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159 Cards in this Set
- Front
- Back
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What are the physiologic changes of aging?
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Nervous system
-Decreased efficiency of blood-brain barrier -Decreased response to changes in temperature -Alteration of autonomic system function (eg. orthostatic hypotension) Skin -atrophy of all skin layers -sweat glands decreased in number or activity (results in potential for hyperthermia MSK -progressive bone loss -atrophy of fibrinocartilaginous and synovial tissues -decrease in lean body mass -increase in proportion of adipose tissue Immune system -decrease in cell-mediated immunity -decreased antibody titers Cardiovascular system -decreased inotropic response -decreased chronotropic response -increased peripheral vascular resistance -decreased ventricular filling Pulmonary system -decreased vital capacity -decreased lung/airway compliance -decreased chemoreceptor response to hypercapnia/hypoxia -decreased ventilatory drive -decreased diffusion capacity Hepatic -decrease in hepatic cell mass -decrease in hepatic blood flow -alteration in microsomal enzymes Renal -decreased renal cell mass -basement membrane thickening -decreased hydroxylation of vitamin D -decrease in total body water -decreased thirst response -decreased renal vasopressin response GI -decrease in gastric mucosa -decrease in bicarbonate secretion -decrease in blood flow to GI system -decreased epithelia regeneration |
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What is the leading cause of hospitalization and death in the elderly?
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Heart disease
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What are the causes of altered pharmacokinetics in the elderly?
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-altered GI motility and blood flow
-decreased lean body mass -increased proportion of adipose tissue -decreased creatinine clearance -decreased hepatic blood flow |
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What are potentially inappropriate medications in the elderly?
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-narcotics
-NSAIDs -muscle relaxants -sedative-hypnotics -anti-histamines |
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What medications are most often implicated in adverse reactions in elders?
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-cardiovascular drubs
-diuretics -non-opioid analgesics -hypoglycemics -anticoagulants |
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What negative effects of NSAIDs should you worry about in elderly patients?
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-azotemia
-hypertension -congestive heart failure (from retention of sodium) -gastric bleeding/perforation |
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What proportion of ED admissions are for elderly patients?
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-43% and 47% of critical care admissions
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What pharmacologic property of medications does not change with age?
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bioavailability
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What is the first line medication for analgesia in the elderly?
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Acetaminophen
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What is the second line agent for analgesia in the ED?
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NSAIDs (keep dose low as there is a ceiling effect to the analgesic properties of these agents)
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What is the third line agent for analgesia in the ED?
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-narcotics (start low and go slow) (patients should exercise, eat high-fiber foods and stay well hydrated)
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What is sundown syndrome?
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- it is the phenomenon that occurs in elderly demented patients: they become highly agitated and disoriented in the dark because of the loss of visual sensory input resulting in the environment becoming unfamiliar
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What are the most common infections in the elderly
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pneumonia
UTI bacteremia or sepsis |
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What are common psychosocial issues in the elderly?
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-ethanol abuse
-iatrogenic dependence on prescription drugs -depression (late life delusion depression and involutional depression) -sundown syndrome |
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What organisms cause pneumonia in the elderly?
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-pneumococcus
-gram-negative organisms -mixed infections -reactivation of TB |
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Discuss atypical presentations of MI in the elderly
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-incidence increases with age
-dynpnea, nausea, vomiting, syncope, flulike symptoms, confusion and weakness may be the presenting complaint -atypical presentations are not more benign than typical presentations. |
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What is the differential diagnosis of abdo pain in the elderly
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-cholecystitis/biliary colic
-nonspecific -appendicitis -obstruction -hernia -perforation -pancreatitis -diverticular disease (the elderly have a higher incidence of vascular causes of abdo pain -> mesenteric schema, ruptured or leaking AAA) |
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What types of depression occur exclusively in elderly patients?
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-late life delusional depression
-involutional depression |
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What proportion of elderly abdo patients presenting to the ED have problems that are surgical in nature?
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->60%
-physicians should strongly consider admission or close observation when symptoms persist and the diagnosis remains unclear |
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What preventive care can be given to the elderly in the ED?
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-vaccination (flu and pneumococcus)
-accident/fall prevention in the home |
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What are the particularities of the physical exam in the elderly.
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-should be more thorough than in a younger patient
-may be misleadingly benign -physiologic changes, cognitive deficit and physical deficits (sequelae from previous strokes, hearing) may affect the physical exam and history -medications may alter the physiologic responses (beta blockers and anti-hypertensives) -fever may be absent despite ad serious infection, when fever is present patients are much ore likely to have serious(non viral) cause -oral temperatures may be spuriously low in elders |
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What are the components of non-microbe-specific immunity?
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-physical barriers
-acute phase response -reticuloendothelial system |
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Discuss the role of secretary IgA in immunity
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-it is the predominant immunoglobulin present in GI, nasal & oral secretions, tears and other mucous fluids.
-it prevents the invasion by organisms through the respiratory or GI tract by preventing adherence. |
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What makes up the reticuloendothelial system?
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-tissue macrophages and their blood-borne counterparts monocytes.
-they remove particulate matter from the lymph and blood. -the tissue component is made up of lymph nodes, spleen, liver, marrow and lung. |
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What is the role of IgE in immunity?
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It is expressed in high concentrations on the surface of mast cells and basophils and is responsible for immediate hypersensitivity response. It is an important defence against helminthic pathogens.
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What are the components of humoral immunity?
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-antibodies (immunoglobulins)
-the complement cascade |
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List therapeutic and diagnostic procedures that employ the use of procedural sedation?
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-fracture or joint reduction
-incision and drainage of abscesses -cardioversion -tube thoracostomy -LP -complex wound repair -imaging studies in young uncooperative patients |
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What is anxiolysis?
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A state of decreased apprehension concerning a particular situation in which the patient's level of awareness doesn't change
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What is the definition of analgesia?
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Relief of pain without the intentional alteration of mental status
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What is the definition of dissociation?
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A trance-like cataleptic state induced by an agent. Protective reflexes, spontaneous respiration and cardiopulmonary stability are retained.
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What is the definition of procedural sedation?
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Administering a sedative or dissociative agent usually along with an analgesic to induce a state that allows a patient to tolerate unpleasant procedures while maintaining spontaneous cardiorespiratory function.
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What is the definition of sedation?
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A controlled reduction of environmental awareness.
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What are the five subgroups of procedural sedation?
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I - minimal sedation
II - moderate sedation III- deep sedation IV - general anesthesia V - dissociative sedation |
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What is minimal sedation?
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Drug-induced state during which patients respond normally to verbal commands. Cognition and coordination may be impaired.
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What is moderate sedation?
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A drub induced state where patients respond purposefully to verbal commands alone or accompanied by tactile stimuli. No interventions are required to maintain a patent airway.
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What is dissociative sedation?
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A translike cataleptic state produced by ketamine. Protective airway reflexes, spontaneous respiration and cardiopulmonary stability are maintained.
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What is the CAGE questionnaire and what are its components?
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It is a simple, rapid, respectful screening tool for alcoholism
Have you ever felt: -the need to cut down on drinking? -annoyed by criticism of your drinking? -guilty about your drinking? -the need to drink an eye opener in the morning? |
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How do you score the CAGE?
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Positive responses to >/= 2 questions identified individuals who require more intensive evaluation
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Other than CAGE, what is another way to identify alcoholism?
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A positive answer to "Have you ever had a drinking problem?" and evidence of EtOH consumption in the previous 24 hours has a greater than 90% sensitivity and specificity for identifying alcoholism.
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What is the definition of hazardous "at risk" drinking?
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Men: >14 drinks per week or >4 drinks/occasion
Women: >7 drinks/week or >3 drinks/occasion >65years: >7 drinks/week or >1 drink/occasion |
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What is the definition of alcoholism?
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A primary chronic disease with genetic, psychosocial and environmental factors influencing its development. It includes impaired control over drinking, preoccupation with and use of EtOH despite consequences and distortion of thinking (denial)
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What is acquired tolerance of EtOH?
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When increasingly larger doses of EtOH are required for the same effect
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Which cytochrome p450 variant is most important in EtOH metabolism?
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CYP2E1
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What is zero order kinetics?
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Rate of elimination is at a constant rate
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What is first-order kinetics?
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rate of elimination is proportional to the concentration of the drug
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At what blood alcohol concentration can diminished fine motor control appear?
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0.02mg% or 20mg/dL
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What conditions can manifest like EtOH intoxication?
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hypoglycemia
hypoxia Co2 narcosis mixed EtOH-drug OD ethylene glycol methanol |
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What is an important distinction between alcohol withdrawal and schizophrenia?
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Schizophrenia - auditory hallucinations
Alcohol withdrawal - visual hallucinations |
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What is the classic presentation of opioid withdrawal?
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-abdo pain
-diarrhea -normal mental status |
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When do signs of EtOH withdrawal usually begin?
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6-24 hours after a decrease in the patient's usual intake
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Can withdrawal occur simply with reduction in EtOH?
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Yes, it does not have to be cessation
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When does minor EtOH withdrawal occur? How does it present?
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6-36 hours
Mild autonomic hyperactivity, nausea, anorexia, tremor, increased HR, hyperreflexia, sleep disturbance, anxiety |
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When does major EtOH withdrawal occur and what are the signs and symptoms?
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>24 hours after EtOH cessation or decrease
anxiety, insomnia, tremor, anorexia, increased HR, increased reflexes, HTN, fever, decreased seizure threshold, auditory and visual hallucinations, delirium |
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What is delirium tremens?
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It is the extreme end of the spectrum of alcohol withdrawal
-gross tremor -frightening visual hallucinations -confusion -hyperadrenergic syndrome -seldom occurs before 72hours post abstinence |
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What is the differential diagnosis of delirium in the alcoholic patient?
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EtOH withdrawal/DT
sepsis meningitis hypoxia hypoglycemia hepatic failure intracranial bleed |
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What medication can be considered in patients with major EtOH withdrawal or DT not responding to IV BZD?
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Haloperidol
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What are the pharmacokinetics of lorazepam?
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T1/2 7-14 hours
steady state 36-48 hours no active metabolites |
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What is the IV dosage of lorazepam in EtOH withdrawal?
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Lorazepam IV 1-4 mg q5-15min (q30-60min if IM)
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What is the differential diagnosis of EtOH related seizures?
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-Withdrawal (EtOH or drugs)
-exacerbation of idiopathic or post traumatic seizures -acute intoxication -metabolic -infectious -trauma -CVA -sleep deprivation -non compliance with anticonvulsants |
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What are criteria for discharge post alcohol related seizure?
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Normal physical exam
Normal imaging study Normal labs seizure/symptom free for 4-6hours |
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What is the management of new onset alcohol related partial seizure?
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-emergency CT scan (those with history of focal ARS do not require an emergency CT provided they return to baseline)
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What is the most common cause of status epileptics? What is the 2nd most common cause?
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-discontinuation or erratic compliance with an anticonvulsant drug regimen
-2nd -> alcohol related seizures |
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Why is lorazepam a preferable anticonvulsant to diazepam?
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It lasts several hours whereas diazepam's anticonvulsant effect lasts only 20-30 minutes
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What is the role of phenytoin in AWS?
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Phenytoin has no benefit over placebo in preventing AWS.
It is not indicated for the treatment of AWS. |
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What lab parameters suggestive of alcoholic liver disease?
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AST:ALT >1.5 suggests alcohol is the cause
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What is the earliest, mildest, most common liver change seen in alcoholism?
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Accumulation of macro vascular fat in the hepatocytes
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What is alcoholic cerebellar degeneration?
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Ataxia of the extremities (especially lower extremities)
wide-based stance uncoordinated gait |
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What is the most common infection seen in alcoholism?
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pneumonia
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What is the most common organism causing pneumonia in alcoholics?
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strep pneumonia
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Which bacterial infection is classically associated with alcoholism?
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Klebsiella pneumonia
TB spontaneous bacterial peritonitis aspiration pneumonia or lung abscess |
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Why is it difficult to differentiate between obesity, alcoholism and Cushing's syndrome?
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Because they all present with facial fullness, weakness, fatigue and easy bruising
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What is alcohol-induced hypoglycaemia?
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-seen in 1-4% intoxicated patients
secondary to -starvation -depletion of glycogen stores -decreased cortisol -impaired growth hormone release -inhibited gluconeogenesis |
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Which patient population is more susceptible to alcohol induced hypoglycaemia? Why?
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Children
Smaller glycogen stores |
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Which minerals are depleted in alcoholics?
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Mg++
Po43- Ca++ K+ Na+ |
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Should K+ and PO43- be replaced in alcoholics requiring admission?
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-empirical treatment is discouraged
-serum levels and renal function should be checked -increased K+ and increased PO43- can produce morbidity and phosphate infusion exacerbates hypocalcemia |
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Should Mg++ be repleated in alcoholics?
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As long as renal function is adequate, empirical Mg++ can be considered
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In what context does alcoholic ketoacidosis most frequently occur?
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Severe chronic alcoholics with a recent binge followed 1-3d by protracted vomiting, decreased food intake, dehydration, abstinence
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What are common presenting complaints of alcoholic ketoacidosis?
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nausea
vomiting abdo pain |
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What are findings in alcoholic ketoacidosis?
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tachypnea
dehydration ketonuria little/no glucosuria may have normal pH |
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When should you think of alcoholic ketoacidosis? How is it diagnosed?
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-In alcoholic patients with increased AG metabolic acidosis
-significant ketones in an o/w normal urine |
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What is the treatment of alcoholic ketoacidosis?
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-NS
-glucose -thiamine -correction of hypokalemia |
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What is alcoholic hepatitis?
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RUQ pain, tender enlarged liver, fever, jaundice, leukocytosis, altered LFTs
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What is cirrhosis?
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Disruption of the normal architecture of the liver by scarring and regenerating nodules of parenchyma
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What is the association of EtOH with pancreatitis?
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It is associated with acute and chronic pancreatitis
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What is the usefulness of lipase in the diagnosis of pancreatitis?
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It is a more reliable indicator of alcoholic pancreatitis, especially when it is more than 3X normal
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What are possible causes of pancreatitis?
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Alcohol
Biliary Tract Disease Hypercalcemia Hypertriglyceridemia Penetrating peptic ulcer disease Abdominal trauma reactions to various other drugs |
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At what blood alcohol level is coma rare?
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<200mg/dL (<43mmol/L)
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What are signs and symptoms of sensorimotor polyneuropathy secondary to EtOH?
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-primarily in the lower extremities
-burning pain and paresthesia -loss of light touch -decreased pin prick -decreased DTR |
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What are the criteria for diagnosis of Wernicke-korsakoff syndrome?
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2 of the following:
-dietary deficiency -oculomotor abnormalities -cerebellar dysfunction -either AMS or mild memory impairment |
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What is Korsakoff psychosis?
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-recent memory impairment
-inability to learn new info or recall previously learned info -apathy -confabulation |
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What is the treatment for Wernicke-Korsakoff
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-abstinence
-adequate diet -thiamine |
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What is the typical response to treatment for Wernicke-Korsakoff
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-ophthalmoplegia and nystagmus response in hrs to days
-ataxia and mental changes may take days to weeks <25% of patients show real recovery 50% show some recovery The remainder show no response |
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What is the most common cause of anemia in alcoholics?
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Megaloblastic anemia resulting from folate deficiency
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What are the findings in anemia of chronic disease?
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serum iron low
TIBC low to low-normal ferritin increased |
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What are the iron study findings in iron deficiency anemia
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serum iron low
TIBC increased serum ferritin low |
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How long does it take for vitamin K to reverse the vitamin K dependent factors (II, VII, IX, X)?
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6-10 hours however alcoholic patients may be unable to produce pre-coagulation factors
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What are the mechanisms by which alcohol is associated with drug interactions?
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-altered absorption
-enhanced metabolism and activated toxic metabolites through CYP 2E1 -additive/synergistic effects -disulfiram-EtOH reaction -congeners |
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What is the triad of fetal alcohol syndrome?
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CNS defects (mild to moderate mental retardation)
-dysmorphology -growth deficiencies |
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What are encapsulated bacteria?
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H influenza
pneumococcus meningococcus |
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What is the 1st immunoglobulin to appear in response to a new antigen?
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IgM
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What is important about IgG?
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It makes up 75% of total IgG
It crosses the placenta |
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What is the role of complement?
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It produces leukocytosis and inflammation and recruits leukocytes to the site of infection
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What are patients with complement deficiencies predisposed to?
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infections with s pneumo, n meningitiditis, n gonorrhea, HIB
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What infections do people with defects in CMI get?
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Intracellular bacterial infections
Mycobacterium TB Listeria Salmonella |
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What is the definition of neutropenia?
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Neutrophils <500 cells/mL or <1000 cells/mL and expected to fall to less than 500
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What is the definition of fever in the neutropenic patient?
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T>38.3 or T 38.0 or higher over 1-2 hours
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Which bacterial infections are more common in neutropenic patients in the 1st world?
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gram + - enterococcus, staph, strep
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Where does aspergillus typically produces infections?
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-lung
-sinuses |
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When should you suspect a fungal infection?
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Neutropenia with persistent fever despite 7d antimicrobial treatment
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What pathogens cause black eschar in the nose?
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aspergillus
mucor |
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What cases RLQ pain and bloody diarrhea in neutropenic patients?
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Necrotizing enterocolitis (typhlitis)
pseudomoas, clostridium or ecoli |
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What precedes viridans strep bacteremia?
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mucositis
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How does viridans strep bacteria present?
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ARDS, toxic shock like syndrome, rash and pneumonia
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Should CXR be done in neutropenic patients?
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Yes, even in the absence of symptoms if suspicion is high and CXR negative then non-contrast CT chest
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When is typhlitis usually seen?
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Acute leukemia
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What organisms may cause diarrhea in febrile neutropenia patients?
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c-diff
cryptosporidium |
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What agents can be used for mono therapy in febrile neutropenia?
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Cefepime
Ceftaxidime Imipenem Meropenem Pip--tazo (add aminoglycoside for seriously ill) |
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What are the limitations of mono therapy agents for febrile neutropenia?
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Not active against VRE or MRSA
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What can be used for febrile neutropenia in patients with beta lactam allergy?
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Aztreonam and vancomycin
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What additional coverage is needed for legionella febrile neutropenia?
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Doxycycline
Azithromycin Fluoroquinolone Erythromycin |
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What additional organism should you consider in febrile neutropenia pneumonia?
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Legionella
Pneumocystis Fungi |
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What is the treatment for penumocystis?
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TMP-SMX
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What is the treatment for fungal pneumonia in febrile neutropenia?
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Amphotericin B
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Which antimicrobials have coverage against anaerobes?
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Clinda
Metronidazole Pip tazo Imipenem Meropenem |
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When should acyclovir be added to the treatment of febrile neutropenia?
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Ulcerative lesions suspicious for herpes or varicella
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What antiviral is used for CMV?
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Gancyclovir (rare in febrile neutropenia)
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Which antibiotics is preferred if viridans?
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(mucositis is suggestive)
-carbapenem or extended spectrum penicillin |
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Should vancomycin be used in the initial therapy of febrile neutropenia?
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No, for fear of resistance
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What are indications for empirical vancomycin in febrile neutropenia?
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-Serious catheter related infection
-Gram positive blood culture -known colonization with penicillin resistance pneumococcus or MRSA -Shock -severe mucositis -institution with frequent MRSA, VRE or S mitts -fluoroquinolone prophylaxis |
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What is the drug of choice for invasive fungal infection in febrile neutropenia?
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Amphtericin B
(aspergillus and some candida are resistant to fluconazole) |
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Which patients are high risk febrile neutropenia?
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-hospitalized when it develops
-co-morbidities -acute leukemia -uncontrolled cancer -hemodynamically unstable -evidence of organ failure -presence of pneumonia, soft tissue infection, abdo pain, AMS -neutropenia expected to last >10d |
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What causes fever in solid tumor cancer patients?
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surgical infection
abscess perforation obstruction |
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Which cancers impair cell mediated immunity?
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Hodgkins disease
Non-Hodgkins lymphoma Hairy cell leukemia |
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Which patients are at highest risk for Legionella pneumonia?
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Cancer patients on high dose steroids
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What is the most common presentation of cryptococcus?
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meningitis
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What immunity is impaired in DM?
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Neutrophil/monocyte/macrophage function is impaired
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What infections are seen more commonly in diabetic patients?
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-rhinocerebral zygomycosis
-malignant otitis externa (pseudomonas) -Staph aureus and gram negative pneumonia -TB -emphysematous cholecystitis and pyelonephritis -pyelonephritis -Fournier's -psoas and epidural abscess -foot infection with osteomyelitis |
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What is substance abuse?
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Maladaptive pattern of drug use associated with some manifested harm to the user or others
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Which drugs of misuse or abuse are most commonly involved in deaths?
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Cocaine
Opiates/opioids Anti-depressants BZD Miscellaneous |
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What are co-ingestants taken with cocaine?
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Organophosphates (they decrease pseudocholinesterase and prolong the effects of cocaine)
EtOH and cocaine -> cocaethylene enhances and magnifies the effect of cocaine |
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What is "cotton fever"
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High fever
tachycardia tachypnea 10-20 min after injection |
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What is the definition of rhabdomyolysis?
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CK levels >5x the upper limit of normal
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What score is useful in detecting substance abuse in adolescents
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RAFFT
Relax Alone Friends Family Trouble |
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What elements of the history are warning signs of potential drug seeking
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Repeated visits for the same complaint
Rapid dose escalation Unusual or multiple allergies Demands for specific agents |
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What are the only positive predictors of potentially violent patients?
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Male gender
Prior history of violence Drug or EtOH abuse |
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What are the guidelines for appropriately restraining patients?
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-hospital policies and procedures guide appropriate and safe use of restraint
-the implementation of restraint or seclusion is limited to emergencies where imminent risk of harm exists to the patient or others -staff is trained and competent to apply restraints safely -staff is trained to minimize the use of restraint -orders for restraint use are provided by a physician and are time limited -patients in restraint are regularly evaluated and monitored -medical records document that the use of restraint or seclusion are consistent with organizational policy |
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What is the dose of haloperidol and the side effects?
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5-10mgIM q 30m minutes
half dose for the elderly onset 10-30 minutes |
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What are the side effects of haloperidol?
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Sedation
orthostatic hypotension EPS (treated with benztropine or benadryl) seizures |
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What is the dose of olanzapine?
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2.5-10mg IM q 2-4
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What are the side effects of olanzapine?
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QT prolongation
Anticholinergic properties EPS - less incidence that with haldol |
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What are medical problems associated with violence?
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Psychiatric
-schizo -paranoid ideation -mania -personality disorders -homosexual panic Situational frustration -mutual hostility -miscommunication -fear of dependence or rejection -fear of illness Antisocial behavior -violence with no associated medical or psychiatric explanation -delirium -dementia -trauma -CNS infection -hypoxia -hypoglycemia -EtOH -sympathomimetics -PCP -LSD etc. |
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How can you prepare the ED to prevent violence?
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Security personnel
Patient searches Alarm systems Limiting access to the ED Use a designated secure examination room Prevention Primary - control factors that encourage the development of frustration and aggression Secondary - responding to previolent behaviours Tertiary - limitation of the actual act of violence |
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Define countertransference
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The negative reaction that patients can arouse in physicians
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Define the difficult patient
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One who interferes with the physicians ability to establish a normal patient-physician relationship
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What are general strategies for dealing with difficult patients?
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Be supportive
Understand the patient's agenda Structure the interview Point out impasses Share your reactions Set limits redirect the interview Take time out Use teamwork |
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What are cognitive distortions?
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Inaccurate assumptions about patients based on prejudicial, sterotyped labels
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What are the strategies for managing negative reactions?
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Maintain appropriate emotional distance
Generate alternatives to negative reactions Attempt to understand the patients behavior as a symptom Look for cognitive distortion Find a rational response to cognitive distortions place negative reactions in perspective by viewing them in context |
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What are the 5 basic steps in crisis intervention?
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Recognize the crisis
Gather basic information Understand the development of the crisis Reproducing the peak tension of the crisis Finding the solution |
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Name the 6 commonly encountered personality disorders and their fundamental pathologic elements?
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Borderline: instability of interpersonal relationships, self- image, and affect accompanied by impulsiveness
Antisocial: violation of the rights of other with lack of remorse Dependent: excessive need to be taken care of Paranoid: distrust and suspiciousness for others Hystrionic: excessive emotionality and attention seeking Narcissistic: grandiosity, need for admiration, lack of empathy |
