ARDS classification
P/F ratio: Normal > 400 < 300= mild ARDS < 200= moderate ARDS < 100= severe ARDS Higher risk, severe ARDS with decreased compliance (20 mL or less) and increased minute ventilation ( 13 L/min or more) C= stiffness R= diameter of airways
BiPAP
Can help decrease CO2 in a hypercapnia patient by augmenting minute ventilation
Contraindications: do not use in pts who are unable to protect their airway or have large secretion burden, caution in patients who are at high aspiration risk
WHO Approach to Pain Management
- +/- Non Opioid (Tylenol) & +/- Adjuvant (NSAID)
- Opioid for mild to moderate pain (Oxycodone, Tramadol, Vicodin)
+/- Non Opioid & +/- Adjuvant - Opioid for moderate to severe pain (IV Opioid)
+/- Non Opioid & +/- Adjuvant
Types of Pain
Acute < 6 months, d/t tissue damage; subsides with interventions and healing of tissue damage
Chronic > 6 months continued/episodic, negative changes in life, treatment to improve functionality of life, frequent re-evals and combination therapy
Cancer: caused by direct tumor involvement of sensory receptors, decreases if responsive to chemo and radiation
Pain location
Nociceptive pain: stimuli from somatic and visceral structures (transduction, transmission, perception, modulation)
Cutaneous: skin
Visceral: poorly localized, from internal organs
Somatic: non localized in muscle, bones, nerves, blood vessels
Tylenol Overdose Treatment
N-Acetylcysteine, administer if any of the following:
- APAP level >200 mg/L at 4 hours
- If unknown time of ingestion and APAP level > 10 mcg/ml
- Serum APAP won’t return in 8 hours and ingestion suspected
- Any evidence of hepatotoxicity
- Repeated excessive APAP ingestions
Serum APAP
Dose: (oral) 140 mg/kg then 70 mg/kg q4h x 17 doses (72 hours)
(IV) 150 mg/kg over 1 hour, then 50 mg/kg over 4 hours, then 100 mg/kg over 16 hours
Indications for transplant after tylenol overdose
Kings Criteria:
- arterial pH < 7.3 after fluid resuscitation
- Creatinine > 3.4
- PT > 1.8 above normal or INR > 6.5
- Grade III or IV encephalopathy
Organisms of Infective Endocarditis
Strep Viridans group (mutans, sanguine) Staph. Aureus Enterococcus HACEK organisms (slow growing gram negative, oral flora) - Haemophilus organisms - Actinobacillus, Actinomycetemcomitans - Cardiobacterium - Eikenella - Kingella
If culture returns quickly, likely not HACEK organism
Vegetation Risk of Emboli
Mitral Valve 25%
Mitral valve, anterior leaflet 40%
Mitral valve, ant. leaflet, size >10mm 50-60%
MV, ant. leaflet, > 10 mm, mobile 60-80%
Inflammatory phase of wound healing
- Platelets release control blood loss, start clotting process;
- recruitment of leukocytes & macrophages;
- Leukocyte infiltrate wound, clean/remove debris and foreign particles;
- Macrophages release growth factor initiating granulation tissue formation
Zones of Carotid Injury
- Zone 1: Sternal notch to cricoid (highest mortality)
- Zone 2: cricoid to angle of mandible (most common, carotid, jugular, vertebral)
- Zone 3: angle of mandible to base of skull (most difficult to expose)
Carotid Artery Endartectomy (CEA) indications
Asymptomatic (plaque >70%) or symptomatic pts
No previous h/o radiation therapy to neck
No previous h/o of CEA to same side
Carotid Artery Stenting (CAS) indications
Plaque not approachable by CEA, high risk of CV complications, < 70 year old, h/o radiation on affected side
> risk of stroke
***symptomatic pts NOT a candidate
Shapes of aneurysm
Fusiform: symmetric bulge, most common
Saccular: Asymmetric, likely d/t trauma or aortic ulcer
Psuedoaneurysm: “false” aneurysm, actual disruption of one or more of wall layers
Calculating Ideal Body Weight (IBW) or Estimate Lean Weight (ELW)
Men: 106 lbs for first 5 feet, add 6 pounds per inch above
Women: 100 lbs for first 5 feet, and 5 lbs per inch above
Add 10% for obese pts.
Subtract 10% for petite pts.
Causes of skin changes with nutritional deficiencies
Pallor: iron, folate, B12 Dermatitis: EFA, Zn, B2, B3 Poor wound healing: Zn, Vit C, protein Scaly texture: Vit A, EFA Skin turgor: poor fluid status
Quick physical exam for evaluating for CVA
FAST exam Facial droop Arm weakness Speech difficulty Time to call
*Gait disturbances, sudden HA
Management of Cerebral Aneurysms
CT, if negative, LP, CTA TXA prevent further bleeding Liberal SBP Nimodipine for treatment of vasospasm Saccular treatment= clipping or OR
Definition of Neutropenic Fever
Single oral fever >38.3 (101 F)
Sustained > 38 (100.4 F) for > 1 hour
Neutropenia: ANC < 500 or ANC expected to decrease to < 500 in next 48 hours
ANC= [(Neutrophil % + Band cells %) x total WBC] / 100
Differentials of positive Anion Gap (Na-(HCO3 + Cl)
Normal < 12
AT MUDPILES Alcohol Toluene Methanol Uremia DKA/Drugs Praldehyde INH/Iron Lactic Acidosis Ethanol/ Ethylene glycol Salicylate/Starvation ketosis
Differentials of positive Osmolar Gap
measure serum osmolality - predicted serum osmolality
Predicted value found online
ME DIE Methanol Ethanol Diuretic Isopropyl Ethylene glycol
Dialyzable Drugs
I STUMBLE Isopropanol Salicylates Theophylline Urea Methanol Barbiturates Lithium Ethylene glycol
Toxidromes
sympathomimetic cholinergic anticholinergic serotonin syndrome opioid intoxification/withdrawal sedative hypnotics
Sympathomimetic toxidrome agents, presentation, treatment
Agents: cocaine, LSD, caffeine, ephendrine, pseudoephedrine
Presentation: dilated pupils, tachy, HTN, hyperthermia, DIAPHORETIC, seizure, CNS excitation, normal bowel sounds
Treatment: Benzos, fluid resuscitation, treat hyperthermia
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