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
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
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
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?
What do you give for angle closure glaucoma?
What can you do for a corneal abrasion?
Remove body if superficial
Patch with ointment
do that blue dye if you want
What do you see with a corneal ulcer?
When do you need to refer for a lid laceration?
Lid margin involved
What's the difference between pre and postseptal cellulitis?
Good eye movements
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
What kinds of problems will give you normal anion gap acidosis?
Gut or kidney stuff:
type 2 RTA
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?
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?
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?
What are the complications of obtaining IV access?
Why a central line?
Long term placement
CV: CVP, pulm artery cath placement
What are some complications of central line placement?
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):