Pages 11-20 Flashcards
Critical decisions and interventions in pneumonia?
- Appropriate room w/ standard and droplet precautions.
- Full set of vital signs w/ pulse ox
- Supplemental oxygen for hypoxic patients.
- Evaluate mental status and ability to protect airway
- If hypotensive: 2 IVs should be established
- Normal saline or lactated ringers
- Should hypotension not respond to fluids, pressors - Antibiotics once diagnosis made
- Early administration improves outcomes - IVF
- O2
Diagnostic testing for pneumonia?
- CXR: may not show early in illness
- If H/P strongly suggest, absence of infiltrate doesn’t prevent the diagnosis and treatment. - ABG: not needed for most patients
- Useful when considering intubation - Sputum evaluation: sensitivity is around 50%
What can lateral CXR show in pneumonia?
Infiltrate in a retrocardiac location
When are Lobar infiltrates seen?
Bacterial infections
When are Interstitial patterns seen?
Pneumocystis carinii and Mycoplasma
When are Cavitary lesions seen?
TB or fungal infection
When are Pulmonary abscesses seen?
Staphylococcus or Klebsiella
Bad prognostic signs for pneumonia in ABG?
Respiratory acidosis with elevation of pCO2 worrisome for impending respiratory failure
Sign of good sputum sample in pnuemonia
Less than 10 squamous cells per HPF and greater than 25 WBC per HPF
Abx for CAP?
- Doxycycline
- Macrolides
- Sulfonamides
- Fluoroquinolones
Abx for Aspiration pneumonia?
- Ampicillin/sulbactam
- Piperacillin/tazobactam
- Clindamycin + aminoglycoside
Abx for Nosocomial pnuemonia?
- Antipseudomonal B-Lactam Plus:
a. Piperacillin/ tazobactam
b. Imipenem
c. Meropenem
d. Cefepime or Ceftazidime - Anti-MRSA agent:
a. Vancomycin
b. Linezolid
Abx for pneumonia in kids?
- Amoxicillin
2. Macrolides
Curb 65 Criteria?
One point for each:
- Confusion
- Urea greater than 19
- Respiratory rate over 30
- SBP under 90 or DBP under 60
- Age over 65
Curb 65 recs?
0-1: Treat as an outpatient
2-3: short stay or watch as outpatient
4-5: Hospitalization, maybe ICU
When do asthmatics need rapid tube intubation?
Severe respiratory distress AND one of the following:
- Albuterol or other therapies do not reverse symptoms
- Significant hypoxia even with O2
- Too tired to breathe on own
How often do asthmatics need airway management?
Acute asthma requires airway management in less than 1% of patients
How is O2 administered in acute asthma?
Usually administered w/ aerosolized B2-adrenergic bronchodilator at 6-8 L / min in a nasal cannula (mild exacerbations) or a non-rebreather (severe exacerbations)
Goal of O2 therapy in acute asthma?
SpO2 more than 92%
Management severe acute asthma exacerbation that is not improving with aerosolized albuterol?
1a. Subcutaneous epinephrine 0.2 mg
or
1b. Terbutaline 0.25 mg
2. Corticosteroids oral or IV: onset 4-6 hours
Negative side effects of epinephrine?
B1 and a-effects which can lead to tachycardia or myocardial ischemia
What is the best predictor of result in acute asthma exacerbation?
Results at 1 hour after initiation of treatment of PFTs and peak flow
How often can nebulized albuterol be used?
Every 20 minutes for up to 3 dose
- Higher doses of a continuous albuterol via a nebulizer is not necessarily more effective than repeated lower doses, but is frequently used in patients with severe exacerbations or when the patient does not respond to the initial 3 doses
What is Ipratropium and when is it used? Best route?
Anticholinergic agent used in severe asthma or Beta-blocker induced asthma
- There is evidence that combining it with a β2-adrenergic agonists may provide additional benefit compared to a β2-adrenergic agonists alone
- IM faster and more consistent delivery than SC
Can theophylline be used in acute asthma exacerbation?
Not recommended in acute asthma
Is there evidence for use of Non-invasive positive pressure ventilation (NPPV) in acute asthma?
- Provides inspiratory assistance as well as PEEP
- Enhances patient breathing in acute respiratory conditions by providing rest in patients w/ significant work of breathing and early fatigue
- Use in COPD and CHF patients has been well established
- Use in acute asthma has been studied and is promising, but needs further evidence
Goal before discharge in acute asthmatic?
To obtain more than 70 percent predicted or personal best FEV1 or PEFR
Describe the treatment of COPD exacerbation?
- Oxygen: to all hypoxic patients w/ suspected COPD
- Use Venturi mask NC
- Avoid use of a non-rebreather mask with 15 L/min of oxygen, unless not responding to lower flow rates
- In patients w/ chronic CO2 retention, may cause respiratory depression w/ the rapid rise in O2 depressing central ventilatory drive
Next step after O2 in COPD exacerbation?
1a. Albuterol : bronchodilators provide most rapid response
- Even after multiple doses a response may occur
- No role for long acting B-agonists (salmeterol)
or
1b) Ipratropium bromide: given every 4 hours
- Combination therapy is not superior
Use of steroids in COPD exacerbation? Difference in treatment course from asthma?
- IV steroid such as methylprednisolone or prednisone orally should be started in the ED to help treat inflammatory component
- Typical regimens are 10-14 days with tapering doses in contrast to 5 day pulse therapy w/ asthma
When to use antibiotics in COPD exacerbation?
Used if signs of infection are present AND in patients with moderate to severe exacerbations
Next step in COPD if not responding to pharm?
NPPV by facemask aids oxygen delivery and decreases work of breathing
- Start early before acute neurologic deterioration or respiratory depression
- Respiratory therapist is invaluable in mgmt
Ventilator settings in COPD exacerbation?
- TV of 4-5 ml / kg of ideal body weight
- Initial flow is typically 50-100%
- Initial mode is typically assist control with a fixed number of ventilations being delivered even if the patient is paralyzed or taking insufficient breaths per minute
How to handle elevated peak pressures in COPD intubation?
Can become increased due to a stacking phenomenon
- Relieve by disconnecting ET and then start w/ a more prolonged expiratory phase or decreasing minute ventilation
When are primary pneumothorax secondary pneumothorax commonly seen?
- Primary: patients w/ no underlying pulmonary disease - Most common in thin, young males with history of tobacco use
- Secondary: patients with underlying pulmonary disease
Presentation of pneumothorax?
- Sudden onset of sharp chest pain, often unilateral
- SOB: often increases over time as pneumothorax grows
- Cough
- Occasionally pain more prominent in back/shoulder
- Tachycardia/tachypnea and
- Hypoxia
- Hypotension
Most common procedures to cause a pneumothorax?
- Central line
- Thoracentesis
- Pacemaker
- Tracheostomy
- Biopsy
- CPR
- PPV
Rx tension pneumothorax?
Needle decompression in the 2nd intercostal space at midclavicular line
- If successful, a chest tube should be placed as needle decompression is only temporizing
- Converts tension pneumothorax to simple pneumothorax
Definition of Large pneumothorax and Rx?
Greater than 20%
- Chest tube is usually indicated
Abx for open fracture?
Cefazolin
When to use MRI in orthopedic complaint?
Objective weakness NOT related to pain, loss of bladder fxn, or suspicion for epidural abscess
What is nursemaids elbow and rx?
Elbow Held adducted, semiflexed, prone
- Radial head displaced from annular ligament
- Hyperpronation reduction works best
Risk factors for septic joint?
- IV drug use
- EtOH
- DM
- Skin infection
- HIV
- Immunocompromisation
- Arthritis
- Joint infection or replacement.
Diagnosis septic joint?
Aspiration:
- Synovial lactate > 10mmol/L
- Synovial WBC 50,000
Coverage and ABX in septic joint?
Cover staff and Neisseria
- Combination of pen / ent or a later-gen cephalosporin
Rx scaphoid injury?
Thumb spica immobilization
Vascular source of scaphoid
Radial artery
What is NEXUS criteria and what is it used for?
To determine if cervical imaging needed in blunt trauma:
1) NO TENDERNESS at posterior midline
2) No focal neuro def
3) Normal level of alertness
4) No intoxication
5) No distracting injury
Ottawa Knee rules?
- Age>55
- Pain at patella or head of fibula
- Inability to take 4 steps
- Inability to flex to 90 degrees
Ottawa Ankle rules?
- Pain at Posterior edge of Med/Lat Malleoli
- Base of 5th Metatarsal
- Medial aspect of Navicular
OR - Inability to bear weight for 4 steps
Signs and symptoms of compartment syndrome?
Pain, paresthesias, pallor, poikilothermia, pulselessness. Can occur anywhere where swelling can occlude blood supply
How to cast foot / ankle injury?
- Immobilize joints above and below
- NON-Circumferential allows for swelling
- UNDER PADDING→PLASTER→ACE.
- Repeat neurovascular exam.
When to use SPICA bracing?
- Scaphoid injuries
- Lunate injuries
- First metacarpal fractures
- Injury to ulnar collateral ligament
- De Quervain tenosynovitis
How to place thumb SPICA?
Distal to IP joint of thumb
- Proximal along distal 2/3 of radial forearm
- Position wrist / hand neutral, extend wrist 20 degrees, abduct thumb (wine glass)
What is a sugar tong and how to use?
Distal ulnar/radius fracture: MCP palmar around elbow to MCP dorsally
How to mold elbow?
Elbow 90 degrees, wrist and hand neutral, wrist extends to 20 degrees, Abduct thumb
Differential of AMS?
"AEIOU TIPS" Alcohol Epilepsy/Electrolytes/Encephalopathy Insulin Opiates/Oxygen (lack there of) Uremia Trauma/Temp Infections Poisons/Psychogenic Shock, Stroke, SAH, Space-Occupying Lesions
What is the AVPU scale?
A=alert
V=responds to verbal stimuli
P=responds to painful stimuli
U=unresponsive
Decreased level of consciousness with cranial nerve findings is what, until proven otherwise?
Brainstem lesion
What does petechiae with AMS make you think of?
Meningococcemia
Workup for AMS?
- Rapid glucose
- CMP
- ABG or VBG
- Thyroid function tests
- Ammonia level
- Serum cortisol level
Rx for hypertensive encephalopathy?
- Nitroprusside
- Labetalol
- Lenoldepam
Rx metastatic CNS lesions with vasogenic edema?
Glucocorticoids
Rx Wernicke’s encephalopathy?
Thiamine
Diagnosis of acute stroke?
Often relies solely on H/P as CT images often do not show acute infarct for 6-72 hours after the interruption of flow
Inclusion criteria for thrombolytics in acute stroke?
- Ischemic stroke w/ measurable defect on stroke scale
- Time of onset less than 3 hours ago
- Over 18 years old
Exclusion criteria for thrombolytics in acute stroke?
- Intracranial hemorrhage on CT
- Clinical picture of subarachnoid
- Known AVM or aneurysm
- Prior intracranial bleed
- Active internal bleeding
- Plt<10k, PT>15s, INR>1.7, on blood thinners
- BP>185/110
- Brain surgery in past 3 m
- Major surgery within 2 weeks
- Pregnant
- Post-MI pericarditis
BP Mgmt in acute stroke?
Patient’s generally autoregulate cerebral perfusion pressure = antihypertensive agents should be withheld unless MAP greater than 120 or systolic greater than 220 - - Patients who receive thrombolytics, blood pressure should be treated if the systolic blood pressure exceeds 180 or the diastolic blood pressure exceeds 105 to reduce the risk of hemorrhage.
Use of antiplatelette therapy and stroke?
- Aspirin proven useful in preventing recurrent stroke or stroke after TIA
- Recommended within 48 hours of onset of symptoms
- Delayed at least 24 hours if received thrombolytics
Presentation of meningitis?
Classic triad: (present in less than 1/2 adult patients) 1. Fever 2. Neck stiffness 3. AMS Others: 1. HA 2. Neck pain 3. N/V
Meningitis presentation in kids?
- Lethargy
- Irritability
- Poor feeding
- Rash
- Bulging fontanel
- Hypothermia
- Kernig’s sign: flexing hip and extending knee elicits pain in the back and legs
- Brudzinski’s sign: passive neck flexion elicits involuntary hip flexion
What is Kernig’s sign?
Flexing hip and extending knee elicits pain in the back and legs
What is Brudzinski’s sign?
Passive neck flexion elicits involuntary hip flexion
Diagnosis meningitis?
Prompt LP is diagnostic procedure of choice
When to do CT before TP in meningitis?
- AMS
- New onset seizures
- Immunocompromised
- Focal neurologic signs
- Papilledema
CSF findings suggestive of bacterial meningitis?
- Positive Gram’s stain w/ identified organism
- Glucose less than 40 mg/dL
- Ratio of CSF/blood glucose less than 0.40
- Protein greater than 200 mg/dL
- WBC greater than 1000/mL
- Greater than 80% polymorphonuclear neutrophils
- Elevated opening pressure of CSF during LP