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77 Cards in this Set
- Front
- Back
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Sick resuscitation alogarithm
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ABCD (pupils, GCS, MAE), Exposure/Environment, Fingerstick, Girls get UPT, Hang ABx, Inject tetanus
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Tox w/u
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Basic labs
LFT's Coags and type and screen UA, UPT Alcohol, urine tox APAP and asa +/-serum Fe levels EKG Calculate AG |
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Whole Bowel Irrigation
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Polyethylene glycol
Kid: 250-500ml/h Adult: 2L/hr po or NGT |
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Deferoxamine
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5mg/kg/h can inc to 15mg/kg/h if no rate-related hypotension; max 6g/d
Indications: serum level >350mcg/dL in symptomatic patient (including protracted vomiting, shock, coma/sz, acidosis Iron-deferoxamine complexes are excreted in urine and change it orange-red. |
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Problems from Fe OD
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liver failure, coma, death
Sx: N/V/hematemesis, diarrhea with stage I |
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Toxic iron ingestion
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10-20mg/kg elemental iron
Serum level between 300-500mcg/dL correlate w/ significant GI and mild systemic toxicity. Serum iron b/t 500mcg/dL and 1000mcg/dL correlate with moderate systemic toxicity Significant morbidity in level >1000 Low levels may be due to variable times to peak levels in different iron preps and don't necessarily mean absence of toxicity. TIBC has little value. BS and WBC are insensitive for predicting Fe levels Radiopaque tablets seen on xray can guide GI decontamination if visualized. |
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Fe preparations
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% elemental iron
Ferrous fumarate 33% Ferrous sulfate 20% Ferrous gluconate 12% |
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Clinical stages of iron poisoning
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Stage 1 onset, 2 latent, 3 systemic toxicity, 4 hepatic, 5 delayed sequelae
Stage I: 30min-6hr: vomit, diarrhea, abd pain, hematemesis, hematochezia Stage II: 4-6h or latent stage: GI sx may resolve but pts may have ongoing clinical illness and progressive systemic deterioration including hypoperfusion and worsening met acidosis Stage III: 6-72h systemic toxicity: coma, lactic acidosis, coagulopathy, shock, sz Stage IV: 12-96h, hepatic stage: hepatic failure wiht jaundice, hypoglycemia, coagulopathy Stage V: Delayed sequelae: vomiting, abd pain, pyloric scarring and gastric outlet, sbo |
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Dehydrated newborn treatment
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2 boluses NS 20mg/kg
Then D51/4NS at 2x maintenance 4ml for each kg of 1st 10kg....4-2-1 rule Add K to mainentence fluids if necessary |
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Vomiting/abd pain/trauma/surgery
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NPO!!! Consider NGT.
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Congenital hypertrophic pyloric stenosis findings on lab and imaging
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Labs: hypochloremic hypokalemic metabolic alkalosis
Imaging: u/s with hypertrophied pylorus >4mm diameter Sx: peristaltic waves after feeding. If palpable olive, pathognomonic and no further diagnostics are necessary. Hx 2nd-3rd week of life Tx: fluid resusitaction, NGT, pylorotomy in OR and not emergent in this case |
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AMS labs
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CBC, BMP, coags, type and screen, asa, apap, lactate, ABG, enzymes, ua, fingerstick
Give DONT |
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ICH neurosurg tx
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ventriculostomy placement
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Coma
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requires bilateral hemispheric pathology (hemorrhage/infarct) or damage to reticular activating system
Other causes: trauma, infarct, hemorrhage, central venous thrombosis, meningitis, hydrocephalus, malignancy, cerebral abscess, toxic OD hepatic/renal failure, sepsis, metabolic derangements (low BS), exposures (ie CO) |
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Indications for defibrillation
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vfib
pulseless vtach |
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Indications for cardioversion
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unstable v tach, SVT, afib/flutter
Can use elective cardioversion in stable patient with these rhythms as alternative to chemical cardioversion. |
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Contraindication for defib/cardioversion
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digoxin toxicity is relative contra
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Size of pads for resuscitation
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pts <10kg or 1 yo use infant pads, all others get adult pads
Peds 2J/kg for first shock and 4J/kg for subsequent shocks Sternum paddle is R of sternum below clavicle and apex paddle is L of nipple in mid axillary line centered on 5th intercostal space; Alternatively AP positioning with sternum paddle over precordium and apex to L of spine directly posterior to heart. |
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PALS possible V tach
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Sync cariovert 0.6 to 1J/kg and if not effective inc to 2J/kg. Sedate if possible with ketamine 1.5mg/kg IV but cardioversion should not be delayed. May attempt adenosine if IV available at 0.1mg/kg (max 6mg) for first dose as a rapid bolus and 0.2mg/kg for second dose.
Amio 5mg/kg IV over 20-30min or procainamide 15mg/kg IV over 30-60min. |
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PALS SVT
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Vagal, carotid sinus/valsalva, adenosine or cardioversion 0.1mg/kg (max 6mg)
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PALS PEA/asystole
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30:2, Epi 0.01mg/kg Q3-5min, consider H's and T's, blood gas, K, glucose
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PALS hyperkalemia
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K= 5-6: Furosemide 1mg/kg/dose, kayexalate 1g/kg in 100ml of water po or 1g/kg PR
K= 6-7: Insulin 0.1U/kg and glucose 2ml/kg of 25% over 15min Bicarb 1-2mEq/kg IV over 5min Albuterol 10-20mg nebulized over 15min K >&: CaCl 10% 20mg/kg IV q4h prn over 10min, Bicarb 1mEq/kg IV over 5min, Insulin 0.1U/kg + glucose 2ml/kg of 25% IV over 30min, albuterol 20mg neb over 15min, furosemide 1mg/kg IV, kayexalate 1g/kg po or pr, dialysis |
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PALS bradycardia
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epi 0.01mg/kg Q3-5min
if inc vagal tone or primary AV block can give atropine 0.2mg/kg *minimum is 0.1mg and max is 1mg), initiate pacing |
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PALS hypokalemia
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<2.5 give IV K 0.5-1meq/kg in 100cc infused over 1hour with continuous tele monitoring
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PALS anaphylaxis
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epi IM 0.01mg/kg 1:1000 IM
IVF 20ml/kg Benadryl 5mg/kg/d div q6h IV/po/IM Cimetidine 10mg/kg (300mg adult) Methylprednisone 1mg/kg/d Vasopressin 0.4U/kg IV/IO Ipatropium 0.5mg neb Albuterol 2.5-5mg Q15min or cont for 10-15mg/h |
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PALS Asthma
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Albuterol 2.5-5mg Q15min or continuous at 10-15mg/h
Methylpred 1mg/kg (BID) Ipratropium 0.5mg Magnesium 25-75mg/kg IV over 20min Epi 0.01mg/kg 1:1000 divided into 3 doses of 0.3mg given at 20 min interval Terbutaline 0.01mg/kg SC repeat in 30min Heliox 70:30 helium to O@ mixture |
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PALS RSI
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epi 0.3mg/kg
Succinylcholine 2mg/kg IV (4mg/kg IM) |
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Dose of defibrillation
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Peds 2J/kg then 4J/kg
If synchronized then use 0.5J/kg then 1J/kg, 2J/kg, 4J/kg |
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Before determining rhythm to be asystole....
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increase gain on monitor and rotate papdlese to 90 degrees or check another lead to r/o fine vfib masquerading as asystole
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Unwitnessed arrest or delay to defib exceeds 5min then
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...perform 5 cycles of CPR b/f defib
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Defib on patient with defib
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place paddle 1inch away from pulse generator
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Cricothyroidotomy: Indications
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ETT contra, can't intubate adn unable to ventilate, anticipated inability to perform ETT intubation and ventilation
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Cricothyroidotomy: Contra
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Absolute contra: tracheal transection w/ retraction into mediasinum, significant damage to larynx or cricoid cartilage
Relative: <12yo (transtrach jet vent), bleeding diathesis, acute laryngeal disease, distorted anatomy |
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Cricothyroidotomy: Technique
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Hyperextend neck if no contra, ID circothyroid membrane b/l thyroid cartilage adn above cricoid cartilage (1 fingerbreadth b/l laryngeal prominence, infiltrate w/ local, sedate (ketamine good if no contra).
Rapid 4 step: position at head of bed as with ETT intubation, Reidentify landmarks, incise skin and cricothyroid membrane with single horizontal stablike incision with large #20 scalpel. If anatomy ambiguous, make vertical incision to ID cricothyroid membrane and then a horizontal incision through membrane. With scalpel still in trachea, insert tracheal hook inferiorly to the blade and pull cricoid ring anteriorly and inferiorly as if performing laryngoscopy, remove scalpel, insert tracheostomy tube or ETT, secre, ventilate, confirm. |
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Cricothyrotomy complications
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Failure to intubate trach, subcut emphysema, bleeding, tube block/airway obstruction, infection, subglottic stenosis
*Notify airway consultants ASAP (anesthesia, ENT, general surgery) *Difficult cric if SHORT (Surgery of neck, Hematoma, Obese, Radiation, Tumor) |
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Transcutaneous Pacing: Indications
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hemodynamically significant bradycardia, bradyasystolic arrest (minimal benefit), predicted or high risk for hemodynamically significant brady (2nd type II and 3rd degree block, ingestion negative chronotropic drugs/toxins, and pacemaker malfunction), overdrive pacing certain tachydysrhythmias, mostly torsades
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Transcutaneous Pacing: Contra
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Relative contra: warm bradycardia hypothermic patient (35/95C) b/f pacing as cold heart more susceptible to vfib.
32C considered warm and dead |
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Transcutaneous Pacing: Technique
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Anterior pad over apex, posterior pad medial to L scapula, pace mode, rate 70, syncronized, increase mA current til capture (50-60mA) and then inc output to 1.25x. If bradyasystolic arrest start on max and decrease until loss of capture. Overdrive pacing set rate at 40bpm faster than pt's HR and slowly inc current until capture, once capture, brief trains of 10 overdrive beats of asynchronous pacing are applied.
Give benzos and opiates for discomfort. Insert transvenous pacer |
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Transcutanous Pacing: complications
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failure to see underlying dangerous rhythm under pacer spikes (vfib), when in doubt, pause pacer to assess.
Can induce dysrhythmias but rare. Pain, skin burn |
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Pericardiocentesis: contraindications
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uremic pts w/ effusion should be managed with dialysis if circumstances permit b/f pericardiocentesis
hemorrhagic tamponade can't be definitively managed by pericardiocentesis and should be performed in as plans for thoracotomy in arrested/near arrested |
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Pericardiocentesis: Technique
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HOB 45degrees, NG/OG if abd distended, prep lower xiphoid area, infiltrate, subxiphoid approach with spinal needle 7.5-12.5cm 18 gauge insert b/t xiphoid process and L costal margin at 30degree angle to skin direct at L nipple. Stylet removed after needle thru skin, advance with u/s and aspirate until pericardial fluid, can use EKG guidance with wide PVC comple and STE when needle against epicardium. If entered, needle should be w/drawn slightly. Aspirate as much fluid as possible, postprocedure xray to r/o PTX
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Pericardiocentesis: Complications
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dry tap, ptx, dysrhythmia, myocardia/coronary vessel lac, hemopericardium, air embolism
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Needle thorocostomy
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14guage antgiocath into 2nd intercostal space along midclavicular line, insert perpendicular to chest wall just superior to 3rd rib, hear rush of air, leave cath in place adn remove needle, insert chest tube.
Complications: cardiac injury/tamponade, chest vessel injury/hemorrhage, pneumonia, arterial air embolism. |
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Chest pain: abrupt onset, sever intensity, ripping or tearing. DDx....
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aortic dissection/esophageal rupture
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CP with pleuritic pain with dyspnea. DDx:
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PE or spontaneous PTX.
Both will have tachypnea and resp distress. Check unilat BS. |
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CP with diastolic murmur...diagnosis
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aortic dissection
Also see BP difference >20mmHg |
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CP with subcutaneous emphysema
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ruptured esophagus
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STE with chest pain
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MI>>>dissection
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Right heart strain
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prominent S in lead I
think PE |
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Clopidogrel dosing
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MI or stroke 75mg po
ACS 300mg po |
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Avoid ntg in which type of MI
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RV infarct- RCA occlusion
The wide Q waves and elevated ST segments in leads II, III and aVF are indicative of acute inferior myocardial infarction (short arrows). The depth of ST segment depression in leads V2 and V3 (long arrows) is more than one half of the amplitude of the ST elevation in lead aVF. This suggests the possibility of left ventricular infarction only. However, slight elevation of the ST segment in lead V1 (arrowhead) suggests accompanying right ventricular (RV) infarction. (Bottom) A second ECG taken one minute later with right-sided V leads quickly confirms the diagnosis of RV infarction, with wide Q waves and elevated ST segments seen in leads V3R through V6R |
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Thrombolytics AMI (alteplase) Dosing
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15mg IV bolus
Then 0.75mg/kg (max 50mg) over next 30minutes Then 0.5mg/kg (max 35mg) over next 60minutes *Give if door to needle time <30min and if PCI not available w/i 90 min of 1st medical contat. NOT recommended for 12-24h unless continued pain w/ STE. Best if w/i 4h of onset sx. Give with aspirin, heparin. Time onset sx </=12hrs and >15min. Give for LBBB or new STE. Don't give if >180/>110, R vs L arm difference >15mmHg, h/o structural CNS disease, head trauma in last 3wks, stroke last 3mo, 2-4wk major trauma/surgery/GI/GU bleed, h/o ICH, bleed problem, pregnancy, serious systemic disease (severe liver/kidney/advanced cancer), relative contra PUD, relative contra use of anticoagulants with higher INR riskier |
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Thrombolytics acute ischemic stroke (alteplase) Dosing
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Give 0.9mg/kg (max 90mg) over 60min.
Give 10% dose over 1 minute and remaining over 60minutes Must give <3hrs from onset sx, absence of ICH/SAH on CT scan, variable/rapidly improving neuro deficits, |
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Contraindications/Precautions/Exclusion of lytics
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active internal bleeding past 21d, don't give heparin/asa for first 24h of fibrinolytic treatment, h/o CVA/ICH/intraspinal event in past 3months (stroke, AVM, aneurysm, neoplasm, recent trauma/surgery), mamor surgery/trauma last 14d, disection, severe uncontrolled HTN ( ), bleeding disorder, prolonged CPR with evidence thoracic trauma, LP last 7d, recent arteria puncture at noncompressible site.
Must have 2 IVs in. |
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Normal PR
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0.12-0.20 and <1box
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Normal QRS
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<.12 or <3small boxes
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Normal QT
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<1/2 R-R interval
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Counting rate on boxes
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300-150-100-75-60-50
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Anterior MI
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Occlusion proximal LAD
Significant Q and T wave inversions in I, V2, V3, V4 STE V2-V4 |
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Anterolateral MI
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Occlusion of L circumflex, marginal branch, or diagonal branch.
Q waves and T wave inversions in I, aVL, V5-V6 STE I, AVL, V5-V6 |
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Inferior MI
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RCA
STE II, III, avF |
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Posterior MI
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Occlusion distal circumflex or posterior descending or distal RCA
ST depression V1-V3 |
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Heparin dosing
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60IU/kg or max 5000IU bolus
12IU/kg or 1000IU/h infusion Adjust to aPTT 50-70sec Check aPTT 3hr, then 6hr Don't use if plts <100,000 |
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Lovenox dosing
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DVT w/ or w/o PE, UA, non Qwave MI:
1mg/kg SC BID STEMI <75yo: 30mg IV bolus + 1mg/kg SC x1, then 1mg/kg SC q12h STEMI >75yo: 0.75mg/kg SC q12h without IV bolus STEMI with renal impairment (<30mL/min): 1mg/kg SC qD |
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RF's aortic dissection
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marfan, FH dissection, aortic instrumentation (cardiac cath, valve surgery)
Check pulse deficit, focal neuro deficit, new diastolic murmur. Check concomittant STEMI |
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Widened mediastinum
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>8cm at level of the aortic arch or T4
<sensitive signs of mediastinal great vessel injury include depression of the left main-stem bronchus, deviation NGT to right, apical pleural hematoma (cap), disruption of the calcium ring in the aortic knob (broken-halo). Get CT angio or TEE if unstable (higher FN and FP rates) |
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Treatment dissection
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Propranolol IV 1mg over 1min q5min prn for target HR 60
Nitroprusside gtt 0.3mcg/kg/min for SBP <120. Can consider enalapril 2-5mg q6h IV Morphine CT surgery |
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Dissection types
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Debakey: I-both, II-ascend, III-descend
Stanford: A ascend (I and II), B descending only (III) |
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Tx of spontaneous PTX
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Small PTX= <3cm between lung anc chest wall->supplemental O2 and repeat film in 6h
Stable with larger pneumothorax: tube thoracostomy Unstable: 14 gauge angio then tube thoracostomy Tube thoracostomy if >15-20% and d/t trauma, enlarging, bilat, HTX w/ PTX< tension, resp symptoms, requires air transport, needs intubation. Catheter aspiration not appropriate for trauma care. Connect to 15-20cm water seal suction and get post-CXR Can d/c if asx, no PTX on admission, no ptx on 6hr repeat CXR |
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Tx Ruptured Esophagus
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RF's: alcohol abuse, cautic ingestion, high yield retrosternal pain followed by vomiting/retching
***Check for subcut air in chest wall CXR: pneumomediastinum/pneumoperitoneum CT chest or gastrograffin swallow study to confirm dx, broad ABX, surgery, |
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Tx methemoglobinemia
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PE: blue/gray cyanosis unresponsive to O2
Labs: basic, enzymes, ABG with PCO2/O2 gap, chocolate brown color, polycythemia, hemolysis, arrhythmias RF's: G6PD defic, dapsone, nitrites/nitrates, aniline dyes, lidocaine, auto-exhaust, pyridium, poppers/sniffers, hereditary metheoglobinemia, cyanide poisoning treatment, smokers higher levels Tx: methylene blue for level Met-Hgb >20%, CHF, anemia, angina. Metylene blue 1mg/kg IV slow and may repeat in 1 hour. Wash skin/remove toxin, gastric lavage <1h, charcoal, exchange transfusion for G6PD pts or >70% MetHgb, atropine for brady, pressors |
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Tx cyanide
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hydroxocobalamine IV 5gm (70mg/kg peds) and may repeat once. Takes up cyaniide and converts it to Vitamin B12. Rash at site, urine and mm red.
Gastric lavage <1h Activated charcoal Hemodialysis HBO RF;s: fire, suicide w/ coma, nail remover, fruit seeds Sx: cherry red skin, cyanosis, bitter almond odor, mydriasis, pulm edema, hypothermia Labs: AG met acidosis, cyanide levels don't correlate with toxicity CXR: pulm edema |
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Tx organophosphates
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Acetylcholinesterase inhibitors cause excess acetylcholine at autonomic ganglion
Sx: brady salivation, V/D, diaphoresis, wheeze, weak, tremor, AMS< sz PE: miosis, fasciulations, odor of garlic, pulm edema, wheeze, nystagmus, CN palsies, hypotension, resp depression, CV collapse Labs: Basic, ABGs, pesticide screen TBC sholinesterase levels, tox screen, CXR for pulm edema, EKG for arrhythmias (inc QT, PR, ST-T wave changes Tx: atropoine 2mg IV q2min (0.05mg/kg peds) for cholinergic sx until bronchial secretions clear; 2-PAM (pralidoxime) 2g IV (peds 50mg/kg max 1g) regenerates cholinesterase if <24h from exposure. Remove exposure and wash skin. Discard leather, charcoal w/o cathartic, lavage if w/i 2-3h, exchange transfusion, hemodialysis for parathion |
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Tx hypercalcemia
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IVF
Furosemide |
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HIV encephalitis/IC encephalitis
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toxoplasmosis, cryptococcal meningitis
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Hyperthermia defn
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>40C
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Hypothermia defn
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<35C
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