Common Problems in Acute Care Flashcards
(272 cards)
1
Q
Amphetamines (e.g. MDMA): presentation
A
euphoria, elation
dilated pupils
agitation, anxiety, insomnia
tachycardia, hypertension
vomiting
decreased appetite
tremors, muscle twitching, bruxism
perspiration, chills, pallor
resolves 24-48 hours after ingestion
2
Q
pneumocystis jirovecii: CXR
A
bilateral interstitial infiltrates
3
Q
pneumocystis jirovecii: treatment
A
TMX-SMZ
4
Q
malignant hyperthermia
A
Genetic disorder that causes a fast rise in body temperature and severe muscle contractions when someone receives general anesthesia with one or more of the following drugs: (DISH-Succ)
- desflurane
- isoflurane
- sevoflurane
- halothane
- succinylcholine
5
Q
malignant hyperthermia: Dx
A
caffeine halothane contracture test
Usually based on clinical signs and symptoms
6
Q
malignant hyperthermia: signs
A
Earliest indication: increased end-tidal CO2 that is resistant to increases in minute ventilation
Late sign: hyperthermia
tachyarrhythmias
tachypnea
acidosis
7
Q
malignant hyperthermia: treatment
A
dantrolene - interferes with muscle contraction by inhibiting calcium ion release from the sarcoplasmic reticulum
8
Q
malignant hyperthermia: ABG
A
respiratory acidosis
9
Q
malignant hyperthermia: SVO2
A
decreased d/t significantly increased O2 consumption
10
Q
organophosphate (insecticide, pesticide) poisoning: S/Sx
A
AMS, slurred speech, coma
Headache
Miosis, blurred vision
Lacrimation
Excessive salivation
Bradycardia
Diffuse wheezing
diaphoresis
N/V/D, cramping
Urination
11
Q
organophosphate (insecticide, pesticide) poisoning: management
A
atropine
sodium nitrite
Wash skin thoroughly
If insecticide was ingested, give activated charcoal
12
Q
cutaneous anthrax: S/Sx, presentation
A
begins 1-7 days after exposure to infected livestock or livestock products
Painless pruritic papule appears and rapidly develops into an ulcer within 24 hours
Over the next 72 hours, the ulcer becomes dry and dark with surrounding edema (“black eschar”)
May cause bacteremia
13
Q
cutaneous anthrax: Dx
A
BC negative unless bacteremia
Tissue biopsy with gram stain, culture, and immunohistochemical stain to confirm Dx
14
Q
arsenic poinsoning: S/Sx
A
diarrhea with negative workup
Leukonychia (white lines on nails)
15
Q
Major causes of anion gap metabolic acidosis
A
MUDPILES
Methanol
Uremia
Diabetic ketoacidosis
Paraldehyde
Iron, Isoniazid
Lactate
Ethanol, Ethylene glycol
Salicylates
16
Q
Normal anion gap
A
8-12
17
Q
How to calculate anion gap
A
Na - (Cl + HCO3)
18
Q
necrotizing fasciitis: S/Sx
A
Early: flu-like symptoms
Later:
-rapidly spreading erythema
-pain extending beyond borders of erythema
-palpable crepitus
-Swelling of affected tissues
-Blisters filled with bloody or yellowish fluid
-Tissue death (necrosis)
-hypotension, sepsis
19
Q
necrotizing fasciitis: labs/Dx
A
CT
20
Q
necrotizing fasciitis
A
Infection of the fascia
Systemic toxicity
21
Q
testicular torsion: presentation
A
acute onset of unilateral testicular pain after exercising
high riding testes
“bell-clapper deformity”
absent cremasteric reflex
22
Q
testicular torsion: management
A
immediate surgical exploration
intraoperative detorsion with fixation of the testes
23
Q
delay in correction of testicular torsion results in…
A
necrosis of testicular tissue d/t ischemia
If surgery is unavailable within two hours, manual detorsion can be attempted
24
Q
WHO Ladder of Pain Management: Step 1
A
Non-opioid +/- adjuvant (not traditionally used as 1st line for pain, e.g. nortriptylline)
25
WHO Ladder of Pain Management: Step 2
Choice from Step 1 [non-opioid +/- adjuvant] PLUS
Codeine
Dihydrocodeine
Oxycodone
Hydrocodone
Tramadol (not with ASA/APAP)
+/- adjuvants
26
WHO Ladder of Pain Management: Step 3
Choice from Step 1 [non-opioid +/- adjuvant] PLUS
Morphine
Hydromorphone
Methadone
Levorphanol
Fentanyl
Oxycodone
+/- Nonopioid analgesics
+/- adjuvants (e.g. surgery for terminal cancer)
27
What is recommended for breakthrough cancer pain?
fentanyl patches for sustained release
28
Metastatic bone pain: management
bisphosphonates -- inhibit bone resorption and prevent the development of cancer-induced bone lesions
29
Stage 1 Pressure Injury
Intact skin with erythema that does not blanch
Does not include purple or maroon discoloration
30
Stage 2 Pressure Injury
Partial-thickness loss of skin with exposed dermis
Wound bed is viable, pink or red, moist, and may also present as an intact or ruptured serum-filled blister
Adipose and deeper tissues are not visible
Should not be used to describe moisture associated skin damage including incontinence associated dermatitis, intertriginous dermatitis, medical adhesive related skin injury, or traumatic wounds (skin tears, burns, abrasions)
31
Stage 3 Pressure Injury
Full-thickness skin loss
Adipose is visible and granulation tissue and epibole (rolled wound edges) are often present
Slough and eschar may be visible but do not obscure the extent of tissue loss
32
Stage 4 Pressure Injury
Full-thickness skin and tissue loss
Exposed or directly palpable fascia, muscle, tendon, ligament, cartilage, or bone
Slough and/or eschar may be visible but do not obscure the extent of tissue loss
Epibole (rolled wound edges), undermining, and/or tunneling often occur
33
Unstageable Pressure Injury
Obscured full-thickness skin and tissue loss
Extent of tissue damage cannot be confirmed because it is obscured by slough or eschar
Stable eschar on the heel or ischemic limb should not be softened or removed
34
Deep Tissue Pressure Injury
Intact or non-intact skin with localized areas of persistent non-blanch able deep red, maroon, or purple discoloration or epidermal separation revealing a dark wound bed or blood filled blister
Do not use to describe vascular, traumatic, neuropathic, or dermatologic conditions
35
Pressure injury management considerations
hypoalbuminemia -- reliable factor for pressure ulcer development (normal: 3.5-5)
wound care specialist consult
dressings
- weeping: hydrocolloid dressing
36
Initial treatment of post-op fever
In the absence of any indication of infection, the first response should include hydration and measures to expand lung function
37
Causes of non-infectious post-op fever
post-op atelectasis
increased basal metabolic rate
dehydration
drug reactions
-amphotericin B
-bactrim
-beta-lactam antibiotics
-procainamide
-isoniazid
-alpha-methyldopa
-quinidine
38
treatment of infectious post-op fever
supportive fluid and acetaminophpen
treat the apparent underlying source
gram stain, C&S all invasive lines or catheters as indicated
39
hypoalbuminemia
Increased risk for drug toxicity and interactions
Indicates protein malnutrition
40
Indications for duodenal tube
Able to use GI tract safely
Does not need tube feeds for >6 weeks
Risk for aspiration
41
Indications for NG tube
Able to use GI tract safely
Does not need tube feeds for >6 weeks
Not at risk for aspiration
42
Indications for PEG
Able to use GI tract safely
Needs tube feeds for >6 weeks
43
Indications for PPN
Unable to use GI tract safely
Does not need nutritional support for >2 weeks
Can administer via PIV
44
Indications for TPN
Unable to use GI tract safely
Needs nutritional support for >2 weeks
Administer via central line
45
Complications of enteral nutritional support
*Involve the solution itself*
Aspiration
Diarrhea (Is formula too concentrated? Switch bolus to continuous feeds? Slow down the rate?)
Emesis
GI bleeding
Mechanical obstruction of the tube
Hypernatremia
Dehydration
Refeeding syndrome
46
Refeeeding syndrome: labs
**Hypophosphatemia**
hypokalemia
hypomagnesemia
hypocalcemia
thiamine deficiency
47
Complications of parenteral nutritional support
*Involve the mode of delivery*
Pneumothorax
Hemothorax
Arterial laceration
Air emboli
Catheter thrombosis
Catheter sepsis
Hyperglycemia
HHNK
48
First and most important step in managing poisoning/drug toxicities
Obtain a detailed history
49
Poisoning/drug toxicities: GI decontamination
Gastric lavage
Activated charcoal -- most beneficial within the first hour of ingestion
Cathartics -- not routinely indicated with activated charcoal
-exception: Sorbitol often used with first dose of activated charcoal
Whole bowel irrigation -- using polyethylene glycol to treat enteric-coated or sustained-release overdoses
Antidotes
50
Acetaminophen intoxication: S/Sx
Usually asymptomatic in the early phase
Around 24-48 hours:
-N/V
-RUQ pain
-Signs of hepatotoxicity: jaundice, elevated LFTs, prolonged PT, -AMS, delirium
51
Acetaminophen intoxication: management
1st line: emesis or gastric lavage
Activated charcoal
**N-Acetylcysteine (Mucomyst) with a loading dose of 140 mg/kg orally, as needed**
52
Acetaminophen intoxication: examples
Acetaminophen
Anacin-3
Panadol
53
Salicylate intoxication: examples
aspirin
54
Salicylate intoxication: S/Sx
Delayed
HA, dizziness, tinnitus
apnea, cyanosis
dehydration
N/V
hyperthermia
metabolic acidosis
elevated LFTs
55
salicylate intoxication: management
activated charcoal
sodium bicarbonate IV to correct severe acidosis (pH <7.1)
treat S/Sx
gastric lavage
56
organophosphate (insecticide, pesticide) poisoning: examples
malathion
parathion
57
antidepressant toxicity: S/Sx
Confusion, hallucinations, blurred vision
Seizures
Hypotension, tachycardia, dysrhythmias
Hypothermia
Urinary retention
58
antidepressant toxicity: management
ICU if CNS or cardiac toxicity evident
Activated charcoal
Dysrhythmias, acidosis/maintain pH: Sodium bicarbonate IV
Seizures: Benzodiazepines
Serotonin syndrome: dantrolene (Dantrium)
Rigors: clonazepam (Klonopin)
Temperature: cooling blankets
59
Opioid toxicity: S/Sx
drowsiness
hypothermia
respiratory depression, shallow respirations
miosis
coma
60
opioid toxicity: management
activated charcoal
naloxone (Narcan)
emetics are contraindicated
61
benzodiazepine toxicity: S/Sx
drowsiness, confusion
slurred speech
hyporeflexia
respiratory depression
62
benzodiazepine toxicity: management
respiratory and BP support
Flumazenil (Romazicon) IV
activated charcoal if recent ingestion
63
beta blocker overdose: S/Sx
delirium
hypotension
sinus bradycardia
bronchospasm
coma
64
beta blocker overdose: management
Charcoal if recent ingestion
glucagon
atropine as needed
stabilization of airway
65
ethylene glycol (antifreeze) overdose: S/Sx
First stage (30 min-12 hrs)
- loss of coordination
- headache
- slurred speech
- N/V
Second stage (12-24 hrs)
- irregular heartbeat
- shallow breathing
- Changes in BP
Third stage (24-72 hrs)
- kidney failure
66
TCA toxicity: treatment
sodium bicarbonate
67
ethylene glycol (antifreeze) overdose: management
Fomepizole (Antizole)
Ethanol (if fomepizole not available)
68
Compartment syndrome
Increased interstitial pressure within a closed fascial compartment (skin, fascia, muscle, bone)
May result from hemorrhage, edema, sustained external pressure on a limb or constrictive casts, dressings, etc.
Should be suspected in any unconscious patient with a swollen limb
69
Compartment syndrome: S/Sx
**severe ischemic pain
parasthesias**
tensely swollen
skin perfusion, arterial pulses normal
passive stretch of muscle is painful
progressive loss of sensory/motor function
repeated examinations are required to check for developing compartment syndrome
70
Compartment syndrome: Diagnostics
Often using a Stryker tonometer; Normal compartment pressure: 0-8 mm Hg
**>30 mmHg: Indicates compartment syndrome and a need for fasciotomy**
- Within 10-30 mmHg of DBP: Indicates inadequate perfusion and relative ischemia of the involved extremity
Delta pressure: perfusion pressure of a compartment
= (diastolic BP) - (intracompartmental pressure)
**<30 mmHg: indicates need for fasciotomy**
71
compartment syndrome: management
release constricting appliances
fasciotomy: effective only if performed within a few hours
72
Dog, cat, human bites: management
Timely, copious, high-pressure irrigation with NS to reduce infection rates
Animal bites: ascertain rabies status
Wounds of the hand or lower extremities should be left open
- >6 hours: leave open to heal by secondary intention
Human and animal bites: ppx ABx to cover staphylococci and anaerobes (e.g. Augmentin) x3-7 days
X-rays as needed
Plastic surgery consultation as appropriate
73
staphylococcus: class
gram positive
74
streptococci: class
gram positive
75
enterococci: class
gram positive
76
bacilli: class
gram positive
77
corynebacterium: class
gram positive
78
serrate marcescens: class
gram negative
79
escherichia coli: class
gram negative
80
klebsiella: class
gram negative
81
pseudomonas: class
gram negative
82
proteus mirabilis: class
gram negative
83
Moraxella catarrhalis: class
gram negative
84
acinetobacter: class
gram negative
85
enterobacter: class
gram negative
86
acute otitis media: most likely pathogen and empiric therapy
S. pneumoniae
Empiric therapy:
-amoxicillin
-augmentin
-cefuroxime
-bactrim
87
sinusitis: most likely pathogen and empiric therapy
S. pneumoniae
Empiric therapy:
-amoxicillin
-augmentin
-cefuroxime
-bactrim
88
acute endocarditis: most likely pathogen and empiric therapy
staphylococcus aureus
vancomycin + ceftriaxone
89
subacute endocarditis: most likely pathogen and empiric therapy
viridian streptococci, enterococci
penicillin + gentamicin
90
peritonitis d/t ruptured viscus: most likely pathogen and empiric therapy
coliforms
bacteroides fragilis
empiric therapy: metronidazole +
-cephalosporin 3rd generation (ceftriaxone, ceftazidime)
-pip/tazo
91
intra abdominal infection: most likely pathogen and empiric therapy
E. coli
Klebsiella
Enterococci
empiric therapy: metronidazole +
-cefuroxime
-ceftriaxone
-ciprofloxacin
-levofloxacin
92
cellulitis: most likely pathogens and empiric therapy
staphylococcus aureus
Group A streptococcus
1st generation cephalosporin (cefazolin)
vancomycin
clindamycin
daptomycin
linezolid
93
s. pneumoniae is the #1 pathogen causing...
otitis media
sinusitis
bronchitis
meningitis
CAP
94
colorectal, non-perforated appendectomy: ABx prophylaxis for staphylococci, streptococci, enteric gram-negative rods
cefazolin
95
colorectal, non-perforated appendectomy: ABx prophylaxis for MRSA+
vancomycin
96
colorectal, non-perforated appendectomy: ABx prophylaxis for enteric gram-negative rods, anaerobes
metronidazole plus:
-cefoxitin
-cefotetan
-cefazolin
97
sepsis: most likely pathogens and empiric therapy
staphylococcus aureus
empiric therapy:
- 1st generation cephalosporins (cefazolin, cephalexin)
- 5th generation cephalosporins (ceftaroline)
vancomycin
linezolid
98
osteomyelitis: most likely pathogens and empiric therapy
staphylococcus aureus
empiric therapy:
- 1st generation cephalosporins (cefazolin, cephalexin)
- 5th generation cephalosporins (ceftaroline)
vancomycin
linezolid
99
CAP: most likely pathogens and empiric therapy
streptococcus pneumoniae
amoxicillin + macrolide (azithromycin)
100
MRSA: empiric therapy
**1st line treatment: vancomycin**
Alternative:
**-daptomycin
-linezolid**
-doxycycline
-ceftaroline
-clindamycin
-bactrim
101
pharyngitis: most likely pathogen and empiric therapy
streptococcus pyogenes
Empiric therapy: vancomycin
102
impetigo: most likely pathogen and empiric therapy
streptococcus pyogenes
Empiric therapy: vancomycin
103
meningitis: most likely pathogen and empiric therapy
staphylococcus pneumoniae
empiric therapy: penicillin G
104
Cephalosporins: best Gram+ coverage
1st generation: cefazolin, cephalexin
105
Cephalosporins: best Gram- coverage
5th generation: ceftaroline
106
Acute rejection of an organ: presentation
Immediate failure of that organ
Flu-like symptoms
107
Acute rejection of an organ: labs/Dx
immediate biopsy of the transplanted organ
108
Acute rejection of an organ: management
1. corticosteroid:
- methylprednisolone
- prednisone
2. antimetabolite:
- azathioprine (Imuran)
- mycophenolate mofetil (CellCept)
- mycophoneolate sodium (Myfortic)
- cyclophosphamide (Cytoxan)
3. calcineurin inhibitor or mammalian target of rapamycin inhibitor:
- calcineurin inhibitors: tacrolimus, cyclosporine
- mTOR inhibitors: sirolimus, temsirolimus, everolimus
109
Shingles: S/Sx
Pain along a dermatomal distribution, usually on the trunk or chest
Grouped vesicle eruption of erythema and exudate along the dermatomal pathway
Regional lymphadenopathy may be present
110
Shingles: management
Treatment:
-acyclovir
-famciclovir
-valacyclovir
If suspected ocular involvement, immediate referral to ophthalmologist
Post-herpetic neuralgia: gabapentin, pregabalin
111
Shingles vaccine
Indicated for all adults >50, regardless of previous vaccine
- two dose regimen with 2nd dose given 2-6 months after 1st dose
112
actinic keratoses
Premalignant
Asymptomatic, small rough flesh colored/pink/hyperpigmented patches
113
actinic keratoses: treatment
liquid nitrogen to freeze off
114
squamous cell carcinoma
arise out of actinic keratoses
Firm, irregular papule or nodule
115
squamous cell carcinoma: management
biopsy and surgical excision (Mohs)
116
seborrheic keratoses
benign, not painful lesions
beige, brown, or black plaques
"stuck on" appearance
117
seborrheic keratoses: treatment
none or liquid nitrogen
118
basal cell carcinoma
Most common skin cancer
Slow growing lesion
Waxy pearly appearance, may be shiny red
Central depression or rolled edge
May have telangiectatic vessels
119
basal cell carcinoma: treatment
shave/punch biopsy and surgical excision
120
malignant melanoma: criteria
highest mortality rate of all skin cancers
Median age at diagnosis: 40
Yes to 2+ = 97% sensitive to malignant melanoma:
- **A**ssymetry
- **B**order irregularity
- **C**olor variation
- **D**iameter >6 mm
- **E**levation, **E**nlargement
121
malignant melanoma: treatment
biopsy and surgical excision
122
brain death criteria
coma
absence of brain stem reflexes
apnea
123
most important feature of headaches to assess in order to determine the type of headache
chronology
124
Components of headache evaluation
Chronology -- most important
Location, duration, quality
Associated activity: exertion, sleep, tension, relaxation
Timing of the menstrual cycle
Presence of associated symptoms
Presence of "triggers"
125
most common type of headache
tension headache
126
tension headache: S/Sx
vise-like or tight in quality
usually generalized
may be most intense around the neck or back of the head
no associated focal neurological symptoms
usually last for several hours
127
migraine headaches: causes
Related to dilation and excessive pulsation of branches of the external carotid artery
Onset usually in adolescence or early adult years
Often family history
Females > males
Nitrate containing foods
Changes in weather
128
migraine triggers
emotional or physical stress
lack or excess sleep
missed meals
specific foods, esp nitrate containing foods
alcohol
menstruation
OCPs
changes in weather
129
migraines: S/Sx
Unilateral, lateralized throbbing headache that occurs episodically
May be dull or throbbing
Build gradually and last typically for 2-72 hours
Focal neurologic disturbances may precede or accompany migraines (may present like TIA)
Follow the trigeminal nerve pathway
Visual disturbances: field deficits, luminous visual hallucinations
Aphasia, numbness, tingling, clumsiness, or weakness
Nausea, vomiting
Photophobia, phonophobia
130
Concerns with new migraines
rule out tumor
131
migraines: labs/Dx
BMP, CBC
VDRL to rule out tertiary syphillis
ESR
head CT to rule out tumor
132
migraines: prophylaxis
Avoidance of trigger foods
Relaxation/stress management
Prophylactic daily therapy if >2-3 acute attacks/month
133
migraines: prophylactic daily therapy
Anticonvulsants: topiramate, valproic acid
Beta-blockers: atenolol, metoprolol, propranolol, timolol
Botox: around face and scalp Q3 months; indicated if >15 headaches/month
CCBs: diltiazem, verapamil
TCAs: amitriptyline, nortriptyline
Calcitonin gene-related peptide (CGRP) inhibitors: eptinezumab, erenumab, fremanezumab, galcanezumab
NSAIDs and certain triptans: naproxen; can be helpful in treating women with migraines that are associated with menstrual cycle
134
migraines: management of an acute attack
Rest in a quiet, dark room
Simple analgesic (ASA) right away
Sumatriptan (Imitrex) 6mg SQ at onset, repeat in 1 hour TID PRN
Sumatriptan (Imitrex) 25mg PO at onset of headache
135
Cluster headaches: incidence
mostly affecting middle aged women
136
Cluster headaches: causes
Often no family history of headache or migraine
May be precipitated by alcohol
137
Cluster headaches: S/Sx
Severe, unilateral, periorbital pain occurring daily for several weeks
Usually occur at night, awakening the person from sleep
Usually lasts less than 2 hours
Pain free months or weeks between attacks
Ipsilateral nasal congestion, rhinorrhea, and eye redness may occur
138
Cluster headaches: management
Treatment of individual attacks with oral drugs is usually unsatisfactory
100% O2
Sumatriptan (Imitrex) 6mg SQ
Ergotamine tartrate aerosol inhalation (Ergostat)
139
most common electrolyte abnormality
hyponatremia
140
hyponatremia: first step in treating
determine the cause
141
hyponatremia: evaluation to determine the cause
Urine sodium
Serum osmolality
Clinical status
142
normal urine sodium
10-20 mEq/L
143
normal urine osmolality
50-1200 mOsm/kg
144
normal serum osmolality
275-295
145
isotonic hyponatremia: labs
serum osmolality 284-295 mOsm/kg
146
isotonic hyponatremia
A laboratory artifact
Occurs with extreme hyperlipidemia or hyperproteinemia
Asymptomatic
147
isotonic hyponatremia: treatment
cut down fat
no fluid restriction
148
hypotonic hyponatremia: labs
serum osmolality <280 mOsm/kg
149
hypotonic hyponatremia
State of body water excess diluting all body fluids
150
hypotonic hyponatremia: first step in management
Assess if the patient is hypovolemic or hypervolemic
If hypovolemic, determine if hyponatremia is due to extrarenal salt losses or renal salt wasting by measuring urine sodium
151
urine sodium >20 mEq/L
suggests renal salt wasting (a problem with the kidneys)
152
urine sodium <10 mEq/L
suggests renal retention of sodium to compensate for extrarenal fluid losses (a problem other than the kidneys)
153
hypovolemic hyponatremia w/urine Na+ <10 mEq/L: causes
dehydration
diarrhea
vomiting
154
hypovolemic hyponatremia w/urine Na+ >20 mEq/L: causes
diuretics
ACE inhibitors
mineralocorticoid deficiency
155
hypervolvemic, hypotonic hyponatremia: causes
edematous states
CHF
liver disease
advanced renal failure
156
hypervolvemic hypotonic hyponatremia: treatment
restrict water
157
hypertonic hyponatremia: serum osmolality
>290 mOsm/kg
158
hypertonic hyponatremia: cause
hyperglycemia -- most common cause
159
rapid correction of hyponatremia can result in...
osmotic demyelination syndrome
160
hypovolemic hyponatremia: management
mild (Na >120): NS
severe (Na <120): 3%
161
hyponatremia w/urine Na+ >20 mEq/L: management
treat the cause (diuretics, ACEIs, mineralocorticoid deficiency)
162
Symptomatic hyponatremia: management
NS with loop diuretic
If CNS symptoms are present, consider 3% saline with loop diuretics
- raise Na+ slowly. Too fast can cause cerebral edema
163
Hypernatremia: causes
Usually due to excess water loss
Always indicates hyperosmolality
Excessive sodium intake is rare
164
normal sodium
135-145 mEq/L
165
hypernatremia: management
Depends on cause
Severe hypernatremia with hypovolemia: NS (isotonic to increase BP) followed by 1/2 NS (when normotensive)
Hypernatremia with euvolemia: free water (D5W)
Hypernatremia with hypervolemia: free water and loop diuretics; may need dialysis
166
Normal potassium
3.5-5.2 mEq/L
167
hypokalemia: causes
Diuretics
GI loss
Excess renal loss
Alkalosis
Trauma patients: elevated serum epinephrine
168
hypokalemia: S/Sx
muscle weakness, fatigue, cramps
constipation or ileus d/t smooth muscle involvement
Severe (<2.5): flaccid paralysis, tetany, hyporeflexia, rhabdomylosis
169
hypokalemia: EKG changes
decreased amplitude
broad T waves
prominent U waves
PVCs, VT, VF
170
hypokalemia: management
If K >2.5 mEq and no EKG abnormalities: oral replacement
If K <2.5 mEq or severe signs/symptoms: 40 mEq/L/hr IV
-check Q3h
-continuous telemetry
**Mg+ deficiency frequently impairs K+ correction**
171
hyperkalemia: causes
Excess intake
Renal failure
Drugs (e.g. NSAIDs)
Hypoaldosteronism
Cell death
Acidosis
172
hyperkalemia: S/Sx
weak, flaccid paralysis
Abdominal distention
Diarrhea
173
hyperkalemia: EKG changes
tall, peaked T waves
174
hyperkalemia: management
Exchange resins (e.g. Kayexalate)
If >6.5 or cardiac toxicity or muscle paralysis is present:
- insulin 10 U with one amp D50
- calcium gluconate
175
normal total calcium
2.2-2.6 mmol/L
8.5-10.5 mg/dL
176
normal ionized calcium
1.1-1.4 mmol/L
4.5-5.5 mg/dL
177
ionized calcium
Does not vary with the albumin level
-Useful to measure when serum albumin is not within normal range
Increases with acidemia, decreases with alkalemia
178
What does a normal calcium level in the presence of low albumin suggest?
hypercalcemia
179
hypocalcemia: causes
hypoparathyroidism
hypomagnesemia
pancreatitis
renal failure
severe trauma
multiple blood transfusions
180
hypocalcemia: S/Sx
increased DTRs
muscle/abdominal cramps
convulsions
Chvostek's sign
Trousseau's sign (captopedal spasm)
prolonged QT
181
Chvostek's sign
twitching of ipsilateral facial muscles on percussion d/t irritability of facial nerve
sign of hypocalcemia
182
hypocalcemia: management
check blood pH for alkalosis
acute: IV calcium gluconate
chronic: oral supplements, vitamin D, aluminum hydroxide
183
hypercalcemia: causes
hyperparathyroidism
hyperthryroidism
vitamin D intoxication
prolonged immobilization
rarely, thiazide diuretics
184
hypercalcemia: S/Sx
fatiguability
muscle weakness
depression
anorexia
N/V
constipation
severe hypercalcemia can cause coma and death
185
hypercalcemia: management
calcitonin if impaired cardiovascular or renal function
NS with loop diuretics
severe: dialysis
186
respiratory acidosis: labs
pH <7.35
pCO2 >45
187
respiratory acidosis: cause
decreased alveolar ventilation
188
respiratory acidosis: S/Sx
somnolence
confusion
coma
myoclonus with asterixis
189
normal pH
7.34-7.45
190
normal pCO2
35-45
191
normal HCO3-
22-26
192
normal PaO2
75-100
193
respiratory acidosis: management
narcan for all patients with no obvious cause
improve ventilation, intubate if necessary
increase rate on ventilator
194
respiratory alkalosis: cause
hyperventilation
195
respiratory alkalosis: labs
pH >7.45
pCO2 <35
serum HCO3 low if chronic
196
respiratory alkalosis: S/Sx
light-headedness
anxiety
parasthesias
stocking/glove tingling
tetany if very severe
197
respiratory alkalosis: management
manage underlying cause
If an acute hyperventilation syndrome is present, have the patient breathe into a paper bag
Decrease rate on ventilator as needed
Sedation if needed
Rapid correction of chronic alkalosis may result in metabolic acidosis
198
metabolic acidosis: labs
pH <7.35
HCO3 <22
199
anion gap formula
Na - (HCO3 + Cl)
200
normal anion gap
5-15
201
metabolic acidosis with increased anion gap: causes
DKA
alcaholic ketoacidosis
lactic acidosis
202
metabolic acidosis with normal anion gap: causes
diarrhea
ileostomy
renal tubular acidosis
recovery from DKA
203
metabolic acidosis: management
treat underlying cause
fluid resuscitation
204
metabolic alkalosis: labs
pH >7.45
HCO3- >26
pCO2 >55 compensatory
205
metabolic alkalosis: causes
post-hypercapnia alkalosis
NG suction
vomiting
diuretics
206
metabolic alkalosis: management
correct volume deficit with NaCl and KCl
-if volume replacement is contraindicated: acetazolamide 250-500mg IV Q4-6 hours
discontinue diuretics
H2 blockers if GI loss
207
1st degree burn
dry, red, no blisters
involves epidermis only
208
2nd degree burn
partial thickness
moist, blisters
extends beyond epidermis
209
3rd degree burn
full thickness
dry, leathery, black, pearly, waxy
extends from epidermis to dermis to underlying tissues, fat, muscle and/or bone
210
Adult Rule of Nines
Each arm = 9%
Each leg = 18%
Thorax: front = 18%, back = 18%
Head = 9%
Perineum/genitals = 1%
211
Parkland formula
4 ml/kg x TBSA % burned = fluid in 24 hours
212
Fluid resuscitation in burns
1/2 of all fluid requirements during the first 24 hours administered within 8 hours of injury
Remaining 1/2 of fluid to be given over the next 16 hours
213
burns: monitoring
metabolic acidosis expected in the early resuscitation phase
hyperkalemia during the first 24-48 hours; hypokalemia following fluid resuscitation/diuresis around 2 days post burn
214
burns: indications for prophylactic intubation
burns to the face
singed nares or eyebrows
dark soot/mucous from nares and/or mouth
215
tar burn injury: management
use a petroleum-based product to remove the burning tar
216
diabetic retinopathy: S/Sx
**microaneurysms are the earliest detectable sign**
-ruptured microaneurysms results in retinal hemorrhages either superficially (flamed-shaped hemorrhages) or in deeper layers of the retina (blot and dot hemorrhages)
cotton-wool spots
217
AV nicking
sign of chronic hypertension
218
Arcus sinilis
a cloudy appearance of the cornea with a gray/white arc or circle around the limbus d/t deposition of lipid material
no effect on vision
cause: hyperlipidemia
219
chemical conjunctivitis: management
self-limiting
flush with normal saline
220
bacterial conjunctivitis: management
self-limiting
antibiotic drops (e.g. levofloxacin, ofloxacin, ciprofloxacin, tobramycin, gentamycin ophthalmic solution)
221
gonococcal conjunctivitis: management
**opthalmic emergency**
ceftriaxone 250mg IM + azithromycin
222
chlamydial conjunctivitis: management
ceftriaxone 250mg IM + azithromycin
223
allergic conjunctivitis: management
oral antihistamines
-refer to allergist/ophthalmologist if no response
steroids are not ordered in primary care because of possible increased intraocular pressure and activation of HSV
224
viral conjunctivitis: management
symptomatic care
-mild: saline drops, artificial tears
-moderate: decongestants, antihistamines, mast cell stabilizers, NSAIDs
Sulfacetamide 10% ophthalmic solution for bacterial (secondary) prophylaxis
225
herpetic conjunctivitis: management
**refer to ophthalmologist**
226
What type of conjunctivitis has purulent discharge?
bacterial
copious: gonococcal
227
What type of conjunctivitis has stringy discharge and increased tearing?
allergic
228
What type of conjunctivitis has watery discharge?
viral
229
What type of conjunctivitis makes the conjunctiva bright red and irritated?
herpetic
230
glaucoma: pathology
increased intraocular pressure
closed angle: acute
open angle: chronic
231
closed angle glaucoma: S/Sx
closed angle: acute
-extreme pain
-blurred vision
-halos around lights
-pupil dilated or fixed
232
open angle glaucoma: S/Sx
Open angle: chronic
-asymptomatic
-elevated IOP
-cupping of the disc (earliest sign)
-constriction of visual fields
233
glaucoma: screening
tonometry: screening recommended by age 40
234
open angle glaucoma: management
Open angle: chronic
-prostaglandin analogs (latanoprost, bimatoprost, tafluprost, travoprost, latanoprostene bunod)
-alpha 2-adrenergic agonists (brimonide, alphagan)
-beta-adrenergic blockers (timolol)
-miotic agents (pilocarpine)
234
closed angle glaucoma: management
closed angle: acute
-carbonic anhydrase inhibitors (acetazolamide)
-osmotic diuretics (mannitol)
-surgery
235
cataract: pathology
clouding and opacification of the normally clear lens of the eye
highest cause of treatable blindness
236
cataract: causes
Aging -- biggest risk factor
heredity
trauma
toxins, drugs, tobacco, alcohol
congenital
diabetes
UV sunlight exposure
237
cataracts: S/Sx
painless
clouded, blurred, or dim vision
difficulty with vision at night
sensitivity to light and glare
fading/yellowing of colors
diplopia in a single eye
halos around lights
the need for brighter light for reading
no red reflex
opacity of the lens
238
cataracts: management
refer to opthalmologist for surgery
239
sodium phosphate enemas: adverse effects
Significant electrolyte abnormalities in patients with renal insufficiency, heart failure, cirrhosis, or elderly frail individuals
240
cutaneous anthrax: management
post-exposure prophylaxis and treatment: 60 days of ciprofloxacin and doxycycline regardless of vaccination status
Penicillin is no longer recommended due to increased resistance
241
inhalation anthrax: treatment
raxibacumab
rifampin
242
Opioid withdrawal: S/Sx
Depressed mood
Insomnia
Mydriasis, lacrimation
Runny nose
Yawning
N/V/D
myalgias
diaphoresis
fever
243
Haemophilus influenzae: class
Gram negative
244
HAP: most likely pathogens and empiric therapy
S. aureus
S. pneumoniae
H. influenzae
empiric therapy:
-pip/tazo
-cefepime
-levofloxacin
-imipenem or meropenem
If MRSA suspected: + vancomycin or linezolid
If high risk of mortality or IV ABx within previous 90 days:
-two of above ABx + vancomycin or linezolid
245
VAP: most likely pathogens and empiric therapy
MRSA
- vancomycin or linezolid
pseudomonas aeruginosa
-pip/tazo
-cefepime or ceftazidime
-imipenem or meropenem
-aztreonam
-levofloxacin or ciprocloxacin
-amikacin or gentamicin or tobramycin
-colistin or polymyxin B
246
necrotizing fasciitis: pathogen and treatment
Group A streptococcus
Treatment: ampicillin, penicillin, and clindamycin
Surgery
247
beta lactam antibiotics: examples
penicillins
cephalosporins
carbapenems
monobactams (aztreonam)
beta lactamase inhibitors (clavulanic acid, sulbactam, and tazobactam)
248
placenta previa
Condition in which the placenta is implanted in the lower uterus, adjacent to or over the os
-Risk factors: multiple pregnancies, multiple surgeries
249
placenta previa: S/Sx
soft, nontender uterus
painless right red vaginal bleeding in the third trimester
250
abruptio placenta
premature separation of the placenta from the uterine wall
-risk factors: diabetes, renal disease, HTN, eclampsia, abdominal trauma
-DIC can occur
251
abruptio placenta: S/Sx
painful dark red bleeding
abdominal pain
252
methanol toxicity: S/Sx, labs
optic disc changes including hyperemia of the optic disc (engorged vessels)
anemia
leukocytosis
high osmolar gap
253
methanol toxicity: management
ethanol
hemodialysis
254
paronychia
infection of the lateral and proximal nail fold
Risk factors:
-nail biting
-diabetes
-sucking
-frequent immersion of hands in water
255
SJS/TEN involves __% of BSA
10-30%
256
Stevens-Johnson Syndrome: presentation
Erythematous, purpuric rash with scattered bullae that are often painful
Mucosal involvement: eyes, mouth, genitals
Involves <10% of BSA
257
Stevens-Johnson syndrome is most often associated with which drug
bactrim
258
treatment for delirium
**1st line: antipsychotics**
precedex
Avoid opioids, benzos
259
Kehr's sign
Pain in the tip of the shoulder caused by irritation of the diaphragm due to the presence of blood in the peritoneal cavity
-characteristically occurs in the left shoulder in patients with a severe splenic injury
Obtain CT A/P
260
Who is at risk for infections caused by cryptococcal meningoencephalitis?
opportunistic infection seen in patients with untreated AIDS
261
Who is at risk for listeria monocytogenes?
neonates
immunosuppressed
pregnant
elderly
262
CAP d/t Legionella spp.: treatment
macrolides (azithromycin)
263
Main sign that a patient will likely need amputation of a limb
necrosis of the digits
264
cytomegalovirus: S/Sx
profound diarrhea with little to no other abdominal or infectious symptoms
265
cytomegalovirus: treatment
ganciclovir (Cytovene)
266
abdominal compartment syndrome
Third spacing of fluids into the abdominal cavity --> distended, tense abdomen, which causes:
-increased pressure on the inferior vena cava, impeding blood return to the heart and causing a prerenal state of shock
-increased thoracic pressure
267
Massive transfusions and large amounts of IV fluid administration are risks for...
abdominal compartment syndrome
268
erythema multiforme
rash most commonly caused by HSV infection
Target lesions demonstrating 3 zones of color change
269
Can a patient's decision to be an organ donor be overridden by family or HCP?
No
Call the local organ procurement agency
270
acute graft vs host disease: presentation
Within the first 100 days after bone marrow transplant
Involves skin, liver, GI system
Often febrile
Early stages can present with morbilliform rash
Sunburn-like rash with blistering is concerning for severe disease
271
Recommended carbohydrate intake
55-60% of diet
Increases with illness and trauma
