Acute 2 Flashcards
Acute and self-limited inflammation of the trachea and major bronchi, presenting with cough and sputum production
acute bronchitis
complication from acute bronchhtis
if they have any focal consolidation- in the xray and it goes deeper and causes pneumonia ***
lower airways- then gas exchange is the problem
tx for acute bronchitis
mucolytics hydration, symptoms management
ANTIMICROBIAL Stewardship
prescribing antibiotics for a viral bronchitis
a cough for about 3 weeks, we do not worry about self-limiting it will clear up on its own
Presence of a chronic cough with excessive sputum production for at least 3 months or more per year in 2 or more consecutive years.
chronic bronchitis
Wheezing, cough and shortness of breath are key components of the disease process
asthma
hypersensitivty reaction asthma
type 1
triggers for asthma
allergens environments, medication related, infections, psychological factors
Airway narrowing
Contraction of smooth muscles (Bronchospasms)
Viscid mucus plugs in the airway
Thickening of bronchial mucosa from edema, cellular infiltration, and hyperplasia of secretory/vascular/ smooth muscle cells
Halting speech, AMS, restlessness, agitation, sitting straight up, diaphoresis, tachypnea, tachycardia
acute asthma exacerbation
Halting speech, AMS, restlessness, agitation, sitting straight up, diaphoresis, tachypnea, tachycardia can all be a sign of what
hypoxia
mild intermittent asthma symptoms
<2 days/week
-Short-acting beta agonist used < 2 times/month
differential diagnosis for asthma
foreign body aspiration
TB, Aspergillosis
Hypersensitivity or aspiration pneumonitis
BB, ACE-I
COPD
CHF
Pulmonary Embolism
hypoxia is defined as
sao2 <88%
hypxemia is defined as
pao2<55
clinical indication for considering a diagnosis of COPD
persistent
late findings of COPD
air trapping, hyperronance, reduced breath sounds
clubbing
pursed lip breathing
neck vein distention
fatigue, pedal ankle edema- cor pulmonale right sided heart failure
diagnostic tests ofr copd
post bronchodilator <70% for copd; after the bronchodilation that is COPD
CAT copd questionnaire 10 or greater
chest xray
chest ct- can rule out lung cancer, check tumors cause smoking can cause lung cancer
e in copd
> 2 moderate exacerrbaiton or > 1 leading to hospitalations
0-1 moderate exacerbations (not leading to hospitalization) cat <10
a
0-1 moderate exacerbations (not leading to hospitalization) cat >10
B
group a treatment copd
bronchodilator
group b treatment copd
LABA and LAMA
group e treatment copd
LABA LAMA ( eosinophils> 300 consider ICS steroids for these patients
The strategies to help the patient quit smoking include
5 a’s
ask, advice, assess, assist and arrange
patients on LABA LAMA and ICS still having an exacerbation
roflumilast fev <50% there’s a problem poorly tolerated, bad n/v/d
azithromycin anti-inflammatory not antibacterial effects; former smoker if they have a lot of mucus
is eosinophils dupilumab chronic bronchitis also for allergic rhinitis, atopic dermatitis
oxygen therapy in stable copd
dont need to saturating 100%; resting oxygen at sea level does not exclude the development of severe hypoxemia when traveling by air; evidence a
oxygen wash out surfactant
collapse of the alevoli
potential indications for hospitalization assessment for copd
severe symptoms sudden worsening of resting dyspnea, high rr, dec oxygen saturation, confusio, drowiness, acute respirtoy failure, cyanosis peripheral edema, failure of an exacerbation to initial management, presence of serious comorbidities (heart failure,)
smoking cessation pharmacological therapies
Oral agents
Bupropion-ssnri, wellbutin can help
Varenicline- most effective decrease craving and withdrawal symptom dopamine effect produced by smoking, reduce withdrawal; can have psychotic episodes and vivid crazy dreams
Nicotine replacement
OTC
Patch, gum, lozenges
Prescription
Nasal spray, inhaler
non invasive positive ventilation
may improve hospitalization free survival in selected patients after recent hospitalization persistent hypercapnia
potential indications for hospitalization assessment for copd- speicifc to ICU
confusion, lethary cona, vomit aspirate, severe dyspnea, acidois ph 7.25, hypoxia despite oxygen and NPV
hypotensive baroreceptors do not work to constrict
Periodic Cough with production of copius sputum
bronchiectasis
Etiology- Post-inflammatory
After severe pneumonia
After obstruction of a bronchus by a foreign body
After healing of tuberculosis
bronchiectasis
Physical Exam
Inspiratory rhonchi during acute exacerbations
Noisy expiration, scattered wheezing
bronchiectasis
Which of the following pharmacological agents may be used to treat nicotine dependence?
Hypnosis
Varenicline
Midazolam
Hydralazine
varenicline
Systemic steroid treatment is indicated in patients with COPD to treat which of the following?
Stable COPD
Decreases in FEV1
Bronchial mucosal congestion and edema
Acute COPD exacerbations
None of the above
acute copd exacerbation
xray of bronchiectasis
honeycomb
When treating bronchiectasis, which of the following therapies is used to improve ciliary function and airway clearance?
Antibiotic therapy
Bronchodilator therapy
Chest physiotherapy
Mucolytic therapy
all of the above
risk factors for the development of lung cancer include
> 55 y, smoking >30 y; presenece of emphysema by ct, bmi <25, family hx and the presence of airflow limitation fev1/fvc<0.7
An autosomal recessive disorder which results in multisystem exocrine organ dysfunction
cystic fibrosis
Thickened secretions in the lungs, pancreatic and biliary ducts lead to chronic respiratory infections, maldigestion, malabsorption, and occasionally, liver disease and diabetes
CF
Typically diagnosed in childhood >10yrs (newborn screening)
CF
diagnostic for CF
skin sweat testing, genetic tests, transepithelial nasal potential difference, testing sputum cultures, malabsorption testing, abnormal chest xray, PFTs with expiratory airflow obstruction
symtoms of CF
cough with sputum, FTT malnutrition, steatorrhea
physical exam for CF
underweight, inspiratory crackles, digital clubbing
Peumonia that occurs 48 hours or more after admission, which was not incubating at the time of admission
HAP
Pneumonia that arises more than 48–72 hours after endotracheal intubation
VAP
treatment for MRSA CAP
vanco and linezolid
PSA CAP treatment
meropenem, imipenem, aztreonam, zosyn, cefepime or ceftrazadine
penem, z, z, cx2
wihtout comorbidities treatment of a CAP
DAM
DOXYCYCLINE, AMOXACILLIAN OR MACROLIDE
Specific high-risk populations patients AT RISK FOR VAP
– COPD*
– ARDS*
– serum albumin level less than 2.2 g/dL (FLUID SHIFTING INTO THE LUNGS)
– Patients requiring intracranial pressure monitoring
- Burns or trauma
- APACHE IV* HOW WE INDENTIFY ICU ACUTE PSHYOLOGIC HEALTH ASSESSMENT, UNDERLYING DISEASES INCREASES THEIR MORTALIITY RISK
bugs:
Streptococcus pneumoniae,
Haemophilus influenzae,
Legionella pneumophila,
Staphylococcus aureus
Viral pneumonia
Mycoplasma pneumonia (“walking pneumonia”)
Chlamydia pneumoniae
Anaerobic pneumonia
Nosocomial bacterial pneumonias
Pneumocystis jirovecii pneumonia,
cytomegalic inclusion virus (CMV)
community acquired pna
Lower respiratory tract infection not acquired in a hospital, long term facility or during recent interaction with a healthcare system.
An acute pulmonary infection of the parenchyma of lung involving the alveoli and the interstitial tissue spaces producing lung field consolidation
cap
testing Urine Antigen for Streptococcus & Legionella
cap
what would you hear on ausculatation of a pna dx
crackles or rhonchi if they are able to clear the secretions
nonpharmacological tx for pna
Hydration
Rest during acute episode and then increase activity slowly
Chest physiotherapy for bacterial pneumonia
O2 Sat >90%
CAP TX WITH ANTIBIOTICS IF THEY DO HAVE A CO MORBIDIEITY
RESP FLUROQUINOLONE OR
AC +DM
AMOXICILLIN/CLAVULANATE OR CEPHALOSPORIN + MACROLIDE/DOXYCYLINE
cap tx antibiotics without comormidities
DAM; DOXYCYCLINE, AMOXACILLAN OR A MACROLIDE
GASTRIC CONTENTS, BACTERIA FROM ORAL, FORGIEN BODY; CHEMICAL OR BACTERIAL
ASPIRATION
TREATMENT FOR ASP. PNA
Only add anaerobic abx if abscess or empyema
Ampicillin/sulbactam 3 gram IV QID
Ceftriaxone 1 gram and Metronidazole
Pip/Tazo 4.5 gm IV TID
WHEN DO YOU CONSULT, REFER OR HOSPITALIZE
MINOR CRITERIA- HYPOTNE, HYPOTHERMIA, LEUKOPENIA, UREMIA, PF RATIO <250, RR >30, CONFUSION DISORIENTATION, MULTILOBAR PNA, THROMBOCYTOPENIA
MAJOR CRITERIA - SEPTIC SHOCK NEED FOR VASOPRESSOR; RESPIRATORY FAILURE REQUIRING MECHANICAL VENTILATION
ONE MAJOR OR THREE MINOR
VAP: Predisposing Factors
Single greater risk is the number of days on mechanical ventilator
VAP: Etiologic Agents
Several studies have reported that greater than 60% of VAP are caused by aerobic, gram-negative bacilli:
Pseudomona aeroginosa,
– Escherichia coli
– Klebsiella pnumoniae
– Acinetobacter species
More recently gram-positive bacteria have become more common: FOR VAP
S. aureus being the predominant isolate
Specific high-risk populations patients FOR VAP
COPD
– ARDS
– serum albumin level less than 2.2 g/dL,
– Patients requiring intracranial pressure monitoring
- Burns or trauma
- APACHE IV
Infective and infected, symptomatic
A few weeks after their initial or years later when latent becomes reactivated; example by stress, steroids, something reactivates the TB
ACTIVE TB
Fever, night sweats, fatigue, cachexia, cough, hemoptysis
TB
CHECK SPUTUM
CXRAY
ACIDE FAST BACILLI
QUANTIFEREON
VAP Bundle
Avoid intubation & prevent reintubation
Use HFNC or NIPPV
HOB > 30° (unless contraindicated)
Oral Care w/toothbrushing
Early enteral vs parenteral nutrition-FEED THE GUT KEEP GOOD FLORA NO TRANSLOCATE OR MOVE INTO THE LUNGS
Minimize sedation
Physical conditioning
Ventilator liberation protocol-SEDATION HOLIDAY DE-ESCALATION OF THE VENT
Change ventilator circuit only if needed
____________can be used in the clinic or emergency department setting to risk stratify a patient’s community acquired pneumonia.
Higher risk of mortality
pneumonia severity index for CAP
Age, sex, nursing home resident, neoplastic disease,CHF hx, cerebrovascular disease hx, renal disease, AMS, temperature extremtiies, pleural effusions
Mortality risk assessment tool=The PSI/PORT Score
what kind of pneumonia:
Cough
Headache
Sore throat
Excessive sweating
Fever
Chest soreness
ATYPICAL
WHAT KIND OF PNEUMONIA?
Fever/shaking chills
Purulent sputum
Malaise
Lung consolidation on physical exam
Increased fremitus, increased you can hear “99”
TYPICAL
NON-PHARM TX FOR PNEUMONIA?
Hydration
Clear the secretions
Rest during acute episode and then increase activity slowly
Chest physiotherapy for bacterial pneumonia
O2 Sat >90%
An 82-year-old female with fever (100.5° F), chills, productive cough and purulent sputum presents to your clinic. She complains of pleuritic chest pain with dyspnea and cough. You suspect CAP. What diagnostic would you obtain to confirm this diagnosis?
Blood culture
Chest x-ray
Sputum culture
Complete blood count
CHEST XRAY
The values of expiratory flow in asthma will be:
Increased
Decreased
Normal
Of little value
DECREASED
> 2 days/week but not daily
-Short acting beta agonist used > 2 times/week but not daily
-Minor limitations in normal activity
STAGE 2 MILD PERSISTENT
-Daily symptoms
-Depending on age, daily use of SABA
-Some limitation in normal activity
MODERATE
Symptoms throughout day
SABA used several times/day
Extremely limited normal activity
SEVERE PERSISTENT
<2 days/week
-Short-acting beta agonist used < 2 times/month
MILD INTERMITTENT
< 2 times/month NIGHTTIME SYMPTOMS FOR ASTHMA
MILD INTERMITTENT
NIGHTTIME SYMPTOMS FOR ASTHMA
> ONCE A WEEK
SEVERE
WAKING UP AT NIGHT
Subjective sensation of pain involving any part of the head, including the scalp, face, sinuses or teeth and cranium or cerebrum; with or without associated symptoms (aura)
headache
headache
Subjective sensation of pain involving any part of the head, including the scalp, face, sinuses or teeth and cranium or cerebrum; with or without associated symptoms (aura)
throbbing headache
migraine
more often in males, headache
cluster
common migraine triggers slide 12 table
alcohol exercise without proper hydration chocolate cheeses aged, light menses, oral contraceptives, smoking, stress, weather changes, red wine, odors like perfumes
first line treatment for migraines
nsaids aspirin ibrophen tylenol
stop before it becomes more complex with n/v
at 4 or 5 headaches a month
can give prophylaxic treatment
prophylactic therapy 4 to 5 days more severe type of pain for first line are the _______
triptans
Serotonin receptor agonist
Effective abortive medication
May be effective in a protracted attack
Sumatriptan (Imitrex)-first line therapy for acute severe migraine attacks
Do not use in pts at risk for CAD
triptans
triptans
Serotonin receptor agonist
Effective abortive medication
May be effective in a protracted attack
Sumatriptan (Imitrex)-first line therapy for acute severe migraine attacks
Do not use in pts at risk for CAD
triptan can cause ______ a problem for patients with hypertension dn a hx of stroke
vasoconstriction
prevention of ischemia stroke
modifiable risk factors slide 25
medication overuse criteria table slide 17
acute ischemic stroke management slide 37
blood pressure management
fibrnolytic, antiplateletes, lmwh, warfarin for afib and keep inr 2-3 and
pradaxa elqiuis and xarelto ( after the stroke to not have another one)
______ hr window
intiial window 3 hours, now we can go into a longer window
monroe kellie hypothesis
csf and brain tisue and blood
cerebral autoregulation
cerebral perfusion pressure
nomral about 50-160
usually see it around
icp nomral
around 10 and we worry when its >15 to 20
things that cause vasodilation in icp/in the brain
hypotehrmia, hypotension, acidosis and hypercarbia
causes of vasoconstriction in the cerebral blood flow
hypertension alkalosis and hypocarbia
make sure you know how to calculate the GCS
epidural hematoma classic presentation
loss of conciousness, lucid intevral
the atery is expanding hematoma
often fracture of the temporal bone and rupture of the middle meningeal artery
epidural hematoma
you pass out at the scene what dx test do you get?
ct brain possible epidural hematoma
first line therapy for depression
ssri
ssri box warning
suicidal thoughts
have the energy to carry out the plan of suicide
about 4 weeks after starting the tx
ssri treat what psychosocial multi diagnoses
ocd, ptsd, depression, anxiety
could be a mixed diagnosis
when would you use snris?
second tx
venlafaxine
Cymbalta
can make the patient have a withsdrawl effect if we stop abruptly
signs and symptoms of seritonin syndrome
SHIVERS
can you mix maois
WITH OTHER SSRI OR SNRIS AND DRUG AND FOOD INTERACTIONS
foods to avoid when taking moais ?
TYRAMINE PRODUCE RICH MEAT WINES ORGAN MEAT WINE CHEESES
carbohydrate-deficient transferrin
low in non alcohol and it will be higher in patients with heavier
carrier protin of iron and disrupted by iron binding ?
WITHDRAWL FROM ALCOHOL HAPPENS AROUND DAY?
5-8 LOOKING FOR SIGNS OF DTS
Carbohydrate deficient transferrin (CDT)
prolonged greater than 4-5 days or weeks, carrier protein disrupted
is usually low in non alcoholics
Carbohydrate deficient transferrin (CDT) is useful for determining recent alcohol consumption.
Alcohol is eliminated from the body by various metabolic mechanisms, including aldehyde dehydrogenase (ALDH), alcohol dehydrogenase (ADH), cytochrome P450 (CYP2E1), and catalase.
Meals high in fat, carbohydrate, or protein can affect the absorption rate of alcohol.
Transamination is the transfer of an amine group from an amino acid to a keto acid, creating a new amino acid and keto acid.
clinical physical exam of a patient with anxiety?
HIGH BP HR TACHY TREMORS DIAPHORESIS ACUTELY
PUPIL DILATED
schizophrenia episodes are linked with
bipolar/mania hyper manic linked with ?
exacerrbation may occur with acutre agitation when exposed to ?
stress
CAGE SCREENING
CUT DOWN, ANNOYED, GUILTY AND THE EYE OPENER*
GREATER THAN 2 IS CLINICALLY SIGNIFICANT
COULD ALSO BE USED FOR DRUG ABUSE AS WELL
MAX SCORE OF THE CIWA
67
we dont want them to go through withdrawl in the hospital
fixed regimen
greatest risk of death happens with
alcohol withdrawal
drugs used in an alcohol withdrawal
LDC
LARGE DIET COKE
Chlordiazepoxide 0.5mg/kg at 12.5mg/min or
Diazepam 0.15mg/kg at 2.5mg/minute or
Lorazepam 0.1mg/kg at 2.0 mg/minute
Titrate to pts. needs once pt. is calm
A change in cognition not due to preexisting, established, or evolving dementia with an onset which develops over a short period and tends to fluctuate during the course of the day
DELIRIUM
Acute onset of confusion, excitement, incoherent speech, and agitation
DELIRIUM
ABCDEF BUNDLE SCCM
Awakening Trial
Breathing Trial
Coordination/Choice of analgesia and sedation
Delirium prevention and management
Early physical mobility
Family engagement
MEDICATIONS FOR DELIIRUM
ICU acquired and post-op delirium treatment of choice is haloperidol
For delirium accompanying alcohol withdrawal or cocaine induced delirium, benzo’s are preferred
Delirium tremens and HTN adjunctive therapy with clonidine can augment sedative effect of a benzo while decreasing bp
SEVERE DISTRESS OF DELIRIUM TREATMENT
HALDOL
STAY AWAY FROM THE BENZOS
And another option is olanzipime
A common form of delirium in the elderly characterized by lethargy rather than agitation
A source of missed diagnoses of delirium in many pt.’s
HYPOACTIVE DELIRIUM
HYPOACTIVE DELIRIUM
A common form of delirium in the elderly characterized by lethargy rather than agitation
A source of missed diagnoses of delirium in many pt.’s
Dementia
Onset is gradual and Stedy
Impairment of memory and confusion unable to do ADLS
Alzheimer’s is the most common type of dementia
Clinical manifestations of dementia
Slow over months to years. Confusion memory deficits misplacing things
The As
Aphasia
Apraxia
Agnosia ability to recognize objects
Criteria for dementia
Take a history do a physical exam
Executive functioning and thinking
This is decreased in dementia cannot carry out ??? Look this up again
First line therapy for dementia
Cholinesterase inhibitors
Donezapil is aricept
Rivaatihmone is exelon we give this with food to increase absorption since they tend to have significant weight loss on this med
Can also give memantine which is nameda it is a methyl aspartate receptors agonist
Dementia management
Dopamine agonist
Carbamazepine (tegretol)
Imipramine (impril)
Trazadone (deseryl)
Hypo and hypermania in bipolar mania acute subjective findings
Rapid pressured speech and racing thoughts physician hyperactivity history of not sleeping extreme impatience insistence on directing treatment and anger and aggressive
_________ can cause acute agitation to flare up and or precipitate the first episode
Extreme stress and serious illnesses can exacerbate schizophrenia or mania episodes
Discontinue these two drugs if you see qtc prolongation
Olanzapine and haldol
Medication overuse criteria
headache occurring greater than 15 days a month
Regular overuse of medication greater than 3 months or more than one drug
These drugs are effective abortive medications and useful in a protracted attack
Triptans
