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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)
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?
- 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?
- 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)
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?
- Dec vision
When do you need to refer for a lid laceration?
- Lid margin involved
What's the difference between pre and postseptal cellulitis?
- Good vision
- Good eye movements
- No pain
- No chemosis
- Dec vision
- Pain with movement
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 :
•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?
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:
- 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?
What are the basic components of the admission note?
- ID/Chief Complaint
- Special Sections
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
- QHS-every night
What are some prohibited abbreviations?
- 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?
- admit to
- IV access/fluids
- 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
- blood at urethral meatus
- scrotal hematoma
- high riding prostate
What are some complications of urinary cath?
- Tissue trauma
- Renal inflammation
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)
- 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?
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?
- Local pain
- Local infxn
- 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)
- Pneumo after out
- Re-expansion pulmonary edema
- 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?
- 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
- (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
- 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
- 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?
- Facilitate testing
- Parenteral nutrition
- Hemodynamic monitoring
What are the complications of obtaining IV access?
- Wrong drug/fluid
Why a central line?
- Long term placement
- Parenteral nutrition
- CV: CVP, pulm artery cath placement
What are some complications of central line placement?
- Arterial puncture
- Cath occlusion
- 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)