Hospital Medicine 2 IP emergencies (Bockern) (Midterm) Flashcards Preview

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Flashcards in Hospital Medicine 2 IP emergencies (Bockern) (Midterm) Deck (57)
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1
Q

Define MET and RRT and what are they?

A
  • MET: Medical Emergency Team
  • RRT: Rapid Response Team

Two names for the same thing: “A multidisciplinary team most frequently consisting of ICU-trained personnel … for evaluation of patients not in the ICU who develop signs or symptoms of clinical deterioration.”

2
Q

The rationale for having MET/RRT?

A
  • Identify deterioration and intervene early (prior to “code blue”)
  • Often signs of decompensation for several hours before cardiac arrest
  • Goals or RRT: Prevent cardiac arrest and ensure goals of care have been addressed
3
Q

Typical members of the RRT?

A
  • ICU resident/fellow/attending
  • Medicine floor team
  • Critical care RN
  • RT
  • Pharmacist
  • House supervisor
  • Security
4
Q

Activation criteria for a Rapid Response?

A
  • Threatened airway
  • RR < 6 or > 30
  • HR < 40 or > 140
  • SBP < 90
  • Symptomatic hypertension
  • Decrease in level of consciousness
  • Unexplained agitation
  • Seizure
  • Significant fall in urine output
  • Subjective concern about the patient
5
Q

Most common causes for RRT activation?

A
  1. Altered neuro/mental status (28%)
  2. Tachycardia (23%)
  3. Tachypnea (13%)
  4. Hypotension (12%)
  5. Hypoxia (8%)
  6. Staff worried (7%)
  7. Chest pain (3%)
  8. Bradycardia (4%)
  9. Hypopnea (2%)
6
Q

Stepwise approach to inpatient emergencies include?

A
  • •BLS assessment
    • Are they breathing?
    • Do they have a pulse?
  • Primary assessment:
    • ABCDE
  • Secondary assessment:
    • SAMPLE
    • DDx
7
Q

The ABCDE of primary assessment during an inpatient emergency?

A
  • Airway
    • +/- O2
    • +/- NIPPV or intubation
  • Breathing
    • +/- O2
    • +/- NIPPV or intubation
  • Circulation
    • IV
    • Monitors
    • Vitals
  • Disability
    • Glucose
    • Neuro assessment
  • Exposure
    • Look at Pts surgical sites, ect.
8
Q

What does SAMPLE stand for in the secondary assessment of a Pt during an IP emergency?

A
  • Signs and symptoms
  • Allergies
  • Medications
  • Past medical history
  • Last oral intake
  • Events leading up to emergency
9
Q

Three steps of making a DDx during the secondary assessment during an IP emergency?

A
  1. What do you think is most likely the diagnosis?
  2. Four or five alternative differentials
  3. Comprehensive differential: systems-based; mnemonics
10
Q

A rapid response is called by the RN for a Pt with AMS. The Pt is a general surgery Pt, but as the hospital medicine PA you respond first. The Pt is 69F hx HTN, T2DM, now s/p gastric antrectomy for severe peptic ulcer disease. She is POD5 due to post-op ileus and inability to tolerate enteral nutrition.

What do you do first?

A
  • BLS
    • Is she breathing
    • Does she have a pulse??
11
Q

A rapid response is called by the RN for a Pt with AMS. The Pt is a general surgery Pt, but as the hospital medicine PA you respond first. The Pt is 69F hx HTN, T2DM, now s/p gastric antrectomy for severe peptic ulcer disease. She is POD5 due to post-op ileus and inability to tolerate enteral nutrition.

After checking BLS what should you do next?

A
  • Primary assessment
    • Airway
      • +/- O2
      • +/- NIPPV or intubation
    • Breathing
      • +/- O2
      • +/- NIPPV or intubation
    • Circulation
      • IV
      • Monitors
      • Vitals
    • Disability
      • Glucose
      • Neuro assessment
    • Exposure
      • Look at Pts surgical sites, ect.
12
Q

A rapid response is called by the RN for a Pt with AMS. The Pt is a general surgery Pt, but as the hospital medicine PA you respond first. The Pt is 69F hx HTN, T2DM, now s/p gastric antrectomy for severe peptic ulcer disease. She is POD5 due to post-op ileus and inability to tolerate enteral nutrition.

The ABCDE of the primary assessment shows the following:

A: patent

B: mild tachypnea, speaking in full sentences

C: sinus tachycardia, warm extremities

D: moves all extremities, glucose 83

E: surgical incision without erythema or discharge

HR 120, T 38.5, RR 22, BP 86/50, SpO2 94%

Monitor: sinus tachycardia

Glucose: 83

Access: 24-gauge that doesn’t work

What immediate interventions need to be made before moving on to the secondary assessment?

A
  • Address IV access
  • Consider fluid bolus for hypotension
  • Tylenol for fever
13
Q

A rapid response is called by the RN for a Pt with AMS. The Pt is a general surgery Pt, but as the hospital medicine PA you respond first. The Pt is 69F hx HTN, T2DM, now s/p gastric antrectomy for severe peptic ulcer disease. She is POD5 due to post-op ileus and inability to tolerate enteral nutrition.

  • Lab results reveal the following:
    • WBC 16 (8.0 yesterday)
    • Cr 2.1 (baseline 1.0)
    • Lactate 4.2
    • CXR shows bibasilar infiltrate

What is her Dx?

A
  • Severe sepsis
  • Hospital acquired pneumonia
  • AKI
14
Q

A rapid response is called by the RN for a Pt with AMS. The Pt is a general surgery Pt, but as the hospital medicine PA you respond first. The Pt is 69F hx HTN, T2DM, now s/p gastric antrectomy for severe peptic ulcer disease. She is POD5 due to post-op ileus and inability to tolerate enteral nutrition.

After performing the primary assessment and making the needed interventions what is your next step?

A

Perform the secondary assessment Including SAMPLE and DDx

15
Q

A rapid response is called by the RN for a Pt with AMS. The Pt is a general surgery Pt, but as the hospital medicine PA you respond first. The Pt is 69F hx HTN, T2DM, now s/p gastric antrectomy for severe peptic ulcer disease. She is POD5 due to post-op ileus and inability to tolerate enteral nutrition.

After a thorough work up she is Dxed with Sepsis, HAPNA, and AKI what is your treatment plan?

A
  • Start Vanco and cefepime
  • Fluids for hypotension
  • Trended lactate until cleared
  • Follow blood cultures
  • When stable D/C IV ABx and transition to PO
16
Q

A rapid response is called by the RN for a Pt with AMS. The Pt is a general surgery Pt, but as the hospital medicine PA you respond first. The Pt is 69F hx HTN, T2DM, now s/p gastric antrectomy for severe peptic ulcer disease. She is POD5 due to post-op ileus and inability to tolerate enteral nutrition.

The secondary assessment reveals the following:

S: Became gradually more confused today

A: Doxycycline

M: MAR notable for frequent Dilaudid dosing

P: HTN, T2DM, now s/p gastric antrectomy for severe peptic ulcer disease, POD5

L: NPO

E: See S

What should you order?

A
  • Labs
    • CBC
    • CMP
    • Lactate
    • Blood cultures
    • UA
  • Imaging
    • CT-H
    • CXR
    • CT Abd/Pel
17
Q

For Pts with AMS what mnemonic helps determine possible DDxs?

A
  • AEIOU-TIPS
    • A
      • Abuse of alcohol/drugs
      • Acidosis
    • E
      • Epilepsy
      • Electrolytes
      • Encephalopathy (Wernicke’s)
      • Endocrine
    • I
      • Infection
    • O
      • Overdose
      • Oxygen (hypoxia)
    • U
      • Uremia
    • T
      • Trauma
      • Tumor
    • I
      • Insulin
    • P
      • Psychiatric
      • Psychosis
      • Poisons
    • S
      • Stroke
      • Shock
18
Q

80 y/o M hx HTN, T2DM, CKD3, was admitted with chest pain, found to have NSTEMI. He was given aspirin and started on a heparin gtt with plans for cardiac catheterization in the morning. At shift change, the night nurse notices the patient is aphasic and has left-sided weakness. She calls a stroke alert. You respond as the hospitalist. What do you do next?

A
  • Brief neuro exam
  • Figure out last time Pt was known to be at baseline
  • Check glucose
  • Start NIHSS
19
Q

80 y/o M hx HTN, T2DM, CKD3, was admitted with chest pain, found to have NSTEMI. He was given aspirin and started on a heparin gtt with plans for cardiac catheterization in the morning. At shift change, the night nurse notices the patient is aphasic and has left-sided weakness. She calls a stroke alert. You respond as the hospitalist. What do you want to order?

A
  • STAT Non-contrast head CT
  • STAT Neuro consult
20
Q

Describe the time frame of a stroke alert.

A
  • 10 minutes: “Doctor to door”
  • 15 minutes: Neurologist to see Pt
  • 25 minutes: Door to CT scan completion
  • 45 minutes: Door to CT interpretation
  • 60 minutes: Door to treatment
  • 3 hours: Admission to ICU
21
Q

Following a large-vessel stroke (E.g. MCA) what procedure may need to be done?

A

Mechanical Thrombectomy may be done up to 24 hours post-stroke, can be done after administration of tPA

22
Q

Define status epilepticus

A

Seizures lasting greater than 5 minutes or recurrent seizures without return to baseline. (Techincal definition is a seizure lasting greater than 30 minutes, but that definition is no longer used)

23
Q

Common causes of seizures

A
  • Metabolic
    • Hypoglycemia
    • Hyponatremia
  • Infection
    • CNS abscess
    • Meningitis
    • Encephalitis
  • Withdrawal
    • Alcohol
    • Antiepileptics
    • Benzodiazepines
  • CNS lesions
    • Cancer
    • CVA
    • Trauma
  • Intoxication
    • Prescription meds
    • MDMA
    • Synthetic cannabinoids
24
Q

After a patient has a seizure what should you order?

A
  • CBC
  • CMP
  • Mg, Phos
  • Lactate
  • Antiepileptic drug levels
  • +/- CT-H
  • +/- LP
  • Urine drug screen
  • EEG
25
Q

First-line interventions for a seizure

A
  • Place in the lateral decubitus position
  • Manage airway/breathing
    • Nasopharyngeal airway
    • May require bag-mask ventilation
  • Lorazepam
    • 4 mg IV (push over 2 min)
    • Repeat 4 mg IV X 1 in 5 minutes if needed
  • If no IV access
    • Midazolam 10 mg IM
  • If glucose is low or unobtainable
    • Thiamine 100 mg IV
    • D50
26
Q

Second-line seizure interventions (Seizure has persisted for 10 minutes)

A
  • Valproic acid
  • Levetiracetam
  • Phenobarbital
  • Fosphenytoin
  • Phenytoin

Any of these will work choose your favorite

27
Q

Third-line seizure intervention (Seizure has persisted for 30 minutes)

A
  • Intubate
  • Midazolam or Propofol drip
28
Q

ACLS medication recommendations for stable wide complex tachycardia

A
  • Adenosine
  • Amiodarone, procainamide, or sotalol
  • Avoid Verapamil
29
Q

ACLS medication recommendations for polymorphic V-Tach

A
  • With prolonged QT (Torsades de Pointes)
    • Magnesium
  • Without prolonged QT
    • Lidocaine or amiodarone
30
Q

ACLS medication recommendations for regular narrow complex tachycardia

A
  • Vagal maneuvers
  • Adenosine
  • Diltiazem or verapamil
  • Beta-blockers
31
Q

ACLS medication recommendations for A-fib or A-flutter with RVR

A
  • Beta-blocker or diltiazem or verapamil
  • Amiodarone
32
Q

ACLS medication recommendations for symptomatic bradycardia

A
  • Treat reversible causes
  • Atropine
  • Epinephrine or transcutaneous pacing
33
Q

69 y.o. male with PMH including HLD who was brought in by ambulance from the Broncos game with shortness of breath. EMS reports that the patient has been experiencing shortness of breath for the last 2-3 weeks which has been progressing but he attributes this to the poor air quality from the smoke (forest fires) while riding his bike. Then over the last hour symptoms have been persistent and have lasted longer than normal so he was evaluated by medical at the game and was found to be tachycardic. He reports some accompanying diaphoresis but denies palpitations, fevers, cough, abdominal pain or chest pain and denies recent trauma. Denies tobacco use or daily alcohol use. Denies history or family history of atrial fibrillation, cardiac disease, cancer, hypertension, GI bleed, diabetes or blood clots. NKDA.

VS PTA: 124/80, pulse 130s-140s, 92% on 2L

Exam:

Gen: in acute distress

CV: Tachycardic with irregular rhythm

Resp: Clear lungs

What is your diagnosis?

A

New-onset A-fib with RVR

34
Q

69 y.o. male with PMH including HLD who was brought in by ambulance from the Broncos game with shortness of breath. EMS reports that the patient has been experiencing shortness of breath for the last 2-3 weeks which has been progressing but he attributes this to the poor air quality from the smoke (forest fires) while riding his bike. Then over the last hour symptoms have been persistent and have lasted longer than normal so he was evaluated by medical at the game and was found to be tachycardic. He reports some accompanying diaphoresis but denies palpitations, fevers, cough, abdominal pain or chest pain and denies recent trauma. Denies tobacco use or daily alcohol use. Denies history or family history of atrial fibrillation, cardiac disease, cancer, hypertension, GI bleed, diabetes or blood clots. NKDA. The Pt is diagnosed with A-fib with RVR.

What do you want to order/know?

A
  • What is causing this?
    • TSH
    • TTE (look for structural abnormalities)
  • S/Sx:
    • Is the Pt symptomatic from A-fib?
    • When did the A-fib start?
  • Diagnosis
    • ECG
  • Treatment goals
    • Rate control
      • Cardioversion or pharmacologic
    • Anticoagulation?
      • Calculate CHADs2Vasc
35
Q

What is CHADS2?

A
  • CHF: 1 pt
  • HTN: 1 pt
  • Age > 75: 1 pt
  • Diabetes: 1 pt
  • Stroke or TIA: 2 pts
36
Q

What is CHA2DS2VASc?

A
  • CHF or LVEF = 40%: 1 pt
  • HTN: 1 pt
  • Age >/= 75: 2 pts
  • Diabetes: 1 pt
  • Stroke/TIA/Thromboembolism: 2 pts
  • Vascular disease: 1 pt
  • Age 65-74: 1 pt
  • Female: 1 pt
37
Q

69 y.o. male with PMH including HLD who was brought in by ambulance from the Broncos game with shortness of breath. EMS reports that the patient has been experiencing shortness of breath for the last 2-3 weeks which has been progressing but he attributes this to the poor air quality from the smoke (forest fires) while riding his bike. Then over the last hour symptoms have been persistent and have lasted longer than normal so he was evaluated by medical at the game and was found to be tachycardic. He reports some accompanying diaphoresis but denies palpitations, fevers, cough, abdominal pain or chest pain and denies recent trauma. Denies tobacco use or daily alcohol use. Denies history or family history of atrial fibrillation, cardiac disease, cancer, hypertension, GI bleed, diabetes or blood clots. NKDA. The Pt is diagnosed with A-fib with RVR and has a CHADSVASC score of 1 initially. At this point what medication should you start?

A

Metoprolol 25mg Q6H

38
Q

69 y.o. male with PMH including HLD who was brought in by ambulance from the Broncos game with shortness of breath. EMS reports that the patient has been experiencing shortness of breath for the last 2-3 weeks which has been progressing but he attributes this to the poor air quality from the smoke (forest fires) while riding his bike. Then over the last hour symptoms have been persistent and have lasted longer than normal so he was evaluated by medical at the game and was found to be tachycardic. He reports some accompanying diaphoresis but denies palpitations, fevers, cough, abdominal pain or chest pain and denies recent trauma. Denies tobacco use or daily alcohol use. Denies history or family history of atrial fibrillation, cardiac disease, cancer, hypertension, GI bleed, diabetes or blood clots. NKDA. The Pt is diagnosed with A-fib with RVR and has a CHADSVASC score of 1 initially. After a TTE is performed the following is found:

  • Heart Rhythm: atrial fibrillation.
  • The left ventricle is normal in size and wall thickness, with severe global hypokinesis and severely reduced global systolic function. The LVEF is visually estimated at 30% [range: 25-30%].
  • Indices of diastolic function are abnormal suggesting elevated left ventricular filling pressure.
  • The right ventricle is mild to moderately dilated. The right ventricular systolic function is mildly reduced.
  • There is moderate left and mild to moderate right atrial dilation.
  • There is moderate mitral valve regurgitation.
  • There is moderate tricuspid regurgitation.
  • Estimated PA systolic pressure is 57 mmHg.
  • No prior study is available for comparison.

What is this Pts new CHA2DS2VASc score and does this change your treatment plan?

A

The CHA2DS2VASc score is now 3 since the TTE showed heart failure and valvular disease. Since the score is >2 the Pt should be started on an anticoagulant as well as starting medication for rate control.

39
Q

69 y.o. male with PMH including HLD who was brought in by ambulance from the Broncos game with shortness of breath. EMS reports that the patient has been experiencing shortness of breath for the last 2-3 weeks which has been progressing but he attributes this to the poor air quality from the smoke (forest fires) while riding his bike. Then over the last hour symptoms have been persistent and have lasted longer than normal so he was evaluated by medical at the game and was found to be tachycardic. He reports some accompanying diaphoresis but denies palpitations, fevers, cough, abdominal pain or chest pain and denies recent trauma. Denies tobacco use or daily alcohol use. Denies history or family history of atrial fibrillation, cardiac disease, cancer, hypertension, GI bleed, diabetes or blood clots. NKDA.

You get called to bedside for HR now in 140’s and patient persistently short of breath. SBP<90. What do you do?

A
  • Begin resuscitation
    • IV access
    • IV fluids
    • Supplemental O2
    • Vitals
    • Set up telemetry
    • Call support
  • Consider other conditions that could be contributing or causing instability
    • Infection
    • Sepsis
    • Hypovolemia
    • Respiratory failure
    • ACS
    • PE
  • Perform initial evaluation
    • 12 lead ECG
    • CBC
    • Trop
    • BNP
    • Chest X-ray
    • UA
  • Secondary eval
40
Q

69 y.o. male with PMH including HLD who was brought in by ambulance from the Broncos game with shortness of breath. EMS reports that the patient has been experiencing shortness of breath for the last 2-3 weeks which has been progressing but he attributes this to the poor air quality from the smoke (forest fires) while riding his bike. Then over the last hour symptoms have been persistent and have lasted longer than normal so he was evaluated by medical at the game and was found to be tachycardic. He reports some accompanying diaphoresis but denies palpitations, fevers, cough, abdominal pain or chest pain and denies recent trauma. Denies tobacco use or daily alcohol use. Denies history or family history of atrial fibrillation, cardiac disease, cancer, hypertension, GI bleed, diabetes or blood clots. NKDA. Pt was diagnosed with new A-Fib with RVR.

You get called to bedside for HR now in 140’s and patient persistently short of breath. SBP<90.

Secondary eval was negative for other causes for the Pts symptoms what is the next step?

A

TEE with cardioversion

41
Q

69 y.o. male with PMH including HLD who was brought in by ambulance from the Broncos game with shortness of breath. EMS reports that the patient has been experiencing shortness of breath for the last 2-3 weeks which has been progressing but he attributes this to the poor air quality from the smoke (forest fires) while riding his bike. Then over the last hour symptoms have been persistent and have lasted longer than normal so he was evaluated by medical at the game and was found to be tachycardic. He reports some accompanying diaphoresis but denies palpitations, fevers, cough, abdominal pain or chest pain and denies recent trauma. Denies tobacco use or daily alcohol use. Denies history or family history of atrial fibrillation, cardiac disease, cancer, hypertension, GI bleed, diabetes or blood clots. NKDA.

You get called to bedside for HR now in 140’s and patient persistently short of breath. SBP<90.

TEE with cardioversion failed to covert the rhythm likely due to underlying heart failure.

When the Pt is ready for D/C what should be done?

A
  • D/C home with:
    • Rhythm control
      • Amiodarone
    • Rate control
      • Metoprolol succinate
    • Entresto
    • Xarelto
    • Spironolactone
    • Lasix
  • At D/C follow up
    • BMP
    • Ischemic eval
42
Q

During an IP emergency where the Pt presents with CP what are some possible DDX?

A
  • ACS
  • Acute aortic dissection
  • PE
  • Tension pneumothorax
  • Pericardial tamponade
43
Q

68 year old female with history of ESRD (on HD), HLD, HTN, who is admitted for acute hyperkalemia (k 6.8 with peaked T waves). She received emergent HD and now is on the floor. The nurse calls you and states that the patient is having chest pain.

What do you do?

  • A.) Do nothing, you are busy, and she’s just finished dialysis (of course she will have chest pain)
  • B.) Go see the patient, order ECG
  • C.) Go see the patient, order ECG, trop, BMP, and call cards
  • D.) Go see the patient, order ECG, and Trop
A
  • D.) Go see the patient, order ECG, and Trop

Do not need to check BMP as it will be inaccurate up to two hours post-dialysis. Don’t call cardiology until you have some information for them such as results of the ECG

44
Q

68 year old female with history of ESRD (on HD), HLD, HTN, who is admitted for acute hyperkalemia (k 6.8 with peaked T waves). She received emergent HD and now is on the floor. The nurse calls you and states that the patient is having chest pain. You go see the patient, order ECG (see picture), and Trop

What does the ECG show?

A

It shows Wellen’s sign which is deep inverted T waves in the precordial leads (best seen in V2 and V3 in this case)

45
Q

What is Wellen’s sign concerning for?

A

Wellen’s sign is concerning for a high-grade stenosis of the LAD artery

46
Q

68 year old female with history of ESRD (on HD), HLD, HTN, who is admitted for acute hyperkalemia (k 6.8 with peaked T waves). She received emergent HD and now is on the floor. The nurse calls you and states that the patient is having chest pain. You go see the patient, order ECG (see picture), and Trop

The ECG shows Wellen’s sign, what do you do next?

A
  • Contact cardiology!
  • In this case, Pt had the following done:
    • PCI to LAD
    • Started in ASA/Plavix/Statin
47
Q

When interpreting and ECG what is a good order to follow?

A
  • Rate
  • Rhythm
  • Axis
  • Intervals
  • ST segments
  • Use the same pattern everytime
48
Q

Common inpatient emergency causes of shortness of breath?

A
  • Infection
  • Volume
  • Clot
49
Q

29 year old w/ a history of severe bullous SLE complicated by lupus nephritis, admitted with progressive anasarca, and AKI on CKD, with renal biopsy confirming lupus nephritis s/p rituximab 1000mg x1. Hospital course c/b Staph Aureus bacteremia now on cefazoline.

At approximately 9:30 PM provider called to bedside by nursing for acute dyspnea with desaturation to 78%, rapidly up-titrated from 2L NC to non-rebreather at 15L. Patient also reportedly coughing up red-tinged sputum.

On arrival, she was saturating 84% on 15L NRB, tachy to 100s, hypertensive to SBP 150s. She appeared to be in respiratory distress, with use of accessory muscles. Coughing up light pink sputum. Lungs were diffusely course to bilateral anterior and posterior auscultation, no wheezes. Heart sounds obscured by lung sounds. 3+ b/l LE edema, extremities warm.

What should you order?

A

General orders for acute SOB

  • ABG
  • Chest X-Ray
  • ECG
  • Stat bedside echo
  • CBC
  • NT-proBNP
  • Trop
  • D-dimer
  • CMP
  • Pending the above further imaging
    • CT-PE
50
Q

29 year old w/ a history of severe bullous SLE complicated by lupus nephritis, admitted with progressive anasarca, and AKI on CKD, with renal biopsy confirming lupus nephritis s/p rituximab 1000mg x1. Hospital course c/b Staph Aureus bacteremia now on cefazoline.

At approximately 9:30 PM provider called to bedside by nursing for acute dyspnea with desaturation to 78%, rapidly up-titrated from 2L NC to non-rebreather at 15L. Patient also reportedly coughing up red-tinged sputum.

On arrival, she was saturating 84% on 15L NRB, tachy to 100s, hypertensive to SBP 150s. She appeared to be in respiratory distress, with use of accessory muscles. Coughing up light pink sputum. Lungs were diffusely course to bilateral anterior and posterior auscultation, no wheezes. Heart sounds obscured by lung sounds. 3+ b/l LE edema, extremities warm.

Labe results show the following:

  • BNP: >20,000
  • Hs Trop: 23 (normal)
  • CBC: hgb 8.4 showing normocytic anemia which is unchanged from the day
  • CMP: Cr 4.2 unchanged from the day
  • ABG: 7.4/34/52/21 (on 15L NRB)

What is on you DDX?

A
  • Volume overload (top of DDX)
  • Diffuse alveolar hemorrhage
  • PNA
51
Q

29 year old w/ a history of severe bullous SLE complicated by lupus nephritis, admitted with progressive anasarca, and AKI on CKD, with renal biopsy confirming lupus nephritis s/p rituximab 1000mg x1. Hospital course c/b Staph Aureus bacteremia now on cefazoline.

At approximately 9:30 PM provider called to bedside by nursing for acute dyspnea with desaturation to 78%, rapidly up-titrated from 2L NC to non-rebreather at 15L. Patient also reportedly coughing up red-tinged sputum.

On arrival, she was saturating 84% on 15L NRB, tachy to 100s, hypertensive to SBP 150s. She appeared to be in respiratory distress, with use of accessory muscles. Coughing up light pink sputum. Lungs were diffusely course to bilateral anterior and posterior auscultation, no wheezes. Heart sounds obscured by lung sounds. 3+ b/l LE edema, extremities warm.

You belive her symptoms are due to volume overload, what should you do next?

A
  • Start 160 IV Lasix
  • Call ICU
  • Intubate Pt
  • Will likely need hemodialysis for volume overload
52
Q

What is NIPPV and what are indications for its use?

A

Non-invasive positive pressure ventilation (CPAP, BiPAP)

  • Indications
    • Cardiogenic pulmonary edema
    • COPD
53
Q

Which Pt’s with respiratory problems are good candidates for NIPPV

A
  • Able to protect airway
  • Able to clear respiratory secretions
  • Cooperative
  • Low risk of aspiration
54
Q

Contraindications for NIPPV use?

A

Cardiac or respiratory arrest are absolute contraindications

55
Q

What is HHF O2

A
  • Heated High Flow O2
    • Heats and humidifies air
    • Can deliver up to 100% FIO2 at rates up to 60 LPM
    • The cannula is similar to normal nasal cannula
      • No issue with mask fit like with BiPAP/CPAP
    • Provides some washout of “dead space”
56
Q

What are some indications for intubation?

A
  • Failure of airway maintenance or protection
  • Failure of ventilation or oxygenation
  • Needed for anticipated clinical course
57
Q

What does FAST stand for in outpatient stroke assesment?

A
  • Face
    • Look for an uneven smile
  • Arm
    • Check if one arm is weak
  • Speech
    • Listen for slurred speech
  • Time
    • Call 911 right away