PGY 1 - Misc COPY Flashcards
1
Q
SIRS Criteria
A
- Temp: > 38 (100.4), < 36 (96.8)
- HR > 90
- Resp: RR > 20 or PaCO2 < 32
- WBC: > 12k, < 4K, >10% bands
2
Q
AMS DDX (30)
A
- A -
- Alcohol: methanol, ethylene glycol, isopropyl, EtOH (AKA, Wernicke’s, DTs)
- Ammonia: liver failure, Reye’s Arterial Gas Embolism,
- Acidosis
- E -
- Encephalopathy: HTN, hepatic Electrolyte: K, Na, Ca, Mg
- Endocrine: Thyroid, Adrenal
- Exposure: Hyper / hypothermia
- I -
- Insulin: Hypoglycemia, DKA, Hyperosmolar non-ketotic state
- O -
- Oxygen: MI, PE, CVA, COPD, hypoxia, O2 toxicity, hypercarbia
- U -
- Uremia: ARF, CRF
- T -
- Trauma: epidural, subdural, SAH, DAI, concussion, NAT
- Toxins: CO, CN, organophosphates, sympathomimetics, opiates, THC, NMS, benzos, ecstasy, GHB, LSD, PCP, serotonin syndrome,
- Tumor
- Thiamine deficiency
- Thyroid (storm or myxedema)
- I -
- Infection: meningitis, encephalitis, sepsis, UTI, CJD, endocarditis, toxoplasmosis, crypto, TB
- P -
- Psych: Delirium, dementia, psychosis
- S -
- Seizure
- Syncope
- Shock (many kinds)
3
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
4
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
- AC 1gm/kg PO/NG/OG
5
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
6
Q
CP DDX (20)
A
- Critical (all systems): MI, tamponade, PNA, PTX, PE, aortic dissection, Boerhaave’s
- Cardiac: angina (stable, unstable, Prinzmetal’s), cocaine, pericarditis, myocarditis, endocarditis, MVP, AS, hypertrophic CM, acute CHF
- Pulmonary: empyema, effusion, pleuritis, asthma, COPD, bronchitis, tracheitis, aspirated FB, CA
- Vasc: aneurysm, SC crisis, acute chest syndrome, arthritis
- MSK: rib fx / contusion, sternal fx, septic SC joint or disloc, costochondritis, arthritis, pec rupture, muscle strain, trauma, thoracic DDD
- Esophageal: Mallory-Weiss tear, GERD, spasm, FB, food impaction, CA
- GI: hiatal hernia, diaphragm rupture, PUD, perforated viscus, hepatitis, cholecystitis, biliary colic, pancreatitis, FHC, splenic infarct / distention
- Breast: mastitis, CA, engorgement
- Neuropathic: zoster, radiculopathy, neuralgia
- Psych: anxiety/panic, somatoform DO
7
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
8
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.
9
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
- K+:
- 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)
- Change to SC insulin when AG closed, tol PO, and pH > 7.2 (2 hr overlap required).
- Fluids: NS bolus, then NS 1-2 ml/kg/hr (or 20 mL/kg in peds)
10
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
11
Q
Ativan for Sz
A
Lorazapam
0.1 mg/kg (4mg) q 5 min
Double for IM
12
Q
Valium for Seizure
A
Diazepam
0.2 mg/kg (10 mg) q 5 min
Double for IM
13
Q
Seizure Tx - No IV
A
Valium 0.5 mg/kg PR (max 10)
Versed (Midaz) 0.2 mg/kg
14
Q
Benzo Options For Seizures
A
15
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
27
Q
STEMI Equivalents
A
