Final Flashcards
1
Q
sympathomimetic
A
- Cocaine, methamphetamine/amphetamines, ecstasy (MDMA), ADHD meds like Ritalin, Adderall, ephedrine, caffeine
- sympathetic stimulation involving epinephrine, norepinephrine, and dopamine
- excessive stimulation of alpha and beta adrenergic system
- tachycardia
- arrhythmias
- Hypertension
- ICH (intracerebral hemorrhage)
- confusion with agitation
- seizures
- rhabdomyolysis- renal failure can result
- CNS excitation -> behavioral agitation -> cardiac excitation ->
2
Q
opioids
A
- morphine, codeine, heroin, methadone, hydrocodone, oxycodone, fentanyl
- Deadly
- respiratory, cardiac arrest
- coma
- miosis
- respiratory depression
- peripheral vasodilation
- orthostatic hypotension
- flushing (histamine)
- bronchospasm
- pulmonary edema
- Seizures
3
Q
anticholinergic
A
- Blockage of ACh receptors -> mostly just muscarinic
- confusion
- agitation
- myoclonus
- tremor
- picking movements
- abnormal speech
- hallucinations
- coma
- peripheral muscarinic effects:
- mydriasis
- anhidrosis
- tachycardia
- urinary retention
- Ileus
4
Q
cholinergic
A
D- diarrhea, diaphoresis U- urination M- miosis BBB- bradycardia, bronchorrhea, bronchospasm E- emesis L- lacrimation S- salivation, seizure
5
Q
sed-hypnotics
A
- CNS depression
- lethargy
- can induce respiratory depression
- can produce bradycardia or hypotension
- Mess with GABA system
6
Q
sympathomimetic treatment
A
benzodiazepine
7
Q
opioid treatment
A
- naloxone
- Ventilation
- Redose: opioids may last longer than antidote
8
Q
anticholinergics treatment
A
- benzos to stop agitation
- physostigmine:
- induces cholinergic effects
- short acting
- may help with uncontrollable delirium
- do not use if ingestion not known -> danger with TCAs
9
Q
cholinergic treatment
A
- antagonize muscarinic symptoms- atropine
- stop aging of enzyme blockage- 2-PAM
- prevent and terminate seizures- diazepam
- supportive care
10
Q
sed-hypnotic treatment
A
- supportive care
- be wary of the benzo “antidote” flumazenil
- an antagonist at the benzo receptor -> RARELY INDICATED
- if seizures develop either because of benzo withdrawal, a co-ingestant or metabolic derangements, have to use 2nd line agents, barbiturates, for seizure control
11
Q
acetaminophen (APAP) antidote
A
N-acetylcysteine (NAC)
12
Q
organophosphate antidote
A
atropine
13
Q
benzodiazepine antidote
A
flumazenil
14
Q
beta-blockers antidote
A
glucagon
15
Q
calcium channels antidote
A
calcium
16
Q
carboxyhemoglobin antidote
A
100% O2
17
Q
salicylate (ASA) antidote
A
alkalization
18
Q
tricyclic antidepressant (TCAs) antidote
A
sodium bicarbonate
19
Q
warfarin antidote
A
vitamin K, FFP (fresh frozen plasma)
20
Q
acetaminophen toxicity
A
- max dose- 4g/day for adults
- 90 mg/kg day kids
- peak serum levels- 4 hours after overdose
- toxicity- 140mg/kg acute ingestion**
- direct hepatocellular toxicity (liver)*
- renal damage and pancreatitis
- lab evidence of hepatic damage
- 150ug/ml at 4 hours
- NAC 140mg/kg** then 70mg/kg every 4 hours for 17 doses
- labs- LFTs (liver function-> bilirubin), coags, lytes, aspirin, ETOH, tox screen
21
Q
stages of acetaminophen toxicity
A
- (0-24 hours): n / v, but most asymptomatic
- latent stage (24-48 hours): subclinical increase in ast/alt/bilirubin
- hepatic stage (3-4days): liver failure, RUQ pain, vomiting, jaundice, coagulopathy, hypoglycemia, renal failure, metabolic acidosis
- IV recovery stage (4days-2weeks): resolution of hepatic dysfunction
22
Q
salicylate (ASA)
A
- aspirin
- weak acid, rapidly absorbed
- messes up acid base balance
- enteric coated has delayed absorption
- toxic dose- 160 mg/kg
- lethal dose 480 mg/kg
- mixed respiratory alkalosis (hyperventilation) - metabolic acidosis (limited ATP production)
- tachypnea, tachycardia, hyperthermia
- altered serum glucose
- dehydration (vomiting, tachypnea, sweating)
- Abdominal pain
- n/v
- tinnitus, hearing loss
- lethargy, seizures, altered mental status
- noncardiogenic pulmonary edema
23
Q
salicylate overdose treatment
A
- activated charcoal
- urinary alkalinization (start if serum level is greater than 35mg/dl)
- 3 amps bicarbonate in 1 L D5W at 150 ml/hr
- neutralize acid base imbalance
- by increasing urinary pH to greater than 8, ASA gets trapped in tubes and cannot be reabsorbed
- dialysis for severe acidemia, volume overload, pulmonary edema, cardiac or renal failure, seizures, coma levels > 100 mg/dl in acute ingestion, or > 60-80 mg/dl in chronic ingestion
24
Q
TCA overdose
A
- blocks sodium channels
- respiratory depression
- death by cardiovascular dysrhythmias and cardiovascular collapse
- most TCAs have anticholinergic effects- dry skin, blurry vision, hot
- severe OD- hypotension, seizures, respiratory depression
- in severe cases- ARDS, rhabdomyolysis, DIC
25
TCA overdose treatment
- Get an ECG to diagnose.
- The antidote is sodium bicarbonate
- Give initial bolus of 2 amps, drip 3 amps in 1 L D5W at 150 ml/hr
- Titrate for a serum pH of 7.45-7.5
- Give lidocaine for persistent arrhythmias
26
hypothalamus
-
- part of diencephalon
- responsible for:
- temperature regulation
- preoptic region of hypothalamus
- water balance
- set point for thermoregulation
27
mechanisms of heat loss
- radiation- 60%: between body and environment lost in the form of infrared radiation
- convection- 15%: air flowing over body
- conduction 3%: physical contact
- involuntary heat loss:
- activation of sweat glands, production of sweat
- capillary dilation
- inhibition of mechanisms that produce heat
- shivering, chemical thermogenesis
- voluntary heat loss:
- limit activity
- move- move to cool environment
- clothing- remove clothing -> cause return to hypothalamic "set point"
28
involuntary heat gain
- constriction of peripheral blood vessels- shunt blood away from areas that are not as important -> goes towards core
- piloerection- goose bumps
- release of thyroxine from thyroid gland- metabolism
- increased production and release of epinephrine
- shivering, increased BMR
- unopposed increase of BMR can raise body temperature 1.1 C/hr
29
hyperthermia categories
- Heat tetany- Respiratory alkalosis (hyperventilation) --> carpopedal spasms possible- paresthesia (pins and needles) due to low CO2
- Heat cramps: Electrolyte imbalance -> hydrate
- Heat exhaustion-Tachycardia, hyperventilation, hypotension
- Heat syncope- Vasodilation, hypotension, dehydration
- Heat stroke:
- Higher than 40.5C
- Anhidrosis, low LOC, seizures, pulmonary edema
- Can be fatal
- hypovolemic shock
- Exertional vs. nonexertional
- Rectal thermometer
- administer lorazepam, chlorpromazine -> to control shivering*
- rhabdomyolysis- increased GFR, give mannitol, sodium bicarbonate, Alkalize urine
- Heat stroke at 43C (critical thermal maximum):
- cellular respiration impaired
- increased cellular membrane permeability
- protein denaturing
- tissue necrosis
30
hypothermia
- at first heart rate, BP, CO rise, shivering, red
| - then as it becomes severe....bradycardic, hypotensive, decreased LOC, undetectable pulse, organ failure, cyanotic
31
frost bite classifications
- first degree- superficial, red, waxy, edema
- second degree- fluid blisters start forming *
- third degree- blood-filled blisters *
- fourth degree- tissue necrosis, full thickness, muscles, tendons, bone
- know the difference between 2nd and 3rd degree
32
role of kidneys
- in retroperitoneal space at level of costovertebral angle (T12-L3)
- 25% of CO
- fluid and electrolyte balance
- blood pressure regulation
- red blood cell synthesis
- metabolic waste removal
- medication metabolism
- acid base balance
33
renal failure
- prerenal- decreased perfusion -> decrease GFR -> decrease urine -> hypovolemia, edema, waste products in blood, heart failure -> increased BUN and creatinine
- intrarenal- trauma, infection, disease of kidney
- postrenal- obstruction of urine flow (renal calculi, prostatic hypertrophy, neoplasms)
34
complications of dialysis
- hypotension- when you take the blood out you arnt getting the same amount of blood flow
- muscle cramps
- nausea and vomiting
- headache
- chest and back pain- electrolyte abnormalities
- febrile reactions
- first use syndromes
- pruritis
- uncommon but serious complications:
- disequilibrium syndrome
- dialyzer reactions
- arrhythmias
- cardiac tamponade
- intracranial bleeding
- seizures
- hemolysis
- air embolism
- dialysis associated neutropenia and complement activation
- hypoxemia
35
BUN
- urea formed by liver, excreted by kidneys
- urea accumulates in blood if renal dysfunction occurs
- normal range is 5-20 mg/dl
- can be affected by hydration status `
36
creatinine
- waste product of creatine phosphate, a high energy molecule found in skeletal muscle tissue, released into blood
- normal value: .5-1.2 mg/dl
- best indicator of renal function*
- increases with renal failure
- creatinine of 3-4 mg/dl indicates decreased of GFR by 50%
37
other lab values for chronic renal failure detection
- urinalysis
- *proteinuria indicates intrarenal or postrenal renal failure
- *ketonuria, glycosuria, elevated specific gravity (hydration status) indicates prerenal origin of renal failure
- serum protein
- serum albumin
- CBC
38
chronic renal failure
- permanent loss of renal function
- 80% of nephrons in the kidneys destroyed
- S/S include changes in urinary habits, nausea, vomiting, dyspnea, or acute coronary syndrome
- treatment:
- fluid administration
- administration of diuretics (long-term solution)
- pain medication
- dialysis - 2-3 times a week
- kidney transplant
39
hyperkalemia: renal failure
- cardiac abnormalities- tented T waves, abnormal EKGs**
- 3.5-5 is normal
- serum potassium greater than 5.5 mEg/L
- electrolyte disorder caused ingestion of potassium supplements, acute or chronic renal failure, blood transfusions, sepsis, addisons disease, acidosis, and crush syndrome
- S/S include weakness, muscle cramps, tetany, paralysis, palpitations, or arrhythmias
40
missing a dialysis appointment
- difficulty breathing
- pitting edema- push in on skin and indentation stays*
- dry flakey skin
- fluid build up
- weakness/fatigue
- increased BP- due to high build up fluid (u cant urinate)
- cardiovascular and pulmonary signs *
- make sure fistula isnt infected
- high BP can cause CRF
41
renal buffering system
- metabolic acidosis -> respiratory compensation -> increase respiratory rate to balance pH imbalance
- respiratory acidosis -> renal compensation
- metabolic alkalosis -> respiratory compensation
- respiratory alkalosis -> renal compensation
42
metabolic alkalosis
- pH > 7.45
- HCO3 is higher than 26
- can occur secondary to:
- excessive bicarbonate ingestion
- blood transfusion
- vomiting nasogastric suctioning
- drug therapy/ abuse
43
metabolic acidosis
- pH < 7.35
- HCO2 is less then 22
- can occur secondary to:
- hypermetabolic state- hyperthyroidism
- anaerobic metabolism
- ketoacidosis
- acute or chronic renal, hepatic, and pancreatic failure
- diarrhea
- diabetes
44
kidney stones
- calcium oxalate and uric acid
- risk factors:
- certain diets: high in protein, sodium and sugar
- digestive diseases and surgery; gastric bypass surgery, inflammatory bowel disease or chronic diarrhea
- other medical conditions: renal tubular acidosis, cystinuria, hyperparathyroidism, certain medications and some urinary tract infections
- testing:
- blood testing: too much calcium or uric acid in your blood
- urine testing: the 24-hour urine collection test may show that your excreting too many stone forming minerals or too few stone preventing substances
- imaging: imaging tests may show kidney stones in your urinary tract (x-rays or CT)**
- analysis of passed stones: urinate through a strainer to catch stones and lab analysis will reveal the makeup of stones
- treatment:
- drinking water- 2-3 quarts/day
- pain relievers: ibuprofen, acetaminophen
- medical therapy: alpha blockers to relax muscles in ureter*
- lithotripsy- sound waves to break up stones
- surgery
- scope through urethra, bladder, ureters
- parathyroid gland removal*
45
pyelonephritis
- fever
- suprapubic pain that radiates through the back to the lower back
- back pain on percussion**
- can be life threatening if sepsis or complications develop
- may present with few symptoms to severe symptoms
- may or may not have associated dysuria
- may have no fever to a fever greater than 103
- costovertebral tenderness is common presentation over the affected kidney
- management:
- IV access- NS bolus 250 ml
- cardiac monitoring
- antipyretics
- pain medications as needed
- antibiotics- readily respond to antibiotic therapy
- sepsis protocol if needed
46
appendix
- umbilical pain
- McBurney's point
- lower right quad
47
spleen
- upper right quad
- pain refers to right shoulder
- uncommon injury
- likely to be injured in a trauma incident -> large hemorrhage
48
acute cholecystitis
- biliary stasis bile levels arnt being secreted properly
- leads to wall thickening
- common in pregnant females, older patients, women
- stones
- epigastric -> URQ -> right scapula
- pain may be crampy initially and then becomes constant
- peritoneum may become irritates causing peritoneal signs and symptoms
- positive murphy sign is present* -> while palpating the right subcostal region patient stops inhaling or complains of pain during the breath
49
acute cholecystitis treatment
- support airway- have suction available, vomiting is common
- oxygen
- IV fluid
- position of comfort
- antiemetics
- analgesics
- sonogram at the facility
- CT scan for gal stones
50
pancreatitis
-epigastric -> ULQ
-may come on suddenly or gradually
-pain is described as going through the body to the back, not around the body
-abdomen is usually distended with rigidity and guarding
-higher frequency in african american, white, and native american males, in that order
-history of alcoholism is the number one risk -> 30%
-onset after binge consumption is common
-40% of people with gallstones can have pancreatitis
-grey turner sign (flanks) and cullen sign (belly button) may be present due to hemorrhagic pancreatitis
-life threatening
TREATMENT*:
-support airway- have suction available as vomiting may occur
-NPO- sometimes
-oxygen
-IV fluid- crystalloids or blood if hemorrhage present
-pain medication (fentanyl or dilaudid)
51
sigmoid diverticulitis
- inflammation of the diverticula (pouches that have developed in the bowel)
- usually localized to the lower left quad
- often severe
- change in bowel habits
- bleeding may be present
- urinary symptoms (may also be present ex. pain with urination)
- fever is common due to inflammation
- peritonitis may be present
- a mass may be palpated if an abscess develops
- CT may be used to confirm disease and severity
- IV fluid- crystalloids or blood is hemorrhage is present
- pain medication
- antibiotics*
- Support airway – have suction available as vomiting may occur-> oxygen
- risk factors:
- NSAID use
- lower fiber use
- chronic constipation
- elderly
52
hepatitis C
- leading cause of chronic liver disease and the #1 indication for liver transplants
- slow (2 week-6 month onset), progressive disease that causes severe liver damage over time
- needle sharing
- 85% of cases become chronic
- NO VACCINE
- spread PARENTERAL
- most common chronic blood borne infection
- sexual contact
- organ transplantation
- treatment is primarily supportive
- 24 weeks course of interferon A are moderately effective with a combination of antiviral drugs
- avoid agents known to cause liver damage, such as ETOH and NSAIDs
- if liver failure develops, transplant is only real option
53
meningococcal meningitis
- caused by Neisseria meningitis, a gram-negative diplococcus bacterium
- only causes disease in humans
- active infection is almost always due to spread from colonization of nasopharynx
- progresses rapidly over 24 hours
- classic triad: fever, nuchal rigidity, and altered mental status (AMS), but headache is also common
- petechiae and palpable purpura (not always)
- stiffness and tiredness
- very contagious
- is it bacterial or viral?
- rapid antibiotic therapy is key to outcome
- do not delay for CT and/or difficult lumbar punctures (LP)
- corticosteroids
- supportive care as indicated
- antibiotic prophylaxis for close contacts and health care providers (this is the ONLY cause of meningitis that needs prophylaxis)
54
Kernig's sign
- place patient supine
- flex the hip and knee 90 degrees
- keep the hip immobile while extending the knee
- positive sign:
- it suggests irritation of meninges
- the patient resists extending the knee -> may be +
- patient has pain in the hamstrings
55
Brudzinski's sign
- place patient supine
- keep the trunk against the stretcher
- touch the chin to the chest (flex neck)
- positive:
- it suggests irritation of meninges
- the patient involuntary flexes hip
56
mumps
- caused by RNA-type virus
- covered by standard childhood immunizations but some sporadic outbreaks in recent years
- fever, malaise, myalgias, headache, then parotitis (swelling of parotid glands)
- complications include meningitis, encephalitis, orchitis/oophoritis, hearing loss
- all other body systems may be involved
- contagious - droplet, direct contact with saliva
- highly infectious and spreads rapidly
- incubation period of 14-18 days
- supportive care
- analgesics and antipyretics
- fluids as needed
- cold packs to inflamed areas
- Acute, communicable and systemic disease
- signs and symptoms include a fever, swelling and tenderness of the parotid salivary glands affecting one or both sides of the neck
- Prevention as part of MMR vaccine
57
H1N1 influenza
- Influenza A type virus with components of two swine, one human, and one avian strain
- Higher attack rate, morbidity, and mortality than typical for seasonal flu among younger persons and pregnant women
- Majority of deaths still in those with co-morbidities
- Spread via airborne and surface droplets
- Incubation period is about 2 days
- Contagious period is from 1 day before symptom onset until fever resolves; longer in immunocompromised patients
- standard precautions with droplet precautions
- airway management as indicated
- supportive care
- IV fluids
- analgesics/antipyretics
- anti-viral therapy per current CDC guidelines:
- severe or complicated disease
- pregnant women
- age <5 or >65 years
58
sepsis from MRSA: MRSA
- Methicillin-resistant Staphylococcus aureus
- Gram positive bacterium resistant to certain antibiotics
- Hospital-acquired strains more virulent than community acquired
- Recent admission and IV are risk factors
- Cellulitis (infection of the skin or the fat and tissues that lie immediately beneath the skin, usually starting as small red bumps in the skin).
- Boils (pus-filled infections of hair follicles)
- Abscesses (collections of pus in under the skin).
- Sty (infection of eyelid gland).
- Carbuncles (infections larger than an abscess, usually with several openings to the skin), and impetigo (a skin infection with pus-filled blisters).
- spread to almost any other organ in the body -> severe symptoms develop
- MRSA that spreads to internal organs can become life-threatening.
- Fever, chills, low blood pressure, joint pains, severe headaches, shortness of breath, and "rash over most of the body
- airway management
- resuscitate with aggressive, large volume IVF
- check glucose
- consider vasopressor agents -> to raise BP
- in hospital, will require specific antibiotic therapy and continued resuscitation and supportive care
59
hepatitis A
- Most common type of hepatitis in the US
- Commonly transmitted through fecal-oral route
- signs and symptoms include vomiting, diarrhea, fever, or abdominal discomfort
- Recommended vaccine
- Treated with IV fluids
- Hand-Washing is key
- spread FECAL, ORAL, PARENTERAL, SEXUAL
- VACCINE -> YES
- acute
60
hepatitis B
- Transmitted through exposure to blood and blood products, sexual contact, or perinatal exposure (mom to fetus)
- Common causes include IV drug use from needle sharing, shared razors, and acupuncture
- signs and symptoms include flu like symptoms and jaundice of the skin and eyes
- Required vaccine in US within 12 hours of birth
- jaundice*
- spread PARENTERAL and SEXUAL
- VACCINE -> YES
61
rubeola (measles)
- resides in the mucus of the nose and throat of the infected person
- airborne illness requiring droplet precautions and hand washing
- signs and symptoms include high fever*, blotch red rash and presence of Koplik spots
- treatment is supportive with hydration
- prevention as part of MMR vaccine
62
rubella (german measles)
- found in respiratory secretions
- transmission by direct contact with nasopharyngeal secretions of infected persons
- signs and symptoms include low grade fever*, rash, and swollen lymph glands behind the ears and at the base of the skull
- treatment is supportive
- prevention as part of MMR vaccine
63
multidrug-resistant organisms: methicillin-resistant staphylococcus aureus (MRSA)
- community acquired (prevalent in nursing homes)
- signs and symptoms include deep abscesses to bones, joints, heart valves, and bloodstream
- handwashing
64
multidrug-resistant organisms: vancomycin-resistant enterococci (VRE)
- resistant to antibiotics
- found in patients with UTI or bloodstream infections
- signs and symptoms unusual urine color or odor, fever, chills, or wound infections
- handwashing
65
multidrug-resistant organisms: clostridium difficile (C-diff)
- caused by antibiotic therapy and unwashed hands by healthcare providers
- infection usually is the stool
- signs and symptoms include diarrhea that has a foul odor and abdominal pain
- handwashing
66
hepatitis D
- spread FECAL, ORAL, SEXUAL, (parenteral?)
| - VACCINE -> YES (same as hep b vaccine)
67
MMR vaccine
- measles
- mumps
- rubella
68
becks triad
1. JVD
2. Distant heart tones
3. Hypotension or narrowing pulse pressure* (numbers getting closer together)
- cardiac tamponade
69
viruses
- H1N1
- mumps
- treated with antipyretics/analgesic
70
compensated shock
- normal blood pressure
- normal to slightly increased heart rate
- tachypnea
- delayed capillary refill
- cool hands and feet
- pale mucous membranes
- restlessness, anxiety
- oliguria
- vasoconstriction maintains blood flow to essential organs, but tissue ischemia occurs in less essential areas
71
decompensated shock
- blood pressure decreasing
- tachycardic >120
- tachypneic > 30-40
- waxy, cool, clammy, skin
- pale or cyanotic mucus membranes
- profound weakness
- metabolic (lactic) acidosis
- anxiety
- absent or decreased peripheral pulses
- blood pressure decreases as the vascular tone decreases
- dysfunction to all organs is imminent
- anaerobic metabolism ensures, causing lactic acidosis
72
irreversible shock
- profound hypotension
- lactate > 8 mEq/L
- metabolic acidosis causes post capillary sphincters to open and release stagnant and coagulated blood
- excessive potassium and acid causes dysrhythmias
- cellular damage is irreversible
73
distributive shock: sepsis
- hyperthermia or hypothermia
- decreased BP
- altered LOC
- infection
- administer oxygen
- give IV fluids bolus
- administer antibiotics
- high WBC
- cultures
74
distributive shock: anaphylactic
- pruritus, erythema, urticaria, angioedema
- increased heart rate, decreased BP
- respiratory distress, wheezing
- antibody-antigen release
- give epinephrine 1:1000 .3-.5 mg subQ or IM for mild reaction
- give epinephrine 1:10,000 .3-.5 IV for severe reaction over 3-10 mins as needed
- give IV fluid bolus
- give diphenhydramine 1-2 mg/kg IV (max 50mg)
- consider corticosteroids
- consider vasopressors
75
distributive shock: neurogenic
- warm, dry, pink, skin*
- decreased BP
- alert*
- normal capillary refill time
- spinal cord injury
- administer oxygen
- give IV fluid bolus
- consider dopamine
- surgery
76
cardiogenic shock
- cool, clammy, skin, pale, cyanotic skin
- tachypnea, decrease BP, altered LOC
- distended neck veins
- decreased capillary refill time
- pump failure: AMI, cardio-myopathy, myocarditis, ruptured chordae tendinea, papillary muscle dysfunction, toxins, myocardial contusion, acute aortic insufficiency, ruptured ventricular septum
- dysrhythmia
- administer oxygen
- give IV fluid bolus (minimal)
- rate correction (medication or pacing/cardioversion)
- inotropes
- vasopressors
- intraaortic balloon pump
- associated with cardiac pump failure
- vasopressors >>>>> over fluids **********
- fluids can overload the system and cause death
77
obstructive shock
- decreased BP
- difficulty breathing, tachycardia, tachypnea
- JVD, unilateral decreased breath sounds, muffled heart tones
- acute pericardial tamponade*
- massive pulmonary embolus*
- tension pneumothorax**
- administer oxygen, perform needle decompression for tension pneumothorax
- consider surgery
- muffled heart sounds
- pulmonary embolus -> blood thinners*
78
hyperglycemia
- elevated blood sugar
- hypotension
- dehydrated
- syncope
- can present same as hypoglycemia
79
normal range for glucose
-60-120
80
diabetic ketoacidosis (DKA)
- build up of ketones in the blood
- commonly seen in kids
- high blood sugar -> 500
- Thrombosis
- hypotensive
- sometimes shock
- dehydrated
- fluid resuscitation
- occurs in absence or near absence of insulin
- NIDDM (type 2) at risk during catabolic stress or when insulin dependent
- common causes include medication non-compliance, infection
- mortality- 9-14% -> increases with age > 65 -> 24-40%
- anorexia, nausea, emesis
- polyuria
- kussmaul respirations- deep, fast labored breathing
- fruity breath
- deterioration mental status
- progressive acidosis
- chest and/or abdominal pain
- children can decompensate very fast!
- electrolyte imbalances
- affects the heart and arrhythmias -> can cause death
- sodium
- chloride
- potassium
81
hyperglycemia hyperosmolar syndrome
- very high blood sugar
- unconscious or unresponsive
- aggressive management
- treat with fluids, insulin
- Present with severe dehydration without ketosis and acidosis
- Glucose > 1000
- Coma, seizures, tremors, hemiplegia
- Causes:
- infection
- MI
- hemorrhage and trauma
- burns
- Similar to DKA treatment, but even more fluid depleted
82
pancreas
- metabolism of cells
- alpha- stimulate release of glucagon and glycogen stores -> promote gluconeogenesis
- beta -stores and release insulin
- delta-inhibit glucagon and insulin via somatostatin
- gamma-secrete pancreatic polypeptide
83
diabetes type 1
- also called juvenile or insulin-dependent diabetes mellitus (IDDM)
- hyperglycemia
- characterized by low production of insulin
- closely related to heredity
- polydipsia (drinking a lot), polyuria (urinating a lot), polyphagia (eating a lot), weight loss, and weakness (TRIAD*)**
- high ketones in urine
- untreated or noncompliant patients may progress to ketosis and diabetic ketoacidosis
- altered mental status and dehydration may progress if left untreated
- do they have dry mouth, skin turgor, blood flow
- give 500-100CC of fluid for adults
- 20CC per kilo for children (weight based
84
diabetes type 2
- not insulin dependent
- also called adult-onset or non-insulin-dependent diabetes mellitus (NIDDM)
- results from decreased binding of insulin to cells
- related to heredity and obesity
- most common form of diabetes
- less risk of fat-based metabolism
- results in less-pronounced hyperglycemia
- hyperglycemic hyperosmolar nonketonic acidosis
- managed with dietary changes and oral drugs to stimulate insulin production and increased receptor effectiveness
- give them oral medications like metformin
85
type 1 vs. type 2 diabetes
- type 1:
- sudden
- any age (mostly young)
- thin of normal body
- ketoacidosis is common
- autoantibodies are present
- endogenous insulin is low or absent
- less prevalent
- type 2:
- gradual onset
- mostly in adults
- often obese
- ketoacidosis is rare
- autoantibodies are absent
- endogenous insulin is normal, decreased or increased
- more prevalent -> 90%-95%
86
sodium: DKA
- variable
- fall by 1.6 for every 100 increasing glucose (pseudohyponatremia)
- falsely low with hypertriglyceridemia
87
chloride: DKA
- hyper in ketoacidosis
- can be elevated due to choice of resuscitation fluid
- hypo associated with severe emesis
88
potassium: DKA
- total body hypokalemia
- intravascular K+ high with acidosis
- at high risk for severe hypokalemia
- treatment:
- aggressive KCl replenishment and maintenace
- do not start insulin until K > 3.5-5
89
DKA: sodium bicarbonate
- never give sodium bicarbonate
- NaHCO3 + H+ -> H2CO3 -> CO2 + H2O
- worsens intracellular acidosis as already man respiratory compensation
- treat underlying cause
90
hypoglycemia
- shaky, hast heartbeat, sweating, dizzy, anxious, hungry, irritable, blurry vision, weakness or fatigue, headache
- glucose
- glucagon
- dextrose (IV)
91
diabetic ketoacidosis vs hyperglycemic hyperosmolar syndrome
- diabetic ketoacidosis:
- 250-600 mg/dL
- young*
- acute
- severe dehydration
- insulin is low
- hyperglycemic hyperosmolar syndrome:
- minimal or none ketoacidosis
- > 900 mg/dL
- elderly*
- chronic
- profound dehydration
- insulin may be normal
92
hypothyroidism
- low BP
- bradycardia
- fatigued
- iodine deficiency
- thyroidectomy can cause
- hair loss
- dry skin
- intolerance to cold
- weight gain
93
hyperthyroidism
- hypertensive
- tachycardia
- everything is elevated
- weight loss
- fine, straight hair
- bulging eyes
- facial flushing
- tachycardia
- increased diarrhea
- menstrual changes
- localized edema
- atrial arrhythmias
- stroke age dependent not atrial fib dependent
- clots can form!
- CHF
- malnutrition/dehydration
- metabolic failure
- drug metabolism
- Caused by:
- graves disease
- toxic multinodular goiter (toxic nodular struma)
- independent or solitary toxic adenoma
- thyroiditis or inflammation of the thyroid gland
94
hypothyroid treatment
- synthroid
- age dependent
- young- 50-100 ug/d
- old 12.5-25 ug/d
- check TSH at 4-6 weeks
- change doses 12.5 to 25 ug increments
- get blood checked by endocrinologist often
- look for underlying infections
- correct hypothermia
- blood volume restoration
- monitor electrolytes
- glucose replacement
- check for drug toxicity (digoxin etc)
95
thyrotoxicosis
- high mortality rate -> 10-20% mortality
- thyroid crisis "storm"
- hyperthyroidism unregulated
- precipitation factors:
- infection
- thyroid manipulation (operation, palpation)
- metabolic disorders (DKA)
- trauma
- MI
- PE
- pregnancy
96
thyroid storm treatment
- pharmacologic control:
- Inhibit conversion of T4 to T3
- consider steroids or PTU
- ipodate sodium (Oragrafin) highly effective
- caution long-term use (“escape”)
- Reduction of hyperadrenergic state
- propranolol (historical)
- cautious of B-blockers in CHF
- Removal of T4
- plasmaphresis or hemoperfusion
- emergent thyroidectomy
97
acid base values
- pH- 7.35-7.45
- PCO3- 35-45
- HCO3- 22-26
98
respiratory acidosis
- pH < 7.35
- PaCO2 is higher than 45
- HCO3 is normal (22-26)
- shallow breathing
- CO2 is being retained
- not breathing fast
- treat with supplemental oxygen
99
respiratory alkalosis
- pH is greater than 7.45
- PaCO2 is less then 35
- HCO3 is normal (22-26)
- hyperventilating
- anxiety attack
- give paper bag, or put on the o2 mask but not actually turn it on
100
buffering mechanisms
- four types of buffering systems in human body:
- protein buffering
- hemoglobin buffering
- carbonic acid-bicarbonate buffering
- phosphate buffering -> phosphate the most common intracellular buffer!
101
rhabdomyolysis
- a breakdown of muscle tissue that causes myoglobin to be released into the bloodstream, causing kidney damage and renal failure
- S/S dark colored urine, weakness, and muscle pain
- urine is dark bc kidney is filtering
- causes:
- prolonged periods of immobilization
- trauma
- crush injuries
- drug abuse
- electrolyte abnormalities
- SIGNS:
- myoglobin/protein in the urine
- elevated creatine levels
- TREATMENT:
- fluid hydration
- osmotic diuretics
- bicarbonate infusion
102
chain of infection
- reservoir/host
- portal of exit
- transmission
- portal of entry
- host susceptibility
