Absolute Thrombolytic Contraindications
Absolute - BAIT SAN
- Bleed or Diathesis
- INR> 1.7
- Plt < 100
- Heparin in 2 days with inc PTT
- Aortic DIssection
- Intracracial Hem
- Trauma in 3 monts
- Stroke < 3 mo
- Av Malform
- Neoplasm
Relative Thrombolytic Contraindications
Relative - I PUSH VASC
- Internal Hem 2 weeks
- Preg
- Ulcer - Peptic
- Stroke > 3 months
- HTN (>180, >110)
- Vascular Access - Noncompressible
- Anticoagulant Use
- Surgery < 3 mo
- CPR > 10 min
PE Thrombolytic Indications
- Hemdynamic Instability
- SBP < 90
- SBP drop > 40
- Persistant hypoxemia despite tx
- Subtotal or total pulmonary artery embolism
- RV Dysfuntion
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Shoulder Reduction Techniques
- Stimson - Prone with weight off bed
- Cunningham - Massage Biceps with arm adducted and flexed, patient shrugs
- Scapular Manipulation - CCW
- Traction-CounterTraction/Milch
- Self Reduction
- FARES - Oscillation
Posterior Shoulder Reduction
Supine
Internally rotatedladducted
Traction
Push on humeral head anteriorly
Dyspnea/Tachypnea DDX (40)
- Critical (all systems): Airway obstruction, anaphylaxis, epiglottitis, PE, pulmonary edema, tension PTX, Fail chest, MI, tamponade, DKA, toxic ingestion, CO poisoning, organophosphates, stroke
- Airway: angioedema, Ludwig’s, RPA, PTA, laryngomalacia, FB, mass, inhalation burn, ingestion burn
- Pulmonary: asthma, pleurisy, COPD, Acute Lung Injury, ARDS, effusion, neoplasm, chemical pneumonitis, pulmonary brosis, aspiration
- Cardiac: Unstable Angina, MI, dysrhythmia, CHF, pericarditis, cardiomyopathy, valvular dz, CHD, pericardial effusion Abdominal: ascites, constipation, free air, obstruction, hiatal hernia
- Psychogenic: hyperventilation, somatization d/o, panic attack
Metabolic/endocrine: renal failure, lyte abnormalities, metabolic acidosis, fever, hyperthyroidism - Infectious: COVID, PNA, empyema, bronchitis, SARS, inuenza, PCP, sepsis, TB
Traumatic: PTX, hemothorax, diaphragm rupture, rib fx, sternal fx, pulm contusion, chest wall burns, pulled intercostal muscle Hematologic: severe anemia, acute chest syndrome (SCD), porphyria - Neuromuscular: MS, Guillain-Barre, Tick paralysis, ALS, polymyositis, botulism
Neck Pen Trauma Zones
Go “Up”
- Sternal Notch to Cricoid
- Cricoid to angle of mandible
- Angle of mandible to base of skull
Hard Signs of Neck Injury
- Hypotension
- Arterial Injury
- Rapidly expanding hematoma
- Deficit (pulse or neuro)
- Bruits or thrills
- Bubbling wound
- Severe hemoptysis
- Severe hematemesis
Soft Signs of Neck Injury
- Hoarseness
- Stridor
- SubQ Emphysema
–> CTA +/- Scope
Neck Pen Trauma Decision Matrix
- Airway Compromise (Expanding Hematoma, Stridor) –> Intubate
- Hards Signs or Unstable –> OR
- Stable and violates platysma –> CTA
- Possible GIT injury –> Endoscopy or Esophargram +/- ABx
- Possible Larygotracheal Injury –> Bronchoscopy
Pen Neck Trauma - Vascular Injuries
MC injured - vein and art
Other concerns (2)
1 Vein = EJ
Vert Art - May be occult –> Neuro Deficits (CN)
IJ - C/f Venous Air Embolism
Shoulder Dystocia
H - call Help (OB, peds, anesthesia)
E - Episiotomy (large)
L - Legs Flexed McRobert’s position
P - suprapubic Pressure
E - Enter the vagina, perform wood’s screw pushing shoulders to the fetal chest
R - Remove posterior arm, pull across face and pull out of birth canal
If still no dice - break clavicle
Breech Delivery
- PUSH IT BACK IN (zavanelli procedure)
- Must have OB en route to do Csx)
- If not help coming
- Cut large episiotomy,
- Sweep out legs and let deliver past umbilicus without any traction,
- Pull 10cm of cord out once umbilicus clears perineum.
- Deliver most accessible arm then the other, may need to rotate.
- Rotate fetus to keep face down (so chin not caught on symphysis).
- Use Mariceau maneuver (Fingers in fetal mouth sometimes via mom’s anus) to flex chin (or place pressure on maxilla) / avoid extension injury to spinal cord.
Multi-Gestation
If baby #1 is breech → C-sx
If both vertex → deliver both
If baby #1 is vertex, #2 breech → deliver #1 and try to rotate #2
Nuchal Cord
reduce when head delivers
check for a second one
Cord Prolapse
- Hand in vagina to elevate presenting part (ie head) to decompress cord
- Pt in knee chest position or deep T-berg
- Tocolysis
- Mg 4gm IV
- Terbutaline 0.25mg SQ
- C-Sx
Post Partum Hemorrhage
- Uterine pressure
- Oxytocin 20 Units IV (after placenta delivery)
- Methergine 0.2 mg IM (contraindicated in HTN and PreE)
- TXA
- Repair lacs
Cardiogenic Shock Tx
Hypotensive - Dopamine
Poor contractility - Dobutamine
CHF FFM
- Tx:
- 100% O2 NRB prn or NIPPV
- NTG 0.4 mg SL q 5 min x 3 or 20-200 mcg/min IV
- Or NTP 0.25-10 mcg/kg/min IV Diuretic
- Diuretics
- Lasix 20-80 mg IV- 0.5-1 mg/kg
- Bumex- 1-3 mg IV (1 mg = 40 mg lasix)
- Foley to monitor I/Os
- ACEI- should be on this, B blocker (both have decreased mortality), +/- diuretic, digoxin, spironolactone as outpatient
If respiratory distress… BiPAP early
If patient tiring/AMS… ETT
If hypotensive/cardiogenic shock… IVF in 250 cc boluses, pressors (may have to use multiple pressors + vasodilator)
Consult cards to discuss lytics, PCI, IABP
Norepinephrine 2-20 mcg/min IV- shock BP < 70
Dopamine 2-20 mcg/kg/min IV- BP <100 shock or persistent oliguria Dobutamine 2-20 mcg/kg/min IV- no signs of shock- poor contractility
Aortic Dissection Tx
- Stat CT surgery consult
- Goal to decrease arterial pressure (decrease shearing forces)
- If tachycardic… Goal HR 60-80
- Esmolol 500 mcg/kg IV, then 50-200 mcg/kg/min
- Diltiazem (if asthma or heart failure) load 0.25 mg/kg then 5-10 mg/hr
- If hypertensive… Goal SBP = 100-120
- Nitroprusside 0.25-10 mcg/kg/min IV
- If single agent preferred…
- Labetalol 0.25-1 mg/kg IV, double q 10 min (max 300mg total), then 1-2 mg/min
- If hypotensive (5%)… r/o pseudohyportension w/ BL BP, check possible causes (hemopericardium, valve dysfxn, systolic dysfxn) before aggressive uid resus
ACS Tx
- ASA 162-325 mg PO
- Allergy to ASA - Prsugrel (C/I in prior TIA/Stroke)
- NTG
- 0.4 mg SL q 5 min x 3, then drip at 20-80 mcg/min IV
- Titrate to pain free
- Beta blockers- ACS with tachydysrhythmias or intractable HTN
ACE I- decrease ventricular dysfunction and death- give within first 24 hours
Anticoagulation
- Heparin 60 u/kg IV (max 5000 u) then 12 u/kg/hr (max 1000u/hr) {Guiac first}
- Discuss Plavix load with cardiologist –Do not give Plavix in AVR STEMI
If STEMI… PCI w/in 90 min, pants/underwear off
If STEMI and no PCI available… check contraindications and give lytics
tPA time in CVA
4.5 hours
PERC
“HAD CLOTS”
H – Hormone (estrogen) use
A – Age > 50
D – DVT/PE history (have they HAD CLOTS?)
C – Coughing blood
L – Leg swelling disparity
O – O2 sats < 95%
T – Tachycardia (>100bpm)
S – Surgery or Trauma (recent)
HEART SCORE - How to Calc
- Suspiciousness of History
- Slightly = 0, Moderately = 1, Highly = 2
- EKG
- Normal = 0, Non-specific = 1, Sig ST change = 2
- Age
- <45 = 0, 45-65 = 1, >65 = 2
- Risk Factors
- None = 0, 1-2 = 2. 3+ = 2
- HTN, HLD, DM, Obesity, Smoking, Fam Hx of CVD <65y, prior atherosclerosis (MI, PCI/CABG, CVA/TIA, PAD)
- Initial Trop
- < normal limit = 0, 1-3 times normal = 1, >3x normal = 2
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Antidotes and Toxidromes47
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PGY 1 - ACLS21
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PGY 1 - Misc27
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PGY 1 - PALS16
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PGY1 - TCCC8
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PGY1 EKGs32
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PGY3 - Misc35
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PGY3 - RSI Meds9
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PGY3 - Vasotropic/Inotropic Drugs23
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PGY3 - EKGs20
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PGY4 - MISC86
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PGY4 - EKGs18
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Oral Boards Study Facts5
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Antibiotics43
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PGY 1 - ACLS COPY21
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PGY 1 - Misc COPY27
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PGY 1 - PALS COPY16
