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Final deck Flashcards

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1
Q

AFIB vs A flutter pathophysiology

A

In atrial fibrillation, the atria beat irregularly. In atrial flutter, the atria beat regularly, but faster than usual and more often than the ventricles. (re-entrant circuirt around the tricuspid valve.)

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2
Q

T/F supraventericular arrythmias have a regular QRS complex

A

T

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3
Q

T/F Ventricular arrythmias (which are a type of tachyarrythmia) have wide QRS

A

T

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4
Q

Types of bradyarrythmias due to the atria

A

Respiratory sinus: RR shortens during inspiration, lenghtens during expiration
Sinus bradycardia: physiological, sick sinus sx, BB, CCB
Sinus pause/arrest: CVD. Absent P wave + escape rhythm
Tachycardia/bradycardia sx: Abnormal supraventricular impulse generation and conduction

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5
Q

Types of bradyarrythmias due to the AV node

A

AV block

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6
Q

Types of supraventricular arrythmias of atrial origin

A

Premature beats: electrolyte imbalance (abnormal/absent P waves)
Sinus tachycardia (max rate is 180, narrow QRS)
Atrial flutter: re-entrant rhythms within the atria
A fib: mechanism unknown
Atrial tachycardia: wither focal atrial tachycardia (regular) or multifocal atrial tachycardia (irregular)

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7
Q

Types of supraventricular arrythmias of AV node entry

A

AVRT: due to an accessory pathway. Abrupt onset. Regular.
AVNRT
Junctional tachycardia (AV node takes over the pacemaker function. can occur in Digitalis toxicity, MI, myocarditis)

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8
Q

Ventricular arrythmias

A

Premature ventricular beats (hypoxia, hyperthyroidism, electrolyte abnormalities)
V Tach (CAD, MI)
Torsades de pointes (long QT, hypokalemia)
V-fib: MI

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9
Q

Cinchonism:

A

headache, hearing/vision loss, tinnitus, psychosis and cognitive impairment, associated with quinidine use

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10
Q

Most common causes of extrinsic SA node dysfunction

A

Drugs, ANS influence.
Hypothyroidism, hypothermia, hypoxia, bezolf-jarish reflex, ICP (Cushings response), hyperkalemia/magnesemia

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11
Q

Bezold Jarish reflex

A

increased vagal tone due to ischemia

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12
Q

TX of arrythmia

A

1- TX underlying cause
2- If can’t treat cause:

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13
Q

What factors contribute to the severity of a burn

A

Depth and surface area involved

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14
Q

How do you decide if the pt is on the right amount of fluids

A

Based on the urine output and clincial stability

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15
Q

Labs needed for DX/MX of burns

A

Pulse oximetry, ABG, electrolyte and creatinine levels

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16
Q

Most common cause of death after burns are

A

shock, sepsis, respiratory failure

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17
Q

Common pathogens that infect burns

A

mrsa, pseudomonas, klebsiella, acinetobacter, candida

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18
Q

Lun-Browder charts to evaluate the surface area of burn involved, the palm rule, wallace’s rule of nines

A

Lun-Browder: age specific
Palm rule: palm is 1% of body area
Wllace’s rule of nines: for adults

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19
Q

Clinical features of burn patient

A

Shock (hypotension, anuria) ARDS
Compartement syndrome (if in abd then JVD, tachycarida, hypotension)
Acute limb ischemia

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20
Q

What triggers a change in respiration?

A

PaCO2 levels

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21
Q

Normal Pa02 calculation

A

109 - 0.4 (age of pt)

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22
Q

ARDS has what

A

bilateral involvemetn and diffuse distribution

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23
Q

Calculate the anion gap (must be corrected for albumin - as there is an increase
the anion gap by 2.5 mEq/L for every 1 g/dL reduction in serum albumin.)

A

[Na] - [Cl + HCO3]
[137] - [104 + 24] mEq/L
10 +/- 2 is normal
If its elevated you are in metabolic acidosis
If low anion gap: wasting issues (diarrhea, renal tubular acidosis) (hypoalbuminemia, hyperkalemia)
If high anion gap: sepsis or liver dx, intoxication, drugs

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24
Q

Effects of acidosis

A

Lungs: hyperventiation (kussmall), shift of ocyHb surve to right (bohr effect)
CV: tachycardia, peripheral vasodilation
increased bone resorption, hyperkalemia, reduced lactate clearance

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25
Where does a CVC go?
Enters through subcalvian vein, or interior jugular vein. lies at border with right atrium
26
What three values influence oxygen delivery to tissues
Hb concentration O2 bound to Hb Pumping of blood by the heart to the tissues O2 delivery (ml/min) = 1.34 (ml/g) x SaO2 (fraction) x Hb (g/dL) x CO (dL/min)
27
Possible methods to increase O2 delivery
blood transfusion O2 crystalloids
28
How todecrease the pts consumption of O2
correct fever no exercise treat increased breathing effort (ventilator) sedate
29
Cardiac arrest manifests as
Apnea, pulselessness, loss of consciousness
30
Most common cuases of cardiac arrest in adults v children
Adults : CAD, hypothermia Kids: hypoxia (airway obstruction)
31
Reversible causes of cardiac arrest (H's and T's)
Hs: hypoxia, hypovolemia, hydrogen ions (acidosis), hypo/hyperkalemia, hypothermia - Ts: toxins, thrombosis (coronary and pulmonary), tamponade, tension pneumothorax ALSO: hypoglycemia, hypocalcemia, hypomagnesemia, anaphylaxis, asthma
32
compression rate
100-120 per minute 5-6 cm deep allow full chest recoil between compression restart CPR immediately after shock delivery 30 compression 2 breaths
33
PEA can be due to
cardiac tamponade pulmonary embolism tension pneumothorax hypovolemic shock
34
Causes of asystole
hypoxia hyperkalemia
35
Define shock
a life-threatening, generalized form of acute circulatory failure associated with inadequate oxygen utilization by the cells
36
circulation evaluation
Several clinical parameters must be integrated to obtain information about patient’ circulation, including heart rate (60-90bpm), blood pressure (90-120mmHg), capillary refill time/CRT, color and temperature of the skin, urine output and edema.
37
fluid challenge
It consists in administering small boluses of fluids (4ml per kg/ 250 mL of crystalloids) over 15 minutes, while vital parameters are checked. A positive fluid challenge test is defined as an increase in cardiac output in response to the increased blood volume (increased pre-load).
38
When is the only time you use colloidal solutions
Rarely in severely low oncotic pressure
38
When is the only time you use colloidal solutions
Rarely in severely low oncotic pressure. They increase Intravascular volume wayyy more than crystalloids do
39
what are the three types of fluids
crystalloids (minerals, dextrose) colloids (albumin, starch) balances IV fluid solutions (the aboce which dont alter homestasis of ECC)
40
Osmolarity vs osmolarity vs tonicity
Osmolality: the concentration of dissolved particles per unit mass of solution (mOsm/kg); preferred term to describe the osmotic pressure of biological systems Osmolarity: the concentration of solutes per unit volume of solvent (mOsm/L); often used interchangeably with osmolality in clinical practice Preferred term to describe the osmotic pressure of parenteral fluids Tonicity: the capacity of an ECF to create an osmotic gradient that will cause water to move into or out of the ICC; cannot be measured and has no unit (dep on Na, K)
41
The best solution for IV fluid resus is
isotonic crystalloids (are normal saline or ringers lactate)
42
T/F IO (intraosseous) access is preferred to CV access for resus
T But the best is peripheral IV
43
Why perform fluid challenge?
to differentiate between hypovolemia and euvolemia
44
Define critical illness
A critical illness is any disease process which causes physiological instability leading to disability or death within minutes or hours. Generally, the perturbation of the neurological and cardiorespiratory systems has the most immediate life-threatening effects.
45
Five parameters for critical illness dx then 5 others after
Level of consciousness RR HR BP urine output Others: age, comorbidities, current drug regime, magnitude of change from baseline
46
What issues are present with breathing
asthma pulmonary edema tension pneumothorax hemothorax
47
OPACS for B (breathing) assessment
Observation of the thorax during the respiratory process (moving symmetrically or asymmetrically, e.g due to an obstruction in one bronchus) Palpation (assess if there is a subcutaneous emphysema) Auscultation: crackles can be heard in case of congestion of the alveoli by fluid as in case of pulmonary edema or pneumonia, while wheezing can appear in case of an asthmatic crises. The obtusity at the bases of the lungs can signal a pleural effusion or a pneumothorax. * Count (respiratory rate): measure it accurately because it is a very important sign in case of critically ill patient. * Saturimetry (normally >96%, in COPD patients the target should be 88-92%).
48
What is the Early warning score?
Takes into consideration the vital parameters and all the deviations from the normality give us a score. The higher is the score the more the patient is critical. This is a very useful tool for the communication among health care professionals. Includes: HR, SPO2, TEMP, SBP, RR, STATE OF CONSCIOUSNESS, O2 0-4: low risk, 7+ high risk
49
What are the three peaks of dying risk after trauma
1: Immediately after (aortic laceration, CNS) 2: 3-4 hours (due to hemorrhages) 3: due to sepsis and multiple organ failure
50
What are the new resuscitatino targets?
damage control surgery permissive hypotension (keep SBP at 80mmHG until major bleed has been stopped) hemostatis resuscitation (restore normal tissue perfusion, preserving clotting)
51
three most important factors causing TIC
acidosis hypothermia blood dilution
52
T/F fibrinogen is the first coagulation factor that reaches critically low values in TIC.
T
53
Steps of hemostatis resuscitation
correct hypothermia correct acidosis correct hypocalcemia (to >1mmol/L) blood componenets tx of coagulopathy
54
what is PCC (a factor concentrate)
It is a powder for dissolution containing pro- and anti-coagulant factors (II – VI – IX – X – PC – PS) and heparin. It is sold in vials of 500 IU or 1000 IU vials. It can be stored at room temperature and quickly dissolved in sterile water. It is the first choice for warfarin reversal.
55
massive transfusion prediction scores
ABC score: it doesn’t require any lab exam, very easy to use, can be used with pre-hospital information. Takes 4 things: presence of penetrating trauma, positive FAST sca, SBP<90, HR>120 Score of <2: unlikely need for massive transfusion. Score of >2: massive transfusion program will likely be necessary. * TASH score: requires lab tests (Hb); 1, SBP; 2, Hb; 3, intra-abdominal fluid; 4, complex long bone and/or pelvic fractures; 5, HR; 6, base excess; and 7, gender. Score of >24: positive, massive transfusion program will likely be necessary
56
Goals of damage control surgery
rapidly control bleeding containing abdominal contamination restrogin patient physiology achieving temporary abdo wall closure
57
When to perfrom emergency thoracotomy
In case of thoracic penetrating trauma with PEA
58
AMS can manifest as
hyperalertness Somnolence lethargy obtundation stupor
59
Four mechanisms of hypoxia
hypoventilazione Bradypnea (<12) V/Q mismatch (COPD, emphysema, p. embolism) Shunt (pneumonia, atelectasia, lung tumor, CHF, ARDS) Diffusion abnormality
60
Define shock
circulatory disorder leads to inadequate organ perfusion, tissue hypoxia and microcirculation disturbance that eventually results in irreversable organ damage
61
What 3 things can help distinguish between the types of shock
Pulmonary capillary wedge pressure CO Systemic vascular resistance
62
what is the shock index?
HR/SBP
63
Parameters of hypovolemic shock and tx options
low CVP LOW Pulmonary capillary wedge pressure LOW CO HIGH SVR HIGH HR TX: fluid resus, blood transfusion, hemostatic control
64
Parameters of cardiogenic shock, causes and tx options
cardiac ischemia, arrythmias, valvulopathy, toxic substances HIGH CVP, HIGH PCWP, LOW CO, HIGH SVR, DISTEDED JVP TX: IV fluids if fluid responsive, inotropic support, vasopressors, diuretics
65
Parameters of obstructive shock, causes and tx options
cardiac tamponade (causes impaired filling of right ventricle), tension pneumothorax (obstructs venous return), massive PE (increases ventricular afterload) HIGH CVP, LOW CO, HIGH SVR, HIGH HR TX: fluid resus, relieve obstructions
66
Types of disdributive shock
septic neurogenic anaphylactic
67
Parameters of septic shock and tx options
flushed skin!! TX: fluid resus, vasopressors, antibiotics, infections source control (abscess, drainage, surgery)
68
Parameters of anaphylactic shock and tx options
epinephrine fluid resus
69
Parameters of neurogenic shock and tx options
due to CNS injury Has bradycardia unlike other shocks TX: fluid resus, vasopressors, atropine if severely bradycardic
70
How many phases does shock have
3
71
Routine investigations for shock
high lactate ABG renal function, liver function, coagulation panel if in sispected stage 3
72
Base deficit in shock pts
if BD> or equal to 10 pt has severe hemorrhagic shock
73
Septic shock management
1 hour bundle: crystalloids 30ml/kg/hr antibiotics vasopressors (start with norepi, if doesnt work add vasopressin)
74
Anaphylactic shock management
epinepphrin IM 1:1000 fluids add anti histamines and corticosteroids only after initial tx
75
tx for refractory shock
corticosteroids (hydrocortisone) bicarbonate mechanical circulatory support (ECMO for ARDS)
76
ACS includes
STEMI NSTEMI Unstable angina (myocardial ischemia at rest or minimal exertion in absence of cardiomyocyte necrosis)
77
Most common sources of sepsis infection
pneumonia abdominal infections UTI
78
SOFA score (range from 0-24, 0 is normal)
The SOFA score assesses the proper functioning or the failure of 6 organs through the results of in-hospital readily available tests: - Lungs (respiration) → PaO2/FiO2 and need for support (oxygenation) - Platelets (coagulation) → platelet count - Liver → total bilirubin concentration - Cardiovascular system (circulation) → ABP (MAP) and need for support (drugs) - Brain → Glasgow Coma Scale - Kidney → creatinine concentration
79
qSOFA score
considers 3 variables that reflect the function of 3 organs only: - Lungs (respiration) → respiratory rate ≥ 22 - Cardiovascular system (circulation) → systolic blood pressure ≤ 100 mmHg - Brain → mental status: altered cognition (if GCS < 15 or if AVPU is not A) If ≥ 2 of these signs are present, the patient should be considered at risk of having an organ dysfunction/sepsis and thus referred to the hospital
80
what three things determine if an antibiotic is correct
timing penetration into infected tissue pharmacodynamic/pharmacokinetic properties
81
septic shock antibiotics should be given
w/in the first hour
82
dont use linezolid for MRSA in septic shock bc?
it is bacteriostatic
83
screen for MDR pathogens
rectal swab for carbapenen reisitant K pneumonia Nasal swab for MRSA cutaneous swab for MDR Acinetobacter baumanii
84
A person is at risk of ESBL-producing microorganism infection if at least one among the following risk factors is present:
Previous therapy with a quinolone or a cephalosporin in the last 3 months ▪ 4 cycles of antibiotic therapy in the last year (especially cephalosporins and quinolones) ▪ Previous isolation of ESBL producing organisms Stay in long term care facilities (LTCF)
85
Define a hypertensive crisis
acute increases in blood pressure (generally defined as ≥ 180/120 mm Hg) that cause or increase the risk of end-organ damage, i.e., damage to the brain (e.g., encephalopathy, stroke), eyes (e.g., retinopathy), cardiovascular system (e.g., ACS, pulmonary edema, aortic dissection), and/or kidneys (e.g., acute kidney injury).
86
define malignant hypertension
severe hypertension with retinopathy (flame hemorrhages, papilledema)
87
which drugs exacerbate hypertenison
MAOi (consuming wine/choc/cheese/cured meat) TCA NSAIDS cocaine amphetamines ecstasy stimuant diet pills
88
Hypertensive emergency management
first hour: reduce BP by 25% For non specific sx: rapid acting oral antiHTN (clonidine, labetalol, prazosin) Aortic dissection: esmolol 500-1000mcg/Kg IV bolus in 1 min then 50mcg IV infusion (follow with vasodilators nitroprusside 0.3-0.5 mcg/kg) P. edema: nitroglycerin 5 mcg/min infusion ACS: nitroglycerin, esmolol AKI: nicardipine 5mg/hour catecholamine excess: benzo 5mg IV bolus
89
if GCS <8 then pt is in a coma so
need to be put ona ventilator
90
The most commonly involved nerve in TBI is
the facial nerve, 7th

Emergencies (10 decks)

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