When is a patient in active labor considered to be stable for transfer?
when baby and placenta have been delivered
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
Assessment: always assess ___ first
For airway/breathing issues what should be considered before definitive procedures?
basic airway meneuvers and adjuncts
What is different about assessing airway in trauma patient?
airway assessment and C-spine stabilization are always combined in trauma
How is OPA measured?
tip of mouth to angle of jaw or tip of earlobe
How is NPA measured?
tip of nose to angle of jaw
When is NPA contraindicated?
Normal adult ETT size?
Pediatric ETT tube size formula?
(16 + age in years) / 4
Consideration for pediatric patients with increased RR?
may rapidly deteriorate
Where is needle decompression performed?
2nd intercostal space at mid-clavicular line
Normal HR in children 1-3?
HR of children >6?
similar to adults
Normal HR for infants?
What causes first heart sound?
closure of AV valves at beginning of systole
What causes second heart sound?
- closure of semilunar valves at beginning of
What causes third heart sound S3?
heart failure, fluid overload
What causes fourth heart sound S4?
Causes of systolic murmur?
- mitral regurgitation
- aortic stenosis
Cause of diastolic murmur?
- mitral stenosis
- aortic regurgitation
First priority in unconscious patient?
Contraindications for MAST (military anti-shock trousers) and PASG (pneumatic anti-shock garment)
- pulmonary edema
- ruptured diaphragm
- LV dysfunction
- abdominal evisceration
What position should patient be in prior to performing orthostatic VS?
lying flat at least 5 min
How should orthostatic VS be performed?
HR & BP at 1 & 3 min after position changes
Positive orthostatic VS changes?
- SBP drop >/= 20
- DBP drop >/= 10
- HR increase >/= 20
ENA recommends triage be performed by a nurse with how much experience?
at least 6 months
4-tiered triage system?
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
What type of triage system is recommended by ENA and American College of Emergency Physicians?
5 tiered system
Use of hyperventilation in head injury patients?
- 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
Consideration for transporting patient with family present?
- Never let family leave before patient
- give map and phone number
Is written consent required from patient to treat?
no, should be obtained after MSE
life or limb threatening situation
3 essential components required for informed consent prior to procedure?
- provider must:
- 1. describe procedure
- 2. explain alternatives
- 3. detail risks
Negligence (medical malpractice)?
action or inaction that does not meet standards of care and results in injury to pt
Four elements of negligence?
- 1. duty to act (relationship established)
- 2. breach of duty/contract (bad care)
- 3. proximate cause (breech was cause of
- 4. result in damage (injury caused by
attempt or threat to touch another person or the person's possessions without his/her consent
- actual contact with a person or the person's possessions without consent
- "unauthorized touching"
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
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
Who is present for Critical Incident Stress Debriefing?
confidential: only those involved and debriefing team present
What should be avoided when interviewing someone?
inquiries about marital status, sexual orientation, religion, age, children
What program covers work related injury issues?
What tasks can be delegated to unlicensed personnel?
What tasks may not be delegated to unlicensed staff?
steps of nursing gprocess, triage, assessment, patient teaching, discharge instructions
Chain of custody in evidence collection?
maintain chain of custody and minimize contact
Documentation when evidence collection is necessary?
document behaviors and use quotations
- 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
Who dictates guidelines or restraints?
JCAHO and CMS
Risks of chemical and physical restraints?
- skin breakdown
- respiratory depression
consciousness depressed but pt maintains own airway and protective reflexes and ability to respond to stimuli
What drugs should be available during conscious sedation?
What consent is required for conscious sedation
need consent for BOTH sedation and procedure
Role of monitor in conscious sedation?
monitor patient throughout procedure and recovery and not assist with procedure
Type of pt education that involves thinking and reasoning?
- info about disease process, discharge instructions
Type of pt education that involves change in attitude of values?
- educating to change health behaviors, importance of immunizations
Type of pt education that requires coordination of the brain and extremities to complete a task?
- crutch walking, use of peak flow meter and inhalers
What is a JCAHO standard in pt teaching?
identify implied and expressed learning needs of the patient or learner
What is the most effective method of education?
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
Documentation by exception?
focus on variances from normal assessment
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
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
- multiple casualty: 100 or less casualties
- mass casualty: >100 casualties
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
SALT for disaster Tx?
- lifesaving interventions
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
Notification of staff members of disaster?
hospital must have disaster call tree system in place
How to prepare for disaster?
Hot or Red Hazmat zone?
danger zone, restricted access
requires proper PPE, basic ABC management only and antidote
Warm or yellow hazmat zone?
control zone: active decontamination
only emergent Tx provided, requires proper PPE
Cold or green hazmat zone?
safe zone: Tx area
staging area, only need standard precautions
generalized inadequate tissue perfusion resulting in widespread impairment of cellular metabolism and dysfunction of critical organs
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
Effects of epi and nor-epi?
increased BP, HR, myocardial contractility, and BF to lungs
release of glucocorticoids
Result of Renin-angiotension-aldosterone system activation?
aldosterone - increases sodium and water reabsorption
inceased secretion of ADH causes water retention
- Alpha: arteries
- Beta 1: heart
- Beta 2: lungs
Why is capillary hydrostatic pressure reduced in shock?
translocation of fluid from interstitial space to intravascular space
increases circulating blood volume
Clinical manifestations of shock in healthy person that is compensated?
may appear relatively normal
Clinical manifestations of compensated shock?
- narrowing pulse pressure with normal BP
- cool clammy skin
- increasing serum glucose
- 1. vessels begin to vasodilate
- 2. organ dysfunction
- 3 anaerobic metabolism
- 4.histamine release
What occurs as vessels dilate in uncompensated shock?
decreased peripheral resistance and BP
decreased venous return to the heart (preload)
Liver disfunction in decompensated shock?
decreased liver function and production of clotting factors
Pancreas dysfunction in decompensated shock?
release of myocardial depressant factor (MDF) resulting in further depression of cardiac function
Lung dysfunction in uncompensated shock?
decreased production of surfactant
Kidney dysfunction in uncompensated shock?
decreased GFR and ability to clear toxins
What occurs in anaerobic metabolism?
cell hypoxia, acidosis (lactic and metabolic)
Effects of histamine release r/t uncompensated shock?
capillary permeability increased
fluid shift from intravascular to interstitial space
Clinical manifestations of uncompensated shock?
- alterations in LOC
- significant tachycardia
- peripheral cyanosis
- decreasing UO
- decreased pulmonary capillary BF and gas exchange
- microcapillary clotting from sluggish BF
What causes decreased pulmonary capillary BF and gas exchange in uncompensated shock?
endothelial damage to lungs resulting in metabolic and respiratory acidosis
Characteristics of irreversible/refractory shock?
- 1. progressive organ dysfunction leading
- to death
- 2. acidosis
- 3. clotting derengements
- 4. cerebral ischemia
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
alteration in circulating volume: preload
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
Class I fluid volume loss associated signs and symptoms?
- up to 15% loss/750mL in adults
- HR <100, BP normal
- essentially normal physical exam
Class II volume loss?
15-30%/750-1500mL in adults
HR >100, BP normal, decreased pulse pressure
pale, anxious, diaphoretic, cool/clammy skin
Class II volume loss?
30-40%, 1500-2000mL for adults
HR>120, hypotensive, decreased pulse pressure
very anxious, confused, oliguria
Class IV volume loss?
>40%, >2000mL in adults
HR>140, hypotension, decreased pulse pressure
lethargic, unresponsive, anuria, cold, pale
Locations for IO insertion?
Which is preferred in adults?
- distal femur
- proximal tibia
- proximal humerus (preferred in adults)
- sternum (requires special device)
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
Ratio of crystalloid to blood and colloid to blood replacement?
3:1 crystalloid to blood
1:1 colloid to blood
Why should all IV fluids and blood be warmed in hypovolemic conditions?
patients with temp <34 C have 50% higher mortality rate
Pediatric fluid and blood replacement criteria in hypovolemic shock?
- 20mL/kg bolus (X2-3) crystalloid
- 10mL/kg PRBC or colloids
impairment of pumping ability/contractility of heart
Primary causes of cardiogenic shock?
- 1. MI - most common
- 2. myocardial contusion
- 3. cardiomyopathies
- 4. valve dysfunction
- 5. ruptured septum
obstruction of forward flow of blood- obstruction causes decreased circulating volume by preventing myocardium from mechanically emptying or filling during diastole
Causes of obstructive shock?
- 1. tension pneumo
- 2. pericardial tamponade
- 3. pulmonary embolism
- 4. aortic aneurysm
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)
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
How to increase and decrease preload?
increase: more volume
decrease: nitroglycerin, furosemide, morphine
Medications to improve contractility?
inotropes: dobutamine, milrinone
stimulates Beta 1 receptors: increased cardiac contractility
Medications to decrease afterload?
- ACE inhibitors
abnormal placement of intravascular volume
3 types of distributive shock?
- 1. septic shock
- 2. anaphylactic shock
- 3. neurogenic shock
toxins released by invading organisms cause vasodilation and activate cellular, humoral, and immunologic systems
massive vasodilation and inceased capillary permeability
Type of toxins released by gram pos and gram neg bacteria?
- gram pos - exotoxins
- gram neg - endotoxins
SIRS - systemic inflammatory Resonse Syndrome?
nonspecific inflammatory response to a variety of stimuli
- 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
SIRS + infection or presumed infection
Sepsis with >/= 1 organ dysfunction
sepsis + hypotension that requires vasopressors (refractory to crystalloids)
Multi Organ Dysfunction Syndrome (MODS)?
involving at least 2 vital organ systems: respiratory, cardiac, nervous, renal, hepatic
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
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
Management of septic shock?
- 1. support ABC's
- 2. volume
- 3. vasopressors
- 4. Tx infection: ABX
- 1. sudden onset
- 2. severe allergic reaction: systemic antigen-antibody reaction, hypersensitivity
- 3. massive vasodilation and increased capillary permeability
Common triggers of anaphylaxis?
- 1. antibiotics
- 2. shellfish
- 3. peanuts
- 4. eggs
- 5. stinging insects (hymenoptera)
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
- 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
What receptors are affected by epinephrine?
alpha and beta equally
What receptors are affected by norepinephrine?
alpha > beta
What receptors are affected by phenylephrine?
what receptors are affected by dopamine?
dopamine, beta 1 and alpha depending in dose
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
- 1. loss of sympathetic vasomotor function
- 2. uncontested parasympathetic response
What type of injuries typically involve neurogenic shock?
spinal cord injuries at or abve level of T6
brain stem injuries, spinal anesthesia, depressant and hypoxia
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
Management of neurogenic shock?
- 1. manage ABC's
- 2. volume: admin with crystalloids
- 3. maintain normothermia
- 4. vasopressors: phenylephrine, NE
- 5. stabilize spine
What percentage of NS stays in the intravascular space?
Issues with large volumes of NS?
hyperchloremic metabolic acidosis
What fluid should be used when transfusing blood products?
isotonic- increases volume without altering NA+ concentration or serum osmolality
isotonic - increases volume and replces intracellular fluid losses
What fluid is most similar to plasma?
LR should be used with caution in pt with what organ dysfunction?
liver dysfunction: lactate is converted in the liver
What metabolic imbalance may be caused by large quantities of LR?
metabolic alkalosis r/t lactate converted to bicarbonate
- hypertonic - increases plasma volume with lower volumes required
- used in conjunction with conventional resuscitation fluids
- improve cerebral perfusion
Hypertonic fluids and intravascular space?
help keep water in intravascular space
Considerations when admin 3.0% saline?
may cause fluid overload ad pulmonary edema
blood and volume replacement
increases O2 carrying capacity of blood
Consideration when admin whole blood?
kept frozen - must give quickly after thawing to preent deterioration of factors V and VII
increases RBC's, HgB, and Hct
increases o2 carrying capacity of blood
O+ and O-
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
replaces clotting factors, plasma proteins, and plasma
used for control of bleeding and replacement from blood loss
Considerations for admin of FFP?
kept frozen and must be admin quickly r/t deterioration of factors V and VII
thrombocytes in plasma
control bleeding and replacement from blood loss
Albumin and other colloid administration?
increases plasma volume and the plasma colloid (oncotic) pressure
Cranial nerve I?
olfactory - sense of smell - rarely tested
Cranial nerve II?
optic - visual acuity, visual fields, detection of light reflex
Cranial nerve III?
Oculomotor - constricts/dilates pupil, elevate upper lid, most extraoxular movements (EOMs), up, down, in
Cranial nerve IV?
trochlear - EOMs - look down, inward
Cranial nerve V?
- corneal reflex
- sensation of face, scalp, oral and nasal cavities (3 branches)
- chewing, jaw movement
Cranial nerve VI?
abducens - EOMs movement of eye laterally
Cranial nerve VII?
Facial - facial movment and expression - raise eyebrow, smile, close eyes, lip movement, show teethc, anterior taste (rarely tested)
Cranial nerve VIII?
Acoustic (vestibulocochlear) - hearing and balance
Cranial nerve IX?
Glossopharyngeal -swallowing, gag reflex, taste on posterior tongue, sensation of the carotid bodies
Cranial nerve X?
- Vagus - sympathetic/parasympathetic responses (HR, BP, RR),
- thoracic and abd viscera, gag reflex, speech
Cranial nerve XI?
spinal accessory - shoulder shrug, head turning
Cranial nerve XII?
hypoglossal - tongue movement
doll's eyes - normal response: while turning head rapidly side to side, the eyes move the opposite direction to where head is turned
ice water calorics: normal response: eyes turn slowly toward the ear in which the ice water is injected into, then rapidly turn away
allow CO2 to build up to stimulate respiratory system to determine if patients will breathe on their own
What is affected with loss of brain stem reflexes?
pupils, gag, cough, and corneals
Cerebral perfusion pressure (CPP) formula?
MAP - ICP
extension - injury to the brainstem
hands and arm extended outward
Decerebrate posturing indicates what type of injury?
flexion - hands clinched and turned inward toward body
Decorticate posturing indicates what type of injury?
injury above midbrain
What does Cushing's Triad indicate?
very late sign of increased intracranial pressure (ICP)
3 characteristics of Cushing's Triad?
- 1. increased systolic BP (widened pulse pressure)
- 2. profound bradycardia
- 3. abnormal respiratory pattern
late sign of increased ICP resulting from shifting of brain tissue
Causes of brain herniation?
- 1. tumors
- 2. bleeding
- 3. swelling
S/S of brain herniation?
altered LOC, posturing, VS changes
S/S of uncal herniation?
same as other herniations and dilated pupils unilaterally or bi-laterally
s/s of central herniation?
same as other herniations and constricted pupils equal
- Motor Response:
- 1 - none
- 2 - abnormal extension
- 3 - abnormal flexion
- 4 - withdraw (flexion) from pain
- 5 - localizes to noxious stimuli
- 6 - obeys commands
- 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
What is indicated by small, reactive, regular shaped pupils?
metabolic imbalances, diencephalic dysfunction
What is indicated by fixed, dilated pupils?
third cranial nerve dysfunction, anoxia
What is indicated by midposition and fixed pupils?
What is indicated by pinpoint, nonreactive pupils?
pontine dysfunction, opiates, miotic drugs
regular cycles of respirations that gradually increase in depth and then decrease in depth to periods of apnea
What do Cheyne-Stokes respirations indicate?
lesions deep in cerebral hemispheres, diencephalon, or basal ganglia
Cenral Neurogenic respiratory changes?
deep, rapid respirations
indicate lower midbrain or upper pons issues
prolonged inspiration followed by a 2-3 sec pause
What is indicated by apneustic respirations?
irregular, unpredictable, shallow, then deep respirations with pauses
What is indicated by ataxic respirations?
upper medulla, lower pons issues
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
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
Diagnosis and evaluation of VP shunt?
- 1. shunt series
- 2. CT or MRI
- 3. shunt tap - CSF studies
What ages is Babinski reflex normal?
approx. age 2
When does anterior fontanel close?
How should tone of infant be assessed?
S/S of meningeal irritation in infants?
shrill cry, irritable, loss of appetite
no organic cause
may have aura and awareness of HA coming on
throb/pulsating in nature
can last up to 7 days
constant non-pulsating pain, cervical muscle tenderness
occur in groups followed by period of remission
excruciating - burning sensation behind eyes, associated with lacrimation and rhinorrhea on affected side
organic etiology: tumor, aneurism
S/S of migraine?
- 1. aura (visual or somatosensory)
- 2. NV
- 3. photophobia/phonophobia
- 4. difficulty concentrating
- 5. visual changes
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
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
When does meningitis occur more?
late winter and early spring
Bacteria responsible for meningitis?
- streptococcus pneumonia
- haemophlus influenza
- Neisseria meningitides
Consideration for infants and geriatrics and meningitis s/s?
often don't show classic signs of meningeal irritation and fever
severe hyperextension and spasticity of the head, neck, and spinal column
occurs in meningitis
Layers of meninges?
- mininges PADS the brain:
- P - pia mater
- A - arachnoid layer
- D - dura mater
- S - skull/skin
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
Diagnostics for meningitis?
- CBC - high WBC(bacterial)/meningococcal usually WBC <10,000
- blood cultures
- clotting studies
When is LP contraindicated?
known or suspected increased ICP
Normal or viral infection LP results?
- 1. clear appearance
- 2. normal pressure
- 3. WBC <500
- 4. glucose and protein normal
- 5. negative gram stain
Bacterial meningitis LP results?
- 1. cloudy appearance
- 2. increased pressure
- 3. WBC >1000
- 4. decreased glucose and elevated protein
- 5. bacteria on gram stain
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
Who makes up 40% of CVA's?
women 65 and older
Risk factors for CVA?
- 1. hyperlipidemia
- 2. CHF
- 3. obesity,
- 4. MVP
- 5. Afib
- 6. smokers
- 7. drug use (cocaine)
- 8. uncontrolled HTN
What does NIHSS measure?
severity and predicts outcomes
brief symptoms that last seconds to 24 hours
Stroke in evolution/progressive stroke?
progressive development of a deficit over time
immediate maximization of deficit - no improvement or decline
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
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
- *dysarthria - difficulty with articulation
- *dysphagia - difficulty swallowing
Diagnostics for CVA?
- 1. non contrast CT scan within 25 min of ED arrival is goal
- 2. MRI
- 3. EKG
- 4. carotid Doppler studies
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
Goals for tPA admin?
within 60 min of ED arrival
within 3 hours of onset of s/s
Max dose of tPA?
90mg or 0.9mg/kg
How should tPA be admin?
10% of dose over 1 minute then rest of drug over one hour