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Promo Boards > PGY3 - Misc > Flashcards

PGY3 - Misc Flashcards

1
Q

Absolute Thrombolytic Contraindications

A

Absolute - BAIT SAN

  • Bleed or Diathesis
    • INR> 1.7
    • Plt < 100
    • Heparin in 2 days with inc PTT
  • Aortic DIssection
  • Intracracial Hem
  • Trauma in 3 monts
  • Stroke < 3 mo
  • Av Malform
  • Neoplasm
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2
Q

Relative Thrombolytic Contraindications

A

Relative - I PUSH VASC

  • Internal Hem 2 weeks
  • Preg
  • Ulcer - Peptic
  • Stroke > 3 months
  • HTN (>180, >110)
  • Vascular Access - Noncompressible
  • Anticoagulant Use
  • Surgery < 3 mo
  • CPR > 10 min
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3
Q

PE Thrombolytic Indications

A
  • Hemdynamic Instability
    • SBP < 90
    • SBP drop > 40
    • Persistant hypoxemia despite tx
  • Subtotal or total pulmonary artery embolism
  • RV Dysfuntion
    *
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4
Q

Shoulder Reduction Techniques

A
  • Stimson - Prone with weight off bed
  • Cunningham - Massage Biceps with arm adducted and flexed, patient shrugs
  • Scapular Manipulation - CCW
  • Traction-CounterTraction/Milch
  • Self Reduction
  • FARES - Oscillation
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5
Q

Posterior Shoulder Reduction

A

Supine

Internally rotatedladducted

Traction

Push on humeral head anteriorly

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6
Q

Dyspnea/Tachypnea DDX (40)

A
  • Critical (all systems): Airway obstruction, anaphylaxis, epiglottitis, PE, pulmonary edema, tension PTX, Fail chest, MI, tamponade, DKA, toxic ingestion, CO poisoning, organophosphates, stroke
  • Airway: angioedema, Ludwig’s, RPA, PTA, laryngomalacia, FB, mass, inhalation burn, ingestion burn
  • Pulmonary: asthma, pleurisy, COPD, Acute Lung Injury, ARDS, effusion, neoplasm, chemical pneumonitis, pulmonary brosis, aspiration
  • Cardiac: Unstable Angina, MI, dysrhythmia, CHF, pericarditis, cardiomyopathy, valvular dz, CHD, pericardial effusion Abdominal: ascites, constipation, free air, obstruction, hiatal hernia
  • Psychogenic: hyperventilation, somatization d/o, panic attack
    Metabolic/endocrine: renal failure, lyte abnormalities, metabolic acidosis, fever, hyperthyroidism
  • Infectious: COVID, PNA, empyema, bronchitis, SARS, inuenza, PCP, sepsis, TB
    Traumatic: PTX, hemothorax, diaphragm rupture, rib fx, sternal fx, pulm contusion, chest wall burns, pulled intercostal muscle Hematologic: severe anemia, acute chest syndrome (SCD), porphyria
  • Neuromuscular: MS, Guillain-Barre, Tick paralysis, ALS, polymyositis, botulism
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7
Q

Neck Pen Trauma Zones

A

Go “Up”

  1. Sternal Notch to Cricoid
  2. Cricoid to angle of mandible
  3. Angle of mandible to base of skull
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8
Q

Hard Signs of Neck Injury

A
  • Hypotension
  • Arterial Injury
  • Rapidly expanding hematoma
  • Deficit (pulse or neuro)
  • Bruits or thrills
  • Bubbling wound
  • Severe hemoptysis
  • Severe hematemesis
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9
Q

Soft Signs of Neck Injury

A
  • Hoarseness
  • Stridor
  • SubQ Emphysema

–> CTA +/- Scope

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10
Q

Neck Pen Trauma Decision Matrix

A
  • Airway Compromise (Expanding Hematoma, Stridor) –> Intubate
  • Hards Signs or Unstable –> OR
  • Stable and violates platysma –> CTA
  • Possible GIT injury –> Endoscopy or Esophargram +/- ABx
  • Possible Larygotracheal Injury –> Bronchoscopy
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11
Q

Pen Neck Trauma - Vascular Injuries

MC injured - vein and art

Other concerns (2)

A

1 Vein = EJ

Vert Art - May be occult –> Neuro Deficits (CN)

IJ - C/f Venous Air Embolism

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12
Q

Shoulder Dystocia

A

H - call Help (OB, peds, anesthesia)
E - Episiotomy (large)
L - Legs Flexed McRobert’s position
P - suprapubic Pressure
E - Enter the vagina, perform wood’s screw pushing shoulders to the fetal chest
R - Remove posterior arm, pull across face and pull out of birth canal

If still no dice - break clavicle

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13
Q

Breech Delivery

A
  • PUSH IT BACK IN (zavanelli procedure)
    • Must have OB en route to do Csx)
  • If not help coming
    • Cut large episiotomy,
    • Sweep out legs and let deliver past umbilicus without any traction,
    • Pull 10cm of cord out once umbilicus clears perineum.
    • Deliver most accessible arm then the other, may need to rotate.
    • Rotate fetus to keep face down (so chin not caught on symphysis).
    • Use Mariceau maneuver (Fingers in fetal mouth sometimes via mom’s anus) to flex chin (or place pressure on maxilla) / avoid extension injury to spinal cord.
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14
Q

Multi-Gestation

A

If baby #1 is breech → C-sx
If both vertex → deliver both
If baby #1 is vertex, #2 breech → deliver #1 and try to rotate #2

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15
Q

Nuchal Cord

A

reduce when head delivers

check for a second one

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16
Q

Cord Prolapse

A
  • Hand in vagina to elevate presenting part (ie head) to decompress cord
  • Pt in knee chest position or deep T-berg
  • Tocolysis
    • Mg 4gm IV
    • Terbutaline 0.25mg SQ
  • C-Sx
17
Q

Post Partum Hemorrhage

A
  • Uterine pressure
  • Oxytocin 20 Units IV (after placenta delivery)
  • Methergine 0.2 mg IM (contraindicated in HTN and PreE)
  • TXA
  • Repair lacs
18
Q

Cardiogenic Shock Tx

A

Hypotensive - Dopamine

Poor contractility - Dobutamine

19
Q

CHF FFM

A
  • Tx:
  • 100% O2 NRB prn or ​NIPPV ​
  • NTG 0.4 mg SL q 5 min x 3 or 20-200 mcg/min IV
    • Or NTP 0.25-10 mcg/kg/min IV Diuretic
  • Diuretics
    • Lasix 20-80 mg IV- 0.5-1 mg/kg
    • Bumex- 1-3 mg IV (1 mg = 40 mg lasix)
  • Foley to monitor I/Os
  • ACEI- should be on this, B blocker (both have decreased mortality), +/- diuretic, digoxin, spironolactone as outpatient

If respiratory distress… ​BiPAP early
If patient tiring/AMS… ETT
If hypotensive/cardiogenic shock… IVF in 250 cc boluses, pressors (may have to use multiple pressors + vasodilator)

Consult cards to discuss lytics, PCI, IABP
Norepinephrine 2-20 mcg/min IV- shock BP < 70
Dopamine 2-20 mcg/kg/min IV- BP <100 shock or persistent oliguria Dobutamine 2-20 mcg/kg/min IV- no signs of shock- poor contractility

20
Q

Aortic Dissection Tx

A
  • Stat CT surgery consult
  • Goal to decrease arterial pressure (decrease shearing forces)
  • If tachycardic… Goal HR 60-80
    • Esmolol 500 mcg/kg IV, then 50-200 mcg/kg/min
    • Diltiazem (if asthma or heart failure) load 0.25 mg/kg then 5-10 mg/hr
  • If hypertensive… Goal SBP = 100-120
    • Nitroprusside 0.25-10 mcg/kg/min IV
  • If single agent preferred…
    • Labetalol 0.25-1 mg/kg IV, double q 10 min (max 300mg total), then 1-2 mg/min
  • If hypotensive (5%)… r/o pseudohyportension w/ BL BP, check possible causes (hemopericardium, valve dysfxn, systolic dysfxn) before aggressive uid resus
21
Q

ACS Tx

A
  • ASA 162-325 mg PO
    • Allergy to ASA - Prsugrel (C/I in prior TIA/Stroke)
  • NTG
    • 0.4 mg SL q 5 min x 3, then drip at 20-80 mcg/min IV
    • Titrate to pain free
  • Beta blockers- ACS with tachydysrhythmias or intractable HTN
    ACE I- decrease ventricular dysfunction and death- give within first 24 hours

Anticoagulation

  • Heparin 60 u/kg IV (max 5000 u) then 12 u/kg/hr (max 1000u/hr) {Guiac first}
  • Discuss Plavix load with cardiologist –Do not give Plavix in AVR STEMI

If STEMI​… PCI w/in 90 min, pants/underwear off
If STEMI and no PCI available​… check​ contraindications​ and give lytics

22
Q

tPA time in CVA

A

4.5 hours

23
Q

PERC

A

“HAD CLOTS”

H – Hormone (estrogen) use

A – Age > 50

D – DVT/PE history (have they HAD CLOTS?)

C – Coughing blood

L – Leg swelling disparity

O – O2 sats < 95%

T – Tachycardia (>100bpm)

S – Surgery or Trauma (recent)

24
Q

HEART SCORE - How to Calc

A
  • Suspiciousness of History
    • Slightly = 0, Moderately = 1, Highly = 2
  • EKG
    • Normal = 0, Non-specific = 1, Sig ST change = 2
  • Age
    • <45 = 0, 45-65 = 1, >65 = 2
  • Risk Factors
    • None = 0, 1-2 = 2. 3+ = 2
    • HTN, HLD, DM, Obesity, Smoking, Fam Hx of CVD <65y, prior atherosclerosis (MI, PCI/CABG, CVA/TIA, PAD)
  • Initial Trop
    • < normal limit = 0, 1-3 times normal = 1, >3x normal = 2
25
Q

Heart Score Interpretation

A
  • 0-3
    • 2.5% risk
    • Home with outpatient f/u
  • 4-6
    • 20.3%
    • Admit for Clinical Observation
  • 7-10
    • 72.7%
    • Early Invasive Strategies

MACE over next 6 weeks

26
Q

Well’s Score Calculation

A
27
Q

Well’s Interpretation

A

2-Tier

0-4 - R/o with Dimer

5+ - CTA

28
Q

Well’s Score Calculation

A
29
Q

PECARN 2+

A
  • Tier 1 - CT if there is… (4% Risk)
    • AMS
    • GCS<15
    • Signs of Basilar Skull Fx
  • Tier 2 - Obs vs CT if there is… (1% Risk)
    • Vomiting
    • LOC
    • Severe HA
    • Severe MOI
      • MVA with Ejection, Rollover, Fatality
      • Bike/Ped vs Vehicle without Helmet
      • Struck by high-impact object
      • Fall > 5 Feet
  • Tier 3 - Observe (<0.05% Risk)
30
Q

PECARN <2

A
  • Tier 1 - CT if there is… (4% Risk)
    • AMS
    • GCS<15
    • Palpable Skull Fx
  • Tier 2 - Obs vs CT if there is… (1% Risk)
    • LOC > 5s
    • Non-Frontal Hematoma
    • Not Acting Normally
    • Severe MOI
      • Fall > 3ft
      • MVA with Ejection, Rollover, Fatality
      • Bike/Ped vs Vehicle without Helmet
      • Struck by high-impact object
  • Tier 3 - Observe (<0.02% Risk)
31
Q

Antiarrythmic Classes

A
  • Class 1 - Na Blockers
    • A - Procainamide
    • B - Lidocaine
    • C- Flecainide
  • Class 2
    • Beta Blockers
  • Class 3 - K Blockers
    • Amiodarone
  • Class 4 - Calcium Channel Blockers
    • Dilt
    • Verapamil
32
Q

AV Nodal Agents

A

ABCD

Adenosine

Beta Blockers

CCB

Digoxin

Prolong PR

33
Q
A
34
Q
A
35
Q
A

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