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1764 Cards in this Set
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Absence of CO2 in which type of patients following intubation is not necessarily an indication of non-tracheal intubation? |
Pts in cardiopulmonary arrest
Poor gas exchange may hamper CO2 detection in the exhaled air in 25 - 40% of pts |
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After intubation, persistance of CO2 after how many breaths indicates tracheal intubation?
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After 6 manual breaths
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Can bupivocaine be buffered with bicarb to reduce the pain of local anesthetic injection?
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NO! Precipitation may result.
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If time is insufficient for full 3 min pre-oxygenation in RSI, how many vital capacity breaths prior to RSI are an adequate substitute?
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8 vital capacity breaths
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List the common amide and ester local anesthetics.
How are they metabolized? |
AMIDES (all have an 'i' in the name):
• Prilocaine • Lidocaine • Bupivicaine, Mepivicaine ESTERS: • Tetracaine • Procaine Metabolism: • AMIDE -- Hepatic microsomal enzs • ESTER -- Plasma cholinesterase enzs |
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Malignant hyperthermia is a rare complication following administration of which drug?
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Succinylcholine
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State the class of the following drugs:
• Propafol • Ketamine • Etomidate |
Propafol -- Imidazole derivative
Ketamine -- PCP derivative Etomidate -- Isopropylphenol derivative |
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What are the benefits, if any, of administering 2% lidocaine vs 1% for local anesthesia?
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2%:
• DELAYED systemic ABSORPTION • Increased concentration --> • Better anesthesia + • LONGER DURATION 1%: • Permits GREATER VOLUME to be injected --> • Greater SPREAD of anesthetic (a fxn of volume injected) --> • LARGER AREA able to be anesthetized |
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What are the cardiovascular effects of:
• Pancuronium • Vecuronium? |
Pancuronium:
• TACHYCARDIA (vagolytic) • HoTN Vecuronium: • HoTN |
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What are the sxs of lidocaine toxicity?
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An ABRUPT CHANGE in MENTAL STATUS is indicative of lidocaine toxicity.
Sx: • Drowsiness • Confusion • Slurred speach • Tinnitus • Ataxia • Vertigo • Paresthesias • Muscle twitching • Sz • Respiratory depression |
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What is the dosing of Propafol used for procedural sedation?
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Initial dose -- 0.5-2 mg/kg
Maintenance -- 0.05-0.1 mg/kg/min In practice: • Give 10-40 mg q 10 sec until desired level of sedation is achieved, then • 20 mg additional doses as needed NOTE: concentration of propafol is 10 mg/ml |
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What is the dosing, time to onset, and duration of action of ketamine for procedural sedation?
Pharmacologic adjunct to minimize secretions? |
Dosing:
• IM: 4-5 mg/kg • IV: 1.5 mg/kg Time to onset: • IM: 5 min • IV: < 1 min Duration of action: • IM: 30-120 min • IV: 15 min Give atropine or glycopyrrolate to decrease secretions |
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What is the MOST serious complication of ketamine use?
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LARYNGOSPASM
(rare, transient, and typically does not require intubation or surgical airway) |
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What is the reversal agent, if any, of pancuronium and vecuronium?
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Neostigmine, edrophonium
Atropine |
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Where is lidocaine metabolized?
Which cohort of pts are at risk for lidocaine toxicity and require dose reduction of up to 50%? |
LIVER
Pts at risk for toxicity: • Liver dz • CHF |
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Which anesthetic should NOT be use with children with suspected ICP?
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KETAMINE -- it increases cerebral blood flow and can increase ICP
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Which local anesthetic class, amide or ester, is more commonly associated with allergic reaction?
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ESTER
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Which local anesthetics can cause methemoglobinemia?
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• Prilocaine
• Benzocaine |
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A-FLUTTER
What drug may be of diagnostic value? How should rate be controlled? What meds are used for chemical conversion? |
Diagnosis: Adenosine b/c the transient AVN block may reveal the flutter waves.
Rate Control: Same as with afib. Ca Ch Bl or ß-Bl. Conversion: Procainamide or quinidine |
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A normal, upright T wave represents ventricular repolarization in which direction?
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EPIcardium to ENDOcardium
(out --> in) |
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A side effect of heparin and LMWH is thrombocytopenia. What is the drug of choice in pts at risk for HIT?
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Hirudin -- it has a low risk of thrombocytopenia
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Bradycardia is often secondary to what type of MI?
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Inferior wall MI
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By what means does morphine work in the tx of ACS and/or CHF pts?
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Morphine:
• Calms the pt --> • Decr catecholamine levels --> • Reduces myocardial O2 consumption --> • Reduces incidence of fatal dysrhythmias Morphine also directly reduces preload and afterload (mildly) |
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By what mechanism does cocaine cause MI?
Why are ß-blockers (relatively) contraindicated? |
Mechanism of MI:
• Hyperaggretory platelets • Vasospasm ß-Blockers contraindication: • Theoretic risk of reducing cardiac output in face of increased peripheral vascular resistance |
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Cardiac Enzymes: State the time to rise, peak and remain elevated for CK and Troponin
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CK:
• Rise; 4-8 hrs • Peak: 12-24 hrs • Remains Elevated: 3-4 days Troponin: • Rise: 6 hrs • Peak: 12-18 hrs • Remains Elevated: 7-10 days |
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Compare and contrast post-MI pericarditis with Dressler's syndrome.
• Etiology • When seen • EKG changes |
Post MI pericarditis:
• Due to pericardial inflammation • Seen 2-4 days post-MI • EKG changes are MASKED by the evolving EKG changes of the MI Dressler Syndrome: • Autoimmune • Seen 1 week to months post-MI • EKG findings typical of pericarditis |
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Compare and contrast the differences between left- and right-sided endocarditis. Which valves are typically affected?
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Left-Sided Endocarditis:
• SYSTEMIC vascular involvement (whole body) • MV most commonly affected • Seen in acquired and congenital valve dz Right-Sided Endocarditis: • PULMONARY vascular involvement • TRICUSPID valve most commonly affected • Seen in IVDU |
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Decribe the protocol for the use of IV NTG, Nipride, Dopamine, Dobutamine and NE in the management of HoTN in the treatment of acute pulmonary edema
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SP > 100 (no s/s shock):
• IV NTG at 10-20 mcg/min. Titrate up 5-10 mcg/min q 5 min until desired effect, or SP < 100 • Nipride 0.1-5 mcg/kg/min • Nipride is reserved for pts with SP > 100 who fail to respond to the standard doses of NTG/ Lasix/ morphine SP 70 - 100 (no s/s shock): • Dobutamine 2 -20 mcg/kg/min • Use with an IV vasodilator SP < 70, with obvious shock: • NE 0.1-0.5 mcg/kg/min |
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Describe orthodromic and antidromic tachcardia in the setting of WPW, and their significance
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Orthodromic Tachcardia: Anterograde conduction through the AVN with retrograde conduction thru the B of K. Will have a NORMAL EKG.
Antidromic Tachycardia: Anterograde thru the B of K, retrograde thru the AVN. Here the restraining effect of the AVN is bypassed, the QRS will be wide, and ventricular rates can exceed 300 leading to Vfib, especially in the setting of afib. |
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Describe the beneficial physiologic effects of ß-blockers
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• Decr HR & contractility --> decr myocardial O2 demand
• Incr time of diastole --> decr myocardial wall tension --> incr coronary blood flow • Decreases the rate of myocardial RUPTURE • Decreases rate of fatal DYSRHYTHMIAS, including Vfib |
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Describe the clinical characteristics of pts with Idiopathic Dilated Cardiomyopathy
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• Sx of left heart failure
• Sx of right heart failure • Systolic dysfunction • Signs of peripheral EMBOLIZATION (acute neurological deficit, flank pain/ hematuria, abdominal pain, pulseless cyanotic extremity) |
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Describe the clinical findings and ETIOLOGY of catecholamine-induced hypertensive crisis.
Foods? |
Sx:
• HA • Palpitations • Sweating • Tachycardia Causes: • Pheochromocytoma (adrenal tumor) • Cocaine intoxication • Acute CLONIDINE WITHDRAWAL • Concomitant MAOI + sympathomimetic agent use [Sympathomimetics: • Tyramine (Chianti wine, aged cheese, beer, pickled herring, chicken liver) • Ephedrine, PPA] |
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Describe the clinical picture of a patient with ACUTE digoxin toxicity (i.e., OD)
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• Young age/ child, o/w healthy
• Acute OD of digoxin • Hyperkalemia • Very high digoxin level • Brady dysrhythmia • AVB |
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Describe the clinical picture of a patient with CHRONIC digoxin toxicity
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• Elderly
• H/o CAD • H/o chronic renal insufficiency • On a diuretic • Normal or low potassium • Normal or low digoxin level • Ventricular dysrhythmia |
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Describe the clinical profile of Hypertrophic Cardiomyopathy (HCM):
Sx? Relieved by? |
• Syncope/ Near syncope
• Sudden DEATH These sx arise 2° to atrial and ventricular dysrhythmias, often during exercise • DOE • CP poorly relieved w/ NTG • CP relieved by lying down is pathognomonic for HCM (but rarely seen) • Palpitations (atrial and ventricular dysrhythmias) |
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Describe the defining characteristics of Idiopathic Dilated Cardiomyopathy (IDC). What is the most common etiology?
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Characterized by:
• Dilation of all 4 chambers • Hypertrophy • SYSTOLIC pump failure Highly associated with VIRAL myocarditis |
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Describe the difference in mechanism of action between NTG and Nipride
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NTG:
• Vasodilator --> decreases preload --> decreases cardiac output • Dilates coronary arteries --> increases coronary blood flow Nipride: • Mixed venous AND arterial dilator --> decreases preload and afterload --> decreases cardiac output |
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Describe the EKG changes in POSTERIOR MI and the associated arterial occlusion.
Isolated posterior MIs are rare. With which other MI is it typically associated? |
Left circumflex occlusion, OR
RCA • ST elevation in V8 and V9 • ST depression and tall R in I, aVL, V1 - V4 (especially V1 and V2) • UPRIGHT T waves (opposite of T wave inversion seen with other infarcts) Posterior MIs typically occur in conjunction with ANTERIOR or LATERAL MIs. |
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Describe the EKG findings in an ANTERIOR MI and the associated artery that is occluded.
Blocks? Pacing? |
LAD occlusion
• ST elevation in I, aVL, V1-V4 • Reciprocal ST depression in II, III and aVF LAD supplies blood to the right bundle and the left anterior fascicle. Thus, NEW RBBB and NEW ANT FASCICLE block suggests LAD occlusion. TEMPORARY PACING is required. |
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Describe the EKG findings in Hypertrophic Cardiomyopathy
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• Septal Q waves > 0.3 mV
• Afib • PVCs Note: The dx of HCM should be considered in any young person with EKG findings suggestive of MI but who does not have a h/o MI |
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Describe the EKG findings in INFERIOR MI and the associated arterial occlusion.
Blocks/ dysrhythmias? |
RCA occlusion
• ST elevation in II, III, aVF • ST depression in I, aVL, V5, V6 Inferior MI predisposes to vagal dysrhythmias (sinus bradycardia and AVB) Note: The EKG changes are exactly reciprocal to anterior MI. |
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Describe the EKG findings in LATERAL MI and the associated arterial occlusion
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LAD/ Left circumflex occlusion
• ST elevation I, aVL, V5, V6 • ST depression in V1, V3R, V4R Lateral MI pts are at risk for developing LV dysfunction |
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Describe the EKG findings in RV MI and the associated arterial occlusion.
What are the typical CV sequalae? |
RCA occlusion
• ST elevation in V3R and V4R RV MI pts are at great risk of developing HoTN and cardiogenic shock. HoTN in this setting will likely respond to IVF; morphine, nitrates and diuretics will further compound the HoTN Note: most RV MIs occur in association with an inferior MI |
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Describe the EKG findings in WPW
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• Short PR
• Delta wave • Wide QRS Note: WPW should be suspected in anyone presenting with a ventricular rate > 200 |
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Describe the EKG findings of Hypercalcemia
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• Shortening of the QT (most reliable finding); nearly always seen when Ca > 13
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Describe the EKG findings of Hyperkalemia
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• Peaked T (early finding)
• QRS widening • Sine Wave (late finding; blending of QRS and T) • Prolonged PR |
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Describe the EKG findings of Hypokalemia.
Hypokalemic pts are more susceptible to which med toxicity? |
• U wave (best seen in V3)
• Flattened T wave (early) followed by inversion (later) • ST depression • Prolonged PR and QT NOTE: Pts are more susceptible to digitalis toxicity with hypokalemia |
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Describe the EKG findings of Hypothermia
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• J Wave
• Prolonged PR • Prolonged QRS • Prolonged QT • Dysrhythmias: sinus brady and afib |
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Describe the EKG findings of Junctional Premature Contractions
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• P is usually inverted in II, III, and aVF
• P wave may occur before, during, or after the QRS • The SA node is not reset, and the next P wave occurs at its usual time |
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Describe the EKG findings of RBBB
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• Wide QRS
• RSR' in V1 • Broad terminal S in lateral leads (I, aVL, V5, V6) • Broad terminal R in aVR • T wave INVERSION (T wave deflection opposite the terminal half of the QRS) and ST depression in V1, V2, V3 |
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Describe the EKG findings of thoracic aortic dissection
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Up to 40% of pts with thoracic aortic dissection have EKG findings c/w AMI/ ischemia
INFERIOR wall pattern is the most common since this involves the RIGHT coronary artery MI pts w/ clinical findings suggestive of thoracic aortic dissection should have a CT or TEE to r/o TAD. |
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Describe the EKG findings w/ Brugada Syndrome.
Why is it bad? Tx? |
Autosomal dominant dz characterized by:
• RBBB • ST elevations in V1 - V3 w/ characteristic down-slope shape • Predisposition to degrade into VFIB Tx: AICD |
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Describe the EKG findings with Digitalis use. QT?
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• Hockeystick ST segment, with concavity directed upwards
• Short QT • Flat or inverted T NOTE: these EKG findings are NORMAL in pts on dig and do not indicate toxicity |
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Describe the EKG findings with LBBB
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• Wide QRS
• LAD • Broad monophasic R in I, V6 • Deep, wide S in V1, often w/o any R • ST depression and T wave inversion opposite the direction of the main QRS in most leads (esp the lateral leads) (rule of Appropriate Discordance) • The normally present small septal Q waves in I, aVL, V5, V6 are absent |
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Describe the EKG/ rhythm findings of Hypomagnesemia
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Ventricular dysrhythmias ( PVC, VTach, Torsades, Vfib)
Essentially same findings as with HYPOKALEMIA, except no U wave: • Prolonged PR & QT • ST depression • Flat or inverted T |
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Describe the heart sounds of HCM and associated provocative maneuvers
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• S4 gallop
• Prominent SEM from LV outflow obstruction and MR The SEM is increased w/ maneuvers that DECREASE LVEDV (eg, Valsalva, exercise...) |
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Describe the murmur of MITRAL regurgitation, acute and chronic
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Acute:
• Holosystolic, late systolic, or crescendo-decrescendo Chronic: • Holosystolic |
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Describe the murmur of MVP and associated provocative maneuvers
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• Late systolic murmur heard best at apex; CLICK
Decreased ventricular volume (VALSALVA) --> • Greater prolapse • INCREASED duration of murmur Increased ventricular volume (SQUAT) --> • DECREASED duration of murmur |
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Describe the pain of thoracic aortic dissection. Match the pain location to the dissection site.
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Pain:
• Abrupt onset • Maximal from onset • Tearing or ripping quality • Pain migrates as dissection propagates Ascending Dissection: • Ant CP radiating to neck/ jaw/ arm Arch Dissection: • Neck and jaw pain Descending Dissection: • Interscapular back pain radiating into abdomen or lumbar area |
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Describe the pathophysiology of thoracic artery dissection.
What factors control its propagation? |
Pathophysiology:
• Intimal tear --> blood leaks into the media --> cleaves it longitudinally from the adventitia Propagation dependent upon: • Blood pressure • Steepness of the pulse wave (rate of change in pressure/time) |
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Describe the significance of isolated Q waves without ST or T wave changes
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Isolated Q waves may be due to an old MI in the presence of LBBB. However, Q waves in I, AVL, V5 and V6 suggest AMI.
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Describe the sx and physical exam findings of pericarditis
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Symptoms:
• Precordial or retrosternal CP, worse w/ inspiration • Sx RELIEVED sitting up and leaning forward • Radiation of pain to the TRAPEZIUS muscle ridge, esp on the left • Dyspnea, low grade fever PE: • Pericardial friction rub is pathognomonic • Friction rub best heard sitting up and leaning forward |
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Describe the use and mechanism of DOPAMINE in pulmonary edema pts
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Dopamine:
• DA increases SVR and cardiac output • In pulmonary edema pts in SHOCK, give on arrival PRIOR to venodilating agents and diuretics. Must also use an IV venodilator with DA after BP stabilized. • Dose is 5-15 mcg/kg/min |
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How are the following antihypertensive drips dosed?
• Nitroglycerine • Nipride • Labetolol • Esmolol • Vasotec (enalapril) • Cardene (nicardipine) |
Nitro:
• Start 5 - 20 µg/min • Titrate to 100/min Nipride: • 0.25 - 10 µg/kg/min Labetolol: • Start 0.25 mg/kg • May double dose q 10-15 min (max 2 mg/kg) Esmolol: • 500 µg/kg over 1 min, then 50 - 300 µg/kg/min Vasotec: 1.25 - 5 mg over 5 min Cardene: • Start 2 - 4 mg/hr • Increase 1-2 mg/hr q 15 min (max 15 mg/hr) |
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How can Restrictive Cardiomyopathy be differentiated from Constrictive Pericarditis?
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RC has a gallop rhythm and Kussmal's sign (JVD on inspiration). CP does not.
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How does hydralazine work as an antihypertensive?
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• ARTERIAL vasodilator
• Afterload reducer |
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How does the ST elevation of pericarditis differ from AMI?
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Pericarditis -- CONCAVE ST elevation
AMI -- Convex ST elevation |
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How is CHF treated in myocarditis? What med is particularly beneficial?
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Tx CHF with the usual protocol. Note:
• Digoxin should be used w/ caution as the inflamed myocardium is very sensitive to it • ACE-I are particularly BENEFICIAL -- they decrease cellular necrosis and inflammation |
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How is D-Dimer used in the diagnostic algorhythm for PE?
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The utility of D-Dimer is that LOW pretest probability + LOW D-dimer = NO PE.
PE Algorhythm: Determine Wells Score: • <= 4 equals low prob • > 4 equals high prob • Low prob + Neg D-dimer = no PE • Low prob + high D-dimer --> CT chest • High probability Wells --> CT Chest • Neg chest CT = no PE • Pos chest CT = PE Note: there is no role for D-dimer testing in pts with high probability PE. Go straight to CT! |
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How likely is it to hear a new heart murmur in IVDU endocarditis?
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Murmur LESS LIKELY to be heard given that the tricuspid valve is difficult to hear
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How should NTG-induced reflex tachycardia be treated?
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ß-blockers
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How should PVCs be treated? What about bradycardia with PVCs (Escape PVCs)?
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Treatment is aimed at correcting the underlying dx. DO NOT treat ASX patients with PVCs of unknown cause!
Brady + PVC: DO NOT give lidocaine! This may suppress the pt's only rhythm. Tx with ATROPINE. |
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In a digoxin-toxic pt, what is the utility of repeat digoxin levels after dig-Fab fragments have been given?
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NONE.
The digoxin assay will measure the Fab fragments along with the digoxin and report a falsely elevated value. |
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In MI pts presenting to a non-PCI hospital, transfer to a PCI-capable hospital within how many hours of presentation improves outcome over thrombolysis alone?
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2 hours
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In patients who present in afib with a ventricular rate greater than 200, what diagnosis should you consider, and why?
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WPW
The AVN does not conduct impulses faster than 150 - 180 bpm. Thus any rate > 200 suggests accessory pathway conduction. |
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In patients with evidence of hyperkalemia in EKG, what guides the decision to use calcium gluconate or calcium chloride?
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Calcium chloride provides 3x the elemental Ca than calcium gluconate, but it can cause significant TISSUE NECROSIS if extravasation occurs.
Ca Chloride should only be used through a LARGE-BORE CENTRAL VENOUS CATHETER. |
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In patients with VTach, what element of the EKG should specifically be checked to r/o Torsades? What is the treatment?
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VTach + QT prolongation should be assumed to be Torsades.
Initial treatment of torsades is with magnesium. Tx sustained torsades with cardioversion; begin with 200j. |
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In patients with wide complex tachycardia, what is the drug of choice, and why?
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AMIODARONE
Pts with wide complex tachycardia should be presumed to be in VTach. If they are stable, they should be converted with amiodarone b/c amio converts BOTH SVT and VTach. Presuming that a wide complex tachcardia is SVT with aberancy and then treating with Ca Ch Bl can be VERY HARMFUL. Ca Ch Bl administered to wide complex tachycardias accelerate the HR, drop the BP, and do not convert the rhythm. |
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In pts with thoracic aortic dissection, what is the mechanism of disparate BP readings in left and right upper extremities?
How often is this seen in aortic dissection? |
Mechanism -- Unilateral extension of the dissection into the subclavian artery.
Occurs in a MINORITY of cases of TAD. |
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In the rate control treatment of afib in a patient with compromised LV fxn (EF < 40%), which are the drugs of choice?
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• Diltiazem
• Amiodarone • Digoxin These drugs do not promote further depression of cardiac function (in contrast to calcium channel blockers and ß-blockers) |
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In the setting of ACS, which thrombolytic drugs should not be given w/ heparin?
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Contraindications:
• Do not give with APSAC • Do not give with streptokinase |
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In which cohort of pts is a DECREASED BNP seen?
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Obese pts
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In which medical conditions other than thrombosis can the D-Dimer test be positive?
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• AMI
• CVA • Trauma • Post-op • Elderly • Pregnancy |
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In which vessel is a transvenous pacer typically inserted?
Is it safe for physical contact to be made with a pt who is being paced? |
Right internal jugular
YES, it's safe to touch the pt |
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In WPW patients in afib, which rate control meds should be AVOIDED?
What are the drugs of choice? |
Contra-Indicated:
• Calcium channel blockers • ß-Blockers • Digoxin • Adenosine These agents block AVN conduction and consequently predispose to conduction down the accessory pathway --> increase in ventricular response --> Vfib Drugs of choice: • Procainamide (prolongs the refractory period of the accessory pathway) • Amiodarone |
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Other than chest pain, what organ-based sxs do pts with thoracic aortic dissection present with?
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Neuro:
• CVA-like sx • Visual changes • Syncope • Acute paraplegia Vascular: • Cold, PULSELESS extremity • AMI (if coronary ostia involved) GI -- MESENTERIC ISCHEMIA GU: • Flank pain • Hematuria |
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Regarding pressor therapy, state the pressors in order from predominantly alpha to beta effects
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Mostly ALPHA:
1 Phenylephrine 2 Levophed 3 Epinephrine MIXED alpha/ beta: 4 Dopamine Mostly BETA: 5 Dobutamine 6 (Milrinone -- Phosphodiesterase inhibitor) 7 Isoproterenol |
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Rheumatic fever causes which valvular diseases?
Which dz does it cause over 90% of all cases? |
• Mitral stenosis (> 90%)
• Mitral reguritation, chronic • Aortic stenosis • Aortic regurgitation, chronic • Tricuspid stenosis • Tricuspid regurgitation |
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State several causes of PVCs. Lytes?
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MI/ ischemia (most common)
Hypoxia CHF HYPOkalemia HYPOmagnesemia Hyperthyroidism Digoxin toxicity |
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State some precipitating factors of CHF.
Meds? |
• Hypoxia (eg, PE, pneumonia)
• COPD • MI/ ischemia • Severe HTN • TachyDYSRHYTHMIAs • Acute myocarditis or endocarditis • ß-blocker or Ca channel blocker use (w/ impaired cardiac fxn) • Dietary Na overload |
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State the 2 major thoracic aortic dissection classification systems
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• Debakey Type I (MOST COMMON) -- Ascending and descending aorta
• Debakey Type II -- Ascending only • Debakey Type IIIA -- Descending only (entirely above diaphragm) • Debakey Type IIIB -- Descending only (dissection traverses diaphragm) • Stanford Type A -- Ascending only (Debakey I and II) Stanford Type B -- Decending only (Debakey Type III) |
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State the 3 most common sources of arterial emboli
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• 1 -- A-fib
• 2 -- MI • 3 -- HIT (Heparin-induced thrombocytopenia with thrombosis) |
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State the ABSOLUTE contraindications to thrombolysis.
Suspicion of...? |
• Any h/o prior brain bleed
• Known structural CNS lesion (eg, AVM, tumor...) • Ischemic CVA w/in 3 mos (unless TIA < 3 hr) • Suspicion of AORTIC DISSECTION • Active bleeding or bleeding disorders |
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State the AHA Class I (ie, tx benefit positively established) criteria for thrombolysis
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• ST elevation > 0.1 in 2 or more contiguous leads
• Time to tx </= 12 hrs • Age < 75 •Old BBB obscuring ST segment analysis with hx suggesting AMI |
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State the AHA Class IIa (ie, likely benefit) criteria for thrombolysis
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• ST elevation > 0.1 in 2 or more contiguous leads
• Age > 75 |
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State the AHA Class IIb (ie, may be beneficial) criteria for thrombolysis
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• ST elevation > 0.1 in 2 or more contiguous leads
• Time to tx between 12 - 24 hrs • SP > 180 or DP > 110 associated with high risk of MI |
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State the AHA Class III (ie, tx NOT indicated, may be harmful) criteria for thrombolysis
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• ST elevation with time to tx > 24 hrs
• ST depression only • No ST elevation • POSTERIOR MI • Presumed NEW BBB |
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State the beneficial effects of NTG in the setting of AMI
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• Dilates collateral coronary vessels
• Has antiplatelet effects Decreases myocardial O2 demand by: • Decreasing preload • Decreasing LV end diastolic volume • Decreasing afterload (which makes it the drug of choice in pts with LV failure) |
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State the blocks associated w/ INFERIOR MI. How are they treated?
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• 1st degree AVB
• Mobitz Type I These blocks are associated with increased vagal tone. They respond to ATROPINE. |
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State the blocks associated with ANTERIOR MI. Cause? Tx?
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Mobitz Type II:
• Generally due to destruction of the infranodal conduction tissue. Sudden progression to complete block may occur • Tx with prophylactic pacemaker BBB: • BBB + ant. MI pts are more likely to develop CHF, AVB, and Vfib. • RBBB + acute anterior MI = higher risk of developing complete heart block and cardiogenic shock |
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State the cardiovascular benefits and mechanism of action of ASA
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Benefits:
• Reduces the risk of AMI • Decreases mortality • Decreases infarct size • Decreases rate of reinfarction Mechanism: irreversibly acetylates platelet cyclo-oxygenase |
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State the causes of LV failure
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• Ischemic heart dz (most common)
• DILATED cardiomyopathy • HTN • Mitral or aortic valve dz • High output states • Coarctation |
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State the causes of myocarditis
|
Viral (most common cause):
• Coxackie • Echo • Adeno • EBV Bacterial: • ß-hemolytic strep (Rheumatic Fever) • Borrelia burgdorferi (Lyme Dz) • Mycoplasma • Neisseria Parasites: |
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State the causes of pericarditis
|
Most common causes:
• IDIOPATHIC • VIRAL (coxackie, echo, adeno, EBV...) Malignancies, metastatic: • Leukemia, lymphoma, lung, breast, melanoma Systemic illnesses: • RA • Rheumatic fever, acute • SLE • Scleroderma • Sarcoidosis Medications • Procainamide • Hydralazine • Anticoagulants Other: • AMI • Dressler's syndrome • Posttraumatic --> Constrictive pericarditis • Uremia • Bacterial pericarditis |
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State the causes of RV failure
|
• LV failure
• Pulmonary arterial HTN (+ RVF = cor pulmonale) • RESTRICTIVE or INFILTRATIVE cardiomyopathy • Myocarditis • MI • PE • COPD • Tricuspid/ pulmonic dz |
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State the clinical end-organ presentations seen in hypertensive emergency
|
• Hypertensive encephalopathy
• CVA, SAH • Aortic dissection • Acute pulmonary edema • AMI/ Ischemia • Eclampsia • Acute renal insufficiency |
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State the contraindications to Calcium Channel Blocker use
|
Do not use concomitantly with:
• IV ß-Blockers • Afib + WPW • Wide QRS tachycardias • SSS • Digoxin toxicity • Advanced AV Block In wide complex tachcardias such as VTach (stable), Ca Ch Blockers accelerate the HR, drop the BP and do not convert the rhythm. |
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State the contraindications to ß-blockers in the setting of ACS
|
• Moderate to severe LV dysfxn (CHF)
• HR < 60 • SP < 100 • Active bronchospasm • 2nd or 3rd degree AVB • PR > 0.24 |
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State the dosing of the following pressors:
• Dopamine • Dobutamine • Levophed Propofol for vent sedation? |
Dopamine:
• 2 - 20 µg/kg/min • DA effects: 2-5 • ß effects: 5-10 • Alpha effects: > 10 Dobutamine: • 2.5 - 20 µg/kg/min Levophed: • 0.5 - 10 µg/min (max 30/min) Propofol: • 5 - 50 µg/kg/min |
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State the drugs and electrolyte disorders that increase the QT interval and predispose to Torsades
|
DRUGS ('PhLAT Class'):
• Phenothiazines • Lithium • Antifungals + Emycin; Amiodarone • TCAs • Class IA Antidysrhythmics -- Procainamide, Quinidine • Class IC Antidysrhythmics -- Flecanide, Propafenone ELECTROLYTES: • Hypokalemia • Hypomagnesemia |
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State the drugs or drug class that constitute the following antiarrhythmic classes:
• Class IA • Class IB • Class IC • Class II • Class III • Class IV |
Class IA:
• Procainamine, Quinidine Class IB: • Lidocaine, Dilantin Class IC: • Flecainide Class II -- ß-blocker Class III -- AMIODARONE Class IV -- CCB |
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State the EKG rhythm findings associated with mitral valve prolapse.
What is NOT seen? |
PALPITATIONS, from:
• PACs • PVCs • Paroxysmal SVT ST segment depression in the inferior leads NOT seen -- afib |
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State the mechanism of action, INDICATIONS for, and contra-I to Glycoprotein IIb/IIIa receptor antagonists
|
Mechanism: Block the final common pathway of platelet aggregation in the presence of platelet activation
Indications: • In pts about to go to cath, give prior to the cath • ACS + refractory sxs • Confirmed NSTEMI • Elevated troponin level G IIa/IIIb antagonists are contraindicated post-cath! |
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State the RELATIVE contraindications to thrombolysis
|
• Severe HTN on admission > 185/110
• Traumatic/ prolonged CPR (> 10 min) • Major SURGERY or internal bleeding w/in 3-4 WEEKS • Pregnancy • Coumadin use • PUD (active) |
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State the risk factors for AAA
|
• Advanced age
• Male • FHx • Smoker • HTN • CAD • PVD • Hypercholesterolemia |
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State the specific complications associated with:
• TPA • SK • APSAC What complication is common to all thrombolytics? |
TPA: cerebral hemorrhage
SK: HoTN, allergic phenomena APSAC: HoTN, allergic phenomena Reperfusion dysrhythmias are common to all thrombolytics (incidence > 50%) |
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State the Stage 1 - 4 EKG changes in pericarditis
|
Stage 1:
• Diffuse ST segment elevation w/ upward concavity (all leads except aVR, V1) • ST depression in aVR, V1 • PR DEPRESSION (v. specific) most prominent in lead II; v. early sign Stage 2: • Hyperacute T waves Stage 3: • ST becomes isoelectric Stage 4: • T wave inversion |
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State the temporal sequence of EKG changes in STEMI
|
1 Hyperacute T waves
2 ST elevation 3 T-wave inversion 4 Q waves |
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State the timing of, and contraindictions to, ACE-I in ACS
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ACE-I, when given w/in the 1st 24 hrs, decrease the incidence of ventricular dysfxn and death. ACE-I should not be given until 6 hrs after initial ACS tx has begun; may potentiate HoTN.
Contraindications: • Class III or IV heart failure • HoTN • Cr > 2.5 • Renal artery stenosis |
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State the toxic side effects of Ticlid that make Plavix a better choice of ADP platelet activation inhibitors
|
Agranulocytosis
Thrombocytopenia |
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State what happens to the pulse pressure in:
Aortic stenosis Aortic regurg -- Acute Aortic regurg -- Chronic |
Aortic Stenosis -- Narrowed
Aortic Regurg, Acute -- Nl Aortic Regurg, Chronic -- Wide |
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The causes of endocarditis vary with the TYPE of valve involved and presence of IVDU. State the causative organisms for:
• Native valve • Prosthetic valve • IVDU |
NATIVE valve:
• VIRIDANS strep (most common, per Sanford) • Non-viridans strep • Staph aureus • Enterococci PROSTHETIC valve: First 60 days post-op: • Staph aureus/ epidermis • Gram-neg and fungi After 60 days post-op: • Same as for native valve IVDA: • Staph aureus • Strep species • G-neg bacilli |
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What anatomical landmark is used to distinguish ascending from descending dissecting TADs?
|
Distal to the LEFT SUBCLAVIAN ARTERY = desecending
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What antidysrhythmic should NOT be used in the management of Mobitz Type II AVB? Why?
How does this differ from the treatment of Wenckebach and narrow complex 3rd degree AVB? |
Do not use ATROPINE in Type II. Atropine can:
• increase the HR --> • increase the AVB --> • decrease the ventricular response rate --> • decrease BP Atropine is OK and warranted for bradycardia in Wenckebach and NARROW complex 3rd degree AVB. Do not use atropine in WIDE complex 3rd degree AVB! |
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What are Libman-Sachs vegitations, and with which condition are they associated?
Where are they found? |
NON-INFECTIOUS, autoimmune vegitations found on the MITRAL valve in SLE pts
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What are the 6 immediately life-threatening diagnoses that must by ruled out in chest pain patients?
|
• ACS
• Tension pneumo • Thoracic aortic dissection • Tamponade • PE • Esophageal rupture |
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What are the cardiac findings seen in the 2nd stage of Lyme disease?
|
FLUCTUATING AVB that may present as SYNCOPY and may require temporary pacing
• Develops 4 wks after bite Myocarditis |
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What are the causes and signs of prosthetic paravalvular leak?
|
Immediately post-op -- suture disruption
Delayed -- endocarditis Signs: Sudden onset of: • Pulmonary edema • Severe HEMOLYTIC ANEMIA --> elevated LDH |
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What are the clinical characteristics of Restrictive Cardiomyopathy?
|
Sx of both right and left-sided heart failure
Note: Sx are very similar to Idiopathic Dilated Cardiomyopathy, but RIGHT-sided CHF sxs predominate |
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What are the clinical findings of thoracic aortic dissection?
• BP • Skin • Pulses • Murmur |
BP:
• Ascending aorta: Nl or decreased • Descending: Increased • 20 mm difference in arms Cool, clammy skin despite elevated BP Unequal or absent pulses (hallmark of dissection) Aortic insufficiency murmur (w/ Type A) Cardiac tamponade (Type A) |
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What are the current indications for thrombolytics in the setting of PE? What med should be given immediately following administration of thrombolytics?
|
• Hemodynamic instability w/ confirmed PE
• Hemodynamic instability in pts w/ strong clinical suspicion of PE, and RV dysfxn by echo • Stable pts with RV DYSFXN and confirmed PE Give full dose HEPARIN immediately following thrombolytics. |
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What are the CXR radiographic signs of PE?
|
Hampton's Hump -- a triangular pleural-based density with a rounded apex that points toward the hilum
Westermark's Sign -- Dilation of the pulmonary vessels proximal to the embolus, with oligemia distally Elevated hemidiaphragm |
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What are the defining cardiac structural characteristics of Hypertrophic Cardiomyopathy (HCM)?
|
HCM is characterized by LEFT ventricular hypertrophy (LVH) WITHOUT associated ventricular dilatation.
The hypertrophy is asymmetric (SEPTUM > free wall) • Atrial dilatation • Nl ventricle size • Impaired diastolic relaxation • Restricted LV filling |
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What are the defining characteristics of Restrictive Cardiomyopathy?
|
DIASTOLIC restriction of ventricular filling:
• end diastolic volume is low • end diastolic ventricular pressure is high • cardiac output is decreased Note: This clinical picture mimics CONSTRICTIVE PERICARDITIS |
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What are the drugs of choice for SVT due to Digoxin Toxicity?
|
• Mag sulfate
• Phenytoin • Lidocaine |
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|
What are the echo and cardiac enzyme findings in myocarditis?
|
Echo:
• Dilated chambers (similar to Idiopathic Dilated Cardiomyopathy) • Either diffuse hypokinesis or focal wall motion abnormalities Cardiac Enzymes: • Rise and fall SLOWLY over a period of days, unlike the rapid rise of AMI |
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What are the echo findings in Restrictive Cardiomyopathy?
|
• Thickened walls
• Normal ventricular cavity • Moderate to markedly dilated atria |
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What are the EKG findings in PE?
|
Evidence of Right heart strain:
• P pulmonale (peaked P in lead II) • LAD or RAD • S1Q3T3 • Afib • RBBB |
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|
What are the EKG findings of pericardial tamponade?
|
Low voltage QRS (non-specific finding)
Total ELECTRICAL ALTERNANS: • Defn: beat to beat alternating pattern primarily affecting the QRS that occurs from shifting pericardial fluid and heart position • PATHOGNOMONIC for pericardial tamponade |
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What are the empiric abx regimens for native and prosthetic endocarditis?
|
Native:
• PCN + • Nafcillin/ oxacillin + • Gent OR • Vanc + gent (in PCN allergic) Prosthetic: • Vanc + • Gent + • Rifampin |
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What are the first-line agents of choice for rate control in pts in afib with normal heart function?
|
• Calcium channel blockers
• ß-blockers Of these, diltiazem is the agent of choice because of its rapid onset and fewer negative inotropic effects. |
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|
What are the indication for a Greenfield Filter in pts w/ DVT?
|
Proximal LE DVT +:
• Contraindication to drug tx • Urgent surgery rqd that precludes anti-coagulation • Medical tx failure |
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|
What are the indications for EMERGENT temporary cardiac pacing?
|
• Hemodynamically unstable bradycardia
• Bradycardia assoc with malignant escape rhythms that fail to respond to meds • Overdrive of refractory tachydysrhythmias • EARLY brady-asystolic arrest (w/in 10-20 min) |
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|
What are the indications for temporary cardiac pacing in the setting of acute MI?
|
• Mobitz II
• 3rd degree AVB • New or age-indeterminate LBBB or RBBB |
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|
What are the indications for thrombolytics in pts with DVT?
|
UNCLEAR!
Thrombolytics are usually reserved for: • < 60 yo w/ massive or limb-threatening iliofemoral thrombosis • Upper extremity DVT w/ sx for < 1 wk and low risk of bleeding |
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|
What are the ophthalmologic, cutaneous, and neurologic findings of endocarditis?
|
Ophtho:
• Conjunctival hemorrhages • Roth spots (retinal hemorrhage w/ central clearing) Cutaneous: • Splinter hemorrhages • Osler's nodes -- TENDER erythematous nodules on fingertips • Janeway lesions -- NONTENDER erythematous macules on fingers, palms, soles • Petichiae Neuro: • Focal motor deficits • AMS |
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|
What are the physical exam findings in AAA?
|
Pulsative mass in epigastric area (seen in 77% of pts w/ ruptured AAA)
Abdominal or femoral BRUITS Distal extremity ischemia |
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|
What are the physical exam findings of CHRONIC aortic regurgitation?
|
'Duz Austin's Quick Muscle Car Blow?'
• Duroziez's murmur -- singsong murmur over femoral artery • Austin-Flint murmur -- presystolic or mid-diastolic murmur • Quincke's pulse -- prominent nail pulsations • deMusset's sign -- head bobbing w/ each beat • Corrigan's (Water-Hammer) pulse -- rapid upstroke, dramatic collapse • High-pitched decrescendo diastolic BLOWING murmur (sine qua non) |
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What are the primary symptoms of MVP?
What symptoms are NOT seen? |
Most common sxs:
• Chest pain • Palpitations NOT SEEN -- sxs of heart failure |
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|
What are the risk factors for infectious endocarditis?
|
• Prosthetic valves
• Congental valve dz (eg, MVP) • Acquired valve dz (eg, RF) • IVDA • Indwelling venous catheters • Extensive BURN injury |
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|
What are the risk factors for thoracic aortic dissection?
|
• HTN (most common)
• Cocaine/ Methamphetamine use (causes HTN ) • Connective tissue dz (Marfans, Ehlers-Danlos, SLE, Giant cell arteritis) • AORTIC VALVE STENOSIS (congenital bicuspid aortic valve) • Pregnancy (3rd trimester) • Turner's syndrome • Tobacco |
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|
What are the Sgarbossa criteria for the diagnosis of AMI in the setting of LBBB?
|
Score of 3 or greater = high likelihood of AMI
5 Points: • Concordant ST elevation > 1 mm in 2 contiguous leads (ie, ST elevation in the same direction as the terminal portion of the QRS) 3 Points: • ST depression > 1 mm in V1-V3 2 Points: • Discordant ST elevation > 5 mm in 2 contiguous leads |
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|
What are the signs of prosthetic valve dysfxn 2° to thrombus formation?
|
Signs of Thrombus:
• CHF (acute onset) • HoTN (acute onset) Signs of Embolic events: • Paralysis • CVA • Abdominal pain • Flank pain/ hematuria • Chest pain • Ischemic extremity |
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|
What are the sx of myocarditis?
With what condition is it often present? |
Often presents with PERICARDITIS
Sx: • Hx of preceding/ concurrent viral illness • Fever • CP • Signs/ sx of CHF • Palpitations/ dysrhythmias |
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|
What are the sx of rupturing AAA?
|
Classic sx:
• SUDDEN onset of severe abd/ back/ flank pain • +/- Syncopy (from hemorrhage) Flank Pain: • Usually LEFT side • W/ hematuria Abd Pain: • LLQ w/ heme + stool Ecchymoses, 2° to bleeding: • On abd wall, flank, scrotum, perineum Femoral Neuropathy: • From femoral nerve compression due to hematoma |
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|
What are the symptoms of endocarditis?
What about in kids? |
Adults -- non-specific sx:
• F/ch/ sweats • Malaise, fatigue • Wt loss • CP • Cough Kids -- most common sxs: • Malaise • Wt loss |
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|
What are the two most common symptoms seen in rheumatic fever?
|
1 Polyarthritis
2 Carditis |
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What are the urinalysis findings in endocarditis?
|
Hematuria in > 50% of pts
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|
What are the V-lead findings on cardiac monitor when inserting a cardiac pacing catheter?
|
Entering R Atrium -- Large P waves > QRS height
Distal Atrium -- P waves become small Traverse TV -- QRS becomes large Tip in Ventricular Wall -- ST elevation |
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|
What are the Well's Criteria for PE?
|
• Suspected PE
• Alternative dx less likely than PE • Pulse > 100 • H/o hemoptysis • H/o malignancy • H/o previous DVT/PE • Immobilization or surgery w/in 4 wks |
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|
What condition should be considered when a young, o/w healthy person presents with new onset BBB or heart block?
|
LYME disease (Stage 2)
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What condition should be immediately suspected in a pt with syncope in the face of thoracic aortic dissection?
|
Pericardial effusion/ tamponade
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|
What condition should be suspected in a pt with aortic regurg and aortic valve endocarditis who suddenly develops complete heart block?
|
ABSCESS formation extending into the interventricular septum
|
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|
What defines aortic aneurisms as TRUE aneurisms?
What is the location of the vast majority of AAAs? |
A true aneurism -- involves all 3 layers of the arterial wall
97% of aneurisms are INFRARENAL |
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|
What drug toxicity is associated with junctional premature contractions?
|
Digoxin toxicity
|
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|
What drugs are indicated for the tx for malignant HTN and hypertensive encephalopathy?
|
Nipride -- drug of choice
Other acceptible agents: • Labetalol IV • Nicardipine IV |
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|
What drugs are used to manage shock in the hypotensive PE pt? What is the role of volume loading?
|
ISOPROTERENOL:
• is a pure ß-agonist and is preferred over dopamine b/c it is a more effective dilator of pulmonary arterioles. • Improves RV contractility • Decreases RV outflow resistance NOREPINEPHRINE: • May be required in the event that Isoproterenol does not increase cardiac output enough to compensate for the decreased PVR --> HoTN worsens PE pts die of RV failure. Volume loading can worsen RV fxn and is usually not very helpful. |
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What dx should be considered in a pt presenting in CHF with no evidence of cardiomegaly or systolic dysfxn?
|
Restrictive cardiomyopathy
|
|
|
What electrolyte abnormalities increase sensitivity to digoxin and predispose to toxicity?
|
• HYPOkalemia
• HYPERkalemia • HYPOmagnesemia |
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|
What electrolyte disorder is a common cause of dysrhythmias in AICD (Automatic Implantable Cardiac Defibrilator)?
|
Hypomagnesemia
|
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|
What etiology is responsible for > 90% of all cases of isolated mitral stenosis?
|
Rheumatic heart dz
|
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|
What factors are associated with increased risk of cerebral edema in kids being treated for DKA?
Is the cerebral edema of DKA an osmotic or vasogenic process? |
Cerebral edema factors:
• Tx with BICARB • High BUN on presentation • Low PaCO2 on presentation • Hyperventilation of an intubated DKA pt to a PaCO2 < 22 This is a VASOGENIC process. Rate of insulin administration is non-contributory. |
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|
What heart conditions warrant abx prophylaxis for infective endocarditis?
|
• Prosthetic heart valves
• H/o bacterial endocarditis • UNREPAIRED complex cyanotic congenital heart defects REPAIRED: • heart defects in the FIRST 6 MOS • congenital heart dz w/ residual defects ADJACENT to a prosthetic patch • Cardiac TRANSPLANT pts who develop VALVULOPATHY |
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|
What is 'Holiday Heart Syndrome'?
|
AFIB with RAPID VENTRICULAR RESPONSE following alcohol binge drinking
Can occur within 2 DAYS of an alcoholic binge |
|
|
What is a 'silent' aortic dissection?
Presentation? |
A painless presentation of thoracic aortic dissection
Pt presents w/ only ischemic or neurologic sx that may appear to be a CVA, MI, or peripheral vascular issue. Be aware of this presentation! Thrombolytics (for suspected AMI, etc) would be DEVASTATING. |
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|
What is Dressler's Syndrome?
|
Late post-MI pericarditis
|
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|
What is Hamman's Crunch?
In which pt position is it best heard? |
A crunching noise synchronous with the heartbeat.
Associated with pneumo-mediastinum or pneumo-pericardium. Best heard with pt in the LEFT LATERAL RECUMBENT position. |
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|
What is Kussmaul's sign?
It which conditions is it found? |
Kussmaul's Sign -- JVD (increase in CVP) with inspiration
Seen in: • Restrictive cardiomyopathy • Pericardial tamponade |
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|
What is Phlegmasia alba dolens?
|
Massive iliofemoral thrombosis associated with ARTERIAL SPASM
• Leg is swollen but NOT tense • Skin is doughy and white PAD occurs in conjunction with phlegmasia cerulea dolens. Once the arterial spasm resolves, the leg reverts to the baseline cyanotic PCD. |
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|
What is Phlegmasia cerulea dolens?
Exam findings? |
An ISCHEMIC form of VENOUS occlusion due to massive ILIOFEMORAL thrombosis
• The leg is TENSE, swollen, painful and CYANOTIC • PETICHIAE and BULLAE may be present • Occasionally results in venous gangrene |
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|
What is Prinzmetal's (variant) Angina?
What is it's relationship with excercise/ exertion? |
CP caused by coronary artery VASOSPASM
Prinzmetal's angina has NO ASSOCIATION with exercise -- the pain may increase, decrease or stay the same |
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|
What is Prinzmetal's angina, and what are the typical instigating factors?
|
Coronary VASOSPASM
1/3 of cases occur in people with nl coronaries Prinzmetals occurs at REST, without provocation. |
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|
What is Pulsus Alternans, and in which condition is it typically found?
Pulsus Paradoxus? |
PULSUS ALTERNANS:
• Alternating STRONG and WEAK beats of an arterial pulse waveform • Indicative of LEFT VENTRICULAR DYSFUNCTION PULSUS PARADOXUS: ('Pulsus-Paradoxus-Pericardial') • Exageration of the nl pulse during inspiration, where the pulse becomes WEAKER during INSPIRATION and stronger during expiration • Seen in PERICARDIAL TAMPONADE and OBSTRUCTIVE LUNG disease |
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|
What is the 'classic triad' of sx in the presentation of PE?
|
• Dyspnea
• Pleuritic chest pain • Hemoptysis |
|
|
What is the 5 year survival of adequately managed CHF?
|
50%
|
|
|
What is the acute treatment and longterm prophylactic treatment of ventricular dysrhythmias due to prolonged QT interval?
|
Acute tx -- Magnesium
Prophylactic tx -- ß-blockers |
|
|
What is the approximate proportion of MIs that occur WITHOUT chest pain?
|
50%
|
|
|
What is the correlation between pt's age, degree of hypertrophy, and severity of sx in Hypertrophic Cardiomyopathy?
|
Directly correlated
Older the pt --> the more hypertrophy --> the worse the sx |
|
|
What is the ddx of hyperacute T waves?
|
• Hyperkalemia
• Acute PERICARDITIS • Initial EKG change in STEMI • LVH • Benign early REPOLARIZATION |
|
|
What is the definition and treatment goal of hypertensive URGENCY?
Management/ meds? |
Defn: DP > 115 w/out evidence of end organ failure. (Others say > 180/120).
Tx goal: GRADUALLY lower BP OVER 24 - 48 hrs Give po HCTZ and d/c to home with good f/u instructions. |
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|
What is the definition of hypertensive EMERGENCY?
|
Severely elevated DP (> 115) w/ evidence of acute end-organ damage
|
|
|
What is the diagnostic algorhythm for the dx of PE in pregnant pts?
|
Test #1: LE DVT u/s
• If positive, tx for PE • If negative, get V/Q Note: D-Dimer test is elevated in pregnant pts and is therefore an unreliable test in this pt population! |
|
|
What is the difference in device life expectancy and need for anti-coagulation between mechanical and tissue prosthetic heart valves?
|
Mechanical:
• Lifespan: > 20 yrs • Requires lifelong anticoagulation Tissue: • Lifespan: 8 - 10 yrs • Following post-op period, anticoagulation optional |
|
|
What is the difference in the mechanism of action between NTG and nitroprusside?
|
NTG:
• Reduces preload Nitroprusside: • Reduces preload • Reduces afterload • Nitroprusside is a mixed venous and arterial dilator. |
|
|
What is the difference regarding post-MI pericarditis and Dressler's syndrome?
Tx? |
Post-MI pericarditis -- Occurs within 4 days of MI
Dressler's -- 2-3 weeks after MI Tx -- NSAIDS |
|
|
What is the dose of SLNTG given to pts in severe pulmonary edema?
|
0.8 - 1.2 mg q 5 - 10 minutes
Note: use higher doses if BP is moderately or severely elevated |
|
|
What is the drug treatment protocol for hypertensive emergency + eclampsia?
|
Drugs of choice:
• Magnesium IV/IM + • Hydralazine IV/IM Other agents: • Labetolol IV • Nipride IV (can be used POST-partum, but not ANTE-partum. Can cause fetal cyanide toxicity) |
|
|
What is the effect of placing a magnet over a pacemaker?
How is the helpful? |
Pacemaker programming is overridden, and the pacemaker will begin pacing at a FIXED RATE
BRADYCARDIA from failure to sense: • Will see normal rate with magnet TACHYCARDIA from pacemaker malfunction: • Rate will slow to normal VERIFICATION of pacemaker function: • If pacer is set for a rate below the pt's rate, will not see pacer spikes. A magnet will 'turn on' the pacer so that spikes will be seen and pacer operation verified. |
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|
What is the effect, if any, of thrombolytics on the incidence of post-MI pericarditis?
|
LOWER incidence
|
|
|
What is the etiology of mitral valve prolapse?
|
Can be:
Autosomal dominant congenital d/o Connective tissue dz: • Marfan's • Ehrlers-Danlos Skeletal abnormalities: • Severe scoliosis Sporadically in o/w nl people |
|
|
What is the formula for determining the normal A-a gradient value corrected for age?
|
Nl A-a gradient = Age/4 + 4
|
|
|
What is the general target BP in the acute tx of hypertensive emergency?
|
Lower BP rapidly and in a controlled manner by 30% of pretreatment levels in the first hour
|
|
|
What is the harm in giving CaChBl to a pt w/ wide complex tachycardias?
|
Ca Ch Bl administered to wide complex tachycardias:
• Accelerate the HR • Drop the BP, and • Do not convert the rhythm |
|
|
What is the incidence of post-MI pericarditis and:
• Transmural MI • Subendocardial MI? When is it typically seen? |
Transmural -- 20% + (b/c the cardiac injury extends TO the pericardium)
Subendocardial -- rare Seen 2-4 days post-MI |
|
|
What is the INITIAL treatment of thoracic aortic dissection?
|
MEDICAL tx to control the forces of propagation: BP, HR, rate of rise of aortic pulse pressure.
ß-Blockers (IV) -- titrate to HR 60-80 Nipride -- titrate to SP 100 - 120 Note: An alternative to ß-Bl and nipride is to use IV LABETALOL as a single agent. Note: If suspicion is high for TAD, begin tx immediately; do not wait for confirmatory study results! |
|
|
What is the management of thoracic aortic dissection based on location?
|
Type A -- immediate surgery
Type B -- medical management unless complications are present |
|
|
What is the maximum blood pressure threshhold for tx with tPA?
|
< 185/110
|
|
|
What is the mechanism of action of digoxin?
|
Inhibition of the membrane Na-K ATPase -->
Increased intracellular Na --> Increased intracellular Ca --> Positive inotropic effect |
|
|
What is the most common cause of aortic stenosis in pts less than, and greater than, 65 yo?
|
< 65 yo:
• Congenital bicuspid aortic valve > 65 yo: • Calcific aortic stenosis |
|
|
What is the most common cause of death in PE pts (other than massive embolization)?
|
Progressive right ventricular failure
|
|
|
What is the most common cause of dilated cardiomyopathy?
|
IDIOPATHIC
Another common cause is viral myocarditis, but this is not as common as idiopathic |
|
|
What is the most common cause of multifocal atrial tachycardia (MAT)?
Other causes? |
Most common cause -- Decompensated COPD
Other causes: • CHF • Theophylline toxicity |
|
|
What is the most common cause of myocarditis in the US? Name the agent.
|
Coxsackie B virus
|
|
|
What is the most common cause of subclavian and axillary vein DVT?
Next most common cause? What is the risk of PE from an upper extremity DVT? |
Most common:
• SUBCLAVIAN CATHETER Also-ran: • EFFORT thrombosis (ie, strenous activity in a young person) Risk of PE -- 15% |
|
|
What is the most common complication of mitral stenosis?
|
Afib
|
|
|
What is the most common dysrhythmia seen in Idiopathic Dilated Cardiomyopathy?
|
Afib
|
|
|
What is the most common symptom seen in pulmonary embolism?
What is the most common arrhythmia? |
Most common sx -- DYSPNEA
Most common arrhythmia -- SINUS TACHYCARDIA |
|
|
What is the most common tumor to cause heart failure?
|
Left atrial myxoma
|
|
|
What is the most common valvular heart dz?
What is the male to female ratio? |
Mitral valve prolapse
F:M --> 2:1 |
|
|
What is the natural progression of symptoms with aortic stenosis?
Tx once sxs appear? |
1 Angina
2 Syncope 3 Heart failure • ('Aortic Stenosis -- ASH') Valve REPLACEMENT is the only effective tx once sx appear |
|
|
What is the pathophysiologic mechanism of WPW syndrome: pre-excitation or reentry?
|
Pre-excitation
|
|
|
What is the prevalence of MVP?
|
10%
|
|
|
What is the rate of onset of sxs with mitral stenosis?
|
Often 10 - 15 years after the onset of murmur
|
|
|
What is the relative incidence of AAA vs TAD?
|
TAD > AAA by 2:1
|
|
|
What is the relative prevalence of ascending vs descending TADs?
|
60% of TADs are DESCENDING
|
|
|
What is the relative sensitivity and specificity of serum myoglobin as an indicator of cardiac injury?
Time to rise and peak? |
Very SENSITIVE --> good 'rule out' test (SNOUT)
Poorly specific Time to rise: 1-2 hours Time to peak: 6 hours |
|
|
What is the risk/consequence of hypokalemia in patients with acute or recent MI?
|
There is a 5 x greater risk of VFIB in hypokalemic pts with MI (if K < 3.9)
K should be maintained > 4.5 in MI pts to reduce risk of vfib |
|
|
What is the role of aggressive lowering of BP in a hypertensive pt with RUPTURED AAA?
|
There is NO EVIDENCE that aggressive lowering of BP is helpful, and it may predispose to unnecessary HoTN
|
|
|
What is the role of CXR in the patient presenting with pacemaker dysfunction?
Tx in stable and unstable pts? |
CXR is used to look for BROKEN leads
STABLE pt -- Cardiology evaluation of the pacemaker UNSTABLE pt -- Transcutaneous pacing in the ED |
|
|
What is the role of steroids in the tx of pericarditis?
What is the rate of relapse upon d/c of steroids? What dx must be excluded before steroids are rx'd? |
Steroids should be RESERVED for pts who fail NSAID tx
25% of pts rx'd w/ steroids will experience relapsing pericarditis when discontinued Steroids should not be used until the presence of bacterial or mycobacterial INFECTION has been excluded |
|
|
What is the significance of T wave inversion without ST or Q wave changes?
|
Ischemia, not acute infarct
|
|
|
What is the thrombolytic agent of choice in the tx of PE? Why?
|
TPA
Preferred b/c: • Significant improvement in hemodynamic parameters in < 2 hrs • Lower risk of bleeding b/c it is given over 2 hrs Note: Streptokinase is also approved for the tx of PE |
|
|
What is the treatment of calcium channel blocker and ß-blocker overdose?
|
• ATROPINE -- for bradycardia
• GLUCAGON -- independent improvement of inotropy and chronotropy • High-dose INSULIN and GLUCOSE -- Definitely helpful for ß-Bl OD; probably helpful with CCB OD • Calcium -- competes for the Ca channel in CCB OD |
|
|
What is the treatment of Idiopathic Dilated Cardiomyopathy?
|
Alleviate the sx of fluid overload:
• Diuretics • Digoxin • Vasodilators (nitrates, ACE-I) Anticoagulants in pts with evidence of thrombi, embolism or afib |
|
|
What is the treatment of myocarditis?
What drugs are CONTRAINDICATED? |
Tx:
• Tx is primarily SUPPORTIVE • High dose IVIG shown to be beneficial in peds (esp w/ Kowasaki's) • Interferon is under investigation Contra-I in EARLY myocarditis: • Steroids • NSAIDS |
|
|
What is the treatment of Restrictive Cardiomyopathy?
What should not be used? |
Tx is aimed at alleviating sxs. Tx usually includes:
• Diuretics • Digoxin (only beneficial if LVH is present) Do NOT use vasodilators. They reduce afterload but produce HoTN and have not been found to be beneficial. |
|
|
What is the treatment of SVT in the setting of WPW with NARROW complex (orthodromic) tachycardia?
|
Treatment is the same as any other SVT b/c the conduction goes thru the AVN.
|
|
|
What is the treatment of WPW with WIDE complex tachycardia (antidromic tachycardia)?
What DON'T you give? |
In stable pts, PROCAINAMIDE or AMIODARONE are the drugs of choice.
DO NOT give AVN blocking agents that you would typically give in SVT. These will knock out the AVN and exacerbate the re-entrant tachycardia, potentially leading to VFIB. Thus, Ca Ch Bl, ß-Bl, digoxin, and adenosine are CONTRA-I, just as they are with WPW + afib. |
|
|
What is the treatment protocol for hypertensive emergency + acute pulmonary edema?
|
IV Nitroglycerine
Other agents: • Nipride IV -- use if BP remains elevated |
|
|
What is the treatment protocol for hypertensive emergency + acute renal insufficiency?
|
Drug of choice:
• Nipride Other agents: • Nifedipine • Labetolol Note: must monitor carefully for THIOCYANATE toxicity |
|
|
What is the treatment protocol for hypertensive emergency + AMI/ ischemia?
|
Nitroglycerine -- preferentially dilates coronary vasculature --> increases coronary perfusion
ß-Blockers -- Decrease myocardial O2 demand Other BP agents: • Nipride -- use if BP still remains elevated. Can increase myocardial ischemia via CORONARY STEAL syndrome |
|
|
What is the treatment protocol for hypertensive emergency + aortic dissection?
|
Drugs of choice:
• IV ß-blocker (esmolol, propranolol) + • IV Nipride Give ß-blocker first to minimize reflex tachycardia associated w/ Nipride Other agents: • Labetolol IV |
|
|
What is the treatment protocol for hypertensive emergency + hemorrhagic CVA?
|
Mild to moderate BP reduction is generally well-tolerated (as opposed to ischemic CVA).
Severe HTN (> 220/120) should be judiciously controlled Drug of choice -- TITRATABLE agents: • Labetalol • Also, esmolol, enalapril, nicardipine |
|
|
What is the treatment protocol for hypertensive emergency + subarachnoid hemorrhage?
|
Drugs of choice -- Ca Ch Bls:
• Nimodipine • Nicardipine These agents lower BP but also DECREASE cerebral VASOSPASM that occurs following SAH. Goal of tx is to reduce BP to pre-hemorrhagic levels. |
|
|
What is the treatment protocol for catecholamine-induced hypertensive emergency?
|
Pheo or MAOI -- Drugs of choice:
• Labetolol IV; OR • Phentolamine (alpha-blocker) FOLLOWED by a ß-blocker Other drugs: • Nipride followed by a ß-blocker Acute Clonidine Withdrawal: • Restart clonidine; or • Labetolol; or • Phentolamine --> ß-Bl Acute Cocaine Toxicity: • Benzo; if HTN persists: • Labetolol; or • Phentolamine --> ß-Bl |
|
|
What is the treatment protocol for hypertensive emergency + ischemic CVA?
|
Tx of HTN with ischemic stroke can be DETRIMENTAL!
Acute reduction in HTN can reduce perfusion to peripheral watershed areas. BP reduction should only be undertaken in pts with severe HTN (> 220/120) IV Nipride or Labetalol are the drugs of choice |
|
|
What is the treatment protocol of ISOLATED CALF DVT?
|
Tx is controversial even though isolated calf thrombi do propagate and embolize.
If an isolated calf DVT is detected, the pt should be anticoagulated and, if the tibial veins are involved, tx'd as a proximal DVT. |
|
|
What is the tx of HCM?
|
ß-Blockers:
• Improve sx are the mainstay of tx • Reduce exertion-related outflow obstruction and decrease myocardial O2 consumption Ca Ch Bl: • Useful in select pts who fail ß-Bl • Contra-I in CHF Amiodarone: • Tx of choice for ventricular dysrhythmias • Used for pts who fail ß-Bl and Ca Ch Bl |
|
|
What is the tx of multifocal atrial tachycardia (MAT)?
Which med is contraindicated? |
Tx:
• Magnesium 2 g IV over 60 sec, then • Mag 1 - 2 g/hr IV Rate control: • Diltiazem or Verapamil Contraindications -- ß-Blockers (b/c these are relatively contraindicated in COPD and CHF, the typical pt population) |
|
|
What is the untreated mortality rate of thoracic aortic dissection?
|
33% w/in 24 hrs
50% w/in 48 hrs >75% w/in 2 wks 90% w/in 1-3 mos |
|
|
What is the value of obtaining an LDH level in assessing a pt with prosthetic valve complications?
|
The level of LDH directly correlates with the severity of hemolysis
Note: hemolysis rarely occurs with tissue prosthetic valves, only mechanical ones |
|
|
What is Virchow's triad?
What is its significance? |
1) Statis (venous)
2) Hypercoagulability 3) Endothelial damage 'SHE' Virchow's triad are risk factors for DVT/ PE |
|
|
What location of MI is typically associated with the following blocks:
• Mobitz I • Mobitz II • 3rd Degree AVB? |
Mobitz Type I: Inferior wall MI
Mobitz Type II: Anteroseptal MI 3rd Degree AVB (NARROW Complex): Inferior wall MI. Usually transient. 3rd Degree AVB (WIDE Complex): Anterior wall MI. Implies significant structural damage. |
|
|
What medical conditions are associated with the following parasites:
Taenia solium Taenia saginata Trypanosoma cruzi? |
Tenia solium:
• NEUROCYSTICERCOSIS • An extremely common cause of seizures worldwide • Associated with eating RAW PORK Taenia saginata: • Beef tapeworm • Causes self-limited GASTROENTERITIS Trypanosoma cruzi: • Causes Chagas disease • CARDIOMYOPATHY • Mega-esophagus |
|
|
What modalities and/or drugs should be AVOIDED in the treatment of digoxin-induced dysrhythmias?
|
Avoid CARDIOVERSION -- digoxin decreases the fibrilatory threshold. Use as a LAST RESORT, and then only at the LOWEST energy level
Avoid: • Bretylium • ß-blockers • CaCh Blockers • Calcium • Class IA antidysrhythmics (procainamide, quinidine) 'BCD -- Dig' |
|
|
What non-aortic aneurism is often seen concommitantly with AAA?
|
POPLITEAL artery aneurism
Popliteal artery aneurisms are the most common non-aortic aneurism |
|
|
What percent of acute MIs are due to coronary vasospasm alone?
|
10%
|
|
|
What percent of elderly adults have an AAA?
What percent are palpable? |
Prevalence -- 2% of elderly
Palpable -- 77-90% |
|
|
What percent of Marfan's patients develop thoracic aortic dissection?
|
50% (although only 10% of all dissections are due to Marfan's)
|
|
|
What percent of pts with MI have initially normal EKGs?
Of this group, what is the rate of combined death and serious morbidity? |
Initially normal EKG -- 8%
Death/morbidity -- Nearly 20% |
|
|
What percent of TAD pts are under the age of 50?
Why? |
20%
Why: • MARFANS • Pregnancy • Turner's |
|
|
What percent of women with acute MI experience atypical sx such as fatigue and insomnia one month prior to the event?
|
75%
|
|
|
What should you suspect with the finding of severe hemolysis in a pt w/ a mechanical prosthetic valve? What other findings will the pt present with?
|
Paravalvular leak
Pts present with: • Fatigue • Orthostasis • Jaundice |
|
|
What structural finding is the hallmark of endocarditis?
|
Vegetation. Can be on:
• Valve leaflets • Endocardium |
|
|
What surgical procedure can be effective in HCM pts who fail medical tx?
|
Septal myomectomy
|
|
|
What therapy should be immediately administered if bleeding complications occur during thrombolysis?
|
• Stop the infusion
• Give Amikar (aminocaproic acid) • Xfuse FFP • Xfuse cryoprecipitate |
|
|
What tx should be provided to INFANTS presenting in the ED with CHF?
|
• O2
• Elevate HOB • Lasix • NTG • Digoxin • Dobutamine |
|
|
What type of cardiomyopathy is most commonly seen 2° to toxins?
Name some toxins |
Dilated Cardiomyopathy
• EtOH • Cocaine • Lithium • Doxorubicin/ Daunorubicin Tip: • 'Td' (Toxin, Dilated) • 'CoLD alcohol' (Cocaine, Lithium, Doxo/Dauno, EtOH) |
|
|
Which 2 diagnoses should be entertained in a pt who becomes acutely hypotensive after receiving vasodilator tx (for the tx of, say, pulmonary edema)?
|
HCM
Aortic stenosis |
|
|
Which artery supplies the AVN in 80% of the population?
|
RIGHT coronary artery
Left circumflex artery supplies the AVN in the remaining 20% |
|
|
Which cardiomyopathy exhibits a 50% autosomal dominant transmission pattern?
|
HCM
|
|
|
Which cardiomyopathy exhibits a disorganized whorled pattern to the myocardial fibers?
Which area of the heart is affected to the greatest extent? |
Hypertrophic Cardiomyopathy (HCM)
The SEPTUM is most greatly affected |
|
|
Which cardiomyopathy is associated with the peripartum period?
|
Dilated cardiomyopathy
|
|
|
Which class of antihypertensive meds are rx'd to 'protect' the kidney in at-risk pts, but must be stopped immediately with any signs of ACUTE renal insufficiency to prevent injury to the kidney?
|
ACE-I
|
|
|
Which cohort of MEDICAL patients are at particular risk for developing pericardial effusion and tamponade?
|
RENAL FAILURE patients
|
|
|
Which cohort of pts are most at risk for endocarditis?
|
• Acquired and congenital valve dz
• Prosthetic valves |
|
|
Which drugs are contra-I in HCM?
|
Agents that INCREASE CONTRACTILITY:
• Digoxin • Isoproterenol Agents that REDUCE PRELOAD: • Nitrates • Vasodilators • Lasix Agents that INCREASE AFTERLOAD: • Phenylephrine (Decreased LV volume = increased outflow obstruction) |
|
|
Which heart muscle diseases are most commonly associated w/ Restrictive Cardiomyopathy?
|
'MRI' -- Metabolic | restrictive | Infiltrative
Metabolic: • Hemochromatosis • Glycogen storage dz Type II Infiltrative: • Amyloidosis (the most common infiltrative cause of RC in the western hemisphere) • Sarcoidosis • Endomyocardial fibrosis (most common cause of RC worldwide) |
|
|
Which leads are reciprocal to the inferior leads?
|
aVL, V2, V3
|
|
|
Which location of infarct is most susceptible to HoTN after administration of NTG?
|
Inferior wall MI with associated RV infarct
|
|
|
Which maneuvers increase and decrease the murmur of MVP?
|
Murmur INCREASE:
• Valsalva • Decrease ventricular volume --> increase duration of MVP Murmur DECREASE: • Squat • Increase ventricular volume --> decrease duration of MVP |
|
|
Which meds and PE maneuvers INTENSIFY the murmur of idiopathic hypertrophic cardiomyopathy?
|
Meds that INCREASE CONTRACTILITY
• Digoxin Meds that DECREASE PRELOAD: • Nitrates • Diuretics Agents that INCREASE AFTERLOAD: • Phenylephrine Maneuvers that DECREASE PRELOAD: • Valsalva |
|
|
Which of the following conditions would be expected to produce a NARROWED and WIDE pulse pressure?
• Thyroid storm • Trauma/ hemorrhage • Pericardial tamponade • Sepsis |
NARROW Pulse Pressure:
• Tamponade • Trauma WIDE Pulse Pressure: • Sepsis • Thyroid storm |
|
|
Which procedures require prophylaxis for bacterial endocarditis in at-risk pts?
|
• Dental procedures w/ gingival manipulation
• Rigid bronchoscopy • Abscess I & D Prophylaxis is NO LONGER RQD for GI & GU procedures |
|
|
Which type of aortic dissection is more common:
thoracic or abdominal? |
Thoracic (2 - 3x more common)
|
|
|
Which valve dz tends to produce more complications: Mitral stenosis or regurg?
|
Mitral STENOSIS
|
|
|
Which valvular diseases are caused by Marfan's Dz?
|
• MVP
• Mitral regurgitation, CHRONIC • Aortic regurgitation, ACUTE |
|
|
Which valvular dz commonly presents with hemoptysis?
|
Mitral stenosis
|
|
|
Which valvular heart conditions are caused by infective endocarditis?
|
• Mitral REGURGITATION, acute
• Aortic REGURGITATION • Tricuspid REGURGITATION • Tricuspid stenosis |
|
|
Which valvular heart disease is caused by acute MI? What is the mechanism?
|
Mitral regurgitation, acute
Caused by abrupt rupture of: • Chordae tendineae • Papillary muscle • Valve leaflet |
|
|
Which valvular heart dz has a female to male 2:1 ratio?
|
MVP
|
|
|
Which valvular heart dz is characterized by a malar rash?
|
Mitral stenosis
malar rash = 'mitral facies' |
|
|
Which valvular heart dz is characterized by a young female athlete who passes out during practice?
|
MVP
|
|
|
Why is afib such a threat to pts with HCM?
|
HCM pts have restricted LV filling and DEPEND ON THE ATRIAL KICK to maintain efficient flow.
Afib = sudden drop in cardiac output = hemodynamic compromise Risk of sudden death from afib is high; cardiovert unstable pts immediately, and anticoagulate w/ Lovenox. |
|
|
With which presentation and or lab findings should you consider ordering a Mg level?
|
• Ventricular dysrhythmia
• Hypokalemia |
|
|
Abrupt cessation of which drug is often associated with thyroid storm?
Why? |
LITHIUM
Most cases of thyroid storm are associated with GRAVE'S DZ and occur after a precipitating event such as Li withdrawal Li inhibits thyroid hormone release from the thyroid |
|
|
All pts presenting with severe sx of hypothyroidism (myxedema coma) should be presumed to have what condition until proven otherwise?
|
BACTERIAL INFECTION
This is the most common precipitant of myxedema coma |
|
|
Comment on the utility of testing for serum ketones in the dx of DKA
|
The nitrprusside test does not detect the presence of ß-hydroxybutyrate, the predominant ketone in DKA.
|
|
|
Describe the skin findings in Graves' disease
|
Peau d' orange INDURATION over the TIBIA
|
|
|
How is insulin dosed in the tx of hyperkalemia?
|
• 10 units of regular insulin in
• 50 ml of D50W • Given over 5 minutes |
|
|
Life-threatening lactic acidosis can occur in patients taking what commonly prescribed medication?
List some predisposing factors to this acidosis. |
METFORMIN
Acidosis predisposed by: • RENAL INSUFFICIENCY • Cr level > 1.5 • Iodinated CONTRAST agents |
|
|
State the medications commonly implicated in producing hypothyroidism
|
• Sulfonamides
• AMIODARONE (up to 15%) • Iodine/ Iodinated contrast • LITHIUM (up to 33%) 'SAIL' Note: Abrupt cessation of lithium can produce thyroid STORM |
|
|
State the serum and urine lab values characteristic of SIADH
|
Dilute serum:
• Serum Na < 135 • Plasma Osm < 280 mOsm/kg Concentrated Urine: • Urine Na > 20 • Urine Osm > 100mOsm/kg water |
|
|
State the sxs and findings of subacute (DeQuervain's) thyroiditis.
Cause? |
Sx/ Findngs:
• Elevated ESR • PAINFUL thyroid enlargement • THYROTOXICOSIS Cause: • VIRAL infection --> • Inflammation + abnormal release of thyroid hormone |
|
|
State the symptoms associated with hypothyrodism
|
• Fatigue
• Lethargy • Confusion • Constipation • Poor appetite • Slowed speach • Dyspnea • Weight gain |
|
|
What agents may be used to BLOCK THE PERIPHERAL EFFECTS of thyroid storm if propranolol is contraindicated (eg, asthma, CHF)?
|
ESMOLOL -- a selective ß-1 blocker
Other effective agents: • Guanethidine • Reserpine |
|
|
What are the Na, K, glucose and skin findings in primary adrenal insufficiency?
Pathophysiology? |
Adrenals don't work -->
No aldosterone --> • HYPONATREMIA • HYPERKALEMIA • Hypoglycemia Pituitary maxes out ACTH production --> Melanocytes stimulated --> HYPERPIGMENTATION |
|
|
What clinical and laboratory findings suggest ADRENAL CRISIS?
Tx? |
Presentation:
• HYPOTENSION unresponsive to fluids and pressors Lab: • HYPONATREMIA (88%) • Hyperkalemia (66%) • Hypoglycemia (66%) Tx: • Hydrocortisone 100 mg, or • Dexamethasone 6-8 mg IV |
|
|
What disease is the most common noniatrogenic cause of HYPOthyroidism?
What is the most common cause overall? |
HASHIMOTO'S thyroiditis (defective thyroid hormone synthesis)
Most common overall cause: • IATROGENIC: Treatment of GRAVES Disease |
|
|
What electrolyte abnormality is associated with SIADH?
Which condition causing altered mental status is SIADH associated? CA? |
HYPOnatremia
SIADH is associated with: • MYXEDEMA COMA • Small Cell lung CA |
|
|
What is myxedema coma?
Presentation? Labs? Tx? |
An exagerated form of hypothyroidism associated with a precipitating event
Sx: • Severely depressed metal status • Hypothermia • Bradycardia • Hypotension • H/o hypothyroidism Labs: • Low T4 • Hypoglycemia • Hypocholesterolemia • Elevated CSF protein Tx: • IV thyroxine bolus • Stress dose steroids to avoid precipitating unrecognized adrenal crisis [Myxedema -- non-pitting edema associated with accumulated mucopolysaccharides (not rqd for dx of mxyedema coma)] |
|
|
What is the indication for demeclocycline?
|
Demeclocycline is reserved for patients with chronic SIADH in whom WATER RESTRICTION has FAILED
|
|
|
What is the mortality rate of myxedema coma, even with aggressive tx?
|
Close to 50%
|
|
|
What is the most common cause of acute adrenal crisis?
|
Abrupt DISCONTINUATION of longterm steroid use
|
|
|
What is the most common precipitant of DKA?
|
INFECTION
|
|
|
What is the pathophysiologic difference between 1° and 2° adrenal insufficiency?
PE findings? |
1° Adrenal Insufficiency:
• Destruction of the adrenal cortex • See skin HYPERPIGMENTATION from the excess ACTH production 2° Adrenal Insufficiency: • Destruction of the HYPOTHALAMUS or PITUITARY gland --> • Decreased ACTH |
|
|
What is the preferred steroid to use in the treatment of thyroid storm?
Why this particular agent? Why give steroids? |
DEXAMETHASONE is the preferred agent b/c it also BLOCKS PERIPHERAL CONVERSION of T4 to T3.
Steroids are given because thyroid storm can PRECIPITATE adrenal crisis. |
|
|
What is the relationship between SIADH and diabetes insipidus?
Labs? |
SIADH:
• EXCESS ADH --> • Decreased H2O excretion --> • HYPOnatremia • Renal SALT WASTING • HIGH URINE Na concentration Diabetes Insipidus: • LACK of ADH • Increased H2O excretion --> • HYPERnatremia • Low urinary Na |
|
|
What is the treatment of thyroid storm?
What med is contraindicated? Why? |
1) Propranolol -- effectively controls the sx
2) Propylthiouracil (PTU) and Methimazole (MMI) -- first line agents that DECREASE SYNTHESIS of thyroid hormone 3) Give IODINE (Lugols) or LITHIUM to prevent hormone release (only AFTER step 2) 4) STEROIDS -- useful b/c pts with thyroid storm often develop adrenal insufficiency as a result of increased metabolic demands Contra-I -- ASA. It displaces T4 from its binding sites and worsens thyroid storm. |
|
|
What lab finding is a major side effect of anti-thyroid drugs (eg, PTU)?
|
LEUKOPENIA
|
|
|
What precipitating MEDS and EVENTS are associated with myxedema coma?
What is the most common? |
BACTERIAL INFECTION is the most common precipitant of myxedema coma
Events: • Decompensated CHF • Infection • Trauma • Burns • Stroke • GI bleed • Hypothermia • Hypoglycemia • Untreated hypothyroidism Meds: • AMIODARONE • LITHIUM • ß-blockers • Diuretics • Dilantin • Sedatives |
|
|
Which of the following is the preferred agent to BLOCK THE SYNTHESIS of thyroid hormone in thyroid storm, PTU or methimazole?
Why? |
PTU, because PTU also inhibits the peripheral conversion of T4 to T3
|
|
|
Which oral hypoglycemic agent has a particularly long half-life such that OD requires admission for observation?
|
Chlorpropamide (Diabinase)
• 1/2 life -- 36 hrs 1/2 life of other agents: • Glyburide -- 10 hrs • Metformin (Glucophage) -- 6 hrs |
|
|
Why is propranolol the drug of choice to block the peripheral effects of thyroid storm?
|
Because propranolol has the additional benefit of slowing the peripheral conversion of T4 to T3
|
|
|
Why must thiamine be given before glucose in pts suspected of having Wernicke syndrome?
|
Glucose may result in DEPLETION of existing THIAMINE stores and result in worsening of sxs.
|
|
|
Discuss anterior nasal packing and epistaxis
|
• Coat the packing with ABX OINTMENT
• Leave in for 3-5 days. Pt may remove on own. • Give prophylactic meds for sinusitis |
|
|
How can an avulsed tooth be treated prior to reimplantation if it has been dry for > 60 minutes?
|
Soak in:
• Citric acid for 5 min --> • Stannous fluoride for 5 min --> • Doxycycline for 5 min |
|
|
How effective are antibiotics in reducing the risk of post-streptococcal glomerulonephritis 2° to GABHS?
|
Abx DO NOT reduce the risk of post-streptococcal glomerulonephritis from GABHS
Abx are given to prevent acute RHEUMATIC FEVER |
|
|
Infection with which organism is virtually clinically indistinguishable from Group A Strep pharyngitis, including causing scarlet fever?
Tx? |
Arcanobacterium haemolyticum
Tx -- erythromycin |
|
|
Mastoiditis is a complication of which condition?
Causative organism? Complications? |
Otitis MEDIA --> Mastoiditis
Organism -- STREP Complications: • Skull osteomyelitis • Meningitis • CN neuropathies ('Media -- Mastoiditis -- Meningitis') |
|
|
Neck abscesses in which location are at greatest risk of eroding into the carotid artery?
|
PARAPHARYNGEAL abscesses
Note: Peritonsillar and retropharyngeal abscesses also can erode into the carotid, but the posterior PARAPHARYNGEAL space is immediately adjacent to the carotid sheath |
|
|
Needle aspiration alone of peritonsilar abscesses miss what percent of abscesses?
What is the cure rate? |
% PTAs missed -- 12-24%
Cure rate -- 94% |
|
|
Other than mechanical airway compromise, state the serious potential complications that can arise from parapharyngeal abscesses
|
Erosion into the carotid sheath, with:
• Carotid artery and vein involvement • HORNER'S syndrome and CN 9 - 12 neuropathies Jugular vein thrombosis -->: • SEPTIC THROMBOPHLEBITIS • Lemierre's Syndrome (post-pharyngeal sepsis) |
|
|
State the Ellis classification system for tooth fractures
|
Ellis I:
• Through enamel only • Tooth appears white Ellis II: • Through dentin • Tooth appears yellow Ellis III: • Through pulp • Bleeding seen |
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State the mechanism, organism, and tx of periorbital cellulitis.
How is pt age a factor? |
Etiology -- age > 5:
• LOCAL skin infxn or trauma Etiology -- age < 5: • Must consider BACTEREMIA, septicemia, and meningitis Organism: • Local invasion -- Staph • Hematogenous -- H flu Tx -- age > 5: • Augmentin (outpt) Tx -- age < 5: • Admit for systemic w/u and IV abx |
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|
State the potential complications of sinusitis
|
Frontal sinusitis extension:
• Pott's Puffy Tumor • Meningitis • Brain abscess • Epidural abscess Paranasal sinusitis extension: • Cavernous sinus thrombosis ETHMOID sinus extension: • Orbital and Periorbital cellulitis |
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|
What are the most common organisms responsible for suppurative parotitis?
Tx? |
Organisms:
• Staph • Anaerobes Outpatient tx: • Augmentin • Pen-allergic: (Clinda or Keflex), + Flagyl Inpatient tx (presumed MRSA, eg nursing home pts): • Vancomycin + Flagyl |
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|
What infection is the number one reason for antibiotic prescriptions in the US?
|
Otititis media
|
|
|
What is the difference in character of the tonsilitis and cervical lymphadenopathy seen in Group A Strep pharyngitis vs EBV?
|
Tonsilitis:
• GAS -- exudative • EBV -- NON-exudative Cervical Lymphadenopathy: • GAS -- anterior • EBV -- posterior |
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|
What is the earliest age of eruption of secondary (permanent) teeth in children?
Why is this important to know? |
• Upper incisors -- 7 yo
• Lower incisors -- 6 yo AVULSED PRIMARY TEETH SHOULD NEVER BE REIMPLANTED! Children presenting to the ED < 6 yo w/ a cc of tooth avulsion should be reassured. The tooth should not be reimplantation. |
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|
What is the epidemiology of croup? Season?
Organism? Xray finding? Toxic or non-toxic appearance? Tx? |
Croup:
• 6 mos - 6 yo; peak incidence of 2 yo • Late FALL or early WINTER Organism -- Parainfluenza Xray -- Steeple sign (symmetric SUBglottic narrowing of the trachea) Appearance -- NONtoxic Tx: • Decadron • Racemic epi for non-responders |
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|
What is the epidemiology of TMJ syndrome?
Bilateral or unilateral? Pharmacologic Tx? |
• Young WOMEN > men
• Concurrent psychiatric disorders likely TMJ syndrome is typically UNILATERAL Tx: • NSAIDS • Muscle relaxers |
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What is the hallmark finding of pts with malignant otitis externa?
|
GRANULATION TISSUE on the floor of the EAC at the junction of cartilage and bone
|
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|
What is the lateral xray finding in epiglottitis?
|
Thumb print sign
|
|
|
What is the maximum normal cervical prevertebral space at C2 and C7 in kids and adults?
|
C2 </= 7 mm
C7: • Kids < 14 mm • Adults < 22 mm |
|
|
What is the most common cause of Ludwig's Angina?
|
DENTAL INFECTION is by far the most common cause (98 - 99%)
|
|
|
What is the most common complication of acute sinusitis?
|
PRESEPTAL cellulitis
|
|
|
What is the most common complication of otitis media?
What is the most common INTRACRANIAL complication? |
Overall -- HEARING LOSS
Intracranial -- MENINGITIS |
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|
What is the most common etiology (bug) of ORBITAL cellulitis?
Kids? Diabetics & immunocompromised? |
Most common -- STAPH aureus
Kids -- consider H flu Immunocompromised -- mucormycosis |
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|
What is the most common organism responsible for acute mastoiditis?
Chronic? |
Acute -- Strep pneumo
Chronic -- Pseudomonas |
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|
What is the most common site of anterior epistaxis?
Posterior? |
Anterior -- Kiesselbach's Plexus
Posterior: • ARTERIAL Bleed -- Sphenopalatine artery ('Palatine -- Posterior') • VENOUS Bleed -- Woodruff's Plexus (Posteriomedial turbinate) Note: of posterior bleeds, arterial bleeding is the more common |
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|
What is the most common VIRAL cause of otitis media?
What fraction of all OM is caused by viruses? |
RSV
Only 1/6 of all OM cases are viral |
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|
What is the most frequent source (not organism) of ORBITAL cellulitis?
|
DIRECT extension from ETHMOID sinusitis
'OD -- Orbital - Direct' |
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|
What is the only ototopical abx approved for use with an OPEN TM, and in infants and CHILDREN?
|
Ofloxacin
|
|
|
What is the role of CT and plain film imaging in the diagnosis of sinusitis?
Sensitivity/ specificity? |
CT:
• Highly sensitive • POORLY SPECIFIC (high false positive rate) • Can be positive with a simple viral URI Plain films: • Exceedingly LOW sensitivity and specificity. Best when used to dx maxillary sinusitis. |
|
|
What is the role of oral abx in the tx of otitis externa with TM perforation?
|
Oral abx may be considered. High risk groups SHOULD received po abx:
• < 2 yo • Diabetic • On steroids • Immunocompromised |
|
|
What is the seasonal predominance of epiglottitis? Presentation?
Rate of onset of sx? Organism? |
Epiglottis is a SUPRAglottic infection
Season -- no predominance Presentation: • Kids 2-6 yo; adults • RAPID onset; pt well until a few hours ago • Hot potato voice • Severe sore throat + painful dysphagia • Drooling (CHILD only) Organism: • H flu • Staph • STREP pyogenes • STREP pneumo |
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|
What is the tx of an Ellis Class III tooth injury?
|
Apply CALCIUM HYDROXIDE to the exposed dentin and pulp
F/u with a dentist in 24 hours |
|
|
What is the tx of hereditary angiodema?
|
EPINEPHRINE -- SQ or racemic neb
FFP may also be helpful Antihistamines and steroids may also be given, but heriditary angioedema responds poorly to them. They are given only if the dx is in doubt. |
|
|
What organisms are typically responsible for ANUG?
Sx? Findings? What disease can ANUG progress to? |
Organisms:
• Spirochetes and • Fusobacteria predominate Sx: • METALLIC taste • Foul breath • Gingival pain • Fever • Cervical LAD Findings: • Gingiva swollen and FIERY RED • 'PUNCHED OUT' interdentate papillae, covered w/ a gray PSEUDOMEMBRANE Can develop into VINCENT'S ANGINA -- extension of ANUG to the tonsils |
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|
What organisms cause cavernous sinus thrombosis?
Presentation? Tx? |
Etiology:
• STAPH • Strep Presentation: • Fever • HA • BILATERAL OCULAR PARALYSIS Tx -- IV abx Adjuncts: • +/- steroids • +/- surgery • +/- heparin |
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|
What patient population is most at risk for malignant otitis externa?
Causative organisms? Findings/ complications? |
At risk population:
• Diabetics • Immunocompromised Organism -- PSEUDOMONAS (as opposed to strep of mastoiditis arising from untreated otitis media) ASPERGILLUS is the most common fungal etiology Complications: • Trismus • CN neuropathies • Temporal bone osteomyelitis • AMS |
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|
Where does the internal carotid artery lie with respect to the palatine tonsil?
|
2.5 cm posterolateral
|
|
|
Clinically, how is arterial gas embolism (AGE) distinguished from decompression sickness (DCS)?
|
AGE is characterized by EMBOLIC-type sxs:
• Focal neurological deficit • Aphasia • LOC |
|
|
Compare and contrast dog vs cat bite wounds.
• Organism(s) • Rate of infection • Type of wound • Abx tx |
Cat:
• Pasteurella multocida (virulent strain), often the SOLE pathogen • 30-80% become infected • Puncture wound; greater depth of penetration • DO TX; prophylax all bites with abx Dog: • Polymicrobial • Pasteurella seen, but less common. Also, less virulent strain. • Only 5% become infected • Tearing mechanism; less penetration • Prophylactic abx NOT RECOMMENDED except for high-risk wounds such as the HAND |
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|
Compare the incidence of rhabdo in lightning strike vs AC current injury victims
|
Lighting -- Rhabdo RARE
• Burns are typically superficial AC current -- Rhabdo COMMON |
|
|
Compare the initial cardiac rhythm often found with victims of:
• Low intensity AC electrical shock (< 1 amp) • High intensity shock (> 10 amp) |
Low intensity -- Vfib
High intensity: • Vfib, or • Asystole |
|
|
Decompression sickness results from the deposition of bubbles of which gas in the blood and tissues?
|
NITROGEN!
|
|
|
Describe the appearance of Brown Recluse spider bite.
Tx? |
'Volcano ulcer' within 2-3 days
Tx: • Most heal w/o intervention in several months • Good wound care • Surgery should be AVOIDED • Possible use of DAPSONE or STEROIDS (mixed results) Antivenom is not available for this spider bite |
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|
Describe the symptomatology and RASH of Rocky Mountain Spotted Fever.
What does the CBC show? |
Rash:
• Initially MACULAR --> • Progresses to PETICHIAL • Begins on the WRISTS, ANKLES, palms and soles • Spreads CENTRALLY Other sx: • HIGH FEVER • Myalgias (especially CALF) • HA • Vomiting • Malaise CBC -- NORMAL |
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|
Describe the unique effects of tarantula encounters.
Sx? |
Sx:
• Severe PAIN at the bite site • MINIMAL ERYTHEMA and swelling • Fatality rare Unique feature: • 'URTICATING HAIRS' embed in victim's skin --> • Intense pruritis --> • Scratch site --> • Transfer to EYES --> • Severe KERATOCONJUNCTIVITIS |
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Discuss the incidence of upper and lower extremity paralysis in lightning strike victims.
How long do these sx typically last? |
UPPER extremity paralysis -- seen in 1/3 of pts
LOWER extremity paralysis -- seen in 2/3 of pts RESOLUTION OVER HOURS is the rule rather than the exception. |
|
|
Discuss volume status and renal function in severely hypothermic pts
|
Hypothermic pts are typically VOLUME-DEPLETED 2° to:
• EtOH • Cold-induced diuresis • 3rd-spacing Cold kidneys lose their ability to concentrate urine, thus --> URINE OUTPUT and specific gravity are INACCURATE in determining volume status. |
|
|
High Altitude Pulmonary Edema (HAPE):
Prophylactic meds? Tx? Sx? |
Prophylaxis:
• Diamox • Nifedipine Tx: • DESCENT • Diamox • Nifedipine (pulmonary artery vasodilator) • Dexamethasone (mod - severe cases only) • Lasix • Morphine Sx: • Dyspnea, cough, HA • Sx WORSE at NIGHT |
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|
In a pt with anaphylaxis who takes ß-blockers, what is the dosing regimine of glucagon?
Side effects? |
1 mg IV q 5 min as necessary to tx relative bradycardia or HoTN
Side effects: • HYPERglycemia • HYPOkalemia • N/V • Dizziness |
|
|
In a pt with sx of acute mountain sickness, what is the relationship between the severity of sx at onset and the predicted clinical course?
|
NO relationship!
Pts must obey even minor sxs because they may morph into severe disability. |
|
|
State the triage tag color code system used in mass-casualty situations
|
RED -- Most urgent:
• Have life-threatening injuries • Will probably survive with immediate care YELLOW -- Urgent, 2nd priority: • Serious but not life-threatening injuries GREEN -- Non-urgent BLACK -- Dead or minimal chance for survival |
|
|
What animals confer the highest risk of transmitting rabies?
|
1 Bats
2 Skunks 3 Racoons 4 Foxes |
|
|
What are Lichtenberg figures?
|
Superficial FERN-like burns that are pathognomonic for LIGHTNING strike
|
|
|
What are the characteristic sxs and findings of BLACK WIDOW spider bite?
Tx? |
Findings:
• TARGET RASH on the affected extremity (PATHOGNOMONIC) • Severe HTN • MUSCLE CONTRACTIONS involving the trunk proximal to the bite site • Board-like ABDOMINAL RIGIDITY Constitutional sx: • Dyspnea • Lightheadedness • Tachycardia Tx: 1) Initial tx with IV opioids and benzos for symptomatic relief 2) IV NTG or Nipride for refractory HTN 3) ANTIVENOM for continued sxs (resolves most sxs w/in 2 hrs) |
|
|
What are the physical characteristics that identify a pit viper?
|
• A 'PIT' between the eye and nostril
• ELIPTICAL pupil • TRIANGULAR head • SINGLE ROW of scales/plates from the anus to near the tip of the tail • RETRACTABLE fangs |
|
|
What are the prognositic signs of frostbite, both negative and positive?
|
Positive:
• Early return of NORMAL SENSATION • Formation of large, clear BLEBS in the affected area Negative: • Residual VIOLACEOUS color on rewarming • Persistent FIRMNESS of SQ tissue • LACK of edema • DELAYED development of hemorrhagic BLEBS |
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|
What are the risk factors for decompression sickness?
Which is most significant? |
DCS risk factors:
• PATENT FORAMEN OVALE • Increased age • Obesity • Dehydration • Fatigue • Cold water dive • Exercise after dive |
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|
What are the sxs of Crotalidae snake bites that indicate that anti-venim is required?
Labs? |
Local sx:
• Severe pain • Progressive edema, or edema > 15 cm • Oozing of NON-CLOTTED blood Systemic sx: • V/D • Fever • Seizures • Paresthesias • METALLIC taste in mouth Labs -- DIC-like picture: • THROMBOCYTOPENIA • Decreased fibrinogen • Increased fibrin split products • Increased PT, PTT Majority of effects are LOCAL at the bite site |
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|
What are the symptoms of acute mountain sickness?
What is the most sensitive indicator of HACE? HACE is typically not seen below what altitude? |
AMS:
• DIFFICULTLY SLEEPING • Nausea • Dizziness • HA • Fatigue HACE -- ATAXIA HACE normally occurs ABOVE 12000 feet |
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|
What indicator is the earliest sign of, and is prognostic for, acute radiation syndrome?
|
Lymphopenia (often seen within 8 hours)
|
|
|
What is the difference in antivenom treatment strategy between Elapidae and Crotalidae snake bites?
|
Elapidae (Coral snakes) -- ALL pts should received antivenom upon presentation, even ASX pts
Crotalidae (Pit viper): • Observation for 4-6 hours • If no signs of envenomation, may DISCHARGE home • Antivenom only required if symptomatic |
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|
What is the effect of hypothermia on the following factors:
• Glucose • HCT • Diuresis/Oliguria? |
Hypothermia causes:
• HYPERgycemia • INCREASED HCT 2% for every 1°C decrease in temperature • Diuresis |
|
|
What is the half-life of carboxyhemoglobin on:
• Room air? • 100% O2 NRBr? • Hyperbaric O2? |
Room Air -- 6 hours
100% NRBr -- 90 min Hyperbaric O2 -- 30 min |
|
|
What is the incidence of rhabdo in lightning strike injuries?
|
LOW!
Lightning strikes cause SUPERFICIAL burns to the skin. Deep tissue injury is rare. |
|
|
What is the incidence of ventricular dysrhythmia in patients with LOW voltage electrical injury?
|
< 10% of patients will develop dysrhythmia
|
|
|
What is the minimum body temperature a hypothermic pt must be warmed to in order to be declared dead?
|
90°F (32.2°C)
|
|
|
What is the most common cause of death in patients struck by lightning?
|
Asystole
|
|
|
What is the most common cause of high altitude death?
|
HAPE
|
|
|
What is the most common EKG finding in heat stroke?
Hypothermia? |
Heat stroke: QT prolongation
Note: QT prolongation is also seen in HYPOthermia Hypothermia -- Afib |
|
|
What is the most common ophthalmic injury following lightning strike?
|
Cataracts
These can develop up to 2 YEARS following the injury |
|
|
What is the pathophysiology of arterial gas embolism?
|
• Too rapid ascent -->
• Rapid expansion of N in alveoli --> • Pulmonary Barotrauma --> • Bubbles in pulmonary vein --> • Air emboli to: Coronary Arteries --> MI Cerebral Arteries --> CVA |
|
|
What is the pneumonic to aid in distiguishing between a coral snake and benign look-alikes (Mexican Milk Snake)?
|
'Red on Yellow -- Kill a Fellow'
'Red on Black -- Friend of Jack' |
|
|
What is the post-exposure prophylaxis of an animal bite at high risk for rabies?
|
• Rabies-immune globulin for PASSIVE immunization
• Human diploid cell vaccine for ACTIVE immunization |
|
|
What is the recommended modality to rewarm a frostbitten extremity?
What is the role of field rewarming and rewarming with direct heat? |
Rapid rewarming in water, 40-42°C for 15-30 minutes, or until thawing is complete
Field rewarming and direct heat rewarming should NOT be done --> High risk of incomplete thawing and refreezing --> Increased tissue loss |
|
|
What is the relationship of time to symptomatology in air gas embolism (AGE) and decompression sickness (DCS)?
|
AGE:
• Sx almost always occur WITHIN 10 MINUTES of surfacing DCS: • Sx typically occur after 10 min |
|
|
What is the response of leukocytes and platelets to acute radiation exposure?
|
Initial INCREASE followed by an accelerated decrease, reaching the nadir at 30 days
|
|
|
What is the role of epi, antihistamines, steroids, and/or NSAIDS in the tx of black widow spider bite?
|
NO ROLE
Black widow bites are not Type I hypersensitivity reactions, so standard 'allergic reaction' treatment will not work. NSAIDS provide little pain relief. |
|
|
What is the role of nifedipine as prophylaxis for acute mountain sickness (AMS) and high altitude pulmonary edema (HAPE)?
|
AMS -- Nifedipine has NO ROLE
HAPE -- IS USED for prophylaxis |
|
|
What is the treatment of jellyfish stings?
|
Liberal use of VINEGAR to deactivate the nematocysts, followed by removal with a gloved hand
|
|
|
What is the treatment of rabies? What is the mortality rate with treatment?
|
100% mortality!
There is NO EFFECTIVE TX if you get the dz. Give HRIG and the rabies vaccine as post-exposure PROPHYLAXIS. |
|
|
What is the treatment of Rocky Mountain Spotted Fever?
Pregnant? When should treatment begin? |
Doxycycline -- drug of choice
Pregnant -- Chloramphenicol Treatment should begin IMMEDIATELY upon suspecting RMSF; very HIGH FATALITY RATE in untreated cases |
|
|
What is the tx of jellyfish stings?
|
• Remove the tentacles with forceps
• Use a weak VINEGAR solution to inactivate the nematocysts, or • Use SALT WATER to wash off the skin. |
|
|
What is the tx of marine sting injury from the tail of stingray, catfish, and stone fish?
Why? |
The toxins in the spines of these creatures are HEAT LABILE (deactivated with heat), therefore...
Immerse the injured extremity in WATER AS HOT AS THE PT CAN STAND (not over 45°C/ 113°F) for 30 to 90 minutes |
|
|
What joints are most commonly affected in decompression sickness?
|
Shoulder and elbow
|
|
|
What percent of patients surviving high-voltage electrical injury will develop rhabdomyolysis?
|
Only 10%
|
|
|
What snakes are members of the Crotalidae family?
What is their relative degree of envenomation? |
Pit vipers:
• Rattlesnake > • Cotton-mouth > • Copperhead |
|
|
What snakes are members of the Elapidae family?
Describe their effects. What are the earliest effects? Tx? |
Coral snakes
Effects: • NEUROTOXIC. Curare-like effects with total FLACCID PARALYSIS • No local edema Sx: • May be delayed up to 12 hours • AMS and cranial nerve findings (eg, PTOSIS, diplopia) are earliest findings ALL pts should be treated with antivenim, even in the ABSENCE of sx. |
|
|
What symptoms are causes by alpha, beta, and gamma rays?
Which is the most common means of radioisotope decay? |
ALPHA:
• Have very superficial penetration • Pose no health hazard unless INHALED BETA: • MOST COMMON means of decay • Penetrate skin to 8 mm • Cause SKIN BURNS on exposed skin • Stopped by clothing GAMMA: • Penetrate deeply • Responsible for ACUTE RADIATION SYNDROME |
|
|
What type of fluid should NOT be used to wash JELLYFISH and SPONGE nematocysts off the skin?
|
FRESH WATER. This will cause the nematocysts to DISCHARGE.
|
|
|
What would be a contraindication to the use of acetazolamide in a pt with Acute Mountain Sickness?
Alternative rx? |
SULFA allergy is a contraindication
Prochlorperazine (Compazine) can be used |
|
|
Which 2 states are responsible for 1/3 of all cases of Rocky Mountain Spotted Fever?
|
• North Carolina
• Oklahoma |
|
|
Which is more injurious: electrical shock from AC or DC current?
|
AC
|
|
|
All patients with GI/ diarrheal sxs lasting greater than 7 days should be tested for what organisms?
|
Parasites
|
|
|
Are pilonidal cysts considered an acquired or congenital problem?
Recurrence rate? |
ACQUIRED (once thought to be congenital)
FREQUENT recurrence despite surgical excision |
|
|
At which cervical level is the upper esophageal sphincter located, and what is the significance of this site?
|
UES (cricopharyngeal muscle) is at C6
This is the most common site of FB obstruction in kids < 4 yo |
|
|
Compare and contrast the incarceration and strangulation rates of UMBILICAL hernias in adults and infants
|
Adult:
• FREQUENT INCARATION • 20 - 30% rate of strangulation Kids -- RARELY incarcerate or strangulate |
|
|
Compare and contrast the severity of peritonitis caused by jejunal and ileal perfs
|
Jejunal perf: More severe because:
• pH is higher (8) • greater number of enzymes Ileal perf: • Associated with considerable BACTERIAL contamination • Frequently walls off, so may initially have only localized findings |
|
|
Compare the pathology of Boerhaave Syndrome with Mallory-Weiss Syndrome
|
Boerhaave:
• Distal posterolateral esophagus, LEFT side • Full thickness tear Mallory-Weiss: • GE junction (90%) • Distal posterolateral esophagus, RIGHT side (10%) • Arterial bleeding from longitudinal MUCOSAL lacerations |
|
|
Compare the rate of sx development with large vs small bowel perf
|
Large bowel perf -- signs and sx are SLOWER in onset because they are largely due to SEPSIS
|
|
|
Compare the sx and lab findings in pyogenic vs amebic liver abscesses
|
BOTH:
• N/V/F/Chill • Abdominal pain • Elevated WBC • Elevated LFTs AMEBIC abscess -- NORMAL bili PYOGENIC abscess -- ELEVATED bili |
|
|
Define HELLP syndrome. What symptoms herald this condition?
|
H -- Hemolysis
EL -- Elevated LFTs LP -- Low platelets Heralded by: • N/V • RUQ pain Pre-eclampsia/ eclampsia may progress to HELLP syndrome. |
|
|
Describe the clinical presentation of mesenteric vascular ischemia. What are the early vs late symptoms?
Which cause(s) are sudden onset, and which are insidious? |
• SEVERE abdominal pain
• DIARRHEA, often heme positive • Early: poorly localized PAIN OUT OF PROPORTION to exam • Late: Distension and peritoneal signs SUDDEN onset -- arterial occlusion INSIDEOUS onset: • Venous thrombosis • Nonocclusive ischemia |
|
|
Describe the epidemiology of Crohn's and UC
|
• 15 - 40 yo
• White > black • Jew > non-Jew • FHx 10 - 15% • Incidence increasing over past 30 years |
|
|
Describe the fever, WBC and stool findings with Shigella?
|
• Often very high fever (104-105° )
• High WBC with left shift • Fecal leuks • Often bloody diarrhea |
|
|
Describe the findings of typhoid (enteric) fever, a possible consequence of Salmonella infection
|
• Relative BRADYCARDIA despite HIGH FEVER
• HA • No diarrhea • Maculopapular 'rose spots' • Meningeal signs |
|
|
Describe the following signs:
• Obturator • Psoas |
Signs associated with appendicitis
OBTURATOR sign: • Pain with internal rotation of the flexed right hip PSOAS sign: • Pain with extension of the right hip |
|
|
Describe the presentation and bowel location of COLONIC ISCHEMIA, aka ischemic colitis.
How is it diagnosed? Tx? (Note, this is DIFFERENT from Mesenteric Ischemia) |
Presentation:
• Acute onset, MILD abdominal CRAMPY pain • Urge to defecate • BRBRP Bowel location: • 75% LEFT colon at splenic flexure (a watershed area) Dx -- COLONOSCOPY • Angio has no role Tx: • Supportive • Bowel rest |
|
|
Describe the sx of GI anthrax.
Time to onset? Means of transmission? Mortality? |
Etiology -- Undercooked, infected MEAT
Sx -- onset in 2 - 5 days: • N/V • Mesenteric ADENITIS --> • BLOODY vomit & diarrhea --> • Septic SHOCK Mortality -- 50% |
|
|
Describe the sxs of amebic dysentery caused by Entamoeba histolytica.
Physical exam findings? Consequences of untreated dz? |
Sx:
• Subacute onset of WATERY DIARRHEA associated with MUCUS, BLOOD, CRAMPS, especially RUQ Findings: • Tender RUQ • Hepatomegaly • Decreased BREATH SOUNDS over the right lower lung field Untreated Dz --> Amebic LIVER ABSCESS |
|
|
Describe the toxin and clinical presentation of scombroid fish poisoning.
Duration of sx? Tx? |
Toxin -- Heat-STABLE toxin with HISTAMINE-like properties
Sx: • Acute allergic rxn-like process (but is NOT an allergic reaction) Duration of sx -- Typically only a FEW HOURS (but can last 1-2 days) Tx -- ANTI-histamine IM • Epi and steroids are NOT indicated |
|
|
Describe the toxin and clinical sx of ciguatera fish poisoning
|
Toxin -- Heat-STABLE neurotoxin
GI Sx: • N/V • Diarrhea • Crampy abdominal pain Neurological Sx: • Distal and PERIORAL paresthesias • Neuromuscular and neurosensory manifestations • REVERSAL OF HOT AND COLD SENSATION is pathognomonic |
|
|
Describe the xray findings in mesenteric ischemia
|
THUMBPRINTING -- irregular thickening of the bowel wall
PNEUMATOSIS intestinalis Gas in the portal venous system |
|
|
Diarrhea is the most common cause of which metabolic acid/base condition?
What acid/base condition does prolonged emesis cause? |
Diarrhea causes HYPERchloremic metabolic ACIDOSIS:
• Bicarb is lost in the stool --> • Kidney readily resorbs chloride. • Will see a NORMAL ANION GAP. Emesis causes HYPOchloremic Metabolic ALKALOSIS: • HCl lost in the emesis |
|
|
Discuss the epidemiology of Hepatitis A virus:
• Infection rate • Cohort & ethnic origin most susceptible • Incubation period |
• Btwn 1/3 to 1/2 of Americans are seropositive
• 1/3 of cases occur < 15 yo (adults have Abs from previous infxn) Greatest prevalence: • American Indians • Native Alaskans Incubation period -- 30 days |
|
|
Discuss the relative sensitivity and specificity of amylase and lipase in the diagnosis of pancreatitis.
For how long do they remain elevated? |
Sensitivity:
• Amylase = Lipase Specificity: • LIPASE >>> Amylase Duration of elevation: • Amylase: 5-7 days • Lipase: 8-14 days |
|
|
Diverticular abscesses less than what size are treated with abx alone?
|
Less than 5 cm
|
|
|
Diverticulosis and diverticulitis are primary and secondary causes of which medical conditions, respectively?
|
Diverticulosis --Primary cause of massive lower GI BLEEDING
Diverticulitis -- Second most common cause of large bowel OBSTRUCTION (#1 cause of large bowel obstruction is TUMOR) |
|
|
Generally speaking, which infectious diarrheal organisms are characterized by fecal leukocytes, and which are not?
|
Fecal leukocyte positive:
• Enteroinvasive organisms (CSS VEY) • UC • Crohn's • Amebiasis Fecal leukocyte negative: • Enterotoxin-producing organisms • Viral diarrhea • Giardia |
|
|
Hemolytic uremic syndrome is associated with which invasive diarrheal-producing organisms?
Which cohort of patients are particularly susceptible? |
HUS is associated with:
• E coli O157:H7 • Shigella CHILDREN are particularly at risk, especially if they have been tx'd with BACTRIM or QUINOLONE. |
|
|
How do left and right sided large bowel tumors typically present?
|
Left side -- Obstruction
Right side --Bleeding |
|
|
How does chest pain caused by esophageal spasm react to NTG administration?
|
Esophageal spasm is RELIEVED with NTG
|
|
|
How does scleroderma and Raynaud's syndrome affect the intrinsic nerve supply to the esophagus?
|
Auerbach's and Meissner's plexuses are DESTROYED
|
|
|
How is the Apt test used in the diagnosis of bloody stools in newborns?
|
The Apt test shows if blood in a newborn's stool is SWALLOWED blood of maternal origin
|
|
|
How is the diagnosis of Giardia made?
|
Most common dx test:
• Finding cysts or trophozoites in the stool Other modalities: • Entero-Test (string test) • ELISA • Duodenal aspiration |
|
|
How long can the neuromuscular and sensory sx of ciguatera fish poisoning last, and ingestion of what substance exacerbates sx?
|
Sx may last for MONTHS
Sx exacerbated by ALCOHOL |
|
|
How long do the sxs of ciguatera fish poisoning usually last?
|
Typically 1 - 2 weeks
Can last up to 8 weeks or more |
|
|
How should the diet be modified in pts with cirrhotic liver dz to help prevent encephalopathy?
Why? |
MINIMIZE PROTEIN in the diet
Protein is metabolized to NH3 |
|
|
If 70% of pts with Hepatitis A virus are asx, why should pts with possible exposure undergo serologic testing?
|
• HAV is a reportable disease
• 30 day incubation period before sxs appear • Immunoprophylaxis should be prescribed for family members and close contacts |
|
|
If the stool culture is negative in an adult with diarrhea, what is invariably the diagnosis?
|
Norwalk virus
|
|
|
If vasopressin is used for the immediate treatment of ruptured esophageal varix, what are the associated side effects, and what med should be given simultaneously to blunt these effects?
|
Side effects:
• HTN • Cardiac and splanchnic ISCHEMIA Infuse NTG simultaneously to blunt these effects |
|
|
In infants with GERD, at what age do the symptoms peak, and at what age do they resolve?
Why do the symptoms resolve? |
Peak -- 4 mos
Resolve: • Most by 12 mos • Nearly all by 24 mos Reason for resolution: • The LES becomes more COMPETENT with age |
|
|
In what site are > 50% of superior mesenteric artery emboli located?
|
Just distal to the origin of the MIDDLE COLIC ARTERY
|
|
|
In which anatomic location are 90% of all anal fissures located?
Women? What is the significance of fissures found outside of these locations? |
90% are POSTERIOR midline
Women -- 10-40% are located in the ANTERIOR midline ECCENTRICALLY located fissures suggest: • IBD • CA of anus or rectum • Lymphoma • Syphilis |
|
|
In which cohort of diarrhea patients should Giardia be a consideration?
|
• HIV
• TRAVELERS in developing countries • Backpackers who drink mountain STREAM water • DAYCARE center exposure |
|
|
In which patient populations do sigmoid volvulus occur?
Mechanism? |
Sigmoid volvulus occurs almost exclusively in:
• ELDERLY, bed-ridden pts with debilitating comorbid diseases • Pts of any age with profound PSYCHIATRIC or neurologic illness Pathophysiology: • CHRONIC CONSTIPATION --> redundant colon --> volvulus |
|
|
Infection with which intestinal parasite can cause FATAL hyperinfection in immunocompromised hosts?
Sx? Eosinophilia? |
Strongyloides stercoralis
Most intestinal infections are ASX, but can have: • Abdominal CRAMPING and • DIARRHEA with mucus and BLOOD EOSINOPHILIA is seen in immunoCOMPETENT individuals only! |
|
|
Infection with which intestinal parasites can cause large blood loss and result in IRON DEFICIENCY ANEMIA?
What is the mode of infection of each of these organisms? Eosinophilia? |
NECATOR americanus (hookworm) -- penetrates the SOLES of the feet
• + EOSINOPHILIA TRICHURIS trichiura (whipworm) -- contaminated food, water • No eosinophllia |
|
|
Ingestion of which pill is most often associated with pill esophagitis?
|
Alendronate
|
|
|
List the most common causes of upper GI and lower GI bleeding in ADULTS
|
UGI:
• 1 PUD (40%) • 2 Gastric erosions (25%) • 3 Varices (20%) • 4 Mallory-Weiss tear (5-15%) LGI: • 1 Upper GI • 2 Diverticulosis • 3 Angiodysplasia |
|
|
Match the mortality rate to the number of Ranson criteria in pancreatitis
|
2 or less -- 1%
3-4 -- 15% 5-6 -- 40% 7+ -- 100% |
|
|
Name the enteroINVASIVE bacterial organisms
|
'CSS VEY'
C -- Campylobacter, C dif* S -- Salmonella S -- Shigella V -- Vibrio parahaemolyticus V -- Vibrio vulnificus E -- EnteroINVASIVE E coli E -- EnteroHEMORRHAGIC E coli O157:H7* Y -- Yersinia *NOTE: These organisms are not invasive but instead produce a CYTOPATHIC TOXIN that destroys the cell wall |
|
|
Papaverine is NOT indicated for mesenteric ischemia 2° to which cause?
|
Venous thrombosis
|
|
|
Pyloric stenosis should be considered in the ddx of vomiting in infants at what age?
|
After the 1st week of life
|
|
|
Severe AFEBRILE bloody diarrhea should prompt suspicion of which organism?
What percent of all bloody diarrhea is it responsible for? |
E coli O157:H7
This causes 36% of all cases of bloody diarrhea |
|
|
State several associated factors that warrant admission for a dx of diverticulitis
|
• Associated ABSCESS
• Bowel wall > 4 mm • Obstruction • Significant comorbidities • Ill appearance |
|
|
State some causes of pancreatitis.
Which drugs are implicated? |
Most common:
• Gallstones • Alcoholism Other causes: • HYPERcalcemia • HYPERtriglyceridemia • Sulfa and Thiazide drugs • ERCP • Mumps |
|
|
State some of the extra-intestinal manifestations of Crohn's and UC
|
'GET, HAVE'
• Gallstones; Renal stones • Erythema nodosum • Thromboembolic dz • Hepatitis • Arthritis (also ankylosing spondylitis) • Vasculitis • (Eye) Uveitis/ conjunctivitis |
|
|
State the gas-forming bacteria that are responsible for emphysematous cholecystitis
|
• E coli
• Clostridium perfringens • Klebsiella • Anaerobes |
|
|
State the intrinsic and extrinsic causes of UPPER esophageal dysphagia.
Are these typically progressive conditions? |
Upper esophageal dysphagia is caused by OBSTRUCTIVE lesions
Intrinsic causes: • Esophageal webs • CA Extrinsic causes: • Compression by thyroid, Zenker's diverticulum, left atrial enlargement, aortic aneurism These obstructive causes are typically PROGRESSIVE: • Solids --> Liquids |
|
|
State the normal and hepatotoxic mechanisms of Tylenol metabolization.
What is the antedote, and how does it work? |
Normal metabolism:
• Glucoronidation • Sulfuronidation • Glutathione metabolization Hepatotoxic metabolism: • When the normal pathways are depleted, APAP is metabolized to NAPQI via cyt-p450 Antidote: • NAC, b/c it reestablishes the glutathione metabolic pathway |
|
|
State the typical cause and time to onset of symptoms in oropharyngeal (transfer) dysphagia, upper esophageal dysphagia, and lower esophageal dysphagia
|
Transfer dysphagia:
• Cause: NEUROMUSCULAR disorders • Time to onset < 2 seconds Upper esophageal dysphagia: • Cause: OBSTRUCTION • Time to onset 2 - 4 seconds Lower esophageal dysphagia: • Cause: LUMINAL NARROWING • Time to onset 4 - 10 seconds |
|
|
State the typical causes of lower esophageal dysphagia
|
Typically caused by LUMINAL NARROWING
Carcinoma (most common cause) • Progressive: Solids --> Liquids Achalasia Esophageal strictures 2° to GERD |
|
|
The symptoms of which bacterial infection mimic appendictis?
|
Yersinia gastroenteritis
Campylobacter |
|
|
Toxic megacolon occurs in both Crohn's and UC. Which has a higher incidence?
|
UC >> Crohn's
|
|
|
What's the difference between an indirect and direct inguinal hernia?
What is the relative incarceration rate? |
INdirect:
• INguinal canal (protrudes through) • Frequently INcarcerates Direct: • Protrudes directly thru Hesselbach's triangle • Consequence of weakened abdominal musculature |
|
|
What are Curling's and Cushing's ulcers?
Etiology? |
Stress ulcers resulting from:
• Acute traumatic insult • CNS tumor • Sepsis Cushing's -- GASTRIC stress ulcer Curling's -- DUODENAL stress ulcer |
|
|
What are Grey Turner's sign and Cullen's sign, and what do they indicate?
|
Grey Turner's -- Bluish discoloration of the left flank
Cullen's sign -- Bluish discoloration around the umbilicus These signs indicate RETROPERITONEAL HEMORRHAGE |
|
|
What are some causes of jejunal rupture?
|
• Potassium tablets
• TB • Crohn's disease |
|
|
What are some predisposing factors for PUD? Which is most significant?
What are NOT predisposing factors? |
Predisposing factors:
• H. PYLORI (most significant) • NSAIDS • Prolonged STEROID use • Smoking NOT factors: • EtOH • Caffeine • Diet |
|
|
What are the 'Rules of 2' for Meckel's diverticulum?
|
• 2% of the population
• 2 feet from the ileocecal valve • 2 inches in length • 2 yo (most common age of presentation) • 2% are asymptomatic • 2:1 male > female • 2 types of ectopic tissue: • Gastric (most common) • Pancreatic |
|
|
What are the 3 most common organisms implicated in spontaneous bacterial peritonitis?
|
1 E coli
2 Klebsiella 3 Strep pneumoniae |
|
|
What are the 3 most typical sites of esophageal foreign body obstruction?
What is the most common site in kids and adults? |
C6 -- UES (cricopharyngeus muscle): Most common obstruction site in KIDS
T4 -- Aortic arch T10-11 -- LES: Most common obstruction site in ADULTS |
|
|
What are the causes of anal fissures?
|
Most common:
• Passage of HARD stool Other: • Frequent DIARRHEA |
|
|
What are the causes of large bowel obstruction?
|
1) Tumor
2) Diverticulitis 3) Volvulus 4) Fecal impaction |
|
|
What are the complications of Shigellosis?
|
• Reiter's syndrome
• HUS • Febrile sz |
|
|
What are the contraindications for insertion of an NG tube?
What is NOT a contraindication? |
Contraindication:
• Posterior laryngeal lacerations • Esophageal tears (eg, Boorhaave's) • CAUSTIC ingestions • Near-total obstruction 2° to stricture Note: Esophageal varices are NOT a contra-I to NGT placement |
|
|
What are the first action items (ie, tx, study, etc) that must be completed in a pt suspected to have Boerhaave Syndrome?
|
• NPO
• Broad spectrum ABX • IVF • Airway maintenance • Emergent SURGICAL CONSULT All these items should PRECEDE any labs or studies |
|
|
What are the GI effects of Aluminum and Magnesium containing antacids?
|
Al -- Constipation
Mg -- Diarrhea |
|
|
What are the guidelines for excision of thrombosed external hemorrhoids?
|
Acute (< 48 hrs) -- EXCISION
NOT acute (> 48 hrs) -- NO excision |
|
|
What are the indications for, contraindications to, and mechanism of action of Misoprostol in the treatment of PUD?
|
Indications: Only indicated for the PREVENTION of NSAID-induced gastric ulcers in high-risk pts (eg, elderly; h/o ulcers)
Contraindication: • PREGNANCY/ Childbearing age women. Causes SPONTANEOUS ABORTION Mechanism: • Prostaglandin E1 analogue • Stimulates local mucus and bicarb production • Enhances mucosal blood flow • Inhibits gastric acid secretion |
|
|
What are the LFT findings in alcoholic hepatitis?
|
AST >> ALT
|
|
|
What are the most common causes of small bowel obstruction?
What are some ancillary causes? |
1) Adhesions
2) Hernia 3) Neoplasm Other causes: • Lymphoma • Intussusception (common < 2 yo) • Gallstone ileus • Crohn's |
|
|
What are the most common sites for peptic and stress ulcers?
|
PUD:
• Lesser curvature of the stomach, or • First part of the duodenum Stress Ulcers -- Body and fundus of the stomach |
|
|
What are the physical and xray findings of Boerhaave's syndrome?
|
Physical findings:
• Hamman's crunch = mediastinal air • Sub-Q air Xray: • LEFT pneumo |
|
|
What are the side effects of cimetadine that make this drug undesireable as an H2 blocker?
|
• Painful gynecomastia
• Reversible IMPOTENCE • CNS dysfunction • Thrombocytopenia • Inhibits cyt-P450 system |
|
|
What are the sx of Shigellosis?
Tx? Tx caveat? |
Sx:
• Abdominal pain • Diarrhea • Fever (often seen) • Blood in stool (35-40% of cases) Tx: • Fluoroquinolone • Anti-diarrheal Note: • High resistance to Bactrim; do not rx! • Antimotility drugs can be rx'd WITH abx, but given alone may actually WORSEN the clinical course. |
|
|
What are the symptoms of Giardia?
What is the incubation period? Blood? |
Sudden onset of:
• Abdominal distention • Crampy abd pain • Flatulence • Pale, loose, FOUL-SMELLING stools Incubation period: 1 - 3 weeks NON-bloody stools |
|
|
What are the three most common complications of PUD?
|
Bleeding (20% of ulcer patients)
Perforation (7%) Gastric Outlet Obstruction |
|
|
What are the two most common causes of diarrhea in AIDS pts?
What drug is not curative but may hasten recovery from infection with ONE of these organisms? |
1) Cryptosporidium
2) CMV HAART (Highly Active Antiretroviral Therapy)/ Nitazoxanide may hasten recovery in CRYPTOSPORIDIUM |
|
|
What are the two most common causes of massive LOWER GI bleed in kids < 2 yo?
|
• Meckel's diverticulum
• Intussusception |
|
|
What are the two most common VIRAL causes of pancreatitis?
Are HIV pts more susceptible to pancreatitis? |
Two most common causes:
• Mumps • Coxsackievirus B Pancreatitis is more common in pts with HIV |
|
|
What are the typical sources of salmonella in patients with salmonella-induced diarrhea?
|
Food-borne:
• Eggs • Poultry Animals: • Pet TURTLES • Pet iguanas |
|
|
What bilirubin and LFT findings suggest a HEMATOLOGIC jaundice process?
|
• Indirect >> Direct bilirubin
• Normal LFTs |
|
|
What bilirubin and LFT findings suggest a hepatocellular/ cholestatic jaundice process?
|
• Direct >> Indirect bilirubin
• Very high AST and ALT |
|
|
What bilirubin and LFT findings suggest an OBSTRUCTIVE jaundice process?
|
• Direct >> Indirect bilirubin
• Very high Alk PhOs ('PhOs -- Obstructive') |
|
|
What conditions are the following parasites associated with:
• Trichuris trichuria • Leishmania braziliensis? |
Trichuris trichuria:
• A whipworm • Causes GASTROENTERITIS --> IRON deficiency ANEMIA and malabsorption Leishmania braziliensis: • Causes cutaneous ulcerations |
|
|
What conditions lead to PIGMENTED gallstone formation?
|
BLOOD DISEASES:
• Hemoglobinopathies • Sickle Cell Dz • Hemolytic anemia |
|
|
What conditions predispose to the formation of CHOLESTEROL gallstones?
Mechanism? |
Obesity
TPN Fasting OCP use Pregnancy ILEAL RESECTION Mechanism: • Malabsorption of bile salts --> • Depleted bile acid pool --> • Can't micellize cholesterol --> • GALLSTONE formation |
|
|
What diagnosis should be considered in a pt with hematemesis, h/o repaired AAA, and normal EGD?
|
Aorto-enteric fistula
|
|
|
What disease sequalae are associated with post-Campylobacter infection?
|
• Guillain-Barre (15% incidence)
• Reiter's Syndrome/ Reactive arthritis • Erythema nodosum |
|
|
What electrolyte abnormality is a CAUSE OF pancreatitis?
|
HYPERcalcemia
|
|
|
What gallbladder ultrasound findings are suggestive of porcelain bladder and indicate a 20% risk of developing gallbladder carcinoma?
|
CALCIFICATION of the gallbladder wall = PORCELAIN gallbladder
|
|
|
What hematologic condition is associated with esophageal webs?
|
Iron deficiency anemia
|
|
|
What is a gallstone ileus?
What is the typical xray finding? |
SBO 2° to FISTULA formation between the gallbladder and intestine with obstruction by a large gallstone
Xray finding -- pneumobilia |
|
|
What is a Mallory-Weiss Tear? Where is it typically located? Most prominent symptom?
|
PARTIAL THICKNESS tear of the mucosa and submucosa
Located in the GASTRIC CARDIA (90%) or RIGHT DPL (distal posterolateral) aspect of the esophagus (10%) Most prominent symptom -- BLEEDING, mild - moderate, resolves spontaneously |
|
|
What is achalasia? What is a diagnostic clue?
|
Achalasia is a disorder characterized by marked increase in the resting pressure of the LES and absent peristalsis in the body of the esophagus
Achalasia causes lower esophageal dysphagia Diagnostic clue: dysphagia to BOTH solids and liquids |
|
|
What is Boerhaave's Syndrome?
What is the most prominent symptom? |
FULL-THICKNESS perforation of the LEFT DPL (distal posterolateral) aspect of the esophagus (an intrinsically weak area)
Most prominent symptom -- CHEST PAIN, severe, lancinating |
|
|
What is characteristic of the emesis in patients with large bowel perforation?
|
Emesis will be FECULENT
|
|
|
What is Charcot's Triad?
What is Reynold's Pentad? What condition are these findings associated with? |
Signs/ Sx of Ascending Cholangitis:
Charcot's triad: • Fever • Abdominal pain • Jaundice Reynold's pentad: • Charcot's triad, + • Shock • Altered mental status NOTE: This is a surgical emergency! |
|
|
What is Loeffler syndrome, and with which organism is it associated?
Other sxs from this organism? |
EOSINOPHILIC PNEUMONITIS
Associated with ASCARIS lumbricoides larval migration through lungs to the intestines. Ascaris produces local GI sxs -- OBSTRUCTION of the biliary duct or small bowel |
|
|
What is Ranson's Criteria for poor prognosis of pancreatitis?
|
On admission ('A sweet LAW'):
• Age > 55 • Glucose > 200 • LDH > 350 • AST > 250 • WBC > 16000 48 hours later ('Her Basic BCP'S''): • > 10% fall in HCT (suggests hemorrhagic pancreatitis) • Base deficit > 4 mEq/L • > 5 mg/dL rise in BUN • Ca < 8 • PO2 < 60 (suggests ARDS) • Sequestration of > 4 L of fluid |
|
|
What is the association between ciguatera fish poisoning and alcohol consumption?
|
Alcohol is associated with return or WORSENING of sx of ciguatera fish poisoning
|
|
|
What is the association of food with abdominal pain in the evaluation of PUD?
|
Gastic ulcer -- pain WORSENED with food
Duodenal ulcer -- pain RELIEVED with food |
|
|
What is the best method to confirm diagnosis of H pylori in the ED setting?
|
SEROLOGY -- has nearly the same sensitivity and specificity as biopsy
|
|
|
What is the cause of back pain associated with PUD?
|
POSTERIOR perforation of a DUODENAL bulb ulcer
|
|
|
What is the cause of CECAL volvulus?
In which patient population does it occur? What are the xray findings? |
Incomplete embryologic fixation of the cecum, ascending colon and terminal ileum to the posterior abdominal wall.
Most common in marathon runners in their 20s to 40s Xray -- massively dilated cecum in the LUQ |
|
|
What is the classic presentation for neoplasm at the head of the pancreas?
|
New-onset painless jaundice
|
|
|
What is the classic presentation of aortoenteric fistula?
Offending organisms? Most common site of the fistula? |
Hx -- Abdominal pain + GI bleeding that resolves spontaneously in a pt with previous AORTIC GRAFT
Organisms: • Staph • E coli Site -- aorta + distal DUODENUM |
|
|
What is the definitive treatment of ruptured esophageal varices?
|
Sclerotherapy
Band ligation Sengstaken-Blakemore tube Gelfoam embolization of the left gastic vein |
|
|
What is the degree of hemorrhage typically seen with PUD perforation?
|
PUD perf rarely is associated with significant hemorrhage
|
|
|
What is the diagnostic criteria for Community Acquired Peritoneal Dialysis (CAPD)-associated peritonitis?
|
• WBC >= 100 (PD fluid) with
• Predominance of neutrophils (> 50%); OR • Gram stain positive |
|
|
What is the difference in anatomical location and presentation in internal and external hemorrhoids?
|
External:
• Arise below the dentate line • Are well-inervated • Presents with very painful THROMBOSIS Internal: • Arise above the dentate line • Are relatively insensitive • Presents with painless BRBPR |
|
|
What is the difference in bowel layer involvement between Crohn's and UC?
|
Crohn's -- Inflammation involves ALL LAYERS of the bowel wall
UC -- Inflammation limited to the mucosa and submucosa |
|
|
What is the difference in gross intestinal involvement between Crohn's and UC?
|
Crohn's -- can occur ANYWHERE in the GI tract from mouth to anus
UC -- disease limited to the COLON only |
|
|
What is the difference in mucosal involvement between peptic ulcers and stress ulcers?
|
PUD -- mucosal defects extend BEYOND the muscularis mucosa
Stress Ulcer -- mucosal defect DOES NOT extend beyond the muscularis mucosa |
|
|
What is the difference in presentation between peritoneal pain and obstructive abdominal pain (such as with intussusception) in pediatric pts?
|
Peritoneal -- Pt remains motionless b/c pain worse with movement
Obstruction -- Pt exhibits restlessness and motion |
|
|
What is the drug of choice for esophagitis due to stuck pills?
|
Sulcrafate
|
|
|
What is the duration of symptoms in Yersinia that sets it apart from the other invasive bacterial organisms?
What is an infrequent complication in adults? |
Sx last 10 - 14 days or longer
2 - 5% incidence in adults of post-infectious: • Polyarthritis • Erythema nodosum |
|
|
What is the immediate pharmacologic treatment of ruptured esophageal varices in the ED?
|
Octreotide (Somatostatin) 50 mcg bolus, then 50 mcg/hr infusion
|
|
|
What is the location of most BLEEDING colonic diverticulae?
What is the location of most colonic AVMs? |
Most diverticula are LEFT-sided, but
Most BLEEDING diverticula are RIGHT-sided. Most colonic AVMs are RIGHT-sided (ie, right-sided bleeding) |
|
|
What is the location of the majority of pediatric and adult intussusceptions?
What are the best diagnostic studies in kids and adults? What is the typical ADULT presentation? |
Location:
• Ped -- ileoCOLIC • Adult -- small bowel Best diagnostic studies: • Ped -- Contrast enema • Adult -- CT Adult presentation: • PARTIAL SBO |
|
|
What is the mechanism of action of lactulose?
|
Degraded in the colon to LACTIC ACID -->
Acidifies the GI tract --> NH3 is TRAPPED and excreted in stool; acts as a CATHARTIC |
|
|
What is the mechanism of action of sulcrafate? In which environment does it work best?
|
• Works LOCALLY at the ulcer site, protecting it from gastric acid
• Works best in an ACID environment (pH < 3.5). Therefore, simultaneous use of antacids should be avoided |
|
|
What is the mechanism of action of the enteroINVASIVE diarrheal organisms?
Which bowel location is affected? |
Invade and damage the cell membrane -->
Inflammatory response --> Blood and mucus in stool NOTE: these organisms act primarily on the LARGE BOWEL |
|
|
What is the mechanism of action of the enteroTOXIN-producing diarrheal organisms?
Which bowel location is primarily affected? |
Toxin released -->
Alters water and electrolyte transport in the epithelial cell --> Profuse watery diarrhea Acts primarily on the SMALL BOWEL |
|
|
What is the minimum PMN count in ascitic fluid that is diagnostic for spontaneous bacterial peritonitis?
What about Community Acquired Peritoneal Dialysis (CAPD)-associated peritonitis? |
Polys:
• SBP -- 250 cells/mm3 (or WBC > 1000) • CAPD -- 100 |
|
|
What is the mortality rate for pediatric pts with pancreatitis?
Adults with ACUTE dz? Adults with CHRONIC dz? |
Peds -- 10%
Acute dz -- 4-10% Chronic dz -- 20% |
|
|
What is the mortality rate of acute mesenteric ischemia?
|
70%
|
|
|
What is the mortality rate of UGI bleed?
What percent of pts require intervention to control bleeding? Of UGI bleeders with known varices, what percent are bleeding from another source? |
Mortality -- 8-10%
Intervention Rqd -- 10% Known Varices w/ Alternate Bleeding Site -- 50% |
|
|
What is the most -- and least -- common viral cause of fulminant hepatitis?
|
Most common -- Hepatitis B and D coinfection
Least common -- Hepatitis C |
|
|
What is the most common cause of bacterial diarrhea?
|
Campylobacter
|
|
|
What is the most common cause of bowel obstruction < 2 yo?
|
Intussusception
|
|
|
What is the most common cause of CONJUGATED hyperbilirubinemia in school-aged children?
What is the significance of conjugated vs unconjugated hyperbilirubinemia in CHILDHOOD? |
Hepatitis A
CONJUGATED bilirubin is always PATHOLOGIC, whereas unconjugated is often physiologic or benign. |
|
|
What is the most common cause of death from acute pancreatitis?
|
ARDS -- due to deactivation of surfactant following pleural effusion with pancreatic enzymes
|
|
|
What is the most common cause of food poisoning?
|
Staph aureus
|
|
|
What is the most common cause of PAINFUL rectal bleeding in adults?
PAINLESS? |
Painful -- anal fissure
Painless -- diverticuLOSIS |
|
|
What is the most common cause of pancreatitis in kids?
Most common infectious cause? |
Most common -- trauma
Infectious -- Mumps |
|
|
What is the most common cause of rectal bleeding in the FIRST YEAR of life?
School-aged children? |
First year -- Anal fissure
School-aged -- Infectious diarrhea |
|
|
What is the most common cause of upper GI bleeding?
Relative percents? |
PUD:
• Duodenal ulcers (most common) -- 29% of all upper GI bleeds • Gastric ulcers -- 16% of upper GI bleeds |
|
|
What is the most common complication of biliary colic?
|
Fluid and electrolyte abnormalities from vomiting
|
|
|
What is the most common electrolyte abnormality seen in pancreatitis?
|
HYPOcalcemia
Note: HYPERcalcemia is a cause of pancreatitis! |
|
|
What is the most common etiology of Community Acquired Peritoneal Dialysis (CAPD)-associated spontaneous bacterial peritonitis?
Minimum PD WBC count to make the dx? |
Gram-positive organisms:
• STAPH (epi and aureus) • Strep spp. Note: this is in contrast to the Gram-NEGs of SBP Dx -- Peritoneal WBC >/= 100, or PMN > 50% |
|
|
What is the most common indication for surgery in pts with acute diverticulitis?
|
ABSCESS formation
|
|
|
What is the most common intestinal parasite and most common cause of water-borne diarrhea outbreaks in the US?
|
Giardia
|
|
|
What is the most common precipitant of hepatic encephalopathy?
|
AZOTEMIA
GI BLEEDING is a very common cause of azotemia |
|
|
What is the most common site for diverticular disease in Japanese and Japanese-Americans?
|
RIGHT colon
|
|
|
What is the most common site of pediatric intussusception?
What is the most common lead point? |
Most common site -- IleoCOLIC
Lead point -- Peyer's patches |
|
|
What is the most common worldwide cause of traveler's diarrhea?
What type of toxins does it produce? What is the second most common cause? |
1A) EnteroTOXIGENIC E coli (esp. Mexico and Central America)
Produces: • Heat-stable toxin, AND • Heat-labile toxin 1) CAMPYLOBACTER (esp. SE Asia) Second most common cause -- SHIGELLA |
|
|
What is the most commonly diagnosed BACTERIAL diarrhea?
|
Campylobacter
|
|
|
What is the most frequent anorectal disorder affecting infants and kids?
|
Anal fissure
|
|
|
What is the most frequent cause of acute diarrhea in children 6-24 mos?
Kids and adults? Season of the year? |
6-24 mos -- Rotavirus
• WINTER and SPRING months most common Kids & adults -- Norwalk virus • Family outbreaks and EPIDEMICS common • WINTER |
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What is the most important diagnostic test in the workup of suspected mesenteric ischemia?
|
ANGIOGRAPHY
|
|
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What is the most reliable SYMPTOM of esophageal perforation (such as from Boorhaave's)?
|
Pleuritic chest pain localized along the course of the esophagus that is EXACERBATED by NECK FLEXION and SWALLOWING
|
|
|
What is the outpatient tx for mild Crohn's dz?
Adjunctive meds? |
• PO steroids
• Sulfasalazine • Metronidazole Azothioprine and 6-MP are immunosuppressive agents that are used in pts with refractive dz, and are used as STEROID-SPARING agents (permit decreased dose of steroids) |
|
|
What is the pathophysiology of gastric and duodenal ulcers?
|
Gastric ulcer -- DAMAGE to the gastric mucosa --> exposure to H+ ions --> ulceration
Duodenal ulcer -- Hypersecretion of gastric acid with markedly increased gastric emptying that OVERWELMS the ability of the duodenum to neutralize the acid |
|
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What is the prevalence of fecal occult blood in diverticulitis?
|
50%
|
|
|
What is the prevalence of seeing free air on xray with anterior and posterior PUD perfs?
|
Anterior -- only 60-70% demonstrate free air
Posterior -- retroperitoneal; NO FREE AIR will be seen |
|
|
What is the probability of passage of a foreign body once it has passed the GE junction?
|
> 90%
|
|
|
What is the recommendation with respect to xraying children with suspected foreign body ingestion?
|
No consensus. NOT ALL CHILDREN require xray.
5 day morbidity rates show no difference between xrayed and unxrayed kids. |
|
|
What is the recurrence rate for sigmoid volvulus?
Tx of choice? |
90% recurrence rate
Tx -- elective resection |
|
|
What is the relapse rate for chronic anal fissures?
|
50%
|
|
|
What is the relative incidence of bowel cancer in Crohn's an UC patients?
|
Crohn's -- 3x general population (small and large bowel)
UC -- 10-30x general population |
|
|
What is the relative rate and ETIOLOGY of mesenteric vascular ischemia from:
• Acute mesenteric artery occlusion • Non-occlusive mesenteric ischemia • Mesenteric venous thrombosis? |
Arterial occlusion:
• 65-75% • Cardiac embolization Nonocclusive: • 20% • Conditions which produce sustained reduction in cardiac output (CHF, MI, hypovolemia) • Medications that decrease vascular blood flow (Digitalis, vasoconstrictors (epi, levo)) Venous thrombosis: • 5-15% • Associated with HYPERCOAGULABLE states (eg, polycythemia, antithrombin III deficiency) • 60% have h/o DVT |
|
|
What is the relative rate of anorectal tumors between anal canal and anal margin neoplasms?
What is their typical malignancy potential and prognosis? |
Anal canal:
• 80% of all anorectal tumors • High-grade malignancy potential • Poor px Anal margin: • 20% of all anorectal tumors • Low-grade malignancy potential • Good px |
|
|
What is the role of abx and loperamide in the treatment of INFECTIOUS diarrhea?
Dosage? |
All pts with suspected infectious diarrhea should be treated with:
• CIPRO 500 po x 1 dose, or bid x 3 days With Cipro contra-indication (eg, peds, pregnant, Cipro allergy): • Bactrim • Imodium (always given with abx) |
|
|
What is the role of anti-diarrheal agents in the treatment of C dif colitis?
|
Anti-diarrheals worsen the condition by allowing for further OVERGROWTH of bacteria
Can cause TOXIC MEGACOLON |
|
|
What is the role of arteriography in the diagnosis of upper GI bleeding?
|
Arteriography is reserved for situations in which endoscopy is unavailable or non-diagnostic
|
|
|
What is the role of gastic lavage in upper GI bleeds?
What about COLD/ ICE water temperature lavage? |
Lavage is useful to:
• Monitor for blood loss and continued bleeding • Prep a pt for endoscopy Lavage is NOT helpful in stopping the bleeding Only ROOM TEMPERATURE saline/ water should be used |
|
|
What is the role of H2 blockers in the tx of Boerhaave Syndrome?
|
None
|
|
|
What is the role of NG tube in the evaluation/tx of lower GI bleed patients?
|
Because up to 11% of patients with hematochezia have UGI bleeding, insert an NGT to look for gross blood. If negative, remove tube.
|
|
|
What is the role of NG tube in upper GI bleed patients?
|
Most patients with UGI bleed SHOULD NOT receive an NGT tube. NG tube does not aid in the dx of UG bleed, and false negative results may occur if the bleeding has stopped.
Gastic lavage may be used to prepare a patient for endoscopy, but this uses a large-bore Ewald tube and not an NG tube. Esophageal varices and Mallory-Weiss tears are NOT contraindications to NG tube placement. |
|
|
What is the role of proteolytic enzymes such as papain in the chemical dislodgement of esophageal food impaction?
|
NOT RECOMMENDED!
3% incidence of esophageal perforation |
|
|
What is the sensitivity of CT in the diagnosis of cholelithiasis?
|
50%
|
|
|
What is the specific IMMEDIATE pharmacological treatment of a ruptured esophageal varix?
|
Octreotide:
• 50 mcg bolus, then infuse 25 - 50 mcg/hr • Octreotide is more effective than vasopressin with less side effects Vasopressin: • Infuse 0.2 - 0.5 units/min |
|
|
What is the specific treatment of E coli O157:H7?
What should NOT be given? |
Supportive only -- NO ABX!
5-10% of pts receiving abx will develop HUS |
|
|
What is the subjective taste of fish with scombroid and ciguatera fish poisoning?
|
Scombroid -- Sharp, metallic, bitter, or peppery taste
Ciguatera -- TasteLESS and odorLESS |
|
|
What is the top normal CBD diameter when evaluating for choledocholithiasis?
|
6 mm
|
|
|
What is the top normal thickness of the gallbladder wall when evaluating for cholecystitis?
|
4 mm
|
|
|
What is the toxin produced by E coli O157:H7?
What is the clinical picture? |
Shigella-like cytopathic toxin
Clinical picture: • Severe abdominal cramping (that mimicks appendicitis) • BLOODY diarrhea • AFEBRILE • May lead to HUS |
|
|
What is the treatment and recurrence rate of sigmoid and cecal volvulus?
|
Sigmoid:
• Non-operative reduction with rectal tube • 90% recurrence rate Cecal -- surgical reduction |
|
|
What is the treatment for ingested alkaline batteries?
|
If the pt is ASX and the battery has passed into the STOMACH, management is expectant (home obs)
If lodged in the esophagus, EMERGENT endoscopic removal Necrosis and perforation can occur within 4-6 hours |
|
|
What is the treatment of C dif colitis? How must the meds be given?
|
Tx:
• Flagyl IV • Vanco PO (for refractory cases) NOTE: Vanco MUST be given po to be effective! ('Vanc-O') |
|
|
What is the treatment of mesenteric ischemia due to arterial, venous, and non-occlusive causes?
|
Arterial:
• Papaverine (an intra-arterial vasodilator, given during angiography) • Surgery based on response to papaverine Venous: • Immediate anticoagulation • Surgery only if there is necrotic bowel Non-occlusive: • Tx is NONOPERATIVE • Papaverine is definite tx |
|
|
What is the treatment of peritonitis in CAPD (Community Associated Peritoneal Dialysis)?
|
IntraPERITONEAL loading dose of:
• Ancef, • Vanc, or • Ceftazidime in the ED, + Abx in the DIALYSATE over the next 10 days CAPD is usually managed in an OUTPATIENT setting |
|
|
What is the treatment of pinworm (Enterobius) infection?
Duration of tx? Family members? |
• Mebendazole or
• Albendazole or • Pyrantel A SECOND DOSE is recommended 2 weeks after the first dose Pinworm is HIGHLY CONTAGIOUS. Family members SHOULD BE tx'd empirically even if they have no sxs. |
|
|
What is the tx of ciguatera fish poisoning?
What about moderate - severe cases? |
Supportive
MANNITOL in mod - severe cases |
|
|
What is the typical etiology of SEVERE esophageal bleeding?
|
Typically caused by a RUPTURED VARIX
Can also be caused by a perforated artery at the base of a PEPTIC ULCER |
|
|
What is the typical presentation of a patient with acute anterior and posterior PUD perforations?
|
ANTERIOR Perf -- Sudden onset of abdominal pain with guarding and rebound (PERITONEAL signs)
POSTERIOR Perf -- Sudden onset of BACK pain (from posterior duodenal ulcer perf) |
|
|
What is the typical presentation of alcoholic hepatitis?
PE? Labs? |
Presentation:
• Most cases are subclinical or asx • Fever • RUQ pain • Jaundice • Anorexia • N/V PE: • Hepatomegaly (as opposed to the shriveled liver in cirrhotics) • Ascites • Fever Labs: • AST 2x > ALT (AST typically < 300) • Elevated WBC |
|
|
What is the typical relationship between food intake and onset of PUD pain?
|
Gastric Ulcer -- Pain occurs shortly after eating
Duodenal Ulcer: • Pain occurs 2-3 hours after meals • Is RELEIVED partially or completely WITH FOOD IE: food causes gastric ulcer pain and relieves duodenal ulcer pain |
|
|
What is the typical tenderness elicited on PE in patients < 2 yo with appendicitis?
What is the rate of evidence of perforation intraoperatively in appy patients < 3 yo? |
Pts < 2 yo typically have DIFFUSE TTP
ALMOST ALL pts < 3 yo with appendicitis have evidence of perforation at surgery |
|
|
What medications can be used to facilitate dislodgement of DISTAL esophageal FOOD impaction?
|
IV Glucagon:
• Relaxes smooth muscle and decreases LES pressure • Begin with 1 mg IV • Give an additional 2 mg if no relief in 20 min SLNTG Nifedipine -- 10 mg SL Carbonated Beverages -- Produce CO2 which increases intraluminal pressure and pushes the food bolus into the stomach |
|
|
What medicines can be used in AIDS pts with crytosporidium diarrhea who fail tx with anti-retroviral (HAART) meds?
|
Nitazoxanide or
Paromomycin |
|
|
What meds/ agents may interfere with stool examination for parasites?
|
• Antacids
• Anti-diarrheals • Rectal contrast |
|
|
What metabolic condition can cause a falsely LOW amylase and lipase in a pt suspected of having pancreatitis?
|
HyperTRIGLYCERIDEMIA
|
|
|
What metabolic conditions, and which electrolyte abnormalities, are associated with constipation?
|
• HYPOthyroidism
• HYPERparathyroidism • HYPOkalemia • HYPERcalcemia |
|
|
What neoplasm is associated with Hepatitis B chronic carrier state?
What percent of infected neonates and adults will be chronic carriers? |
Hepatocellular CA
Percent chronic carriers: • Neonates -- 90% • Adults -- 10% |
|
|
What organism is associated with recurrent BACTEREMIA in AIDS pts?
Proctocolitis? |
BACTEREMIA -- Salmonella
PROCTOCOLITIS -- Campylobacter |
|
|
What organism is responsible for 100% of the cases of amebic liver abscess?
Tx? Which is more common, pyogenic or amebic liver abscesses? |
Entamoeba histolytica
Tx: • Non-surgical (as opposed to pyogenic liver abscesses) • Flagyl 750 tid x 7 days AMEBIC >> pyogenic abscesses |
|
|
What organism is responsible for ciguatera fish poisoning?
|
Gambierdiscus toxicus
|
|
|
What OTC med commonly causes black stool?
|
Pepto bismol
Iron |
|
|
What parasitic agent invades the bladder wall and causes hematuria?
Tx? |
SCHISTOSOMA haematobium
Tx -- Praziquantel |
|
|
What percent of all colonic obstructions are due to volvulus?
What is the relative prevalence of sigmoid vs cecal volvulus? |
Percent of all colonic obstructions:
• 10-13% Relative Prevalence: • Sigmoid: 60% • Cecal: 40% |
|
|
What percent of all upper GI hemorrhages are due to Mallory-Weiss tears?
|
5-15%
|
|
|
What percent of gastic and duodenal ulcers is H pylori responsible for?
|
70% of gastric ulcers
95% of duodenal ulcers |
|
|
What percent of hepatitis B and hepatitis C patients are chronic carriers?
What is the infection rate for needlestick injuries with Hep C infected blood? |
Chronic carriers:
• B -- < 5% • C -- 80-90% Hep C infection needlestick infection rate -- 1.8% |
|
|
What percent of intussusceptions occur in children and adults?
Which cohort is more likely to have an identifiable abnormality causing the intussusception? |
Adults -- 5%
Children -- 95% Indentifiable abnormality: • Children -- 2-8% • Adults -- 95% (75% are NEOPLASMS) |
|
|
What percent of patients infected with H pylori will develop a peptic ulcer in their lifetime?
|
15 - 20%
|
|
|
What percent of patients with upper GI and lower GI bleeds will have melena?
|
UGI -- 70%
LGI -- 30% |
|
|
What percent of pts with early appendicitis will have fever?
|
20% (low sensitivity)
|
|
|
What percent of PUD patients experience hemorrhage?
What is the ratio of duodenal vs gastric ulcer bleeding? |
15%
Duodenal bleed 2x > Gastric bleed |
|
|
What percent of PUD perforations are accompanied by hemorrhage?
|
10%
|
|
|
What percent of stones in the CBD are detected via ultrasound?
|
Only 50%
|
|
|
What percent of the US population is colonized with H pylori by age 50?
What percent of people w/ H pylori will develop PUD? |
Colonized -- 50%
Develop PUD -- 15-20% |
|
|
What percent of upper and lower GI bleeders will have melanotic stools?
|
Upper -- 70%
Lower -- 33% |
|
|
What serum cancer marker is associated with hepatocellular carcinoma?
|
Alfa fetoprotein (AFP)
|
|
|
What sized objects cannot reliably pass thru the pylorus and require endoscopic removal?
|
Objects longer than 5 cm and wider than 2 cm
|
|
|
What substance is used to test for fecal leukocytes in stool?
|
Methylene blue
|
|
|
What test can be used to evaluate for laxative abuse?
|
3% Sodium Hydroxide test:
• Phenolphthalein (the most commonly abused laxative) is present if stool TURNS RED with 3% NaOH and if the reaction is abolished with the addition of HCl |
|
|
What type of disorders typically cause oropharyngeal (transfer) dysphagia?
What finding is highly suggestive? |
NEUROMUSCULAR disorders:
• Account for 80% of cases • Difficulty swallowing LIQUIDS is particularly suggestive • CVA • Polymyositis • SCLERODERMA (>50% c/o dysphagia) • MS Infectious/ Inflammatory: • Pharyngitis • Aphthous ulcers • Botulism |
|
|
What type of pain is characteristic of retrocecal appendicitis?
|
Pain that radiates to the FLANK
This type of pain is typically slow in onset as it develops, whereas RENAL COLIC is characterized by acute onset of flank pain |
|
|
What ultrasound finding is very suggestive of acute appendictitis?
What is the sensitivity of u/s in the detection of appendicitis? |
Noncompressible, immobile appendix > 6 mm in diameter
Sensitivity -- 85% |
|
|
What unrelated symptoms may accompany Rotavirus diarrhea?
|
URI and pneumonia sx
|
|
|
What value of LIPASE is most sensitive and specific in the dx of pancreatitis?
|
Lipase at least 2x normal
|
|
|
What visible skin finding often accompanies anal fissures?
|
A sentinal pile
|
|
|
What volume of infectious load is required to spread Shigella?
Salmonella? |
Shigella:
• A VERY SMALL amount -- only 50 - 100 organisms Salmonella: • Very large inoculum rqd |
|
|
What will be the orientation on xray of a flat object (eg, coin) lodged in the trachea and esophagus?
|
Trachea:
• Alignment consistent with vocal cord orientation • Round on the LATERAL view Esophagus: • Round on the PA view |
|
|
What xray finding confirms necrotizing enterocolitis in the premature newborn with diarrhea?
|
Pneumatosis intestinalis
|
|
|
What xray finding is characteristic of gallstone ileus?
|
Pneumobilia (air in the biliary tree)
|
|
|
Which antibiotics and medicines are often implicated in esophagitis?
|
Abx:
• Doxycycline • Tetracycline Other agents: • NSAIDS • KCl • FeSO4 |
|
|
Which antibiotics are most commonly associated with C dif toxin?
|
Clindamycin
Cephalosporins PCNs |
|
|
Which bacterial agent is responsible for 'camper's diarrhea'?
|
• Giardia
• Campylobacter |
|
|
Which bacterial cause of diarrhea is associated with increased risk of sepsis, osteomyelitis, meningitis and infected aneurisms?
|
Salmonella
Associated w/ 'SOMA': • Sepsis • Osteo • Meningitis • Aneurism (infected) |
|
|
Which bacterial cause of diarrhea is commonly associated with seizures?
|
Shigella
|
|
|
Which bacterial cause of diarrhea is extremely contagious and requires only a very small bacterial load to transmit the disease?
|
Shigella
|
|
|
Which cohort of patients are most at risk for Entamoeba histolytica infection?
What sx do >80% of pts display? |
Greatest risk:
• Male homosexuals • AIDS pts > 80% of pts are ASX CARRIERS |
|
|
Which cohort of patients have the highest prevalence of acalculous cholecystitis?
What is the common complication? |
• ELDERLY
• DIABETICS • Post-partum • Post-op • Burns • Major trauma • Vascular dz • Sepsis • CHF Complication: • Gangrene --> PERFORATION |
|
|
Which constipation tx OSMOTICALLY draws fluid into the bowel lumen?
|
• Mag citrate
• MOM • Lactulose • GoLytely (sorbital/ polyethylene glycol) |
|
|
Which constipation tx STIMULATES MOTILITY and increases gut mucosal secretion of Na and water?
|
Dulcolax (bisacodyl)
|
|
|
Which diarrhea-producing organism is associated with drinking untreated WELL WATER?
Which cohort of pts is most susceptible? |
Aeromonas hydrophila
AIDS pts/ immunocompromized most susceptible |
|
|
Which diarrhea-producing organisms produce sxs consistent with acute abdomen?
|
Campylobacter
E coli O157:H7 Yersina (produces mesenteric adenitis often confused with appendicitis) |
|
|
Which diarrheal organism is associated with 'rice water' stools?
|
Vibrio cholera
|
|
|
Which diarrheal organism is associated with contaminated water from remote STREAMS and WELLS?
|
Giardia
'Backpackers' diarrhea |
|
|
Which disease, Crohn's or UC, has a higher rate of periANAL involvement?
Rectal? |
Both have perianal involvement, but perianal complications are seen in over 90% of CROHN'S pts
Note: Crohn's has a VERY LOW rate of RECTAL involvement |
|
|
Which disease, Crohn's or UC, is characterized by 'cobblestoning'?
What is cobblestoning? |
CROHN'S has cobblestoning
Cobblestoning is the appearance of the mucosa 2° to criss-crossing of the deep longitudinal ulcerations that alternate with normal mucosa. |
|
|
Which disease, Crohn's or UC, is characterized by crypt abscesses?
|
UC
|
|
|
Which disease, Crohn's or UC, is characterized by perianal fistulas and abscesses?
|
BOTH -- More common in CROHN'S, however
NOTE: Only UC has CRYPT abscesses |
|
|
Which disease, Crohn's or UC, is characterized by skip lesions, and which has continuous mucosal involvement?
|
Skip lesions -- Crohn's
Continuous mucosal involvement -- UC |
|
|
Which disease, Crohn's or UC, is more likely to present with bloody diarrhea?
|
UC
|
|
|
Which electrolyte abnormality is the most common cause of adynamic ileus?
Others? |
HYPOkalemia
Others: • HYPOmagnesemia • HYPOnatremia • HYPOcalcemia • Uremia |
|
|
Which esophageal veins are part of the portal system and responsible for esophageal varices in liver patients?
|
Coronary and Short Gastric veins
|
|
|
Which fish are associated with scombroid fish poisoning and ciguatera fish poisoning?
|
Scombroid:
• TUNA (Mahi mahi) Ciguatera: • Grouper • Snapper • Barracuda • King fish • Jack |
|
|
Which infectious diarrheal agent comes from eating raw or undercooked oysters, shrimp and seafood?
Tx? |
Vibrio parahaemolyticus
Tx: • Self-limiting disease • Doxy |
|
|
Which infectious diarrheal agent is associated with shigella-like toxin?
|
Enterohemorhagic E coli
|
|
|
Which infectious diarrheal agents are associated with exposure to infants in daycare centers?
|
Cryptosporidium
Giardia |
|
|
Which infectious diarrheal organism is associated with hemolytic uremia syndrome (HUS), especially in kids on antibiotics?
|
Enterohemorrhagic E coli O157:H7
|
|
|
Which infectious diarrheal organisms are associated with eating poorly cooked or raw shellfish?
|
• Norwalk virus
• Vibrio cholera • Vibrio parahemolyticus |
|
|
Which organism is associated with VOMITING and cramps after ingestion of leftover fried rice?
Rate of onset of sx? Duration of sx? |
Bacillus cereus
Rate of onset -- 2-3 hrs Duration -- 10 hrs |
|
|
Which organisms are associated with food poisoning?
Sx? Rate of onset of sx? Associated foods? |
Staph aureus:
• The MOST COMMON cause of food poisoning • Associated with proteinaceous products such as mayonnaise and meats that have been SITTING OUT (potato salad, sliced ham) • Severe, sudden VOMITING seen after 1-6 HOURS; sx are short-lived Clostridium perfringens: • Common cause of food poisoning • Associated with precooked or REHEATED meat, poultry • DIARRHEA occurs w/in 6-12 hrs • Fever, N/V are RARE • Sx resolved by 24 hrs |
|
|
Which parasitic organisms produce eosinophilia?
|
'A Strong, Fine SHIP'
• Ascaris lumbricoides • Strongyloides stercoralis • Filariasis • Schistosomiasis • Hookwork (Necator) • Isospora belli • Pinworm (Enterobiasis) |
|
|
Why do the elderly have the highest rate of constipation?
|
GI transit times are longer --> increased water absorption from the stool
|
|
|
Why is morphine not recommended for pain relief in pts with diverticulitis?
|
Morphine can increase the intraluminal pressure of the bowel, increasing the risk of perforation
|
|
|
With respect to the dentate line, what is the anatomic location of anal CANAL and anal MARGIN neoplasms?
|
Canal -- Proximal to the dentate line
Margin -- Distal to the dentate line |
|
|
With which condition is intestinal angina associated?
|
Acute mesenteric ischemia
|
|
|
With which diarrheal diseases are anti-motility agents contraindicated? Why?
|
• C dif
• Crohn's • UC Anti-diarrheals in these disorders predispose to TOXIC MEGACOLON |
|
|
Compare and contrast the bloodwork findings of Henoch-Schonlein Purpura, TTP, HUS, and ITP.
Coombs? |
HSP and ITP are NOT hemolytic diseases, so there is no destruction of RBCs and no schistocytes
HSP -- INCREASED platelets ITP -- DECREASED platelets HUS and TTP: • Schistocytes • DECREASED platelets • Severe anemia (from hemolysis) • Increased reticulocytes • DIRECT Coombs negative COAGS are normal in all of these disorders |
|
|
Cyanosis results when what percent of the hemoglobin is methemoglobin?
What will the pulse ox and ABGs read? |
10-15% of the total total hemoglobin
(> 1.5 g/dL methemoglobin) Pulse Ox: • Will be artificially HIGH ABG: • Normal PAO2 • DECREASED SaO2 |
|
|
For transfusion of which blood product is ABO matching NOT required?
|
PLATELETS
HLA matching may be performed, however. |
|
|
Hemophilia A and B are characterized by a deficiency in which clotting factors?
State the effect on the following clotting indices: • PT • PTT • Bleeding time |
A (classic hemophilia) -- VIII
B (Christmas dz) -- IX Best Christmas for 9 yo'" • PTT -- PROLONGED (b/c VIII and IX reflect the intrinsic pathway) • PT -- Normal (extrinsic pathway) • Bleeding time -- NORMAL (reflects vascular integrity and platelet fxn) |
|
|
How can the risk of renal injury be minimized in severe transfusion reaction?
|
ALKALINIZE the urine to prevent precipitation of Hgb in the renal tubules
|
|
|
How can TTP and HUS be differentiated from one another?
|
VERY DIFFICULT!
HUS often presents with DIARRHEA following O157:H7 or Shigella infection TTP usually has NEUROLOGICAL impairment Labs are the same |
|
|
How do sickled RBCs affect the spleen?
|
Microvascular SLUDGING
--> Vaso-OCCLUSION --> Splenic MICROINFARCTION --> Functional ASPLENISM --> Predisposition to overwhelming SEPSIS from ENCAPSULATED organisms |
|
|
How is hemoglobin S different from normal hemoglobin:
• Chemical composition? • Oxygen-binding? |
Hb:
• 2 alpha-globin chains • 2 ß-globin chains HbS: • 2 alpha-globin chains • 2 ß-globin chains w/ amino acid substitutions HbS binds O2, but when deoxygenated it polymerizes and deforms the RBC into a sickle shape |
|
|
How should fever without a source be treated in sickle cell pts?
|
Most sickle cell pts are ASPLENIC by age 5 and are at risk for OVERWHELMING SEPSIS.
Sickle cell pts with fever of unknown source or unexplained leukocytosis REQUIRE ADMISSION for w/o. |
|
|
Neutropenia is defined as an ANC < what value?
State the formula for calculating the ANC. |
Neutropenia = ANC < 1500
ANC = WBC x (% poly + % band) |
|
|
Of the four species of organisms that cause malaria, which is the most LETHAL?
Why? Eosinophilia and WBC? |
Plasmodium FALCIPARUM
Causes intravascular SLUDGING --> • AMS • RENAL FAILURE Eosinophilia is NOT SEEN with malaria WBC is NORMAL with malaria |
|
|
Schistocytes, an indication of microangiopathic hemolytic anemia (MAHA), are found in which disorders?
What is the most common cause of MAHA? |
• AORTIC STENOSIS (the most common cause of MAHA)
• TTP • HUS • DIC • HEELP • HIT Note: Schistocytes are NOT found in ITP or HSP |
|
|
State in order the four most common types of lung CA
|
• 1 -- Adenocarcinoma
• 2 -- Squamous cell CA • 3 -- Small cell (aka Oat cell) CA • 4 -- Large cell CA |
|
|
State some causes of ITP.
Most common cause? |
Most common cause -- recovery from a VIRAL ILLNESS
Other causes of low platelets: • SLE • HIV • CLL • Hepatitis C • Meds (Heparin, Quinidine) • Antiphospholipid Ab Syndrome |
|
|
State the potential malignancy associated with the following skin conditions:
• Acanthosis nigricans • Dermatomyositis • Erythema multiforme • Erythema nodosum • Psoriasis |
Acanthosis nigricans:
• AdenoCA of the STOMACH Dermatomyositis: • Breast, ovary, female genital tract CA HEMATOLOGIC malignancy: • Erythema multiforme • Erythema nodosum • Psoriasis |
|
|
State the relative response rates of small cell and non-small cell lung CAs to chemo
|
Small cell -- respond WELL to chemo
Non-small cell -- responds poorly to chemo: • AdenoCA • SCC • Large cell CA |
|
|
State the typical presenting lung mass location of:
• Squamous cell CA • AdenoCA • Small cell CA Central or peripheral? |
CENTRAL Mass:
• Squamous cell • Small Cell Peripheral Mass: • Adenocarcinoma ('Adeno -- Away') |
|
|
To which locations do testicular cancer typically metastasize to?
What percent of pts presenting with testicular CA will already have mets at the time of presentation? |
Met sites:
• Lumbar spine • Lymph nodes • Lungs % with mets at presentation: • More than 1/3 |
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|
What adverse side effects are associated with Coumadin use?
Which cohort of pts is most at risk? |
BLEEDING
SKIN NECROSIS: • Seen 3-8 days after beginning coumadin • Caused by thrombosis of small cutaneous vessels • Seen primarily in pts with protein C deficiency |
|
|
What ages are affected by ITP?
|
All ages. 50% of new cases are in kids.
|
|
|
What are the lab findings in ITP?
|
Normal CBC except for LOW PLATELETS
Normal coags Elevated bleeding time |
|
|
What are the lab findings in the paraproteinemias,
Multiple myeloma and Waldenström's Macroglobulinemia? Tx? |
Bloodwork:
• RBC ROULEAUX formation • Factitious HYPONATREMIA • Very high serum VISCOSITY Tx: • Vigorous IVF • Plasmapheresis |
|
|
What are the lab findings in TTP?
What about haptoglobin, retic, bili and Coombs? Coags? |
• Severe anemia
• Platelets < 20,000 • Schistocytes (or helmet cells) • Decreased haptoglobin • Elevated retic count • Elevated indirect bili (from the hemolysis) • Direct Coombs test NEGATIVE NORMAL COAGS |
|
|
What are the neurologic sx associated with FOLATE deficiency?
|
NONE!
Ataxia is seen in vitamin B12 deficiency (pernicious anemia) |
|
|
What are the risk factors associated with breast cancer in MEN?
What is NOT a risk factor? |
• KLINEFELTER syndrome (50x increase)
• Testicular abnormalities • Nipple discharge • Jewish Gynecomastia is NOT a risk factor |
|
|
What are the sx of pernicious anemia resulting from vitamin B12 deficiency?
Labs? Most common cause? |
Pernicious anemia sx:
• ATAXIC gait • Profound generalized WEAKNESS Labs: • PANCYTOPENIA • Macrocytic indices Cause: • Atrophic gastritis |
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|
What are the vitamin K dependent factors in the clotting cascade?
Intrinsic? Extrinsic? |
Vit K Factors:
• 2, 7, 9, 10 INTRINSIC: • 12, 11, 9, 8 EXTRINSIC: • 7 |
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|
What are typical causes of HYPERphosphatemia, and what are the symptoms?
|
Hyperphosphatemia is most commonly seen in RENAL FAILURE
Other causes -- any process that results in rapid, extensive cell damage --> phosphate release: • HEMOLYSIS • RHABDO • Tumor lysis syndrome Sx are manifest thru HYPOCALCEMIA: • Tetany |
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What distinguishes the purpura of Henoch-Schonlein Purpura from ITP, TTP, HUS and RMSF?
|
HSP purpura is PALPABLE
ITP, TTP, HUS are non-palpable RMSF exihibits raised MACULES that becomes PETICHIAL |
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What drug may prevent the need for factor replacement in pts with MILD hemophilia (factor levels of 5% of normal or greater)?
Mechanism? |
Desmopressin (DDAVP)
DDAVP is though to cause release of vWF that will carry additional factor VIII |
|
|
What is an important cause of aplastic crises in patients with underlying hemolytic anemia?
|
Parvovirus B19
NOTE: Parvovirus B19 also caues Erythema Infectiosum (Fifth Disease) |
|
|
What is one of the most common causes of pediatric acute renal failure?
|
HUS
|
|
|
What is the age of peak incidence of HUS?
What are the diagnostic findings? |
6 mos - 4 yo
Dx: • Acute renal failure • Microangiopathic hemolytic anemia (schistocytes) • Fever • Thrombocytopenia • Often w/ gastroenteritis 2° to EHEC or shigella Note: very difficult to distinguish from TTP |
|
|
What is the association between mesothelioma and smoking?
|
Mesothelioma is NOT strongly associated with smoking
It is associated w/ asbestosis |
|
|
What is the clinical presentation of von Willebrand Dz?
Coag/ blood tests? Where is vWF made in the body? |
Characterized by SKIN and MUCOSAL bleeding
Unlike with hemophilia, hemearthrosis is uncommon Labs: • PT/ PTT/ Platelets NORMAL • Bleeding time elevated vWF is made in the vascular ENDOTHELIUM, not the liver |
|
|
What is the ddx of hyperviscosity syndrome?
|
Excessive serum PROTEIN production:
• Multiple myeloma • Waldenström's macroglobulinemia MASSIVE #s of WBCs produced: • CML • Blast crisis |
|
|
What is the difference in presentation in pts with platelet disorders vs coagulation factor deficiencies?
|
Platelet disorders:
• Mucocutaneous bleeding • Petichiae • Ecchymosis • Epistaxis • GI/ GU bleeding Coagulation Factor Deficiencies: • Bleeding into joints and potential spaces |
|
|
What is the FIRST action that should be taken regarding hemopheliacs who present with new HA, blunt head injury, or localizing neurological sxs?
|
FACTOR REPLACEMENT
Factor replacement should never be held up for imaging, PE, or diagnostic studies |
|
|
What is the formula for determining the amount of Factor VIII and IX replacement required in:
• Hemophilia A (classic hemophilia) • Hemophilia B (Christmas Dz)? |
Hemophilia A:
• Factor VIII rqd = wt (kg) x 0.5 x % change in factor activity rqd Hemophilia B: Factor IX rqd = wt (kg) x 1.0 x % change in factor activity rqd % Change rqd: 100%: • GI bleed • CNS bleed • Epistaxis 50%: • Deep muscle • Joint • Oral mucosa |
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|
What is the incidence of von Willebrand disease?
Tx? Emergency tx/ Pre-op? |
Incidence -- 1%
vWD is the most common congenital bleeding disorder DESMOPRESSIN (DDAVP) is the mainstay of tx: • DDAVP induces the release of vWF from the endothelium • DDAVP promotes hemostasis on the endothelium Emergency tx/ Pre-op: • CRYOPRECIPITATE |
|
|
What is the indication for:
• Leukocyte-poor PRBCs • Irradiated PRBCs • Washed PRBCs • IgA-deficient PRBCs? |
Leukocyte-poor:
• H/o simple febrile reaction to transfusion • Leukocyte poor blood minimizes risk of HIV and CMV transmission (eg, potential BONE-MARROW recipients) Irradiated: • Irradiated PRBCs prevent T-cell proliferation. Use in: • Neonates • Immunocompromized pts • TRANSPLANT pts Washed: • In washed cells, PLASMA has been REMOVED. Use in: • Plasma hypersensitivity (ie, IgA deficiency) IgA-free: • IgA decificiency |
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|
What is the leading cause of death in sickle cell pts?
|
Acute Chest Syndrome
|
|
|
What is the mechanism of action of Coumadin?
Why is there a THROMBOGENIC period immediately upon starting Coumadin? |
Blocks the activation of:
• II, VII, IX, X (vitamin K-dependent factors) • Protein C and S Initially thrombogenic b/c: • Longer 1/2-life of the thrombogenic vit K dependent factors compared with Prot C and S |
|
|
What is the most common cause of death with ITP?
|
Intracerebral hemorrhage
|
|
|
What is the most common cause of MAHA?
|
Aortic stenosis
|
|
|
What is the most common cause of SIADH?
|
Small cell lung CA
|
|
|
What is the most common cause of SVC syndrome?
|
LUNG CA most common
Also: • Breast • Testicle |
|
|
What is the most common precipitating event for TTP? Other causes?
|
#1 Pregnancy
Others ('QuITS'): • Quinidine • Infection (esp HIV) • Ticlidopine • SLE |
|
|
What is the most common presenting symptom in ITP?
|
PETICHIAE (not typically seen in TTP or HUS)
Except for petichiae and bruising, the pt should have a NORMAL exam |
|
|
What is the most common unilateral neck mass in an adult?
|
Squamous Cell CA, metastatic to cervical LNs
|
|
|
What is the pentad of sx that comprise TTP?
|
1 Fever
2 MAHA (RBC shear --> schistocytes) 3 Thrombocytopenia 4 Renal failure 5 Neuro sx (AMS, CVA) |
|
|
What is the role of O2 in the tx of sickle cell vaso-occlusive crisis?
|
O2 is commonly given but it has NEVER BEEN PROVED to affect incidence, duration, or severity of the pain crisis.
|
|
|
What is the role of vWF and fibrinogen in primary hemostasis?
|
vWF binds the platelet/ platelet plug to the vascular endothelium
Fibrinogen forms the platelet plug that binds the platelets together |
|
|
What is the Rule of 10s concerning pheochromocytoma?
How is the diagnosis made? Tx? Why are ß-blockers contra-indicated? |
Rule of 10s:
• 10% bilateral • 10% malignant • 10% extra-adrenal (90% are in the adrenal medulla) • 10% associated with familial disorders (MEN) Dx -- detection of urinary: • Metanephrines and • VMA • (diagnostic sensitivity of 98%) Tx -- Phenoxy'B'enzamine (an alpha-'B'locker) ß-Blockers contra-indicated b/c they may lead to UNOPPOSED ALPHA STIMULATION |
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|
What is the toxic dose of elemental iron?
What percent of elemental iron is contained in: • Ferrous gluconate • Ferrous sulfate • Ferrous fumate? |
Toxic Dose of Elemental Iron:
• Sx'atic -- 20 mg/kg • Serious Poisoning -- 40 mg/kg Elemental Iron Content: • F. Gluconate -- 12% • F. Sulfate -- 20% • F. Fumarate -- 33% |
|
|
What is the treatment of HUS?
|
Mild cases:
• Supportive More severe: • Hemodialysis may be necessary for severe renal failure • Plasmapherisis may help • Steroids may be beneficial 'HPS for HUS' Overall, HUS has LOW mortality |
|
|
What is the treatment of ITP?
What is the threshhold for tx? |
Treatment is based on the platelet count:
• > 50,000 -- no tx rqd • < 20,000, or bleeding -- Tx Tx ('ItP''): • I -- IVIG for chronic, recalcitrant cases • P -- Prednisone po taper in asx pts • Methylprednisolone 30 mg/kg/day IV for mucocutaneous bleeding • P -- Platelet transfusion Rho(D) is as effective as IVIG but is considerably MORE EXPENSIVE Dz is often self-limiting in children Splenectomy for recalcitrant cases |
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|
What is the treatment of TTP?
What is contraindicated? |
Tx:
• Plasmapheresis -- reduces mortality from 90% to 10-15% • Corticosteroids • Splenectomy • Platelet-poor FFP Contra-I: • PLATELET transfusion (exept for life-threatening bleeding or intracranial hemorrhage) |
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|
What is the typical cause of tumor lysis syndrome?
What are the most common lab findings? What are the most serious complications of tumor lysis syndrome? |
TLS results from RAPID CELLULAR DEATH following chemotherapy.
Lab findings: • Hyperkalemia • Hyperphosphatemia • Hyperuricemia Complications: • Renal insufficiency • Dysrhythmia |
|
|
What lab test helps discern between TTP and DIC?
|
DIC -- ABNORMAL coags
TTP -- normal coags |
|
|
What neoplasm is associated with molar pregnany?
|
Chorionic carcinoma
|
|
|
What type of cancer constitutes 90% of all breast cancers in MEN?
|
Invasive carcinomas such as INFILTRATING DUCTAL CARCINOMA
|
|
|
What WBC and glucose levels correlate strongly with a serum IRON level > 300 mg/dL?
|
WBC > 15000
Glucose > 150 |
|
|
When is toxicity from acute radiation therapy typically seen, and what are the symptoms?
|
Typically occurs 3 weeks after the onset of radiation
Sx: • Crampy abdominal pain • Tenesmus • Rectal bleeding |
|
|
Which cohort of patients is at greater risk for infection with Salmonella and encapsulated organisms?
|
Sickle cell patients
Asplenic patients |
|
|
Which conditions do hypersegmented PMNs suggest?
Megaloblastic Anemia? |
Hypersegmented PMNs:
• Vitamin B12 deficiency • Folate deficiency Megaloblastic Anemia: • Folate deficiency |
|
|
Which lung cancers are associated with asbestosis?
|
• Adenocarcinoma
• Squamous cell CA 'Asbestosis -- A S' |
|
|
Which meds are associated with HEMOLYSIS in pts with G6PD deficiency?
What other conditions can cause an oxidative stress in G6PD pts that promotes hemolysis? |
Meds:
UTI Drugs: • SULFA drugs • Nitrofurantoin • Phenazopyridine (Pyridium) • Dapsone Other conditions: • Infection • Metabolic acidosis • FAVA beans |
|
|
Which two types of lung CA are most commonly associated with superior vena cava obstruction?
Other CA? |
Small cell CA (46%)
Squamous cell CA (25%) Lymphoma (25%) |
|
|
Which type of lung CA has the highest rate of metastases?
|
Small cell (Oat cell) CA
|
|
|
Which type(s) of lung CA is most associated with cavitation?
|
Large cell CA
Squamous cell CA |
|
|
Why do multiple myeloma pts often present with decreased mental status?
|
AMS from HYPERCALCEMIA, resulting from lytic bone lesions
|
|
|
• By how much,
• At what rate, and • Over what period of time should the Na concentration be corrected with hypertonic saline (HTS) in a seizing pt with hyponatremia? |
• HTS should only be used for INITIAL correction
• Na increase of 4-6 mEq/L is typically sufficient to stop the sz, regardless of the total Na deficit • The rise of serum Na should NOT EXCEED 2 mEq/hr • Thus, HTS should be INFUSED OVER 2-3 hours (ie, 4 or 6 / 2 mEq/hr) |
|
|
Albendazole or Mebendazole is the tx for which parasitic infections?
|
• PinWORM (Enterobius)
• HookWORM (Necator) • WhipWORM (Trichuris) • Ascaris • Trichonosis |
|
|
Between which ages is Rocky Mountain Spotted Fever most often seen?
Least common ages? |
Most common: 5 - 9
Least common: 10 - 29 |
|
|
By what percent is the rate of recurrence of genital herpes reduced with daily oral acyclovir?
|
Reduced by 75%
|
|
|
Cefepime monotherapy provides adequate coverage against which organisms?
|
Cefepime covers:
• Pseudomonas • All gram-negatives • All gram-positives EXCEPT MRSA |
|
|
Compare and contrast condyloma acuminata and condyloma lata
|
Condyloma acuminata:
• Caused by HPV • Are GENITAL WARTS Condyloma lata ('Alotta Smelly Syphilitic Weeping Warts'): • Caused by Treponema palidum (SECONDARY syphilis) • WEEPING • Wart-like • Emit FOUL ODOR |
|
|
Compare and contrast the typical skin location where basal cell and squamous cell carcinomas are found
|
BCC:
• Most commonly occurs on the FACE • 1/3 of all cases are on the NOSE • Frequently appears in SUN-PROTECTED AREAS such as behind the ear SCC: • Also common to the head and neck • Occurs in areas of MAXIMAL SUN EXPOSURE 'BCC: B -- Behind ear' SCC: S -- Sun expoosed'" |
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|
Contrast the physical exam findings of chickenpox vs smallpox.
Which is characterized by oropharyngeal lesions? |
Chickenpox:
• Lesions are at DIFFERENT STAGES of development on the same body part • Lesions BEGIN on the TRUNK or SCALP and spread to the extremities Smallpox: • Lesions are all at the SAME STAGE • Lesions START on the FACE and EXTREMITIES and spread centrally Oropharyngeal lesions are seen in BOTH conditions |
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|
Describe the calcium and potassium findings with ethylene glycol overdose
|
Ethylene glycol metabolized to oxalic acid -->
Binds to Ca = Calcium Oxalate --> Excreted in urine --> HYPOCALCEMIA HYPERKALEMIA seen, probably from the metabolic acidosis |
|
|
Describe the sxs and location of egg casings in pts with BODY lice.
Systemic sx? |
Sx:
• Pruritis • Lice bites --> small, pruritic, erythematous spots --> • Scratching --> SYSTEMIC findings --> • Fever • Regional LYMPHADENOPATHY Egg casing location: • Firmly bound to THICK, TERMINAL hair shafts (not fine body hair) |
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|
Describe Type I Hypersensitivity reactions:
• Mechanism? • Prior sensitivity? • Examples? |
Type I -- IMMEDIATE hypersensitivity reaction
• Mediated by IgE antibodies Prior exposure is REQUIRED (to have the preformed anti-bodies to the antigen) Examples: • Anaphylaxis • Food • Hymenoptera venoms • MSG • PCN, ASA, NSAIDS, Vanc, Bactrim |
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|
Describe Type II Hypersensitivity reactions:
• Mechanism? • Examples? |
Mechanism:
• Complement system • IgG or IgM mediated Examples: • Blood transfusion • ITP • Immune hemolytic anemias • Pemphigus • Goodpasture's |
|
|
Describe Type III Hypersensitivity reactions:
• Mechanism? • Examples? |
Immune-complex mediated
Examples: • Td toxoid • Post-strep. GLOMERULONEPHRITIS • Serum sickness • Arthus reaction (swelling and redness at the site of an injection) |
|
|
Describe Type IV Hypersensitivity reactions:
• Mechanism? • Examples? |
DELAYED cell-mediated reaction
• Mediated by T CELLS rather than antibodies Examples: • Contact dermatitis • Tuberculin skin test |
|
|
Discuss the calcium-phosphate product and location of calcifications in ESRD pts
|
A calcium-phosphate product (Ca x PO4 levels) > 72 predicts systemic calcification
Location of systemic calcification: PSEUDOGOUT VASCULATURE: • Small vessels --> necrosis • CARDIAC and PULMONARY vasculature --> life-threatening |
|
|
Discuss the findings of disseminated gonococcal infection
|
• Fever/ Chills
• Polyarticular ARTHRITIS • EXTENSION tendon TENOSYNOVITIS of the hands and feet RASH: • Begins as PETICHIAE or PAINFUL RED PAPULES on the FINGERS and distal extremities --> • Either resolve, or become VESICO-PUSTULAR --> • Gray, necrotic centers |
|
|
Discuss the role of
• Bicarb • Calcium • Insulin + Glucose • Kayexalate • Hemodialysis in the tx of HYPERkalemia |
Bicarb:
• Works in 10 minutes • Move K from extra- to intra-cellular; does not lower the total body K • The LEAST EFFECTIVE means of treating hyperkalemia! Calcium: • Works in 5 minutes • Stabilizes the cardiac myocyte; does NOT LOWER the K level Insulin + Glucose -- works in 30 minutes Kayexalate: • Works in 60 minutes • Exchanges Na for K HD -- for refactory cases |
|
|
Egg allergy is a contraindication to receiving which vaccination?
|
Influenza
|
|
|
How can the anion gap guide the treatment algorhythm for DKA?
|
The presence of substantial ketoacids is what accounts for the AG acidosis.
When the AG returns to normal, ketoacidosis has resolved and IV insulin can be transitioned to SQ insulin with 30-60 minutes of overlap |
|
|
How does vomiting lead to hypokalemia?
|
HYPOVOLEMIA -->
• Aldosterone secreted --> • Na & HCO3 retained, K excreted in the urine HCl lost in vomit --> • Metabolic alkylosis --> • K shifts into the cells in exchange for H+ |
|
|
How is calcium-phosphate metabolism altered in ESRD?
|
• Kidney cannot excrete PO4 -->
• Hyperphosphatemia --> • SYSTEMIC CALCIFICATION • Kidney cannot produce 1,25-dihydroxycholecalciferol (vit D) --> • Hypocalcemia --> • 2° Hyperparathyroidism --> • Increased PTH --> • High bone turnover --> • RENAL OSTEODYSTROPHY |
|
|
How is the diagnosis of cutaneous anthrax made?
Gram stain? Anthrax' is the Greek word for what?" |
Clinically:
• Papule --> ulcer --> BLACK ESCHAR • EDEMA out of proportion to the size of the lesion • PAINLESS Gram Stain: • Sporulating gram-POSITIVE RODS • Rarity of PMNs on gram stain Athrax means COAL (= BLACK eschar) |
|
|
In pts with ESRD and renal osteodystrophy, state the
• Sx • Lab findings • Tx |
Sx:
• Weakened bones --> FRACTURES • Muscle weakness w/ diffuse PAIN Lab: • High ALK PHOS • High PTH Tx: • Phosphate-binding gels • Vit D replacement • Subtotal parathyroidectomy |
|
|
In the presence of a CD4 count less than 200, state the AIDS-defining conditions
|
• ESOPHAGEAL candidiasis
• Cryptococcosis • Cryptosporidiosis • CNS toxoplasmosis • Disseminated histoplasmosis • Isosporiasis • TB • MAV complex • PCP pneumonia • Recurrent BACTERIAL pneumonia • Recurrent SALMONELLA septicemia • Progressive multifocal leukoencephalopathy • CMV retinitis • Kaposi sarcoma • Primary CNS lymphoma |
|
|
In which cohort of patients is HYPOmagnesemia most common?
What else? |
Alcoholics -- seen in 30-80% of alcoholics
('Drunks') Also seen in: • Diuretic use • Diarrhea • Diabetes • DKA |
|
|
Ivermectin is the tx for which parasitic infections?
|
• Strongyloides
• Onchocerciasis • Cutaneous Larva Migrans 'Alan IVERson is STRONG' |
|
|
La belle indifference is diagnostic for what disorder?
|
NONE!
La belle indifference is seen in half of pts with conversion disorder, but it is just as often seen in pts with organic disease. |
|
|
Name some causes of HYPERcalcemia
|
'Milk CHISL':
• Milk-alkali syndrome • Cancer • Hyperparathyroidism • IBD • Sarcoidosis • Laxative abuse |
|
|
Praziquantel is the tx for which parasitic infections?
|
Schistosomiasis
|
|
|
Regarding the effect of cyclosporine and tacrolimus in transplant pts, which meds will:
• Increase drug levels • Decease drug levels • Enhance nephrotoxicity? |
Increase levels:
• Macrolide abx • Antifungal meds Decrease levels: • Rifampin • Anticonvulsants Increase nephrotoxicity: • Aminoglycosides • Amphoteracin B |
|
|
State some common causes of hyperuricemia.
Drugs? |
• Tumor lysis syndrome
• Lead poisoning • Thiazides • Pyrizanamide |
|
|
State the formula used to calculate the volume of hypertonic saline (HTS) required to increase the serum Na by4 mEq.
|
Rqd Volume =
Total Na Deficit / (Na bag conc - Na current) Total Na Deficit = (Na desired - Na current) x TBW TBW = kg x 60% Example -- 70 kg; HTS = 513 mEq/L; desired Na raise = 4 mEq/L Rqd Vol = (110-106) x (70 x 0.6)/(513-106) = 412 ml |
|
|
The rash of which infectious disease is characterized as 'circumoral pallor in the setting of facial flushing, and a sandpaper rash'?
|
Scarlet fever from GABHS
|
|
|
The rash of which infectious disease is described as 'dewdrop on a rose petal'?
|
The vesicular stage of varicella zoster (chickenpox)
|
|
|
What ABG metabolic dysfunction is the most common finding in sepsis?
|
RESPIRATORY ALKALOSIS:
• Sepsis --> • Increased respirations --> • Blow off CO2 --> • Resp Alk |
|
|
What agent can reverse the neuromuscular paralysis effects of severe HYPERMAGNESEMIA?
|
IV Calcium
|
|
|
What agents are implicated in serum sickness?
|
Usually DRUG exposure:
• Long acting PCN • Sulfonamides • ASA • Digoxin • Dilantin May also be to anti-toxin tx (eg, tx of snakebite, etc) |
|
|
What are some common causes of epidural abscesses?
What is the role of LP in the diagnosis? |
Hemotogenous spread:
• IVDU • Bacterial endocarditis • Dental abscesses • UTI Contiguous spread: • Osteomyelitis • Retropharyngeal abscess LPs are CONTRAINDICATED b/c of potential mass effect. If meningitis is suspected, perform LP after a mass lesion is ruled out. |
|
|
What are the adverse effects of bicarb administration in the tx of DKA?
What about in kids? |
• Na overload --> HYPERTONICITY
• Worsening HYPOKALEMIA • LEFT-SHIFT of the oxygen dissociation curve • CSF ACIDOSIS In kids: • Increased risk of CEREBRAL EDEMA |
|
|
What are the causes of hypervolemic hyponatremia?
Mechanism? Urine labs? Tx? |
Extrarenal Causes:
• CHF • Cirrhosis • Nephrotic syndrome. The hyponatremia of extrarenal cause is due to 2° HYPERALDOSTERONISM (compensation for LOW volume state) Renal Causes: • ARF • CRF Extrarenal -- U-Na < 20 Renal -- U-Na > 20 Tx -- water restriction |
|
|
What are the common side effects of cyclosporine and tacrolimus?
What is NOT a common side effect? |
Cyclosporine:
• NEPHROTOXICITY (dose-related) • Hyperkalemia • Hyperuricemia • HTN • Hirsutism • Hyperplasia (GINGIVAL) Tacrolimus: • NEPHROTOXICITY (dose-related) • Hyperkalemia • Hyperglycemia NOT seen: • Osteoporosis (these are steroid-SPARING drugs) |
|
|
What are the encapsulated organisms that cause 'overwhelming sepsis' in asplenic pts?
What are the findings of overwhelming post-splenectomy infection (OPSI)? |
• Strep pneumo
• Neisseria meningititis • H flu • Capnocytophagia OPSI findings: • Septic shock • Adrenal hemorrhage • DIC |
|
|
What are the findings of Onchocerciasis?
Tx? |
Known as RIVER BLINDNESS
Larvae invade the eyes and cause blindness Tx: • IVERMECTIN, single dose • Pretreat with PREDNISONE to prevent ocular inflammation from massive worm death |
|
|
What are the findings of Trypanosoma cruzi infection (Chagas Dz)?
|
• Lymphadenopathy
• Fever • Myocarditis • MEGAESOPHAGUS Note: pts will not typically present until complications such as CARDIOMYOPATHY develop |
|
|
What are the laboratory findings in Hyperosmolar Hyperglycemic State (HHS, aka HONC)?
|
HHS:
• HCO3 > 15 • pH > 7.3 (ie, no acidosis) • Glucose > 600 • Elevated serum Osm > 315 • ABSENT or minimal KETOSIS |
|
|
What are the major complications of untreated Rocky Mountain Spotted Fever?
Mortality rate? |
• Shock
• DIC • CHF • ARDS Mortality rate -- 3-6% |
|
|
What are the most common causes of HYPOphosphatemia in the ED?
|
HYPOphosphatemia:
• Respiratory alkalosis • Tx of DKA • Alcoholism Mech -- intracellular shift of phosphate |
|
|
What are the ocular and extremity sx of botulism that distinguish it from other illnesses that cause paralysis?
|
Prominent OCULAR signs/sxs:
• Ptosis • EOM palsies • Markedly DILATED and FIXED pupils Muscle weakness: • UE > LE • Proximal > distal |
|
|
What are the prodromal symptoms of herpes zoster?
How soon before the rash are they seen? |
Prodromal sx:
• HA • PHOTOPHOBIA • Malaise • Hypersensitive skin RARELY -- fever, N/V Sx appear 1-5 days prior to the rash |
|
|
What are the stimuli for aldosterone secretion?
Mechanism? Drugs that affect aldo? How? |
LOW FLOW to the kidney --> Aldo secretion:
• Hypovolemia • Renal artery stenosis • CHF, cirrhosis Mechanism: • Works in the COLLECTING DUCT • --> Na RESORPTION + • --> K, H+ secretion SPIRONOLACTONE inhibits aldo: • Na lost in urine, • K, H+ retained |
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What are the sx and exam findings of HYPOcalcemia?
|
Neurological sx:
• Carpopedal spasm • Hyperreflexia • Twitching • Paresthesias • Perioral paresthesias • Chvostek's sign -- upper lip twitch with facial nerve tapping • Trousseau's sign -- carpopedal spasm with BP cuff inflated > 3 min |
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What are the sx and treatment of HYPERcalcemia?
Tx in cancer pts? |
Sx:
• AMS • Dehydration • POLYURIA • Stones, Bones, Psychic Groans, Abdominal Moans Tx: • IVF -- rapidly lowers the Ca level by enhancing URINARY EXCRETION • BISPHOSPHONATES -- reduces bone resorption • Lasix (loop diuretics) Other tx: • Glucocorticoids -- useful in pts with underlying hematologic MALIGNANCY or GRANULOMATOUS dz |
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What are the sx of acute HIV syndrome?
When are they typically seen? |
Acute HIV Syndrome -- FLU-LIKE sx
Seen 2 - 6 WEEKS after exposure |
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What are the sx of Erythema Multiforme?
Etiology? Tx? |
Sx:
• TARGET lesions (sometimes with bullae) • Can look v. similar to URTICARIA • Involve PALMS & SOLES, extremities, face, lips • Mucosal involvement is almost NEVER seen in EM minor • Mildly pruritic Etiology -- Infectious: • Herpes Simplex Virus • MYCOPLASMA Etiology -- Drugs: * SULFA • PCN • Anticonvulsives NOTE: 50% of all cases are IDIOPATHIC. HSV is the next most important cause. EM is not typically caused by drugs (but SJS and TEN are). Tx: • Self-limiting • (IVIG plays NO ROLE) |
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What are the sxs of Hyperosmolar hyperglycemic state (HHS, aka HONC)?
Rate of onset? Lab and sx correlation? |
Sx ('SHIVA'):
• Sz • Hemiparesis • INSIDIOUS onset • Vision loss • AMS/ Coma There is NO CORRELATION between the degree of confusion and rate of development of hyperOsm. |
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What are the the sxs associated with the two stages of leptospira?
Fulminant disease? Means of transmission? |
Stage 1 -- ABRUPT ONSET of:
• CONJUNCTIVAL ERYTHEMA • Fever • HA • Myalgias • Sx last 1 week Stage 2: • Mild MENINGEAL irritation Fulminant illness -- WEIL'S FEVER: • Hepatitis + • ARF Transmitted by contact with URINE and FECES of various WILD and DOMESTIC animals |
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What are the typical PRESENTING sx of:
• Diphtheria • Tetanus • Botulism? |
DIPHTHERIA:
• Weakness of PALATE muscles TETANUS: • Trismus BOTULISM; • Blurred vision • Photophobia • Diplopia |
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What conditions are the following parasites associated with:
• Trichuris trichuria • Leishmania braziliensis? |
Trichuris trichuria:
• A whipworm • Causes GASTROENTERITIS --> Iron deficiency anemia and malabsorption Leishmania braziliensis: • Causes cutaneous ulcerations |
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What electrolyte abnormality is associated with receipt of multiple doses of activated charcoal?
In what percent of pts will this occur? |
HYPOnatemia
6% |
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What happens to the following electrolytes with acute renal failure:
• Potassium • Phosphate • Calcium • Sodium • Magnesium? |
ARF causes:
• HYPERkalemia • HYPERphosphatemia • HYPERmagnesemia • HYPOcalcemia (INCR Phos --> DECR Ca) Clinically insignificant: • HYPERnatremia |
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What is acute hypophosphatemic syndrome?
Typical cause? |
Sx:
• AMS • CHF • RHABDO • Severe reversible MYOPATHY --> PARESIS Cause: • In chronically MALNOURISHED pts given DEXTROSE --> • Insulin is secreted --> • Phosphate DRIVEN INTRACELLULARLY |
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What is an anaphylactoid reaction?
Examples? |
A Type I hypersensitivity reaction that is NOT Ig-E/ immune-mediated.
DIRECT RELEASE of inflammatory mediators occur; Ig-E is not involved Example -- Reaction to: • Iodinated CONTRAST material • Giving N-acetyl cystine IV (NAC) too quickly (over 15 min instead of 60) |
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What is erythema nodosum? Causes?
Most common cause? |
EN is an inflammatory eruption of SUBCUTANEOUS FAT
CAUSES: Infection: • Mycoplasma pneumonia • EBV • Chlamydia • IBD/ Yersinia/ Campylobacter • Strep infection • TB Drugs: • Sulfonamides • OCP (MOST COMMON CAUSE) Pregnancy Hodgkin's Lymphoma |
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What is euvolemic hyponatremia?
Urine lab? Causes? Tx? |
Euvolemic hyponatremia reflects EXCESS FREE WATER
Causes: • SIADH • Psychogenic polydipsia • Hypothyroidism • Cortisol excess Lab -- U-Na > 20 mEq/dl Tx: • Free water restriction • Tx of the underlying disorder |
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What is hypovolemic hyponatremia.
Causes? Urine labs? Tx? |
Occurs when Na loss exceeds free water loss. Both TBW and body Na stores are low.
Extrarenal causes: • Vomiting • Diarrhea • Severe sweating • Third-spacing • GI drainage tubes Renal causes: • Diuretics • Salt-wasting nephropathies Urine Labs: • Extrarenal -- U-Na < 20 • Renal -- U-Na > 20 (kidneys NOT able to do their job) Tx -- correct the dehydration with NS |
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What is pseudohyponatremia?
|
Falsely low Na due to excessive plasma:
• Lipid • Protein • Glucose |
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What is serum sickness?
Sx? When are the sx typically seen after exposure to the offending agent? |
Serum sickness is a Type III systemic ALLERGIC REACTION.
Sx: • Urticarial or mac-pap rash • Fever • Myalgias • Arthritis Seen 5 - 14 DAYS after exposure. |
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What is the association between REM sleep and sleep aid medications?
|
Sleeping aids DECREASE REM sleep
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What is the diagnostic criteria for SIRS? For sepsis?
|
SIRS:
• Temp > 38 or < 36°C • RR > 20, or PaCO2 < 32 • HR > 90 • WBC > 12 or < 4; or > 10% bands Sepsis: • SIRS + suspected or proven infection |
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What is the difference between Munchausen syndrome and Malingering?
|
Muchausen syndrome:
• PATHOLOGICAL LYING and medical imposturing over years in order to meet psychological needs and ASSUME THE PATIENT ROLE Malingering: • Feigning symptoms for SECONDARY GAIN (eg, avoid jail or work; homeless looking for a bed) • Frequently associated with anti-social personality disorder |
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What is the difference between Sensitivity and Positive Predicted Value?
|
SENSITIVITY is the fraction of pts with a disease who have a positive test result
PPV is the fraction of pts with a positive test result who have the disease |
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What is the difference between Specificity and Negative Predicted Value?
|
SPECIFICITY is the fraction of pts w/o the disease that have a negative test result
NPV is the fraction of pts with a negative test result who do not have the disease |
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What is the effect of HYPOcalcemia on the QT interval and seizure threshold?
|
HYPOcalcemia -->
• Prolongs QT interval • Causes seizures Note: HYPERcalcemia shortens the QT |
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What is the effect of HYPOmagnesemia on potassium?
Mechanism? |
HYPOmagnesemia causes HYPOkalemia
Mechanism: Magnesium is a cofactor in the formation of ATP, and consequently Na-K-ATPase channel function HYPOmag --> EFFLUX of Mg from cell --> Reduced Na-K-ATPase activity --> K not taken into the cell --> K lost in the URINE |
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What is the effect of THIAZIDE diuretics on calcium levels?
|
Thiazides INCREASE Ca resorption in the distal tubule
Contraindicated in hypercalcemia NOTE: Thiazides increase Ca --> PANCREATITIS |
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What is the empiric abx treatment of a nursing home patient in septic shock of unclear etiology?
What about an otherwise young, healthy individual? |
Nursing home patients are at high risk for nosocomial infection:
• MRSA • Pseudomonas Must cover for these organisms Tx -- Nursing home pt: • Vancomycin + • Zosyn Tx -- Healthy pt in non-MRSA area: • Ampicillin + • Gentamycin |
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What is the epidemiology & presentation of Pemphigus Vulgaris?
Type of reaction? Sign? Treatment? |
Epidemiology:
• 40-60 yo • Autoimmune d/o • JEWS, Middle Eastern, or Mediterranean descent • A type II hypersensitivity reaction Sx: • Begins as ORAL BLISTERS --> Rupture --> Painful oral ULCERS, slow to heal • Migrates to painful BULLOUS, desquamating lesions on skin • NIKOLSKI'S sign -- positive Oral ulcers preceed cutaneous dz by several MONTHS Tx: • Steroids • Abx for 2° infection |
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What is the etiology of erysipelas?
What system does it affect? Describe the rash |
Etiology -- GABHS (strep pyogenes)
Exhibits extensive LYMPHATIC involvement Rash: • Very PAINFUL • Skin is erythematous, indurated and SHARPLY DEMARCATED • 'St Anthony's Fire' • 70 - 80% of cases involve the LEGS |
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What is the formula for the correction of sodium with elevated glucose?
What is the pathophysiology of the hyponatremia? |
Na should be increased by a factor of 1.6 for every 100 units that glucose is elevated over normal (ie, 100)
Mechanism: • Hyperglycemia causes INTRACELLULAR SHIFT of Na into the cell |
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What is the formula to correct POTASSIUM in the face of acidosis?
|
K should be DECREASED by 0.6 for every 0.1 decrease in the pH below 7.4
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What is the general antimicrobial coverage of clindamycin?
|
Excellent GRAM POSITIVE coverage
Excellent ANAEROBIC coverage No gram negative coverage No atypical coverage |
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What is the incubation period for rabies?
How is it spread throughout the body? |
Incubation -- 30-60 days
Spreads up peripheral nerves to the CNS. |
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What is the initial dosing of epinephrine in anaphylaxis?
If unresponsive to initial dose? In non-anaphylaxis? How should it be administered? |
Anaphylaxis:
• 0.1 mg IV over ~5 minutes How to administer: • Mix 0.1 mg (= 0.1 ml of 1:1,000 epi) in 10 ml of NS • Give at 1-2 ml/min • Watch for adverse reactions (tachydysrhythmia, chest pain, HTN) If unresponsive: • Epi drip • Mix 1 mg epi (1 ml of 1:1,000) in 500 ml NS • Run at 0.5 - 2 ml/min • Titrate to effect Non-Anaphylaxis: • 0.3 - 0.5 mg of 1:1,000 IM in thigh (not SQ!) q 5 min prn |
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What is the most common cause of anaphylaxis?
|
FOOD allergies
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What is the most common cause of death in TEN?
|
Sepsis
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What is the most common electrolyte abnormality seen in rhabdomyolysis?
Tx of this abnormality? |
HYPOcalcemia...
...b/c: • Calcium floods the intracellular space when myocyte membranes fail • Resulting HYPERPHOSPHATEMIA Tx of hypocalcemia is NOT recommended unless sxs are severe or hyperkalemia occurs |
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What is the most common form of skin cancer?
Describe the lesion. |
BASAL CELL CARCINOMA
Pearly white papule with raised borders and telangiectasias over the surface of the lesion |
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What is the most serious complication of panic disorder?
Rate of this complication? |
Suicide
Up to 20% |
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What is the organism responsible for Cat Scratch Dz?
Tx? |
Bartonella hensellae
Tx -- Azithromycin |
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What is the presentation of pityriasis rosacea?
Tx? |
Begins with a single, large, 2-6 cm, mildly pruritic 'HERALD PATCH' on the TORSO that is often misidentified as RINGWORM
• Followed in 1-2 weeks by symmetric eruption of 1-2 cm, salmon-colored, oval, PRURITIC PAPULES with a ring of SCALE. • Lesions are on abdomen and back in a 'Christmas Tree distribution' Tx: • Resolves spontaneously in 2-3 months • UVB will hasten the resolution of pruritis |
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What is the relationship between Erythema Multiforme, Stevens-Johnson syndrome, and Toxic Epidermal Necrolysis (TEN)?
Sx of TEN? Etiology? Tx? |
All 3 diseases are part of a CLINICAL SPECTRUM. EM is benign. TEN is a more severe form of SJS based on the DEGREE of epidermal DETACHMENT:
• SJS -- < 10% body surface area • TEN -- > 30% body surface area Sx -- TEN: • Epidermal desquamation • Most severely affects MUCOUS MEMBRANES (mouth, eyes, vagina) Etiology -- Drug reaction: * SULFONAMIDES • PCN • Anticonvulsants • NSAIDS Tx: • D/c the offending med • Burn unit -- IVF • IVIG |
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What is the risk of contracting AIDS after mucocutaneous exposure?
Parental exposure? |
Mucocutaneous -- 0.09%
Parental -- 0.32% |
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What is the role of benztropine and the anticholinergics in the control of tardive dyskinesia?
|
Anticholinergics are INEFFECTIVE
These meds tx extra-pyramidal adverse reactions |
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|
What is the tx of FOOD-BORNE botulism?
Abx? What percent decrement in FVC is the threshhold for intubation? |
Tx:
• PURGE GI TRACT • Antitoxin Abx have NO ROLE! FVC < 30% of predicted |
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|
What is the tx of Leptospira?
When should tx begin? |
Pen G or DOXY
Effective when started w/in 4 DAYS of onset of illness |
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What is the tx of tetanus?
|
Tetanus immune globulin (TIG)
Tetanus toxoid (Td) FLAGYL |
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What percent of pts with major depression commit suicide?
Schizophrenia? |
Major Depression -- 20%
Schizophrenia -- 15% |
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|
What percent of pts with UNTREATED cutaneous anthrax will develop systemic sxs and die?
|
20%
|
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When does acute rheumatic fever typically occur following GABHS pharyngitis infection?
|
2-4 weeks
|
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Where are the lesions of scabies typically found in ADULTS?
What is characteristic of the pruritis? |
• WEB SPACES of hands and feet
Males -- Penile shaft Females -- Areola PRURITIS often PERSISTS after tx and DOES NOT indicate tx failure. |
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Which cohort of patients are most at risk for central pontine myelinolysis (osmotic demyelination syndrome)?
Presentation? |
Pts most at risk:
• Alcoholics • Chronic malnutrition Presentation: • Altered MS (lethargy to coma) • 6th nerve palsies • Gaze palsies • Rigidity • Paresis UE > LE ... all 2°/2 too rapid correction of HYPOnatremia present > 48° Most pts present 1-6 days following treatment |
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Which cohort of pts are most susceptible to Fournier's gangrene?
Predominant organisms? |
Immunocomprised:
• Diabetics • Alcoholics • Chronic steroid use Predominant organisms: • Bacteroides • Ecoli Other organisms: • Gram negative rods • Anaerobes |
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Which hyponatremic pts require the administration of HYPERtonic saline?
|
Pts with SEIZURES or COMA 2° to hyponatremia
|
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Which meds are the first-line agents for treating community-acquired outpatient MRSA?
|
Bactrim + Rifampin
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Which pt population has the highest rate of completed suicide?
Suicide attempts? Black or white? |
COMPLETED suicide -- Elderly white male
ATTEMPTED suicide -- Women > Men White > Black |
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Which sex has a greater prevalence of simple phobias?
|
Female
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A bursal fluid WBC count greater that what value is suggestive of septic bursitis?
What is the rate of positive bursal cx? Organism? |
> 10,000 per mm3
CX -- positive only 50% of the time Organism -- Staph |
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After which bone fractures is fat emboli syndrome typically seen, and how many days after injury does it usually occur?
|
Seen after:
• LONG BONE fractures (usually TIBIA and fibula) in young adults • HIP fractures in elderly Occurs after 1 - 3 days |
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After which week of pregnancy is HTN of pregnancy considered part of pre-eclampsia?
|
> 20 - 24th week of pregnancy
|
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At what minimum HCG level should an IUP be able to be detected with pelvic and transabdominal ultrasound?
What are the corresponding EGAs? |
Pelvic -- 1500 mIU/ml (>/= 5 wks EGA)
Transabdominal -- 3000 mIU/ml (>/= 5.5 weeks EGA) |
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Compare the limb presentation of femoral neck fracture vs posterior hip dislocation
|
Femoral Neck Fx:
• Externally rotated • Shortened • Abducted Posterior Hip Dislocation: • Internally rotated • Shortened • Adducted |
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Define Boehler's angle.
What is Boehler's angle used to assess? What is the normal value? |
Boehler's angle evaluates the CALCANEUS is the setting of calcaneal fractures
Normal angle -- 20-40° Angles < 20° are suggestive of compression of the posterior facet Angle between the following lines: • Post facet -- Ant facet, & • Post facet -- Post tuberosity |
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Define HELLP syndrome. What symptoms herald this condition?
Are the coags affected? |
H -- Hemolysis
EL -- Elevated LFTs LP -- Low platelets Heralded by: • N/V • RUQ pain Pre-eclampsia/ eclampsia may progress to HELLP syndrome. Coags are NORMAL (as opposed to DIC) |
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Define Monteggia fracture.
Which nerve is most at risk for injury? |
Monteggia fx =
• Proximal ulna fx + • Radial head dislocation Nerve at risk -- RADIAL |
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Describe the 2nd and 3rd stages of Lyme disease
|
Stage 2:
• NEURO findings, most commonly BELL'S PALSY (but bilateral) • Cardiac findings, commonly fluctuating AVB that may present as SYNCOPY and may require temporary pacing • Develops 4 wks after bite • Hematogenous dissemination of spirochetes Stage 3: • Polyarthritis, migratory • Seen in large joints, particularly the KNEES • Large effusions common • Pts have minimal joint pain • Seen in 50 - 60% of pts • Occurs w/in 6 months |
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Describe the clinical findings in tick paralysis.
Recovery? Cause? |
• ASCENDING flaccid paralysis
• LOSS of DTRs • Absence of bulbar findings • Complete recovery seen within 48 hrs of tick removal Caused by a NEUROTOXIN from the DERMACENTOR tick. This is NOT an infectious dz! |
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Describe the early clinical picture and joint involvement in rheumatoid arthritis
|
Early clinical picture:
• Prodromal of fatigue, weakness, muscle pain, lasting for weeks to months • Symmetric swelling of joints, typically hand, wrist and elbows, in an additive pattern • Up to 90% of RA pts have GREAT and LITTLE TOE MTP involvement Hand findings: • MCP and PIP involvement • Ulnar deviation of MCPs • SPARING of DIP • Swan neck deformity • Boutonniere deformity |
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Describe the epidemiology and clinical findings in Reiter's syndrome
|
Epidemiology:
• Males 15 - 35 yo • HLA-B27 Clinical: • Appears 2-6 wks after CHLAMYDIAL or dysentery infx (SHIGELLA, Salmonella, Camp, Yersinia) Classic Triad of: • Arthritis (wt-bearing jts of lower extremities; 'LOVER'S HEEL') • Conjunctivitis • Urethritis Also seen: • Painful oral and penile ulcers (balanitis circinata) • SAUSAGE DIGITS • Keratoderma blennorrhagia (waxy plaques on palms and soles) |
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Describe the epidemiology and clinical picture of ankylosing spondylitis.
Extra-articular manifestations? |
Epidemiology:
• MALE > Female • Age < 40 Clinical: • Sacroiliitis that develops into BAMBOO SPINE • MORNING STIFFNESS that improves with exercise • UVEITIS -- the most common extra-articular manifestation • Plantar fasciitis • Achilles tendinitis |
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Describe the epidemiology of gonococcal arthritis
|
Young WOMEN > men (4:1)
Sx are most common during: • Last two semesters of pregnancy • Postpartum • After menstruation Rarely do patients report concommitant cervicitis and urethritis |
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Describe the etiology and sx of toxic shock syndrome
|
Etiology:
• Staph TSS toxin-1, or • Strep pyogenes (GABHS) exotoxins A and B Sx: • Diffuse DESQUAMATING SUNBURN-like rash • High fever • HoTN • Leads to multisystem organ failure |
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Describe the first stage of Lyme disease
|
Stage 1:
Erythema (chronicum) migrans rash: • Seen 1 wk to one month after tick bite at the site of the bite • 'Bullseye lesion'; Bright red border with central clearing • Quickly multiplies and spreads to thigh, groin and axilla Non-specific viral sxs |
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Describe the plain film findings consistent with lunate DISLOCATION
|
PA:
• Piece of pie sign = triangular appearance of the lunate Lateral: • Spilled teacup sign |
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Describe the sometimes fatal syndrome associated with allopurinol. Which patients are most at risk?
|
Syndrome of:
• Exfoliative rash • Fever • Hepatitis At-risk patients: • Preexisting renal insufficiency • Taking diuretics |
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Discuss babesiosis:
• Cause • Mechanism • Sx • Labs • Tx |
Caused by a PROTOZOAN parasite from the IXODES tick ('Babe-y (I)') that infects ERYTHROCYTES.
Sx -- malaria-like: • HEMOLYTIC ANEMIA • Intermitent SWEATS • HA • Fever • Myalgia • SPLENOMEGALY May cause OVERWHELMING SEPSIS in asplenic pts Labs: • Pancytopenia • Elevated LFTs Tx: • CLINDA + QUINIDINE |
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Discuss Colorado tick fever:
• Cause • Sx • Labs • Duration of sx |
A tick-borne illness caused by a self-limiting RNA VIRUS
Sx: • BIPHASIC FEVER pattern ('SADDLEBACK' fever curve). Each fever phase lasts 2-4 days. • Severe retro-orbital HA • Photophobia • Back pain Labs -- DECREASED WBC Duration -- entire course of illness usually lasts 2 weeks |
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Discuss Relapsing Fever.
• Organism • Sx • Labs • Diagnostic test • Tx |
Cause ('R&B'):
• TICK-borne illness caused by Borrelia SPIROCHETE (different from the Lyme Borrelia) • Reservoir -- wild Rodents Sx: • Fever, chills • Myalgia, arthralgia Labs: • Decreased platelets • Elevated WBC • Elevated ESR Test -- Giemsa stain Tx: • Doxy,or • E-mycin |
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|
Discuss the changes in maternal physiology during pregnancy
|
• Blood volume -- Expands at 10 weeks EGA; peaks at 28 weeks at +45% --> state of hypervolemia, relative anemia
• HR: increases 10-20 bpm in 2nd trimester • SP and DP decrease by 10-15 mm Hg. • Respiratory: Increased baseline ventilation --> respiratory alkalosis --> decreased maternal ability to compensate for respiratory compromise GI: Decreased motility --> increased risk of aspiration. |
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Discuss the contents and their function of the anterior and lateral compartments of the lower leg
|
ANTERIOR Compartment:
Contents: • DEEP peroneal nerve • Anterior tibial artery Function: Motor: DORSIFLEXION of the FOOT • Sensation: Dorsal FIRST WEB SPACE • Pulse: Dorsalis pedal LATERAL Compartment: Contents: • SUPERFICIAL peroneal nerve • No major arteries Function: • Motor: Foot EVERSION • Sensation: DORSAL foot (but not in the 1st web) |
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Discuss the contents and their function of the superficial posterior and deep posterior compartments of the leg
|
SUPERFICIAL Posterior Compartment:
Contents: • SURAL nerve • No major arteries Function: • SENSATION lateral inferior 1/3 of leg to lateral 5th toe • ANKLE PLANTAR flexion DEEP Posterior Compartment: Contents: • TIBIAL nerve • Posterior tibial + peroneal arteries Function: • Sensation of SOLE of foot • TOE flexion • Posterior tibial PULSE |
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Discuss the lab value changes of blood during pregnancy.
HCT WBC Coags |
• HCT -- decreases to low 30s
• WBC -- up to 18000 is normal in the 2nd and 3rd trimesters • ESR -- 70-80 • PT/PTT/INR -- normal • Fibrinogen -- increased • d-Dimer -- increased |
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|
Eclampsia can occur up to how many days post-partum?
|
Up to 10 days post-partum
|
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|
Fractures thru which part of the scaphoid have the greatest risk of AVN?
What is the overall risk of non-union and AVN? |
PROXIMAL POLE fxs have the highest risk of AVN
Incidence of AVN -- 3% Incidence of non-union -- 5 - 10% |
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|
How can myositis ossificans be discerned radiographically from osteosarcoma?
|
MYOSITIS OSSIFICANS
Calcifications are: • Associated with a bone's DIAPHYSIS • Located intially in the PERIPHERY of the soft tissue OSTEOSARCOMA Calcifications are: • Associated with a bone's METAPHYSIS • EXTEND from the center (ie, bone) to the periphery |
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|
How can urticaria be differentiated from erythema multiforme?
|
Both conditions can look exactly the same
URTICARIA: • Histamine -- relieves itching • SQ epi -- CLEARS the rash ERYTHEMA MULTIFORME: • Histamine -- relieves the itching • SQ epi -- NO IMPROVEMENT in sx |
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|
How does the lupus anticoagulant and antiphospholipid antibody affect PTT and clotting?
|
These PROLONG PTT, but
are paradoxically associated with INCREASED CLOTTING --> • Recurrent CVAs • Recurrent PEs |
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|
How is the treatment of septic joint due to gonococcus different from staphlococcal septic joint?
|
Gonococcal septic joint usually responds to ANTIBIOTICS --> open joint washout is rarely required
Note: GC is the most common form of septic arthritis in young, sexually active individuals |
|
|
How much radiation is in:
• CXR • Plain abdominal film (1 view) • LS series (3 view) • CT chest • CT abdomen • Ambient radiation exposure over 9 mos? |
• CXR -- < 5 MILLI-rad
• Plain abd (1 view) -- 0.1 rad • LS series -- 0.5 rad • CT chest -- < 1 rad • CT abdomen -- 2.5-3.5 rad • Ambient -- 50-100 MILLI-rad |
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|
In mallet finger injury (DP fx), fx's greater than what percent of the articular surface require referral for surgical fixation?
|
25%
|
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|
In addition to septic arthritis, what other conditions can exhibit very high joint fluid white counts (> 50,000) with a preponderance of PMNs (often > 80%)?
|
• RA
• Gout • Pseudogout |
|
|
In compartment syndrome, what are the EARLIEST findings?
|
Earliest findings:
1) Pain 2) Paresthesia All others are late findings! |
|
|
In the prevention of acute gouty arthritis, which med decreases uric acid production, and which med increases uric acid excretion?
|
Decreased production -- Allopurinol
Increased excretion -- Probenecid |
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|
In the work-up and diagnosis of female pelvic pain, UNILATERAL pain is never _______________?
|
Unilateral pain is NEVER PID!
|
|
|
In what anatomical position should an injured hand be splinted?
|
• Wrist extended 30°
• MCPs flexed to 90° • IP joints extended |
|
|
In which autoimmune diseases is Raynaud's phenomenon found?
Which is the most common? |
SCLERODERMA (most common)
Other diseases: • RA • SLE Raynaud's is the EARLIEST SIGN of scleroderma. Nearly 100% of scleroderma pts have Raynaud's. |
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|
Name and describe the test used to evaluate for Achilles tendon rupture
|
Simmonds' (Thompson's) test -- pt lays prone with foot hanging over the end of the bed. Examiner squeezes belly of the calf. Absence of plantar flexion indicates Achilles tear.
NOTE: even with a complete tear of the Achilles, pt may still be able to plantarflex foot using the peroneus and posterior tibial musculature. |
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|
Name and describe the test used to evaluate for popliteus tendinitis.
What is the typical patient chief complaint? |
Webb test -- Pt bends knee to 90° and internally rotates leg. Examiner attempts to externally rotate leg as pt resists. Pain = positive test
Chief complaint -- Pain in the posterior or posteriorlateral aspect of the knee, often made worse with running and walking DOWNHILL This is an overuse injury seen in athletes caused by excessive eccentric quadriceps load with activity. |
|
|
Reduction of hip dislocations within what period of time significantly reduces the incidence of AVN?
|
6 hours
|
|
|
Severe disturbances of which electrolytes can cause severe, reversible MYOPATHY?
Rate of onset? Findings? |
HYPOkalemia (< 2)
HYPERkalemia (> 7) HYPERmagnesemia HYPERcalcemia HYPOphosphatemia ACUTE rate of onset Findings: • FLACCID paralysis • DTR usually PRESERVED |
|
|
Should breast-feeding be continued in the female patient with mastitis?
|
YES, because:
• Breast feeding assures continued drainage of the site • The infant is already colonized and will not be harmed |
|
|
State in order the joints typically affected by septic arthritis
|
1) knee (40-50%)
2) hip (13%) 3) shoulder (10-15%) 4) fingers, wrist, elbow, ankle (3-8%) |
|
|
State the American College of Rheumatology diagnostic criteria for SLE
|
Need 4 or more criteria during any interval period:
Dermatology: • Malar or discoid rash • Photosensitivity • Oral ulcers Arthritis, SYMMETRIC ('Hitch-hiker's thumb') Renal -- persistent PROTEINURIA CV: • PERICARDITIS • Pleuritis Neuro: • Seizures • Psychosis Immune/ Heme: • Hemolytic anemia • Leukopenia • Lymphopenia • Thrombocytopenia • ANA • Anti-DNA Ab • Anti-Smith Ab • Antiphospholipid Ab • Lupus anticoagulant |
|
|
State the causative organism for each of the following tick-borne diseases:
• Babesiosis • Colorado tick fever • Ehrlichiosis • Relapsing fever • Tick paralysis |
Babesiosis -- Protozoan PARASITE from the Ixodes tick ['Baby (y-->I)']
Colorado Tick Fever -- RNA virus Ehrlichiosis -- Gram-neg intracellular BACTERIA Relapsing Fever -- Borrelia SPIROCHETES from Ornithodoros ticks ('R&B') Tick paralysis -- NeuroTOXIN from the DERMACENTOR tick |
|
|
State the epidemiology and xray findings of SCFE
|
Epidemiology:
• Most common in BLACK MALES • Associated with the onset of PUBERTY • 10 - 15 years of age • Bilateral 40% • Classically, OBESE with underdeveloped genitalia; OR • TALL, THIN and rapidly growing most common Xray -- asymetry of the femoral neck; 'scoop slipping off the ice cream cone' |
|
|
State the epidemiology of SLE.
What is the classic triad of symptoms at initial presentation? |
• Female > male (11:1)
• Childbearing years • BLACK > white Presentation triad: A woman of childbearing age with: • Fever • Joint pain • Malar or butterfly rash |
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|
State the mechanism of injury of Osgood-Schlatter dz.
Sxs at rest? With activity? |
Mechanism -- repetitive pulling on the tuberosity by the patella ligaments
Sx at REST -- NONE Sx w/ activity -- Pain |
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|
State the names and describe the tests used to evaluate for bicipital tendinopathy
|
Yergason's test:
• Elbow at 90° flexion and held against body • Pt RESISTS examiner SUPINATION of the forearm Speed's test: • Elbow straight, forearm supinated, arm extended 60° • Pt elevates arm against resistance Pain over biceps tendon is a positive test |
|
|
State the Ottawa Knee Rules
|
Order an xray if any one of the following apply:
• Age > 55 • TTP at the fibular head • Isolated TTP of the patella • Inability to flex > 90° • Inability to take 4 steps both immediately at time of injury and in the ED |
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|
State the physical exam findings of the hand in RA
|
• MCP and PIP affected
• DIP is spared • Subluxation with ulnar deviation of MCPs • Swan neck deformity • Boutoniere's deformity |
|
|
State the relationship between joint fluid viscosity and joint infection.
What lab test can evaluate viscosity? |
Viscosity decreases with infection
Drip test -- Normal jt fluid will form a string approx 5 - 10 cm long when dripped from a syringe. A decrease in this length indicates reduced viscosity and joint infection. |
|
|
State the two methods for reducing hip dislocations
|
Stimson's method -- reduction in PRONE position
Allis method -- reduction in SUPINE position 'Deutchland über Alles!' |
|
|
Through which part of the scaphoid do 70 - 80% of fractures occur?
|
the WAIST
|
|
|
Up to how many degrees of angulation is acceptable with the following metacarpal neck fractures:
• Index • Middle • Ring • Small finger? |
Thumb: 20°
Index: 15° Middle: 15° Ring: 20° Small: 40° |
|
|
What 2° injury can be a consequence of pisoform fractures?
|
Impingement on Guyon's canal with subsequent ulnar nerve injury
|
|
|
What 4 critical conditions should always be considered in the ddx of a female patient with pelvic pain?
|
• Ectopic
• Tubo-ovarian abscess • Ovarian torsion • Appendicitis |
|
|
What are some extra-articular complications of rheumatoid arthritis?
|
• MONONEURITIS MULTIPLEX (also seen in PAN)
• Degeneration of the transverse ligament between dens and C1 ring • Cricoarytenoid joint involvement • Pulmonary fibrosis • Exudative pleural effusion • Pericarditis • Myocarditis • Carpel tunnel syndrome • Sjogrens and Felty's syndromes • Sub-Q nodules |
|
|
What are the 3 most commonly fractured carpal bones, and in what order?
|
1) Scaphoid
2) Triquetral 3) Lunate |
|
|
What are the adverse consequences of bacterial vaginosis during pregnancy?
|
Increased incidence of:
• Premature ruptured membranes • Preterm birth • Post-c-section endometritis |
|
|
What are the common neurologic sxs seen in thoracic outlet syndrome?
|
• Pain or Paresthesias in the:
• ULNAR nerve distribution, OR • RADIAL nerve distribution in the OUTER ARM |
|
|
What are the complications of shoulder distocia during vaginal delivery?
How should it be addressed? |
Complications:
• Fetal HYPOXIA --> Brain damage • Brachial plexus, humerus, clavicle injuries Tx (in order): 1 Liberal median episiotomy 2 McRobert maneuver (knees over chest) 3 Suprapubic pressure to push the anterior shoulder below the symphysis 4 Rubin maneuver (push the most accessible fetal shoulder toward the fetal chest) 5 Wood corkscrew maneuver -- rotate baby 180° (clockwise) 6 Grasp posterior arm --> sweep over face and out vagina |
|
|
What are the contraindications to colchicine in acute gout?
|
• Hematologic,
• Renal, or • Hepatic dysfunction |
|
|
What are the crystal characteristics of joint fluid found in gout and pseudogout?
|
Gout:
• Monosodium URATE crystals • NEGATIVE birefringence • NEEDLE shaped Pseudogout: • CALCIUM pyrophosphate • POSITIVE birefringence • RHOMBOID (or rod) shaped |
|
|
What are the diagnostic criteria for Reflex Sypathetic Dystrophy (aka Complex Regional Pain Syndrome)?
|
• Allodynia
• Burning pain • Edema • Color changes • Hair growth changes • Sweating changes • Temperature changes • Demineralization on xray |
|
|
What are the findings of mild pre-eclampsia?
|
HTN
Proteinuria Generalized edema (not always present) |
|
|
What are the GI complaints seen in SLE?
|
• ORAL ulcerations -- usually accompany dz flares
• ESOPHAGEAL dysmotility • CRAMPY abdominal pain |
|
|
What are the longterm sequalae of gout?
|
• Renal stones
• Tophi |
|
|
What are the major and minor Jones criteria for rheumatic fever?
|
'SPEC FEAR'
Major: • Sub-Q nodules • Polyarthritis (symmetric) • Erythema marginatum • Carditis • Chorea Minor: • Fever • Elevated ESR, CSR • Arthralgia • PROLONGED PR + SUPPORTING EVIDENCE of prior group A strep: • Elevated/increasing strep Ab titer • Positive rapid strep or throat cx • Recent scarlet fever |
|
|
What are the most COMMON complications following posterior elbow dislocations?
What is the most SERIOUS? |
Most common:
1 Ulnar nerve injury 2 Median nerve injury Most serious -- brachial artery injury |
|
|
What are the most common joints involved in pseudogout?
|
• KNEE
• Ankle • Elbow • Wrist |
|
|
What are the most common organisms responsible for pediatric septic arthritis in:
0 - 2 months 2 - 36 months > 36 months? |
0 - 2 months:
• 1 -- Staph aureus • 2 -- GBS • 3 -- Gram neg • 4 -- NEISSERIA 2 - 36 months: • 1 -- Staph aureus • 2 -- STREP sp. • 3 -- Gram neg • 4 -- H FLU > 36 months: • 1 -- Staph aureus • 2 -- STREP sp. • 3 -- Gram neg • 4 -- NEISSERIA |
|
|
What are the names and locations of the nodes associated with osteoarthritis?
|
• Bouchard's nodes -- PIP
• Heberden's nodes (osteophytic spurs) -- DIP 'Bouchard's -- Before' (ie, comes before Heberden's on the finger) |
|
|
What are the physical exam and lab findings in bacterial vaginosis?
Vaginal pH? |
• Homogenous, gray-white discharge that COATS the VAGINAL WALLS
• Fishy odor on KOH test • Clue cells (epithelial cells covered with bacteria) .• pH > 4.5 |
|
|
What are the relative contraindications to arthrocentesis?
|
• Bleeding diasthesis
• Coagulation therapy • Infection over site • BACTEREMIA |
|
|
What are the risk factors for chorioamnioitis?
Age and parity? Causative organisms? Abx? |
Risk factors:
• NULLiparity • Young age • Multiple vaginal exams • Extended labor with ruptured membranes Organisms: • E coli • Group B strep Abx: • Ampicillin + Gentamicin • PCN allergic: Vanc/ Emycin/ Clinda + Gent |
|
|
What are the risk factors for gout?
|
'THE DOMP'
• Thiazides • HTN • EtOH • DM • Obesity Gout occurs in: • Middle-aged men • Postmenopausal women |
|
|
What are the risk factors for, and consequences of, pneumonia in pregnancy?
|
Risk factors for pneumonia:
• Anemia • Asthma Consequences of pneumonia: • Preterm labor and/or delivery • Low birthweight infant |
|
|
What are the risks inherent to breech presentation births?
|
• Inadequate cervical dilation (from absence of pressure from the head)
• Entrapment of the fetal head (2° to incomplete dilitation) • Umbilical cord prolapse (more common in premies) • Fetal spinal cord injury (if the head is in hyperextension (rare)) |
|
|
What are the symptoms of fat emboli syndrome (2° to a fracture)?
What sx is pathognomonic? |
• Acute respiratory distress
• Altered MS • Tachcardia • Fever • Diffusely scattered PETICHIAE (pathognomonic, but late finding) |
|
|
What are the warning signs of impending seizure in a pre-eclamptic patient?
|
• HA
• Visual disturbances • Epigastric/ RUQ pain • HYPER-reflexia |
|
|
What cancers are HSV associated with?
|
Cervical CA
Vulva CA |
|
|
What common medication often exacerbates SLE symptoms?
|
Oral contraceptives
SLE pts should use only LOW-ESTROGEN OCPs |
|
|
What common medication often exacerbates SLE symptoms?
|
Oral contraceptives
SLE pts should use only LOW-ESTROGEN OCPs |
|
|
What conditions are associated w/ MIGRATORY arthritis?
|
• HSP
• GC • Sepsis • Mycoplasma pneumonia • Lyme Dz • Rheumatic fever • Bacterial endocarditis ('He Gently SMyLed Right Back') |
|
|
What consequent injuries are associated with supracondylar fx in kids?
|
• BRACHIAL artery injury
• MEDIAN nerve injury • Volkmann's ischemic CONTRACTURE |
|
|
What does the Judet view of the pelvis provide?
|
Helpful for viewing the ACETABULUM
|
|
|
What drugs are most commonly implicated in drug-induced Lupus?
|
• Procainamide
• Hydralazine Note: OCPs EXACERBATE established SLE |
|
|
What drugs are used in the management of SLE?
|
Oral steroids
ANTIMALARIAL drugs control the cutaneous and musculoskeletal manifestations of SLE: • Hydroxychloroquine • Chloroquine Immunosuppressive agents for tx failure/ severe disease |
|
|
What is a Barton's fracture?
|
An INTRA-ARTICULAR Colles or Smith's fx with RADIOCARPAL DISLOCATION
|
|
|
What is a Jersey finger?
Which finger is most commonly affected? |
Jersey Finger -- avulsion of the FDP at the level of the DIP joint. Occurs with a strong extension force against a flexed finger.
The RING FINGER is affected 75% of the time |
|
|
What is a Stener lesion, and what is its significance?
Incidence? |
Seen in GAMEKEEPER'S thumb
Pathology: • ADDUCTOR POLICIS tendon inserts between the 2 ends of the ruptured UCL --> Prevents UCL healing Incidence -- 29% of UCL injury |
|
|
What is Behcet's disease?
Hallmark? Epidemiology? Sx? |
• A chronic relapsing vasculitis
• HYPOPYON UVEITIS is the hallmark (rarely seen) Epidemiology: • JAPANESE males; young adults • HLA-B5 Sx: • Oral ulceration • Genital ulceration • Uveitis • Arthritis (knees, ankles) |
|
|
What is Legg-Calve-Perthes Disease?
• Epidemiology? • Presentation? • Xray findings? |
LCP disease is osteochondrosis of the femoral head
Epidemiology: • MALE > female • Typically 4 - 9 yo • Usually UNILATERAL Presentation: • Non-toxic • Limp • Hip pain radiating to groin or inner thigh Xray: • Caffey's crescent line -- Subchondral STRESS FX in the femoral head. This then leads to frank osteochondrosis |
|
|
What is the acceptable safe threshold for fetal radiation exposure?
What is the teratogenic threshold? |
Safe fetal threshold -- 5 rads
Teratogenic threshold -- 10 rads |
|
|
What is the antibiotic of choice for the treatment of UTI in the 3rd trimester of pregnancy?
|
Amoxicillin or Augmentin
|
|
|
What is the association between antiphospholipid antibody syndrome and pregnancy?
|
APS predisposes to recurrent SPONTANEOUS ABORTIONS
|
|
|
What is the cause of Ehrlichiosis?
|
A tick-borne infection caused by Gram-negative intracellular BACTERIA
|
|
|
What is the concern with POSTERIOR sternoclavicular joint dislocations?
|
Posterior SCJ dislocations are associated with severe, life-threatening superior mediastinal injuries such as great vessel and esophageal disruption.
CT scanning of the chest is mandatory |
|
|
What is the consequence of contracting rubella during pregnancy?
What is the risk of neonal contraction of this disease? |
Neonatal Rubella Syndrome:
• Cataracts • Deafness • Patent ductus arteriosus Risk is 50% in the 1st month of pregnancy, and only 10% in the 3rd month |
|
|
What is the consequence of vaginal delivery in a woman with active HSV lesions?
|
50 - 80% MORTALITY from neonatal herpes
|
|
|
What is the difference between a Bennett's fx and a Rolando's fx?
|
Bennett's -- INTRA-ARTICULAR fx thru the base of the 1st MC with DISLOCATION of the CMC
Rolando's fx -- a COMMINUTED Bennett's fx |
|
|
What is the difference between a Jones fx and a pseudo-Jones (aka Dancer's) fx?
|
Jones Fx:
• Fx of the DIAPHYSIS of the 5th MT • High incidence of NONUNION Dancer's Fx: • Fx of the BASE of the 5th MT • Readily heals w/o complication |
|
|
What is the differential dx of ASYMMETRIC arthritis?
|
Asymmetric AND Symmetric:
• GC • Lyme • Reiter's Asymmetric only: • Henoch Schonlein Purpura |
|
|
What is the dose of magnesium used to prophylax against seizures in pre-eclamptic patients?
What is the target blood level? Mechanism? |
Loading dose -- Mag 6 g over 20 min
Drip -- 2 g/hr Target Mg level: 4 - 7 mEq/L Mechanism: • Membrane stabilization • Vasodilation |
|
|
What is the epidemiology of ERYTHEMA NODOSUM?
|
• FEMALE 5x > Male
• Age: 20s-30s; kids too |
|
|
What is the epidemiology of Polyarteritis Nodosa (PAN)?
Vessels and organ systems affected? Labs? |
PAN is a small and medium vessel vasculitis that affects NEURO and GI systems
Epidemiology: • MALE > female Associated with: • Nervous system -- MONONEURITIS MULTIPLEX (multiple peripheral neuropathies in a stepwise fashion: eg, R wristdrop --> L footdrop...) • GI (MESENTERIC ISCHEMIA) Also seen: • Renal (hematuria, HTN) • Coronary arteries Labs -- p-ANCA negative |
|
|
What is the epidemiology of Takayasu's arteritis?
Pathophysiology? |
Epidemiology:
• Japanese FEMALES • 10 - 20 yo Pathophysiology: • Affects AORTA and the proximal portion of the major branches • Marked thickening of the intima and adventitia --> OBSTRUCTION, ischemia |
|
|
What is the incidence of patella fractures in preschool-aged children?
|
Very LOW!
|
|
|
What is the leading cause of death in pregnancy?
|
Thromboembolic disease
|
|
|
What is the major cause of death in ECLAMPSIA?
|
Intracranial hemorrhage
|
|
|
What is the minimum age of validation of the Ottawa Knee Rules?
|
2 yo
|
|
|
What is the minimum volume of fetal blood required to be detected by the Kleinhauer-Betke test?
How much blood is required for Rh sensitization? |
Blood for KBT -- 5 ml
Blood for sensitization -- ONLY 0.01 ml |
|
|
What is the most common cause of postpartum hemorrhage in the first 24 hours after delivery, and after 24 hours?
|
1st 24 hours -- uterine atony
After 24 hours -- retained products of conception |
|
|
What is the most common ligamentous knee injury in children?
|
MEDIAL COLLATERAL ligament
|
|
|
What is the most common precipitating event for TTP? Other causes?
|
#1 Pregnancy (2nd trimester)
Others ('QuITS'): • Quinidine • Infection (esp HIV) • Ticlidopine • SLE .. |
|
|
What is the normal vaginal pH?
|
</= 4.5
|
|
|
What is the normal vaginal pH?
During pregnancy? What is the pH of amniotic fluid? |
Normal pH: </= 4.5
Pregnancy pH -- 3.5-6.0 Amniotic fluid -- 7.1-7.3 |
|
|
What is the Parkland formula for fluid replacement in burn victims?
|
4 cc/ kg/ % BSA burned
Give 50% over the 1st 8 hours, and 50% over the next next 16 hours NOTE: Must add maintenance fluids to this volume! |
|
|
What is the pathognomonic lab finding in a pt with Babesiosis?
Other lab findings? |
Pathognomonic:
• 'MALTESE CROSS' formation -- intra-erythrocytic PARASITES on GIEMSA-stained blood smear Labs: • PANCYTOPENIA • Elevated LFTs |
|
|
What is the PE test for
extensor pollicis longus function? Which nerve? |
Lift thumb off flat surface while palm is flat and down
Radial nerve |
|
|
What is the rate of HCG rise, and at what week do HCG levels plateau in pregnancy?
|
HCG doubles every 2 days, and PEAK at 8 weeks
|
|
|
What is the rate of missed scaphoid fractures on plain film?
|
15%
|
|
|
What is the recommended abx and duration of treatment for EARLY Lyme disease?
Pregnant/ Lactating/ Children? Severe disease? |
Early Dz:
• Doxy 100 bid, or • Amoxicillin 500 qid, or • Cefuroxime 500 bid. • Tx is for 20 - 30 days Pregnant/ Lactating/ Kids < 8 yo: • Amoxicillin Severe Dz: • PCN IV 20 million units, or • Rocephin 2 g qd |
|
|
What is the recommended treatment for EARLY Lyme disease?
Pregnant; Lactating; Children? Severe disease? |
Early Dz:
• Doxy 100 bid, or • Amoxicillin 500 qid, or • Cefuroxime 500 bid • Tx is for 20 - 30 days Pregnant/ Lactating/ Kids < 8 yo: • Amoxicillin Severe Dz: • PCN IV 20 million units, or • Rocephin 2 g qd |
|
|
What is the relative incidence of femoral and sciatic nerve injury in posterior hip dislocations?
|
Sciatic nerve injury -- COMMON (10%)
Femoral art/nerve injury -- rare |
|
|
What is the relative occurance of Neisseria gonorhoeae in mono- vs poly-articular arthritis?
|
Mono -- only 20% of cases
Poly -- much more common |
|
|
What is the relative prevalence of ovarian torsion in pregnant women?
What is the most common ultrasound finding? |
INCREASED RISK in pregnancy -- 20% of all cases occur during pregnancy
Most common U/S finding: • Ovarian ENLARGEMENT 2° to obstructed venous drainage Note -- Doppler imaging of blood flow is very difficult b/c of the dual blood supply --> High FALSE POSITIVE rate |
|
|
What is the relative rate of femoral neck fractures seen in posterior vs anterior hip dislocations?
|
Posterior -- 10%
ANTERIOR -- 77% |
|
|
What is the relative risk of radiation exposure to the fetus between VQ scan and CT in the workup of PE?
|
VQ > CT
|
|
|
What is the role of abx prophylaxis of Lyme disease in patients with tick bites?
|
Prophylaxis is not recommended after tick bites, even in endemic areas, except perhaps:
• Pregnant patients • Prolonged tick attachment in small children |
|
|
What is the role of abx prophylaxis of Lyme disease in pregnant patients with tick bites?
|
Prophylaxis is not recommended after tick bites, even in endemic areas, except perhaps:
• Pregnant patients • Prolonged tick attachment in small children |
|
|
What is the role of measuring serum uric acid levels in pts with acute gouty arthritis?
|
SERUM uric acid levels are not helpful in diagnosing ACUTE gouty arthritis. In the acute phase, uric acid may be normal.
|
|
|
What is the rule when evaluating ANY patient with monoarticular arthritis?
|
Monoarticular arthitis is SEPTIC arthritis until proven otherwise
|
|
|
What is the sensation, motor, and reflex test to evaluate L3 function?
|
Sensory -- Distal medial thigh
Motor -- Hip flexion Reflex -- n/a |
|
|
What is the sensation, motor, and reflex test to evaluate L4 function?
|
Sensory -- Medial foot
Motor -- Knee extension/ quads Reflex -- Knee jerk |
|
|
What is the sensation, motor, and reflex test to evaluate L5 function?
|
Sensory -- 1st dorsal web space
Motor -- Great toe and ankle dorsiflexion • Ask pt to WALK ON HEELS Reflex -- n/a |
|
|
What is the sensation, motor, and reflex test to evaluate S1 function?
|
Sensory -- Lateral foot
Motor -- Plantar flexion • Ask pt to WALK ON TIP-TOES Reflex -- Ankle jerk |
|
|
What is the sensitivity of ESR and CRP in the diagnosis of osteomyelitis?
|
ESR -- 90%
CRP -- greater than 90% |
|
|
What is the significance of:
• Early decelerations, • Variable decels, & • Late decels in fetal monitoring? |
Early Decels -- from compression of the fetal HEAD. Are typically benign.
Variable -- from CORD compression. Are typically benign. Late -- indicates UTEROPLACENTAL insufficiency. Bad! |
|
|
What is the treatment for the seronegative spondyloarthropathies?
Is there a role for abx? |
NSAIDS are the mainstay of tx
Tetracycline is helpful in CHLAMYDIA-triggered reactive arthritis, but not in arthritis with a GI cause (Crohn's, UC) |
|
|
What is the treatment of bacterial vaginosis?
|
Flagyl (or clinda) for a minimum of 7 days
|
|
|
What is the treatment of Erythema Nodosum?
|
• High dose ASA or NSAIDS
• Supersaturated potassium iodide soln (rarely) 'Nodosum -- NSAIDS' |
|
|
What is the treatment of pre-eclampsia?
|
• Absolute bedrest
• Observation Prophylactic anti-HTN meds are NOT REQUIRED unless SP > 170 or DP > 105 (essentially hypertensive urgency) Prophylactic MAGNESIUM |
|
|
What is the treatment of rhabdomyolysis?
What medicine is contraindicated? |
• Aggressive IVF rehydration
• Urine output 200 - 300 ml/hr • Urine alkalination with BICARB (helps keep myoglobin soluble --> aids in excretion): 1 amp in 1 L NS, rate of 100 ml/hr, or 3 amp in D5W @ 250/hr, or 2 amp in D5W @ over 1 hr • Maintain urine pH > 6.5 to prevent ARF • Mannitol Contra-I: • LASIX -- it acidifies the urine NOTE: can reverse excessive urine alkalinization with acetazolamide (Diamox) -- causes excretion of bicarb |
|
|
What is the treatment of Rocky Mountain Spotted Fever?
Pregnant? When should treatment begin? |
Doxy
Pregnant -- Chloramphenicol Most classes of abx are effective Treatment should begin IMMEDIATELY upon suspecting RMSF; very HIGH FATALITY RATE in untreated cases |
|
|
What is the typical mechanism of posterior shoulder dislocation?
|
Seizure
Electrocution |
|
|
What is the typical organism responsible for paronychias in:
• Adults • Children • Chronic cases? |
Adults:
• Staph aureus • Strep Kids -- anaerobes 2° to thumb sucking Chronic cases -- consider Candida albicans |
|
|
What is the typical presentation of N gonorrhoeae septic arthritis?
What is its prevalence? |
N gonorrhoeae septic arthritis most commonly presents as POLYARTICULAR arthritis
Accounts for 20% of all monoarticular arthritis Accounts for 'a larger proportion' of polyarticular arthritis |
|
|
What is the vaginal pH in patients with vulvovaginal candidiasis?
|
NORMAL (</= 4.5)
|
|
|
What is transient (toxic) synovitis?
• Epidemiology? • Presentation? • Joint fluid analysis? |
NON-SPECIFIC INFLAMMATION of the synovium of the hip, often FOLLOWING a VIRAL ILLNESS
Epidemiology: • 18 mos - 12 yo (usually 5-6 yo) • MALE > female • The MOST COMMON cause of hip pain in children Presentation: • Limp or inability to bear weight • Hip, knee or thigh pain Joint fluid: • 5000 - 15000 WBC • PMN < 25% Note: this condition a DIAGNOSIS OF EXCLUSION. Must first r/o septic joint. |
|
|
What is Wegener's granulomatosis?
Epidemiology? Organ systems affected? Labs? Prognosis? |
A NECROTIZING granulomatous vasculitis that primarily affects the RESPIRATORY tract and KIDNEYS.
It begins as URI/ sinus sxs. Epidemiology: • MALE > female • Mean age of onset: 45 yo Labs -- c-ANCA positive Pts typically DIE of renal disease/ GLOMERULONEPHRITIS within one year |
|
|
What lateral foot xray finding is an indication of Lisfranc injury?
Which artery is at risk of injury? |
Lateral xray shows DORSAL displacement of the metatarsals
Trauma to the DORSALIS PEDIS artery may occur |
|
|
What med can be given to patients with acute gout attacks and contraindication to NSAIDS?
|
Adrenocorticotropic hormone (ACTH) 40 - 80 IU IM
|
|
|
What medical conditions are carpal tunnel syndrome associated with?
|
• RA
• Collagen vascular diseases • Pregnancy • Menopause • Diabetes • Hypothyroidism |
|
|
What medical conditions should readily come to mind in a patient presenting with a rash to the PALMS and SOLES?
|
• Kowasaki Dz
• Erythema multiforme • Rocky Mountain Spotted Fever • Neisseria gonorrhoeae • 2° syphilis • Bacterial endocarditis |
|
|
What medicine is MOST effective in reducing the sx of 1st trimester N/V?
|
Pyridoxine (B6)
|
|
|
What meds are currently indicated for the outpatient tx of endometritis?
|
Doxy or Clinda
|
|
|
What neurologic finding occurs in about 20% of pts with MEDIAL epicondylitis?
|
ULNAR neuropathy
|
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|
What non-immunosuppressive drugs are effective in treating the cutaneous and musculoskeletal manifestations of SLE?
Side effects? |
• Chloroquine
• Hydroxychloroquine Side effects: • Retinopathy -- irreversible • Corneal deposits -- reversible |
|
|
What organism should be suspected in a fisherman/ swimmer presenting with a felon?
Tx? |
Aeromonas hydrophilia
Tx -- Flouroquinolone |
|
|
What percent of blood cultures and gram stains are positive in patients with septic arthritis?
|
50%
GS > Cx |
|
|
What signs and symptoms are associated with the HELLP syndrome?
|
Sx:
• RUQ pain • N/V Signs: • RUQ TTP • Generalized edema • Jaundice • GI bleed • Hematuria |
|
|
What sx is almost pathognomic for Brucellosis?
|
MALODOROUS PERSPIRATION
|
|
|
What test is the most sensitive, and what is the most specific, for diagnosing SLE?
|
Most sensitive -- ANA
Most specific -- anti-Smith Ab ('ANA Nicole Smith') |
|
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What test is used to examine integrity of the
flexor digitorum superficialis of the INDEX FINGER? |
Pt holds piece of paper between the pulp of the thumb and IF. If FDS of the IF is intact, pt will be able to hold the paper w/ DIP HYPEREXTENDED (ie, PIP bent, DIP relaxed).
If FDS is injured, pt must flex the DIP to retain the sheet. |
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|
What test(s) are used to dx Rocky Mountain Spotted Fever?
|
• Skin bx
• Immunofluorescent staining |
|
|
What type of emergency contraceptive best minimizes the risk of N/V as a side effect?
|
Progestin-only OCP
|
|
|
What type of heart disease is associated w/ the seronegative spondyloarthropathies?
|
VALVULAR heart disease
|
|
|
What xray finding is suggestive of pediatric supracondylar fx?
|
NORMAL elbow:
• At least 2/3 of the superimposed condylar heads should lie ANTERIOR to a line drawn longitudinally thru the middle of the humeral shaft. Supracondylar fx: • The condyles are displaced POSTERIORLY • Posterior fat pad sign |
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When a POSTERIOR fat pad sign is seen, what is the most likely implied fracture in adults and kids?
|
Adults -- Radial head fx
Kids -- Supracondylar fx |
|
|
Where are fracture blisters typically seen? List in order of frequency.
|
1 ANKLE
2 elbow 3 foot 4 knee |
|
|
Which antibiotics are associated with tendinopathy/ rupture?
|
Flouroquinolones
|
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|
Which are the tendons affected in De Quervain's tenosynovitis?
Name and describe the associated diagnostic test. |
• APL
• EPB Finkelstein's test: • Thumb held in a fist • Pt ulnarly deviates wrist • Pain over radial wrist is a positive test |
|
|
Which cohort of patients are most at risk for pre-eclampsia?
|
First pregnancy
Extremes of age: • < 17 yo • > 35 yo |
|
|
Which disease is associated with erythema marginatum, and which is associated with erythema (chronicum) migrans?
|
Erythema marginatum -- Rheumatic Fever (Major Jones criteria)
Erythema (chronicum) migrans -- Lyme Dz |
|
|
Which diseases comprise the seronegative spondyloarthropathies?
What are their common characteristics? |
Diseases:
• Ankylosing spondylitis • Reiter's • Psoriatic arthritis • Arthropathy of inflammatory bowel Common characteristics: • HLA-B27 • Sacroiliac involvement • Absence of rheumatoid factor |
|
|
Which foot bone is most at risk for AVN following fx?
|
TALUS
|
|
|
Which fractures are a consequence of ANTERIOR shoulder dislocation?
|
• Hill-Sachs deformity -- posteriorlateral indentation of the humeral head
• Bankart fx -- fracture of the anterior glenoid rim from impaction of the posteriorlateral humeral head |
|
|
Which immunizations are safe, and which are contraindicated, in pregnancy?
|
Safe -- KILLED viruses:
• Td • Diphtheria • Hep B • Rabies Contraindicated -- LIVE attenuated viruses: • MMR • Smallpox |
|
|
Which joints are most commonly affected in psoriatic arthritis?
Behcet's Dz? |
Psoriatic arthritis -- PIPs and DIPs
Behcet's -- Ankles and knees |
|
|
Which meds are associated with precipitation of SLE?
|
• Hydralazine
• Procainamide • Isoniazid |
|
|
Which nerves are at risk for injury in anterior shoulder dislocation, and how should they be tested?
|
Axillary nerve:
• Sensory -- touch over the lateral deltoid • Motor -- motor funtion of the lateral deltoid Musculocutaneous nerve: • Touch and flexion of the forearm musculature |
|
|
Which part of the clavicle is most commonly fractured?
Mechanism? |
80% of fractures are in the MIDDLE 1/3
Mechanism -- direct force applied to the lateral aspect of the shoulder |
|
|
Which rheumatic diseases are associated with alopecia?
|
• SLE
• psoriasis |
|
|
Which rheumatic diseases are associated with pulmonary fibrosis?
|
• Scleroderma
• Ankylosing spondylitis • RA ('SARs'') |
|
|
Which tendon is most frequently affected by calcific tendonitis?
Makeup of the deposits? Epidemiology? |
SUPRASPINATUS tendon is most commonly affected
Deposits -- hydroxyapatite Epidemiology: • FEMALE > male • RIGHT shoulder > left |
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|
Which tendons form the anatomic snuff box?
|
EPB
EPL |
|
|
Which two vasculidities exhibit pulmonary HEMORRHAGE?
Which is c-ANCA positive, and which is negative? |
Goodpasture's syndrome:
c-ANCA NEGATIVE Wegener's granulomatosis: c-ANCA POSITIVE Note: GOODPASTURE'S has a greater degree of pulmonary hemorrhage than Wegener's |
|
|
While Staph aureus is the most common cause of septic arthritis overall, state the organism responsible for septic arthritis in the following groups of people:
• Infants < 6 mos • 6 - 24 months • IVDU |
< 6 months:
• E coli • GBS 6 - 24 months: • Kingella kingae • (H flu) IVDU: • Staph aureus • Pseudomonas |
|
|
Why are sulfa drugs not safe in the 3rd trimester of pregnancy?
|
Can cause neonatal:
• Hemolysis • Kernicterus • Hyperbilirubinemia |
|
|
With respect to DVT risk and Virchow's triad, pregnancy is considered a ________________.
|
Pregnancy is a HYPERCOAGUABLE state
|
|
|
With respect to the pregnant female, when is the highest risk of DVT?
In which trimester is coumadin no longer contraindicated? |
Highest risk of DVT -- POST-PARTUM period
Coumadin is contraindicated THROUGHOUT pregnancy due to its strong association with fetal malformation even after organogenesis |
|
|
With what rheumatologic condition is temporal arteritis associated?
|
Polymyalgia rheumatica
|
|
|
What is the mechanism of extra-pyramidal symptoms?
Tx? Which EPS symptoms are NOT improved with this tx? |
Mechanism:
The MOTOR CORTEX travels through the PYRAMIDS of the medulla (corticospinal and corticobulbar tracts) --> synapse on cranial nerve nuclei and anterior horn cells is SC The EPS pathway INDIRECTLY targets the anterior horn cells outside the pyramidal system Tx -- anticholinergics: • Atropine • Benztropine EPS syptoms NOT improved with anti-cholinergics: • Tardive dyskinesia |
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|
A positive India Ink stain of the CSF most likely indicates which organism?
What is the treament? |
Cryptococcus neoformans
Tx ('ABC') -- Amphotericin B + flucytosine Mild cases: • Either itraconazole or fluconazole are acceptable, but less effective |
|
|
Amaurosis fugax is a result of ischemia to which artery?
|
The ophthalmic artery off the internal carotid
|
|
|
Auditory hallucinations may be experienced by pts with isolated sz activity in which lobe?
|
FRONTAL lobe
|
|
|
Central and peripheral vertigo indicate injury to which structures, respectively?
|
CENTRAL:
• Cerebellum, or • Brainstem PERIPHERAL: • CN VIII or • Inner ear, or • Middle ear |
|
|
Compare and contrast myasthenic crises and cholinergic crises in myasthenia gravis patients.
How can a test dose of edrophonium distinguish between the two? |
Myasthenic crisis:
• Results from an acute DEFICIENCY in ACh (eg, new onset dz; not taking meds) • Produces severe muscle weakness and respiratory compromise • Edrophonium IMPROVES sx Cholinergic crisis: • Results from an overdose of acetylcholinesterase inhibitor (eg, pt takes TOO MUCH of his pyridostigmine or neostigmine) • See CHOLINERGIC toxindrome (DUMBELS) b/c there is now an excess of ACh • Edrophonium WORSENS muscle weakness |
|
|
Compare and contrast the sx of acute labyrinthitis vs Meniere's dz
|
Labyrinthitis:
• ATAXIA • Nystagmus • Vertigo • Vomiting Meniere's: • RECURRENT episodes of... • TINNITUS • HEARING LOSS • Vomiting • Severe vertigo • Weakness |
|
|
Compare the differences in gait seen in central vs peripheral vertigo patients
|
PERIPHERAL:
• Pts usually CAN WALK, even in the acute phase CENTRAL: • Pts CANNOT even STAND or take a single step w/o falling over |
|
|
Compare the following features of central vs peripheral VERTIGO:
• Otic sx • N/V • Rate of onset • Severity of sx • Effect of change in head position • Neuro deficits |
CENTRAL vertigo:
• GRADUAL onset • NOT affected by change in head position • ATAXIA • Mild - moderate intensity • May see other neuro deficits [• NO hearing loss or tinnitus • NO N/V] PERIPHERAL vertigo: • Often HEARING LOSS and TINNITUS • N/V are COMMON • ABRUPT onset • Worsened by change in head position • Often moderate-SEVERE intensity • No other neuro deficits |
|
|
Compare the nystagmus seen in peripheral vs central vertigo
|
PERIPHERAL:
• Does not change direction with gaze to either side • AMPLITUDE increases when looking in the direction of the FAST phase • Nystagmus FATIGUES with FIXATION • Vertical nystagmus NEVER seen CENTRAL: • Nystagmus CHANGES DIRECTION when looking in the direction of the FAST phase • NO FATIGUE with fixation • Vertical nystagmus may be seen |
|
|
Consciousness = arousal + cognition.
Which anatomic locations are responsible for these functions, and what lesions are necessary to blunt consciousness? |
• Arousal -- Reticular Activating System
• Cognition -- Cerebral cortices To blunt consciousness, must knock out either: • BILATERAL cerebral cortices, OR • RAS |
|
|
Define Delirium
|
Extreme CONFUSIONAL STATE characterized by:
• Increased ALERTNESS • Increased PSYCHOMOTOR activity • DISORIENTATION, and • often accompanied by HALLUCINATIONS |
|
|
Describe the DTR findings with hypothyroidism
|
DELAYED DTRs
(Delayed, NOT decreased!) |
|
|
Describe the exam findings of LACUNAR infarcts.
Etiology? |
• PURE MOTOR or PURE SENSORY deficits
• Caused by infarcts of small penetrating arteries, most commonly to the basal ganglia and pons • Associated with CHRONIC HTN |
|
|
Describe the findings of POSTERIOR cerebral artery infarction
|
• Findings are predominantly VISUAL CORTEX, especially homonymous hemianopia
Also see: • MEMORY deficit • Complex HALLUCINATIONS • SENSORY deficits can be severe • NO motor deficits or aphasia Note: pts might be UNAWARE of the deficits until formally assessed |
|
|
Describe the interpretation of oculovestibular testing (ie, cold water calorics)
|
Fast COWS:
• Cold -- Opposite • Warm -- Same (This describes the direction of FAST nystagmus) BRAINSTEM + CORTEX intact: • Nystagmus AWAY (COWS) BRAINSTEM intact, cortex not: • Eyes will tonically deviate TOWARD the tested side Brainstem + cortex out: • No response |
|
|
Describe the ophthalmoplegia findings common to diabetics.
Pupils? |
• Isolated CN III or VI palsies
• Often painful • Pupils are SPARED |
|
|
Describe transverse myelitis:
• Presentation • Etiology • Rate of progression • Spinal location most commonly affected |
Presentation -- Sx very similar to CORD COMPRESSION (paraplegia, sensory loss, sphincter dysfxn)
Etiology -- Unknown; 30% of cases are post-viral Progression -- usually RAPID, with max deficit at 24 HOURS Location -- THORACIC cord (60-70%); cervical involvement is rare |
|
|
Discuss the classification of partial (focal) seizures
|
Classified according to LOC:
• Simple -- no LOC • Complex -- positive LOC or altered mentation. |
|
|
Dysfunction of which cranial nerve results in ptosis?
|
CN III
|
|
|
Hemi-neglect is caused by a stroke in which location?
|
PARIETAL lobe of the NON-dominant hemisphere
|
|
|
How are the symptoms of cluster headaches different from migraine headaches?
|
Migraine HA:
• 'Throbbing' • N/V • PHOTOPHOBIA/ Phonophobia Cluster HA: • 'Boring/ Tearing/ Lancinating' • Pain is almost always retro-orbital and in the TEMPORAL region (due to V1 involvement) • No N/V • No Photo/ phonophobia Cluster HAs exhibit AUTONOMIC INSTABILITY; SYMPATHETIC: • Ptosis • Miosis • Forehead and facial SWEATING PARASYMPATHETIC: • Rhinorrhea • Lacrimation • Nasal congestion |
|
|
How can Eaton-Lambert syndrome be distinguished from myasthenia gravis?
Autonomic dysfunction? CN involvement? Muscle Involvement? DTRs? |
ELS:
• CNs SPARED • Grip strength INCREASES with repeated stimulation • Weakness of PELVIC girdle and THIGH muscles • AUTONOMIC dysfunction is common • DTRs are drastically reduced or ABSENT MG: • BULBAR involvement • GRIP strength WORSENS with repeated stimulation • PROXIMAL muscle weakness • Autonomic dysfunction is uncommom • DTRs preserved |
|
|
How does the ingestion of alcohol affect the sx of myasthenia gravis, if at all?
|
Alcohol may WORSEN sxs
|
|
|
How is oculocephalic (Doll's Eye) testing interpreted in the comatose patient?
|
Doll's Eye reflex (movement of eyes in direction opposite of head movement) = INTACT brainstem
The brainstem is intact because the eyes are able to FIXATE on an object while the head is being turned. |
|
|
How is the vertigo of cerebellar infarct different from the vertigo of cerebellopontine angle tumors?
|
Cerebellar infarct -- CENTRAL vertigo
CPA tumors -- PERIPHERAL vertigo |
|
|
In patients with ischemic stroke and severe HTN, what are the exceptions that mandate emergent reduction in BP?
|
Concomitant:
• MI • Aortic dissection • Acute renal failure due to malignant HTN |
|
|
In pts with acute ischemic stroke, what two pretreatment pt characteristics increase the risk of intracerbral hemorrhage with tPA?
|
Increasing stroke SEVERITY
Signs of INFARCTION on CT: • Hypodensity or • Mass effect |
|
|
In what percent of children, between which ages, will febrile seizures occur?
What is the rate of relapse? |
2-5% of all kids between 6 mos - 5 yo will experience febrile sz
20 - 30% will have at least one recurrence First time seizures in infants < 6 mos old may indicate significant underlying pathology and warrant full w/u. |
|
|
Internuclear ophthalmoplegia occurs from lesions to what brain structure?
CNs affected? Physical exam findings? Monocular vs binocular? Are lesions bilateral or unilateral? |
MLF
CNs -- VI and III Monocular eye mvmt -- normal Binocular mvmt: • NYSTAGMUS in the ABDUCTED eye (Contralateral) • INABILITY to ADDUCT the ipsilateral eye Lesions are BILATERAL (ie, identical PE findings as above with each eye) |
|
|
Ischemia to the posterior circulation (the cerebellum) produces what symptoms?
What percent of cerebral blood flow is from the posterior circulation? |
• N/V
• Vertigo • Ataxia • Dysarthria • HA 20% |
|
|
Lateral medullary syndrome (Wallenberg syndrome) is due to occlusion in which cerebral artery?
Symptoms/ findings? |
PICA -- posterior inferior cerebellar artery
FACIAL findings: • Nystagmus (CENTRAL) • IPSILATERAL: - Horner's - Loss of PAIN and TEMP - Loss of CORNEAL REFLEX EXTREMITY findings: • CONTRALATERAL loss of pain and temperature |
|
|
Locked-In syndrome is due to an occlusion of which cerebral artery?
|
BASILIC artery
|
|
|
Simple febrile seizure criteria apply to ages 6 mos - 5 yo. Which children within this age bracket meeting the criteria for simple febrile seizure still require an LP for evaluation of seizure?
|
The AAP recommends that:
• ALL kids< 12 mos should receive an LP • All kids < 18 mos should be strongly considered |
|
|
State some Extra-Pyramidal (EPS) symptoms
|
EPS symptoms -- 'T-ROAD':
• Tremor, torticollis, trismus • Tardive Dyskinesia (CHOREOathetotic movements of the limbs) • Rigidity (and bradykinesia) • Opisthotonos (severe muscular spasticity --> extreme HYPER-EXTENSION posture ('bridging')) • Oculogyric crisis • Akathesia -- a state of SEVERE restlessness and AGITATION • Dystonia -- involuntary muscle contractions (eg, twisting of the neck or FACIAL muscles) |
|
|
State the critical diagnoses to consider in syncope
|
• SAH
• CVA • MI • AAA • Thoracic Aortic dissection • Dysrhythmia • CRITICAL AORTIC STENOSIS • HYPERTROPHIC CARDIOMYOPATHY |
|
|
State the motor function tests for C5, C6, C7, C8
|
C5 -- Lateral deltoid
C6 -- Biceps C7 -- Triceps C8 -- Hand intrinsics |
|
|
State the prophylactic medicine of choice for:
• Tension HA • Cluster HA • Migraine HA |
Tension HA -- Amitriptyline
('Tension -- TCA') Cluster HA -- Verapamil ('Cluster -- CCB') • Note: O2 is the tx Migraine HA -- PROPRANOLOL (drug of choice) Also: • Valproate • Neurontin • Amitriptyline • Verapamil |
|
|
State the sx of pseudotumor cerebri (benign intracranial hypertension).
PE findings? CT? |
Sx:
• HA • N/V • Dizziness • DIPLOPIA • BLURRED VlSION/ vision loss Findings: • Visual field defects • PAPILLEDEMA • CN VI palsies (either unilateral or bilateral) CT: • SMALL ventricles • Enlarged cisterna magna • NO hydrocephalus |
|
|
To what level should hemorrhagic stroke victims have their BP reduced?
|
Target SBP is 140 - 160, or patient's pre-stroke level if it is higher
|
|
|
What anti-cholinergic manifestation may be seen in both botulism and diphtheria?
|
Acute URINARY RETENTION
|
|
|
What are some risk factors for ruptured aneurysm causing SAH?
|
• Poorly controlled HTN
• MARFAN'S • POLYCYSTIC KIDNEY disease • Tobacco • Excessive EtOH use • Stimulant drug use |
|
|
What are the associated risk factors for the development of pseudotumor cerebri (idiopathic intracranial hypertension)?
Describe the typical pt. |
Risk factors:
• High dose VITAMIN A therapy • Chronic STEROID use Typical pt: • Young woman • OBESE 'Fat woman being tx'd for asthma who eats lots of carrots' |
|
|
What are the characteristics of temporal lobe seizures?
|
These are PSYCHOMOTOR seizures. Characterized by:
• Change in affect • Confusion • Hallucinations |
|
|
What are the characteristics of trigeminal neuralgia?
Cause of attack? |
• Explosive onset
• Severe intensity • Lasts 2 sec - 2 min • Unilateral • ALMOST ALWAYS involves V2 or V3 Attacks often precipitated by STIMULATION of a TRIGGER ZONE, eg: • Chewing • Tapping on the mandible... |
|
|
What are the classic findings in Guillain-Barre syndrome?
Sensory? CSF? Autonomic findings? |
Classic Findings:
• Progressive ASCENDING motor weakness (of more than one limb), + • LOSS of DTRs (universal areflexia) Pts may INITIALLY complain of: • Peripheral SENSORY deficits • PARESTHESIAS in toes CSF: • 'Cytoalbumin dissociation' = • Elevated PROTEIN, w/ • NORMAL WBC • 50% of pts will not experience an increase in protein in the first week of illness AUTONOMIC DYSFUNCTION is common: • Urinary retention • Ileus • Postural HoTN • Tachycardia |
|
|
What are the CSF finding in cryptococcal meningitis?
|
• Elevated opening pressure
Only slightly abnormal CSF: • Slightly decreased glucose • Slightly elevated protein • WBC with preponderance of LYMPHOCYTES |
|
|
What are the elements of Wernicke's encephalopathy and Wernicke-Korsakoff syndrome?
Tx? |
Wernicke's:
• Altered MS • Oculomotor dysfunction • Ataxia Wernicke-Korsakoff: • Above, +: • Confabulation • Memory disturbance Tx -- THIAMINE. Also: • Magnesium • Glucose • IVF |
|
|
What are the findings of CEREBELLAR lesions?
|
ACUTE onset of:
• Nystagmus • Dizziness • N/V • Ataxia NO FOCAL FINDINGS seen. NOTE: Cranial nerve findings may be evident if the hemorrhage compresses the brainstem. |
|
|
What are the findings of PONTINE hemorrhage?
|
Sudden onset of:
• Coma • QUADriparesis • MIOSIS • Gaze paresis • Ataxic RESPIRATORY pattern |
|
|
What are the indications for acute BP reduction in patients with ISCHEMIC stroke?
|
• Candidate for tPA
• MI • Aortic dissection • Renal failure • BP > 220/120 |
|
|
What are the irritating side effects of triptans in the tx of migraine HA?
What sx is a limiting factor in their use? |
Side effects:
• Tingling • Paresthesias • Sensation of warmth • Vasoconstriction with ANGINA Limiting sx: REBOUND HA |
|
|
What are the presenting findings of subarachnoid hemorrhage?
What medical condition is a predisposing factor SAH? |
Sx:
• Sudden onset • Worst HA of life • 'Thunderclap' Associated w/ h/o POLYCYSTIC KIDNEY dz |
|
|
What are the spinal fluid finding in pts with tuberculous meningitis?
Bacterial meningitis? |
Both:
• Increased WBC • Elevated protein • Decreased glucose • Elevated opening presssure Tuberculous: • Predominance of LYMPHOCYTES Bacterial: • Predominance of PMNs |
|
|
What are the symptoms of myasthenia gravis?
Pathophysiology? Pupillary status? |
Sx:
• PROXIMAL muscle weakness • Bulbar sx: • Ptosis • Diplopia • Dysarthria... Pathophysiology -- MG is an autoimmune disorder in which Ab's block the ACh receptors Pupils are NOT INVOLVED |
|
|
What are the symptoms of normal pressure hydrocephalus (NPH)?
LP? What is NOT a sx? What is the typical MISdiagnosis? |
Sx -- 'Wet, Wobbly, Wacky':
• Urinary incontinence • Ataxia • Dementia NPH is often misdiagnosed as PARKINSON'S or Alzheimer's LP opening pressure -- NORMAL HEADACHE is NOT a feature of NPH |
|
|
What are the two most common causes of NEONATAL seizures?
|
HYPOnatremia
Also -- HYPOcalcemia |
|
|
What are the typical presenting sxs of cryptococcal meningitis?
What is NOT a sx? Incidence in AIDS pts? |
In an HIV+ individual:
• Chronic HA • Fever • N/V NOT seen -- meningismus Cryptococcal meningitis is seen in 10% of AIDS pts |
|
|
What clinical presentation and CSF findings suggest HSV meningitis?
Which HSV strain is most commonly implicated? Diagnostic test? |
Clinical presentation:
• Altered mental status (eg, normally well-behaved teen acting beligerant and strange) • HA • Seizures CSF -- elevate RBCs Strain: • Adults -- HSV-1 • Neonates -- HSV-2 (via delivery thru genital tract) Test: PCR analysis of CSF |
|
|
What condition is associated with pelvic girdle and thigh weakness?
|
Eaton-Lambert Syndrome
|
|
|
What conditions are associated with mononeuritis multiplex?
|
• RA
• PAN • Temporal arteritis |
|
|
What deficit does ischemia of the anterior cerebral artery (ACA) produce?
|
• Contralateral deficits
• Hemiparesis + hemisensory loss of the LEG NOTE: • ACA: LE >> UE • MCA: UE + face >> LE |
|
|
What deficit does ischemia to the MIDDLE cerebral artery produce?
Hemisphere influence? Visual deficits? |
Peripheral:
• CONTRAlateral face, arm and leg weakness w/ hemisensory changes • FACE + ARMS > legs DOMINANT Hemisphere: • Aphasia (receptive or expressive) NON-dominant Hemisphere: • Neglect • Dysarthria • Inattention • Apraxia Other possible findings: • Homonymous hemianopsia • Conjugate eye deviation |
|
|
What diagnosis should be suspected in a young adult with trigeminal neuralgia?
|
Trigeminal neuralgia is a disease of adults older than 40, and typically in the 50-60s.
Consider MULTIPLE SCLEROSIS |
|
|
What drug should be given either po or via NGT immediately upon dx of subarachnoid hemorrhage?
How should HTN be controlled? |
NIMODIPINE 60 po q4h prevents vasospasm
Tx HTN with either: • Nicardipine • Labetolol |
|
|
What facial, extremity, gait and/or constitutional sxs are associated with cerebellopontine angle tumors?
Horners? |
Findings SEEN:
• Decreased hearing • Ataxia • PERIPHERAL vertigo Findings NOT seen: • No sensation abnormalities, either facial or peripheral • No Horners |
|
|
What is a common cause of MENINGITIS in HIV patients?
What is the most sensitive diagnostic test? Tx? |
Cryptococcus
Test: • Cryptococcal antigen > India ink prep Note: SERUM crypto Ag test is 95% sensitive Tx ('ABC') -- Amphotericin B (+ flucytosine) |
|
|
What is the average length of a seizure?
What is the definition of status epilepticus? What is the treatment? |
New 'operational' Definition:
• Any sz > 5 min (this is more that 17 standard deviations > the typical sz length of 1 min) Traditional Definition: • Any sz lasting 30 min, or • Recurrent szs w/o an interictal return to baseline The treatment of status pts who fail benozos, Dilantin and Phenobarb is: • Intubation; • Barbiturate coma, OR • Isoflurane anesthesia |
|
|
What is the biochemical cause of drug-induced parkinsonism?
Which drugs? Tx? |
Butyrophenones (eg, Haldol and droperidol) cause parkinsonism by:
• DOPAMINE antagonism • Disinhibition of cholinergic neurons in the basal ganglia Tx: • Bromocryptine (DA agonist) • Benztropine/ Benadryl (Anticholinergics) |
|
|
What is the classic presentation of botulinum toxin exposure?
DTRs? What concomitant toxindrome is seen? Mechanism? |
DESCENDING symmetric paralysis which typically starts in the BULBAR muscles
Pts present with: • Dysarthria • Diplopia • Dysphagia • Ptosis DTRs are PRESERVED Botulinum toxin produces ANTIcholinergic SXs (prevents the presynaptic release of ACh) ['ABC' -- ANTIcholinergic - botulinum] |
|
|
What is the ddx of bilateral facial nerve palsy?
|
• LYME disease
• Myasthenia gravis • Guillain-Barre • Lymphoma • Sarcoidosis • Brainstem tumors |
|
|
What is the definition of simple febrile seizure?
|
Definition:
• Age range 6 mos - 5 yo • Sz is associated w/ a fever • No evidence of CNS infection Typical features: • GENERALIZED sz lasting < 15 min • Only 1 sz in a 24 hour period • No post-ictal focal neurological deficit |
|
|
What is the difference between a CLASSIC and a COMMON migraine
|
Classic Migraine:
• Migraine WITH aura Common Migraine: • Migraine WITHOUT aura or other neurologic sxs |
|
|
What is the difference between generalized and partial seizures? Which is more concerning?
|
Generalized -- involves BILATERAL cerebral hemispheres (thus LOC b/c both hemipheres are involved)
Partial -- Involves only one hemispere. Potentially more concerning b/c a MASS LESION is much more likely. |
|
|
What is the difference in duration of action of DHE vs the triptans?
How is this useful clinically? |
DHE -- 72 hrs
Triptans -- 3-6 hrs DHE is well-suited to the treatment of CHRONIC, DAILY migraines. |
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What is the effect of cooling on the symptoms of myasthenia gravis?
What is the bimodal peak of MG? |
Cooling IMPROVES sx
Bimodal peak of the disease: • 20s (FEMALE > male) • 50s (MALE > female) |
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|
What is the epidemiology of cluster HAs?
Season preference? Frequency and duration? |
• MALE > Female
• Avg age of onset: 28 - 30 yo • Cluster period: 6 - 12 weeks, with remissions lasting 12 months • Exacerbations more common during SPRING and FALL • Occur qd - tid • Last between 45 - 90 min |
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What is the epidemiology of temporal arteritis?
Anatomical location? Associated with which rheumatologic condition? Sx/ findings? Labs? |
Epidemiology:
• FEMALE > male • Age > 50 • Branches of the carotid artery • Occurs in up to 30% of pts w/ PMR Sx: • Severe throbbing unilateral HA, especially WORSE at NIGHT • Malaise, wt loss, fever • JAW CLAUDICATION • Blurred vision, eye pain, or blindness 2°/2 MONONEURITIS MULTIPLEX • Tender, pulseless temporal artery Labs: • ESR > 50 (and often > 100) |
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What is the guideline for determining the expected amount of WBCs in CSF fluid following a traumatic tap?
|
1 WBC for every 700 RBCs
|
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What is the hallmark of BRAINSTEM lesions concerning location of consequent neuro deficit?
CORTICAL lesions? |
The hallmark of brainstem lesions is 'Crossed Signs':
• IPSILATERAL cranial nerve deficit + • CONTRALATERAL hemiparesis and hemisensory loss NOTE -- the oculomotor nerve is NOT located in the brainstem! (eg, remember 'blown pupil' with uncal herniation) Cortical Lesions: • CONTRALATERAL motor deficits • CONTRALATERAL sensory deficits • CONTRALATERAL CN deficts |
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What is the MEDICAL tx of pseudotumor cerebri (idiopathic intracranial hypertension)?
Mechanism? |
Acetazolamide -- decreases CSF production
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What is the mnemonic for treatable causes of altered mental status?
|
AEIOU-TIPS
A -- Alcohol E -- Epilepsy, electrolytes, encephalopathy I -- Insulin O -- Opiods, OD U -- Uremia T -- Trauma I -- Infection P -- Psychiatric S -- Shock, SAH, Snake bite |
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What is the mortality from meningococcemia?
What syndrome is associated with meningococcemia? |
50% mortality
Waterhouse-Friderichsen Syndrome (10% of cases): • Massive, bilateral hemorrhage/ infarct of the ADRENAL MEDULLA |
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What is the mortality from VP shunt infections?
|
30 - 40%
|
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What is the mortality rate for subarachnoid hemorrhage (SAH)?
|
50%
|
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What is the mortality rate of Guillian-Barre syndrome?
% of survivors w/ disability? Effect of age on severity of illness? |
Mortality rate: 4-15%
% w/ disability: 20% ELDERLY have a more severe course |
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What is the most common cause of epidural spinal cord compression?
|
85 - 90% of cases are due to METASTATIC DISEASE
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What is the most common cause of focal ENCEPHALITIS and intracranial MASS LESIONS in AIDS patients?
CT head findings? Tx? |
CNS Toxoplasmosis
CT -- Ring-enhancing lesions (signet rings) Tx: • Pyrimethamine + • Sulfadiazine + • Folinic acid ' Toxo -- In a Ring of Fire (Pyr'), you Die (SulfaDIazine)' |
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What is the most common cause of internuclear ophthalmoplegia?
Other causes? |
MULTIPLE SCLEROSIS
Other causes: • Vascular lesions (brainstem) • Wernicke syndrome • Hypertensive emergency • SLE |
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What is the most common etiology of non-traumatic subarachnoid hemorrhage?
Other causes? |
Ruptured SACCULAR (Berry) ANEURYSM causes > 80% of SAHs
Other causes: • AVM • Cavernous hemangioma • Mycotic aneurysm • Blood dyscrasia |
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What is the most common metabolic cause of seizure activity?
|
Hypoglycemia
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What is the most common neurologic manifestation of SLE?
|
Seizures
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What is the most common side effect of DHE?
|
NAUSEA
Always pretreat with an antiemetic. |
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What is the most commonly affected spinal level for spinal stenosis?
Sx? |
L5 most common, then
L4, L3, L2 Sx: • LBP • Sx worse with erect posture • Sx IMPROVED with SITTING, walking uphill (forward-leaning posture) |
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What is the most feared and most devastating complication of subarachnoid hemorrhage?
Predictive factor? Specific pharmacologic tx? |
VASOSPASM
Responsible for 14-32% of deaths and permanent disability from SAH Predictive factor -- a LARGE amount of BLOOD in the BASAL CISTERN SAH pts receive NIMODIPINE to minimize the risk of vasospasm |
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What is the optimal 1st, 2nd and 3rd line agents in the tx of seizures in adults and children?
|
Adults/ Kids:
• 1 -- Benzos • 2 -- Dilantin • 3 -- Phenobarb [Kids: • 1 -- Benzos • 2 -- Phenobarb • 3 -- Dilantin] |
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What is the pathophysiologic hallmark of Amyotrophic Lateral Sclerosis (ALS)?
Findings? |
Hallmark -- Degeneration of BOTH UPPER and LOWER motor neurons
Findings -- Mixed MOTOR neuropathy. No sensory impairment. UPPER motor neuron: • Spasticity • HYPERREFLEXIA LOWER motor neuron: • Dysarthria • Dysphagia • Difficulty chewing • Extremity weakness • Fasciculations • Atrophy |
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What is the relationship between pseudotumor cerebri (idiopathic intracranial hypertension) and hydrocephalus?
Which cranial nerve is affected? |
Hydrocephalus is NEVER found on CT
ABDUCENS nerve is commonly affected |
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What is the risk of subsequent stroke in a patient who presents with TIA and concommitant amaurosis fugax?
|
LOW!
Aspirin is TWICE as effective in preventing strokes in TIA pts w/ amaurosis fugax vs pts with hemispheric ischemia |
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|
What is the role of steroids in the treatment of meningitis in children > 1 month old?
|
Steroids DECREASE the incidence of neurologic complications due to:
• HIB Steroids DO NOT improve, and actually may worsen, meningitis due to: • Strep pneumo • N. meningitidis |
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What is the treatment of cluster HA?
What tx is NOT indicated? |
Tx:
• OXYGEN -- 75% of pts will have complete relief of sx w/in 15 min • Sumatriptan/ DHE NOT INDICATED: • Narcotics • Benzos • Steroids |
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|
What is Todd's Paralysis?
|
Todd's paralysis is an atypical post-ictal state characterized by FOCAL MOTOR DEFICIT that may persist for 24 hrs
|
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|
What percent of patients who present with optic neuritis will ultimately develop MS?
What percent of MS patients develop optic neuritis? |
25-30% lifetime risk of developing MS with a presentation of optic neuritis
50% of pts with MS will experience optic neuritis |
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|
What percent of trigeminal neuralgia patients have:
• Multiple sclerosis? • Intracranial lesion? • Fail med tx and require ablation? • Experience remission for 6 mos? |
MS -- 2-4 %
Intracranial lesion -- 10% Require surgical ablation -- 30% Experience 6 mos remission -- 50% |
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Where does the rash of meningococcemia typically begin?
|
Begins as petichiae on WRISTS and ANKLES in 70% of individuals
|
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|
Which arteries compose the anterior cerebral circulation?
|
Anterior cerebral circulation = the region of the brain supplied by the INTERNAL CAROTID arteries:
• Anterior cerebral artery • Middle cerebral artery • Ophthalmic artery |
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|
Which arteries compose the posterior cerebral circulation and supply blood to the:
• cerebellum • brainstem • visual occipital lobe • medial aspect of the temporal lobe? |
Subclavian artery -->
Vertebral artery --> Basilar artery --> Bifurcate to form the two posterior cerebral arteries |
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|
Which bacterial cause of diarrhea is commonly associated with seizures?
|
Shigella
|
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Which disease, Eaton-Lambert Syndrome or myasthenia gravis, is associated with absent DTRs, and in which are DTRs preserved?
|
DTR preserved -- MG
DTR ABSENT -- ELS ('Weak thighs -- weak knee jerk') |
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Which electrolytes (other than glucose) are often implicated in acute confusional states?
|
HYPOnatremia
Also, HYPERcalcemia ('Stones, Bones...') |
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|
Which hemisphere is the dominant hemisphere in right-handed individuals?
Left-handed? |
Right-handed: LEFT hemisphere
Left-handed: LEFT hemisphere in 80% of individuals |
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|
Which organism should be considered in pts at the extremes of age with meningitis?
Abx of choice for this organism? |
Listeria
Abx: • AMPICILLIN • Bactrim |
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|
Why is ergotamine contraindicated in breast-feeding moms?
|
Ergotamine can cause:
• N/V • Diarrhea • SEIZURES in breastfeeding infants |
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|
With what malignancy is Eaton-Lambert Syndrome most often associated?
What is ELS, and what are the symptoms? Which receptors are targeted? |
ELS most often associated with OAT-CELL CA
ELS is an autoimmune disorder that targets PRE-synaptic voltage-gated CALCIUM CHANNEL receptors Sx: • Aching, weakness and fatigue of PELVIC GIRDLE and THIGH muscles • ABSENT DTRs • Cranial nerves are SPARED • Grip strength INCREASES with repeated stimulation |
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Within how many hours of onset of symptoms must a stroke patient be in order to be a candidate for tPA?
BP must be below what threshhold to be a tPA candidate? |
3 hours
BP < 185/105 |
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Describe the etiology and symptoms of vitreous hemorrhage.
APD? |
Etiology:
• Diabetic retinopathy • Retinal detachment Sx similar to retinal detachment: • Floaters (early) • PAINLESS visual loss (late) Note: APD = concommitant RETINAL detachment |
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Discuss the management and treatment of hyphemas.
Home vs inpatient? |
• Ophtho consult (mandatory)
• Elevate HOB to prevent obstruction of the trabecular network with blood products Meds: • DILATE the eye to prevent further stretch on traumatized iris vessels • Control elevated IOP as necessary Disposition: • Outpt management if < 1/3 of the anterior chamber is involved |
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|
On fundoscopic exam, which are larger, retinal arterioles or venules?
|
Retinal VENULES
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Pain with consensual light reflex is highly suggestive of what condition?
|
Iritis
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|
State several causes of painLESS and painFUL vision loss
|
PainLESS vision loss:
• CRAO • CRVO • Retinal detachment • Vitreous hemorrhage PainFUL vision loss: • Acute angle closure glaucoma • Optic neuritis |
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|
State some precipitating factors for acute narrow angle glaucoma?
|
• Dim light
• Anti-cholinergic meds • Sympathomimetic meds |
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Untreated retrobulbar hemorrhage may result in irreversible vision loss after how many minutes?
Cause of the vision loss? Tx? |
Irreversible vision loss in 90 MINUTES
Mechanism of blindness -- mechanical compression of the CENTRAL RETINAL ARTERY or VEIN Tx -- Lateral canthotomy |
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|
What are the causes of monocular diplopia?
|
• Refractive error
• DISLOCATED LENS • Iridodialysis (2x pupil s/p trauma) • Functional |
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|
What are the exam finds of Epidemic Keratoconjunctivitis?
Causative organism? |
Findings:
• Diffuse punctate CORNEAL LESIONS • Tender PREAURICULAR lymphadenopathy • Scleral erythema Organism: • ADENOVIRUS |
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What are the fundoscopic findings seen in:
• Glaucoma • Vitreous hemorrhage • Macular degeneration? |
Glaucoma:
• Cloudy cornea • Mid-dilated pupil Vitreous hemorrhage: • Reddish haze with black reflex (absence of normal red reflex) Macular degeneration: • Grayish-green subretinal membrane |
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|
What are the fundoscopic findings with:
• Central retinal artery occlusion • Central retinal vein occlusion? |
Central retinal ARTERY:
• Pale gray retina • 'Cherry red spot' on the macula • Boxcar retinal venules Central retinal VEIN: • Disc edema with tortuous veins ('Blood and thunder') |
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|
What are the symptoms and findings in optic neuritis?
Desaturation? Region affected? Pupil? |
• Monocular EYE PAIN, worse with movement
• RED vision desaturation • CENTRAL vision loss • Rapid progression • APD |
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|
What are the symptoms and treatment of retrobulbar hemorrhage?
|
Sx:
• PROPTOSIS • Vision loss • Decreased EOM • Increased IOP Tx: • LATERAL CANTHOTOMY. Time is precious! Do not wait for the ophthalmologist; do it yourself. For suspected IOP: • Carbonic anhydrase inhibitor • Beta-blocker • Mannitol |
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|
What is chalcosis?
What is the ophtholmologic consequence? |
Golden deposits in the eye due to inflammation from COPPER-containing foreign bodies
Can lead to ENDOPHTHALMITIS and rapid visual loss |
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|
What is iridodialysis?
|
Double pupil seen with blunt trauma
|
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What is iridodonesis?
|
Shimmering of the iris associated with POSTERIOR lens DISLOCATION
|
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|
What is the earliest ocular physical exam finding of papilledema?
Caveat? |
LOSS of VENOUS PULSATIONS
However, venous pulsations may be absent in up to 50% of normal individuals. |
|
|
What is the major complication of central retinal VEIN occlusion?
|
Thrombosis -->
Increased intra-ocular pressure --> GLAUCOMA |
|
|
What is the medical tx of iritis?
|
• Topical anticholinergics (eg, homatropine)
• Topical steroids |
|
|
What is the most common OCULAR complication of AIDS? Tx?
|
CMV retinitis
Tx: • Gangcyclovir • Foscarnet |
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|
What is the rate of rebleed of traumatic hyphemas?
|
30%
|
|
|
What is the risk of periorbital cellulitis progressing into orbital cellulitis?
|
Periorbital cellulitis CANNOT progress to orbital cellulitis in the absence of trauma due to a thick fibrous layer separating the orbit from more superficial tissues
|
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|
What is the significance of retinal hemorrhage in neonates?
|
Almost 1/2 of all neonates delivered vaginally have retinal hemorrhage.
Resolution occurs in 1 month. Retinal hemorrhage after 1 mos indicates child abuse. |
|
|
What is the treatment for acute narrow angle glaucoma?
|
Acetazolamide (IV)
Mannitol Topical steroids Topical Alpha-agonists: • Apraclonidine (Ioptic) • Brimondine (Alphagan) Topical ß-blockers Topical Cholinergic AGONIST: • Pilocarpine (administered 1 hr after beginning tx) |
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|
What is the typical presentation of a patient with retinal detachment?
|
FLOATERS with or without PAINLESS visual loss
|
|
|
What occular condition is characterized by small white ulcers located at the margin of the limbus?
|
Allergic conjunctivitis to the toxin secreted by STAPH aureus
|
|
|
What ophthalmologic condition does CMV cause in AIDS pts?
|
Chorioretinitis
Found in 5-10% of AIDS pts |
|
|
What ophthalmologic condition spontaneously develops in sickle cell patients?
|
HYPHEMA
|
|
|
What organism is responsible for chronic ORBITAL cellulitis lasting from weeks to months?
|
Aspergillus
|
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|
What should be your first action once an open globe is suspected?
Abx? |
Apply a SHIELD to the eye!
Parental abx such as vancomycin and gentamicin SHOULD be administered to prevent endophthalmitis |
|
|
Which eyelid edge/ margin lacerations require repair, and which do not?
|
< 1 mm -- DOES NOT require suturing; will heal spontaneously w/o lid notching
> 1 mm -- REQUIRES repair to prevent notching |
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|
Which med is specifically contraindicated in the tx of glaucoma in sickle cell pts?
Why? |
CARBONIC ANHYDRASE INHIBITORS
Acetazolamide LOWERS THE AQUEOUS pH in the anterior chamber --> Increases SICKLING --> CLOGS trabecular meshwork outflow --> INCREASED IOP |
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|
Which topical meds are contraindicationed in acute narrow angle glaucoma?
|
Anticholinergics =
Cycloplegic mydriatics eg, Homatropine |
|
|
At what age is surgical cricothyroidotomy acceptable in children in respiratory distress?
|
Generally 12 yo, when the cricothyroid membrane becomes PALPABLE
|
|
|
At what ages do the ethmoid, maxillary, frontal and sphenoid sinuses become aerated?
What is the rate of acute, severe sinus infections in childhood? |
Maxillary & Ethmoid -- birth
('ME') Frontal & Sphenoid -- age 6 to 7 ('Sphenoid -- Seven') Rate of severe sinus infections in childhood -- INFREQUENT |
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|
Bullous impetigo is an infection of which age group?
Etiologic agent? |
Affects:
• Newborns • Young children Etiology: • Staph • GABHS |
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|
By what mechanism does diphtheria exhibit its pathological effects?
What are the most serious consequences of the disease? Tx? |
Mechanism -- Exotoxin
Complications: Most serious findings: • MYOCARDITIS • Enlarging gray PSEUDOMEMBRANE that can cause airway OBSTRUCTION • Pharyngeal muscle PARALYSIS --> • Generalized paralysis (QUADRIPARESIS) Other findings: • Nephritis • Hepatitis • 'Bull neck' -- marked cervical LAD Tx: • Macrolide abx • ACTIVE Immunization • Anti-toxin (Dose based on the severity of illness) |
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|
Cervical spine injuries in young children (< 11 yo) commonly occur in which region?
|
Upper c-spine (as opposed to the lower c-spine in adults)
|
|
|
Compare and contrast rubeola (measles) vs rubella (German measles)
|
Rubeola (measles):
• Caused by PARAMYXOvirus • KOPLIK spots pathognomic • Cough, coryza, conjunctivitis • Fever (can be HIGH) • GENERALIZED pruritic rash; begins on FACE; rapidly becomes CONFLUENT Rubella: • Generalized LAD • '3-day' RASH that begins on FACE and spreads to trunk and limbs • LOW-GRADE fever • Characteristic suboccipital and posterior auricular lymph nodes |
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|
Compare the rate of pediatric incarcerated inguinal and umbilical hernias
|
Inguinal -- FREQUENT incarceration, especially in the 1st year
Umbilical -- RARELY incarcerate |
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|
Contrast the presentation of Chlamydia trachomatis pneumonia vs RSV pneumonia in infants.
Extra-pulmonary findings? |
Chlamydia trachomatis:
• 3 wks - 3 mos of age • No wheezing • Dry, STACCATO cough • CONJUNCTIVITIS often precedes the infection RSV: • 3 mos - 5 yo • Wheezing |
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|
Describe Roseola Infantum (aka 6th Disease; Exanthem Subitum). Etiology?
|
Etiology:
• Human Herpesvirus 6 (HHV-6) • 6 - 12 months old • Sudden onset HIGH FEVER (103-106°) --> may see febrile sz • Virtually NO OTHER SX • Fever resolves after 3 days Just when the pt appears to be better: • SUDDEN RASH to chest, arms, neck (NOT FACE) • Rose-colored macules and papules Self-limiting -- no tx rqd |
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|
Describe the 3 phases of Kowasaki's disesase: Acute, Subacute, and Convalescent.
Platelets?. |
Acute (Day 1 - 11):
• FEVER + most of the other formal diagnostic criteria (conjunctivitis, strawberry tongue, palmar/plantar erythema/edema, rash, unilateral cervical LAD) • MYOCARDITIS (most common cause of death in this phase) Subacute (Day 11 - 20): • Gradual resolution of above sx • THROMBOCYTOSIS • Periungual desquamation • Risk for developing coronary artery THROMBOSIS greatest now • Cause of death: MI, ANEURISM rupture, myocarditis Convalescent phase (Day 21 - 60): • Begins when ALL SX have RESOLVED • Ends when ESR and platelets have normalized • Death may occur from MI secondary to thrombus |
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|
Describe the 3 stages of Bordetella pertussis.
Fever? What is the treatment? When are cultures most useful? CBC? |
CATARRHAL phase:
• Non-specific URI-like sxs • Lasts 1-2 weeks • Abx (MACROLIDES) effective in this stage only • Cx only useful in this phase • If significant FEVER is present, look for ANOTHER DX! PAROXYSMAL phase: • Coughing FITS, worse at NIGHT • Infants: Paroxysmal, STACCATO cough • Kids: 'Whoop' • Associated with POST-TUSSIVE emesis • INFANTS may have severe APNEIC/ choking spells, and dehydration (consider ICU) • Lasts from 1 - 6 weeks CONVALESCENT phase: • CHRONIC, intermittent cough • Lasts several months Adjunctive tx: • ß-agonists • Steroids CBC -- May see VERY HIGH WBC |
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|
Describe the epidemiology, presentation and PE FINDINGS of intussusception.
Location? Dx and tx? |
Epidemiology:
• The most common cause of intestinal obstruction from 3 mos - 6 yo. • Rare < 3 mos old • MALE > female (4:1) Presentation: • Well-appearing child with abrupt onset of severe COLICKY abdominal pain • Child looks great in between episodes Findings: • 'CURRANT JELLY' stool (late manifestation) • SAUSAGE-shaped tumor mass in right abdomen • Ileo-colic is the most common type Dx and Tx: • Dx is CLINICAL • Ultrasound can also be used to dx • Air contrast enema is diagnostic and frequently curative |
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|
Describe the etiology, presentation and lab findings of Henoch-Schonlein Purpura
|
Etiology -- immune-mediated vasculitis
Sx: • RASH -- PALPABLE maculpapular eruption on legs and buttocks • Abd Pain -- due to vasculitis or INTUSSUSCEPTION • Arthritis -- asymmetric Lab: • microscopic hematuria (indicates GLOMERULONEPHRITIS) • Moderate THROMBOCYTOSIS and leukocytosis |
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|
Describe the rash of hand-foot-mouth disease.
Etiology? |
• Small VESSICLES on the palms, soles and buttocks
• Intraoral lesions on the soft palate, gingiva and tongue Etiology -- Coxsackievirus A16 |
|
|
Discuss pediatric umbilical hernias.
• Rate of incaration/ strangulation • Epidemiology • Tx |
Pediatric umbilical hernias RARELY incarcerate or strangulate
Incidence: • BLACK -- 65% • White -- only 10% Closure/ tx: • By 2nd year of life, most will have closed spontaneously • Age 3 or 4 -- only 20% of hernias remain • Age 4 -- refer persistent hernias for surgical consult |
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|
Discuss the ddx and workup of jaundice in newborns
|
Age 2-3 DAYS:
• Physiologic breakdown of fetal RBCs most common Age > 3 Days: • SEPSIS is the primary consideration DDx of Jaundice > 1 wk: • Sepsis • Hepatitis • TORCHS • Congenital biliary atresia • Sickle Cell • G6PD deficiency • Hemolytic anemia • Hypothyroid • Breast milk jaundice |
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|
Discuss the epidemiology, symptoms, rash, and treatment of SSSS (Staphlococcal Scalded Skin Syndrome).
SSSS often follows which conditions? |
Children < 2 yo
Sx: • Often follows URI or conjunctivitis • Mucous membranes NOT involved Rash: • Diffuse erythema --> • SANDPAPER-like skin --> • Bullae --> • Desquamation in large sheets (of SUPERFICIAL epidermis; NO scarring) • NIKOLSKY's sign Tx -- Nafcillin |
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|
Discuss the role of prophylactic abx in patients who come in contact with individuals with pertussis.
When is prophylaxis no longer required? What duration of immunity is provided with the vaccine? |
Abx -- E-mycin -- are effective EARLY in the disease (ie, catarrhal phase) and for prophylaxis. They are less effective as the dz progresses.
DO PROPHYLAX exposed individuals, however... ...prophylaxis is NOT REQUIRED after the infected pt has had SX > 3WEEKS Vaccine Immunity: only 4 - 8 years! |
|
|
Fractures of which bones are red flags for child abuse?
What about infants? |
Red Flag Location:
• Rib • Humerus • Metaphyseal • Scapula Fx type: • Spiral • Multiple fxs Infants -- ANY fx (esp femur, spiral or not) |
|
|
How can Toxic Epidermal Necrolysis (TEN) be distinguished clinically from SSSS?
|
TEN -- extensive MUCOUS MEMBRANE involvement
SSSS-- NO mucous membrane involvement |
|
|
How does malrotation with midgut volvulus typically present?
Is this urgent? |
• Most present in FIRST WEEK of life
• Toxic appearance • BILIOUS emesis This is a SURGICAL EMERGENCY. Bowel necrosis occurs within as little as 3 hours. |
|
|
How does the hyperoxia test (administering 100% supplemental O2) help differentiate between cardiac and pulmonary causes of infantile cyanosis?
|
IMPROVEMENT in O2 sat with supplemental O2 indicates a PULMONARY cause of cyanosis
The hallmark of shunt is failure to improve oxygenation with supplemental O2 b/c blood bypasses the lungs and never sees the increased O2 concentration. |
|
|
How is the Apt test used in the diagnosis of bloody stools in newborns?
|
The Apt test shows if blood in a newborn's stool is SWALLOWED blood of maternal origin
NOTE: Min of 5 cc of swallowed maternal blood is rqd for the Apt test to be positive |
|
|
How should PO dexamethasone be administered to kids?
Dosing? |
Give the IV solution as po. No vile taste, and no associated vomiting. No need to dilute.
Dosing: • 0.3 mg/kg of the 10 mg/ml IV soln |
|
|
In infants with GERD, at what age do the symptoms peak, and at what age do they resolve?
Why do the symptoms resolve? |
Peak -- 4 mos
Resolve: • Most by 12 mos • Nearly all by 24 mos Reason for resolution: • The LES becomes more COMPETENT with age |
|
|
In what percent of children, between which ages, will febrile seizures occur? What is the rate of relapse?
|
2 - 5% of all kids between 6 mos - 5 yo will experience febrile sz.
20 - 30% will have at least one recurrence First time seizures in infants < 6 mos may indicate significant underlying pathology and warrant full w/u. |
|
|
In which age group is intussusception most typically seen?
|
6 - 18 mos old
|
|
|
In which cervical spine levels are pseudosubluxation seen in the pediatric population?
Incidence? |
C2-3: Seen in nearly 50% of pts < 8 yo
C3-4: 15% incidence |
|
|
Name some frequent and infrequent complications of EBV
|
FREQUENT:
• Benign elevation of LFTs (80%) • Neutropenia (50-80%) • Thrombocytopenia (25-50%) • Headache (50%) INFREQUENT: • Jaundice (5%) • Autoimmune hemolytic anemia (3%) • Meningoencephalitis (1-5%) • Tonsillar hypertrophy with airway obstruction (< 5%) • Splenic rupture (< 0.5%) |
|
|
Nasotracheal intubation is contraindicated in children under what age?
Uncuffed ET tubes are indicated in children less than what age? |
< 9 yo for both
|
|
|
Other than meningitis, what condition should be suspected in a child with ill appearance, fever and meningismus?
|
Retropharyngeal abscess
In a child w/ suspected meningitis, if CT of the head and LP are normal such that meningitis is ruled out, order a SOFT TISSUE CT of the NECK to evaluate for RPA. |
|
|
Simple febrile seizure criteria apply to ages 6 mos - 5 yo. Which children within this age bracket meeting the criteria for simple febrile seizure still require an LP for evaluation of seizure?
|
The AAP recommends that:
• ALL kids< 12 mos should receive an LP • All kids < 18 mos should be 'strongly considered' |
|
|
State the difference between H flu, Staph and Strep pyogenes regarding method of spread and WBC findings in periorbital and orbital cellulitis?
|
Spread:
• H flu -- HEMATOGENOUS • Staph/ GABHS -- local invasion WBC: • H flu: >15000 • Staph/ GABHS: normal |
|
|
State the incidence of pneumonia as a function of age in the pediatric population
|
Pneumonia develops more often in EARLY childhood than at any other age
The incidence of pneumonia in children DECREASES as a function of age |
|
|
State the lab findings in Reye's Syndrome. What is the sine qua non finding?
What is the treatment? |
Labs:
• ELEVATED NH3 (sine qua non) • LFT 3x normal • Prolonged PT • HYPOglycemia (esp in infants) • Elevated BUN (dehydration) Tx -- Mild dz: • D10W + IVF • Lactulose (corrects ammonia) • Neomycin (corrects ammonia) • FFP, Vit K (corrects coags) Tx -- Severe dz: • ICP monitoring • Lasix, mannitol |
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|
State the location of airway obstruction in patients with inspiratory, expiratory and biphasic stridor
|
Inspiratory -- at or ABOVE the larynx
Expiratory -- Bronchial or lower trachea Biphasic -- BELOW the larynx |
|
|
State the probable cardiac problem in infants presenting with CHF at the following ages:
• Day 1 • 1st Week • 2 Weeks • 1 Month • 3 Months • 1-2 Years |
Day 1 -- Patent ductus arteriosus
1st Week -- Hypoplastic left heart syndrome 2 Weeks -- Coarctation of the aorta ('2 -- COarctation') 1 Month -- VSD 3 Months -- SVT 1-2 Years -- Kowasaki's |
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What 3 agents are most often implicated in APNEIC episodes and AFEBRILE PNEUMONITIS in very young infants (< 3 months)?
|
• RSV
• Chlamydia trachomatis • Pertussis |
|
|
What adverse reaction can occur with chronic, improper use of inhaled ß-agonists?
|
Tachyphylaxis
|
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|
What antibiotic is similar in form to tetracycline and should also be avoided in children < 8 yo for risk of tooth staining?
|
Doxycycline
|
|
|
What are common causes of stridor in children < 6 mos and > 6 mos of age?
|
< 6 Months:
• Laryngotracheomalacia (resolves by age 2) • Vocal cord paralysis/ paresis • Arnold-Chiari malformation > 6 Months: • Croup • Epiglottitis • Retropharyngeal abscess • FB aspiration |
|
|
What are Pastia's Lines associated with?
|
Scarlet Fever
Pastia's lines appear where scarlet fever rash becomes confluent, typically in the armpits and groin |
|
|
What are the 'Rules of 2' for Meckel's diverticulum?
|
• 2% of the population
• 2 feet from the ileocecal valve • 2 inches in length • 2 yo (most common age of presentation) • 2% are ASYMPTOMATIC • 2:1 male > female • 2 types of ectopic tissue: • Gastric (most common) • Pancreatic |
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|
What are the 4 most common causes of severe diastolic HTN in children?
|
• Coarctation
• Renal artery stenosis • Chronic pyelonephritis • Chronic glomerulonephritis |
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|
What are the antibiotics of choice for outpatient management of pediatric sinusitis?
PCN allergic? |
Initial:
• Amoxicillin 80 mg/kg/day Persistent: • Augmentin 40 mg/kg/day, OR • Cefprozil 30 mg/kg/day PCN allergic: • Clindamycin |
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|
What are the clinical findings of RSV pneumonia in children? How is it treated?
Most common in which season? |
• Cough
• Coryza • Fever Tx: • Primarily supportive • Albuterol nebs • RIBAVIRIN may be used WINTER and SPRING predominance ('rSv -- Spring') |
|
|
What are the complications of Reye's syndrome?
|
• CEREBRAL EDEMA with herniation
• Renal failure • Pancreatitis |
|
|
What are the congenital infections that cause JAUNDICE?
|
TORCHS:
• Toxo • Rubella • CMV • HSV • Syphilis |
|
|
What are the diagnostic criteria for Kowasaki's Disease?
|
FEVER >/= 5 days (high and usually unresponsive to abx); PLUS 4 of the following 5:
1) Bilateral CONJUNCTIVITIS 2) Cervical LAD (usually UNILATERAL) 3) Changes in lips and oral mucosa: • STRAWBERRY TONGUE • Erythematous/ fissured lips 4) Extremity features: • Hand and foot ERYTHEMA or indurative EDEMA • Periungual desquamation 5) Polymorphous RASH, most prominent in the PERINEUM or trunk |
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|
What are the elements of Tetrology of Fallot?
|
• Pulmonic stenosis (RV outflow tract obstruction)
• RVH • VSD • Overriding aorta |
|
|
What are the findings of sickle cell Sequestration Crisis and Aplastic Crisis?
Most common age? Etiology? |
SEQUESTRATION Crisis:
• 6 mos - 6 yo most common • SPLENOMEGALY • Abdominal pain • Very low H/H • SHOCK APLASTIC Crisis: • Usually precipitated by an INFECTION that suppresses erythropoisis (Parvovirus B19) • LOW RETIC COUNT is pathognomonic • Very low H/H • SHOCK |
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|
What are the indications for hospital admission in a neonate with jaundice?
|
• Suspicion of sepsis (ie, jaundice after day 3 of life)
• Bili >= 20 |
|
|
What are the major bacterial pathogens of sinusitis in childhood?
|
• Strep pneumoniae
• Moraxella catarrhalis • Non-typable H flu |
|
|
What are the most common causes of bronchiolitis, in order?
What is the role of respiratory isolation? |
1 RSV
2 Parainfluenza 3 Influenza 4 Adenovirus 5 Rhinovirus Pts with bronchiolitis SHOULD be placed in respiratory isolation to prevent spread |
|
|
What are the most common causes of:
• Bacterial tracheitis • Epiglotittis • Peritonsillar Abscess • Retropharyngeal Abscess? |
Bacterial Tracheitis -- Staph
Epiglotittis: • Strep pneumo • H flu PTA: • Strep PYOGENES • Staph RPA -- Polymicrobial |
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|
What are the symptoms of infantile botulism?
Etiology? |
• Constipation
• Difficulty sucking • Difficulty swallowing • HYPOTONIA Etiology -- HONEY ingestion |
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|
What are the typical symptoms of a 'tet spell' in infants with Tetrology of Fallot?
|
Periods of cyanosis that occur during FEEDING or CRYING
|
|
|
What are the xray findings in Tetralogy of Fallot?
|
Boot-shaped heart
Decreased pulmonary vascular markings |
|
|
What are typical presenting symptoms of neonatal sepsis?
What is rarely seen? |
Typical Presentation:
• Poor feeding • Vomiting • Irritabililty • HYPOthermia RARELY seen: • Bulging fontanelle • Shock • Stiff neck |
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|
What diagnosis should be considered in all children with sx of UNILATERAL wheezing?
|
FB aspiration
|
|
|
What diagnosis should be suspected in a child with recurrent pneumonia in the same location?
|
Aspirated foreign body
|
|
|
What drug is given for meningitis prophylaxis in at risk individuals due to:
• HIB • N. meningitidis • Strep pneumonia? |
HIB -- rifampin
N. meningitidis -- rifampin Strep pneumo -- NONE |
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|
What dx should be suspected in a child with croup who suddenly becomes TOXIC?
Organism? Findings? |
BACTERIAL TRACHEITIS
Organism -- Staph Findings: • STRIDOR • Pseudomembranes and purulent secretions |
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|
What form of IV glucose should be administered to hypoglycemic infants?
Rate? |
D10W: 2-4 ml/kg @ 2 ml/min
|
|
|
What is Legg-Calve-Perthes Disease?
• Epidemiology? • Presentation? • Unilateral or bilateral? • Xray findings? |
LCP disease is osteochondrosis of the femoral head
Epidemiology: • MALE > female • Typically 4 - 9 yo • Usually UNILATERAL Presentation: • Non-toxic • Limp • Hip pain radiating to groin or inner thigh Xray: • Caffey's crescent line -- Subchondral STRESS FX in the femoral head. This then leads to frank osteochondrosis |
|
|
What is one of the most common causes of pediatric acute renal failure?
|
HUS
|
|
|
What is Reye's Syndrome?
What is the typical presentation? What is the mortality rate and means of death? Which med is a predisposing factor? |
Reyes syndrome is a NONinflammatory ENCEPHALOPATHY
PRESENTATION: Viral illness (esp chicken pox, flu) --> Protracted vomiting --> Lethargy, confusion --> Stupor, coma Death: • 15% death rate • Usually due to cerebral HERNIATION Predisposing med -- Aspirin |
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|
What is the age of peak incidence of HUS?
What are the diagnostic findings? |
6 mos - 4 yo
Dx: • Acute renal failure • Microangiopathic hemolytic anemia (schistocytes) • Fever • Thrombocytopenia • GI -- bloody diarrhea from HUS or ETEC |
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|
What is the age of presentation of retropharyngeal abscess? Why?
What is the rate of sx development? |
Age 6 mos - 4 yo
Rare after age 4 b/c repeated URIs have OBLITERATED the retropharyngeal lymph nodes by this age. RPAs evolve INSIDEOUSLY over a few days following a relatively minor URI. |
|
|
What is the causative organism for impetigo and bullous impetigo?
Tx? |
Impetigo:
• GABHS • Mupirocin oint Bullous impetigo: • STAPH • PO abx |
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|
What is the clinical treatment of Tetrology of Fallot 'tet spells'?
|
Stepwise tx:
• Assume Knee-Chest position • O2 • IVF resuscitation • Morphine • alpha-AGONISTS (Phenylephrine) |
|
|
What is the common characteristic of ductal dependent congenital cardiac lesions?
Name the lesions. When do these pts present? Tx? |
Ductal dependent lesions are OUTFLOW tract obstructions
Lesions: • Critical aortic stenosis • Coarctation of the aorta (stenosis) • Hypoplastic left heart syndrome • Tricuspid atresia (closed valve) • Transposition of the great vessels Presentation: • 'Gray baby syndrome' within HOURS to DAYS of delivery Tx -- Prostaglandin E1 (potent ductal dilator) |
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|
What is the consequence of contracting rubella during pregnancy?
What is the risk of neonatal contraction of this disease? |
Neonatal Rubella Syndrome:
• Cataracts • Deafness • Patent ductus arteriosus Risk is 50% in the 1st month of pregnancy, and only 10% in the 3rd month |
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|
What is the definition of bronchiolitis?
Etiology? |
BRONCHIOLITIS -- In children < 2 yo, the clinical syndrome of:
• Wheezing • Chest retractions, and • Tachypnea. Etiology: • RSV (50 - 70% of cases) Also: • Influenza • Parainfluenza • Echovirus • Rhinovirus |
|
|
What is the definition of simple febrile seizure?
|
Definition:
• Age range 6 mos - 5 yo • Sz is associated w/ a fever • No evidence of CNS infection Typical features: • GENERALIZED sz lasting < 15 min • Only 1 sz in a 24 hour period • No post-ictal state or focal neurological deficit |
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|
What is the diffence between breast milk jaundice and breast-feeding jaundice?
Child age at onset? Type of bilirubin? Tx? |
Breast-FEEDING jaundice:
• Occurs in the FIRST WEEK of life • 'Feeding -- First' Breast milk jaundice: • Occurs in the SECOND to third week of life • Develops in 2% of breast-fed infants Both have elevated UNconjugated bilirubin levels Tx: • TEMPORARY witholding of breast milk until the jaudice self-corrects • Phototherapy may be required for bili levels > 18 |
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|
What is the difference in presentation between pediatric peritoneal pain and obstructive abdominal pain (such as with intussusception)?
|
Peritoneal -- Pt remains motionless b/c pain worse with movement
Obstruction -- Pt exhibits restlessness and motion |
|
|
What is the dose of Rocephin in febrile infants in whom meningitis has NOT been ruled out?
|
Rocephin 100 mg/kg, to facilitate CSF drug delivery
|
|
|
What is the epidemiology and etiology of rectal prolapse (procidentia) in kids?
What layer of the bowel wall are involved? |
Epidemiology:
• Under 2 yo • MALE > Female Etiology: • Malnutrition • Cystic fibrosis Involves the bowel MUCOSA only |
|
|
What is the epidemiology of bronchiolitis?
Season predominance? Organism? Presentation? |
Epidemiology:
• 2 mos - 2 yo (2-6 mos most common) • WINTER and SPRING Organism -- RSV Presentation -- RESPIRATORY DISTRESS: • Tachypnea • Nasal flaring • Retractions • Wheezing (often difficult to discern this dz from asthma) • Prolonged expiration |
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|
What is the epidemiology of croup? Season predominance?
Organism? Xray finding? Toxic or non-toxic appearance? Tx? |
Croup:
• 6 mos - 6 yo; peak incidence of 2 yo • Late FALL or early WINTER Organism -- Parainfluenza Xray -- Steeple sign (symmetric SUBglottic narrowing of the trachea) Appearance -- NON-toxic Tx: • Cool mist; oxygen • Hydration • Decadron • Racemic epi for non-responders |
|
|
What is the epidemiology of Kowasaki's Disease?
Which vessels does it primarily affect? Season? |
Epidemiology:
• Peak incidence 1 - 2 yo • 80% of cases < 5 yo • ASIANS (but all races affected) • MALE > female • WINTER and SPRING ('Spring roll') Kowasaki's dz primarily affects the CORONARY arteries |
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|
What is the epidemiology, presentation, and PE findings with pyloric stenosis?
|
Epidemiology:
• 1st born males • Familial Presentation: • SECOND or third week of life (seldom after the 3rd month; usually wks 2-6) • NON-BILIOUS vomiting followed by HUNGRY REFEEDING PE: • 'Olive' near the lateral margin of the right rectus muscle just below the liver edge |
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|
What is the ETIOLOGY and findings of Erythema Infectiosum
(Fifth Disease)? |
Etiology -- Parvovirus B19
Hallmark -- SLAPPED CHEEK appearance Findings: • Erythematous mac-pap rash to trunk and limbs 1-2 days AFTER appearance of facial rash • Central clearing • Rash may recurr after a few weeks [NOTE: Parvovirus B19 also causes Aplastic Crises in sickle cell pts] |
|
|
What is the etiology and presentation of erysipelas?
|
Etiology -- GABHS
Presentation: • Flu-like sx -- Fever, chills, HA, malaise Rash: • 'St Anthony's Fire' • Hot, swollen, confluent erythematous plaque • Sharply demarcated margins Exhibits extensive LYMPHATIC involvement |
|
|
What is the etiology and presentation of Herpangina?
|
Etiology -- Enteroviruses (Coxsackie and Echo)
Presentation: • ACUTE onset with fever to 104° • HA, sore throat, anorexia Rash: • 2 mm vessicles in the POSTERIOR PHARYNX with hyperemic borders --> ulcerate |
|
|
What is the exanthem typically seen in mycoplasma infections?
|
Erythema multiforme
|
|
|
What is the formula for the estimated weight of a child (in kg)?
|
(age x 2) + 8
|
|
|
What is the formula for the low end of systolic BP for a child:
• < 1 month old • 1 month - 1 year • Age 1 - 10 • > 10 yo? |
• < 1 month: 60
• 1 mo - 1 yr: 70 • Age 1-10: 70 + (2 x age) • >= 10 yo: 90 |
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|
What is the formula for the proper ET tube size in a child?
Distance from mid-trachea to incisors? |
ET Tube size:
• (age + 16)/4 Dist from mid-trach to incisors: • (age/2) + 12 |
|
|
What is the incubation period of chickenpox?
Prodrome sx? When does communicability begin? |
Incubation period -- 14-21 days
Prodrome: • Fever • Malaise • Anorexia Communicability: • Begins 5 days BEFORE the appearance of the RASH |
|
|
What is the most common cause of bowel obstruction < 2 yo?
|
Intussusception
|
|
|
What is the most common cause of death in Kowasaki's disease during the ACUTE PHASE (Day 1 - 11)
|
Myocarditis
|
|
|
What is the MOST common cause of death in Kowasaki's Disease?
|
MI secondary to THROMBOTIC OCCLUSION in an aneurysmal or stenotic coronary artery
|
|
|
What is the most common cause of massive lower GI bleed in kids < 2 yo?
|
• Meckel's diverticulum
• Intussusception |
|
|
What is the most common cause of pancreatitis in kids?
Most common infectious cause? |
Most common -- trauma
Infectious -- Mumps |
|
|
What is the most common cause of true hemoptysis in the pediatric population?
|
cystic fibrosis
|
|
|
What is the most common season for the following pediatric pneumonias:
• Parainfluenza • RSV • Influenza? |
Parainfluenza -- FALL
RSV -- WINTER Influenza -- SPRING |
|
|
What is the most common VIRAL cause of otitis media?
|
RSV
|
|
|
What is the most feared complication of DKA treatment in kids?
|
CEREBRAL EDEMA
This is almost exclusively a complication of pediatric DKA |
|
|
What is the most frequent cause of acquired pediatric cardiac disease in the US?
|
Kowasaki's disease
|
|
|
What is the most frequent etiology of infectious conjunctivitis in neonates?
Young child? |
Neonate -- Chlamydia trachomatis
Child: • Adenoviruses • Hemophilus species |
|
|
What is the most frequent sign of pneumonia in children?
How many breaths per minute can fever increase an infant's respiratory rate per degree celcius? |
Tachypnea
Fever -- 10 resp increase per 1° C |
|
|
What is the most serious complication of Bordetella pertussis in infants?
Tx? |
APNEA --> hypoxia, death
• Admit all infants to the ICU Tx -- macrolide |
|
|
What is the optimal 1st, 2nd and 3rd line agents in the tx of seizures in adults and children?
|
Adults:
• 1 -- Benzos • 2 -- Dilantin • 3 -- Phenobarb Kids: • 1 -- Benzos • 2 -- Phenobarb • 3 -- Dilantin |
|
|
What is the presentation of Listeria monocytogenes infection AFTER the neonatal period?
Source of infection? |
Presentation -- typically bacteremia or sepsis
Mode of transmission: • Soft cheeses • Deli meats • Vegetable products |
|
|
What is the relationship between Prostaglandin E1 and Indomethacin with respect to pediatric heart conditions?
Side effects? |
PG-E1 PREVENTS closure of the ductus arteriosus. Side effects:
• HoTN • Apnea Indomethacin CLOSES the ductus arteriosus |
|
|
What is the risk of bacteremia and Serious Bacterial Infection in neonates (0 - 28 days) with fever?
Which organisms? |
Risk of bacteremia -- 5%
Risk of SBI -- 15% Organisms -- pathogens encountered during the birthing process: • GBS • E coli • Listeria |
|
|
What is the role of abx prophylaxis of Lyme disease in kids with tick bites?
|
Prophylaxis is not recommended after tick bites, even in endemic areas, except perhaps:
• Pregnant patients • Prolonged tick attachment in small children |
|
|
What is the role of racemic epi, nebs, and steroids in infants with bronchiolitis?
|
Racemic Epi -- the mainstay of tx for WHEEZING
• 0.5 cc in 3.5 cc of NS (= 0.1% soln) • Continue to use if there is improvement after the first dose, o/w of no use Albuterol & Atrovent -- limited role. Inferior to racemic epi Steroids -- no benefit |
|
|
What is the role of steroids in the treatment of meningitis in children > 1 month old?
Adults? |
Steroids DECREASE the incidence of neurologic complications due to:
• HIB Steroids DO NOT improve, and actually may worsen, meningitis due to: • Strep pneumo • N. meningitidis in Peds pts ADULTS -- benefit seen in both: • HIB • Pneumococcal meningitis |
|
|
What is the significance of retinal hemorrhage in neonates?
|
Almost 1/2 of all neonates delivered vaginally have retinal hemorrhage.
Resolution occurs in 1 month. Retinal hemorrhage after 1 mos indicate child abuse. |
|
|
What is the specific treatment for hospitalized infants with RSV (bronchiolitis)?
|
Aerosolized RIBAVIRIN
|
|
|
What is the treatment of Henoch-Schonlein Purpura?
|
• Hydration +
• Steroids and • IVIG to prevent glomerulonephritis in severe cases |
|
|
What is the treatment of Kowasaki's disease?
What med is contra-indicated, and why? |
Tx:
• IV gamma globulin • ASPIRIN Contraindicated -- STEROIDS (may increase the risk of coronary aneurism rupture) |
|
|
What is the tx of HUS?
|
Mild cases:
• Supportive More severe: • STEROIDS may be beneficial • PLASMAPHERESIS may help • Hemodialysis may be necessary for severe renal failure Overall, HUS has low mortality |
|
|
What is the typical newborn weight loss over the first 3 days of life?
When is this weight regained? |
5 - 10% weight loss in the 1st 3 days
Birth weight regained by day 10 |
|
|
What is the typical presentation of Meckel's diverticulum?
|
PAINLESS rectal bleeding in a 2 yo
Meckel's is the most common cause of substantial GI bleeding in children |
|
|
What is the typical tenderness elicited on PE in patients < 2 yo with appendicitis?
What is the rate of evidence of perforation noted intraoperatively in appy patients < 3 yo? |
Pts < 2 yo typically have DIFFUSE TTP
ALMOST ALL pts < 3 yo with appendicitis have evidence of perforation at surgery |
|
|
What is the window of opportunity for giving Prostaglandin E1 in cyanotic babies with presumed cardiac anomalies?
Downside to giving PGE1? |
6 weeks
No downside! You will never be faulted for giving PGE1. |
|
|
What is transient (toxic) synovitis?
• Epidemiology? • Presentation? • Joint fluid analysis? |
NON-SPECIFIC INFLAMMATION of the synovium of the hip, often FOLLOWING a VIRAL ILLNESS
Epidemiology: • 18 mos - 12 yo (usually 5-6 yo) • MALE > female Presentation: • Limp or inability to bear weight • Hip, knee or thigh pain Joint fluid: • 5000 - 15000 WBC • PMN < 25% Note: this condition a DIAGNOSIS OF EXCLUSION. Must first r/o septic joint. |
|
|
What neonatal conditions are associated with maternal use of SULFA drugs in the THIRD trimester?
|
Hyperbilirubinemia
Kernicterus Hemolysis |
|
|
What organism is primarily responsible for tinea capitis, and what is the treatment?
|
Trichophyton tonsurans
Oral GRISEOFULVIN is required Note: Trichophyton is responsible for most dermatophyte infections in general |
|
|
What organisms are most commonly associated with bacteremia in children 3 - 36 months of age?
• Overall • Pyelo • Gastro • Osteo |
Overall:
1) Strep pneumoniae -- accounts for > 80% of all cases of Occult Bacteremia 2) Neisseria meningitidis Pyelonephritis -- E coli Gastroenteritis -- Salmonella Osteo -- Staph aur |
|
|
What percent of children with asthma will outgrow the dz by adulthood?
|
50%
|
|
|
What percent of intussusceptions occur in children and adults?
Which cohort is more likely to have an identifiable abnormality causing the intussusception? |
Adults -- 5%
Children -- 95% Indentifiable abnormality: • Children -- 2-8% • Adults -- 95% (75% are NEOPLASMS) |
|
|
What percent of untreated children with Kowasaki's Disease will develop coronary artery aneurysms?
|
20 - 30%
|
|
|
What prenatal tests are used to predict:
• Fetal lung maturity • Premature delivery |
Fetal LUNG maturity:
• Lecithin-to-sphingomyelin ratio Fetal PREMATURITY: • Fetal fibronectin test |
|
|
What workup does the febrile infant with high temperature with documented RSV bronchiolitis require?
|
WORKUP for occult bacteremia (including blood cxs) is NOT NECESSARY unless the child looks SEPTIC
|
|
|
Where are Koplik spots located in pts with measles?
|
On the BUCCAL mucosa opposite the 2nd molar
|
|
|
Which antibiotic is implicated in a diffuse truncal morbilliform rash in the setting of pharyngitis?
Why? |
Ampicillin (also amoxicillin)
in patients with infectious MONONUCLEOSIS, ampicillin causes this rash |
|
|
Which pneumonia is notorious for being particularly rapid in onset and progression of sx?
|
Staph aureus
|
|
|
Why do children in the catarrhal phase of pertussis present with dehydration?
|
Because their severe, frequent, paroxysmal cough often prevents eating and drinking
|
|
|
Compare the sensitivity and specificity of spiral CT and VQ scan in the dx of PE
|
CT and HIGH PROBABILITY VQ have similar SPECIFICITY for PE (93% & 98%)
CT and LOW PROBABILITY VQ have similar SENSITIVITY for PE (78% & 82%) However, a negative CT is not considered as sensitive as a normal VQ |
|
|
Define Immersion Syndrome
|
Sudden death after submersion in very cold water, presumably due to vagally-mediated asystole or Vfib
|
|
|
Define when a patient is said to be suffering from ARDS
|
• PERMEABILITY pulmonary edema + • Reduced lung COMPLIANCE (ie, high airway resistance on vent) + • Severe HYPOXIA refractory to supplemental O2 |
|
|
Describe some signs and symptoms of extrapulmonary TB
|
TB Meningitis
Genitourinary TB: • Dysuria with WBCs but W/O bacteria Pleural TB (EXUDATIVE effusion) Miliary (disseminated) TB: • Sx depend on the location of the lesions • CXR -- small NODULAR densities uniformly distributed throughout both lung fields |
|
|
Describe the circuitous, self-sustaining mechanism of ARDS that frequently leads to irreversible pulmonary fibrosis if the inciting event is not controlled
|
Insult ==>
• Inflammatory response (Enzyme cascade: complement system, coagulation pathways) --> • Microvascular (MV) damage --> • INCREASED PERMEABILITY of the MV membrane --> surfactant inactivated --> • Protein and fluid flux into the lung + DECREASED lung COMPLIANCE --> |
|
|
Describe the CXR findings in CMV pneumonia
|
• Bilateral interstitial or reticulonodular infiltrates
• Begins in the PERIPHERY of the lower lobes and spreads centrally and superiorly |
|
|
Describe the CXR findings in PCP pneumonia.
The degree of elevation of what lab is prognostic of the disease course? |
CXR:
• Bilateral diffuse interstitial or alveolar infiltrates • Begin in perihilar region; extend in a BATTLEWING pattern • May see SPONTANEOUS PNEUMO Lab -- Increased LDH. The higher the LDH, the worse the prognosis |
|
|
Describe the CXR findings of Klebsiella pneumonia
|
• UPPER lobe infiltrate or abscess formation
• Bulging minor fissure (35%) |
|
|
Describe the CXR findings of Staph aureus pneumonia
|
• Patchy infiltrate that is initially multicentric or peripheral
• ABSCESSES common |
|
|
Describe the CXR findings of Strep pneumo pneumonia
|
Single lobar infiltrate in the LLL, RLL, or RML
|
|
|
Describe the etiology and clinical picture of Chlamydial pneumonia.
Lab? Diagnostic test? Tx? |
Etiology:
• Common cause of atypical pneumonia in young adults (CLUSTERS) • Spread person-to-person by droplet transmission Clinical picture: • Dry, STACATTO cough • Pharyngitis, HA, myalgias Lab -- EOSINOPHILIA Dx -- Nasopharyngeal cx or serology Tx -- Macrolide, doxy |
|
|
Describe the mechanism of action of ß-agonists and anticholinergic agents (eg, ipratropium) in asthma. Which size airways do each act upon?
|
ß-Agonists:
• Primary effect is on the SMALL airways • Promote bronchodilation by increasing cAMP Anticholinergics: • Primary effect is on the LARGE airways • Inhibit VAGALLY-mediated bronchoconstriction --> decreases cGMP --> bronchodilation |
|
|
Describe the pathophysiology of TB
|
• Bacilli phagocytized by alveolar macrophages -->
• TB proliferates in these cells to form the primary focus of infxn (Ghon complex) in lower lobes --> • Can spread thru lymphatics and blood to distant sites Most common distant sites: • Upper lobes of lungs • Bone • Kidney • Brain >90% of pts are asx. Reactivation occurs in the immunocompromised. |
|
|
Describe the relationship of cold agglutin titers and complement-fixing Ab titers in the diagnosis of Mycoplasma pneumonia
|
Cold agglutin titers:
• Elevated in up to 60% of pts • Neither sensitive nor specific for the dx Complement-fixing Ab titers: • A 4-FOLD increase is DIAGNOSTIC • An initial titer > 1:64 is very suggestive |
|
|
Describe the sxs of fat emboli.
When are sx typically seen? Labs? Urine? Tx? |
Emboli pass THROUGH the lung -->
See: • Typical SYSTEMIC emboli sequalae • THROBOCYTOPENIA • Petichiae on the UPPER BODY • Often leads to ARDS • Sx seen after 1 - 3 DAYS • May see FAT GLOBULES in the URINE Tx -- primarily supportive |
|
|
Describe the typical clinical picture of a pt with Mycoplasma pneumonia
|
• 3 < age < 40
• Dry cough • Fever, chills, HA, malaise, URI sxs • Conjunctivitis • Pharyngitis • BULLOUS MYRINGITIS |
|
|
Describe the typical clinical picture of a pt with Strep pneumo pneumonia
|
• Acutely ill
• Abrupt onset • SINGLE acute SHAKING CHILL • Cough productive of RUST-colored or green sputum • Tachypnea and tachycardia • Sharp chest pain with marked splinting on the affected side |
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|
Discuss the evolution with time of the CXR in pts with aspiration pneumonia
|
• Radiographic changes are delayed with respect to signs and sxs
• ATELECTASIS -- Earliest finding • INFILTRATE -- After 6-12 hrs • Infiltrate may be mistaken for pulmonary edema |
|
|
Exposure to which chemicals can cause sulfhemoglobinemia?
What is the treatment? |
• Phenacetin
• Acetanilid Treatment -- supportive. Sulfhemoglobinemia is IRREVERSIBLE |
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|
How are fat emboli different from venous thromboemboli?
|
FAT emboli PASS THROUGH the lung and enter the arterial circulation
Venous emboli LODGE in the lung |
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|
How are PNEUMONIC plague and BUBONIC plague transmitted?
Organism? |
Pneumonic plague:
• Inhalation of infected droppings from rodents and HUMANS Bubonic plague: • Enters the skin from a FLEA BITE Caused by Yersinia pestis |
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|
How does Klebsiella pneumonia typically present?
Sputum appearance? |
• SUDDEN onset of cough followed by MULTIPLE (as opposed to Strep pneumo) shaking chills
• Pleuritic chest pain • Thick 'CURRANT JELLY' sputum • Cyanosis |
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|
How does the pH of pleural fluid help determine the etiology of the effusion?
What is the treatment of empyema? |
Nl pleural pH: 7.65
pH < 7.0 -- empyema pH < 6.0 -- esophageal rupture CHEST TUBE is mandatory for empyema; it must be drained as soon as possible |
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|
How is the dx of PCP pneumonia made?
|
Bronchoalveolar lavage
PCP CANNOT be cultured! |
|
|
How is the PCWP, FiO2 and PAO2 used to diagnose ARDS?
Acute lung injury? |
ARDS:
• PCWP </= 18 (indicates NON-cardiogenic pulmonary edema) • PAO2:FiO2 </= 200 Acute lung injury: • PAO2:FiO2 </= 300 Note: • In this calculation, FiO2 is expressed as a decimal (ie, 0.5) |
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|
How long does it take for steroids to exert an effect on pulmonary mechanics when given for, say, acute asthma exacerbation?
Is outpatient tapering required? |
Steroids take 6 - 24 hours to exert an effect
NO NEED TO TAPER outpatient steroid therapy unless the pt is taking chronic oral steroids |
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|
In general, what type of infection is linezolid (Zyvox) used to treat?
|
Linezolid is generally restricted to the tx of VANCOMYCIN-RESISTANT infections
|
|
|
In HIV pts, which type of pneumonia is most likely with:
CD4 > 800 CD4 between 250 - 500 CD4 < 200? |
CD4 > 800:
• Bacterial pneumonia CD4 250 - 500: • TB • Cryptococcus • Histoplasmosis CD4 < 200: • PCP |
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|
In ventilator management, which is a better gauge of alveolar pressure, peak pressure or plateau pressure?
Why? |
PLATEAU pressure
Most of the pressure during the inspiratory cycle is absorbed by the medium-sized bronchi and not the alveoli. There is little risk of barotrauma to the ALVEOLI with high peak pressures as long as the PLATEAU pressure is acceptable. |
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|
In which cohort of patients is a MILIARY pattern of TB most like to be seen?
|
• Extremes of age
• Immunocompromised |
|
|
In which cohort of patients is H flu pneumonia most common?
|
• Elderly or debilitated
• Diabetic • Alcoholic • Immunocompromised |
|
|
In which cohort of TB patients is a large unilateral pleural effusion most likely to be seen?
|
The ELDERLY
|
|
|
Is PEEP required in ventilator patients with acute asthma?
|
No. Asthma pts exhibit intrinsic air trapping which generates auto-PEEP.
|
|
|
Name several causes of EXUDATIVE pleural effusion
|
• RA
• SLE • Sarcoidosis (trans or exudative) • Bacterial pneumonia • TB • Dressler's syndrome • PE (trans or exudative) • Lung infarct • Pancreatitis • Esophageal rupture • Malignancy |
|
|
Name several causes of pleural TRANSUDATES
|
Cardiac:
• Constrictive pericarditis • CHF (most common cause of effusion) • Sarcoidosis (both trans and exudative) Renal: • Nephrotic syndrome • Peritoneal dialysis GI: • Cirrhosis Heme: • Hypoalbuminemia |
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|
Name several drugs that are associated with ARDS
|
'COASTal Calif Hwy '
• Cyclosporin • Opiates • AMIODARONE • Salicylates • TCA • Chemo agents • HCTZ |
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|
Name the 5 mechanisms that result in hypoxemia
|
• Hypoventilation
• Low inspired O2 content • R --> L shunt • V-Q mismatch • Diffusion impairment |
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|
Of the 5 mechanisms of hypoxemia, hypoxemia improves w/ supplemental O2 for all EXCEPT which one?
Etiology? |
The hallmark of R --> L SHUNT is failure to increase O2 content with supplemental O2
Common causes of Shunt: • Pulmonary consolidation • Pulmonary atelectasis • ARDS • Vascular malformations |
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|
Of the 5 mechanisms of hypoxemia, which cause an increase in the A-a gradient?
|
Increase the gradient:
• R --> L shunt • V-Q mismatch • Diffusion impairment Hypoventilation and decreased inspired O2 do not affect the gradient |
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|
Of the fungal mycoses, which is most likely to cause disseminated disease?
What geographic location is this organism found? |
Blastomyces ('Blastomyces blasts throughout the body')
Endemic to the Mississippi and Ohio river valleys |
|
|
State several risk factors for death from asthma
|
• 1 prior ICU admission
• 2 or more ADMISSIONS in past year • 3 or more ED visits in past year • Use of 2 or more ß-AGONIST cannisters in past month • Current or recent STEROID use |
|
|
State the causes of central and peripheral cyanosis
|
Central:
• Shunt • V/Q mismatch • Methemoglobinemia • Sulfhemoglobinemia • Cyanide Peripheral: • Low cardiac output • Arterial or venous obstruction • Cold extremities |
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|
State the common side effects of the following TB drugs:
• Pyrazinamide • Rifampin • Ethambutol • Streptomycin |
PZA:
• Hepatitis • Hyperuricemia RIF: • Hepatitis • ARF • Hemolysis • Thrombocytopenia • ORANGE DISCOLORATION of tears, urine, saliva EMB: • Optic/ retrobulbar neuritis • Visual field loss Streptomycin: • CN VIII palsy |
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|
State the treatment for each of the following pneumonias:
• Chlamydial • Psittacosis • Q Fever • Legionaire's • Tularemia • CMV • Hantavirus • PCP |
• Chlamydial -- Tetracycline, emycin or doxy (''Ted')
• Psittacosis -- Tetracycline ('PT') • Q Fever -- Tetracycline, chloramphenicol, doxy ('QTc Dr') • Legionaire's -- advanced macrolide • Tularemia -- Streptomycin ('TS eliott') • PCP -- Bactrim; Pentamidine vs Primaquine + Clinda. Steroids for mod to advanced dz ('PCP for PCP') • CMV -- IV gangcyclovir or foscarnet. Ig for bone marrow recipients. • Hantavirus -- IV ribavarin ('Rodent -- Ribavarin'') |
|
|
What 3 discrete infections does parainfluenza virus cause in children?
|
• Pneumonia
• Croup • Bronchitis |
|
|
What adverse signs should be watched for when increasing PEEP in ARDS pts?
|
Increased PEEP -->
• Decreased venous return --> • Decreased CO and O2 delivery |
|
|
What are some complications of Mycoplasma pneumonia?
|
• Aseptic meningitis
• Guillain-Barre • Glomerulonephritis • CHF • Myocarditis • Erythema multiforme • Erythema nodosum • Hemolytic anemia |
|
|
What are the 1st, 2nd and 3rd most common causes of pleural effusions?
|
#1: CHF
#2: Bacterial pneumonia,TB #3: Malignancy |
|
|
What are the 3 stages of Bordetella pertussis?
Fever? What is the treatment? When are cultures most useful? CBC? |
CATARRHAL phase:
• Non-specific URI-like sxs • Lasts 1-2 weeks • Abx (MACROLIDES) only effective in this stage • Cx only useful in this phase • If significant FEVER is present, look for ANOTHER DX! PAROXYSMAL phase: • Coughing FITS, worse at NIGHT • Associated with POST-TUSSIVE emesis • INFANTS may have severe APNEIC/ choking spells, and dehydration (consider ICU) • Lasts from 1 - 6 weeks CONVALESCENT phase: • CHRONIC, intermittent cough • Lasts several months Adjunctive tx: • ß-agonists • Steroids CBC -- May see VERY HIGH WBC |
|
|
What are the abx of choice for Staph aureus pneumonia?
|
IV oxacillin or nafcillin
|
|
|
What are the cardiovascular effects of NIPPV?
|
NIPPV increases intrathoracic pressure -->
• Decreases preload --> • Decreases afterload --> • Improves cardiac output |
|
|
What are the CDC guidelines for the evaluation and tx of acute pharyngitis?
|
Centor Criteria:
• Fever • Absence of cough • Swollen, tender anterior cervical LAD • Tonsillar exudate Score of 3 or more -- Rapid strep test, or tx presumptively Score of 2 -- Rapid strep test, or do not tx or test Score of 0 or 1 -- Do not tx or test |
|
|
What are the clinical clues to the dx of pulmonary TB?
|
• High fever
• Night sweats • Cough (dry --> productive) • HEMOPTYSIS |
|
|
What are the clinical findings of RSV pneumonia in children? How is it treated?
Most common in which season? |
• Cough
• Coryza • Fever Tx: • Primarily supportive • Albuterol nebs • Ribavirin may be used WINTER and SPRING predominance |
|
|
What are the CXR findings in ARDS?
Heart size? |
DIFFUSE bilateral interstitial and alveolar infiltrates with a NORMAL sized heart (ie, non-cardiogenic pulmonary edema)
|
|
|
What are the CXR findings of Influenza?
|
NORMAL CXR
|
|
|
What are the lab and CXR findings of Legionella Pneumonia?
What is the treatment? |
Lab:
• High WBC • High PMNs, NO ORGANISMS • Elevated LFTs • Low Na (<130) • Proteinuria CXR: • Unilateral patchy infiltrate in LL --> consolidation • Pleural effusion Tx -- Advanced MACROLIDE |
|
|
What are the most common bacterial isolates for the following pneumonias:
• CAP • Nosocomial aspiration? |
CAP aspiration:
• STREP species • Staph • H flu Nosocomial aspiration: • Gram-negative bacilli (including Pseudomonas) • Staph aureus |
|
|
What are the most common lung locations for aspiration pneumonia?
|
Recumbent aspiration:
• POSTERIOR segment of the UPPER lobes • SUPERIOR segment of the LOWER lobes Upright aspiration: • Right lower lobe |
|
|
What are the most commonly implicated organisms in respiratory infection in COPD pts?
|
• Strep pneumonia
• H flu • Moraxella |
|
|
What are the risk factors for Primary (idiopathic) Spontaneous Pneumothorax?
|
• Marfan's Syndrome
• Male 3x > Female • MVP • SMOKING |
|
|
What are the risk factors for, and consequences of, pneumonia in pregnancy?
|
Risk factors for pneumonia:
• Anemia • Asthma Consequences of pneumonia: • Preterm labor and/or delivery • Low birthweight infant |
|
|
What are the signs and symptoms of Psittacosis pneumonia?
What are the lab and CXR findings? |
• High fever ( up to 105)
• Severe HA, often the MAJOR C/O • Flu-like syndrome • Hepatosplenomegaly • LeukoPENIA ('Birds fly high, WBCs fly low') • Proteinuria • Elevated LFT • Elevated complement fixation Ab titer • Patchy perihilar or lower lobe infiltrates |
|
|
What are the signs and symptoms that help distinguish bronchitis from pneumonia?
|
Productive cough and purulent sputum are found in BOTH bronchitis and pneumonia
Pneumonia: • Fever > 100.4 • HR > 100 • R > 24 • Pleuritic chest pain • Focal lung findings • ABSENCE of rhinorrhea and sore throat |
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|
What are the sx of INHALATIONAL anthrax?
Rate of progression? Tx? Mortality improvement w/ tx? |
Begins as a FLU-LIKE illness that deteriorates into SEPTIC SHOCK and RESPIRATORY FAILURE w/in 24 - 48 hrs of sx onset
Tx: • Cipro • Doxy • Pen G Mortality rate is 90%. Tx decreases mortality by up to 50%. |
|
|
What are the two most common causes of ARDS (account for over 50% of all cases)?
|
#1: Sepsis, especially Gram-negative sepsis
#2: Aspiration |
|
|
What are the tx options for small (<15-20%), atraumatic, minimally symptomatic pneumothoraces in otherwise healthy individuals?
|
Inpt vs Outpt observation
Consider repeat CXR in ED in 6 hrs. If pneumo unchanged, may d/c to home with instructions for repeat CXR in 24 hrs |
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|
What class of medicines may be used to reduce PAWP in ARDS pts?
Which should be avoided? Why? |
Use diuretics
AVOID vasodilators which can increase pulmonary shunting |
|
|
What CXR view can assist in the diagnosis of pneumothorax?
|
Full expiration view
: |
|
|
What does the A-a Gradient measure?
What is the formula for calculating the A-a Gradient? What is a normal A-a Gradient value? How must the A-a gradient must be measured? |
The A-a gradient measures how well alveolar O2 is transferred from the lungs to the circulation.
A-a Gradient = 145 - PaCO2 - PaO2 A normal A-a gradient is under 10 mm Hg. The gradient increases with age (age/4 + 4). Note: the A-a gradient must be measured in the UPRIGHT position! The gradient increases if taken supine. |
|
|
What dysrhythmias and EKG findings are VERY commonly associated with COPD pts?
|
Multifocal Atrial Tachycardia (COPD is the most common cause)
Afib P pulmonale: • Peaked P waves (> 2.5 mm) in II, III and aVF The 'Rs' ('COPD-'R'): • RAD • RBBB • Poor R wave progression Low voltage |
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|
What electrolyte abnormalities are associated with repeated ß-agonist use in asthma?
Mechanism? |
• Hypokalemia
• Hypomagnesemia • Hypophosphatemia Mechanism -- Intracellular shift |
|
|
What endotracheal cuff type can help reduce the incidence of aspiration?
|
High volume, Low pressure
|
|
|
What factors point to a dx of uncomplicated acute bronchitis vs pneumonia?
|
Bronchitis:
• Acute cough less than 1 - 2 weeks (the cough is often productive) • No prior lung dz • No auscultatory findings c/w pneumonia • Associated URI sx w/ above findings |
|
|
What geographic location is Coccidioides imitis found?
Cryptococcus? |
Coccidioides -- In the arid SOUTHWEST
Cryptococcus -- ubiquitous throughout the WORLD |
|
|
What is a common source of false-negative spiral CT findings in the dx of PE?
|
SUBSEGMENTAL PEs
|
|
|
What is required for the dx of ACTIVE TB?
|
Positive sputum AFB x 3
|
|
|
What is the approach to initial vent settings in pts intubated for severe asthma exacerbation?
|
Permissive Hypercapnia
• This technique increases the time of expiration to minimize air trapping Initial vent settings: • Volume-cycled • TV 6 - 8 ml/kg • R 8 - 10 • Inspiratory flow rate 60 L/min • If PIP exceeds 50 cm H20, switch to pressure-controlled ventilation |
|
|
What is the classic physical exam finding with mucormycosis (zygomycosis)?
What is the etiology of this finding? |
Necrotic, BLACK appearing mucosa
Mechanism: • Rapid invasion of vasculature with subsequent INFARCTION of affected tissues. |
|
|
What is the clinical picture of Q Fever Pneumonia?
Lab findings? How is it treated? |
• Pt looks ill
• High fever, shaking chills • Severe HA • Non-productive cough Lab: • Elevated LFTs • Proteinuria • Pt develops HEPATITIS ('HQ -- Headquarters') Tx; • Tetracycline or • Chloramphenicol or • Doxy ('QTc' d') |
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|
What is the clinical picture of Tularemia pneumonia?
Mortality rate? Tx? |
• High fever (104 - 106)
• Shaking chills • Nonproductive cough • Hepatosplenomegaly • Maculopapular RASH ('Tick causes rash') Mortality rate is 5-30% without abx tx Drug of choice -- Streptomycin |
|
|
What is the criteria for a positive PPD test?
What can cause a false positive PPD? |
• >= 5 mm for HIV pts
• >= 10 mm for nursing home pts, IVDU • >= 15 mm in healthy people False positive -- can be from infxn with non-tuberculous mycobacterium |
|
|
What is the definition of massive hemoptysis?
|
• > 50 cc in a single expectorant, or
• Hemptysis in the ED > 100 ml, or • > 600 cc/ 24 hrs, or • Blood transfusion required |
|
|
What is the difference between a pleural transudate and exudate?
What is the criteria for classifying a pleural effusion as EXUDATIVE? |
• Transudate -- from excessive hydrostatic pressure (CHF) or low serum protein concentration
• Exudate -- from lymphatic blockage or pleural capillary damage Exudate (one or more): • Pleural/ serum protein > 0.5 • Pleural/ serum LDH > 0.6 • Pleural LDH > 200 • Pleural cholesterol > 60 |
|
|
What is the difference in rate of onset of xray findings in pulmonary contusion vs ARDS?
|
Pulmonary contusion :
• CXR findings within 6 hours • Findings localized to the side of injury ARDS: • Findings delayed, usually 24 - 72 hours post-injury • Findings are diffuse on CXR |
|
|
What is the difference in treatment for CMV pneumonia in AIDS and transplant recipients?
|
• For both groups, IV gangciclovir or foscarnet
• BONE MARROW recipients also receive IMMUNOGLOBULIN |
|
|
What is the earliest CXR finding in pts with cystic fibrosis?
|
Hyperinflation
|
|
|
What is the etiologic agent suggested by pneumonia accompanied by a SINGLE rigor?
|
STREP PNEUMONIAE
|
|
|
What is the etiology and clinical picture of Legionella Pneumonia?
|
Etiology:
• Found in water systems • Season: summer/fall • COPDers, debililtated most affected Pulmonary: • BAD FLU SX: high fever, rigors, HA, myalgias • Dry --> productive cough • Pleuritic chest pain GI: • N/V/D/ ABD PAIN Neuro: • Altered MS • Gait disturbance • Seizures Clinical clues: • Failure to respond to ß-lactams/ ceph/ gent • Onset w/in 10 days of hospital d/c |
|
|
What is the etiology of Hantavirus pneumonia?
Describe the clinical picture, CXR, and tx. |
Etiology:
• Inhalation of RODENT urine and feces Clinical picture: • Prodrome of fever, myalgia, malaise • Evolves into severe respiratory distress and SHOCK CXR -- bilateral interstitial infiltrates Tx -- supportive and IV ribavirin ('RODENT -- ribavirin') |
|
|
What is the etiology of Psittacosis? Treatment?
|
Inhalation of infected BIRD droplets
Tx -- tetracycline |
|
|
What is the etiology of Q Fever Pneumonia?
Organism? Who is most susceptible? Organism survival characteristics? |
Organism -- Coxiella burnetii
Etiology -- inhalation of infected feces, placenta and uterine excretions of sheep, goats, CATTLE, cats Slaughterhouse workers and dairy farmers are most commonly affected Can survive for 18 - 42 months in dried soil and milk |
|
|
What is the etiology of Tularemia Pneumonia?
What are the different forms of the dz? |
Harbored in hard TICKS, wild RABBITS, and cats
• ULCEROglandular (skin -- most common) • Oculoglandular • Oropharyngeal |
|
|
What is the hallmark of ARDS?
|
Severe hypoxia that is unresponsive to increased concentrations of inspired O2
|
|
|
What is the hallmark of Mycoplasma pneumonia infection?
|
The hallmark is the DISPARITY between the clinically benign appearance of the pt and the extensive CXR findings
|
|
|
What is the hallmark of primary TB in children?
|
Marked BILATERAL hilar adenopathy
|
|
|
What is the incidence of TB in HIV-infected pts?
|
TB approaches 60%
|
|
|
What is the initial 4 drug regimine for active TB?
What prophylactic medicine must be given with INH to prevent INH-induced neuropathy? |
• INH
• Rifampin (RIF) • Pyrazinamide (PZA) • Ethambutol (EMB) Must give B6 with INH it to prevent INH-induced neuropathy |
|
|
What is the microbiological shape of H influenza?
|
Gram negative pleomorphic ROD. Exists in both encapsulated and unencapsulated types
|
|
|
What is the microbiological shape of Klebsiella pneumoniae?
|
Gram negative encapsulated bacillus that occurs in pairs. Short and plump.
|
|
|
What is the microbiological shape of Staph aureus?
|
Large gram-positive cocci in pairs and clusters
|
|
|
What is the microbiological shape of Strep pneumoniae?
|
Gram positive LANCET-shaped encapsulated DIPLOCOCCUS
|
|
|
What is the most common cause of bacterial pneumonia?
What is the second most common? What season is the peak incidence? |
#1: Strep pneumoniae
#2: H flu Peak incidence: winter/early spring Strep pneumo is responsible for 60 - 90% of all bacterial pneumonias |
|
|
What is the most common cause of death in solid-organ transplant recipients?
What about in the first 6 months? |
INFECTION is the most common cause of death overall
1st 6 mos: • CMV, especially CMV pneumonitis |
|
|
What is the most common cause of hemoptysis?
Of massive hemoptysis? |
Most common cause:
• Infection --> BRONCHITIS Massive hemoptysis: • Bronchiectasis • TB • Lung abscess • Neoplasm (esp. bronchogenic CA) CHF can also cause hemoptysis |
|
|
What is the most common cause of pleural effusions in 1) developed and 2) undeveloped countries?
|
Developed -- CHF
Undeveloped -- TB |
|
|
What is the most common cause of spontaneous pneumothorax in AIDS pts?
|
PCP pneumonia
|
|
|
What is the most common cause of viral pneumonia in adults?
What is its association with bacterial pneumonia? |
Influenza
80% of adults will get an associated bacterial pneumonia with the flu, typically staph aureus |
|
|
What is the most common CXR finding in pulmonary embolism?
|
Elevation of the hemidiaphragm
Seen in 50% of pts |
|
|
What is the most common etiology of pneumonia in:
• Newborns (0 - 1 mos) • 3 wks - 3 mos • 3 mos - 5 yo • 5 - 15 yo? |
Newborns (0 - 1 mos):
1) GBS 2) E coli 3) Klebsiella Also -- Listeria NOTE: The newborn age is the only age where BACTERIAL agents are MORE COMMON than viral agents 3 wks - 3 mos: • Chlamydia TRACHOMATIS 3 mos - 5 yo: VIRAL: 1) RSV 2) Parainfluenza 3) Influenza 4) Adenovirus 5) Rhinovirus Also, Strep pneumo 5 - 15 yo: ATYPICALS: • Mycoplasma • Chlamydia pneumoniae Also, Strep pneumo |
|
|
What is the most common pathogen in patients with cystic fibrosis?
What is the most common isolate(s) in NEWLY DX'D individuals? Any other pathogens? |
PSEUDOMONAS
97% of CF pts are colonized with Pseudomonas by age 3 Newly Dx'd: • Staph • H FLU ASPERGILLUS fumigatus is also found |
|
|
What is the most common pulmonary infection worldwide?
What are the symptoms? |
Histoplasma capsulatum
Sxs: • ASYMPTOMATIC • 80-90% prevalence by age 20 in endemic areas |
|
|
What is the most common viral and bacterial cause of rhabdomyolysis?
|
Viral -- Influenza
Bacterial -- Legionella |
|
|
What is the most common xray finding in suspected aspiration of a foreign body in a child?
|
HYPERINFLATION of the affected lung with expiration
|
|
|
What is the most common xray finding with PRIMARY TB?
Reactivation TB? |
Primary TB:
• Lobar pneumonia + • Hilar adenopathy Reactivation TB: • Lesions in the APICAL and POSTERIOR segments of the UPPER lung |
|
|
What is the most effective xray position to view a pleural effusion?
How much fluid must be present to be detected on CXR? |
Lateral decubitus -- 5-50 cc of fluid can be detected
PA/ lat -- 200+ cc required for detection |
|
|
What is the most sensative and specific test for Legionella?
|
URINE antigen testing
|
|
|
What is the most serious complication of varicella (chickenpox) infection in adults?
|
Varicella pneumonia
|
|
|
What is the number one cause of bacterial pneumonia is HIV patients?
|
Strep pneumo
|
|
|
What is the primary risk factor for developing lung abscesses?
|
Any patient who is at risk for ASPIRATION is at risk for developing a lung abscess
Pts w/ POOR ORAL HYGIENE are at particular risk |
|
|
What is the rate of reabsorption of intrapleural air per day?
|
1.25% per day, increased with administration of 100% O2
|
|
|
What is the role of abx and steroids in the treatment of near-drowning victims?
|
Abx and steroids have NO ROLE in the tx of near-drowning
|
|
|
What is the specific CXR finding in 75% of patients with lung abscesses?
Why? |
75% of the time the abscess communicates with a BRONCHIOLE. Will see:
• Cavitary lesion with an AIR-FLUID level |
|
|
What is the tx of ARDS?
|
Tx is primarily supportive
• Vent with PEEP • PAWP should be maintained as LOW as possible while still maintaining peripheral perfusion Find and treat the CAUSE of the ARDS. |
|
|
What is the tx of PCP pneumonia?
Moderate to severe dz? What is used as prophylaxis? |
• BACTRIM is the mainstay of tx
• Alternate tx: • Pentamidine (IV, inhalation); • Primaquine/ Clinda combo • Steroids are a useful adjunct in moderate to SEVERE PCP • Prophylaxis -- Bactrim ('PCP -- Pentamidine; Clinda, Primaquine') |
|
|
What is the typical WBC found in pneumococcal pneumonia?
|
WBC 12000 - 25000+
|
|
|
What medications are known asthma triggers?
|
• NSAIDS
• ASA • ß-blockers • MSG |
|
|
What meds should be strongly considered in pts with severe asthma exacerbation with inadequate ventilatory effort with inhaled nebs?
|
Epi 1:1000, 0.3 mg SQ q 20 min x 3
Terbutaline 1 mg/ml, 0.25 mg SQ q 20 min x 3 |
|
|
What organisms are responsible for lung abscesses in immunocompetent and compromised individuals?
What is the treatment? |
ImmunoCOMPETENT:
• Predominantly ANAEROBIC ImmunoCOMPROMISED: • Predominantly AEROBIC bacteria such as: • Staph aureus • E coli • Klebsiella • H flu Tx -- Clindamycin is the drug of choice |
|
|
What percent improvement in FEV1 can be expected in pts given MAGNESIUM who present with severe ASTHMA exacerbation?
What are the main side effects of Mg? |
10%
Side effects -- HoTN (rarely clinically significant) and fatigue |
|
|
What percent of pts with PRIMARY TB fail to demonstrate clinically apparent disease?
How are pts with primary TB identified? |
90%
Primary TB is characterized by: • Positive PPD test • Hilar adenopathy • Often lobar infiltrate |
|
|
What pneumonia is of particular concern to transplant recipients and pts with advanced AIDS?
|
CMV
• The most common cause of death in bone marrow transplant recipients • Pneumonia occurs within 1-3 mos of transplantation AIDS • In AIDS pts, must have a positive cx to make the dx |
|
|
What RSI medication adjuncts should be considered in the intubation of an acute asthma exacerbation pt?
|
Lidocaine
• Administer prior to induction to minimize bronchospasm Ketamine: • Ketamine is a bronchodilator • Use as the induction agent or as sedation for the intubated pt |
|
|
What should be the suspected diagnosis in a patient with an ANTERIORLY located lung abscess?
|
CANCER
|
|
|
What sputum finding may VZV (varicella zoster) pneumonia reveal?
|
multinucleated giant cells
|
|
|
When is tube thoracostomy mandatory in the setting of pneumothorax?
|
• Significant underlying lung pathology
• Expanding pneumo • Pneumo > 25% • Bilateral or tension pneumo • Trauma • SOB • On PPV • Previous contralateral pneumo |
|
|
When should anaerobes be considered as an etiology of aspiration pneumonia?
|
Anaerobes are NOT a common source of aspiration pneumonia UNLESS h/o:
• Chronic ALCOHOLISM • Severe gum dz • Putrid sputum • Lung abscess on xray |
|
|
Which bacterial pneumonias are noted for green sputum?
|
• Strep pneumo
• Staph aureus • H flu • Pseudomonas |
|
|
Which fungal organisms are endemic to the Mississippi and Ohio river valleys?
|
• Histoplasma capsulatum (90% of pts are asx)
• Blastomyces dermatiditis |
|
|
Which geographic area of the US is Hantavirus most commonly found?
|
Southwestern US ('4 Corners'):
• New Mexico • Arizona • Colorado • Utah |
|
|
Which groups of people are most at risk for contracting Psittacosis?
|
• Pet shop employees
• Poultry workers • Vets |
|
|
Which infectious diseases are transmitted by SMALL airborne droplets (< 5 micrometers)?
What is the safe exposure zone? |
'I want my MTV!'
• Measles • TB • Varicella Droplets can travel VERY FAR in the air. Patients must be placed in RESPIRATORY ISOLATION. |
|
|
Which infectious diseases are transmitted via LARGE airborne droplets (> 5 micrometer)?
What is the safe exposure zone? |
'PMS':
• Pertussis • Mumps • Strep pneumo 'DNR': • Diphtheria • N. meningitides • Rubella Safe distance is > 3 FEET. Droplets rarely travel further than that. Respiratory isolation rooms are NOT RQD. Wear a mask when within 3 feet of pt. |
|
|
Which is a more useful test in evaluating asthma patients in the ED, PEFR or FEV1?
|
PEFR
PEFR is preferred over FEV1 in the ED because of its portability |
|
|
Which non-viral pathogens are most implicated in Uncomplicated Acute Bronchitis?
What percent of UAB etiology are viral and non-viral? |
• Mycoplasma pneumoniae
• Chlamydia pneumoniae • Legionella • Bordatella pertussis ('My CLuB') Viral cause: 75 - 95% Non-viral cause: 5 - 25% |
|
|
Which part of the lung is affected by bronchiectasis?
|
Bronchiectasis involves injury to the walls of MEDIUM-sized BRONCHI
|
|
|
Which physiologic receptors monitor and react to increased CO2? How do they respond?
|
Medullary chemoreceptors react to increased CO2 by increasing respiratory rate and TV
|
|
|
Which pneumonia is associated with dry, STACATTO cough and EOSINOPHILIA?
|
Chlamydial infections (trachomatis and pneumoniae)
|
|
|
Which pneumonia is characterized by 'currant jelly' sputum?
|
Klebsiella
|
|
|
Which pneumonia is characterized by bloody or rusty sputum?
|
Pneumococcus
|
|
|
Which pneumonia is characterized by foul-smelling sputum?
|
Anaerobic infection
|
|
|
Which pneumonias are associated with hemoptysis?
|
• Pneumococcus
• Staph aureus • TB • Influenza • Klebsiella 'A Pointy STIK in your lung makes your lung bleed' |
|
|
Which pt population is most at risk for Klebsiella pneumonia?
|
• Alcoholics
• Diabetics • COPD |
|
|
Who gets PCP Pneumonia? What are the stats for PCP in HIV pt?
What is the clinical picture? |
Immunocompromised:
• AIDS/HIV (w/ CD4 < 200) • Transplant/ chemo pts • Premature or malnourished infants • PCP is the MOST COMMON opportunistic infection seen in HIV pts • PCP is the leading cause of death in HIV pts Clinical Picture: • SLOW, INSIDIOUS onset • SOB, non-productive cough, fever • May see SPONTANEOUS PNEUMO |
|
|
With BiPAP, what setting is the equivalent to adjusting PEEP?
How should the BiPAP be set in COPD pts? |
EPAP (Expiratory PAP)
COPD: • IPAP must be > EPAP in order to have an inspiratory gradient • If oxygenation does not improve, increase EPAP (and consequently IPAP to maintain the gradient) to stent open additional alveoli |
|
|
With respect to tracheostomy tubes, when is the greatest risk of creating a false passage with tube reinsertion?
When is air trapping an issue? |
Greatest risk of creating a false passage:
• First 7 days post-op AIr trapping: • Occurs when the pt cannot fully exhale • Often seen when a SOLID TUBE is used for tube exchange |
|
|
Amanita mushroom toxicity is associated with which organ system failure?
Sx? What is the importance of time to onset of sx? |
Liver failure
Sx: • Jaundice • GI sxs Time to onset of sx: CYTOTOXIC mushrooms: • Cause ORGAN SYSTEM failure • Sx onset > 6 hr from ingestion PHYSIOTOXIC mushrooms: • Cause only TRANSIENT CNS and GI toxicity • Sx onset < 6 hr from ingestion |
|
|
Basophilic stippling on RBCs is an indication of what disorder?
|
LEAD poisoning
|
|
|
Clonidine is an effective tx for withdrawal from which class of substances?
|
Opioids
|
|
|
Compare the incidence of hepatotoxicity 2° to Tylenol OD in children vs adults.
Why? |
Children are relatively IMMUNE to TYLENOL HEPATOTOXICITY
Adults Tylenol Metabolism: • GLUCURONIDATION > Sulfate conjugation Kid Tylenol Metabolism: • SULFATE > Glucoronidation The preferential sulfate pathway in kids is proposed to provide immunity from toxicity. |
|
|
Concerning Tylenol ingestion, what are the guidelines for NAC administration when the time since ingestion or the quantity of pills is unknown?
|
1 Draw a Tylenol level.
2 Draw a 2nd level 4° later. 3 Calculate the 1/2-life. If the 1/2-life is > 4°, begin NAC. |
|
|
Cyanosis results when what percent & amount of the total hemoglobin is deoxygenated?
Methemoglobinemia? Sulfhemoglobinemia? |
Deoxygenation:
• 10-15% of the total hemoglobin • > 4 - 5 g/dL Methemoglobinemia: • > 1.5 g/dL Sulfhemoglobinemia: • > 0.5 g/dL |
|
|
Define the anacronym 'DUMBELS'.
Which toxindrome does this represent? Substances that cause this toxindrome? Antidote? |
CHOLINERGIC toxindrome
D -- Diarrhea U -- Urination M -- Miosis B -- Bronchorrhea, Bradycardia E -- Emesis L -- Lacrimation S -- Salivation Etiology: • Organophosphate poisoning • Carbamate poisoning Antidote -- ANTIcholinergics: • Atropine • Pralidoxime (2-PAM Chloride, reserved for organophosphate toxicity) |
|
|
Describe the clinical picture of a patient with ACUTE digoxin toxicity
|
• Young age/ child, o/w healthy
• Acute OD of digoxin • Hyperkalemia • Very high digoxin level • Brady dysrhythmia • AVB |
|
|
Describe the clinical picture of a patient with chronic digoxin toxicity
|
• Elderly
• H/o CAD • H/o chronic renal insufficiency • On a diuretic • Normal or low potassium • Normal or low digoxin level • Ventricular dysrhythmia |
|
|
Describe the early sxs of iron toxicity
|
• Abdominal pain
• Lethargy • HEMATEMESIS • BLOODY diarrhea |
|
|
Describe the pharmacologic effects of TCAs that cause toxicity:
• Alpha inhibition • Antihistamine • GABA-A antagonism • K-channel blockade • Na-channel blockade |
Alpha inhibition:
• Peripheral vasodilation --> HoTN Antihistamine: • Sedation, coma GABA-A antagonism: • Seizures K-channel blockade: • Delayed repolarization --> PROLONGED QT ('Kay is a Cutie') Na-channel blockade: • Decreased contractility • Prolonged action potential ('quinidine-like effect') --> • Prolonged PR, QRS and RAD |
|
|
Dimercaprol is an antidote for which metal poisonings?
|
• Mercury
• Arsenic • Lead The antidote for 'MAL' is BAL (British anti-Lewisite = Dimercaprol) Note: DMSA has largely replaced EDTA + BAL as the tx for Pb toxicity |
|
|
Discuss the presentation of CYANIDE toxicity.
Cyanosis? ABG? Mechanism? |
Presentation:
• Severe HYPOXIA • Profound ACIDOSIS 2°/2 lactate production from anaerobic metabolism. Cyanosis -- ABSENT: • The binding of O2 to Hgb is unaffected • NORMAL SaO2 and PaO2 on ABG Mechanism: • Inhibition of cytochrome oxidase --> • Inhibited mitochondrial oxidative phosphorylation --> • Cellular anoxia |
|
|
Discuss the Pulse Ox and PaO2 findings with carbon monoxide poisoning
|
Pulse Ox -- ARTIFICIALLY HIGH b/c the pulse ox confuses COHb w/ OxyHb.
PaO2 -- NORMAL, because CO does not affect the amount of O2 dissolved in the blood. |
|
|
Following esophageal ingestion of which acid is the administration of calcium gluconate indicated?
|
HYDROFLUORIC ACID -- Ca is depleted by binding with the extremely electronegative fluoride ion
|
|
|
For which substances is charcoal INEFFECTIVE?
For which substances is whole bowel irrigation indicated? |
'HAIL' for both
H -- Heavy metals A -- Acid/ alkali (but not WBI here!) I -- Iron L -- Lithium |
|
|
For which toxic substances is hemodialysis indicated?
|
'Boy, Dialysis LoVES Me!'
B -- Barbiturates (Phenobarb) D -- Digoxin L -- Lithium V -- Valproic acid E -- Ethylene glycol S -- Salicylates Me -- Methanol |
|
|
Garlic is the odor observed for poisoning with which substances?
|
• Selenium
• Organophosphates • Arsenic ('Garlic odor SOArs thru the air') |
|
|
How can anticholinergic toxicity be distinguished clinically from sympathomimetic toxicity?
|
Both have similar sx:
• Tachycardia • HTN • MYDRIASIS • Urinary retention EXCEPT: • Anticholingeric -- DRY axilla • Sympathomimetic -- DIAPHORESIS |
|
|
How can GHB intoxication be distinguished from FLUNITRAZEPAM (Rohypnol), barbiturate, and CARISOPRODOL (Soma) intoxication?
|
Difficult! All have very similar CNS depressant effects.
GHB is characterized by RAPID RECOVERY of consciousness, whereas the others are all slow recovery. |
|
|
How is Na-channel blockade manifested on the EKG in TCA toxicity?
Tx? |
EKG:
• Prolonged PR • Prolonged QRS • RAD TX: • Serum alkalination with BICARB |
|
|
How should hyperkalemia be corrected in patients with digoxin toxicity?
What is specifically contraindicated? |
DO NOT give calcium! It can potentiate toxicity -- 'Stone Heart'
Treat with Fab fragments. |
|
|
How well do CNS sxs of lithium toxicity correlate with serum blood levels?
Why? |
POOR CORRELATION b/c of delayed uptake and elimination by the brain
|
|
|
In salicylate poisoning, what sx correlates with serum salicylate levels?
What finding correlates with mortality? |
Correlation with BLOOD levels:
• Reversible sensorineural HEARING LOSS Correlation with MORTALITY: • BRAIN salicylate concentration |
|
|
In which toxindromes is FEVER seen?
|
Withdrawal:
• EtOH Intoxication: • Cocaine • PCP • Ecstasy • Amphetamine Syndromes: • NMS • Serotonin • Lethal catatonia • Malignant hyperthermia |
|
|
Ingestion of METHYLENE CHLORIDE (paint remover) is associated with which toxicity as it is degraded in the body?
|
Increased CARBON MONOXIDE levels
|
|
|
Ingestion of nitrobenzene causes elevated levels of which toxin?
|
METHEMOGLOBIN
|
|
|
Ingestion of the pits of which fruits can cause CYANIDE toxicity?
Other community acquired sources of CN toxicity? |
Pits of:
• Peaches • Apricots • Cherries Other sources: • Burning polyurethane or NYLON • SILVER electroplating or recovery • PEST fumigation |
|
|
Intoxication with which drug may induce VERTICAL nystagmus?
|
PCP
|
|
|
List the hydrocarbons that cause multi-system toxicity if ingested.
What is the role of GI decontamination with hydrocarbon ingestion? |
'CHAMP'
• Camphor • Halogenated hydrocarbons • Aromatic hydrocarbons (Toluene, Benzene) • Metals • Pesticides Activated charcoal should be used when the ingested substance is a TOXIC substance, as above. If the substance is non-toxic, decontamination is not indicated. |
|
|
Match the following antidotes to their respective syndromes:
• Cyproheptadine • Bromocryptine • Dantrolene |
Cyproheptadine -- Serotonin syndrome
Bromocryptine -- Neuroleptic Malignant Syndrome Dantrolene -- Malignant Hyperthermia |
|
|
NAC administered within how many hours of Tylenol ingestion is 100% effective in preventing toxicity?
|
8 hours
|
|
|
Name 3 MAOI drugs
|
• Tranylcypromine
• Isocarboxazid • Phenelzine ('TIP') |
|
|
Neuroleptic Malignant Syndrome is very similar to Lethal Catatonia and Malignant Hyperthermia.
What clues help to differentiate these three entities? |
Lethal catatonia:
• Is a type of heat exhaustion and follows a period of MANIC HYPERACTIVITY • Autonomic instability is ABSENT Malignant hyperthermia: • Occurs after exposure to certain ANESTHETIC agents Neuroleptic Malignant Syndrome: • Associated w/ neuroleptic use • AUTONOMIC INSTABILITY present |
|
|
Nitroprusside urine dipstick turns purple in the presence of which substance?
|
Acetoacetate (eg, in DKA)
|
|
|
Once deferoximine is administered for iron toxicity, what will its effect be, if any, on subsequent serum iron level measurements?
|
Serum iron levels will be FALSELY DEPRESSED by up to 50%
|
|
|
State 4 medical conditions that can be brought on by LITHIUM toxicity
|
• HYPOthyroidism/ MYXEDEMA coma
• Nephrogenic DIABETES INSIPIDIS • SEROTONIN syndrome • Prolonged QT |
|
|
State the causes of pseudocyanosis.
How can pseudocyanosis be distinguished clinically from true cyanosis? |
'Iron PAC Man'
Heavy metals: • Iron (hemachromatosis) • Gold, Silver • Lead • Arsenic Drugs: • Phenothiazines • Amiodarone • Chloroquine • Minocycline Pseudocyanosis -- skin DOES NOT BLANCH with pressure |
|
|
State the metabolic findings associated with valproic acid toxicity
|
Elevated:
• AMMONIA • Na Decreased: • CARNITINE • Ca Metabolic acidosis |
|
|
State the pneumonic for cause of ANION GAP metabolic acidosis
|
'CAT MUDPILES'
C -- Cyanide, CO A -- Alcohol Intox, Alcoholic Ketoacidosis T -- Toluene M -- Methanol U -- Uremia D -- DKA P -- Paraldehyde I -- Iron, Isoniazide L -- Lactic acidosis E -- Ethylene glycol S -- Salicylate |
|
|
State the sx of opioid withdrawal.
What sx are NOT seen? Tx? Is this life-threatening? |
Opioid w/d sx:
• Mydriasis (opposite of intox sx) • Diarrhea (opposite of intox sx) • N/V • HTN • Piloerection • RHINORRHEA • SNEEZING • YAWNING Sx NOT seen: • Seizure • AMS Tx: • CLONIDINE; • Methadone or • Buprenorphine NOT life-threatening! |
|
|
State the sxs of serotonin syndrome.
Neuro findings? |
• Autonomic instability
• Rigidity, LE > UE COEXISTANCE of: • Hyperreflexia • Clonus |
|
|
To which organ system is ethylene glycol toxic?
|
EG is NEPHROTOXIC:
• Directly by metabolites • Indirectly by Ca Oxalate CRYSTAL deposition in the tubules --> renal failure |
|
|
What is the antidote for anticholinergic OD, and what is the caveat to its use?
|
Physostigmine
May precipitate SEIZURES and aggravate ARRHYTHMIAS * Rarely used * |
|
|
What adverse reactions are associated with isoniazide use?
|
Most common -- PERIPHERAL NEUROPATHY
• Thus, tx concomitantly with B6 Most severe -- HEPATITIS OD -- Sz |
|
|
What are normal levels of carbon monoxide in non-smokers and smokers?
|
Non-smoker -- 1-2%
Smoker -- 5-10% |
|
|
What are some common causes of methemoglobinemia?
Abx? Tx? |
Causes:
• Benozocaine • Lidocaine • Prilocaine • NTG (nitrates) • Nitroprusside (nitrites) • Sulfonamides • Chloroquine • Reglan • Pyridium • Aniline dyes Tx -- methylene blue |
|
|
What are the clinical features of Neuroleptic Malignant Syndrome?
Timing of NMS with respect to med ingestion? Tx? |
Sx:
• Autonomic instability • Hyperthermia (fever) • LEAD-PIPE RIGIDITY • Altered MS • Tremors • Myoclonus • Dysarthria • Coma Note: Autonomic instabilty = • Tachycardia • Labile HTN • Vasoconstriction • Diaphoresis Sx may occur at ANY TIME while taking a neuroleptic, including when the med is D/C'd. TX: • Neuroleptics are D-2 antagonists. Thus, NMS is thought to be due to a relative insufficiency of dopamine => • BROMOCRYPTINE (a dopamine agonist used in Parkinson's) • BENZO's for FEVER and sedation |
|
|
What are the clinical symptoms of digoxin toxicity?
|
FLU-LIKE syndrome:
• malaise, N/V, diarrhea Visual disturbances: • Blurred vision, halos, COLOR aberations Mental status change: • Confusion, drowsiness, psychosis |
|
|
What are the common etiologies of cyanide poisoning?
|
• Nitroprusside drip
• Smoke inhalation victims |
|
|
What are the common signs of TCA overdose?
|
• CNS depression
• Sz • ANTI-CHOLINERGIC toxicity • Depression of CARDIAC contractility and conduction --> • Prolonged QRS and QT |
|
|
What are the EKG effects of TCA overdose?
Mechanism? Tx? |
• Wide QRS
• Wide complex tachycardia • Prolonged QT Mech -- Na-channel blockade Tx -- bicarb |
|
|
What are the findings of Dilantin toxicity?
|
Levels 20 - 30:
• Lateral gaze NYSTAGMUS ('DiLANtin -- LATeral gaze nystagmus') Levels 30 - 40: • Increased lateral nystagmus • VERTICAL nystagmus • Ataxia Levels > 40: • AMS • SEIZURES • Psychosis • Dysarthria |
|
|
What are the findings typical of MDMA (Ecstasy) intoxication?
|
MDMA is a synthetic derivative of METHAMPHETAMINE.
Sympathomimetic Findings: • Agitation • Tachycardia • Hyperthermia Other: • Mild hallucinations • Increased interpersonal emotions |
|
|
What are the indications for dialysis in Ethylene Glycol poisoning?
|
• EG > 20 mg/dL
• Signs of nephrotoxicity • Metabolic acidosis present |
|
|
What are the indications for dialysis in Methanol poisoning?
|
• Signs of visual or CNS dysfunction
• Methanol > 20 mg/dl • pH < 7.15 • Ingestion > 30 ml of methanol |
|
|
What are the indications for hyperbaric O2 therapy in cases of CO poisoning?
|
• pH < 7.2
• COHb > 25% • Coma • Persistent sx after 4 hrs of 100% O2 • Exposure during PREGNANCY • Neonatal exposure |
|
|
What are the most common EKG findings with digoxin toxicty?
|
• PVCs -- the most common dig-induced dysrhythmia
• PAT with AV block is pathognomonic for dig toxicity • Junctional Tach (common) • Afib |
|
|
What are the most common precipitants of chronic lithium toxicity?
|
• RENAL FAILURE
(Li is eliminated entirely by the kidney, and is absorbed by the PCT) • DEHYDRATION |
|
|
What are the names of the TCA drugs?
|
• Amitriptyline
• Nortriptyline • Doxepin • Desipramine • Clomipramine |
|
|
What are the organ-system effects of salicylate OD?
|
• Cerebral edema
• Pulmonary edema • Direct nephrotoxicity |
|
|
What are the physiological effects of GHB?
What characteristic is most specific for GHB intoxication? |
GBH is a precursor to GABA, the major CNS inhibitory neurotransmitter.
GHB is a CNS depressant: • Ataxia • Rapid sedation • Respiratory depresssion • Coma Other effects: • Bradycardia • Mild hypothermia GHB specific characteristic: • RAPID RECOVERY of consciousness from a severely depressed CNS state |
|
|
What are the specific indications for hemodialysis in pts with SALICYLATE OD?
|
• NEURO signs/sx (confusion, coma)
• RENAL failure • PULMONARY edema • Severe CARDIAC toxicity • Severe acid-base imbalance • Rising ASA levels despite bicarb • ASA > 90 mg/dl in any pt |
|
|
What are the sx of acute and chronic lead toxicity?
Labs? |
ACUTE:
• Abdominal pain • Ataxia • ARF • Gout • Memory loss CHRONIC: • Encephalopathy • MOTOR neuropathy, classically WRIST DROP Labs: • Anemia • Basophilic stippling on RBCs |
|
|
What are the sx of ALPHA-2 AGONIST toxicity (eg, clonidine)?
Mechanism? Anything special about it's effect on blood pressure? |
Alpha-2 agonists presynaptically INHIBIT central SYMPATHETIC OUTFLOW -->
SympathoLYTIC effects Sx: • Miosis (C in 'SCOOP') • Bradycardia • HoTN • AMS • Respiratory depression NOTE: • HTN is often seen BEFORE HoTN in acute ODs b/c clonidine also possesses some PERIPHERAL ALPHA-1 AGONIST activity. |
|
|
What are the sx of AMPHETAMINE withdrawal?
Anything in particular to worry about? |
Minor Sx:
• Depression • Cramps, Diarrhea • HA Major Sx: • Psychosis • Arrhythmia • MI LIFETHREATENING: • HYPERPYREXIA -- leads to multisystem organ failure |
|
|
What are the sx of ANTI-CHOLINERGIC toxicity?
|
• Hot as a hare
• Blind as a bat • Dry as a bone • Red as a beet • Mad as a hatter Sx: • AMS • Tachycardia • Mydriasis • Decreased bowel sounds • URINARY RETENTION • Dry axilla |
|
|
What are the sx of lithium toxicity?
Tx? |
NEURO SX PREDOMINATE:
• TREMOR • AMS • Sz • Hyperreflexia • Ataxia GI: • N/V • Abdominal pain Renal: • DIABETES INSIPIDIS Cardiac: • Bradycardia • HoTN • PVCs TX: • VOLUME resuscitation w/ NS • Whole bowel irrigation (remember 'HAIL') • Hemodialysis • Kayexalate (!) |
|
|
What are the sx of metal fume inhalation (seen in foundry workers)?
|
FLU-like sx
|
|
|
What are the sx of SYMPATHOMIMETIC syndrome?
|
• Tachycardia
• HTN • MYDRIASIS • Diaphoresis • Urinary retention |
|
|
What body location is considered one of the most sensitive sites for observing central cyanosis?
|
Tongue
|
|
|
What diagnosis should be suspected when a FAMILY presents in the wintertime with a cc of non-specific flu-like sxs?
|
Carbon monoxide poisoning
|
|
|
What drugs are implicated in serotonin syndrome?
What clinical finding is a diagnostic clue? Antidote? |
• SSRI
• MAOI • TCA • Lithium • CATECHOLAMINE releasers (cocaine, amphetamines, dextromethorphan) • Demerol • Sumatriptan Clinical Clue -- Muscle rigidity, LOWER Extremity > UE Antidote -- Cyproheptadine |
|
|
What effect do the phenothiazines have on the seizure threshold?
Name some phenothiazines |
Phenothiazines LOWER the sz threshold
Examples: • Chlorpromazine (Thorazine) • Thioridazine (Melaril) • Fluphenazine (Prolixin) • Prochlorperazine (Compazine) |
|
|
What is a treatment for valproic acid toxicity?
Mechanism? |
Dialysis
CARNITINE: • Why? Valproic acid toxicity is characterized by elevated NH3 levels. • Carnitine depletion --> • Urea cycle impairment --> • Elevated NH3 |
|
|
What is considered a contraindication to the use of benztropine in the tx of acute dystonic reaction?
|
Age < 3
|
|
|
What is one of the earliest symptoms of salicylate toxicity?
|
OTIC symptoms such as tinnitus and altered hearing
|
|
|
What is the absolute contraindication to physostigmine use?
Why? |
TCA overdose -- high potential for causing SEIZURES and ASYSTOLE
NOTE: TCA overdose causes ANTIcholinergic sxs. Physostigmine is a cholinergic agonist (ie, antidote to anticholinergic syndrome). |
|
|
What is the amount of 40% methanol ingestion required to cause:
• Blindness? • Death? |
Blindness -- 1 teaspoon
Death -- 1 tablespoon |
|
|
What is the antidote for cyanide toxicity?
What about cyanide toxicity from SMOKE INHALATION? |
HYDROXOCOBALAMIN
• Converts CN to cyanocobalamin (vit B12!) 'OLD SCHOOL' TX KIT: NON-smoke inhalation: • Amyl NITRITE pearls, inhaled while the next two items are being prepared: • Sodium Nitrite • Sodium thiosulfate The goal of tx is to INDUCE METHEMOGLOBINEMIA with nitrites which pull the CN molecule off the electron transport chain, then DETOX THE CN with thiosulfate SMOKE INHALATION: • Do NOT use NITRITES! Creating methemoglobinemia will worsen the poor oxygenation already present from the CARBON MONOXIDE • Go straight to the Na Thiosulfate |
|
|
What is the antidote to hydrogen sulfide exposure?
|
Sodium NITRITE --> methemoglobinemia
[Same mechanism as for CN poisoning] |
|
|
What is the antidote to INH toxicity?
|
Pyridoxine (B6)
|
|
|
What is the antidote to Iron toxicity?
|
Deferoximine
|
|
|
What is the antidote to Lead toxicity?
Which order should these meds be given? Why? |
• Dimercaprol (BAL)
• EDTA DMSA (Succimer/ Chemet): • Has largely replaced EDTA + BAL as the tx of choice • Used for outpt chelation tx NOTE: BAL should be given BEFORE EDTA to prevent the chelated lead from crossing the BBB ('D before E') |
|
|
What is the antidote to Nitrite (-caines) toxicity?
|
Nitrates and nitrites cause METHEMOGLOBINEMIA
Antidote -- Methylene blue |
|
|
What is the antidote to organophosphate (cholinergic) toxicity?
|
The antidote is ANTI-cholinergics:
• Atropine • Pralidoxime (2-PAM Chloride) |
|
|
What is the caveat in interpreting the ABG in the ED of a CO poisoning pt?
|
O2 given by EMS will UNDERESTIMATE the degree of toxicity.
COHb levels ON-SCENE correlate best with clinical presentation. |
|
|
What is the color of a pt's skin with CO poisoning?
|
PALE or CYANOTIC
(The classic cherry red color is rarely seen) |
|
|
What is the ddx of pinpoint pupils?
|
'SCOOP'
S -- Sedative hypnotics C -- Cholinergics, Clonidine O -- Opiods O -- Organophosphates P: • Phenothiazines • Physostigmine (a cholinergic) • PCP • Pilocarpine (topical) • Pontine hemorrhage |
|
|
What is the duration of action of Naloxone?
|
1 - 2 hours
|
|
|
What is the duration of sx of organophosphate toxicity?
Why? |
May persist for WEEKS to MONTHS because of:
• Low regeneration time for cholinesterase • Persistent mobilization of the lipophilic toxins |
|
|
What is the effect of salicylate poisoning on the CSF?
Effect on PT? |
CSF glucose -- May be EXTREMELY LOW
PT -- PROLONGED • ASA inhibits the formation of vit K clotting factors |
|
|
What is the endpoint of atropine administration for the treatment of cholinergic (organophosphate) toxicity?
What is the most common cause of death? |
The endpoint is REDUCTION of BRONCHORRHEA
Tachcardia and HTN are NOT indications to stop atropine! NOTE -- It is not uncommon to use up ALL THE ATROPINE in the HOSPITAL on one pt! RESPIRATORY FAILURE is the most common cause of death. |
|
|
What is the formula for calculated osmolality?
|
Calculated osmolality =
(2 x Na) + (BUN/2.8) + (glucose/18) + (EtOH/4.6) |
|
|
What is the hallmark of bupropion (Wellbutrin) overdose?
Time to sx manifestation in regular release and SR? |
SEIZURES
Buproprion has a low toxic-to-therapeutic window Time to sz: • Regular release -- sz w/in 4° • Sustained release -- up to 24 hrs (ADMIT for obs) |
|
|
What is the lowest single, acutely ingested dose of Tylenol that is hepatotoxic in an adult?
Child? |
Adult -- 7.5 g
Child -- 150 mg/kg |
|
|
What is the mechanism and eletrolyte findings of hydroflouric acid (HF) exposure?
Sx? Labs? Tx? |
Early findings:
• Severe pain despite an often benign appearing lesion • Acidosis (from release of the H ion into the tissue) • Hypocalcemia (bound by F ion) • Hypomagnesemia (bound by F ion) Later findings: • HYPERkalemia (from tissue destruction) • Sudden-onset dysrhythmias Tx: CALCIUM GLUCONATE, either: • Topical • SQ • Intraarterial |
|
|
What is the mechanism of action of heparin and LMWH?
|
Heparin:
• Binds to antithrombin III to inactivate thrombin (factor II) LMWH: • Inhibits factor X(a) |
|
|
What is the mechanism of action of TCAs?
|
TCAs are ANTI:
• alpha-1 • Muscarinic • Histamine • GABA • Serotonin reuptake • Norepinephrine reuptake • Fast Na channel TCAs are anti-everything EXCEPT anti-dopamine! |
|
|
What is the most common reason for failure to alkalinize the urine in pts receiving IV bicarb for ASA toxicity?
|
FAILURE to give adequate amounts of POTASSIUM
|
|
|
What is the most common source of scalp burns in women?
Tx? |
ACETIC ACID found in hair neutralizer
Tx: • Irrigation • PO abx. Scalp infections are very slow to heal b/c of hair and intrinsic scalp flora. |
|
|
What is the most commonly ingested alcohol, after ethanol?
Labs? |
Isopropanol
Labs: • Metabolized to ACETONE • FALSELY elevated CREATININE level • NO anion gap • POSITIVE osmolal gap b/c of KETOSIS |
|
|
What is the most serious side effect of clozapine, a new-generation antipsychotic?
|
Agranulocytosis
|
|
|
What is the only effective treatment for seizures caused by isoniazid OD?
|
Pyridoxine (B6)
|
|
|
What is the pathophysiology of alcoholic ketoacidosis?
Alcohol level? Ketones? Anion gap? Osmolal gap? Tx? |
EtOH binge --> vomiting, STARVATION, dehydration --> acidosis
EtOH -- ZERO/ low • AG -- YES • Osmolal gap -- NO • Ketones -- NO (b/c the ketones of AKA are ß-hydroxybutyrate and not detected by the nitroprusside test) Tx -- This is a STARVATION condition. Very important to begin GLUCOSE even if the glucose is normal. |
|
|
What is the patient odor seen with:
• Chloral hydrate • Turpentine • Camphor? |
Chloral hyrdrate -- Pears
Turpentine -- Violets ('TV') Camphor -- Mothballs |
|
|
What is the patient odor seen with:
• Cyanide • Zinc • Toluene? |
Cyanide -- Almonds
Zinc -- Fishy odor Toluene -- Glue |
|
|
What is the patient odor seen with:
• Isopropyl Alcohol • Phosgene • Methysalicylate? |
Isopropyl alcohol -- Fruit-like
Phosgene -- Hay Methylsalicylate -- Wintergreen |
|
|
What is the primary symptomatic predictor of whether an ingested toxic mushroom is a cytotoxic or physiotoxic mushroom?
|
TIME to SX ONSET
Cytotoxic: • Causes permananent liver damage • Sx onset > 6 hr from ingestion Physiotoxic: • Causes transient CNS and GI sx • Sx onset < 6 hr from ingestion |
|
|
What is the rationale for using hyperbaric O2 in the tx of CO poisoning?
|
HBO may decrease the risk of post-exposure NEUROLOGIC sequalae:
• Memory change • Cortical blindness • Parkinsonism These sx may not manifest for 2-40 days after exposure |
|
|
What is the relationship between the onset of Serotonin Syndrome sxs and instigating med ingestion?
|
Serotonin syndrome occurs SOON AFTER med intake
|
|
|
What is the relationship between timing of sx and concentration of exposure to hydroflouric acid?
|
The higher the concentration the earlier the sx
Sx from exposure to household RUST REMOVER (6 - 12%) can take up to 24° |
|
|
What is the relative incidence of hypoglycemia in children and adults with ß-blocker OD?
|
CHILDREN >>> adults
|
|
|
What is the relative severity of carbamate vs organophosphate toxicity?
|
CARBAMATE toxicity is LESS SEVERE (ie, less CNS sx) b/c carbamates DO NOT CROSS the BBB.
|
|
|
What is the role of Kayexalate in the tx of lithium toxicity?
|
Kayexalate not only ADSORBS lithium and PREVENTS ABSORPTION, it also...
ENHANCES ELIMINATION once it is absorbed. |
|
|
What is the role of Pralidoxime (2-PAM Chloride) in the tx of cholinergic syndrome?
|
2-PAM is used only for ORGANOPHOSPHATE toxicity b/c OP's IRREVERSIBLY bind to ACh-esterase
It is NOT USED for carbamate toxicity since carbamates do not irreversibly bind to the ACh-esterase molecule |
|
|
What is the specific antidote for Lomotil (atropine 0.025 mg)/ diphenoxylate 2.5 mg) ingestion in a child?
What dose can cause death? |
Diphenoxylate is a synthetic opioid -- give NALOXONE
As little as 7.5 mg of diphenoxylate (3 tabs) has caused death in children. |
|
|
What is the specific treatment for hydrofluoric acid burns?
PE findings? |
CALCIUM GLUCONATE
May be given topically, SQ or intra-arterial. TITRATE treatment to PAIN; if pt still has pain, more Ca Gluconate is rqd. PE findings: • Depends of the concentration • Pt will c/o severe pain. Low concentration burns may not be visually evident for up to 24 hrs. |
|
|
What is the specific treatment for salicylate toxicity (ASA, oil of wintergreen, pepto bismol)?
Discuss the target serum and urine pH values. Role of Potassium? |
Urine Alkalinization:
• Bicarb IV bolus and drip • Maintain a URINE pH of 7 - 8 without exceeding a SERUM pH of 7.5 Serum pH: • Maintain > 7.4 to prevent CNS salicylate toxicity If good UO, serum pH > 7.4, and URINE is ACIDIC: • Give POTASSIUM If serum pH < 7.4 and URINE is ACIDIC: • Give more BICARB If worsening serum or urine pH despite adequate bicarb and K --> DIALYSIS |
|
|
What is the specific treatment of Phenobarbital overdose?
|
Alkalinization of the urine with BICARB to maintain a urine pH of 7 - 8
('PhenoBARB -- Bicarb') HEMODIALYSIS for severe poisoning with significant RENAL or HEPATIC failure |
|
|
What is the taste/ smell of ethylene glycol?
|
Sweet
|
|
|
What is the toxic metabolite of Methanol, and to which organ system is it toxic?
|
Methanol --> Formic acid
Accumulates in the BRAINSTEM --> • Blindness • Death |
|
|
What is the treatment of ACE-I induced angioedema?
|
Try standard tx first (usually ineffective):
• Epi • Steroids • Anti-histamine FFP -- contains kinase II which cleaves bradykinin (built up from the inhibition of ACE) --> reduces angioedema |
|
|
What is the treatment of calcium channel blocker and ß-blocker overdose?
|
• Atropine -- for bradycardia
• Glucagon -- independent improvement of inotropy and chronotropy • Calcium -- competes for the Ca channel in CCB OD • High-dose insulin and glucose -- Definitely helpful for ß-Bl OD; probably helpful with CCB OD |
|
|
What is the treatment of Ethylene Glycol toxicity?
|
FOMEPIZOLE:
• Alcohol dehydrogenase inhibitor --> EG NOT broken down into Calcium Oxalate, OR ETHANOL: • ADH preferentially metabolizes this --> EG not broken down; + • Thiamine • Pyridoxine (B6) • Bicarb (for the acidosis) • Calcium for hypocalcemia • HD |
|
|
What is the treatment of Methanol toxicity?
|
• FOMEPIZOLE:
Alcohol dehydrogenase inhibitor --> Methanol is PREVENTED from breaking down to formic acid, OR • ETHANOL: ADH preferentially metabolizes this --> Methanol not broken down • FOLATE (converts formic acid to CO2 and H2O) • Bicarb (for the acidosis) • Hemodialysis |
|
|
What is the treatment of Tylenol toxicity?
|
N-acetylcysteine (NAC):
Loading dose: • 140 mg/kg PO, OR • 150 mg/kg IV over 60 min THEN • 70 mg/kg q4° x 72° |
|
|
What is the tx of seizures caused by TCA OD?
Mechanism? |
• Benzos
• Barbiturates These are GABA-A AGONISTS that counter the anti-GABA-A effects of TCAs |
|
|
What is usually the most significant complication to isopropyl alcohol toxicity?
|
HEMORRHAGIC GASTRITIS
|
|
|
What med is associated w/
ORANGE DISCOLORATION of tears, urine, saliva? |
RIFAMPIN
|
|
|
What meds are contra-indicated in salicylate toxicity?
|
BENZOs:
Decreased respiratory drive --> Respiratory acidosis --> Increased ASA in the CNS ACETAZOLAMIDE -- while this alkalinizes the urine, it worsens systemic acidosis --> Increased ASA in the CNS |
|
|
What metabolic complication of valproic acid is found with BOTH therapeutic use and OD?
Mechanism? |
Elevated AMMONIA
Mechanism -- DEPLETION of CARNITINE and interference with the UREA CYCLE, NOT from hepatotoxicity |
|
|
What must the lab tech do to a blood sample to discern between methemaglobinemia and sulfhemaglobinemia?
|
Add CYANIDE to the sample.
Cyanide binds only to methemaglobin. The dx of sulfhemaglobinemia is made if methemaglobin was not eliminated after addition of cyanide. |
|
|
What physiologic processes/ conditions produce endogenous carbon monoxide?
|
CO is produced from the DEGRADATION OF HEME:
• Rhabdomyolysis • Hemolytic anemia • Newborns with breakdown of fetal Hb |
|
|
What substances cause an increased osmolal gap?
|
• Ethanol
• Methanol • Ethylene glycol • Isopropyl alcohol • Acetone • Propylene glycol |
|
|
Which chemical agents react violently with water such that irrigation of exposed skin with water is contraindicated?
|
Calcium oxide (Lime)
Titanium tetrachloride Chlorosulfonic acid |
|
|
Which classes of anti-psychotic meds are implicated in neuroleptic malignant syndrome?
Which two drugs are most frequently implicated? |
ALL CLASSES are implicated:
• Haldol -- D2 antagonist • Atypical Antipsychotics • Phenothiazines -- acetylcholinesterase inhibitor (Anticholinergic and alpha-adrenergic blocker) Most frequent cause: • Haldol • Chlorpromazine (Thorazine) |
|
|
Which cohort of adult pts are particularly at risk for lead encephalopathy?
What is the most common means of occupational exposure? |
'Moonshiners' b/c they often use LEAD-containing RADIATORS to distill the alcohol
Occupational exposure -- INHALATION |
|
|
Which commonly prescribed opioid may predispose to QRS prolongation, especially when taken with TCAs?
|
Darvocet
(The Na-channel blockade effect of TCAs prolongs the entire action potential) |
|
|
Which drug is the most commonly ingested agent in drug-related deaths in children and adolescents?
|
TCAs
|
|
|
Which opioids are NOT detected in a UDS?
|
Synthetic opioids:
• Fentanyl • Demerol • Darvocet • Ultram |
|
|
Which toxindromes cause autonomic instabililty?
|
Neuroleptic Malignant Syndrome
Serotonin Syndrome |
|
|
Why is propranolol the most dangerous of all the ß-blockers to OD on?
|
Highly lipophilic -->
Readily enters the CNS --> SEIZURES and COMA |
|
|
Which cohort of patients are most susceptible to SCIWORA injury?
|
Kids </= 8 yo
|
|
|
What is the most important factor in determining the outcome of penetrating cardiac injury?
|
CORONARY ARTERY injury
This is more important and prognostic than even comminuted single-chamber injury. |
|
|
In the average adult, how much CSF surrounds the brain and spinal cord, and how much CSF is produced daily?
|
150 cc surrounds the brain and spinal cord
500 cc is produced daily (20 cc/hr) |
|
|
What is the recommendation for antibiotic prophylaxis in PENETRATING SCI?
|
Give IV antibiotics
|
|
|
What are the indications for early ventilatory support in pts with flail chest?
|
• Age > 65
• Severe head injury • Comorbid pulmonary dz • PaO2 < 60 on supplemental O2 • Fx of 8 or more ribs • 3 or more associated injuries • Shock |
|
|
What are the findings seen in Anterior, Middle, and Posterior fossa fractures?
|
Anterior:
• Raccoon eyes • CSF rhinorrhea Middle: • Battle's sign • Hemotympanum • Otorrhea • Hearing loss • Facial nerve palsy Posterior: • CN IX and X injury (impairment of swallowing and airway maintenance) |
|
|
What external fetal monitoring signs indicate fetal distress and are an indication for emergent C-section?
|
• Fetal tachycardia
• Lack of beat-to-beat or longterm variability • LATE decelerations |
|
|
Describe pediatric needle cricothyrotomy
|
• Insert 12 - 16 gauge angiocath in the inferior portion of the cricothyroid membrane
• Attach the adapter from a #3 ET tube to the angiocath • BAG VENTILATE, or use high flow O2 if available |
|
|
Define Level I, II, and III disaster level classification
|
Level I:
• Disaster response is provided by the resources WITHIN the affected community Level II: • Disaster reponse involves mutual aid within for SURROUNDING COMMUNITIES or regions Level III: • Need for STATE and FEDERAL involvement |
|
|
In women < 12 weeks pregnant, what is the RhoGAM dose? Greater than 12 weeks?
|
< 12 weeks -- 50 mcg
> 12 weeks -- 300 mcg |
|
|
What is the etiology and symptoms of CAUDA EQUINA syndrome?
|
Etiology: Peripheral nerve injury
Symptoms: • Decreased rectal tone • Urinary retention (often manifests as OVERFLOW incontinence) • Saddle anesthesia |
|
|
What is the most common site of fracture of the mandible?
|
The ANGLE of the mandible
|
|
|
What pre-induction agents should be used to help blunt a rise in ICP in head-injury patients?
|
• Lidocaine
• +/- Fentanyl |
|
|
What MAP should be maintained to achieve adequate cerebral perfusion?
What systolic pressure does this correlate to? |
MAP of 90 mm Hg
SP 120 - 140 mm Hg |
|
|
In hemothorax, what chest tube output rate warrants thoracotomy in adults and kid?
What is the most common source of the bleeding? |
Adults:
• Initial drainage -- 1500 cc • Drainage > 250 ml/hr x 4 hours • Continuous drainage > 200 cc/hr Kids: • Initial drainage -- 150 cc • Continuous drainage > 4 ml/kg/hr Bleeding source: • PARENCHYMAL VESSEL DAMAGE; also • Intercostal and internal mammary artery damage |
|
|
In trauma pts with suspected pericardial tamponade, what is the indication for pericardiocentesis vs thoracotomy?
|
ED THORACOTOMY is indicated for pts who have LOST VITAL SIGNS in the ED.
PERICARDIOCENTESIS is for pts with measurable vital signs. Often the pericardial blood will be clotted and unaspiratable, and thoracotomy in the OR will be required. |
|
|
Which anesthetic should NOT be use with children with suspected ICP?
|
KETAMINE -- it increases cerebral blood flow and can increase ICP
|
|
|
Define Class III hemorrhage and state the clinic findings
|
Class III:
• 30 - 40% blood loss • 1500 - 2000 cc Findings: • Marked tachycardia • Decreased systolic pressure • Altered MS |
|
|
What percent of traumatic placental abruptions may present with NO VAGINAL BLEEDING?
|
Up to 63%
|
|
|
What are the characteristics of spinothalamic tract injury?
|
CONTRALATERAL loss of pain and temperature
Note: Light touch is transmitted through both the dorsal columns AND spinothalamic tracts. |
|
|
What finding is prognostic of subsequent cardiac complications with traumatic myocardial contusion?
|
Abnormalities on INITIAL EKG
|
|
|
What are the anatomical landmarks for Zone I, II, and III neck injuries?
|
Zone III:
• Base of the skull --> • Angle of the mandible Zone II: • Angle of the mandible --> • Inferior margin of the cricoid cartilage Zone I: • Inferior margin of the cricoid cartilage --> • Clavicle |
|
|
DIscuss the pathophysiology and role of hyperventilation for TBI in the ED.
What range should PaCO2 be maintained? |
Hyperventilation is NO LONGER RECOMMENDED as a prophylactic intervention during the 1st 24 hours of TBI.
Hyperventilation --> decreased CO2 --> cerebral VASOCONSTRICTION --> reduced ICP, but ALSO leads to CEREBRAL ISCHEMIA. PaCO2 should be maintained between 30-35 mm Hg. |
|
|
What echocardiographic finding is diagnositic of pericardial tamponade?
|
Right ventricular diastolic collapse
|
|
|
How should fluid resuscitation be managed in the elderly?
|
Serial crystalloid boluses of 250 - 500 cc should be given. Strong consideration should be made for EARLY and MORE LIBERAL use of RBC transfusions.
Geriatric trauma patients are at risk for decompensation from OVERLY AGGRESSIVE volume repletion as from inadequate resuscitation. |
|
|
What is the most common incomplete spinal cord syndrome in trauma patients?
|
CENTRAL cord syndrome
|
|
|
What is the most common complication of pulmonary contusion?
|
Pneumonia
|
|
|
Which tissues/organs can be harvested AFTER death, and how long after death can they be harvested?
|
• Cornea
• Bone, cartilage, skin, tendons, fascia • Saphenous vein • Heart valves These organs can be harvested up to 24 hours after death if the body is refrigerated w/in 4 hours of death |
|
|
What organism is associated with human fight-bites?
|
Eikenella corrodens
|
|
|
In which pt cohort is pulmonary contusion more likely, children or adults?
|
CHILDREN, because their chest walls are much more compliant, permitting more energy tranfer to the lungs.
|
|
|
What is the most likely cause of fetal bradycardia?
|
Acute hypoxia
|
|
|
Regarding DPL, what RBC count is considered positive in blunt, and penetrating, trauma?
|
Blunt: > 100,000
Penetrating: > 5000 |
|
|
Discuss the typical etiology, history, and CT findings of EPIDURAL HEMATOMA
|
Etiology -- Blunt trauma to the temporal or temporoparietal area with associated skull fx and middle meningeal artery fx
Classic Hx -- LUCID INTERVAL followed by immediate LOC. Pt then awakens, and again falls unconscious --> Ipsilateral FIXED and DILATED pupil with contralateral hemiparesis CT -- BICONVEX shaped lesion (football-shaped) |
|
|
What is the most sensitive indicator of placental abruption?
|
FETAL DISTRESS
|
|
|
Define the Cushing response in severe head injury
|
Triad of:
• HTN • Bradycardia • Decreased respiratory rate |
|
|
What is the 'Lap-Belt Complex' in children?
What percent of blunt abdominal trauma will result in intestinal injuries? What part of the bowel is most commonly injured site? |
Lap-Belt Complex:
Intestinal or mesenteric injury with concomitant lumbar spine injury due to a lap belt If spine or intestinal injury is present, LOOK for injury in the other location Intestinal injuries occur in < 5% of blunt abdominal trauma. The JEJUNUM is most commonly injured |
|
|
State the indication for, and dosing of, Rhogam in pregnant patients with abdominal trauma.
|
Indications: Give to ALL Rh-negative pregnant women.
Exceptions: 1) Prior maternal sensitization; 2) a known Rh-neg fetus; 3) a known Rh-neg father. Rhogam protects against Rh isoimmunization if given within 72 HOURS of FMH. Dosing: No uniform agreement. Two options: 1) 50 mcg for EGA 12 weeks or less and 300 mcg for 13+ weeks; OR 2) 300 mcg for ALL gestational ages. |
|
|
What is the most common cause of death under and over the age of 1?
|
Under 1 -- Suffocation
Over 1 -- MVCs, with HEAD TRAUMA as the leading cause of death |
|
|
What are the symptoms of VERTEBRAL artery injury following trauma?
|
Sx of POSTERIOR circulation dysfunction:
• N/V • Central vertigo • Visual changes The vertebral arteries combine to form a single basilar artery, so there are NO LATERALIZING SX. |
|
|
What abdominal injuries are associated with solitary lap belt use?
|
JEJUNAL and MESENTERIC lacerations
|
|
|
What are the physical exam findings with orbital blowout fractures?
Xray? |
Floor fxs:
• Limitation of upward gaze with diplopia • Numbness to ipsilateral cheek and lip (infraorbital nerve injury) • TEARDROP SIGN on xray -- prolapse of orbital tissue into the maxillary sinus |
|
|
What is the significance of finding hematuria in a pediatric blunt trauma patient vs an adult?
|
Pediatric -- The degree of hematuria DOES CORRELATE with the SEVERITY of injury
Adult -- No correlation |
|
|
What are the characteristics of the ideal induction agent during RSI for a patient with suspected elevated ICP?
Name these ideal agents. |
The ideal induction agent should both BLUNT THE RISE IN ICP and NOT DECREASE MAP.
THIOPENTAL 3-5 mg/kg (in a normotensive pt), or 0.5-1.0 mg/kg (in a hypotensive pt). Thiopental has a RAPID ONSET and is SHORT-ACTING. It is a CARDIODEPRESSANT in higher doses, so in hypotensive patients the dose must be reduced. FENTANYL 3-5 mcg/kg ETOMIDATE 0.3 mg/kg |
|
|
At what level should a chest tube be placed in non-pregnant and pregnant trauma patients?
|
Normal site -- 5th IC space
Pregnant -- 3rd or 4th IC space (b/c of elevated diaphragm) |
|
|
What is the equation that relates Cerebral Perfusion Pressure, Mean Arterial Pressure, and Intracerebral Pressure? In what CPP range does cerebral autoregulation operate?
|
CPP = MAP - ICP
CPP autoregulation of blood flow occurs between 50 - 150 mm Hg. |
|
|
Autonomic dysfunction (eg, HTN, high fever, sweating) is characteristic of what type of traumatic injury?
|
Diffuse axonal injury
|
|
|
What are the most common signs of increased ICP following cerebral trauma, and what is the management?
|
Signs: Vomiting, dizziness, irritability, HA, decreased LOC
Tx: • MILD hyperventilation (PaCO2 30-34) • Tx shock per standard trauma protocol; DO NOT withhold fluids • Mannitol 0.5-1.0 g/kg • Lasix 1.0 mg/kg • Elevate HOB Steroids have NO ROLE in ICP management. |
|
|
What is the surgical/ diagnostic protocol for Zone I, II and III neck injuries?
|
Zone I and III:
• Because these are technically difficult areas in which to operate, w/u is INITIALLY NON-OPERATIVE Zone I: • Angio • Esophagoscopy/ Esophagram Zone II: • PE is notoriously unreliable. Thus: • MANDATORY exploration vs... • SELECTIVE exploration based on angio and esophageal studies Zone III: • Angio |
|
|
What is the most common cervical spine fracture in the elderly?
|
Odontoid fx -- C2
|
|
|
What is the maximum normal cervical prevertebral space at C2 and C7 in kids and adults?
|
C2 </= 7 mm
C7: • Kids < 14 mm • Adults < 22 mm |
|
|
What is a sensitive indicator of underlying chest injury in pediatric trauma?
|
Presence of a RIB FX.
Children have relatively compliant chest walls and may not show external evidence of serious intrathoracic trauma. |
|
|
State the normal vaginal fluid pH, and the pH of amniotic fluid?
|
pH of 7: suggestive of AMNIOTIC FLUID
pH of 5: consistent with VAGINAL SECRETIONS |
|
|
What is the methylprednisolone protocol for suspected pediatric spinal cord injury?
|
Loading dose: 30 mg/kg over 15 min. Should be given within 8 hrs of injury.
Maintenance dose: 5.4 mg/kg, begun 45 min after the 15 min initial bolus given. If steroids begun within 3 hr of injury, tx is for 24 hrs. If steriods begun within 3-8 hours of injury, tx is for 48 hours. |
|
|
Anterior wedge fxs are in general STABLE fxs. What subset are potentially unstable?
|
Fxs that involve > 50% of the height of the vertebral body
|
|
|
Define Class II hemorrhage and state the clinic findings
|
Class II:
• 15 - 30% blood loss • 750 - 1500 cc Findings: • Tachycardia • Narrow pulse pressure with NORMAL systolic pressure • Delayed capillary refill |
|
|
In TRAUMATIC myocardial infarction, what medicines are contraindicated?
|
THROMBOLYTICS!
The myocardium is contused and presumed to have some degree of bleeding |
|
|
What threshold for Pediatric Trauma Score (PTS) and Revised Trauma Score (RTS) should transfer to a pediatric trauma center be considered?
|
PTS < 8
RTS < 12 |
|
|
What is the relative risk of SCI in thoracic vs cervical or lumbar spine injuries? Why?
|
T-SPINE injuries are less common but usually cause SIGNIFICANT INJURY
Reason: • T-spine canal is relatively NARROW --> larger spinal cord diameter relative to canal diameter |
|
|
What is a Jefferson fracture? Mechanism?
Associated spinal cord injury? |
Blowout fx of the C1 ring
Mechanism -- AXIAL load Although unstable, SCI usually is NOT SEEN |
|
|
What is the correlation between the severity of MATERNAL injury and fetal distress in trauma patients?
|
In traumatic events (particularly apparently minor ones), the severity of maternal injury may be a POOR PREDICTOR of fetal distress and outcome
|
|
|
In electrical shock, what organ system is the preferential path for conduction?
|
The electrical/ nervous system
|
|
|
What are the CXR findings with traumatic aortic rupture?
|
• DEVIATION of the ESOPHAGUS more than 1-2 cm to the right of the spinous process at T4
Note: NGT IN NORMAL POSITION virtually EXCLUDES traumatic aortic rupture! • Widened mediastinum • Depression of the LEFT mainstem bronchus > 40° below horizontal • LEFT apical pleural cap (obliteration of the medial aspect of the left upper lobe apex) • Widening of the paratracheal stripe to the RIGHT • Multiple rib fxs (especially 1st and 2nd) • Blunting of the aortic knob |
|
|
What is the mechanism, etiology and symptoms of CENTRAL CORD syndrome?
|
Etiology:
• HyperEXTENSION injuries in arthritic older adults; • Disruption of blood flow to the SC; • Cervical spine STENOSIS predisposes to this injury Symptoms: • FLACCID paralysis, UE > LE and distal > proximal muscle groups • Loss of PAIN and TEMPURATURE (UE > LE) SACRAL SPARING is usually noted, but severe injury may cause decreased rectal tone |
|
|
What is the 'transition zone' between thoracic and lumbar vertebrae, and what is its significance?
|
T11 - L2: transition between the FIXED thoracic vertebrae and the MOBILE lumbar vertebrae.
This is the MOST VULNERABLE site for traumatic injuries. Cord injuries here are typically LESS SEVERE because the width of the canal is greater. |
|
|
What is the role of ED thoracotomy in BLUNT trauma patients?
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NO ROLE!
ED thoracotomy should be reserved for PENETRATING trauma pts who lose signs of life either enroute or in the ED |
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What DPL approach should be performed on a pregnant patient?
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The DPL should be performed with an OPEN, SUPRAUMBILICAL technique.
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What are the contraindications to nasotracheal intubation?
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Midface and basilar skull fxs
APNEA -- pt must be spontaneously breathing for the procedure to be successful |
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What is the most common anatomic site of blunt traumatic aortic rupture?
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Ligamentum arteriosum just distal to the left subclavian artery off the DESCENDING AORTA
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What are the characteristics of SPINAL SHOCK?
What is the first reflex to return? |
• Initial LOSS of all REFLEX activities and sensation
• FLACCID PARALYSIS • LOSS OF RECTAL TONE Spinal shock generally resolves over 24-48 hours with the return of the BULBOCAVERNOSUS reflex occuring first Patients are typically WARM, peripherally VASODILATED, BRADYCARDIC and HYPOTENSIVE. Note: SCI cannot be deemed complete until the window for spinal shock has completely closed |
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What does a boggy prostate indicate?
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Assume URETHRAL DISRUPTION. A Foley should NOT be placed.
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What is the most common site of vertebral fracture in FALLS?
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The thoracolumbar junction, T12-L2
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Discuss the typical etiology, history, and CT findings of SUBDURAL HEMATOMA (acute & chronic)
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Etiology -- Sudden accel-decel of brain parenchyma with tearing of the BRIDGING VEINS --> blood clots between dura and arachnoid
Acute SDH -- sx develop within 14 days of injury Chronic SDH -- > 2 weeks CT -- Acute: • Hyperdense (white) CRESCENT-SHAPED lesion that CROSSES suture lines CT -- Chronic: • Hypodense (dark) lesion as the iron in the blood is phagocytized |
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What are contraindications to organ donation?
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Age > 80
Death 2° to 'TIC exposure': • TOXIC exposure • INFECTIOUS dz • CA (although corneas can still be harvested) |
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Discuss the typical location of spinal injuries in children vs adolescents and adults
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Children < 12 yo -- 50% of spine injuries, and 67% of cervical spine injuries, occur BETWEEN OCCIPUT AND C2
Adolescents & Adult -- Typically experience LOWER CERVICAL injuries |
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What is the relationship between maternal blood loss, maternal vital signs, and fetal blood flow in the setting of trauma?
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A pregnant woman can lose 30-35% of total blood volume before she manifests sx of hypotension and shock.
Uterine arteries constrict, restricting fetal blood flow, before maternal hypotension is evident. |
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At what fetal age does radiologic imaging have the greatest adverse effect on:
1) Fetal viability and 2) Fetal malformation 3) Neuropathology? |
VIABILITY risk --
• weeks 1 & 2 TERATOGENESIS risk -- • weeks 2-8 NEUROpathology risk -- • weeks 8-15 |
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For pediatric patients in shock, what is the fluid resuscitative protocol?
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Give up to three 20 ml/kg boluses of crystalloid. If still hypotensive, give PRBC in boluses of 10 ml/kg.
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What is the NEXUS criteria for obtaining C-spine films?
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C-spine films required if ANY of the following present:
1) Posterior midline C-spine TTP 2) Intoxication 3) Altered mental status 4) Focal neurologic deficit 5) Painful distracting injury |
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What potential adverse effect does tetanus prophylaxis have on the fetus?
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NONE! Perfectly safe.
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What are the cardiovascular effects of SCI at the cervical and thoracic levels?
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SYMPATHETIC DENERVATION -->
Loss of alpha tone --> 1) arterial and venous DILATION --> Hypotension, WARM extremities 2) unopposed parasympathetic tone --> BRADYCARDIA NOTE: BLOOD LOSS must be presumed to be the cause of hypotension until proven otherwise. |
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Describe the symptoms, CT findings, and initial pharmacological management of Subarachnoid Hemorrhage (SAH)
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Presentation -- Blood in the CSF, HA, photophobia and mild meningeal signs
CT -- Blood in the cisterns Management: • NIMODIPINE reduces the likelihood of death or severe disability by 50% • Use NIFEDIPINE for BP control |
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What is the mechanism of injury of vertebral wedge fractures?
Neurologic sxs? Column(s) affected? Stable or unstable? |
• Wedge fxs result from FLEXION injury
• No neuro deficit • Column affected -- ANTERIOR only • Stable, unless > 50% of vertebral height involved |
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Define Class IV hemorrhage and state the clinic findings
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Class IV:
• > 40% blood loss • > 2000 cc Findings: • Obvious shock |
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After how many hours of warm ischemia do extremities begin to exhibit irreversible ischemia?
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6 hours
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What is the most common site of injury in mycardial contusion?
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RV (because it is most anterior)
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What is the incidence of fetal-maternal hemorrhage in the setting of signficant trauma?
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FMH occurs in OVER 30% of pregnant patients with signficant trauma
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Discuss pancreatic injury in children. How common?
Typical mechanism of injury? Utility in measuring pancreatic enzymes? |
Pancreatic injury is UNCOMMON in children.
TRAUMA is the most common cause of pancreatitis in children, most often from HANDLEBAR injuries. AMYLASE is often elevated, but the degree of elevation does not correlate with the degree of pancreatic injury. |
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What is a Hangman's fracture? Mechanism?
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Bipeduncular fx of C2
Mechanism -- Extreme hyper-EXTENSION from: • JUDICIAL hangings • High velocity MVA |
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What is the treatment protocol for hypertensive emergency + aortic dissection?
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Drugs of choice:
• IV ß-blocker (esmolol, propranolol) + • IV Nipride Give ß-blocker first to minimize reflex tachcardia associated w/ Nipride Other agents: • Labetolol IV |
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What are the symptoms of vascular injury 2° to blunt neck trauma, and when do they most commonly occur following trauma?
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Sx of carotid artery dissection or thrombosis:
• Stroke-like sxs Occur between 1 and 24 hours after injury |
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When should ED thoracotomy be considered in both blunt and penetrating PEDIATRIC trauma?
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Open thoracotomy should ONLY BE CONSIDERED in children with PENETRATING trauma who experience LOSS OF VITAL SIGN IN THE ER.
There is NO ROLE for thoracotomy in BLUNT trauma with no vital signs on presentation to the ED. |
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What test determines the presence of fetal cells in the maternal circulation?
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Kleinhauer-Betke test
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What percent of major blunt trauma in pregnant women results in placental abruption?
In blunt trauma, what percent of all fetal losses result from placental abruption? |
% of major trauma w/ abruption -- 40%
% of fetal loss from abruption -- 50-70% |
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Define Class I hemorrhage and state the clinic findings
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Class I:
• 0 - 15% blood loss • 0 - 750 cc Findings: • Slight increase in HR (< 100) |
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Of the following factors, which is the best predictor of identifying traumatic abnormality on head CT in a well-appearing INFANT s/p blunt head injury:
• Age • LOC • Sz • Vomiting |
AGE is the best predictor. The YOUNGER the age, the greater likelihood of findings.
All the other factors are poorly sensitive and specific. |
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What is the mechanism of injury of transverse process fractures?
Neurologic deficits? Stable or unstable? |
• Result from FLEXION injury
• No neuro deficit • Stable |
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In an uncooperative pt with moderte TBI (GCS of 9-13), how should the ERP proceed?
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The ERP should INTUBATE with a short-acting paralytic, then obtain CT of the head
Sedation alone is ineffective and should be used INFREQUENTLY |
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Regarding LUMBAR vertebral flexion-distraction fractures, describe the:
• Mechanism of injury • Typical location of fracture • Typical stability |
Mechanism -- seat belt injuries with typically the lap belt alone
Location: -- POSTERIOR AND MIDDLE COLUMNS. The intact anterior column prevents subluxation Stability: unstable |
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What is the most common cause of injury in the elderly?
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Falls
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Where is the preferred site for intraosseous line placement in an ADULT pt?
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Distal tibia just proximal to the medial malleolus
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Why is cricothyroidotomy contraindicated in young children?
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• The cricothyroid membrane is the NARROWEST level of the pediatric airway
• Risk of significant BLEEDING --The cricothryoid artery extends horizontally over the membrane |
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What are the signs and sxs of traumatic aortic rupture?
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Sxs:
• Retrosternal or interscapular pain Signs: • Harsh systolic murmur of AR • Upper extremity HTN with DECREASED femoral pulses • Pulse deficits • Voice change in the absence of laryngeal injury • Ischemic pain in the extremities • Paraplegia |
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What is the AVPU system for documenting level of consciousness?
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A: Alert
V: responds to verbal stimuli P: responds to painful stimuli U: Unresponsive Scoring is either yes or no. |
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What is the incidence of post-traumatic pediatric head injury seizures, and what is the role of seizure prophylaxis?
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Sz occur in 5% of hospitalized pts. Of these:
• 50% will NEVER have another sz • 25% will have RARE sz • 25% will have FREQUENT sz Tx -- Controversial for 0 or 1 sz. DO treat: • 2 or more sz • Sz lasting > few minutes • GCS < 8 (even w/o any noted sz activity) Proximity of sz to the event predicts long-term risk of epilepsy; immediate sz = less risk. |
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What organs are most commonly injured in BLUNT and PENETRATING trauma?
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Blunt:
1) Spleen 2) Liver 3) Kidney Penetrating: 1) Small bowel 2) Liver 3) Colon |
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What is the methyprednisolone protocol for suspected SCI? What is thought to be its neuroprotective mechanism? What is its role is PENETRATING trauma?
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Treatment must be started within 8 hours of injury.
Initial bolus: 30 mg/kg over 15 minutes; 45 minute pause 5.4 mg/kg/hr over 23 hours Mechanism: inhibition of free radical-induced lipid peroxidation. Steroid therapy has NOT BEEN SHOW TO BE EFFECTIVE in penetrating SCI. |
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Injury to which neck zone is most ammenable to surgery?
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Zone II due to the relatively uncomplicated surgical exposure and vascular control
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What is normal ICP?
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ICP < 15 mm is normal
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Nasotracheal intubation is contraindicated in children under what age?
Uncuffed ET tubes are indicated in children less than what age? |
< 9 yo for both
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What are the characteristics of dorsal column injury?
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IPSILATERAL loss of vibration and proprioception
NOTE: Light touch is transmitted through both the dorsal columns AND spinothalamic tracts |
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What is the test for the BULBOCAVERNOSIS reflex and the CREMASTERIC reflex?
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Bulbocavernosis: The penis is squeezed to see if the anal sphincter simultaneously contracts.
Cremasteric: Run a pin or blunt instrument up the inside of the thigh; observe for scrotal rise. |
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With what level spinal cord injury should a patient routinely be intubated? Why?
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C5 or above.
The roots of the phrenic nerve which supply the diaphragm emerge at the 3rd, 4th and 5th cervical vertebrae. |
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What is the trauma algorhythm for patients with blood at the urethral meatus?
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Retrograde urethrogram -->
If normal, insert Foley --> Retrograde cystogram to evaluate for bladder injury |
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What are the findings of a basilar skull fracture?
Where is the fracture typically located? Are antibiotics recommended? |
Most common site -- petrous portion of temporal bone
Commonly associated with torn dura and CSF LEAK FROM THE EAR Findings: • Battle sign (mastoid ecchymosis) • Racoon eyes • Hemotympanum • Vertigo • Decreased hearing • 7th nerve palsy Basilar skull fx can lead to MENINGITIS. Prophylactic abx are recommended: 3rd GENERATION CEPHALOSPORIN. |
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Identify the three-column classification of thoracolumbar injuries. What defines an UNSTABLE fracture?
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Anterior Column -- anterior vertebral body + anterior longitudinal ligament
Middle Column -- posterior wall of the vertebral body + posterior longitudinal ligament Posterior Column -- the bony complex of the vertebral body + posterior ligamentous complex UNSTABLE Fx -- must have disruption of 2 columns. Vertebral compression fx of > 50% are generally considered unstable. |
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Discuss the symptoms and COMPLICATIONS of abruptio placentae in trauma.
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Findings:
• PAINFUL vaginal bleeding • TETANIC uterine contractions Consequences: • Fetal death • DIC • AMNIOTIC FLUID EMBOLISM from the introduction of placental contents into the maternal circulation |
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In general, which organs are most likely to be damaged by blast injuries, hollow or solid?
Other than TM perf, which organ is most susceptible to damage? |
AIR-FILLED >> solid
• Large bowel rupture is common The LUNGS are most severely affected NOTE: In UNDERWATER explosions, SOLID organs are most susceptible to injury. |
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What is a Clay-Shoveller's fracture? Mechanism?
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Avulsion fx of the spinous process of C6 - T3 (C7 is most common)
Mechanism -- Forceful FLEXION against cervical neck muscle resistance |
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During an ED thoracotomy, which nerve is at risk for transection and must be identified to preclude injury?
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LEFT PHRENIC NERVE
This nerve should be VISUALIZED after the chest is open and immediately prior to performing a PERICARDOTOMY. |
