syncope and discharge Flashcards
1
Q
syncope
A
- sudden, transient LOC
- inability to maintain postural tone
- higher incidence and morbidity in elderly
2
Q
near syncope
A
- premonition of syncope without LOC
- shares same pathophys
3
Q
etiologies of syncope
A
- neurologic
- reflex mediated/ vasovagal/ faint/ psychogenic shock
- cardiac syncope/ dysrhythmia
- orthostatic hypotension
4
Q
what are the most common causes of syncope
A
- vasovagal
- orthostatic
5
Q
neurologic syncope
A
- rarely primary cause
- TIA
- subclavian steel
- basilar a migraine
- vertebrobasilar atherosclerosis
- SAH
6
Q
SAH
A
- may present with syncope d/t increases pressure -> decreased cerebral perfusion
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
8
Q
tx of SAH
A
- consult neurosurg stat
9
Q
what is the stimulus for vasovagal syncope
A
- fear
- emotional stress
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- causes increased sympathetic response then inappropriately withdrawn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
11
Q
warning signs of vasovagal syncope
A
- rarely occurs without signs
- nausea
- feeling flushed
- dizziness
- pt reports “not feeling well”
12
Q
how do you abort vasovagal syncope and why
A
- reclined position
- trandelenburg position
- increased central circulation and cerebral perfusion
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
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
15
Q
possible causes of cardiac syncope
A
- HOCM
- severe AS
- ischemic heart disease
- prolonged QT
- lyme disease
16
Q
what PE findings suggest cardiac syncope
A
- lack of defensive injuries to hands or knees
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
18
Q
what do you do if HR is too fast
A
- cardioversion
19
Q
what do you do if HR is too slow
A
- transcutaneous pacing
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
VNA care
- pts need part time nursing or rehab but cant get out of the house
26
skilled nursing facility (SNF)
- 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
acute rehab/ short term rehab
- no medical needs
- improved conditioning
- must be able to participate in 2-3 hours of therapy a day
- usu stay 2-6 weeks
28
long term acute care
- condition stabilized
- dont need acute care
- require more care than with VNA, STR, or SNF
- may need to be on vent long term
29
hospice care
- 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
alcohol withdrawal syndrome
- can be life threatening*
- can occur as soon as 6 hours, peaks 2-3 days
- can last 7 d
31
what is the most severe consequence of alcohol withdrawal
- delirium tremens
| - can be fatal if untreated
32
pathophys of alcohol withdrawal
- etoh enhances gaba -> reduced excitability
- etoh inhibits NMDA -> up-regulation
- abrupt cessation -> higher brain excitability
33
kindling phenomenon
- long term changes in neurons after repeated alcohol detox
- increased obsessive thought and alcohol cravings
- withdrawal worsens
34
alcohol cessations days 0-1
- anxiety
- HA
- palpitations
- GI upset
35
alcohol cessations days 1-2
- tonic clonic seizures (can be as early as 2 horus)
| - hallucinations: visual, auditory, tactile
36
delirum tremens
- agitation
- disorientation
- tachycardia
- HTN
- diaphoresis
- fever
- peaks days 5-7
37
key aspects of history for alcohol withdrawal
- 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
what lab finding suggests alcohol abuse
- AST significantly > ALT
39
c/i to OP treatment of alcohol withdrawal
- 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
what is PAWS score
- 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
what is CIWA
- 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
goals of alcohol withdrawal care
- safe withdrawal
- humane and protect dignity
- prep for ongoing tx of SUD
43
general tx of alcohol withdrawal
- correct fluids, electrolytes, nutrition- often need K and Mg
- thaimine before glucose to prevent Wernicke's encephalopathy
44
what is Wernicke's encephalopathy
- 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
sx triggered withdrawal regimens
- CIWA every hour
- admin librium, valium or ativan q1 hour if CIWA 8-10
- show to be less medication and shorter duration
46
fixed tx regimens for withdrawal
- admin regimen every 6 hours
- librium, valium, ativan
- PRN based on CIWA 8-10
47
pharm tx options for withdrawal
- 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
adjunct meds for withdrawal tx
- haldol- good for agitation and hallucinations but lowers sz threshold
- atenolol- good for vitals, consider CAD
- clonidine: ANS sx
- phenytoin
