Acute care Flashcards
(68 cards)
1
Q
ETT size
A
(Age / 4) + 4 = uncuffed ETT size
2
Q
Cholinergic drugs
A
- organophosphates
- carbamates (neostigmine, pyridostigmine)
- alzheimer’s drugs e.g. donepezil
3
Q
Cholinergic toxidrome
A
DUMBELLS
- diaphoresis
- urination
- miosis
- bronchorrhea/ bradycardia
- emesis
- lacrimation
- lethargy
- salivation
4
Q
Cholinergic toxidrome management
A
- 100% oxygen
- early endotracheal intubation (avoid succ)
- PPE, remove clothing and vigorously irrigate skin
- atropine q5 min until secretions and wheezing stops
- inhaled ipratropium
- pralidoxime with atropine
5
Q
Anticholinergic drugs
A
- TCAs (weakly)
- antihistamines
- benztropine
- atropine and cyclopentolate
- many neuroleptics
- Jimson weed
6
Q
Anticholinergic toxidrome
8
A
- dilated pupils
- blind as a bat
- red as a beet
- dry as a bone
- hot as a desert
- mad as a hatter
- absent bowel sounds
- tachycardia
7
Q
Management of anticholinergic
A
- lorazepam for agitation
- water spray and cooling fans for hyperthermia
- consider activated charcoal
- if TCA with prolonged QRS –> sodium bicarb
- consider physostigmine (only pure anticholinergics)
8
Q
Sympathomimetic drugs
A
- cocaine
- amphetamine/meth
- MDMA
- ephedrine
9
Q
Sympathomimetic toxidrome
A
- mydriasis
- diaphoresis (different than anticholinergic!!)
- hypertension
- tachycardia
- seizures
- hyperthermia
- psychosis
- agitation
10
Q
Management sympathomimetic
A
- activated charcoal if within 1 hr
- HTN –> lorazepam, phentolamine
- hyponatremia - fluid restriction or 3% NS
- agitation -> lorazepam
- hyperthermia –> cool water mist and fans
11
Q
LSD vs. PCP
A
LSD: tachy, widened pupils, diaphoresis, visual hallucinations
PCP: HTN, narrowed pupils, hyperthermia, nystagmus and rigidity
12
Q
Serotonin syndrome
A
<12hrs SHIVERS - shivering - hyperthermic - increased reflexes/clonus - vitals unstable - encephalopathy - restless - sweating
13
Q
Neuroleptic Malignant Syndrome
A
3-4 days FEVER - fever - encephalopathy - vitals unstable - elevated enzymes (elevated CPK) - rigidity of muscles
14
Q
Antidepressants acute toxicity
- citalopram
- venlafazine
- buproprion
- quetiapine
A
- citalopram/escitalopram: seizures, proloned QT
- venlafaxine: serotonin syndrome, prolonged QT and QRS
- buprioprion: prolonged QT and QRS, seizures
- quetiapine: prolonged QT and QRS, hypotension
15
Q
Opioid toxidrome
A
- bradycardia
- hypotension
- resp depression
- miosis
- coma
16
Q
activated charcoal indications
A
- within 1-2 hrs of ingestion
- can give later if drug slowly GI emptying e.g. anticholinergic
- avoid in severe caustic ingestion, compromised airway reflexes
17
Q
Activated charcoal fails if…
A
- Potassium
- hydrocarbons
- alcohols
- iron
- lithium
- solvents
18
Q
Intralipid antidote for…
A
- for life-threatening Iv overdosis of local anesthetics, buproprion, amitiptyline
19
Q
Antidotes
- iron
- CO
- pesticide
- nifedipine
- amitryptyline
- methanol
- glyburide
A
Iron= Deferoxamine Carbon monoxide= Oxygen Pesticide =Atropine nifedipine= Glucagon (textbook but not real life) amitriptyline=Sodium bicarb methanol=Fomepizole (or ethanol) Glyburide=Gluocse
20
Q
Hydrocarbons e.g. gasoline, nail polish remover, lighter fluid
- management
A
- CXR stat and repeat in 4-6 hrs post ingestion
- oxygen +/- bronchodilators
- can D/C at 4-6hrs if asymptomatic and normal CXR (watching fro perihilar infilatrates, pneumatocele and resp deterioration ver 24-48hrs)
21
Q
Metformin overdose
A
lactic acidosis
22
Q
glyburide/sulfonylurea management
A
- charcoal if < 2hrs
- manage hypoglycemia with IV dextrose
23
Q
Tylenol overdose stages
toxic dose is 150mg/kg or 7-8 g in an adult
A
- 0-24hrs: asymptomatic or N+V
- 24-72hrs: RUQ pain and onset of hepatocellular injury
- 72-96hrs: maximal hepatotoxicity, deaths
- > 4 days: recovery
24
Q
Tylenol overdose management
A
- activated charcoal within 1 hr (not if sedated or suspect GI obstruction)
- NAC doing based on nomogram, best if started within 8hrs
25
Salicylate poisoning
- respiratory alkalosis
- anion gap metabolic acidosis --> pulmonary/cerebral edema
- N+V, GI bleed
- tinnitus or hearing loss
hyperglycmemia --> hypoglycemia
- diaphoresis
26
Management salicylate poisoning
- charcoal up to 6hrs
- glucose to all pts with altered mental status
- treat hypokalemia
- alkalinize serum (to prevent needing dialysis)
27
Iron poisoning
| - stages
1. 30 min- 6hrs: N+V+D
2. 6-12hrs - "quiescent"
3. 12-24hrs - metabolic acidosis, shock, GIB, coagulopathy, resp failure
4. 2-3 days: ARDS, liver failure
5. 3-4 weeks: GI stricutre at gastric outlet
28
Management of iron poisoning
- fluid resuscitation
- whole bowel irrigation if tablets seen on AXR or if < 6hrs form ingestion (textbook answer)
- Iv deferoxamine must be giver early
29
Toxic alcohols
| - lab findings
- Isopropyl alcohol: ketosis without acidosis
- high osmolar gap = osmolality - (2x Na +gluc + BUN)
- wide anion gap acidosis for methanol and ethylene glycol
30
TCA overdose (features)
- wide QRS (and qt prolongation)
- weakly anticholinergic
- sedation
- hypotension
- seizures
31
TCA overdose management
- activated charcoal
- frequently require intubation because obtunded
- sodium bicarb for QRS > 100
- norepi if hypotensive
32
One-tablet toxins
CV collapse:
- propranolol - CV collapse + hypoglycemia
-CCB - CV collapse
- clonidine - bradycardia + CNS depression
Hypoglycemia:
- propranolol
- glyburide - hypoglycaemia
Seizures etc:
- camphor - seizures
- theophylline - seizures, dysrhtyhmia
- TCA - seizures, hypotension, dysrthyhmia
33
Prevention of submersion injuries - most effective strategy
- 4 sided fence with self-locking, self-closing gates
34
Risk factors for submersion injuries
- leaving children unattended
- alcohol or drug abuse
- limited swimming ability
- underlying medical condition (seizure disorder, toxin, prolonged QT, syncope)
35
Indications for cervical spine immobilization in submersion injury
- does not delay removal from water
| - certain circumstances: diving, alcohol or substances, trauma
36
Investigations in drowning
- arterial blood gas
- electrolytes, urea, creatinine
- CXR for signs of ARDS
- ECG
- ethanol level
- core temperature
37
Good prognostic factors in submersion
```
Good prognosis:
- immediate bystander CPR (most impt)
- return of spontaneous circulation in < 10 min
- submersion < 5 min
- pupils equal and reactive at scene
- normal sinus rhtyhm at scene
Poor prognosis:
- delayed CPR, ROSC > 25 min, submersion > 10 min
```
38
Complications of submersion
- ARDS
- pulmonary edema
- PNA
- cerebral edema leading to increased ICP
- trauma
- hypothermia
39
Hypothermia
| - definition and associated sx
- core temp < 35C
- accompanied by hypoglycemia, hypocalcemia, hypokalemia, metabolic acidsois
- associated with pancreatitis
40
ECG findings in hypothermia
- marked sinus bradycardia
- first degree AV block
- Osborn or J waves
- prolonged QT
41
```
Principles of rewarming
- pulseless
- good pulse
- VF
drugs
```
pulseless --> CPR
avoid CPR in T<28 and good pulse
VF --> defb x 3 but no more until T>= 30
drugs rarely effective until T>= 30, dont give until 30C
42
Heatstroke - diagnosis, sx and management
Core T>40C with CNS dysfunction
- headache, disorientation, dizziness, weakness, gait disturbance
Mgmt: cool until 38.5, fluid and salt replacement orally
43
Complications of heatstroke
- hyponatremia
- seizure
- rhabdomyolysis
- DIC
- multisystem organ failure
44
Burn classification
1. superficial
2. superficial partial thickness
3. deep partial thickness
4. full thickness
1. epidermis only - red, pain, no blisters
2. epidermis and 1/2 dermis - pink, pain, moist, blisters
3. epidermis and >1/2 dermis - pale, dry, less tender, speckled; often need grafts
4. subcutaneous tissue - pale, charred leathery, non-tender - most require grafting
45
Indications for early intubation in burns/fire
- carbonaceous sputum
- singed nasal hairs
- soot in airway
- hoarseness
- drooling
46
Parkland formula (for children >= 5)
- 4cc/kg/BSA over 24hrs with 1st half in 8hrs, 2nd hafl over 16hrs,
- add maintenance to Parkland!
(use NS or ringer's lactate)
47
Admission criteria for burns
| 11
- burns covering > 10% of total BSA
- full thickness burns
- electrical burns
- chemical burns
- inhalation injury
- suspected NAI
- burns to face, hands, feet, perineum, genitals or major joints
- burns in pts with preexisting medical conditions
- associated injuries
- pregnancy
- inadequate home or social evironment
48
High tension wire injury
- muscle damage
- compartment syndrome
- rhabdo
- ARF
- CNS injury common
- VF/arrest common
monitor U/A and ECG
49
carbon monoxide diagnosis and management
- normal pulse ox and arterial pO2
- COHb > 3%
- remove from source
- treat if COHb > 10% on 100% FiO2
- hyperabric oxygen (best if < 6hrs of exposure) if COHb > 25% (>20% in child), CNS symptoms
50
cyanide poisoning antidote
- hydroxycobalamin kit
| - indicated if increased lactate or decreased BP
51
5 reasons to intubate:
- airway patency
- airway protection
- resp distress/failure/arrest
- cardiac dysfunction
- procedures
52
DOPE mnemonic
displacement
obstruction
PTX
equipment
53
Ventilation settings to improve 1. oxygenation
| 2. ventilation
```
O2:
- increase PEEP
- increase FiO2
CO2:
- increase rate
- increase tidal volume
```
54
5 causes of hypoxemia
1. low FiO2
2. hypoventilation
3. V/Q mismatch
4. shunt
5. impaired alveolar-capillary diffusion
55
Severe/impending failure status asthmaticus treatment
- oxygen
- salbutamol
- systemic steroids IV
- Mg SO4
- adjuncts: ketamine, HFNC, NIPPV,
- PICU
- IM or SC epi if no IV access and sudden deterioration
avoid intubation
- R/o complications e.g. PTX
56
Pediatric ARDS
| - mod-severe management summary
1. Vt<6mL/kg
2. plateau pressure <28-32cm H20
3. generous PEEP (up to 10-15cm H20
4. HFOV = rescue
5. permissive hypercapnia
6. target sat 88-92
7. consider prone positioning
8. prevent fluid overload
57
Shock examples
- hypovolemic: dehydration, anemia
- obstructive: tension PTX, tamponade, PE
- cardiogenic: myocarditis, arrhythmia
- distributive: anaphylaxis, sepsis
- dissociative: CO/cyanide poisoning
- adrenal crisis
58
Shock definition
inadequate delivery of oxygen to meet demand
59
Defibrillation doses
| Epi resusc dose
1. start with 2J/kg
2. 2nd dose 4J/kg
Epi 0.01mg/kg = 0.1mL/kg of 0.1mg/mL (1:10,000)
60
Bradycardia with a poor pulse HR
- chest compression if < 60
| - give epi 0.01mg/kg
61
Indications for adenosine
- SVT if have IV in place
| - consider in wide complex tachy if regular and monomorphic if not in shock
62
Synchronized cardioversion dosing
- begin with 0.5-1J/Kg
| - increase to 2J/kg
63
Status epilepticus algorithm
1. benzo - IV preferred
2. repeat benzo - IV preferrred
3. fos/pheny or phenobarb load
4. other agent not given in 3
5. midazolam infusion
64
cerebral perfusion pressure
MAP - ICP
65
Management of increased ICP
- increase venous drainage: HOB to 30 degrees, c-collar not too tight, head midline
- osmotic therapies: Hypertonic saline 2-5mL/kg IV
- control ICP surge:analgesia, sedation, anti-seizure, anti-pyretic, NM blockade in severe cases
- CSF removal
- mass removal eg.. hematoma
- reduce cerebral blood volume e.g. hyperventilation
- increase intracranial space
66
Goals for preventing 2ndary injury in TBI
avoid: hypotension (most impt), hypoxia, hyperthermia, hyponatremia, hypo/hypercapnia, hypo/hyperglycemia
67
Apnea test in NDD
- final PaCO2>= 60
- final PaCO2>= 20 above pre-test
- final pH<= 7.28
- absence of resp effort
68
2 ways to reduce pulled elbow
1. hyperpronation
| 2. supination + flexion
