Endoscopy 

q4 Serial CBC 

2 large bore IVs

Fluid resuscitation

Proton Pump Inhibitors 

Colonoscopy 

Serial CBCs

2 Large bore IVs

Proton Pump Inhibitors

ABX- concern for bowel perf 

Abdominal CT

(Abdominal decompression with NG, Correct Electrolytes, Sugical Intervention in 3/4 patients)

Blue discoloration in perinumbilical area

Indicated intra-abdominal bleeding

Blue discoloration of flank

Indicates retroperitoneal bleeding

Bruising of scrotum and labia

Indicates pelvic bleeding

Deffered left shoulder pain

Indicates phrenic nerve irritation related to splenic rupture 

Gold Standard for Abdominal Trauma

CT scan

(Ultrasound and Lab work) 

Intra-Abdominal Pressure

(Parameters and Gold Standard)

> 12 mmHg is intra-abdominal hypertension

>20 mmHg is considered abdominal compartement sydrome in the presence of one organ failure

Gold standard diagnosis is bladder pressure monitoring 

Needs immediate surgical decompression laparotomy 

Constant severe abdominal pain that radiates down back and flank

Grey's Turners or Cullen's signs

Elevated amylase and lipase

CT scan is gold standard/ERCP for stone removal

80% caused by alcohol and biliary stones 

TPN- NO ENTERAL FEEDS

Facial Muscle twtiching seen when cheek is tapped 

Hypocalcemia

More O2 is RELEASED from hemoglobin

-Low pH

-Increase in PaCO2

-Increase in body temperature

-Increase in 2,3-DPG

O2 not easily released from hemoglobin (Loves O2)

-Increase in pH

-Decrease in PaCO2

-Decrease in body temperature

-Decrease in 2,3-DPG 

>95%

This is the oxygen carried on the hemoglobin 

PaO2 <60mmHg on FiO2 50% or greater

P to F ratio < 200 mmHg

Decrease in lung compliance

Patchy bilateral infiltrates on chest x-ray 

PAOP > 18-25 mmHg

pulmonary edema due to back up of blood flow into lungs 

Fever

Productive purulent cough

Pleuritic chest pain

Elevated WBCs 

Blood stasis

Hypercoaguability

Vessel Injury 

Pulmonary angiography

Sudden onset of chest pain, dyspena, tachypnea, and feeling of doom

Most are in the right due to blood flow

Can cause RBBB and ST depression 

Pulmonary Artery Pressures > 25 mmHg

Gold standard diagnosis is right-sided heart catherization 

Wheezing, expiratory stridor, chest tightness 

Gold standard is pulmonary fuction test

Bronchdilators, Beta-agonists, Inhaled corticosteroids

Substernal retractions, acessory muscle use, inspiratory and exspiratory wheezes

IV steroids, epi, and mag (relaxes smooth muscle) 

Air trapping

Hyperinflated lungs

Pink Puffers

Barrel chest

Distance breath sounds 

Normal PaO2 but SOB 

3 months per year for a least 2 years

Chronic cough and sputum production

Blue bloaters 

Coarse crackles, gurgles, and expiratory wheezes 

Hypoxia and gurgles 

Pulmonary Contusion: occurs 24-72 hrs after insult and resolves in 3-7 days (CT gold standard) 

Flail Chest: Paradoxical movement, mechanical ventilation, 2-3 weeks chest wall should be stabile 

> 400 ml of fluid in lungs (hemothorax) will show signs of shock 

CT is gold standard

ASTOP for chest tubes: A) Assessment, S) Site, T) Tubing, O) Output, P) Prescence of tidaling or bubbling

NEVER CLAMP TUBE= Pneumothorax 

BG >500

pH < 7.3 --> HCO3 < 15 mEq

Ketones in urine and serum

Anion gap >15

Elevated BUN, K, and Mag

Phos may be low 

Kussmal respirations 

4-6 L IV fluids

Insulin drip

Add D5 and K once BG < 250 mmHg

May give Bicarb in certain cases 

BG >800 mg/dL

Osmolality >350 ml

pH normal

Treat with 8-10 L of fluids and insulin drip (takes less insulin) 

Main problem is hypocalcemia

Parathesias

Chvotek's Trousseau's 

8-12 mmHG

> 18 indicates heart failure 

Right Ventricular End Diastolic Pressure 

(RVEDI)

Pulmonary Vascular Resistance 

(PVR)

Systemic Vascular Resistance 

(SVR)

Mixed Venous Oxygen Saturation

(SvO2)

Pure a1 agonist

Arterial vasoconstriction

Dosage: 2-200 mcg/min 

Great for sedation related hypotenion and neurogenic shock 

Side Effects: bradycardia 

Both a1 and beta1 effects (a>b)

Vasoconstriction, increased MAPs, and increased HR

Dosage 2-30 mcg/min 

Great for spetic shock and hypovolemic shock 

Side Effects: Tachyarrhytmias 

Equal a1 and b1 effects

Will increase HR, MAP, and cause vasoconstriction

Dosage: 1-10 mcg/kg/min

Great in septic shock when increased contractility is needed 

Both a1 and b1 effects (B>a)

Primarily increase HR and contractility at high doses causes vasoconstriction

Dosage 1-10 mcg/kg/min

Great for low CO, bradycardia

Works on V1 and V2 receptors

Causes vasoconstriction and increased MAPs 

Dosage: 0.3-0.4 units/min

Second line vasopressor for shock 

Pure B activity B1>B2

Increase HR and contractility, will cause some vasodilation and may decrease preload and afterload 

Dosage: 2-20 mcg/kg/min 

Great for cardiogenic shock and septic shock with low CO

Side Effects: pt develops tolerance overtime 

Phosphodiesterase inhibitor 

Causes increased contracilitily and vasodilation (increases CO and decreases preload and afterload)

Dosage 0.375-0.75 mcg/kg/min

Great for cardiogenic shock

Side Effects: arrythmias and hypotension 

Nitric oxide mediated smooth muscle dialation

Prominent in venous system- decreases preload and dilates coronary arteries

Dosage: 5-10 mcg/min --> 200mcg- 400mcg/min 

Great for angina

Can cause HA and Hypotension 

Nitroprusside

(Nipride)  

Direct vasodilator: venous and arterial

Reduces preload and afterload

Dosage: 0.2-10 mg/kg/min

Great for hypertensive crisis and CHF exacerbations

Side Effects: HA, hypotension, rapid BP changes, cyanide toxicity

Nicardipine

(Carvedilol) 

Calcium channel blocker, effects vasulcar smooth muscle 

Especially effective in vasodilation of coronary and cerebral vasculature

Dosage 5-15 mg/hr

Great for hypertensive crisis and CAD 

Blocks B1, B2, and a1 (B>a)

Decreases contractility, HR, and afterload

Dosage 0.25-3 mg/min

Great for aortic dissection and hypertensive crisis

Side effects: hypotension, bradycardia, bronchospasm 

B1 selective blocker

Main effect is decreased HR

Dosage 25-300 mcg/kg/min

Great for aortic dissection and atrial fibrillation

Very short acting 

Loop diuretic

Inhibits the reabsorption of K, Ca, and Na

Causes significant loss to reduce preload

Dosage: 1-20 mg/hr

Great for CHF and pulomnary edema 

Lisinopril, Captopril, Enlapril

Used for BP control

Can cause hyperkalemia and dry cough

Standard post MI med

Causes reduction in BP and hyperkalemia

Utilized when ACEs arent toelrated 

Beck's Triad 

(Pericardial Tamponade)

Narrow pulse pressure

JVD

Muffled heart sounds 

Want heart Low and Slow

Hypertension, difference in BP in arms, and widen mediastinum on X-ray

Need Labetolol and esmolol to lower HR and slow it down 

Feeds inferior portion of the heart

ST elevation in II, III, and aVF

Feeds anterior portion of the heart

ST elevation in V1-V4

V3 and V4 feed septum 

Feed lateral portion of the head

ST elevation in I, aVL, V5 and V6

0-6

Elevated within 4-8 hrs of cardiac injury

Peaks 12-24 hours

Baseline is 24-48 hours

0-0.3

Elevated 4-6 hrs after onset of symptoms

Peaks 18-24 hours

Baseline after 2 weeks 

> 12,000 

Peaks 2-4 days after cardic injury

Due to stress and tissue necrosis

10-100 pg/mL

Released with myocardial stretch

Reflect HF

Helps to differeniate between cardiac versus pulmonary issues

Percutaneous Coronary Intervention

90 min balloon to door 

When someone has a PFO and Right heart pressures are greater than left pressures causes a left shunt on unoxygenated blood

This allow unoxygenated blood to enter systemic circulation and cyanosis 

Pain

Pallor

Pulseless

Parathesia

Paralysis

COLD AND WHITE 

Caused by trauma, clot, or compartment syndrome 

Warm and red 

Caused by Virchow's triad 

Defined as SBP < 180 or DBP > 120 

Reduced 10% 1st hr, and 15% 2-3rd hr (reducing too quickly causes cerebral edema) 

Nitroprusside, Nicardepine, Nitroglycerin, Labetalol, Esmolol 

Turmor of the adrenal glands that secretes epi and norepi

New onset HTN that is refractory and mood swings

24 urine to measure catecholamines 

No more pain is bad sign, looks shocky, needs surgery ASAP if 4-6 cm

Keep BP and HR low post surgery 

GLOBAL ST ELEVATION 

Beck's Triad 

Elevated WBCs and friction rub 

Pulmonary Signs and Symptoms

Edema 

SOB

Fatigue 

Peripheral and organ edema

Hepatomegaly

Splenomegaly

Pitting edema

wt gain 

Dobutamine and Milrinone

Diuretics

Beta Blockers 

Global Cardiac dilation

Systolic dysfunction= poor contraction

Reduced EF, Low CO, and Increased HR

Hypertrophic Cardiomyopathy

(HOCM/IHSS)

Muscle dilation-thick wall, atrial enlargement

Stiff ventricles= poor filling because they can't relax

Reduced EF and SV

TREAT WITH BETA BLOCKERS!!!!

No intropes or nitrates 

Sudden death in young athletes 

Fibrous walls

Poor filling then poor pumping

Resembles constrictive pericarditis 

Few treatment options 

Initate within 6-12 hours after ROSC

Must be unresponsive after ROSC

Arrest to ROSC < 60 mins

32-34 C degrees for 24 hours

Rewarm at 0.25 degrees C/hr 

Increased preload

Increased Afterload

Decreased CO/CI

Decreased Tissue perfusion 

PAWP >18 mmHg

Decreased Preload

Increased afterload 

Decreased CO/CI

Decreased tissue perfusion 

4 x weight of patient x BSA of burn in ml

Used for burn hypovolemia 

Caused by sedation, spinal anesthesia, and spinal cord injury

No SNS compensatory mechanisms so patient is HYPOTENSIVE and BRADYCARDIC 

Bronchospasm, airway edema, massive vasodilation 

NEEDS IM EPI 

Temperature < 36 C or > 38

HR > 90

RR > 20

PaCO2 < 32 mmHg

WBC > 12,000 or < 4,000 or 10% bands 

Need two or more criteria: considered sepsis when organism is identified 

Decreased Preload

Decreased Afterload 

Increased CO/CI

Decreased tissue perfusion 

4.7-6.1 million/mm3 Males

4.2-5.4 million/mm3  Females 

Hemostasis

(Clot Formation)

Phase 1: Damage to blood vessel causes vascular spasm to slow/stop blood up to 30 mins

Phase 2: VWF causes platelet adhension to injury site 

Phase 3: Coagulaiton (Intrinisic Pathway or Extrinisic Pathway --> Common Pathway

Phase 4: Clot retraction in 2 to 3 days 

Phase 5: Fibrinolysis

Prothrombin --> Thrombin

Fibrin --> Fibrinogen 

Platelets < 100,000

PT/INR > 15 seconds

PTT > 60-90 seconds

Fibrinogen decreased (< 200 mg/100 dL)

FSP increased (> 10mg/dL)

D-Dimer increased (> 2mg/dL)

< 150,000 platelets

Onset 5-14 days after reciveing Heparing 

Hit Antigen assay

Give Argatroban 

NO Platelets- increases immuneresponse 

Platelet count 10,000-50,000

Slide smear will reveal platelets large in size which indicates increased bone marrow production

IVIG, plasmaphoresis,immunosupress, sometimes splenctomy 

Hbg < 7g/dl

Hct < 21%

Find underlying cause and treat oxygenation 

PRBC= increases Hbg by 1-2 g/dl and Hct 2-3%

Platlets= increases count by 6,000

FFP= increases clotting factors by 20%

Cyroprecipitate= increases fibrinogen by 75 mg/dl

Hepatitis

Hyperkalemia

Hypocalcemia

Hypothermia

Fluid overload

Oxyhemoglobin dissociation curve to left because bank blood has low levels of 2,3-DPG 

In frontal lobe

Can't talk/ expressive aphasia 

Temporal lobe

Recognizes speech/ receptive aphasia 

7 cervical, 12 thoracic, 5 lumbar, 5 fused sacral

C4- ability to breathe without assistance

T4- autonomic dysreflexia 

20 ml/hr produced

150 ml in system

If foramen of Monroe is occluded then CSF cannot drain 

Olfactory 

Smell

Pt identify common smell

Optic

Visual Acuity

Pt reads eye chart 

Occulomotor

Eye movements

PUPILS- dilation and constriction 

Trochlear

eye movements in cardinal directions 

Trigeminal

Facial sensation

Can pt feel you touching their face 

Abducens

Eve movements in cardinal directions 

Facial 

Have patient smile 

Vestibulocochlear 

Hearing and balance 

Glossopharyngeal

Pt talk and gag? 

Vagus

Pt cough and gag see cardiac effects 

Acessory spinal

Have pt shrug shoulders 

Tongue

Stick out tongue 

Normal range is 0-15 

Higher P2 in waveform indicates reduced compliance

For every 10 degrees elevation in HOB it drops ICP by 1 mmHg

Increased ICP

Increased BP, widened pulse pressure, bradycardia 

Gold standard diagnostic head ct without contrast 

tPa: 3.5-4 hrs post onset 

Dosed at 0.9 mg/kg of body weight

Vital signs q15 min for 2 hours, 30 min for 6 hrs, q1 for 16 hrs

ICH, AVM, SAH

Highest risk of rebleeding is 24 hours post bleed

Maintain SBP 120-140 to prevent vasospasm

Risk for vasospasm 3-21 days post bleed 

Indicative of Basillar skull fracture

Bruise on the mastoid bone 

Battle's Sign

Racoon's Eyes

Rhinorrhea or Otorrhea

Cranial nerve dysfunction (I, II, III) 

DECREASED glucose

Increased WBCs

Increased protiens

Cloudy appearance 

Acethylcholine receptors or block

Give cholinesterase inhibitors

Aminoglycosides block cholinesterase inhibitors 

180 L/day or 125 ml/min 

Normal adult urine volume is 1-2L a day 

Filtration occurs when SBP 80-170 mmHg 

90-130 ml/min 

Good measure of GFR 

5-6.5 

Urine is more alkaline after meals and during infection

Urine is more acidic on awakening due to intermittently hypoventilation during sleep 

> 5.5

Peaked T waves, and widened QRS when K+ is > 6.5

Muscle weakness and hypoactive reflexes

Give Calcium Chloride, albuterol, D50 and Insulin, Kayexcelate

< 3.5

Weakness, abdominal distention, N/V, Lethargy, inverted T waves, ventricular ectopy 

KCL 10-20 mEq/hr

May need mag first 

> 145

Altered LOC, lethergy, seizures, coma, muscle weakness

Free water replacement 

< 135

Disorientation, decreased mentation, irritability, seizures, lethargy, coma, N/V, respiratory arrest 

Replace serum sodium and identify cause 

> 10.5 

Lethargy, confusion to coma, weakness to flaccidity, dehydration, N/V, abdominal pain, constipation 

Give phosphates, corticosteroids, and decreased vitamin D intake 

< 8.5

Weakness, muscle spasms, ileus, hyperreflexia, seizures, tetany, drowsiness to coma, shallow respirations

PVCs, Prolonged ST and QT intervals, Bradycarida, QRS looks wide 

Give calcium chloride 

> 4.5

Just like hypocalcemia presentation

Give phosphate binders (Tums)

< 3.0

Mailase, muscle weakness, anorexia, hypercalcemia

Provide PO or IV phosphorus 

> 2.5

Neuromuscular and cardiac depression, drowsiness, bradycardia, decreased RR, cardiac arrest 

Provide saline, loop diuretics, and HD

< 1.5

Hyperreflexia, tetany, seziures, Chvoteck's and Trousseau's

Same as hypocalcemia

Mag IV