Test 1 misc 2 Flashcards
submersion injury timeline to poor outcome in normal water temp
4-5 min
severe resp complication of submersion injury
ARDS
Post Submersion Neuro Class
Alert, fully conscious
A
Post Submersion Neuro Class
Obtunded, stuporous but arousable; purposeful response to pain; normal respiration
B
Post Submersion Neuro Class
Comatose; not arousable; abnormal response to pain; abnormal resp
C
Post Submersion Neuro Class
flexor to pain, cheyne stokes
C1
Post Submersion Neuro Class
Extensor response to pain; central hyperventilation
C2
Post Submersion Neuro Class
Flaccid; apneic
C3
initial chest x ray expectation for submersion injury
Initial Chest x-ray can be normal, show patchy infiltrates (frequently in the periphery or bibasilar regions) or show pulmonary edema.
what pH imbalance do you expect in submersion injury
resp acidosis that leads to metabolic acidosis due to lactic acid buildup
Treating submersion injury
Some patients require positive pressure for 48-72 hours,
§ Antibiotics and steroids are not indicated unless the pt becomes febrile
§ Hypovolemia should be treated with isotonic crystalloids (10-20 mL/kg). inotropic support with dopamine, dobutamine or epi can be required if continued hypertension or poor perfusion are ongoing.
Abnormal CT= most likely death
§ Is the patient is symptomatic evaluation via arterial BG, and chest x-ray should be done. Also consider a CBC, coag studies, and electrolyte panel.
submersion injury obs time and necessary orders if well appearing
prolonged time frame after submersion incident because even mild hypoxia can increase permeability of pulm capillaries with alveolar fluid leak and surfactant damage
Pulse oximetry monitoring
ABG if resp distress
Chest x ray (all submersion victims)
symptoms commonly seen with submersion injury
anxiety, vomiting, cough, wheezing, hypothermia, altered mental status, metabolic acidosis, respiratory failure, and finally respiratory/cardiac arrest.
Kline, Andrea M.; Haut, Catherine. Lippincott Certification Review: Pediatric Acute Care Nurse Practitioner (p. 1031). Wolters Kluwer Health. Kindle Edition.
______ should be used to prevent atelectasis and overcome intrapulmonary shunting
Positive end expiratory pressure
CN impairment initially in Botulism
Bulbar Palsy IX X XI XII
Treatment in Infant Botulism
mostly supportive by assisting in breathing
Presentation of Infant Botulism
§ Usually starts from the head down, with oculobulbar muscle weakness, blurring of vision, dipoplia, ptosis, ophthalmoplegia, dysarthria, and dysphagia.
§ Infants usually present listless, feeding poorly, have a weak cry, and are constipated. This is followed by a descending pattern of weakness with the upper limbs, lower limbs, and ultimately the respiratory muscles.
§ Occurs more frequently in infants less than 6 months of age but can occur up to 1 year of age.
§ S&S- constipation, lethargy, poor feeding, excessive drooling, and increasing weakness.
§ On physical exam, general hypotonia and symmetrical cranial nerve palsies are present. Infants appear to have expressionless face. CRANIAL NERVE PALSIES ARE ALWAYS PRESENT, and part of the definitive diagnosis.
management for infant botulism
§ There is an infant botulism antitoxin (BIG-IV) -Administration of human botulism immune globulin intravenous (BIG-IV).
available and if used early markedly shortens the intensive care course. Abx are not usually recommended because they will lyse bacteria and release more toxin into the circulation.
§ Feed via NG tube or NJ tube.
bacteria that causes botulism
bacteria,
Kline, Andrea M.; Haut, Catherine. Lippincott Certification Review: Pediatric Acute Care Nurse Practitioner (p. 572). Wolters Kluwer Health. Kindle Edition.
•Infants have weak cry, expressionless face, ptosis, and sluggish pupillary responses. Gag, suck, and swallow reflexes are diminished or may be absent.
Botulism
causes of meningitis in Neonates
Group B Strep,
E. Coli
Listeria monocytogenes
Klebsiella species
causes of meningitis in infants 3 months-9mos
Strep Pneumoniae Nesseria meningitidis (group B strep is responsible for small amounts of meningitis H. influenzae type B
causes of meningitis in children 10-18 yrs
N. meningitidis is responsible for the majority of bacterial meningitis cases.
streptococcus pneumonia
H. influenzae
meningitis in unvaccinated children, what etiology to consider
IF CHILDREN ARE UNVACCINATED!!! Think possibly H. influenzae type B, also if in an underdeveloped countries.
most common cause of viral meningoencephalitis
Enterovirus
Bacterial meningitis usually involves the fluid in the ______ space
subarachnoid
causes of Meningitis in 5 yr old
N. Meningitis
Strep pneumoniae
Meningeal signs of meningitis
Severe throbbing headache
Photophobia
nuchal rigidity
Kernig sign: Passive extension of the knee in supine position, resulting in back pain and resistance. • Brudzinski sign: • Passive flexion of the neck, resulting in involuntary flexion of the knees and hips.
csf changes associated with bacterial meningitis
Increased WBC increased protein decreased glucose increase pressure increased lactate (>25 is indicative of bacterial meningitis
abx for meningitis with recent neurosurgery or ventricular shunt
vancomycin + cefepime; vancomycin + ceftazidime; or vancomycin + meropenem. •
abx for meningitis with basilar skull fx
vancomycin + 3rd-generation cephalosporin.
abx for meningitis older than 1 mos
empirical broad-spectrum antimicrobial coverage with VANCOMYCIN, and either cefotaxime or ceftriaxone should be started.
§ ACYCLOVIR should be initiated for all infants and children with suspected HSV encephalitis.
most common cause of meningitis in children
viral meningitis - specific agent not usually specified but (Enterovirus >80% of cases)
other echovirus, coxsackievirus, arbovirus, mumps, EBV, Cytomegalovirus, Varicella, adenovirus, HSV
csf changes in viral meningitis
glucose normal, slightly decreased
Protein slightly increased
WBC - mildly increased
what is the gold standard for diagnosis of HSV meningitis
CSF PCR for HSV
management of viral meningitis
self limiting - resolves in 7-10 days
control seizures
acyclovir if HSV meningitis is suspected
differences/additional symptoms in HSV meningitis
function: ataxia, focal neurologic signs, acute encephalopathy (high suspicion).
Kline, Andrea M.; Haut, Catherine. Lippincott Certification Review: Pediatric Acute Care Nurse Practitioner (p. 604). Wolters Kluwer Health. Kindle Edition.
GBS has what shape bacteria (ie: gram neg, gram pos…)
gram positive cocci
what is the gold standard test for determining if a case of meningitis is bacterial in etiology
CSF bacterial culture
steroid injections make you more at risk for what kind of meningitis
fungal infection
what csf test tests for fungal meningitis
beta-D-glucan
suspect viral meningitis over bacterial when you see what in csf
normal glucose and protein levels along with a lower WBC with a monocytic predominance
if pathogens make it into the brain parenchyma itself, the response is
Encephalitis
most common cause of pure encephalitis
enterovirus
temporal lobe enhancement on CT is a symptom of
HSV encephalitis
presence of RBCs in CSF is suggestive of
Herpes Simplex encephalitis
Ampicillin covers what type of meningitis
Listeria monocytogenes
Medications to avoid with eating disorders
TCAs - cardiotoxicity in malnourished individuals
Bupropion - increased risk of seizures in individuals with eating disorders
complications of Bulimia nervosa
erotion of enamil
sialadenosis (swelling of parotid gland)
bad breath
Russels sign - calleouses on knuckles from making yourself vomit
Tears in distal esophagus or stomach itself (Mallory Weiss syndrome - abd pain and hematemesis)
Amenorrhea
type 2 DM
Russels sign
sign of Bulimia nervosa - callous on knuckles
Mallory weiss syndrome
associated with Bulimia nervosa - tears in distal esophagus or stomach resulting in abd pain and hematemesis
Bulimia Nervosa: What does BP HR: Electrolytes: Ph:
Dehydration causes
Hypotension (<90/50)
Tachycardia HR >100
Electrolytes low NA Cl Mg phosphorous K+
General Metabolic Alkalosis
Lab tests to order in Bulimia nervosa
Serum electrolytes serum creatinine BUN CBC with diff LFTs Urinalysis
Pharm for Bulimia Nervosa
SSRI
choice is Fluoxetine
If they dont respond, try diff SSRI - Sertraline
If dont respond or tolerate -> Either tricyclic antidepressant Trazodone MAOIs Topiramate
Med you cant describe for a pt with Bulimia nervosa
Bupropion - increased risk of seizures in individuals with eating disorders
Binge Eating disorder treatment
Psychotherapy is first line
second line is
SSRI s
third line is Topiramate
Mod severe cases may benefit from Lisdexamfetamine
what is the unintentional Food regurgitation disorder
called: Rumination Disorder
nor due to a medical disorder
not purposeful
associated with mood disorders
What diagnostics rule out other differentials for Rumination disorder
High resolution impedance manometry testing
upper GI endoscopy
initial management for rumination disorder
Education and treatment of mood disorder
Diaphragmatic abd breathing immediately after a meal and for 10-15 min after
if initial mgmt of rumination disorder doesnt work, what meds can you try
Baclofen
increases LES tone
decreases LES relaxation
diagnostic criterion for PICA
strong cravings to eat non-food items >= month
has to be culturally inappropriate
should not happen in the context of another health condition such as schizophrenia, autism or another eating disorder
what is PICA associated with
anemia (esp iron deficiency)
emotional trauma
malnutrition
comorbid psychiatric disorders
complications with PICA
nutritional deprivation anemia toxicity constipation intestinal obstruction parasitic infections jaw or tooth injury weight changes
treatment for PICA
1) Nutritional rehab and psychotherapy
Identify substance -> decrease exposure -> healthier alt to decrease cravings
If comorbid psych disorders -> SSRIs
significant food restrictions at least once a week for 3 months with fear of gaining weight and BMI below 18.5
Anorexia
cycles of binging and purging once a week for 3 months with normal weight or over weight (BMI >18.5)
Bulimia
large amounts of food that causes lots of insulin to be released which leads to cellular intake of electrolytes and produces arrhythmias
Refeeding syndrome
expected weight gain in anorexia in hospitalized vs outpatient patients
2-3 lbs/week (hospitalized)
0.5-1lb/week (outpatients)
how many kcal/kg/day in anorexia treatment
30-40 kcal/kg/day
in bulimia, what acid base disorder is seen
metabolic alkalosis
Salicylate intoxication Hyperventilation Hyperthyroidism Interstitial pulmonary disease CNS diseases
causes what acid base imbalance
Resp alkalosis
High pH
low CO2
diarrhea will cause what acid base imbalance
metabolic acidosis
low pH
low HCO3
Methanol Uremia DKA Paraldehyde Isoniazid and iron lactic acid ethanol glycol ethanol induced ketoacidosis salicylates
All do what do your anion gap and give you what kind of a acid base imbalance
increased anion gap metabolic acidosis
low pH
low HCO3
Loss of gastric acid due to vomiting NG suctioning Diuretic use Alterations to parenteral nutrition Excessive bicarb administration
all put you at risk for what kind of acid base balance
metabolic alkalosis
high pH
High bicarb
