Multisystem (14%)

Question 1

Normal ABG values

Answer 1

 pH: 7.35-7.45
 PaCO2: 35-45
 HCO3: 22-26

Question 2

Compartment syndrome

Answer 2

 When pressure within a closed muscle compartment exceeds the perfusion pressure and results in muscle and nerve ischemia and death of tissue
 6 P’s – pain, poikliothermia, pallor, pulselessness, paresthesia, paralysis
 Common areas – LOWER LEG, forearm, wrist, hand
 A strong pulse does not rule out compartment syndrome
 Treatment – OR for fasciotomy

Question 3

Distributive shock (e.g., anaphylaxis, neurogenic, septic) (minus cardiac parameters and treatment)

Answer 3

• What is happening: massive vasodilation
• Pathophysiology: systemic event causes the loss of the normal response to vascular smooth muscle and vasoconstriction coupled with a direct vasodilation
• Common causes: septic shock, anaphylaxis, and neurogenic shock

Question 4

Distributive shock cardiac parameters

Answer 4

• SBP: < 90
• CVP: ↓ (plenty of fluid but vessels are wide open so they seem empty)
• CO/CI: ↓ (fluid isn’t returning to heart because vessels are too wide)
• SVR: ↓ (vessels are wide open)
• SvO2: ↓ or ↑

Question 5

Distributive shock treatment (per each cause)

Answer 5

• Septic: treat cause of infection
• Anaphylactic shock: volume replacement, epinephrine, glucocorticoids (IV or PO; extends life of Epi), antihistamine
• Neurogenic shock: volume replacement followed by alpha antagonists (ex: phenylephrine)

Question 6

Hypovolemic shock

Answer 6

• What is happening: nothing to fill up the vessels
• Pathophysiology: most common form of shock in trauma; multiple organ failure d/t inadequate circulating volume leading to inadequate tissue perfusion
• Common causes: acute hemorrhage, severe hydration, severe burns
• Cardiac pressures: SBP < 90, ↓ CVP (nothing in vessels), ↓ CO/CI (no fluid to circulate), ↑ SVR (vasoconstriction to try and compensate). ↓ SvO2 (not enough fluid to circulate to oxygenate)
• Treatment: treat underlying cause; volume replacement; transfuse PRN

Question 7

Cardiogenic shock

Answer 7

• What is happening: have enough fluid, but pump isn’t working
• Pathophysiology: inadequate tissue perfusion secondary to loss of contractile function; “pump failure”
• Common causes: acute MI, acute HF, dysrhythmia
• Cardiac pressures: SBP < 90, ↑ CVP (fluid backs up), ↓ CO/CI (pump isn’t working), ↑ SVR (not d/t vasoconstriction, rather fluid backing up putting pressure on vessels), ↓ SvO2 (can’t pump blood out to circulate)
• Treatment: treat underlying cause; support CO with inotropes; support oxygenation

Question 8

Obstructive shock

Answer 8

• What is happening: something blocking the filling of vessels and ventricles
• Pathophysiology: obstructive filling leads to the inability to produce good CO
• Common causes: PE, tension pneumothorax, cardiac tamponade
• Cardiac pressures: SBP < 90, ↑ CVP (fluid is backed up), ↓ CO/CI (vessels and ventricles can’t fill so they can’t pump anything out), ↑ SVR (fluid backing up putting pressure on vessels), ↓ SvO2 (can’t fill so can’t put out oxygenated blood)

Question 9

Sepsis

Answer 9

 Pathophysiology: dysregulated response to infection resulting in severe vasodilation, tissue perfusion, and organ dysfunction
 Initially will be in hyperdynamic shock/”warm shock” but as compensatory mechanisms fail, will progress to hypodynamic shock/”cold shock”
 Treatment is based on the surviving sepsis management

Question 10

Surviving sepsis management of septic shock

Answer 10

 Within 3 hours of presentation: measure lactate, obtain blood cultures prior to antibiotics, administer broad spectrum antibiotics, administer 30 ml/kg crystalloid for hypotension or lactate ≥ 4
 Within 6 hours of presentation: apply vasopressors (levophed) (for hypotension that doesn’t respond to initial fluid resuscitation to maintain MAP ≥ 65; if persistent hypotension after initial fluid bolus or if lactate was ≥ 4 – reassess volume status, re-measure lactate if initial was elevated
 Follow-up: repeat focused exam (after initial fluid resuscitation)
 Overall goals of treatment: CVP 8-12, MAP ≥ 65, urine output ≥ 0.5 ml/kg/hr, and SvO2 > 70%

Question 11

Hemodynamic parameters

Answer 11

 CVP (2-6 mmHg): reflects the amount of blood returning to the heart
 PCWP (8-12 mmHg): left ventricular pressure when mitral valve is open
 SVR (900-1400): the resistance of the systemic vascular bed
 CO (4.8-6.4): volume of blood pumped out of the heart in 1 minute
 CI (2.5-4.2): amount of blood pumped by the heart in 1 minute based on BSA
 SvO2 (70-75%): the amount of O2 in the blood that’s returning to the heart

Question 12

Ventilator modes: assist control (AC)

Answer 12

 Ventilator delivers a specific number of preset supported breaths
 Additional patient breaths trigger a fully-assisted breath
 May be pressure or volume targeted
 Do not use in tachypnea (can lead to hyperinflation and respiratory alkalosis)

Question 13

Ventilator modes: synchronized intermittent mandatory ventilation (SIMV)

Answer 13

 Ventilator delivers a minimum number of breaths that are synchronized with patient’s efforts
 Additional patient breaths are possible with a TV that’s determined by patient’s effort
 May be pressure or volume targeted

Question 14

Non-invasive positive pressure ventilation (NIPPV)

Answer 14

 CPAP – constant pressure maintained throughout respiratory cycle with no additional inspiratory support
 BiPAP – a set expiratory positive airway pressure and inspiratory positive airway pressure

Question 15

Common causes of fever

Answer 15

 Infectious – bacterial (most common cause in acute care setting), viral, fungal, rickettsial, parasitic
 Non-infectious – autoimmune, inflammatory, drug reaction

Question 16

Post-op causes of fever

Answer 16

 Most commonly the result of volume contraction (dehydration) or atelectasis
 Bacterial
 Volume contraction (dehydration)
 Atelectasis

Question 17

Post-op causes of fever - bacterial

Answer 17

 Common findings – fever, leukocytosis, surgical site drainage
 Diagnostic workup – evaluate for point of invasion, cultures
 Treatment – antibiotics only with signs of bacterial infection, remove offending items (foley, lines, et.c)

Question 18

Post-op causes of fever - volume contraction

Answer 18

 Common findings – azotemia, decreased skin turgor, decreased PO intake/inadequate IV hydration
 Diagnostic workup – metabolic panel, determine estimated blood loss and replacement, evaluate I&Os, urine output is most reliable indicator of perfusion
 Treatment – isotonic fluids, increase PO fluid intake

Question 19

Post-op causes of fever - atelectasis

Answer 19

 Common findings – atelectasis present on CXR, lack of incentive spirometer use, cough, SOB, decreased lung sounds
 Diagnostic workup – evaluate use of incentive spirometer, diagnosis of exclusion
 Treatment – encourage incentive spirometer, OOB to chair and ambulation, splinting, evaluate med use that decreases respiratory drive

Question 20

Principles of HIV - dx and tx for the acute care provider

Answer 20

• Transmitted via sexual, parenteral, or vertical transmission
• Flu-like syndrome weeks after initial viral acquisition and infection – suggests period of high viral replication
• ELISA SCREENING: > 99.9% sensitivity (screening, cheaper)
• Western blot CONFIRMS to 99.8% specificity (for confirmation)
• CD4+ count indicates level of functional immunity – used to initiate therapy
• Viral load measures viral replication – used to titrate therapy
• Consider beginning antiretroviral therapy regardless of CD4 count OR if clinically immunocompromised

Question 21

HIV - PrEP (pre-exposure prophylaxis)

Answer 21

• Used for individuals who don’t have HIV but are at high risk
• When to start – as soon as possible following a risk behavior assessment and lab testing confirms absence of HIV
• Duration – daily treatment should continue until risk becomes low d/t less risk exposure

Question 22

HIV - PEP (post-exposure prophylaxis)

Answer 22

• Used after a single high-risk event to minimize possibility of HIV infection
• Given to those without HIV who is at a high risk of HIV acquisition through isolated exposure within the past 72 hours
• When to start – as soon as possible following the event and always within 72 hours of possible exposure
• Duration – 28 days

Question 23

Active TB

Answer 23

• Manifestations – significant coughing ≥ 3 weeks, chest pain, hemoptysis or sputum production, weakness/fatigue, weight loss, night sweats, fever
• Diagnostics – positive skin test or serologic result, CXR consistent with TB, abnormal sputum
• Treatment – patient will take several drugs for 6-9 months; first-line agents that are the core of treatment are: isoniazid, rifampin, ethambutol, pyrazinamide, and direct observation therapy

Question 24

Latent TB

Answer 24

• Manifestations – none
• Diagnostics – positive skin test or serologic result, normal CXR, normal sputum
• Treatment – isoniazid for 6-9 months; rifampin for 4 months; direct observation therapy

Question 25

Primary trauma survey

Answer 25

* A – airway, alertness, and cervical spine stabilization (suction, airway adjuncts, definitive airway) * B – breathing, ventilation, and oxygenation (skin color, breathing effectiveness, O2, assist ventilation, EtCO2 measurement) * C – circulation, hemorrhage control, and volume replacement (heart sounds, central pulse assessment, control hemorrhage, establish 2 large bore IVs, warm crystalloid boluses, consider need for blood transfusion) * D – disability (evaluate GCS, assess pupils, consider head CT, consider intubation if GCS < 8) * E – exposure and environmental control (expose patient, ensure warming methods are applied, consider preserving evidence if crime-related) * The only time the order of this changes is if the patient is acutely bleeding – stop bleeding first and then proceed with ABCDE

Question 26

Secondary trauma survey

Answer 26

* F – full set of vitals and family presence * G – get resuscitation adjuncts and labs * H – history (MOI, info from field, medical hx, etc.) * H – head-to-toe assessment (complete head-to-toe, identify additional injuries, re-evaluate previous interventions) * I – inspection (inspect posterior surface, determine need for backboard removal)

Question 27

Chronic pain management

Answer 27

* Step 1 (mild pain, non-opioids) – aspirin, acetaminophen, NSAIDs, ± adjuvants * Step 2 (moderate pain, weak opioids) – codeine, hydrocodone, oxycodone, tramadol, ± NSAIDs, ± adjuvants * Step 3 (severe pain, strong opioids) – morphine, hydromorphone, methadone, fentanyl, ± NSAIDs, ± adjuvants * Step up if pain continues to be persistent or pain increases * For acute pain, step 1 is acute score of 1-3, step 2 is acute score of 4-6, and step 3 is acute pain score of 7-10

Question 28

Burn sources (mechanisms of injury)

Answer 28

* Thermal – caused by heat source such as a hot item, steam, smoke, etc. * Chemical – caused by a chemical agent such as acid or alkali substance * Electrical – caused by AC or DC current * Radiation – caused by a form of radiation such as sun exposure or cancer treatments

Question 29

Treatment of burns

Answer 29

* Safety – of patient and provider * Stop the burning process – wipe chemical away, deactivate chemical, remove hot items (ex: jewelry) * Pain control – typically with opioids, but dictated by extend, degree of burn, and other comorbidities * Fluid replacement (use Parkland formula if > 15-20% of TBSA) * Maintain urinary output of 0.5 ml/kg/hr

Question 30

Parkland formula

Answer 30

* For burns > 15-20% of TBSA * 24-hour fluid replacement = 4 ml/kg/% TBSA burn * ½ of volume in 8 hours from TIME OF BURN and remaining ½ in the remaining 16 hours

Question 31

Liver transplant rejection

Answer 31

* Common occurrence, 60% * Slight elevation of transaminases * Signs and symptoms of liver failure – fever, malaise, anorexia, abdominal pain, ascites * Diagnosis typically made with biopsy after functional complications have been excluded

Question 32

Heart transplant rejection

Answer 32

* 50-80% chance of rejection * Typically asymptomatic * Signs of left ventricular dysfunction – dyspnea, nocturnal dyspnea, orthopnea, syncope * Tachydysrhythmias – atrial > ventricular * Diagnosis usually established by routine surveillance

Question 33

Pancreas transplant rejection

Answer 33

* 20-30% rejection * Typically asymptomatic * Fall in urinary amylase * Hyperglycemia – late sign * Diagnosis is made via allograft biopsy

Question 34

Kidney transplant rejection

Answer 34

* 10% rejection rate * Elevated serum creatinine from baseline (most common) * Decreased urine output, edema, worsening HTN * Evaluate for other causes – infection, surgical complications, obstructions * Diagnosis is made via percutaneous renal biopsy

Question 35

Lung transplant rejection

Answer 35

* Most common type of transplant rejection, most patients have 1 episode of rejection * Vague, non-specific signs and symptoms – fever, dyspnea, non-productive cough * CXR is non-diagnostic * Diagnosis is made by fiberoptic bronchoscopy with lavage and biopsy * Infection must be ruled out

Question 36

Transplant rejection general treatment concepts

Answer 36

* Steroids * IV fluid resuscitation * Treat for shock state * Consult/transfer to transplant surgery service – anti-rejection medication levels * Loading doses of anti-rejection meds

Question 37

Opioid overdose

Answer 37

* Manifestations – respiratory depression, change in mental status, pupil changes (miosis) * Diagnostics – typically a subjective/manifestation-based diagnosis, UDS (little help), CXR (only if concerned for aspiration) * ED-focused treatment: airway management, naloxone hydrochloride (Narcan) for respiratory depression * Naloxone: 0.04-2 mg IV bolus, consider IV infusion when multiple doses are administered, may need up to 10 mg IV for methadone overdose, can be administered SQ/IM/SL

Question 38

Acetaminophen overdose

Answer 38

* Manifestations – typically asymptomatic; n/v, abdominal pain * Diagnostics – made based on hx of overdose (need timeframe); APAP/acetaminophen serum level (at least 4 hours after ingestion); liver enzyme testing (elevated transaminases); INR (suggestive of liver failure) * ED-focused treatment – indicated by patients with a toxic overdose (150 mg/kg is toxic limit); administer N-acetylcysteine within 8 hours of ingestion; oral or IV routes * Oral dosing: loading dose of 140 mg/kg, then 70 mg/kg every 4 hours for 17 doses * IV dosing: 1st option (150 mg/kg over 1 hour, then 50 mg/kg over 4 hours, then 100 mg/kg over 16 hours); 2nd option (150 mg/kg over 1 hour, then 14 mg/kg for 20 hours)