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COVID-19 Flashcards

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USMLE® Step 1 flashcards
1
Q

Which scoring system is used to assess the severity of pneumonia ?

A

CURB-65 score:

  • Confusion
  • Urea > 7 mmol/L (19 mg/dl)
  • RR ≥ 30 breaths/min
  • Blood pressure (SBP < 90 mmHg or DBP ≤ 60 mmHg)
  • Age > 65.

Score 0–1, low risk of death
• may be suitable for treatment at home

Score 2, moderate risk of death
• consider for short stay hospitalization or close outpatient treatment

Score ≥ 3, high risk of death
• 4–5 consider for ICU hospitalization.

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2
Q

What is the definition / criteria of Acute Respiratory Distress Syndrome ?

A
  1. Acute onset:
    – ≤1 week of known insult or new or worsening respiratory status.
  2. Origin of oedema:
    – Respiratory failure not fully explained by cardiac failure or fluid overload.
    – Need objective assessment (e.g. echocardiography) to exclude hydrostatic cause of oedema if no risk factor present.
  3. Severity of oxygenation impairment (if ABG available).
  4. Bilateral opacities, not fully explained by effusions, lobar/lung collapse or nodules on chest x-ray or CT.
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3
Q

What to do if the following occurred when assessing a patient that has ARDS ( Acute Respiratory Distress Syndrome ?) or not :

1 -No arterial blood gas analyser to assess degree of hypoxaemia

2- No mechanical ventilation.

3- No chest radiograph or CT scan. ?

A

1 - SpO2/FiO2 ≤ 315 is ARDS

2- Remove PEEP and CPAP from definition

3- Use ultrasound to document bilateral chest opacities.

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4
Q

What is the definition of ARDS ( Acute Respiratory Distress Syndrome) on ultrasound ?

A

ARDS defined as B-lines and/or consolidations

present without effusions on both sides.

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5
Q

What is the definition of sepsis ?

A

– Suspected or documented infection
– And acute, life-threatening organ dysfunction
– caused by dysregulated host response to infection.

(Infection and acute, life threatening organ dysfunction.)

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6
Q

What is the definition of septic shock ?

A

– circulatory, cellular and metabolic dysfunction associated with higher mortality.
– hypotension unresponsive to fluid challenge.
– requires vasopressors to maintain mean arterial pressure of 65 mmHg or greater.
– serum lactate > 2 mmol/L (when available).

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7
Q

What is the clinical features of shock?

A

• Hypotension:
– SBP <100 mmHg or
– MAP <65mmHg ,or
– SBP decrease of > 40 mmHg of baseline.

• Clinical signs of hypoperfusion:

  • altered sensorium
  • prolonged capillary refill
  • mottling of the skin
  • reduced urine output.

• Elevate serum lactate > 2 mmol/L.

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8
Q

What is the qSOFA score ?

A

Also known as a quickSOFA. It is a bedside prompt that may identify patients with suspected infection who are at greater risk for a poor outcome outside the intensive care unit (ICU).
One point for:
- Low blood pressure (SBP≤100 mmHg).
- High respiratory rate (≥22 breaths per min).
- Altered mentation (Glasgow coma scale<15).

2 or more points are associated with a greater risk of death or prolonged intensive care unit stay.

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9
Q

What are the most common pathogens of community acquired pneumonia CAP ?

A

Most common pathogens:

  • Streptococcus pneumoniae
  • Hemophilus influenzae
  • Moraxella catarrhalis
  • Legionella pneumophila
  • non- pneumophila Legionella
  • Chlamydia pneumonia
  • Mycoplasma pneumoniae
  • Klebsiella pneumonia
  • Staphylococcus aureus

Less common, unless at risk or in high prevalence country:

  • Mycobacterium tuberculosis
  • Burkholderia pseudomallei
  • Rickettsial infections
  • Coxiella burnetti (Q fever)
  • Leptospira spp
  • Chlamydia psittaci
  • Bortedella pertussis
  • Salmonella sp.
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10
Q

What are the most common pathogens of Hospital acquired pneumonia HAP ?

A

Resistant pathogens include:
- methicillin-resistant S. aureus (MRSA).
- non-fermenters such as Pseudomonas aeruginosa,
Acinetobacter baumannii.
- extended spectrum beta-lactamase (ESBL) producers such as E. coli, Klebsiella, Enterobacter.

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11
Q

What are the indications of oxygen therapy ?

A

Patients with SARI who have signs of severe illness:
– severe respiratory distress
– sepsis with hypoperfusion or shock
– alteration of mental status
– or hypoxaemia
• SpO2 <90% (if patient is haemodynamically normal)
• SpO2 < 94% (if patient with any emergency signs of airway, breathing or circulation)
• SpO2 < 92–95% (if pregnant woman).

• In children, clinical signs that should trigger
oxygen therapy include (when pulse oximeter not
available):
– central cyanosis
– nasal flaring
– inability to drink or feed (when due to respiratory distress)
– grunting with every breath
– depressed mental state (i.e. drowsy, lethargic)
– and in certain conditions (severe lower chest indrawing, RR ≥ 70 bpm, head nodding).

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12
Q

How to initiate oxygen therapy in patients with SARI ?

A
  • In adults and older children, start with 10– 15 l/min via face mask with reservoir bag.
  • Less ill patients can start with 5 L/min by nasal cannula.
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13
Q

How to monitor O2 levels in blood ?

A
  • Pulse oximeters.

- Blood gas analysis.

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14
Q

What is the target of oxygen therapy in patients with SARI ?

A

Titrate oxygen to target:
– SpO2 ≥ 90% in adults and children
– SpO2 ≥ 92–95% in pregnant patients
– SpO2 ≥ 94% if child or adult with signs of multi-organ failure, including shock, alteration of mental status, severe anaemia until resuscitation has stabilized patients, then resume target ≥ 90%.

  • Titrate oxygen up and down to achieve target
  • Wean oxygen when patient is stable.
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15
Q

What is the antibiotic regimens for severe CAP in adults ?

A

B-lactam e.g. ampicillin-sulbactam, cefuroxime, cefotaxime or ceftriaxone

•and antibiotic against atypical pneumonia (e.g. macrolide or doxycycline) or respiratory flouroquinolone (e.g. levofloxacin).

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16
Q

What is the antibiotic regimens for severe CAP in adults If community-acquired methicillin-resistant S. aureus (CA-MRSA) is suspected ?

A

B-lactam e.g. ampicillin-sulbactam, cefuroxime, cefotaxime or ceftriaxone

•and antibiotic against atypical pneumonia (e.g. macrolide or doxycycline) or respiratory flouroquinolone (e.g. levofloxacin).

+
vancomycin or linezolid.

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17
Q

What is the antibiotic regimens for severe CAP in adults If immunosuppressed ?

A

• consider anti-pneumocystis treatment (e.g. sulfamethoxazole/trimethoprim).

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18
Q

What is the antibiotic regimens for HAP?

A

Anti-pseudomonal coverage:

  • cephalopsorin with antipseudomonal activity(e.g. ceftazidine, cefepime)
    OR
  • carbapenem (e.g. meropenem or imipenem not ertapenem).
    OR
  • B-lactam/B-lactamase inhibitor (e.g. piperacillin/tazobactam).
    OR
  • aztreonam (if penicillin allergic)
    plus (double coverage can be considered if > 10% isolates are MDR).
    OR
  • flouroquinolone (e.g. levofloxacin (high dose) or ciprofloxacin)

OR
- aminoglycoside (e.g. tobramycin, amikacin, gentamicin).

AND anti-methicillin-resistant S. aureus antibiotic: vancomycin or linezolid.

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19
Q

What are the Five principles of sepsis management?

A
  1. Recognize patients with sepsis and septic shock.
  2. Give appropriate antimicrobials within 1 hour.
  3. Give a targeted resuscitation during the first 6 hours.
  4. Monitor-record-interpret-respond.
  5. Deliver quality care.
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20
Q

What are the interventions to improve tissue perfusion is patients with septic shock ?

A
  • Crystalloid fluids
  • Vasopressors
  • Inotropes
  • Packed red blood cell (PRBC) transfusion
21
Q

What is the equation of Mean Arterial Pressure (MAP) ?

A

MAP= [SBP+(2*DBP)] ÷3

22
Q

What are the Resuscitation targets in patients with septic shock?

A
  1. Improved BP:
    • mean arterial pressure (MAP) ≥ 65 mmHg
    • SBP > 100 mmHg.
  2. Adequate urine output:
    • ≥ 0.5 mL/kg/hr.
3. Skin examination:
• capillary refill < 2–3 sec if < 65 years; 
< 4.5 if > 65 years
• absence of skin mottling
• well felt peripheral pulses
• warm dry extremities.
  1. Improved sensorium.
  2. Normalized lactate levels (if initial level high).
23
Q

What is the risk of starting normal saline with patients with septic shock ?

A

Hyperchloremic acidosis.

24
Q

What are the types of fluid that should be given to patients with septic shock ?

A 
Crystalloid fluid is preferred:
– Lactate Ringers (LR*).
– Ringer’s Acetate (RA).
– PlasmaLyte (PL).
– Normal saline (NS)

– Albumin as effective as crystalloids in septic shock
• Use in addition to crystalloid, when substantial crystalloids are needed for intravascular volume repletion.

25
Q

How to give fluids in patients with septic shock (Fluid challenge) ?

A
  • Give fluid for resuscitation as a fluid challenge (also termed bolus or loading).
  • Give initial fluid challenge of 20–30 mL/kg over 30– 60 minutes (or faster).
  • Perform sequential evaluations to assess clinical response.

• If shock persists, continue to give additional fluid challenges (i.e. 250–500 mL) over 30 minutes as
long as there is a clinical response.

26
Q

How can you help your patient raising his/her BP by using normal physiology in patients with septic shock?

A

By Passive leg raise (PLR) technique:

  • Passive leg raise technique is a way to “mimic” fluid loading by moving 300 mL of blood from the lower extremities to the right heart to predict if further fluid loading may be helpful.
  • Requires real-time, direct measurement of cardiac output to assess effect.
  • Patient must not be stimulated, coughing or in discomfort as this may increase sympathetic stimulation and alter cardiac output effects.
27
Q

What do you do if MAP remains < 65 mmHg after giving fluid bolus in patients with septic shock ?

A

Start vasopressors:

• Vasopressors are potent vasoconstrictors and increase myocardial contractility to a lesser extent:
– Administer through a CVC.
– Give at a strictly controlled rate, titrate to desired effect. – Discontinue when no longer needed to minimize risks.

• Start vasopressors after initial fluid bolus:
– But can be given early, during ongoing resuscitation when shock is severe and diastolic pressure is low.
– Do not delay administration.

28
Q

What are the vasopressors that can be used in patients with septic shock ?

A

• Norepinephrine (first choice, titrate): – potent vasoconstrictor with less increase in HR.

• Epinephrine (alternative, titrate):
– potent vasoconstrictor, and also has inotropic effects
– can add as additional agent to achieve desired effect
– can use as an alternative to norepinephrine (if not available).

• Vasopressin(fixed dose 0.03 U/min ):
– Can be used to reduce norepinephrine dose
– Can add as additional agent to achieve effect
– Caution if patient not yet euvolemic.

• Restrict dopamine use because it may be associated with increased mortality and increase in tachyarryhthmia.

29
Q

What are the Inotropes used in septic shock?

A

Dobutamine is first choice inotrope. If not available, then epinephrine:
– Start at 2.5 μg/kg/min (max 20), titrate to improve clinical markers of perfusion and cardiac output.

– Do not aim to increase cardiac output to supranormal levels.

– Risks include tachyarrhythmias and hypotension.

30
Q

When to use PRBCs in septic shock ?

A

Give PRBCs transfusion when there is severe anaemia:
- Hb ≤ 70g/L (7.0 g/dL) in absence of extenuating circumstances such as myocardial infarction, severe hypoxaemia, or acute haemorrhage.

• Targeting higher thresholds (≥ 90–100 g/L) does not lead to better outcomes in patients with sepsis.

31
Q

Though preference is for central delivery, norepinephrine, dopamine or epinephrine can be given via peripheral IV.

What are the risks of IV infusion ?

A
  • Extravasation of medication.

- Local tissue necrosis.

32
Q

Though preference is for central delivery, norepinephrine, dopamine or epinephrine can be given via peripheral IV.

It requires close nursing care to check infusion site.

What will you do if tissue necrosis occur ?

A
  • Stop infusion and consider injection of 1 mL phentolamine solution subcutaneously.

– Phentolamine is a vasodilator – 5–10 mg in 10 mL of NS.

33
Q

What are the methods of delivery of invasive ventilation?

A
  • Endotracheal tube (preferred)
  • Nasotracheal tube
  • Laryngeal mask (short-term, emergency)
  • Tracheostomy (emergency airway, or long-term ventilation)

Requires sedation, appropriate equipment and trained staff.

34
Q

What are the short /long term complications of ICU patients ?

A 
1- VAP : Ventilator-associated pneumonia.
2- CRBSI: Catheter-related bloodstream infection.
3- UTI
4- VTE
5- Pressure ulcers 
6- Functional disability.
7- Cognitive impairment 
8- Psychiatric disorders. 
9- Gastric ulcer bleeding.
10- Delirium.
11- Poor nutrition.
12- Prolonged ventilation.
35
Q

What is the pharmacological prophylaxis of VTE in ICU patients ?

A

– low molecular weight heparin (LMWH):
• enoxaparin 40 mg subcutaneously daily
• dalteparin 5000 units subcutaneously daily
• in renal failure, reduce dose of LMWH (except dalteparin)
* superior to LDUH twice daily dosing in regards to reduction in PE, HIT, cost saving and ease of administration.

– low dose unfractionated heparin (LDUH):
• 5000 units subcutaneously every 8 hours or every 12 hours.

36
Q

How to Prevent gastric ulcers and related bleeding in ICU patients ?

A

● Reduce risk factors:
– maintain hemodynamics (e.g. early resuscitation) – liberate from IMV as soon as possible (e.g. SBT)
– start early enteral nutrition for mucosal protection.

● Pharmacologic reduction of acid production:
– histamine-2 receptor blockers (H2R)
– proton pump inhibitor (PPI):
• more effective in preventing clinically important GI bleed but may be associated with increase risk of pneumonia and Clostridium difficile infection.

37
Q

What is the dose of Fentanyl in intubation ?

A

0.5 - 2 ug / Kg IV bolus every several minutes titrated to sedative effect.

38
Q

What is the benefit of Fentanyl in intubation ?

A
  • Rapid onset of action.
  • Short acting.
  • Reversible with Naloxone.
39
Q

What are the cautions should be taken into consideration when using Fentanyl for intubation ?

A
  • Chest wall rigidity with rapid administration.
  • Respiratory depression.
  • Does not inhibit patient awareness of procedure.
40
Q

What is the dose of Midazolam in intubation ?

A

0.1 - 0.3 mg/kg bolus titrated to sedative effect every several minutes.

41
Q

What is the benefit of Midazolam in intubation ?

A
  • Provides amnesia.
  • Rapid onset.
  • Short acting.
  • Reversible with Flumazenil
42
Q

What are the cautions should be taken into consideration when using Midazolam for intubation ?

A
  • Additive respiratory depression when combined with narcotics.
  • Does not provide analgesia.
43
Q

What is the dose of Lidocaine in intubation?

A

1 - 1.5 mg/kg IV bolus 2-3 minutes before laryngoscope.

44
Q

What are the benefits of Lidocaine in intubation ?

A
  • Blunts hemodynamic and tracheal response to intubation

- May reduce elevation of intracranial pressure during laryngoscopy.

45
Q

What are the cautions should be taken into consideration when using Lidociane for intubation ?

A

Should not exceed 4 mg/kg total due to neurotoxicity (seizures).

46
Q

What is the dose of Propofol in intubation?

A

1 -2 mg/kg IV bolus

47
Q

What are the benefits of Propofol in intubation ?

A
  • Rapid onset
  • Short acting
  • Provides amnesia
48
Q

What are the cautions should be taken into consideration when using Propofol for intubation ?

A
  • Severe hypotension in volume-depleted patients.
  • Does not provide analgesia.
  • Respiratory depression.
49
Q

What are the forms of acute respiratory failure ?

A
  • Hypoxemic :
    • Room air PaO2 =/< 60 mmHg.
    • Abnormal PaO2/FiO2 ratio.
  • Hypercapnic:
    • PaCO2 =/< 50 mmHg with pH < 7.36.
  • Mixed

Medical (6 decks)

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