Part 20 Flashcards
(108 cards)
1
Q
DOC for benzo overdoae
A
Flumazenil
2
Q
Low vs high bleeding risk procedures
A
Low is minor derm or dental procedures, cataract, endoscopy without biopsy, high risk includes polypectomy, ortho or plastic surgery, kidney liver or spleen biopsy
3
Q
INR goal for high bleeding risk procedure
A
<1.5
4
Q
Bridging therapy is done for high risk thrombotic patients, and in moderate with a low bleeding risk. What are some examples of high risk pts?
A
recent VTE, known thrombophilic state, chadvasc score >5
5
Q
andexanet alfa
A
reverses all factor xa inhibitors
6
Q
Time dual antiplatelet therapy indicated for in balloon angio without Stent, drug eluting Stent, and bare metal Stent
A
14 days, 6 months, and 30 days
7
Q
What blood pressure Med should you hold the day of surgery?
A
ACE inhibitor and ARBs
8
Q
Most common noncardiac cause of chest pain
A
GERD
9
Q
3 diseases within acute coronary syndrome
A
-Unstable angina (impending MI, no myocardial damage yet)
-STEMI
-NSTEMI
(both cases cardiac biomarkers are elevated)
10
Q
Most common life threatening conditions resulting in chest pain (6)
A
- Acute coronary syndrome
- Cardiac tamponade with pericarditis (rare)
- aortic dissection (ripping tearing pain radiating to back)
- pulmonary embolus
- tension pneumothorax
- esophageal rupture/boorhave syndrome (thru violent vomiting or retching
11
Q
Beck’s triad for cardiac tamponade
A
- hypotension
- muffled heart
- JVD
12
Q
Aortic dissection definition, diagnosis (2), treatment (3)
A
- Breaking in integrity of aortic wall, often background history of marfan syndrome or hypertension, symptoms include sharp ripping shearing pain radiating to back, may have weak or absent peripheral pulses or new murmur of aortic insufficiency
- CT with contrast or Transesophageal echocardiogram
- IV labetalol or IV nitroglycerin followed by surgical approach
13
Q
Pulmonary embolism definition, diagnosis (2), treatment (2)
A
Commonly occurs after surgery or immobilization, pain often pleuritic and described as crushing, shooting, accompanied by dyspnea, signs can include tachycardia, tachypnea, hemoptysis, hypoxemia, EKG may show sinus tach (most commonly)*** and S1Q3T3 right heart strain pattern (15%)
- D dimer highly sensitive, CT of chest is diagnostic
- anticoagulation, emboleectomy if large
14
Q
Tension pneumothorax definition and treatment options (2)
A
Collapsed lung with air or gas trapped and allowed to move in but not out resulting in shifting of mediastinum away from affected lung compressing heart and decreasing cardiac output, sharp pleuritic chest pain with associated dyspnea, decreased or absent breath sounds, tracheal deviiation, tachycardia, tachypnea, hypotension, cyanosis, subcutaneous emphysema, JVD
-Chest tube, needle thoracotomy
15
Q
Diagnostic gold standard study of choice after CXR, EKG, enzymes for CAD is….
A
….cardiac catheterization
16
Q
Pericarditis definition and EKG finding (1)
A
- Inflammation of the pericardial sac most often viral in origin but can also be due to malignancy, end stage renal disease, dresslers (post MI), sees sharp crushing substernal with pleuritic component, aggravated by supine position, may hear friction rub
- sees diffuse ST segment elevation on EKG
17
Q
S3 represents ___ dysfunciton, S4 represents ___ dysfunction
A
Systolic, diastolic
18
Q
Diagnostic studies for chest pain patients (7)
A
- EKG
- CXR
- Cardiac enzymes, LFTs, amylase/lipase, D dimer, CBC
- stress testing
- echocardiogram
- cardiac catheterization (coronary angiography)
- CT/VQ
19
Q
Pericarditis is worse in what position?
A
Supine
20
Q
Preferred routes of administration for ACLS medications (2)
A
-IV or IO
21
Q
In cardiac arrest (Vfib and pulseless v tach) persists after at least 1 attempt of defib and 2 min of CPR, what should be administered?
A
Epi 1mg IV q3-5 min while CPR is performed continuously
22
Q
What may be administered in cardiac arrest (VF or pulseless VT) unresponsive to defibrillation, CPR, and epinephrine?
A
Amiodarone, 300mg IV, 150mg IV repeat dose
23
Q
When is magnesium sulfate (2g IV) used in cardiac arrest?
A
Polymorphic ventricuar tachycardia with torsades de pointes
24
Q
Asystole/PEA are nonshockable rhythms that after initiating CPR for 2 min can give this drug
A
1mg epi every 3-5min IV/IO
25
1st line treatment for nonstable bradycardia (BPM <50)
atropine .5mg bolus repeat every 3-5 min max 3 mg
26
2nd line treatment for nonstable bradycardia (BPM <50)
Dopamine infusion 2-10mcg/kg/min or epi (same dosing)
27
1st line treatment for nonstable tachycardia (BPM >150)
Immediate syncronized cardioversion narrow regular 50-100J or narrow irregular 120-200J
28
1st line treatment for narrow QRS stable SINUS tachycardia (BPM>150)
No medication indicated, just monitor
29
1st line treatment for narrow QRS stable nonsinus tachycardia (BPM>150)
Adenosine 6mg IV push by 20mL saline flush, 2nd dose 12mg IV (warn the patient they will experience transient chest discomfort, dyspnea, flushing, short lived tho)
30
2nd line treatment for narrow QRS stable nonsinus tachycardia (BPM>150) or control of heart rate in stable patients tachycardic patients (2)
- Rate control with IV nondihydropyradine ca2+ channel blocker such as diltiazem or verapamil
- B blocker (metoprolol, atenolol, labetalol)
31
1st line treatment for wide QRS stable nonsinus tachycardia (BPM>150)
Amiodarone (150mg/10min)
32
Morphine sulfate function
Opioid analgesic that also dilates blood vessels, IV morphine controls pain of MI and improves hemodynamics by promoting vasodilation, and reduces anxiety, useful in ACS but need to be cautious about respiratory depression, can reverse with naloxone (2-4mg IV)
33
Lidocaine function
Suppress ventricular fibrillation by raising threshold of fibrillation via same ca2+ channel activity that inhibits pain, can be used as alternative to amiodarone in cardiac arrest (Vfib or pulseless vtach)
34
B blocker use in ACLS
Used to suppress supraventricular tachycardia (atrial fib and flutter) and reduce myocardial ischemia in MI,
35
Atropine adverse effects (4)
- blurred vision
- dilated pupils
- dry mouth/nose
- difficulty urinating
36
Concurrent administration of ca2+ channels with IV B blockers can cause severe....
...hypotension
37
Red flags of headache (7)
- fixed neurological deficits
- extremely abrupt onset
- papilledema
- new onset in patients <5 or >50
- signs of infection
- altered level of consciousness
- new headache in cancer or immunocompromised patient
38
Primary vs secondary headaches
Primary is caused by benign intrinsic causes (migraine, tension, cluster) vs secondary caused by underlying causes (lesion, infection, etc)
39
Kernigs sign
Test for meningitis by seeing severe stiffness in hamstrings causing inability to straighten leg when hip is flexed to 90 degrees
40
Brudzinski's sign
Test for meningitis that if positive sees patients hips and knees flex when the neck is flexed manually by the provider
41
Most helpful study in identifying CNS infection
Lumbar puncture (perform a CT prior to exclude any intracranial mass or bleed that could cause pressure issue and herniation of brain)
42
Rule of RBCs in the CSF tubes for determining a brain bleed while performing a lumbar puncture
Should normally see the number of RBCs decrease over time when drawing tubes from an LP, if consistent amount then can indicate a brain bleed presence
43
Decreased glucose in CSF analysis following LP is predictive of...
...infectious meningitis
44
Classic triad of meningitis
- fever
- nuchal rigidity (inability to flex due to rigidity of neck muscles, if flexion is painful but full range of motion present then nuchal rigidity is absent)
- altered mental status
45
Subarachnoid bleed characteristics and diagnostic studies (3) and treatment options (4)
Most are aneurysmal with sudden onset severe thunderclap headache that may be associated with brief loss of consciousness or seizures
- noncontrast CT and if nondiagnostic then lumbar puncture with elevated RBC that does not diminish in tubes 1-4, digital subtraction angiography highest resolution to detect suspected aneurysm is gold standard diagnosis
- IV fluids, antiepileptic therapy, ET tube, potential neurovascular surgery
46
Subdural bleed characteristics, diagnostic study (1), prognosis (1), and treatment (1)
- bleed in potential space between dura and arachnoid membranes, most are from tearing bridging veins that drain from the surface of brain to the dural sinuses, head trauma most often cause***
- CT of head most widely used diagnostic tool
- overall mortality is up to 50%
- neurosurgery immediately
47
Migraine cocktail components for migraine in emergency setting that has failed to respond to normal treatment (4)
- Antiemetic such as metaclopraide
- diphenhydramine
- Ketorlac (toradol)
- IV fluids
48
Eschar definition
Dark dry scab or falling away of dead skin caused by a burn
49
Electrical burns can pass thru skin and thus we need to consider...
....damage done to internal organs as well
50
3 zones of a burn
- Zone of coagulation - tissue is dead and no circulation, full thickness type burn
- Zone of stasis - reduced circulation but tissue might not be dead but can still occur
- Zone of hyperemia - circulation is intact but inflamed
51
Burn classification (2)
- Partial (1st and 2nd degree) - erythema and vesicle formation, painful, either superficial (dry red like sunburn), superficial partial thickness (blisters but blanches), or deep partial (blister and does not blanch)
- Full thickness (3rd degree) - painless, almost never recovers, if extends to fascia or muscle then 4th degree
52
What qualifies as a minor burn (7)
- partial thickness burn <10% 10-50 y/o
- partial thickness burn <10% under 10 or greater than 50 y/o
- full thickness burn <2% on any patient without other injury
- must be isolated injury
- does not involve face, hands, perineum, or feet
- does not cross major joint
- not circumferential (circumferential can lead to compartment syndrome
53
Estimation of extent of burn injury rule of 9's in an adult
```
Face - 9%
neck - 1%
Front core - 18%
back core - 18%
arm - 9%
leg - 18%
```
54
Estimation of extent of burns injury rule of 9's in a child
```
Face - 18%
front core - 18%
back core - 18%
arm - 9%
leg - 14%
```
55
Cardiac arrest in children is usually not from a ____ cause, rather result of ____ or ____*****
cardiac, respiratory failure, shock
56
Why do children in presence of apnea see more tissue hypoxia than adults?
Because they have a higher metabolic rate
57
PALS protocol
- General assessment
- Primary assessment ABCDE
- secondary assessment
- condition specific protocol between upper airway obstruction, lower, lung tissue disease, and disorderd control of breathing
58
302 psychiatric admission*****
Involuntary admission requiring a petitioner and physician and involvement of county crisis team often when at risk to themselves or others to admit to a psychiatric ward, must offer voluntary option first
59
201 psychiatric admission****
Voluntary admission by adult or emancipated minor understanding the legal aspects and signs form to a psychiatric ward
60
Admission to a psych unit medical clearance by a provider rules (3)
- need to assure observed behavior is not medically induced
- need to assure that there is not co-existent medical condition that requires acute medical or surgical care
- Need minimum testing such as electrolytes, BUN, creatinine, CBC, LFT, O2 sat or ABG, EKG, CT if recent head trauma
61
First 3 steps of BLS
- verify scene safety
- check responsiveness
- shout for help, activate emergency response system
62
The 4th step of BLS is dependent on the age, if they are an adult then.....
If they are a child then....
....Get AED if alone or otherwise send another to get it
....Immediately start 2 min CPR compressions first before going to get an AED
63
The 5th step of BLS is to do what?
Assess the breathing and pulse at the same time WITHIN 10 seconds, and depending on assessment of these determines the next directional step of the algorithm
64
If a patient after the 5th step of BLS assessment has pulse and breathing, what should be done?
Wait with patient
65
If a patient after 5th step of BLS assessment has a pulse but no breathing, what should be done?
Provide rescue breaths every 5-6 seconds in adults or 3-5 seconds in kids, and check the pulse the next 2 minutes to see if it goes away, consider moving to the opioid overdose algorithm if suspected
66
If a patient after the 5th step of BLS assessment has no pulse and no breathing, what should be done?
CPR 30 compressions 100-120bpm and 2 breaths (head tilt or jaw thrust) 5-6 seconds each in adults or 15 compressions 100-120bpm and 2 breaths 3-5 seconds each in children, move into the primary survey and repeat CPR until AED arrives
67
Primary survey BLS (ABCDE)
Airway (Maintain airway patency using assisted airway device if needed and secure it, ensure continuous quantitative waveform capnography (CO2 35-45), use adjuncts as necessary (OPA,NPA, suctioning))
Breathing (Give supplemental O2, 100% for arrest, titrate to at least 94% otherwise, agonal gasps don't cout as breathing)
Circulation (Obtain IV/IO access, check blood glucose/temp/caprefill/BP (90 systolic at least))
Disability (Assess pupils and neuralogic functioning, look for AVPU (alert, voice, pain, unresponsive))
Exposure (Remove clothing look for bleeding/trauma/burns/bracelets)
68
In BLS, once the AED arrives, what is the next 2 steps to take?
- Turn it on
- - Place pads avoiding hairy chest or wet conditions
69
Secondary survey ACLS (SAMPLE)
```
Signs/symptoms
Allergies
Medications
PMH
Last meal/liquid
Events leading up to
```
70
In ACLS AED use, if the rhythm is analyzed to be shockable, then what 2 rhythms could it be?
- Ventricular fibrillation
- - Pulseless ventricular tachycardia
71
After shocking with the AED initially in ACLS, what should be done? What about on the next five consecutive repeats?
- CPR 2 min, then analyze if the rhythm is shockable or not again
- CPR 2 min +1mg epi every 3-5 min IV/IO then analyze if the rhythm is shockable or not again
- CPR 2 min + 300mg bolus amiodarone IV/IO then analyze if the rhythm is shockable or not again
- CPR 2 min +1mg epi every 3-5 min IV/IO then analyze if the rhythm is shockable or not again
- CPR 2 min + 150mg bolus amiodarone IV/IO then analyze if the rhythm is shockable or not again
- CPR 2 min +1mg epi every 3-5 min IV/IO then analyze if the rhythm is shockable or not again
72
In ACLS AED use, if the rhythm is analyzed to be not shockable, then what 2 rhythms could it be?
- Asystole
- - Pulseless Electrical Activity (PEA)
73
After a rhythm is analyzed not to be shockable in ACLS (either initial AED determination, switch from a previously shockable rhythm, or failure of signs of ROSC), what should be done? What should be done the next 2 times?
- CPR 2 min +1mg epi every 3 min IV/IO
- CPR 2 min
- if no signs of ROSC repeat the first
74
Upon obtaining ROSC, what is the next steps that should be taken? (3)
- Get o2 to >94%
- Get SBP >90mmHg
- Get 12 lead EKG and analyze
75
Upon ROSC checking if the patient can follow commands, if they cannot what should be done initally? After this, or if they can, what should be done?
- Temperature therapy
- - Advanced critical care admission
76
In ACLS AED use, if bradycardia (BPM<50) is found, what should be done?
Ask is the patient stable, if yes then monitor O2, IV/IO, BP, and 12 lead EKG, if not administer atropine .5mg bolus every 3-5 min max 3 mg, if still not stable do dopamine infusion 2-10mcg/kg/min, if still not stable consult an expert
77
In ACLS AED use, if tachycardia (BPM>150) is found, what should be done?
If stable, get a 12 lead EKG and begin performing vagal maneuvers, if no, immediate synchronized cardioversion (if narrow regular complex 50-100J, narrow irregular 120-200 J)
78
In ACLS AED use, if stable tachycardia does not resolve with vagal maneuvers, after getting an EKG what should be done?
Ask if it is a wide QRS >.12 sec complex, if wide then give amiodarone 150mg/10min, if narrow do adenosine 6mg IV push, and possibly 2nd dose 12mg
79
What is the 4 steps of the opioid OD ACLS algorithm
- Begin CPR
- administer naloxone 2mg intranasal or .4 IM
- repeat after 4 minutes
- if patient does not respond then begin CPR in the BLS algorithm (if does, stimulate and reasses)
80
What are the 7 steps of the ACLS acute coronary syndrome algorithm
- when suspected clinically, begin O2 to get to 94%
- Gain IV access 2 ports
- 12 lead EKG
- Aspirin 125mg chewable unless GI bleed or true allergy
- Sublingual nitroglycerin every 3-5 min unless RV infarct, hypotension, or PDE5 use (can use morphine alternatively)
- Notify cath lab (if none then give tPA in 30 min)
- Order CXR and troponin levels
81
What are the 7 steps of the ACLS stroke algorithm
- Suspect with facial droop, arm drift, or slurred speech (cincenati stroke scale)
- Find out last known normal
- supportive care
- Within 10 min get stroke team mobilized and CT
- Perform NIH assessment
- If patient doesn't qualify for ischemia give aspirin
- If does qualify for ischemia give tPA fibrolytic therapy within 3 hours of last known normal
82
Triage definition
Process of sorting/assessing the urgency of an illness or wound in order to decide the order of treatment
83
Emergency Severity Index (ESI)
5 level triage algorithm that provides clinically relevant stratification of patients into 5 groups, with 1 being the most severely unstable needing immediate intervention and majority are admitted, 2 are potentially unstable and need to be seen within 10 minutes, often requiring lab testing and admission, 3 are stable and should be seen urgently within 30 minutes, often require lab testing and medication and most often are discharged, 4 is stable and may be seen nonurgently require minimal testing or procedure and are expected to be discharged, 5 may be seen nonurgently and require no testing or a procedure, often need prescription refill, are expected to be discharged
84
Mass casualty situation
Tag individuals who will not be worth the resources to save, dead or dying (black tagged), get those that are critical immediately into hospital (red tagged), get those that have more time on the back burner (yellow tagged) or those that are walking wounded who are seen last or can bring themselves somewhere for treatment (green tagged)
85
Lethal 6 of chest trauma
- airway obstruction (look if they are struggling to breath, listen for stridor, call for help and consider a cric)
- tension pneumothorax (look for bruising, wounds, chest wall, hypotension)
- open pneumothorax (similar but from external wound causing the 1 way valve suction of air comressing the mediastinum)
- massive hemothorax
- flail chest (ribs broken in 2 spots resulting in floating ribs that upon inhalation see retraction of the ribs rather than expansion, poor outcome requiring rib plating)
- cardiac tamponade (JVD, muffled heart tones, hypotension)
86
What is the treatment for a tension pneumothorax? (1) What is the next intervention? (1)
- 1st 2nd intercostal space midclavicular line needle decompression
- Tube thoracostomy (chest tube)
87
What is the treatment for a cardiac tamponade? (1)
Subxyphoid extraperitoneal approach to needle aspiration decompression (often picked up on FAST exam)
88
>3 rib fractures in elderly sees increase in mortality __% per rib - don't underestimate them, monitor vital capacity in the ICU!
5%
89
Cavitation
Refers to how wound capability increases when velocity increases due to shock wave around it and is hence why bullets can cause much more injury than knife stabbing
90
Tension vs simple pneumothorax
- Tracheal deviation away from side of decreased breath sounds indicates tension
- No tracheal deviation or tracheal deviation toward the side of decreased breath sounds indicates simple
91
Open pneumothorax definition and treatment option (1)
- Stab or shot wound that causes sucking chest wound every time inhalation occurs causing pressure creating a situation similar to tension pneumothorax
- treated with 3 way patch and eventually a chest tube
92
4 components of a blast injury
1) wall of air (primary) - can cause globe injuries, perforation of hollow viscus, TBI
2) flying debris (secondary) - blunt or penetrating trauma
3) displacement (tertiary) - getting blown back
4) other (quaternary) - burn or collapse of building
93
Blood in the peritoneum often does not produce....
....peritoneal signs, massive hemoperitoneum may be present without abdominal distension
94
A positive FAST exam would indicate need for immediate... (note that up to half of FAST exams can give false negatives as well!)
...Referral to the OR
95
Best diagnostic study for hemodynamically stable*** patient suspected of intra-abdominal injury
CT scan
96
In a GSW in the abdomen we want to do a good ___ exam before going for surgery
Peripheral neurological exam
97
Diagnostic modality of choice in gunshot wound patient, what is the best imaging study?
- Surgical exploratory laparotomy
- - X ray (NOT CT)
98
Appendicitis in late term pregnancy patient presentation
Right upper quadrant pain
99
Placenta previa increases risk with...
....multiparity
100
Bright red uterine bleeding (sometimes painless) in pregnant patients is....
....placenta previa until proven otherwise
101
Abruption risk factors (5)
- maternal hypertension
- increasing maternal age and parity
- prior abruption
- cocaine use
- trauma
102
Abruption presents as...
Sudden onset painful vaginal bleeding, tenderness on palpation
103
Classic triad of ectopic pregnancy
Amenorrhea
Abdominal pain
Abnormal vaginal bleeding
104
Most ectopic pregnancies occur on the___ side
right
105
Diagnosis of ectopic pregnancy
- hCG and US transvaginal
- - laparoscope (diagnostic and therapeutic)
106
Eclampsia signs and symptoms
- hyperreflexia
- sudden spike in BP
- RUQ or epigastric pain
- visual blurring
- shaking
107
Treatment of eclampsia (2)
- mag sulfate (dose to retain normal reflexia in the patient
- - hydralazine
108
Rape kit components
| 12
- scrape under fingernails
- comb pubic hair
- cut off a few patient's pubic hairs
- collect any other loose hair and dried blood
- take clothes in separate bags
- examine GU area with woods light
- saline wet mount for sperm # and motility
- collect vaginal aspirate or washings
- GC chlamydia culture
- U/A
- blood for VDRL and HIV
- drug screen for date rape and blood alcohol
