Misc (combined from lectures) Flashcards
GCS
Best eye response
Spontaneously (+4) To verbal command (+3) To pain (+2) No eye opening (+1) Not assessable (trauma, edema, etc) (+1C)
Best verbal response Oriented (+5) Confused (+4) Inappropriate words (+3) Incomprehensible sounds (+2) No verbal response (+1) Intubated (+1T)
Best motor response Obeys commands (+6) Localizes pain (+5) Withdrawal from pain (+4) Flexion to pain (+3) Extension to pain (+2) No motor response (+1)
Centor Criteria
To determine testing for strep pharyngitis:
1 - absence of cough
2 - fever >38
3 - tonsilar exudates
4 - tender lymphadenopathy (anterior)
If 1 - no testing, no tx.
If 2-3, rapid strep, tx if +. Confirm with cx.
If 4, don’t test just treat.
Strep Pharyngitis Treatment
Penicillin (benzathine) IM 1.2 million U
OR - Penicillin V PO for 10d
OR - Amoxicillin PO for 10d
OR - if pen allergy, azithromysin PO for 5 d
treat with entire course to prevent rheumatic fever
Spontaneous bacterial peritonitis
ascites + T>100F OR abd pain OR AMS OR ascitic PMN >250 cells/mm3.
Most 2/2 gut bacteria but can also be 2/2 strep. Usually no organisms ID’d.
Rx broad spectrum abx: cefotaxime vs amp/gent.
Liver failure lab abnormalities
increase PPT, ALT/AST, bili, ammonia, LDH
decreased plts
What is tramadol
Opioid analgesic used for pain, moderate - severe
50-100 mg PO q4-6h prn
Vertigo treatment
antihistamines (meclizine, denadryk), benzos (diazepam/valium, loraz/ativan), antiemetics (compazine, phenergan/promethazine, reglan/metoclopramide, zofran)
MRSA Abx coverage
clinda, doxy, bactrim (can’t use doxy or bactrim in preg pts)
Hypotension in sepsis treatment
2L NS, if refractory, levophed(norepi) - 2-4 mcg/min IV; Start: 8-12 mcg/min IV, then titrate to effect; pts w/ septic shock may require higher doses
Bites: Abx prophylaxis
Augmentin 875/125 mg bid x5d
Human: always treat
Cat: 80% infection rate: augmentin, same dose
Dog: only 5% infx on hand/foot. same Tx
Uncomplicated UTI Rx, preg UTI Rx, pyelonephritis Rx
- Nitrofurantoin monohydrate/macrocrystals (100 mg orally twice daily for 5 days);
- Bactrim (TMP-SMX); one double strength tablet [160/800 mg] twice daily for 3 days);
- Fosfomycin (3 grams single dose)
PREGNANT UTI
keflex (cephalexin), Unasyn (amp-sulb), Nitrofur.
PYELO Rx: Cipro 500 mg PO BID x7d
Fluoroquinolones are the only oral antimicrobials recommended for outpt empirical treatment of acute uncomplicated pyelo.
Osmolarity and Osmolar Gap Calculation
Calculated osmolarity = 2 x Na + Glu/18 + BUN/2.8
(can add ETOH/4)
OG = true osmolarity - calculated osmolarity = 10-20
Elevated anion gap calculation & causes
MUDPILES/MUKPILES
M - methanol
U - uremia
D - DKA [K - ketoacidosis (diabetic, alcoholic, starvation)]
P - paracetamil (tylenol), propelene glycol
I - INH, iron
L - lactic acidosis
E - ethylene glycol (antifreeze –> Ca oxalate)
S - salicylates + acute solvent inhalation (huffing)
Lorazepam
Ativan
Ativan
Lorazepam
Midazolam
Versed
Versed
Midazolam
Diazepam
Valium
Valium
Diazepam
VZV/Herpes Zoster Ophthalmicus
Reactivation of dormant varicella zoster virus residing within the ophthalmic nerve (the first division of the trigeminal nerve)
Viral prodrome
Preherpetic neuralgia
Rash, transitioning from papules to vesicles to pustules to scabs.
Hutchinson’s sign: cutaneous involvement of the tip of the nose, indicating nasociliary nerve involvement. A positive Hutchinson’s sign increases the likelihood of ocular complications associated with HZO.
Vanc Dosing
20 mg/kg - cellulitis, skin/soft tissue infection, UTI
20 mg/kg - Dialysis patients
25 to 30 mg/kg - Pneumonia, meningitis, osteomyelitis, endocarditis, septic shock
MAXIMUM DOSE 2000 mg
Normal Gap Acidosis Differential
"HARD UP" Hyperventilation Acetazolamide, Addison’s disease RTA Diarrhea, ileostomies, fistulae Uremia Pancreatoenterostomies
Top 2 causes of metabolic acidosis + resp alkalosis
aspirin OD or sepsis (lactic acidosis + hyperventilation)
Hypomagnesemia causes (6)
malabsorption alcoholism diarrhea redistribution (insulin) RTA diuretics
How to treat eclampsia
Mg and deliver
Mg - halves rate of progression from pre -> eclampsia
Eclamptic seizures – more effective than phenytoin or benzodiazepines
Dose: 4g over 5min -> 1g/hr (aim for a level of 2-4mmol/L)
Adverse effects of high levels = muscle weakness, respiratory muscle fatigue, slowed cardiac conduction (>7.5mmol/L) -> arrest (>12.5mmol/L)
toxicity unlikely if tendon reflexes are present
Ketamine (Dosing, & Contraindications)
Sedative/hypnotic for RSI.
RSI Dose: 1-2 mg/kg - give around 100-150 mg
Use for asthmatics, hypotensives.
Contraindications: extreme HTN, cocaine, tachycardia, increased IOP or ICP
Etomidate (Indications, Dosing, & Contraindications)
Sedative/hypnotic for RSI. No analgesic effects, mild increase in airway resistance. Can cause myoclonus.
RSI Dose: 0.3 mg/kg - give around 20-30 mg
Drug of choice for HTN or tachycardic pts!!! (no hemodynamic instability)
Contraindications:
adrenal insufficiency, (causes adrenocortical suppression).
Rocuronium
Competitive inhibitor of ACh receptors, prevents all muscle action. No fasciculations (non-depolarizing)
1 mg/kg (~70-100 for adults), effect in 45-60 secs, duration of action 45 min.
USE IN KIDS!!!
Succinylcholine
Ach analog that stimulates all receptors and then wear them out, transient fasciculations, then paralysis. Increases K.
Dose: 1.5 mg/kg (~100 for adults)
45 sec to effect
Duration: 6-10 min
DONT USE IN KIDS
Contraindications: Causes HYPERKALEMIA (beware in renal pts, Crush or burn injury over 48h old, rhabdo, Malignant hypothermia)
Denervating diseases/injuries (MS, ALS, old strokes, old cord injury, prolonged immobilization)
3 ways to confirm placement of tube
Listen to chest
End tidal CO2 (waveform capnog)
CXR
Still desatting w/ ET tube, what could be wrong?
DOPES
D - Displacement of tube O - Obstruction of the ETT P - PTX (also: PE, pulmonary edema, collapse, bronchospasm, mucus plugging) E - equipment — ventilator problems S - ‘Stacked breaths’
What other 2 sedatives hypnotics can you use for RSI other than ketamine and etomidate?
Versed/Midazolam (0.2 mg/kg –> ~15 mg)
Propofol (1.5-3 mg/kg –> ~100 mg)
Causes of HYPERcalcaemia
Nature Bones, stones, groans and psychic moans
Causes>90% from Malignancy and Hyperparathyroidism
Basically: Tumour, increased PTH and increased Vit D
3 Ocular emergencies that need treatment IMMEDIATELY (before consult!)
- Chemical burn(alkali-worst, acid, solvents, detergents)
- Acute central retinal artery occlusion (CRAO)
- Elevated IOP from
- Retrobulbar hematoma
- Acute angle closure glaucoma
- Ocular compartment syndrome
SIde effect of Proparacaine Eye Drops
Can cause keratitis with prolonged use! Don’t send patients home with this!
Retinal exam findings with central retinal artery occlusion
Box cars and cherry red spot (macula)
3 Most common causes of increased intraocular pressure
- retrobulbar hemorrhage (recent ocular trauma or surg)
- AA closure glaucoma
- Ocular compartment syndrome (congestion/sinusitis –> orbital cellulitis
Causes of Acute monocular vision loss
GO CART MTV
Glaucoma Optic neuritis CRAO, CRVO Amaurosis fugal Retinal detachment Trauma Migraine**** Temporal arteritis (GCA) Vasculitis
6 causes of an afferent pupillary defect
retinal detachment
ischemic optic disease or retinal disease
severe glaucoma causing trauma to optic nerve
optic neuritis
direct optic nerve damage (trauma, radiation, tumor)
very severe macular degeneration
retinal infection (CMV, herpes)
Treatments for acute angle closure glaucome
acetazolamide, beta blocker timolol, alpha agonist ilodipine, Mannitol, steroid
What group gets central retinal artery occlusion frequently
Sickle cell disease
What does central retinal vein occlusion look like on retinal exam?
blood and thunder (retinal bleeds everywhere)
What 2 disease/symptoms occur with temporal arteritis?
GCA + polymyalgia rheumatica. They are at risk for monocular vision loss 2/2 inflammation of the ocular arteries
Rx: Corticosteroids are the mainstay of therapy.
Red Eyes: Diseases with perilimbal involvement (2) vs. Sparing (2)
Perilimbal involvement:
Iritis
Uveitis
Perilimbal sparing: Kawasaki Dz
Conjunctivitis
What’s Hutchinson’s Sign and why is it bad?
Vesicles on the tip of the nose that precedes the development of ophthalmic herpes zoster. Means nasociliary branch of the trigeminal nerve involved, which innervates cornea too, and can lead to painful vesicles on cornea & blindness,
Name the 12 cranial nerves
CN I – Olfactory CN II – Optic CN III – Oculomotor CN IV – Trochlear CN V – Trigeminal CN VI – Abducens CN VII – Facial CN VIII – Vestibulocochlear CN IX – Glossopharyngeal CN X – Vagus CN XI – Accessory CN XII – Hypoglossal
Which bug is bacterial conjunctivitis most likely?
Strep, treat with Polytrim or moxifloxacin
Polytrim is similar to bactrim, which covers GP skin flora and MRSA
Moxifloxacin is a fluoroquinolone that covers strep, enterics, and atypicals
What is superficial punctate keratitis?
inflammatory response to bright light (welding, snowboarders, tanners, etc.)
death of small groups of cells on the surface of the cornea Eye, watery, and sensitive to light, and vision may decrease somewhat. Most recover fully.
Define High Quality CPR (4)
Compressions 100-120/minute
Depth: 2 inches in adults, allow full recoil
Minimize time off chest (interruptions less than 10 sec)
Ventilate ~1 breath every 6-10 secs – do not hyperventilate.
malignant hyperthermia Rx?
dantrolene
Post intubation sedation options
Most commonly for medical patients: fentanyl & propofol
- Bolus fentanyl 100 mcg/IV (1-2 mcg/kg bolus)
- Start fentanyl drip at 50 mcg/hour
- Start propofol drip at 20 mcg/kg/min
Titration:
- fentanyl, increase 25 mcg/hour
- propofol, increase 10 mcg/kg/min
Post intubation sedation for trauma patients:
Fentanyl and Midazolam/versed + Vec (0.1 mg/kg)
Post intubation sedation for trauma patients
Trauma: Fentanyl and Midazolam/versed + Vec (0.1 mg/kg)
Difficult laryngoscopy mnemonic
LEMON
Look externally Eval the 3-3-2 rule Mallampati Obstruction (ex. Subglottic stenosis) Neck mobility
ETT size and depth in premature infants
Premature tube size 0.1X gest age in weeks and then downsize to next smaller tube
Ex. 34 weeks –> 3.4 –> 3.0
Depth: 3X size of tube (ex tube size 3.0 x 3 = 9 cm)
Massive Transfusion Protocol
MTP → 1:1:1 (PRBC’s, platelets and plasma) has better survival
Blood is then sent every 20-25 minutes
Abx choice for typical community acquired PNA
ceftriaxone + azithromycin
plus zosyn or levaquin if pseudomonas
Abx choice for atypical community acquired PNA
(for mycoplasma, chlamydia, legionella)
azithromycin, doxy, or levaquin
