Internal/ Emergency Flashcards
Shock
Defn: 90mmHg or 30mmHg below pts normal systolic. (But sometimes clinical judgement won’t be in this defn)
Severity of hypotension: brain, skin, kidneys, myocardium, met acid, inc lactate, inc urea, inc Cr, inc cardiac enzymes.
Resolution of shock:
- Normalization of hemodynamic state (BP, HR, urine output), normal volume status
- ½ the lactate in the first couple hrs
- Maximal tissue O2
- Resolution of acidosis + return to normal metabolic parameters
Syncope
- Defn: global cerebral hypoperfusion -> sudden transient LOC + loss of postural tone -> spontaneous recovery
- Lifetime prevalence of ~40%, F>M
- Pre-syncope: sensation of impending syncope w/o LOC
- Prodrome: nausea, warmth, pallor, lightheadedness, diaphoresis, and/or blurred vision.
- San Francisco syncope rule for high risk pts (CHF, Hct 5 yr mortality ~50%
- ECG, continuous telemetry, event monitor/ loop recorder, ECHO, exercise test, ischemia evaluation
a) Arrhythmia (15%)
- More likely if no prodrome before syncope, or occurred while supine. Suspicious of long QT syndrome if fam hx of sudden death or syncope in family.
b) Structural
- Aortic stenosis, mitral stenosis, HOCM
c) Ischemic
- Neurocardiogenic (33%)
- Inc parasymp or dec symp cause
- No inc in mortality
- Most commonly vasovagal (sudden dilatation + brady -> hypotn, cerebral hypoperfusion). May have a trigger - pee/poop, cough, fear, pain, phlebotomy, prolonged standing
- Could also be from carotid sinus hypersensitivity/ stenosis (turning head, tight collar) -> can try to reproduce w carotid massage, carotid US
- Often associated with prodrome, esp if >10s or if young - Orthostatic Hypotension
- 30 (systolic) : 20 (HR) : 10 (diastolic)
- Hx of prolonged standing or posture change
- Investigate hypovolemia, ANS disorder, and their drugs
- Give fluids
Chest Pain
Ddx
- Serious 6: ACS, PE, pericarditis/ pericardial tamponade, pneumothorax, aortic dissection, esophageal rupture
- Other: valvular disease (aortic stenosis), MSK, GERD, esophagitis, cholecystitis, pancreatitis, panic attack, cocaine, syndrome X in women
Labs/ Investigations
- ECG, CXR, ECHO, cardiac enzymes (CK, CK-MB, cTnI)
- Dyspnea: ABG, pulse oximetry
- PE: D-dimer, contrast-enhanced spiral CT, or VQ lung scan
Shortness of Breath (SOB)
a
Admitting a Patient - AD DAVID FOR
A - Admit to __ under Dr. ___. Allergies
D - Diagnosis
D - Diet type - diabetic diet, low salt cardiac, etc
A - Activity level - complete bed rest, as tolerated, etc
V - Vitals / IV - and how often to take them
I - Investigations - blood work, imaging, consults, etc to rule in/ out ddx
D - Drugs. Daily weight if required.
F - Fluid restrictions/ ins + outs if required. Foley catheter.
O - O2 + route + how much, if required.
R - Special requirements - contact or resp precautions, isolation, etc
Problem list
- For each problem, try to have a ddx, investigations/ plan to narrow down, and plan to watch for/ avoid complications of the issue
- If person has pain, note the changes in pain control doses needed, and the amount of PRNs they use
Sample Medication Orders - B SAPPED
B - Bowel protocol S - Sleep A - Abx P - Pain control P - Pre-admission meds E - Emesis protocol D - DVT prophylaxis
Amyloidosis
- Amyloid (abnormal protein from bone marrow) builds up in organs, usually heart, kidneys, liver, spleen, nervous system, digestive tract.
S+S
- Depends on the type, ie AL vs AA, etc
- Waxy skin, easy bruising, enlarged muscles (ie tongue, deltoids), S+S of HF, cardiac conduction abnormalities, hepatomegaly, heavy proteinuria or nephrotic syndrome, peripheral and/or autonomic neuropathy, impaired coagulation
Dx
- Biopsy confirms
- ECHO: inc thickness of ventricular wall, AV valves, atrial septum, pericardial effusion
Tx
- No cure but aim to dec sx and progression
- Ex: chemo, BMT, meds directed at the sx
SIRS -> Sepsis -> Severe sepsis -> Septic shock.
SIRS - >=2 of: >38 or 90, RR >20 or PaCO2 12 or 10% bands
Sepsis: SIRS + source of infection
Severe sepsis: sepsis + [cardiovascular organ dysfunction or ARDS or dysfunction of >=2 other organs]. Or also have read lactic acidosis, SBP <90 or SBP drop ≥ 40 mm Hg from nornal
Septic shock: severe sepsis + hypotn unresponsive to fluids.
Shock - Obstructive
P/E: dec cap refill, inc JVP, cool extremities
Etiology: dec CO from blood flow obstruction/ inc afterload. Ex: massive PE, tension pneumo, pericardial tamponade
Ddx: IVC (clot, tumour), resp (embolus, pneumothorax), cardiac (embolus, tamponade, myxoma)
Tx: underlying cause/ remove obstruction, volume challenge. May need thrombolytics (PE), urgent drainage (tamponade)
Shock - Hypovolemic
- Most common
P/E: dec cap refill, low JVP, cool extremities, pallor
Etiology: dec intravascular volume
Pathophys: baroreceptor activation -> vasoconstriction, inc HR/CO, narrowing of pulse P -> dec CO
Ddx: bleed (AAA, dissection, GI, ectopic), excess fluid loss (vomiting, diuresis, burns, ascites), dehydration
Tx: aggressive fluids - rapid infusion of 10 ml/kg of NS or ringer’s and assess response. Hemorrhage may then need surgical or interventional control.
Shock - Distributive
Sub-categories: anaphylactic, neurogenic, septic
P/E: inc cap refill, inc JVP, warm extremities, tachycardia
Etiology: dec systemic vascular resistance (vasodilation)
Ddx: sepsis, anaphylaxis, drugs, anaphylaxis, neurogenic
Tx: initial fluids to replenish preload so the body can compensate with inc CO - 10 ml/kg of NS or ringer’s and assess response. Be cautious of fluid overload.
Shock - Cardiogenic
P/E: dec cap refill, inc JVP, cool extremities, +/- pulmonary edema depending on if L or R heart is affected
Etiology: dec contractility. Ex: acute MI (acute MR from papillary muscle rupture, ventricular septal defect, free wall rupture), RV infarction, dec cardiac contractility (sepsis, myocarditis, cardiomyopathy), mechanical obstruction (AS, HCM, MS, pericardial tamponade), acute AR
Ddx: ischemia, infarct, drugs, lytes, cardiomyopathy
Tx: underlying cause, inotropes. Be cautious of fluids. May need urgent angio or surgery.
Contraindications to Thrombolytics
______ missed
- Low platelets, inc PTT
- Hypoglycemia (2nd guess it being a stroke)
Common Abx
Vancomycin
Pip-tazo
Ceftriaxone
Levofloxacin
Doxycyline
Ciprofloxacin
Cloxacillin
Cephalexin
