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218 Cards in this Set
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What are known risk factors for cardiogenic shock (4)?
|
Elderly
Female Ischemic Event CHF/ DM pg 385 |
|
|
Causes of Cardiogenic Shock (5)?
|
AMI, RV infarct, depressed cardiac contractility, Obstruction to forward flow (valve stenosis or tamponade), Regurge
pg 385 |
|
|
Cardiogenic shock is characterized by ___ and ___.
|
hypoperfusion and hypotension
pg 386 |
|
|
___ % of cardiogenic shock after AMI is caused by mechanical complications.
|
25%
pg 386 |
|
|
What lab markers are specific for cardiogenic shock?
|
None; but cardiac enzymes, lactate, lytes, mag, LFTs, and BNP are needed
pg 386 |
|
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ED care for cardiogenic shock is temporizing, what is the treatment of choice?
|
revascularization by cardiac cath or surgical intervention
pg 387 |
|
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When is Positive Pressure Ventilation recommended in cardiogenic shock?
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If pt is stable and cooperative, but it does decrease preload and worsens hyoptension
pg 388 |
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In AMI, ___ and ___ should be given unless there is an absolute contraindication.
|
ASA and Heparin
pg 388 |
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T/F: BB should be given to pts w/ acute ST elevation MI or NSTEMI who are in cardiogenic shock, or who are at risk for cardio shock.
|
False- Should NOT
pg 388 |
|
|
What are 4 inotropic meds you can use in cardiogenic shock?
|
Dopamine, Dobutamine, Norepi, Milrinone
pg 388 |
|
|
Which method is preferred in AMI cardiogenic shock for definitive txmt; thrombolytics or cath lab?
|
Cardiac cath is definitive
pg 388 |
|
|
What were the results from the SHOCK trial for 3 and 6 yr survival rates?
|
Early revascularization had higher survival rates than medical stabilization
pg 388 |
|
|
Which murmur with syncope will appear well at rest but is at risk for a catastrophic event.
|
Aortic Stenosis
pg 415 |
|
|
What is required in pt's with valvular dz or prosthetic valves before procedures?
|
Abx
pg 415 |
|
|
What is the most common cause of mitral stenosis?
|
Rheumatic Heart Dz
pg 415 |
|
|
What is seen on the EKG of mitral stenosis?
|
Biphasic or notched P waves and right axis deviation due to progressive left atrial enlargement.
pg 416 |
|
|
What are the most common causes of mitral regurge?
|
AMI, ischemia, MVP, or collagen-vascular dz
pg 417 |
|
|
What is acute mitral regurge's pathophysiology?
|
papillary muscle or chordae tendineae
pg 417 |
|
|
In severe mitral regurge, how should a pt be treated?
|
optimize hemodynamics, tx pulm edema w/ O2, nitrates, diuretics, and intubate for resp failure
pg 418 |
|
|
What is the classic triad of Aortic Stenosis?
|
dyspnea, chest pain, and syncope
pg 418 |
|
|
Syncope in the setting of exertion or a systolic murmur should raise the possibility of ____.
|
Aortic Stenosis
pg 419 |
|
|
What is a late peaking systolic murmur at right sternal border w/ radiation to the carotids?
|
Aortic Stenosis
pg 419 |
|
|
What do symptomatic Aortic Stenosis pt's require for txmt?
|
valve replacement, 75% die w/in 3yrs w/o surgery
pg 419 |
|
|
What are the most common causes of Aortic Stenosis?
|
Infective Endocarditis, aortic dissection at the root, and blunt chest trauma
pg 419 |
|
|
What is an Austin Flint murmur and what is it related to?
|
murmur in the left lateral decub at apex, associated w/ aortic regurg
pg 420 |
|
|
54yo homeless M c/o fever, swelling of the leg and belly x 3 days. Admits to IV drug use. 84/64, 18, 110, 103.1 92%. Exam soft, blowing holosystolic murmur along left lower border, +JVD, and HSM. What are your concerned for?
|
Tricuspid Regurg 2/2 infective endocarditis
pg 421 |
|
|
T/F: Prosthetic valves are more durable with lower failure rates, but have higher risk for thromboembolic events.
|
False: Mechanical valves
pg 421 |
|
|
When is a heart valve replacement pt at the greatest risk for embolism?
|
3 months postoperative
pg 421 |
|
|
How long do mechanical heart valve pt's need to be anticoagulated?
|
Lifelong
pg 421 |
|
|
Acute onset of __, ___, and ___ may be associated with mech valve failure, tearing of bioprosthesis, or a large clot obstructing a valve.
|
Resp distress, pulm edema, and cardiogenic shock
pg 422 |
|
|
56yo F with mech mitral valve replacement 12 months ago c/o SOB, cough, and dizziness. Exam reveals quiet S1 and S2. What do you suspect?
|
Valve dysfunction, since mech valves have loud clicking sound
pg 422 |
|
|
Heart vavle replacements are anticoagulated to INR btwn 2-3 and 2.5-3.5. If severe bleeding is suspected how do you treated?
|
FFP (hold Vit K due to overcorrection leading to thromboembolism)
pg 422 |
|
|
What is the definition of cardiomyopathy?
|
dz that alters cardiac structure, function, or electrical properities
pg 423 |
|
|
Cardiomyopathies are broken down into primary and secondary. What are some examples of Primary?
|
Primary - Genetic (hypertrophic, conduction dz), Mixed (dilated and restrictive), and Aquired
pg 423 |
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|
Cardiomyopathies are broken down into primary and secondary. What are some examples of Secondary?
|
Secondary - Toxin (ETOH, cocaine, methamphetamines), Infiltrative (amyloidosis), Storage (hemochromatosis), and Metabolic
pg 423 |
|
|
What is the second leading cause of death among adolescents and the leading cause of sudden death in athletes?
|
Hypertrophic cardiomyopthy
pg 423 |
|
|
This cardiomyopathy is the most common, has diminished cardiac output, and normal wall thickness.
|
Dilated Cardiomyopathy
pg 424 |
|
|
What two medications have proven to improve survival in dilated cardiomyopathy pts?
|
BB and ACE-I
pg 424 |
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|
17yo AAM c/o chest pain, DOE, and syncope while playing bball game. Has uncle that died of massive heart attack. What are you concerned for?
|
Hypertrophic obstructive cardiomyopthy (HOCM)
pg 425 |
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|
What type of heart condition has a murmur accentuated by valsalva, standing after squatting and is quieted with squatting?
|
Hypertrophic cardiomyopathy and MVP
pg 425 |
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|
What should you do with the pt with exercise intolerance, CP, and a murmur?
|
echo, admission and cardiology eval
pg 426 |
|
|
T/F: Syncope in pt with HOCM may preceed sudden cardiac death.
|
True
pg 426 |
|
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54yo F c/o DOE, cough, JVD and bilat pitting edema. Normal CXR. No cardiac hx. What heart dz can mimic CHF?
|
Restrictive cardiomyopathy presents like CHF without the cardiomegaly
pg 426 |
|
|
What other diagnosis must be r/o when considering restrictive cardiomyopathy and why?
|
Constrictive Pericarditis b/c it can be surgically corrected
pg 426 |
|
|
What is the most important and common physical exam finding in pericarditis?
|
Pericardial friction rub
pg 426 |
|
|
How does CP present in pericarditis?
|
More severe in the supine position and relieved with sitting up and leaning forward.
pg 427 |
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What type of EKG changes will you see early in pericarditis?
|
ST and T wave changes globally
pg 427 |
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Differentiating pericarditis from ____ is a common problem and can be difficult when only a single 12-lead EKG is done.
|
early repolarization
pg 427 |
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If the ST amplitude to T wave amplitude ratio is > __%, acute pericarditis is likely.
|
25% or 0.25
pg 427 |
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What are some EKG findings in late Stage 3 Pericarditis?
|
ST normalization and T wave inversion
pg 427 |
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65yo M c/o dyspnea at rest and exertion. Denies CP. VS: 98/88, 124, 18, 95%, 99.1. +JVD, distant heart sounds. EKG is low voltage otherwise normal. What is the concern for?
|
Cardiac Tamponade
pg 429 |
|
|
A value of ___mmHg usually seperates true tamponade from lesser restricted cardiac filling problems.
|
25mmHG
pg 429 |
|
|
__ ___ is not diagnostic of cardiac tamponade and may be noted in other cardiopulmonary processes.
|
Pulsus Paradoxus
pg 429 |
|
|
What are the three most common causes of cardiac tamponade?
|
Metastatic malignancy (40%)
Acute idiopathic (15%) Uremia (10%) pg 429 |
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What other EKG finding may be present with cardiac tamponade?
|
Electrical Alternans
(variation of the R to R amplitude) pg 430 |
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|
How should you initially treat cardiac tamponade in order to increase cardiac output?
|
volume expansion (500-1000cc of NS)
pg 430 |
|
|
How can you differentiate restrictive pericarditis from CHF on exam?
|
Kussmaul sign (inspiratory neck vein distention) rare in CHF
pg 430 |
|
|
What are the 3 types of aneurysms?
|
True (all layers), pseudo (partly vessel wall), and mycotic (infxn of the wall)
pg 453 |
|
|
An AAA is defined as __cm or greater and repair is indicated for __cm or greater.
|
3cm and 5cm
pg 454 |
|
|
What is the most common presenting symptom in AAA?
|
back or abdominal pain (sudden and severe)
pg 454 |
|
|
What are Cullen and Grey Turner signs and what do they indicate?
|
Cullen - ecchymosis around the umbilicus
Grey-Turner - flank ecchymosis indicates AAA rupture pg 454 |
|
|
At what size are AAA more likely to rupture?
|
>5cm
pg 454 |
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|
All symptomatic AAA require _____ or transfer of the pt to an institution capable of ____.
|
emergency surgical consult, emergency repair
pg 456 |
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|
What is the best txmt for AAA with HTN?
|
BB, Esmolol
pg 456 |
|
|
What is the most common peripheral aneurysm?
|
Popliteal
pg 457 |
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Describe symptoms for a femoral/ iliac artery aneurysm.
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pulsatile mass in the groin or upper thigh, scrotal hematoma, or acute limb ischemia
pg 457 |
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Describe symptoms for a hepatic artery aneurysm.
|
Quinke Triad - jaundice, biliary colic, and upper GI bleed)
pg 457 |
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Describe symptoms for a splenic artery aneurysm.
|
left upper quad pain, undifferentiated shock, or intra-abdominal hemorrhage
pg 457 |
|
|
Describe symptoms for a subclavian/ innominate artery aneurysms.
|
upper limb ischemia,
pg 457 |
|
|
Describe symptoms for a anastomotic aneurysm.
|
may occur in aortic, iliac, or femoral artery (may erode in to intestine)
pg 457 |
|
|
What does the presence of myoglobinemia, renal failure, and peripheral muscle infacrtction indicated after with an occlusive arterial dz?
|
Reperfusion Injury
pg 458 |
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|
Why are drug users at risk for arterial occlusive dz?
|
injection drug users result in local vasospasm
pg 458 |
|
|
What are the 6 P's of acute limb ischemia?
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pain, pallor, paralysis, pulselessness, paresthesias, and polar
pg 458 |
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Two uncommon presentations of DVTs are painful blue inflammation of the limb or white inflammation of the limb are?
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Phlegmasia cerulea dolens and phlegmasia alba dolens
pg 460 |
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|
What is a normal ABI, what does higer and lower than normal indicate?
|
Normal 0.91-1.3, >1.3- vascular calcification, <0.91- chronic obstructive arterial dz
pg 461 |
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|
A difference of __ mmHG or more btwn any two adjacent levels accurately localizes the site of obstruction for segmental pressures.
|
30mmHg
pg 462 |
|
|
At what anatomical level does Duplex US lose it's effectiveness?
|
below the popliteal
pg 462 |
|
|
What 5 interventions are useful for the ED txmt of acute limb ischemia?
|
Heparin 80units/kg bolus, 18units/kg/h, ASA 81mg, Dependent positioning, Pain control, Environmental protection
pg 462 |
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|
Percutantous transluminal angioplasty (PTA) and revascularization is recommended < __ days for thrombolysis in the limb.
|
<14 days
pg 462 |
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|
Priorities in the evaluation of hemoptysis are (4):
|
1) Ensure adequate oxygenation and ventilation
2) confirming a pulmonary source 3) Attempting to identifying the cause of hemoptysis 4) appropriate disposition pg 473 |
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|
The most common causes of hemoptysis in children are (3)?
|
cystic fibrosis, foreign body, and congenital heart disease
pg 473 |
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What are the most common causes of hemoptysis in adults (6)?
|
1. bronchitis, 2. PNA, 3. lung abscess, 4. TB, 5. lung CA, 6. bronchiectasis
pg 474 |
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How does brisk hemoptysis typically kill a pt?
|
fills the anatomic dead space in the airway and asphyxiates rather than exanguinates
pg 474 |
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|
Mild hemoptysis is <__mL of blood in 24hrs, moderate is __ to __mL in 24hrs, and massive is >__mL in 24hrs.
|
< 20mL, 20-600mL, and > 600mL
pg 474 |
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What is a better measure of hemoptysis in the ED?
|
speckled blood in sputum, gross hemoptysis, or massive hemoptysis interferring with ventilation
pg 474 |
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Pt w/ massive hemoptysis on warfarin should get ___ w/o waiting for coag studies.
|
FFP
pg 476 |
|
|
What is the % risk of neoplasm for a smoker with mild hemoptysis and a normal CXR?
|
5-20%
pg 476 |
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|
How do you differentiate btwn common cold cough and bronchitis?
|
Common cold has postnasal drip and throat clearing
pg 476 |
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|
What is the most common cause of bronchitis?
|
respiratory viruses (flu,parainflu, RSV, coronavirus, adenovirus, rhinovirus)
pg 477 |
|
|
Most common cause of the common cold?
|
Rhinovirus
pg 477 |
|
|
What are three known causes of bacterial bronchitis?
|
Bordetella pertusis, Mycoplasma, and Chlamydophilia
pg 478 |
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|
URIs are indistinguishable from bronchitis, however, cough will last __ days in bronchitis and PFTs may be abnormal.
|
5 days (can persist up to 20days)
pg 478 |
|
|
How do you r/o PNA on clinical grounds (5)?
|
All 5 must be met: 1) HR >100, 2) RR >24, 3) T>100.4, 4) CXR shows consolidation
5) Age >64yo pg 478 |
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|
T/F: Acute bronchitis is primarily a bacterial illness and rountine txmt w/ abx is indicated.
|
False: mainly viral and no abx indicated
pg 479 |
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|
What should H5N1 (Avian flu) be tx'd with?
|
Oseltamivir 7-10 days
pg 479 |
|
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What does the Amer Coll of Chest Phys say about abx, antitussives, mucolytics, and bronchodilators in bronchitis?
|
abx- no
antitussives - yes mucolytics - no bronchodilators - yes, if wheezing pg 479 |
|
|
What is an empyema?
|
pus in the pleural space
pg 491 |
|
|
What are the diagnostic criteria for empyema?
|
Aspiration of grossly purulent material on thorocentesis and, + culture, glucose <40, pH <7.1, or LDH >1000
pg 492 |
|
|
What is the txmt of choice for empyema?
|
Zosyn 3.375 - 4.5g q 6 hrs or
Imipemem 0.5-1.0g IV q 6 hrs pg 492 |
|
|
Where do lung abscess typically occur?
|
basal segments or posterior upper segments
pg 492 |
|
|
How should you tx a lung abscess?
|
Medical management is successful 70-90% with clindamycin 600mg IV and metronidazole
pg 494 |
|
|
___ ___ is the slow growing aerobic rod that has acid fast properties responsible for TB infxns.
|
Mycobacterium tuberculosis
pg 494 |
|
|
What is a Ghon complex in relation to TB?
|
area of primary scarring and calcification associated w/ hilar lymphadenopathy
pg 495 |
|
|
What are Rich foci in relation to TB?
|
similar to Ghon complexes in the lungs, but these involve the CNS
pg 495 |
|
|
How useful is the CXR in r/o TB?
|
no cavitations and no apical infiltrate yield NPV of 97%
pg 495 |
|
|
What is the most common way to detect exposure to TB?
|
The Mantoux skin test
pg 496 |
|
|
When should a ED provider initiate TB meds?
|
should not unless directed to by provider who will monitor and follow pt
pg 498 |
|
|
What is the HIV+ pt's risk of TB compared to the regular population?
|
2x
pg 498 |
|
|
If you are considering the dx of TB you should offer __ testing, which may provide early dx and txmt.
|
HIV testing
pg 498 |
|
|
What is multidrug resistant TB (MDR-TB)?
|
resistance to at aleast INF and RIF
pg 498 |
|
|
How long are oral medications given for MDR-TB?
|
15-18months
pg 499 |
|
|
What is Miliary TB?
|
dz that results from widespread hematogenous spread
pg 499 |
|
|
What are some controls to reduce the transmission of TB in the ED?
|
High airflow w/ exhaust
High-efficancy filters UV germicidal irradiation Neg pressure rooms PPI pg 499 |
|
|
What is the most common risk factor for spontaneous pneumothorax?
|
smoking
pg 500 |
|
|
If there is a questionable PTX on standard CXR, what is another CXR that could help?
|
Lateral decub CXR
pg 500 |
|
|
What does the Amer Coll of Chest Phys describe as a small PTX?
|
< 3cm from thoracic apex to lung
pg 502 |
|
|
What determines the PTX pt's treatment options?
|
pt's clinical status
pg 502 |
|
|
What are the criteria for a stable pt with a PTX?
|
RR <24, No dyspnea at rest, HR 60-120, Normal BP, O2 >90%, and absence of hemothorax
pg 502 |
|
|
What does giving O2 to a PTX do?
|
increases pleural air resorption 3-4x faster than w/o
pg 503 |
|
|
What should pt's with unresolved PTX avoid?
|
Flying and diving
pg 504 |
|
|
Name some hypercoaguable states.
|
Thrombocytopenia, Polycythemia Vera, Antiphopholipid snydrome, CA, Factor V Laden, Protein C and S deficiency
pg 1462 |
|
|
What is a normal platelet count?
|
150,000-300,000/mm3
pg 1462 |
|
|
What is a normal bleeding time?
|
2.5 - 10minutes
pg 1462 |
|
|
What is primary hemostasis?
|
platelet interaction w/ the vascular subendothelium that results in formation of platelet plug. pg 1462
|
|
|
How do you measure secondary hemostasis?
|
PT, aPTT, INR, Fibrinogen Level
|
|
|
What is secondary hemostasis?
|
"coagulation cascade", the activated coagulation proteins that strengthen the platelet plug
pg 1464 |
|
|
What is Factor V Leiden deficiency?
|
genetic disruption of Protein C from binding and inhibiting Factor Va, leading to hypercoaguable state. pg 1464
|
|
|
What is virchow's triad?
|
hypercoagulability, venosis stasis, and endothelial injury
pg 1470 |
|
|
What is antithrombin and what two anticoagulation drugs affect it?
|
Antithrombin - protein that inhibits the function of IXa, Xa and thrombin. Heparin and Lovenox work by increasing the rate of antithrombin
pg 1470 |
|
|
How does Protein C work?
|
Protein C cleaves Factor Va and VIIIa (intrinsic and extrinsic pathways) and it Vit K dependent
pg 1470 |
|
|
How does Protein S work?
|
It increases the inhibitory properities of Protein C by 20 fold
pg 1470 |
|
|
What is the most prevalent hypercoagulable disorder?
|
Factor V Leiden mutation (Activated Protein C resistance) 5% of white in US
pg 1471 |
|
|
If a pt develops warfarin-induced skin necrosis, what clotting disorder should they be evaluated for?
|
Protein C and S deficiency
pg 1472 |
|
|
This clotting disorder is also know as "sticky blood syndrome" and is seen in women w/ multiple preg losses, DVTs, livedo reticularis, microthrombi.
|
Antiphospholipid syndrome
pg 1473 |
|
|
What is a typical presentation of Heparin Induced Thrombocytopenia (HIT)?
|
5-15days after start of heparin, thrombosis, MI, stroke, >50% drop in platelets
pg 1474 |
|
|
T/F: People with sickle cell trait are more likely to present early in life with vascular obstructive crisis.
|
False: TRAIT have normal life span and are usually asymptomatic
pg 1481 |
|
|
What is the initial management of sickle cell pts in vaso-occlusive pain crisis?
|
aggressive pain management, hydration, search for cause and complications
pg 1481 |
|
|
T/F: A common practice is to develop a broad assessment and txmt protocol for sickle cell crisis pt's who frequently come to ED.
|
False: plan should be individualized
pg 1482 |
|
|
What some common presentations of sickle cell crisis?
|
Bone pain, Acute Chest Syndrome (leading cause of death), Abdominal crisis (liver/ gbag), GU system (kidney infarct/ priapism) pg 1484
|
|
|
What organism in sickle cell dz are you concerned for causing osteomyelitis?
|
Salmonella
pg 1485 |
|
|
What is a normal H/H for a sickle cell pt?
|
Hemoglobin - 6-9
Hematocrit -18-27 pg 1485 |
|
|
What organisms are sickle cell pt's particularly at risk for and why?
|
Encapsulated organisms (H. Flu and S. Pneumo) due to functional asplenia
pg 1485 |
|
|
What are the Thalassemias?
|
group of hereditary disorders caused by defective synthesis of globin chains leading to defective hemoglobin. pg 1486
|
|
|
Which thalassemia will present with microcytosis, basophilic stippling, hypochromia on smear, and elevated HbA levels?
|
Beta-Thalassemias (minor)
pg 1487 |
|
|
What is the most common enzymopathy of RBCs?
|
G6PD
pg 1487 |
|
|
How does G6PD affect the RBCs?
|
the deficient G6P does not clean up oxidative metabolites, which then damage RBC membranes leading to hemolysis in the spleen. pg 1487
|
|
|
What is a serious complication of G6PD in the neonate?
|
Neonatal jaundice, elevated bilirubin induces neurotoxicity
pg 1488 |
|
|
24yo c/o fatigue, dizziness, and ab pain. VS: 132/88, 110, 18, 99.1, 99%. Exam: jaundice, pallor, and spleen enlargement. What is the concern?
|
Hemolytic Anemia
pg 1488 |
|
|
What is the difference btwn spherocytes and schistocytes?
|
Spherocytes - intravascular hemolysis
Schistocytes - extravascular hemolysis pg 1489 |
|
|
What are two classic microangiopathic snydromes?
|
Thrombocytopenic Purpura (TTP) and Hemolyticuremic Syndrome (HUS)
pg 1490 |
|
|
How do TTP and DIC differ?
|
TTP does not involve fibrin, therefore coagulation studies will be normal
pg 1491 |
|
|
What microangiopathic snydrome occurs about 1 week into a case of infectious diarrhea, often bloody w/o fever?
|
Hemolyticuremic Syndrome, 2/2 Shiga toxin producing E. coli
pg 1491 |
|
|
Which prosthetic heart valve most often results in macrovascular hemolysis?
|
Mitral Valve replacement
pg 1492 |
|
|
Local tumor effects on the airway: what size ET is recommended for intubation?
|
5-0 to 6-0.
pg 1509 |
|
|
Where is the most common location for neoplastic mets in the spinal cord?
|
Thoracic spine
pg 1509 |
|
|
73yo M c/o LBP, weakness and numbness in the lower ext. Pt w/ hx of prostate CA. What is the concern and txmt?
|
Metastic dx causing Malignant Spinal Cord Syndrome, txmt: decadron 10mg IV and imaging, pg 1510
|
|
|
Malignant spinal cord compression is considered a _____ emergency.
|
radiotherapy
pg 1510 |
|
|
63yo F c/o facial swelling and cough x 3 weeks. Hx of small cell cancer treated with chemo 5 yrs ago. + bilat JVD and swollen neck. What is the concern?
|
Superior Vena Cava syndrome
pg 1511 |
|
|
What 3 CAs are most related to hypercalcemia?
|
Breast, Lung, Multiple Myeloma
pg 1512 |
|
|
Clinical sx of __ are related to the rate of rise in the serum calcium level.
|
hypercalcemia
pg 1512 |
|
|
Slow increases in serum calcium levels may be ___ until reaching high levels.
|
asymptomatic
pg 1512 |
|
|
What drug is no longer recommended routinely for the tx of hypercalcemia due to malignancy?
|
Furosemide
pg 1512 |
|
|
68yo M arrival EMS, confusion, lethargy and seizure at home. VS: 142/88, 78, 16, 98.9 100% on 2L. Family reports poor appetite, nausea, fatigue. Hx of bronchogenic cancer and chemo x 1 month. Labs WNL except chem: 120/4.5-110/28-10/.07<160. What is the concern?
|
SIADH - suspect in CA pts with normovolemic hyponatremia
pg 1512 |
|
|
What is the mainstay of txmt for SIADH in the CA pt?
|
water restriction
pg 1512 |
|
|
T/F: The constellation of hypoglycemia, hyponatremia, hypokalemia, and hypotension despite volume and vasoconstrictors is adrenal insufficiency.
|
False: Hyperkalemia
pg 1512 |
|
|
What is the most lifethreatening cause related to tumor lysis syndrome?
|
hyperkalemia - aggresive IVF, Beta agon, NaBicarb, glucose, insulin, calcium
pg 1513 |
|
|
What is the definition of absolute and severe neutropenia and what does it indicate?
|
An absolute neutraphil count (ANC) < 1000/mm3, severe is <500/mm3 and indicates weakened immunity
pg 1513 |
|
|
When are you most likely to see a CA pt at risk for neutropenia?
|
5-10 days after chemo, chemo is the most common cause
pg 1513 |
|
|
7yo M w/ AML, treated with chemo has temp of 103.1. What three areas need careful inspection on exam?
|
3 areas- oral cavity, the perianal area, and entry sites of catheters, pg 1513
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___ examination is contraindicated in the neutropenic pt and should be w/ held until ___ administration.
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digital rectal exam, antibiotic admin.
pg 1513 |
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Who should you consult with when a febrile CA pt presents?
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their oncologist
pg 1513 |
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What is the main type of bacteria that are found on blood cultures of febrile CA pts?
|
Gram + 60-70%
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Thromboembolism is the second leading cause of death in CA pts. How does anticoagulation differ from nonCA pts?
|
It doesn't. Do not appear at increased risk for related bleeding.
pg 1515 |
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What two medications are black box warnings for rapid tranquilization if a pt is known or suspected to have prolonged QT?
|
The Butyrophenones - Haloperidol and Droperidol
pg 1952 |
|
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When is medication induced QTc prolongation considered significant?
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>500ms
pg 1953 |
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T/F: QTc prolongation does not directly correlate w/ the clinical risk of dysrhythmias or torsades de pointes.
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True
pg 1953 |
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Which antipsychotics are more specific to dopamine receptors and have fewer adverse effects, typical or atypicals?
|
Atypicals
pg 1953 |
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The FDA has black box warnings on atypical antipyschs for off label use in managing agitation and psychosis in what pt?
|
elderly w/ dementia
pg 1953 |
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What is the most common side effect to antipsych meds and how do you treat?
|
Dystonic Rxns (msc spasms of neck, face, back)
Txmt: Benztropine 1mg BID-QID, or Benadryl 25mg TID pg 1954 |
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This reaction to neuroleptic drugs includes rigidity, fever, autonomic instability (tachy, diaphoresis), and confusion and has a mortality rate of 20%.
|
Neuroleptic Malignant Syndrome
pg 1954 |
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The abrupt cessation of __ after long term use is associated with w/drawal syndrome similar to ETOH, including restlessness, tachycard, tremors, HTN, seizures.
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Benzo's
pg 1955 |
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T/F: Parenteral benzo's are ineffective for flumazenil induced withdrawal seizures.
|
True
pg 1955 |
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What the two major side effects seen with heterocyclic antidepressants (big pic)?
|
Anticholinergic (hot, dry, red, urinary retention) and Cardiovascular (prolong QT)effects, pg 1956
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Tyramine containing foods are contraindicated when taking MAO-Is. What are some?
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beer,aged cheese, wine, pickled herring, yeasts, chopped liver, yogurt, sour cream, fava beans, pg 1957
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Why are BB contraindicated in MAO-I overdose?
|
may intensify vasoconstriction and worsen HTN
pg 1957 |
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When MAO-Is are combined with ___ a variety of adverse effects can occur; HoTn, HTN, fever, neuromuscular irritability.
|
Meperidine (Demoral)
pg 1957 |
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Which antidepressant is well tolerated, low side effects, and used for obesity and smoking cessation?
|
Bupropion (Wellbutrin)
pg 1957 |
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For the dx of panic disorder, the attacks must not be accounted for by ____ or ____.
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another pyschiatric or medical disorder
pg 1962 |
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What must you try to identify in pt's who present w/ psychiatric complaints or panic attacks?
|
domestic violence and sexual abuse
pg 1963 |
|
|
Panic disorder is a diagnosis of ___.
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exclusion
pg 1963 |
|
|
What class is considered the drug of choice in depression due to it's side effect profile and safety?
|
SSRIs
pg 1964 |
|
|
When are benzo's indicated for panic disorder or depression?
|
short term relief, SSRIs and CBT are txmt of choice
pg 1964 |
|
|
What two things must be r/o in order to diagnose Conversion Disorder?
|
Organica medical problem and psychological problems
pg 1965 |
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|
Substance abuse is defined as?
|
1/4 must be met
1. failure to fullfill obligation 2. recurrent use which is physical hazardous 3. recurrent legal problems 4. continued use despite social/ personal problems pg 1967 |
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90% of these occur w/ in the first 48hrs of an alcoholic's last drink.
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alcohol withdrawal seizures
pg 1968 |
|
|
CIWA max score is 67, what is the target goal to reduce and maintain the score range?
|
0-7 range
pg 1969 |
|
|
Long acting benzo's (diazepam) decrease alcoholic withdrawal seizures by what %?
|
93% (from 8% chance to 0.5% chance of suffering seizure)
pg 1969 |
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What medication should not be given to a pt who has used heroin in the past 24hrs b/c it will precipitate withdrawal?
|
Buprenorphine
pg 1971 |
|
|
What is the best route to give Beprenorphine for opioid withdrawal?
|
Sublingual (SL), IV has resulted in fatal overdose
|
|
|
What does C.A.G.E. stand for in relation to alcohol screening?
|
C- cut down use
A- annoyed people w/ drinking G- felt guilty about use E- eye opener pg 1972 |
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What are the four key elements for principle of intervention (aka brief negotiated interview) when discussing drugs of abuse?
|
1. Establish rapport - trust
2. Provide feedback - express concern 3. Enhance motivation - readiness to change 4. Negotiate and advise - offer resources pg 1972 |
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Transplant pts with fever can be transplant rejection or true infection, how do you choose which to treat for?
|
You treat for both until a source can be found
pg 1998 |
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|
What is obesity and morbid obesity defined as?
|
Obesity - BMI > 30kg/m2
Morbid Obesity - BMI >40kg/m2 pg 2012 |
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What four problems are obese pt's more at risk for?
|
Cardiopulm dz
Thromboembolism Pregnancy related disorder Trauma pg 2013 |
|
|
What are three common complications from gastric bypass (bariatric) surgery?
|
anastomotic leak
acute gastric distention nonsurgical complications (PE, ulcers, dumping syndrome) pg 2013 |
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What should not be performed if an obese pt complains of gastric distention in the first few days following surgery?
|
nasogastric tube- risk of disrupting the suture lines. notify surgery
pg 2013 |
|
|
Opioids and benzos are lipophilic, how should they be initially dosed and subsequently dosed in obese pts?
|
by Total Body Weight initially and then by Ideal Body Weight subsequently
pg 2015 |
|
|
Why do antibiotics need dosage adjustments in obese pts?
|
decreased tissue perfusion in obese pts results in lower concentrations of abx in skin and soft tissues
pg 2014 |
|
|
What is critical in airway management in obese pts?
|
Preoxygenation b/c they will desat faster than norma adults
pg 2016 |
|
|
What is order of preference for central line placement in the obese pt?
|
femoral, subclavian, and int jugular
pg 2016 |
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|
What is the GRIEV_ING mnemonic for delivering death notification?
|
G- gather family
R- resources (chaplain) I- identify self, the deceased E- educate V- verify member is dead _ - give family space I- inquire questions N- nuts and bolts (organ donation, personal belongings) G- give contact info pg 2019 |
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|
In a medical examiner case of the deceased what must not be done to the pt?
|
do not remove resusitative lines
pg 2020 |
|
|
T/F: Emerg provider should render needed emerg txmt even when consent cannot be obtained.
|
True
pg 2022 |
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|
Can a minor consent or refuse txmt w/o parental involvement?
|
yes if the mature minor sufficiently understands the nature and consequences
pg 2024 |
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|
According to EMTALA, does a nurse triage meet hospital obligation for a medical screening exam?
|
No
pg 2027 |
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|
Under EMTALA, does stabilization require the underlying medical condition to be resolved?
|
No
pg 2027 |
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|
Under EMTALA, are you required to screen and examine a pt brought in by police for exam?
|
Yes
pg 2029 |
|
|
Terminal events, such as CPR, should or should not be listed as the proximate cause of death?
|
Should not, they do not indicate the dz process that caused death
pg 2030 |
