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320 Cards in this Set
- Front
- Back
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Penicillins are bacteri __
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cidal
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Penicillins are most effective against gram ___
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positive
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Which component of penicillin binds the PBP
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Beta lactam ring
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The attack point of beta-lactamases such as penicillinase is the ____
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Beta Lactam ring
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Natural Penicillins
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Penicilin V and G
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Which PCN's are effective with MSSA (besides methicillin)?
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Nafcillin, oxacillin, cloxacillin, dicloxacillin
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Nafcillin, oxacillin, cloxacillin, dicloxacillin are collectively known as?
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Antistaphylococcal PCNs
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What is the drug of choice for MSSA?
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Nafcillin
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Extended spectrum PCN's that are used for gram negatives?
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Ampicillin and amoxicillin
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What extended spectrum PCN's used for gram - is most effective against listeria?
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Ampicillin
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What extended spectrum PCN against Gram - has the best oral availability
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Amoxicillin
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Antipseudomonals PCNs
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Ticarcillin, piperacillin
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What generation has more gram (-) coverage, 1st or 3rd
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3rd
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What generation cephalosporin has more beta lactamase resistance, 1st or 3rd
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3rd
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What generation cephalosporin has better CSF penetration, 1st or 3rd
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3rd
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Can you use cefipime in a patient who had an anaphylatic rxn to amoxicillin?
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No
Cross reactivity |
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Can you use aztreoname in a patient who had an anaphylatic rxn to amoxicillin?
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Yes
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Does imipenem have similar or differing MOA as PCN/Ceph
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Similar
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Is imipenem effective against pseudomonas
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Yes
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What is imipenem also used in combination with?
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cilastatin (inhibits renal dehydrogenase)
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Is imipenem effective against MRSA
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No
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Sulbactam action
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bind to beta lactamase and inactivate the enzyme (suicide inhibitors)
Extend the PCNs spectrum against lactamase producers |
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Cilastatin action
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Inhibits renal dehydropeptidase
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Name a monobactam
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Aztreonam
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Aztreonam (the MAGIC bullet for gram ___) only binds the PBP's in gram ___
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Negative
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Does Aztreonam have cross reactivity with PENs/Ceph
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No
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Vancomycin MOA
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inhibits transglycosylase
cell wall synthesis inhibitor |
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T/F Vanco is bactericidal?
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True
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T/F Vanco is a beta lactam?
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False
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What are the only 2 oral uses of Vanco?
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Colitis (C diff)
Enterocolitis (s. aureus) |
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DOC for Pseudomembranous colitis (c diff)
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Metronidazole but vanco alternative
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Vanco spectrum is limited to gram ___
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positive
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Vancomycin is toxic to which 2 systems
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Nephrotoxicity and Ototoxicity
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Adverse SE with rapid infusion of Vanco?
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Red man syndrome
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What is the DOC for MRSA
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Vancomycin
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What is ESBL?
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Extended spectrum beta lactamases
Hydrolyze: PCN, Ceph, Monobactams In gram - organisms Klebsiella pneumoniae and E. coli |
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What is the DOC for treating a ESBL gram negative bacteria?
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Carbapenams (imipenem)
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List Extended spectrum PCN's
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ampicillin, amoxicillin
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List Antistaph PCN
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Nafcillin, oxacillin, methicillin, dicloxacillin, cloxacillin
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List Beta lactams
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Ceph
PCNs Carbapenems Monobactams |
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List 1st generation cephalosporins
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1. Cephalexin
2. Cefazolin |
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List 2nd generation cephalosporins
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1. Cefoxitin
2. Cefaclor 3. Cefprozil |
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3rd generation cephalosporin list
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1. Ceftriaxone
2. Ceftazidime 3. Cefotaxime 4. Cefdinir |
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4th generation cephalosporin list
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Cefepime
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Cough during cerumen removal secondary to stimulation of which nerve branch?
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Arnold branch of CN X
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Unilateral tinnitus, hearing loss, vertigo?
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Meniere's Disease
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Referred otalgia in adults (know eagles syndrome)
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dental
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Referred otalgia in kids?
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Tonsilitis
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Evaluation of tumors of specific nerves is best achieved with
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MRI's
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What makes small cell carcinoma have an increased sensitivity to chemotherapy
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Its rapid doubling time
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Why is small cell carcinomal not amenable to surgery
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metastisizes via bloodstream early, 80% disseminated at Dx
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Associated paraneoplastic syndrome?
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SIADH
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CT suspiscious for lung cancer, next step to Dx?
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Bronchoscopy and Biopsy
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Why may an apical lung tumor cause hoarseness?
|
Compression of the R recurrent layrngeal nerve
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Pleural tumor associated with
|
mesothelioma
|
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Central lung tumor associated with
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squamous cell
small cell |
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Peripheral lung tumor associated with
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adenocarcinoma
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|
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Ill defined borders?
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small cell
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Glandular with mucin
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adenocarcinoma
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well differentiated, white-gray tissue
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squamous cell
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Otitis externa associated with
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pseudomonas aeruginosa
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Otitis media with effusion?
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air bubbles, air fluid levels
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Sinuses present at birth
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ethmoidal
|
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Pathology in meconium aspiration
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chemical irritation
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|
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When does surfactant production begin?
|
28 weeks
|
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What initiates surfactant release?
|
physical stretch
|
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What stimulates surfactant production?
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cortisol
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At what age are the lungs matured?
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34 weeks
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Transient tachypnea of the newborn most common in
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c-section
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ground glass cxr in newborn
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hyaline membrane dz
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patchy infiltrate on cxr in newborn
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neonatal pneumonia
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spongy airless area base of the left lung on cxr in neonate
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pumonary sequestration
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Birth defect associated with polyhydraminos
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TEF
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scaphoid abdomen/peristaltic lung sounds ..think?
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Diaphragmatic hernia
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Histoplasma capsulatum
|
true pathogen
ohio river valley guano of birds, starlings, chickens, bats mostly asymptomatic need heavy infecting dose flu like, patchy pneumonia snowstorm pattern survives phagocytosis |
|
|
Coccidioidies immitus
|
True pathogen
nutritionally dimorphic Southwest desert Inhale arthrospores (dust) Antiphagocytic Spherules in stained sputum Dx most asymptomatic flu-like, fever, cough, headache |
|
|
Blastomyces dermatiditis
|
True pathogen
ohio river valley cutaneous nodules dogs |
|
|
Aspergillus fumigatus
|
Opportunistic
hyphae that septate and exhibit acute angle branching inhale alllergic rxns to colonization to invasion/destruction lung tissue with spread to brain, skin, and organs --> death |
|
|
Mucor Species
|
Rhizopus
Neutropenia GI, CV, skin, nerves, BV acute pneumonia with fever and cough and s/sx of pulmonary infarction pleuritic chest pain hemoptysis |
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Stachybotrys chartum
|
sick building syndrome
allergy, asthma, iron overload slimy black mold |
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Southwest desert
|
coccidiodies immitus
|
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Cutaneous Lesions
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Blastomyces dermatiditis
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|
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Neutropenic
|
mucor species
|
|
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Ohio River valley
|
Histoplasmosis and blastomyces dermatiditis
|
|
|
Sporulating Organisms
|
Histo
Blastomyces Coccidiodies immitis |
|
|
Slimy black mold
|
stachybotrys chartum
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|
Major sx of acute sinusitis
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nasal/post nasal drainage
facial pain/pressure nasal obstruction/congestion hyposmia/anosmia cough not due to asthma |
|
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bacterial acute sinusitis
|
sx worsening after 5-7 days, persisting >10 or out of proportion
unilateral midfacial, periorbital or forehead pain Unilateral purulent rhinorrhea pain worsened by bending over, valsalva, or toothache poor response to decongestants facial swelling, conjunctival infection, meningeal or other signs of spread outsides the sinuses |
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Chronic sinusitis dx
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nasal congestion/fullness
nasal obstruction.block nasal purulence/drainage facial pressure/pain hyosmia.anosmia fever 1 major 2 minor or 2 major Nasal endoscopy, CT |
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Most sensitive indicator in children <6 months old for infectious pneumonia
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tachypnea
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Pertussis manifestations
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afebrile
scleral hemmorrhages post tussive emesis -- cough so bad you throw up |
|
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Chlamydia trachomatis pneumonia manifestations
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afebrile
conjunctivitis staccato cough eosinophilia rhinopharyngitis scattered inspiratory rales |
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RLL pneumonia may cause abdominal pain that mimics ____
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appendicitis
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Asthma Sx
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intermittent dry cough and expiratory wheeze
Limited physical activity Repeated, dry night time cough Colds that don't go away |
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Asthma: improvement >__ % in FEV1 in response to albuterol
|
12
|
|
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Tx of asthma
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step up and step down approach
|
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Most common bacterial pathogens in kids for sinusitis
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Strep pneumo
Nontypable Hib Moraxella catarrhalis |
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Suppurative or acute otitis media
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infection
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Non suppurative or secretory otitis media, or otitis media with effusion
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Non infective inflammation accompanied by effusion
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AOM (acute otitis media) manifestations
|
variable
rupture of TM w/ purulent otorrhea fever ear pain (holding or tugging at ear) irritable No sx Fullness, bulging, retraction of TM Erythema of TM Scarring.abormal whiteness of TM Decreased mobility of TM |
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Otitis externa
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swimmers ear
ear pain accentuated by moving pinna or tragus itching conductive hearing loss serous or purulent secretions |
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Sx GABHS phyaryngitis
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Group a beta hemolytic strep pharyngitis
rapid onset fever headache abdominal pain strawberry tongue |
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5 A's of anesthesia
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awareness
amnesia analgesia autonomic stability appropriate surgical conditions |
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T/F
There is a high mortality with renal dz and anesthesia Good physical activity = good outcome |
True
True |
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ASA 1
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normal healthy pt
|
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ASA 2
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mild systemic disease
-pregnancy * -obese -smoker |
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ASA 3
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severe systemic dz that limits activity
-stroke pt |
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ASA 4
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incapacitating dz that is constant threat to life
-septic shock -hepatic failure |
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ASA 5
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a moribund pt not expected to survive 24 hours
-ruptured aneurysm |
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ASA 6
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declared brain death whose organs are being harvested
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E classification
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emergency procedures
|
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ASA std monitors
Oxygenation |
Pulse Ox
Oxygen analyzer |
|
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ASA std monitors
Ventilation |
Capnography
end tidal co2 |
|
|
ASA std monitors
Circulation |
ECG
BP Stethoscope |
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|
ASA monitors what 4 things
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1. oxygenation
2. ventilation 3. circulation 4. temperature |
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A pre op fasting time of __ hours recommended for food (solids and milk)
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6
|
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Fried or fatty foods shouldn't be eaten ___ hours prior to surgery
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8
|
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____ should not be allowed the day of surgery
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gum
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water and clear fluids are allowed up to __ hours before surgery
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2
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Tea and coffee with milk are ok until ___ hours before surgery
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6
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Pts are under an increased risk of ___ when under anesthesia
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Aspiration
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|
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If pt has full stomach and needs emergency surgery must use
|
Rapid sequence induction
cricoid pressure |
|
|
Pts with increased risk of aspiration
|
Diabetics
Obese Pregnant GERD |
|
|
Malignant hyperthermia cause
|
Autosomal dominant inherited myopathy
Defect in Ca release/control May occur at any time during anesthetic |
|
|
Malignant hyperthermia (MH) Dx
|
Muscle Biopsy
|
|
|
Tx of MH (malignant hyperthermia)
|
Dantrolene
stop triggers cool diuresis |
|
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MH Signs
|
hypermetabolic disorder
Increased CO2 prod Increased O2 consumption Tachycardia Temperature increase--late sign Metabolic and resp acidosis Muscle Rigid Hyperkalemia |
|
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Causes of nasal mucosa congestion
|
allergies
infection medications pregnancy |
|
|
Pediatric sinusitis signs
|
cold lasting >10-14 days
thick yellow green drainage postnasal drip headache irritable/fatigue swellling around eyes |
|
|
Rhinitis Sx (4)
|
Sneezing
nasal itching rhinorrhea nasal congestion |
|
|
Artery involved in anterior epistaxis
|
Internal maxillary artery (internal carotid)
|
|
|
Artery involved in posterior epistaxis
|
Opthalmic artery (external carotid)
|
|
|
Anterior epistaxis Tx
|
squeeze nose
evacuate clots Insert cotton pledgets Topical vasoconstrictor Identify source Cautery w/ silver nitrate -- NEVER BOTH sides |
|
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Posterior epistaxis Tx
|
Posterior nasal packing
Endoscopic Cauterization -- NEVER BOTH sides Arterial Ligation |
|
|
Anterior epistaxis
|
kids and adults
trauma 90% |
|
|
Posterior Epistaxis
|
10%
Elderly Coagulopathy |
|
|
Dx of nasal papillomas
|
Seeing them
|
|
|
Tracheal Stenosis
|
Rare
Intrinsic cartilage malformations or external compression by vessels/vascular ring Intrinsic due to post C shaped rings Mutations inf FGF receptor Intense retraction, Respiratory distress, try to intubate--> like hit a rock Fusion of cartilaginous rings |
|
|
TEF (trans esophageal fistula)
|
VACTRL syndrome
verterbral anomalies, cardiac, term (good outcomes) renal, limb FULL OF SECRETION vomit when they eat belly distention |
|
|
Congenital diaphragmatic hernia effect on lungs
|
CDH
compression of the lungs pulmonary hypoplasia pulmonary HTN -respiratory distress at birth |
|
|
MAS (meconium aspiration syndrome)
|
airway obstruction
alveolar and parenchymal edema and inflammation Increased pulmonary vasoreactivity (increase resistance and decrease compliance) Vascular remodeling Ischemia/necrosis Surfactant dysfxn |
|
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MAS Tx
|
pulmonary toilet
respiratory assistance PPHN management Correct metabolic state manage seizures Surfactant replacement |
|
|
PPHN features
|
labile hypoxemia and increased sensitivity to stimuli
ductal shunt foraminal shunt murmer of tricuspid insufficiency |
|
|
PPHN Tx
|
sedation and minimal stimulation
oxygen acidosis correction NO* ECMO * |
|
|
Bronchopulmonary dysplasia (BPD) features
|
severe respiratory failure
hypoxemia, hypercapnea, cor pulmonale CXR- increased densities from fibrosis(hazy, hyperinflation) |
|
|
BPD Tx
|
slowly wean off 02
|
|
|
RDS
|
no surfactant
increase surfact tension get collapse |
|
|
RDS Tx
|
surfactant
|
|
|
TTN
|
transient tachypnea of newborns
Wet lung syndrome |
|
|
Transient tachypnea of newborns (Wet lung) Features
|
delayed/altered lung fluid absoprtion
absence of labor/ c-section =cause Acute distress at birth Rapid improvement Benign course usually |
|
|
TTN Tx
|
supported
|
|
|
cystic adematoid malformation
|
multilocular large cysts with broad spectra
|
|
|
congenital lobar emphysema
Congenital large hyperlucent lobe (CLHL) |
cartilage abnomality LUL
|
|
|
Pulmonary sequestration
|
airless spongy area base of lung
|
|
|
Fetal circulation
|
umbilical vein --> ductus venosus --> IVC --> RA --> Foramen ovale --> LA --> LV -->aorta --> Body --> umbilical arteries
|
|
|
Empyema pleural effusion
|
due to infection
parapneumonic effusion exudative-fibropurulent |
|
|
Metastatic Cancer
|
Malignant pleural effusion
BLOODY EFFUSION |
|
|
Lymphoma Effusion
|
chylothorax (lymph fluid)
|
|
|
Tension pneumo signs
|
respiratory distress
chest pain decreased-absent breath sounds on affected side Hypotension mediastinal/tracheal shift to opp side compression of opp lung Can lead to sudden death |
|
|
Tx Tension Pneumo
|
immediate decompression
insert large needle then chest tube |
|
|
Hemathorax causes
|
intercostal/internal mammary artery
fractured rib deep pulmonary laceration aorta heart |
|
|
Hemothorax presentation
|
dyspnea
decreased breath sounds dullness to percussion on affected side |
|
|
Hemothorax Tx
|
Large bore IV access for rapid fluid resuscitation
AND THEN chest tube |
|
|
Tension pneumo cause
|
presence of a one way valve that allows air to enter the pleural space and not escape i.e. air under pressure
|
|
|
cardiac tamponade pathogenesis
|
rapid accumulation of pericardial effusion or blood
|
|
|
cardiac tamponade signs
|
dysnpea
orthopnea fatigue hypotension diaphoresis tachycardia narrowed pulse pressure shock distant heart sounds |
|
|
Cardiac tamponade Tx
|
US - dx
rapid volume resuscitation pericadiocentesis Subxiphoid pericardial window in the stable pt |
|
|
Cardiac tamponade associated with ___ ____
|
Beck's Triad
|
|
|
What is beck's triad
|
muffled heart sounds
hypotension distended neck veins (JVD) |
|
|
The organism responsible for most of the coinfections with the flu is ...
|
strep pneumo
|
|
|
What clinical manifestation of strep pneumo is most frequently involved as a cause of morbidity and mortality in an older adult
|
pneumonia
|
|
|
malaise, low grade fever, diffuse aches, and a dry cough..dx influenza b...to prevent an outbreak the members of the nursing home should receive what drug?
|
Neuraminidase inhibitor
|
|
|
66 male, chest pain--sudden onset, cough productive of purulent and blood tinged sputum, fever, consolidating pneumonia..etiology?
|
strep pneumo
|
|
|
If sputum culutres are negative, what other cultures should be ordered to confirm strep pneumo?
|
Blood
|
|
|
oxidase positive organism producing a green diffusible pigment ...
|
pseudomonas aeruginosa
|
|
|
What would you perscribe pseudomonas that is sensitive to fluoroquinolones, vanco, AG, chloramphenicol...
|
levofloxacin
|
|
|
Adenocarcinoma
Location Population |
peripheral in location
Common in non smokers and women |
|
|
Squamous cell carcinoma
|
cough up blood
lesion growing in central airway Tx pallitive not curative |
|
|
Small cell carcinoma
|
centrally located
VERY aggressive smoking related staged by limited and extensive Therapy: chemotherapy NO SURGERY low survival |
|
|
Mesothelioma
|
most common primary pleural tumor
Asbestos exposure |
|
|
Mesothelioma s/sx
|
gradual onset of SOB
chest pain-severe and unremitting dullness to percussion decreased breath sounds on involved side nodular irregular pleural thickening on xray |
|
|
Mesothelioma prognosis
|
75% die within one year
|
|
|
Mesothelioma Tx
|
Tri-modal: chemo, radiotherapy, and surgery (limited success)
Help but can't cure |
|
|
Pancoast's Tumor and syndrome
|
Tumor in superior pulmonary sulcus in apical part of lung
Pain-shoulder or medial scapula Radicular pain +/- muscle wasting Horner's Syndrome |
|
|
Pancoast tumor Tx
|
Radiation followed by tumor and chest wall resection
|
|
|
malignant effusions
|
exudates
can be serious, serosanguinous or bloody |
|
|
Hamartoma
|
a tumerous lesion--> abnormal mixture of cells and tissues
Nodular and well circumscribed irregular lobules of cartilage--may contain calcified areas |
|
|
Risk factors for lung cancer
|
smoking
air poullution Molecular genetics |
|
|
Grading
|
levels of differentiation
|
|
|
Well differentiated tumor
|
resembles the normal counterpart
|
|
|
Stage
|
Extent of cancer
size of the tumor Involvement of local structures Metastisis |
|
|
Which is most important indicator of cancer Px...grade or stage?
|
Stage
|
|
|
IgE role in hypersensitivity rxn
|
crosslinking allergin specific IgE triggers mast cell degranulation
|
|
|
Mechanism of Type 1 hypersensitivity rxn
|
allergen taken up by APC (DC) which then activate TH2. TH2 produces IL-4 which promotes IgE production. IgE will bind to the surface of the mast cell via FCr receptors..subsequent exposure triggers mast cell degranulation
|
|
|
Wheal and Flare
|
Occurs because of histamine release
|
|
|
Allergic rxn to flora and fauna
|
rhinorrhea, sneeze, nasal itching and obstruction, conjunctivitis, swelling around eyes, pale swollen nasal mucosa
|
|
|
Hypersensitivity pneumonitis
|
allergic disease
T CELLS, antibody, immune complex (NOT IgE) Allergens are microorganisms |
|
|
50 y/o farmer complains of progressively worsening chronic cough, weight loss, dyspnea, decreased ability to work. He is a non smoker, no known allergies, neg PPD. His blood cell count and IgE are normal, but his FEV1 and FVC are reduced. What is likely cause of his problem?
|
Hypersensitivity pneumonitis
|
|
|
Anaphylaxis
|
IgE bound to mast cells
Allergen triggers mast cell degranulation Systemic release of inflammatory mediators Resp: nasal obstruction, increase mucus, dyspnea wheezes Cardio: hypotension, shock Skin: urticaria, angioedema, erythema, itchy GI: pain, nausea, diarrhea Hematologic: thrombocytopenia DIC |
|
|
Tx anaphylaxis
|
ABC, vitals, alert
EPI |
|
|
aerobic
oxidase positive lactose non fermenter What antibiotic do you use? |
Piperacillin/Tazobactam
|
|
|
What has been used to increase the immunogenicity of the strep pneumo vaccine
|
conjugation of the bacterial polysaccharides with an immunogenic protein
|
|
|
A case of the flu is Dx in a nursing home. The remaining pts haven't had the flu vaccine what do you do?
|
Administer tamiflu immediately to everyone in the nursing home
|
|
|
A 73 vet smoke 1-2 ppd cough, fever, 4 days, diarrhea last 2, chronic bronchitis...xray has consolidation in RLL. Sputum has abundant leukocytes, PMN. Gram stain and acid fast stain are negative. Blood cultures negative..what is it?
|
Legionnaire's Dz
|
|
|
Possibility of transbronchial biopsy is discussed but the pt refuses. What is an alt dx procedure for Legionnaires....
|
antigen detection in the urine
|
|
|
Transbronchial biopsy is discussed to determine Legionnaire's but the pt refuses what alt dx test could you do?
|
antigen detection in urine
|
|
|
What causes fever
|
Release of TNF alpha and IL-Ib activated by macrophages
|
|
|
66 with chemo develops persisten fever not affected by broad spectrum antibiotics...a CBC reveal profound neutropenia and white exudate (resemble cotton wool ball) seen in right eye. Organism grown in sabouraud's agar..where did it come from?
|
endogenous flora (candida albicans--immunocompromised)
|
|
|
Invasive aspergillosis risk factors
|
myelosuppression
prolonged neutropenia AIDS, organ transplant Phagocytic cells play a role in defense |
|
|
Invasive Aspergillosis
|
invasive infection (growth of hyphae in tissues)
Sx: cough, high fever, pleuritic chest pain TLR polymorphisms put at increased risk septate hyphae with acute angle branching |
|
|
Allergic bronchopulmonary aspergillosis
|
asthmatics, CF pts
wheezing, fever, expectoration of rubbery brown mucus plugs polymorphisms in TLR Central breonchiectasis Immediate cutaneous reactivity to aspergillus skin test antigen Eosinophilia |
|
|
Opportunist fungi (Rhizopus, Mucor)
|
neutrophil defects
diabetes rhinocerebral pulmonary |
|
|
Sick house building syndrome
|
stachybotrys
allergy, asthma, exposure to fungi derived volatile organic compounds, respiratory, GI, neuro problems Pulmonary hemorrhage, hemosiderosis |
|
|
Micro ..when you see allergy with fungal infections think...
|
IgE
|
|
|
Pen G and V effective against gram __
|
positive
|
|
|
SE of penicillin G
|
allergies
diarrhea, GI NEUROTOXICITY superinfections -- c diff-pseudomembranous colitis |
|
|
ESBL best Tx and most common producers
|
Imipenem
Klebsiella pneumoniae and E. coli |
|
|
Antistaph agents DOC for
|
MSSA
|
|
|
Antistaph SE
|
blood dyscrasia
acute interstitial nephritis hepatotoxicity |
|
|
Extended spectrum used for gram
|
negatives
|
|
|
Ampicillin and Amoxicillin uses
|
HELPS
h influenza e coli listeria proteus salmonella ampicillin: enterococcus, listeria amox: lyme dz, h pylori |
|
|
Ticarcillin and Piperacillin uses
|
HELPS + psuedomonas, klebsiella, serratia
|
|
|
often used ticarcillin and pipercillin in ____ pts
|
immunocompromised
|
|
|
1st to 4th there is
__ activity against gram - __ resistance to beta lactamases __ ability to cross BBB |
INCREASING
|
|
|
cephalosporins and penicillins MOA
|
Bactericidal
|
|
|
Cephalosporins SE
|
allergic rxns
superinfections hypoprothrombinemia (coag abnormalities) Alcohol intolerance (disulfiram like rxn) Due to MTT groups (2 and 3) |
|
|
Half life ___ with 3>2>1
CSF entry exclsuively _ and _ generations Renal elimanation ___ 3>2>1 |
Increases
3rd and 4th Decreases |
|
|
1st generation ceph uses
|
prophylaxis of surgical procedures
|
|
|
2nd generation ceph uses
|
G + and HEN PEcK
H. influenza Enterobacter Neisseria Proteus E.Coli Klebsiella |
|
|
2nd generation ceph SE
|
allergic rxns
blood dyscrasias pseudomembranous colitis |
|
|
am i gonna pass
|
yes! =)
|
|
|
3rd generation cephs real use
|
SERIOUS G - INFECTIONS often combined with AG
Tx if CAP if hospitalized but not ICU pts |
|
|
4th generation cephs use
|
PSEUDOMONAS
staph a and strep pneumo SE like other cephs but NO disulfram like effects |
|
|
Imipenem MOA
|
bactericidal
sig post antibiotic effect |
|
|
Carbapenems DOC for
|
Enterobacter
Pseudomonas infections ESBL producing klebsiella Mixed infections -- on other antimicrobials or immunocompromised Good for gram - pneumo and bactermia complicated UTIs |
|
|
Always use Imipenem with ___
|
cilistatin
|
|
|
carbapenems SE
|
nausea, vomit, diarrhea
Seizures Cross reactive with pens Expensive |
|
|
Monobactam (Aztreonam) effective only against?
|
Only effective against GRAM NEGATIVES
|
|
|
Aztreonam uses
|
serious Gram negative infections
MDR pseudomonas No cross reactivity with PCN |
|
|
c diff pseudomembranous colitis
DOC and ALT |
DOC: metrionidazole
Alt: Vancomycin |
|
|
Pseudomembranous colitis
|
one of the most common health care associated infections
diarrhea, fever, stools with shreds of mucous membranes and lots of neutrophils Overgrowth of C diff. Ceph - cause potentially fatal |
|
|
Structural differences to remember in pediatrics
chest wall? what type of breathers? narrowest part of airway? airway diameter? |
chest well is very compliant
babies are obligate nasal breathers narrowest part of the pediatric airway is at the cricoid cartilage airway diameter is much smaller |
|
|
Pores of Kohn and canals of Lambert not well developed so __________
|
decreased collateral ventilation, propensity for atelectasis
|
|
|
chest wall differences in kids
ribs? chest wall? recoil? muscle mass? |
horizontal
more compliant less outward recoil less |
|
|
FRV
|
volume left over when done with regular breathing
|
|
|
TV
|
regular breathing
|
|
|
Maintaining FRC in infants
|
Glottic braking (creates PEEP)
Alteration of stretch receptor set points (halts expiration prior to sig lung deflation) Increased respiratory rate to maintain adequate minute ventilation Recruitment of abdominal wall muscles (belly breathers) |
|
|
Early Neuromuscular dz
|
respiratory muscle weakness
increased recruitment of resp muscles = fatigue Less respiratory reserve (hypoventilation) lower FRC, smaller Vt, tachypnea |
|
|
Late Neuromuscular dz
|
Chronic low tone and low volume ventilation
(kyphoscoliosis, contracture of the costo vertebral joints) Fxnal consequences (decreased chest wall complaince) |
|
|
Airflow
Structural changes in the infant airway |
thicker epithelium
more mucous glands less developed cartilage increased smooth m equal number of branches smaller diameter |
|
|
small change in diameter = _______ problem
|
exponential
|
|
|
Asthma structural changes
|
smooth muscles constriction
inflammation and edema of bronchial wall increased mucous obstructed airflow intermittent complete obstruction = crackles Partial obstruction = wheezing |
|
|
Wheezing in asthma
|
polyphonic
|
|
|
T/F you can use pulse ox to monitor CO2 on someone with supplemental O2
|
False, can underestimate
|
|
|
V/Q mismatch
|
shunt blood to well ventilated places and constrict blood flow to underventilated places
|
|
|
actual true shunt
|
direct connection b/w venous and arterial -- large amount of blood
|
|
|
Apnea
|
pause of 2 respiratory cycles
central obstructive or mixed |
|
|
Infections associated with Apnea
|
RSV
Pertussis |
|
|
Receptors in lung
|
stretch
irritant J |
|
|
Control of breathing
|
Cortex/voluntary control
CV (arterial baroreceptors) Chemoreceptors Skin/Face Receptors Muscle Receptors Upper airway receptors Lung receptors |
|
|
3 groups of neurons control respiration
|
DRG (basic rhythm)
VRG (drive, SNS stim, dyspnea) Pneumotaxic center (controls off switch of insp ramp signal = frequency control) |
|
|
Physiologic changes during sleep
|
decrease in medullary chemoreceptor response to hypercarbia
decrease in carotid body chemoreceptor response to hypoxia Decrease in dilator muscle tone Decrease in intercostal muscle activity Decrease in diaphragmatic efficiency |
|
|
Congenital central hypoventilation syndrome
|
failure of autonomic control of breathing
severely impaired response to hypoxia and hypercapnia Worse at sleep NIV, trach/vent |
|
|
ROHHAD
|
rapid onset obesity
later onset of alveolar hypoventilation hypothalamic dysfxn and autonomic dysregulation |
|
|
Obesity hypoventilation syndrome
|
obesity and daytime hypoventilation
decreased response to hypoxia and hypercapnia increased work of breathing due to obesity, OSA, resp muscle impairment and decreased central ventilatory drive NIV overnight |
|
|
SIDS
|
<1 year of age
unexplained supine sleeping breast feeding immunizations no co sleeping or fluffy sleeping surfaces resp monitors not effectve Don't smolke!! |
|
|
Pediatric airway
size? position? Large __ and ___ Epiglottis is __ Narrowest portion? |
smaller
more anterior epiglottis is floppier Larger tongue Larger occiput Narrowest poriton of airway is cricoid |
|
|
Obligate nasal breathers --> ___
Increased airway and chest wall compliance ____ Smaller airways --> ___ |
nasal congestion --> apnea
easier airway obstruction exponentially easier to obstruct |
|
|
Classic syndrome associated with airway obstruction
|
down syndrome
|
|
|
Evaluation of FB aspiration
2 out of 3 rule |
1. Hx of witnessed aspiration/choking
2. Suggestive physical findings 3. Suggestive x ray findings |
|
|
Focal findings of FB
|
polyphonic wheezing
crackles decreased breath sounds |
|
|
FIndings in FB aspiration
|
monophonic wheezing
unilateral hyperresonance shift of the trachea |
|
|
Infections of upper airway causing obstruction
|
retropharyngeal or peritonsillar abscess
epiglottis croup diptheria rec'd |
|
|
Infections of larynx or trachea causing airway obstruction
|
bacterial tracheitis
papillomatosis |
|
|
Recurrent Respiratory papillomatosis
|
HPV
contract airway lesions Tx: antiviral, HPV vaccine, surgery |
|
|
Airway clearance mechanisms
|
1. cough
2. mucociliary clearance |
|
|
CF occurs mainly in the
|
whites
inherited autsomal recessive disorder |
|
|
CF mechanism
|
CFTR deffect
Change in chloride ion transport --> thick dehydrated secretions Abnormal airway surface liquid --> disrupt mucociliary clearance pancreatic obstruction leads to pancreatic insufficiency |
|
|
CF exam findings
|
crackles, wheezes (poly or mono), decreased air exchange, nasal polyps clubbing
|
|
|
monophonic
|
large airway
|
|
|
polyphonic
|
small airway
|
|
|
Tx for CF
|
chest physiotherapy
meds to thin secretions broad spectrum antibiotics Nutritional support Molecular CTFR channel modifiers |
|
|
is pulse ox a good measurement in anemia?
|
NO
|
|
|
common teratogens (6)
|
infections
physical chemical social drugs metabolic chromosomal abnormalities |
|
|
Choanal atresia
|
blockage of posterior nasal aperture
unilateral or bilateral bilateral- noisy breathing ,upper airway obstruction cyanosis worse with feeding |
|
|
micrognathia
|
small jaw
|
|
|
macroglossia?
Tx? |
large tongue
Tx surgery |
|
|
glossoptosis
|
fxnal macroglossia
|
|
|
ankyloglossia
|
tongue-tied
|
|
|
Pierre-Robin
|
triad of u shaped palate
micrognathia glossoptosis cause upper airway obstruction Tx: prone position, gavage feed |
|
|
Beckwidth-Wiedeman
|
large baby
large organs |
|
|
Tracheoesophafeal fistula (TEF)
|
most common blind esophageal pouch
immediately symptomatic excessive secretions, drooling, resp distress, inability to feed Aspiration pneumonia Dx: cannot pass catheter into stomach Tx: surgery |
|
|
Tracheal atresia
|
partial or complete absence of trachea below larynx
Lethal unless fistula present cyanosis, severe respiratory distress, no audible cry, unable to ventilate/intubate |
|
|
Tracheal stenosis
|
segmented
severe resp distress, cyanosis, difficult feeding, stridor, wheezing Dx - CxR Tx: surgical |
|
|
Tracheal malacia
|
dynamic collapse of trachea during expiration
defect in cartilagenous portion -- lack of rigid support Need bronchoscopy Most improve spontaneously |
|
|
Bronchial anomalies Tx
|
supportive
|
|
|
Diaphragmatic hernia
|
posterolateral defect of the diaphragm
Herniation of abdominal viscera into the thoracic cavity 5x more common on the Left side |
|
|
Bronchiogenic cysts pathogenesis
|
anomalous budding of foregut
don't communicate with tracheobronchial tree unilocular |
|
|
Dx of AOM
|
requires the presence of middle ear effusion and otalgia, otorrhea, bulging red or yellow TM, fever
|
|
|
Pathogenesis AOM
|
eustachian tube dysfxn --> bacteria multiply --> effusion/suppuration --> perforation and or resolution
|
|
|
AOM causitive organisms
|
RSV, parainfluenza
triad: hi non typable, strep pneumo, moraxella catarrhalis |
|
|
Strep pneumo characteristics
|
gram positive
lancet shaped diplococci sensitive to optochin M antigen |
|
|
Haemophilus influenza
|
often missed in gram stain
|
|
|
Moraxella catarrhalis
|
gram negative diplococcus
oxidase positive |
|
|
T/F expect a middle ear effusion for 1-3 months following a resolved AOM
|
True
|
|
|
Pathophysiology of sinusitis
|
obstruction of natural ostia
|
|
|
causes of acute sinusitis
|
Triad
Strep pneumo Hin (non typable) Moraxella catarrhalis |
|
|
Tx of acute sinusitis
|
commonly resolves sponatenously
topical decongestant |
|
|
When do you treat acute sinusitis with antibiotics
|
length of sx ( 2 weeks minimum) should be your strongest reason to treat with antibiotics
|
|
|
squamous cell carcinoma
|
arise in larger bronchi
spreading by direct extension and L.N mets Early hematogenous metastases keratin pearl formation/intracellular bridges Tumors erode bronchial epithelium |
|
|
adenocarcinoma
|
malignant tumor w/ glandular differentiation
women and non smokers peripherally located contain mucin may show foci of atypical bronchiolar and alveolar proliferation Arise in association with a peripheral scar or honeycombing |
|
|
small cell carcinoma micro
|
higly malignant
cells are small/scant ill defined cell borders finely granular chromatin absent or inconspicuous nucleoli round oval or spindle shaped cells nuclear molding prominent |
|
|
small cell carcinoma
|
tumors arise in both major bronchi
more advanced stages --> nodular growth involving lung parenchyma central necrosis w/ anthracosis Early Mediastinal LN involvement** |
|
|
Small cell carcinoma EM
|
typical neurosecretory type granules
present in a cytoplasmic proces/beneath cell membrane |
|
|
SCC risk factors
|
SMOKING
MOST aggresive |
|
|
Carcinoid tumors
|
low grade malignant epithelial neoplasms
most arise in the main to segmental bronchi Peripheral origin Tumor is polypoid and endobronchial in the major bronchi Bicameral or iceberg shaped in intermediate sized bronchii Solid and nodular in periphery of the lung well defined with a smooth lobulated granular ivory to pink glistening cut surface EM -- dense core granules |
|
|
tracheoesophageal fistula - leech
|
spit and sputter
|
|
|
Branchial cleft cyst
|
congenital cyst
arises in lateral neck chronic inflammation increased lymphocytes well demarcated see later in life |
|
|
Sequestration -- Leech
|
mass of lung tissue
without any normal connection to the airway system blood supply NOT from pulm aa. but from aorta problems via mass effect Extra- distended abdomen Immature lung Intralobar -- pneumonia |
|
|
cystic adenomatoid malformations-- leech
CCAM |
Types 1-3
Type 1: large cysts 2: assoc with other anomalies medium sized cysts As increase type increase lung involvement and worse prognosis |
