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*Review TD 2020 > Acute Care > Flashcards

Acute Care Flashcards

(72 cards)

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1
Q

Indications for Intubation?

When to call anesthesia?

A
  • Airway patency
  • Airway protection
  • Respiratory distress/failure/arrest
  • Cardiac dysfunction
  • Procedures

– Upper airway obstruction
– Mediastinal mass
– Known/anticipated difficult airway

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2
Q

Ventilator: how to improve oxygenation?

- assessment

A

Increase FiO2
Increase PEEP

O2 saturation

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3
Q

Ventilator: how to clear CO2?

- assessment

A

Increase RR
Increase PIP

  • pH, CO2
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4
Q

O2 dissociation curve: left shift?

  • what is happening to O2
  • causes
A

Loading

increased pH
decreased DPG
deceased temp

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5
Q

O2 dissociation curve: right shift?

  • what is happening to O2
  • causes
A

Releases

decreased pH
increased DPG
increased temp

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6
Q

High flow nasal canal

how does it work

A
  • Upper + lower airway distending pressures
  • Dead space washout
  • Secretion clearance
  • More tolerable
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7
Q

What type of shock is anaphylaxis?

A

distributive

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8
Q

Oxygen delivery formula

A

CaO2 = (Hb xSat x1.34) + (PaO2 x 0.003)

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9
Q
  • Shockable rhythms?
  • PALS order of shock/epi
  • dose of epi?
A

VT
Vfib

shock - shock - epi
CPR ongoing q 2min shock

Epinephrine 0.01mg/kg

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10
Q

PALS
CPR instructions
rate

ratio

A

– Rate 100 – 120 compressions / minute
– Minimize interruptions
– Allow full chest recoil
– Push 1/3 diameter

Single rescuer 30 : 2
Two or more rescuers 15 : 2
Advanced airway (ETT or LMA) = continuous compressions, 10 breaths/min

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11
Q

Defibrillation dose

A

2 J/kg then 4 J/kg

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12
Q

Status Epilepticus Algorithm

A

1) Benzodiazepine (IV preferred)
2) Repeat Benzodiazepine (IV preferred)
3) Fos/Phenytoin or Phenobarbital load
– Typically Fos/Phenytoin for > 1y, phenobarb < 1y
4) Other agent not given in #3
5) Midazolam infusion (other options also possible…)

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13
Q

When do you hyperventilate in TBI

A

If herniating

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14
Q

What do you want to avoid in TBI/increased ICP?

A 
Hypotension
hypoxia
hyperthermia
hyponatremia
hypo/hypercapnia
hypo/hypergylcemia
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15
Q

Management of TBI

A

• Increase venous drainage
– HOB to 30 degrees
– Head midline
– C-collar not too tight

• Osmotic Therapies
– Hypertonic saline (preferred agent 2-5mL/kg IV over 10-20 mins)
– Mannitol

• Control ICP surge stimuli (may require intubation)
– Analgesia, sedation, anti-seizure, anti-pyretic
– Neuromuscular blockade in severe cases

• CSF removal (especially if hydrocephalus present)
– Extraventricular drainage

• Space-occupying mass removal
– Hematoma

• Reduce Cerebral Blood Volume * (in setting of herniation)
– Hyperventilation (PCO2 20 – 30 mmHgàtitrate to pupillary/vital sign
improvement)

• Increase Intracranial Space
– Decompressive Craniectomy

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16
Q

Brain death?
Newborn <30d and ≥36wga
Infant 1-12m
Children ≥ 1yo

A

Newborns: < 30 days and ≥ 36 wks gestation
– 2 full exams w apnea tests w ≥ 24h interval between exam
– ≥ 48h after birth
– Exam must include oculocephalic & suck reflexes
– Minimum body temp is 36 C

Infants: 30 days ≥ and ≤ 1 year
– Full, separate exams must be performed, but no fixed interval – Exam must include oculocephalic reflex

Children ≥ 1 year old to adults
– Still need two physicians, but can perform exam, including apnea testing, concurrently
– If examined separately, apnea test must be repeated

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17
Q

Apnea test criteria

A

Final PaCO2 ≥ 60 mmHg
Final PaCO2 ≥ 20 mmHg above pre-test baseline
Final pH ≤ 7.28
Absence of respiratory effort during test duration

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18
Q

Most effective prevention strategy for submersion injury

A

a four-sided self-closing fence with a self-locking gate

at least 4ft high

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19
Q

Risk factors for submersion injury

A
  • Leaving children unattended
  • Alcohol or drug abuse (50% of adult drownings) Limited swimming ability
  • Underlying medical conditions(?):
    Seizure disorder, toxin, prolonged QT, syncope
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20
Q

what minimum temp for discontinuing resus

A

35

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21
Q

What are good prognostic indicators for submersion injury?

A

1: Immediate bystander CPR

Other:

  • Return of spontaneous circulation in < 10 min
  • Submersion < 5 min
  • Pupils equal and reactive at scene
  • Normal sinus rhythm at scene
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22
Q

What are poor prognostic indicators for submersion injury?

A
  • Delayed CPR
  • Return of spontaneous circulation > 25 min
  • Submersion > 10 min
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23
Q

What are complications of submersion injury?

A 
ARDS
Pulmonary edema
Pneumonia
Cerebral edema leading to increased ICP 
Trauma
Hypothermia
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24
Q

Temp of hypothermia?
Temp when shivering stops?
Association?

A

<35
32
Pancreatitis
hypoglycemia, hypocalcemia, hypokalemia, metabolic acidosis

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25
ECG at <28 deg C
Osborn waves Marked sinus bradycardia First degree AV block Osborn or J waves Associated with prolonged QT and bradycardia
26
When do you start passive and active rewarming?
< 34 deg C - passive rewarming | < 30 deg C - active rewarming
27
How many times can you defibrillate if T < 30?
3 times
28
Heat stroke
``` Core T > 40 C with CNS dysfunction Headache Disorientation Dizziness Weakness Gait disturbance ```
29
Complications of heat stroke
``` Hyponatremia Seizure Rhabdomyolysis DIC Multi-system organ failure ```
30
Burns - SA
Age > 9: Rule of 9’s Age < 9: Child’s palm = 1% BSA (not superficial) Parkland = 4 cc/kg/BSA over 24 hours (1st half in 8 hours, 2nd half in 16 hours) ADD TO MAINTENANCE
31
Burns - bugs? | Antibiotics?
No prophylactic Abx Early infection: Staph aureus, GAS Late infection: Pseudomonas, Bacteroides
32
Signs of smoke inhalation?
- Singed nasal hairs - Soot in the airway - Hoarseness - Drooling
33
Cholinergic drugs
``` Pesticides organophosphates + carbamates DUMBELLS Diaphoresis Urination Miosis Bronchorhea and bradycardia Emesis Lacrimation Lethargy Salicavation ``` Tx: Atropine Pralidoxime
34
Anticholinergic drugs
Jimson weed, TCA, atropine, Benadryl, gravel, neuroleptics, etc ``` Tachycardia Confused hyperthermia Dry skin Flushed Mydriasis Urinary retention Absent bowel sounds ``` Activated charcoal Physostigmine only if PURE anticholinergic ingestion
35
Sympathomometic
Cocaine Methamphetamine Ectasy/MDMA Ephedrine ``` Mydriasis Diaphoresis Hypertension Tachycardia Seizures Hyperthermia Psychosis Severe agitation ``` Activated charcoal Supportive
36
Difference between anticholinergic toxidrome and sympathomometic
sympathomometic has diaphoresis
37
PCP
nystagmus
38
What can't you use activated charcoal for?
shiny things ``` Potassium Hydrocarbons Alcohols Iron Lithium Solvents ```
39
Serotonin syndrome
Altered LOC Autonomic instability Neuromuscular hyperactivity
40
Opioid ingestion
``` Bradycardia Hypotension Respiratory depression Miosis Coma ``` TX: naloxone
41
Neuroleptic Malignant syndrome
Antipsychotics Fever muscle rigidity Altered LOC Autonomic dysfunction
42
How to tx seizure after Anesthetic
Benzo | Intralipid
43
Hydrocarbons - biggest risk
Aspiration pneumonitis
44
Acetaminophen - toxic dose - complications - tx
150 mg/kg (7.5 grams in adult) Anion gap metabolic acidosis Acute tubular necrosis Fulminant liver failure NAC draw levels 4 hours after ingestion if timing unknown if timing unknown draw levels and start NAC right away
45
Radio opaque drugs
``` Chloral hydrate Opioid packets (latex) Iron and other heavy metals Neuroleptics (early) Sustained-release tablets / Salicylates (early) ```
46
isopropyl alcohol
ketosis w/o acidosis
47
methanol
tx w fomepizole if not yet metabolized (IE OSM GAP PRESENT)
48
TCA
Inhibit norepinephrine and serotonin reuptake Block cardiac fast Na channels → wide QRS Block muscarinic receptors → weakly anticholinergic Block histamine receptors → sedation Block alpha receptors → hypotension Block GABA receptors → seizure ``` Activated charcoal Frequently require intubation because obtunded NaHCO3 for QRS > 100 Norepinephrine infusion if hypotensive **Physostigmine contraindicated ```
49
Calcium Channel Blockers
Bradycardia and hypotension Normal LOC ``` High dose insulin euglycemic therapy (positive inotropic effects) Atropine Q2-3 minutes Calcium gluconate bolus or infusion Glucagon but causes severe N/V Insulin infusion plus IV D10W ```
50
When should you X-ray an ankle?
``` Tenderness at: - posterior or tip of medial malleolus - posterior or tip of lateral malleolus - base of 5th metatarsal - navicular Or inability to bear weight immediately and now in ED ```
51
How best to assess pain in a child >8yo post op
Visual pain analog
52
Reasons a brain dead person would not be candidate for organ donation?
Severe untreated systemic sepsis Acquired immunodeficiency syndrome Active viral hepatitis B or C, CMV Viral encephalitis Active extra cranial malignancy Risk of rare viral or prion protein illnesses (Creutzfeldt-Jakob dz) Recipient of cadaver human pituitary growth hormone Undiagnosed acute or progressive neurological d/o w or w/o dementia Active West Nile Virus or Rabies Active disseminated TB
53
Xray findings of RPA
Widening of retropharyngeal space | Reversal of the normal cervical spine curvature
54
Who do you treat w abx for bite? | What abx?
``` moderate and severe wounds; all cat bites; patients who have diabetes mellitus immunocompromised, face and hand involvement, have deep puncture wounds. ``` The recommended course is 3 to 5 days. The antimicrobial agents recommended for prophylaxis include: penicillin V potassium, amoxicillin, a first-generation cephalosporin in penicillin-allergic patients, and erythromycin in patients allergic to penicillin and cephalosporin.
55
Staph Scalded Skin Syndrome tx
Cloxacillin
56
Child in house fire with soot coating his nostrils and mouth. Alert and oriented. Next step?
Intubate
57
Initial vent settings after intubation? PEEP PIP VT
PEEP typically 5 PIP: 15-25, targeted based on gas CO2 VT: 7-10mL/kg for healthy lungs
58
TCA overdose treatment
Activated charcoal Intubation if obtunded NaHCO3 for QRS > 100 Norepinephrine infusion if hypotensive **Physostigmine contraindicated
59
Pulled elbow
hyperpronation | supination - flexion
60
Epi dose for - Shock - anaphylaxis
- Shock: 0.01mg/kg | - anaphylaxis: 0.1mg/kg
61
Antidote for benzo overdoer
Flumazenil
62
How long should you observe after drowning?
6-8 hours
63
Signs of inhalational injury?
``` Singed nasal hairs Carbonaceous sputum Stridor/wheeze Facial burns hoarseness stridor ```
64
How to treat dehydration? - Mild - Mod - Severe
- Mild: ORT 50ml/kg over 4 hours + replace ongoing loses - Mod: ORT 100ml/kg over 4 hours + replace ongoing loses - Severe: IVF 20-40ml/kg over 1 hour repeat if necessary ORT when possible
65
Left shoulder pain in trauma?
splenic rupture
66
Indications for admission with a burn?
burns affecting >15% of body surface area Full thickness (3rd degree burns) electrical burns 2ary high tension wires or lightning chemical burns inhalation injury, regardless of amount of BSA burned inadequate home or social environment suspected child abuse or neglect burns to: face, hands, feet, perineum, genitals, major joints burns in patients with preexisting medical conditions that may complicate acute recovery phase associated injuries (fractures) pregnancy
67
Necrotizing fasciitis Bug Mgmt
Strep pyogenes (GAS) IV penicillin + clinda and surgery consult
68
MVC with abdominal wall bruising, unable to urinate or move legs
Chance fracture L1/L2
69
Child given suppositories Vomiting, recurrent tonic spasms, conscious, mouth open most of the time What is this How do you treat
Acute Dystonic Reaction Benadryl
70
What kind of meds are gravol and Benadryl;?
Anticholinergic
71
Abdo trauma - investigations?
CT if stable FAST if unstable
72
RPA - abx
Clindamycin

*Review TD 2020 (16 decks)

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