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Therapeutics II > syncope and discharge > Flashcards

syncope and discharge Flashcards

1
Q

syncope

A
  • sudden, transient LOC
  • inability to maintain postural tone
  • higher incidence and morbidity in elderly
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2
Q

near syncope

A
  • premonition of syncope without LOC

- shares same pathophys

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3
Q

etiologies of syncope

A
  • neurologic
  • reflex mediated/ vasovagal/ faint/ psychogenic shock
  • cardiac syncope/ dysrhythmia
  • orthostatic hypotension
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4
Q

what are the most common causes of syncope

A
  • vasovagal

- orthostatic

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5
Q

neurologic syncope

A
  • rarely primary cause
  • TIA
  • subclavian steel
  • basilar a migraine
  • vertebrobasilar atherosclerosis
  • SAH
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6
Q

SAH

A
  • may present with syncope d/t increases pressure -> decreased cerebral perfusion
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7
Q

work up for SAH

A
  • H&P
  • O2, IV, monitor
  • rainbow labs
  • glucose
  • stat noncontrast CT
  • can consider LP if CT is nondx- would show xanthochromia
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8
Q

tx of SAH

A
  • consult neurosurg stat
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9
Q

what is the stimulus for vasovagal syncope

A
  • fear

- emotional stress

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10
Q

pathophys of vasovagal syncope

A
  • abnormal autonomic NS reflex
  • causes increased sympathetic response then inappropriately withdrawn
  • replaced by increased vagal tone
  • hypotension +/- bradycardia -> decreased cerebral perfusion -> syncope
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11
Q

warning signs of vasovagal syncope

A
  • rarely occurs without signs
  • nausea
  • feeling flushed
  • dizziness
  • pt reports “not feeling well”
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12
Q

how do you abort vasovagal syncope and why

A
  • reclined position
  • trandelenburg position
  • increased central circulation and cerebral perfusion
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13
Q

treatment of vasovagal syncope

A
  • sips of fluid as tolerated, small snack
  • glucose + caffeinated drinks best
  • IVF ONLY if IV already in place
  • recheck pt pulse and BP
  • reposition pt to sitting, then standing slowly as tolerated
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14
Q

cardiac syncope

A
  • dysrhythmias vs structural
  • massive PE may cause syncope
  • no absolute high or low HR that causes syncope
  • syncope occurs suddenly without warning signs or premonitions
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15
Q

possible causes of cardiac syncope

A
  • HOCM
  • severe AS
  • ischemic heart disease
  • prolonged QT
  • lyme disease
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16
Q

what PE findings suggest cardiac syncope

A
  • lack of defensive injuries to hands or knees
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17
Q

initial work up for cardiac syncope

A
  • cardiac monitor and EKG
  • CBC, CMP, coags, serial trops
  • HCG
  • PCXR
  • if suspect massive PE get CTPA
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18
Q

what do you do if HR is too fast

A
  • cardioversion
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19
Q

what do you do if HR is too slow

A
  • transcutaneous pacing
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20
Q

orthostatic hypotension

A
  • fall in SBP > 20 when assuming upright pos

- most likely to occur within first 3 min after pt is upright

21
Q

why does orthostatic hypotension occur

A
  • mainly d/t volume depletion
  • can be d/t meds like BB or diuretics
  • insufficient autonomic response -> decreased cerebral perfusion
22
Q

what population is orthostatic hypotension most common in

A
  • elderly
23
Q

assessment of orthostatic hyptension

A
  • assess mental status
  • resting HR
  • get orthostatic vitals in supine and standing (HR and BP)
  • assess for signs of dehydration
  • assess for GIB
  • labs not usu done unless H&P suggests abnorm
24
Q

treatment of orthostatic hypotension

A
  • based on clinical/ and or lab findings
  • withhold HTN meds temporarily
  • best rest
  • increased PO intake, possible IVF
  • refer to GI if GIB, potential blood products
25
Q

VNA care

A
  • pts need part time nursing or rehab but cant get out of the house
26
Q

skilled nursing facility (SNF)

A
  • focused on medical care
  • no longer need acute care but not ready for home
  • must have 3 day stay in hosp within 30 days of going to SNF
  • medicare pays 100% for first 20 days then copay after that
  • usu stay a few days- several weeks
27
Q

acute rehab/ short term rehab

A
  • no medical needs
  • improved conditioning
  • must be able to participate in 2-3 hours of therapy a day
  • usu stay 2-6 weeks
28
Q

long term acute care

A
  • condition stabilized
  • dont need acute care
  • require more care than with VNA, STR, or SNF
  • may need to be on vent long term
29
Q

hospice care

A
  • dx of terminal illness and life prognosis of < 6 mo
  • can bea t home or in fascility
  • if pt lives > 6 mo just renew the benefit
30
Q

alcohol withdrawal syndrome

A
  • can be life threatening*
  • can occur as soon as 6 hours, peaks 2-3 days
  • can last 7 d
31
Q

what is the most severe consequence of alcohol withdrawal

A
  • delirium tremens

- can be fatal if untreated

32
Q

pathophys of alcohol withdrawal

A
  • etoh enhances gaba -> reduced excitability
  • etoh inhibits NMDA -> up-regulation
  • abrupt cessation -> higher brain excitability
33
Q

kindling phenomenon

A
  • long term changes in neurons after repeated alcohol detox
  • increased obsessive thought and alcohol cravings
  • withdrawal worsens
34
Q

alcohol cessations days 0-1

A
  • anxiety
  • HA
  • palpitations
  • GI upset
35
Q

alcohol cessations days 1-2

A
  • tonic clonic seizures (can be as early as 2 horus)

- hallucinations: visual, auditory, tactile

36
Q

delirum tremens

A
  • agitation
  • disorientation
  • tachycardia
  • HTN
  • diaphoresis
  • fever
  • peaks days 5-7
37
Q

key aspects of history for alcohol withdrawal

A
  • how much etoh use
  • duration of use
  • time since last drink
  • hx of prev withdrawal
  • concurrent med and psych conditions
  • abuse of other agents
38
Q

what lab finding suggests alcohol abuse

A
  • AST significantly > ALT
39
Q

c/i to OP treatment of alcohol withdrawal

A
  • abnormal labs
  • no support network
  • acute illness
  • high risk delirium tremens
  • long term intake of large amounts of alcohol
  • poorly controlled med conditions
  • severe sx
  • urine drug screen pos for other substances
40
Q

what is PAWS score

A
  • prediction of alcohol withdrawal severity score
  • part A: threshold criteria- drank in last 30 days, + BAL on admisison
  • part b: pt interview
  • part c: BAL > 200, si of increased autonomic activity
41
Q

what is CIWA

A
  • clinical institute withdrawal assessment
  • 10 item assessment tool
  • quantify severity of withdrawal
  • provide guidance on monitoring and meds
  • 8 or less: mild
  • 15+: severe, increased risk DT and sz
  • repeated q2 hours
42
Q

goals of alcohol withdrawal care

A
  • safe withdrawal
  • humane and protect dignity
  • prep for ongoing tx of SUD
43
Q

general tx of alcohol withdrawal

A
  • correct fluids, electrolytes, nutrition- often need K and Mg
  • thaimine before glucose to prevent Wernicke’s encephalopathy
44
Q

what is Wernicke’s encephalopathy

A
  • d/t thiamine def (B1)
  • opthalmaplegia
  • cerebellar dysfunction
  • confusion
  • korsakoff’s is late manifestation- amnestic syndrome that is not reversible
  • may progress to severe psychosis
45
Q

sx triggered withdrawal regimens

A
  • CIWA every hour
  • admin librium, valium or ativan q1 hour if CIWA 8-10
  • show to be less medication and shorter duration
46
Q

fixed tx regimens for withdrawal

A
  • admin regimen every 6 hours
  • librium, valium, ativan
  • PRN based on CIWA 8-10
47
Q

pharm tx options for withdrawal

A
  • BZDs- safe effective, prevent sz and delirium
  • phenobarb is coming into favor, matched pathophys of alcohol withdrawal
  • valium and librium are longer acting
  • ativan is immed acting, better for trouble metabolizing, elderly, and liver failure
48
Q

adjunct meds for withdrawal tx

A
  • haldol- good for agitation and hallucinations but lowers sz threshold
  • atenolol- good for vitals, consider CAD
  • clonidine: ANS sx
  • phenytoin

Therapeutics II (8 decks)

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