BSC MISC Family Med EOR Guide spring 2023

FAMILY MED EOR BLUEPRINT URGENT CARE (4%) RESP FAILURE/ARREST  RESP DYSFUNCTION resulting in abnormalities of OXYGENATION or VENTILATION (CO2 elimination) severe enough to threaten function of vital organs  pO2 <60 mmHg + PCO2 >50 mmHg  CAUSES (full list on p 316 in Current)  ASTHMA  OBST  PULM EDEMA 2T ARDS, INJURY, ↑ HYDROSTATIC PRESSURE, MITRAL REGURG  AIR EMBOLISM  RIB FX, FAIL CHEST, PNEUMO  FEVER, INFECTION, DRUGS  SSX  those of UNDERLYING DZ combined w HYPOXEMIA (low O2 in blood) + HYPERCAPNIA (excessive CO2 in bloodstream)  HYPOXEMIA = cyanosis, restlessness, confusion, anxiety, delirium  HYPERCAPNIA = HA + dyspnea cardinal signs  LABS  obtain ABG  TX  treat underlying disease  RESP SUPPORTIVE CARE for adequate gas exchange  GENERAL SUPPORTIVE CARE  NONVENT ASPECTS OF TREATMENT  INSPIRED O2 CONC should be LOWEST VALUE -> ARTERIAL HEMOGLOBIN SATURATION of 90%  VENTILATOR ASPECTS  FULL FACE MASK or NASAL MASK of BiPAP  FIRST LINE COPD  pts w ARDS or SEVERE IMPAIRED OXYGENATION need to be INTUBATED  You can have NONINVASIVE, TRACHEAL INTUBATION, MECHANICAL VENT  comps w MECHANICAL VENT include: ET TUBE MIGRATION into MAIN BRONCHUS, loss alveolar integrity, ACUTE RESP ALKALOSIS 2T OVERVENTILATION (common), or PNA  GENERAL SUPPORT  adequate NUTRITION = key  Watch out for overfeeding of carbs with conventional enteral feeding methods because it can cause increase CO2 production  Watch out for hypokalemia and hypophosphatemia may worsen hypoventilation  Support from family DETERIORATING MENTAL STATUS  "CONFUSED" PT frequently comes to medical attn 2T judgment of someone  DELIRIUM = acute change in attn + mental fxn; disturbance of wake-sleep cycles and fluctuating confusion.  DEMENTIA = chronic confusional state with insidious onset.  The two conditions can and frequently do coexist. ALLERGIC RXN/ANAPHYLAXSIS  Allergen exposure followed by acute onset of illness involving the skin or mucosal tissue and either resp compromise of hypotension (systolic <90 mmHg) 1  Types of anaphylaxis  IgE dependent: acute syndrome initiated by new allergen exposure after prior silent exposure in which the pts body made IgE antibodies (can NOT occur on first time exposure)  Idiopathic anaphylaxis: without known immunologic mechanism and can occur with first time exposure  SSX  Occur within 30 min usually  First have skin manifestation like urticaria then respiratory distress, GI symptoms, and hypotension  Labs: elevated serum levels of mast cell mediators such as tryptase and histamine BURNS  The first 48hrs of burn care offer the greatest impact on morbidity and mortality of a burn victim.  Extent: Remember rule of nines for estimating total burn surface area  only 2 nd and 3rd degree burns are used to calculate this  Depth:  1 st degree may be red or gray but will demonstrate good cap refill and NO blister initially  2 nd degree the wound is blistered which shows partial thickness injury to dermis  3 rd degree is progressive loss of adnexal structures  Burns greater than 20% of total body surface area cause systemic metabolic derangements and can result in shock  You want to do a full trauma workup on these pts “ABCDE”  General edema may develop of soft tissue, upper airway, and in lungs as well  Generalized cap leak may occur in severe burns  need to replace volume with crystalloids  Management:  Pain control with NSAIDs or opioids is critical  Chemoprophylaxis: tetanus status, topical abx  Surgical management with escharotomy or fasciotomy (indicated for compartment syndrome)  DEBRDIEMENT with regular dressing changes and cleaning of the burn 3 RD TRIMESTER BLEEDING  5-10% of women have vaginal bleeding  Placental causes: placenta previa, placental abruption, vasa previa  Nonplacental causes: labor, infection, disorders of the lower GI tract, systemic dz  Approach depends on underlying cause, gestational age, degree of blood loss, over status of mom and fetus  Management-  General measures  Monitor mom and fetus  CBC with platelets and INR obtained and repeated serially if bleeding continues  US to determine placental location and digital pelvic exam after US  Anti-D immune globulin may be required for women who are Rh neg  Placenta Previa  Occurs with placenta implants over the internal cervical os.  Risk factors: previous C-section, increasing maternal age, multiparity, smoking  Painless vaginal bleeding is characteristic sx (range from light spotting to perfused) 2  Evaluation is the appropriate initial management approach. For pregnancies that have reached 37 weeks gestation or beyond with continued bleeding, delivery is generally indicated.  Pregnancies at 36 weeks or earlier are candidates for expectant management and a subset of these women can be discharged if the bleeding and contractions completely subside.  Morbidly Adherent Placenta  Describing an abnormally adherent placenta that has invaded into the uterus.  The condition can be further classified depending on whether the depth of invasion is limited to the endometrium (accreta), extends into the myometrium (increta), or invades beyond the uterine serosa (percreta).  Risk Factor: uterine scar from previous c-section  After delivery of the infant, the morbidly adherent placenta does not separate normally, and the bleeding that results can be torrential. Emergency hysterectomy is usually required to stop the hemorrhage, and transfusion requirements are often massive.  should be suspected in any patient with one or more prior cesarean deliveries and an anterior placenta previa.  Placental Abruption  Premature separation of the placenta from its implantation site before delivery  Risk factor: HTN, cocaine use, smoking  Sx: vaginal bleeding, uterine tenderness, frequent contractions / coags and hypovolemia can occur  Indication for IMMEDIATE delivery because there is a high risk of fetal death SPIDER BITES & SCORPION STINGS  Toxins of most spider bites in US only cause local pain, redness, and swelling  Black widow spider bites cause generalized muscular pain, muscle spasms, rigidity  Tx: pain relief with parenteral opioids or muscle relaxants, latrodectus anti-venom saved for the really young and old due to hypersensitivity reaction  Brown recluse causes progressive local necrosis as well as hemolytic reaction (rare)  Tx: early excision of bite site (when extensive necrosis) or oral corticosteroids  Scorpion stings in the US only cause local pain  Tx: analgesics there is also an antivenom FB ASPIRATION  Pt will have inspiratory stridor if high in the airway  Wheezing and decrease breath sounds in low in the airway  80% of FB are in the RIGHT mainstem or lobar bronchus / 20% are in upper airway  Complications include  Pneumonia  ARDS  Asphyxia  DX studies: CXR: expiratory radiograph  Treatment: BRONCHOSCOPY: treatment for removal  Culture obtained in pneumonia is suspected  With coins on xray  If coin is in trachea the coin appears flat in LATERAL view  If coin is in esophagus coin appears flat in AP view      CARDIAC FAILURE  Heart can’t pump enough blood to meet metabolic demands. MCC is CAD!!  Forms of heart failure  Left sided: MCC is CAD and HTN