SHOCK & Emergency Care Flashcards
Drugs that Inhibit Sweating & may cause Heat Cramps, Heat Syncope, Heat Exhaustion or Heat Stroke…
All the Antis: AntiCholinergics AntiHistamines AntiSpasmotics Anti-Depressants (TriCyclics) AntiEmetics Alcohol
1 All Time Bad Drug for Heat Stroke
Tricyclic Antidepressants!!!
Why use these AT ALL?
Tricyclic antidepressants are used to treat depression
anxiety
headaches
chronic pain and irritable bowel syndrome.
Nerve Pain (Diabetes II)
They’ve been around for fifty years. They’re not addicting at all. Side effects sometimes limit their use.
They have anticholinergic Hot as a hare, dry as a bone, constipation, urinary retention sorts of side effects and that makes them pretty dangerous in certain settings
Heat Cramp to Stroke Cascade
Heat Cramps
Heat Exhaustion
Heat Stroke
Heat Syncope doesn’t usually lead to Heat Stroke and is most often associated with the elderly and their medications.
Who gets heat syncope
Elderly Inactive folks on Meds:
They get dependent edema, then poor venous return, then reduced cardiac output, then reduced blood supply to brain, dizziness, altered mental status and syncope.
Treatment for heat syncope
COOL them down, wet towels, axillary cervical groin & head cold compresses
Trendelenberg position to preserve blood flow to brain and
Rehydrate with sports drinks, not water.
Also, give sugar, just in case.
Who gets heat cramps?
Active people exercising or who exercised in the heat:
They get really sweaty, lose their salt and water and skew their electrolytes then get cramps and shaking in their legs (usually)
Rx for Heat Cramps
COOL down
DRINK Sports drink
STRETCH out crampy muscles
If Severe, may need cooled IV saline
DON’T exercise in the heat of the day anymore. Get up early and do it.
What stage in the cascade are we at when the core temperature actually rises?
Heat Exhaustion or Heat Stroke
If your hot but still clammy with dilated pupils - exhaustion
If you’re hot and DRY - Stroke
Both pts go to the hospital for cooling therapies
Hot, clammy w/dilated pupils
Heat exhaustion
Rehydrate with cooled saline or ringers
No altered mental state (usually)
Hot DRY, pupils constricted w/altered mental state?
Heat Stroke
Big End Organ Damage in Heat Stoke
Rhabdo
Hyperventillation causes Resp Alkalosis, then dehydration causes acidosis, then coagulation dysfunctions follow and DIC
What happens if you only drink water when over heated?
You are not replacing lost salt and you may skew your electrolytes into Hyponatremia with its attendant : cramps arrythmias headache seizures N/V Deressed reflexes Coma
Labs for Heat Stroke Pt
CBC - what are those platelets up to?? You’ve lost so much water, your blood is too thick!
ABG - are we still in alkalosis or have we crossed the line into lactic acidosis?
BMP - How about those electrolytes? How are
Na+, K+, Mg+
AND how are the kidneys doing?
Classic Urine description in Heat Stroke
Machine Oil Urine
Contains casts and Myoglobin as Rhabdo &Dehydration have shut down the kidneys
Most common cause of death in heat stroke?
DIC
Body Temp in Heat Stroke
Over 40C
105F
Worst Headache of my life
SubArachnoid Hemorrhage
Get brain CT
Test of choice for endocarditis dx?
TEE
Trans esophageal Echo
Cocaine and alcohol use, female gender, smoking, HTN and African American heritage are risk factors asst with this neurologic disorder
Sub Arachnoid Hemorrhage
Arterial blood supply to the brain is located mainly in the subarachnoid space. Arterial bleeds occur here, if not traumatic then aneurysms.
Subdural vs Epidermal Hemorrhages
Epis are usually traumatic arterial bleeds and are typically symptomatic quickly as pressure increases quickly. Most likely to bleed? Middle Meningeal from side impact to the temple.
Subdurals are usually venous bleeds from broken bridge veins and symptoms come on slowly, over days even a week. Slowly increasing pressure alters mental status and balance as more blood bleeds into the space
Smoking, advanced age and anticoagulant use are risk factors for this acute neurologic disorder in which pt’s present with altered level of consciousness
Intracranial Hemorrhage
Smoking damages the endothelium of arteries, Age weakens the vessels and anticoagulants prevent clotting. A deadly combo
Name the 5 Fs of gallbladder dz
Fat Forty Fertile Female Flatulent
1 Cholinergic Antidote?
Atropine
Use for severe Brady and Sludgy things like organophospate toxicity or Sarin gas
DON’T regimen for 911 comas of unknown origen
D dextrose IV
O oxygen -high flow
N naloxone
T thiamine
Benzo Toxicity Antidote
Flumanazil (Romazicon)
Meningitis post exposure Rx
Rifampin + Cipro
TIMI score over 6
High risk of MI subsequent mortality from Acute Coronary Syndrome (NSTEMI and/or Unstable Angina)
IgE activation, Degranualtion of Basophils and Histamine release:
Anaphlaxis
No spleen and in sepsis, guess which pathogen…
Strep pneumo
Aslpenic Pts should always be vaccinated against Neisseria Meningitis, Strep Pneumo and HFlu
Think the NHS proticol
HASECK organisms have a predilection for causing:
Endocarditis
Haemophilis-es and various other bad guys but none that are familiar by name. They all get lumped under HASECK as their favorite spot seems to be the endocardium.
Staph Aureaus and Strep Viridians also favor endocardium which is how IV drug users and dental patients end up being classed together as endocarditis risks.
Streptococcus Bovis
(S. Bovis) is associated with which two life threatening infections?
Endocarditis (with the HASECK and S.Aureau and Strep Viridans)
Colon Cancer (with Strep Gallolyticus)
Stupor
Neurological State in which VIGOROUS STIMULI are required to elicit response (loud verbal + sternal rub)
Symetrically reactive but DILATED pupils suggests what sorts of drug use?
Amphetamines + Hallucinogens
Cocaine
Anticholinergics
Anticholinergics like Belladonna and Datura may be ingested in error OR…. some brainiac may aspire to experience ANTICHOLINERGIC DELIRIUM - an effect of Solanaceae toxicity (usually atropine and scopolamine from belladonna/datura)
OR… note these drugs are used for bradycardia, motion sickness (scopolamine patches) and for overactive bowel syndromes as they essentially shut down the bowel
Antidote is Physostigmine
Causes Tachycardia, Hyperthermia, Mydriasis/photosensitivity, Delirium, Memory loss, coma and death
Describe the effect of Increased Intracranial Pressure on Bp, Hr and Respiratory rate:
Bp will rise, possibly very high
Hr + Respirations will fall, possibly
very low as the cardiac + respiratory centers on the Medulla are squashed
Which kind of cranial bleed occurs as a result of head trauma, causes a brief loss of consciousness after which Pt returns to conscious but thereafter develops headache Nausea + Vomiting …. coma death…
Epidural (arterial) Bleed
These are often caught before its too late as the sxs don’t wait to appear like a subdural bleed (venous) will.
The #1 culprit in these is the Middle Menangial Artery from temporal trauma (Side Impact MVA)
Worst HA you’ve ever had AND photophobia
Think SubArachnoid bleed aka brain aneurysm
Intracerebral bleeds usually present more like a stroke, not the sudden onset though an aneurysm outside the subarachnoid space is often the cause of ICH
Empiric Abx for suspected Meningitis:
Rocephin (Cephtriaxone)
Family/Dorm Mates get RiFampin and Cipro as preventative but actual pt gets Rocephin until lumbar puncture gives us the actual pathogen.
What are Janeway Lesions
Nontender palmar/solar nodules or macules are Hallmark for Endocarditis
Likewise Splinter Lesions at the edge of the nailbed
and
Osler Nodes - painful raised red nodules on the fingers + toes.
Abd Pain/Bloating with N/V in a Pt who has had abdominal surgery (especially laprascopic) suggests what?
SBO
Small Bowel Obstruction
Depressurize the bowel with NG Tube and give supportive care unless Upper GI Endoscopy or CT/KUB shows volvulus, in which case surgery may be needed.
Bloody Stool, left sided abd pain with or without fever
Diverticulitis but don’t rule out Colon Cancer until after endoscopy.
Have to wait to scope until bout has calmed down though.
Central Venous Pressure (CVP) goal when treating shock
8-12 mm Hg
Remember, it’s being tested just before entering the SVC, where venous pressure is at its lowest.
If its a hemorrhage, add whole packed blood and FF Plasma. If it isn’t a blood loss situation, find out what it IS caused by and fix it
how do we test registration?
Recall Three Words after a period of at least 5 minutes:
House, Car Dog
How do we evaluate a Pt’s appearance on physical exam
Gait, Facial Expression/expressiveness, Handshake and Dress
Heat Stroke Sxs:
Hot (really hot, over 104F) + Dry
Red
Constricted Pupils
Sweaty, Dilated Pupils, Normal Temperature
Heat Exhaustion
96-93F
93-85
Below 85
96-93 Tachy, Shivers
93-85 Brady, no Shivers, Drowsy
Below 85 Unconscious, not
Drowsy, Heat may be in VFIB
Viper (rattler) Bite Sxs
Edema around site
Hemolysis
Coagulopathy
Elapid (coral/cobra) Bite Sxs
Respiratory Depression Paralysis Ptosis (droopy eye) Dysphagia Blurred Vision
WPW SVT, medicine?
Amiodarone
Rather prefer to cardiovert @50 then 100 Joules but DO NOT Rx WPW with Adenosine!!!
Look for delta waves on keg
Tinnitus is a CLUE to what kind of common drug toxicity?
Salicylate Poisoning
Aspirin poisoning presentation
Anxious, tinnitus, tachypnea/tachycardia, Altered mental status/confusion METABOLIC ACIDOSIS in the setting of normal BG or HYPOGLYCEMIA (not DKA…) Even when BG is normal, for some reason with aspirin poisoning, BG to the brain is decreased and its this that causes the confusion/AMS
Common in the elderly who are often on 81mg/day now but whose Kidneys are not at peak function.
Aspirin toxicity has no Antidote. Treatment focuses on:
1) Getting it out of the GI system. Gastric lavage w/activated charcoal if within 1-4 hrs.
2) If enteric coated aspirin was ingested, try whole bowel lavage with polyethylene glycol (Miralax, Ducolax)
3) Give Dextrose boluses to increase BG to the brain even if BG is normal
4) Alkinalize Urine with BiCarb infusion but… KEEP A GOOD EYE on your K+!!! If if drops even to low normal, this won’t work.
How is Aspirin Inactivated + Cleared?
Aspirin is a weak acid whose bioavailability is enhanced by acidic conditions and compromised by alkalosis
The liver conjugates aspirin with Albumin - this form is inactive. At small doses (less 4 grams in a healthy adult less in elderly/ill) the liver conjugates at 1st order leaving some active metabolites. At high doses(over 4g), all the liver pathways get saturated and much more active metabolite circulates in the blood.
Renal Clearance then assumes primary position, whereas it was secondary before the liver was overwhelmed. Renal Clearance of the mild acid increases with urine alkalinity. You can increase renal excretion 10-20 fold by increasing normal pH 5 to pH 8.
Alkinization of urine involves bicarb IV and monitoring of urine pH - ALSO MONITOR [K+]. If K+ is low or low/norm, IT may not follow Bicarb into the urine, if low K+ may be replaced by H+ and keeing urine pH low.
Name the 4 Mainstays in Aspirin Toxicity Treatment:
Aspirin toxicity has no Antidote. Treatment focuses on:
1) Getting it out of the GI system. Gastric lavage w/activated charcoal if within 1-4 hrs.
2) If enteric coated aspirin was ingested, try whole bowel lavage with polyethylene glycol (Miralax, Ducolax)
3) Give Dextrose boluses to increase BG to the brain even if BG is normal
4) Alkinalize Urine with BiCarb infusion but… KEEP A GOOD EYE on your K+!!! If if drops even to low normal, this won’t work.
Carbon Monoxide Poisoning Dx Test
Carboxy Hb levels
Normal is under 3% in NONsmokers
Smokers can have up to 15%
Carboxy Hb forms when CO displaces O2 on the Hb molecule. This occurs not only in CO inhalation toxicity but also in Methylene Chloride poisoning. Methylene Chloride is solvent used in paints which gets metabolized by the liver into CO which then binds up the Hb. This is the problem with huffing paint. It can be absorbed dermally or ingested in addition to inhalation.
Benzodiazapene Toxicity, Dx + Rx:
Pure Benzo overdoses don’t usually cause death but mixed with alcohol or other sedative/hypnotics, Benzos can potentiate adverse and lethal effects of the other drugs:
Nystagmus is a clue you have benzos on board
Respiratory depression can also occur at very large doses, usually IV
Classic Antidote is Flumanizil, but its use in massive benzo overdose is controversial d/t potential side effects.
911 Rx for seizures (straight up or toxicity related)
Lorazapam IV or Diazapam nasal or rectal or IV or PHENOBARBITOL for normal seizures, think twice about using them if poisoning is suspected as benzos can potentiate the effects of other drugs that may be on board.
Phentoin (dilantin) for POISON caused seizures
so as to avoid benzo complications.
Activated Charcoal dose + regimen
1g/Kg in the first hour, preferably via Gastric Lavage.
Not so effective after 1 hr though some try it up to 3hrs.
TCA toxicity on EKG
Check out aVR & aVL for the brugada-like “M” sign, curved R waves with a sharp S, not usually too tall…
TCA antidote is BICARB IV
Tests for your comatose pt arriving in the ER with NO history or suggestions as to how he got this way
DONT therapy: Dextrose, O2, Naloxone and Thiamine also Flumanizil
EKG!!!!!!!!!!!!!!! CBC Blood Tox CMP Head CT withOUT contrast Blood Gases if respirations are depressed Urine screen Blood Glucose Stick
Drug classes that cause hyperthermia
The Antis + Ethanol/Sedative withdrawal
Drugs that cause hypOthermia
Alcohol
Hypnotics
Neuroleptics that end in "zine"
phenothiazines
Opiates
HypoglycemiaPupils dilate (mydriasis) with
Anticholinergics (atropine…)
Hypoxia/death
Sympathomimetics (stimulants)
Myosis/Pupils constrict with
Opiates
Cholinergics (all the Antis…)
Sedative/Hypnotics
FIRST thing to check on the med list of the BRADYCARDIC pt, usually older pt…
BETA BLOCKERS!!!!!!
BB + CCBs can cause significant brady and are often used together in AFIB Rx but if renal clearance is compromised….. too much can remain active in the blood!
Pt will obviously also be hypotensive
Inhalent toxicity in the ER
Comes down mainly to CO poisoning as the chemicals are degraded in the liver to CO.
Protect the airway!!!!!!!
O2, hyperbaric if necessary
Sedate if combative
Rx bronchospasms w/Albuterol nebs PRN
CCl4 toxicity - Dry Cleaning…
Mucomyst helps (0:
Alkyl-Nitrite (Poppers) toxicity Rx
Alkyl-Nitrites are alkyl esters of Nitric Acid. They are gaseous at room temperature and cause massive but brief dilation of blood vessels and relaxation of smooth muscle (including sphincters…). Poppers are mainly associated with the gay culture where they are commonly used to enhance sexual pleasure.
If inhaled, they may cause problems related to bottoming out of BP and the surge in blood to the brain: usually a headache after 5 or so minutes.
The big problem is usually when they’re ingested or WORSE when they’re aspirated into lung tissue.
Ingestion causes methemoglobinuria - RX is Methylene Blue
Aspiration can cause lipoid pneumonia and I can easily prove fatal.
Of course these should never be used with Viagara/Cialis or any other vasodilators d/t potential for irreversible BP drop.
Dilated pupils + Hot/dry
Anti-Cholinergic poisoning (any of the ANTIS) give Atropine to counter hot as a hare/dry as a bone with sludge side effects
Dilated pupils + wet
Cholinergic poisoning (sludgy - Atropine or organophosphates) give physostigmine to counter sludge with hot as a hare/dry as a bone
Cushings Triad for? Consists of?
Brain Herniation usually due to trauma/ intra-cranial bleed/ increased pressure
1) HTN
2) Widening Pulse pressure - SBp and DBp diverge over time. SBp rises and DBp falls
3) Bradycardia
Intracerebral Hemorrage
Caused by Trauma or Hemorrhagic Stroke
Sub arachnoid vs Sub Dural
Sub Arach = burst aneurysm - Arterial/Fast/Pain
SubDural= Venous, concussion, slow, ache
Sub Arachnoid vs Intracerebral
Sub Arach = severe HA without N/V
Intracerebral= severe HA WITH N/V
The vomit center gets compressed quickly in IC whereas a Sub Arach bleed will take a while to affect the vomit center.
Cushings Response
Hypothalamic response to decreased O2, sends Epi to the heart to speed it up in Bradycardia.
CD4 under 250
Do HIV test or if + already look for infection
If under 200, Rx with Bactrim DS until CD4 is back over 200
If under 50, add Azithromycin until back over 200.
AIDS PPD (+)
Greater than 5mm- even a small rxn in an HIV+ person bears further investigation.
Normal is 10mm
Aplenic pts get what kind of pneumo?
Strep pneumo
Are petechiae or rash more worrisome in Neisseria Menningititus?
Septic here, not CNS
Petechiae (begins at wrists & ankles works its way to trunk) . Rash is earlier, still time to treat with… Cephtriaxone
Empiric for contacts is rifampin 2 days or Cipro
Gold std dx for meningococcal dz
PCR
polymerase chain run
Bacterial Meningitis, cell type clue
85% of the leukocytes will be polymorphonuclear
Empiric Bacterial Meningitis Rx
Cephtriaxone & Vanco - vanco usually too big to get thru the BBB but its porous in Meningitis.
ADD
Ampicillin in neonates and over 50s
Necrotizing Fascitis Rx
AClCi or ACC
Ampicillin + Clindamycin + Cipro
Endocarditis signs
Janeway - painless palms & soles
Osler - painful, fingers
Roth - red rimmed white spots on retina
Endocarditis Staph, Pseudomonas or Strep P
Vanco or Gentamycin IV
Endocarditis Strep Viridans & Group D strep
Pen G or Vanco
Pneumonia in Neonates
(Group B Strep, Listeria, E. Coli & Klebsiella) empiric RX
Ampicillin IV
Infant (1-3mo) pneumonia causes + Rx
Chlamydia
Gonorrhea
Given at birth but take longer to develop as pneumonia
Rx is Erythromycin or IV Amox/Ampicillin
Pneumo 3-5 yrs
Bug + Rx
3-5 is usually VIRAL Pneumo
RSV or Influenza
get vaccines
Tamiflu if in first 3 days
If bacterial try Amox or Macrolide
5-18 Pneumonia
is usually Mycoplasma
Macrolide
Adult Pneumo Community Acq
Strep Pneumo give Penn G or Cephtriaxone
25% Strep pneumo is macrolide resistant
Hypnotic Toxidrome
BIG PUPILS (like Mogli)
Nystagmus
Cool Dry Skin
Ataxia (stumbly)
Neurogenic Shock Causes
Brain Injury
Anesthesia
This is LOW Bp WITHOUT any compensatory tachycardia
Visible sign may be venous pooling of blood in lower extremities.
Try Epi/Nor with Vasopressin
Septic shock sign
Fever/Ill
IV therapy doesn’t bring Bp up
There IS compensatory tachycardia
This pt will die of DIC as their plasma continues to leak out leaving RBCs to clot in their veins & arteries
Try Epi + Vasopressin
Histamine Blocker?
But get ABX running ASAP
Maybe FFPlasma?
Abdominal Pain? Get a
CT
Histotoxic Hypoxia?
Toxin inhibits Hb’s ability to take up oxygen, mitochodrial failure follows
CO and Cyanide toxicity work this way
Neurogenic Shock
Fight or Flight Autonomic gets knocked out by CNS trauma
No Epi is released so Vessels dilate - Low Bp
Nothing opposes Vagus so Heartbeat Slows - Bradycardia
Spinal Shock
Is not circulatory in nature
Occurs when there is a spinal injury, usually a transaction and there is initially no change in vitals
There IS a loss of sensation distal to the spinal lesion followed by a loss of motor control and hyperreflexia in those joints distal to the lesions.
EPI + Dopamine are first line with NOR ad ADH/Vasopressin, try to restore the sympathetic neurotransmitters and thus sympathetic tone to the peripheral vasculature and also tie Vagus some opposition at the heart.
If Vagus is still dominant after Epi/Dopamine is administered, ATROPINE may help
