Orientation Review Flashcards
Narcan
Best for pt with pinpoint pupils (not reliable), low RR, stigmata of narcotic use. Give 2mg to adult or child. Not in a helicopter or if intubated. SE vomiting, reports of HTN, pulmonary edema
OPENING GAMBIT
- O2 2. O2 Sats 3. IV access 4. ECG monitoring 5. 12-lead EKG, +/- portable CXR
PINPOINT PUPILS
opioid OD, pontine hemorrhage, cholingeric OD, organophsophage
narcan dose for ROCLAVAX
10mg
glucose dose for infant
D10 at 10cc/kg
glucose dose for child
D25 at 4cc/kg
glucose dose for adult
D50, give 50cc (1amp)=25g
5 patients who need thiamine
- The cachectic calorie malnourished 2. disheveled alcoholic 3. malabsorption syndromes (short gut, gastric bypass, etc) 4. hyperemesis gravidarum 5. anorexia nervosa
Wernicke’s Triad
- encephalopathic 2. ataxic 3. lateral rectus palsy/nystagmus
Mneumonic for things that narcan can reverse. Name them
ROC-LAVA-X reserpine, opiates, clonidine, lomotil, ACEi/ARBs, valproate, aldomet (methyldopa), xanaflex (tizanadine, like soma)
Causes of hypoglycemia
All hypoglycemics need it Re-ExPLAAAINeD Renal failure: insulinase in kidney. If little blood getting through, insulin not getting metabolized Exogenous insulin or oral hypoglycemics Pituitary insufficiency Liver disease: hepatitis, hepatoma, tylenol OD, etc Adrenal failure; Alcohol ingestion (esp in children); Aspirin toxicity Infection (sepsis UPO in children); Insulinoma Neoplasm: insulinoma, malnutrition, loss stores Drugs: ASA, oral agents, beta-blockers (block sympathetic outflow)
Sulfonylurea overdose rx
octreotide-suppresses endogenous insulin secretion
glucagon side effets
bad nausea and vomiting, rebound hypoglycemia
How much does 1 amp D50 raise blood glucose?
200
What if D50 doesn’t raise BGL?
think insulin or oral hypoglycemic OD
How to make epi drip?
1mg epi in 1L of NS → 1mg/cc; piggy back into high flow IV with NS wide open Start at 1cc/min for 1µg/min. If no response @ 1-2 minutes → Increase to 2cc/min or 2µg/min
Parkland formula
4cc/kg x BSA Burned; 1st ½ in the 1st 8 hours since burn; 2nd ½ in the next 16 hours (this is in addition to maintenance IVF!)
Rule of 15
[Bicarb + 15] = expected PCO2 = expected last two digits of the pH
Delta Gap
compare the (gap – 14) to the (bicarb – 24). Should be equal and in opposite direction for a single metabolic disturbance
Osmoles and alcohols
346: Multiply osmolar gap x 3 for methanol mg %, x4 for ethanol, and x6 for isopropyl alcohol.
GAP ACIDOSIS and a RESPIRATORY ALKALOSIS
SEPSIS with hyperventilationrule out ASA toxicityrule out Bleeding, and breathing hard due to pain Alcohol withdrawal; a keto-acidosis with tachypnea
Anion-gap acidosis differential
MUDPILES Methanol Uremia DKA and other ketoacidoses paraldehyde isoniazid, iron lactic acidosis ethylene glycol salicylates
Two types lactic acidosis
Type A = hypoxic tissue makes lactate (hypoperfusion, Carbon Monoxide, Cyanide, Methemoglobinemia) Type B = impaired lactate clearance (Iron, INH toxicity, Methanol, Salicylates, diabetes, sepsis, liver damage, alcoholism, Metformin, genetic)
Non-anion gap acidosis
HAARD UPS Hyperventilation—chronic Adrenal insufficiency Acetazolamide Renal Tubular Acidosis Diarrhea Uretero-enteric diversion Pancreatic fistula Saline over-infusion in diarrhea
Treatment symptomatic hypoglycemia
1) 1 amp D50 2) Ask about DRUGS (short or long-acting insulin, sulfonylurea) and SUICIDALITY 3. GLUCAGON stimulates glycogenolysis/gluconeogenesis (!! N/V, rebound HYPOglycemia!!) 4. OCTREOTIDE for type-II diabetic or sulfonylurea OD, will suppress native insulin secretion 5. Watch the K+!!
Treatment thyrotoxicosis
(1) Dexamethasone (2) Propranolol (3) PTU (4) Oral potassium-iodide
Causes of hyperK
1) NOT – hemolyzed sample 2) Renal Failure 3) Acidosis 4) Adrenal insufficiency 5) Cell Breakdown—Rhabdo, Post-Ictal, Tumor Lysis
The 5 causes of Sine Wave on EKG and Their Treatments:
1) HyperK → Calcium Choloride 2) TCA overdose → NaBicarb 3) Beta-blocker overdose → glucagon, insulin, calcium 4) CaChannel blocker overdose → calcium, insulin 5) Severe Acidosis → NaBicarb
HyperK treatment
- CaCl 10cc, max at 2 amps. This is for the wide QRS, stabilizes membranes 2. 10U Regular Insulin IV + 2amps D50 3. Albuterol or other Beta-Agonist 4. NaBicarb if acidotic 5. IV Fluids, especially in DKA, rhabdo, tumor lysis, adrenal insufficiency
1 U of insulin moves how much glucose into cell?
4g
The 5 EKG findings of Hypokalemia:
(1) Flat T (2) U wave (3) LONG QT (4) Non specific ST Wave changes (5) V-tach or Torsades
The 5+ causes of HypOKALemia:
(1) Insulin; (2) Alkalosis; (3) Albuterol, beta agonists; (4) Renal—diuretics, hyperaldosteronism; (5) GI—vomiting, diarrhea, fistula, pancreatic/biliary losses; (6) HypOMagnesemia (hypokalemia is a better indicator than the actual Mg level!)
When to give hypertonic saline in hyponatremia?
seizure, coma
How much hypertonic saline to give in hyponatremia with seizures?
100cc over 10minutes, then drip 100cc over 1 hour
Hyponatremia: sodium correction goals
Raise Na by 2-3mEq acutely. (Then, no more than 0.5mEq per hour or 12mEq per day)
The 5 causes of DKA
(1) Insulin lack (2) Indiscretion with sugar (3) Infection (4) Ischemia–brain, heart, bowel (5) Infant on board
DKA Treatment
The 5 treatments for DKA: 1. Fluid: 1L bolus, then 500cc/hr for 4 hours (too much = CEREBRAL EDEMA!) 2. Insulin: load 0.1 unit/kg IV -then- maintain 0.1 unit/kg/hr IV (subQ when Gap is closed), GIVE HOME DOSE LONG ACTING INSULIN 3. Potassium – If K > 5.1, recheck in 1 hour. If K
When to add glucose in DKA?
-When blood glucose drops to about ~250, SLOW the insulin, ADD DEXTROSE.
When to add potassium in DKA treatment?
When K at 4.0
Treatment of AKA:
- Hydrate (NS or D5NS) 2. Provide carbohydrate (sandwich) 3. Replete vitamins and minerals (banana bag) 4. Give K and magnesium (banana bag) 5. Treat underlying cause: pancreatitis, CNS, sepsis, pna, gi bleed, etc.
Hypercalcemia
- NS (125-250cc/hr) to trade saline in, calcium out. 2. Lasix to insure good urine output. 3. Bisphosphonate (on admission).
5 causes of Altered Mental Status:
- Vital Sign Abnormalitieshypoxia, hypercarbia, hypoperfusion, hypertensive encephalopathy, severe fever or hypothermia; 2. Toxic/Metabolic Hypoglycemia, high or low Sodium (not K), Acidosis/Alkalosis, Uremia, Hepatic encephalopathy, any drug or poison 3. Structural brain lesion—mass, bleed, demyelination 4. CNS infection—encephalitis, 5. Psychiatric causes, Dementia
Wrenn’s seizure distinguishing characteristics
- Post-Ictal State—confusion, paralysis, sore muscles, fatigue for hours 2. Amnestic during sz—will not recall a “lightheaded” feeling 3. Post-Ictal State—confusion, paralysis, sore muscles, fatigue for hours 4. Fell so hard there was trauma—head or tongue lac, as opposed to slumping or swooning 5. History of true seizure
Positive orthostatics
Systolic drop >20, Diastolic >5, or HR rises by 20 in 1 minute of standing
syncope workup
H&P, orthostatics, vital signs, ECG, CBC (anemia), electrolytes, BGL
San Fransisco syncope rules: admit if patient has any of the following
(a) history of CHF; (b) shortness of breath; (c) SBP < 30
3 major categories for syncope causes
(1) Cardiovascular MI; PE; Tamponade; Arrhythmia (bradycardia most common); Aortic Stenosis (chest pain, short of breath, syncope); HOCM (syncope following exertion!!); Hypovolemia; autonomic dysfunction; carotid sinus hypersensitivity (turning head or neck surgery); pulmonary hypertension; **Brugada syndrome (2) Neurologic *Vertebrobasilar insufficiency/Subclavian Steal ; increased ICP (4) Neurovascular or metabolic Vaso-vagal syncope; Hypoglycemia
Vertebrobasilar insuffiency-symptoms?
(5D’s—Drop attack, Dizzy, Dysarthria, Dysphagia, Diplopia)
Brugada Syndrome ECG findings
triad of (1) Saddle-shaped ST elevation in V1-3; (2) RBBB; (3) T-wave inversion.
Seizures-5 causes
(1) vital sign abnormality—hypoxia, hypoperfusion, HTN emergency, Febrile (2) toxic/metabolic—hypoglycemia, hyponatremia, alcohol withdrawal, (3) structural brain lesion—mass, blood (4) CNS infection—herpes encephalitis (5)underlying seizure disorder, off of meds
vital sign abnormalities with seizure
hyperthermia, tachycardia (later bradycardia), hypoxia (and acidosis)
5 treatments of status seizures
- ABC/NGT-turn on side (if not intubated!), protect, give O2, check sats, check GLUCOSE, narcan 2. Benzo-(ativan 1-2mg up to 6-8, IM too) 3. Consider causes with specific antidotes-if pregnant, give Mg 6 grams 4. Keppra 1g load, or phosphenytoin 20mg/kg @100-150mg/min 5. barbiturates (if you can manage airway)
Phenytoin vs. fosphenytoin
*Phenytoin (the original) is slower, can cause hypotension, long QRS and Stevens Johnson’s syndrome *Phosphenytoin is dosed the same but pushed faster, can cause asystole!
Alcoholic having seizure-what other diagnostic test to get?
CT
5 causes of seizures that need more than benzos
- hypoxia-O2 2. hypoglycemia-D50 3. hyponatremia-hypertonic saline 4. ecclampsia-Mg 5. INH toxicity-B6 *SAH and herpes encephalitis can cause sz refractory to benzos
Bell’s palsy treatment
prednisone valtrex eye lube, tape shut at night, protect in wind
Discriminating HA features that are very worrisome
(1) WHOML, first migraine, sudden onset or syncopeSAH until proven otherwise (2) Coagulopathy— 1. heparin/coumadin/plavix; 2. dialysis (cyclical brain swelling/shrinking); 3. uremic (bad platelets); 4. liver dz (low Factor VII); 5. hemophiliac (3) Cancer or HIV—mass lesion (4)Trauma, even a few weeks ago—old SDH in elderly fall patient; older than 50 (5)Fever, stiff neck, altered mental status, focal neuro complaints/deficits
To do LP without head CT:
(1) non-focal exam; (2) normal mental status; (3) normal eyes including DISCs; (4) young and otherwise healthy. This never happens, and meningitis patients need antibiotics in 30 minutes, so… Blood Cx (50% will tell you the bug)Antibiotics (no change in cells, protein, glucose, or even gram stain in 4 hours)CTLP
Empiric tx of bacterial meningitis:
(1) Caffeine 250mg IV over 30 min (2) IV fluids (3) Caffeinated soda, 2 liters per day (4)Blood patch
The 5 treatments of Migraine:
- Compazine 10mg (or Reglan, Phenergan, Thorazine, Droperidol—longQT!); 2. Benadryl 25mg 3. DHErgotamine-45 (not in old or pregnant) 4 .Morphine 5. Home on high dose Motrin
5 treatments of cluster headache
- 100% O2 2. Intranasal Lidocaine 4% on soaked gauze; 3. Proparicaine in affected eye 4. Migraine remedies 5. Home on 2 weeks Prednisone 40-60mg with taper
Management of TIA/Acute Stroke
ABCs—prevention by keeping NPO N/G/T—check for hypoglycemia Activate Stroke Team Stat head CT Thrombolytics within 3 hours of symptoms
Special studies for TIA
(1) Carotid duplex; (2) MRI/MRA; (3) TEE
Send ?stroke/?TIA pts home on
Send home on: (1) ASA; (2) Plavix if already on ASA; (3) heparin/coumadin if already on plavix