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141 Cards in this Set
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Distinguish between acute and chronic pain.
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acute - duration is usually short (< 6 mo); caused by tissue damage
Chronic: Continual or episodic pain of longer duration (> 6 mo.); combination therapy is usually needed to effectively treat |
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What are the different pain locations:
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cutaneous: skin ex: sunburn
Visceral: poorly localized, around organs. Somatic: non-localized; originates in muscle bone, nerves, blood vessels, and supporting tissue. ex: bruise, dislocated knee Neuropathic: frequently caused by a tumor; involves nerve pathway injury or compression ex: sciatica, herpes zoster |
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What is the most reliable indicator of the existence and intensity of acute pain?
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the patient
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WHO's ladder of Pain Mgmt - describe the steps.
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3 step progressive ladder
starts w/ aspirin, acetaminophen or an NSAID, continuing to build through the 3 steps with heavier narcotics added, while maintaining the initial choice of aspirin, acetaminophen or nsaid. Step 1: non-opiods-ASA, APAP, NSAIDS, adjuvants (gabapentin amytriptyline) Step 2: now on opiods APA or ASA + codeine hydrocodone dihidrocodeine tramadol Adjuvents (tylenol #3) Step 3 Keep on first opiod morphine hydromorphone methadone levorphanol fentanyl oxycodone nonopiod analgesics adjuvants |
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what is recommnended for break through cancer pain?
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Use of fentanyl patches for sustained release
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What is fever?
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an increase in body temp above normal 37C; used to determine presence of infection
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What are some causes of fever?
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any infection, i.e. bacterial, viral, rickettsial, fungal or parasitic
autoimmune disease (SLE, arteritis) CNS disease (cerebral hemorrhage, brain tumor, MS) - interference w/ thermoregulatory process rather than fever Malignant neoplastic disease (primary and liver mets) Hematologic disease (lymphoma, leukemia) CV Disease (MI, phlebitis, PE) GI disease (IBD, alcoholic hepatitis) Endocrine disease (hyperthyroidism, pheochromocytoma) Misc. causes (familial mediterranean fever, hematoma) Neuroleptic Malignant Syndrome from antipsychotics Seratonin syndrome malignant hyperthermia |
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What do you treat a fever with?
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antimicrobials only when a microbe is present
antipyretics treat underlying condition |
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Post Op Fever Causes are:
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postop atelectasis
increased basal metabolic rate dehydration drug reactions (Ampho B, Bactrim, beta-lactam antibiotics, procainamide, INH, methyldopa, quinidine) |
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What are some infectious causes of Post-Op fever?
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usually accompanied by subjective complaints and a WBC with a left shift (Increase in bands, i.e. bandemia)
WBC over 30,000 is usually NOT due to infection (think leukemia) surgical incisions IV sites point of entry for catheters Urinary tract lungs sinusitis: NGT abscess |
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What is the initial treatment for post-op fever in the absence of any indication of infection?
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hydration and lung inflation
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What do you treat a post-op infectious fever with?
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supportive fluid and APAP
treat underlying source gram stain and C&S all invasive lines or catheters as indicated GET CULTURES BEFORE MEDS |
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What are the components of HA eval?
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***Chronology***
location, duration, quality assoc. activity: exertion, sleep, tension, relaxation Timing of menstral cycle presence of assoc s/s presence of "triggers" |
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What is the single most common type of HA?
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Tension HA
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What are s/s of tension HA?
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vise-like or tight in quality
generalized may be most intense about the neck or back of the head no assoc focal neurological symptoms usually last for several hours |
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How do you treat a tension HA?
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OTC analgesics, relaxation
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What are the 2 categories of migraine HAs?
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classic migraine (with aura) and common migrane (without aura)
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what are migrains thought to be related to?
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dilation and excessive pulsation of the branches of the external carotid artery; typically lasts 2-72H following the trigeminal nerve pathway
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What are the causes/incidences of a migraine?
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onset usually in adolescence or early adult years
often there is a family hx females more than males a variety of "triggers", ex. emot or phys stress, lack of excess of sleep, missed meals, specific foods, alcoholic beverages, menstruation, use of oral contraceptives nitrate containing foods changes in weather |
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what are the s/s of a migraine?
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unilateral, lateralized throbbing HA that occurs episodically
may be dull or throbbing build gradually--can last several hours or longer focal neurologic disturbances may precede or accompany migraines visual disturbances common-field defects, luminous visual hallucinations (i.e. stars, sparks, or zigzag of lights aphasia, numbness, tingling, clumsiness or weakness may occur n/v photophobia and phonophobia |
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Physical exam findings for migraine?
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normal usually, may have neuro deficits
appear ill careful neuro exam for focal deficits or findings supportive of a tumor |
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Lab/Diagnostics for migraine
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r/o tumor
blood chemistries, BMP CBC VDRL (syphillis) ESR CT scan |
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Management for migraine?
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avoid triggers
relaxation prophylactic daily therapy if attacks occur more than 2-3 times a month, i.e. amitryptyline, depakote, propranolol, imipramine, clonidine, verapamil, topamax, neurontin, methysergide, magnesium |
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What is the management for an accute migraine?
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rest, dark, quite room
ASA right away Imitrex 6 mg SQ at onset, may repeat in 1 H (total 3x day) Imitrex 25 mg p.o. at onset of HA |
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What is a cluster HA?
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very painful syndromes, mostly effect middle aged men
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What are the causes/incidence of cluster HAs?
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often no family hx
may be precipitated by ETOH ingestion chac by severe, unilateral, periorbital pain occurrinmg daily for several weeks usually occur at nite, awakening client from sleep usually last < 2H; pain free months or weeks between attacks ipsilateral nasal congestion, rhinorrhea and eye redness may occur |
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Phys Exam findings w/ cluster HA?
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eye redness and rhinorrhea, otherwise normal
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Whats the mgmt for cluster HA?
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treatment of individual attacks with oral drugs usually unsatisfactory
Imitrex 6 mg SQ may help Inhalation of 100% may help Ergotamine tartrate aerosol inhalation (Ergostat) may be effective |
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What are nutritional considerations and support for Cluster HAs?
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albumin levels of <3.5 indicate protein malnutrition; edema can be expected if the albumin level is <2.7
hgb < 12 for women and < 13.5 for men can indicate lack of iron or protein resulting in inadequate o2 perfusion clinical observations should be used to support lab data (e.g. hair not easily plucked, musculature, clear nail beds free of ridges, pink moist mucous membranes, etc.) |
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When giving a transfusion of 1 unit of PRBC, how much can you expect your Hgb and PCV to go up?
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1 hgb
3 pcv |
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When determining the type of nutrition support for your patient, what should you prescribe/order?
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can they take oral supplements? if they arent effective:
can they use GI tract? are they going to need supplementation for more than 6 weeks? if so, you need an enterostomal tube. if not, go with NG tube. are they at risk for aspiration? yes--duodenal tube no--NG tube if they cant use GI tract you will have to use parenteral, ex: diverticulitis are they going to need support for more than 2 wks? yes--central vein. No--peripheral vein--no dextrose > 10%--will sclerose the vein |
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What are some complications of enteral nutritional support?
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aspiration, diarrhea, emesis, GI bleed, mechanical obstruction of the tube, hypernatremia, dehydration
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name some complications of parenteral nutritional support.
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pneumo
hemothorax arterial laceration air emboli catheter thrombosis catheter sepsis hyperglycemia HHNK |
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What are you evaluating when deciding if a pt has hypernatremia?
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urine Na (norm 10-20) if > 20 problem is prob w/ kidneys, if < 10 prob outside the kidney
serum osmolality (usually 2x Na) norm 275-285 clinical status |
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What does measuring urine Na help do?
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distinguish renal from non-renal causes.
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Your patient appears to have an isotonic hyponatremia. what will you look at first?
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hyperlipidemia or hyperproteinemia
body water is normal and pt is symptomatic treatment: cut down fat (no fluid restriction) |
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what would you expect to see with a hypotonic hyponatremia?
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too much water!! everything diluted out! so would see a serum osmolality < 280. assess if the pt is hypovolemic or hypervolemic
if hypovolemic, assess whether hyponatremia is due to extrarenal salt losses or renal salt wasting |
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what would you attribute a urine Na+ <10?
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dehydration
diarrhea (C. diff) vomiting (use NGT suction) these are all non-renal problems! |
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what would you think with a urine Na+ > 20 and pt is hypovolemic?
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low volume & kidneys cant conserve Na+--a kidney problem! attribute it to diuretics, ACE inhibitors, Mineralcorticoid deficiency
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why would a pt develop a hypervolemic, hypotonic hyponatremia (need to restrict water)?
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edematous states
CHF liver disease advanced renal failure |
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when would you be likely to see a hypertonic hyponatremia (serum osmolality > 290 mosm/kg)?
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hyperglycemia--usually from HHNK
osmolality is high and the Na is low |
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if urine Na is > 20 and the patient is on diuretics, what would you do?
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stop the diuretic
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how do you manage hyponatremia?
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treat cause
treat underlying condition if hypovolemic, give NS IV If urine Na > 20, treat the cause if hypervolemic, implement water restriction if pt symptomatic, givwe NS IV w/ loop diuretic If CNS symptoms are present, consider 3% NS IV w/ loop diuretics |
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what are some causes of hypokalemia?
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diuretic use
GI loss excess renal loss alkalosis |
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what are s/s hypokalemia?
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muscular weakness, fatigue and muscle cramps
constipation or ileus due to smooth muscle involvement if severe (<2.5) may see flaccid paralysis, tetany, hyporeflexia and rhabdo. "calves hurt" |
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how does hypokalemia effect the EKG?
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decreased amplitude, broad T waves, prominent U waves, and PVCs, V-tach or V-FIB.
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how do you manage hypokalemia pharmacologically?
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oral replacement if > 2.5 and no EKG abnormalities
IV replacement at 10 mEq/H if cant take PO if < 2.5 mEq or severs s/s are present, may give 40mEq/L/hr IV--check q3H and institute continuous monitoring ***Mag deficiency frequently impairs K+ correction*** |
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what are some causes of hyperkalemia?
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excess intake, renal failure, drugs (e.g. NSAIDS), hypoaldosteronism and cell death. shifts of intracellular K+ to the extracellular space occur with acidosis. K+ increases 0.7mEq/L w/ each 0.1 drop in pH
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S/S of hyperkalemia?
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weakness, flaccid paralysis
abdominal distention diarrhea |
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would you see flaccid paralysis in hyper or hypo kalemia?
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both
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what tests would you do for hyperkalemia?
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probably not EKG changes untill K+ is higher than 6.5 and then only 50% of people BUT peaked T waves are a classic finding
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how do you manage hyperkalemia?
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kayexalate
if over 6.5 or cardiac toxicity or muscle paralysis give 10U reg insulin w/ one amp of D50 (pushes K+ into the cell) |
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When drawing a calcium, what other lab would you want to get with it?
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albumin--it binds to albumin
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what is a normal calcium lab value? ionized calcium lab value?
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8.5-10.5 and 4.5 to 5.5
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what is the most important role of calcium?
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a mediator of neuromuscular and cardiac function
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why do we draw an ionized CA as opposed to a regular CA?
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ionized calcium doesnt vary with the albumin level (useful to measure the ionized calcium level when the alb is not normal)
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What 3 elements regulate calcium?
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vit D
parathyroid hormone calcitonin |
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Does acidemia increase or decrease ionized calcium? alkalemia?
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acidemia-increases
alkalemia-decreases |
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how much calcium is bound to albumin in the blood?
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50%
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what would a normal calcium level in the presence of a low albumin level suggest?
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hypercalcemia
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what is the formula for calcium correction?
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0.8 (norm albumin-4 minus serum albumin) plus serum calcium
you assume that the normal albumin is 4 |
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what are some causes of hypocalcemia?
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hypoparathyroidism, hypomagnesemia, pancreatitis, renal failure, severe trauma, multiple blood transfusions
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what are some of the signs of hypocalcemia? hint: low calcium has high signs
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increased dtrs
muscle abdominal cramps carpopedal spasm (trousseaus sign) convulsions chvostek's sign (cheek) **prolonged QT interval*** |
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how do you manage hypocalcemia?
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check blood ph for alkalosis (alk causes ionized ca to go down)
if acute, IV calcium gluconate if chronic, oral supplements, vit D, aluminum hydroxide |
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what are some causes of hypercalcemia?
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hyperparathyroidism, vit D intoxication, prolonged immobilization, rarely-thiazide diuretics will promote hypercalcemia
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What are S/S of hypercalcemia? hint-everything is low
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fatiguability
muscle weakness depression anorexia N/V constipation **severe hypercalcemia can cause coma and death **serum Ca++ > 12 is considered a medical emergency!!! |
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how do you manage hypercalcemia?
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may need calcitonin if impaired cardiovascular or renal function
may need dialysis if > 12, begin NS infusion with loop diuretics |
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What is pH and pCO2 in respiratory acidosis?
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pH<7.35 w/ pCO2 >45
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what is respiratory acidosis the result of?
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acute resp failure, decreased alveolar ventilation (they are coding or dead) At first there is a sharp rise in pCO2, but in 6-12H will evoke the renal compensatory mechanism but this takes several days to manifest
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S/S resp acidosis?
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somnolence, confusion, coma
myoclonus with asterixis increased cerebral blood flow causes increased ICF pressure causing increased ICP |
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How do you diagnose resp acidosis?
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low arterial pH (<7.35)
pCO2 > 45 Serum HCO3 > 26 Low serum chloride (<93) in chronic patients |
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how do you manage resp acidosis?
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narcan (0.04 to 2mg) if needed
improve ventilation, intubate increase rate on vent |
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What are the lab values in resp alkalosis?
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high pH (>7.45)
low pCO2 serum HCO3 low, if chronic |
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what causes resp alkalosis?
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hyperventilation decreases pCO2 and increases pH. Clinical symptoms related to decreased cerebral blood flow.
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how do you manage resp alk?
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manage underlying cause. if acute hyperventilation syndrome, have pt breathe into a paper bag; decrease rate of vent; sedate, rapid correction of chronic alk may result in metabolic acidosis
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what is the hallmark sign for metabolic acidosis?
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low serum HCO3!!! anion gap helps some too
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what is the formula for the Anion gap?
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sodium minus (bicarb + chloride)
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what causes a increased anion gap?
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DKA
alcoholic KA Lactic acidosis drug or chemical anion |
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Your patient has renal tubular acidosis. what would you expect the anion gap to be?
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normal
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you have a patient with an anion gap of 25. what would you know about this pt?
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the higher the gap, the higher the acidosis and the sicker the pt
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how do you treat metabolic acidosis?
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treat underlying disorder
fluid resuscitation HCO3 generally not indicated if the acidosis is due to hypoxia or DKA HCO3 IS indicated if significant hyperkalemia is present |
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What is the hallmark sign for metabolic acidosis?
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low serum HCO3!!!!!
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what can cause metabolic acidosis?
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diarrhea, c-diff
iliostomies renal tubular necrosis recovery from DKA all of these would have a normal anion gap |
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what is metabolic alkalosis characterized by?
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high plasma HCO3 and compensatory pCO2 rarely exceeds 55 mmHg. If pCO2 is >55, superimposed resp acidosis is likely
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what does Diamox (acetazolamide) do when given in metabolic alkalosis?
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acidifies the urine
Bicitra alkalizes the urine |
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What does ROME stand for?
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respiratory opposite
Metabolic equal |
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what would you see in terms of diagnostics and lab work with metabolic alkalosis?
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pH > 7.45
pCO2 > 45 and < 55 HCO3 > 26 Serum K and Cl- decreased maybe increased anion gap |
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whats considered a 1st, 2nd, and 3rd degree burn?
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1st-dry, red, no blister, epidermis only ex: sunburn
second decree (partial thickness)-moist, blisters, extends beyond epidermis--blisters! 3rd degree (full thickness)-dry leathery, black, pearly, waxy; extends from epidermis to dermis to underlying tissue, fat, muscle and/or bone |
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how do you measure the extent of a burn injury?
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Rule of Nines
each arm = 9% each leg = 18% thorax = 18% front and 18% back neck = 1% head = 9% perineum/genitals = 1% |
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how do you approximate a burn patients total body surface area?
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the size of his/her palm is approx 1% of the TBSA
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What is the Lund and Browder chart?
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takes into consideration TBSA according to age w/ specific calculations (%) for each body part burned
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What is the formula for fluid resusitating in burns?
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approx 4ml/kg x TBSA during the first 24H
give 1/2 during the 1st 8H, then the remaining divided by 2 This is called the Parkland formula |
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what fluids do you administer to a burn pt?
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crystalloid
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what pH is expected during the early resuscitation phase?
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metabolic acidosis
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when is the best time to monitor the burn pt for hyper and hypo kalemia>
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hyper during 1st 24-48H
hypo following fluid resus/diuresis around 3 days post burn |
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what are indications for prophylacic intubation for burn pts?
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laryngeal edema
burns to face singed nares or brows dark soot/mucous from nares and/or mouth |
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Emergent burn care: what do you do?
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submerse injured area in clean water asap
dont use ice, lotions, toothpaste, lard, butter or other products wrap the area in a clean, wet towel and transport to nearest hospsital sterile NS is used in initial treatment (no betadine, peroxide or other products) maintain norm temp (37-37.5) pain mgmt w/ fent and/or morphine |
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dog and cat bites: pearls?
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cat bites more prone to infection
copious high pressure irrigation w/ NS or LR using 18-19 g needle to reduce rate of infection ascertain rabies status xray if skull bite primary closure controversial wounds of hands or LE leave open wound older than 6H is generally left open to heal by secondary intention plastic sx as needed antib-controversial (augmentin 3-7 days) |
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most common causes of cellulitis?
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outpatients-strep pyogenes (Gp A Strep)
S. aureus - less common Other strep (Gp B, C, G) -rare Inpatients Gram negative organisms (KEEP)-klebsiella, e. coli, enterobacter, and pseudamonus) then S. aureus (gm +) we think its MRSA Strep |
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how do you treat CA MRSA?
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bactrim or doxy or clindamycin (clin can use for acne too)
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how do you treat inpatient skin infections with group A strep?
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Bactrim + beta lactam (PCN, amoxicillin, 1st generation cephalosporin like keflex) OR
Doxy w/ beta lactam clindamycin |
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In GI decontamination management, what is the most important step of your assessment?
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pt history
always rule out multiple ingested agents |
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what is the agent of choice for forced emesis?
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ipecac-for use at home --ingestion of solids only
dont use for ingestions of corrosives or detergents (e.g. bleach, liquid plumber, soap, etc.) as either erosion of the esophagus may occur or aspiration |
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how long do you perform gastric lavage?
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until clear, may not help if OD over 30 min. because pill fragments may be gone
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what is the dose for activated charcoal?
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1g/kg to a max of 50g mixed w/ water; repeated dose q4H; 1st dose most effective when combined with a cathartic like sorbitol
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what can be used for severe ingestions?
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forced diuresis, dialysis, hemoperfusion, and plasmapheresis
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Name 3 examples of acetaminophen.
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tylenol
anacin-3 panadol |
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what are the s/s of acetaminophen toxicity?
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usually asymptomatic at first
around 24-48H N/V RUQ pain jaundice, high LFTs, prolonged PT, alter mental status, delerium |
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how do you treat an acetaminophen intoxication?
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emesis for recent ingestions; gastric lavage/activated charcoal
*N-Acetylcysteine (Mucomyst) with a loading dose PO should be ordered as needed |
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what do you give for benzo OD?
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flumazenil (romazicon)
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What do you give for opiod OD?
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narcan
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what are s/s salicylate intoxication?
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N/V, tinnitis, dizziness, HA, dehydration, hyperthermia, apnea, cyanosis, metabolic acidosos, elevated LFTs
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how do you manage salicylate intoxication?
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Emesis for recent ingestions; gastric lavage/ activated charcoal
socium bicarb IV for severe acidosis (7.1) |
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What are some examples of organophosphate (insecticide) poisoning?
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malathion
parathion |
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what are s/s of organophosphate poisoning?
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N/V, cramping, diarrhea, excessive salivation, HA, **blurred vision and miosis, **bradycardia, mental confusion, slurred speech, coma
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how do you treat organophosphate poisoning?
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if insecticide was ingested, activated charcoal should be ordered; wash skin thoroughly, and give **atropine--drug of choice for organophosphate toxicity
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what are the s/s of antidepressant toxicity?
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confusion, hallucinations, blurred vision, urinary retention, hypotension, tachycardia, dysrhythmias, hypothermia, seizures
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how do you manage antidepressant OD?
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admit to ICU if CNS or cardiac toxicity evident
gastric lavage/activated charcoal sodium bicarb IV to counter dysrhythmias and maintain pH **Benzodiazepine IV (e.g., valium) as needed to control seizures |
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if you OD on narcotics, what do you see with the pupils?
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miosis at 1st
miosis is pupil constriction, they get little mydriasis from crack cocaine and uppers uppers dilate, sedation constricts |
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what do you treat seratonin syndrome with?
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dantrolene sodium (Dantrium); clonazepam (Klonopin) used to treat rigor; cooling blankets to control temp
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what s/s would you see w/ narcotic toxicity? i.e. codeine, heroin, morphine, opium
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drowsiness, hypothermia, resp depression, shallow respirations, MIOSIS: pinpoint pupils
NOTE: cocaine causes mydriasis coma |
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how do you mange narcotic toxicity?
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emetics are contraindicated
GL/AC narcan stadol |
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What does a benzo OD look like?
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drowsiness, confusion, slurred speech, respiratory depression, hyporeflexia
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how do you manage a benzo OD?
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resp and blood pressure support
flumazenil (Romazicon) IV GL/AC |
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is HIV a contraindication for a transplant?
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No, but AIDS is
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what does acute rejection of a atransplanted organ look like?
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immediate failure of that organ
flu-like symptoms (e.g., faver, chills, malaise, etc.) immediate biopsy should be done |
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what are the anti-rejection drugs taken to lower lymphoid cells?
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cacineurin inhibitor + anti metabolite + steroid
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what are s/s of herpes zoster?
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pain along a dermatone, usually on the trunk
grouped vesicle eruption of erythema and exudate along the dermatomal pathway regional lymphadenopathy |
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how do you treat shingles?
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acyclovir
famciclovir valaciclovir |
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is varicilla a live vaccine?
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yes--dont give to immunosuppressed ppl
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what do you do for ocular involvement w/ shingles?
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refer to opthalmologist immediately
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what is given for post herpetic neuralgia?
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neurontin, lyrica
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zostavax is the vaccine for shingles. at what age is it recommended?
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age 50
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what is actinic keratosis?
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small patches on sun-exposed body parts
premalignant (leads to squamous cell) asymptomatic; small patches; may be tender rough, flesh colored, pink or hyperpigmented |
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How do you treat Actinic Keratosis?
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liquid nitrogen
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what is squamous cell carcinoma and how do you treat it?
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arises out of actinic keratoses
firm, irregular papule or nodule develop over a few months: 3-7% metastasis see on prolonged, sun-exposed areas in fair skin ppl keratitic, scaly bleeding treat w/ biopsy and surgical excision (Mohs) |
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What is seborrheic keratoses?
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benign, not painful
beige brown or black plaques "stuck on" appearance 3-20mm in diameter. treatment is none or can use liquid nitrogen |
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what does basal cell carcinoma look like?
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waxy, pearly appearance (may be shiny red)
most common skin CA Slow growing lesion (1-2cm after years) central depression or rolled edge may have telangiectatic vessels treatment: shave/punch biopsy and surgical incision |
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what is malignant melanoma?
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DONT FORGET ABCDEE
highest mortality rate of all skin cancers median age at diagnosis = 40 may metastasize to any organ asmmetry border irregularity color variation diameter > 6cm elevation enlargement if you have 2 of these from ABCDEE, its a 97% shot of being MM biopsy and surgical incision |
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what is the criteria for brain death?
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normothermic
no gag no CNS function no spontaneous respirations nystagmus |
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what can you give to reduce excessive secretions with terminal extubation?
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scopolamine
give morphine for tachypnea |
