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118 Cards in this Set
- Front
- Back
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What defines a reticulocyte?
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Presence of a ribosomal network
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What are causes of rapid intravascular rbc loos?
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-Mechanical hemolysis in DIC
-massive burns -toxins (brown recluse spider and cobra) -infections (clostridium and malaria) -ABO incompatible transfusion -G6P deficiency with oxidant stress -cold agglutinin hemolysis -immune complex hemolysis |
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In what conditions is hemoglobin transport impaired?
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-CO poisoning
-cyanohemoglobin -methemoglobinemia -sulfhemoglobinemia |
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What blood tests are altered by transfusion?
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-folate
-B12 -antiglobulin (coombs) -iron -TIBC -reticulocyte |
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How can you classify the approach to anemia?
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-increased destruction
-decreased production -acute loss |
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What are the causes of microcytic anemia?
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-iron deficiency
-porphyrin deficiency (sideroblastic anemia, lead poisoning) -globin deficiency (thallasemia) -anemia of chronic disease |
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What are the lab findings in iron deficiency anemia?
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Decreased serum iron
Increased TIBC Decreased % saturated TIBC decreased ferritin (may be increased as an acute phase reactant) absent bone marrow iron stain |
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How long after iron replacement should you see a response in iron deficiency anemia?
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1 week
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What is thalassemia?
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Autosomal dominant defect reflected as a decrease in the globin chain synthesis
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What is the evolution of thalassemia major?
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Patients are transfusion dependent and die of iron deposition in tissues or infection
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What characterizes thalassemia minor?
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Microcytic anemia
decreased MCV normal iron |
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What is sideroblastic anemia?
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a defect in porphyrin synthesis
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What are findings in sideroblastic anemia?
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Increased serum iron
increased serum ferritin increased transferring saturation |
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What causes megaloblastic anemia?
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Defective DNA synthesis due to a lack of vitamin B12 or folic acid
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What are the classic neurologic manifestations of vitamin B12 deficiency?
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Paresthesias in hands and feet, decreased proprioception, weakness and spasticity of lower extremity
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What are causes of macrocytic anemia?
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Vitamin B12 deficiency
Folate deficiency Liver disease hypothyroidism hemolysis |
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When should you suspect aplastic anemia?
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Decreased hemoglobin
normal indices (normochromic, normocytic) decreased reticulocytes exposure to chemicals or drugs |
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What cells are seen on the peripheral smear in intravascular hemolysis?
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schistocyte
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What cells are seen on the peripheral smear in extravascular hemolysis?
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spherocyte
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what is an early finding in hemolysis?
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decreased haptoglobin
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What is Bili total?
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unconjugated and conjugated bilirubin
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What is bili direct?
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conjugated bilirubin
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What are the causes of folate deficiency?
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Inadequate intake
-alcoholism -poor diet (overproessed foods) Impaired absorption -sprue, blind loop syndrome -phenytoin, barbs Increased requirements -pregnancy -increased cell turnover -lymphoproliferative Metabolic block -MTX -trimethoprim Increased excretion/destruction secondary to dialysis |
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Causes of B12 deficiency?
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Inadequate intake
-vegetarianism -chronic EtOH Inadequate absorption -lack of intrinsic factor -sprue -IBD -pernicious anemia Inadequate use |
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Which drugs cause aplastic anemia?
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-chloramphenicol
-phenylbutazone -anticonvulsants -insecticides -solvents -sulfonamides -gold -benzene |
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What drugs are associated with hemolysis in G6P deficiency?
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Analgesic and antipyretics: ASA and phenacetin
Antimalarials: primaquine, quinine, Nitrofurans Sulfa drugs Naphthalene Fava beans Methylene blue |
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At what platelet levels can you see serious spontaneous hemorrhage?
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<20,000
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What is the best test for determining platelet function?
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bleeding time
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How do you interpret bleeding time?
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<8min is normal
8-10 min is borderline >10 min abnormal The patient needs to have platelet count of >100,000 |
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What common medication increases PTT?
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heparin
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What causes decreased fibrinogen?
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Overconsumption (DIC)
Decreased production (liver disease) |
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What does thrombin time measure?
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It measures conversion of fibrinogen to fibrin
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What is the approximate incidence of HITs and when does it occur?
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~3% with UFH
~1% with LMWH within 5-7days of treatment |
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What is the presentation of HIT?
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Arterial or venous thrombi
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How do you treat thrombosis in delayed onset HIT?
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fondaparinux, lepirudin
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What drugs may cause thrombocytopenia?
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heparin
LMWH digitoxin ASA phenytoin sulfonamides GPIIb/IIIA inhibitors |
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When should platelets be given in ITP?
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Life threatening bleeding
Also give IVIG 1g/kg methylprednisolone 30mg/kg IV |
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What are the distinguishing features of HUS vs TTP?
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HUS has less CNS involvement and more renal impairment
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What are the classic findings in TTP?
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MAHA
thrombocytopenic purpura renal impairment fever fluctuating neuro symptoms |
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What is the treatment of TTP?
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Plasmapheresis - it decreases mortality from 90 to 17%
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What are causes of TTP?
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Mostly idiopathic
Quinine Clopidogrel and ticlopidine |
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What is vWD?
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Disorder of Factor VIII which causes abnormal platelet adhesion
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What is the differential diagnosis of thrombocytosis?
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Autonomous (primary thrombocythemia)
reactive iron deficiency infection/inflammtion trauma post-splenectomy |
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What increases PT?
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An extrinsic pathway abnormality mediated through factor VII (the factor with the shortest half life)
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What inherited disorders cause altered PTT?
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hemophilias
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What is hemophilia A?
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Factor VIII deficiency
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What is the treatment of a laceration in hemophilia?
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Suture
lidocaine with epi observe for 4 hours re-assess in 24 hours |
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What is the dosage of Factor VIII?
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Mild (increases factor by 5-10%) 12.5U/kg
Moderate (increases factor by 20-30%) 25U/kg Severe (increases factor by 505) 50U/kg |
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Which hemophiliacs require admission?
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Deep laceration
hematoma in area that may impinge (eye, mouth, neck, back, spine) Major trauma (without injury) Head trauma |
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What are treatment for vW disease?
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Humate-P
desmopressin |
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What is hemophilia B?
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Factor IX deficiency
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What replacements can be given in Hemophilia B?
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Factor IX
PCC FFP |
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How is Factor VIII given?
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Initial dose and then repeat 1/2 initial dose q8-12 hours
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How is Factor IX given?
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dosing schedule is q 24 hours
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Which bleeding problems do not require treatment with Factor VIII in hemophiliacs
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abrasion
laceration spontaneous epistaxis mucosa or tongue bites |
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Which lesions require minor 912.5U/kg) FVIII treatment in hemophiliacs?
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-deep lacerations
-early hemarthroses -hematuria |
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Which lesions require moderate (25U/kg) FVIII treatment in hemophiliacs?
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traumatic epistaxis
traumatic oral laceration late hemarthrosis muscle hematoma |
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Which lesions require severe Factor VIII (50U/kg) replacement in hemophiliacs?
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Any major bleeding
Soft tissue/muscle hematomas |
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What is the sequence in DIC?
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1.Platelets and coags are consumed
2. thrombin is formed which directly activates fibrinogen 3.Fibrin is deposited in multiple organs 4.Fibrinolytic system lyses fibrin and impairs thrombin 5.Fibrin degradation products are released 6. COagulation inhibitor levels are decreased |
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When must you consider DIC?
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Purpura, a bleeding tendency and signs of organ injury particularly the CNS and kidney
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What are lab findings in DIC?
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peripheral smear -> low platelets and schistocytes
decreased platelet count (<100,000) increased PT increased PTT thrombin time increased fibrinogen low fibrin degradation products - large amount serum creatinine or US maybe abnormal |
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What is the treatment of DIC?
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reverse the triggering mechanism
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What is replacement therapy in DIC?
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If active bleeding -> FFP, cryo, blood
monitor for bleeding, decreased fibrin degradation products and increased platelets |
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What is the definition of neutropenia?
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ANC <500cells/mm3 or <1000cells/mm3 with predicted decrease to <500
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What is the definition of fever in a cancer patient?
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A single oral temp >/= 38.3 or >38 degrees for at least 1 hour
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What is appropriate empiric therapy for febrile neutropenia?
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Cefepime
pip-tazo -imipenem -meropenem |
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When should vanco be added to the treatment for febrile neutropenia?
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-suspected catheter related infections
-skin or soft tissue infections -pneumonia -hemodynamic instability -known colonization with MRSA -positive blood cultures for gram + organisms |
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What is the recommendation for blood cultures?
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2 sets: either 1 peripheral and 1 central or 2 peripheral
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What are the most common pathogens in febrile neutropenia?
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Gram + pathogens (staph aureus, staph epidermidis, strep epidermidis)
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When is penumocystis jiroveci seen in febrile neutropenia?
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Corticosteroid use or hematologic malignancy which results in lymphocyte dysfunction
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What is SVC syndrome?
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Acute or subacute process caused by obstruction through the SVC secondary to compression, infiltration or thrombosis
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What is the most common cause of SVCS
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malignancy - most commonly lung CA
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What are signs of SVC syndrome?
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Facial swelling
periorbital edema dyspnea thoracic and neck vein distention |
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What should you think of in patients with SVCS and back pain?
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Rubin's syndrome
(venous obstruction and spinal cord compression) -> MRI of the vertebral spine |
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What clinical entities mimic the diagnosis of SVCS?
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pericardial tamponade
heart failure |
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When should immediate radiotherapy be undertaken for SVCS?
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in patients who present with stridor due to central or laryngeal airway obstruction or laryngeal edema
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What is the preferred therapy for SVCS?
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chemotherapy
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What are temporizing measures for SVCS?
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Elevate head of the bed
diuretics steroids -> limited effectiveness except with respiratory compromise |
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What is acute tumor lysis syndrome?
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Constellation of metabolic disturbances that occur as a result of ongoing cell death in rapidly growing tumor
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When is acute tumor lysis syndrome commonly seen?
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After chemo for hematologic malignancies including leukemia and high grade NHL (Burkitt's)
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What are RF for acute tumor lysis syndrome?
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-increased LDH (>1500U/L)
-Advanced disease (with abdominal invasion) -preexisting renal dysfucntion -post-treatment renal failure -acidic urine -young age -dysfunction concentrating urine -volume depletion |
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What are the biochemical hallmarks of acute tumor lysis syndrome?
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Hyperuricemia
Hyperkalemia Hyperphosphatemia Hypocalcemia Lactic acidosis ARF cardiac dysrhythmias |
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What is the most important intervention in tumor lysis syndrome?
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hydration
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What is the volume order in TLS?
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Infusion of 4-5L/day with 2-3L urine/day
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What is given to treat hyperuricemia in TLS?
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Allopurinol 600-900 mg/day
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what are criteria for HD in TLS?
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Serum K+ 6mmol/L
UA 590mol/L phosphate 3.2mmol/L or rapidly rising volume overload symptomatic hypocalcemia |
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What causes hyperviscosity syndrome?
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Excessive elevation of paraproteins or cellular blood components
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Where are the effects of sludfing seen?
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In the microcirculation of the CNS, visual system or cardiopulmonary system
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What is the most common cause of HVS?
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Waldenstrom's macroglobulinemia
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What is the classic triad of HVS
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-visual distrubances
-mucosal bleeding -neurologic manifestations |
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What is a clue to HVS?
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Lab unable to perform chemical tests because of serum stasis and increased viscosity jams analyser
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In what patients should you consider HVS?
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Patients with unexplained somnolence and coma (it is often a presenting characteristic of dysproteinemias and leukaemia)
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What is the treatmetn for HVS?
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Emergency leukopheresis and plasmapheresis
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What are temporizing measures for HVS?
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-rehydration and diuresis
-two unit phlebotomy if known paraproteinemia |
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What is the most common life-threatening metabolic disorder associated with cancer?
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Hypercalcemia
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What are mechanisms of hypercalcemia in cancer?
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1. Patients with metastatic bone involvement
2. tumor produced hormone substances like PTH, peptides and prostaglandins |
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Which cancers are often complicated by hypercalcemia?
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breast
lung head neck multiple myeloma leukemia |
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What are non-neoplastic causes of hypercalcemia?
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Hyper PTH
Hyper TSH Renal insult adrenal insult Drugs (thiazide, lithium, calcium carbonate) -hypervitaminosis (A+D) Pagets Milk alkali syndrome acromegaly sarcoid |
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What are signs of hypercalcemia?
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-itching
-CNS - paranoia, fatigue, lethargy -renal polydipsia, polyuria -anorexia, nausea, vomiting, constipation -CVS - HTN, dysrhythmia |
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What is the ED managment of symptomatic hypercalcemia?
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Dehydration correction over 1-2 hours
then lasix 40-60 mg IV monitor K+ for hypokalemia bisphosphonates |
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What are adjuvent treatments for hypercalcemia?
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Mithramycin
prednisone calcitonin |
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Which tumors are most commonly associated with pericardial involvement?
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Breast
Leukemia Lung Hodgkins and Non-hodgkins lymphoma sarcoma melanoma GI primary |
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What is Beck's triad of cardiac tamponade?
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Increased JVP
hypotension muffled heart sounds |
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What is pulses?
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Exaggeration of the normal inspiratory decrease in SBP (>12mmHg)
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How do you measure pulsus paradoxes?
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Semi-recumbant
20mmHg above SBP deflate until heard with only expiration then deflate until heard in inspiration and expiration |
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What is Kussmaul's sign?
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Paradoxical increase in venous distention with inspiration
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What 3 herniation syndromes are described?
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Uncal
Central Tonsillar |
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What symptoms are seen with uncal herniation?
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Rapid decrease in consciousness
unilateral Pupillary dilatation ipsilateral hemiparesis |
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What are symptoms of central herniation?
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decreased LOC
small reactive pupils Cheyne stokes no focal signs |
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What are symptoms of tonsillar herniation?
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Rapid decreased in LOC
Occipital HA vomiting hiccups meningismus HTN |
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What are therapies for increased ICP?
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-hyperventilation 25-30mmHg
-mannitol 1g/kg IV -dexamethasone 12-24 mg IV (not shown to improve outcomes) |
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Which cancers cause epidural spinal cord compression?
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Lymphoma
Lung Breast Prostate |
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Where does most epidural cord compression occur?
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Thoracic (68%)
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What is the management of spinal cord compression?
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Dex 10-100mg IV then 4-24 mg q 6hours
Radiation oncology consult Radiotherapy |
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What diagnosis tests are done on CSF in cancer patients with suspected meningitis?
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-cell count and differential
-gram stain -india ink stain -protein and glucose -bacterial and fungal cultures -cryptococcal antigen test -cytology |
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What organisms cause brain abscesses?
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Aspergillus
phycomycetes toxoplasma gondii |
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What organisms cause encephalitis?
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Herpes zoster
T gondii |
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What is empiric treatment for meningitis?
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3 gen cephalosporin (ceftriaxone)
vanco ampicillin (listeria) ceftazidime and aminoglycoside (pseudomonas) |
