Toolbox

We have these tools

Vitals!

• Vitals indicate that the organism is alive• There are only 4 true vitals: heart rate,

respiratory rate, temperature, and blood pressure

• Some include pain• The rest are bonus metrics• BGL, SpO2, CO2, EKG, GCS

Heart Rate!

• Kind of a misnomer.• This value should read ‘pulse.’• Because associated with it are rate

(obviously), strength, regularity, symmetry, and presence.

• Always palpate a pulse. Bilateral palpation is even better.

• I sometimes do this on the dorsalis pedis pulse of supine patients.

Respiratory Rate!

• Also a misnomer• Should read ‘ventilation’• Associated with it are all the mechanical

aspects of breathing, including rate, depth, pattern, work of breathing, and symmetry

Temperature!

• It’s either relevant, or it’s not• Irrelevant more often than not• Increased heart rate and mouth breathing are

associated with highly variable oral temps• The only true temps are esophageal, rectal,

urinary (from a Foley cath), you know, core temps.

• Axillary temps? Please.

Blood pressure!

• High is associated with many exciting and excruciating ways to die early!

• Really high is probably a kidney problem!• Low means you’re probably in shock.• Systolic perfuses the brain (minus ICP)• Diastolic perfuses the heart• Low pulse pressure means tamponade• High pulse pressure means increased ICP

Pain!

• Scale of 1-10• People are hilarious. They’re all like, “11!”• But if 10 is the worst pain they can imagine• They all have pretty shitty imaginations• Mostly used as a trending tool• And to titrate pain medication

Glascow Coma Scale

• Seems like bullshit to me• Values have little interoperator reliability• Does not accurately stratify severity• But does indicate a trend in “oh shit” factor• In the same way an almost arbitrary scale of 3-

15 would

Hemipelegic Migraines

• People who are faking them will often not know that the tongue, when stuck out, points ipsilateral to the lesion.

• So they point their fake droopy tongue towards their fake droopy arm.

• Like a faker.

Speaking of hemipelegia

• We all know the Cincinnati stroke scale• Make ‘em do the thriller thing, smile, and tell

you they’re having a nice day (they think you’re an asshole)

• You should also probably check bilateral radial pulses

• Just in case they have a dissecting thoracic aneurism and the tunica intima is obstructing the lumen of the vessels leaving the thoracic aorta.

Unknown Unconscious?

• Pinpoint pupils? Probably an opiate. Narcan!• Low BGL? Probably hypoglycemia. D-50!• High BGL? HHNK or DKA! Normal saline!• No pulse? Push on their chest!• Not breathing? Squeeze a bag at their face!

Electrolytes wonky?

• Reflexes• EKG• They may need hypertonic saline, but we

don’t have that, so sodium bicarb

Reflexes

• They test an arc from the limb to the spine• It seems like hypo- or hyperreflexia would

have to be determined by establishing a healthy baseline.

• So I don’t really know their use• Not really done in the field• Except perhaps the Babinski reflex• Also, highly operator dependant.

Speaking of Operator Dependant …

• Fundoscopy is tough• You have to get really close to a lot of people

before you get good at it• Most people don’t get good at it• Except ophthalmologists• Cause they have to• From it you can determine diabetes and

increased ICP

Percussion!

• Another thing people don’t do anymore!• Requires a keen ear and a large sample of

normal resonance to be sensitive• And even when you’re sensitive, it’s not

particularly specific• But neither is auscultation

Hyponatremia

• Can be caused by diuretics or endurance athletics.

Hypocalcemia

• Negative inotropic effect

Hyperkalemia

• Oh shit! This can cause every dysrhythmia.• Fatal within seconds• Wide QRS• Serum levels are cause the dysrhythmia.• If you can cause cellular uptake, you fixed the

problem• Albuterol- rapid fix• Insulin + glucose = the cellular symporter uses

K.

Want to know proteinurea?

• Shake their pee!• High protein = super foamy

Adenosine

• Because you can’t figure out how to double the paper speed.

• Stops the heart for 5-10 seconds• Restarts slowly• And will probably return to its normal pace• Unless it’s a WPW• In which case you’ve killed them

Wanna see how their heart’s electricity is doing?

• EKG! There’s a thing for that!• Long intervals all around? Consider metabolic

phenomena.• Low amplitude all around? Probably

tamponade.

EKG

• Possible use for determining neuromuscular weakness?

Calcium channel blocker

• Dihydropyridine (amlodipine, nifedipine, Celvidipine!)

• Phenylalkylamine (verapamil)• Benzothiazepine (diltiazem)• Overdose? Hit em with calcium

gluconate/calcium chloride per SOP, pressors to temporize, then 1 unit/kg insulin.

Beta Blockers

• Nonselective (propanolol, alprenolol)• B1 selective (esmolol, metoprolol)• B2 selective (butaxamine, useless)• B3 selective (SR 59230A, useless)

Potassium Channel Blockers

• Amiodarone• Sotalol

Sodium Channel Blockers

• Class 1a (quinide, procainamide)• Class 1b (lidocaine, phenytoin)• Class 1c (encainide, propafenone)• TCAs!

ACE Inhibitors

• Sulfhydryl- Captopril• Dicarboxylate- Lisinopril, Benazipril• Phosphonate- Fosinopril• They can cause fibrosis of the lung

parenchyma, and a chronic dry cough

Diuretics

• HCTZ- One of the few things that can still cause hyponatremia, besides ultramarathoning.

Gradients!

• High O2, low CO2, glucose, insulin.• The rest of the body is meant to keep the few

grams at the front of your brain alive.• Hydrostatic pressure gradient between left

ventricle and brain.• Cerebral perfusion pressure is mean arterial

pressure minus the ICP.

pH

• Dem free H+ ions are a bitch.• You can get them from lactic acid• And the strong ion gap (difference between

Na+ and Cl-)• And, surprisingly, Albumin. That shit’s got a

net negative charge

Albumin

• The chief protein in your plasma• Primarily used as a “big thing” to facilitate

oncotic pressure.• Too big to cross the endothelium of the

capillaries• So fluids rush out of the interstitial space to

dilute it• Assists in “Starling’s forces”

Immunoglobulins

• They’re the other proteins in your plasma• And tears• I’d imagine they contribute to oncotic

pressure• But they have more specialized purposes• Mostly immune function• You get your starter dose of them from breast

milk• Not now, hopefully, but during infancy

Sodium Bicarb!

• You can breath out that CO2• And keep all that sodium• Which is good for things like TCA overdose,

which block sodium channels• Never push

CSF

• Brain buoyancy!

Labs!

• They seem like they’d be useful• But there are a lot of normal ranges to

remember• A good one to know is lactate• 2 mmol/dL (often just said 2)= sepsis• 4 mmol/dL = oh shit value