CEN review class

  1. When is a patient in active labor considered to be stable for transfer?
    when baby and placenta have been delivered
  2. EMTALA transfer guidelines?
    • *written consent
    • *documented risks/benefits
    • *must send records/results
    • *document name/address of any on-call
    •   physician who refuses or fails to appear
    •   in reasonable time
    • *direct communication between transferring
    •  and receiving providers
    • *receiving must have available beds
    • *document receiving physician and phone #
    • *experienced staff/equipment during transfer
  3. Assessment:  always assess ___ first
    airway
  4. For airway/breathing issues what should be considered before definitive procedures?
    basic airway meneuvers and adjuncts
  5. What is different about assessing airway in trauma patient?
    airway assessment and C-spine stabilization are always combined in trauma
  6. How is OPA measured?
    tip of mouth to angle of jaw or tip of earlobe
  7. How is NPA measured?
    tip of nose to angle of jaw
  8. When is NPA contraindicated?
    midface trauma
  9. Normal adult ETT size?
    6.5/8.0
  10. Pediatric ETT tube size formula?
    (16 + age in years) / 4
  11. Consideration for pediatric patients with increased RR?
    may rapidly deteriorate
  12. Where is needle decompression performed?
    2nd intercostal space at mid-clavicular line
  13. Normal HR in children 1-3?
    90-120
  14. HR of children >6?
    similar to adults
  15. Normal HR for infants?
    100-160
  16. What causes first heart sound?
    closure of AV valves at beginning of systole
  17. What causes second heart sound?
    • closure of semilunar valves at beginning of
    • diastole
  18. What causes third heart sound S3?
    heart failure, fluid overload
  19. What causes fourth heart sound S4?
    ventricular hypertrophy
  20. Causes of systolic murmur?
    • mitral regurgitation
    • aortic stenosis
  21. Cause of diastolic murmur?
    • mitral stenosis
    • aortic regurgitation
  22. First priority in unconscious patient?
    protect airway
  23. Contraindications for MAST (military anti-shock trousers) and PASG (pneumatic anti-shock garment)
    • pulmonary edema
    • ruptured diaphragm
    • LV dysfunction
    • pregnancy
    • abdominal evisceration
  24. What position should patient be in prior to performing orthostatic VS?
    lying flat at least 5 min
  25. How should orthostatic VS be performed?
    HR & BP at 1 & 3 min after position changes
  26. Positive orthostatic VS changes?
    • SBP drop >/= 20
    • DBP drop >/= 10
    • HR increase >/= 20
  27. ENA recommends triage be performed by a nurse with how much experience?
    at least 6 months
  28. 3 tiered triage system?
    • emergent
    • urgent
    • non-urgent
  29. 4-tiered triage system?
    • life-threatening
    • emergent
    • urgent
    • non-urgent
  30. 5-tiered triage system?
    • 1 resuscitation- seen immediately
    • 2 emergent/very urgent - seen in 10 min
    • 3 urgent seen within 30 min
    • 4 semi-less urgent - seen in 60 min
    • 5 non-urgent seen in 120 min
  31. What type of triage system is recommended by ENA and American College of Emergency Physicians?
    5 tiered system
  32. Use of hyperventilation in head injury patients?
    not recommended
  33. Research process?
    • 1 ID problem
    • 2 Review research/data that addresses
    •    the question
    • 3 evaluate findings for validity, relevance,
    •    and applicability
    • 4 integrate the new info into practice
    • 5 Evaluate changes in practice for sesired outcome
  34. Consideration for transporting patient with family present?
    • Never let family leave before patient
    • give map and phone number
  35. Is written consent required from patient to treat?
    no, should be obtained after MSE
  36. Implied consent?
    life or limb threatening situation
  37. 3 essential components required for informed consent prior to procedure?
    • provider must:
    • 1. describe procedure
    • 2. explain alternatives
    • 3. detail risks
  38. Negligence (medical malpractice)?
    action or inaction that does not meet standards of care and results in injury to pt
  39. Four elements of negligence?
    • 1. duty to act (relationship established)
    • 2. breach of duty/contract (bad care)
    • 3. proximate cause (breech was cause of
    •     injury)
    • 4. result in damage (injury caused by 
    •     negligence)
  40. Assault?
    attempt or threat to touch another person or the person's possessions without his/her consent
  41. Battery?
    • actual contact with a person or the person's possessions without consent
    • "unauthorized touching"
  42. What is required by law to be reported?
    • 1. gunshot & stab wounds (self-inflicted also)
    • 2. anything r/t violence
    • 3. communicable diseases
    • 4. child/elder/spouse abuse
    • 5. death within 48 hrs admission to hospital
    • 6. poisonings
    • 7. fetal deaths
    • 8. animal bites
  43. Blood alcohol consent for law enforcement?
    only draw blood with pt express consent

    may draw without pt consent with search and seizure warrant but cannot use physical force
  44. Who is present for Critical Incident Stress Debriefing?
    confidential:  only those involved and debriefing team present
  45. What should be avoided when interviewing someone?
    inquiries about marital status, sexual orientation, religion, age, children
  46. What program covers work related injury issues?
    OSHA
  47. What tasks can be delegated to unlicensed personnel?
    technical tasks
  48. What tasks may not be delegated to unlicensed staff?
    steps of nursing gprocess, triage, assessment, patient teaching, discharge instructions
  49. Chain of custody in evidence collection?
    maintain chain of custody and minimize contact
  50. Documentation when evidence collection is necessary?
    document behaviors and use quotations
  51. Preserving evidence?
    • 1. minimal handling
    • 2. paper bag each item
    • 3. don't cut thru holes or marks in clothing
    • 4. hands:  don't wash, consider bagging
    •     in paper bags
    • 5. delay cleaning patient & wounds when
    •     possible
  52. Who dictates guidelines or restraints?
    JCAHO and CMS
  53. Risks of chemical and physical restraints?
    • skin breakdown
    • strangulation
    • respiratory depression
  54. Moderate/conscious sedation?
    consciousness depressed but pt maintains own airway and protective reflexes and ability to respond to stimuli
  55. What drugs should be available during conscious sedation?
    naloxone/flumazenil
  56. What consent is required for conscious sedation
    need consent for BOTH sedation and procedure
  57. Role of monitor in conscious sedation?
    monitor patient throughout procedure and recovery and not assist with procedure
  58. Type of pt education that involves thinking and reasoning?
    • cognitive
    • info about disease process, discharge instructions
  59. Type of pt education that involves change in attitude of values?
    • affective
    • educating to change health behaviors, importance of immunizations
  60. Type of pt education that requires coordination of the brain and extremities to complete a task?
    • psychomotor
    • crutch walking, use of peak flow meter and inhalers
  61. What is a JCAHO standard in pt teaching?
    identify implied and expressed learning needs of the patient or learner
  62. What is the most effective method of education?
    demonstration
  63. Documentation of rapidly occurring interventions?
    • use a designated recorder
    • chronicle events
    • critical pt need evidence of frequent, serial assessment and interventions to help ID trends
  64. Documentation by exception?
    focus on variances from normal assessment
  65. Definition of a disaster?
    usually develops suddenly and unexpectedly

    requires immediate coordinated and effective responses by multiple gov agencies and private organizations

    sudden & massive disproportion b/t hostile elements of any kind and survival resources which can be brought into action in shortest possible time
  66. Phases of a disaster?
    • 1. warning: impending danger
    • 2. impact: disaster occurs
    • 3. isolation: time from impact until outside 
    •     help arrives.  Utilize available resources
    • 4. Rescue: assistance from outside sources
    •     arrives, continuous reassessment of event
    • 5. Restoration:  days to years, slowly scale
    •     down response
    • 6. Normal Operations:  all functions return
    •     to baseline
  67. Multiple casualty?
    Mass casualty?
    • multiple casualty:  100 or less casualties
    • mass casualty: >100 casualties
  68. Disaster triage color code?
    • Red = immediate/emergent:  life-threatening
    • injury, airway compromise, etc

    Yellow = Delayed/urgent:  major illness/injury, requires Tx within the hour

    Green = Minor/nonurgent - walking wounded, can self-treat, can wait several hours

    Black = deceased/expectant - dead or expected to die:  full arrest, massive full thickness burns, fatal injureis
  69. SALT for disaster Tx?
    • sort
    • assess
    • lifesaving interventions
    • treatment/transport
  70. Incident Command System?
    each incident will require specific chain of command

    establish command center

    each hospital must list chain of command and each person's duties
  71. Notification of staff members of disaster?
    hospital must have disaster call tree system in place
  72. How to prepare for disaster?
    have drills
  73. Hot or Red Hazmat zone?
    danger zone, restricted access

    requires proper PPE, basic ABC management only and antidote
  74. Warm or yellow hazmat zone?
    control zone:  active decontamination

    only emergent Tx provided, requires proper PPE
  75. Cold or green hazmat zone?
    safe zone: Tx area

    staging area, only need standard precautions
  76. Shock?
    generalized inadequate tissue perfusion resulting in widespread impairment of cellular metabolism and dysfunction of critical organs
  77. Compensated shock?
    stimulation of SNS to release catecholamines which stimulate beta and alpha receptors

    Decreased renal BF activates renin-angiotensin aldosterone system

    Reduced capillary hydrostatic pressure

    Clinical manifestation:  anxiety, hyperventilation, narrowing pulse pressure with normal BP, cool clammy skin, increasing serum glucose
  78. Effects of epi and nor-epi?
    increased BP, HR, myocardial contractility, and BF to lungs

    release of glucocorticoids
  79. Result of Renin-angiotension-aldosterone system activation?
    vasoconstriction

    aldosterone - increases sodium and water reabsorption

    inceased secretion of ADH causes water retention
  80. Adrenergic receptors?
    • Alpha:  arteries
    • Beta 1:  heart
    • Beta 2:  lungs
  81. Why is capillary hydrostatic pressure reduced in shock?
    translocation of fluid from interstitial space to intravascular space

    increases circulating blood volume
  82. Clinical manifestations of shock in healthy person that is compensated?
    may appear relatively normal
  83. Clinical manifestations of compensated shock?
    • anxiety
    • hyperventilation
    • narrowing pulse pressure with normal BP
    • cool clammy skin
    • increasing serum glucose
  84. Uncompensated shock?
    • 1. vessels begin to vasodilate
    • 2. organ dysfunction
    • 3 anaerobic metabolism
    • 4.histamine release
  85. What occurs as vessels dilate in uncompensated shock?
    decreased peripheral resistance and BP

    decreased venous return to the heart (preload)
  86. Liver disfunction in decompensated shock?
    decreased liver function and production of clotting factors
  87. Pancreas dysfunction in decompensated shock?
    release of myocardial depressant factor (MDF) resulting in further depression of cardiac function
  88. Lung dysfunction in uncompensated shock?
    decreased production of surfactant
  89. Kidney dysfunction in uncompensated shock?
    decreased GFR and ability to clear toxins
  90. What occurs in anaerobic metabolism?
    cell hypoxia, acidosis (lactic and metabolic)
  91. Effects of histamine release r/t uncompensated shock?
    capillary permeability increased

    fluid shift from intravascular to interstitial space
  92. Clinical manifestations of uncompensated shock?
    • alterations in LOC
    • hypotension
    • significant tachycardia
    • peripheral cyanosis
    • decreasing UO
    • decreased pulmonary capillary BF and gas exchange
    • microcapillary clotting from sluggish BF
  93. What causes decreased pulmonary capillary BF and gas exchange in uncompensated shock?
    endothelial damage to lungs resulting in metabolic and respiratory acidosis
  94. Characteristics of irreversible/refractory shock?
    • 1. progressive organ dysfunction leading
    •     to death
    • 2. acidosis
    • 3. clotting derengements
    • 4. cerebral ischemia
  95. Clinical manifestations of irreversible/refractory shock?
    • 1. cold, pale, mottled skin
    • 2. extremely weak, thread pulses
    • 3. significant tachycardia & dysrhythmias
    •     deteriorating to bradycardia
    • 4. severe hypotension
    • 5. hypothermia
  96. Hypovolemic shock
    alteration in circulating volume:  preload
  97. Causes of hypovolemic shock?
    loss of blood, plasma, or other body fluids

    • 1. massive blood loss
    • 2. vomiting/diarrhea
    • 3. diabetes insipidus
    • 4. burns
    • 5. DKA
    • 6. excessive diaphoresis
  98. Class I fluid volume loss associated signs and symptoms?
    • up to 15% loss/750mL in adults
    • HR <100, BP normal
    • essentially normal physical exam
  99. Class II volume loss?
    15-30%/750-1500mL in adults

    HR >100, BP normal, decreased pulse pressure

    pale, anxious, diaphoretic, cool/clammy skin
  100. Class II volume loss?
    30-40%, 1500-2000mL for adults

    HR>120, hypotensive, decreased pulse pressure

    very anxious, confused, oliguria
  101. Class IV volume loss?
    >40%, >2000mL in adults

    HR>140, hypotension, decreased pulse pressure

    lethargic, unresponsive, anuria, cold, pale
  102. Locations for IO insertion?

    Which is preferred in adults?
    • distal femur
    • proximal tibia
    • proximal humerus (preferred in adults)
    • sternum (requires special device)
  103. When should central line access be used for fluid volume loss?
    • last option
    • should be placed once stabilized and via sterile technique unless no other option
  104. Ratio of crystalloid to blood and colloid to blood replacement?
    3:1 crystalloid to blood

    1:1 colloid to blood
  105. Why should all IV fluids and blood be warmed in hypovolemic conditions?
    patients with temp <34 C have 50% higher mortality rate
  106. Pediatric fluid and blood replacement criteria in hypovolemic shock?
    • 20mL/kg bolus (X2-3) crystalloid
    • 10mL/kg PRBC or colloids
  107. Cardiogenic shock?
    impairment of pumping ability/contractility of heart
  108. Primary causes of cardiogenic shock?
    • 1. MI - most common
    • 2. myocardial contusion
    • 3. cardiomyopathies
    • 4. valve dysfunction
    • 5. ruptured septum
  109. Obstructive shock?
    obstruction of forward flow of blood- obstruction causes decreased circulating volume by preventing myocardium from mechanically emptying or filling during diastole
  110. Causes of obstructive shock?
    • 1. tension pneumo
    • 2. pericardial tamponade
    • 3. pulmonary embolism
    • 4. aortic aneurysm
  111. Clinical manifestations of cardiogenic shock?
    • 1. restlessness, apprehensive, confused, obtunded
    • 2. chest pain
    • 3. pale, cool, clammy skin
    • 4. thread peripheral pulses
    • 5. delayed cap refill
    • 6. EKG changes/dysrhythmias
    • 7. shallow, rapid breathing
    • 8. decreased UO
    • 9. metabolic acidosis
    • 10. hypoxemia/hypocapnia
    • 11. weak or muffled heart sounds, S3 gallop
    • 12. distended neck veins (RV failure)
  112. Management of cardiogenic shock?
    • 1. ABC's
    • 2. EKG
    • 3. anticipate need for thrombolytics
    • 4. manage preload
    • 5. improve contractility
    • 6. decrease afterload
    • 7. anticipate need for IABP
    • 8. correct obstruction:  needles thorocostomy, pericardiocentesis
  113. How to increase and decrease preload?
    increase:  more volume

    decrease:  nitroglycerin, furosemide, morphine
  114. Medications to improve contractility?
    inotropes: dobutamine, milrinone
  115. Dobutamine?
    stimulates Beta 1 receptors:  increased cardiac contractility
  116. Medications to decrease afterload?
    • nitroprusside/nipride
    • ACE inhibitors
  117. Distributive shock?
    abnormal placement of intravascular volume
  118. 3 types of distributive shock?
    • 1. septic shock
    • 2. anaphylactic shock
    • 3. neurogenic shock
  119. Septic shock?
    toxins released by invading organisms cause vasodilation and activate cellular, humoral, and immunologic systems

    massive vasodilation and inceased capillary permeability
  120. Type of toxins released by gram pos and gram neg bacteria?
    • gram pos - exotoxins
    • gram neg - endotoxins
  121. SIRS - systemic inflammatory Resonse Syndrome?
    nonspecific inflammatory response to a variety of stimuli
  122. SIRS criteria?
    • Must have 2:
    • 1. temp <36C or >38C
    • 2. HR >90
    • 3. tachypnea >20 or PaCO2 <32
    • 4. WBC <4000 or >12,000 or >10% band formation
  123. Sepsis?
    SIRS + infection or presumed infection
  124. Severe Sepsis?
    Sepsis with >/= 1 organ dysfunction
  125. Septic shock?
    sepsis + hypotension that requires vasopressors (refractory to crystalloids)
  126. Multi Organ Dysfunction Syndrome (MODS)?
    involving at least 2 vital organ systems:  respiratory, cardiac, nervous, renal, hepatic
  127. Clinical manifestations of septic shock?
    • 1. tachycardia
    • 2. increased CO/index
    • 3. decreased vascular resistance
    • 4. widened pulse pressure
    • 5. normal BP or mild hypotension
    • 6. flushed skin
    • 7. decreased LOC
  128. Late septic shock clinical manifestations?
    • 1. progressive decline in LOC
    • 2. profound hypotension
    • 3. pale, cool, clammy/mottled skin
    • 4. weak, thread, peripheral pulses
    • 5. severe acidosis
    • 6. hypoxemia & increased work of breathing
    • 7. systemic and pulmonary edema
  129. Management of septic shock?
    • 1. support ABC's
    • 2. volume
    • 3. vasopressors
    • 4. Tx infection:  ABX
  130. Anaphylactic shock?
    • 1. sudden onset
    • 2. severe allergic reaction: systemic antigen-antibody reaction, hypersensitivity
    • 3. massive vasodilation and increased capillary permeability
  131. Common triggers of anaphylaxis?
    • 1. antibiotics
    • 2. shellfish
    • 3. peanuts
    • 4. eggs
    • 5. stinging insects (hymenoptera)
  132. Clinical manifestations of anaphylactic shock?
    • 1. anxiety, impending doom
    • 2. pruritus
    • 3. uricaria, rash
    • 4. sudden HA, ABD pain
    • 5. dyspnea, tachypnea
    • 6. syncope
    • 7. angioedema
    • 8. skin warm & flushed (early)
    • 9. skin cool & clammy (late)
    • 10. stridor &/or wheezing
    • 11. nasal flaring
    • 12. use of accessory muscles
    • 13. profound respiratory distress
  133. Sepsis Bundles?
    • within 3 hours:
    • obtain lactate
    • blood cultures before antimicrobials
    • broad spectrum ABX
    • 30mL/kg crystalloid bolus for hypotension or lactate >4

    • within 6 hours:
    • vasopressor if hypotensive despite fluids (NE preferred)
    • goal MAP >/= 65
    • measure CVP and ScVO2
    • rre-measure lactate
  134. What receptors are affected by epinephrine?
    alpha and beta equally
  135. What receptors are affected by norepinephrine?
    alpha > beta
  136. What receptors are affected by phenylephrine?
    alpha only
  137. what receptors are affected by dopamine?
    dopamine, beta 1 and alpha depending in dose
  138. Medications for anaphylactic shock?
    • epinephrine 1:1000 (1mg/1ml) 0.1-0.5mg IM/SQ or IV in severe cases (1:10,000) 1mg/10mL
    • antihistamines:  H1 blockers- Benadryl
    •   H2 blockers - famotidine, ranitidine
    • volume replacement
    • vasopressors
  139. Neurogenic shock?
    • 1. loss of sympathetic vasomotor function
    • 2. uncontested parasympathetic response
  140. What type of injuries typically involve neurogenic shock?

    Other causes?
    spinal cord injuries at or abve level of T6

    brain stem injuries, spinal anesthesia, depressant and hypoxia
  141. Clinical manifestations of neurogenic shock?
    • 1. hypotension & BRADYCARDIA
    • 2. warm, dry, flushed skin
    • 3. poikilothermia - can't control temp
    • 4. spinal shock - neurogenic motor dysfunction or areflexia noted below the level of the lesion
  142. Management of neurogenic shock?
    • 1. manage ABC's
    • 2. volume: admin with crystalloids
    • 3. maintain normothermia
    • 4. vasopressors: phenylephrine, NE
    • 5. stabilize spine
  143. What percentage of NS stays in the intravascular space?
    33%`
  144. Issues with large volumes of NS?
    hyperchloremic metabolic acidosis
  145. What fluid should be used when transfusing blood products?
    NS
  146. NS?
    isotonic- increases volume without altering NA+ concentration or serum osmolality
  147. LR?
    isotonic - increases volume and replces intracellular fluid losses
  148. What fluid is most similar to plasma?
    LR
  149. LR should be used with caution in pt with what organ dysfunction?
    liver dysfunction: lactate is converted in the liver
  150. What metabolic imbalance may be caused by large quantities of LR?
    metabolic alkalosis r/t lactate converted to bicarbonate
  151. 3.0% saline?
    • hypertonic - increases plasma volume with lower volumes required
    • used in conjunction with conventional resuscitation fluids
    • improve cerebral perfusion
  152. Hypertonic fluids and intravascular space?
    help keep water in intravascular space
  153. Considerations when admin 3.0% saline?
    administer slowly

    may cause fluid overload ad pulmonary edema
  154. Whole blood?
    blood and volume replacement

    increases O2 carrying capacity of blood
  155. Universal donor?
    AB
  156. Consideration when admin whole blood?
    kept frozen - must give quickly after thawing to preent deterioration of factors V and VII
  157. PRBC?
    increases RBC's, HgB, and Hct

    increases o2 carrying capacity of blood
  158. Universal donor?
    O+ and O-
  159. Consideration with admin of PRBC r/t blood clotting?
    no significant amnt of clotting factors/platelets

    consider transfusion of FFP and platelets after every 4-5 units PRBC
  160. FFP?
    replaces clotting factors, plasma proteins, and plasma

    used for control of bleeding and replacement from blood loss
  161. Considerations for admin of FFP?
    kept frozen and must be admin quickly r/t deterioration of factors V and VII
  162. Platelets?
    thrombocytes in plasma

    control bleeding and replacement from blood loss
  163. Albumin and other colloid administration?
    increases plasma volume and the plasma colloid (oncotic) pressure
  164. Cranial nerve I?
    olfactory - sense of smell - rarely tested
  165. Cranial nerve II?
    optic - visual acuity, visual fields, detection of light reflex
  166. Cranial nerve III?
    Oculomotor - constricts/dilates pupil, elevate upper lid, most extraoxular movements (EOMs), up, down, in
  167. Cranial nerve IV?
    trochlear - EOMs - look down, inward
  168. Cranial nerve V?
    • trigeminal
    • corneal reflex
    • sensation of face, scalp, oral and nasal cavities (3 branches)
    • chewing, jaw movement
  169. Cranial nerve VI?
    abducens - EOMs movement of eye laterally
  170. Cranial nerve VII?
    Facial - facial movment and expression - raise eyebrow, smile, close eyes, lip movement, show teethc, anterior taste (rarely tested)
  171. Cranial nerve VIII?
    Acoustic (vestibulocochlear) - hearing and balance
  172. Cranial nerve IX?
    Glossopharyngeal -swallowing, gag reflex, taste on posterior tongue, sensation of the carotid bodies
  173. Cranial nerve X?
    • Vagus - sympathetic/parasympathetic responses (HR, BP, RR),
    • thoracic and abd viscera, gag reflex, speech
  174. Cranial nerve XI?
    spinal accessory - shoulder shrug, head turning
  175. Cranial nerve XII?
    hypoglossal - tongue movement
  176. Oculocephalic reflex?
    doll's eyes - normal response:  while turning head rapidly side to side, the eyes move the opposite direction to where head is turned
  177. Oculovestibular reflex?
    ice water calorics:  normal response:  eyes turn slowly toward the ear in which the ice water is injected into, then rapidly turn away
  178. Apnea test?
    allow CO2 to build up to stimulate respiratory system to determine if patients will breathe on their own
  179. What is affected with loss of brain stem reflexes?
    pupils, gag, cough, and corneals
  180. Cerebral perfusion pressure (CPP) formula?
    MAP - ICP
  181. Normal ICP?
    1-15
  182. Normal CPP?
    60-70
  183. Decerebrate posturing?
    extension - injury to the brainstem

    hands and arm extended outward
  184. Decerebrate posturing indicates what type of injury?
    brainstem
  185. Decorticate posturing?
    flexion - hands clinched and turned inward toward body
  186. Decorticate posturing indicates what type of injury?
    injury above midbrain
  187. What does Cushing's Triad indicate?
    very late sign of increased intracranial pressure (ICP)
  188. 3 characteristics of Cushing's Triad?
    • 1. increased systolic BP (widened pulse pressure)
    • 2. profound bradycardia
    • 3. abnormal respiratory pattern
  189. Brain Herniation?
    late sign of increased ICP resulting from shifting of brain tissue
  190. Causes of brain herniation?
    • 1. tumors
    • 2. bleeding
    • 3. swelling
  191. S/S of brain herniation?
    altered LOC, posturing, VS changes
  192. S/S of uncal herniation?
    same as other herniations and dilated pupils unilaterally or bi-laterally
  193. s/s of central herniation?
    same as other herniations and constricted pupils equal
  194. GCS?
    • Motor Response:
    • 1 - none
    • 2 - abnormal extension
    • 3 - abnormal flexion
    • 4 - withdraw (flexion) from pain
    • 5 - localizes to noxious stimuli
    • 6 - obeys commands

    • Eye
    • 1 - none
    • 2 - opens to pain
    • 3 - opens to speech
    • 4 - spontaneous

    • verbal response
    • 1 - none
    • 2 - incomprehensible words or sounds
    • 3 - verbalizes but inappropriate words
    • 4 - confused but converses
    • 5 - oriented and coverses
  195. What is indicated by small, reactive, regular shaped pupils?
    metabolic imbalances, diencephalic dysfunction
  196. What is indicated by fixed, dilated pupils?
    third cranial nerve dysfunction, anoxia
  197. What is indicated by midposition and fixed pupils?
    midbrain dysfunction
  198. What is indicated by pinpoint, nonreactive pupils?
    pontine dysfunction, opiates, miotic drugs
  199. Cheyene-Stokes respirations?
    regular cycles of respirations that gradually increase in depth and then decrease in depth to periods of apnea
  200. What do Cheyne-Stokes respirations indicate?
    lesions deep in cerebral hemispheres, diencephalon, or basal ganglia
  201. Cenral Neurogenic respiratory changes?
    deep, rapid respirations

    indicate lower midbrain or upper pons issues
  202. Apneustic respirations?
    prolonged inspiration followed by a 2-3 sec pause
  203. What is indicated by apneustic respirations?
    pons issue
  204. Ataxic respirations?
    irregular, unpredictable, shallow, then deep respirations with pauses
  205. What is indicated by ataxic respirations?
    upper medulla, lower pons issues
  206. Assessment findings of a ventriculoperitoneal (VP) shunt malfunction?
    • 1. vomiting
    • 2. HA
    • 3. irritability
    • 4. inconsolable
    • 5. high pitched cry
    • 6. fever
    • 7. redness along shunt line
    • 8. fluid around shunt valve
  207. Causes of VP shunt malfunction?
    infection:  fever, warm, redness, swelling near reservoir, s/s of increased ICP

    obstruction:  altered LOC, emesis (often w/o nausea), pupil changes, VS changes indicative of increased ICP
  208. Diagnosis and evaluation of VP shunt?
    • 1. shunt series
    • 2. CT or MRI
    • 3. shunt tap - CSF studies
  209. What ages is Babinski reflex normal?
    approx. age 2
  210. When does anterior fontanel close?
    9-18 months
  211. How should tone of infant be assessed?
    resting position
  212. S/S of meningeal irritation in infants?
    shrill cry, irritable, loss of appetite
  213. Primary HA?
    no organic cause
  214. Migraines?
    may have aura and awareness of HA coming on

    throb/pulsating in nature
  215. Tension HA?
    can last up to 7 days

    constant non-pulsating pain, cervical muscle tenderness
  216. Cluster HA?
    occur in groups followed by period of remission

    excruciating - burning sensation behind eyes, associated with lacrimation and rhinorrhea on affected side
  217. Secondary HA?
    organic etiology:  tumor, aneurism
  218. S/S of migraine?
    • 1. aura (visual or somatosensory)
    • 2. NV
    • 3. photophobia/phonophobia
    • 4. difficulty concentrating
    • 5. visual changes
  219. What type of precipitating events may bring on migraines?
    • 1. emotional events
    • 2. metabolic - fever, menses
    • 3. flickering lights or TV
    • 4 foods
    • 5. fatigue
    • 6. alcohol abuse
    • 7. sleep deprivation
  220. Tx of HA?
    • 1. heat (muscular)
    • 2. cold (vascular)
    • 3. dark room
    • 4. massage
    • 5. analgesics
    • 6. oxygen for a cluster HA
    • 7. preventative drugs:  vasoconstrictors, beta blockers, anticonvulsants
  221. When does meningitis occur more?
    late winter and early spring
  222. Bacteria responsible for meningitis?
    • streptococcus pneumonia
    • haemophlus influenza
    • Neisseria meningitides
  223. Consideration for infants and geriatrics and meningitis s/s?
    often don't show classic signs of meningeal irritation and fever
  224. Opisthotonus?
    severe hyperextension and spasticity of the head, neck, and spinal column

    occurs in meningitis
  225. Layers of meninges?
    • mininges PADS the brain:
    • P - pia mater
    • A - arachnoid layer
    • D - dura mater
    • S - skull/skin
  226. S/S of meningitis?
    • 1. illness or exposure
    • 2. altered LOC
    • 3. HA (occipital)
    • 4. fever, chills
    • 5. vomiting, diarrhea
    • 6. seizures
    • 7. bulging fontanel in infants
    • 8. cyanosis, mottled skin
    • 9. neck and back pain
    • 10. restless/irritable
    • 11. lethargic
    • 12. high pitched cry
    • 13. anorexia, poor feeding
    • 14. meningeal signs:  nuchal rigidity, pain upon neck flexion, photophobia, positive Kernig's/Brudzinski's sign
    • 15. petechiae
    • 16. purpura
  227. Diagnostics for meningitis?
    • CBC - high WBC(bacterial)/meningococcal usually WBC <10,000
    • BMP
    • blood cultures
    • clotting studies
    • urinalysis
    • CXR
  228. When is LP contraindicated?
    known or suspected increased ICP
  229. Normal or viral infection LP results?
    • 1. clear appearance
    • 2. normal pressure
    • 3. WBC <500
    • 4. glucose and protein normal
    • 5. negative gram stain
  230. Bacterial meningitis LP results?
    • 1. cloudy appearance
    • 2. increased pressure
    • 3. WBC >1000
    • 4. decreased glucose and elevated protein
    • 5. bacteria on gram stain
  231. Tx of meningitis?
    • 1. strict isolation:  mask, gown, gloves
    • 2. undress completely - check skin
    • 3. ABC's, O2, frequent VS, seizure precautions
    • 4. IVs ASAP
    • 5. antibiotics EARLY
    • 6. antipyretics
    • 7. monitor mental status
    • 8. treat any family members/healthcare
    • workers exposed if bacterial within 24 hours
  232. Who makes up 40% of CVA's?
    women 65 and older
  233. Risk factors for CVA?
    • 1. hyperlipidemia
    • 2. CHF
    • 3. obesity,
    • 4. MVP
    • 5. Afib
    • 6. smokers
    • 7. drug use (cocaine)
    • 8. uncontrolled HTN
  234. What does NIHSS measure?

    normal score?
    severity and predicts outcomes

    0
  235. TIA?
    brief symptoms that last seconds to 24 hours
  236. Stroke in evolution/progressive stroke?
    progressive development of a deficit over time
  237. Completed stroke?
    immediate maximization of deficit - no improvement or decline
  238. S/S of anterior stroke (carotids)?
    • 1. altered LOC
    • 2. motor deficit: contralateral hemiparesis
    •     or hemiplegia
    • 3. sensory deficit:  contralateral
    • 4. speech deficit:  dysphasia:  expressive,
    •     receptive, or global
    • 5. Visual deficit:  loss of vision in half of vision field
  239. S/S of posterior stroke?
    • 1. altered LOC
    • 2. motor deficit in more than one limb
    • 3. visual deficit:  field deficits, cortical         blindness, diplopia
    • 4. Loss of coordination - cerebellum
    • 5. cranial nerve deficit: 
    •    *dysphonia - difficulty producing voice
    •      sounds
    •    *dysarthria - difficulty with articulation
    •    *dysphagia - difficulty swallowing
  240. Diagnostics for CVA?
    • 1. non contrast CT scan within 25 min of ED arrival is goal
    • 2. MRI
    • 3. EKG
    • 4. carotid Doppler studies
  241. Treatment of CVA?
    • 1. maintain ABC's
    • 2. frequent neuro checks
    • 3. HOB elevated in neutral in-line position
    • 4. frequent VS - BP goal </= 185/110
    • 5. anticoagulation - ischemic stroke only
    • 6. mechanical clot retrieval procedures (FDA
    •     approved for 8 hours from onset s/s)
    • 7. IV tPA 
    • 8. Intra-arterial tPA - not currently FDA
    •     approved
  242. Goals for tPA admin?
    within 60 min of ED arrival

    within 3 hours of onset of s/s
  243. Max dose of tPA?
    90mg or 0.9mg/kg
  244. How should tPA be admin?
    10% of dose over 1 minute then rest of drug over one hour
Author
mbeklj
ID
342324
Card Set
CEN review class
Description
CEN review class
Updated