ASM readings

Question 1

t/f hypoglycemia is a common SE of metformin

Answer 1

FALSE

rare to get it, but possible

only common in the -ides

Question 2

s/s of hypoglycemia

Answer 2

weating, shakiness, anxiety, nausea, dizziness, palpitations, slurred speech, blurred vision, headache, seizure, focal neurologic deficits, and altered mental status rang- ing from confusion to coma.

Question 3

Why do you have an anion gap metabolic acidosis in DKA?

Answer 3

ketone body formation

Question 4

why might a nitroprusside test for serume or urine ketones be falsely low or negative in DKA?

Answer 4

it only detects acetoacetate, not β-hydroxybutyrate

acetoacetate is often converted to β-hydroxybutyrate in DKA

Question 5

when trying to get rid of glucose during DKA, your body will try to pee it out - but what electrolyte problems result from this?

Answer 5

loss of things that follow water
NaCl
Ca2+
PO4 3-
Mg2+

k+ loss from vommiting OR high from acidosis and insulin def (as insulin drives K+ into cells)

psedohyponatermia is common

Question 6

Mng of K+ abnormalities in DKA

Answer 6

> 5.2 = IV insulin
3.3-5.2 and urine o/p = K+ and insulin (K-rider)
<3.3 = K+ until > 3.3 then follow above

Question 7

2 dosing options for insulin

Answer 7

0.1 U/kg bolus, then 0.1 U/kg/hr
0.14 U/kg/hr without a bolus

need to know this

Question 8

A patient is acidotic and has normal k+, what is there totaly body k+

Answer 8

LOW

Question 9

when do you give bicarbonate for DKA

Answer 9

pH <6.9 until pH > 7.0

Question 10

goal for DKA
glucose
bicarb
pH
electrolytes

Answer 10

glucose < 200 (75 mg/dL/hr every hour - check this)
bicarb >17.99
pH >7.3
electrolytes every 2 hours

Question 11

what is a complication of DKA treatment and the fix?

Answer 11

cerebral edema
fixed with mannitol

Avoiding rapid correction of sodium, glucose, and hypovolemia may reduce risk.

Question 12

disposition for DKA

Answer 12

ALL get admitted

Question 13

MC stroke

Answer 13

iscehmic

presents with motor deficits MC, but can be sensory, balance, AMS,

Question 14

what exactly is a TIA?

Answer 14

transient episode of neurological dysfunction caused by ischemia but WITHOUT an acute infarc- tion of brain tissue.

TIA episodes typically lasts less than 1 to 2 hours

Question 15

1 historical piece of information is

Answer 15

last known normal

let’s you know if they can get rTPA

Question 16

anterior cerebral artery stroke

Answer 16

con- tralateral leg weakness and sensory change

Question 17

Middle cerebral artery stroke

Answer 17

contralateral hemiparesis (arm > leg), facial plegia, and sensory lo

Question 18

what signs can a baisalr artery stroke lead to?

Answer 18

oculomotor
Horner’s
locked-in (basic)

Question 19

MC symptoms of an internal carotid dissection?
Vertebral artery dis- sections?

Answer 19

unilateral head pain (68% #1), neck pain (39%), or face pain (10%)

vertebral = neck pain #1 aslo HA

Question 20

SAH symptoms

Answer 20

thunderclap HA

Question 21

RF for SAH

Answer 21

excessive alcohol consumption, polycystic kidney disease, family history of SAH, Marfan’s syndrome, and Ehlers–Danlos syndrome

Question 22

If you are considering thrombyltic therapy for stroke, what do you use?

Answer 22

Calculate a National Institutes of Health Stroke Scale (NIHSS) score if thrombolytic therapy may be considered.

Question 23

Imaging for stroke

Answer 23

emergent NON-contrasted CT scan of the brain (best interpreted by a neuroradiologist) is essential to determine whether hemorrhage or a stroke mimic is present. Most acute ischemic strokes will not be visualized on a CT scan in the early hours of a stroke.

Question 24

when are SAH best seen on CT

Answer 24

6 hours of symptom onset

Question 25

w/up for SAH w/ negative CT

Answer 25

LP to look for blood

or CTA (actually better)

Question 26

initial management for stroke or SAH

Answer 26

1. O2 > 94%
2. non-contrast CT (w/in 25 min) and coag studies
3. NPO
4. Supine unless CI
5. Tylenol if fever
6. Reverse anticoag if hemmoragic

Question 27

when should you get HEAD CT? begin thrmobyltic therapy by? admitted to a stroke center?

Answer 27

25 minutes (will be normal in ischemic stroke or white in hemmoragic)
60 min
3 hours

Question 28

BP goals for intracerebral hemorage

Answer 28

140-160

If BP is > 220, then aggressive reduction

labetolol, nicardipine, clevidipine

Question 29

mng for acute ischemic stroke who is NOT a thrombyltic candidate

Answer 29

permissive hypertension with max of 220/120 or signs of end organ damage

reduce 15% in first 24 hours if outside of this range

Question 30

inclusion criteria for rtPA

Answer 30

1. 18+
2. onset of symptoms < 4.5 hours ago
3. NIHSS score > 23 or diagnosed with ischemic stroke

Question 31

mng for acute ischemic stroke who IS a thrombyltic candidate

Answer 31

185/110 with labetolol or nicardipine followed by the thrombylitic 60 min infusion with informed consent

-neuro checks
-keep BP <180/105 after rTPA
-admit to stroke unit or ICU

aspirin at 24-48 hours after rTPA

Question 32

after thrombyltic therapy with rTPA for stroke, what CANNOT be taken

Answer 32

aspirin or heparin within 24 hour window (aspirin is taken AFTER this though)

Question 33

when do you get endovascular thrombectomy for stroke

Answer 33

Alternative if rt-PA is CI or ineffective in a patient with a persistent potentially disabling neuro deficit (NIHSS ≥6)

Indication: large artery occlusion in the anterior circulation (dx by CTA or MRA) with small infarct core and no hemorrhage (dx by MRI)

Treatment must occur within 24 hours of symptom onset and performed at a stroke center with surgeons experienced in procedure

Question 34

what is the management of TIA?

Answer 34

aspirin or clopidogrel or aspirin plus extended-release dipyridamole

admit if ABCD >= 4
subacute stroke on CT
>50% ipsilateral stenosis
infarct on MRI
Recent TIA with/in past mouth
Other conditoins warranting admission
Acute cardiac process/arrythmia
Barriers to rapid OP follow up

Question 35

management of SAH and goal BP

Answer 35

<140 MAP with
labetolol
nicardipine
nimodpine and ICU admission for neurosurgery

reverse any coag issues

Question 36

what environmental changes can help with delirium?

Answer 36

adequate lighting and emo- tional support may help patient condition

Question 37

what type of dementia may have exaggerated or asym- metric deep tendon reflexes, gait abnormalities, or extremity weakness

Answer 37

vascular
fix HTN

Question 38

Dementia-like symptoms with increased motor tone and other extrapyramidal signs may suggest

Answer 38

Parkinson’s disease

Question 39

Consider _____ if urinary incontinence and gait disturbance are noted

Answer 39

normal pressure hydrocephalus

confirm with CT

Question 40

What is the Cushing reflex and when is it sometimes seen?

Answer 40

hypertension and bradycardia
seen in coma

Question 41

Coma from ______may be abrupt in onset, with abnormal extensor posturing and loss of pupillary reflexes and extraocular movements

Answer 41

posterior fossa or infratento- rial lesions

Question 42

you are in a coma and have pinpoint pupils, what might be the cause

Answer 42

Pontine hemorrhage

Question 43

way to detect psedo/psychogenic coma

Answer 43

manual eye opening (there should be little or no resistance in an unrespon- sive patient)

Question 44

imaging for a coma patient

Answer 44

head CT 1st line, below are if it is not diagnostic:

LP if non-dx and SAH or infection is plausible
MRI for baisalr artery thrombosis (common after non-dx CT)
EEG if seizure history

Question 45

mangement of ICP during coma

Answer 45

1. elevate bed 30 degrees
2. mannitol
3. dexamethasone if brain edema associated with a tumor

Question 46

discharge management for coma

Answer 46

Discharge patients with readily reversible causes of coma if home care and follow-up care are adequate and a clear cause of the episode is found and reversed. Admit all other patients for further evaluation and management.