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CDM2 - Final > Van Bockern - Inpatient Emergencies > Flashcards

Van Bockern - Inpatient Emergencies Flashcards

1
Q

what labs did we decide to order for the HIV pt who presented w. AMS after biting off and swallowing his finger (5)

A

CBC
urine tox
viral load
blood cultures
lactate

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2
Q

dx to not forget on your differential in pt w. AMS and multiple sexual partners

A

neurosyphilis

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3
Q

what imaging did we order for the HIV pt who bit off his finger

A

CT-head
hand xr
abd xr

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4
Q

what was the treatment plan for the HIV pt who bit off his finger (3)

A

vanco
unasyn
IVF

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5
Q

what does MET stand for
what does RRT stand for

A

medical emergency team
rapid response team

same same

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6
Q

multidisciplinary team most frequently consisting of ICU-trained personnel for eval of pt’s not in the ICU who develop signs/symptoms of clinical deterioration

A

MET/RRT

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7
Q

when does the MET/RRT intervene

A

prior to code blue (deterioration)

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8
Q

goal of MET/RRT (2)

A

prevent cardiac arrest
ensure goals of care have been addressed

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9
Q

MET/RRT includes (7)

A

ICU residents/fellow/attending
medicine floor team
critical care RN
RT
pharmacy
house supervisor
security

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10
Q

denver health RRT includes (5)

A

critical RN
floor RN
pharmacy
RT
PA hospitalist

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11
Q

activation criteria for MET/RRT (10)

A

RR < 6 OR > 30
HR < 40 OR > 140
SBP < 90
symptomatic HTN
decrease in level of consciousness
unexplained agitation
seizure
significant fall in urine output
subjective concern about pt
per ACLS criteria 2015

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12
Q

top 3 reasons for MET/RRT activation

A
  1. AMS
  2. tachycardia
  3. tachypnea
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13
Q

3 components of structured assessment

A
  1. BLS -> are they breathing
  2. primary assessment -> ABCDE
  3. secondary assessment -> SAMPLE, ddx
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14
Q

what does ABCDE stand for

A

airway
breathing
circulation
disability
exposure

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15
Q

how do you manage airway/breathing (3)

A

O2
NIPPV
intubation

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16
Q

how do you manage circulation (3)

A

IV
monitor
vitals

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17
Q

how do you manage disability (2)

A

glucose
neuro assessment

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18
Q

how do you manage exposure

A

look at pt
surgical sites

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19
Q

what does “sample” stand for

A

signs/symptoms
allergies
meds
pmh
last PO
events leading up to

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20
Q

basic interventions during primary assessment

A

IV/O2/monitor
vitals/glucose

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21
Q

what does aeiou tips stand for

A

abuse of etoh/drugs
acidosis
epilepsy/electrolytes/encephalopathy/endocrine
infection
overdose/O2
uremia
trauma/tumor
insulin
psychiatric/psychosis/poisons
stroke/shock

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22
Q

69 yo f w. HTN, T2DM
s/p gastric antrectomy for PUD, POD5 due to post op ileus and inability to tolerate enteral nutrition

airway patent, mild tachypnea but speaking in full sentences, sinus tachy, warm extremities, BG 83, surgical incision looks good

what is your initial intervention (3)

A

address IV access
fluid bolus for hypotn
APAP for fever

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23
Q

for previous pt:

s: gradually more confused throughout day
a: doxy
m: MAR notable for frequent dilaudid dosing
p: HTN, T2DM, s/p gastric antrectomy w. post op ileus
l: NPO
e: gradual confusion

what labs/imaging do you order

A

labs: cbc, cmp, lactate, blood cultures, UA
imaging: CT-H, CXR, CT abd/pelvis

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24
Q

previous pt’s labs:

WBC 16.0 (up from 8)
Cr: 2.1 (baseline 1.0)
lactate: 4.2
CXR: bibasilar infiltrates

what is your ddx (3)

A

severe sepsis
HAP
AKI

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25
Q

go to tx for HAP

A

cefepime

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26
Q

tx for previous pt

A

cefepime PLUS vanco (HAP)
fluids for hypotn
trended lactate q 1-2 hr
blood cultures
d/c w. PO abx

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27
Q

what’s the purpose of trended lactates

A

check for sepsis tx efficacy

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28
Q

what does FAST stand for

A

face
arms
speech
time

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29
Q

80 yo m w. PMH HTN, T2DM, CKD3 - admitted w. CP - has NSTEMI
he was given ASA and started on heparin gtt w. plans for cardiac catheterization in the morning

you take over pt and he is aphasic w. left-sided weakness - she calls a stroke alert

what is the most important next step

A

ask last normal!

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30
Q

initial stroke alert includes (4)

A

brief neuro exam
last known normal!!
glucose
start NIHSS stroke scale

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31
Q

after stroke alert, what imaging do you order

A

CT-H w.o contrast
plus neuro consult

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32
Q

time frame for stroke alert

A

10 min: door to doctor
15 min: neurologist
25 min: door to CT completion
45 min: door to CT interpretation
60 min: door to tx
3 hr: admission to ICU

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33
Q

time of stroke onset =

A

last time seen normal

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34
Q

timeframe for tPA

A

0-4.5 hr

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35
Q

timeframe for mechanical embelectomy for all
vs
for some

A

for all: 0-6 hr
for some: 6-24 hr

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36
Q

for our NSTEMI pt with the stroke alert:
BG and vitals are normal
last known normal was 2 hr ago
initial NIHSS is 12
CT-H shows massive intraparenchymal bleed

what do you do

A

consult neuro -> reverse heparin

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37
Q

mean time to tx for stroke pt’s

A

144 min

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38
Q

what outcomes improve with each 15 minutes of earlier tPA administration

A

lower in-house mortality
lower rates of ICH
more independent ambulation at d.c
higher rate of d.c to home

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39
Q

clinical definition of status epilepticus

A

sz lasting > 5 min
OR
recurrent sz w.o return to baseline mental status

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40
Q

technical definition of status epilepticus

A

sz lasting > 30 min

but you shouldn’t let someone seize for that long duh

41
Q

5 causes of seizure

A

metabolic
infxn
withdrawal
CNS lesion
intoxication

42
Q

2 metabolic causes of sz

A

hypoglycemia
hyponatremia

43
Q

3 infectious causes of sz

A

CNS abscess
meningitis
encephalitis

44
Q

withdrawal from what 3 drugs can cause sz

A

etoh
benzos
antiepileptics

45
Q

intoxication from what 2 illicit drugs can cause sz

A

MDMA
synthetic canabinoids

46
Q

what diagnostics are included in sz work up

A

CBC, CMP, Mg, Phos, lactate
antiepileptic drug levels
+/- CT-H, lumbar puncture
urine tox
EEG

47
Q

first line management of status epilepticus (4)

A

lateral decubitus position
airway/breathing
lorazepam vs midazolam
BG level

48
Q

when do you use lorazepam for status epilepticus

A

if you have IV access ->
4 mg IV push over 2 min
repeat 4 mg IV x 1 in 5 min PRN

49
Q

when do you use midazolam for status epilepticus

A

if no IV access -> 10 mg IM

50
Q

when do you use thiamine for status epilepticus

A

if BG is low or unobtainable ->
100 mg IV, followed by D50

51
Q

management of sz that persist at 10 min despite first line tx (4)

A

valproic acid
levetiracetam
phenobarbital
fosphenytoin vs phenytoin

52
Q

management of sz that persist at 30 min despite first and second line tx (2)

A

intubate
midazolam vs propofol gtt

53
Q

69 yo M, PMH HLD
BIBA from Broncos game
progressive SOB x 2-3 weeks - consistent x 1 hr
tachycardic w. diaphoresis
VS: 124/80, 130s-140s, 92% on 2L
acute distress
irregular rhythm
clear lungs

what is his EKG showing

A

afib

54
Q

for prev pt, what is his CXR showing

A

cardiomegaly

55
Q

for previous pt, what diagnostics do you order (6)

A

trop
TTE
BNP
BMP
Mg
TSH

56
Q

2 methods for rate control in afib

A

cardioversion
pharmacologic

57
Q

CHADS2 and CHA2DS2VASc

A
58
Q

for Broncos game pt w. Afib and cardiomegaly, what pharm do you start

A

metoprolol 25 mg q 6 h
CHADS score is 1 -> no AC

59
Q

for Broncos game pt w. afib and cardiomegaly, TTE shows HF and valvular dz -> CHADS score is now 3 - what do you do now

A

start AC

60
Q

for Broncos pt w. HF and afib - HR goes into the 140s and SOB persists - sbp drops to <90

what do you suspect?
what do you do? (2)

A

suspect: afib w. RVR

do: repeat EKG
begin resuscitation -> IV access/fluids, O2, vitals, tele, call support

61
Q

what conditions could lead to afib with RVR (6)

A

infxn
sepsis
hypovolemia
respiratory failure
ACS
PE

62
Q

initial work up for afib w. rvr

A

EKG
CBC
trop
BNP
CXR
UA

63
Q

why is UA helpful in afib w.rvr work up

A

to look for infxn

64
Q

in Broncos game pt w. afib and cardiomegaly, afib for secondary causes of afib was negative -
what do you do next

A

TTE with cardioversion

65
Q

why would the Broncos game pt not cardiovert

A

his HF is too decompensated -> need to get HF under control first

66
Q

how do you get decompensated HF under control so that you can cardiovert the Broncos game pt

A

d.c home with:
amiodarone
metropolol succinate
entresto
xarelto
spironolactone
lasix

67
Q

what is the role of metropolol succinate

A

rhythm control
remodeling agent
*added benefit of mortality reduction in CHF

68
Q

what is the role of amiodarone

A

rate control

69
Q

what is the role of entresto or ACEI

A

afterload reducer

70
Q

what needs to be done at follow up eval for Broncos game pt (2)

A

BMP
ischemic eval

71
Q

2 types of HF

A

HFrEF: LVF <40%
HFpEF: LVF >50%

72
Q

1 cause of HFrEF

A

MI

73
Q

1 cause of HFpEF

A

HTN

74
Q

tx for HFrEF

A

bb
ACEI

75
Q

tx for HFpEF

A

treat underlying cause

76
Q

Ddx for CP in Inpatient/ED setting

A

TTAPED:

tension PTX
tamponade
acs
PE
esophageal rupture
dissection

77
Q

-68 yo f - PMH ESRD (on HD), HLD, HTN
-admitted for hyperkalemia (K+ 6.8) w. peaked t waves
-received emergent HD and is now admitted to the floor and is having CP

what do you do

A

order EKG
order trop
go see pt

78
Q

why wouldn’t BMP be helpful for previous pt (little old lady w. CP)

A

she just got done with dialysis

79
Q

why don’t you call immediately cardiology consult in little old lady with CP

A

need objective data before you call a consult

80
Q

here is the EKG with the little old lady w. CP
what is it showing?
what do you do now?

A

wellen’s sign -> high grade stenosis of the LAD
deep T wave inversions V2-V4

now call cards

81
Q

what does cards do for little old lady w. CP

A

PCI to LAD

82
Q

what meds should the little old lady w. CP be on after her PCI (3)

A

ASA
plavix
statin

83
Q

pathophys behind IP SOB emergencies (3)

A

infxn
volume
clot

84
Q

-29 yo w. hx of bullous SLE complicated by lupus nephritis w. progressive anasarca and AKI on CKD
-renal bx confirms lupus nephritis s/p rituximab 1,000 mg x1
-hospital course c/b (complicated by) s. aureus - now on cefazoline
-you are called to bedside when pt desats to 78% and is coughing up red tinged sputum - pt is titrated from 2L NC to non-breather
-when you get there, SpO2 is 84% on 15L NRB, tachy to 100s, and sbp 150’s - lungs are course to bilateral anterior and posterior auscultation, no wheezes - heart sounds are obscured
-3+ bl LE edema, warm extremities

what do you order

A

work up for SOB:
ABG
CXR
EKG
stat bedside echo
CBC
CMP
BNP, trop, dimer
CT-PE based on results

85
Q

CXR for lupus pt
labs for lupus pt:
BNP > 20,000
trop: 23 (nl)
CBC: normocytic anemia - hgb 8.4
CMP: Cr to 4.2 (stable)
ABG: 7.4/34/52/21 on 15L NRB

what’s your ddx

A

volume overload
DAH (diffuse alveolar hemorrhage)
PNA

86
Q

how do you manage SLE pt w. SOB

A

160 IV lasix asap
call ICU
intubate
probs will need HD

87
Q

what is NIPPV (aka NPPV)

A

non invasive positive pressure ventilation ->
CPAP
BiPAP

88
Q

2 indications for NIPPV

A

cardiogenic pulmonary edema
COPD

89
Q

4 indications that a pt is a good candidate for NIPPV

A

able to protect airway
able to clear respiratory secretions
cooperative
low risk of aspiration

90
Q

absolute contraindication for NIPPV

A

cardiac or respiratory arrest

91
Q

what type of O2 delivery are vapotherm and optiflow

A

heated high flow O2

92
Q

heated high flow O2 delivers __% FIO2 at flow rates up to __ L/min

A

100%
60 L/min

93
Q

besides O2 delivery, other benefit of heated high flow O2

A

washout of dead space

94
Q

2 indications for intubation

A

failure of airway maintenance or protection
failure of ventilation or O2

95
Q

2 components of secondary assessment

A

SAMPLE
ddx

96
Q

ddx for volume overloaded pt (4)

A

CHF
CKD
iatrogenic (too much IVF)
liver dz

97
Q

labs to order for fluid overload work up

A

CMP
BNP
TTE
UA
US -> if concern for cirrhosis

98
Q

why is UA helpful in fluid overloaded pt

A

assess for nephrotic syndrome

99
Q

Tx for fluid overloaded pt

A

Lasix

CDM2 - Final (9 decks)

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