ER week 3

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what is AVPU?
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Terms in this set (73)
what is AVPU?
A - alert
V - responds to Verbal stimuli
P - responds to Painful stimuli
U- unresponsive
what is one of the FIRST indicators to change when the level of perfusion is diminishing?
Level of consciousness
an acutely disturbed state of mind that occurs in fever, intoxication, and other disorders and is characterized by restlessness, illusions, and incoherence of though and speech
ACUTE CHANGE: attention, awareness, and cognition
delirium
<5 min, 70-95% sensitive, 95% specific (good diagnostic tool)
confusion assessment method
easy to administer, easy to score, 95% sensitive good screening, 51% specific
ottawa 3DY
"Would you be comfortable leaving your family member home alone for 3 months if you went away on a trip to Paris and if other members of the family were also away?" A "No" suggests there is a cognitive impairment. A "Yes" from the caregiver suggests an independent patient with no cognitive impairment.
bergman-paris question
this offers the clinician the opportunity to identify delirium in critical care pts, especially on mechanical ventilation. makes use of nonverbal assessments to evaluate the important features of delirium
the confusion assessment method for the intensive care unit (CAM-ICU)
what are the components of ottawa 3DY?
what is the date? = 1
day of the week? = 1
spell the word WORLD backwards = 1
year it is = 1
NEED 3 CORRECT
what is the 5 min neuro exam and what are the components?
Saskatoon Screening Exam
1. Mental status
2. Cranial nerves
3. motor
4. reflexes
5. sensory
6. coordination & gait
what happens if you give glucose BEFORE thiamin in an altered pt?
precipitate wernicke's encephalopathy
what is Boerhaave's syndrome?esophageal rupture cp characterized by sudden onset, sharp, substernal CP following forceful vomitingrelatively preserved left ventricular function SBP >140 CXR shows pulmonary edema symptom onset < 48 hrhypertensive AHFDoes not meet criteria for hypertensive HF, pulmonary edema, or cardiogenic shock Systolic blood pressure <140 mm Hg and >90 mm Hg Typically associated with increased peripheral edema Symptom onset over several days to weeksacute on chronic HFtx for acute HF with a BP >150/100add IV nitro or nitroprussidetx for acute HF with BP < 100stop nitrates and monitor for persistent HotN or symptomssystolic BP > 220 mgHg or diastolic BP >125 WITHOUT evidence of acute end-organ damage tx: - reduced to <160/<100 over hours to days - MAP should NOT be lowered by > 25-30% over first 2-4 hoursHTN *urgency*acute hypertensive injury to heart, brain, retina, kidney, aorta, and/or eclampsia tx: - reduce to "safe" range w/o causing further damage - tx primary site of end organ damageHTN *emergency*encephalopathy or nephropathy accompanying hypertensive retinopathymalignant hypertensiontype of dissection: proximal to the left subclavian artery - death may occur within hours, rupture into pleural cavity also possible tx: - LOWER BP to systolic 100-120 and pulse pressure - urgent intervention!! - grafting and replacing diseased portion - may need to replace aortic valve with reattachment of coronary arteriesstanford type Atype of dissection: - proximal descending thoracic aorta beyond the left subclavian artery tx: - LOWER BP - urgent surgery if malperfusion of renal, visceral, or extremity vessels - goal to restore flow into ischemic tissues; accomplished via bypass and/or endovascular stentingstanford type B dissectionif there is a critically ill pt that cannot stand up for a CXR, and you suspect PTX, what should you look for?deep sulcus sign (deep lateral costophrenic anglewhat is the pathophysiologic hallmark of asthma?reduction in airway diameter caused by smooth muscle contraction, vascular congestion, bronchial wall edema, and thick secretionswhat is the MC cause of acute asthma exacerbation?viral respiratory infectionscore muscles: *external* intercostals diaphgram accessory muscles Sternocleidomastoid pectoralis minormuscles of inspirationcore muscles *internal* intercostals diaphragm accessory muscles abdominals quadratus lumborummuscles of expirationDoes not improve with usual doses of inhaled bronchodilators and steroids hypoxemia, tachypnea, tachycardia, accessory muscle use, and wheezing might need - iv magnesium sulfate - noninvasive positive pressure ventilation (cPAP/BiPAP) - ketamine - epistatus asthmaticussigns of uncompensated respiratory acidosis in COPDpCO2>44mg pH < 7.35what are some of the MC pathogens associated with copd exacerbations and what are common abx used?strep pneum h. influenza moraxella catarrhalis abx: - macrolids (azithromycin) - tetracycline (doxy) amoxicilin +/- clavulanic acidTheophylline (oral) Aminophylline (IV) Improving mechanics of breathing of smooth muscle & diaphragm Anti inflammatory effect Increases the power of steroids Cons: Side effects- Nausea and vomiting; Needs to be monitored closely due to small therapeutic indexmethylxanthineswhat score is compatible w/ DIC?5 +(pediatric presentation), vaso-occlusive congestion/ pooling, hypovolemia >> Shock. Findings of enlarged tender spleen, 2g drop hb, marked reticulocytosis, tx: NS IVFspleen sequestrationcaused by pneumonia, thrombosis, fat embolism new patchy infiltrate, fever, cough, wheezing, tachycardia, hypoxemia, pleuritic chest pain 1-3d post admit, leading cause of death w/ SC, infectious. Tx o2, analgesia, hydrate w/ IVF, blood cultures, antibiotics, exchange transfusion.acute chest syndromeRisk Factors/Causes: Metastatic cancers 85-95%; epidural abscess/hematoma or disc herniation. Pathophysiology: metastasis seeds in vertebra, grow, erode surrounding area, cause compression, mechanical instability sign/symp: back pain (thoracic MC) constant, worse when supine and at night, preceding neuro impairment by 7 weeks weakness>sensory thoracic MC B/l upper/lower weaknessspinal cord compressionsymptoms/sign of SVC: *facial/neck edema*, cyanosis, plethoragrade Isymptoms/sign of SVC: head or neck edema, mild dysphagia, cough, impaired head muscle movement, visual disturbances "head fullness" *dyspnea, cough* arm swelling, *chest discomfort*grade IIMedical Emergency occur frequently, difficult to distinguish life threatening infections. Most common life threatening complication of cancer treatment. low ANCfebrile neutropeniacriteria for febrile neutropenialow ANC < 1500 + fever 38C (100.4) or single temp > 100.91. Tumor releases hormones 2. Osteolysis of bone due to metastasis, 3. Vitamin D osteo-absorption Epidemiology: 20-30% cancer pt's Symptoms/Signs: [pneumonic: moans, bones, stones, abdominal groins, psychiatric overtones- hyperparathyroid sx] Mild to severe, symptoms proportional to Ca level Ca <12 mg/dl : nonspecific, constipation, fatigue, depression or asymptomatic, Ca 12-14 mg/dl : polyuria/polydipsia, anorexia, nausea, muscle weakness, depression, Ca >14 mg/dl: cognitive dysfunction, hyporeflexia >16mg/dl psychosis stupor, coma Shortened QTc interval, bradycardia, Hypertension PE: dehydration, horizontal band keratopathyhypercalcemia of malignancyIM q 12 hrs (if refractory), trend Ca every ~6 hrs, effects can take a few days (decreases bone break down via inhibit osteoclast, increases renal Ca excretion) Increase excretion w/ IV Fluids, (avoid Loop diuretic if possible, possibly needed w/ CKD pt's), Dialysis- if severe hypercalcemia decrease intestinal absorptioncalcitoninwhat is Lights Criteria and what does it evaluate?exudative effusions pleural to serum protein ratio >0.5, pleural to serum LDH >0.6, pleural fluid LDH >2/3 of upper limit normal LDHMassive release of toxic cellular material from highly chemo sensitive cancers such as ALL, Burkitt lymphoma, other cancers Risk Factors/Causes: hematological > solid tumor, high blast counts/blast crisis, ALL, spontaneous Pathophysiology: metabolism/excretion of breakdown products impaired, hyperuricemia/hyperphosphatemia/ hyperkalemia can develop >>> AKI develops due to crystallization, deposition of uric acid, CaPO4 (Calcium Phosphate) Epidemiology: 5-10% acute leukemias- ALL, Burkitt, solid malignancies- breast, SCLC, germ celltumor lysis syndrome; hyperuricemiawhat 2 drugs can be used in tumor lysis syndrome?allopurinol and rasburicasewith which type of shock should you NOT give multiple boluses?cardiogenic shockwhat is the mc cause of pathologic fractures?osteoporosishow are fractures indicated?by disruption of the cortexa severe form of oblique fracture in which the plane rotates along the long axis of the bone. these fractures occurs secondary to rotational forcespiral fracturea fracture in which the break lines runs nearly parallel to the long axis of the bone. can be considered a long oblique fracturelongitudinal fracturea fracture in which the break line is perpendicular to the long axis of the bonetransverse fracturea fracture in which the break line is at oblique angle to the long axis of the boneoblique fracturethe bone is broken into more than 2 fragmentscomminutedthis is where a vertical force drives the distal fragment of the fracture into the proximal fragmentimpacted fracturefracture through one cortexgreenstick fracturebuckling of the cortextorus fractureorthopedic emergency requires emergency orthopedic consultation bleeding must be controlled management: - IV abx - tetanus prophylaxis - pain control - surgery for washout and reductionopen fracturethis is defined in terms of the abnormal position of the distal fracture fragment in relation to the proximal bone. types include: - angulation - rotation - change of bone length - loss of alignmentdisplacement of fracturesthis is the angle away from the normal that the distal fragment makes with the proximalangulationwhat is the MC pediatric elbow fracture?supracondylar fractureon exam, there is dec sensation to the volar aspect of the thumb, index finger, middle finger, and half of the ring finger. which nerve was injured?median nervewhich ROM will a pt with a median nerve injury NOT be able to do?inability to oppose thumb-pinkyflexor pollicis brevis muscle receives most of innervation from what nerve? *(flex thumb at MCP joint)*ulnar nervethis controls the flexion at the distal interphalangeal joint of the index finger and the joint of the thumb *OKAY SIGN*anterior interosseous nervethis is typically seen w/ lateral displacement resulting in brachial artery laceration or occlusion cubitus varus can also occur from a compartment syndrome in which the brachial artery supply becomes compressedsupracondylar fracturepalpate webbing space btwn thumb and index finger, including *dorsal* surface of handradial nerve sensationpalpate webbing space btwn thumb and index finger, including *palmar* surface of handmedian nerve sensationpalpate between little finger and distal ring finger on the palmar and dorsal surface of handulnar nerve sensationthe ability to extend wrist and fingers at the knuckle joint if cast is over hd, only assess extension of fingersradial nerve motorthe ability to bring thumb and little finger together so they are touchingmedian nerve motorthe ability to abduct all fingersulnar nerve motorwhat is the most common presentation of a supracondylar fracture?posteriomedial displacement (cant give thumbs up) (radial nerve at risk)lateral displacement of the distal fragments in a supracondylar fractures places what nerve and artery at risk?median nerve and brachial arterydistal radius with dorsal displacementcolles (scaphoid fx)what is the most common life threatening complication of cancer tx?febrile neutropeniawhat is the most common paraneoplastic manifestationhypercalcemia