-
Where can you do venipuncture?
Back of hand/forearm: allows free movement of arm. If a vein problem occurs later, you can move up.
Antecubital fossa: for short infusions. Prevents bending of arm.
-
When can you use the lower extremities for venipuncture?
- Foot: venous plexus of sorsum, medial marginal vein, arch
- Ankle: great saphenous
- As a last resort. Not on diabetes/PVD patients.
- Obtain an order for the site. Monitor for phlebitis and thrombosis.
-
When do you use a central vein?
- 1. chemo, hyperalimentation
- 2. Shock
- 3. Obese
-
What are some complications of IV therapy?
- Infiltration (dislogement of IV into surrounding tissues)
- Thrombophlebitis (red streak)
- Bacteremia
-
What are the indications for IV Push?
- Emergency cardio pulm
- Loading dose
- Reduce discomfort of IM injection
- Deliver drugs to patients who can't do IM, orally
-
What's the total content of Na and K in the body spaces?
- Na (ECF): 140mEq x 14 L = 1960mEq
- K (ICF): 140mEq x 28L = 3920mEq
-
What percent of your body is water?
What about the ICF?
ECF?
Interstitial fluid?
Plasma?
- TBW = 60% (42L for a 70 kg man)
- ICF: 2/3 of TBW (28L)
- ECF: 1/3 of TBW (14L)
- Interstitial: 3/4 of ECF (10.5L)
- Plasma: 1/4 of ECF (3.5L)
-
What do you do for an isotonic fluid loss (large blood loss)?
- Give NS (0.9%) = isoosmotic to plasma
- Consider transfusion
-
What do you do with a hypotonic volume loss? Like in the setting of a patient taking lithium and developing DI?
- We've lost free water
- 5% dextrose, D5W
-
Isolated water loss (1/2 of total ECF) has occurred from the ECF space. After equilibration how much water loss would have occurred from the ECF and ICF spaces?
1/3 rd from the ECF and 2/3 rd from the ICF
- As compared to an isotonic loss, which does not cause a loss
- of water from the intracellular space
-
What do you do in the setting of SIADH (hyponatremic hypervolemia)
Nothing. Find the underlying cause and it'll correct itself.
-
What do you give for a guy with HTN (on HCTZ)/diarrhea and low serum Na, high urine osmolality?
- NS
- Volume restoration will take away stimulus for ADH and Na will correct rapidly from there on.
-
What do you do for a penetrating eye injury?
- Hard shield
- No ointment
- Keep NPO
- Refer ASAP
-
What do you give for angle closure glaucoma?
- Acetazolamide 500mg)
- Refer
-
What can you do for a corneal abrasion?
- Remove body if superficial
- Dilating drop
- Patch with ointment
- do that blue dye if you want
-
What do you see with a corneal ulcer?
- Pain
- Dec vision
- Injection
- Inflitrate
- Hypopyon
-
When do you need to refer for a lid laceration?
- Large
- Medial
- Lid margin involved
-
What's the difference between pre and postseptal cellulitis?
- Pre:
- Good vision
- Good eye movements
- No pain
- No chemosis
- Post:
- Dec vision
- Pain with movement
- injection
Either way, refer for cultures, CT, IV antibiotics, maybe surg
-
What's the cause of pink eye?
Adenovirus - infectious for one week
-
You are working this month at the ICU, you have a 75 y/o patient with COPD that has the following values :
• PCO2=60mmhg
• Tidalvolume=600ml
• RR=20/min
•Your attending wants the PCO2 to be 43 in the next hour, what should you do ?
- PCO2 X MV=CONSTANT
- •60 X (20X600)=43 X MV (new )
- •60 x 20=43x RR (new )
- •RR (new )60X20/43=27.9
- •Increase the respiratory rate to 28
-
What's the Kassirer-Bleich equation?
[H}=24 x PCO2/HCO3
Change in H of 10 will correspond with change in pH by 0.1
-
What's the normal pH range for blood?
7.35-7.44
-
What's Winters's Formula?
- Use for metabolic acidosis (HCO3<24)
- PCO2 = 1.5(HCO3) + 8 +/-2
pCO2 is about = last 2 digits of pH!!!
-
What's the relationship between HCO3 and PCO2?
- Increase bicarb by 1
- =Increase PCO2 by 0.7
-
How do pCO2 (over 40) and bicarb change in respiratory acidosis?
- Increase pCO2 by 10
- Acute: increase bicarb by one
- Chronic: increase bicarb by 3
-
How do pCO2 (less than 40) and bicarb change in respiratory alkalosis?
- Decrease pCO2 by 10
- Acute: decrease bicarb 2
- Chronic: decrease bicarb by 5
-
How do pH and pCO2 relate in respiratory condition?
- 10 up or down
- Acute: 0.08
- Chronic: 0.03
-
What kinds of problems will give you normal anion gap acidosis?
- Gut or kidney stuff:
- diarrhea
- type 2 RTA
- pancreas stuff
-
What are some causes of metabolic alkalosis?
- Loss of Hydrogen:
- GI, Renal loss, H into cells, Exogenous, Contraction alkalosis
-
How do you calculate serum osmolarity?
What should the osm gap be?
(2xNa) + BUN/2.8 + Glu/18
10 mOsm (measured-calculated)
-
How do you calculate the A-a gradient?
[150-1.25(PaCO2)]-PaO2
-
What are the basic components of the admission note?
- ID/Chief Complaint
- HPI
- PMHx
- PFSHx
- ROS
- Allergies
- Meds
- Special Sections
- Exam
- Assessment
- Plan
-
What are the indications for ABG?
- 1.Adequacy of ventilatory acid-base and oxygenation status.
- 2.Quantitate response to therapy and/or diagnostic eval
- 3.Monitor severity and progression of disease
-
What are the contraindications of ABG?
- 1. Inadequate blood supply to hand (Allen's test)
- 2. Don't puncture through a lesion or if PVD is in the limb.
- 3. No femoral punctures out of the hospital
- 4. A coagulopathy or medium to high dose anticoagulants may be a relative contraindication (not aspirin)
-
What are in indications and contras for metered dose inhalers?
1. Need to deliver an aerosol to the lower airways.
1. None - specific substances may have some, check that out.
-
Which opioids are good for moderate to severe pain control?
- Oral route is best for all...
- Morphine: gold standard, not easy on the stomach, no ceiling
- Oxycodone: no IV, better GI, no ceiling
- Hydromorphone (Dilaudid): shorter 1/2life, more potent
- Meperidine (Demerol): short 1/2life, PO needs high doses (not given, usually), chronic usage inc....shouldn't really use this.
-
What are the indications for paracentesis?
- 1. Diagnostic: ascites, peritonitis
- 2. Therapeutic: large ascites
-
What are the relative contraindications for paracentesis?
- 1. severe thrombocytopenia
- 2. coagulopathy (inr >2)
- 3. preggers
- 4. severe bowel distension
- 5. distended urinary bladder
- 6. ab wall cellulitis
-
What are the indications for LP?
- Diagnostic: infections, hemorrhages, pseudotumor, hydrocephalus, meningitis, MS, GBS
- Therapeutic: anesthesia, chemo, contrast
-
Contraindications for LP?
- Increased ICP
- Bleeding diathesis
- Suspected spinal epidural abscess
-
What do you get in the LP tubes (1-4)?
- 1: protein and chemistry
- 2: gram stain and culture
- 3: cell count and diff
- 4: backup, extra tests
-
Complications of LP?
- 1. post LP HA: caffeine, supine
- 2. radicular and lower back pain
- 3. infections
- 4. bleeding
- 5. cerebral herniation
- 6. epidermoid tumors
-
What are some common abbreviations?
- PRN-as needed
- Q-every
- QHS-every night
-
What are some prohibited abbreviations?
- U-unit
- QD-once daily
- QOD-every other day
- Trailing zero - 2.0
- Lack of leading zero - .9
- MS-morphine or mg sulfate
- MSO4 (ok?)
- MgSO4 (ok?)
-
What are the components of the admission orders?
- ADCVANDISMAL
- admit to
- dx
- condition
- vitals
- allergies
- nursing
- diet
- IV access/fluids
- sedation/special
- meds
- activity
- labs/xrays/other studies
-
What are indications for NG tubes?
- Dx: eval upper GI, aspirate contents, ID esoph/stomach on CXR, admin contrast to GI
- Therapeutic: gastric decompression, bowel rest, gastric lavage, bowel irrigation, med admin, feeding
-
What are the contraindications for NG tubes?
- Absolute: severe facial trauma, recent nasal surgery
- Relative: coag problem, esophageal varice/stricture, recent banding, alkaline ingestion
-
What are the indications for urinary catheter?
Decomp bladder, urine specimen, dx GU bleed, monitor output, prevent obstruction post surg
-
What are the contras for urinary cath?
- Urethral trauma
- pelvic fractures
- straddle impacts
- Signs
- blood at urethral meatus
- scrotal hematoma
- high riding prostate
-
What are some complications of urinary cath?
- Tissue trauma
- Infeciton
- Renal inflammation
- Nephro-cysto-lithiasis
- Pyelo
-
How do you calculate maintenance IVF?
- For a 70 kg man:
- Normal requirement: 35 x 70 = 2500 mL/d
- oral liquids 1200 (5 cups)
- solid food 1300 (1000 from water, 300 by metabolism)
- Output
- Urine: 1600
- insensible loss: 800
- stool: 100
- sweat loss up to 2L/d; each C degree of fever + 200ml/d
-
How do you replace fluids in a burn patient?
- 4 x %BSA x Wt(kg)
- give half over the first 6-8 hours, then remainder over 14-16 hours
-
How do you correct hypernatremia?
- Net water loss.
- Symptomatic (over hours): rapid correction of sodium (falling by </= 1mmol/l per hour)
- Asymptomatic or Chronic: no more than 0.5mmol/L/hr
-
How do you calculate the free water deficit?
- ((Dosing factor)(weight(kg))x((serum Na/140)-1)
- (Dosing factor =0.6 if male and 0.5 if female)
-
How do you manage diabetes insipidis?
- Replace ongoing water losses:
- Measure urine output and replace with ivf in a 1:1
- Need frequent Na in order to titrate rate of infusion to match losses
- For central DI:
- Prostacyclin inhibitors (indocin)
-
How do you fluid manage hypercalcemia?
Restore circulating volume, reverse vasoconstriction, dec tub ca conc to prevent stone
200-300 mL/h then adjust to maintain urine output at 100-150mL/h
treat primary disorder
-
How do you fluid manage rhabdomyolysis?
NS 1-2L/h
If you get a diuresis, get output to 200-300mL/h
-
What are the indications for thoracentesis?
- 1. Dx cause of pleural effusion
- 2. Reduce respiratory sx in patients with large effusions
-
What are the contraindications for throacentesis?
- 1. Severe heme/resp compromise
- 2. Coagulopathy or platelet dysfunction
- 3. Don't go through sites of cutaneous infection on chest wall
-
What are some potential complications of thoracentesis?
- Pneumo
- Local pain
- Local infxn
- Hemo
- Organ injury (abdom)
- Air embolism
- Postexpansion pulmonary edema
-
What are the indications for chest tubes?
- 1. Spontaneous pneumo (large, progressive, sx)
- 2. Iatrogenic pneumo (large, progressive, sx)
- 3. Pneumo of any size if on a vent
- 4. Tension pneumo
- 5. Hemo (PF Hct/Serum Hct >50%)
- 6. Parapneumonic effusion or empyema
- 7. Pleurodesis for recurrent effusion
- 8. Flail chest segment, severe contusion requiring vent
- 9. Prophylactic?
-
What are the contras for chest tube?
- 1. no absolute
- 2. infection over insertion site
- 3. anticoags
-
What are some complications of chest tubes?
- Block tube (clot, lung)
- Empyema
- Pneumo after out
- Re-expansion pulmonary edema
- Hemo
- Lung lac
- Diaphragm/Ab cavity penetration
- Stomach/colon injury (hiatal hernia not recognized)
- SQ tube
- Tube too far
- Tube falls out
-
What are the indications for a bone marrow biopsy?
- Eval of BM function
- Dx some infections
- Dx tumors
- Determine dz progress
- Eval chemo
- Monitor recovery in transplant patients
-
What are the contras for BM biopsy?
- Severe bleeding disorder
- Infection over site
- Previous radiation therapy
- *can be performed in the setting of severe low platelets
-
What are some possible risks of BM biopsy?
- Bleeding/Infection
- Pain
- Reaction to anesthetic
-
Where can you get some of that BM aspirate?
- posterior iliac crest (R or L lateral decubitus, prone)
- tibia (supine)
- anterior iliac crest (supine)
- sternum! (supine)...NEVER here for biopsy
-
What are the basics for prescriptions?
- Patient name
- (address)
- Weight
- Date
- (Medical indication)
- Physician signature
- Contact information for doc
-
What's the Rx, Sig, Disp for prescription writing?
- Rx: medication name, strength, form
- Sig: directions (amount, route, frequency, duration)
- Dispense: Quantity and number of refills
- Signature and printed name (NPI, office #, DEA #)
-
Who gets a + TST with 5 mm induration?
- Recent contact to person with TB
- HIV
- Fibrotic changes on CXR consistent with prior TB
- Immunosuppressed (transplants, drugs, steroids, TNFalpha antagonist)
-
Who's positive with 10mm induration on the TST?
- medical conditions
- IVDusers
- recent immigrants from high-prevalence countries; travelers more than 2-3 months
- M. tb lab personnel
- employees and residents like you and me (prisons, nursing homes, shelters)
- kids under 4 or kids exposed to high risk adults
-
What does it mean to have a booster reaction to a TST?
LTBI can give a false negative, and giving the test stimulates immune response, causing + tests later on. Positive reactions to subsequent tests could be interpreted as new infections instead of latent ones.
LTBI = INH for 9 months
-
What are the indications for IV access?
- Fluids
- Drugs
- Facilitate testing
- Parenteral nutrition
- Hemodynamic monitoring
-
What are the complications of obtaining IV access?
- Infection
- Bleeding
- Infiltration
- Phlebitis
- Thrombosis
- Wrong drug/fluid
-
Why a central line?
- Long term placement
- Drugs
- Parenteral nutrition
- CV: CVP, pulm artery cath placement
-
What are some complications of central line placement?
- Infection
- Bleeding
- Arterial puncture
- Pneumo
- Thrombosis
- Cath occlusion
- Misplacement
- Air embolism
-
What's the deal with the PSA?
It's ok. No standard recommendations for prostate cancer screening.
- A better tool is the free PSA:
- <10% free = cancer
- >25% free = BPH
- Another tool is the PSA density (PSA over prostate volume):
- <0.15 indicates low-risk of progression
-
How do you diagnose prostate cancer?
Transrectal ultrasound guided biopsy (TRUSP)
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