Common Problems In Acute Care

Front 1

Types of Pain
1. Acute
2. Chronic

Back 1

1. Acute: duration < 6 mos; caused by tissue damage
2. Chronic: continual or episodic pain of longer duration > 6 mos; combination therapy is usually needed to treat

Front 2

Locations
1. Cutaneous
2. Visceral
3. Somatic
4. Neuropathic

Back 2

1. Cutaneous: localized on the skin of the surface of the body
2. Visceral: poorly localized as in the internal organs
3. Somatic: Non localized; originates in muscles, bones, nerves, blood vessels, and supporting tissue
4. Neuropathic: frequently caused by a tumor; invovles nerve pathway injury or compression

Front 3

Subjective (pain) Finding

Back 3

i.e. the patient's self report or physical evidence is the most reliable indicator of the existence and intensity of acute pain

Front 4

WHO ladder of pain management

Back 4

3 Step Ladder: progressive with ASA, tylenol or NSAID, heavier narcotics (maintain initial choice of ASA, tylenol or NSAID

Front 5

WHO 3 steps ladder examples of meds
Step 1
Step 2
Step 3

Back 5

Step 1: ASA, APAP, NSAIDs, +/- adjuvants
Step 2: ASA or APAP +: codeine, hydrocodone, oxycodone, dihydrocodeine, tramadol (not available with ASA/APAP), +/- adjuvants
Step 3: Morphine, Hydromorphone, Methadone, Levorphanol, Fentanyl, Oxycodone, +/- nonopiod analgesics, +/- adjuvants

Front 6

WHO 3 steps ladder examples of meds
Step 1
Step 2
Step 3

Back 6

fentanyl patches

Front 7

Pain Management

Back 7

conservative but LIBERAL

Front 8

Fever

Back 8

an increase in body temp above 37 C; monitoring of body temp is commonly used to determine the presence of an infection

Front 9

Causes of Fever

Back 9

1. Bacterial, viral, ricketts, fungal, or parasitic
2. Autoimmune (SLE, arthritis)
3. CNS disease (cerebral hemorhage, brain tumor, MS)- interference with thermoregulatory process rather than fever
4. Malignant neoplastic disease (primary/liver mets)
5. Hematologic disease (lymphoma, leukemia)
6. CV disease (MI, phlebitis, PE)
7. GI disease (IBD, alcoholic hepatitis)
8. Endocrine disease (hyperthyroidism, pheochromocytoma)
9. Miscellaneous causes (familial Mediterranean fever, hematoma)
10. Neuroleptic malignant syndrome

Front 10

Treatment of Fever

Back 10

1. antibiotics only when microbe is present
2. Antipyretics
2. Treat underlying condition

Front 11

Post-operative fever, non-infectious causes

Back 11

1. Bacterial, viral, ricketts, fungal, or parasitic
2. Autoimmune (SLE, arthritis)
3. CNS disease (cerebral hemorhage, brain tumor, MS)- interference with thermoregulatory process rather than fever
4. Malignant neoplastic disease (primary/liver mets)
5. Hematologic disease (lymphoma, leukemia)
6. CV disease (MI, phlebitis, PE)
7. GI disease (IBD, alcoholic hepatitis)
8. Endocrine disease (hyperthyroidism, pheochromocytoma)
9. Miscellaneous causes (familial Mediterranean fever, hematoma)
10. Neuroleptic malignant syndrome

Front 12

Poste operative fever, infectious

Back 12

WBC >30K usually not infectious; Fever assoc with bandemia, left shift and subjective complaints
1. lungs
2. abscess, intra-abdominal
3. IVs
4. Central lines, point of entry, culture?
5. Sinusitis, NGT
6. UTI
7. surgical incissions

Front 13

Initial treatment of post-operative fever

Back 13

In absence of indication of infection, initial treatment is hydration and lung expansion

Front 14

Treatment of infectious post-operative fever

Back 14

1. supportive hydration and acetaminophen
2. treatment of underlying source
3. Culture and gram stain of catheter source, invasive lines

Front 15

Components of Headache Evaluation

Back 15

1. Chronology is the most important history item
2. Assess duration, quality, location
3. Associated symptoms
4. Associated activities: exertion, sleep, tension, relaxation
5. Timing to menstrual cycle
6. Presence of "tirggers"

Front 16

Tension Headache
-signs and symptoms
-labs, diagnostics
-management

Back 16

the single most common type of HA
signs and symptoms
1. vise like or tight in quality
2. generalized
3. most intense at the back of the head or neck
4. usually not associated with neurological symptoms
5. usually last for several hours
-no specific labs or diagnostics
-management: OTC analgesics, relaxation

Front 17

Migraine Headache
- 2 types
-definition

Back 17

1. classic migraine: with aura
2. common migraine: without aura
migraine associated with dilation and excessive pulsation of the branches of the external carotid artery; lasts 2-72 hours following the branches of the trigeminal nerve pathway

Front 18

Migraine Headache
Incidence/Causes

Back 18

1. usual onset in adolescence or early adulthood
2. family history
3. more females affected than males
4. TRIGGERS: associated with certain activities: lack or oversleeping, physical or mental stress, menstrual period, oral contraceptive, missed meals, specific foods
5. nitrate containing foods
6. changes in weather

Front 19

Migraine symptoms

Back 19

1. unilateral, lateralized throbbing headache
2. could be dull or throbbing
3. photophobia, phonophobia
4. starts gradually and may last for several hours or longer
5. nausea, vomiting
6. focal neurologic deficits may precede or accompany migraine
7. visual disturbances accompany migraines: field defects, luminous visual field hallucinations (stars, sparks, zigzag of lights)
8. aphasia, numbness, weakness, clumsiness, or tingling may occur

Front 20

Migraine Physical exam findings

Back 20

1. many times normal findings but focal deficits as above
2. careful neuro exam of focal deficits or findings suggestive of tumor
3. appears ill

Front 21

Migraine laboratory or diagnostics

Back 21

baseline labs to rule out organic causes
labs: CBC, BMP, VDRL, ESR
CT scan

Front 22

Migraine Headache
Incidence/Causes

Back 22

1. avoidance of triggers
2. relaxation or stress management techniques
3. Drugs: elavil, magnesium, depakote, inderal, imipramine, clonidine, verapamil, topiramate, gabapentin, methysergide

Front 23

Management of Migraine acute attack

Back 23

1. rest in dark, quiet room
2. take ASA, may provide some relief
3. Sumatriptan (Imitrex) 6 mg, SC at onset of HA, may repeat in an hour for a total of 3 doses per day
4. Sumatriptan 25 mg PO at onset of HA

Front 24

Cluster Headaches
-Causes/Incidence
-Physical Exam

Back 24

very painful headaches mostly affecting middle aged men
1. usually no history of of HA, or migraine HA
2. ipsilateral rhinorrhea, sinusitis
3. occurs at night, awakening pt from sleep
4. severe, periorbital, unilateral pain occurring daily for several weeks
5. usually lasts for less than 2 hours; may have pain free periods for weeks or months between attacks
5. precipitated by alcohol consumption
Physical exam usually normal; may find rhinorrhea, eye redness

Front 25

Cluster Headaches Management

Back 25

1. oral pain meds usually unsatisfactory
2. sumatriptan sc 6 mg maybe effective
3. ergotmaine aerosol maybe effective
4. Inhalation of 100% O2 maybe helpful

Front 26

Nutritional Considerations and Support
-common Laboratory test for nutritional status
-Hgb
-clinical findings

Back 26

1. Albumin <3.5 in nutritional protein deplete; 2.7 can find edema
2. <12 for women or <13.5 for men indicate lack of iron or protein resulting in inadequate oxygen perfusion
3. findings that support lab data are: lack of hair, loss of musculature, nail beds with ridges, dry mucous membranes

Front 27

First consideration for nutritional support is...

Back 27

1. avoidance of triggers
2. relaxation or stress management techniques
3. Drugs: elavil, magnesium, depakote, inderal, imipramine, clonidine, verapamil, topiramate, gabapentin, methysergide

Front 28

Nutritional decision tree
GI tract use okay or GI tract use not okay:
OK to use GI tract then...

Back 28

Can Use GI tract?:
Yes; if > 6 wks: enterostomal tube, if less than 6 weeks: nasoenteric tube: if nasoenteric tube and at risk for aspiration, then nasoduodenal tube, if no aspiration risk: NG tube

Front 29

Nutritional decision tree
GI tract use okay or GI tract use not okay:
NOT OK to use GI tract then...

Back 29

Can Use GI tract?:
NO to GI tract use then PARENTERAL NUTRITION; If > 2 weeks needed, then Central vein, if < 2 weeks, then peripheral vein

Front 30

Complications of Enteral Nutrition

Back 30

1. aspiration
2. emesis
3. diarrhea
4. obstruction of the tube
5. hypernatremia
6. dehydration
7. gi bleeding

Front 31

Complications of parenteral nutrition (may occur in up to 50% of pts)

Back 31

1. pneumothorax
2. hemothorax
3. arterial laceration
4. infection of catheter
5. hyperglycemia
6. HHNK
7. catheter thrombosis
8. air emboli

Front 32

Hyponatremia: the most common electrolyte imbalance with multiple causes and the first step in treatment is to determine the cause
Evaluation...

Back 32

1. Serum osmolality (280-295), usu 2x the Na
2. Urine Na (10-20)
3. Clinical status

Front 33

Urine Na

Back 33

Urine Na helps explain causes of renal versus non-renal causes. For example, UNa of >20 suggests renal salt wasting (problem with the kidneys); UNa <10 suggests renal retention of Na to compensate for extrarenal fluid loses (problem is other than the kidney)

Front 34

Isotonic Hyponatremia
-define
-assessment and management

Back 34

psuedohyponatremia; 284-295; a laboratory artifact: result of severe hyperlipidemia or hyperproteinemia; body water is normal; pt is asymptomatic; cut down on fat; fluid restriction not necessary

Front 35

Hypotonic Hyponatremia
-define
-Assessment
-causes

Back 35

<280; state of body water excess diluting all body fluids; clinical signs arise from water excess
1. Assess whether patient is hypovolemic or hypervolemic
2. if Hypovolemic, assess whether hyponatremia is due to extra renal salt loses or renal salt wasting
a. Hypovolemic with UNa <10: (dehydration, diarrhea, vomiting)
b. Hypovolemic with UNa >20: low volume and kidneys cannot conserve Na (1. Diuretics, 2. mineralocorticoid deficiency, 3. ace inhibitors)
c. Hypervolemic, hypotonic hyponatremia (need to restrict water); (edematous states, CHF, liver disease, advanced renal failure)

Front 36

Hypertonic Hyponatremia
-define
-assess
-cause

Back 36

1. >290; osmolality is high and Na is low
2. Hyperglycemia, usu from HHNK

Front 37

Management of Hyponatremia

Back 37

1. treatment based on cause
2. treat the underlying condition
3. if hypervolemic, implement water restrition
4. if hypovolemic, give NS IV
5. if UNa >20, treat the cause (1. Diuretics, 2. mineralocorticoid deficiency, 3. ace inhibitors)
6. if the patient is symptomatic, treat with NS with IV loop diuretic
7. if patient has CNS symptoms, consider 3% NS with loop diuretic

Front 38

Complications of parenteral nutrition (may occur in up to 50% of pts)

Back 38

usually due to excess water loss; usually indicate hyperosmolality (deficit of water); excess of Na is rare

Front 39

Hypernatremia
-management

Back 39

1. Severe hypernatremia with hypovolemia is treated with NS followed by 1/2 NS
2. Hypernatremia with euvolemia is treated with free water (D5W)
3. Hypernatremia with hypervolemia is treated with free water and loop diuretics, may need dialysis

Front 40

Hypokalemia
-define/causes

Back 40

is caused by chronic use of diuretics, GI loss, renal loss, and alkalosis; elevated serum epinephrine in trauma patients may contribute in hypokalemia

Front 41

Hypokalemia
-signs and symptoms

Back 41

1. muscle weakness, cramps, fatigue
2. if severe (<2.5 mEq/L) may see flaccid paralysis, rhabdomyolysis, tetany, hyporeflexia
3. may see ileus or constipation due to smooth muscle involvement

Front 42

Hypokalemia
-laboratory tests and diagnostics

Back 42

EKG:
1. low voltage
2. broad T waves
3. prominent U wave
4. PVCs, Vtach, Vfib

Front 43

Hypokalemia
-management

Back 43

<280; state of body water excess diluting all body fluids; clinical signs arise from water excess
1. Assess whether patient is hypovolemic or hypervolemic
2. if Hypovolemic, assess whether hyponatremia is due to extra renal salt loses or renal salt wasting
a. Hypovolemic with UNa <10: (dehydration, diarrhea, vomiting)
b. Hypovolemic with UNa >20: low volume and kidneys cannot conserve Na (1. Diuretics, 2. mineralocorticoid deficiency, 3. ace inhibitors)
c. Hypervolemic, hypotonic hyponatremia (need to restrict water); (edematous states, CHF, liver disease, advanced renal failure)

Front 44

Hyperkalemia
-define

Back 44

common causes include excess intake, renal failure, hypoaldoesteronism, drugs (NSAIDS), cell death and acidosis. Intracellular K shifts extracellularly with acidosis. K rises 0.7 mEq/L for every 0.1 decrease in pH.

Front 45

Hyperkalemia
-signs and symptoms

Back 45

1. flaccid paralysis, weakness
2. abdominal distention
3. diarrhea

Front 46

Hyperkalemia
-laboratory and diagnostics

Back 46

EKG:
1. tall, peaked T waves are classic
2. 50% of patients with K >6.5 mEq will not have any ECG changes; ECG not particularly sensitive

Front 47

Hyperkalemia
-management

Back 47

1. exchange resins (Kayexelate)
2. if severe, > 6.5 mEq/L, give insulin 10 units with one amp of D50 (pushes K into cell)

Front 48

Calcium
-function
-normal value
-other useful information

Back 48

Calcium is an important cellular ion that is involved in both neuromuscular and cardiac function. Normal total Calcium is 8.5-10.5 mg/dL (2.0-2.2 mmol/L) and normal ionized calcium is 1.1-1.4 mmol/L (4.5-5.5 mg/dL)
1. Ionized calcium does not vary with serum albumin (so useful to measure this when serum albumin is low)
2. Calcium regulation is dependent on Vit D, calcitonin, and PTH
3. decrease in pH increases ionized calcium and an increase in pH decreases ionized calcium
4. total calcium is dependent on serum albumin. 50% of calcium is bound to albumin so a normal total calcium with a low albumin suggests hypercalcemia
5. corrected calcium= 0.8x(4 - pt. serum albumin) + serum Ca; 4 is normal serum albumin

Front 49

Hypocalcemia
-causes

Back 49

caused by hypoparathyroidism, hypomagnesemia, pancreatitis, renal failure, trauma, multiple blood transfusions

Front 50

Hypocalcemia
-signs and symptoms

Back 50

1. increased DTRs
2. carpopedal spasm (Trosseau's sign)
3. muscle, abdominal cramps
4. Chovostek sign
5. convulsions
6. prolonged QT interval

Front 51

Hypocalcemia
-management

Back 51

1. if acute, calcium gluconate
2. if chronic, oral supplements, Vit D, aluminum hydroxide
3. check blood pH, look for alkalosis

Front 52

Burns
-categories

Back 52

1. First degree: dry, red, no blisters, affects epidermis only
2. Second degree: moist, blisters, extends beyond epidermis
3. Third degree: dry, leathery, black, waxy, pearly, affects epidermis and beyond dermis, may affect other tissues such as muscle, bone, fat

Front 53

Measuring extent of burn area
-rule of nines
-palm
-chart

Back 53

1. rule on nines
a. each arm is 9%
b. each leg is 18%
c. thorax is 18% front, 18% back
d. neck is 1%
e. head is 9%
f. perineum, genitals is 1%
2. the patient's palm approximates 1% of the total body surface area TBSA
3. Lund and Browder chart: used in most tertiary burn center because it takes into account the TBSA based on age and specific percentage of area burned

Front 54

Burns, Fluid resuscitation
-how much to give
-timing of delivery
-when to start
-common problem of fluid resuscitation
-example
-what to monitor

Back 54

1. generally fluid replacement is 4ml/kg
2. 1/2 of the fluid needs in a 24 hr period is given in the first 8 hours and the remainder in the next 16 hrs; 1/2 of fluid in 8 hrs, then 1/4 of fluid in 8, then 1/4 of fluid in 8
3. deliver fluid at burn site, not at hospital or burn center
4. most common problem is under fluid resuscitation
5. Parkland formula: 4 ml/kg x TBSA % burned; crystalloids not colloid
6. monitor for metabolic acidosis for the initial fluid resuscitation in the first 24 hours; monitor for hyperkalemia for the the first 24-48 hours and hypokalemia around the third day after fluid resuscitation and when diuresis starts

Front 55

Burns, prophylactic intubation
-indications

Back 55

Laryngeal edema is the main reason for prophylactic intubation. Intubation is done when there are:
1. Burns to the face
2. Singed nares, eyebrows
3. coughing up black mucous, soot from nares or mouth

Front 56

Emergent Burn Management Pearls

Back 56

1. submerge the burned area in clean water ASAP
2. Do not use lard, butter, lotion, or other products on the burn
3. wrap the burn in clean, wet towels during transport
4. Sterile NS is used initially for treatment (no betadine, peroxide, etc)
5. Affected areas are covered with sterile towels
6. Pain is controlled with IV fentanyl, morphine, and versed as an amnesiac
7. For tar burns, use petroleum based products to remove the tar such as bacitracin, petrolatum jelly, mayonnaise
8. keep normothermic 37-37.5, very important
9. Silver Sulfadiazine is a common antibacterial, antifungal used in second or third degree burns