National Registry Study Guide PDF

National Registry Study Guide J. Peter Dale’s PEARLS 1 ) High heart rate, low blood pressure. Think bleed-dehydration 2) Flat jugular veins when supine. Think bleed/dehydration/HHNK 3) Hot skin in a shock patient. Think septic shock – look for the source • National Reg > commonly will present pt w...

National Registry Study Guide J. Peter Dale’s PEARLS 1 ) High heart rate, low blood pressure. Think bleed-dehydration 2) Flat jugular veins when supine. Think bleed/dehydration/HHNK 3) Hot skin in a shock patient. Think septic shock – look for the source • National Reg > commonly will present pt with an open wound of some kind, often an infected bug bite (must be a source) • National Reg > commonly presents a nursing home patient > consider folly catheter as source • Bacteria must have gotten into the bloodstream via lymph system to be septic > presentation may be with a red streak (lymphangitis) • Temperature down is a late sign in septic shock • Cause is always bacterial > produce endo/exotoxins that cause the shock 4) Female patient on birth control and/or smoking with SOB. Think PE • Nat Reg > classically uses a 35yo female smoker • Predisposing factor for PE > travel or some long period of inactivity > also recent surgery (hips/knees) > cancer • PE mimics R side failure > blocks blood flow up through the lungs > blood backs up into the R heart > causing Edema and JVD 5) Hives, laryngeal edema. Think allergic or anaphylactic • Stridor generally exists with anaphylaxis related throat swelling • Laryngeal edema also caused by trauma/localized infection (Ludwig’s angina) • Hive is simply a swollen capillary bed • Uticaria is hive related itching • IgE > antibody responsible for anaphylaxis > Histamine from mast cells, IgE attaches and causes them to burst 1 • Edema causes increased hydrostatic pressure 6) Cool clammy skin. Think shock (sympathetic response) 7) Sudden onset after eating of vomiting/diarrhea think allergic or anaphylactic shock • Food poisoning generally takes 12 hours 8) cool clammy skin above, warm dry skin below, with low Bp, low HR > think neurogenic shock (does not have to be trauma) • Classic difference between neurogenic and spinal shock > spinal is temporary • Neurogenic shock comes with any disruption in blood flow (not just trauma) 9) Getting patient to the hospital isn’t good enough. Did you treat the MI or Shock? 10) Hives think allergic or anaphylactic shock? 11) Person on ACE Inhibitor with laryngeal edema and stridor think allergic response/ anaphylactic shock • ACE Inhibitors are given for HTN • Most common ACE Inhibitor (Lisinopril) any with a “pril” ending (Prinivil/Zestril) • 54 yo male throat feels like it is closing > no history anaphylaxis > hands and feet stiff > consider ACE inhibitors > classic cause of laryngeal edema 12) If it’s wet and sticky and isn’t yours, don’t touch it. 13) Black tarry stools. Think lower GI bleed • Black tarry stool is the same as Melina • Hematochezia > bright red bleeding > most commonly a hemorrhoid • Dividing line of the upper and lower GI is the Ligament of Tritz • Coffee ground emesis > generally due to an ulcer 14) Patient states “feels like my heart is beating out of my chest” think SVT • Most common cause of SVT is WPW (Wolf Parkinson White Syndrome) • Delta wave would present on ECG > slurred p wave line right into the QRS • C/O SOB and chest pain, lungs may be wet • SVT will/can result in L side failure > backup blood to the lungs 2 • Tx > stable v unstable > cardiovert (@100Jules) v. Adenosine (6mg/12/12) 15) Crushing substernal chest pain, think MI • Nat Reg question that is so simple it is misleading > what is the classic sign of a heart attack > answer is crushing substernal chest pain • Other signs include toothache and bad belly ache • Tx > Morphine / Oxygen / Nitro / Aspirin 16) Sudden onset SOB think PE 17) JVD think Right side failure (PE, Tension Pneumo, Cardiac Tamponade, COPD) 18) COPD patients are hypercarbic • Cant blow off CO2 > normal blood gases are between 35-45 > hypercarbic is over 45 19) Any female of child bearing age with belly pain has an ectopic pregnancy • Having a Tubal Ligation increases the risk but it is used to throw you off • Transport ectopic pregnancy in a position of comfort not Left Lateral Recumbent 20) Tall skinny males with sudden onset SOB think Spontaneous Pneumo • This is a closed pneumo > often presents with a history of smoking • Marfrans Syndrome > tall skinny people affected > genetic disease that presents with weakness in arterial walls > often an aneurysm history 21) If the patient has history of HTN think (MI, stroke, aneurysm) 22) Number one cause of pulmonary edema is left sided failure. Number one cause of left sided failure is MI. Number one cause of right sided failure is left sided failure. This means that if you hear wet lungs you must ask yourself is he having an MI • R sided failure seen with any COPD pt 23) Remember belly insults can refer pain to the shoulders (ruptured spleen/liver/ ectopic pregnancy) 24) Never trust a diabetic 25) The only reason not to disrobe a trauma patient is environmental 3 26) Abruptio Placentae • Signs and Symptoms > Vaginal bleeding but no increase in pain, sudden sharp tearing pain, stiff boardlike abdomen, massive hemorrhage – complete abruption o Occurs in the 3rd trimester – NR scenario pt presentation with painful tearing/ripping sensation sometimes with blood Acute Mountain Sickness • Signs and Symptoms > Lightheadedness, Breathlessness, Weakness, Headache, Nausea, Vomiting o occurs at what altitude (6600) and this is the least serious of the altitude related illness > return to where you were or remain where you are at and it will go away…fluids recommended Addison’s Disease (Hypoadrenalism) • Signs and Symptoms > Progressive weakness, fatigue, decreased appetite, weight loss, hyperpigmentation of the skin, vomiting or diarrhea o Adrenal disease > hypoadrenalism > possibly an autoimmune disease can also be caused by an intense stressor on the system > cessation of adrenal gland function Allergies and Anaphylaxis • Signs and Symptoms > Flushed Skin, Itching, Hives, Swelling of skin, cyanosis, respiratory difficulty, sneezing, coughing, wheezing, stridor, laryngeal edema, lyrngospasm, bronchospasm, vasodilation, increased heart rate, decreased blood pressure, nausea and vomiting, abdominal cramping, diarrhea, dizziness, headache, convulsions, tearing o Tx simple allergic reaction > benydril o Tx for anaphylaxis > epinephrine > actual antibody driver behind this reaction is IgE which is attached to Mast cells and mobile mast cells (basophils) > anaphylaxis is a type 1 allergic reaction > signs and symptoms most concerning (Stridor/edema) > most common cause (eat/ absorb/inhale/injection) Injection most serious thus the key concern of insects is the hymenoptera - Epi is the drug of choice because it both dilates the bronchioles and constricts the vessels (both alpha and beta qualities) Alzheimer’s Disease 4 • Signs and Symptoms > Problems with short term memory, shuffling gait, stiffness of body muscles, aphasia (speech disorder), psychiatric disturbances, decorticate(severe) Angina Pectoris • Signs and Symptoms > Sudden onset of chest discomfort, pain may radiate, possible epigastric pain, possible labored breathing, elevation in blood pressure during episode, chest pain lasting 3-5 minutes sometimes as long as 15 min. o Key words to differentiate between a heart attack > there is no death of cardiac muscle in angina > the angina caused by a spasm is prinzmetals angina and it is thought to be a calcium disturbance (muscle contraction responsibility) Tx for angina > MONA – stable angina v. unstable angina (preinfarction angina) o Stable (occurs with activity and is relieved with rest) o Unstable (occurs at rest/lasts beyond 15min/crescendo attacks) Asthma • Signs and Symptoms > Dyspnea, wheezing, cough, one-to-two word dyspnea(severe), Pulsus paradoxus(severe – pulse becomes weaker as you inhale), tachycardia, decreased oxygen saturation, agitated and anxious(severe) o Have you ever been intubated (the first question you should ask) > most severe sign/symptom that would indicated imminent death (absence of wheezing or any sounds) Tx for asthma is albuterol and oxygen and epinephrine if severe – Drug classification for asthma (beta 2) – cause of the pulses paradoxis in the asthmatic pt (pressure due to air trapped in the lungs which compresses the heart and stops the pulse) Black widow spider bite • Signs and Symptoms > Immediate localized bite, redness, swelling, progressive muscle spasms of all large muscle groups, nausea and vomiting, sweating, seizures, paralysis, decreased level of consciousness • Treatment > IV muscle relaxants may be necessary for severe spasms, Diazepam 2.5 – 10mg IV, Calcium Gluconate 0.1 – 0.2/kg of 10% solution IV, Antivenin if available 5 o identified by the red hour glass on thorax > muscle spasms in the big muscles will always present as a key sign (stomach muscles/thigh) > know the above treatment of Diazepam and calcium gluconate for spasms Brown Recluse Spider Bite • Signs and Symptoms > Painless, a small erythematous macule surrounded by a white ring forms around the site, chills, fever, nausea and vomiting, joint pain, (localized pain, redness, swelling – 8 hours after bite), tissue necrosis at site days to weeks after bite o venom is tissue necrotic > tx is generally surgical > fiddle back identification Carbon Monoxide Poisoning • Signs and Symptoms > headache, nausea and vomiting, confusion, tachypnea, agitation, loss of coordination, chest pain, loss of consciousness, seizures, cyanotic or bright cherry red skin(late sign) o Incomplete burning of fossil fuels > affinity for hemoglobin for CO molecule as opposed to O2 is 200x > Tx is to remove from environment and receive definitive treatment in a hyperbaric chamber > most common signs are headache and nausea shared among the people in the house (looks like the flu) Cardiac Contusion • Bruise to the heart > blunt trauma to the sternum > Tx dependent on presentation > treat what the pt has. Cardiac Tamponade • Increases in pressure on the heart due to fluid in the pericardial sack. • Signs and Symptoms > Dyspnea and orthopnea, clear lung sounds, rapid and weak pulse, blood pressure readings show a decrease in systolic pressure, pulsus paradoxus, and narrowing pulse pressures, muffled or faint heart sounds o presentation with Becks Triad > JVD/muffled heart tones/narrowing pulse pressure > definitive Tx is pericardial centesis > differentiation between this and a tension pneumo is done with the lung sounds which are normal in tamponade and diminished or absent with tension pneumo 6 Cardiogenic Shock • Signs and Symptoms > Acute onset of chest pain or SOB, Altered mental status or unconsciousness, general weakness, restlessness, confusion, coma (severe), dyspnea, productive cough, labored breathing, paroxysmal nocturnal dyspnea, tripoding, tachycardia o Shock caused by cardiac origin > #1drug used to treat this is dopamine Chest Wall Injuries • Signs and Symptoms > Blunt or penetrating trauma to the chest, Erythema, Ecchymosis, Dyspnea, Pain on breathing, Limited breath sounds, hypoventilation, crepitus, paradoxical motion of chest wall o flail chest tx (stabilize the flail segment with a bulky dressing but never use a sandbag too much weight decreases respirations) when the pt breathes in the flail segment moves IN not out > when you breath IN your chest normally moves OUT. o Sucking chest wound > tx use an occlusive dressing sealed on 3 sides > monitor for loss of compliance with bagging. Chicken Pox • Signs and Symptoms > respiratory symptoms, Malaise, Low grade fever, Rash that starts on the face/trunk o classification of the virus is herpies zoster Chronic Bronchitis • Signs and Symptoms > Produce considerable quantities of sputum, productive cough for at least 3 months per year for 2 or more years, overweight, cyanotic, rhonchi, Right-heart failure if they have JVD, ankle edema, and hepatic congestion > “Blue Bloaters” o person has COPD what will their acid base problem be? (all COPD are hypercarbic) due to COPD the person will have R side heart failure > the term used to describe this process is core pulmonale (defined as R side hypertrophy secondary to pulmonary hypertension) o Classic sign of R side failure is JVD/peripheral edema o #1 cause of chronic bronchitis is smoking and the injury is to the bronchials > overproduction of mucus is the pathophysiology this 7 mucus is produced by goblet cells Coral Snake Bite • Signs and Symptoms > Localized numbness, weakness, drowsiness, ataxia, slurred speech and excessive salivation, paralysis of the tongue and larynx, drooping of eyelids, double vision, dilated pupils, abdominal pain, nausea and vomiting, loss of consciousness, seizures, respiratory failure, hypotension o as opposed to a pit viper the venom is neurotoxin > “red on yellow will kill a fella” o the more you move the faster the poison spreads > put a light constricting band between you and the bite Crohn’s Disease • Signs and Symptoms > GI Bleeding, recent weight loss, intermittent abdominal cramping/pain, nausea and vomiting, diarrhea, fever o caused by a destruction of the lining of the intestine that sometimes produces fissures and lots of cramping > increases the incidence of colon cancer Croup • Signs and Symptoms > Loud cough (barking like a seal), tachypnea, grunting while breathing, wheezing, acute respiratory distress during the night o it is viral > classic sign is the seal bark cough > Tx racimic epinephrine > comes on more gradually than epiglotitus o not treated with racemic epi in field due to danger of rebound congestion within 30-60 minutes Cyanide Poisoning • Signs and Symptoms > Burning sensation in the mouth and throat, headache, confusion, combative behavior, hypertension, tachycardia, seizures, coma, pulmonary edema o generally caused by some form of combustion > apple seeds/fruit seeds/ peach pits is the unusual way NR presents this problem > odor generally is of almonds > Tx requires 3 drugs (amal nitrate/sodium nitrite/sodium theosulfate) Generally knowing amal nitrate is the key. Key problem the person will complain of is a burning sensation in the mouth and throat > this poisoning kills us as a result of cellular asphyxia 8 Decompression Illness • Signs and Symptoms > Joint and abdominal pain, fatigue, paresthesis, CNS disturbances o “the Bends” > product of what gas law (Henrys Law)can produce pneumothorax/embolism/stroke > Cassons Disease > Tx (hyperbaric chamber) Diabetic Ketoacidosis (Diabetic Coma) • Signs and Symptoms > Slow onset, Diuresis, Dry warm skin, excessive hunger and thirst, malaise, tachycardia, feelings of physical weakness, kussmauls respirations, fruity or acetone like smell, hyperglycemia, acidic pH, hypokalemia, decrease mental fcn, coma o bottom line it is caused by the body burning fat instead of sugar > and it is an incomplete burning of these fats in the liver that produces the acids > will result in high blood sugar > rapid respirations that are deep (Kussmauls) > skin will be warm and dry > fruity acetone breath and hypokalemic and will have potassium problems as well > diabetes mellitus type 1 (no insulin produced this leads to the DKA) > 3 classic signs of diabetes mellitus (polyuria (excessive urination due to sugar in urine) polydypsia (excessive thirst) polyphagia (excessive hunger) > what causes the polyuria NR type question > caused by hyperosmolarity (too much sugar/too many particles in the urine) > all diabetics are dehydrated Diverticulitis • Signs and Symptoms > Lower left side pain, low grade fever, colicky pain, nausea and vomiting, tenderness on palpation, cool clammy skin(severe), tachycardia(severe), diaphoresis(severe), hematochezia(severe) o no way for us to determine in the field > an inflammation of the diverticuli > belly ache/blood in poop/etc….what would be the least likely to cause death (diverticulitus) > c/o alternate bouts of diarrhea and constipation with some blood in the stool Emphysema 9 • Signs and Symptoms > Barrel Chest, Decreased chest excursion with prolonged expiratory phase, rapid resting respiratory rate, thin, pink in color, hypertrophy of accessory muscles, pursed lips, clubbing of fingers, right heart failure if they have (JVD, peripheral edema, or hepatic congestion), Severe signs include > confusion, agitation, somnolence, one-to-two word dyspnea, use of accessory muscles > “Pink Puffers” o R side failure > body senses it is low on O2 so it produces more RBC’s > too many red blood cells (polycythemia) causes the pink coloration > generally a problem with the alveoli > #1 cause is smoking o Alveoli are stuck open and air is stuck in Encephalitis • Signs and Symptoms > Decreased level of consciousness, fever, headache, drowsiness, coma, tremors, stiff neck and back, seizures o infection of the brain > often caused by west Nile virus spread by mosquitoes and birds > produces the same signs and symptoms as any trauma or insult to the head > Bp up/pulse same or down/breathing erratic (cushings reflex) > would also present with a stiff neck (nucal rigidity) Epiglottitis • Signs and Symptoms > Muffled voice or cry, sore throat, pain with swallowing, difficulty swallowing, drooling, possible stridor o Bacterial with sudden onset classically found in tripod position bent over and drooling > Tx includes O2 possible bag valve mask with contraindication for intubation o Never put anything in their mouths o Generally strikes older kids 3-4yo > adults can also get this Graves Disease (Hyperthyroidism) • Signs and Symptoms > Agitation, Emotional changeability, insomnia, poor heat tolerance, weight loss despite increased appetite, weakness, dsypnea, tachycardia o hyperthyroidism > poor heat tolerance as classic sign with weight loss due to very high metabolism Heat (muscle) cramps 10 • Signs and Symptoms > Cramps in fingers, arms, legs, or abdominal muscles, mentally alert, weakness, dizziness or faint, moist and warm skin o 3 different heat disorders > this is caused by electrolyte imbalances > Tx with water and electrolyte fluids > you can have heat cramps and heat exhaustion at the same time Heat Exhaustion • Signs and Symptoms > Increased body temperature, cool and clammy skin, rapid and shallow breathing, weak pulse, possible diarrhea and muscle cramps, weakness, headache, anxiety, paresthesia, impaired judgment o not the same as heat cramps but you can have both together and that is a common presentation > exhaustion involves the body temperature starting to rise vs. cramps that involve the imbalance of electrolytes > diarrhea and nausea common > tx by removal from the environment and cool Heatstroke • Signs and Symptoms > Cessation of sweating, hot skin that is dry or moist, very high core temp, deep respirations that become shallow, rapid at first but may later slow, rapid full pulse may slow later, hypotension with low or absent diastolic reading, confusion or disorientation or unconsciousness, possible seizures o Sweating stops but the person may still be wet (at the transition from heat exhaustion) > body temp must be above 105. Key sign is the pulse become bounding and then slows becoming weak as they go into cardiovascular collapse Hemothorax • Signs and Symptoms > Blunt or penetrating chest trauma, signs and symptoms of shock, dyspnea, dull percussive sounds over site of collecting blood • Treatment > Administer 02, Initiate 2 large bore IV’s, Keep an eye on breath sounds (commonly there can be a transition into a tension penumo > generally die from shock prior to this) o Blood in the lungs > tap over air (hyperresonant sound) over blood (hyporesonant sound) > show signs of hypovolemic shock prior to signs of respiratory difficulty > it requires a couple of units of your blood to 11 cause this problem > flat jugular veins is a common finding (differentiates it from tension penumo) Hyperadrenalism (Cushings Syndrome) • Signs and Symptoms > Weight gain, a moon face appearance, buffalo hump, thinning to almost transparent skin (bruises easily), mood swings, impaired memory or concentration o Buffalo hump (fat pad at about C7) Hyperthermia • Signs and Symptoms > Diaphoresis, increased skin temp, flushing, altered level of consciousness o anyone with an increased body temperature – Pyrogen is something that causes a fever (foreign protein/bacteria etc) > Determination of the cause of the temperature issue…environmental or internal. Sometime they erythema/Rugor/Redness of skin) Hypoglycemia (insulin shock) • Signs and Symptoms > Altered mental status, early signs (restless, impatient, complaint of hunger), bizarre behavior, diaphoresis, tachycardia, hypoglycemic seizure(possible comatose), quick onset o blood sugar less than 90 with signs and symptoms – Insulin shock is a type of hypoglycemia (refers specifically to a person with diabetes type 1 who takes too much insulin and it drives the sugar out of the blood stream or they take the normal amt of insulin then throw up or something to put them in an insulin dominant position > sweaty, irrational, altered mental status, warm Hypothermia (mild) • Signs and Symptoms > Lethargy, Shivering, Lack of coordination, Pale cool dry skin, early rise in blood pressure/heart/respiratory rates o temp between 90-95 – lethargy – shivering to attempt to rewarm yourself > this will generally come in the form of a pt who is hypothermic has a bp of 60/40 and hr of 40 and some PVC’s possibly > they want you to treat the bradycardia and use that algorithm to mess up. They need to be warmed which will allow for the PVC’s to go away and the rates to normalize 12 Hypothermia (severe) • Signs and Symptoms > No shivering, dysrhythmias (asystole), loss of voluntary muscle control, hypotension, undetectable pulse and respirations o Below 90 temp > lost the ability to warm themselves (no shivering) at 86 degrees the onset of cardiac dysrhythmias occurs (A Fib/V Fib) J Waves (Osborne waves) present on ECG. Treat gently and with a resuscitation issue use first line drugs and reevaluate Hypothyroidism (Myxedemia) • Signs and Symptoms > Fatigue, Decreased mental function, lethargy, cold intolerance, constipation, decreased appetite with increased weight gain o Myxedemia > classic question > what disease state causes a decrease in core temperature (hypothyroidism) > also leads to an intolerance of cold > if the person is very tolerant of heat this is also a sign. Lung Cancer • Signs and Symptoms > Altered mental status, one-to-two word dyspnea, cyanosis, hemoptysis, hypoxia, cough, dyspnea, hoarseness, vague chest pain, fever and chills, pleuritic chest pain, crackles, wheezes, diminished breath sounds heard in affected lung > severe signs > cachexia, profound weight loss o main cause is smoking and genetics > generally ends up dying from a wasting (Cachexia) of the muscles > these people have many pulmonary embolisms and bleeding out due to cancer infringing on a large vessel in the lungs Marine Animal Injection (Jelly Fish) • Signs and Symptoms > Intense local pain/swelling, Weakness, nausea and vomiting, dyspnea, tachycardia, hypotension or shock(severe) 13 • Treatment > Establish/maintain airway, apply a constricting band between the wound and heart no tighter that a watchband to occlude lymphatic flow only, apply heat or hot water, inactivate or remove any stingers o Venom designed to interact with other marine animals > oceans are cold so the venom is designed to operate at the cooler temperature > heat the area to disable the venom (hot pack) Measles • Signs and Symptoms > Full body rash, hacking cough, runny nose, high fever, watery red eyes, koplik’s spots (small red spots with blue white centers that appear inside the mouth) o viral disease Meningitis • Signs and Symptoms > High fever, headache, stiff neck, nausea and vomiting, discomfort looking into bright lights, confusion, sleepiness, seizures(late) o • viral or bacterial (more lethal) virus tends to go away in 7-10 days > classic signs are high fever > 6 year old kid with high temp for 2 days you should first suspect meningitis > nucal rigidity (stiff neck) other class signs > kernigs sign positive and bredinsky sign (stiffness of the spinal column) > often develop a rash on the thorax (meningialcocal rash) > spreads airborne Spread airborne so you must wear a mask Myocardial Infarction • Signs and Symptoms > Chest pain, elevated blood pressure during episodes, chest pain lasts more than 30 minutes, pain can radiate to arms, neck, and posterior to the back, acute onset of nausea and vomiting, nitroglycerin and rest offer no/little relief, frightened “feeling of impending doom” o MI results in death of tissue (not in angina) > classic sign is crushing substernal chest pain > nitro generally offers little relief with MI > pain can radiate to the arms/jaw/teeth > in females there is often no chest 14 pain and they may only have a stomach ache > old/diabetics tend to have no chest pain with the heart attack > always listen to the lungs for pulmonary edema (#1 cause is left side failure) most heart attacks occur in the left ventricle Mumps • Signs and Symptoms > Fever, headache, loss of appetite, swelling and pain in the parotid glands o viral Nitrogen Narcosis • Signs and Symptoms > Altered level of consciousness, impaired judgment o also known as rapture of the deep > caused by an overabundance of nitrogen in the blood stream latching onto the neurons and causing a drunkenness > hyperbaric chamber as tx. > occurs on bottom Open Pneumothorax • Signs and Symptoms > Penetrating chest trauma, sucking chest wound, frothy blood at wound site, dyspnea, hypovolemia • Treatment > High flow O2, cover opening with sterile occlusive dressing taped on 3 sides o sucking chest wound > tx place a gloved hand over the injury then and occlusive dressing and monitor for signs of a tension pneumo Parkinson’s Disease • Signs and Symptoms > Tremor, Rigidity, Bradykinesia, Postural Instability o disease that generally strikes in the 5/6 decade of life/unknown etiology > tremor and rigidity of muscles are the classic signs > shuffle gait > bradykenesia (slow muscle movement) > caused by a lack of dopamine in brain (neurotransmitter) tx is to give them this as a supplement. Pericardial Tamponade 15 • Signs and Symptoms > Dyspnea and possible cyanosis, JVD, Weak thready pulse, decreasing blood pressure, shock, narrowing pulse pressure o Word used to describe the signs and symptoms (Becks Triad > JVD, narrowing pulse pressure, muffled heart tones) How to differentiate between this and tension pneumothorax the definitive way is breath sounds (tension pneumo would be diminished on one side > tamponade would be equal) > can occur from a bleed or medical problem such as right side failure (venous system leak into pericardium) or pericarditis which would cause some fluid to enter this space o Pericarditis would cause ST changes in all the leads across the board Pit Viper Bites • Signs and Symptoms > fang marks, swelling and pain at the wound site, continued oozing at the wound site, weakness, dizziness, faintness, sweating and or chills, thirst, nausea and vomiting, diarrhea, tachycardia and hypotension, bloody urine and gastrointestinal hemorrhage (late), ecchymosis, necrosis, shallow respirations progressing to respiratory failure, numbness and tingling around face and head • Treatment > Keep the patient supine, immobilize the limb with a splint, maintain the extremity in neutral position/do not apply constricting bands, O2, start IV with crystalloid fluids, transport, DO NOT > apply ice, cold pack or Freon spray to the wound, apply an arterial tourniquet, apply electrical stimulation from any device in an attempt to retard/reverse venom spread o Fang marks, sometimes will try to confuse you and say that you only see a single mark > still can be a snake > place a light constricting band (do not stop arterial or venous blood flow) o 3 types > rattlesnakes/watermocisons/cottonmouth Placenta Previa • Signs and Symptoms > Painless bright red vaginal bleeding o Takes place in the 3rd trimester > key signs will always be painless bright red bleeding Pneumomediasteinum • Signs and Symptoms > substernal chest pain, irregular pulse, abnormal heart sounds, reduced blood pressure, narrow pulse pressure, change in voice 16 o Esophagus/trachea/great vessels run in this space > air in here pushes on your heart > trauma (torn trachea for example) can cause this or the bends (air bubbles out into this space) > If you put pressure on the heart for any reason it creates narrowing pulse pressure Pneumonia • Signs and Symptoms > chills, deep productive cough, yellow to brown sputum often streaked with blood, pleuritic chest pain o Bacterial or viral > normally it appears first in left lower lobe, especially bacterial > this is the lobe that is the least affected by normal respirations > it is clearly worse to have bilateral pneumonia > classic picture is difficulty breathing, productive cough sometimes described as greenish/yellowish sputum that smells bad, chills makes it more indicative of a bacterial pneumonia > Tx take to the hospital and sometimes a breathing treatment helps Pneumothorax • Signs and Symptoms > Trauma to chest, chest pain on inspiration, hyperinflation of chest, diminished breath sounds on affected side o • Air in the pleural space > open (requires a puncture wound) v. closed (classic name for closed pneumo in an MVA is the paper bag syndrome) > tall skinny male sudden chest pain possible smoker usually onset during exertion (weakens alveoli) likely spontaneous peneumo > sometimes you will see marfrans syndrome used in conjunction with this (it is a connective tissue disease in which the blood vessels are weakened in these people leading to aneurysms) > tension pneumo (JVD/tracheal deviation/decreased lung sounds on one side or the other and sometimes narrowing pulse pressure) > Tx is simply to decompress the chest > tap on a chest that has a tension pneumo the sound is described as hyperresonant (hemothorax is hyporesonant) Treatment (open pneumo) > first step is to cover with a gloved hand and place an occlusive dressing Poisonous Plants and Mushroom Ingestion • Signs and Symptoms > Excessive salivation, lacrimation, diaphoresis, abdominal cramps, nausea and vomiting, diarrhea, decreasing levels of consciousness eventually coma 17 o Most kill us because of an effect on the parasympathetic system > Acronym is SLUDGE similar to organophosphates to describe signs/ symptoms o Most common killer among mushrooms > deathcap mushroom (Amanita phalloides) Pulmonary Contusion • Signs and Symptoms > Blunt or penetrating chest trauma, increasing dyspnea, hypoxia, increasing crackles, diminishing breath sounds, hemoptysis, signs and symptoms of shock o Bruise to the lung (alveoli) > this prevents the air exchange in that tissue and will cause an effect with the pulse ox and the person can be short of breath. This can have a severe effect > some of the blood can leak into the alveoli and produce blood in a cough > there will be a history of trauma to the chest Pulmonary Embolism • Signs and Symptoms > Sudden onset of severe unexplained dyspnea, possible pleuritic chest pain, possible cough, labored breathing, tachypnea, tachycardia o Classic is the 35 yo female on birth control that may smoke and suddenly develops calf pain and shortness of breath > high flow O2 and transport o Also anyone immobilized for a long period of time (travel/hospital bed/ etc) as well as knee and hip surgery > sometimes these people will be in AFib > Homens test use to be done in the field > positive sign was a painful response to the dorsiflextion of the calf > we no longer do this because it is not very accurate and you can dislodge the clot o Thrombus is a blood clot an embolus must be moving and can be anything o Respirations in someone with a PE should be high to compensate for the blockage > this will result in respiratory alkalosis (signs and symptoms are hyperventilation syndrome > numbness and tingling in hands/lips and carpal pedal spasms > no need to treat this in a person with a PE because you don’t want to slow their respirations down > this is not a psychogenic cause) o Suspect this with a pt that presents with pregnancy, long bone fracture, long flight or period of inactivity, sudden shortness of breath Pneumothorax 18 • Signs and Symptoms > sudden onset sharp pleuritic chest or should pain, decreased breath sounds on involved side, hyperresonace to percussion of the chest, tachypnea, diaphoresis, pale Scorpion Stings • Signs and Symptoms > Burning and tingling effect, numbness, slurred speech, restlessness, muscle twitching, salivation, abdominal cramping, nausea and vomiting, seizures o Only one has enough venom to kill us (Bark scorpion > found in Arizona) can sting multiple times Severe Acute Respiratory Syndrome (SARS) • Signs and Symptoms > Sore throat, Rhinorrhea, chills or rigors, myalgias, headache, diarrhea > Severe Signs > cough, sputum production, respiratory distress, respiratory failure o Virus > attacks the upper respiratory system Stroke and Intracranial Hemorrhage • Occlusive > generally have a window of 3-4.5 hours for treatment > thrombosis in the brain > gradual onset > often occurs after a period of rest • Hemorrhagic > complains of the worst headache of their life > bleed in the brain • Signs and Symptoms > Facial drooping, headache, confusion and agitation, dysphasia, aphasia, dysarthria, vision problems, hemiparesis, hemiplegia (half the body is paralyzed), paresthesia, inability to recognize touch, gait disturbances or uncoordinated fine motor movements, dizziness, incontinence, coma o Person with a stroke will sometimes C/O not knowing where a part of their body is (Proprioception) which is the ability to be aware of the location of your body parts. > 19 • o Cincinnati stroke scale is about 97% accurate o Tx > get them to the hospital > never give a stroke pt anything by mouth (part of the esophagus is also affected and it will get stuck) o Most common cause of a stroke is diffuse ischemia to the cerebrum Stroke patient that presents with hyperthermia > probably a malignant stroke affecting the hypothalamus o • generally a fatal complication of the stroke The most common emboli is a thrombi Tension Pneumothorax • Signs and Symptoms > chest trauma, severe dyspnea, ventilation/perfusion mismatch, hypoxemia, hyperinflation of affected side of chest, diminished then absent breath sounds, cyanosis, diaphoresis, altered mental status, JVD, hypotension, hypovolemia • Treatment > O2, Needle thoracentesis, secure catheter in space, create a flutter valve Thyrotoxic Crisis “thyroid storm” • Signs and Symptoms > High fever(106 or higher), irritability, delirium or coma, tachycardia, hypotension, vomiting, diarrhea o Thyroid product gets to its destination by latching onto proteins > if for some reason this product falls off the proteins at one time you would have a thyroid storm > many causes including the ingestion of a large amt of thyroid product (such as medication) can also be caused by illness/trauma/etc > generally death is caused by hyperthermia Tricyclic Antidepressant Toxicity 20 • Signs and Symptoms > Dry mouth, blurred vision, urinary retention, constipation, confusion > severe signs > hallucinations, hyperthermia, respiratory depression, seizures, tachycardia, hypotension, cardiac dysrhythmias o Tx with sodium bicarb > ph normal for blood stream is 7.35-7.45 so raise the ph and create more of an alkaline state that causes the tricyclic to drop off > this causes the dysrhythmias to go away Tuberculosis • Signs and Symptoms > nausea, weakness, fatigue, rapid weight loss, fever, night sweats, cough, chest pain, hemoptysis (coughing up of blood – pinkish froth, mucus) • NIOSH/OSHA standards call for use of N95 respirators when caring for TB pts o Bacterial infection > old name was consumption > normally spread though inhalation > your lungs attack it and wall it off > sometimes the bacteria will become active again and burst out of the sphere in which it is encased and this would result in active TB > it can also be systemic resulting in sores on legs and such Upper GI Bleeding • Signs and Symptoms > Abdominal Discomfort, upset stomach, gas pain, tearing pain in upper quadrants, nausea and vomiting, hematemesis (vomiting of blood), Melena (Black tarry stool), tachycardia o Division between upper and lower gi system is the ligament of tritz > upper is generally in the stomach (coffee ground emesis often from an ulcer or history of ingestion of a caustic substance or alcoholic or long term aspirin use) #1 cause of ulcers in the US is bacteria Upper Respiratory Infection • Signs and Symptoms > Fever, chills, myalgias (muscle pain), fatigue Withdraw Syndrome • Signs and Symptoms > coarse tremor of hands, tongue, eyelids, nausea and vomiting, general weakness, increased sympathetic tone, tachycardia, sweating, hypertension, orthostatic hypotension, anxiety, irritability or a depressed mood, hallucinations, poor sleep 21 Additional Information NORMAL VITALS Age Group Respiratory/min Heart/min Systolic Blood Pressure Birth 30-60 100-180 60-90 Infant (1year) 30-60 100-160 87-105 Toddler (1-3) 24-40 80-110 95-105 Preschool (3-5) 22-34 70-110 95-110 School age (6-12) 18-30 Adolescence (13-18) Adult 12-20 65-110 12-26 60-90 60-100 97-112 112-128 120/80 APGAR > evaluate this score at 1 and 5 minutes following birth 22 Rule of 9’s • Infant > Anterior head/neck (9) > Posterior head/neck (9) > Anterior Arm (4.5) > Posterior Arm (4.5) > Anterior upper Trunk (9) > Posterior upper Trunk (9) > Anterior lower trunk (9) > Posterior lower trunk (9) > Anterior Leg (7) > Posterior Leg (7) • 23 • Respirations are not part of the GCS scale – Scale includes (Verbal/Motor/Eye) Components of the INITIAL IMPRESSION 1. Form a general impression 2. CSpine control as needed 3. Assess baseline mental status 4. ABC’s 5. Determine Priorities RESPIRATORY Fick principle > the way we evaluate oxygenation of blood in the body • Air must be 21% O2 and the proper Torr pressure • Ventilation must occur • Pulmonary respiration > alveolar gas exchange • Transport of oxygenated blood by the heart/blood/circulatory system • Cellular respiration > exchange of O2/CO2 in the cells 24 Chemoreceptors > monitor the levels of O2 and CO2 and pH of the CSF and they provide feedback to the respiratory centers to modify the rate and depth of breathing based on the bodys need at a given time • PaCO2 normal is 35-40 o • The normal persons respirations are driven by their level of CO2 o Thus a pt with a PaCO2 of 60% is breathing too slowly o Increased CO2 = Hypercarbia o Hypocarbia > low CO2 levels in the blood, will present hyperventilating (respiratory alkalosis) with carpal pedal spasms. Blowing off too much CO2 PaO2 normal is 80-100 Rhonchi > mucus in the airway > sounds like blowing bubbles through a milkshake • Crackles > fluid in the lower airways > pulmonary edema Stridor > upper airway obstruction and foreign body airway obstructions and epiglottitis in children older than 3-4 Bilateral wheezes caused by > fluid in the lower airways, asthma > bronchoconstriction (lower airway) Kussmaul’s respirations are for elimination of acid > thus you also see them with an aspirin overdose • Think DKA with Kussmauls Respirations What causes snoring respirations? > soft tissue in the back of the throat (tongue) • With a trauma the first step with snoring respirations is to reposition the airway using the modified jaw thrust maneuver ET Tube placement > in the average adult it requires 15cm to reach the vocal cords • • Intubated patient problem assessment o D > Displacement of the tube o O > Obstruction o P > Pneumothorax o E > Equipment failure Best way to determine good respirations is the end tidal CO2 detector 25 • Aggressive intubation may cause laryngeal edema • Least advised way to insert an ET Tube is Digitally • Sellick’s Maneuver (cricoid pressure) > makes glottis more accessible and prevents regurgitation COPD Pts breath off the hypoxic drive (the amount of OXYGEN in the blood > PaO2) • Hypercarbia > Increased levels of CO2 in the body, common in COPD patients o The hypercarbic patient will be breathing too slow • Main reason to intubate a COPD pt is respiratory distress > so they can save energy • COPD causes core pulmonale > right sided hypertrophy secondary to pulmonic hypertension due to pulmonary vessel constriction • Pulsus Paradoxis > a drop in pulse during inspiration > occurs in any disease that places additional pressure on the heart (COPD, Asthma) o • COPD Patient > air is trapped in the alveoli creating additional mechanical compromise during inspiration What is the most frequent infection that affects smokers? Bronchitis and then pneumonia Surfactant > a liquid protein substance that coats the alveoli in the lungs, decreases alveolar surface tension, and keeps the alveoli expanded; a low level in a premature baby contributes to respiratory distress syndrome • Atelectasis > alveolar collapse that prevents the use of that portion of the lung for ventilation and oxygenation > lack of surfactant also with drowning/chest injury/anything that keeps you from taking a deep breath Respirations > transport O2 and CO2 across membrane • Respirations (gas exchange) > exchange of gases between living organisms and environment • Ventilation (mechanical) is air movement in and out of the lungs > does not guarantee respiration • Tidal volume (500mL) is the average volume of gas inhaled and exhaled in 1 respiratory cycle o 350 of that is in the alveoli, 150 in dead space 26 • Hering-Breuer Reflex > stretch receptors that prevent the lungs from over expanding What gives you the best seal when using a BVM > E-C 2 person BVM use Best way to monitory respiratory status is > End tidal CO2 Monitor Nasal intubation is contraindicated with presence of apnea Primary concern of Cheyne-stokes respirations is minute volume (breathing too fast) Pulmonary edema > treated with nitro/lasix/morphine Terbutaline > a selective beta 2 agonist that can be used as a breathing treatment Kussmaul’s Sign > flat jugular veins > rise on jugular veins on inspiration • As you breath in pressure in the chest rises and the pressure on the heart is increased > this causes blood to backup (COPD/Asthma) Succinylcholine dose is 1-1.5 mg/kg > this is a drug used for RSI Phrenic nerve controls the diaphragm Person coughing > possible TB > what is the best BSI to take > place N95 respirator on yourself > never place the respirator on the patient Lungs contain the Beta2 receptor sites and are made up of smooth muscle CARDIOLOGY – CIRCULATORY Coronary Artery Disease (CAD) > any abnormal condition that effects the hearts arteries that produces various effects, especially reducing the flow of O2 and nutrients to the myocardium. Coronary arthrosclerosis is the leading cause • the most common form is atherosclerosis (soft plaque buildup > also occurs in the carotid arteries) blood swirling noise is a bruit o Arthrosclerosis > occlusion of arteries with fatty deposits and cellular debris > caused by diabetes, smoking, obesity, HTN o Arteriosclerosis > calcification of the arteries causing loss of elasticity > caused by HTN and diabetes Prinzmetal’s Angina > caused by a coronary artery spasm (which is an abnormal or involuntary constriction of the muscle in an artery of the heart). 27 • A form of unstable angina resulting in recurrent episodes of chest pain while at rest • Spasm usually occurs near a blockage or area of atherosclerosis > often experienced at night CHF > Pedal edema, ascites - excess fluid in the space between the tissues lining the abdomen and abdominal organs (the peritoneal cavity), pulmonary edema (right side failed first) • CHF Patients > why intubate? > they will get tired of breathing Right sided failure presents with peripheral edema, ascites (fluid in abdomen), tachycardia, JVD • Vital signs associated with right sided failure > increased blood pressure, increased heart rate, normal respirations • Cor pulmonale > heart disease that develops secondary to chronic lung disease, usually affecting primarily the right side of the heart > right sided hypertrophy secondary to pulmonary HTN commonly due to COPD Classic sign of left heart failure is pulmonary edema • Pt presents with chest pain and he is placed on 12 lead that shows ST elevation in leads 2/3/AVF > this means what > he is having an inferior wall MI affecting the L ventricle > the pt has pulmonary edema. Why? > a backup in the system > back pressure due to the left ventricle not filling up and causing increased hydrostatic pressure in the lungs • Left side heart failure > pulmonary edema, cyanosis, tachycardia, SOB, rales, coughing, blood tinged sputum • Wheezing in cardiac pt caused by left side failure and fluid in the lungs is known as cardiac asthma Pulses Alterans • Occurs with Left heart failure/dysfunction • Ejection fraction with Left failure will decrease causing reduction in stroke volume > tachycardia may initially occur to compensate > after this first cycle the next cycle is effected by the increased blood volume remaining in the heart (causes the heart to stretch more) and increases the heart contraction. Thus there is a weak > strong > weak > strong pulse quality alternation • A mechanical problem Electrical Alterans 28 • An effusion (fluid) around the pericardium can blanket the electrical activity of the heart > the electrical amplitude will appear to be strong to weak to strong to weak • Associated with pericarditis and may be accompanied by atrial arrhythmias Pulses Paradoxis • A marked drop in pulse during normal quiet inspiration > typical finding in cardiac tamponade, less common in pericarditis, COPD • Air trapped in lungs > pressure gets greater with inspiration • Pulsus paradoxus > lungs impinging on the heart > involves a drop in Bp of 10 or more Stokes Adams Syndrome > a condition involving sudden fainting which usually lasts for less than a minute and may include seizures. Before the attack the pt becomes pale and during recovery the pt often feels hot and flushed. The fainting occurs when there is a lack of O2 to the brain due to heart rhythm problems involving slowing of the heart • Transient heart blocks are common cause • Overdose that commonly causes stokes adams due to causing heartblocks > digitalis (causes cardiac dysrhythmias and heartblocks) Calcium channel blockers • Anti-hypertensive > blocks cellular uptake of calcium > decrease in SA and AV node automaticity > slow conduction of AFib and Aflutter • Verapamil 2.5-5mg • Cardizem 0.25mg/kg • Chief side effects are hypotension and bradycardia • Calcium channel blocker OD treated with calcium Beta Blockers > blood pressure medication • Blocks beta 1 and beta 2 receptor sites • Decreases heart rate and Bp • Propranolol (beta 1/beta2 blocker) > for OD give glucagon • Acebutolol 29 • Esmolol • Metoprolol (lopresser) • Ateneolol > beta 1 specific (tenorium) • Beta blocker overdoses are sometimes treated with insulin Aortic aneurysm > separation of the tunica media from the tunica adventia > pain is referred to the left shoulder, upper back, possible chest pain • Chest pain that radiates towards the back > aortic aneurism > will have deficit pulses on one side • Called to the scene where you find an old woman complaining of flank pain and abdominal pain that gets worse with palpitation? Think AAA (history of HTN) • Ascending aortic aneurysm > AAA > pain referred to lower back, possible pulsating mass in abdomen and feeling of an impending bowel movement o AAA > radiates to the hip > presents with a Hx of hypertension but may be hypotensive now > may need to poop or have a pulsating mass • 57 yo male in cardiac arrest, supine, pain in back for several days > AAA • Common cause of idioventricular rhythm is AAA • Tall and skinny people tend to be more prone to Aneurysms • Thoracic aneurysm will have tearing chest pain that radiates to the back/ shoulder blades > there will likely be a radial pulse discrepancy A 67yo M was working in his garden when his wife saw him collapse. She calls 911 and meets you as you arrive on the scene. She states her husband had nausea all morning and complained of low back pain about 1 hour prior to his collapse. He has an hx of hypertension which is controlled by medication. Your assessment reveals no pulse and the pt is apneic (absence of breathing). The pt also has a large distended abdomen. The monitor shows an idioventricular rhythm > what is you impression? How do you treat it? What was the most likely cause of his arrest? • AAA > CPR (PEA algorithm) • Idioventricular rhythm generally associated with hypovolemia • HTN > consider MI/aneurysm/stroke Marfan Syndrome > a connective tissue disorder > it is inherited and affects many parts of the body. Marfan syndrome can lead to a AAA (the aorta weakens and tears – aortic dissection) 30 MI > death of cardiocytes (Myocyte is a muscle cell) • Best sign of an MI > Crushing Substernal Chest Pain • Levine’s sign is when they put their hand across their chest • Nitro and morphine when used to treat an MI are being used to Decrease preload • Sometime treated with NaHCO3 (sodium bicarb) because the pt went into acidosis as a result of the lack of perfusion from the MI, cells moved to anaerobic metabolism and generate acid. • Describe the actions of ASP (ASA) and why it is used to treat an MI > ASA does not break up clots or thin the blood > it is a platelet aggregate inhibitor > platelets become more slippery keeping the clots from getting larger o The body’s clot response > generally will wall the clot off with a thin membrane over the plaque buildup in a coronary artery > contributes to an MI because this can break apart and create a mobile clot o Acetylsalicylic acid also found in willow tree and in oil of wintergreen Angina > there is no injury to the cardiac tissue Heart sounds • S1 > mitral and tricuspid (Lub) • S2 > atrial and pulmonic valves (Dub) • S3 > CHF (Kentucky) seen in older adults/elderly with heart disease > often indicates CHF > indicative of valve failure • S4 > CHF (Tennnessee) sound heard just before S1 > often indicates CHF Note location of positive and negatives in various leads 31 Note the views offered by each of the given leads Note location of key anatomical features of the heart The heart is a sodium potassium pump which requires energy in the form of ATP created by aerobic metabolism • Resting potential > normal electrical stage of a cardiac cell > K inside/Na outside 32 • In action potential the cardiac cell depolarizes • Repolarization is the movement back to resting potential Cardiac output (CO) = Stroke Volume (SV) x Heart Rate CO=SVxHR Starlings law > states that the greater the volume of blood entering the heart during diastole (end diastolic volume) the greater the volume of blood ejected during systolic contraction (stroke volume) • Loss of this efficiency is CHF Cardiac Plexus > a nerve plexus of the autonomic nervous system supplying the heart and neighboring structures > situated near the heart and the arch and ascending part of the aorta • Area supplies heart with sympathetic nervous system connection • Vegas nerve is the parasympathetic connection Blood and IV fluids have the same osmolarity (Isotonic) Rhythm Hallmarks • VFib > chaotic and irregular > no pulse/no breathing • 1st degree heart block > long PRI • 2nd degree Wenckebach type 1 > PRI grows then drops a beat • 2nd degree Type 2 classical block > PRI constant with the conducted beats/ dropped beats present • 3rd degree complete block > No correlation between the P’s and QRS’s • Junctional Rhythms > No Pwave or an inverted Pwave VTach is fast regular and wide complex • Stable VTach > Amiodarone 150mg IV over 10min (repeat as needed to max dose 2.2g/24 hours) • Unstable VTach > Synchronized Cardioversion Asystole on the monitor > Step 1 is to check another lead • CPR > Epinephrine 1mg IV/IO every 3-5 min > Atropine 1 mg IV/IO (asystole or sloe PEA) • Does not get paced 33 • CPR is being performed on an elderly pt at a nursing home > monitor shows asystole > next move is to check it in another lead Vagal maneuvers (Valsalva maneuver) will work only on the supraventricular tachycardias • They sometimes try to get you to use this maneuver on other rhythms • #1 cause is Wolf Parkinson White Syndrome – tell tale sign is short PR Interval and the delta wave – Reentry phenomena > (delta wave > slurred upstroke of QRS complex) • SVT is over 160 beats and regular generally o What is the initial treatment for a pt in SVT who is stable?  Vagal down then give 6mg of Adenosine (6>12>12) Most common re-perfusion dysrhythmia > second degree type 1 block (Wenckebach) When ST Elevation is seen across all leads think Pericarditis > pt may present with chest pain and flu like symptoms Prehospital care of a pt in atrial flutter without signs of shock would be treated with > IV, O2, Supportive care, transport. Absolute refractory period > a short period immediately after depolarization in which myocytes are not yet repolarized and are unable to fire or conduct an impulse When does the relative refractory period begin? • The period between the effective refractory period and the end of the refractory period; a period of a few milliseconds following the absolute refractory period during which the excitation threshold of neural tissue is raised and a stronger than normal stimulus is required to initiate an action potential. • At the apex of the T wave Becks Triad > associated with Cardiac Tamponade (trauma/pericarditis) > needs caridocentesis • JVD • Muffled Heart tones • Narrowing pulse pressure 34 Lidocaine calculation 2g in 500mL so 2000mg/500mL = 4mg/mL > infused at 2mg so that is 30 drips/min Dopamine is 800mg in 500mL reduce the mg to micrograms 800,000 micrgrams/ 500mL > 1600 micrograms/mL > administer 2-10micrograms/kg/min Nitro > dilates the coronary arteries (reducing the workload on the heart) • Provides more room for blood to get though the vessels to ischemic areas • Decreases the preload and Bp Morphine sulfate overdose > depression of the respiratory drive (Narcan to reverse) Digitalis toxicity > heartblocks and yellow vision Lidocaine overdose > numbness, tingling, and seizures Hypertensive emergency treatment > IV at TKO, O2, transport o Signs/symptoms > headache, blurred vision, bloody nose (epistaxis), Tinnitus (ringing in ears) Claudication > decrease in arterial perfusion of the calf muscle > pain when walking > relief if you stop walking. Central vein access > concern for pneumothorax and pericardial tamponade Orthostatics are the same as a tilt test You find a 42yo M who has experienced a sycope episode while playing golf. He is now complaining of dizziness and nausea. His Bp is 70/40, you apply the monitor and see sinus tach with a rate of 160, after giving him O2 and fluid challenge with no change you would do what? • Assume this is cardiac related and perform a 12 lead > with back pain you should also have concern about a AAA Angiotensin causes blood vessels to constrict and drives blood pressure up o Renin/angiotensin system is designed to keep the blood pressure up o Kidney activates angiotensin 1 > sent to the lungs converts to Angiotensin converting enzyme (ACE) > converted to Angiotensin 2 (causes vasoconstriction and secretion of aldesterone which makes the body hold water and drives the Bp up. LDL = bad cholesterol > HDL = good cholesterol (it’s good to be high) 35 Hypocalcaemia > low levels of calcium in the blood > leads to arrhythmias (as in any electrolyte imbalance) > a “relative” hypocalcaemia is commonly produced due to hyperventilation syndrome IV flow is least affected by the length of the catheter as opposed to its diameter Poiseuille’s law > the law that the volume flow of an incompressible fluid through a circular tube is equal to pie/8 > essentially the larger the diameter the more fluid can go though the tube to the 4th power Pulse pressure is the difference between the systolic and diastolic pressures • MAP (Mean Arterial Pressure) is 1/3 pulse pressure + Diastolic • MAP = Diastolic Pressure + 1/3(Systolic-Diastolic) Beta 1 response to Epi is increased heart rate NEUROLOGY Anatomy • Cerebrum > Higher thought and judgment, sight, memory, cognitive function • Cerebellum (Athletic Brain) > controls balance and fine motor control • Parasympathetic neurotransmitter > acetylcholine o • Works on the vagus nerve Sympathetic neurotransmitter > norepinephrine o Works on the Beta, Alpha, and Dopaminergic Receptor sites • Cerebral Spinal Fluid > floats the brain (50% of the sugar volume in the entire body) • Brain 3-6 seconds without perfusion > this is followed by a loss of consciousness Cranial Nerves • 3rd Cranial Nerve (oculomotor) > allows for pupil constriction and eye movements 36 o With a head injury and brain swelling you sometimes see constricted pupils > this is due to pressure on the tentorium of the brain which is the location of the 3rd CN • 5th Cranial Nerve (Trigeminal) > Trigeminal Neuralgia (Tic de Leroux) > a painful condition of this nerve which is responsible for most facial sensation • 7th Cranial Nerve (Facial) > Bells Palsy is swelling of the 7th CN due to an immune or viral disorder > causes facial paralysis and is commonly mistaken for stroke • 10th Cranial Nerve (Vagus) > parasympathetic nerve connection between brain and numerous organs Seizure Stages • Aura > a sensation the pt gets before a seizure • Tonic Phase > Body wide rigidity (tense>relax>tense) • Clonic Phase > rhythmic contraction of major muscle groups > arm, leg, head movements, lip smacking, biting, teeth clenching • Postseizure > major muscles relax > eyes may roll back • Postictal > reset period for the brain > may last several minutes to several hours Types of Seizure • General seizure > whole body • Partial seizure > just part of the body • Pseudoseizures > these are fake seizures • Grand mal seizure > (tonic/clonic) > unconscious with entire body muscle contraction alternating with jerking phase • Petit Mal Seizure > 10-30 seconds of seizure (called an absence seizure) > marked by starring episodes or the loss of motor control 37 • Status Epilepticus > seizure that lasts for longer than 4-5 minutes or 2 or more seizures back to back. o Tx is valium > Flumazenil (Romazicon) will reverse Valium • Anticonvulsants > Dilantin, Tegretol, Dopakote • Epilepsy is a common chronic neurological disorder that is characterized by recurrent unprovoked seizures Benzodiazepines > sedative hypnotic drugs that provide muscle relaxation and mild sedati