Rosen Flashcards
“can’t intubate and can’t oxygenate” approach
topical anesthesia, IV sedation, no paralytic
(3) indications for intubation
failure to protect airways, failure to oxygenate or ventilate, predicted/anticipated outcome
(4) factors in assessing airways
difficult to BMV, difficult to intubate, extraglottic insertion, extraglottic ventilation
double set-up airway
RSI intubation equipment, cricothyrotomy
Difficult Laryngoscopy RFs
LEMON (Box 1.1)- look externally for signs (gestalt; if pt cannot bite upper li with lower teeth, difficult intubation), evaluate the 3-3-2 rule, mallampati score, obstruction/obesity, neck mobility (AnkSp, RA)
3-3-2 rule
3 of own fingers between open incisors, 3 own fingers along floor of mandible, 2 own fingers from laryngeal prominence to underside of chin; if receeding mandible and high riding larynx: impossible to intubate as operator cannot displace tongue to overcome acute angle for a direct view
Mallampati scale
requires awake patient for cooperation; assess oropharynx; class I (soft palate, uvula, fauces(back of throat) tonsillar pillars seen), II soft palate, uvula, fauces, class III (soft palate, base of uvula), IV: only hard palate
Definition of shock
failure to oxygenate and perfuse tissues adequately; hypoperfusion leading to organ failure
(5) Categories of Shock (as per Rosen’s)
Primary Infusion of volume (hemorrhage, hypovolemia), volume infusion and vasopressor support (septic, anaphylactic, central neurogenic, drug OD), Improvement of pump function/cardiac (MI, cardiomyopathy, dysrhythias), obsructive (PE, tamponade, valvular), toxins (CO, methemoglobinemia, hydrogen sulfide, cyanide)
Hemorrhagic Shock presentation (Vitals)
tachycardia (heart contraction increases), diastolic bp increases –> narrowing of pulse pressure –> decrease in ventricular filing –> decreased sBP; however it is VERY VARIABLE
Initial Bloodwork Abnormalities in Shock
worsening base deficit >-2; base deficit more negative first before pH (acidosis) occurs; lactate > 2.0
3 Major effects of septic shock
hypovolemia, cardiovascular depression, induction of systemic inflammation
Cardiogenic shock definition
> 40% of myocardium becomes dysfunctional (ischemia, inflammation, immune injury): LV dysfunction in ECHO
Neurogenic Shock definition
disruption between sympathetic and parasympathetic connections between SC and heart; peripheral vasodilation and bradycardia
Criteria for Circulatory Shock (4 must be met to meet criteria)
ill appearance/altered mental status, HR > 100, RR > 22 or paCo2 < 32, arterial base deficit of < -4 or lactate > 4, UO < 0.5, arterial hypotension > 30 mins duration, continuous
Types of hemorrhagic shock
- simple hemorrhage (normal vitals, normal base deficit); 2. hemorrhage with hypoperfusion (base deficit < -4 or persistent HR > 100; 3. hemorrhage shock (hypotension, tachypnea, tachycardia, altered LOC)
Types of cardiogenic shock
- cardiac failure
2. cardiogenic shock
Management of Hemorrhagic Shock
- ABCs - ventilation and oxygenation; 2. control hemorrhage (Traction, direct pressure), obtain urgent consultation if uncontrollable; 3. pRBC; 4. Treat dysrhythmias
Management of Cardiogenic Shock
- help with increased work of breathing using oxygen and PEEP if pulmonary edema; 2. vasopressors or inotropic support; 3. seek to reverse the insult; consider intraaortic balloon pump counterpulsation for refractory shock
Management of Septic Shock
- ABCs; 2. fluid resuscitation 20 ml/kg; begin antimicrobial treatment; vasopressors if necessary
Definition of 1:1:1
pRBC: FFP: platelets
Complications of IV vasopressors
potential for limb damage from extravasation from peripheral IV injection; use central line to prevent this
Purpose of IV vasopressors
increase cardiac output and oxygen delivery to vital organs when volume resus fails
Norepinephrine doses for septic shock
5 - 30 mcg/min; 0.05mcg/kg/min boluses, then titrated at 3 and 5 mins interval until MAP > 65; no maximum but less effective after > 30 mcg/min
Dobutamine uses
inotropic effects; used with norepi to increase CO and maintain adequate oxygen delivery in cardiogenic shock
Role of PPV/ventilation in shock
reduces work of breathing (thus preventing decreased cerebral blood flow, and oxygen consumption from accessory muscles), prevents suction effect (high neg thoracic pressure required if airway resistance) of LV thus preventing impedement of LVEF
True or False; Circulatory shock can occur with normal arterial blood pressure and not all pts with arterial hypotension have circulatory shock
true
True or False: urine output is a reliable index of vital organ perfusion with shock; normal is? what output indicates severe renal hypoperfusion?
0.5 is abnormal; 1.0 ml/kg/hr is normal; it is true
Massive Transfusion Protocol
pRBC, platelets (if < 50 and bleeding), FFP (if INR > 1.5), cryo (if fibrinogen < 1.0); level 1 transfuser (1L in 90 seconds), warm fluids
CRASH II Trial
published in Lancet 2010; TXA siginficantly reduced all-cause mortality in trauma patients with significant hemorrhage; no significant differences between TXA and none for vaso-occlusive events
Indication and dose of TXA in trauma/hemorrhagic shock
1g over 10 mins, then infuse 1 g over 8 hours
Definition of sepsis
- known infection, 2. causing organ dysfunction 3. and is life-threatening
Definition of septic shock
- sepsis; 2. shock (hypotension requiring pressors after volume resus) and 3. lactate > 2
MGMT of septic shock
- antibiotics within 1 hour and source control; 2. fluid resuscitation, norepi if MAP < 65
MGMT of anaphylactic shock
- epi 0.5 mg IM; 2. diphenhydramine 50 mg, 3. prednisone 50 mg; 4. ranitidine 150 mg
Difficult BVM Criteria
MOANS: mask seal (beard), obstructive/obesity, age > 55, no teeth, stiffness of chest (COPD, asthma, pregnancy)
Difficult extraglottic device Criteria
RODS: restricted mouth opening, obstruction/obesity, distorted anatomy, stiffness to ventilate
Difficult cricothyrotomy criteria
SMART: surgery, mass (abscess, hematoma), access/anatomy problems (edema, obesity), radiation, tumor
Cormack Lehane grading view (1-4) with DL
1 - 4; 4; not even the epiglottis; 2a: arytenoids and portion of vocal cords; 2b: arytenoids only
Pathophysiology of cocaine
release of dopamine, epinephrine, norepi and serotonin; most importantly involved in adrenergic stimulation by norepi and epi; Norepi causes vasoconstriction by stimulation of alpha adrenergic receptors on vascular smooth muscles; epinephrine causes increased myocardial contractility and heart rate through beta1 adrenergic receptors; reuptuake from synaptic clefts is inhibited; local anaesthetic (Na channel blockade)
Metabolite of cocaine in plasma detected by urine tox
benozyl ecgonine
ethanol + cocaine
can potentiate cocaine stimulatory effects
Signs and Symptoms of Cocaine Use
diaphoresis, tachycardic, mydriasis (dilated pupils), HTN –> agitated, combative and hyperthermic; rare: hypertensive emergency, delirium, seizures
Urgent things to evaluate in cocaine abuse
hyperthermia, hypertensive emergencies, cardiac dysrhythmias
Cocaine Route of Administration
inhalation (crack; onset seconds, duration 10 - 20 mins), intranasal (onset: 5 mins, duration: 30 mins); IV (onset seconds, duration 90 mins)
Sympathomimetic Toxidrome
CNS excitation, diaphoresis, HTN, hyperthermia, increased motor tone, tachycardia, mydriasis (dilated pupils)
RFs and Mechanism for hyperthermia in cocaine abuse
increased motor tone and generating excessive heat; vasoconstriction and salt and water depletion compromises cooling; risk of fatality when > 41.4
Normotemperature + cocaine; tests to order
CK and lytes (r/o rhabdomyolysis)
Cardiac Complications of Cocaine
AD, pulmonary edema, MI, intracranial hemorrhage, stroke, infarction of anterior spinal artery/bowel/renal/retina, placental insufficiency and infarction in gravid uterus, dysrhythmias
Dysrhythmias in cocaine abuse
sinus tachycardia, AFib, SVTs due to catecholamine surge;; TdP from K+ blockade or wide-complex tachycardia from fast Na channels on myocardium, transient conduction abnormalities consistent with Brugada type pattern, hyperkalemia from rhabdomyolysis
Chronic cocaine use
“Cocaine washout”: profoundly sleepy bur arousable and oriented; crackl dancing: transient choroathetoid movement disorder related to dopamine abnormalities, psychosis and paranoia,
Complications of inhaled crack cocaine
oropharyngeal burns, PTX, pneumopericardium, pneumomediastinum
Complications of intranasal cocaine
sinusitis, nasopalatine necrosis or perforation
DDx of stimulant abuse/sympathomimetic toxidrome
other sympathomimetics (amphetamine, PCP), thyrotoxicosis, lithium toxicity, CNS infections, benzo withdrawal, heat stroke, serotonin syndrome, NMS
Complications from designer amphetamines (i.e., ecstasy)
hypnatremia from SIADH or excessive free water
Signs of PCP abuse
multidirectional nystagmus, highly combative behaviour
Difference between sympathomimetic abuse vs. anticholinergic abuse
anticholinergic: dry skin, acute urinary retention
Serotonin Syndrome Signs and Symptoms
altered mental status, hyperthermia, agitation, hyperreflexia, clonus, diaphoresis
NMS Signs and Symptoms
“FARM” - fever, autonomic instability, rigidity, mental status change
Drawbacks of urine tox screen, in cocaine specifically
measures metabolite (benzoyl ecgonine) that persists for at least 3 days
Inv for cocaine abuse
ECG (dysrhythmias, ischemia, hyperK, QRS prolongation from Na blockade), CXR (PTX, pneumomediastinum, FB), BW (CBC, lytes, extended lytes, Cr, CK (serum +urine myoglobin), +/- CT Head (subarachnoid)
Rare Cocaine Adulerant: Levamisole - Complications
agranulocytosis, vasclopathy + thrombosis, dermal ulcer and purpura
Acute MGMT of Agitated Patient with Sympathetic Abuse
rapid assessment of vital signs + core temperature, r/o hypoxia/hypoglycemia/hyponatremia), sedation with benzodiazepines, ECG, urinalysis, CK
Benzos for Agitated Patient with suspected sympathomimetic abuse
diazepam 5 - 10 mg q5 mins, lorazepam (1 - 2 mg IV q5mins), midazolam 10 mg IM
Rx for Acute cocaine abuse
benzodiazepines (lorazepam 1 - 2 mg IV q5 mins; midazolam 10 mg IM), butyrophenone antipsychotics (haldol 2 - 5 mg IM q20-30mins)
MGMT of Stimulant-Induced Hyperthermia
Cooling: identify temperature, large bore IV rapid infusion of crystalloid, sedation and muscle relaxation with benzos, rapid cooling within 20 mins with ice water immersion, paralysis and intubation if necessary; monitoring: UO with foley, labs (liver function, PTT, bacterial cultures, UA, Cr, CK)
Minutes of hyperthermia (>41 degrees) until end organ failure
20 mins
Intubation Sedation for cocaine abuse
rocuronium (1mg/kg; succinylcholine may precipitate hyperkalemia if rhabdomyolysis is present
Rx for acute hypertensive emergencies in cocaine
phentolamine: direct alpha adrenergic antagonist IV 1 mg q3mins with monitoring; other rx: NG, hydralazine; AVOID BETA BLOCKERS
Anti-HTN medications to avid in cocaine abuse
beta blockers; due to beta-adrenergic antagonism causing paradoxical HTN from unopposed alpha-receptor activity –> coronary artery spasm and HTN
Dysrhythmias in cocaine MGMT
if not responding to benzos, can consider CCB (diltiazem); r/o hyperkalemia, sodium channel blockade (cyclic antidepressants + cocaine), ischemia; can consider sodium bicarb for sodium channel reversal
RF for cocaine cardiac CP
cocaine causes coronary artery vasoconstriction, enhances platelet aggregation
Causes of CP in cocaine abuse
coronary thrombosis, endocarditis, ischemia/infarct, LV apical ballooning, pericarditis; AD, FBA, infection, pneumomediastinum, pneumopericardium, PTX, pulmonary infarction, intestinal ischemia or infarct
Cocaine body packing MGMT
continuous monitoring; if retained packet, remove with whole bowel irrigation with PEG; can consider OR/surgery in event patient develops acute toxicity, bowel obstruction or leaking packet
Cocaine body stuffers MGMT
usually much less doses and will not be lethal; do not require WBI but do monitor 8 - 12 hours
Admission for cocaine abuse
cardiogenic shock, CHF, dysrhythmias, ECG changes, elevated cardiac enzymes, persistent CP/SOB or abnormal vital signs, pre-existing CAD or stent placement, requiring vasodilating pharmacotherapy, persistent symptoms
Amphetamines complication
same as stimulants: hyperthermia, hypertensive emergencies, dysrhythmias, MI, hyperkalemia; however less sodium channel blockade; longer duration of action
MDMA complications
same as stimulants, but higher risk of hyponatremia due to release of vasopressin
methamphetamine (crystal meth) complications
same as stimulants but longer duration of action and ++paranoid delusions persisting for 15 hours
ephedrine and ephedria complications
similar to amphetamine, used in chinese herbal products, higher risk of strokes
khat and methcathinone complications
stimulant occuring in plant catha edulis; smoking khat is usually asx; can be associated with elevated manganese concentration
bath salts complications
similar to sympathomimetics: agitation, hyperthermia, rhabdomyolysis
T or F: rapid sedation with IV benzo is the key for most symptoms from cocaine and other stimulants
true
T or F; hyperthermia is a high risk event for cocaine OD and body temperature must be reduced slowly
false - reduce temp quickly!
T or F; short-acting antihypertensive agents(phentolamine, nitroglycerin) are recommended for cocaine-induced hypertension including CP
T
what anti-hypertensive should be avoided in cocaine/stimulant OD?
beta-blockers for potential unopposed alpha adrenergic activity resulting in coronary vasoconstriction and HTN
what IV Rx can be used for wide-complex cocaine indued arrhythmias?
sodium bicarb for sodium channel blockade reversal
which groups of cocaine users may require emergent surgical intervention and WBI?
cocaine body packers
T or F; amphetamine symptoms last shorter than cocaine
false; they last longer!
what are MDMA patients specifically at high risk for?
hyponatremia secondary to vasopressin release, presents similar to SIADH in that high urine sodium levels
what can bath salt ingestions cause?
sympathomimetic effects; rhabdomyolysis, hyperthermia, severe agitation
MGMT of cocaine-induced HA
r/o SAH with CT head AND lumbar puncture
Average time for fracture healing in healthy adults
2 months - 4 months (femur/large bones)
T or F: oblique fractures heal quicker than transverse fractures
True
Malunion
residual deformity exists after healing
Nonuion
failure of fracture to unite
(3) signs to return to normal activity/fully healed
pain free, weight bearing and Xray showing bridging bone at 3+ cortices
Signs of compression fracture on XRay
increased density vs lucency (in typical fractures)
Use of CTs in fracture
confirm possible fracture, CSpine trauma, vertebral fractures relativel to spinal canal, articular surfaces (Salter Harris type fractures)
Salter-Harris Fracture Classifications
SALTR: Type I - Slipped, Type II - above or away from joint, Type III: Lower, Type IV: through or transverse or together, Type V: Ruined or rammed
Osteomyleitis in fractures MGMT
IV antibiotics (cefazolin +/- gentamycin), emergent washout of debris, coverage with moist dressing
MGMT of open fractures
- Control hemorrhage with sterile pressure, remove debris; 2. Splint with reduction unless vascular compromise; 3. Irrigate with saline, cover with saline soaked sponges after arrival; 4. Begin IV antibiotics prophylaxis 5. Administer tetanus, +/- tetanus IG for large crush wounds
Crush/Open injuries of the fingers/toes MGMT
thorough irrigation, antibiotics PO (no evidence), outpt follow-up
Estimated blood loss in fractures (forearm vs. pelvis)
100 mL in forearm, femur 1L, 3L in pelvis
Fracture of femoral neck MGMT
emergent reduction and fixation, r/o compartment syndrome/vascular injury
neurapraxia definition
contusion or traction injury of intact nerve; transiet paralysis and slight sensory loss; normal function usually returns in weeks - months
axonotmesis definition
more severe injury of axons within intact epineurium; Schwann tubes remain in continuinty and spontaneous healing is possible but slow
Neurotmesis definition
complete severing of nerve, requiring surgical repair
Normal two-point discrimination value at the fingertip
4 mm
Nerve injured in distal radius fracture
median nerve
Nerve injured in elbow injury
median or ulnar
Nerve injured in shoulder dislocation
axillary
Nerve injured in sacral fracture
cauda equina nerve
Nerve injured in acetabulum fracture
sciatic nerve
Nerve injured in hip dislocation
femoral nerve
Nerve injured in femoral shaft fracture
peroneal nerve
Nerve injured in knee dislocation
tibial or peroneal nerve
Nerve injured in lateral tibial plateau fracture
peroneal nerve
Life or Limb threatening emergency in open fracture
ostemyelitis
Life or Limb threatening emergency in fracture with vascular disruption
amputation, especially popliteal
Life or Limb threatening emergency in major pelvic fracture
hemorrhagic shock
Life or Limb threatening emergency in hip dislocation
AVN of femoral head
Life or Limb threatening emergency in compartment syndrome
ischemic contracture, myoglobinuria, renal failure
Associated life-threatening causes to r/o in the ED with AKI/azotemia
pulmonary edema, hyperkalemia
Definition of acute anuria
< 100 cc of urine/day
Approach to AKI/azotemia (elevated Cr)
r/o pre-renal and post-renal causes first, then investigate renal causes
5 factors affecting electrical injuries
circuit type, current, resistance, voltage, current pathway, current duration
resistance of body tissue from lowest to highest
lowest: nerve, blood vessels, highest: fat, bone
4 types of skin burns from electrical injuries
entrance and exit burns, arc burns, flash burns, thermal burns
skin spot diagnosis associated with lightening injuries
lichtenberg figure (ferning pattern)
(2) medical conditions where CPAP or BIPAP is effective
copd, CHF
proportion of BMV being impossible and difficult
impossible in 1/600, difficult in 1/50
neck obstruction mechanism of making difficult intubation
i.e., epiglottitis, head and neck cancers, ludwig’s angina, neck hematoma, glottis swelling or polyps, compromise laryngoscopy, passage of ETT, BMV or all three
“RODS” for difficult extraglottic placemenet
restricted mouth opening, obstruction/obesity, distorted anatomy, stiffness (ILD, asthma, COPD)
“SMART” for difficult cricothyrotomy
surgery, mass, access/anatomy problems, radiation, tumor
CL system for laryngoscopy view
grade1: all of glottic structures seen, grade 2: portion of glottis, arytenoid cartilatge+ VC, grade 3: only epiglottis, grade 4 none.
Confirmation of tube placed in intubation
ETCO2 continuous, or colour if not available, U/S to see cricothyroid membrane or trachea to confirm, aspiration technique of air through ETT with ETT cuff deflated easy if in trachea, hard if in esophagus (collapsed), bougie inserted to see resistance (R mainstem)
blood supply to pericardium
internal mammary artery
pericardial chest pain
sharp, pleuritic pain that varies with position - relieved sitting up, worse with lying flat, deep inspiration or swallowing, can radiate to trapezius or isolated shoulder pain
DDx of chest pain
costochondritis, pleuritis, infection, PE, ACS
evolution of ECG in pericarditis
1st satge: first hours, diffuse ST segment elevation and ST segment depressions, concurrent PR segment depressions; 2nd stage: ST and PR normalize but T-waves flatten followed by symmetric deep T wave inversions
percentage of patients with classic CP and ECG of pericarditis
2/3 only!
key ECG changes with ST elevation in pericarditis and STEMI
ST elevation in pericarditis are concave (smile) rather than convex upwards (STEMI); in pericarditis, simultaneous T wave inversions are not seen, and are diffuse
MGMT pericarditis
NSAIDS (ibuprofen) 1st line, if no relief within 1 week; colchicine can be added to reduce risk of recurrent pericarditis
criteria to admit for pericarditis
significant pericardia effusion, ACS , hemodynamic instability
uremic pericarditis is associated with ____
occult infections
T or F: uremic pericarditis can have a normal ECG
true - it is often normal bc little epicardial inflammation
Etiology of pericarditis - infectious
viral, bacterial, fungal, parasite, rickettsia
Etiology of pericarditis - post-injury
penetrating trauma, blunt trauma, surgery, MI, radiation, medication
Etiology of pericarditis systemic disease
uermia, mets cancer, RA, SLE, sarcoidosis, scleroderma, dermatomyositis, amloidosis
MGMT o furemic pericarditis
NSAIDS are not helpful - consider dialysis (usually renal failure, dialysis pts), can consider steroids later on
percentage of pts having MI-associated pericarditis
20% of pts with transmural MI experience post-MI pericarditis
T or F: post-MI pericarditis and Dressler’s are the same
false - Dressler’s is delayed complication of MI vs. post-MI percarditis can happen 2-4 days after
Dressler’s syndrome sx
fever, pleuritis, leukocytosis, friction rub, pericardial or plerual effusion in MI pts
MGMT of Dressler’s syndrome
NSAIDS
cancers associated with neoplastic pericardial disease
lung, breast, lymphoma, leukemia
other infectious causes of pericarditis
rickettsia conorii (Mediterranean spotted fever, treated with doxy), mycoplasma pneumoniae, nocardia asteroides (pericardiectomy, long term antibiotics), chlamydia, EBV, CMV, H. actinomycetemcomitans (Rx: chloramphenicol), coccidioidomycosis, varicella, TB
minimum amount of fluid needed to see cardiomegaly on CXR
200 - 250 cc
complications of pericardiocentesis
dysrhythmias, PTX, myocardial perforation, coronary or internal mammary artery laceration, liver laceration
3 stages for tamponade to develop
fluid filling recesses of parietal pericardium, fluid accumlating faster than rate of parietal pericardium to stretch, fluid accumulation exceeding body’s ability to increase blood volume to support RV filling pressure
Beck’s triad
hypotension distended neck veins, muffled heart sounds
ECG finding for cardiac tamponade
decreased voltage, electrical alternans
US signs for cardiac tamponade
pericardial effusion AND chamber collapse
MGMT of cardiac tamponade
++IVF to increase preload, pericardiocentsis
definition of electrical alternans
alternating QRS amplitude
Etiology for purulent pericarditis
steptococcus, staphlococcus, candida
cause of spontaneous penumopericardium
increase in intra-alveolar pressure above atmospheric pressure –> rupture of alveoli
clinical sx for pneumopericardium
Hamman’s sign, mediastinal crunch
