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Urgent Care/Critical Care (inpt) > bad things > Flashcards

bad things Flashcards

1
Q

Toxic-metabolic coma

A

characterized by lack of focal physical examination findings.

pupils-small and reactive, but may be large in severe sedative poisoning as from barbiturates

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2
Q

structural coma

A

hemispheric (supratentorial) vs posterior (infratentorial) fossa

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3
Q

supratentorial comas

A

progressive hemiparesis or asymmetric muscle tone and reflexes

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4
Q

infratentorial lesions

A

may cause abrupt coma, abnormal extensor posturing,

loss of pupillary reflexes and extraocular movements, brainstem compression w/ loss of brainstem flexes may develop rapidly

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5
Q

coma neurologic exam

A
  • *cornerstone of assessment

* *reference point for serial assessment

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6
Q

breath associated with midbrain-hypothalamus issues

A

central-reflex hyperpnea

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7
Q

Lower pons problem

A

apneustic, cluster, ataxia

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8
Q

medulla

A

loss of automatic breathing

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9
Q

Goals in emergency coma

A

o Stabilize the airway, ventilation and circulation
o Identify and treat reversible causes, such as hypoglycemia and opioid toxicity.
o Consider empiric naloxone. Administer thiamine before glucose in hypoglycemic patients with a history of alcohol abuse or malnutrition.
o If elevated ICP is suspected, elevate the head to 30 degrees and keep at midline. Mannitol will help reduce ICP.

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10
Q

catatonia

A

CF: stupor, excitement, mutism (inability to speak), posturing.

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11
Q

conversion reactions

A

o Fairly rare– not!
o Oculocephalics may or may not be present
o The presence of nystagmus with cold water calorics indicates the patient is physiologically awake

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12
Q

allergic rxn, anaphylaxi

A

severe immediate hypersensitivity rxn

IgE mediated and anaphylactoid reactions- no previous sensitizing exposure

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13
Q

what is a ddx for anaphylaxis?

A

MI, gastroenteritis, asthma, carcinoid, epiglottis, herediatry angioedema, vasovagal rxn

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14
Q

what do you discharge a pt in anaphylaxis with?

A

antihistamin and prednisone

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15
Q

how do you treat hereditary angioedema

A

C1 esterase inhibitor replacement (may substitue FFP)

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16
Q

Acute Abdomen issues- PMHx?

A

surgery, MI, dysrhythmias, coagulopathies, vasculopathies, gynecologic

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17
Q

hearing high-pitched tinklin sounds in bowel?

A

may be SBO

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18
Q

Carnett sign

A

place hands on maximum point of tenderness and have the patient flex or do a sit up. . if pain got worse, muche more likely to be a MSK problem then an internal

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19
Q

where do you start when examining abdominal pain?

A

XR, then US, the CT scan

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20
Q

what are the most common types of burns?

A

**SCALD

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21
Q

Zones of coagulation

A

non viable area of tissue at the epicenter of the burn

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22
Q

zone of ishcemia or stasis

A

surrounding tissues (both deep and peripheral) to the coagulated areas, which are not deviatlized initially, but can progress irreversibly to necrosis over several days if not resuscitated properly

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23
Q

zone of hyperemia

A

peripheral tissues that undergo vasodilatory changes due to neighboring inflammaotry mediator relesease, but are no injured thermally and remain viable

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24
Q

burn depth classification

A

first to 4 th degree

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25
Q

1st degree burn

A

superficial burns

  • epidermal only
  • caused by sun or minor flash
  • no blisters/edema
  • skin is pink or red and dry
  • hypersensitivity
  • rapid healing, 3-6 days
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26
Q

2cd degree

A

partial thickness

  • involves dermis
  • superficial or deep
  • healing time varies (2-3 wks)
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27
Q

superficial partial thickness

A

-caused by flame, scalding, chemicals
-minimal damage to skin appendages
-edema/blister formation (fluid filled)
-skin is pink or red
-blanches w/ pressure
blister= 2cd or 3rd degree

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28
Q

depp partial thickness

A
  • deeper dermis invloved some skin appendges
  • grease, flame, or chemcial
  • moderate edema, mixed w. pallor
  • skin pale or dry
  • thicker-walled blisters, many of which are ruptured
  • decreased sensation, healing takes greater than>21 days
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29
Q

3rd degree

A 
full thickness
-destruction of epidermal anddermal layers
-exposure to prolonged heat
-EDEMA, think pearly white or charred 
-painless
this requires skin grafting,
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30
Q

“poking” or the rubbing test

A

poke the wound bed, if hte pt kicks you it is superficial partial thickness; if ask what are you doing, then deep or partial or 3rd degree

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31
Q

forth degree

A

burn reaching the muscle layer or bone

-extensive damage to nerves–> little to no sensation of pain

32
Q

pre-hospital managment

A
  • Stop the burning process
    o Remove clothing, irrigation of chemicals, etc.
  • Cool the burn surface – how?
  • Cover / protect burn wound
    o Prevent heat loss, keep clean
  • Do not put ice or cold water especially on larger burns as it carries a risk of hypothermia. Instead wrap in clean sheet of dry cloth or blanket before transferring to the ED.
33
Q

Emergency managment

A

Focuse on pt!! not burn wound at first

ABCDEF

IV morphine and LR NS

**need to put urinary catheter in to monitor resusciation efforts

34
Q

base line labs?

A

ABG, CBC, hematocrit, BUN, creatinine, electrolytes, glucose, UA, CO level, EKG,

carboxyhemoglobin

35
Q

how to stop the buring process?

A

sterile water, but if chemical burn watch out bc water can activate it

36
Q

Calculation of Burn area

A

“rule of 9”
- % of 2nd and 3rd degree burns
- Head is 9%, each arm is 9%, front of each leg is 9%, back of each leg is 9%, front of torso is 18%, back of torso is 18%, groin is 1%
- Patient’s hand is approximately 1% TBSA
- Modify for children
- Lund–Browder charts, more accurate based on age and body part
- First degree burns are not considered in surface area calculations.
Extent of Burn

37
Q

2cd degree burnts

A

> 10% TBS

or any burns to face, hanges, feet, genitalia, perineum, major joings

38
Q

3rd degree

A

any body part

electric injury, chemical burns, inhalation inuries, burns accompanied by trauma

39
Q

Fluid REsuscitation

A

SIRS, edema, decreasd CO, increased PVR, acture renal failure

40
Q

Baxter/Parkland formula

A

total V of the first 24 hours of resuscitaiton with RL

4 ml/kg/%TBSA

half volume given in the first 8 hours, while the remaining volume delivered over 16 hours

41
Q

why do you need fluid resuscitation?

A

edema max in 2cd 24 hours post burn > decreased intravascular fluid> decreased CO > increased PVR (post void residual) > BURN SHOCK (distributive and hypoolemic) and then the hypoperfusion of tissues leads to acutre renal failure and possible brain damage

**want to avoid burn shock!!!!

42
Q

what is important to monitor during resuscitation?

A

Urine output!!

  • maintain 30-50 mL/hr in adults, and 1 ml/kg in children
43
Q

Burn Wound Management

A

-Cleanse and Debride (greater than 2 cm)
-topical abx
Silver Sulfadiazine and Mafenide acetate
-vaseline gauze

44
Q

ABX for burns

A

most common pathogens are

S. Aureus and Pseudomonas

45
Q

Silver Nitrate

A

applied as an occlusive dressing- but not eschar penetration

46
Q

Siver Sulfadiazine

A

most commone, limited eschar penetration

47
Q

Mafenide Acetate

A

good gram + and - coverage
Penetrates eschar
** large amounts can block the cation of carbonic anhydrase and lead to metabolic acidosis
EXTREMELY PAINFUL

48
Q

Silver Products

A

antimicrobial activity

  • kills microbes on contact by poisoning microbe cellular respiration
  • speed of action directly correlated / sliver ion dose
  • silver resistance is not see
  • safe and non-
49
Q

Silver Ion

A
  • histologically decrases wound surface inflammation
  • decreases wound surface exces metalloproteinase by decreasing zinc, essential for metalloproteinase (MMP) activity
  • silver oxidized to sulfur bonds
  • increased wound Ca (pro epithelialization effect)
50
Q

ABX

A 
systemic ones not indicated unless:
wound invasion (discoloration of the wound, erythema and induration at wound margin, fever >101.5), positive blood culutre, positive wound biopsy/culture
51
Q

SIRS

A

systemic inflammatory response sydrome- common rexn to burns

52
Q

surgical managment of burns

A
  • Tangential excision and split thickness skin grafting (for 3rd degree burns and deep second degree)
  • Fascial excision w. split thickness skin grafting for some deep 3rd
53
Q

when are deep dermal burns and full thickness burns excised?

A

about day 3, coverage is attained by neumerous methods, autography is best, but allographing can work

other methods: epidermal cell culture, artifical skin, porcine xenograph

54
Q

Complications of sever burns

A

inhalation injury, hypovolemic shock, neurogenic shock secondary to pain, renal failure, multiorgan system dysfunction, gastric/duodenal ulceration (Curling’s ulcers)

**most common- infection of the burn wound

55
Q

Marjolin’s Ulcer

A

chronic healing burn wounds that undergo malilgnant transformation in to a squatomus cell carcinoma

56
Q

Eschartomy/Fasciotomy

A

assess need in circumferential burns of the extremities or anterior turnk–> compartment syndrome!!

57
Q

Escharotomy

A

surgical incision into necrotic skin resulting from a sever burn; inelastic leathery dead skin cuases tourniquet like effect

58
Q

Fasciotomy

A

surgical excision of fascia to relieve tension or pressure in muscle compartment

  • compartment syndrome
  • electrical burn w/ muscle injurty
59
Q

the 5 Ps;- Indications for escharotomy / fasciotomy (5 Ps)

A

Pallor-cyanosis of distal unburned skin on limb
Pain-unrelentin deep tissue pain
Paraesthesia-progressive numbness
paralysis- usually late finding
Pulselessness- progressive decrease or absence of pulse

60
Q

chest escharotomy

A

indicated to relieve respiratory distress

61
Q

extremity escharotomy

A

o Circumferential full-thickness burns may impair circulation due to increase in edema
o Procedure
 Avoid major vessels, nerves, all tendons
 Mid-medial or mid-lateral aspect
 Extend down through eschar, to subcutaneous fat

62
Q

Extremity compatment Syndrome

A

Edema w/in deep investing muscle fascia

63
Q

what can cause compartment syndrome

A

high voltage electricity, massive IV fluid infusion, crush injury, delayed escharotomy

64
Q

what pts have th highest risk of developing compartment syndrome?

A

those w/ circumferential burns

65
Q

What is pressure is suggestion iv compartment syndrome

A

30 mmHg, but if they are in the 40s- need an emergency fasciotomy or eschartomy

66
Q

Inhalation injury

A

CO poisoining–> injury above or below the glottis; 33% of pts admitted to burn centers

67
Q

when to suspect inhalation injury?

A

enclosed space, facial burns, singed nasal and facial hair, carbonaceous deposits in oropharynx

68
Q

what inhalation injuries cause?

A

smoke particles and toxins cause damage to airways that triggers inflammation, mucosal ulceration or necrosis of epithelium:

c

69
Q

complications of inhalation injuries

A

pulmonary edema, bronchospasma, PNA, ARDS

**PNA is the most common cause of morbidity in smoke inhalation patients

70
Q

Inhalation injury above the glottis

A

heat exchange capacity efficient; most heat damage occurs above the vocal cords

71
Q

inhalation injury above the glottis complication

A

laryngeal edema!! can occur at any time (usually w/in 24 hours of the injury

72
Q

Inhalation injury below the glottis

A

almost always chemical
aldehydes, sulfur oxides, phosgenes adherent to sruface of smoke particles–> direct damage to epithemlium of large airways

73
Q

how do you dx inhlation injury?

A

fiberoptic bronchoscopy: erythema, edema, mucosal ulceration or carbonaceous mater in

74
Q

tx in inhalation injury

A

mostly supportive: humidified O2, pulmonary physiotherapy, mucolytic agents and bronchodilator

2-3 wks heal`

75
Q

CO poisoining

A

Hg affinity 240 X that of O2

> 7% carboxyhemoglobin

76
Q

sx of CO poisoning

A

cherry red skin color, agitation and decreased LOC

cyanosis and tachypnea unlikely bc CO2 removal unaffected

77
Q

TX of CO

A

100% O2, hyperbaric O2 rarely needed

Urgent Care/Critical Care (inpt) (8 decks)

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