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Asthma Flashcards

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USMLE® Step 1 flashcards
1
Q

Definition of asthma

A

Chronic inflammatory disorder with increased responsiveness of airways to stimuli
Reduction in airway diameter from smooth muscle contraction, vascular congestion, bronchial wall edema and thick secretions

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2
Q

3s of asthma

A

Swelling, secretion, spasm

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3
Q

Extrinsic asthma

A

Allergic, type I hypersensitivity from environmental allergens

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4
Q

Intrinsic

A

Non-allergenic
Believed to be from excess Ach
Exercised induced bronchospasm

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5
Q

Triggers

A

Allergens, irritants, cold, high humidity, infections, physical exertion, excitement/emotional stress ASA, NSAIDs, betablockers

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6
Q

Airway signs

A

One-two word sentences

Tachypnea, increased WOB, accessory muscle use, cyanotic, cough, stridor

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7
Q

Wheezes

A 
May not always be present
Mild-moderate only expiratory
Moderate - loud and both phases
Severe - loud or decreased
Silent chest - oh shit!
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8
Q

Milk

A

Expiratory wheezes

Full sentences, may be agitated, tachpnea, not using accessory muscles, HR under 100 SP02 95

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9
Q

Moderate

A

Breathless at rest, prefers to sit, phrases, agitated, increase RR, accessory muscles, HR 100-120, pulsus paradoxus possible O2 90-95%

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10
Q

Severe

A

Resps over 30, HR >120 sats under 90

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11
Q

Imminent resp arrest

A

Drowsy, confusion, paradoxical thoracoabdominal movement, silent ches, bradycardia usually beta agonists don’t work

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12
Q

ASTHMATIC differential

A 
Asthma
Stasis (pulmonary edema)
Toxic (gas, smoke, poison)
Heart (CHF, ARDS, cardiac asthma) 
Mechanical (FBAO)
Allergy/aspiration
Trauma/tumor
Infection
COPD, cystic fibrosis
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13
Q

Tubing

A

Risk of barotraumas and pneumothorax, can further bronchoconstriction and breath stacking (auto peep)

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14
Q

Auto-peep

A

Inspiration is greater than expiration, intrathoracic pressure increases and decreases CO
Risk of tension pneumo
Slower resp rate 6-10 min, smaller tidal volumes (6-10mL/kg) short inspiratory time and longer expiratory 1:4 or 1:5

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15
Q

Ventolin

A

Stimulates sympatho receptors in resp tree causing bronchodilation

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16
Q

Atrovent

A

Reverses only cholinergic mediated bronhospasm, blocks bronchoial constriction, inhibits mucus, can take up to 60 mins works in 30 seconds, 50% at 30 minutes persists for 6 hours

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17
Q

Corticosteroids

A 
Reverse inflamm, speeds recovery, reduces rate of relapse, 4-6 hours for clinical effect
Dex 8mg IV IM IO
Pred 50 mg PO
Methylprednisolone 125mg IV/IO 
No repeats
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18
Q

Epi pros and cons

A

B2 bronchodilation
B1 increased O2 demandes
0.3mg 1:1000 IM max 0.9mg

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19
Q

Status asthma

A

Failed to respond to continuous aggressive tx after 4 hours
Turns to refractory status asthma
progresses to PEA, be very aware of barotrauma
same ACLS drugs

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20
Q

Poison control #

A

1 800 332 1414

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21
Q

Questions

A

bring pills to hospital

What, how much, when, txs, vomited, suicide attempt, underlying illness?

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22
Q

Reduction of absorption

A

Ipecac (rarely used)
Gastric lavage
Activated charcoal

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23
Q

Enhance elimination

A

Cathartics (laxative)

Whole bowel irrigation

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24
Q

Surface absorbed

A

Organophosphates, cyanide, household chemicals, poison ivy, poison oak

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25
Q

Antichols

A

antihistamines, antipsychotics, antidepresssants, antiparkinsonian

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26
Q

S&S antichol

A 
Red as a beet
Dry as a bone
Blind as a bat
Mad as a hatter
Hot as a hare
Flushing, dry skin and membranes, mydriasis (dilation), fever, altered LOC, tachycardia
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27
Q

Common TCAs

A

Amitriptyline (elavil)
Amoxapine (asendin)
Clomipramine (anafranil)
Doxepin (sinequan)

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28
Q

4 main pharmo properties of TCAs

A

Inhibit Norepi, serotonin reuptake
Antichols
Direct alpha-adrenergic block
Inhibits K+ channels in myocardium and Na+ in brain and myocardium

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29
Q

Common TCA S&S

A

Delerium, coma, seziures, resp depression, sinus tach, long PRI QRS and QT, heart blocks, hypotension, ventricular arrhythmias, blurred vision, mydriasis

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30
Q

TCA management

A

ABCs
BGL, IVs
Heart blocks, long PRI, wide QRS,
Brugada pattern (incomplete RBBB with ST elevation V1, V3)
bradycardia, ventricular dysrhythms including PMVT
Wide QRS key for tx w/ bicarb

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31
Q

TX TCA

A

no more than 40mL/kg
Bicarb 1-2mEq/kg for refract hypotension and initial seizure
Seizures tx with benzos (remember check monitor for dysrhythmia that looks like a seizure)
Torsades 2g mag in 50mL over 5
GCS less than 8 consider advanced airway as it predicts cardiotoxicity and or seizures
Pressors for refract hypotension, nor epi if not then epi

32
Q

Drugs for TCA

A

Bicarb, benzos, mag, pressors, intubation

33
Q

Activated charcoal

A 
Not effective for
Cyanide
Mineral acids
Caustic alkalis
Ethanol
Methanol
Organic solvents
NG/OG or orally
34
Q

Contras in activated charcoal

A

Corrosive agent or petroleum distillate (may cause vomiting)

Dose 1gm/kg PO NG, OG same for peds

35
Q

Cholinergic toxicity

A

Cholinesterase inhibitors prevent ACh from reuptake. Similar effects as organophosphate, S&S depend on if its muscarinic or nicotinic

36
Q

S&S of chol tox

A

Miosis (constricted)/dim vision
Tight chest
Muscular weakness, cramps diarrhea, breathing difficulty and convulsions

37
Q

BMSLUDGE

A 
Bradycardia/bronchospasm
Miosis (constrict)
Salivation/sweating
Lacrimation
Urination
Defication
GI upset
Emesis
38
Q

Organophopshates

A 
Acephate (orthene)
Chlorphoxim (baythion-C)
Chlorpyifos (dursban, lorsban)
Diazinon
Dimethoate (cygon, defend)
Ethoprop (mocap)
Fenitrothion (sumithion)
Fenthion (baytex)
Malathion (cythion)
Naled (Dibrome)
Terbufos (counter)
39
Q

TX

A

Decontaminate, assist ventilations, monitor for tordsades,

atropine 2-4mg q 1-5, watch for non cardiogenic pulmonary edema, avoid succ’s/prolonged paralysis

40
Q

AHS atropine dose

A

2mg q 5 until reversal of symptoms

41
Q

Pralidoxime Hydrochloride (2-PAM)

A

Antidote only for organophosphate. Binds to site different than organophosphate and boots it off. Must be given early

42
Q

Sympatho OD

A

Intracranial hemorrhage possible from HTN
Aortic dissection possible
Sodium channel blockade with some
Benzos, fluid, maybe beta blockers, maybe bicarb, and ice to groin, neck, axilla

43
Q

Unopposed alpha receptor stim

A

Thought to be because beta block blocks beta 2 (peripheral vasodilation) but A1 is still hit.
LITFL says minor increase in BP, minor drop in heart rate, safe to give

44
Q

Bicarb for stims

A

Cocaine blocks sodium channels like TCA. Tx wide QRS with bicarb

45
Q

Narcan dose

A

0.4mg q 2 max 1.6
0.8mg q 5 max 3.2
2mg intranasal (1mg/nare) q3-5 max 4mg

46
Q

Peds narcan

A

IV or IM 0.1mg/kg max 2mg single dose, max total 10mg (same for intranasal but max 2mg)

47
Q

Anxiolytic OD (Benzos, barbs) presentation

A

Decreased LOC, delirium, slurred speech, combative, coma, resp depression, apnea, hypotension, bradycardia, diaphoresis, hypothermia, nystagmus

48
Q

Benzo reversal

A

Flumazenil, selective competitive GABA receptor antagonist

49
Q

Barbs drug tx

A

Bicarb. Alkalization of urine enhances elimnation of phenobarb and other long acting barbs via ion trapping.

50
Q

Salicylate OD

A

protip, oil of wintergreen is high in salicylates

Elimination mostly hepatic but renal excretion becomes important

51
Q

Salicylate acute/chronic toxicity

A

Acute is around 150mg/kg
More commonly chronic, vague symptoms and insidious onset. Commonly in oldies as they can’t excrete as much as they take in
Diagnosis on presence of salicylate ingestion + mixed metabolic anion gap acidosis and no other explanation

52
Q

S&S of salicylate toxicity

A

Hyperventilation as they directly stimulate resp center, resp alkalosis may be first sign. Increased resps means fluid lossess
Metabolic acidosis from compensation of resp alkalosis and impaired glucose metabolism
As acidosis builds, more drug moved intracellulary, toxicity worsens
Anion gap positive acidosis

53
Q

S&S salicylates continued

A

Cerebral and pulmonary edema, poorly understood why, possibly increased cap perm
Hypovolemia and hypokalemia from large amounts of fluid losses (vomiting, diarrhea)
Tachycardia, arrhythmias
Hypoglycemia
May need tubing
Tinnitus

54
Q

Salicylate tx

A

Fluid, control hyperthermia, tx hypoglycemia, benzos if seizing, bicarb considered.
Activated charcoal if ingestion has been within 60 minutes

55
Q

Acetaminophen pathology

A

Rapidly absorbed, peaks at 2 hours, steady state at 4 hours
Metabolized CYP3A4 and 2E1 into NAPQI (n-acetyl-p-benzoquinonimine) which is highly toxic
Glutathione in liver normally deactivates it, OD uses up all the glutathione

56
Q

Acetaminophen S&S

A

N/V Diaphoresis pallor lethargy malaise RUQ pain liver enlargement hypoglycemia
Elevated AST, ALT, bilirubin

57
Q

TX

A

ABCs, BGL N-acetylcysteine, hepatoxicity risk at 8 hours post ingestion typically

58
Q

NAC mechanism

A

Replenishes stores of glutathione

59
Q

NAC dose adults

A

150mg/kg in 200mL of D5 over 15-60 minutes
Then 50ml/kg in 500mL of D5 over 4 hours
Then 100mg/kg in 1000mL over 16 hours

60
Q

Acetaminophen toxic dose starting point

A

7000mg single ingestion, 150mg/kg (wiki says 10000 and 200mg/kg)

61
Q

Beta blocker OD, propranolol

A

Propranolol most common, its non selective and has membrane-stabilizing effects responsible for CNS depression, seizures, prolonged QRS (sodium channel blockade)

62
Q

Beta blocker OD physiology

A

Blocks 1 - reduced hrt rate, BP, myocardial contractility and MVO2
Blocks 2 - inhibits relaxation of smooth muscle in vessels, bronchi and GI system and genitourinary
Also inhibits glycogenolysis and gluconeogenesis which may result in hypoglycemia

63
Q

Beta blockers S&S

A

Heart blocks, bradycardia, conduction delays, bronchospasm (if underlying airway disease) decreased LOC (lipid soluble ones like propranolol and acebutolol)

64
Q

Beta blockers tx

A

Glucagon increases cAMP, often will cause nausea and vomiting consider prophylatic ondanstron
Insulin increases CO also through non-alpa and non-beta receptor methods
CaCl regulates action potential excitation threshold 8-16mg/kg (100-1000gm)

65
Q

AHS betablocker/CCB protocol

A 
Tx with heart block protocol
Tx hypoglycemia
20mL/kg IV/IO map 65 max 40mL/kg
Glucagon 2mg SIVP q 10 max of 6mg
Zofran 4mg
Calcium chloride for refractory hypotension, 1g SIVP q 10 max 3g
Wide QRS bicarb 1mEq/kg q 5 max 2 mEq/kg
STILL hypotensive, OLMC for norepi 0.1mcg/kg/min titrate to effect 0.3mcg/kg/min max
66
Q

Calcium channel names

A

Verpamil, Isoptin, Nifedipine, Adalat, Diltziazem

67
Q

4 cardiovascular effects of calcium channel blockers

A 
Peripheral vasodilation
Negative chronotropy (rate)
Negative intotropy (contractility)
Negative dromotropy (conduction)
68
Q

S&S CCB OD

A

Decreased LOC, hypotension, bradycardia, various degrees of heart block, seizures, hyperglycemia

69
Q

CCB OD TX

A 
Calcium chloride - overwhelms CCB
Insulin - increased CO ithout A/B receptors
TCP (brady cardia with SBP under 90)
Glucagon
Pressors
70
Q

Procedural sedation

A

For pacing too
0.05mg/kg max 2.5mg versed +
1mcg/kg fentanyl max 100
0.5mg/kg ketamine instead if SBP under 100 (consider half dose if pt over 65)

71
Q

S&S dig tox (usually chronic)

A 
Tachyarrythmias + heart blocks
Head, irritability, psychosis
Yellow-green vision
Anorexia, N/V
Palpitations, syncope, dyspnea
Atrial tach with block, junctional tach, ectopy
72
Q

Dig OD patho

A

Inhibition of Na+/K+ ATPase pump which raises intracellular Ca2+ and Na+ plus loss of K+ which increases force of myocardial contraction (inotropic effect)
Dig also increases automaticity of purkinje but slows AV conduction

73
Q

Dig TX

A

Fluid
Atropine/TCP bradycardia
No calcium for hyperK (relative contra, give digibind first)
Digibind (digoxin immunie fab) 400mg IV over 15 minutes
800mg RIVP if cardiac arrest

74
Q

Ethylene glycol

A

In antifreeze, small amounts can lead to severe tox, kids sometimes drink as its sweet and fluorescent

75
Q

Methanol

A

Windshield washer fluid, small amounts can lead to tox

76
Q

Ethylene glycol and methanol

A

Stopped at slide 64

Advanced medical (24 decks)

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