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Emergency Medicine > Vitals and Pain Management > Flashcards

Vitals and Pain Management Flashcards

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1
Q

what is the onset/duration of versed/midazolam

A

onset: 1-3 min
duration: 1 hr

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2
Q

what is the HTN emergency workup?

A

*Testing should be guided by presenting symptoms
Studies you may consider :
1. EKG : ST changes, suggesting ischemia
2. UA : Hematuria, casts, proteinuria suggesting renal impairment
3. CXR : pulmonary edema c/w CHF or Widened Mediastinum c/w Aortic dissection
4. Electrolytes: elevated Cr, hyperkalmeia
5. head CT: concern for stroke
6. Urine preg: preeclampsia
7. Urine tox

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3
Q

what is the onset/duration of ketamine

A

onset: w/ 1 min
Lasts: 10-20 min (long post procedural observation period)

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4
Q

what drug classes could you use to treat severe HTN, asymptomatic? and at what BP

A

Treat if BP is greater than 180-200/110-120

  1. diuretics
  2. betablockers
  3. ace inhibitors
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5
Q

DDX for bradycardia

A
  1. Medications
  2. drugs
  3. brain injury (cerebellar injury)
  4. Heart blocks
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6
Q

how do you evaluate a patient before a procedural sedation?

A
  1. Hx- last meal, allergies, substance use/abuse, previous anestheisia use/complications
  2. PE- airway, heart lungs
  3. fasting preferred

*pts w/ severe cardiac or pulm. problems are poor candidate

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7
Q

when would you use an ACE inhibitor to treat severe HTN, asymptomatic?

A

HF, renal disease, stroke, DM

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8
Q

4 month girl, w/ Fevers, pulling at her right ear. Mom hasn’t given her anything. How will you treat this child’s pain?

  1. Motrin
  2. Tylenol
  3. Aspirin
A

Tylenol bc less than 6 months

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9
Q

what is Reye’s syndrome

A

acute brain and liver swelling, occurs when kids w/ chicken pox or flu get ASA

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10
Q

side effects of opiods

A
  1. Nausea and vomiting(25%)
  2. Constipation
  3. Urinary retention
  4. Respiratory depression (Much more pronounced IV
  5. Sedation
  6. Miosis (constricted pupils)
  7. Pruritis (itchy nose)
  8. Antitussive, antidiarrheal
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11
Q

what is the onset/duration with propofol

A

onset: 1-2 min
lasts: 5-10 min

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12
Q

what is IO (interosseous) administration and why is it helpful?

A

inject into bone marrow

  • marrow functions as a noncollapsible venous access route when peripheral veins may have collapsed because of vasoconstriction
  • This approach is particularly important in patients in shock or cardiac arrest, when blood is shunted to the core due to compensatory peripheral vasoconstriction
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13
Q

when is ASA used?

A

type of NSAID
-decrease risk of non-fatal MIs, CA

-avoid in children and adolescents (Reye’s) and 3rd trimester (hemorrhage)

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14
Q

drug seeking behavior clues

A
  1. from out of town
  2. lost or stolen prescription
  3. ED visits on weekends or night
  4. frequent ED visits w/o F/U appointments
  5. unusual knowledge of controlled substances
  6. requests specific drug
  7. do not permit PE
  8. create sense of urgency
  9. long list of drugs they are allergic too
  10. chronic pain- dental, back, exploit ortho injury
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15
Q

when do you have to assess end organ damage with HTN?

A

if greater than 180/120

**We don’t’ diagnose HTN; we identify high blood pressure, and determine the need to evaluate for end organ damage

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16
Q

what are limits to pulse oximetry?

A
  1. hypoperfusion- below 80mmHg systolic
  2. hypothermia
  3. anemia (if Hct is less than 5g/dL)
  4. nail polish
  5. does not assess ventilation
  6. does not detect abnormal hemoglobins (falsely reassuring pulseox readings)
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17
Q

when would you use a beta blocker to treat severe HTN, asymptomatic?

A

angina, post MI, migraines, SVT

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18
Q

what precaution should you take before you administer Naloxone (Narcan) if someone has a hx of opiate abuse?

A
  • restrain the patient

- titrate up every 2-3 min until breathing

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19
Q

what is procedural sedation?

A

A pharmacological state of profound sedation with maintenance of all protective reflexes, spontaneous ventilation is adequate and airway is maintained

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20
Q

what is the difference btwn Cox1 and Cox2 inhibitors

A

-same analgesia
-Cox2 are:
50% less GI toxicity
increased risk for MI and CVA

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21
Q

A 5y/o girl stubs her toe. This child weighs 20 kgs and mom doesn’t know how to dose Motrin. How much do you prescribe?
A. 50 mg
B. 100 mg
C. 200 mg

A

motrin: 10mg/kg

20kg x 10mg/kg = 200mg

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22
Q

BP measurements can vary by ____ mmHg based on ___ and ___

A

8-10mmHg

based on auscultation and palpation

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23
Q

what are the normal vitals for a child 1-8 years old

A

BP: 80-110 systolic
HR: 80-100bpm
RR: 15-30

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24
Q

who ALWAYS needs a rectal temp?

A

kids with febrile seizure

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25
Q

what foods contain tyramine and what are its effects on BP?

A
  • aged cheeses, beer on tap, red wine, soy sauce, fermented meats like summer sausage
  • cause HTN
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26
Q

what does general anesthesia require

A
  • support of airway
  • breathing
  • CV fxns

*pt cannot maintain airway or airway reflexes

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27
Q

what is the onset of action and duration of morphine (MSO4)?

A

onset: 5-10 min
lasts: 2-6 hrs

*slowest onset btwn fentanyl and dilaudid

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28
Q

how do NSAIDS work?

A

Potent inflammatory action occurs through inhibition of prostaglandin synthesis at wound site (reducing inflammation, pain and fever)
-Aka, inhibits COX-1 and COX-2

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29
Q

types of hydrocodone

A

Norco (hydo + T)
Vicodin (hydro + T)
Vicoprofen (hydro+ ibup.)

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30
Q

when is morphine sulfate (MSO4) typically used?

A
  • cardiac use for pain relief/vasolidation

- decreases preload

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31
Q

what constitutes vital signs?

A

BP, pulse, RR, temp, pulse ox, pain

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32
Q

what are 2 commonly used reversal agents

A
  1. flumazenil (benzo reversal– ie. versed/midazolam)

2. Naloxone (Narcan)- opiate reversal

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33
Q 
convert to degrees F. 
37C=
38C=
39C= 
40C=
A 
37C= 98.6F this is normal temp
38C= 100.4 **this is fever
39C= 102.2
40C= 104
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34
Q

common IV narcotics/opiods

A

hydromorphone
fentanyl
morphine
**most can be given IM and PO too

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35
Q

what level of procedural sedation?
Cognitive function and coordination may be impaired, but ventilation, cardiovascular function is not
-normal response to verbal stimulation

A

mild sedation/anxiolysis

  • maintain airway
  • no cardiac monitoring required
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36
Q

50 M c/o constipation and urinary retention since he got pain meds fro his sprained ankle last week. What is he most likely on?

  • percocet
  • ultram
  • ibuprofen (what else should he be on)
A

percocet

*if on ibuprofen should also be on a PPI

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37
Q

what is suboxone

A

-Used for managing opioid addiction/ short and long term replacement therapy
-Buprenorphine and naloxone
(naloxone is an opioid antagonist and ‘kills the high”; would induce rapid withdrawal symptoms if misused IV)
*Less sedation than methadone

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38
Q

why is IV adminstration better than IM for pain control

A
  1. Less painful, especially with repeat doses
  2. Easier to titrate, more rapid onset of action
  3. No delayed respiratory depression
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39
Q

how do you calculate MAP

A

MAP = (2x diastolic) + systolic /3

*diastole counts twice as much as systole bc 2/3 of the cardiac cycle is spent in diastole

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40
Q

what drugs could you use to lower BP with a hypertensive urgency

A
  1. Beta-blocker (ex. labetolol)
  2. ACE inhibitor (ex. Captopril)
  3. nitroglycerin tab or spray
  4. clonidine (drops BP quickly but has a rebound effect)
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41
Q

DDX for tachypnea

A
  1. Pneumonia
  2. Asthma Exacerbation
  3. Heart failure
  4. Pulmonary embolism
  5. Anxiety
  6. Drug intoxication
  7. Metabolic Acidosis
  8. Lung Trauma, rib fx
  9. Pain
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42
Q

how do you manage hypertensive emergencies?

A
  1. immediate but careful reduction in BP is indicated
    - excessive hypotensive response may lead to ischemic complications

*reduce MAP no more than 10-20% in the first hour

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43
Q
  • what is the dosage of percocet

- what is the dosage of percodan

A

percocet: 5/325mg, 10/650mg (oxy and tylenol)
percodan: 2.5/325mg, 5/325mg (oxy, ASA)

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44
Q

what kind of drug is Brevitol/ methohexital

A

barbiturate

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45
Q

what is a normal MAP?

A

usually 70-110

*MAP of ~60 is needed to perfuse the coronary arteries, brain and kidneys

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46
Q

PMH of what conditions are associated with HTN?

A

HTN, CAD, DM, Renal insufficiency

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47
Q

what is hydrocodone?

A
  • semi synthetic derivative of codeine
  • less potent than oxycodone
  • fewer GI SE than codeine
  • used for mild-mod. pain
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48
Q

what are the goals of conscious sedation

A

relief of pain and anxiety, facilitation of the procedure, rapid onset, short duration, no hemodynamic compromise, easily titrated, safe

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49
Q

why were propoxyphene/darvocet (2010) and meperidine/demerol d/c’ed

A

propoxyphene/darvocet- cause arrhythmias

meperidine/demerol- decrease seizure threshold and leads to CNS toxicity, high abuse potential

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50
Q

22 year old male, 8 hours RLQ pain. F, V. Afraid of needles . CT shows appendicitis. What do you give him for pain?
A. Tylenol 500 mg PO
B. Percocet 5/325 PO
C. Dilaudid 1 mg IV

A

Dilaudid 1mg IV

*No PO bc going to OR

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51
Q

what is the most accurate way to check temperature

A

rectal temp- place for 3 minutes (closer to core temp and more sensitive)

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52
Q

43 year old male, presents with right great toe pain, redness, Also taking Pepcid because he has had a GI bleed before. How do you treat his pain?

  1. Tylenol 650 mg tid
  2. Naproxen 500 mg bid
  3. Percocet 5/325 qid Prn
A

percocet

*not naproxen bc he has a hx of GIB

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53
Q

what patients are at risk for inadequate pain management?

A
  • elderly
  • children
  • non english speakers
  • males
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54
Q

onset of action and duration for hydromorphone (dilaudid)

A

Onset: 3-5min IV
Lasts: 2-4 hrs

onset speed:
Fentanyl > dilaudid > MSO4

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55
Q

problems w/ codeine

A
  • 8-10% of patients do not have the enzyme to convert it to its active form, so no benefit
  • 3-30% of people are rapid metabolizers - respiratory fatalities/OD
  • Recent publicity of pediatric deaths s/p use of Tylenol w/codeine
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56
Q

what is the opiate of choice for most brief PSA procedures

A

fentanyl bc of its rapid onset of action
-less likely to cause hypotension than other opiates
and if chest wall rigidity occurs can use naloxone to reverse respiratory depression

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57
Q

what happens if you use a too narrow or too wide cuff when taking BP?

A

too narrow: overestimates BP
too wide: underestimates BP

*if obese, and BP seems high- check w/ bigger cuff

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58
Q

A 5y/o girl stubs her toe. This child weighs 20 kgs and mom ALREADY gave her Motrin. How much Tylenol do you prescribe?
A. 100 mg
B. 300 mg
C. 500 mg

A

Tylenol: 15mg/kg

20kg x 15mg/kg = 300

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59
Q

what constitues pre-hypertension

A

120-139/80-89 in primary care

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60
Q

what is allodynia

A

pain provoked w/ gentle touch of the skin

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61
Q

side effects of methadone

A

linked to fatal arrhythmias/ QT prolongation

*should not be prescribed in the ED

62
Q

what level of procedural sedation
-“A medically induced state of depressed consciousness”
-Maintains airway and airway reflexes
Age appropriate responses expected, purposeful withdrawal to painful stimuli, may respond to “Open your eyes”. Eyes will close.

A

Moderate sedation/ “conscious sedation”

*the goal for most ED

63
Q

DDX for tachycardia

A
  1. Fluid or blood loss
  2. Anxiety
  3. Pain
  4. Sepsis
  5. Allergic Reaction
  6. Fever
64
Q

what are some behavioral responses to pain

A
  • crying
  • yelling
  • cursing
  • withdrawal type behavior
  • posturing
  • other vocalizations
  • not really reflective of the urgency of the pts condition
65
Q

how do you assess ventilation?

A

requires an end tidal CO2 monitor

**a surgical patient can get 100% oxygen and have high Pulse ox reading, but if not ventilated, the oxygen is not providing alveolar ventilation

66
Q

what is the difference between hypertensive emergency and hypertensive urgency

A

HTN emergency: Elevated BP WITH end organ damage
(ex. ARF-acute renal failure, MI, CHF, SAH, stroke)

HTN Urgency: symptomatic elevated BP WITHOUT end organ damage
-BP greater 180/120 used to suggest treatment

67
Q

when are the 3 levels of procedural sedation most commonly used?

A
  1. Mild- pain control
  2. Moderate- Fx reduction, huge back abscess drainage, severe lacerations, cardioversion, chest tube insertion (*Goal of most ED)
  3. Deep painful procedures
68
Q

what is Ketorolac and when is it used?

A

AKA toradol

  • IV version of highly effecitive NSAID
  • great for renal colic, migraines
  • caution in renal impairment pts, GI bleed
69
Q

what are the most common sites recommended for IO insertion

A
  1. tibial tuberosity (flat surface, thin layer overlying tissue, ease of ID landmarks, away from airwary/chest)
  2. distal tibia
  3. distal femur
  4. sternum
  5. humerus
70
Q

what is the max dose of intranasal meds

A

1mL q nostrl

71
Q

what is pain

A

an unpleasant sensory and emotional experience with actual or potential tissue damage or described in terms of such damage

72
Q

what is the criteria for ED discharge?

A
  1. Stable vital signs for 30 minutes
  2. No evidence of respiratory distress
  3. Minimal nausea, able to tolerate PO fluids
  4. Ambulation equal to pre-procedure
  5. Alert, oriented, and able to retain discharge instructions
  6. Responsible person to watch patient
73
Q

what is the trend for BP

A

lower in newborns and higher with age

74
Q

causes of low oxygenation

A
  1. In CO, we accept lower O2 sats as normal
  2. hypoventilation
  3. probe not on (look at waveforms on monitor)
  4. V/Q mismatch (Atalectasis, pneumonia, PE, ARDS, CHF)
75
Q

what class of drug is ketamine?

A

dissociative agent (derived from PCP)

76
Q

what are side effects of fentanyl?

A
  • Glottic
  • Chest wall rigidity (barrel chest)
  • Easy to OD on patches
77
Q

how do these present?

  1. pulmonary edema
  2. aortic dissection
  3. ACS
  4. preeclampsia
  5. hypertensive encephalopathy
  6. SAH
  7. ischemic stroke
  8. renal failure

(HTN emergency can result in these)

A
  1. pulmonary edema- crackles in lungs
  2. aortic dissection- ripping CP to back
  3. ACS- cp, EKG changes, elevated trop
  4. preeclampsia-proteinuria, HA, edema
  5. hypertensive encephalopathy-mental status changes
  6. SAH- sudden, worse HA ever
  7. ischemic stroke- neuro deficits
  8. renal failure- decrease UOP, elevated creatinine
78
Q

Non-narctoic pain meds

A
  1. acetaminophen (tylenol)

2. NSAIDs

79
Q

what is the difference between oral temp and rectal temp?

A

oral temp is usually btwn 0.6C (1F) LOWER than rectal

80
Q

what is the downside to IO insertion

A
  1. usually need to remove by 72 hrs- increasing risk of infection
  2. pt and provider unease
81
Q

how do you convert lbs to kg and vise versa

A

-divide lbs by 2 and subtract 10%
OR
lbs / 2.2 = kgs

Kg–> lbs
kg x 2.2 = lbs

82
Q

what is tramadol and when is commonly used?

A

aka Ultram

  • weak synthetic narcotic
  • used for chronic pain and fibromyalgai

*less constipating than most opiods

83
Q

What are the normal vital signs in an adult?

A

BP: 90-120/60-80
HR: 60-100bpm
RR: 12-20

84
Q

what % of ED visits are related to and how fast do they expect the pain to be relieved?

A

60%

within 30 minutes

85
Q

when would someone use Brevitol/ methohexital

A
  • fast orthopedic procedures

- Induces a short period of unconsciousness w/ airway reflexes intact

86
Q

Things to consider when selecting narcotics

A
  1. route of administration (OR?)
  2. suitable initial dose
  3. frequency of adminstration
  4. side effects
  5. will the opioid be used for in/out patient

**indication for moderate-severe pain

87
Q

what is the duration of action for pain and half life of methadone

A

duration: 4-5 hrs

half life: 5 days

88
Q

what are the indications and complications with Etomidate

A

indications: ultra short acting sedative w/ few hemodynamic effects

complications:
- does not tx pain
- myoclonus (tx w/ versed)
- Adrenal suppression-bad in trauma and sepsis

89
Q 
how do you treat 
-Laryngospasm
-Emergence Rxn
-Hypersalivation
that can occur w/ Ketamine?
A
  • Laryngospasm: positive pressure ventilation and BVM (bag valve mask)
  • Emergence Rxn: versed
  • Hypersalivation: atropine or glycopyrralate
90
Q

DDX for bradypnea

A
  1. Alcohol or drug overdose
  2. Sedative or hypnotic medications
  3. Impending respiratory failure
  4. OSA/ Sleep apnea
91
Q

what are the different levels of procedural sedation?

A
  • Minimal: mild, “anxiolysis” for pain control
  • Moderate: “conscious sedation” pt is sleepy but arousable to voice or light touch
  • Deep: requires painful stimuli (sternal rub) to evoke a purposeful response
92
Q

indications for NSAID use

A
  • mild-moderate pain
  • gout, arthritis, acute MSK injuries, pelvic pain
  • inflammatory condition
  • fever

*avoid NSAIDS in 3rd trimester pregnancy

93
Q

side effects of ASA

A
  • increased GIB and ICH
  • GI effects in 50% (enteric coated helps)
  • Reyes in children/adolescents
  • hemorrhage in 3rd trimester
94
Q

what are the side effects of versed/midazolam

A
  • Respiratory depression
  • Cardiovascular depression

*reversed w/ Flumazenil [benzo reversal] or Naloxone (narcan)

95
Q

what are side effects of morphine (MSO4)

A
  • Significant histamine release→ hypotension and pruritis (itchy nose)
  • Linked to increased NSTEMI
96
Q

common PO narcotics/opiods

A 
oxycodone
hydrocodone
codeine
methadone
tramadol
97
Q

NSAID side effects

A
  1. GI: gastritis, perforated ulcers. 10-20% of users will experience dyspepsia. Risk increases w/ age greater than 60, smoking, known PUD or GI Bleed
  2. Pulmonary: Bronchospasm (esp. in asthma)
  3. Hematology: impair coagulation (platelet dysfunction)
  4. Renal Failure: esp w/ renal disease, dehydrated, post op, have lost more than 10% of blood
  5. Ortho: may delay bone healing in acute fx
  6. CV: worsen HTN
98
Q

what is the sequelae of poor pain management

A
  1. Unnecessary suffering
  2. Delayed healing
  3. Altered immune response
  4. Altered stress response
  5. Development of chronic pain
99
Q

what should you do if you suspect a patient is drug seeking?

A
  1. Attempt to contact patient’s physician to confirm history
  2. Confirm patient has provided a copy of a photo ID and SSN
  3. Check the CO PDMP
  4. talk to the the patient about your concerns “sorry we got you hooked”
100
Q

what are some of the Cons of propofol?

A
  • Cannot use w/ egg allergy (Supplied in emulsion of soybean oil and purified egg phosphate)
  • Hypotension
  • Respiratory depression, apnea- supportive care
  • Painful injection (can give w/ lidocaine)
101
Q

What is the AHA recommended way of taking BP?

A
  1. pt seated for 5 mins prior, w/ arm supported at heart level
  2. appropriate size cuff (bladder should be 80% or completely encircle the arm)
  3. no smoking or ingesting caffeine 30 min prior
  4. take 2 or more readings separated by 2 minutes should be averaged (or more if they differ by more than 5mmHg)
102
Q

How can a fever be beneficial?

A

delays growth and reproduction of some bacteria and viruses and enhanced immunologic function at moderately elevated temperatures (although some of the benefits are reversed at temperatures approaching 40ºC)
**tx fever if child is uncomfortable (increase fluids as well)

103
Q

what drugs are used to manage opioid addiction/withdrawal

A
  • methadone

- Suboxone (buprenorphine and naloxone)

104
Q

what is naloxone

A

an opioid antagonist and ‘kills the high”; would induce rapid withdrawal symptoms if misused IV

105
Q

what is the trend for RR

A

higher in newborns and lowers with age

106
Q

what is ketamine and what is it used for?

A
  • dissociative agent (derived from PCP)
  • Prevents perception of visual, auditory or painful stimuli
  • Sedation for prolonged procedures
  • Has analgesic, sedative, and amnestic properties
  • Relaxation of bronchial Sm.M., maintenance of airway reflexes
107
Q

Vital sigs are normal parameters. They suggest, but do not guarantee a hemodynamically stable patient because:

A
  1. Fail to detect acute blood and fluid loss
  2. May fail to identify serious illness in infants
  3. Meds may blunt an appropriate response, especially in elderly
108
Q

what is the most accurate way to check HR

A
  • listen to apical rate for 60 sec. (or 30sec if better than 15sec)
  • check for quality and regularity

**ALWAYS DOCUMENT AND FIND OUT WHY HR IS ABNORMAL

109
Q

what is the initial dose for Ketorolac/Tradol

A

30mg IM or 15mg IV

110
Q

MAP of ____ needed to perfuse the coronary arteries, brain and kidneys

A

about 60

111
Q

what is the onset/duration for tramadol/ultram

A

peaks 3 hrs

lasts 6 hrs

112
Q

why would fentanyl be used over other pain meds?

A
  • 100x more potent than MSO4
  • Minimal histamine release or hypotension
  • comes in IM, IV, PO, transdermal patch, lollipops
113
Q

nonpharmacologic treatment for pain

A
  • heat/cold (ice/heating pad)
  • immobilization/elevation
  • explanation /reassurance
  • distraction
114
Q

Causes of hypotension

A
  1. Acute blood or fluid loss
  2. Sepsis
  3. Anaphylaxis
  4. Medications, drug overdoses
  5. Fit people
115
Q

when is propofol used?

A
  • -To help w/ N/V, sedation, hypnosis
  • Anti-emetic
  • Rapid on and off
  • Easy to titrate
116
Q

what are abnormal forms of hemoglobin?

A

carboxyhemoglobin, methemoglobin, sick hemoglobin

117
Q

what are the indications for versed/midazolam

A
  • Sedation, muscle relaxation, amnesia, anticonvulsant, anxiolytic
  • given to treat emergence rxn w/ ketamine
  • frequently given w/ Fentanyl making it “conscious sedation”

*comes in multiple routes of administration

118
Q

what are common barbiturates used for pain control/sedation

A

-Brevitol/ methohexital

119
Q

common sedation medications

A
  1. Opioids-Fentanyl
  2. Benzodiazepines-Versed (midazolam)
  3. Dissociative agent -Ketamine
  4. Sedative hypnotics-Propofol
  5. Etomidate – sedative
  6. Barbiturates-Brevitol (methohexital)
120
Q

what is the dosing for Tylenol

A
  • max adult: 4gms/day
  • peds: 15mg/kg QID

-Toxic dose: greater than 140mg/kg –> metabolize by liver and can cause liver failure

121
Q

hypertensive emergency can result in what?

A
  1. pulmonary edema
  2. aortic dissection
  3. ACS
  4. preeclampsia
  5. hypertensive encephalopathy
  6. SAH
  7. ischemic stroke
  8. renal failure
122
Q

what is considered chronic pain?

A

-pain that persists longer than 3 months
OR
-pain that persists beyond the reasonable time for an injury to heal or a month beyond the usual course of an acute disease

123
Q

how do monitor under procedural sedation/ what do you need

A
  1. hemodynamic- cardiac monitor, auto BP q 5min
  2. Resp/airway- continuous pulseox, suction equip., supp O2, bag valve mask, end tidal CO2
  3. level of consciousness
  4. IV access, reversal agents, COR cart
  5. provider skill set
124
Q

what is an ultra short acting sedative?

-what is its onset/duration

A

Etomidate

onset: 30-60 sec
lasts: 5-10 min.

125
Q

side effects of tramadol/ultram

A
  • Induce a serotonin syndrome- in ppl on SSRIs or TCAs
  • Decreased seizure threshold
  • QT prolongation
  • W/D sx: beyond simple opioid w/d (mood swings, aggression)
126
Q

when would Tylenol be a good pain med to use

A
  • mild-moderate pain, not for inflammatory conditions
  • no anti-platelet effect
  • best for children less than 6 months
127
Q

treatment of acute opiate withdrawal

A

symptom management

-may offer clonidine 0.1-0.3mg TID prn

128
Q

5 predictors of difficult airway acess

A
  1. obesity w/ short neck
  2. reduced neck movement (exceeds 15 degrees)
  3. reduced TMJ movement (inability to protrude lower teeth beyond upper teeth)
  4. Receding mandible
  5. thyromental distance of less than 3 fingers (thyroid notch to tip of jaw)
129
Q

Pain Med Regimen in ED

A
  1. Motrin 600-800 TID and/or Tylenol 1 g TID-QID
  2. then, Norco 5/325 or Percocet 5/325 1 tab QID prn, w/ colace, prune juice, metamucil; driving precautions (sedative, hypotension)
  3. rarely –Dilaudid 2 mg QID prn +/- NSAIDs
130
Q

what are some physiologic responses to pain

A
  • increased BP
  • increased HR
  • tachypnea
  • nausea
  • diaphoresis
  • skin color changes (pale, flushed)
  • *vital signs are not reliable guides to pain relief
131
Q

what is the onset/duration of Brevitol/ methohexital

A

onset: 1 min
duration: 5-10 min.

132
Q

how can you assess pain?

A 
OPQRST
onset (activity at time)
Provoking factors
Quality
Radiation
Severity
Time course
133
Q

acute opiate withdrawal symptoms

A
  • Mydraisis
  • yawning
  • increased bowel sounds
  • piloerection
  • restlessness
  • flu like sx- n/v, abdominal cramping
  • rhinorrhea, lacrimatino
  • myalgias, arthralgies,
134
Q

what is codeine and when is it typically used

A
  • combined w/ ASA or Tylenol

- great anti-tussive (Phenergan w/ codeine)

135
Q

adverse rxns w/ Brevitol/ methohexital

A
  • Respiratory depression or aspiration
  • Significant hypotension (usually requires a fluid bolus and bagging the pt)
  • Caution in pts w/ seizures, may precipitate
136
Q

when w/ a hypertensive emergency would you want to lower BP fast?

A

with an aortic dissection or ischemic stroke

*OTHERWISE lower slowly!

137
Q

what level of procedural sedation?

  • May require assistance maintaining airway reflexes
  • Cardiovascular function is usually maintained
  • Patient may not be able to respond to tactile or verbal stimuli – but, may respond purposefully to repetitive or painful stimuli
A

deep sedation

138
Q

intranasal med administration is commonly indicated when?

A
  • pain control
  • seizures
  • sedation
  • palliative care
  • opiate OD
139
Q

what is the onset of action and duration of fentanyl

A

Rapid onset: 1-2 min
Lasts: 30-40 min

*strongest and fastest

140
Q

what is the dosing for NSAIDs

A

Ibuprofen: 10mg/kg qid
max: 40mg/kg/day

adult max: 2400mg/day

141
Q

causes of hypertension

A
  1. Medication non-compliance
  2. Pain, anxiety (white coat syndrome)
  3. Poor cuff size
  4. Medical History: HTN, CAD, DM, renal insufficiency,
  5. Drugs : cocaine, meth, decongestant
  6. MAOI (older antidpressants) use with tyramine containing food
  7. Pheochromocytoma
  8. Renal Stenosis
  9. “Hypertensive Emergencies”
142
Q

10 adverse effects w/ Ketamine

A
  1. Increased muscle tone
  2. Random movements of the extremities
  3. High street value “Special K”
  4. Takes a long time to wear off
  5. Hypertensional increased ICP- avoid in head injury
  6. Increased IOP- avoid in glaucoma or eye injury
  7. Emergence Rxn- tx w/ versed
  8. Laryngospasm (esp. in infants)
  9. Hypersalivation- tx w/ atropine or glycopyrralate)
  10. Vomiting (use w/ Zofran)
143
Q

what are the normal vitals for an infant 1-12 month old

A

BP: 70-95 systolic
HR: 100-150
RR: 25-50

144
Q

what are the different Mallampati classes used to assess ease of intubation

A

I- soft palate, uvula, and pillars are visible
II- soft palate and uvula are seen
III-Soft palate and base of uvula are seen
IV- only hard palate is seen

145
Q

causes of oligoanalgesia (inadequate pain control)

A
  1. Pre-occupation with diagnosis and treatment of the underlying medical problem
  2. Concerns about masking symptoms- ok to tx sx
  3. Fears about causing or contributing to addiction
  4. Underestimation of pain experienced by the patient
  5. A pain free interval after acute traumatic injuries
  6. Reluctance of patients to complain of pain or demand treatment
146
Q

speed of onset (fast to slowest) for
morphine
fentanyl
dilaudid

A

Fentanyl / Dilaudid / morphine

*same w/ potency

147
Q

when would you use a diuretic to treat severe HTN, asymptomatic?

A

uncomplicated HTN

148
Q

what vital sign in kids are typically normal bu thtne can suddenly crash?

A

RR

-if borderline fine but they are working or look sick, thing again about observing longer

149
Q

when would you use hydromorphone (dilaudid)

A
  • Stronger than MSO4, with less pruritis, nausea, and hypotension
  • Excellent F given PO
150
Q

what meds are COX1 inhibitors and what are COX2 inhibitors and topical NSAIDs

A

COX1: ibuprofen, naproxen, ASA, indomethacin, ketorolac

COX2: celebrex

Topical: diclofenac gel

Emergency Medicine (22 decks)

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