Medical Notes on AAA and Related Conditions PDF

**THE FINAL!** **[AAA]** - Symptoms - Pain - Dull, vague pain in the abdomen, back or flank - Can be acute and severe in ruptured AAA - Mass - Sensation of a pulsatile mass in the abdomen - Hypotension - Usually manifesting as sync...

**THE FINAL!** **[AAA]** - Symptoms - Pain - Dull, vague pain in the abdomen, back or flank - Can be acute and severe in ruptured AAA - Mass - Sensation of a pulsatile mass in the abdomen - Hypotension - Usually manifesting as syncope - Occurring in cases of ruptured AAA - Associated complications - Diminished femoral pulses - "Blue Toe" Syndrome - Due to micro emboli from aortic thrombus - Duodenal obstruction leading to vomiting and weight loss - Vertebral body erosion leading to sever back pain - Where is the best place for a AAA to rupture? - Best place for them to rupture is in the back or posterior because it can tamponade and hold pressure on itself, if its anterior and it ruptures you are DEAD DEAD - Grey turners sign - Flank ecchymosis - Severe severe back pain! - Treatment: - Medical management - Control hypertension, quit smoking and control other risk factors - Could give a STATIN and/or an ACE inhibitor they can be beneficial - Those with small aneurysms 4.0 to 5.4 should have monitoring using an ultrasound or a CT every 6 to 12 months - Those that are smaller than 4.0 should be monitored every 3 years - An open repair is harder on the patient, there is cross clamping and you will have to monitor kidneys and urine output as well as pedal pulses and to make sure the extremities can still move properly. - Also make sure that you are keeping everything as normal as possible due to if they get too excited the graft can bust or too low it can clot off and cause more issues. - Monitor neurologic status, peripheral perfusion status and renal perfusion status. **[Hemodynamic Monitoring]**  **[Hemodynamic Monitoring]** - CO - Normal cardiac output is 4-8 liters - Heart rate X stroke volume - CI - Normal cardiac index is 2.5 to 4.5 liters - SV - Is the amount of blood ejected from each ventricle with each heartbeat - Normal amount is 50-100 ml/beat - Right and left ventricle eject the same amount - Example: Heart rate is 100 bpm - Stroke volume is 50 ml/beat - Cardiac Output= 5000ml/beat or 5 L/min - SVR - SVR is the resistance of the systemic vascular bed - Systemic vascular resistance - Normal value is 800-1200 - Opposition encountered by the left ventricle - PVR - PVR is the resistance of the pulmonary vascular bed. - Pulmonary vascular resistance - Normal value is 50-250 - Normally one sixth of the SVR - Opposition encountered by the right ventricle - Potential complications of a Swan Ganz Catheter - Air emboli, thromboembolism, catheter displacement, infection, inaccurate pressures, **[Cerebral Perfusion Pressure]** - CPP=Pressure needed to ensure blood flow to brain - CPP=MAP-ICP - Which ever is highest - Know how to do the calculation - Normal cerebral perfusion pressure is 60-100 - Factors that affect cerebral blood flow - Trauma and bleeding **[ICP]** - Some factors that influence the ICP: - Arterial pressure - Venous pressure - Think MAP - Posture - Keep the head of the bed up, you do not want them to lay flat - Normally ICP is less than 15mm HG - If its greater than 20 then we are concerned for the brain matter - If you do not intervene with increased ICP then you can have pockets of infarction in our brain - Neuro assessments are KEY - To monitor the external transducer needs to be level at 0 at the foramen of Monro at the tragus at the ear it needs to be leveled and zeroed, and anytime you move them re-zero it! - Keep the patient at 30 degrees to be able to drain the cerebrospinal fluid - 20-30 ml of cerebrospinal fluid an hour and you need take it off slowly if you take it off too fast its bad juju - If you lay them flat or roll them and them put the head of the bed back up you can have Dumping - Signs of increased ICP - Decerebrate posturing (extensor) arms away from the body - Decorticate posturing (Flexor) arms close to the body - Headache often continuous and worse in the morning - Vomiting with no nausea and projectile! - Changes in level of consciousness - Affect goes from calm, cool and collected to agitated as hell to comatose - Cushing Triad! - Systolic hypertension - Bradycardia - Irregular respirations - HIGH fever! - Make sure to keep them in the dark and quiet, limit the bugging of the patient and cluster care but you want them to stay calm and quiet, don't touch - DRUG THERAPY - Mannitol (osmitrol) - Plasmic and osmotic effect can cause pulmonary edema and CHF - Decreased cerebral spinal fluid production - Hypertonic saline solution 3% saline- or normal saline - Low sodium can cause brain issues! - Monitor blood pressure- hypotension and sodium levels! - Can cause potassium shifts - Move massive amounts of water out of the brain cells and shove them back into the blood that's how we get the brain swelling to go down - **[IT CAN BE A FIRST LINE TREATMENT, especially if the patient has sodium problems as well as swelling in the brain]**! - Corticosteroids - Seen with brain tumors we do not give steroids to pts with a traumatic brain injury just tumor pts - Monitor glucose levels! Hyperglycemia and infections, because infections love sugar, and monitor GI bleeding - You will also see a pt on a stomach pill due to steroids - Lasix - We give these 4 drugs to decrease brain swelling - Antipyretics - Cooling blankets, never let them shiver, it will increase pressures - Barbiturates - Not common, but can use if nothing else is working we can give these as a sedative. Continuous EEG (continuous brain waves) - Antiseizure medications - Because they are prone to seizures **[Cerebral Vasospasms/subarachnoid Hemorrhage]** - Silent Killer - You have no signs and symptoms until it happens - Worse headache of their life - HHH Therapy - Hypertension, hypervolemic, hemodilution - Calcium channel blocker for "brain protection"-in effort to prevent vasospasm\-\-- - Most frequent surgical procedure to prevent rebleeding is clipping of the aneurysm. - Coiling is another procedure - Protect the brain **[Brain Death ]** - How do you test for brain death? - Oculocephalic (doll eyes) - Assessing cranial nerves, eyelids are held open Dr. shake the patients head from side to side, if the eyes deviate from opposite side that the head is going, if the eyes do not move they are brain dead - Oculovestibular (cold water in the ear) - Apnea Test- - Are they able to breathe on their own, shut the machines off and if they cant breathe after 1 minute they meet brain death criteria **[Ischemic Stroke Vs Hemorrhagic Stroke ]** - CT First to establish whether there is a bleed or not - Ischemic Stroke- they are not bleeding - Time of onset is KEY - Remember FAST - Facial drooping, arm weakness, and slurred speech and TIME! - 60 minutes time limit to get that MED after you get stroke like symptoms - Hypertension is common after a stroke - TPA is common but do a CT first - GI bleed, previous head trauma or stroke in the past 3 months or a major surgery within 14 days or any internal bleeding within 22 days or any type of bleeding it can lead to problems - Aspirin is used within 24 to 48 hours of stroke - Platelet inhibitors and anticoagulants - May be used in thrombus and embolus stroke patients after stabilization - Hemorrhagic stroke - They are bleeding! DO NOT give them anticoagulants, and platelet inhibitors are contraindicated DO NOT give TPA! They will bleed out and DIE - HHH Therapy - Hypertension, hypervolemic, hemodilution **[Traumatic Brain injury ]** - Raccoon eyes - Severity depends on how bad it is - Can cause PTSD - Get a hobby, no alcohol, no street drugs etc. **[Ventilator ]** - PEEP: positive end-expiratory pressure - Maintain airway pressure at the end of expiration - Makes the alveoli stay open longer - High level of PEEP may lead to barotrauma, decreased cardiac output - Use caution in pts with a brain injury, increased ICP, low cardiac output and hypovolemia - YOU HAVE TO WATCH FOR CARDIOVASCULAR ISSUES, DECREASED CARDIAC OUTPUT! - PEEP IS USUALLY -5-10 if they are at a 5they are ready to be extubated - ACV: assist-control ventilation - Breaths are delivered at a set rate and tidal volume - When a pt has a breath of their own, they will still get set tidal volume, the rate will never fall below the rate set by the vent - Used for patients who do not have spontaneous breaths or need assistance in breathing - It doesn't matter if the machine is breathing for them or they are breathing themselves its set rate no matter what. - SIMV: synchronized intermittent mandatory ventilation - Breaths are delivered at a set rate and tidal volume - When the patient initiates a spontaneous breath the preset tidal volume is NOT delivered. The pt must self-regulate the volume of spontaneous breaths - If you are breathing over the vent that's on you, that's your own tidal volume. - PS: pressure support ventilation - Preset level of positive airway pressure so that gas flow is greater than pts inspiratory flow rate - Reduces the work of breaths - Pt self regulates their respiratory rate and tidal volume and can be used with SIMV so the patient doesn't fatigue - THEY HAVE TO BE ABLE TO INITIATE THEIR OWN BREATHS **[Greatest control to the least control ]** - PC-IVR - PC - CMV/ACV - SIMV-PS - SIMV - CPAP **[Noninvasive ventilation!]** - People who do not want to be intubated - Comfort care patients - They have to be able to get the mask off so they do not aspirate if they vomit - Continuous positive airway support (CPAP) - Restores functional residual capacity and is similar to PEEP, The pressure is delivered continuously during spontaneous breathing and prevents the patients airway pressure from falling to 0 - Provides 1 level of positive pressure support. As they breathe in and breath out, they wear a tight fitting mask and it does increase the work of breathing because they have to exhale against the pressure. - Use caution in using a cpap with a person with heart problems because they are already tired and this makes them tire out more. - Bilevel positive airway pressure (Bi-PAP) - Provides 2 levels of positive level pressure, the patient must be able to spontaneously breathe and cooperate with this treatment - The patients have to be able to take the mask off themselves, they have to be awake and alert enough and able to breathe spontaneously to get support from these two devices - Good seal and good fitting mask, no secretion at risk of aspiration or altered mental status, they will need a sitter at the bedside to keep them from pulling it off **[Intubation drugs]** - Common Sedation agents - Benzodiazepines: Ativan (lorazepam), Versed (midazolam) - Antidote flumazenil (Romazicon) - Propofol (Diprivan) - Dose related effects - Doses of 5-50 mcg/kg/min produce state of deep sedation - Common NMB agents - Zemuron (rocuronium) - Norcuron (vecuronium) - Tracrium (atracurium) - Pavulon (pancuronim) - Succinylcholine ***[RAPID SEQUENCE INTUBATION DRUGS]*** - Common sedating agents - Etomidate - Ketamine - Propofol/Diprivan- max is 50 any more that goes into anesthesia - Half life is 2-4 minutes - You need to change the tubing at least every 12 hours and they have to have a dedicated IV line for this drug and its own pump - Versed- - Common paralyzing agents - Emuron (Rocuronium) ROC - Norcuron (Vecuronium) VEC - Succinycholine SUC - NEVER EVER EVER GIVE RSI drugs until the provider is at the bedside - How deep are they sedated? - Raas scale - How sedated someone is- the goal is 0 to a negative 2 - The higher the negative number the less sedation they are SNOWED - The higher the positive number the more sedation they need they are going to be swinging if they are at a 4! - CPOT- Monitor pain level- agitated, blood pressure, get an assessment of what the patient looks like most of the time you just put them on a fentanyl drip - Train of 4 - Delivers 4 successful stimulating currents to elicit muscle twitching - Goal is 1-2 twitches out of 4 - 0 twitches they are either brain dead or way to SNOWED! Check the box first and see if something is wrong with it, if there's not the pt is brain dead. **[ABGS ]** - Ph- 7.35-7.45 - PaCO2- 45-35 Respiratory - HCO3-22-26- metabolic - Acidosis Alkalosis **[End Stage COPD]** - Can cause pulmonary hypertension and Cor Pulmonale (right sided heart failure) - Small meals, they cant breathe so they need smaller meals - Rest - Bronchodilators - Corticosteroids - Prone to get infections so make sure you keep them safe from infections **[Esophageal Varices]** - Enlarged swollen veins 2^nd^ to portal hypertension - Fragile tissue bleeds easily - Massive hemorrhage is life threatening - Watch for coarse hard/ sharp foods - Alcohol - Acid reflux - NSAIDS - Drug therapy - The goal is to stop the bleeding - Sandostatin - Vasopressin- but this can cause issues with the heart so its not given very often - Nitro - Nonselective beta blockers - How do you treat those? - Endoscopic ligation - Banding of varices or clip ligation - Balloon tamponade - But monitor airway with the balloon tamponade **[Acute Pancreatitis]** - Abdominal pain that is close to the belly button and radiates to the back its caused by fatty foods!, bowel sounds are decreased or absent, low grade fever, grey turners sign, Cullen's sign, SHOCK- Atelectasis can go into pneumonia! - Can give Demerol or Dilaudid IV for pain - Anticholinergics - H2 blocker/PPI like Zantac or Prilosec - Pt should be NPO **[Cirrhosis ]** - You know this don't worry about studying it - But avoid alcohol, aspirin, acetaminophen and NSAIDS **[Hepatic encephalopathy]** - Terminal complication of liver disease - Associated with rising ammonia levels - (Normal 15-45 mcg N/dL ) - Liver unable to convert ammonia to urea - Results in cerebral edema - Asterixis - Flapping hand tremor-early sign! - You have bad bad breathe - Give Lactulose to poop out the ammonia **[HHS VS DKA]** - DKA - Diabetic ketoacidosis - Ketosis - Type 1 mostly get this type 2 can but less likely - Precipitating factors - Illness/infection- think fever and GI issues like vomiting and they aren't taking their insulin because they are not eating - Undiagnosed diabetes - Malfunctioning pumps - Manifestations - Dehydration- thirsty, warm flushed dry skin, - Metabolic acidosis- Kussmaul respirations - Polyuria - Polydipsia - Generally more rapid onset - Acidosis is the key feature - Fruity breath - Respiratory manifestations - Glucose levels are generally lower than HHS - HHS - Less common than DKA it affects type 2 diabetics - Can be confused all the way to comatose and is deadly if left untreated - Sky high blood sugars - Severe osmotic diuresis - Manifestations - Severely dehydrated and cannot get enough to drink - Altered LOC - Polyuria, - Seizures - Common causes - UTIS - Pneumonia - Sepsis - Any illness - Newly diagnosed type 2 diabetes - Generally lower in onset - Acidosis isn't likely - No fruity breath - Respirations not as rapid - Glucose levels generally higher than DKA **[Hyperthyroidism]** - Myxedema - Puffiness - Facial and periorbital edema - Mask like affect - Older adults - Myxedema coma - Bad juju - Thyroid storm/crisis - Caused by infection, trauma, emotional stress, DKA, digitalis toxicity, graces disease and thyroidectomy - Manifestations - Hyperthermia, hypertension, tachycardia, dyspnea, heart failure, shock, Abd pain, vomiting, diarrhea, agitation, confusion, psychosis. - Cool them down, replace fluids, stabilize heart, administer 02, - Give them TAPAZOLE, IODINE, AND PROPANOLOL **[Retroperitoneal aortic rupture]** - If intra-abdominal hemorrhage is suspected - *focused abdominal sonography for trauma* (FAST) to determine the presence of blood in the peritoneal space (hemoperitoneum) - Medical Emergencies\*\* - FAST EXAM **[Suctioning ]** - Every 2-4 hrs. and PRN unless contraindicated - Pre-oxygenate - Don't exceed 10 sec - Monitor O~2~ sats and EKG for dysrhythmias - NO NORMAL SALINE in ETT! **Elevated Potassium TX** - Calcium gluconate - Bicarb - Insulin - Glucose - Kayexalate (exchanges sodium or K+) POOP IT OUT! - dialysis **[Chronic And Acute Renal Failure]** - acute kidney failure - sudden loss of kidney function caused by an illness, injury or a toxin that stresses the kidneys - potentially reversible if caught early enough - Always put them on a cardiac monitor! - Chronic kidney disease - A long and usually slow process where the kidneys lose their ability to function - Hemodialysis - Requires rapid blood flow and access to a large blood vessel - FAST you do this one if you need shit done ASAP - CRRT - Continuous renal replacement therapy - Method for treating acute kidney injury - Continuous rather than intermittent - Can be done at the bedside - Peritoneal Dialysis - Dextrose osmotic agent **[MI]** - Unique to each individual patient - Ranging from no symptoms to sudden cardiac arrest - Chest pain radiating to neck, jaw, shoulder, back, or left arm, tightness - May be epigastric (indigestion) - May deny pain but describe vague feeling of discomfort - May include shortness of breath, cold sweat, weakness, paresthesia's of arm, nausea and vomiting - DELAY HISTORY TAKING IF IN PAIN - Aspirin - 81-325 mg chewable or swallowed - Nitrates - SL, IV, topical - Monitor the blood pressure, it can bottom out the blood pressure because it promotes vasodilation - Helps coronary collateral circulation - Myocardial oxygen consumption - Morphine Sulfate - IV, 2-8mg diluted in NS - Monitor respiratory rate - Antidysrhythmic - Beta-adrenergic Blockers - Propranolol (Inderal), Metoprolol ( Lopressor), Atenolol (Tenormin) - Calcium Channel Blockers - Nifedipine (Procardia) - Ace Inhibitors - Helps when left ventricle is impaired **[STEMI Vs NSTEMI]** - STEMI- - Transmural is all the way through the layers - Floppy movement at risk for heart failure - Q-wave- MI may result in a development of a wide deep q wave - ST segment elevations - T wave changes - Enzyme elevations - Reciprocals - Can give thrombolytic therapy drugs to bust the clots up but got to give within 30 minutes of arrival to the ED, the window of therapy is 6 to 8 hours if any longer not a candidate- can cause crazy bleeding - NSTEMI - Doesn't go all the way through the layers - St segment depressions - T wave changes - No Q wave development - Mild enzyme elevations - No reciprocals **[Stable Vs Unstable Angina ]** - Three types of angina - Stable - Classic angina/ effort angina - Unstable Angina - Crescendo angina - Variant angina - Prinzmetal angina Electrolytes issues and how they look on a strip IABP - Monitor vitals, and urinary output because it can slip out, level of consciousness, - On blood thinner as well **[Name That Rhythm ]** C:\\DOCUME\~1\\emclimor\\LOCALS\~1\\Temp\\\\msotw9\_temp0.bmp **Sinus Brady** - below 60 bpm - causes- - Valsalva maneuver, vagal stimulation - treatment - Symptomatic - atropine, dopamine, pacing, epi if symptomatic - Asymptomatic - Eh just watch it  **Sinus Tachy** - 101-180 bpm - Causes - Exercise, fever, pain, hypotension, hypovolemia, anemia - Treatment - Asymptomatic/Stable - Vagal - IV betablockers - Metoprolol, adenosine, calcium channel blockers - Symptomatic/unstable - Synchronized cardiovert that bitch C:\\DOCUME\~1\\emclimor\\LOCALS\~1\\Temp\\\\msotw9\_temp0.bmp **Idioventricular escape** - You are an idioit if you swim with upside down sharks  **Sinus Arrythmia** - More common in kids - Speeds up and slows down with breathing C:\\DOCUME\~1\\emclimor\\LOCALS\~1\\Temp\\\\msotw9\_temp0.bmp **SVT- Atrial tachycardia** - 150-250 bpm - The p wave has an abnormal shape or hidden in the t-wave - Treatment - Stable - Vagal, - IV adenosine is the drug of choice to convert svt back to normal sinus - Iv beta blockers - Calcium channel blockers - Unstable - Synchronized cardiovert but ablation if reoccurring  **A FIB** - 350-600 bpm - New onset call provider - Treatment - Stable - Calcium channel blockers - Cardizem - Digoxin - Unstable - CCB, Digoxin, cardiovert, but will need anticoag to prevent clots! C:\\DOCUME\~1\\emclimor\\LOCALS\~1\\Temp\\\\msotw9\_temp0.bmp **PAC** - Theres an extra beat and the p is upright - Think nursing kids! Stress and overly caffeinated - Treatment - Asymptomatic - Nothing - Symptomatic - Lay off the caffeine and can use betablockers  **Asystole** - They dead, CPR and EPI, no shockable rhythm C:\\DOCUME\~1\\emclimor\\LOCALS\~1\\Temp\\\\msotw9\_temp0.bmp **A-flutter** **Sawtooth** - 200-350 bpm - Treatment - Stable - CCB- Cardizem, digoxin, - Ablation is treatment of choice - Unstable - Synchronized cardioversion, adenosine- let the beat drop! - Anticoag therapy to keep from getting CLOTS!  **Normal sinus with a PJC** - No p its hidden if you don't see it think of it as inverted - Looks like a unicorn horn - C:\\DOCUME\~1\\emclimor\\LOCALS\~1\\Temp\\\\msotw9\_temp0.bmp **Junctional escape** - The p wave escaped - Treatment - Asymptomatic - Atropine if the heart rate is slow - Symptomatic - pace  **Normal Sinus Rhythm** - Don't make it something it isn't C:\\DOCUME\~1\\emclimor\\LOCALS\~1\\Temp\\\\msotw9\_temp0.bmp **VTACH** **Tombstones!** - Treatment- - Stable - Cardioversion-sedate them if time allows so give lidocaine and amiodarone - Unstable - Amiodarone, lidocaine, immediate DEFRIBULATION, CPR  **1^st^ degree heart block looks like normal sinus but it isn't the pr interval is a little long** C:\\DOCUME\~1\\emclimor\\LOCALS\~1\\Temp\\\\msotw9\_temp0.bmp **3^rd^ degree heart block** There are more Ps than there should be -cat ears - Treatment - pacemaker  **PVC unifocal** - treatment - symptomatic - lidocaine, amiodarone C:\\DOCUME\~1\\emclimor\\LOCALS\~1\\Temp\\\\msotw9\_temp0.bmp **Mobitz 2 classical** They are classy they stay together Extra p waves - treatment - transcutaneous pacing - temporary pacemaker  **VFIB** You need to d fib shock the shit out of them - Treatment - DEFIB the VFIB - C:\\DOCUME\~1\\emclimor\\LOCALS\~1\\Temp\\\\msotw9\_temp0.bmp **Wenckebach** - Treatment - Asymptomatic - Observe, have transcutaneous pacer on standby - Symptomatic - Atropine, temporary pacemaker to increase the heart rate **[Cardiac Cycle ]** - [SA NODE]: located at the junction of the superior vena cava and the RA. It is the normal pacemaker of the heart and initiates impulses at rate of **60-100 beats a minute** - [INTERATRIAL AND INERNODAL PATHWAYS]: carry impulse through the atria and into the AV node - [AV NODE]: referred to as AV junction, located in the lower aspect of the interatrial septum and has many functions - Relays impulse from atria to ventricle - Delays to allow for ventricle filling - [Assumes role as pacemaker is SA FAILS rate is **40-60 beats a minute**] - **Blocks too many atrial impulses** - [BUNDLE OF HIS]: continuous with AV node; breaks into 2 branches (bundle branches) and extend down septum; relays impulse from AV node to ventricles via bundle branches - [BUNDLE BRANCHES]: **[RIGHT]** carries impulse to RV, **[LEFT]** carries impulse of LV, made up of 2 branches - [PURKINJE SYSTEM]: continuous with bundle branches, enables impulse to spread over all parts of ventricles, can assume pace maker role if higher site fails [(20 to 40 beats a minute)] - **[Pneumothorax]** - Simple: chest tube - Open: cover wound, then chest tube - **Tension**: needle decompression, then chest tube **[Femur Fracture ]** - Femur fracture blood loss - estimated blood loss in the study group averaged 1,276 mL - Compartment syndrome - Rhabdomyolysis - ↑ lactic acid leading to metabolic acidosis - ↑ myoglobin's leading to renal failure - Decreased blood flow to kidneys - Crystallization of myoglobin in renal tubules - Toxic effect of myoglobin on renal tubules - ↑ K+ - Can be from prolonged immobility compromised circulation secondary to pressures **[Autonomic Dysreflexia]** - Occurs above T6 injuries after spinal shock subsides - Sudden pounding headache, hypertension, diaphoresis, flushed face/chest, pale extremities, nausea, bradycardia - Primary triggers - tight clothing, distended bladder or bowel, skin stimulation, pain, fecal impaction - interventions - sit upright, or HOB at 45 degrees - assess the triggers - give nitroglycerine, nitroprusside, or hydralazine - Cath or check for impaction **[Spinal Cord Injury]** - Critical that initial care & management be initiated ASAP to limit further destruction - Spinal Shock - Loss of deep tendon reflexes and sphincter reflexes - Flaccid paralysis below level of injury - Neurogenic Shock - Occurs in cervical or high thoracic injuries - Loss of sympathetic nervous system innervation causing unopposed parasympathetic response - Decreased cardiac output - Hypotension - Bradycardia - Temperature dysregulation- they cant regulate their temperature - !(media/image26.jpeg) **[Trauma ]** - ABCDEFG - Alertness and airway with cervical spine stabilization and/or immobilization - Breathing - Circulation - Disability - Exposure and environmental control - Facilitate adjuncts and family - Get resuscitation adjuncts **[Bites]** - Cat bites are the worse and require antibiotics - Dog bites are bad for larger areas - Human bites just suck - If you get bit on the hands, feet, over joints, or bit 6 to 12 hours ago get antibiotics - Rabies shots if you get bit by a raccoon **[Poisoning ]** - Call poison control - Narcan for opioids - Charcoal if able to take it and have no bowel issues **[Drowning ]** - Treatment - Correct hypoxia - Correcting acid-base and fluid imbalances - Supporting basic physiologic functions - Rewarming if hypothermia is present - Surfactant! Monitor that if they are on a vent **[Burns ]** - Airway - Fluid Resuscitation - Parkland Baxter Formula - 4ml LR per kg of body weight per % of total body surface area burned = total fluid requirements for first 24 hour after burn - ½ of total in 1^st^ 8hr - ¼ of total in 2^nd^ 8 hr. - ¼ of total in 3^rd^ 8 hr. - Drug therapy - VTE - Nutrition