not give blindly
- Thiamine: for most patients is acceptable
- Naloxone: for suspected narcotic overdose
- Dextrose: for low blood sugar - Concerns: Wernicke’s syndrome and Korsakoff’s psychosis
Altered mental status
- Reversible
- Loss of memory and orientation
- Associated with chronic alcohol intake and diet deficient in thiamine
- Symptoms: ataxia, nystagmus, diplopia, neuropsychiatric disorders
Wernicke’s syndrome
- Potentially permanent psychosis
- Characterized by disorientation, muttering delirium, insomnia, delusions, and hallucinations
- Symptoms: painful extremities, bilateral foot drop, bilateral wrist drop (rare), and pain on pressure over the long nerves
Korsakoff’s psychosis
- “Brain attack”
- Injury or death of brain tissue due to interruption of cerebral blood flow
- Atherosclerotic heart disease (and all cardiac risk factors) are associated with the onset
- Long-term use of birth control pills increases risk
- Predisposing factors: hypertension, diabetes, high blood lipids, sickle cell disease, atrial fibrillation
- Examples: TIA, occlusive, hemorrhagic, cerebellar infarct
- Assessment
A. Perform complete detailed exam (Cincinnati, NIHSS, LAMS)
B. Assure assessment of blood glucose level
C. Monitor ECG, 12-lead if possible (12-lead abnormalities may mimic myocardial ischemia or injury) - Signs: facial drooping, headache, aphasia/dysphasia, hemiparesis, hemiplegia, paresthesia, gait disturbances, incontinence
- Symptoms: confusion, agitation, dizziness, vision problems
- Management
A. Assure airway, breathing, and circulation
B. Oxygen to maintain SpO2 above 94%
C. Ventilate carefully based on PetCO2 and SpO2
D. Patient in position of comfort or lateral recumbent
E. Begin IV of normal saline TKO
F. Protect paralyzed or weakened extremities
G. Transport to hospital with specific capabilities (draw blood samples; comprehensive vs. primary)
Stroke
- Temporary interruption of blood supply to the brain
- Resembles strokes in every way except that the patient recovers fully without interventions (within 24 hours)
Transient Ischemic Attack
- Caused by the occlusion of the cerebral artery, denying the flow of blood to parts of the brain
- Embolic and thrombotic strokes
Occlusive stroke
A solid, liquid, or gaseous mass carried to the brain from another part of the body
Embolic stroke
- Blood clot carried to the brain, usually from pulmonary tissues or the heart
- Atrial fibrillation is often a cause
Thrombotic stroke
- Rupture of blood vessels in the brain; in some cases, in the areas around the brain (subarachnoid)
- May present with sudden onset, severe headache (immediate thunderclap)
Hemorrhagic stroke
- Usually seen in patients under 50 years of age
- Dizziness (walk as if drunk), ataxia, can’t touch nose with fingers, vertical nystagmus, CT scans can’t pick up (requires MRI)
Cerebellar infarct
What is the criteria to transport to a comprehensive stroke center?
- Onset > 3 hours
- Surgery in last 14 days
- MI/previous stroke in last 3 months
- Hemorrhage in last 21 days
- Age < 18
- NIHSS > 8
- Posterior fossa infarct assessment failure (cerebellar infarct)
A. Finger to nose test - right hand (normal/missed); left hand (normal/missed); vertical nystagmus (positive/negative)
- A temporary alteration in behavior due to the massive electrical discharge of one or more groups of neurons in the brain
- “Cerebral fibrillation”
- Epidemiology: alcohol, epilepsy, infection, overdose, uremia, trauma, insulin, pregnancy, poisoning, stroke, shock
- Generalized, partial, status epilepticus
- Assessment
A. Obtain detailed history including: history; recent history of head trauma (subdural hematoma); alcohol or drug use; history of fever, headache, or stiff neck (meningitis); history of diabetes, heart disease, or stroke
B. Check current medications - common anticonvulsants include: phenytoin (Dilantin), phenobarbital, carbamazepine (Tegretol), valproic acid (Depakote) - Physical exam
A. Assess for signs of head trauma, tongue injuries, evidence of alcohol or drug use, blood sugar, cardiac monitoring - Signs and symptoms: convulsing activity; postictal may be: unconscious, bizarre behavior, tongue lacerations, incontinent
- Management
A. Protect patient during active convulsing; assure airway; suction as needed; DO NOT force object between clinched teeth; administer O2, 15 L/min by NRB; establish IV, normal saline TKO
B. If blood sugar was low, administer dextrose (give 100 mg thiamine with dextrose)
C. Position patient in recovery position - Treatment
A. Diazepam up to 10 mg (0.2 mg/kg) - short duration (15-20 min)
B. Midazolam 5-10 mg (0.1 mg/kg) - short duration (15-20 min)
C. Lorazepam 4-10 mg (0.05-0.1 mg/kg) - long duration (45 min)
D. Sodium bicarbonate 1 med/kg IV push - TCA overdose
E. Magnesium sulfate 4 g over 5-10 min - pregnancy
F. Naloxone up to 10 mg - narcotic overdose
Seizure
- Initial, localized electrical discharge of the brain, spreading to entire cortex
- Grand Mal (tonic-clonic) - generalized motor seizure (airway!)
A. Aura - subjective sensation preceding the seizure
B. Tonic phase - muscle rigidity and contraction
C. Clonic phase - muscle spasms and rhythmic jerking
D. Postictal - awakening phase, seen as slow improvement in mental status - Petit Mal (absence seizure) - brief loss of awareness and pauses of activity
- Pseudoseizures (hysterical seizures) - psychological disorders, usually seen as an outburst
Generalized seizures
- Usually remain confined, but may march
- Simple (focal motor, Jacksonian, Jacksonian March)
A. Chaotic movement localized to one area of the body; can march through body, ending with a focal motor seizure in a different site than that of origin - Complex (psychomotor)
B. Loss of contact with surroundings and unusual behavior or personality
Partial seizures
- Recurrent seizures, unbroken by a lucid interval
- Also consider continuous seizures and several recurrent seizures
- Management
A. Diazepam up to 10 mg (0.2mg/kg) - short duration (15-20 min)
B. Midazolam 5-10 mg (0.1mg/kg) - short duration (15-20 min)
C. Lorazepam 4-10 mg (0.05-0.1mg/kg) - long duration (45 min)
Status epilepticus
- A transient loss of consciousness due to inadequate flow of blood to the brain with rapid recovery of consciousness upon becoming supine (commonly known as fainting)
- Cardiovascular causes: dysrhythmias, bradycardia, or tachycardia
- Non-cardiovascular causes: hypoglycemia, TIA, metabolic disorders, anxiety attack
- Management
A. Differentiate possible cause
B. Assure airway management
C. Administer oxygen as needed
D. Reassure
E. Treat underlying cause
Syncope
- Vascular headaches - migraine, cluster
- Non-vascular - tension, organic
- Assessment
A. Perform history - general health, previous medical conditions, medications, previous experience with complaint, time of onset
B. Physical exam - evaluate neurological status and indications of recent injury - Management
A. Mostly supportive; consider rehydration and anti-emetics; narcotics can be used for severe headaches; patients may know what is needed
Headache
- Disabling pain lasting minutes to days
- Characterized by intense or throbbing pain, photosensitivity, nausea, vomiting, and diaphoresis
- Frequently unilateral in presentation and may be preceded by an aura or warning
- More common in women than men
- Vascular headache
Migraine
- Occur as a series of one-sided headaches that are sudden and intense
- Symptoms may include: nasal congestion, drooping eyelid, and irritated watery eye
- More common in men than women
- Vascular headache
Cluster
- Brought about by stress and emotional tension
- Often begins as a mild headache in the morning, worsening throughout the day
- Non-vascular headache
Tension
- Caused by tumors, infections, or other diseases of the brain, eye, or other body system
- Non-vascular headache
Organic
- Assessment
A. Symptomatic of many illnesses
B. Focused assessment
- Include a detailed neurological exam
- Specific signs and symptoms: nystagmus, nausea and vomiting, dizziness - Management
A. Maintain airway and administer high-flow oxygen; position of comfort; IV access; determine blood glucose level; consider antiemetics
“Weak and dizzy”
- Tumor to the brain and spinal cord
- Benign and malignant; brain abscess
- Assessment
A. Perform history - general health, previous medical conditions, medications, previous experience with complaint, time of onset, seizure activity, headache, nosebleed; type and timing of prior treatment (chemotherapy, radiation therapy, holistic and other nontraditional approaches, experimental treatment) - Management
B. Mostly supportive; consider pain management; maintain compassion
Neoplasms
- Grow similarly to normal cells
- Grow relatively slow
- Confined by a membrane
- Pose a greater threat in the brain and spinal cord because of limited room for growth
- Can cause impaired function relatively easily, and death if untreated
Benign neoplasms
- Cancerous tumors
- Can quickly metastasize (frequently the result of cancer elsewhere in the body)
- Risk factors - genetics, exposure to radiation, tobacco, occupational, pollution, medications, diet, viruses
Malignant neoplasms
- A collection of pus localized in an area of the brain
- Will present much like a neoplasm
- Management is supportive
Brain abscess
- Alzheimer’s disease, muscular dystrophy, multiple sclerosis, dystonias, Parkinson’s disease, central pain syndrome, Bell’s palsy, amyotrophic lateral sclerosis, myoclonus, spina bifida, poliomyelitis
- Management
A. Supportive; assure adequate ventilations; prepare for communication difficulties
Degenerative neurological disorders
- Devastating neurologic disorder effecting elderly individuals
- Most common cause of dementia in the elderly
- Results from the death and disappearance of nerve cells in the cerebral cortex
- Causes marked atrophy of the brain
- Initially patients will have problems with short-term memory
- Progression
A. Problems with thought and intellect; shuffling gait; stiffness of the body muscles - Eventually aphasia and psychiatric disturbances
Alzheimer’s disease
- A group of genetic diseases (Duchenne is the most common form)
- Characterized by progressive muscle weakness and degeneration of the skeletal muscle fibers
- May affect heart and other involuntary muscles
- May develop at any age
- Prognosis varies depending on the type
Muscular dystrophy
- An unpredictable disease of the central nervous system
- Involves inflammation of the certain nerve cells and followed by the demyelination of the nerve sheath
- Signs and symptoms include:
A. Weakness of one or more limbs, sensory loss, paresthesia, changes in vision; come and go over the years and range from mild to severe
Multiple sclerosis
- A group of disorders characterized by muscle contractions that cause twitching and repetitive movements, abnormal postures, and freezing in the middle of an action
- Early symptoms include: deterioration in handwriting, foot cramps or a tendency of one foot to drag after walking; initial symptoms can be mild and may be noticeable only after prolonged exertion, stress, or fatigue
Dystonias
- A chronic and progressive motor system disorder characterized by tremor, rigidity, bradykinesia, and postural instability
- Caused by a limited amount of dopamine available to the brain
- Patients with this disease may exhibit dementia or depression
Parkinson’s disease
A condition resulting from the damage or injury to the brain, brainstem or spinal cord characterized by intense, steady pain described as burning, aching, tingling, or a “pins-and-needles” sensation
Central pain syndrome
- The most common form of facial paralysis
- Involves inflammation of the facial nerve
- Characterized by one-sided facial paralysis, inability to close the affected eye, pain, lacrimation, drooling, hypersensitivity to sound and impaired taste
Bell’s palsy
-endocrine disease
-inadequate insulin production
- affects body’s ability to metabolize glucose
diabetes mellitus
Temporary, involuntary twitching or spasms of muscle or group of muscles
Myoclonus
- A neural defect that results from the failure of one or more of the fetal vertebrae to close properly during the first month of pregnancy
- Leaves a portion of the spinal cord unprotected
- Can usually be repaired after birth, but any nerve damage already done will be permanent
- Three most common forms
A. Myelomeningocele - most severe form; the spinal cord and meninges protrude through the opening in the spine
B. Meningocele - normal development of the spinal cord; meninges protrude through the opening
C. Occulta - most mild form; skin covering the opening in the malformed vertebrae
Spina bifida
- An infectious, inflammation viral diseases of the central nervous system
- Sometimes results in permanent paralysis
- It is characterized by fatigue, headache, fever, vomiting, stiffness of the neck, and pain to the hands and feet
- Because of available vaccines, polio is nearly eradicated from the western hemisphere
Poliomyelitis
- Low back pain
- Causes - disc injury, vertebral injury, cysts and tumors, other causes
- Assessment
A. Evaluate history - speed of onset; risk factors such as vibration or repeated lifting; determine if pain is related to a life-threatening problem - Management
A. Consider c-spine (immobilize if in doubt); consider analgesics
Back pain/spinal disorders
An exaggerated response by the immune system to a foreign substance
Allergic reaction
- An unusual or exaggerated (systemic) allergic reaction
- A life-threatening emergency causing nearly 1000 deaths each year (most from PCN injections and Hymenoptera stings)
Anaphylaxis
- Immune response
A. Isolates and destroys invading antigens in the body
B. Cell-mediated immunity - phagocytosis of invading antigen
C. Humoral immunity - releases antibodies to neutralize antigen - Antibodies (Immunoglobulins)
A. IgM - first produced antibody; largest immunoglobulin
B. IgG - most prevalent antibody; has a memory to recognize repeat invasions
C. IgE - least concentrated; it is the antibody of allergic and anaphylactic reactions
D. IgA - present in mucous membranes
E. IgD - present in very low concentrations
The immune system
- Genetically predetermined immunity that is present at birth
- Inflammatory system
A. Complement cascade and leukocytes
Innate immunity
- Immune system
A. Antibodies and activated T-cells
Adaptive immunity
- Type of immunity that begins to develop after birth and is continually enhanced by exposure to new pathogens and antigens throughout life
- Contact with disease causing agent (catching chickenpox)
Natural acquired immunity
Deliberate contact with disease causing agent (vaccination)
Artificial acquired immunity
- Maternal passage of antibodies (MatAb)
- Nursing (IgA in breast milk)
Natural passive immunity
Exposure to live pathogen (development of memory B-cells and T-cells)
Natural active immunity
- Short-term immunity (temporarily-induced immunity)
A. Transfer of antibodies (transfusion)
Artificial passive immunity
Vaccination - stimulates immune response without causing disease; creates antibodies
Artificial active immunity
Protection from infection or disease that is 1) developed by the body over time after exposure to an antigen (active acquired immunity) or 2) transferred to the person from an outside source such as from the mother through the placenta or as a serum (passive acquired immunity)
Acquired immunity
- Initial entry of antigen
- Body responds by creating antibody
- After initial response, antibody attaches to basophil and mast cells to await repeat contact
- On second exposure, antibodies are released from basophil and mast cells; cells release histamine, heparin, leukotriene (slow reacting substance of anaphylaxis)
- Result is bronchoconstriction, vasodilation, capillary permeability, angioedema (ACE inhibitors)
Sensitization
- Mild allergic reaction
A. Gradual onset, mild flushing, rash, urticaria, mild bronchoconstriction (mild wheezing), mild cramps, diarrhea - Severe allergic reaction
A. Sudden onset, severe flushing, rash, urticaria, severe bronchoconstriction and laryngospasm, severe cramps, altered vital signs, altered mentation
Allergies
- Causes: antibiotics, drugs, foreign proteins, foods, Hymenoptera stings, hormones, blood products
- Signs and symptoms
A. Skin - flushing, itching, hives (urticaria), edema
B. GI - nausea/vomiting, cramps, diarrhea
C. Nervous - dizziness, headache, convulsions
D. Respiratory - dyspnea, sneezing, coughing, wheezing, stridor, laryngeal edema and spasm
E. Cardiovascular - vasodilation, tachycardia, hypotension - Management
A. Scene safety - consider source of problem
B. Assure airway, ventilation, and oxygenation
- Supraglottic airways contraindicated
- Cricothyrotomy may be indicated
C. Begin IV of normal saline
D. Pharmacological
- Albuterol 2.5-5 mg every 20 min for max of 3 doses
- Diphenhydramine (mild, moderate, severe) 25-50 mg IM, IV, or IO
- Epinephrine (moderate and severe) 0.3-0.5 mg (1:1000 & 1:10,000 : allergic reactions & anaphylaxis)
- Sodium methylprednisolone (severe, consider in moderate) 125mg IV or IO
Anaphylaxis
what is the role of insulin?
It increases glucose for the cells of the general body.
It increases the production of glycogen, protein, and fat in the liver.
It is released when blood glucose levels are high
what is the role of glucagon ?
In the liver, glucagon promotes the breaking of glycogen back into glucose (glycogenolysis)
Additionally, it promotes gluconeogenesis, or the converting of protein and fats into glucose.
Can glucose be used as energy when insulin is not available?
No, the body turns to fat for fuel. The fat is broken down to fatty acids and waste products are collectively called ketones. BGL continues to rise
Where is glucose filtered?
The kidneys
What is an important test for diabetes, consisting of the average blood sugar over the past 2-3 months?
A1c, glycated hemoglobin. The higher the greater risk for diabetes
what type is insulin dependent DM?
type 1
What type of DM is non-insulin dependent and is rather controlled by hypoglycemic agents, diet, and exercise?
type 2 DM
what medical emergency is caused by missed insulin injections, stress/ catecholamine release, or binge eating leading to hyperglycemia with a BGL of approximately 400 mg/dL ?
Diabetic ketoacidosis ( DKA)
signs and symptoms of DKA
- polyuria, polydipsia, polyphagia
- warm, dry skin
- nausea vomiting, abdominal pain
- tachycardia
-hypotension
-kussmauls respirations - fruity odor on breath
- slow decline in LOC.
- “Master Endocrine Gland”
- Divided into anterior and posterior lobes
- Posterior responds to nervous signals from hypothalamus
- Anterior responds to hormone signals from hypothalamus
- Anterior hormones
A. Growth hormone, adrenocorticotropic hormone, thyroid-stimulating hormone, follicle-stimulating hormone, lutenizing hormone, prolactin - Posterior hormones
A. Antidiuretic hormone, oxytocin
Pituitary gland
- “Third eye”; responds to light by releasing melatonin
- May have role in daily and lunar cycles, reproductive cycles, seasonal affective disorder
Pineal gland
- Responsible for body’s metabolic rate
- Principle hormones: thyroxine, triiodothyronine, calcitonin
Thyroid gland
- Located on posterior, lateral surfaces of thyroid
- Regulates blood calcium levels
- Principle hormone: parathyroid hormone
Parathyroid gland
- In children, large gland responsible for cell-mediated immunity
- In adults, degenerates into non-distinct mass of fat and fibrous tissues
- Principle hormone: thymosin - matures T lymphocytes
Thymus
- Adrenal medulla
A. Inner segment of adrenal gland; closely tied to autonomic nervous system - Adrenal cortex
A. Outer layers of endocrine tissue, which secrete steroidal hormones - Adrenal medulla hormones
A. Epinephrine and norepinephrine - Adrenal cortex hormones
A. Glucocorticoids (cortisol), mineralocorticoids (aldosterone), androgenic hormones (estrogen, progesterone, testosterone)
Adrenal gland
- Combination organ
A. Exocrine tissues called acini - secrete digestive enzymes into small intestine
B. Endocrine tissues secrete hormones from islets of Langerhans
C. Responsible for maintenance of blood sugar through glycogenolysis and gluconeogenesis - Principle hormones
A. Glucagon - released from alpha cells when blood sugar level drops
B. Insulin - released from beta cells when blood sugar rises
C. Somatostatin - released from delta cells; tells all to slow down
Pancreas
- Produce hormones responsible for sexual maturity, gamete production, and pregnancy
- Principle hormones: estrogen and progesterone
Ovaries
- Produce hormones responsible for sexual maturity and gamete development
- Principle hormone: testosterone
Testes
What hormone does the placenta secrete?
Human chorionic gonadotropin
What hormone does the kidneys secrete?
Renin
What hormones does the digestive tract secrete?
Gastrin and secretin
What hormone does the heart secrete?
Atrial natriuretic hormone
- Disease of inadequate insulin production
- Affects body’s ability to metabolize glucose (glucose is essential in energy production)
Diabetes mellitus
What is the normal blood sugar range?
80-100 mg/dL fasting
120-140 mg/dL following meal
At what blood sugar level is a patient considered hypoglycemic?
< 80 mg/dL
At what blood glucose level is a patient considered hyperglycemic?
> 140 mg/dL
- Insulin dependent diabetes mellitus (IDDM)
- Very low level of, or no, insulin production
- Often begins early in life (juvenile onset)
- Hereditary is the greatest risk factor
A. Other causes: viral infections, autoimmune disorders - Leads to heart disease, strokes, blindness, kidney failure, distal tissue necrosis
Type I diabetes mellitus
- Non-insulin dependent diabetes mellitus (NIDDM) - controlled by hypoglycemic agents, diet, and exercise
- Decline in production of insulin and receptor site response
- Most common form of diabetes (approx. 90%)
- Hereditary and obesity are greatest risk factors
Type II diabetes mellitus
- Hyperglycemia; blood sugar may exceed 400 mg/dL
- Causes: missed insulin injections, stress (catecholamine release), binge eating
- Signs and symptoms
A. Polyuria, polydipsia, polyphagia; warm, dry skin; nausea/vomiting; abdominal pain; tachycardia; low blood pressure; deep, rapid respirations; fruity breath odor; slow decline in level of consciousness - Management
A. Treat dehydration - normal saline titrated to blood pressure
B. Field administration of insulin not advised - not harmful, but ineffective; insulin does not correct emergent problem
C. Correction of acidosis should occur in hospital
Diabetic ketoacidosis (DKA)
- Pathophysiology
A. Found in type II diabetics; results in blood glucose levels up to 1000 mg/dL
B. Insulin activity prevents buildup of ketones
C. Sustained hyperglycemia results in marked dehydration - often related to dialysis, infection, and medications
D. Very high mortality rate - Causes - physiological stress
- Signs and symptoms
A. Polyuria, polydipsia, polyphagia; warm, dry skin; orthostatic hypotension; tachycardia; gradual mental impairment (may take days) - Management
A. Treat dehydration - normal saline titrated to blood pressure
B. Field administration of insulin not advised - not harmful, but ineffective; insulin does not correct emergent problem
Hyperglycemic hyperosmolar nonketotic coma (HHNK)
- Hypoglycemia
- Causes - excessive administration of insulin, excess insulin for dietary intake, overexertion resulting in lowered BGL
- Signs and symptoms
A. Weak, rapid pulse; normal blood pressure; cool, clammy skin; weakness, incoordination; headache; irritable, agitated behavior; decreased mental function or bizarre; rapid onset unconsciousness - Management
A. Aimed at correcting blood sugar
B. Pharmacological - D10, glucagon
Insulin shock
- A thyroid disorder
- Pathophysiology - probably hereditary in nature
A. Autoantibodies are generated that stimulate thyroid tissue to produce excessive hormone - Signs and symptoms
A. Agitation, emotional changeability, insomnia, poor heat tolerance, weight loss, weakness, dyspnea, tachycardia, new onset atrial fibrillation, protrusion of eyeballs or goiters - Management - supportive
Grave’s disease
- A thyroid disorder
- Pathophysiology
A. Worst case scenario of hyperthyroidism
B. Life-threatening emergency, usually associated with severe physiologic stress or overdose of thyroid hormone
C. Results when thyroid hormone moves bound state to free state within the blood - Signs and symptoms
A. High fever (106F or higher)
B. Reflected in increased activity of sympathetic nervous system
- Irritability, delirium, or coma; tachycardia and hypotension; vomiting and diarrhea - Assessment and management
A. Support airway, breathing, and circulation
B. Monitor closely and expedite transport
Thyrotoxic crisis (thyroid storm)
- A thyroid disorder
- Pathophysiology
A. Can be inherited or acquired
B. Chronic untreated hypothyroidism creates myxedema
- Thickening of connective tissue in skin/other tissues
- Infection, trauma, CNS depressants, or cold environment can trigger progression to myxedemic coma - Signs and symptoms
A. Fatigue, slowed mental function; cold intolerance, constipation, lethargy; absence of emotion, thinning hair, enlarged tongue; cool, pale dough-like skin; coma, hypothermia, and bradycardia - Management - supportive
Hypothyroidism and myxedema
- An adrenal disorder; hyperadrenalism
- Pathophysiology
A. Often due to abnormalities in anterior pituitary or adrenal cortex
B. May also be due to steroid therapy for non-endocrine conditions such as COPD or asthma
C. Long-term cortisol elevation causes many changes
- Atherosclerosis, diabetes, hypertension; increased response to catecholamines; hypokalemia and susceptibility to infection - Signs and symptoms
A. Weight gain; “moon-faced” appearance; fat accumulation on upper back; skin changes and delayed healing of wounds; mood swings; impaired memory or concentration - Management - supportive
Cushing’s syndrome
- An adrenal disorder; adrenal insufficiency
- Pathophysiology
A. Due to destruction of adrenal cortex; often related to heredity; stress may trigger crisis
B. May be related to steroid therapy - sudden withdrawal can trigger crisis - Signs and symptoms
A. Progressive weakness, fatigue, decreased appetite; unintentional weight loss; hyperpigmentation of skin and mucous membranes; vomiting or diarrhea; hyperkalemia and other electrolyte disturbances; unexplained cardiovascular collapse; salt craving - Management - supportive
Addison’s disease
- An adrenal disorder
- Genetic defect of adrenal glands
A. Cannot produce vital corticosteroids; treated with hormone replacement; requires extra attention to common illnesses and stress inducing situations (injury, exercise, etc) - In emergencies, fever, vomiting, cardiorespiratory depression; needs solu-cortef IM; may be off protocol
- Off-protocol care
A. Confronted with need for “patient provided” medication - contact medical control; assist patient, parent, caregiver; listen to caregiver
Congenital adrenal hyperplasia
What are respiratory causes of dyspnea?
Aspiration, asthma, COPD (chronic bronchitis and emphysema), pneumonia, pleuritis, non-cardiac pulmonary edema, pleural effusion, pulmonary embolism, toxic inhalation
What are upper airway causes of dyspnea?
Foreign body
Infections: croup, epiglottitis, Ludwig’s angina
What are neuromuscular causes of dyspnea?
Muscular dystrophy, Guillain-Barre’s syndrome, myasthenia gravis, amyotrophic lateral sclerosis
What are miscellaneous causes of dyspnea?
Anemia, hyperthyroid disease, metabolic acidosis, psychogenic hyperventilation
What are intrinsic factors that would exacerbate underlying respiratory conditions?
Genetics, stress, upper respiratory infection, exercise
What are extrinsic factors that would exacerbate underlying respiratory conditions?
Tobacco smoke, allergens, drugs, occupational hazards
What are the functions of the upper airway?
Warm, filter, humidify, conduct
What is the pathway of air, starting from the nares/mouth?
Nares/mouth, turbinates/oral cavity, nasopharynx/oropharynx, laryngopharynx, larynx, trachea, primary bronchi, secondary (lobar) bronchi, tertiary (segmental) bronchi, quaternary (subsegmental) bronchi, bronchioles, terminal bronchioles, respiratory bronchioles, alveolar ducts, alveoli
What makes up the nasal cavity?
Nares and turbinates
- Parallel to nasal floor
- Provide increased surface area
A. Filtration, humidifying, warming
Turbinates
- Cavities formed by cranial bones
- Appear to further trap bacteria, and act as tributaries for fluid to/from Eustachian tubes/tear ducts
- Commonly become infected
- Fracture may cause CSF leak
- Extremely delicate and vascular tissues
A. Improper or overly aggressive placements of tubes or airways will cause significant bleeding which may not be controlled by direct pressure
Sinuses
- Large muscle attached at the mandible and hyoid bones
- Most common airway obstruction
Tongue
- Lined with mucous membranes and cilia
- Nasopharynx - from the nasocavity to the soft-palette
- Oropharynx - soft palate to the hyoid bone
- Hypopharynx (laryngopharynx) - from the hyoid bone to the larynx
Pharynx
- Lymph tissue - filters bacteria
- Frequently infected and swollen
- Posterior tongue
Tonsils/adenoids
- Attached to hyoid bone - “horseshoe-shaped” bone between the chin and mandibular angle
- Supports trachea
- Made of 9 cartilages
Larynx
- First tracheal cartilage; “shield-shaped”; cartilage anterior; smooth muscle posterior
- Laryngeal prominence - “Adam’s apple” anterior prominence of thyroid cartilage
- Glottic opening directly behind
Thyroid cartilage
- “Drops” to protect airway
- Leaf-like structure
Epiglottis
- Narrowest part of adult trachea
- Patency heavily dependent on muscle tone
- Contain vocal bands
- White bands of cartilage
- Produce voice
Glottic opening
- “Pyramid-like” posterior attachment of vocal bands
- Important landmark for endotracheal intubation
Arytenoid cartilage
“Hollow pockets” along the lateral borders of the larynx
Pyriform fossae
- First tracheal ring
- Completely cartilaginous
- Compression occludes esophagus (Sellick maneuver)
Cricoid ring
- Fibrous membrane between cricoid and thyroid cartilage
- Site for surgical and alternative airway placement
Cricothyroid membrane
- Located below cricoid cartilage
- Lies across trachea and up both sides
Thyroid gland
Oxygenated vessels that branch across and lie closely alongside trachea
Carotid arteries
Deoxygenated vessels that branch across and lie closely to the trachea
Jugular veins
What is the function of the lower airway?
Exchange of O2 and CO2
What is the location of the lower airway?
From the fourth cervical vertebrae to xiphoid process; from glottic opening to pulmonary capillary membrane
- A cartilaginous structure; 4-5” long
- Uniformly stacked “C” shaped cartilaginous rings
- Smooth muscle and a ciliated columnar epithelium compose the internal lining
- Posterior wall separates the trachea from the esophagus
Trachea
- Cartilaginous structures
- Composed of incomplete, randomly arranged, cartilaginous rings
- Covered with smooth muscle, elastic bands, and ciliated columnar epithelium
- Primary, lobar, segmental, and subsegmental
Bronchi
Which primary main stem bronchi is angled at 30 degrees and results in more FBAO and ETT failures?
Right main stem bronchi
How many lobar bronchi are on the left side? The right side?
2 on left, 3 on right
- Conducting ducts
- Lost of the cartilaginous rings
- Smooth muscle and columnar epithelium (mostly without cilia) remain
Bronchioles
- Last of the bronchiole structures which SOLELY conduct air
- Remaining bronchioles are small enough in size and close enough to the alveolar capillaries that gas exchange begins to occur
Terminal bronchioles
- Bronchioles where gas exchange is able to take place
- Start of the respiratory unit - also composed of alveolar ducts and alveoli
Respiratory bronchioles
What alveolar cells are involved in gas exchange?
Type I cells
What alveolar cells secrete surfactant?
Type II cells
What structures make up the conducting system?
Nares/mouth, turbinates/oral cavity, nasopharynx/oropharynx, laryngopharynx, larynx, trachea, primary bronchi, lobar bronchi, segmental bronchi, subsegmental bronchi, bronchioles, terminal bronchioles
What structures make up the respiratory unit?
Respiratory bronchioles, alveolar ducts, alveoli
The process of air movement
Ventilation
The process of diffusion and movement of gases
Respiration
- An active process
- Diaphragm contracts and moves down and outward, intercostal muscles contract and pull ribs up and outward, lungs expands, negative pressure in the lung cavity, positive pressure in the atmosphere, air flows in
Inspiration
- A passive process
- Diaphragm relaxes and moves upward, intercostal muscles relax and ribs go back to normal position, lungs recoil, positive pressure in the lung cavity, negative pressure in the atmosphere, air flows out
Exhalation
- Located in carotid bodies, arch of the aorta, and medulla
- Stimulated by decreased PaO2, increased PaCO2, and decreased pH
- Cerebrospinal fluid (CSF) pH is primary control of respiratory center
Chemoreceptors
What nervous system control is the main respiratory center that initiates impulses to produce respiration?
Medulla oblongata
Which center is located in the lower pons and assumes respiratory control if the medulla fails to initiate impulses?
Apneustic center
Which center is located in the upper pons and controls breathing rates and patterns?
Pneumotaxic center
- Hypoxemia is a profound stimulus of respiration in a normal individual
- Hypoxic drive increases respiratory stimulation in people with chronic respiratory disease
Hypoxic drive
What is the stretch receptor that is the back up structure located in the pleural apices and is responsible for the prevention of over expansion of the lungs?
Hering-Breuer reflex
What are the requirements for pulmonary perfusion?
Adequate blood volume (hemoglobin), intact pulmonary capillaries, efficient pumping action by the heart
Respectively, what are volumes of total lung capacity? Vital capacity? Inspiratory reserve? Tidal volume? Expiratory volume? Residual volume?
6000mL, 4800mL, 3000mL, 500mL, 1200mL, 1200mL
What are the regulatory structures/functions of ventilation?
Medulla oblongata, stretch receptors, changes in PCO2, COPD patients
What are some upper airway obstructions that cause problems with ventilation?
Trauma, epiglottis, FBAO, inflammation of the tonsils
What are some lower airway obstructions that cause problems with ventilation?
Trauma, obstructive lung disease, mucous accumulation, smooth muscle spasms, airway edema
What are chest wall impairments that cause problems with ventilation?
Trauma, hemothorax, pneumothorax, emphysema, pleural inflammation, neuromuscular diseases (such as multiple sclerosis or muscular dystrophy)
What are neurological control issues that cause problems with ventilation?
Brainstem malfunction (CNS depressant drugs, CVA or other medical neurologic conditions, trauma), phrenic/spinal nerve dysfunction (trauma, neuromuscular diseases)
What are some alveolar pathologies that cause problems with diffusion?
Asbestosis and other environmental lung diseases; blebs/bullaes associated with COPD; capillary bed pathology (severe atherosclerosis)
What are some inhalation injuries/interstitial space pathologies that cause problems with diffusion?
- Pulmonary edema
A. High pressure (aka cardiogenic) - left heart failure; idiopathic pulmonary hypertension
B. High permeability (aka non-cardiogenic) - ARDS, asbestosis, environmental lung disease, near-drowning, post-hypoxia, inhalation injuries
What are some problems of perfusion?
- Inadequate blood volume/hemoglobin levels
A. Hypovolemia and anemia - Impaired circulatory blood flow
A. Pulmonary embolus - Capillary wall pathology
A. Trauma
- Altered but effective difficulty breathing with increase work effort and sustained air movement
- Indicators:
A. Normal mental status with mild anxiety, minimal or mild cyanosis, altered breath sounds, chest tightness, slight tachycardia, decreased SpO2 that improves with oxygen, altered high or low EtCO2 - Management
A. Supplemental oxygen, inhaled bronchodilators, anti-inflammatory medications
B. Assisted ventilations and intubation NOT INDICATED
Respiratory distress
- Ineffective difficulty breathing with maximum work effort and minimal air movement
- Indicators
A. Alterations in mental status, severe cyanosis, pallor and diaphoresis, absent breath sounds, audible stridor, 1-2 syllable dyspnea, fatigue, tachycardia > 130 bpm, the presence of retractions/use of accessory muscles, decreased SpO2 with supplemental oxygen, altered (almost always low) EtCO2 - Management
A. Start with basics - supplemental oxygen, inhaled bronchodilators, anti-inflammatory medications
B. Assess effectiveness
C. Consider aggressive action - assisted ventilations, intubation (PA), IV access, IV bronchodilators, IV steroids, chest percussion
Respiratory failure
- Bronchial - loud, high pitched; expiratory phase usually longer
- Bronchovesicular - softer, medium pitched; equal phases
- Vesicular - soft, low pitched
Normal breath sounds
- Snoring - partial upper airway obstruction (tongue)
- Stridor - harsh, high pitched inspiratory sound; edema to trachea and upper airway
- Wheezing - partial obstruction of bronchi or bronchioles; from edema, bronchoconstriction, foreign objects
- Rhonchi (low wheezes) - rattling sounds in larger airways (fluid, mucus)
- Rales (crackles) - fine crackling sounds in smaller airways
- Pleural friction rub - rubbing sound; breakdown of pleural fluid (pleurisy)
Abnormal breath sounds
- High pitched, heard at end of inspiration
- Discontinuous
- Not cleared by cough
- Caused by fluid in lower airways
Fine crackles (fine rales)
Type of abdominal pain that originates in the walls of the abdominal cavity
- described as sharp and localized
- usually seen in bacterial and chemical irritations
Somatic pain
- Lower, more moist sound heard during the mid-inspiration
- Not cleared by cough
- Caused by fluid in lower airways
Medium crackles (rales)
Type of abdominal pain that:
- originates in the walls of hollow organs
- described as dull, poorly localized
- usually seen with bacterial infections
- ex: appendicitis, pancreatitis, cholecystitis
Visceral Pain
Type of abdominal pain that originates in an area other than where felt
- caused by an embryonic origin of nerves
-ex: diaphragmatic injury, AAA, appendicitis
Referred pain
Ecchymosis in periumbilical region only
Cullen’s sign
Ecchymosis in the flank and periumbilical region, often associated with a pancreatic injury
Grey-Turner’s sign
The term for hemorrhaging of the proximal esophagus, stomach, and duodenum
Causes:
- peptic ulcer disease
- gastritis
- varix rupture
- Mallory-Weiss tear
- esophagitis
- duodenitis
S/S:
-general abdominal discomfort
- hematemesis
- melena
- classic signs and symptoms of shock
- changes in orthostatic vital signs
Upper Gastrointestinal Bleeding
An Upper GI disease involving portal hypertension caused by liver cirrhosis from alcoholism/ ingestion of caustic substances.
S/S
- hematemesis
- dysphagia
- painless bleeding
- hemodynamic instability
- classic signs of shock
Esophageal Varices
GI disease where damage to the mucosal GI surfaces occurs
- there is pathological inflammation causing hemorrhage and erosion of the mucosal and submucosal layers of the GI tract
S/S:
- rapid onset of severe vomiting/ diarrhea
- hematemesis, hematochezia, melena
- diffuse abdominal pain
-classic signs of shock
Acute gastroenteritis
GI disease that stems from LONG term mucosal changes/ permanent damage
Chronic gastroenteritis
GI disease caused by erosions caused by gastric acid. Terminology is based on the portion of the tract that is affected.
- S/S:
-abdominal pain
- observe for signs and symptoms of hemorrhagic rupture
Peptic ulcer
Bleeding distal to the ligament of Treitz
- diverticulitis
- colon lesions
- rectal lesions
- inflammatory bowel disorder
S/S:
- determine acute vs chronic
- quantity/ color of blood in stool
- abdominal pain
- signs of shock
Lower Gastrointestinal bleeding
A lower GI disease with an unknown cause. S/S include abdominal cramping, nausea, vomiting, diarrhea, fever, weight loss
Ulcerative colitis
Lower GI disease that occurs with pathologic inflammation that can affect the entire GI tract.
- The mucosa may be damaged.
-hypertrophy and fibrosis of underlying muscle may also be damaged
Crohn’s disease
The lower GI disease that includes the inflammation of small out-pockets in the mucosal lining of the intestinal tract
S/S:
- abdominal pain/ tenderness
-LLQ sharp/ rapid onset
- fever, nausea, vomiting
- signs of lower GI bleeding
Diverticulitis
lower GI complication that includes a mass of swollen veins in the anus or rectum
- idiopathic
- may present with with limited bright red bleeding and painful stools
Hemorrhoids
Blockage of the hollow space of the small or large intestine
Bowel obstruction
Inflammation of the appendix, lack of treatment can cause rupture and subsequent peritonitis
S/S:
- nausea, vomiting, low grade fever
- pains localized to RLQ (McBurney’s point)
- radiates to umbilicus
Appendicitis
Inflammation of the gallbladder
S/S:
- URQ abdominal pain (Murphy’s sign)
- nausea, vomiting
- pain occurs after a meal high in fats
- pain radiates to right shoulder
Cholecystitis
Gall stone
“ fat, forty, fertile, fair skinned, flatulent, female”
Cholelithiasis
Inflammation of the pancreas
- can be from alcohol abuse, gallstones, elevated serum lipids, or drugs
S/S for mild:
-epigastric pain
-abdominal distention
- nausea/ vomiting
- elevated amylase and lipase levels
S/S for severe:
- refractory hypotensive shock and blood loss
- respiratory failure
Pancreatitis
Inflammation or infection of the liver that causes injury to liver cells
S/S include:
- URQ abdominal tenderness
- loss of appetite, weight loss, malaise
- clay- colored stool, jaundice, scleral icterus
- photophobia, nausea, vomiting
Hepatitis
Dysfunction BEFORE level of the kidneys
- most common and easiest to reverse
- caused by hypovolemia, cardiac failure, cardiovascular collapse, renal vascular anomalies
Pre-renal acute renal failure
Dysfunction within the kidneys themselves
- caused by a small vessel/ glomerular damage
- tubular cell damage (ischemic or toxic)
- interstitial damage ( acute pyelonephritis, allergic reactions)
Renal Acute Renal Failure
Dysfunction distal to the kidneys
Causes:
- abrupt obstruction to both ureters
- abrupt obstruction to the prostate
- abrupt obstruction to the urethra
Post-Renal Acute Renal failure
What medications are used to treat hyperkalemia and acidosis?
Sodium bicarbonate 1 mEq/ kg + calcium chloride 1g
Causes similar to Renal Acute Renal Failure
– Microangiopathy, glomerular injury
– Tubular cell injury
– Insterstitial injury
• Congential causes
– Polycystic diseases
– Renal hypoplasia
• May impair other essential functions of the kidney
– Maintenance of blood volume with proper balance of
water, electrolytes, and pH
• Increased sodium, water, and potassium retention
– Retention of key compounds such as glucose with
excretion of wastes such as urea
• Loss of glucose and buildup of urea within the blood
– Control of arterial blood pressure
• Disruption of the renin-angiotensin loop resulting in HTN
– Regulation of erythrocyte development
• Development of chronic anemia
Chronic renal failure
Renal complication when “ too much insoluble stuff accumulates in the kidneys
Findings include:
– Severe pain in one flank that increases in intensity and
migrates from the flank to the groin
– Painful, frequent urination with visible hematuria
– Prior history
• Physical Exam
– Difficult due to patient discomfort
– Often fell need to walk, usually in slumped position
– Tachycardia with pale, cool, and moist skin
Renal Calculi / kidney stones
Infection of this tract that presents with:
– Abdominal pain
– Frequent, painful urination
– A “burning sensation” associated with urination
– Difficulty beginning and continuing to void
– Strong or foul-smelling urine
– Similar past episodes
And this is found upon examination:
– Restless, uncomfortable appearance
– Presence of a fever
– Vital signs vary with degree of pain
Urinary Tract Infection
Twisting of spermatic cord
– Disrupts blood supply to the
testicle
– Results in severe pain
– A significant EMERGENCY
because the testicle will die
after a few hours
Testicular Torsion
Antidote for acetaminophen OD
N-acetylcysteine, 140 mg/kg
Antidote for atropine OD
Physostigmine, 0.5 to 2 mg IV
Antidote for benzodiazepine OD
Flumazenil, 0.2 mg q 1 min to total of 1 to 3 mg
Antidote for cyanide poisoning
– Amyl nitrite, inhaled 20 to 30
seconds each minute
– Hydroxocobalamine (cyano-kit)
Antidote for Ethylene glycol / Methyl Alcohol
Ethyl alcohol, 1 mL/kg of 80 to 100
proof
Antidote for nitrates
Methylene blue, 0.2 mL/kg of 1%
solution over 5 min
Antidote for Opiate OD
Naloxone, 0.4 to 2.0 mg IV
Antidote for Organophosphates / Nerve Agent exposure
– Atropine, 2 to 5 mg
– Pralidoxime, 1 g
- Loud, course sounds; most often continuous
- Coughing may clear sounds
- Caused by mucus accumulation in larger airways
Rhonchi
- Musical noise; heard continuously during inspiration or expiration
- Caused by partial airway obstruction
Wheeze
- Dry, rubbing or grating sound
- May be localized or over lateral anterior surface
- Caused by pleurisy
Pleural friction rub
“Eupnea”
Normal breathing pattern
- Cyclic wax and wane
- Usually involves periods of apnea
- Seen in stroke, head injury, CHF
Cheyne-stokes respirations
- Deep, rapid respirations
- Seen in metabolic disease
Kussmaul’s respirations
- Rapid respirations
- Seen in cerebral injury and increased ICP
Central neurogenic hyperventilation
- Irregular rate and depth
- Seen in CNS dysfunction and increased ICP
Ataxic (Biot’s) respirations
- Deep, gasping inhalation with long slow exhalation
- Brief periods of apnea
- Seen in pons damage and brain stem stroke
Apneustic respirations
What does the pulse oximetry percentage reflect?
The amount of saturated hemoglobin
What causes the oxygen dissociation curve to go left?
Decreased temperature, alkalosis (increased pH), decreased CO2
What causes the oxygen dissociation curve to go right?
Increased temperature, acidosis (decreased pH), increased CO2
What does end-tidal CO2 measure and correlate to?
Measures carbon dioxide in expired air and correlates to carbon dioxide in arterial blood
What is the normal range for EtCO2? What are the waveform phases?
Range: 35-45 mmHg
Phase I - baseline, initial exhalation (dead air)
Phase II - expiratory upstroke
Phase III - alveolar plateau, extended expiration
Phase IV - end of expiration, onset of inspiration
What causes elevated EtCO2?
- Respiratory - respiratory depression, COPD, hypoventilation, partial blocked airway
- Circulatory - increased cardiac output, ROSC
- Metabolic - pain, hyperthermia, malignant hyperthermia, shivering, muscle exertion, acids/acidosis, bicarbonate admin, seizure
What causes decreased EtCO2?
- Respiratory - hyperventilation, bronchospasm, mucus plugging, shunting, COPD
- Circulatory - cardiac arrest, pulmonary embolism (dead air space), hypovolemia, hypotension
- Metabolic - hypothermia, sedation/anesthesia
- Circuit problems - airway disconnection, deflated ET cuff, dislodged tube, kinked/obstructed tube
What causes a sudden drop in EtCO2 to zero?
Esophageal intubation, ventilator disconnection or defect in ventilator, defect in CO2 analyzer, kinked endotracheal tube
What causes a sudden decrease in EtCO2?
Leak in ventilatory system, obstruction in ventilation system, partial disconnection of ventilator system, partial airway obstruction (secretions or mucus)
What causes an exponential decrease in EtCO2?
Pulmonary embolism, cardiac arrest, hypotension (sudden), severe hyperventilation
What causes a gradual lowering over time of EtCO2?
Hypovolemia, decreasing cardiac output, decreasing body temperature, hypothermia, drop in metabolism
What causes a sudden increase in EtCO2?
Accessing an area of lung previously obstructed, release of tourniquet (arterial), sudden increase in blood pressure
What causes a gradual increase over time of EtCO2?
Rising body temperature, hypoventilation, partial airway obstruction (foreign body), reactive airway disease
What would cause a flat EtCO2 waveform?
Hypopharyngeal intubation; a missed or dislodged intubation
What causes a shark fin EtCO2 waveform?
Asthma
What causes a declining alveolar plateau EtCO2 waveform?
Emphysema - ineffective exhalation
What happens to the EtCO2 waveform when ROSC occurs?
Causes “jump” in carbon dioxide release which causes an increase in EtCO2; sudden rise indicates improvement in circulation
What should the EtCO2 waveform look like in order to consider the termination of effort?
Carbon dioxide levels consistently less than 10 mmHg for over 20 minutes
Non-statistical ability to survive
- Don’t just measure EtCO2, we drive it
- PaCO2 35-39 mmHg optimizes cerebral blood flow
- Correlates to an EtCO2 of 32
A. Typically accomplished with 10-12 VPM
B. Hypoventilation (VR < 10) - hypercapnea and engorgement of blood
C. Hyperventilation (VR of 18-20) - hypocapnea and profound vasoconstriction; is beneficial with increased ICP by restricting blood flow; use only with s/s of increased ICP or herniation (Cushing’s triad, pupillary abnormalities, posturing)
Traumatic brain injury
- Helps to keep airway open during and after inhalation
- Eases/assists patient’s own breathing
- Used in the treatment of CHF, COPD, asthma
CPAP
- Augments patient’s own breathing
- Uses two levels of positive pressure
A. Exhalation - variably positive or near ambient
B. Inspiration - variably positive, and is always higher than the expiratory pressure - Intended to be used with room air (can have oxygen supplement)
Bi-PAP
What part of the nervous system contains the brain and spinal cord?
Central nervous system
What part of the nervous system innervates the body?
Peripheral nervous system
Which part of the nervous system controls sensory and motor neurons?
Somatic nervous system
Which part of the nervous system controls regulatory nerves?
Autonomic nervous system
What is the basic unit of the nervous system that operates through the same system as the cardiac conduction system?
Neuron
Which type of neuron is the efferent nerve?
Motor neuron
Which type of neuron is the afferent nerve?
Sensory neuron
What cranial nerve provides sensory input for the ophthalmic (forehead), maxillary (cheek), and mandible (chin) regions, as well as the motor input for the chewing muscles?
Trigeminal CN V
What cranial nerve provides motor input to the lateral rectus muscle of the eye?
Abducens CN VI
What cranial nerve provides sensory input to the tongue and motor input to the facial muscles?
Facial CN VII
What cranial nerve provides sensory input for hearing and balance?
Acoustic CN VIII
What cranial nerve provides sensory input for the posterior pharynx and taste of the anterior tongue, as well as motor input for the facial muscles?
Glossopharyngeal CN IX
What cranial nerve provides sensory input for the taste to posterior tongue, as well as motor input to the posterior palate and pharynx?
Vagus CN X
What cranial nerve provides motor input to the trapezius and sternocleidomastoid muscles?
Accessory CN XI
What cranial nerve provides motor input to the tongue?
Hypoglossal CN XII
What structure exits the skull through the foramen magnum and carries impulses down to the body and up to the brain?
Spinal cord
Which route has efferent (motor) fibers?
Ventral route
Which route has afferent (sensory) fibers?
Dorsal route
What set of nerves leave the spinal cord in 31 pairs between the vertebral discs?
Peripheral nerves
What nervous system contains somatic (voluntary) and visceral (autonomic) innervations?
Peripheral nervous system
Which part of the PNS contains somatic sensory (afferent) nerves that transmit sensations of touch, pressure, pain, temperature, and position?
Somatic sensory
Which part of the PNS contains somatic motor (efferent) nerves that carry impulses to skeletal muscles?
Somatic motor
Which part of the nervous system contain the visceral innervations, the sympathetic nervous system, and the parasympathetic nervous system?
Autonomic nervous system
Which part of the ANS has afferent tracts that sense when the bladder is full and signal the need to defecate?
Visceral sensory
Which part of the ANS has efferent tracts that innervate the involuntary cardiac and smooth muscles?
Visceral motor
Which part of the ANS is the “fight-or-flight” mechanism that branches from thoracic and lumbar nerves that increases heart rate and blood pressure, pupillary dilation, increased blood sugar, and bronchodilation?
Sympathetic nervous system
Which part of the ANS branches from the cranial and sacral nerves that decreases heart rate, causes bronchoconstriction, pupillary constriction, and increases digestive activity?
Parasympathetic nervous system
What is decorticate posturing?
Arms are flexed, legs are extended; lesion at or above upper brain stem
What is decerebrate posturing?
Stiff and extended extremities; retracted head; brainstem lesion
What is a carotid bruit?
Carotid arteriosclerosis decreases cerebral blood flow
What are 12-lead changes associated with increased ICP?
Wide ST segments, broad T waves
Deep S waves in V1-V3
What is the myelinated sheath that wraps around the axon and acts as an insulator?
Schwann cell
What is at the end of an axon terminal that releases neurotransmitters that are received by the next neuron’s dendrite or by the site of action?
Synapse
What part of the brain is responsible for conscious thought and sensory interpretation, has two hemispheres separated by the central sulcus, and is connected by the corpus callosum?
Cerebrum
Which part of the brain is responsible for coordination and balance, fine motor movement, equilibrium, posture, and muscle tone?
Cerebellum
Which part of the brain is located along the walls of the third ventricle; is the site of the thalamus, hypothalamus, and the limbic system; and regulates temperature, water balance, sleep, stress, and emotions?
Diencephalon
Which part of the brain contains the mesencephalon (mid-brain) that controls some motor coordination and eye movement; the pons that acts as the connection pathway and controls the respiratory and cardiac rates; and the medulla oblongata that controls respiratory and cardiac regulation?
Brain stem
What part of the mid-brain is the connection center and controls respiratory and cardiac rates? What centers are found in the structure?
Pons; Apneustic and pneumotaxic center
What part of the mid-brain controls respiratory and cardiac regulation, and contains the cardioinhibitory center, cardioacceleratory center, and vasomotor center?
Medulla oblongata
What sensory and motor interpretations is controlled by the frontal lobe?
Personality, association, speech, smell, taste, and motor interpretations in the leg, trunk, arm, hand, and face
What sensory and motor interpretations are controlled by the parietal lobe?
Visual association area, and sensory interpretations in the leg, trunk, arm, hand, and face
What sensory and motor interpretations are controlled by the temporal lobe?
Hearing and speech
What sensory and motor interpretations are controlled by the occipital lobe?
Vision and primary visual area
What system is located along the brainstem and maintains consciousness and response to stimuli?
Reticular Activating System (RAS)
What arteries and structure assures cerebral perfusion?
Carotid and vertebral arteries; Circle of Willis
What cranial nerve is provides sensory input for smell?
Olfactory CN I
What cranial nerve provides sensory input for sight?
Optic CN II
What cranial nerve provides motor input for pupil constriction and innervates the rectus and oblique muscles of the eye?
Oculomotor CN III
What cranial nerve provides motor input for the superior oblique muscles of the eye?
Trochlear CN IV
What questions do you want to ask someone who is processing toxins/ foreign substances through gastric absorbtion?
- ask patient:
– What, when and how much, was ingested?
– Did you drink any alcohol?
– Have you attempted to treat yourself?
– Have you been under psychiatric care? Why?
– What is your weight?
S/S + management for an anticholinergic OD.
Ex: incidental anticholinergic such as antihistamines, phenothiazines, TCA, cold medicines
Signs and Symptoms
– Dry skin and membranes
– Thirst
– Dysphagia
– Blurred near vision
– Fixed, dilated pupils
– Hypertension, tachycardia
– Hyperthermia
– Seizures
– Respiratory failure
• Management
– Supportive care
– Benzodiazepines as
needed for seizures
– Physostigmine (not
generally used
prehospital)
S/S and management of phenathiazines.
These medications are used to treat serious mental and emotional issues but may be for other purposes such as antiemetics.
Ex: haloperidol, promethazine, thioridazine
Signs and Symptoms
– Parkinsonian
appearance
– Dystonia
– Dysphagia
– Eye muscle spasm
– Rigidity / Tremors
– Neck spasms
– Shrieking
– Jaw spasm
– Laryngospasm
• Management
– Supportive care
– Diphenhydramine, 25
to 50 mg IV bolus
S/S and management for a sympathomimetic OD
Ex: amphetamines, cocaine, aminophylline
Signs and Symptoms
– CNS excitation
• Excited delirium
– Seizures
– Extreme hypertension
– Hypotension with
caffeine
– Tachycardia
– Hyperthermia
• Management
– Maintain airway and
ventilation
– Begin IV access
– Administer diazepam for
excited states
– Consider use of
chemical restraint (PAI /
RSI)
– If hyperthermic, begin external cooling
Management for ingestion/ surface absorption of caustic substances
– Acids
• Cause significant damage at sites of exposure
• Are rapidly absorbed into the bloodstream
– Alkalis
• Slower onset of symptoms allows for longer contact and more
– Perform standard toxicologic emergency procedures
– Maintain an adequate airway
• Esophageal airways are contraindicated
Rinse external contact with copious amounts of water
• 5 minutes minimum for acid
• 15 minutes minimum for alkali
S/S and management for a TCA overdose
Signs & Symptoms of Severe Toxicity
– Confusion, hallucinations, hyperthermia
– Respiratory depression, seizures
– Tachycardia, hypotension, cardiac dysrhythmias,
widening of QRS complex
• Management
– Bicarbonate may be indicated for seizures
– Monitor and treat cardiac dysrhythmias
– Avoid use of flumazenil, which may precipitate seizures
Serotonin syndrome
Triggered by increasing the dose or by adding selected drugs, typically in newer antidepressants such as trazodone, bupropion, and SSRIs
• Marked by agitation, anxiety, confusion, insomnia, headache,
coma, salivation, diarrhea, abdominal cramps, cutaneous
piloerection, flushed skin, hyperthermia, rigidity, shivering,
incoordination, and myoclonic jerks.
S/S for lithium OD
Prescribed to treat bipolar disorder.
– Narrow therapeutic index
• Signs & Symptoms
– Thirst, dry mouth, tremors, muscle twitching, and
increased reflexes
– Confusion, stupor, seizures, coma, nausea, vomiting,
diarrhea, bradycardia, and dysrhythmias
• Treatment
– Activated charcoal is not effective with lithium
S/S and management for salicylates
Common Overdose Drug
– Includes aspirin, oil of wintergreen.
• Signs & Symptoms
– Tachypnea, hyperthermia, confusion, lethargy, coma,
cardiac failure, and dysrhythmias
– Abdominal pain, vomiting, pulmonary edema, ARDS
• Treatment
– Standard toxicologic emergency procedures
• Activated charcoal is indicated.
S/S for an NSAID OD
Includes
– Ibuprofen, keterolac, naproxen sodium.
• Signs & Symptoms
– Headache, tinnitus, nausea, vomiting, abdominal pain,
drowsiness
– Dyspnea, wheezing, pulmonary edema, swelling of
extremities, rash, itching
Problems with inhaled toxins
Displace oxygen
– Atmospherically
– Hematologically
• Pulmonary tissue burns
– Gas reacts with water to form acid/alkali
• Absorbed as systemic toxins
– Immediate effects
– Long-term effects
S/S and management of inhaled toxins
History and physical exam
– Central nervous system effects:
• Dizziness, headache, confusion, seizure, hallucinations, coma
– Respiratory effects:
• Cough, hoarseness, stridor, dyspnea, retractions, wheezing,
chest pain / tightness, pulmonary edema, rales, rhonchi, apnea
– Cardiac effects
• Dysrhythmias
Management
Initiate supportive measures
– Oxygenation
– Ventilation
• Poison Control may recommend specific
treatment if HazMat is not indicated
• Transport considerations
– Hyperbaric therapy
S/S of hemoglobinopathies such as carbon monoxide and methemoglobin
Signs and Symptoms
– Headache, nausea,
vomiting, dizziness,
dyspnea, seizures,
coma, death
– Cutaneous blisters,
gastroenteritis
– Epidemic occurrences
with carbon monoxide
– Cyanosis, chocolate
blood, with non-
functional hemoglobin
S/S of cyanide poisoning with treatments
Signs & Symptoms
– Odor of almonds
– Burning sensation in the mouth and throat
– Headache, confusion, and combativeness
– Hypertension and tachycardia
– Seizures and coma
– Pulmonary edema
Management
– Ensure rescuer safety
– Initiate supportive care
– Administer antidote:
• Amyl nitrite
– 20 to 30 seconds per
minute, inhaled
• Sodium nitrite
• Sodium thiosulfate
Hydroxocobalamine
• Vitamin B-12
• Converts cyanide to be excreted in urine
• 5g over 15 minutes (repeated once as if needed)
S/S and management of Carbon Monoxide inhalation
Signs & Symptoms
– Headache
– Nausea and vomiting
– Confusion or other altered mental status
– Tachypnea
– 100% oxygen saturation (saturated with CO)
Management
– Ensure rescuer safety
– Remove the patient from the
contaminated area
– Initiate supportive measures
• High-flow oxygen
• Monitor SpO2
– Low saturation is cause for
concern
– Hyperbaric therapy
S/S for Acetylcholinesterase Inhibition
- organophosphates such as parathion, malathion, diazanon, and trithion
- nerve agents such as sarin (GB), so an (GD), tabun (GA), GF, and VX
SLUDGE and DUMBBELLS
Salivation, Lacrimation, Urination, Diarrhea, Gastritis,
Emesis
• (Diarrhea, Urination, Miosis, Bradycardia, Bronchospasm,
Emesis, Lacrimation, Lethargy and Salivation / seizures)
– Bradycardia or tachycardia
– Hypotension or hypertension
– Muscle cramps and weakness
– CNS Alterations
– Respiratory and cardiovascular depression
S/S and treatment for scorpion stings
Signs & Symptoms
• Localized burning and
tingling sensation
• Slurred speech,
restlessness, muscle
twitching, salivation,
nausea, vomiting, and
seizures
– Treatment
• Supportive
Snakebite treatment
Keep the patient supine and calm
• Wash site
• Immobilize limb, neutral or below level of heart
• Apply high-flow oxygen
• Establish IV access
• Controversial
– Constricting bands or tourniquets
– Ice, cold packs
• DO NOT apply electrical
stimulation
Treatment for marine animal injuries
Treatment
– Wash area with Sea Water
– Old treatments (no longer recommended)
• Flush with:
– Vinegar
– 1/4 strength ammonia
– Baking soda solution
– Alcohol
– Urine
– Apply meat tenderizer paste
Treatment for marine animals that puncture such as spine fish and animals.
-Usually stepped on by a victim
Treatment
– Supportive care, assure ventilation and circulation
– Place injured area in HOT water, 105-115 degrees
(avoid pain medications initially)
– If patient has severe spasms:
• Administer Calcuim Gluconate, 10mL of 10% solution, IV push
Treatment for marine animals that bite and cause envenomation
• Most cause respiratory paralysis
• Some can be deadly in less than five minutes
• Includes:
– Blue-ringed octopus, sea snakes, cone shells
Treatment
– Supportive
– Assure ventilations and
circulation
• May have to continue
resuscitation for hours
– Pressure immobilization
technique still
recommended
S/S and management for contact dermatitis
- poison oak
- poison ivy
- poison sumac
Signs & Symptoms
– Itching
– Rash
– Vesicles
Treatment
– Supportive
– Topical cortisone cream
Management for insect bites and stings
Most from hymenoptera
– Wasps, bees, fire ants
– Venom causes pain, edema, and
local irritation
– Systemic problems are anaphylactic
Management
– Wash the area
– Remove stingers, if present
• Use care not to disturb the venom sac
– Apply cool compresses to the injection site
– Observe for and treat allergic reactions and/or
anaphylaxis
S/S and symptoms for Black Widow Spider
– Dime sized, shiny black
– Red, reddish orange
hourglass shaped mark
on ventral abdomen
– May have stripes or
spots matching spot
– Neurotoxin
Signs & Symptoms of Bite
– Immediate pain, redness, and swelling
– Progressive muscle
spasms of all large
muscle groups
– Nausea, vomiting,
sweating, seizures,
paralysis, and altered
level of consciousness
Treatment
– Follow general treatment guidelines
– Provide supportive care
– Consider using muscle relaxants to
relieve severe muscle spasms
• Diazepam 2.5–10mg IV
• 0.1–0.2 mg/kg of a 10% calcium
gluconate solution IV
S/S and management for Brown Recluse Spider
– Found primarily in the
South and Midwest
– Small, brown, spindly
spider with dark brown
fiddle shape on the back
or thorax
– Necrotoxin
Signs & Symptoms of
Bite
– Localized, white-ringed
maculae
– Progresses to localized
pain, redness, and
swelling over next 8
hours
– Chills, fever, nausea,
vomiting, and joint pain
may develop
– Tissue necrosis develops
over subsequent days
and weeks
Treatment
– Supportive
– Transport for excision of
necrotic area
What is the three most common addictions?
Tobacco, alcohol, marijuana
- Effects
A. Known carcinogen, COPD, testosterone reduction, breast enlargement in men, cognitive dysfunction - Signs and symptoms
A. Euphoria, dry mouth, green and/or brown residue on back of tongue, dilated pupils, body tremors, altered sensation - Management
A. Supportive, speak quietly, oxygen if respiratory impairment is noted
Marijuana
- Effects
A. Brain dysfunction, cardiac myopathy, cognitive functioning reduction - Signs and symptoms
A. CNS depression, slurred speech, disordered thought, impaired judgement, nystagmus, diuresis, stumbling gait, stupor, coma - Management
A. ABCs, respiratory support, oxygen, IV access, Thiamine 100 mg IV, D10W if low blood sugar
Alcohol
- Effects
A. Apathy, organ damage, tolerance, habituation - Signs and symptoms
B. AMS and coordination, nystagmus, hypotension, respiratory depression - Management
A. Support respirations, oxygen, IV access - Examples: thiopental, phenobarbital, primidone
Barbiturates
What is an involuntary jerking of the eyes, whether stationary or moving?
Nystagmus
- Effects
A. Tolerance, habituations, liver complications - Signs and symptoms
A. AMS, hypotension, slurred speech, respiratory depression, bradycardia, seizures - Management
A. Protect the airway, support respirations, oxygen, IV access, benzodiazepines as needed for seizure activity - Examples: secobarbital (Seconal), diazepam (Valium), chlordiazepoxide hydrochloride (Librium), triazolam (Halcion), phenobarbital, alprazolam (Xanax)
Sedatives
- Effects
A. Tolerance, habituations, bone pain, generalized weakness, jaundice - Signs and symptoms
A. Respiratory insufficiency, AMS, slurred speech, dysrhythmias, decrease/loss of reflexes, decreased body temp, nystagmus - Management
A. Require large overdosage before serious toxicity occurs, support respirations, consider Flumazenil (1-10mg) - Examples: diazepam (Valium), chlordiazepoxide hydrochloride (Librium), alprazolam (Xanax), triazolam (Halcion), lorazepam (Ativan), flunitrazepam (Rohypnol)
Benzodiazepines
- Effects
A. Apathy, organ damage, respiratory arrest, brain damage - Signs and symptoms
A. Severe respiratory depression, aphasia, loss of muscle tone/paralysis, hypothermia, seizures, death - Management
A. Aggressive airway intervention (intubate), 100% oxygen (support ventilations), IV access, transport
GammaHydroxyButarate (GHB)
- Effects
A. Apathy, end organ damage, infectious diseases, death - Signs and symptoms
A. CNS depression, pupil constriction, respiratory depression, hypotension, bradycardia, hypothermia - Management
A. Support respirations (do not intubate until Naloxone has been given), establish IV access, consider Naloxone (0.4-2.0 mg) - Examples: heroin, codeine, propoxyphene (Darvon), meperidine (Demoral), morphine, methadone
Narcotics
- “Starter heroin” - combination of heroin and ground up cold medicine (Tylenol PM; acetaminophen and diphenhydramine)
- Effects
A. Euphoria, disorientation, lethargy, sleepiness, hunger - Withdrawal
A. Begins within twelve hours, headache, chills, muscle pains, muscle spasms, anxiety, agitation, disorientation, disassociation
Cheese
- Powdered form
- Effects
A. Structural degradation of the upper airway, cardiac myopathy, infectious diseases, psychosis, end organ damage, death - Signs and symptoms
A. Euphoria, hyperactivity, dilated pupils, psychosis, HTN, tachycardia, chest pain, hyperthermia, vasoconstriction - Management
A. ABCs, support respirations, oxygen, IV access, violent patients can have heart attacks during struggle, cardiac arrest likely (monitor ECG carefully)
Cocaine hydrochloride
- Crack
- Effects
A. Excitability, aggressiveness, scarring of mid-to-lower airways, organ damage, cardiopulmonary arrest - Signs and symptoms
A. Euphoria, hyperactivity, dilated pupils, psychosis, HTN, tachycardia, chest pain, callouses or burn marks on dominant thumb and forefinger - Management
A. ABCs, support respirations, oxygen, IV access, violent patients can have heart attacks during struggle, cardiac arrest likely (monitor ECG closely)
Cocaine free-base
- Effects
A. Psychosis, infectious diseases, cardiac myopathy, end organ damage, death - Signs and symptoms
A. Exhalation, hyperactivity, dilated pupils (dark glasses), hyperthermia, HTN, tachycardia, psychosis, seizures - Management
A. Supportive, patient may “crash”, treat threats to life, consider benzodiazepines for excited delirium and hyperthermia
Methamphetamine
- Effects
A. Hypovolemia, dehydration, hyperthermia, psychosis, stroke, organ damage, death - Signs and symptoms
A. Dilated pupils, bruxism, cracked teeth, hyperthermia, HTN, tachycardia, psychosis, dysrhythmias, death - Management
A. Remove external stimuli, initiate controlled cooling (consider benzodiazepines), oxygen via NRB (12-15 liters), initiate IV access, transport
3,4 - Methylinedioxymethamphetamine (Ecstasy)
- Effects
A. Excitability, aggressiveness, organ damage, hyperthermia, delusional or hallucinatory behavior - Signs and symptoms
A. Psychosis, nausea, dilated pupils, rambling sounds, headache, dizziness, hallucinations, distorted senses - Management
A. Safety first (patients can be violent), reassure the patient, provide dark and quiet transport - Examples: LSD, PCP, mescaline, mushrooms, ketamine
Hallucinogens
- Effects
A. Excitability, aggressiveness, organ damage, hypothermia, ventricular irritability, CPR - Classes
A. Volatile solvents - model glue, cleaning fluids, fuels
B. Aerosols - freons, lubricants, hydrocarbons
C. Anesthetics - amyl nitrate, nitrous oxide (N2O)
Inhalants
