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86 Cards in this Set

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History and Physical (H/P) = dependent on degree:
1st- and 2nd-degree burns are erythematous and painful; blisters are also seen in 2nd-degree burns
3rd-degree burns are painless and skin appears charred, leathery, or gray
Electrical burns may appear similar to 3rd-degree burns, show severe damage at entrance and exit sites of electrical current, and have cardiac and neurologic symptoms (e.g., ventricular fibrillation, seizures, loss of vision)
Burns
Injury to epithelial surface and deeper tissues caused by exposure to significant heat, radiation, caustic chemicals, or electrical shock
Classified by depth of involvement
1st degree: epidermis only involved
2nd degree: partial-thickness dermal involvement
3rd degree: full-thickness dermal and some fatty tissue involvement
Extent of burns are estimated by “rule of 9s”
Complications =
Infection (especially Pseudomonas, sepsis), stress ulcers (Curling's type), aspiration, dehydration, ileus, renal insufficiency (caused by rhabdomyolysis), compartment syndrome, epithelial contractions (may limit range of motion)
Electrical burns are associated with myocardial infarction (MI), cataracts, and seizures
Risk factors for mortality include age >60 yr, >40% body surface area involvement, and inhalation injury; patients carry a 0.3%, 3%, 33%, or 90% chance of death if they have 0, 1, 2, or 3 of these risk factors, respectively
Burns secondary to electrical shock are sometimes called 4th-degree burns because they may involve muscles, bones, and other internal structures.
Parkland's formula: lactated Ringer's solution given in total volume of [(4 mL) ×(kg body weight) × (% body surface area burned)].
Treatment =
Remove any burning agents to prevent further injury (e.g., burning or soaked clothing); caustic chemicals should be diluted or neutralized
Outpatient treatment is sufficient for 1st-degree and minor 2nd-degree burns (e.g., cooling and cleansing, bandaging, topical antimicrobials)
Inpatient treatment (e.g., intravenous [IV] hydration, wound care, possible escharotomy) required for 2nd-degree burns >10% body surface area, 3rd-degree burns >2% body surface area; or 2nd- and 3rd-degree burns affecting face, hands, genitalia, or major skin flexion creases
2nd- and 3rd-degree burns >25% body surface area or involving the face require airway management (frequently intubation), IV fluids, and careful control of body temperature (increased risk of hypothermia)
Patients with significant smoke inhalation (diagnosed by increased carboxyhemoglobin levels) should receive high-flow O2 and close monitoring for respiratory compromise requiring intubation
Cardiac and neurologic issues in electrical burns should be managed to decrease mortality
Nasogastric tube should be placed when there is gastrointestinal (GI) involvement (ileus will frequently develop)
Generous use of analgesics and/or regional anesthesia for pain control
Antimicrobial agents (e.g., topical silver sulfadiazine or bacitracin) should be used in dressings to decrease risk of infection, and tetanus toxin should be administered if immunization status unknown or not up to date
Nonadherent bandaging or biologic dressings should be applied directly to severe burns; dressings should not be wrapped around affected areas because of potential swelling and constriction
Surgical débridement and exploration should be performed to remove necrotic tissue and to determine extent of deeper tissue involvement; plastic reconstructive surgery with skin grafting may be needed
H/P = prolonged submersion in liquid (pools, bathtubs, and buckets are frequent sites); cyanosis, decreased consciousness; patient may not be breathing or may have cardiac arrest
Fresh water: hypotonic fluid is absorbed from alveoli into vasculature, resulting in decreased electrolyte concentrations and red blood cell (RBC) lysis
Salt water: hypertonic fluid creates an osmotic gradient that draws fluid from pulmonary capillaries into alveoli and causes pulmonary edema and increased serum electrolyte concentrations
Drowning
Hypoxemia resulting from submersion in some type of fluid, usually water
Aspiration of any type of water causes pulmonary damage (i.e., decreased lung compliance, ventilation-perfusion mismatch, shunting) and cerebral hypoxia, but pathophysiology of late-stage drowning varies by fluid type
Fresh water: hypotonic fluid is absorbed from alveoli into vasculature, resulting in decreased electrolyte concentrations and red blood cell (RBC) lysis
Complications = correlate with degree and length of hypoxemia, and include brain damage and hypothermia
Treatment = secure airway and perform resuscitation; supplemental O2, nasogastric tube placement, maintenance of adequate body temperature; any symptoms of hypoxia following aspiration require inpatient admission for neurovascular monitoring and possible diuresis and bronchodilator therapy
H/P = patient eating or child playing with small objects; gagging, coughing, or wheezing that progresses to stridor with increased severity of obstruction
Choking
Aspiration of foreign body into trachea or bronchi preventing normal gas exchange
Food is common cause in all ages; toys, coins, and other small objects are common in children
The right middle bronchus is most common location of aspirated items that pass beyond the trachea because of its greater vertical orientation compared with the left main bronchus.
Complications = atelectasis, pneumonia, lung abscess; hypoxemia can cause complications similar to those seen with drowning
Radiology = chest x-ray (CXR) may be useful in identifying item and determining location; bronchoscopy may visualize item
Treatment =
Actively coughing patients should be encouraged to remain calm and to keep coughing to dislodge object
Patients unable to breathe should be given the Heimlich maneuver
Emergent tracheotomy may be required in a patient with continued obstruction
Bronchoscopy may be required to remove objects
Administration of IV corticosteroids before extraction attempt may ease removal by decreasing bronchial inflammation
Heat Emergencies
H&P=Weakness, headache, substantial sweating
Lab=Usually normal
Heat Exhaustion
Body Temperature=Slightly increased
Complications=Progression to heat stroke
Treatment=Hydration (oral unless progressive symptoms), electrolyte replacement
Heat Emergencies
H&P=Confusion, blurred vision, nausea, no or little sweating
Lab=Increased WBC, increased BUN, increased creatinine
Heat Stroke
Body Temperature=Substantially elevated
Complications=Rhabdomyolysis, seizures, brain damage, death
Treatment= Cool environment, spray patient with water and then fan; benzodiazepines to relax muscles
H/P = evaluation should assess Level of consciousnesS, sensation, motor activity, bowel and bladder continence, Pupil responsiveness to lighT (nonresponsiveness or unequal response suggests cerebral injury), Oculocephalic refleX (i.e., while head of unconscious patient is turned, patient's eyes normally remained fixed at a point in space [doll's eyes]; absence of this reflex in a comatose patient suggests vestibular, cranial nerve, pontine, or medullary injury), presence of skull fracture (e.g., discoloration over mastoid, blood draining from ears or nose), and intracranial pressure
Head trauma
Head trauma can result in cerebral or subarachnoid hemorrhage
Cerebral damage can be at the point of insult (i.e., coup) or on the opposite side of the head (i.e., contrecoup)
Radiology = head computed tomography (CT) should be performed for any unconscious patient to detect intracranial hemorrhage; x-rays (anteroposterior, lateral, open-mouth odontoid) or cervical CT should be performed to detect skull or cervical fractures
Treatment = maintain cerebral perfusion; decrease high intracranial pressure with mannitol, corticosteroids, or hyperventilation; refer any intracranial injury to neurosurgery for possible decompression
H/P = thorough neurologic examination must be performed to detect any deficits in sensation, motor activity, or autonomic function
12 Ps: Paired ocular movement, Papilledema, Paralysis, Paresthesias, Patellar and other reflexes, Pee (incontinence), Pressure (blood and intracranial), Psychological (mental) status, Ptosis, Pulse rate, Pupils (size, symmetry, reflexes), Pyramidal signs.
Spinal cord trauma
Neurologic injury in any segment of the spinal cord from trauma resulting from direct injury, compression, or inflammation
Radiology = x-ray should examine all cervical vertebrae and other vertebral sections of spine considered at risk for injury; CT is replacing x-ray as the standard tool for assessing bony injury of the spine; magnetic resonance imaging (MRI) should be performed in any patient with a normal CT scan and abnormal neurologic examination or central spine pain to rule out ligamentous injury or cord edema
Treatment = spine must be stabilized until injury ruled out; give intravenous (IV) corticosteroids for 24 hr if presenting within initial 8 hr following injury (unless pregnant, isolated cauda equina injury, or child); injuries should be referred to orthopaedic surgery or neurosurgery for definitive treatment
H/P = examination should focus on cervical neurologic deficits and signs of vascular damage in neck (e.g., hematoma, worsening mental status)
Neck trauma
Neck is divided into zones based on anatomic site of injury; injury can involve trachea, esophagus, vascular structures, cervical spine, or spinal cord
Radiology = potential studies include cervical x-ray, CT of cervical spine, carotid Doppler ultrasound, esophagogastroduodenoscopy (EGD), angiography, or bronchoscopy (particularly zones I and III)
Treatment =
Penetrating trauma with stable vital signs may be treated conservatively
Exploration of zones I and III is difficult and should be carried out only if vascular injury suspected
Intubation is frequently required because of airway occlusion
Prophylactic antibiotics may be indicated because of increased risk of contamination by oropharyngeal flora
H/P = examination should look for signs of pneumothorax (e.g., hyperresonance, decreased breath sounds), flail chest (e.g., multiple rib fractures), tamponade (e.g., decreased breath sounds, jugular venous distention, and pulsus paradoxus), and aortic rupture (e.g., unstable vital signs); ECG and central venous pressure are useful in assessing cardiac function
Chest trauma
Can result in injury to lungs, heart, or GI system
Aortic rupture (caused by sudden acceleration and deceleration), tension pneumothorax, hemothorax, and cardiac tamponade are potentially fatal injuries
Radiology =
CXR and neck x-rays may show pneumothorax, hemothorax, cardiac hemorrhage, aortic injury, or rib fractures
Chest CT is important to assess for air leaks, hematoma formation, and pulmonary collapse
EGD and bronchoscopy are used to assess injury to esophagus and bronchi
Angiography can detect vascular injury
Treatment = urgent thoracotomy for thoracic cavity hemorrhage; pericardiocentesis for suspected cardiac tamponade; chest tube for pneumothorax or hemothorax; ventilatory support may be required for multiple rib fractures (flail chest)
H/P =
In cases where exploratory laparotomy is not automatically performed, examination must look for signs of abdominal bleeding (e.g., decreased blood pressure, cyanosis, anxiety, flank discoloration, severe abdominal tenderness, abdominal rigidity, shock)
Peritoneal lavage (i.e., saline infused by catheter into abdominal cavity and then removed and examined) is useful for detecting presence of blood or fecal matter in uncertain cases
Abdominal trauma
Can cause injury to any abdominal organ or severe bleeding from the aorta, aortic branches, mesentery, spleen, or liver
Penetrating trauma requires exploratory laparotomy
blunt trauma may be treated conservatively absence signs of an acute abdomen
Sites of significant (>1,500 mL) blood loss frequently not found by physical examination include blood left at the injury scene, pleural cavity bleeding (seen with CXR), intra-abdominal bleeding (seen with CT or ultrasound [US]), pelvic bleeding (seen with CT), and bleeding into the thighs (seen on x-ray).
The hemodynamically unstable patient with blunt trauma should be taken to the operating room and not to radiology
Radiology =
CT and is sensitive for detecting abdominal fluid
Focused abdominal sonography for trauma (FAST) is a quick and sensitive means of determining the presence of free abdominal fluid and solid organ injury and has become the primary test performed for evaluation of blunt abdominal trauma at most trauma centers
Abdominal x-ray may detect free air or large collections of blood, but is of less utility than CT or FAST
Treatment =
All penetrating abdominal trauma needs exploratory laparotomy
Diagnosed intra-abdominal bleeding or visceral damage from blunt trauma requires laparotomy for repair if the patient is hemodynamically unstable
Retroperitoneal hematomas in the upper abdomen (pancreas, kidneys) require laparotomy for repair
Low retroperitoneal bleeding should be treated with angiography and embolization if caused by blunt trauma and laparotomy if from penetrating trauma
H/P =
Examination should look for blood at the urethral meatus or hematuria (indicative of urologic injury), “high-riding” prostate on rectal examination (urethral injury in men), or scrotal or penile hematoma
Pelvic examination should be performed in women
Patients with a pelvis fracture should be given a thorough neurovascular examination
Genitourinary and pelvic trauma
Injury can result from initial insult or indirectly from fracture of the pelvis
Radiology =
Intravenous pyelogram (IVP) can detect renal pelvis injury
Retrograde urethrogram or cystogram can detect urethral or bladder injury
X-ray can detect pelvis fracture
CT can detect renal damage and pelvic blood collections
Treatment =
Penetrating injuries need surgical exploration
Urethral, intraperitoneal bladder, and renal pelvis injuries require cystoscopy and surgical repair; extraperitoneal bladder and renal parenchymal injuries may be treated nonoperatively
Pelvic fractures may be treated nonoperatively if stable and with open reduction and internal fixation when unstable
H/P = a thorough neurovascular examination must be performed; gross deformities are indicative of fracture
Extremity trauma
Injury can involve bones, vasculature, soft tissues, or nerves in extremities
Radiology = x-ray or CT detects fractures; angiography can detect vascular injury; MRI may be required to detect soft tissue injuries
Treatment =
Superficial or soft tissue wounds require irrigation and approximation (e.g., sutures, Steri-Strips, dermatologic adhesive)
Bone injury alone is treated with immobilization, if stable and internal, or external fixation, if unstable
Combined bone, vessel, and nerve injuries are treated by fracture repair followed by vascular and neurologic repair; fasciotomy in any patient with a combined bone and neurovascular extremity injury because of the high risk of compartment syndrome.
Large wounds frequently require débridement or amputation
H/P = immediate assessment of cardiovascular stability, mother should be evaluated for injury before the fetus, examination should be performed with mother in left lateral decubitus position to minimize IVC compression, obstetric assessment performed following maternal stabilization
Trauma during pregnancy
Leading cause of nonobstetric maternal death
Anatomic differences
Inferior vena cava (IVC) compression by the uterus makes pregnant women more susceptible to poor cardiac output following injury
Decreased risk of GI injury from lower abdominal trauma because of superior displacement of bowel by the uterus (but greater risk of GI injury from upper abdominal or chest trauma)
Low risk of fetal death with minor injuries (high risk in life-threatening injuries)
Trauma increases the risk of placental abruption
Treatment = needs of mother are prioritized; caesarian section should be performed for fetuses >24 wk of gestation that are in distress or in any mother with cardiovascular compromise not responsive to early cardiopulmonary resuscitation (CPR); mother should be monitored for 4–48 hr (based on severity of trauma) to detect fetal distress; RhoGAM should be given to any Rh- mother with bleeding
Criteria that should be met in posttraumatic pregnant women before discharge are contractions no more frequent than every 10 minutes, no vaginal bleeding, no abdominal pain, and a normal fetal heart tracing.
H/P = Abdominal paiN (severe or crampy, rapidly or gradually progressive), nausea, vomiting, possible history of recent surgery; fever, abdominal tenderness (with possible Rebound tendernesS, rigidity, GuardinG, spasm, or mass), possible hypotension; pelvic or testicular examination should be performed to rule out gynecologic or testicular condition
Acute abdomen
Severe abdominal pain and rigidity lasting up to several hours that requires prompt treatment
SAUCED HIPPO: Strangulation of bowel, Appendicitis, Ulcer (peptic), Cholangitis, Ectopic pregnancy, Diverticulitis, Hemorrhage (GI), Ischemia (mesenteric, splenic, cardiac), Pancreatitis, Pelvic inflammatory disease (PID), Obstruction.
Labs = increased white blood cell count (WBC) in cases of infection or bowel perforation; increased amylase in pancreatitis; increased liver function tests with hepatobiliary dysfunction
Radiology = abdominal or pelvic CT or abdominal radiograph helpful to recognize bowel gas patterns, air collections, and calcifications; IVP, barium studies, or US may also be helpful
Treatment = adequate pain control; emergent laparotomy or laparoscopy may be needed, depending on pathology
Acute Abdomen
H&P=Previous surgery, abdominal distention, crampy pain, nausea, vomiting, high-pitched bowel sounds
Obstruction/strangulation (from adhesions, hernias, tumors)
Diagnosis=CT or AXR shows distended loops of bowel and air-fluid levels; barium studies may locate site of obstruction
Treatment=Surgical lysis of adhesions, hernia repair, surgical excision of tumors
Acute Abdomen
H&P=Left lower quadrant pain (may progress over several days), blood in stool
Diverticulitis
Diagnosis=CT or AXR may show free air from perforation; increased WBC
Treatment=Surgical repair
Acute Abdomen
H&P=Sudden severe pain, hematemesis, hematochezia, hypotension
Massive GI hemorrhage (perforation)
Diagnosis=Colonoscopy or EGD visualizes lesion; technetium scan may detect smaller bleeding sources
Treatment=Octreotide, angiography with embolization, surgical repair of detectable site of bleeding
Acute Abdomen
H&P=Right lower quadrant and perium-bilical pain, psoas sign, rectal examination tenderness
Appendicitis
Diagnosis=Increased WBC; thickened appendix or fecalith on CT if unruptured; free air on CT or AXR if perforated
Treatment=Appendectomy
Acute Abdomen
H&P=Severe abdominal pain out of proportion to examination bloody diarrhea
Mesenteric ischemia
Diagnosis=Bowel wall thickening and air within bowel wall on CT; increased WBC and serum lactate
Treatment=NPO, antibiotics, resection of necrotic bowel
Acute Abdomen
H&P=Upper abdominal and back paiN, nausea, vomiting, history of gallstones or alcoholism
Pancreatitis
Diagnosis=CT shows inflamed pancreas; increased amylase and lipase
Treatment=Nasogastric tube, NPO, analgesics
Acute Abdomen
H&P=AmenorrheA, lower abdominal pain, possible vaginal bleeding, or palpable pelvic mass
Ruptured ectopic pregnancy
Diagnosis=US unable to locate intrauterine pregnancy in presence of positive urine pregnancy test
Treatment=Surgical excision
Acute Abdomen
H&P=Lower abdominal pain, vaginal discharge, cervical motion pain
Pelvic inflammatory disease
Diagnosis=Increased WBC; positive serology for Chlamydia or Neisseria gonorrhoeae
Treatment=Antibiotics, treat sexual partners
H&P=H/P = symptoms begin after anesthesia use; rigidity, cyanosis, tachycardia, continually rising body temperature
Malignant hyperthermia
Rare genetic disorder in which certain anesthetics (e.g., halothane, succinylcholine) induce hyperthermia
Uncontrolled hyperthermia can lead to arrhythmias, disseminated intravascular coagulation (DIC), acidosis, cerebral dysfunction, and electrolyte abnormalities
Labs = mixed acidosis acutely; abnormal increase in muscle contraction following in vitro treatment with halothane or caffeine (testing performed as outpatient)
Treatment = evaporative cooling (i.e., patient sprayed with water and placed in front of fans), cold inhaled O2, cold GI lavage, cool IV fluids, dantrolene, stop offending agent
Transplant Indication
Aplastic anemia, induction chemotherapy, leukemia, lymphoma, hematopoetic disorders
Bone marrow
Improved quality of life and long-term survival if surviving >1 yr post-transplant
Transplant ContraIndication
Donor-recipient mismatch, recipient with high-risk for developing post- transplant infection
Transplant Indication
Severe heart disease (CAD, congenital defects, cardiomyopathy) with estimated death within 2 yr without transplant
Heart (may be performed with lung transplant)
Acute rejection common, higher mortality risk in initial 6 months, 70% 5-yr survival
Transplant ContraIndication
Pulmonary hypertension, smoking (prior 6 months), renal insufficiency, COPD, >70 yr of age, terminal illness
Transplant Indication
COPD (particularly α1-antitrypsin deficiency), primary pulmonary hypertension, cystic fibrosis; estimated death with 2 yr
Lung
Most have at least 1 episode acute rejection, pneumonia common, 56% 3-yr survival, chronic rejection common
Transplant ContraIndication
Smoking (prior 6 months), poor cardiac function, renal or hepatic insufficiency, terminal illness, >65 yr of age, HIV
Transplant Indication
Chronic hepatitis B or C, alcoholic cirrhosis, primary biliary cirrhosis, primary sclerosing cholangitis, biliary atresia, progressive Wilson's disease
Liver
40% acute rejection, success correlates with patient health at time of surgery (generally 60–70% 5-yr survival)
Transplant ContraIndication
Alcoholism, multiple suicide attempts (e.g., acetaminophen poisoning), liver cancer, cirrhosis from chronic hepatitis (may receive transplants from donors with hepatitis)
Transplant Indication
End-stage renal disease requiring dialysis (glomerulonephritis, DM, polycystic kidney disease, interstitial nephritis, renal hypertension)
Renal
Living-donor kidneys have 20% acute rejection and 91% 5-yr survival; cadaver kidneys have 40% acute rejection and 85% 5-yr survival
Transplant ContraIndication
Stable health (dialysis is always an option for unstable patients)
Transplant Indication
DM type I with renal failure
Pancreas (frequently performed with renal transplant)
80% 3-yr survival, acute rejection common
Transplant ContraIndication
Age >60 yr, CAD, PVD, obesity, DM type II
H/P = maculopapular rash, abdominal pain, nausea, vomiting, diarrhea, recurrent infections, easy bleeding
Labs = increased liver function tests, decreased immunoglobulin levels, decreased platelets; biopsy of skin or liver detects an inflammatory reaction with significant cell death
Graft vs. host disease
Reaction of donor immune cells in transplanted bone marrow to host cells
Host is immunocompromised to avoid transplant rejection and is unable to prevent attack by donor cells
Risk factors = HLA antigen mismatch, old age, donor-host gender disparity, immunosuppression
Complications = patients without an early response to therapy frequently develop chronic disease with skin sclerosis, hepatic insufficiency, GI ulceration, and pulmonary fibrosis
Treatment = corticosteroids, tacrolimus, and mycophenolate are useful for decreasing graft response; thalidomide and hydroxychloroquine are used in chronic disease
H/P = lethargy, weakness, severe shivering, confusion; decreased body temperature, possible arrhythmias, hypotension
Electrocardiogram (ECG) = J waves, possible ventricular tachycardia (Vtach) or ventricular fibrillation (Vfib)
Hypothermia
Body temperature <95°F/35°C from cold exposure
Risk factors = alcohol intoxication, elderly
In the final stage of hypothermia, the patient will stop shivering, be unable to maintain body temperature, and will undergo a fatal increase of blood viscosity.
Treatment = warm patient externally (e.g., warm bed, bath, blankets) or internally (e.g., warm IV fluids or ingested fluids); treat arrhythmias and hypotension as appropriate (see Chapter 1, Cardiovascular Disorders)
poisoning therapy
only useful in initial 1–2 hr after ingestion and only for noncaustic agents; rarely performed
Induced vomiting
poisoning therapy
blocks absorption of poisons
not useful for alcohols or metals
Charcoal
repeat doses every few hours
not useful for alcohols or metals
poisoning therapy
usually reserved for intubated patients within initial hour after ingestion
Gastric lavage
poisoning therapy
(e.g., salicylates, phenobarbital)
may help in cases where increased urination helps remove toxin
Diuretics
poisoning therapy
used in cases of severe symptoms or when other treatments are unsuccessful
Dialysis or exchange transfusion
poisoning therapy
Supportive care
airway protection, IV hydration, cardiac support (e.g., treatment for hypertension, hypotension, arrhythmias); control of seizures is an important adjunct to management of the poison itself
Type of Bite
Pain and swelling at bite, progressive dyspnea, toxin-induced DIC
Snake (rattlesnake, copperhead, water moccasin, coral snake)
Complications=Effects more severe in children; increased mortality without prompt treatment
Treatment=
Immobilize extremity and cleanse wound; antivenin likely required
Type of Bite
Severe pain and swelling at bite, increased sweating, vomiting, diarrhea
Scorpion
Complication=Acute pancreatitis, myocardial toxicity, respiratory paralysis
Treatment
Antivenin, atropine, phenobarbital
Type of Bite
Abdominal pain, wound pain, vomiting, jaundice, DIC
Spider (black widow, brown recluse)
complication=DIC; brown recluse bites more severe
Treatment
Black widow: calcium gluconate, methocarbamol
Brown recluse: dexamethasone, colchicines, dapsone
Type of Bite
Pain and swelling at bite, penetrating trauma, depending on size of bite
Mammals
complication=Infection (staphylococci, Pasteurella multocida, rabies virus)
Treatment
Saline irrigation, débridement, tetanus and rabies prophylaxis, antibiotics for infection
Type of Bite
Pain and swelling at bite, tender local lymphadenopathy
Human
complication=High incidence of infection with primary closure or delayed presentation
Treatment
Saline irrigation, broad coverage antibiotics, débridement, thorough documentation
H/P = sufficient exposure, headache, dizziness, nausea, myalgias; cherry-red lips, mental status changes, possible hypotension
Carbon monoxide poisoning
Hypoxemia that results from inhalation of carbon monoxide from car fumes, smoke, or paint thinner
Carbon monoxide displaces O2 on hemoglobin (Hgb) and prevents O2 delivery to tissues
Labs = increased carboxyhemoglobin on blood gas analysis
Treatment = 100% O2 (displaces carbon monoxide from Hgb) or hyperbaric O2 therapy; patients with smoke inhalation may require intubation secondary to upper airway edema
Vfib and Vtach
ABC->SHOCK
treatment protocol for Vfib or Vtach by the mnemonic Shock, Shock, Shock, Everybody Shock, Anybody Shock, Little Shock, Big Shock, Mama Shock, Papa Shock, Baby Shock: Shock (200 J) →Shock (300 J) →Shock (360 J) →Epinephrine →Shock (360 J) → Amiodarone →Shock →Lidocaine →Shock →Bretylium →Shock →Magnesium →Shock → Procainamide →Shock →Bicarbonate (sodium) →Shock.
detectable cardiac electrical conduction with the absence of cardiac output
Pulseless electrical activity (PEA)
due to H&Ts(hypovolemia, hypoxia, hypothermia, hypo/hyperkalemia, hydrogen ion=acidosis) & (Tension penumo, thrombosis CAD/PE, tamponda, tablets of drugs)
ABC->causes(H&T)-> epinepherine q3-5 min -> atropine q3-5 min
absence of cardiac activity
Asystole
ABC->transcutaneous pacing -> epinephrine q3-5 min -> atropien q3-5 min
Toxicology
Nausea, hepatic insufficiency
Acetaminophen
Antidote
N-acetylcysteine
Toxicology
Dry mouth, urinary retention, QRS widening on ECG
Anticholinergics
Antidote
Physostigmine
Toxicology
Sedation, respiratory depression
Benzodiazepines
Antidote
Flumazenil
Toxicology
Bradycardia, hypotension, hypoglycemia, pulmonary edema
β-blockers
Antidote
Glucagon, calcium, insulin, and dextrose
Toxicology
Bradycardia, hypotension
Calcium channel blockers
Antidote
Glucagon, calcium, insulin, and dextrose
Toxicology
Tachycardia, agitation
Cocaine
Antidote
Supportive care
Toxicology
Headache, nausea, vomiting, altered mental status
Cyanide
Antidote
Nitrates, hydroxocobalamin
Toxicology
Nausea, vomiting, visual changes, arrhythmias
Digoxin
Antidote
Digoxin antibodies
Toxicology
Excessive bleeding, easy bruising
Heparin
Antidote
Protamine sulfate
Toxicology
Neuropathy, hepatotoxicity
Isoniazid
Antidote
Vitamin B6
Toxicology
Decreased consciousness, nausea, abdominal pain
Isopropyl alcohol
Antidote
Supportive care
Toxicology
Headache, visual changes, dizziness
Methanol
Ethanol, dialysis
Toxicology
Pinpoint pupils, respiratory depression
Opioids
Naloxone
Toxicology
Nausea, vomiting, tinnitus, hyperventilation, anion gap metabolic acidosis
Salicylates
Charcoal, dialysis, sodium bicarbonate
Toxicology
Hypoglycemia
Sulfonylureas
Octreotide and dextrose
Toxicology
Tachycardia, dry mouth, urinary retention, QRS widening on ECG
Tricyclic antidepressants
Sodium bicarbonate, diazepam
Toxicology
Excessive bleeding, easy bruising
Warfarin
Vitamin K, FFP
Toxicology
Severe oropharyngeal and gastric irritation or burns, drooling, odynophagia, abdominal pain, gastric perforation symptoms
Caustics (acids, alkali)
Copious irrigation (do not induce emesis or attempt neutralization), activated charcoal
Toxicology
Ataxia, hallucinations, seizures, sweet breath
Ethylene glycol
Ethanol, dialysis
Toxicology
Salivation, lacrimation, miosis, vomiting, diarrhea, increased urination, paralysis, decreased consciousness
Organophosphates (insecticides, fertilizers)
DUDE SLOP: Diarrhea, Urination, ↓ consciousness, Emesis, Salivation, Lacrimation, Ocular miosis, Paralysis
Atropine, pralidoxime, supportive care
Toxicology
Nausea, constipation, hepatotoxicity
Iron
Deferoxamine
Toxicology
Peripheral neuropathy, anemia
Lead
EDTA, dimercaprol
Toxicology
Renal insufficiency, tremor, mental status changes
Mercury
Dimercaprol
H/P = several red flags should raise suspicion in history (e.g., inconsistent with injury, vague details, changes in story, blame placed on others, implausibility), parental actions (e.g., aggressive nature, delay in seeking treatment, lack of emotional attachment or concern), and physical examination (e.g., injuries inconsistent with history, multiple injuries at various stages of healing, pathognomonic injuries, signs of neglect, abnormal behavioral responses to being examined)
multiple simultaneous facial injuries, bruises in patterns of objects, bruises over trunk and abdomen, multiple burns (especially in shape of object), rib or skull fractures, long bone fractures in nonambulatory children.
Child abuse
Neglect, the most prevalent form of child abuse, constitutes the failure to provide the physical, emotional, educational, and medical needs of a child
Treatment = physician has obligation to report any suspected cases of abuse to child protective services
Suspected cases should be well documented
H/P = presentation to physician frequently for a vague symptom (e.g., chronic abdominal pain, headaches, depression, recurrent sexually transmitted diseases); history may be inconsistent with injury; partner may be very attentive or vigilant during visit
Spousal or partner abuse
Patient should be interviewed without partner present
Treatment = initial approach should focus on safety of patient; provide victim with information on safety plans, escape strategies, legal rights, and shelters; care should be taken not to force victim into any action; reporting of abuse is typically nonmandatory (unless it involves child abuse)
H/P = multiple bruises or fractures, malnutrition, depression, or signs of neglect
patient >60 yr of age
Elder abuse
Treatment = placement in a safe facility; facilitate contact with social services that can help facilitate safe care; physician has obligation to report suspected cases to an official state agency
H/P =
Detailed history must be collected and thoroughly documented in cases where patient reports assault
Examination should focus on entire body, with particular attention to genitals, anus, and mouth to look for signs of assault
Patients who have not admitted to being assaulted may appear depressed or very uncomfortable with examination
Sexual assault
Nonconsensual sexual activity with physical contact; forced intercourse is rape
Victims can be children or adults
Another health care worker (chaperone) must be present when a sexual examination is performed, and the patient should be made to feel as comfortable as possible with the history and physical examination.
Labs =
Collect oral, vaginal, and penile cultures to test for sexually transmitted diseases
In cases of rape, all injuries must be well documented and vaginal fluid and pubic hair should be collected for evidence (i.e., rape kit)
Pregnancy testing should be performed to look for incidental conception occurring during assault
Treatment = careful and well-documented collection of all details and evidence important to future follow-up and legal action; referral to social support systems and counseling is very important; appropriate treatment should be given for infections
Types of Blood Products Used in Transfusions
Rarely used except for massive transfusions for severe blood loss
Whole blood
Donor blood not separated into components (full volume blood)
Types of Blood Products Used in Transfusions
Product of choice for treatment of low Hct due to blood loss or anemia
Packed RBCs
RBCs separated from other donor blood components (2/3 volume of transfusion unit is RBCs)
Types of Blood Products Used in Transfusions
Elective surgery or chemotherapy
Autologous blood
Blood donated by patient before elective surgery or other treatment
Blood is frozen until needed by patient
Types of Blood Products Used in Transfusions
Warfarin overdose, clotting factor deficiency, DIC, TTP
FFP
Plasma from which RBCs have been separated
Types of Blood Products Used in Transfusions
Warfarin overdose, clotting factor deficiency, DIC, TTP
Smaller volume than FFP
Preferable to FFP in cases where large transfusion volume is unwanted
Cryoprecipitate Clotting factor and vWF-rich precipitate collected during thawing of FFP
Types of Blood Products Used in Transfusions
Thrombocytopenia not due to rapid platelet destruction
Platelets
Platelets separated from other plasma components
Types of Blood Products Used in Transfusions
Specific clotting factor deficiencies (e.g., hemophiliac)
Clotting factors
Concentrations of a specific clotting factor pooled from multiple donors
H/P = occurs in patient receiving transfusion; pain in vein receiving transfusion, chills; flushing, pruritus; fever, jaundice
Transfusion reactions
Reaction that occurs when incompatible blood is infused into a patient
Labs = both patient's and donor's blood should be rechecked and retyped
Treatment = acetaminophen, diphenhydramine, stop transfusion; mannitol or bicarbonate may be required in severe reactions to prevent hemolytic debris from clogging vessels; vasopressors may be required if significant hypotension develops
Transfusion reactions
most common reaction; caused by HLA antigen antibodies
Febrile nonhemolytic
recurrence is uncommon
treated with acetaminophen
Transfusion reactions
caused by ABO incompatibility
Acute hemolytic
severe destruction of host RBCs
requires aggressive supportive care
Transfusion reactions
caused by Kidd or Rh antibodies
Delayed hemolytic
no acute therapy needed, but determine responsible antibody type to help prevent future reactions
Transfusion reactions
rapid onset of shock and hypotension
Anaphylactic
caused by transfused anti-IgA IgG antibodies in patient with IgA deficiency
requires epinephrine, volume maintenance, and airway maintenance
Transfusion reactions
caused by plasma present in donor blood
Urticarial
treated with diphenhydramine