Acute 2 Flashcards
1
Q
Acute and self-limited inflammation of the trachea and major bronchi, presenting with cough and sputum production
A
acute bronchitis
2
Q
complication from acute bronchhtis
A
if they have any focal consolidation- in the xray and it goes deeper and causes pneumonia ***
lower airways- then gas exchange is the problem
3
Q
tx for acute bronchitis
A
mucolytics hydration, symptoms management
4
Q
ANTIMICROBIAL Stewardship
A
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
5
Q
Presence of a chronic cough with excessive sputum production for at least 3 months or more per year in 2 or more consecutive years.
A
chronic bronchitis
6
Q
Wheezing, cough and shortness of breath are key components of the disease process
A
asthma
7
Q
hypersensitivty reaction asthma
A
type 1
8
Q
triggers for asthma
A
allergens environments, medication related, infections, psychological factors
9
Q
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
A
acute asthma exacerbation
10
Q
Halting speech, AMS, restlessness, agitation, sitting straight up, diaphoresis, tachypnea, tachycardia can all be a sign of what
A
hypoxia
11
Q
mild intermittent asthma symptoms
A
<2 days/week
-Short-acting beta agonist used < 2 times/month
12
Q
differential diagnosis for asthma
A
foreign body aspiration
TB, Aspergillosis
Hypersensitivity or aspiration pneumonitis
BB, ACE-I
COPD
CHF
Pulmonary Embolism
13
Q
hypoxia is defined as
A
sao2 <88%
14
Q
hypxemia is defined as
A
pao2<55
15
Q
clinical indication for considering a diagnosis of COPD
A
persistent
16
Q
late findings of COPD
A
air trapping, hyperronance, reduced breath sounds
clubbing
pursed lip breathing
neck vein distention
fatigue, pedal ankle edema- cor pulmonale right sided heart failure
17
Q
diagnostic tests ofr copd
A
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
18
Q
e in copd
A
> 2 moderate exacerrbaiton or > 1 leading to hospitalations
19
Q
0-1 moderate exacerbations (not leading to hospitalization) cat <10
A
a
20
Q
0-1 moderate exacerbations (not leading to hospitalization) cat >10
A
B
21
Q
group a treatment copd
A
bronchodilator
22
Q
group b treatment copd
A
LABA and LAMA
23
Q
group e treatment copd
A
LABA LAMA ( eosinophils> 300 consider ICS steroids for these patients
24
Q
The strategies to help the patient quit smoking include
A
5 a’s
ask, advice, assess, assist and arrange
25
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
26
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
27
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,)
28
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
29
non invasive positive ventilation
may improve hospitalization free survival in selected patients after recent hospitalization persistent hypercapnia
30
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
31
Periodic Cough with production of copius sputum
bronchiectasis
32
Etiology- Post-inflammatory
After severe pneumonia
After obstruction of a bronchus by a foreign body
After healing of tuberculosis
bronchiectasis
33
Physical Exam
Inspiratory rhonchi during acute exacerbations
Noisy expiration, scattered wheezing
bronchiectasis
34
Which of the following pharmacological agents may be used to treat nicotine dependence?
Hypnosis
Varenicline
Midazolam
Hydralazine
varenicline
35
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
36
xray of bronchiectasis
honeycomb
37
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
38
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
39
An autosomal recessive disorder which results in multisystem exocrine organ dysfunction
cystic fibrosis
40
Thickened secretions in the lungs, pancreatic and biliary ducts lead to chronic respiratory infections, maldigestion, malabsorption, and occasionally, liver disease and diabetes
CF
41
Typically diagnosed in childhood >10yrs (newborn screening)
CF
42
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
43
symtoms of CF
cough with sputum, FTT malnutrition, steatorrhea
44
physical exam for CF
underweight, inspiratory crackles, digital clubbing
45
Peumonia that occurs 48 hours or more after admission, which was not incubating at the time of admission
HAP
46
Pneumonia that arises more than 48–72 hours after endotracheal intubation
VAP
47
treatment for MRSA CAP
vanco and linezolid
48
PSA CAP treatment
meropenem, imipenem, aztreonam, zosyn, cefepime or ceftrazadine
penem, z, z, cx2
49
wihtout comorbidities treatment of a CAP
DAM
DOXYCYCLINE, AMOXACILLIAN OR MACROLIDE
50
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
51
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
52
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
53
testing Urine Antigen for Streptococcus & Legionella
cap
54
what would you hear on ausculatation of a pna dx
crackles or rhonchi if they are able to clear the secretions
55
nonpharmacological tx for pna
Hydration
Rest during acute episode and then increase activity slowly
Chest physiotherapy for bacterial pneumonia
O2 Sat >90%
56
CAP TX WITH ANTIBIOTICS IF THEY DO HAVE A CO MORBIDIEITY
RESP FLUROQUINOLONE OR
AC +DM
AMOXICILLIN/CLAVULANATE OR CEPHALOSPORIN + MACROLIDE/DOXYCYLINE
57
cap tx antibiotics without comormidities
DAM; DOXYCYCLINE, AMOXACILLAN OR A MACROLIDE
58
GASTRIC CONTENTS, BACTERIA FROM ORAL, FORGIEN BODY; CHEMICAL OR BACTERIAL
ASPIRATION
59
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
60
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
61
VAP: Predisposing Factors
Single greater risk is the number of days on mechanical ventilator
62
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
63
More recently gram-positive bacteria have become more common: FOR VAP
S. aureus being the predominant isolate
64
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
65
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
66
Fever, night sweats, fatigue, cachexia, cough, hemoptysis
TB
CHECK SPUTUM
CXRAY
ACIDE FAST BACILLI
QUANTIFEREON
67
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
68
____________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
69
what kind of pneumonia:
Cough
Headache
Sore throat
Excessive sweating
Fever
Chest soreness
ATYPICAL
70
WHAT KIND OF PNEUMONIA?
Fever/shaking chills
Purulent sputum
Malaise
Lung consolidation on physical exam
Increased fremitus, increased you can hear “99”
TYPICAL
71
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%
72
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
73
The values of expiratory flow in asthma will be:
Increased
Decreased
Normal
Of little value
DECREASED
74
>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
75
-Daily symptoms
-Depending on age, daily use of SABA
-Some limitation in normal activity
MODERATE
76
Symptoms throughout day
SABA used several times/day
Extremely limited normal activity
SEVERE PERSISTENT
77
<2 days/week
-Short-acting beta agonist used < 2 times/month
MILD INTERMITTENT
78
< 2 times/month NIGHTTIME SYMPTOMS FOR ASTHMA
MILD INTERMITTENT
79
NIGHTTIME SYMPTOMS FOR ASTHMA
> ONCE A WEEK
SEVERE
WAKING UP AT NIGHT
80
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
81
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)
82
throbbing headache
migraine
83
more often in males, headache
cluster
84
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
85
first line treatment for migraines
nsaids aspirin ibrophen tylenol
stop before it becomes more complex with n/v
86
at 4 or 5 headaches a month
can give prophylaxic treatment
87
prophylactic therapy 4 to 5 days more severe type of pain for first line are the _______
triptans
88
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
89
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
90
triptan can cause ______ a problem for patients with hypertension dn a hx of stroke
vasoconstriction
91
prevention of ischemia stroke
modifiable risk factors slide 25
Control, hypertension, control, diabetes, smoking sensation, treat heart, disease, control, a fib, for example with warfarin treat the TIAs, for example, with aspirin or other antiplatelwts
92
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)
93
______ hr window
intiial window 3 hours, now we can go into a longer window
94
monroe kellie hypothesis
csf and brain tisue and blood
95
cerebral perfusion pressure
nomral about 50or 60-100
Map-ICP
usually see it around
96
icp nomral
around 10 and we worry when its >15 to 20
97
things that cause vasodilation in icp/in the brain
hypotehrmia, hypotension, acidosis and hypercarbia
98
causes of vasoconstriction in the cerebral blood flow
hypertension alkalosis and hypocarbia
99
make sure you know how to calculate the GCS
eye opening has 4, following commands- motor has 6 and verbal has 5
100
epidural hematoma classic presentation
loss of conciousness, lucid intevral
the atery is expanding hematoma
101
often fracture of the temporal bone and rupture of the middle meningeal artery
epidural hematoma
102
you pass out at the scene what dx test do you get?
ct brain possible epidural hematoma
103
first line therapy for depression
ssri
104
ssri box warning
suicidal thoughts
have the energy to carry out the plan of suicide
about 4 weeks after starting the tx
105
ssri treat what psychosocial multi diagnoses
ocd, ptsd, depression, anxiety
could be a mixed diagnosis
106
when would you use snris?
second tx
venlafaxine
Cymbalta
can make the patient have a withsdrawl effect if we stop abruptly
107
signs and symptoms of seritonin syndrome
SHIVERS
108
can you mix maois
WITH OTHER SSRI OR SNRIS AND DRUG AND FOOD INTERACTIONS
109
foods to avoid when taking moais ?
TYRAMINE PRODUCE RICH MEAT WINES ORGAN MEAT WINE CHEESES
110
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 ?
111
WITHDRAWL FROM ALCOHOL HAPPENS AROUND DAY?
5-8 LOOKING FOR SIGNS OF DTS
112
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.
113
clinical physical exam of a patient with anxiety?
HIGH BP HR TACHY TREMORS DIAPHORESIS ACUTELY
PUPIL DILATED
114
exacerrbation may occur with acutre agitation when exposed to ?
stress
115
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
116
MAX SCORE OF THE CIWA
67
we dont want them to go through withdrawl in the hospital
fixed regimen
117
greatest risk of death happens with
alcohol withdrawal
118
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
119
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
120
Acute onset of confusion, excitement, incoherent speech, and agitation
DELIRIUM
121
ABCDEF BUNDLE SCCM
Awakening Trial
Breathing Trial
Coordination/Choice of analgesia and sedation
Delirium prevention and management
Early physical mobility
Family engagement
122
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
123
SEVERE DISTRESS OF DELIRIUM TREATMENT
HALDOL
STAY AWAY FROM THE BENZOS
And another option is olanzipime
124
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
125
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
126
Dementia
Onset is gradual and Stedy
Impairment of memory and confusion unable to do ADLS
Alzheimer’s is the most common type of dementia
127
Clinical manifestations of dementia
Slow over months to years. Confusion memory deficits misplacing things
The As
Aphasia
Apraxia
Agnosia ability to recognize objects
128
Criteria for dementia
Take a history do a physical exam
128
Executive functioning and thinking
This is decreased in dementia cannot carry out
Dementia can affect executive functioning, which is the ability to plan, organize, and complete tasks. As dementia progresses, people may have more difficulty with thinking and completing tasks.
130
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
131
Dementia management
Dopamine agonist
Carbamazepine (tegretol)
Imipramine (impril)
Trazadone (deseryl)
132
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
133
_________ can cause acute agitation to flare up and or precipitate the first episode
Extreme stress and serious illnesses can exacerbate schizophrenia or mania episodes
134
Discontinue these two drugs if you see qtc prolongation
Olanzapine and haldol
135
Medication overuse criteria
headache occurring greater than 15 days a month
Regular overuse of medication greater than 3 months or more than one drug
136
These drugs are effective abortive medications and useful in a protracted attack
Triptans
137
Sudden headache of intense severity that radiates into the posterior neck region, and it is worsen by neck and high of movements
Subarachnoid hemorrhage
138
Patient presents with elevated BP nausea, vomiting, Neuro deficits and a headache
Rule out inter, cerebral hemorrhage, ICH
139
Patient presents with a severe headache, severe decrease level of consciousness and severe vocal deficit the word severe we’re thinking
ICH
140
Patient presents with a moderate headache, decrease level of consciousness, but a severe focaldeficit
Infarction so a possible stroke, an actual blockage because of the deficit
141
Patient presents with severe headache, moderate decreased level unconsciousness, and a mild deficit we’re thinking
Subarachnoid hemorrhage SAH
142
NIH Stroke scale 11 items
Zero is normal maximum possible score is 42
143
Why do we use the NIH Stroke scale?
Used to quantify the severity of the stroke
144
Scale of severe NIH range
21-42
145
Differential diagnosis that look like a stroke
Post ictal seizure, paralysis, migraine, severe migraine with neurological deficits, hypoglycemia
146
What is going to be your initial diagnostic testing for a patient with a possible stroke?
CT brain to rule out any blood and to see if there’s any blood
When you do the mri you then see the occlusion
147
24 hours after the TPA to break up the cloth, what do you give?
Anticoagulant antiplatelet therapy
148
Inclusion criteria for fibrinolytic therapy for acute ischemic stroke in the 0 to 3 hour window timeframe
Age, 18 years or older, clinical diagnosis of ischemic stroke, causing neurological deficits, time of symptom onset well establish to be less than 180 minutes before treatment would begin
149
Exclusion criteria for fibrinolytic therapy Stroke 0 to 3 hour
Evidence of hemorrhage on CT, only minor resolving stroke symptoms, subarachnoid, hemorrhage, active internal bleeding within the last 21 days, known bleeding disorders, like platelet count less than 100,000, patient who had received heparin within 40 hours three months of intercranial surgery or a previous stroke, within 14 days of major surgery, witness, seizure, acute, LP within seven days, history of AV malformation or aneurysm, repeated systolic blood pressure greater than 185 or diastolic pressure greater than 110
150
Localizing pain in the gcs
They are pushing you away
151
Withdrawing from pain gcs
Pulls away from the pain
152
Extension
Decerebrate posturing
153
Flexion
Decorticate posturing
154
When we have secondary systemic injury to the brain we need to do what management
Avoid fever avoid hypotension avoid hypoxia and avoid anemia
155
What is the pathology that happens to the brain as a secondary brain injury
Massive depolarization of brain cells. And compensatory mechanisms are insufficient to prevent damage
156
When does diffuse axon injury occur
High speed rotational forces the brain in bumping the skull and thus the axon are shearing
Shearing forces
Diffuse not focal
157
With diffuse axon injury you’d expect their gcs to be high or low
Low
They will also…..
And poor outcome
They won’t have increased ICP
Non focal global axonal damage wide spread
158
Treatment for elevated ICP
Mild hyperventilate 30-35
Osmotic therapy
Sedation
CPP
Anti epilepsy drugs
Temperature regulation
Glucose hemostatic and glucoxorticoid are not used anymore
159
Epidural hematoma results as a rupture of
The middle menongeal artery
160
This can often occur from a fracture of the temporal bone
Epidural hematoma
161
Classic presentation of an epidural hematoma
Lucid interval
Arterial bleed
Immediate loss of consciousness and then they completely deteriorate
162
Surdural hematoma is what kind of bleed
Venous bleed slow diagnosis not apparent for hours to days after injury
High morbidity high mortality
163
How does a subdural occur
Rupture of the bridging veins in the sibdural space
164
A late sign of increased ICP the last ditch attempt of the brain to train to regulate itself
Cushing triad
Irregular respirations
Bradycardia and hypertension
165
Cushing triads signs
Bradycardia
Hypertension
Irregular respiration
166
Osmotic therapy used for
Increased ICP
167
How does the mannitol osmotic therapy work on elevated ICP
Creates an osmotic gradient drawing water actoss the blood brain barrier leads to a decrease in interstitial volume and a decrease in ICP, the goals going to be to monitor serum osmolality to maintain less than 320
168
Do we want hyper or hypoventilation in patients with ICP
We want to avoid hyperventilating as it can make them alkalotic and then cause basoconstriction and that’s bad
169
Seizure medications for a patient with increased iCP
We can give them AEDs due to patients with TBI are higher risk for seizures and then cause increased metabolic states and cause more damage
170
Induced hypothermia when
To prevent secondary brain injury
To also protect the neurons
Fevers worse than outcomes after a stroke and possibly severe head injury by aggravating secondary brain injury. We also do this protocol status post, cardiac arrest.
171
seizures caused by metabolic disorders include
Metabolic disorders
Acidosis
Electrolyte imbalance
Hypoglycemia
Hypoxia
Alcohol or barbituate withdrawl
Drug intoxication
172
focal onset seizures signs symptoms and how do you distinguish
the patient is aware, or impaired awareness; focal to bilateral tonic clonic and they can have motor versus non motor
173
generalized seizures how do they present
this is more dangerous happening in both hemispheres, patients can do into rhabdomyosis- that even leads to ATN
impaired awareness, motor have tonic clonic and the non motor is absence
174
diagnosing a seizure what would you do first?
History and Physical
Labs- CBC, glucose, liver and renal function tests, VDRL, electrolytes, ANA, ESR, ABG, serum antiepileptic drug levels
UA, drug screen
looking for a secondary cause
175
when you do a CT or MRI for a seizure patient what are you looking for?
seocndary cause, brain tumor cva, brain bleed
epipelpsy the ct and mri is normal
176
gold standard test to rule in a seizure
an eeg
they would have to have a seziure in order to truley diagnosis, the ct and or mri is ruling OUT other causes
177
what does an LP rule in or out for the seizure/epilepsy?
new onset seizure activity and an inc WBC
rule out epilipsey and rule in bacterial menigitis
178
can a comatose patient have an active seizure?
yes
179
what a the two newer agents of AED medications given for new onset seizure broad spectrum from generlaized to focal?
L's***
lamotrigine and levetiracetam
180
pharmacological therapy for seizure patients
titrate dosages to acheieve adequate serum levels, step up therpay if needed, phenytonin and labumin levels and then possibiliy taper down if too much in the system
181
Seizure activity persisting for more than 5 minutes
Drug noncompliance
W/D from AEDs, ETOH or Benzos
CNS infection
Metabolic disturbances
Sleep deprivation
Stroke, trauma, or encephalitis.
status epilepticus
182
complications of status
183
inital drug of choice treatment for status epi
BENZO
IM midazolam or IV lorazepam or IV diazepam
IV is not the only route to go
pam*****lam****dam*****
184
the brain is dependent on _____ for nutrition
glucose, if there is no glucose or to mcuh it gets fried
185
during a seizure/status epil. episode you check a sugar and it is less than 60, treatment?
give 100mg thiamine IV then d50w IV
186
if the benzos dont work in a status seizure episode what can you give?
IV fosphentyonin, IV valporic aicd or IV levetiracetam
this the second phase treatment
187
complications of seizures/status epilepticus
htn, lactic acidosis, hyperthermia, respiratory complications, aspiration, rhabdomyolysis and overal irreversible neurological damage
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rapidly progressive with poor prognosis. Total surgical removal is usually not possible and response to radiation therapy is poor.
glioblastoma tumor
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clinical features of a glioblastoma
nonspecific, and complaints of increased ICP. As the tumor grows, focal deficits develop
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from the dura mater or arachnoid. Compresses rather than invades adjacent neural structures. Symptoms vary with tumor site. Tumor usually benign and readily detected by CT
meningioma
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treatment for a menigioma
surgical, may reoccur if removal is incomplete and may undergo radiation to decrease the risk of reoccurance
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astrocytoma clinical features
similar to glioblastoma but course is more protracted often extending for several years
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treatment for a astrocytoma
variable
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clinical manifestations of a patient with a tumor
headache, n/v, weakness or hemiparesis, sensory disturbances, AMS, impair gait, aphasia, agraphia? papilledema or diplopia on the side of the tumor compressing? diminished visual acuity; and they could have generalized of focal seizure activity
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hydrocephalus text group she didnt say make sure you know?
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encephalopathy same did she say make sure you know? text group
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Autoimmune disease destroys myelin sheath surrounding axons.
Follows an acute infectious illness by 1-3 weeks in 2/3 of cases.
Campylobacter jejuni, CMV, EBV, mycoplasma pneumonia
GB
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Clinical presentation of GB
ascending weakness
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Autoimmune Disease characterized by antibody-mediated destruction of acetylcholine receptors located at the postsynaptic side of neuromuscular junctions.
MG
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early sign of MG
ptosis drooping of one eye lid
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The diagnosis of brain death is a clinical diagnosis that consists of three cardinal findings:
irreversible coma,
loss of brainstem reflexes and apnea
they should have fixed metabolic derangements
off sedation for 48 hours
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central cord syndrome
* Seen with cervical trauma usually in pts with preexisting
cervical spondylosis who sustain a hyperextension injury.
* Motor weakness more severe in arm than legs
* Varying sensory dysfunction depending on which sensory
Tracts are injured
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* Seen with cervical trauma usually in pts with preexisting
cervical spondylosis who sustain a hyperextension injury.
* Motor weakness more severe in arm than legs
* Varying sensory dysfunction depending on which sensory
tracts are injured
central cord syndrome
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most common type of incomplete spine cord
central cord syndrome
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Rare injury
resulting from
disruption of the
posterior column
* Decrease in touch,
proprioception,
vibration
posterior cord syndrome
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posterior cord syndrome
Rare injury
resulting from
disruption of the
posterior column
* Decrease in touch,
proprioception,
vibration
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this refers to a condition where the posterior columns of the spinal cord within the bundle of nerve roots at the end of the spinal cord are damaged, leading to a loss of proprioception (body position awareness) and vibration sensation below the level of the injury, often accompanied by difficulty with balance and walking due to impaired sensory feedback
cauda equina region posterior cord syndrome
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posterior cord
this refers to a condition where the posterior columns of the spinal cord within the bundle of nerve roots at the end of the spinal cord are damaged, leading to a loss of proprioception (body position awareness) and vibration sensation below the level of the injury, often accompanied by difficulty with balance and walking due to impaired sensory feedback
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Difficulty walking and maintaining balance due to impaired proprioception
Unsteady gait
Loss of vibration sensation in the legs and feet
Positive Romberg sign (swaying when standing with eyes closed)
posterior cord syndrome
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loss of ____ & ______ function
bowel and bladder function
posterior cord syndrome
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can a tumor from posterior cord syndrome cause difficulty balancing and unsteady gait
yes
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Brain Death is a clinical diagnosis that is
made by a physician
APRN’s can participate in the care of the
pt but are ______able to make the diagnosis
of Brain Death.
NOT
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apnea test steps
Preoxygenate with 100%
Minute ventilaltion set to
pt’s norm (but never less
than 40)
Pt separated from vent
Oxygen insufflated into
ETT
After 8-10 minutes arterial
blood sampled.
If apnea persists despite a
rise in arterial PCO2
>20mmHG, the test is
positive and consistent
with a diagnosis of brain
death.
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exams to determine brain death
No spontaneous movement
* Absence of Brain Stem reflexes
* Fixed and dilated pupils
* Absent corneal reflex
* Absent doll’s eyes (oculocephalic reflex)
* Absent gag reflex (pharyngeal reflex)
* Absent vestibular response to caloric
stimulation
Apnea – must perform apnea test
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exclusions from brain death diagnosis
Exclude other confounding conditions before performing
brain death examination
* Hypothermia (<32 degrees)
* Drug intoxication or poisoning
* Severe electrolyte, acid base, or endocrine disturbance
* Hypothermia, locked in syndrome, Guillain-Barre
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