Module 1

Question 1

Vasoconstriction is an early compensatory mechanism of hypovolemic shock. Why does this occur?

Answer 1

decreased BP triggers baroreceptors to activate the sympathetic nervous system, this causes increased sympathetic tone and release of catecholamines (epinephrine and norepinehrine), which result in increased HR, increased venous tone, increased myocardial contraction, and increased cardiac output

Question 2

causes of distributive shock?

Answer 2

sepsis, anaphylaxis, neurogenic (spinal cord injury)

Question 3

List 3 types of shock

Answer 3

Pump (cardiogenic shock)
Pipes (Distributive shock)
Volume ( hypovolemic shock)

Question 4

Presentation of ectopic pregnancy

Answer 4

first trimester
bleeding
abd pain

Question 5

3 stages of shock

Answer 5

compensated, uncompensated, irreversible

Question 6

compensated shock

Answer 6

hormonal and chemical compensatory mechanisms activated to maintain homeostasis and maintain cardiac output

normal vital signs and few objective findings

Question 7

Uncompensated shock

Answer 7

oxygen supply and demand become unbalanced

Vital signs change

Question 8

Irreversible shock

Answer 8

Stage at which the amount of cellular damage and cell death is so great that permanent and significant organ damage has occurred and death is inevitable

Question 9

Why is universal screening for domestic violence important in the ED?

Answer 9

• universal screening normalizes these important questions that should be asked
• opens lines of communication
• ED may be only access point in healthcare for individuals who are victims of violence
• patients who are experiencing violence may not necessarily come in for issues related to the violence

Question 10

What are some risk factors for an ectopic pregnancy?

Answer 10

• previous tubal surgery or tubal abnormality
• previous ectopic pregnancy
• in utero DES exposure
• history of PID, chlamydia or gonorrhea
• current IUD use

Question 11

What are the treatment options for an ectopic pregnancy?

Answer 11

Methotrexate (IM) - requires close monitoring after dose for effectiveness (serial hCG measurements) and strict criteria for use
- Surgical treatment (salpingostomy or salpingectomy)

Question 12

Geriatric giants (12)

Answer 12

Delirium
Depression
Dementia
Drugs
Deconditioning
Falls
Pain
Incontinence
Malnutrition
Dehydration
Sleep disturbance
Elder abuse

Question 13

7ps of RSI

Answer 13

Preoxygenate
prepare
pretreat
paralysis with induction
protection
placement confirmation
post-intubation care

Question 14

Ketamine for intubation

Answer 14

patient may dissociate
causes an intermittent increase in blood pressure and heart rate
can cause laryngospasm

Question 15

Versed

Answer 15

May cause some hemodynamic effects such as decreased blood pressure, HR and RR BP

Question 16

Succinylcholine

Answer 16

avoid in patients with renal insufficiency, burns, hyperkalemia and malignant hyperthermia
duration 4-10 mins
increases ICP
depolarizing

Question 17

Rocuronium

Answer 17

takes 60-90 seconds to take effect
duration 25-35 mins
contraindicated in soy, egg and peanut allergies
Has antidote
Nonpolarizing

Question 18

Propofol

Answer 18

Don’t use in hypotension

Question 19

3 anatomical differences in the elderly

Airway

Answer 19

Osteoporosis/Kyphosis- may pose a challenge to applying the C-collar and also increase risk of bone breaks due to trauma and falls
Dentition- false teeth help to maintain structure of airway but can pose a risk if they don’t fit well or during intubation should be removed.
Diminished cough reflex- increased risk for aspiration, difficulty swallowing, increased risk of choking.
Decreased esophageal peristalsis- again risk for aspirations
Dry mouth (not normal but due to medications or disease) - also increases risk of infection, choking, ability to speak etc.

Question 20

3 anatomical differences in the elderly

Breathing

Answer 20

Supply often less than sensitive changes in demand- with little exertion need more oxygen and can become SOB easily.
Less efficient V/Q- Decline in exercise tolerance->fatigue
Stretched out alveoli.
Altered chemoreceptor function- so not as sensitive to hypoxia and hypercapnia as a younger person
Mucociliary transport- Cilia line the trachea and are less effective because of their decreased number and so decreases immunity
Chest wall and lungs grow in proportion to the body and correlate with height when one is young. Around age 55, respiratory muscles begin to weaken, chest wall compliance begins to decrease and a loss of elastic recoil that affects V/Q
Kyphosis/scoliosis and stooped posture of the ages also contribute to chest expansion so more DEAD SPACE and decreased expiratory flow

Question 21

3 anatomical differences in the elderly

Circulation

Answer 21

Left ventricle increases by 30% by 80 years of age and consequently there is left atrial enlargement. By age 65 there is a 35% reduction in coronary blood flow. This can cause dysrhythmias.
Contraction of the older heart is prolonged, most likely because of slow release of calcium into the myoplasm during systole. Reduced efficiency and contractile strength of the heart muscle are reflected in a reduced cardiac output that decrease by 1% per year from the average baseline of 5L/min and a SV decline of 0.7% per year.
This is a normal part of aging because decreased overall energy demands on cardiac function is expected of the older body. However, sudden demands for more oxygen and energy result in poor response of heart function attributed to the limited cardiac reserve.
Heart valves thicken and valvular disease in the aged is often misdiagnosed because it is assumed that murmurs are a result of the arteriosclerotic process.
SA rate of less than 50 is common but not necessarily disease. The pacemaker cells (of SA, AV and Bundle of His) decrease in number as myocardial fat, collagen and elastin fibers increase.