CFRN Exam 489 Questions with Verified Answers,100% CORRECT

CFRN Exam 489 Questions with Verified Answers What is the worst stressor in transport? - CORRECT ANSWER Vibration. Physical effects on crew & patient plus affects ECG and increases ETCO2. Increase padding to decrease vibration Gravitational forces cause what? - CORRECT ANSWER Pooling of blood Negative impacts on transport - CORRECT ANSWER Fatigue Dehydration Cold, high, & dry What stressor impacts physical assessment most? - CORRECT ANSWER Noise Vision Impairment - CORRECT ANSWER Night vision affected as early as 5000 feet MSL Avoid inside light and use supplemental O2 Most common reason for patient death during flight? - CORRECT ANSWER Cardiac tamponade Tension pneumothorax Hypovolemia Fuel vapors cause what? - CORRECT ANSWER Eye irritation AMS Nausea Flicker Vertigo - CORRECT ANSWER Sunlight through wind milling propeller can cause seizures. Cover patient's eyes to prevent. Occurs @ 4-20Hz Barotitis Media - CORRECT ANSWER Obstruction of eustachian tubes cause pain, tinnitus, vertigo on descent. Ask the patient to yawn or swallow. Barogastralgia - CORRECT ANSWER Unclamp NG/OG tube during ascent to relieve pressure Barodontalgia/aerodontalgia - CORRECT ANSWER Warm compresses to relieve dental pain on ascent What happens to an untreated PTX during ascent? - CORRECT ANSWER Any untreated PTX will expand on ascent and may needle needle decompression or chest tube placement Boyle's law Barosinusitis - CORRECT ANSWER Obstruction of the sinus passages may cause pain or epistaxis on ascent. Use valsalva maneuver to equate pressure Boyle's "Balloon" Law - CORRECT ANSWER Temperature is constant Trapped gas expands with altitude (your pressure will decrease with altitude) i.e. air splints, chest tubes, ET cuff pressure, hollow organs (insert NG/OG), increase IVF rate, IABP purge -insert chest tube for rotor wing -no air transport for pneumocephalus air in the cranial cavity -bi-valve a cast that is 7 days old -no air splints Henry's Law "Heineken" Law - CORRECT ANSWER N2 bubbles cause decompression sickness "the bends" The amount of gas dissolved in a solution is directly proportional to the pressure of gas over a solution. The more concentrated the gas that comes in contact with a liquid is the more that gas will be dissolved in the liquid or if the partial pressure is twice as high twice as many molecules will hit the surface of the liquid which is then captured in the solution based on the solubility Charles "Centigrade" Law - CORRECT ANSWER Charles is cold For every 1000 ft you ascend (go up) your temperature decreases 2 degrees Celcius or for every 150m you go up temp decreases 1 degree Celcius An increase in altitude leads to a decrease in temperature. Gas expands as temperature increases and gas decreases and temp decreases Dalton's "Gang" Law - CORRECT ANSWER More O2 required at higher altitude (altitude hypoxia) because it moves molecules further apart The total pressure of a gas mixture is the sum of the partial pressure of all gases. Gases: Oxygen 21% Nitrogen: 78% Trace 1% at all levels, but further apart as you ascend (Dalton's disperse) When pressure of gases changes (your altitude) each component of gas does not change in other words as the aircraft ascends gas expansion causes the available oxygen to decrease because the molecules are further apart Gay-Lussac's Law "Charle's Brother" - CORRECT ANSWER Pressure in O2 tanks (changes PSI) decreases as temperature drops and increases with heat. At a given mass and constant volume of gas the pressure exerted on the side of the container is directly proportional to the to its absolute temperature Graham's Law - CORRECT ANSWER Diffusion rate of gas through a liquid is related to solubility of the gas (Graham=gray matter) Combined Gas Law (Boyle's, Charles, Gay-Lussac) - CORRECT ANSWER The ratio of the product of pressure and volume and the absolute temperature of a gas is equal to a constant Atmosphere Zones - CORRECT ANSWER 0ft 760mmHg=1 atm 18,000ft=380mmHg=1/2 atm; 34,000ft=190mmHg =/4 atm; 48,000 ft=95mmHg= 1/8 ATM physiologic sea level to 10,000ft physiologic deficient 10-50,000ft (oxygen of pressurization required to survive), space equivalent, space Water Pressure - CORRECT ANSWER 0 is 1 ATM or 14.7 psi 33 ft below surface 2 ATM 29.2 psi 66 ft below surface 3 ATM 44.1 psi 99 below surface 4 ATM 58.8 psi 132ft below surface 5 ATM 73.5 psi Divers Alert Network (DAN) - CORRECT ANSWER 24 hr hotline for diving related questions or Air Gas Embolism (AGE) d/t Boyle's Law - CORRECT ANSWER inexperienced diver breath holding compressed air during ascent forces air through alveoli into the skin in the chest & neck. Greatest pressure difference @ 4 feet depth just below the surface. May result in a PTX or ischemia from air embolus. Tx: transport in pressurized cabin or 1000 feet MSL in rotor wing to immediate HBO Decompression Sickness Henry's Law - CORRECT ANSWER Decompression sickness 1-painful joints, mottled skin, itching "cutis marmorata" Decompression sickness 2-neurologic stroke-like symptoms, AMS syncope, dizziness Bends - CORRECT ANSWER Limb/joint pain from N2 bubbles under the skin Chokes - CORRECT ANSWER Chest pain & respiratory distress (sensation from suffocation) from N2 gas bubbles in the pulmonary vessels Creeps - CORRECT ANSWER Paresthesia, tingling and itching from N2 bubbles under the skin Staggers - CORRECT ANSWER Neurologic disturbances as N2 comes out of the blood and forms gas bubbles Treatment for bends, creeps, and staggers - CORRECT ANSWER Ground transport preferred for all DCS illnesses Administer O2 Possible HBO therapy Stages of Hypoxia - CORRECT ANSWER Indifferent: 0-10,0000 decrease in night vision @ 4000 ft (smokers lose 20% of their night vision at sea level which is equivalent to 5000ft) unaware of symptoms Compensatory: 10,000-15,000ft night vision 50% CNS symptoms change in LOC, irritability, drowsiness Disturbance: 15,000-20,000ft SPO2 70-80% happy drunk vs. mean drunk not coordinated Critical: 20,000-25,000ft SPo2 60-70% seizures coma death Hypoxic Hypoxia - CORRECT ANSWER Insufficient oxygen to RBCs as in altitude hypoxia a deficiency in alveolar O2 exchange Hypemic hypoxis - CORRECT ANSWER lack of RBCs to carry O2 as in anemia, blood loss, Co poisoning, sickle cell disease Transfuse blood prior to transport Hypemic rhymes with anemic Histotoxic hypoxemia - CORRECT ANSWER Incapable of using O2 as in cyanide, carbon dioxide, alcohol, or narcotic poisoning Stagnant hypoxemia - CORRECT ANSWER Inability to mobilize or move RBCs due to reduced cardiac output as in G forces, temp extremes, and heart failure, PE or shock states Types of transportation - CORRECT ANSWER Ground-lg pieces of equipment Rotor-rapid pt to pt transfer not pressurized used when short out of hospital time is crucial Fixed wing-pressurized, larger, good long distance transport Secure Landing Zone - CORRECT ANSWER Use a prearranged LZ to increase safety Permanent Helipad - CORRECT ANSWER Must have 2 approach and departure heading, landing beacon, perimeter, lighting on helipad, windsock, security, and a fence around the pad Non-designated (unsecured) LZ - CORRECT ANSWER 100 ft x 100ft smooth and level 1 approach, and departure heading w/ spotlights directed toward obstacles at night Hospital helipads may be used as meeting pt w/ approval of facility What does PIC need to do before approaching aircraft? - CORRECT ANSWER Give the okay signal prior to approaching and that PIC sees you Where to approach the helicopter from? - CORRECT ANSWER Approach from 3 o' clock or 9 o' clock Where not to approach the helicopter from? - CORRECT ANSWER 12 or 6 o' clock Approach the helicopter in what position? - CORRECT ANSWER Crouching with visor down and secure all loose items protect from rotorwash When aircraft is on a slope which direction do you approach from? - CORRECT ANSWER Approach from and depart to downhill direction to avoid low rotor blades In Flight Safety - CORRECT ANSWER Secure all equipment so that it does not become a projectile Dim lights or use red, amber, blue, green lighting Practice situational awareness and observe for hazards and know where your exit and bearings are in aircraft How do you report hazards to rest of crew? - CORRECT ANSWER Location, hazard, heading Clock position and level Wires are the greatest danger Combative patients in flight - CORRECT ANSWER Evaluate combative patients prior to take off and use chemical restraint for safety for incarcerated patients only guns are allowed, but no mace or pepper spray Effective flight communication - CORRECT ANSWER Use plain language Be familiar w/ NATO-phonetic alphabet No abbreviations Microphone - CORRECT ANSWER Pause for second after keying microphone Headset mic should barely touch lips & be 2-3 inches from mouth Talk @ a normal level do not yell Radio reports should be no longer than how many seconds & no what in flight? - CORRECT ANSWER 60 seconds No cell phones If pilot states, "I will be landing on runway 33" this means what? - CORRECT ANSWER Heading upon final approach will be 330 degrees Communicate with air traffic control every how many minutes when in flight vs grounded? - CORRECT ANSWER Every 15 minutes in flight Every 45 minutes when grounded Emergency Action Plan activated when? - CORRECT ANSWER 15 mins after failing to report in so activated 30 mins after last communication while in air 60 mins after last communication while on ground VHF low band FM - CORRECT ANSWER greatest signal and range but more noise interference What does a repeater radio do? - CORRECT ANSWER Repeats to another frequency CRM & CAMTS regulations the most common is what? - CORRECT ANSWER single pilot flight paramedic flight nurse possibly RT or flight provider/MD/NP Rotary wing pilot in command requirements - CORRECT ANSWER Must have commercial pilot license 2000 hours total flight time 1200 in helicopter 1000 hours as PIC 100 as PIC at night Airline transport cert recc but not required 5 hours total area orientation w/ 2 separate night flights Fixed wing PIC - CORRECT ANSWER 2000 hours total 1000 hours as PIC 100 hours PIC @ night Must have ATP certificate Who has ultimate authority over mission? - CORRECT ANSWER PIC, but all crew members have the right to refuse a mission "3 to go 1 to say no" Sterile cockpit - CORRECT ANSWER during all critical phases of flight: takeoff, landing, refueling, taxiing, changing headings Uniform - CORRECT ANSWER protective, flame retardant clothing (NOMEX) including sturdy footwear and reflective material on uniforms Must allow 1/4" space b/w suit & undergarments (cotton no polyester) What is first on and last off w/ uniform? - CORRECT ANSWER Helmets or headsets Visor down on helmet as much as possible When can you unbuckle during flight? - CORRECT ANSWER Only when PIC says okay or when flight is straight and level Pre-mission checklist - CORRECT ANSWER crew check equipment check weather check Self induced stressors for staff - CORRECT ANSWER "DEATH" drugs exhaustion alcohol tobacco hypoglycemia FAR Part 91 - CORRECT ANSWER applies when no patients on board FAR 135 "Air Taxi" Rules - CORRECT ANSWER 8 hours from bottle to throttle Duty day 14 hours max w/ total flying time 8 hours max Flying in bad weather - CORRECT ANSWER You can fly in marginal weather, but in bad weather you need to divert to nearest facility What is the #1 cause of crashes? - CORRECT ANSWER pushing the weather is #1 night flights is #2 Visual Flight Rules (VFR) - CORRECT ANSWER Can only fly in weather conditions where you can see (visual meteorological conditions-IMC) A pilot may use IFR in good weather, but cannot use VFR in bad weather If unexpected weather occurs while using VFR switch to Inadvertent Instrument Meteorological Conditions IIMC "double IMC" Squawk 7700 - CORRECT ANSWER General emergencies Squawk 7600 - CORRECT ANSWER Communications failure Squawk 7500 - CORRECT ANSWER Hijacks Ground transport vehicle emergencies - CORRECT ANSWER Must have at least 2 years driving experience Perform daily equipment checks Drug testing required following any accident Secure equipment-apply @ least 3 straps on patient @ chest, hips, and knees Use child safety seats. Where do most common accidents happen w/ ground ambulance - CORRECT ANSWER Entering an intersection or making a turn and if you are in a crash get out and get on the curb. Need 100 feet or 30m in front and rear and if obstructed by a hill or something else you need to have a second warning device like a cone What do you do if water is covering the road? - CORRECT ANSWER Turn around and look for another route If there is dense fog what do you do? - CORRECT ANSWER Pull over and call for a police escort Pre-Crash Sequence - CORRECT ANSWER Lay patient flat Secure and shut off oxygen valve and secure equipment Assume the crash position -secure seatbelts & sit up straight, knees together w/ feet apart & flat on the ground, cross arms over chest and tuck chin to chest and pray! Emergency Locator Transmittor (ELT) - CORRECT ANSWER should activate by impact of G force (4 Gs) or turn on manually by flipping switch from "arm" to "on" ELT heard on 121.5, 243, or 406 MHz Post Crash Sequence - CORRECT ANSWER Priority is safety of self, crew, then patient If PIC is incapacitated how do you disengage? - CORRECT ANSWER Too ****ing Bad Throttle Fuel Battery What order of egress do you exit aircraft? - CORRECT ANSWER PIC Medical team Patient What position of the aircraft do you meet at after crash? - CORRECT ANSWER 12 o' clock then clockwise What are your priorities after crash? - CORRECT ANSWER Shelter Fire Securing a water source Then create a smoke signal (burn tires for smoke) 3 minutes w/o oxygen, 3 hours w/o shelter, 3 weeks w/o food Most die from hypothermia and exposure to elements so shelter is crucial What will rescue crews look for and what do you not hide in for shelter? - CORRECT ANSWER Missing vehicle & do not shelter in or near it as it may ignite What should you grab in a hard landing? - CORRECT ANSWER The survival kit Water Landing - CORRECT ANSWER Do not exit aircraft until all violent motion stops Minimize heat loss by bringing knees to chest and putting arms across chest Survivors should huddle together to decrease heat loss Protect against exposure, care of raft, and signaling for help are the priorities Industrial accident - CORRECT ANSWER Priority is not getting contaminated Rotor land downhill and downwind away from the chemical hazard Transportation accident - CORRECT ANSWER Priority is of crew & their safety & pt safety Mass casualties disaster response - CORRECT ANSWER START or JumpStart CBRNE - CORRECT ANSWER chemical biologic radiation nuclear explosives decontamination-wash w/ soap & water prior to transport Evidence Based Practice - CORRECT ANSWER VAPS, CAUTI, DVT prophylaxis etc. Uses applied research Research Methods - CORRECT ANSWER Quantitative-numbers Numeric-deductive Qualitative-words Legal Issues - CORRECT ANSWER Occurrence reports are typically not allowed in malpractice suits Administrative Law - CORRECT ANSWER Practice w/in your scope of practice Criminal Law - CORRECT ANSWER Assaults Civil Law - CORRECT ANSWER Seeking financial compensation Tort: Unintentional - CORRECT ANSWER Negligence or malpractice (professional negligence) A deviation from accepted standard of performance, failure to exercise a degree of care Duty - CORRECT ANSWER Breach of duty malfeasance is medication error nonfeasance is failing to follow an order forseeability, causation, injury, damages Quasi-intentional: defamation, breach of confidentiality Intentional-assault is fear of harm battery is touching w/o consent or false imprisonment Abandonment is handing over care to someone who isn't at same level/skillset/scope of practice as you HIPAA - CORRECT ANSWER Health Insurance Portability and Accountability Act sharing information w/ right people EMTALA (Emergency Medical Treatment and Active Labor Act) - CORRECT ANSWER All patients need a medical screening Do not transport patient if they have not had a physical exam facility must stabilize w/in capabilities prior tor transfer sending facility is responsible for choosing appropriate personnel to transport to higher level of care send records and labs, imaging, etc. and consent form never leave the facility w/ pt until facility accepts the patient 4 types of consent - CORRECT ANSWER Implied: emergency when pt cannot consent Express: request for tx from coherent pt Involuntary: legally determined to be in best interest of pt Informed: pt understands risk, benefits, alternatives Mandatory: elder/child abuse, etc. keep patient safe Autonomy - CORRECT ANSWER Protect pt's right to make own healthcare decision Beneficence - CORRECT ANSWER Acting in the patient's best interest Malfeasance - CORRECT ANSWER Do no harm. Does the benefit outweigh the risk of weather? Verascity - CORRECT ANSWER Honesty Justice - CORRECT ANSWER Fair & equal tx for everyone Ex. Not based on payment-EMTALA Death Notification & Forensics - CORRECT ANSWER Say "dead" or "died" Direct quotes Evidence in paper bags Use body diagrams Save paint chips or debris Don't cut through holes in clothing General Adaptive Syndrome - CORRECT ANSWER Alarm: Body perceives stress & releases adrenaline Resistance: fight or flight through SNS Exhaustion: resting and digesting through parasympathetic Quality Assurance is the responsibility of whom? - CORRECT ANSWER The QA manager What is Quality Assurance and what does it focus on? - CORRECT ANSWER Focuses on audits What is quality improvement and who is responsible for it? - CORRECT ANSWER QI is the responsibility of leadership & focuses on statistics Outreach & community Education - CORRECT ANSWER These are community based programs and not referrals Critical Incidence Debriefing - CORRECT ANSWER Structured for those directly involved in the event & happen 24 hours but no more than 72 hours post event. Voluntary meeting that supports resilience. Secondary Traumatic Stress - CORRECT ANSWER Recurring thoughts & dreams about the patients (intrusion into life) & sleep disturbance CPP - CORRECT ANSWER MAP-ICP Normal: 70-90mmHg Want closer to 60 w/ TBI GCS - CORRECT ANSWER 4 eye 5 verbal 6 movement/motor 8 intubate Pupillary Response - CORRECT ANSWER Ipsilateral pupil dilation Seen in uncal herniation Posturing - CORRECT ANSWER Decorticate-flexion Decerebrate-extension MAP - CORRECT ANSWER (2*DBP) + SBP/3 Normal: 70-90 Coronary Perfusion Pressure - CORRECT ANSWER The difference between pressure in the aorta and pressure in the coronary vessels Normal: 50-60 S1 - CORRECT ANSWER Lub closure of AV valves beginning of systole loudest @ 5th ICS mitral area S2 - CORRECT ANSWER Dub closure of semilunar valves beginning of diastole loudest @ 2nd ICS S2 is louder when there is a PE S3 - CORRECT ANSWER 3rd heart sound ventricular gallop heard in heart failure and cor pulmonale S4 - CORRECT ANSWER 4th heart sound atrial gallop heard in HTN & aortic stenosis Murmurs from Regurgitation - CORRECT ANSWER Valves are closed Murmurs from StenOsis - CORRECT ANSWER Valves are Open Systolic Murmurs - CORRECT ANSWER Mitral & tricuspid regurgitation Aortic & pulmonic stenosis Diastolic Murmurs - CORRECT ANSWER Mitral & tricuspid stenosis Aortic & pulmonic regurgitation Straps for patient transport go where? - CORRECT ANSWER Chest, hips, & knees If loaded head first secure shoulders Do you use air splints for transport for extremity fx? - CORRECT ANSWER NO! Airways - CORRECT ANSWER NPA, OPA, ETT (preferred), cricothyrotomy, EGA, LMA Pediatric cuffed ET tube equation - CORRECT ANSWER (age + 16)/4 (age/4) + 4 When to consider needle cricothyrotomy - CORRECT ANSWER severe nasal/facial fx No nasal intubation or NG tube for severe facial fx Needle cric 45 degrees caudally for 11yo LEMON airway difficulties - CORRECT ANSWER Look externally Evaluate 3-3-2 rule Mallampati score (I-IV) -score III or more is more difficult airway Obstruction/obesity -FB, secretion, swelling tissue Neck mobility (decreased in older adults) -place in sniffing position, neck flexed head extended 3-3-2 Rule - CORRECT ANSWER Alignment of oral, tracheal, laryngeal axes w/ laryngoscope should be less difficult w/ pt whose mouth is open 3 pt's finger breadths, mental-hyoid distance is at least 3 finger breadths, & whose hyoid-thyroid notch is at least two finger breadths MOANS - CORRECT ANSWER Mask seal-facial anatomy, trauma, FB, secretions make mask seal difficult Obesity/obstruction-BMI 35, prego, supraglottic obstruction Age-55 higher risk ventilation No teeth Stiff lungs-it is more difficult to exchange gas in pt's who have acute/chronic dz that necessitates use of higher inspiratory pressure RSI LOADS - CORRECT ANSWER Lidocaine-may reduce risk of ICP (No succ if malignant hyperthermia, crush/burns, renal failure, ALS, Myasthenia Gravis, Guillain barre) Atropine to prevent reflex brady in peds Defasciculating agent: etomidate may decrease steroids so avoid in sepsis & adrenal crisis Ketamine is drug of choice for asthma Fentanyl may cause chest wall rigidity Succ is what BMF uses RODS difficult supraglottic airway placement - CORRECT ANSWER Restricted mouth opening obstructed upper airway Distorted anatomy Stiff lungs SHORT assessing potential difficulty w/ surgical airway - CORRECT ANSWER Surgery Hematoma or other mass Obstruction/obesity Radiation Tumor Most accurate confirmation of ETT placement - CORRECT ANSWER ETCO2 35-45 increase vent rate if high decrease vent rate if low Where should ETT sit? - CORRECT ANSWER 3-45cm above the carina What should the ETT cuff be inflated to? - CORRECT ANSWER 20cm Assist Controol - CORRECT ANSWER Used most in ER setting/post arrest and can result in over inflation (stacking vent) Normal adult tidal volume - CORRECT ANSWER 6-10mL/kg IDEAL body wt 4-6mL/kg in ARDS Ventilation-hypercarbic problems - CORRECT ANSWER Adjust tidal volumes FIRST then rate Oxygenation-hypoxic problems - CORRECT ANSWER Adjust FiO2 FIRST then add PEEP High Pressure Vent Alarms - CORRECT ANSWER Kinked tube Bronchospasm Obstruction from secretions Intra-abdominal compartment pressure increasing Low Pressure Vent Alarms - CORRECT ANSWER Cuff leak Disconnection Non-Invasive Ventilation - CORRECT ANSWER CPAP, BiPAP Advantages of NIV are it reduces WOB, improves oxygenation Contraindications of NIV-hemodynamic instability, impaired mental status, stop if BP drops What best reflects oxygen delivery and consumption? - CORRECT ANSWER SvO2 Normal urine output - CORRECT ANSWER 0.5-1ml/kg/hr 30-50cc/hr 1-2ml/kg/hr pedi patients Shock Pathophysiology - CORRECT ANSWER Baroreceptors sense a decrease in stretch and stimulate the SNS. SNS releases catecholamines from adrenal glands to increase HR, contractility, vasoconstriction, & glycogenolysis. Chemoreceptors detect low O2 & increase RR & BP Hypoperfusion of kidneys triggers rennin to activate angiotensin I to angiotensin II and stimulate aldosterone & ADH. Lethal Trauma Triad - CORRECT ANSWER Hypothermia Acidosis Coagulopathy Reasons for metabolic acidosis - CORRECT ANSWER DKA, shock, renal dz, diarrhea, salicylate toxicity Causes for anion gap acidosis-MUDPILES MUDPILES-causes of anion gap acidosis - CORRECT ANSWER Methanol poisoning Uremia Diabetic Ketoacidosis Paraldehyde poisoning Iron, Isonizide poisoning, Lactic acidosis Ethylene glycol poisoning, Ethanol ketoacidosis Salicylate poisoning, starvation ketoacidosis, sepsis HARD UP Non-anion gap acidosis - CORRECT ANSWER Hyperchloremia 2/2 saline, TPN Addisons dz or acetazolamide Renal tubular acidosis Diarrhea Ureteral diversion procedures Pancreatic problems-pseudocyst or fistula Metabolic alkalosis - CORRECT ANSWER Prolonged vomiting administer K+ Respiratory acidosis - CORRECT ANSWER respiratory depression drugs hypoventilation asthma compensated as in COPD Tx by assisting ventilation Respiratory alkalosis - CORRECT ANSWER hyperventilation 2/2 anxiety, infxn, PE Oxyhemoglobin Dissociation Curve left shift - CORRECT ANSWER Cause-CO poisoning Decreased Temperature, CO2 Hemoglobin holds onto O2 Anion Gap Calculation - CORRECT ANSWER Na-(Cl+HCo3) Normal 12 Oxyhemoglobin Dissociation Curve right shift - CORRECT ANSWER Bohr effect MVC Frontal Impact - CORRECT ANSWER Aorta tear d/t shearing @ ligamentum arteriosum MVC Lateral Impact - CORRECT ANSWER Clavicle, ribs, liver/spleen MVC Rear End Impact - CORRECT ANSWER Highest risk of SCI Stab Wounds - CORRECT ANSWER Most commonly injured are hollow organs like stomach or bowel GSWs most commonly injury bowels Child in lap belt restraint - CORRECT ANSWER Risk of hollow organ (bowel) injury and chance fx Chance fx-T10-L2 flexion-distraction injury Child falls - CORRECT ANSWER Risk of head trauma Stages of Shock - CORRECT ANSWER Compensated-restless, narrow pulse pressure Decompensated-progressive, decreased LOC, HR 100bpm, thready pulses, and cool skin, BP low Irreversible-Multisystem failure, unresponsive, brady, marked hypotension Classes of Shock - CORRECT ANSWER Class 1-Pulse 100bpm pulse pressure narrowed Class II- pulse 100-120bpm Class III-SBP drops, Class IV-pulse 140 Permissive Hypotension - CORRECT ANSWER MAP=50 less risk of dislodgement of clot mostly seen in pelvic fx and abdominal penetrating injury No permissive hypotension in elderly, TBI, peds Hypovolemic Shock - CORRECT ANSWER Tank is low-loss volume replace volume lost Preload low Afterload high Cardiogenic Shock - CORRECT ANSWER Pump failure-think heart damage Tx: inotropic support, controlled fluid, antidysrhythmic agent, no pericardiocentesis Preload high Afterload high Obstructive Shock - CORRECT ANSWER Mechanical failure-think cardiac tamponade, tension PTX, abdominal compartment syndrome, supine vena cava syndrome, massive PE, excessive PEEP, air embolism, Tx: Relieve the obstruction Preload high Afterload high Distributive Shock - CORRECT ANSWER Pipe problem-maldistribution in the pipes Decreased afterload Decreased SVR Neurogenic=bradycardia d/t unopposed parasympathetic vagal activity, bradypnea, hypotension tx w/ levo and IVF to help w/ vascular tone Septic CO/CI high tx w/ abx, pressors early sepsis is warm phase Anaphylactic vasodilation & bronchospasm tx w/ epinephrine and histamine blockers & IVF Balanced Resuscitation - CORRECT ANSWER Limit crystalloids to 1 L Hemostatic Resuscitation - CORRECT ANSWER 1:1:1 ratio and bleeding control pRBC:platelets: FFP Universal RBC donor - CORRECT ANSWER O negative Universal plasma donor - CORRECT ANSWER AB negative RH positive - CORRECT ANSWER Males and postmenopausal women How much does each unit of PRBC increase Hemoglobin by? - CORRECT ANSWER 1 g/dL Hgb and 3% hematocrit What do you need to replace during blood transfusions and why? - CORRECT ANSWER Need to replace calcium b/c citrate in pRBC binds with calcium and renders it inactive Be aware of metabolic acidosis b/c pH 7.1 Pediatric rapid infusion - CORRECT ANSWER 20mL/kg warmed crystalloids over 5-10mins w/ 3 way stop cock and a 20mL syringe. packed RBC bolus @ 10mL/kg TXA, Tourniquets, Hemostatic Dressings - CORRECT ANSWER Transexamic acid-antifibrinolytic so clots do not dissolve Quick clot Immobilization log roll & spinal motion restriction - CORRECT ANSWER Log roll can cause secondary injuries including SCI and hemorrhage from pelvic fx Lift & slide preferred to log roll Spinal motion restriction-rigid cervical collar and keeping head, neck, and torso in alignment Spine board are preferred for transfer only Monroe-Kellie Doctrine - CORRECT ANSWER when one content in the skull increases, another must decrease to compensate and maintain normal ICP Volume pressure relationship Normal Adult ICP & when is considered elevated? - CORRECT ANSWER 0-15mm Hg Elevated if sustained 20mmHg Normal Infant ICP - CORRECT ANSWER 2-6mmHg Normal Young child ICP - CORRECT ANSWER 3-7mmHg Older child ICP - CORRECT ANSWER 10-15mmHg Cerebral Perfusion Pressure - CORRECT ANSWER CPP=MAP-ICP Normal 70-90 Want 60 mmHg in TBI pts and do not allow hypotension Cushings Triad - CORRECT ANSWER s/s of increased ICP WIDEned pulse pressure bradycardia decreased respirations Basilar skull fracture - CORRECT ANSWER CSF rhinorrhea and otorrhea Sterile dressing under nose Periorbital ecchymosis=raccoon's eye Mastoid ecchymosis=battle's sign Subarachnoid hemorrhage - CORRECT ANSWER Thunderclap headache Nuchal rigidity Vomiting w/o nausea Starfish shape on CT Epidural hematoma - CORRECT ANSWER Middle Meningeal Artery tear from temporal bone rapid unresponsiveness, followed by lucid pd, then unresponsive Looks like an "eyeball" on CT Tx: burr hole Uncal Herniation - CORRECT ANSWER Ipsilateral pupil dilation w/ contralateral hemiparesis seen w/ epidural hematoma Subdural hematoma - CORRECT ANSWER Tear of the venous or bridging veins Crescent shape on CT Drunks and Elderly or Shaken Impact Syndrome in infants Slower decompensation of mental status from hours to weeks (acute or chronic) Shaken Impact Syndrome - CORRECT ANSWER Triad of subdural hematoma, retinal hemorrhage, and posterior rib fx Spinal Cord Injury - CORRECT ANSWER Increased risk of SCI if fall 20ft in adults and 3x height in child SCIWORA-seen in children under 8 years and no radiologic abnormality Anterior Cord Syndrome - CORRECT ANSWER Most common Lose motor Keep vibration and proprioception Central Cord Syndrome - CORRECT ANSWER Can walk into bar, but can't get a drink Uppers impacted more than lowers Brown-Sequard Syndrome - CORRECT ANSWER Hemi-section of the cord - ipsilateral (same side) spastic paralysis and loss of position sense - contralateral (opposite side) loss of pain and thermal sense From penetrating injury usu seen in stab wounds Common causes post traumatic seizures - CORRECT ANSWER Fever, drug/alcohol withdrawl, electrolyte imbalances Autonomic Dysreflexia - CORRECT ANSWER relieve the trigger! use labetolol or nitroprusside to decrease BP Chest Wall Injuries - CORRECT ANSWER Rib fx-painful-may puncture organs (right suspect liver, left suspect spleen) Flail chest-paradoxical chest movement d/t 2+ rib fx at 2 or more places. Immediately intubate and fix w/ sx Open PTX - CORRECT ANSWER Sucking chest wound on inhalation and bubbling on exhilation Tx: O2, occlusive dressing secured @ 3 sides on end exhilation. Remove if s/s increased respiratory distress b/c a tension ptx is happening Tension PTX - CORRECT ANSWER Life threatening obstructive shock. The risk is PEA arrest. S/S: Respiratory distress, JVD, hypotension, increased inspiration, absent or reduced breath sounds on affected side Tracheal deviation to the unaffected side Tx: Needle decompression @ 2nd intercostal space mid clavicular line or 5th AAL and insert chest tube Hemothorax - CORRECT ANSWER 1500mL considered massive hemothorax Tx: Chest tube @ 4-5th intercostal space MAL and consider autotransfusion if blunt trauma Pulmonary contusion - CORRECT ANSWER S/S: wheezing, rhonchi, crackles Dx: Fluffy infiltrates on CXR Risk ARDS-judicious use of IVFs Keep SPO2 94-98% Blunt cardiac injury - CORRECT ANSWER May be associated w/ fx sternum right ventricle is most commonly damaged ST segment elevation, ST, PVCs, hypotension, requries cardiac monitoring, ECHO, supportive tx Pericardial tamponade - CORRECT ANSWER Beck's triad: hypotension, JVD, muffled heart sounds See tachycardia, anxiousness, restlessness, electrical alternans (alternating QRS amplitude), low EKG voltage and pulsus paradoxus (BP falls 10 pts on inspiration) Tx: Pericardiocentesis Great vessel injury-Aortic dissection - CORRECT ANSWER Aorta shears at ligamentum arteriosum from blunt trauma S/S: New onset murmur, widened mediastinum, obscured aortic knob on CXR. Tx: IVF, Labetolol b/c want HR 60-80bpm and avoid reflex tachycardia and nitropursside to keep BP 100-120mmHg MTP if active bleeding Hollow organ injury Abdominal evisceration Bowel rupture - CORRECT ANSWER Abdominal evisceration-cover w/ dry sterile dressing-wet lowers body temp-no good Bowel rupture-Lap belt/restraint injury assoc w/ chance fx (T12-L2) transverse colon most often injured Solid Organ Injury Splenic injury Liver injury - CORRECT ANSWER Splenic injury #1 injured in blunt trauma LUQ pain to left shoulder- Kehr's sign Gade IV 25% spleen injured. Grade V completely shattered. Liver injury MVC w/ restraints d/t cavitation RUQ pain, shock, cullen's sign-ecchymosis around umbilicus Grade I hematoma Grade VI vascular avulsion Ruptured Diaphragm - CORRECT ANSWER Most from penetrating injury below the left 4th ICS (the liver protects the right side so that's why you don't see it as much) Persistaltic gurgling in left chest Progressive scaphoid abdomen Kehr's sign left shoulder pain referred pain from LUQ s/s worse when supine Grey Turner's sign - CORRECT ANSWER discoloration over the flanks suggesting intra-abdominal bleeding. Bladder/Urethral Injury - CORRECT ANSWER Urge to pee but cannot Do not place u-cath if blood in meatus b/c this is assoc w/ pelvic fx What does hematuria suggest? - CORRECT ANSWER Renal/kidney injury What abdominal injury is commonly missed? - CORRECT ANSWER Pancreatic injury and you will see epigastric pain radiating to back Abdominal compartment syndrome - CORRECT ANSWER Highest risk pts: prego, chronic ascites, morbidly obese, major abd surgery, peritonitis If pt is alarming high pressure on vent for no other reasons suspect abd compartment syndrome. Where do you level the transducer for abdominal compartment syndrome - CORRECT ANSWER @ the symphysis pubis w/ pt in supine position Normal reading for abdominal compartment syndrome - CORRECT ANSWER 12-15mmHg 20mmHg sustained requires decompression Where do you place a pelvic binder? - CORRECT ANSWER @ the level of the greater trochanter and prepare for MTP Compartment syndrome - CORRECT ANSWER S/S: pain out of proportion for injury, unrelieved pain by analgesia, pain on passive movement, shiny taut skin Most often in lower legs or forearm Weak or absent pulses is a late sign pain, pallor, paresthesia, paralysis, poikliothermia, pulselesness Normal pressure for extremities in neutral position @ level of heart Elevated pressure Treatment - CORRECT ANSWER 0-10mmHg Elevated 20mmHg Fasciotomy 30 Rhabdomyolysis - CORRECT ANSWER Crush injuries, burns, working out May cause intrarenal failure (ATN) S/S: myalgia, dark colored urine Labs: Increased CK, myoglobin, K+ Tx: Large volumes of IVF w/ sodium bicarb to alkalinize urine, mannitol, call receiving facility to prepare for dialysis if urine remains dark. Goal: urine output 100mL/hr Amputations - CORRECT ANSWER Hemorrhage control of stump in top priority via direct pressure to site or tourniquet 2 inch rule 2 inches wide 2 inches above site and tight enough to compress veins & arteries. Mark time applied! Do not release tourniquet until provider present and ready to manage bleed Place amputated part in saline moist gauze place in bag and place bag on top of ice to prevent frostbite. Obvious bone deformity - CORRECT ANSWER Position of comfort, stabilize limb, and reassess pulses Open fracture - CORRECT ANSWER High risk of hemorrhage and infection Dislocations - CORRECT ANSWER Hurt like a mofo and can cause nerve damage Chemical burns - CORRECT ANSWER brush off dry chemicals like lime alkalis like anhydrous ammonia and lye (cause saponification) are more severe than most acids Hydrofluoric acid-use calcium to inactivate fluoride Asphalt (tar) apply emollient like vaseline and cool immediately Phenols (carbolic acid) irrigate w/ 50% PEG (Miralax) to neutralize Electrical burns - CORRECT ANSWER Risk of rhabdomyolysis that can lead to ATN Watch out for cardiac irregularities Want IVF, sodium bicarb to get urine alkalization, and goal UO 100mL/hr Lightening Strike - CORRECT ANSWER Lace or feathering appeareance (Lichtenberg figures) What is the fluid of choice for burn resuscitation? - CORRECT ANSWER LRS Half of total amount goes in over first eight hours from the time of the burn! Adult Thermal Burn/Parkland Formula - CORRECT ANSWER 2mL*kg*BSA for 24 hr calculation Parkland is 4mL Child Thermal Burn Calculation - CORRECT ANSWER 3mL*kg*BSA for 24 hr calculation Electrical Thermal Burn Calculation - CORRECT ANSWER 4mL*kg*BSA for 24 hr calculation Urinary output goals for burns - CORRECT ANSWER 0.5-1mL/kg/hr for adults (35-70mL/hr in 70kg patient) 1-2mL/kg/hr in pediatrics Circumferential burns - CORRECT ANSWER Watch out for compartment syndrome esp in chest May need escharotomies prior to transport Transport considerations for burns - CORRECT ANSWER Escharotomies prior to transport Cover with clean dry sheet to prevent heat loss No ointments Radiological Burns - CORRECT ANSWER S/S: nausea, vomiting, diarrhea, malaise, anorexia, GI bleed, red skin but w/ no blisters Decontaminate your patient prior to transport Inhalation Injuries - CORRECT ANSWER Secure airway immediately if hoarse voice, stridor, or carbonaceous sputum Carbon Monoxide (CO) poisoning - CORRECT ANSWER 100% non rebreather until CO 10% (1 hour) O2 sats will be normal d/t left shift of oxyhemoglobin dissociation curve ST segment depression d/t hypoxia Prego pts get hyperbaric chamber to get O2 to fetus What is the antidote for hydrogen cyanide (carpet burning)? - CORRECT ANSWER Hydroxocobalamin Mandible Fx - CORRECT ANSWER Malocclusion and lower lip/jaw paresthesia, airway occlusion from loss of tongue control LeFort I - CORRECT ANSWER Free floating maxilla, lip laceration free floating palate at alveolar ridge LeFort II - CORRECT ANSWER pyramidal shape fx, nasal fx free floating maxilla to orbit LeFort III - CORRECT ANSWER Free floating face through up to nasal bone mid orbit Craniofacial separation Ruptured Globe - CORRECT ANSWER Tear drop shaped pupil d/t extrusion of aqueous humor Decreased IOP Tx: Surgery Blow in fx - CORRECT ANSWER Orbital fx Exopthalamus CN III pain and limited upward gaze on EOM Blow out fx - CORRECT ANSWER Orbital fx Enopthalmus CN III pain and limited upward gaze on EOM Hyphema - CORRECT ANSWER Blood in anterior chamber of eye that gives vision a red tinge Zone 1 neck injury - CORRECT ANSWER Most lethal Zone 2 neck trauma - CORRECT ANSWER Most common neck injuries are here Zone 3 neck trauma - CORRECT ANSWER Tracheobronchial Injury occurs w/ what type of injuries and what sign? - CORRECT ANSWER Clothesline type injury or penetrating injury Hamman's sign hear a crunch w/ the heartbeat and SQ emphysema, dysphonia-hoarseness, stridor, increasing hematoma-respiratory distress Tx: Fiberoptic intubation into right mainstem below level of injury or emergency repair Seizures in neonates will exhibit what sign? - CORRECT ANSWER Lip smacking check BGT What is the first line of meds for seizures? - CORRECT ANSWER Benzos (Ativan) Meningitis - CORRECT ANSWER Fever and nuchal rigidity Kernig & Brudzinski sign Irritability, shrill and inconsolable cry in infants w/ arched back Kernig's Sign - CORRECT ANSWER When supine w/ hip flexed 90 degree angle patient cannot straighten their leg Meningeal irritation Brudzinski's Sign - CORRECT ANSWER Involuntary flexion of knees when neck if flexed Meningeal irritation or SAH Is glucose low or high in bacterial meningitis? - CORRECT ANSWER Low b/c bacteria eat glucose If patient has purpuric or petechial non blanching rash w/ concern for meningitis what should be priority? - CORRECT ANSWER Getting patient into isolation Shunt dysfunction - CORRECT ANSWER hx of hydrocephalus, vomiting, and decreased LOC Tx; LP to remove CSF and fix the shunt Ischemic strokes get TPA @ what dose/rate and in what time frame? - CORRECT ANSWER 0.9mg/kg 10% as bolus right away Remaining goes in over 1 hour TPA must go in w/ in 4.5 hours of onset of symptoms Need to tx HTN w/ Labetolol and if decreased LOC during infusion stop it and notify provider Guillan-Barre Syndrome (GBS) - CORRECT ANSWER demyelination exposes nerves, which become inflamed, causing weakness, tingling, and numbness; starts at the feet and moves upward (ascending symmetrical paralysis) after viral illness. Monitor for breathing pattern d/t potential diaphragm paralysis Acute Coronary Syndrome (ACS) - CORRECT ANSWER Assess EKG for T wave inversion for ischemia, ST segment elevation for injury Troponins increase over how many hours? - CORRECT ANSWER 4-8 hours Inferior MI - CORRECT ANSWER II, III, aVF Right coronary artery Epigastric pain, bradycardia, hypotension, second degree type I heart block Get right sided EKG Anterior MI - CORRECT ANSWER I, II, III, IV LAD artery Crushing CP, dyspnea, ventricular dysrythmias, cardiogenic shock (crackles, S3), difficult to detect in left BBB Lateral MI - CORRECT ANSWER I, aVL, V5, V6 Circumflex artery Right Ventricular MI - CORRECT ANSWER V4R @ 5th intercostal space right MCL Caution w/ preload reducing agents like NTG and Morphine aka don't use them Give 250cc bolus IVF for hypotension Printzmetal (variant) angina - CORRECT ANSWER vasospasm of coronary vessels. hallmark sign is CP @ rest Tx: NTG to dilate vessels Left Heart Failure - CORRECT ANSWER Left ventricle backs up to lungs from CAD, MI S/S: Nocturnal dyspnea, orthopnea, pulmonary edema Tx: diuretics, NIPPV, IAPBP, VAD See elevated PAOP on PA cath Right Heart Failure - CORRECT ANSWER Back up to rest of body (systemic circulation) seen w/ cor pulmonale, COPD, PE, RV MI S/S: JVD, ascites, peripheral edema See elevated CVP (RAP) Pulmonary Edema - CORRECT ANSWER fluid in the air sacs and bronchioles BNP Normal 100 Elevated 100-200 is heart failure 500 severe HF Kerley B lines on CXR Avoid CCB & BB since they decrease contractility How to treat sinus tachycardia - CORRECT ANSWER Treat based on cause: fever, pain, dehydration, anxiety Stable narrow complex tachycardias - CORRECT ANSWER treat w/ vagal maneuvers Adenosine 6mg rapid IVP Not effective at 6mg? Go to 12mg adenosine IVP Stable wide complex tachycardias - CORRECT ANSWER Amiodarone 150mg slowly Lidocaine if d/t prolonged QTi Procainamide 20-50mg/min up to 17mg/kg or Sotalol Unstable tachycardia - CORRECT ANSWER synchronized cardioversion sync on R waves see dot above R wave Consider sedative prior to shocking-shocking hurts! 0.5-1 joule/kg for pediatric pts Bradycardias - CORRECT ANSWER Correct underlying cause of bradycardia (respiratory distress-assist breathing w/ BVM) Atropine 0.5mg IVP q 3-5mins for low degree blocks up to 3mg total Remember! Atropine is ineffective for high degree heart blocks or heart transplant pt consider giving isoproterenol Consider transcutaneous pacing Epinephrine infusion @ 2-10mcg/min Dopamine infusion @ 2-20mcg/kg/min Pacemakers for refractory brady or high degree heart blocks Transcutaneous pacing - CORRECT ANSWER Anterior-posterior or atnerior-lateral pad placement Set rate @ 60-80mA and increase until you see capture Capture is the electrical spike seen before the waves Mechanical capture is palpable pulse that correlates to paced beat but do not use the carotid pulse Transvenous and permanent pacemakers recognize failure to capture and failure to sense Failure to capture - CORRECT ANSWER Pacer delivers a stimulus at the appropriate time but no depolarization occurs. No P or QRS wave after pacer spike. Failure to pace - CORRECT ANSWER the pace maker fails to initiate an electrical stimulus when the pacemaker is due to fire. This is noted by the absence of a pacer spike on the rhythm strip. Cardiac arrest - CORRECT ANSWER Defibrillation for shockable rhythms pVT and Vfib Adult biphasic 120-200 joules Adult monophasic 200-360 joules Pediatric 2-4joules/kg initially then 4 joules/kg No longer than 10 seconds off chest Do not do a pulse check after shock unless you see an organized rhythm Find the cause so look for Hs & Ts esp for asystole Cardiac arrest meds - CORRECT ANSWER Epinephrine 1mg/10mL 1mg IV/IO q 3-5 mins Amiodarone 300mg then 150mg for refractory VFib Lidocaine 1-1.5mg/kg if VF d/t prolonged QT Hs - CORRECT ANSWER hypoxemia, H+ ions, hyper/hypokalemia Ts - CORRECT ANSWER Toxins, Trauma, Tension PTX, Tamponade, Thrombosis Wolff Parkinson White WBW - CORRECT ANSWER Accessory pathway disorder See delta waves, short PR intervals, wide QRS upstroke Risk tachycardia Prolonged QTi - CORRECT ANSWER Erythromycin, Haldol, TCAs Elavil or Tofranil Tx: Sodium bicarb and Mg Dissecting Aortic Aneurysm - CORRECT ANSWER -20mmHg BP difference between arms ripping/tearing back pain lower extremity weakness w/ AAA Type 1 ascending thoracic tear see stroke like symptoms this is much worse Risk w/ EDS and Marfans pts Tx: Beta blocker first to prevent reflex tachycardias want HR b/w 60-80bpm then nitroprusside to reduce BP to 100 SBP Hypertensive crisis - CORRECT ANSWER Goal to decrease BP by 20-25% over 1-2 hours Nitroprusside is a preload and afterload reducer or labetolol (preferred w/ CAD) Calculate MAP Pericarditis Dressler's Syndrome - CORRECT ANSWER Pleuritic retrosternal CP worse w/ inspiration & supine positioning Global diffuse concave ST segment elevation on ECG Friction rub heard best @ left sternal border w/ diaphragm while patient holds breath Tx: Lean patient forward and give NSAIDS Accidental sheath removal - CORRECT ANSWER oh shit hold direct pressure Emphysema - CORRECT ANSWER pink puffer increased AP diameter d/t hyperinflation Auto-PEEP Decrease tidal volume to 6mL/kg Chronic Bronchitis - CORRECT ANSWER Blue bloater secondary polycythemia so more prone to clots Chronic CO2 retention so decreased respiratory drive Tx: SABA, inhaled anticholinergics, corticosteroids Acute Lung Injury - CORRECT ANSWER Acute onset, bilateral infiltrates "ground glass opacities" on CXR, P/F ratio 201-330mmHg ARDS - CORRECT ANSWER Pathologic shunt (extreme V/Q mismatch) resulting from refractory hypoxemia Damage to Type II alveolar cells P/F ratio 200 White out/ground glass appearance on CXR Tx: O2, lower tidal volumes 6mL/kg and high PEEP, prone, and give surfactant to prevent alveolar collapse Asthma - CORRECT ANSWER Hyperreactive airway, dyspnea, tachypnea, expiratory wheezing, absent breath sounds are ominous Tx: SABA, inhaled anticholingergics, corticosteroids, ketamine DO NOT USE PEEP if intubated Increase I:E time instead to 1:3 or 1:4 to prevent auto PEEP Pulmonary Embolus - CORRECT ANSWER S/S: Tachycardia, tachypnea, sense impending doom, accentuated S2 heart sounds, RBBB and right axis deviation Increased risk if on birth control, sedentary, venous stasis, damage Dx: Pulmonary angiography (gold standard) Tx: ABCs, heparin, fibrinolytics GI Bleed - CORRECT ANSWER Most caused by portal hypertension/cirrhosis Tx: Octreotide & Vasopressin Bowel Obstructions - CORRECT ANSWER Get worse during flight d/t Boyle's Law (trapped gas expands w/ altitude) Keep NPO and insert NG/OG tube Pancreatitis - CORRECT ANSWER Sudden sharp epigastric pain radiating to back Amylase & Lipase elevated Calcium decreased (Chvostek's & Trousseau's signs) Risk of pleural effusion & ARDS Hepatitis - CORRECT ANSWER Vowels from the bowels (A&E fecal oral transmission) Hep B body fluids-sexually transmitted Hep C circulation-IVDU Jaundice/fatigue Hepatic Encephalopathy - CORRECT ANSWER Increased ammonia level from liver failure S/S: ascites asterixis Tx: Lactulose Hyperkalemia - CORRECT ANSWER Tall tented T waves Widenened complex Sine wave-not a good sign! Tx: Calcium gluconate (cardiac stabilizer), insulin & dextrose, sodium bicarb or albuterol to shift K+ Hypokalemia - CORRECT ANSWER Flattened T waves Tx: K+ Hyponatremia - CORRECT ANSWER Risk seizures Tx: NS Hypocalcemia - CORRECT ANSWER See w/ pancreatitis pts Chvostek's or Trousseau's signs Give calcium gluconate Hypomagnesemia - CORRECT ANSWER Prolonged QTi so risk of torsades de pointes Give Mg DKA - CORRECT ANSWER sicker quicker hypovolemic shock-fluid resuscitation is priority causes metabolic acidosis causing kussmaul's respirations to compensate ketones in urine BUN/CREAT elevated d/t dehydration Monitor glucose and K+ carefully can deplete K+ s then insulin infusion and make sure K+ good insulin bolus can cause cerebral edema Base tx on closing the anion gap Add dextrose containing fluids when BGT reaches 250-300mg/dL HHS - CORRECT ANSWER Sicker longer Higher blood sugars since gradual increase in glucose No ketones or acidosis Require more fluids, but less insulin compared to DKA Diabetes Insipidus - CORRECT ANSWER "Die" ADH Low volume, hypernatremia See w/ head injury, lithium & dilantin toxicity Tx: Desmopressin (ADH) SIADH - CORRECT ANSWER "Si" ADH Volume overload, hyponatremic Risk of seizures d/t hyponatremia See w/ oat cell carcinoma or head injury Tx: hypertonic saline Thyroid Storm - CORRECT ANSWER Tachycardic, anxious, exophthalmos, pulmonary edema Dx: Low TSH but T3 & T4 elevated NO ASA b/c ASA elevated T4 higher Tx w/ beta blockers Myxedema coma - CORRECT ANSWER Give Levothyroxine See popsicles this is why nobody is dead until they are warm and dead Adrenal crisis - CORRECT ANSWER See this w/ sudden d/c steroids or acute Addison's Disease Hyponatremic & Hyperkalemic Tx: NS and Glucocorticoids Caution w/ etomidate DIC - CORRECT ANSWER Most often seen in OB emergencies and G- sepsis Decreased platelets, low Fibrinogen, low H&H Elevated d dimer and FDP prolonged PT and PTT SIRS - CORRECT ANSWER 2 or more of the following -Temp 38C or 36C -HR 90 -RR 20 -WBC count 12,000uL or 4,000uL or 10% immature forms Sepsis - CORRECT ANSWER SIRS + suspected/unknown source of infection Severe Sepsis - CORRECT ANSWER Organ dysfxn, lactic acidosis, platelets 100,000, oliguria Needs & responds to fluids (30mL/kg/hr) Septic shock - CORRECT ANSWER requires pressors levo is pressor of choice then dopamine 30mL/kg/hr IVF Abx Airborne precautions - CORRECT ANSWER MTV or My chicken hez tb measles (rubeola), chickenpox (varicella) Herpes zoster/shingles TB SARS and Avian Droplet precautions - CORRECT ANSWER spiderman! sepsis, scarlet fever, streptococcal pharyngitis, parvovirus, pneumonia, pertussis, influenza A&B diptheria, epiglottitis, rubella, mumps, meningitis, mycoplasma or meningeal pneumonia, adeNovirus (Private room and mask) Contact precautions - CORRECT ANSWER RSV, MRSA, VRE, CDiff, Hep A Gown & Gloves Anaphylaxis - CORRECT ANSWER Epinephrine is priority Steroids Histamine blockers-benadryl & pepcid or zantac Severe hypothermia will see what on EKG? - CORRECT ANSWER Osborne or "J" wave Hypothermia Rewarming - CORRECT ANSWER Rewarm from core w/ warmed O2, IVF, warm foley lavage Do not warm externally d/t temp drop when removing warming equipment Heat Stroke - CORRECT ANSWER a condition marked by fever and often by unconsciousness, caused by failure of the body's temperature-regulating mechanism when exposed to excessively high temperatures. Rapid cooling to 102 degrees Benzos to prevent shivering Risk of rhabdo & renal failure Submersion injury - CORRECT ANSWER Secure airway and rewarm patient immediately Venomous Pit Vipers - CORRECT ANSWER Antivenom only if enlarging hemorrhagic vesicles Do not apply ice or tourniquets Black widow spider - CORRECT ANSWER abdominal cramps tx w/ pain medication Opiate toxicology - CORRECT ANSWER Assist w/ breathing BVM Narcan Half life of Narcan is 30-60 mins Sympathomimetics (cocaine) - CORRECT ANSWER tachycardia, dilated pupils teeth clenching is sign of using Molly Tx: benzodiazepines Risk of violence w/ hallucinations Benzodiazepine toxicity - CORRECT ANSWER Flumazenil (romazicon) assist w/ breathing watch out for sz b/c reduces sz threshold Acetaminophen toxicity - CORRECT ANSWER Charcoal N-Acetycysteine Salicylate toxicity - CORRECT ANSWER Metabolic acidosis Sodium bicarb tx to promote excretion and dextrose Iron toxicity - CORRECT ANSWER Antidote Deferoxamine and it turns urine vin rose color as iron is excreted Cholinergic toxidrome - CORRECT ANSWER Organophosphates exposure SLUDGE + bronchorrhea Decontaminate patient first then tx w/ atropine 2-PAM until secretions are decreased Anticholinergic toxidrome - CORRECT ANSWER Blind as a bat (Mydriasis) Mad as a hatter (Altered mental status) Red as a beet (vasodilation, flushed) Hot as a hare (febrile) Dry as a bone (no secretions/diaphoresis) Bowel and bladder lose their tone Heart runs alone (tachycardia) Atropine, antihistamines, scopalamine, antipsychotics Ethylene glycol/methanol intoxication - CORRECT ANSWER Cause an anion gap & metabolic acidosis 5-10% ethanol infusion or Fomepizole (Antizol) Tricyclic antidepressants toxicity - CORRECT ANSWER Elavil Tofranil Prolongs QTi puts pt at risk for Torsades de Pointes watch for seizures and coma tx w/ bicarb and magnesium Digoxin toxicity - CORRECT ANSWER -Cholinergic—nausea, vomiting, diarrhea, blurry yellow-green halo vision (think van Gogh), arrhythmias, AV block. -Can lead to hyperkalemia, which indicates poor prognosis Dig Fab fragments is the tx Calcium toxcity - CORRECT ANSWER Initial antidote is Ca+ and tx bradycardia Beta Blocker toxicity - CORRECT ANSWER Glucagon and tx bradycardia Extrapyramidal reactions - CORRECT ANSWER Dystonia-muscle spasms from haldol or thorazine Tx: Diphenhydramine Stage 1 of labor - CORRECT ANSWER begins with onset of regular contractions and ENDS when cervix is completely effaced and dilated Stage 2 of labor - CORRECT ANSWER typically lasts from a half an hour to two hours and involves the actual delivery of the baby Stage 3 of labor - CORRECT ANSWER delivery of neonate to placenta Fetal monitoring - CORRECT ANSWER Normal FHT are 120-160bpm Variability is good Late decelerations and no variability are bad signs Fundal height @ umbilicus @ how many weeks? - CORRECT ANSWER 20-24 weeks (viable fetus) Decreased fetal movement - CORRECT ANSWER Hypoxia to fetus How to avoid fetal vena cava syndrome - CORRECT ANSWER Tilt patient 15 degrees to left side Ectopic pregnancy - CORRECT ANSWER 6-8 weeks gestation Tx w/ Rhogam and surgery Gestational (PIH) Hypertension - CORRECT ANSWER HTN, proteinuria, HA, diplopia, edema Tx: Magnesium sulfate to decrease sz threshold and anti-hypertensives (Apresoline or Labetolol preferred) Eclampsia - CORRECT ANSWER seizures tx w/ benzos monitor for respiratory depression and loss of DTR while on Mg infusion If toxic administer Calcium gluconate Abruptio placenta - CORRECT ANSWER Severe knife-like abdominal pain radiating into back NO pelvic exam until u/s performed A bunch of pain Placenta previa - CORRECT ANSWER painless bright red vaginal bleeding NO pelvic exam until u/s performed Prolapsed cord - CORRECT ANSWER position in knee chest position Insert sterile gloved hand to lift presenting part off cord Tocolytics like Mg or Terbutaline to decrease pressure of cxns Rupture of membranes - CORRECT ANSWER Nitrazine paper turns blue Imminent delivery urge to push vaginal bleeding crowning Emergency c section - CORRECT ANSWER If decelerations w/ loss of variability or sustained bradycardia Breech Presentation - CORRECT ANSWER Mauriceau's maneuver Shoulder dystocia-McRoberts maneuver Newborn Resuscitation - CORRECT ANSWER Warm, dry, stimulate, blow by O2 Assist ventilations @ 40-60 breaths/minute if HR 100bpm Begin compressions if HR 60 @ 3:1 and goal is to get HR 100bpm Preductal right wrist O2 sats @ 1 min. is 60-65% 90% in 10 mins Meds (epi) are last resort Narcan is not indicated initially APGAR @ 1 and 5 mins If mother is diabetic administer D10% PRN and do blood sugar early Fundal massage - CORRECT ANSWER Post partum hemorrhage to enhance uterine atony then pitocin (oxytocin) HELLP is DIC in OB emergencies decreased platelets OB Trauma - CORRECT ANSWER Turn on side 15 degrees to avoid aorta caval vena caval syndromes Uterine Rupture - CORRECT ANSWER Increased risk if prior c section, hemorrhagic shock, palpable fetal parts Abruptio placentae - CORRECT ANSWER Ripping abdominal back pain "a lot" of pain dark red bleeding (scant) Congenital heart defect left to right shunt - CORRECT ANSWER acyanotic (pink) VSD - CORRECT ANSWER ventricular septal defect aka CHF PDA - CORRECT ANSWER patent ductus arteriosus Indomethacin to close PGE1 to keep open (causes apnea) Coartication of Aorta - CORRECT ANSWER Check BP in upper and lower extremities Right to left shunt - CORRECT ANSWER cyanotic (blue) Tetralogy de Fallot - CORRECT ANSWER Boot shaped heart Normally has low SPO2 Knee to chest position Scaphoid abdomen - CORRECT ANSWER diaphragmatic hernia Tx: OG tube & intubation Omphalocele - CORRECT ANSWER abdominal contents herniated through the umbilical cord Choanal atresia - CORRECT ANSWER Narrowing or blockage of nasal airways (remember babies are nose breathers) Pierre-Robin - CORRECT ANSWER Small lower jaw, tongue is displaced back (glossoptosis) and leads to cleft palate so more difficult airway Pediatric subdural hematoma - CORRECT ANSWER shaken impact syndrome Pediatric rib fractures - CORRECT ANSWER high risk for underlying thoracic and abdominal solid organ injures kids ribs are pliable and don't just break consider child abuse Pediatric splenic injury - CORRECT ANSWER fall of bicycle abdominal pain Pediatric small bowel rupture - CORRECT ANSWER think chance fracture (T12-L2) seen w/ lap belt injuries Pediatric spiral fracture - CORRECT ANSWER child abuse Estimate of weight w/ age - CORRECT ANSWER 1=10kg 3=15kg 5=20kg age in years *2 + 8=wt in kgs When do you use the isolette - CORRECT ANSWER under 5 kgs or 30 days old Holliday-Segar 4-2-1 Rule - CORRECT ANSWER Pediatric ETT, suction, chest tube calculation - CORRECT ANSWER ETT-(age + 16)/4 Suction catheter 2*ETT size ETT depth 3*ETT size Chest tube 4*ETT size When to insert OG tube - CORRECT ANSWER immediately after intubation Infant ventilator settings - CORRECT ANSWER FiO2 100% initially Rate 16-20 PEEP 3-5 Intussusception - CORRECT ANSWER Telescoping of bowel S/S: sausage shaped mass, currant jelly stools Tx: air or barium enema Volvulus - CORRECT ANSWER malrotation of the bowel tx: surgical repair Croup - CORRECT ANSWER laryngotracheobronchitis upper airway obstruction seal like cough low grade fever steeple sign on CXR nebulized, racemic epi, dexamethasone Epiglottitis - CORRECT ANSWER Drooling Keep kid calm, stay away thumb print sign on lateral neck xray bacterial HIB infectio n high fever protect the airway Asthma - CORRECT ANSWER chronic disorder of lower airways hyperactivity, bronchospasm, mucus production status asthmaticus is an exacerbation that is unresponsive to tx including hypoxia, hypercarbia, resp failure s/s: tachypnea, expiratory wheezing, prolonged expiratory phase, absence of breath sounds is ominous tx: saba like albuterol, anticholinergics like ipratropium bromide, IV magnesium, heliox, ketamine NO PEEP in mechanical ventilation Hypotension is an early or late sign in pediatric cardiac emergency? - CORRECT ANSWER Late Tx: IVF bolus @ 20mL/kg over 10-15 mins using push pull w/ 3 way stop cock Cardiogenic shock fluid bolus - CORRECT ANSWER 5-10mL/kg over 10-30 mins Hypotension - CORRECT ANSWER SBP 60 neonates SBP 70 infants 70 + (2*age years) for ages 1-10 Bradycardia in pediatric patients - CORRECT ANSWER ominous sign Defibrillation dose in peds - CORRECT ANSWER 2-4 joules/kg first shock then up to 10 joules/kg subsequent shocks Synchronized cardioversion in peds - CORRECT ANSWER 0.5-1 joules/kg unstable tachycardia Infant seizures - CORRECT ANSWER rhythmic lip smacking Status epilepticus - CORRECT ANSWER continuous tonic clonic seizures for up to 5 mins or longer turn pt on side tx hypoglycemia and hyponatremia midazolam intranasally Refractory sz give benzos first, phenytoin (dilantin) or fosphenytoin (cerebryx), pheno, prop, ketamine Geriatric airway considerations - CORRECT ANSWER check for dentures/partials leave dentures in for BVM use care when inserting OPA risk of bleeding-anticoagulants difficult airway d/t arthritis can limit visualization Geriatric fluid bolus and hemodynamic considerations - CORRECT ANSWER Give smaller fluid boluses Transfuse blood early to increase O2 Beta blockers mask s/s early shock Add PT, PTT, INR to trauma labs Administer Vitamin K, plasma, other reversal agents for anticoagulation Bariatric Emergencies - CORRECT ANSWER High flow O2 over 15 mins prior to flight to prevent barobariatrauma from Boyle's law Drug dosages like hydrophilic meds (benzos, prop, fent) are all based on pt's ideal body wt Keep pt in ramped position @ 45 degrees to intubate Intra-Aortic Balloon Pump - CORRECT ANSWER Primary purpose of IABP is to increase myocardial oxygen supply while decreasing myocardial oxygen demand -achieves this through counter pulsation IABP triggers by - CORRECT ANSWER ECG deflates on R wave peak or arterial line tracing if poor ECG quality inflates @ closure of aortic notch, dicrotic notch IABP indications - CORRECT ANSWER Cardiogenic shock mechanical complications post MI (mitral regurg, ventral septal defect, papillary muscle dysfunction) Absolute contraindications to IABP - CORRECT ANSWER Aortic aneurysm Aortic insufficiency Severe aortic disease Aortic stents Relative contraindications to IABP - CORRECT ANSWER AAA Severe peripheral vascular dz Tachyarrhythmias When does the IABP inflate? - CORRECT ANSWER During diastole to increase myocardial oxygen supply and perfuse coronary arteries When does IABP deflate? - CORRECT ANSWER Right before systole to decrease myocardial oxygen consumption and afterload IABP Timing Errors - CORRECT ANSWER Early inflation is bad since still balloon inflation begins before systole is complete Late inflation causes suboptimal coronary artery perfusion Early deflation causes suboptimal coronary artery perfusion and afterload reduction Late deflation is VERY BAD since it increases afterload and myocardial oxygen consumption What ratio do you use for IABP - CORRECT ANSWER 1:1 ration initially then up to a HR of 120bpm 1:2 or 1:3 can be used w/ extreme tachycardia or in weaning of IABP What position to avoid w/ IABP - CORRECT ANSWER Do not elevate HOB 30 degrees and do not flex the knee What to assess for IABP - CORRECT ANSWER Radial arteries and urine output to determine if IABP has migrated at all Mechanical hemolysis to RBC will cause what? - CORRECT ANSWER Decrease in H&H What does the presence of rust colored flakes in the helium line indicate? - CORRECT ANSWER Balloon rupture This is an emergency! clamp the line, stop pumping, disconnect the patient from the IABP IABP Boyle's Law - CORRECT ANSWER The balloon will expand on ascent but the machine will compensate Cardiac arrest on IABP - CORRECT ANSWER Perform CPR & defibrillation per usual Ventricular Assist Device - CORRECT ANSWER A VAD is used for patient's w/ end stage heart failure Battery operated mechanical pumps that help the left ventricle pump blood to the body Audible hum Barely/no palpable pulse SBP 70-90 via doppler over brachial or radial pulse Pulmonary Artery Catheter - CORRECT ANSWER 20-25cm at right atrium 30-35 @ right ventricle 40-45 @ pulmonary artery 50+ for obstructive pressure Where do you transduce a PA