PGY 1 - Misc Flashcards

1
Q

SIRS Criteria

A
  1. Temp: > 38 (100.4), < 36 (96.8)
  2. HR > 90
  3. Resp: RR > 20 or PaCO2 < 32
  4. WBC: > 12k, < 4K, >10% bands
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2
Q

AMS FFM

A
  • ASAP: ABCs, IV, O2, monitor/EKG, accu✓, VS w rectal temp, C-collar if ?, ± RSI/ETT, full primary survey.
    • If accu✓ < 80… give 1 amp D50 IV
    • If malnourished… Thiamine 100mg IV
    • If drugs… Narcan 0.4-2mg IV/IM
    • If ↓BP… IV fluid bolus x 2
  • Hx: Pt, family bystanders, EMS, medical records, meds, SAMPLE hx
  • Exam:review VS, reassess life threats, evidence of trauma or toxidromes, GCS, pupils/papilledema
  • Labs: VBG w co-ox, CBC, BUN/Cr, lytes, gluc, LFT, lipase, coags, EtOH, NH3, lactate, TSH, T&C/S, ASA, APAP, drug levels, UA, hCG, UDS. CSF: cell counts, GS/Cx, prot/gluc, ±HSV PCR, ± crypto antigen Rads:CXR, ± FAST, CT head non-con(before LP!)
  • Tx:supportive, guided by clinical picture
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3
Q

Multi Ingestion FFM

A
  • ASAP: ABCs, IVs, O2, monitor, VS, accu✓, EKG.
    • Intubate PRN but may try Narcan first
  • Hx: meds/drugs/chemicals, timing, amount, intentional vs accidental, N/V, meds @ home, SAMPLE hx
  • Exam: pupils/nystagmus, GCS, gross neuro, szs, CV/pulm, pulses, skin, smells, toxidromes?
  • Labs: APAP, ASA, EtOH, CBC, BUN/Cr, lytes, gluc, LFTs, coags, osmolality, VBG, UA, UDS, hCG; levels of any known drug ingested
  • Rads: CXR, KUB
  • Treatment:
    • Supportive care always
    • If recent (<1-2 hrs) PO ingestion…
      • AC 1gm/kg PO/NG/OG
        • Ineffective for EtOH, hydrocarbons, acid/alk, iron, lithium
        • Pt must protect AW or intubate, give antiemetic.
      • If malnourished or EtOH….
        • D50 1 amp IV
        • Thiamine 100mg IV
        • Mg 2 gm IV
      • If sustained rel, iron, or body packer
        • WBI w Golytely 500-2000 ml/hr via NGT til clear rectal effluent
      • If known ingestion…use specific Antidote if available
      • If in doubt (scared)….call Poison Control 1-800-222-1222
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4
Q
  • ActiChar
    • When
    • Doesn’t work for:
    • Considerations
A
  • Within 1-2 hours
  • “CHARCOAL”
    • Caustic/Corrosive
    • Heavy Metals
    • Alcohols/glycols
    • Rapidly absorbed substances
    • Cyanide
    • Other insoluble drugs
    • Aliphatic hydrocarbons
    • Laxitives
  • Must protect airway, give antiemetics
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5
Q

CP FFM

A
  • ASAP: ABCs, 2 LB IVs, O2, monitor, VS, EKG w/in 10 min
  • Hx: pain OPQRST, CAD risks (> 50 yo, HTN, DM, HL, FHx, smoking, cocaine), PE risks (recent surg/immob, estrogen meds/preg, cancer, prior clot), CV and pulm path, SAMPLE hx
  • Exam: JVD, trachea ML, M/R/G, W/R/C, decr BS, ttp, AAA, mass, hemoccult, edema, pulses, DVT, clubbing, diaphoresis, cyanosis,pallor
  • Labs: CBC, BUN/Cr, lytes, gluc, Trop/CK/MB, ± BNP, ± coags, ± d-dimer
  • Rads: CXR, ± Echo, ± CT
  • Add’l studies: serial ECGs, BLBP
  • Life threats:
    • Arrhythmia: meds vs Shock
    • Hypotension: IVF, Dopamine 2-10 mcg/kg/min or Norepinephrine 2-10 mcg/min IV, ± IABP/ cath
    • Pulm edema (CHF): BiPAP, NTG 20-80 mcg/min IV or NTP 0.25-10 mcg/kg/min IV, Lasix 20-80 mg IV, Dobutamine 2-10 mcg/kg/min IV (if low EF & SBP >100)
    • STEMI: ASA 4 x 81 mg, Heparin 60u/kg IV then 12u/kg/hr IV (max 4000, 1000) or Lovenox 1mg/kg SC.
      • Ask Cards: Plavix & GPIIb/IIIa?
      • Adjuncts: O2, NTG, Metoprolol 5mg IV q 5 m x 3.
    • Aortic Dissection: 2 LB IVs, T+C 4u PRBCs, Call CT/vasc or transfer.
      • Goal HR 60-80: Esmolol 500 mcg/kg IV then 50-200 mcg/kg/min or Labetalol 0.25-1 mg/kg IV double q 10min (max 300mg total) then 1-2mg/min.
      • Goal SBP 100-120: NTP.
    • PE:
      • Heparin 80u/kg then 18u/kg/hr or Lovenox 1mg/kg SQ. Consider Lytics if in shock, severe resp distress, hypoxic, or RV dysfxn on echo.
    • Tamponade:
      • 2 LB IV, ± Pericardiocentesis, CT surg
    • Tension PTX: off vent, Needle D, chest tube
    • Boerhaave’s: IVF, Zosyn 3.375 gm IV, Gentamicin 7mg/kg IV, CT/gen surg consult
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6
Q

GIB FFM

A
  • ASAP: ABCs, 2 LB IV and bolus, O2, monitor, EKG
  • Hx: BRB PO vs PR vs melena, cirrhosis, liver failure, varicies, EtOH, PUD, ASA, NSAIDs, prior bleed anticoag use (why?), coagulopathy, recent endoscopy, abd surgery, trauma, diverticulosis; SAMPLE hx
  • Exam: perfusion, liver stigmata (jaundice, asterixis, caput medusae, hepatomegaly, ascites), rectal/ hemoccult, ± anoscopy
  • Labs: T&C, CBC, BUN/Cr, lytes, gluc, Trop/CK/MB, LFTs, coags, UA, ± lipase, ± ammonia; CXR, fibrinogen
  • Treatment:
    • If shock… 2-6 u O neg or typed PRBCs, FFP 10-15 ml/kg (if coagulopathy), and PLT 1 u (if ASA or plt <50k)
    • Reverse bleeding disorders:
      • Vit K if INR high- 10 mg IV
      • DDAVP (0.4 mcg/kg IV over 10 minutes) if plt or renal disorder
    • If massive hematemesis… Intubate to protect airway; Slegstaken- Blakemore tube for rescue only
    • If Upper GI bleed…
      • Protonix 80 mg IV then 8 mg/hr for PUD
      • For varices:
        • Octreotide 50 mcg IV then 50 mcg/hr for varicies
      • If cirrhotic - Rocephin 1g IV (regardless of presence of varices)
    • Consults: Call GI (upper) or Surgery (lower), ± IR for tagged RBC scan vs embolization; ICU for admit.
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7
Q

DKA FFM

A
  • DKA
    • = DM (usually type 1) + ↑↑↑gluc + ↓insulin + ↑ketones.
    • DKA pts ∼100 ml/kg fluid depleted.
  • Causes
    • 6 I’s: Infection,insulin lack, Infarction, Indiscretion, Injury, IUP/puberty
    • +Trauma, surgery, endocrine diseases.
  • ASAP: ABCs, 2 LB IVs, O2, monitor, VS
  • Hx: polyuria, polydipsia, fatigue, N/V, abd pain, HA/AMS; prev DKA / EtOH / AKA; meds, SAMPLE hx
  • Physical: Dry, ↑HR, ↑RR (compensation for acidosis), Kussmaul resp (deep rapid breathing), lethargy, abd ttp, acetone odor
  • Labs: Accu✓, VBG w lytes, CBC, BUN/ Cr, gluc, Ca/Mg/Phos, ketones, lactate, lipase, LFTs, blood cx; UA w cx, hCG; CXR, ± EKG (for ↑K or ischemia)
  • Flowsheet: q 1 hr VS, BUN/Cr, lytes, strict I/Os; q 4 h Ca, Mg, Phos
  • Treatment :
    • Fluids: NS bolus, then NS 1-2 ml/kg/hr (or 20 mL/kg in peds)
      • Switch to D5Half once gluc < 250 mg/dl.
    • Insulin:0.1 u/kg/hr.
      • Change to SC insulin when AG closed, tol PO, and pH > 7.2 (2 hr overlap required).
        • Hold if K < 3.5
        • Do not drop gluc > 100 mg/dl/hr.
        • Electrolytes:
          • K+:
            • Add 20-40 mEq/L to IVF til K > 4.5 K (corr) =
            • Expect drop of 0.6 mEq per 0.1 pH of acidosis (hypo K = #1 cause of death) (insulin and correcting acidosis will shift K into cell)
            • Phos: replete if < 1.0
            • Na (corr) = add 1.6 per 100 of gluc > 200
        • If cerebral edema …
          • S/Sx: HA/AMS, N/V, papilledema, sz
          • Rads: Head CTTx:
          • Mannitol 1 g/kg IV, Intubate PRN
          • (CE risk fx: kids and severe lab abnormalities)
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8
Q

Seizure/Status IAI

A
  • ASAP: ABCs (NP airway/BVM), IV, O2, monitor, VS, accu✓ (if ↓BS give 1 amp D50), protect pt (? C-spine), intubate if
    hypoxia/aspiration
  • Hx / exam: onset, duration, precipitants, last sz, meds, compliance, PMHx (CVA, TIA, ICH, CA, arrhythmias), tox, pregnant, trauma;
  • PE: GCS, pupils, MSE, neuro, skin
  • Labs: CBC, BMP, Ca, Mg, LFTs, UA, hCG, UDS, coags, blood/urine cxs
  • Levels: EtOH, dilantin, tegretol, valproate, INH, theophylline
    Other: Head CT, EKG
  • Treatment:
    • Benzos x2
    • Phenytoin OR Phosphenytoin OR Keppra
    • Intubate - Propofol
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9
Q

Ativan for Sz

A

Lorazapam

0.1 mg/kg (4mg) q 5 min

Double for IM

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10
Q

Valium for Seizure

A

Diazepam

0.2 mg/kg (10 mg) q 5 min

Double for IM

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11
Q

Seizure Tx - No IV

A

Valium 0.5 mg/kg PR (max 10)

Versed (Midaz) 0.2 mg/kg

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12
Q

Benzo Options For Seizures

A
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13
Q

Seizure Treatable DDx:

A
  • Eclampsia: Mg 4g IV → delivery
  • EtOH/malnutrition: Thiamine 100 mg IV, Mg 2g IV
  • INH: Pyridoxine/B6 4gm IV
  • Meningitis: Rocephin 2g IV and Dex 10 mg IV
  • OD: AC 1g/kg via OG/NG p intubation
  • Hyperthermia: cool
  • Electrolytes: correct
  • Trauma: neurosurgery consult
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14
Q

Asthma ABG

A

PaO2 < 60

<42 - severe

Also severe if PEFR < 40%

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15
Q

Asthma Tx

A
  • Consider NIPPV early
  • HFNC 20-30 LPM
  • DuoNeb 5mg/0.5mg x 3 (1/2 if kids)
  • Continuous Albuterol Nebs
  • Solumedrol 125mg (2mg/kg) or Decadron 10mg (0.6 mg/kg)
  • Mag 2g (75 mg/kg)
  • Epinephrine IM
  • Terbutaline 0.5 mg SC q 20 min x 3
  • Heliox 80/20
  • Ketamine- 0.1 mg/kg → 0.5 mg/kg/hr for 3 hours
  • Intubate - allow hypercapnia, prolonged exp phase (I:E 1:4-8), minimal PEEP
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16
Q

Anaphylaxis FFM

A
  • Moderate Sx:
    • Epinephrine 0.3-0.5 mL IM (1:1,000), may repeat q 5 min prn (Peds = 0.01 mL/kg IM q 5 min prn)
  • Severe sx:
    • Push dose epi
    • Epi drip:
  • Local infiltration: 0.1-0.2 mL 1:1000 SC Epinephrine at rxn site
  • Nebulizer: 0.5ml of 2.25% Epinephrine sol in 2.5 ml NS (airway cart to bedside)
  • H1 blocker: Diphenhydramine
    • 50 mg PO/IV
    • Peds = 1 mg/kg PO/IV (max 300 mg/d)
  • DuoNebs
  • Steroids:
    • Solumedrol 125-250 mg IV (Peds = 40-80 mg IV)
    • Dexamethasone 10 mg PO/IV (Peds = 0.6mg/kg up to 10 mg)
  • H2 Blockers: Pepcid
  • Kitchen sink: for refractory ↓BP:
    • Glucagon 1-5 mg IV over 5 min, then 5-15 mcg/min drip (helpful in patients on B blockers- improves
  • inotropy by increasing cAMP)
17
Q

Heat Stroke cool until

A

102

18
Q

Hypothermia: No ACLS until…

A

30 celcius

19
Q

HyperKalemia

  • FFM
  • Tx
A
  • ASAP:ABCs, IV x 2, O2, monitor, VS, EKG
  • If wide QRS… Calcium (not with dig tox)
    • CaCl (CVL) 10% 10mL- IV push (3 times more Ca)
    • CaGluc 1gm IV (10 mL of 10% sol) over 5
      • Peds = CaGluc 100 mg/kg, max 1 gm)
    • Do not give if dig toxic!
  • Drive K into cells:
    • Insulin and glucose :
      • 10 units IV push
      • 25-40 gm D50 (1-2 amps)
    • Albuterol 5mg cont nebs x 30 min (Peds = 2.5mg cont Albuterol nebs)
  • Remove K:
    • Lasix: 40-80 mg IV, (peds = 1 mg/kg IV)
    • Kayexalate = BS
  • If renal failure… Dialysis, nephro consult
20
Q

Increased ICP IAI

A
  • CPP= MAP - ICP
  • ASAP: ABCs, IV, O2, monitor, VS
  • Tx:
  • Elevate head of bed 30 degrees
  • Call Neurosurgery to discuss the following interventions…
  • Intubate
  • Fentanyl- 3 mcg/kg (if not hypotensive)
  • Hyperventilation to PCO2 26-30 mmHg (temporizing measure only)
  • Mannitol 1 gm/kg IV - Not shown to help
  • Hypertonic saline- 250 cc bolus q6hr prn goal Na 155
  • +/- Seizure PPx
  • +/- Steroids (Decadron)
  • If intracranial bleed… correct coagulopathy if present
21
Q

NEXUS Criteria

A
  • Focal neurologic deficit
  • Midline TTP
  • AMS
  • Intoxication
  • Distracting Injury

Avoid > 65yo

22
Q

Meningitis Tx Infants < 1 month

A

Amp + Gent

Decadron

23
Q

Meningitis/Encephalitis Tx - Kids/Adult

A

Vanc + Rocephin

Add Amp if >50 or immunocomp

Decadron

24
Q

STEMI Equivalents

A