 Treatment for Complications?

Thanks to Candice, Janet, Shannon M

Venipuncture
Blood Collection & Handling

Which are not equivalent?

 Tiger top = mottle top
 Lavender = pink
 Yellow = green
 SST = tiger top

Which is not a preservative used in blood collection tubes?

 Sodium citrate
 Heparin
 EDTA
 Warfarin

Which order is correct for a blood draw?

 Yellow, red, light blue, green, mottled, grey
 Red, yellow, lavender, green, SST, grey
 Green, red, yellow, light blue, grey, mottled
 Yellow, SST, light blue, green, red, grey

Mnemonic for Order of Blood Draw Tubes: Stop Red Light Green Light Ready Go
(Sterile = yellow  Red  Light blue  Green  (Light, lavender?)  Ready =
red/grey mottled = SST  Go = grey = glucose)

Which order is correct for a blood draw?

 Septicemia, hCG, glucose, electrolytes
 Suspected septicemia, INR, CBC, glucose (?)
 Glucose, electrolytes, hormones, INR
 CBC, INR, ferritin, DNA, ESR

Match the following

1) Whole blood a) Grey
2) Serum b) SST = tiger top = mottle top
3) Plasma c) Yellow
4) IgG d) Black
5) CBC e) Purple, lavender, light blue, pink
6) INR f) Green
7) Some metals g) Brown
 8) Hormones
9) Ferritin
10) ESR
11) Cholesterol
12) DHEA
13) DNA testing
14) Ionized calcium
15) Pb
16) Electrolytes
17) Septicemia
18) Fasting glucose
19) BUN
20) Used in hospitals only
21) For immediate onsite use

Which of the following is not an error in blood collection?

 Fill lavender tube half full
 Shake grey top tube vigorously
 Complete purple top tube analysis within 48 hours
 If you want to measure ionized calcium, make sure to place the tourniquet more
than 3 inches from the cubital crease
 Freeze a lavender top tube
 Analysis of red top tube when sample has a pinkish hue
 Use yellow top tube first

What do you say to a lab tech who just got promoted?

Coagulations!

Safety & Complications

If the patient faints, you should do all of the following, except:

 Remove the needle first, even if it means you can’t break their fall
 Stay with the patient for 10 minutes and don’t let them drive for at least 15
 Loosen their collar, and have them put their head between their knees
 Note in the chart that they fainted

Which is not a reason for failure to draw blood?

 You passed through the vein to the other side
 The vein rolled to the side because your insertion was too slow
 Defective tube
 You took up too much skin slack

Which is/are not indicated if you miss the vein (select all correct answers)?
 Try again (up to 5 times in one arm is okay)
 Palpate with gloved finger before you assume the tube is defective
  Try the other arm
 Use the popliteal or dorsal-pedis veins
 Repuncture below your first puncture

Which is not a cause of petechia or excessive bleeding?

 Cancer
 Elderly
 ASA
 Thrombocytophilia

Q: Why does Dracula consider himself a good artist?

A: Because he likes to draw blood!

If your patient has had a mastectomy, which is correct?

 Blood draw on the same side as a mastectomy, even if the arm is not
edematous, is contraindicated
 Blood draw on an edematous arm is contraindicated
 Following double mastectomy, use the veins of the legs
 If both arms are edematous, do not use the hands

Which is false about drawing blood?

 It is best to apply a tourniquet for one minute or less, or else hemoconcentration
may occur
 A pinkish hue in an SST tube means that hemolysis has taken place
 Hemolysis is caused by using too small a gage needle
 Using too much alcohol when swabbing the injection site can cause hemolysis

Which result would not be altered by hemolysis?

 PPT
 Total protein
 Potassium
 Iron

Which of the following is not a concern for allergic reaction during blood draws or IV
therapy?
 Sensitivity to Asteraceae
 Latex gloves in someone with a Rhus tox allergy
 Plastic bags containing IV solutions
 Vitamin B1
 Hepatitis C

When selecting an injection site, avoid all of the following except:

 Exzema
 Nevi and freckles
  Tattoo
 Scar tissue

If you cause a bruise (hematoma), all except which of the following are recommended?
 Heat
 Apply direct pressure
 Elevate the area
 Keep the arm straight, not bent
 Suggest no heavy lifting

MM, a 44-yo female is in hospital and you have been given permission to do some IV
therapy using an existing IV port. When you arrive, MM’s injection site is red with
streaking. The site is tender to the touch, and the vein feels hard. She has flushed
cheeks, and is feeling warm. You suspect:
 Thrombosis and recommend a heparin flush
 Phlebitis and recommend removing the needle and applying a cold compress
 Cellulitis and recommend IV antibiotics
 Thrombophlebitis and prepare for a law suit

Q: What does a weight-conscious vampire drink?

A: Blood Light.

Which of the following is false about speed shock?

 Likely caused by too fast a push
 Can be caused by a magnesium infusion
 Remove the needle
 S/S include flush, perspiration, vertigo, decreased pulse rate, arrhythmia, coma

Which of the following Crash Cart matches is incorrect?

 Oxygen for shock
 Unrefrigerated calcium gluconate for Mg overdose
 Amyl nitrate for syncope
 Benadryl in Epipen for anaphylactic shock

You’ve been doing a Mg push, and your patient tells you they’re starting to feel funny.
Which of the following adverse reactions could not be caused by Mg IV (pick 2):
 Mental confusion, fatigue, perspiration, irritability, palpitations = hypoglycemia
 Tingling in the extremities, shakes, convulsions = hypocalcemia
 Tingling in the extremities, shakes, convulsions = hypoparathyroid
 Mental confusion, fatigue, perspiration, irritability, palpitations = hypocalcemia

PT, a 32 yo male is coming in for his first IV treatment with you. After some time, he
begins to describe a throbbing in his chest and says that he can feel his heart beating.
You take his pulse and note that it is 105 bpm. His breathing is laboured. What is
happening and what should you do?
  Allergic response – administer Benadryl
 Hypoglycemia – administer D5W
 Hypocalcemia – administer calcium gluconate
 Hypercalcemia – administer Mg chloride

Q: Why are vampire families so close?

A: Because blood is thicker than water!

Lab results can be altered by all except one of the following:

 Fasting (glucose down, TGs down, electrolytes down)
 Exercise (platelet factors up, creatinine up, AST up, electrolytes up)
 Stress (WBC up, albumin up, glucose up)
 Age (cholesterol up, DHEA and estrogen down)
 Posture (cholesterol up, TG up, calcium altered)
 Pregnancy (RBC down, hCG up, albumin down)

Which of the following drug or supplements does not cause the listed alteration to lab
results?
 OCP depletes B vitamins
 Vitamin C interacts with the fecal occult test, and can affect glucose readings
 Methotrexate lowers folic acid levels
 Vitamin D increases ionized calcium values

Top Ten Things To Do While Giving Blood (by Tina Mancuso and Paul Coen)
10. Watch the bag fill.
9. Hyperventilate.
8. Pull the tube out of the bag and drink from it.
7. Race to see who fills their bag first (requires two or more people).
6. Puncture the bag near the top and see whether they pull the needle out of your
arm before the blood squirts out.
5. While they're not looking, substitute a bag of orange liquid and complain they
gave you too much Tang.
4. Insist that you want to give 2 pints.
3. Faint.
2. Tell them you saw the bag twitch.
1. Yell, "Hey, you used that needle on the last guy!"

IV Therapy
History + Minerals

Which is the incorrect “history of IV therapy” match?

 Christopher Wren invented the 1st hypodermic needle – a bird feather!
 James Blundell gave the 1st blood transfusion after a post-partum hemorrhage
  Ignatius Semmelweiss 1st suggested hand washing and received the Lancet’s
doctor of the year award one decade later
 Dr. Stan Duddrick originated TPN, giving starving adults vitamins and nutrients

Which is not a major safety concern when doing injections

 Introducing air (especially IM)

You are treating a patient with ulcerative colitis and want to give Vitamin C
intravenously. You are planning to give 800 mg per treatment. You have been supplied
with a vial containing 500 mg/ml. Use this information to answer the following 2
questions.

The the volume of Vitamin C required for the treatment is:

a) 1.5 ml
b) 8 ml
c) 1.6 ml
d) 2 ml

Before you give the treatment, you should screen the patient for the following
conditions:
a) scurvey, osseous lesions, rheumatic fever, tuberculosis
b) kidney stones, diabetes mellitus, treatment with coumarin
c) autoimmune disease, inflammation, stress, pregnancy
d) sensitivity to citrus fruits

You are giving calcium gluconate IV push. Before administering it, you
should have asked about:
a) how the Leafs are doing in the play-offs
b) if the patient has been experiencing constipation, nausea or vomiting (Ca can
do this)
c) if the patient is being treated with cardiac glycosides (arrhythmia)
d) b and c

Iron can be given parenterally in the following ways:

a) IV only (note: IV only in hospital, not in office d/t anaphylaxis risk)
b) IV and IM
c) IV, IM, SC
d) IV, IM, SC, ID (ID – would make a big bubble since you’d need so
much)

1) Isoniazide, Hydralazine, Penicillamine and the BCP can all lead to the deficiency of:
a) Niacin
b) Folic acid
c) Vitamin B5
d) Pyridoxine
2) In very high doses, the following two Vitamins may falsely elevate serum cholesterol,
AST and ALT:
a) Vit D and Vit K
b) Vit E and Vit K
c) Vit K and Vit A
d) Vit D and Vit E

Colchicine

1. A 34 year old male walks in to your office complaining of a fever that comes and
goes. He also has a pain in his right knee and left hip. Upon physical examination you
notice tender and swollen cervical lymph nodes, and his liver seems to be enlarged.
You run some lab work and find his ESR @ 56 mm/hr (quite high. You suggest a
parenteral protocol of (note: diagnosis is Schnitzler’s syndrome; familial Mediteranean
would be a good guess too):
A. 2 mg colchicine
B. 50 mg magnesium
C. 8 mL hydroxycobalamine
D. 7 mg colchicines (this would be a toxic dose)

2. Four patients enter your office at the same time. Each has gout in their big toe and
each is in a lot of pain. You know that colchicine is the best treatment for gout, but you
only have one dose. Who do you treat?
A. a 27 year old woman in her 2nd trimester
B. a 12 mute boy who’s only form of communication is the shaking of his diltizam
pills (seizures)
C. an obese patient eating a donut and drinking a humungous rootbeer
D. a 40 year old virgin who appears to have been flung through a billboard while
riding his bike when he wasn’t wearing his helmet (head injury)

3. Which of the following is NOT a likely sign of colchicines toxicity:

A. BM suppression
B. splenic rupture
C. pancytopenia
D. agranulocytosis

1) Which of the following is not a CI of colchicine?

a) Hypertension
b) Pregnancy
c) Renal Disease
d) Hepatic Disease

2) Which of the following is not an indication for colchicine?

a) Acute pseudogout
b) Hepatic porphoryias
c) Rheumatoid arthritis
d) Psoriatic arthritis

3) A patient was given colchicine for gout at 4mg and shortly thereafter started to
exhibit symptoms of:
a) nausea and headaches
b) nausea and diarrhea
c) Diarrhea and vomiting
d) Diarrhea and headaches

4)The patient from question 3 received his treatment with colchicine IV and a
somplication ensued. Which of the following is a possible complication of iv
colchicine?
a) Collapsed veins
b) Varicose veins
c) Extravasation of veins
d) Inflammation of veins (note – this could also happen, if not properly flushed)

Answers: 1) a 2) c 3) b 4) c

Ozone
32yr male patient came into your office for ozone therapy.....you proceed to insufflate ozone into
his lungs and are halfway into the treatment when he starts to experience respiratory
distress....This is because:
A. he is choking on his chewing gum
B. you should never put ozone into the lungs
C. you are administering more than 3-5mcg/ml
D. he is a smoker and the ozone is increasing the oxygen saturation

Ozone and hydrogen peroxide (H2O2) are CI in porphorias, sickle cell anemia, thalessemia
because (PS - to make this question harder, could give S/S and/or labs for eg thalessemia  Hb
aren’t as good at carrying O2  body makes more RBC; diagnostic = electrophoresis; this pt
looks iron def’t (low ferritin in alpha, ?higher in beta)), but giving Fe longterm doesn’t solve the
problem):
A. they increase the activity of the RBC
B. the RBC are already compromised in these diseases and ozone and H2O2 treatment will
cause further cell damage
C. ozone and H2O2 are antioxidants
D. ozone and H2O2 need to be given with Vitamin C

Chelation

Which of these lab values should be monitored, if warranted, in a patient before

receiving EDTA chelation therapy? (note: a) could also be correct because depending
on their initial iron level and overall metal status
a) Ferritin
 b) Creatinine
c) Prothrombin Time
d) Glucose

Which of these substances does EDTA have the least affinity for? (Al is hard to chelate
and most things that can do it are very toxic)
a) Pb
b) Hg
c) Cd
d) Al

During the course of treatment a patient exhibits nervousness, sweating, weakness and
intense hunger. Which course of action would be best to take? (If they are
hypoglycaemic you want to have the needle still in so you can admin glu; a) is correct if
pt goes into shock)
a) Call 911 and begin emergency protocols
b) Provide the patient with some juice/crackers
c) Alter dose of EDTA given (Saunders says: not really, just feed them beforehand,
because Mg will be released when you pick up Ca)
d) Both B & C
e) All of the above

What, in IV, could push someone into hypoglycaemia?

 Mg (^ATP production & breakdown catecholamines --> feel hungry)

Calcium-EDTA is best for chelating out which substance?

a) Pb
b) Ca
c) Hg
d) Al

After a course of treatment with DMSA a 53 year old female patient experiences fatigue
and dark red urine. Lab results indicate Hb = 9g/dL (low), increased reticulocyte count
(compensation), indirect bilirubin = 3mg/dL and LDH (bone, LV, HT) levels above normal
levels. Which of these conditions does the patient most likely have?
a) Von Willebrand’s disease (PT diagnostic g/t def’y Factor VIII?)
b) G6P-dehyrogenase deficiency (DMSA can cz haemolytic anemia m/b d/t Cu Ez
pathways)
c) Iron deficiency anemia (MCV, ferritin… important in diagnostis; we may not have
enough answer to really rule this out – thanks JB!)
d) Hemophilia (mostly male, plus would have caught it by now)