Module 3 - Cardiovascular and Medical Emergencies Flashcards
Hypoxic Hypoxia
aka Altitude Hypoxia Is a deficiency in the alveolar oxygen exchange, which can be caused by low barometric pressure.
Hypemic hypoxia
Is a reduction in the oxygen-carrying capacity of the blood.
Stagnant hypoxia
Occurs when conditions exist that result in reduced total cardiac output, pooling of the blood within certain regions of the body, a decreased blood flow to the tissues, or restriction of blood flow.
Histotoxic hypoxia
aka tissue poisoning Occurs when metabolic disorders or poisoning of the cytochromic oxidase enzyme results in a cell’s inability to use molecular oxygen.
Which patient is not affected with altitude temperature changes?
A. Cardiac patient
B. Burn patient
C. Head injured patient
D. Spinal cord injured patient
A: Cardiac patients are usually not affected with altitude temperature changes.
Your patient presents with epigastric pain, nausea, and vomiting for the last hour. He describes his chest pain as “heavy in nature.” What does the following 12-lead ECG show? [inferior mi ecg]
C: Inferior wall MI presents with ST elevation in leads II, III, and aVF. Reciprocal changes are present in leads I, aVL, and V1-V4.
Inferior MI - II, III, aVF would show reciprocal changes in
reciprocal changes seen in I, aVL, V1-V4
Anterior-septal wall MI identified in V1-V4, would show reciprocal changes in
reciprocal changes seen in II, III, aVF, aVL
Lateral wall MI identified in I, aVL, V5, V6 would show reciprocal changes in
reciprocal changes seen in II, III, aVF
Posterior wall MI identified in V6 would show reciprocal changes in
reciprocal changes seen in V1-V4
CPK as a marker
onset 4-6 hours, peaks 24 hours
CPK-MB as a marker
onset 4-6 hours, peaks 12-20 hours
LDH as a marker
onset 8-12 hours, peaks 2-4 days
Troponin I normal range (most sensitive test)
0-0.1 ng/mL; onset 4-6 hours, peaks 12-24 hours, returns to normal in 4-7 days
Troponin T normal range (most sensitive test)
0-0.2 ng/mL; onset 3-4 hours, peaks 10-24 hours, returns to normal in 10-14 days
Your patient is experiencing left ventricular diastolic failure. Therapy should be focused on
A. Augmentation of left ventricular clearing
B. Decreasing afterload
C. Decreasing preload
D. Diuretics and relief of anxiety
D. Diuretics and relief of anxiety. Relieving ischemia, treating atherosclerosis, and correcting renal artery stenosis are most helpful. In addition, efforts to keep patients dry, maintain a slow sinus rhythm, and control blood pressure provide a basic approach to diastolic dysfunction. When
Your patient is exhibiting ST elevation in leads II, III, and AVF. ST depression is noted in V1-V3. Which of the following may prove hazardous?
A. Isotonic fluid bolus
B. Heparin
C. GII/BIIIa inhibitors
D. Nitroglycerin
D. Nitroglycerin
Explain consideration of Nitro administration with a RVI
Hypotension, with distended neck veins and clear lungs occurs in patients with (RVI). This is because of occlusion of the proximal right coronary artery, the blood supply to the right ventricle. RVI patients are volume dependent because of inadequate preload to the left ventricle. The basis of therapy for a RVI is large volumes of intravenous fluids prior to administering medications that may decrease preload and inotropic support. RVI accompanies inferior-posterior wall MIs in 30-50% of patients.
Clot busting and prevention
ASA G2BIIIA inhibitors—Reopro Integrelin Aggrastat Heparin Thrombolytics—Retavase tPA Streptokinase
Treatments for Heart rate and myocardial O2 demand reduction
Beta-blockers Calcium-channel blockers
Thrombolytics - Relative & Absolute CI’s, Complications
Relative contraindications: HTN, recent trauma, pregnancy Absolute contraindications: Active internal bleeding, Suspected aortic dissection, Known intracranial neoplasm, Previous hemorrhagic stroke, Stroke within the last year. Complications: bleeding, intracranial hemorrhage, dysrhythmias, cardiac tamponade, pulmonary edema
Preload reduction management for AMI/Unstable angina
Nitrates (5-200 μg/min) Morphine (2-4 mg every 5-15 minutes)
Electrical alternans may be caused by
A. Pulmonary embolus
B. Pericardial tamponade/effusion
C. Tension pneumothorax
D. Diaphragmatic rupture
B. Pericardial tamponade/effusion
Antidote for Coumadin overdose is
A. Protamine sulfate
B. Glucagon
C. Vitamin K, FFP
D. Physostigmine
C. Vitamin K, FFP
Anterior infarct – Coronary artery involved?
LAD
Inferior infarct – Coronary artery involved?
RCA
Lateral infarct – Coronary artery involved?
LCX
Septal infarct – Coronary artery involved?
LAD
Posterior infarct – Coronary artery involved?
LCX or RCA
Wellen’s syndrome is ____ and it presents on ECG by __.
Associated with critical stenosis of the proximal LAD and impending infarct ECG: V2-V3 segment turns down into a negative T at a 60-90-degree angle
A Transmural MI vs Subendocardial (nontransmural)
Extends through the full thickness of the myocardium and includes the endocardium and epicardium Vs. Necrosis is limited to the subendocardial surface
Dressler’s syndrome
Is a secondary form of pericarditis that occurs in the setting of injury to the heart or the pericardium, the outer lining of the heart. It is also known as post MI syndrome and postcardiotomy pericarditis. Largely a self-limiting disease that very rarely leads to pericardial tamponade. Consisting of a persistent low-grade fever, chest pain (usually pleuritic in nature), a pericardial friction rub, and /or a pericardial effusion. The symptoms tend to occur within 2-5 days post MI but can be delayed for a few weeks or even months after infarction. It tends to subside in a few days.
Pericardial effusion
Is the development of pericardial fluid as response to injury, acute pericarditis. Electrical alternans can be present on the ECG.
Cardiac tamponade
Consists of cardiac output being compromised by the fluid around the heart. Beck’s triad can be indicative for the presence of tamponade, which includes muffled heart tones, hypotension, and jugular vein distension (JVD).
Beck’s Triad is
can be indicative for the presence of tamponade which includes: muffled heart tones hypotension jugular vein distension (JVD).
Management of cardiac tamponade
ABCs intravenous fluids pericardiocentesis
S1 heart sound: Description - Location to hear - May indicate -
S1 heart sound: Description - A normal S1 sound is low pitched and of longer duration than S2. Location to hear - Best heard over the mitral area at the apex which is approximately at the fifth intercostal space, midclavicular left side of the chest. May indicate - Corresponds to the closure of the mitral and tricuspid valves (atrioventricular—AV valves) at the beginning of ventricular contraction or systole.
S2 heart sound: Description - Location to hear - May indicate -
S2 heart sound: Description - A normal S2 sound is higher pitched and of shorter duration than S1 Location to hear - The second heart tone, or S2, “Dub” is best heard over the aortic area which is located at the second intercostal space at the base of the heart, right sternal border. A normal S2 sound is higher pitched and of shorter duration than S1. May indicate - Corresponds to closure of the aortic and pulmonic valves (semilunar valves) at the end of ventricular systole.
S3 heart sound: Description - Location to hear - May indicate -
S3 heart sound: Description - Abnormal heart sound that may sound like the word “Ken-tu-cky” in three fairly evenly spaced sounds. Location to hear - The S3 sound is heard immediately after S2 and is normal in children and young adolescents but usually disappears after the age of thirty. May indicate - When heard in adults, an S3 is called a “gallop” and indicates left ventricular failure.
S4 heart sound: Description - Location to hear - May indicate -
S4 heart sound: Description - Abnormal heart sound that may sound like the word “Tennessee” where the three syllables come quick followed by a pause. Location to hear - The S4 sound is heard immediately before the S1 and may be present in infants and children. May indicate - The S4 is produced with decreased compliance of the ventricle and may indicate MI or shock.
Protamine sulfate is used for
heparin overdose
Your patient has a chief complaint of dyspnea and weakness with the following vitals: BP 72/64, HR 112, RR 28, SpO2 88%, temp. 99.1°F. He is on 6 L/minute of oxygen via NC. The ECG shows ST with frequent PVCs. Physical exam reveals profound vesicular rales and bronchial wheezing. Your most likely diagnosis is
A. CHF
B. ARDS
C. Asthma
D. Cardiogenic shock
D. Cardiogenic shock
Treatment for compensated bradydysrhythmias with a pulse and heart rate <60 beats per minute.
Compensated: SBP > 90-100 mmHg without S/S of shock Good LOC Treat the underlying cause, place combo pads as an anticipatory measure.
Treatment for uncompensated bradydysrhythmias with a pulse and heart rate <60 beats per minute.
Decompensated: SBP < 90-100 mmHg, ALOC may be present and other S/S of shock present F—Fluids A—Atropine (not rec. in 2nd ˚ AVB Type II or CHB) E—External pacing D—Dopamine drip E—Epinephrine drip
Treatment for compensated tachydysrhythmias with a pulse and heart rate >160 beats per minute.
Compensated: SBP > 90-100 mmHg without S/S of shock and good LOC Supportive care Vagal maneuvers—narrow complex tachycardia (SVT) Medications Application of combo pad as an anticipatory measure
Treatment for uncompensated tachydysrhythmias with a pulse and heart rate >160 beats per minute.
Decompensated: SBP < 90-100 mmHg with S/S of shock; ALOC may be present. Consider sedation Synchronized cardioversion beginning at 100 joules Medications
Tx for Cardiogenic shock (hypotension present with S/S of pulmonary edema—left ventricular failure)
Inefficient pumping of the heart with hypotension Dobutrex, dopamine, and Inocor to improve cardiac output Vasodilators such as Nipride, NTG, and Levophed IABP and LVAD therapy
Right-side ventricular heart failure:
Back up of fluid to the right side of the heart and body Increased jugular venous distention (JVD) Sacral edema Pedal edema
Left-side ventricular heart failure:
Back of fluid to the left side of the heart and lungs Rales
Treatment of cardiac tamponade includes all of the following, except
A. Force fluids
B. Pericardiocentesis
C. Rapid transport
D. Needle thoracostomy
D. Needle thoracostomy Intravenous fluids, pericardiocentesis, and rapid transport are all indicated for management of a patient presenting with cardiac tamponade. Needle thoracostomy is indicated for a patient presenting with a tension pneumothorax.
You are transporting a forty-five-year-old man with acute respiratory distress syndrome (ARDS) and MODS secondary to probable organ rejection after a heart transplant. During transport the patient becomes bradycardic with heart rate in the 30s with hypotension. Which of the following therapies will likely prove fruitless?
A. 250-500 mL saline bolus
B. Dopamine 5-20 μg/kg/min
C. Transcutaneous pacing
D. Atropine 0.5-1 mg IV push
D: The administration of Atropine will not work with patients who have had a heart transplant because of denervation of the vagus nerve. Atropine works by blocking the vagus nerves, thereby increasing heart rate. Symptomatic bradycardia, second degree Type II block, high-grade AVB and CHB require placement of a pacemaker. Complications of pacing can include oversensing and failure to sense; failure to capture, myocardial penetration/perforation, and cardiac tamponade.
Your patient presents with following parameters: CVP 20, CI 1.1, PA S/D 8/4, wedge 3, and SVR 1,800. What is your diagnosis?
A. Hypovolemic shock
B. RVMI
C. CHF/LVF
D. Sepsis
B: RVI because of the low PAWP. Review
You are transporting a fifty-year-old man from ICU to another facility for further evaluation. The patient has been diagnosed with AMI. He has been complaining of increasing CP, SOB, and dramatic weight loss. He appears very nervous, and you note tremors. His ECG shows AF at 148. The patient may be experiencing
A. Addison’s disease
B. Thyrotoxicosis (grave’s dieases)
C. Myxedema coma
D. Cushing’s syndrome
B: Thyrotoxicosis, also known as Grave’s disease, thyroid storm and hyperthyroidism. Avoid Aspirin because it increases T3, T4 levels and can worsen condition.
Grave’s disease
Hyperthyroidism Exophthalmos— “Marty Feldman” or “Betty Davis” protruding eyeballs Atrial fibrillation is common Anxiety, tremors Weight loss Treatment: correct electrolytes and glucosteroids
Myxedema coma
Hypothyroidism Infection common cause; coarse hair, deep voice, thinning or loss of the outer third of the eyebrows (Queen Ann’s sign) Women > 60 years; occurs in the winter months Fatigue Weight gain Treatment: levothyroxine
Addison’s disease
Acute renal insufficiency Hypotension is common: caution with etomidate administration Fatigue Weight loss Treatment: supportive care
Cushing’s disease
Hyperaldosteronism Hypertension Women have facial hair, moon-face, buffalo hump Upper body obesity, thin arms and legs Treatment: decrease or initiate steroids
The formula to calculate MAP is:
A. 2/3 DBP × SBP
B. 2 × DBP + SBP divided by 3
C. 2 × SBP + DBP
D. 2 + DBP × SBP divided by 3
B: (2 × DBP) + SBP divided by 3 = MAP. Normal MAP is 80-100 mmHg.
Normal coronary perfusion pressure (CPP) is
A. 50-60 mmHg
B. 70-90 mmHg
C. 80-100 mmHg
D. <50 mmHg
A: Normal coronary perfusion pressure is 50-60 mmHg. It can be calculated by using the following formula: DBP − PWCP. Remember that your HEAD is higher than your HEART (50-60 mmHg).
Cerebral perfusion pressure can be calculated by using the following formula: MAP − ICP. Normal range for cerebral perfusion pressure is 70-90 mmHg. Remember that your HEAD is higher than your HEART.
MAP − ICP. Normal range for cerebral perfusion pressure is 70-90 mmHg. Remember that your HEAD is higher than your HEART (50-60 mmHg).
When performing a pericardiocentesis, the insertion site is
A. Below the subxyphoid process
B. Just right of the subxyphoid process
C. Just left of the subxyphoid process
D. Above the subxyphoid process
C: The emergent treatment of choice is pericardiocentesis. A large bore needle is placed just to the left of the patient’s sub-xyphoid process and with negative pressure applied to the syringe, it is directed toward the left scapula (shoulder) while monitoring the ECG for the presence of ventricular ectopy. As little as 15-20 mL of blood to improve the patient’s condition.
The initial treatment of a patient with a suspected cardiac tamponade
The initial treatment of a patient with a suspected cardiac tamponade is a rapid intravenous fluid bolus. This measure improves filling pressures and temporarily improves cardiac output until pericardiocentesis can be performed.
You are transporting a seventy-five-year-old man with a diagnosis of inferior wall MI. During the flight you note the following rhythm. Vital signs are: 70/palp, HR 150, RR 24, SpO2 94% on high flow oxygen with NRM at 15 L/min. He is awake and complains of chest pain and SOB. How will you manage this patient? [image vtach]
A. Administer lidocaine and nitroglycerin
B. Administer normal saline bolus
C. Consider sedation and synchronize cardiovert at 100 joules
D. Have the patient cough forcefully
C. Consider sedation and synchronize cardiovert at 100 joules
sixty-year-old man complains of chest pain for three days with a low-grade fever. Patient complains of increased pain when lying in supine position and states that the chest pain decreases when sitting forward. What is the most likely diagnosis?
A. Pulmonary embolism
B. Pleurisy
C. Pericarditis
D. Pericardial tamponade
C: Pericarditis is an inflammation of the pericardium which can present with chest pain radiating to the back and relieved by sitting up forward and worsened by lying down, is the classical presentation. Other symptoms of pericarditis may include dry cough, fever, fatigue, and anxiety.
How is the coronary perfusion pressurecalculated?
A. DBP − PCWP
B. DBP + PCWP
C. SBP − DBP
D. SBP − PCWP
A. DBP − PCWP
Inferior wall MI is caused by an occlusion of which coronary artery?
A. LAD
B. RCA
C. Circumflex
D. Inferior vena cava
B. RCA
What medications would you expect to administer to a patient presenting with severe chest/abdominal pain, diaphoresis, and is restless? SBP is 170/palp and heart rate in 116. You note a difference in blood pressures when taken on each arm.
A. Nitroglycerin and atenolol
B. Nipride and b-blockers
C. Lasix and nitroglycerin
D. Bumex and Dobutrex
B: Nipride and Beta-blockers.
Three types of Aortic dissection
Debakey classification system describes three types: I = occurs in the ascending aorta and extends distally beyond the aortic arch II = process is limited to the ascending aorta (Marfan’s) III = dissection distal to the origin of the left subclavian artery and extends distally to abdominal aorta.
Most common site for aortic dissection
Ascending aorta
Classic S&S of Aortic Dissection
S/S: severe pain, originating in the back or sub-sternal region
CXR findings of Aortic dissection
CXR Findings: Mediastinal widening Extension of aortic shadow beyond calcified aortic wall Localized bulge on aortic arch Tracheal deviation Left pleural effusion
Management of Aortic dissection
Management: Lower SBP to 100-110 mmHg Beta-blockers blockers to slow the heart rate and decrease ejection fraction (metoprolol, esmolol), pain analgesics Fluids only if hypotensive HTN crisis: Nipride, Hyperstat to patient’s normal within 30-60 min Surgery
All of the following are signs of cardiac tamponade, except
A. Pulsus paradoxus
B. Pulsus alternans
C. Kussmual’s sign
D. Pulseless electrical activity (PEA)
B: The patient suspected of having a cardiac tamponade will exhibit signs and symptoms of decreased cardiac output such as, cool, clammy skin, altered mental sratus, tachycardia, pulsus paradoxus (a drop in systolic blood pressure > 15 mmHg during normal inspiration), distant muffled heart tones, jugular venous distention, unless the patient is hypovolemic, hypotension, and electrical alternans.
A sign of hyperventilation and hypocalcemia is
A. Kehr’s
B. Grey Turner’s
C. Trousseau’s
D. Brudzinski’s
C: Trousseau’s sign is observed in patients with low calcium. This sign may be present before other manifestations of hypocalcemia such as hyperreflexia and tetany and is generally more sensitive than the Chvostek sign of hypocalcemia. https://www.youtube.com/watch?v=Ry5Rh3wO8Sw
You are transporting a sixty-year-old man complaining of severe chest pain and midscapular pain. He is short of breath and is hypertensive in the upper extremities. You auscultate a harsh systolic murmur. Your diagnosis of this patient is
A. Cardiac tamponade
B. Aortic rupture
C. Myocardial rupture
D. Tension pneumothorax
B: Aortic rupture with 90% of patients who die at the scene. Chest x-ray findings: widening mediastinum and loss of aortic knob shadow
The MD has ordered a brain natriuretic peptide (BNP), which would evaluate the patient for
A. Sepsis
B. Hypovolemia
C. Right ventricular MI
D. CHF
D: BNP is a blood test used to measure the amount of BNP hormone in the blood. BNP is produced by the heart and shows how well the heart is functioning. Normally, only a low amount of BNP is found in the heart. But if the heart has to work harder for a longer period of time, such as in heart failure, the heart releases more BNP, increasing the blood level of BNP. Lab findings— normal BNP level: 0-99 picograms per milliliter (pg/mL); Abnormal BNP level: 100 pg/mL or greater is indicative that heart failure may be present.
Levine’s sign relates to
A. Meningitis; neck pain
B. Pancreatitis; periumbilical bruising
C. Cardiac; clenched fist over chest
D. Splenic injury; left shoulder
Clutching of the chest, may be cardiac in origin
Murphy’s sign
RUQ pain, may indicate gallbladder disease
Grey Turner’s
Retroperitoneal bruising, may indicate pancreatitis or trauma
Cullen’s
Periumbilical bruising, may indicate pancreatitis or intra-abdominal bleeding
Kehr’s
Shoulder pain, may indicate spleen injury on the left side or ectopic pregnancy/rupture on either side
Halstead’s
Marbled appearance of the abdomen, may indicate necrosis of the pancreas
Hamman’s
Crunching sound heard with auscultation, may be synchronized with heart rate/pulse, may indicate tracheobronchial injury
Kussmaul’s sign is a
A. Rise in venous pressure with inspiration
B. Crunching sound synchronized to heart beat
C. Decrease of the SBP of > 10 mmHg with inspiration
D. Marbled appearance of the abdomen
A: Kussmual’s sign is a rise in venous pressure with inspiration (JVD), which can be indicative of (RVI) and cardiac tamponade.
A S3 Heart Tone is
Abnormal heart sound “ventricular gallop” that is associated with CHF, mitral regurgitation, and cardiomyopathy.
A S4 Heart Tone is
Abnormal heart sound “atrial gallop” that is associated with dilated or restrictive cardiomyopathy, aortic, and pulmonic stenosis.
Orthopnea
Increased shortness of breath in supine/lying position and is relieved by sitting and/or standing up.
Paroxysmal nocturnal dyspnea (PND)
Medical symptom, also known as cardiac asthma. It is defined as sudden, severe shortness of breath at night that awakens a person from sleep, often with coughing and wheezing. It is most closely associated with CHF. PND commonly occurs several hours after a person with heart failure has fallen asleep.
Dilated cardiomyopathy
Ventricular dilation, contractile dysfunction, and symptoms of heart failure.
Hypertropic cardiomyopathy
Inappropriate LV hypertrophy (thickening of left ventricle) with preserved or enhanced contractile function. Systolic murmur can be present. Etiology unclear—IHSS (idiopathic hypertrophic subaortic stenosis).
Restrictive cardiomyopathy
Least common. Endocardial scarring of the ventricle with impaired diastolic filling.
Cardiomegaly
A medical condition wherein the heart is enlarged.
Drug of choice for treating a GI bleed is
A. Normal saline
B. Nipride
C. Whole blood
D. Sandostatin
- D: Sandostatin (octreotide) is a vasoactive peptide used in the management of upper gastrointestinal esophageal varices. The mechanism of action is believed to be a reduction of splanchnic blood flow. Treatment is primarily with endoscopic banding and IV octreotide.
A common problem seen with hepatic encephalopathy is
A. Hyperkalemia
B. Increased ammonia levels
C. Low protein levels
D. Low BUN
B. Increased ammonia levels Most ammonia in the body forms when protein is broken down by bacteria in the intestines. The liver normally converts ammonia into urea, which is then eliminated in urine. Ammonia levels in the blood rise when the liver is not able to convert ammonia to urea. This may be caused by cirrhosis or severe hepatitis.
You are transporting a fifty-year-old man from a rural facility. Your patient’s ECG is demonstrating ST at 112 with peaked P waves. The ABG indicates pH 7.2, pCO2 18, HCO3 12 and pO2 108. CMP reveals Na 130, K 2.3, Cl 95, HCO3 10, BUN 48, creat 2.2, and glucose of 685. The most appropriate diagnosis would be
A. Cardiogenic shock
B. DKA
C. Hyperglycemic, hyperosmolar nonketotic syndrome
D. Dehydration
Diabetic ketoacidosis (DKA) is problem with insulin. Treatment goal for both are aimed at administering fluids, insulin, and correcting electrolyte imbalances to control the hyperglycemia and to prevent shock and other complications.
Main problem with DKA is
Lack of or low insulin production
Main problem with HHNK is
Problem is high sugar with high serum osmolarity
DKA is most likely to occur in an
insulin-dependent patient
HHNK is most likely to result in
Severe dehydration
DKA results in ____ in the urine and ____ pH levels
keytones Acidotic (low pH)
DKA serum glucose is usually <
<1000 mg/dL
HHNK serum glucose is usually >
>1000 mg/dL
Recommended urinary output when caring for an adult patient should be
A. 100 mL/hr
B. 30-50 mL/hr
C. 1-2 cc/kg/hr
D. >200 mL/hr
B: Normal adult urinary output ranges from 30-50 mL/hour. Pediatric range is from 1-2 mL/kg/hour.
Expected urinary output in electrical injuries is for adults and pedi
100 mL/hour in the adult patient 2-4 mL/kg/hour in the pediatric patient.
A patient presenting with meningitis may exhibit which sign on assessment?
A. Cullen’s
B. Grey Turner’s
C. Kernig’s
D. Levine’s
C: Kernig’s and Brudzinski’s signs are physical examination results that are strongly suggestive of meningitis. A “stiff neck” is one of the general warning signs of meningitis, and these are some of the first steps to investigate such a finding.
Pericarditis can be misdiagnosed as: What is the classic sign of pericarditis, and what are some other common signs?
MI and vice versa. The classic sign of pericarditis is a friction rub. Other signs include diffuse ST-elevation and PR-depression on ECG in all leads except aVR and V1; cardiac tamponade (pulsus paradoxus with hypotension), and CHF (elevated jugular venous pressure with peripheral edema).
Test to determine if the friction rub heard is pleuritic versus pericardial…
Ask Pt to hold their breath while auscultating the chest. If the friction rub is still heard while the patient is holding their breath, it is most likely a pericardial friction rub. If the friction rub is not heard, then it is most likely a pleuritic friction rub.
To elicit Trousseau’s sign…
A blood pressure cuff is placed around the patient’s arm and inflated to a pressure greater than the systolic blood pressure and held in place for three minutes. This will occlude the brachial artery. In the absence of blood flow, the patient’s hypocalcemia and subsequent neuromuscular irritability will induce spasm of the muscles of the hand and forearm. The wrist and metacarpophalangeal joints flex, the DIP and PIP joints extend, and the fingers adduct. https://www.youtube.com/watch?v=Ry5Rh3wO8Sw
Chvostek sign
It refers to an abnormal reaction to the stimulation of the facial nerve. When the facial nerve is tapped at the angle of the jaw, the facial muscles on the same side of the face will contract momentarily (typically a twitch of the nose or lips) because of hypocalcemia (i.e. from hypoparathyroidism, pseudohypoparathyroidism, hypovitaminosis D) with resultant hyperexcitability of nerves.
How PND and simple Orthopnea differ when laying down/sitting up….
PND is often relieved by sitting upright but not as quickly as simple orthopnea. Also unlike orthopnea, it does not develop immediately upon lying down.
If an acute hemorrhage episode occurs during transport,
maintenance of airway and circulating volume is the first priority.
Hepatic encephalopathy
(also known as portosystemic encephalopathy) is the occurrence of confusion, altered level of consciousness, and coma as a result of liver failure. In the advanced stages, it is called hepatic coma or coma hepaticum. It may ultimately lead to death. It is caused by accumulation in the bloodstream of toxic substances that are normally removed by the liver.
Hepatic encephalopathy is reversible with treatment. This relies on suppressing the production of the toxic substances in the intestine. This is most commonly done with
with the laxative lactulose or with nonabsorbable antibiotics.
Kernig’s sign is a way to demonstrate that the neck is not simply “stiff” but is irritated. To test…
With the patient lying flat, the examiner flexes the hip ninety degrees and then attempts to extend the lower leg at the knee. Pain on extension is a positive sign. If positive but the straight leg raise also produces back pain, the combined sign may be due to low back muscle spasm, herniated disk, or sciatic nerve inflammation.
To test for Brudzinski’s sign
The patient lies on his or her back, and the examiner puts one hand behind the patient’s head and the other on the chest. Using the hand behind the neck to raise the head but pressing on the chest with the other hand, if the hips and knees flex, the neck sign is positive. Chin to chest the hips will flex
Gestational Diabetes
Results when pregnant women, who have never had diabetes before, have a high blood glucose level during pregnancy. It may precede development of Type II diabetes. Risks to the fetus include macrosomia (high birth weight); increased fetal insulin may inhibit surfactant production. A cesarean section may be performed if there is marked fetal distress or an increased risk of injury associated with macrosomia, such as shoulder dystocia.
Murphy’s sign would indicate which of the following conditions?
A. Splenic injury
B. Cardiac problem
C. Pancreatitis
D. Gallbladder
D. Gallbladder Right upper quadrant pain, may indicate gallbladder disease
Treatment of pancreatitis would include all of the following, except
A. Fluid resuscitation
B. NPO and place OG/NG tube
C. Morphine for pain
D. Antibiotics for sepsis
C: Morphine has been contraindicated for pain treatment in acute pancreatitis because of its presumed opioid-induced sphincter of Oddi dysfunction.
Pancreatitis is _____ Commonly triggered by _____ and ______ .
Pancreatitis is the inflammation of the pancreas caused by the release of activated pancreatic enzymes. The most common triggers are biliary tract disease and chronic heavy alcohol consumption.
2 Forms of Pancreatitis
Acute pancreatitis is sudden. Chronic pancreatitis is characterized by recurring or persistent abdominal pain with or without steatorrhea (presence of excess fat in the feces, foul-smelling stools that float because of high fat content) or diabetis mellitus.
Hallmark sign of pancreatitis
Severe upper abdominal pain, with radiation through to the back, is the hallmark of pancreatitis.
Liver Function Tests
Ammonia - NH3 Albumin - Alb Alkaline Phosphatase - ALP Immunoglobulins - Serum Electrophoresis Prothrombin time - PT Platelets - PLT Alanine Aminotransferase - ALT Asperate Aminotransferase - AST Gamma-glutamyl-Transpeptidease - GGT Billirubin - Indirect/direct Bili
The patient presenting with HHNK has a problem with
A. Sugar
B. Insulin
C. Overhydration
D. Ketoacidosis
A. Sugar Problem is usually higher levels of sugar (higher than DKA), high serum osmolarity, severe dehydration, lack of ketones, and acidosis. Patient with HHNK may also experience more severe and sudden neurologic changes than the patient with DKA.
The treatment of diabetes insipidus is
A. Aggressive fluid replacement and vasopressin
B. Restrict fluids and mannitol
C. Aggressive fluid replacement and Dilantin
D. Aggressive fluid replacement and octreotide
Aggressive fluid replacement and the administration of vasopressin (Pitressin). Vasopressin increases peripheral vascular resistance, which in turn increases arterial blood pressure. It plays a key role in the regulation of water, glucose, and salts in the blood.
Vasopressin MOA
Vasopressin is a peptide hormone which is synthesized by the hypothalamus and is stored in the pituitary gland. It controls the reabsorption of molecules in the tubules of the kidneys by affecting the tissue’s permeability. Vasopressin increases peripheral vascular resistance, which in turn increases arterial blood pressure. It plays a key role in the regulation of water, glucose, and salts in the blood.
Diabetes insipidus (DI) is _______ and is commonly caused by _____
A condition where the kidneys are able to conserve water; hence the phrase “peeing like a racehorse.” The most common cause is a deficiency of arginine vasopressin (AVP), also known as antidiuretic hormone (ADH)
Syndrome of inappropriate antidiuretic hormone (SIADH) is _______ and is commonly caused by _____
Occurs when excessive levels of antidiuretic hormones (arginine vasopressin, AVP) are produced, which causes the body to retain water. Common causes include heart failure, diseased or injured hypothalamus, certain cancers, such as lung cancer, brain tumors.
Symptoms of Diabetes Insipidus
Symptoms include excessive thirst and excretion of large amounts of severely diluted urine.
Symptoms of SIADH
Symptoms include weight gain, nausea, vomiting, altered mentation, irritability, and seizures.
Adrenal insufficiency, weight loss, hypotension—the patient may be experiencing
A. Addison’s disease
B. Thyrotoxicosis (Grave’s diease)
C. Myxedema coma
D. Cushing’s syndrome
A: Acute renal insufficiency, also known as Addison’s disease. Hypotension is common: caution with etomidate administration, Symptoms: fatigue and weight loss.
Myxedema coma is also known as
A. Thyroid storm
B. Adrenal insufficiency
C. Hypothyroidism
D. Hyperaldosteronism
C: Hypothyroidism Infection common cause; coarse hair, deep voice, thinning or loss of the outer third of the eyebrows (Queen Ann’s sign) Women > 60 years; occurs in the winter months Fatigue, weight gain
Tx for myxedema
Myxedema aka Hypothyroidism - Tx: Levothyroxine
Most common presentation of a patient with hypothyroidism are all of the following, except
A. Cold intolerance with coarse hair
B. Almost exclusively over the age of sixty
C. >90% of cases occur in the winter
D. Primarily in men
D: Hypothroidism occurs primarily in women, almost exclusively over the age of sixty, with 90% of the cases occurring in the winter months.
Drug of choice for profound hypotension in septic shock is
A. Isotonic crystalloid solution
B. Levophed
C. Nipride
D. Dobutamine
B: Levophed (norepinephrine) indication is mainly used to treat patients in vasodilatory shock states such as septic and neurogenic shock. Levophed functions as a peripheral vasoconstrictor (alpha-adrenergic action) and as an inotropic stimulator of the heart and dilator of coronary arteries (beta-adrenergic action).
You are managing a patient who has been diagnosed with hepatic encephalopathy. His ammonia levels are elevated. Your management in preparing this patient for transport is to inhibit elevated protein level by
A. Administering whole blood
B. Stop GI bleeding and evacuate bowel of blood
C. Aggressive fluid resuscitation
D. Aggressive pain control
B. Stop GI bleeding and evacuate bowel of blood Evacuation of gut-derived toxins (intestinal blood, bacteria) and administration of Lactulose (orally or as an enema) is one of the cornerstones of the treatment of hepatic encephalopathy.
Lactulose works by
Lactulose may be given orally to acidify the ammonia in the colon and form the ammonium that can be easily excreted. It is used as a laxative for evacuating blood from intestines and for reducing ammonia production by intestinal bacteria.
Grey Turner’s sign may indicate
A. Meningitis
B. Splenic injury
C. Pancreatitis
D. Gallbladder
Grey Turner’s sign refers to bruising of the flank areas. It can take up to twenty-four to forty-eight hours to appear, and it can predict a severe attack of acute pancreatitis. May also be accompanied by Cullen’s sign (periumbilical bruising) or Halstead’s sign (marbled abdomen), which then may be indicative of pancreatic necrosis with retroperitoneal or intra-abdominal bleeding.
Repeated doses of etomidate can cause
A. Increased ICP
B. Acute adrenal insufficiency
C. AMI
D. Pulmonary edema
B: Etomidate (Amidate), which is classified as a sedative-hypnotic can block the adrenal gland’s production of cortisol and other steroid hormones, possibly resulting in temporary adrenal gland failure. This may cause abnormal salt and water balance, lowered blood pressure, and, ultimately, shock.
A type of angina that can occur at rest, while sleeping, or after exercise is called
A. Silent
B. Prinzmetal’s
C. Stable
D. Unstable
B. Prinzmetal’s Can occur at rest, while sleeping, or after exercise
A clinical sign that indicates hypocalcemia may be present is
A. Kehr’s
B. Grey Turner’s
C. Chvostek’s
D. Brudzinski’s
C: Chvostek’s sign also known as the Weiss sign, is one of the signs of tetany seen in hypocalcemia. It refers to an abnormal reaction to the stimulation of the facial nerve.
Your patient presents upper body obesity with thin arms and legs. He has a rounded face “buffalo hump” and is complaining fatigue. He is hypertensive and hyperglycemic. What condition is he most likely presenting?
A. Myxedema coma
B. Thyroid storm
C. Addison’s disease
D. Cushing’s syndrome
D: Cushing’s syndrome.
Causes other than Pancreatitis of Grey Turner’s sign
Other causes of Grey Turner’s sign can include blunt abdominal trauma, ruptured abdominal aortic aneurysm, and ruptured/hemorrhagic ectopic pregnancy.
Patients with known Addison’s disease should not be given what sedative?
Patients with known Addison’s disease (acute renal insufficiency) should not be given etomidate. Etomidate can block the adrenal gland’s production of cortisol and other steroid hormones, possibly resulting in temporary adrenal gland failure.
Cullen’s sign may indicate
A. Meningitis
B. Pancreatitis
C. Gallbladder disease
D. Cardiac problem
B. Pancreatitis Periumbilical bruising, may indicate pancreatitis or intra-abdominal bleeding
Stable angina is defined as
Onset with physical exertion or emotional stress • Pain lasts 1-5 minutes • Pain is relieved by rest
Unstable angina is defined as
Stable angina that has changed in frequency, quality, duration, or intensity • Pain lasts longer than 10 minutes despite rest and NTG therapy
Variable angina is defined as
Spontaneous episodes of chest pain frequently noted at rest or on early rising • Circadian pattern • Relieved by NTG
Silent angina is defined as
Objective evidence of ischemia in asymptomatic patients
Mixed angina is defined as
Combination of stable and variant angina
Hemoglobin Test - Normal Range - High/Low
Normal Range 10-12 Low levels is called anemia, which can be caused by hemorrhage, lead poisoning, sickle cell anemia, suppression by chemotherapy agents and other causes. High levels: Dehydration can cause falsely high levels, which disappears once proper fluids have been administered. Or living at high altitudes and smoking.
Hematacrit Test - Normal Range - High/Low
Normal Range 36-52% High in COPD patients Low in dehydrated or hemorrhage.
Platelets Test - Normal Range - High/Low
Normal: 140K - 400K Low levels of < 100 is called thrombocytopenia, can be caused by infection with hepatitis C, chronic liver disease, infection with HIV, pregnancy (HELLP), chemotherapy, systemic lupus, chronic lymphocytic leukemia, treatment with certain medications such as heparin and quinidine, and aplastic anemia (blood disorder that causes the body to stop making enough new blood cells). Thrombocytosis - High levels of platelets. (Kawasakis Disease)
WBC Test - Normal Range - High/Low
Normal : 4.5-10.5 Increases with infection and is known as leukocytosis. A decrease is called leucopenia.
Sickle-cell disease (SCD) or sickle cell anemia is
a genetic blood disorder characterized by red blood cells that assume an abnormal, rigid sickle shape.
Vaso-occlusive crisis (painful crisis) is managed with
hydration, analgesics, and NSAIDs.
Diphenhydramine is often administered for itching associated with
opioid administration
A hemolytic crisis may require
blood transfusions.
Sodium labs: normal values & significant findings
Normal: 135-145 <120 can cause seizures, managed with slow IV administration of hypertonic saline. Recommended to be maintained at 155 for head injured/bleed patient to help reduce ICP.
Potassium labs: normal values & significant findings
Normal: 3.5-5.5 >7.0 can cause ventricular dysrhythmias, peaked/tented T waves >5 mm in height on the ECG.
Calcium labs: normal values & significant findings
Normal: 8.8-10.4 Chvostek’s and Trouseau’s sign.
Chloride labs: normal values & significant findings
Normal: 95-112
SaCO2 labs: normal values & significant findings
Normal 24-30 <20 may indicate dehydration; assess for acidosis
BUN labs: normal values & significant findings
Normal: 6-23 - Should be approx. 10-20x Creatinine level May indicate blood in the gut, dehydration, or renal failure. Should be approximately 10-20x Creatinine level
Creatinine labs: normal values & significant findings
Normal: 0.6-1.4 > 1.4 may indicate renal failure.
Serum OS labs: normal values & significant findings
Normal: 285-295 Maintain at <320 in head injured/bleed patients to reduce ICP and maintain adequate CPP. Serum OS can be decreased with the administration of mannitol, hypertonic saline, and furosemide.
Magnesium labs: normal values & significant findings
Normal: 1.5-2.5 Levels of 4-8 are indicated to prevent seizures in the pre-eclamptic pregnant patient. Levels >10 can be toxic and may require the administration of calcium.
Ammonia labs: normal values & significant findings
Normal: Adult: 14-45 Pediatrics: 40-80 Increases in Reye’s syndrome, hepatic encephalopathy.
Anasarca
Also known as “extreme generalized edema” is a medical condition characterised by widespread swelling of the skin due to effusion of fluid into the extracellular space. It is usually caused by either congestive cardiac failure, liver failure (cirrhosis of the liver), or renal failure/disease.
Ascites
is an accumulation of fluid in the peritoneal cavity.
Whipple’s Triad
Is a collection of three criteria that suggest a patient’s symptoms result from hypoglycemia.
Wellen’s syndrome
Is associated with critical stenosis of the proximal LAD and impending infarct. V2-V3 segment turns down into a negative T wave at a 60-96-degree angle.
Acute arterial occlusion is S&S’s
Sudden interruption of blood flow o Pain o Pallor o Pulselessness—distally o Parethesias—burning o Cool extremity
