Critical Care Paramedic Study Guide: Endocrine & Neurological Emergencies, Exams of Nursing

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Hyperthyroidism/Grave's Disease/Thyrotoxicosis/"Thyroid Storm" (pg.111) - Correct Answer ✅Patient presents with weight loss, palpitations, nervousness, heat intolerance Exophthalmos (AKA proptosis) 'bulging of the eye' AVOID Aspirin (ASA) - Prevents binding of thyroglobulin, making the situation worse Treatment: IV Fluids 1st, Beta Blockers (Propanolol), Steroids (Dexamethasone), and Tylenol for fever. Septic Shock (pg.113) - Correct Answer ✅Someone who is in shock second degree to sepsis (infection in the bloodstream) Hypotensive with normal HR Hypotensive while being refractory to fluids Patient needs IV fluid therapy and vasopressors Levophed (Norepinephrine) is vasopressor of choice in profound hypotension

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Do not use Etomidate in RSI (due to its adrenal suppression) *Also do not use Etomidate in Addison's Disease also due to the adrenal suppression Pancreatitis (pg.113) - Correct Answer ✅Pain that is usually centered in the upper middle or upper left abdomen. Often radiates from the front of the abdomen through to the back, begins or worsens after eating, lasts a few days, and may feel worse when a person lies flat on their back. The digestive enzymes in the pancreas are destroying the pancreas. Increased lipase levels (usually >3x normal) *Amylase may also be increased but Faudree did not preface this in his study guide notes. Demerol for pain (b/c Morphine has the ability to cause spasms of the Sphincter of Oddi) Typically requires surgical intervention. Grey Turner's Sign (pg.113) - Correct Answer ✅Flank ecchymosis caused by hemorrhagic pancreatitis.

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Cullen's Sign (pg. 113) - Correct Answer ✅Periumbilical ecchymosis caused by hemorrhagic pancreatitis. Hypothyroidism/Myxedema Coma (pg. 112) - Correct Answer ✅Patient presents with fatigue, cold intolerance, weight gain, puffy eyelids, sparse hair, possibly goiter. Primarily occurs in women.

90% cases in winter (b/c the patient has cold intolerance and is not suffering from hypothermia)

Officially Myxedema Coma upon changes in LOC. Treatment: Levothyroxine (Synthroid) (T4) or Triostat (T3) IV Cushing's Syndrome (pg.112) - Correct Answer ✅Buffalo hump, moon face, thin arms and legs, purple striae on abdomen. Causes: Excessive use of corticosteroids (Iatrogenic, from corticosteroid treatment(s)) or Tumor

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Treatment: Usually resolves when corticosteroids are stopped or tumor is removed. Adrenal Insufficiency/Adrenal Crisis (pg. 112) - Correct Answer ✅Also known as (AKA): Addison's Disease Patient presents with depression, malaise, salt craving, and bronze colored skin like JFK. Treatment: Oral steroids (Prednisone) Negative Adrenocorticotropic hormone (ACTH) testing, also known as corticotropin or cosyntropin test. No Etomidate in RSI due to adrenal suppression. Laboratory Values Basic Metabolic Panel (BMP or CHEM7) (pg.106) - Correct Answer ✅Sodium (Na+) Primary Extracellular Cation: 135-145 mEq/L [Helps nerves and muscles interact] Potassium (K+) Primary Intracellular Cation: 3.5-5.0 mEq/L MOST DANGEROUS ABNORMALITY [Responsible for cell excitability, resting membrane potential]

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Chloride (Cl-) Extracellular Anion 95-105 mEq/L [Maintains osmotic pressure, and helps the stomach produce HCl or Hydrochloric Acid] Carbon Dioxide (CO2 gas) 22-26 mEq/L [Acid Base Balance contributor] BUN Blood Urea Nitrogen 6-24 mg/dL Indicates ability of Renal Clearance Cr Creatinine 0.7 -1.4 mg/dL Renal Clearance Glucose (Blood Glucose Level) 80-120 mg/dL Burns (pg. 126) - Correct Answer ✅1st Degree - Sunburns 2nd Degree - Blisters "Partial Thickness" 3rd Degree - Completely Destroyed Tissue "Full Thickness) Burn Formulas (pg. 126) - Correct Answer ✅Brooke - 2cc x kg x BSA = fluids over 24hrs (1st half in 1st 8 hrs from time of burn)

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Universal "Consensus Formula" - 2-4cc x kg x BSA = fluids over 24hrs (1st half in 1st 8hrs from time of burn) Parkland - 4cc x kg x BSA = fluids over 24hrs (1st half in 1st 8hr from time of burn) Only for 2nd and 3rd degree burn types. What is the preferred burn formula? (pg. 126) - Correct Answer ✅Parkland Formula is the preferred burn formula. Lactated Ringers is the preferred fluid administered. BSA Burn % Child (pg. 126) - Correct Answer ✅Head and Neck - 18% Each Arm - 9% (Both Arms 18%) Each Leg - 14% (Both Arms 28%) Anterior Trunk - 18% Posterior Trunk - 18% Palmer Method: The palm represents 1% BSA in both Adults and Children.

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BSA Burn % Adult (pg. 126) - Correct Answer ✅Head - 9% (Face 4.5%) Neck - 1% Each Arm - 9% (Both Arms 18%) Each Leg - 18% (Both Arms 36%) Anterior Trunk - 18% Posterior Trunk - 18% Palmer Method: The palm represents 1% BSA in both Adults and Children. Average Urine Output: 30-50 mL/hr for Adults Burns >20% (pg. 126) - Correct Answer ✅Possibility for Adynamic Ileus (Decreased Bowel Movement) Causes problems in-flight due to the expansion of wet gasses is restricted (Boyle's Law) Newton's 1st Law of Motion (pg. 130) - Correct Answer ✅Law of Inertia

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Unless it is acted upon by a force, a body at rest will remain at rest and a body in motion will move at constant speed in a straight line. Newton's 2nd Law of Motion (pg. 130) - Correct Answer ✅Force = Mass x Acceleration (F = M x A) When a force is applied to a body, the body accelerates, and the acceleration is directly proportional to the force applied and inversely proportional to the mass of the body. Newton's 3rd Law of Motion (pg. 130) - Correct Answer ✅For every reaction there is an equal and opposite reaction. Killers in Flight (pg.130) - Correct Answer ✅Tension Pneumothorax Pericardial Tamponade Hypovolemia The most definite assessment of shock is: (pg.130) - Correct Answer ✅Lactic Acidosis (Lactate >4 mmol/L) Normal Range of Lactate 2-4 mmol/L

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The most commonly damaged organ in trauma is: (pg.130) - Correct Answer ✅Skin Urine Output (pg.108) - Correct Answer ✅Infant 2cc/kg/hr Child 1cc/kg/hr Adult 0.5cc/kg/hr (Normal 30-50 cc/hr) 1 cc = 1 mL Spinal Shock (pg.99) - Correct Answer ✅Due to the swelling of the spinal cord after trauma. Decreased Systemic Vascular Resistance SVR< Treat with IV fluids and vasopressors Can treat with high dose steroids (however, controversial) Neurogenic Shock (pg.99) - Correct Answer ✅Distributive Shock Causes a decrease in sympathetic nervous system outflow (unable to vasoconstrict or increase HR) Occurs due to spinal cord swelling after trauma Decreased Systemic Vascular Resistance SVR< However, a normal heart rate (HR normal) Hypotension, no tachycardia

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Warm, red skin Treat with IV fluids and vasopressors Meningitis (pg.99) - Correct Answer ✅Caused by inflammation of the meninges Disease is carried in the Cerebral Spinal Fluid (CSF) Treatment based on cause (bacterial, viral, fungal) Triad of Nuchal Rigidity (Neck Stiffness), Photophobia (Intolerance of bright light), and Headache. PPE: Gloves, Mask, and Gown. Brudzinki's Sign: (pg.99) - Correct Answer ✅The appearance of involuntary lifting of the legs when lifting the patient's head with the patient lying supine. Kernig's Sign: (pg.99) - Correct Answer ✅Severe stiffness of the hamstrings causes an inability to straighten the leg when the hip is flexed to 90 degrees. "Kicking Kernig's" Neurological Emergencies (p.92) - Correct Answer ✅MAP (Mean Arterial Pressure) = SBP + (2 x DPB)/ Normal Range: 80-100 mmHg.

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Ideal MAP 90 mmHG. CPP (Cerebral Prefusion Pressure) = MAP - ICP Normal Range: 60-80 mmHg. Keep CPP above 60 mmHG. ICP Normal Range: 0-10 mmHg. ICP >20 mmHg has high mortality. (Monroe-Kellie Doctrine) ICP Transducer is placed at the foramen of Monro (level of ear). Signs/Sx of Herniation (pg.92) - Correct Answer ✅Change in LOC Pupil Reaction Decorticate (Abnormal Flexion) Brainstem Decerebrate Posturing (Abnormal Extension) Cushing's Triad (pg.92) - Correct Answer ✅Results from increased intracranial pressure leading to brainstem herniation Irregular or Decreased Respirations, Bradycardia, Hypertension w/ Increased Pulse Pressure.

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Treatment of Brainstem Herniation (pg.93) - Correct Answer ✅Paralyze (RSI) Intubate (RSI) Hyperventilate (Goal PaCO2 30-35 mmHg) Mannitol (Decrease fluid in the cranial vault, 1g/kg bolus over 5 minutes) Hypertonic Saline (Give slowly to prevent Central Pontine Myelinolysis) Barbituate Coma (Lowers O2 Demand) Hypoxia and Hypercapnia cause cerebral blood vessels to dilate, increasing blood flow and volume, furthering increasing ICP Treatment of Seizures caused by Herniation: Benzodiazepine, and then Phenytoin (Dilantin) or Fosphenytoin (Cerberyx). Phenytoin (Dilantin): 1 Gram loading dose at 50 mg/minute Lasix (Furosemide) can be used in the setting of hernation after Mannitol (but not as affective).

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Central Pontine Myelinolysis is caused by reversing hyponatremia too quickly. RAISIN BRAIN SHRINKAGE What should you NOT use for treatment of Brain Herniation? (pg.93) - Correct Answer ✅Do NOT use Hypotonic Solutions or Glucose! Hyponatremia is associated with cerebral edema Hyperglycemia makes brain injuries worse, most likely with cerebral edema (Swelling) Respiratory Changes in Cerebral Herniation (pg.92) - Correct Answer ✅Cheyne-Stokes: Breathing becoming shallower until it stops for a while (apnea), and then breathing starts again, rapidly cresendos to a peak before decreasing again. Pediatric Age Range (pg.88) - Correct Answer ✅Neonate: Birth to 28 days Infant: 28 days to 1 y/o Toddler: 1y/o to 2y/o Child: >2 y/o

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Pediatric Emergency Intervention Formulas (pg.88) - Correct Answer ✅ETT Diameter: (16 + AGE)/ If required ETT size > or = 5.5 mm CUFFED ETT should be used. If <5.5 use an UNcuffed ETT. SUCTION INSERTION CHEST TUBE (2/3/4) 2 x ETT Size = Suction/NG Foley Diameter (EX: 5.0 ETT = 10fr Suction/NGFoley) 3 x ETT Size = ETT Insertion Depth (EX: 7.0 ETT = 21cm ETT Insertion Depth) 4 x ETT Size = Chest Tube (EX: 5.0 ETT Size = 20fr Chest Tube) Normal Systolic BP = 90 + (2 x AGE) Hypotensive Systolic BP = 70 + (2 x AGE) Defibrillation 2J/kg Pediatric Fluid Emergency Resuscitation (pg.88) - Correct Answer ✅Neonate/Infant: 10cc/kg (< 1 y/o) Toddler/Child: 20 cc/kg (> 1 y/o) (No more than 2 fluid bolus infusions)

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Average Circulating Blood Volume: 80-90 mL/kg Pediatric Maintenance Fluids "4/2/1" (pg.89) (Non Emergency) - Correct Answer ✅1-10 kg -> 4cc/kg/hr 10-20 kg -> 2cc/kg/hr

20 kg -> 1cc/kr/hr Example: 25kg child needs fluids. 1st 10kg = 40 cc 2nd 10kg = 20 cc last 5kg = 5cc Answer: Total Fluid Required 65 cc/hr 1 cc = 1 mL Pediatric Glucose Management (pg.89) - Correct Answer ✅D stick or BGL < 60 mg/dL Neonate 2cc/kg D Infant/Toddler 2 cc/kg D Child 2 cc/kg D

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Pediatric Airway Problems (pg. 89) - Correct Answer ✅Stridor (Upper Airway Inhalation Problem) Wheezing (Lower Airway Inhalation Problem) Bronchiolitis (pg.89) - Correct Answer ✅Swelling of the bronchiole walls >90% Viral Most Common Viral Causes: Respiratory Syncytial Virus (RSV) Highly Contagious S/S: Cough, Dyspnea, Nasal Flaring, Wheezing/Crackles upon Lung Sounds Assessment Treatment: Supportive care, O2, Fluids, Contact Isolation. Croup (pg.90) - Correct Answer ✅Swelling of the vocal cords Most likely viral causation/infection Gradual onset with Upper Respiratory Infection (URI), no drooling upon assessment "Seal Like" Barking Cough Steeple Sign on A/P Neck X-Ray

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Treatment with Racemic Epinephrine (aerosolized) and Steroids (Decadron). NOT usually life threatening Epiglottitis (pg.90) - Correct Answer ✅Swelling of the Epiglottis Most likely bacterial causation/infection Sudden onset, DROOLING Patient presents in the "Tripod Position" Thumb Sign on lateral neck X-Ray (thumbprint) Do not disturb child due to rapid airway loss Treatment: Antibiotics, humidified O Respiratory Syncytial Virus (pg.91) - Correct Answer ✅Lower Respiratory Infection RSV can cause Apnea! More common in those with: Congenital Heart Defect (CHD), Hyaline Membrane Disease (HMD), and Bronchopulmonary Dysplasia (BPD). Treatment: Usually self-limiting. Supportive care and oxygen therapy rendered.

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Tocolytics (pg.77) - Correct Answer ✅Drugs that CEASE uterine contractions Terbutaline (Brethine): Stops tetanic contractions of the uterus IMMEDIATELY SQ 0.25 mg q 15 minutes However, very short acting (like Succinylcholine for RSI - works fast, but not for very long). Terbutaline is also a Beta 2 Agonist used in asthma. Magnesium Sulfate "Mag" MgSO Mechanism of Action - CNS depressant, smooth muscle relaxant. Used to both prevent seizures in Pre-Eclampsia and as a tocolytic in pre-term labor. -> Loading dose 4-6 Grams IV over 30 minutes Continuous infusion rate 2 Grams/hour Also, very long acting (like Rocuronium for RSI - takes longer to work but lasts longer). Mag toxicity can occur, do a "Mag Check" to look for decreased DTRs, Pulmonary Edema Antidote for MgSO4 is CALCIUM GLUCONATE.

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Premature Rupture of Membranes (PROM) (p.77) - Correct Answer ✅A mother's "water breaks", and signifies that delivery is imminent. If this occurs and the baby is preterm you must PREPARE FOR DELIVERY! The amniotic sac (membrane) surrounding the baby protects it from infection (sepsis). Administer steroids to stimulate fetal lung maturity! Pre-Eclampsia (pg.80) - Correct Answer ✅HTN/Proteinuria/Edema NO SEIZURES Risk Factors - Extremes of Age, 1st Pregnancy Often causes late decelerations Eclampsia (pg.80) - Correct Answer ✅HTN/Proteinuria/Edema GENERALIZED SEIZURES Seizures are treated with Valium/Diazepam Give MgSO4 to depress seizure activity ->Signs of Mag toxicity is decreased DTRs (hyporeflexia), pulmonary edema ANTIDOTE for MgSO4 Calcium Gluconate

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Maternal Hemorrhage (pg.80) - Correct Answer ✅EMERGENCY - Placenta Abruption "painful" bleeding. Any MVA or blunt trauma is this DX. until ruled out. Causes exsanguination & placental insufficiency NON-EMERGENCY - Placenta Previa painless, bright red bleeding. No vaginal exam! Postpartum Hemorrhage (PPH) >500mL blood loss Vigorous fundal massage! Bimanual uterine compression Pitocin (pg.80) - Correct Answer ✅Drug that causes contraction of the uterus to help stop bleeding. Synthetic Oxytocin Often used for uterine atony (loss of muscle strength) after placental delivery in the setting of continued maternal hemorrhage. Methergine (pg.80) - Correct Answer ✅Drug that causes contraction of the uterus to help stop bleeding.

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Oxytocin (pg.81) - Correct Answer ✅Released by the pituitary gland in large amounts; After distention of the cervix, and uterus during labor, facilitating birth. After stimulation of the nipples. During breastfeeding. (This is one reason why babies are placed on mother's chest after birth). Uterine Rupture (pg.81) - Correct Answer ✅Spontaneous tearing of the uterus "Stomach is as hard as a board" Caused by peritonitis. "Fetal parts presenting under the mother's skin" #1 cause of maternal death is trauma #1 cause of fetal death is maternal death Rh Negative Mothers (Rh=) (pg.81) - Correct Answer ✅Rhogam prevents mother's immune response to the baby's Rh+ (positive) cell - prevents the mother's immune system from attacking the baby. Occurs with the second pregnancy. If a mother is Rh= (negative), ALWAYS administer Rhogam. Rhogam supplied by the blood bank or transfusion services department in hospital. Mother has Rh antibodies to Rh+ antigens.

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The majority of the population of Rh+. Administration of Rhogam occurs: At 28 weeks gestation, after delivery, after any trauma/bleeding/potential bleeding where firstborn baby's blood cells are transferred to the mother's circulatory system. Miscellaneous Obstetrics Pearls (pg.82) - Correct Answer ✅Do not pull on the umbilical cord after delivery of the baby, this can cause uterine inversion. Uterine inversion requires manual replacement. Gestational diabetic mothers are more likely to give birth to children with hypoglycemia and also large-sized neonates (fetal macrosomia). This is b/c the baby's pancreas produces insulin at normal levels, and once no longer inside the mother, the glucose levels drop dramatically. HYPOGLYCEMIA IS A COMMON CAUSE OF SEIZURES IN THE NEWBORN. Miscellaneous Obstetrics Pearls (pg.82) (Condition vs. Treatment) - Correct Answer ✅Condition vs. Treatment

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HTN = Labetolol, Hydralazine, Methyldopa Post-Partum Hemorrhage = Fundal Massage, Pitocin, and Methergine. Eclampsia (Seizures) = Valium (Diazepam) Uterine Contractions = Terbutaline, MgSO4 Pre-Eclampsia/Eclampsia = MgSO4 MgSO4 (Magnesium Sulfate) Neonatal Emergencies (pg.83) - Correct Answer ✅Birth to 28 days old Infant heads are larger in proportion to the rest of the body. This results in a natural sniffing position. Neonates/Infants are obligate nasal breathers. Suction the mouth 1st, then the nose. May utilize bulb syringe, DeLee Suction, or 10fr or 14 fr suction catheters.

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Airways secretion and edema causes serious problems earlier than in adults. Consider nagogastric tubes in all intubated neonates. Meconium (pg.83) - Correct Answer ✅Meconium is sterile (consists of hair, teeth, skin cells, & etc.). Deep suction (below vocal cords) is ONLY indicated if the neonate is not vigorous if meconium is present at birth. Surfactant is inactivated by meconium. IsoletteTM Incubator (pg.83) - Correct Answer ✅Device to put any preterm or term infant to maintain heat, provide supplemental oxygen, and to protect from the environment. Patient must be secured inside the incubator during flight. Preterm neonate <5kg Distress in a neonate Infants/Pediatrics lose heat quicker than adults due to their BSA to Mass Index Ratio. Neonatal Infection Disease (p.83) - Correct Answer ✅Top 3 Killers in the 1st 24hrs

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1. Sepsis (Groub B Streptococcus Infection TX:AMP-GENT)
2. Respiratory Complications
3. Cardiac Problems Tetralogy of Fallot (pg.87) - Correct Answer ✅Right to Left Shunt Consists of Pulmonary Stenosis, Aortic Coarctation, Transposition of Great Vessels - the Aorta and Pulmonary arteries are switched, and Ventricular Septal Defect (VSD). "Tet Spells" sudden cyanosis and syncope TX: Knees to chest, Morphine further tx. perform RSI, Intubate, and 100% O2. Miscellaneous Neonatal Information (pg. 87) - Correct Answer ✅An umbilical cord has 2 Arteries 1 Vein If the newborn only has 1 Artery and 1 Vein in the cord (single artery cord), the Renal System is likely to be affected.