Van Bockern - Inpatient Emergencies Flashcards by Alice Richards

what labs did we decide to order for the HIV pt who presented w. AMS after biting off and swallowing his finger (5)

CBC
urine tox
viral load
blood cultures
lactate

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dx to not forget on your differential in pt w. AMS and multiple sexual partners

neurosyphilis

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what imaging did we order for the HIV pt who bit off his finger

CT-head
hand xr
abd xr

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what was the treatment plan for the HIV pt who bit off his finger (3)

vanco
unasyn
IVF

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what does MET stand for
what does RRT stand for

medical emergency team
rapid response team

same same

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multidisciplinary team most frequently consisting of ICU-trained personnel for eval of pt’s not in the ICU who develop signs/symptoms of clinical deterioration

MET/RRT

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when does the MET/RRT intervene

prior to code blue (deterioration)

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goal of MET/RRT (2)

prevent cardiac arrest
ensure goals of care have been addressed

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MET/RRT includes (7)

ICU residents/fellow/attending
medicine floor team
critical care RN
RT
pharmacy
house supervisor
security

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denver health RRT includes (5)

critical RN
floor RN
pharmacy
RT
PA hospitalist

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activation criteria for MET/RRT (10)

RR < 6 OR > 30
HR < 40 OR > 140
SBP < 90
symptomatic HTN
decrease in level of consciousness
unexplained agitation
seizure
significant fall in urine output
subjective concern about pt
per ACLS criteria 2015

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top 3 reasons for MET/RRT activation

AMS
tachycardia
tachypnea

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3 components of structured assessment

BLS -> are they breathing
primary assessment -> ABCDE
secondary assessment -> SAMPLE, ddx

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what does ABCDE stand for

airway
breathing
circulation
disability
exposure

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how do you manage airway/breathing (3)

O2
NIPPV
intubation

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how do you manage circulation (3)

IV
monitor
vitals

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how do you manage disability (2)

glucose
neuro assessment

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how do you manage exposure

look at pt
surgical sites

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what does “sample” stand for

signs/symptoms
allergies
meds
pmh
last PO
events leading up to

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basic interventions during primary assessment

IV/O2/monitor
vitals/glucose

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what does aeiou tips stand for

abuse of etoh/drugs
acidosis
epilepsy/electrolytes/encephalopathy/endocrine
infection
overdose/O2
uremia
trauma/tumor
insulin
psychiatric/psychosis/poisons
stroke/shock

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69 yo f w. HTN, T2DM
s/p gastric antrectomy for PUD, POD5 due to post op ileus and inability to tolerate enteral nutrition

airway patent, mild tachypnea but speaking in full sentences, sinus tachy, warm extremities, BG 83, surgical incision looks good

what is your initial intervention (3)

address IV access
fluid bolus for hypotn
APAP for fever

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for previous pt:

s: gradually more confused throughout day
a: doxy
m: MAR notable for frequent dilaudid dosing
p: HTN, T2DM, s/p gastric antrectomy w. post op ileus
l: NPO
e: gradual confusion

what labs/imaging do you order

labs: cbc, cmp, lactate, blood cultures, UA
imaging: CT-H, CXR, CT abd/pelvis

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previous pt’s labs:

WBC 16.0 (up from 8)
Cr: 2.1 (baseline 1.0)
lactate: 4.2
CXR: bibasilar infiltrates

what is your ddx (3)

severe sepsis
HAP
AKI

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go to tx for HAP

cefepime

tx for previous pt

cefepime PLUS vanco (HAP) fluids for hypotn trended lactate q 1-2 hr blood cultures d/c w. PO abx

what's the purpose of trended lactates

check for sepsis tx efficacy

what does FAST stand for

face arms speech time

80 yo m w. PMH HTN, T2DM, CKD3 - admitted w. CP - has NSTEMI he was given ASA and started on heparin gtt w. plans for cardiac catheterization in the morning you take over pt and he is aphasic w. left-sided weakness - she calls a stroke alert what is the most important next step

ask last normal!

initial stroke alert includes (4)

brief neuro exam last known normal!! glucose start NIHSS stroke scale

after stroke alert, what imaging do you order

CT-H w.o contrast plus neuro consult

time frame for stroke alert

10 min: door to doctor 15 min: neurologist 25 min: door to CT completion 45 min: door to CT interpretation 60 min: door to tx 3 hr: admission to ICU

time of stroke onset =

last time seen normal

timeframe for tPA

0-4.5 hr

timeframe for mechanical embelectomy for all vs for some

for all: 0-6 hr for some: 6-24 hr

for our NSTEMI pt with the stroke alert: BG and vitals are normal last known normal was 2 hr ago initial NIHSS is 12 CT-H shows massive intraparenchymal bleed what do you do

consult neuro -> reverse heparin

mean time to tx for stroke pt's

144 min

what outcomes improve with each 15 minutes of earlier tPA administration

lower in-house mortality lower rates of ICH more independent ambulation at d.c higher rate of d.c to home

clinical definition of status epilepticus

sz lasting > 5 min OR recurrent sz w.o return to baseline mental status

technical definition of status epilepticus

sz lasting > 30 min but you shouldn't let someone seize for that long duh

5 causes of seizure

metabolic infxn withdrawal CNS lesion intoxication

2 metabolic causes of sz

hypoglycemia hyponatremia

3 infectious causes of sz

CNS abscess meningitis encephalitis

withdrawal from what 3 drugs can cause sz

etoh benzos antiepileptics

intoxication from what 2 illicit drugs can cause sz

MDMA synthetic canabinoids

what diagnostics are included in sz work up

CBC, CMP, Mg, Phos, lactate antiepileptic drug levels +/- CT-H, lumbar puncture urine tox EEG

first line management of status epilepticus (4)

lateral decubitus position airway/breathing lorazepam vs midazolam BG level

when do you use lorazepam for status epilepticus

if you have IV access -> 4 mg IV push over 2 min repeat 4 mg IV x 1 in 5 min PRN

when do you use midazolam for status epilepticus

if no IV access -> 10 mg IM

when do you use thiamine for status epilepticus

if BG is low or unobtainable -> 100 mg IV, followed by D50

management of sz that persist at 10 min despite first line tx (4)

valproic acid levetiracetam phenobarbital fosphenytoin vs phenytoin

management of sz that persist at 30 min despite first and second line tx (2)

intubate midazolam vs propofol gtt

69 yo M, PMH HLD BIBA from Broncos game progressive SOB x 2-3 weeks - consistent x 1 hr tachycardic w. diaphoresis VS: 124/80, 130s-140s, 92% on 2L acute distress irregular rhythm clear lungs what is his EKG showing

afib

for prev pt, what is his CXR showing

cardiomegaly

for previous pt, what diagnostics do you order (6)

trop TTE BNP BMP Mg TSH

2 methods for rate control in afib

cardioversion pharmacologic

CHADS2 and CHA2DS2VASc

for Broncos game pt w. Afib and cardiomegaly, what pharm do you start

metoprolol 25 mg q 6 h CHADS score is 1 -> no AC

for Broncos game pt w. afib and cardiomegaly, TTE shows HF and valvular dz -> CHADS score is now 3 - what do you do now

start AC

for Broncos pt w. HF and afib - HR goes into the 140s and SOB persists - sbp drops to <90 what do you suspect? what do you do? (2)

suspect: afib w. RVR do: repeat EKG begin resuscitation -> IV access/fluids, O2, vitals, tele, call support

what conditions could lead to afib with RVR (6)

infxn sepsis hypovolemia respiratory failure ACS PE

initial work up for afib w. rvr

EKG CBC trop BNP CXR UA

why is UA helpful in afib w.rvr work up

to look for infxn

in Broncos game pt w. afib and cardiomegaly, afib for secondary causes of afib was negative - what do you do next

TTE with cardioversion

why would the Broncos game pt not cardiovert

his HF is too decompensated -> need to get HF under control first

how do you get decompensated HF under control so that you can cardiovert the Broncos game pt

d.c home with: amiodarone metropolol succinate entresto xarelto spironolactone lasix

what is the role of metropolol succinate

rhythm control remodeling agent *added benefit of mortality reduction in CHF

what is the role of amiodarone

rate control

what is the role of entresto or ACEI

afterload reducer

what needs to be done at follow up eval for Broncos game pt (2)

BMP ischemic eval

2 types of HF

HFrEF: LVF <40% HFpEF: LVF >50%

#1 cause of HFrEF

#1 cause of HFpEF

HTN

tx for HFrEF

bb ACEI

tx for HFpEF

treat underlying cause

Ddx for CP in Inpatient/ED setting

TTAPED: tension PTX tamponade acs PE esophageal rupture dissection

-68 yo f - PMH ESRD (on HD), HLD, HTN -admitted for hyperkalemia (K+ 6.8) w. peaked t waves -received emergent HD and is now admitted to the floor and is having CP what do you do

order EKG order trop go see pt

why wouldn't BMP be helpful for previous pt (little old lady w. CP)

she just got done with dialysis

why don't you call immediately cardiology consult in little old lady with CP

need objective data before you call a consult

here is the EKG with the little old lady w. CP what is it showing? what do you do now?

wellen's sign -> high grade stenosis of the LAD deep T wave inversions V2-V4 now call cards

what does cards do for little old lady w. CP

PCI to LAD

what meds should the little old lady w. CP be on after her PCI (3)

ASA plavix statin

pathophys behind IP SOB emergencies (3)

infxn volume clot

-29 yo w. hx of bullous SLE complicated by lupus nephritis w. progressive anasarca and AKI on CKD -renal bx confirms lupus nephritis s/p rituximab 1,000 mg x1 -hospital course c/b (complicated by) s. aureus - now on cefazoline -you are called to bedside when pt desats to 78% and is coughing up red tinged sputum - pt is titrated from 2L NC to non-breather -when you get there, SpO2 is 84% on 15L NRB, tachy to 100s, and sbp 150's - lungs are course to bilateral anterior and posterior auscultation, no wheezes - heart sounds are obscured -3+ bl LE edema, warm extremities what do you order

work up for SOB: ABG CXR EKG stat bedside echo CBC CMP BNP, trop, dimer CT-PE based on results

CXR for lupus pt labs for lupus pt: BNP > 20,000 trop: 23 (nl) CBC: normocytic anemia - hgb 8.4 CMP: Cr to 4.2 (stable) ABG: 7.4/34/52/21 on 15L NRB what's your ddx

volume overload DAH (diffuse alveolar hemorrhage) PNA

how do you manage SLE pt w. SOB

160 IV lasix asap call ICU intubate probs will need HD

what is NIPPV (aka NPPV)

non invasive positive pressure ventilation -> CPAP BiPAP

2 indications for NIPPV

cardiogenic pulmonary edema COPD

4 indications that a pt is a good candidate for NIPPV

able to protect airway able to clear respiratory secretions cooperative low risk of aspiration

absolute contraindication for NIPPV

cardiac or respiratory arrest

what type of O2 delivery are vapotherm and optiflow

heated high flow O2

heated high flow O2 delivers __% FIO2 at flow rates up to __ L/min

100% 60 L/min

besides O2 delivery, other benefit of heated high flow O2

washout of dead space

2 indications for intubation

failure of airway maintenance or protection failure of ventilation or O2

2 components of secondary assessment

SAMPLE ddx

ddx for volume overloaded pt (4)

CHF CKD iatrogenic (too much IVF) liver dz

labs to order for fluid overload work up

CMP BNP TTE UA US -> if concern for cirrhosis

why is UA helpful in fluid overloaded pt

assess for nephrotic syndrome

Tx for fluid overloaded pt

Lasix

Van Bockern - Inpatient Emergencies Flashcards

(99 cards)