ER/ICU/Critical Care Flashcards
antidote for arsenic
dimercaprol, succimer, or penicillamine
antidote for methanol, ethylene glycol (antifreeze)
fomepizole, ethanol
vasopressors
phenylephrine NE EPI Dobutamine Dopamine Isoproterenol
Phenylephrine
alpha 1 agonist
use in septic shock
Epinephrine
A1, A2, B1, B2 agonist that vasoconstricts at high doses
use:anaphylaxis, septic shock
dopamine
b1 agonist at low doses, a1 agonist at high doses
use: cardiogenic shock, not renal -protective
dobutamine
beta-1 agonist
use in cardiogenic shock
isoproterenol
beta 1 agonist, beta 2 agonist
use in cardiac arrest
Packed RBCs
RBCs that have been separated from other blood components
this is suitable for a patient who has lost a lot of blood (trauma, surgery, etc)
vasopressin
ADH analog with weak pressor effect
uses: resistant septic shock
ACLS: VF, PEA
Platelets
active bleeding due to thrombocytopenia
Fresh frozen plasma
plasma from which cellular components have been removed
Use in warfarin overdose, clotting factor deficiency, DIC, TTP
Cryoprecipitate
precipitate rich in clotting factors and von Willebrand factor, collected while FFP is thawing
smaller volume than FFP
Specific clotting factors
pooled from multiple donors
Albumin
given after large- volume paracentesis (>5L of ascites from abd)
to prevent hypotension and maximize colloid pressure
given in cases of hypoalbuminemia
Transfusion reactions
nonhemolytic febrile reaction caused by cytokines generated by cells in the blood while in the blood is in storage
onset 1-6 hours after transfusion
fever, chills, malaise
no hemolysis
treat with acetaminophen
acute hemolytic reaction
1/250,000 transfusions
Due to ABO incompatibility
main reason is clerical error
onset during transfusion
antibody- mediated hemolysis
fever, chills, nausea, flushing, tachycardia, tachypnea, hypotension
AB+
universal recipients
O-
universal donors, but can only receive blood from other O-
delayed hemolytic reaction
caused by antibodies to Kidd of Rh (D) antigens
Occurs 2-10 days after transfusion
slight fever, less- severe hemolysis, mild increase in unconjugated bilirubin
anaphylactic reaction
1/150,000 transfusions shock hypotension angioedema respiratory distress
maybe 2/2 anti IgA IgG as that IgA- deficient patients have but maybe don’t know about
Treatment iV fluids, airway maintenance
for these patients, provide extra-washed RBCs when possible
Minor allergic reactions
caused by plasma present in donor blood, leads to urticaria
treat with diphenhydramine
Post- transfusion purpura
thrombocytopenia developing 5-10 days after transfusion, primarily in women who are sensitized by pregnancy
how to treat severe anemia due to autoimmune hemolytic anemia
pRBC
treat hemophilia
give specific clotting factor (8 or 9)
treat DIC
FFP, platelets
treat shock due to trauma or postpartum hemorrhage
pRBCs, IV fluids
to maintain blood pressure during large volume paracentesis
albumin
for hemorrhage due to warfarin overdose
FFP
need for vWF-rich blood product
cryoprecipitate
give for thrombocytopenia
platelets
high doses optimize the alpha-1 vasoconstriction
epinephrine
ADH analog
vasopressin
best choice for anaphylactic shock
epinephrine
best choice for septic shock
NE
best choice for cardiogenic shock
dobutamine
causes vasoconstriction but with bradycardia
phenylephrine
What physiologic pressure does PCWP approximate
LAP
What are the preferred vessels to target in the placement of a Swan- Ganz catheter
R. IJ
L. subclavian
what 2 cardiovascular diseases are the biggest risk factors for CHF
hypertension and ischemic heart disease
Polyarteritis nodosa
necrotizing inflammation of small or medium arteries, leading to ischemia of the affected tissue
PAN can affect any tissue, but it often affects the kidneys, heart, GI tract, muscles, nerves, and joints
SPARES THE LUNGS
Risk factors: Hepatitis B, hepatitis C
Labs: increased WBC, increase ESR
proteinuria, hematuria if there is kidney disease
negative for ANCA
Renal angiography may show aneurysms
Temporal (giant cell) arteritis
subacute granulomatous inflammation of external carotid and vertebral arteries
granulomas where macrophages cluster around
more common in older women
associated with polymyalgia rheumatica
unilateral or bilateral headache,
scalp pain, temple tenderness, jaw claudication, and transient or permanent blindness in one eye
Labs: ESR, if elevated get a temporal artery biopsy
multinucleated biopsy
Start treatment- prednisone, continue until biopsy results are available,
If positive, keep going on high-dose prednisone, then taper off
Aspirin
calcium, vitamin D to prevent osteoporosis 2/2 steroids (this goes for anyone on steroids for more than 3 months)
Takayasu arteritis
arteritis in one of the 3 main branches of the aorta
inflammation of the arch of the aorta
Cerebrovascular ischemia
Myocardial ischemia
Asian heritage, women ages 10-40 (young)
Can cause vertigo, syncope, fever, decreased pulses in the limbs (“pulseless disease:)
If you find poor pulses in the upper extremities think about takayasu arteritis
CTA to look for stenosis and defects in vascular walls
Treat with steroids, immunosuppressive agents,
or surgically bypass obstructed
Eosinophilic granulomatosis with polyangiitis (Churg- Strauss)
inflammation of small and medium arteries
associated with asthma, nasal polyps, sinusoidal obstruction
H and P: fatigue, malaise, mono or polyneuropathy, tender skin nodules, palpable purpura, papular rash
labs: eosinophilia, p-ANCA
Eosinophilia DDx (CANADA-P)
Collagen vascular disease (PAN, dermatomyositis)
Atopic diseases (allergies, asthma, Churg-Strauss, allergic bronchopulmonary aspergillosis)
Neoplasm
Adrenal insufficiency (Addison disease)
Drugs (NSAIDs, penicillins, cephalosporins)
Acute interstitial nephritis
Parasites (strongyloides, ascaris > Loffler eosinophilic pneumonitis)
Other causes: HIV, hyper-IgE syndrome, coccidiomycosis, etc).
Tx: steroids and immunosuppressive agents
Henoch- Schonlein Purpura
IgA immune complex- mediated vasculitis, affecting arterioles, venules, and capillaries
CHildren> adults
recent URI LE palpable purpura arthritis arthralgias abdominal pain renal disease from IgA deposition in the kidney
often self- limited but we can use steroids in patients who have GI symptoms
Granulomatosis with polyangiitis (Wegener’s)
focal necrotizing vasculitis
granulomas in the lung and upper airway
glomerulonephritis
c-ANCA positive
Thromboangiitis obliterans (Buerger disease)
vasculitis of small and medium- sized peripheral arteries and veins
affects young male smokers (30s-40s)
Clinical presentation: intermittent claudication superficial nodular phlebitis Raynaud phenomenon Gangrene, auto-amputation of the digits
Treatment: stop smoking and it will go away
Kawasaki disease
necrotizing vasculitis
infants and young children
Asian descent
diagnostic criteria (mucocutaneous lymph node syndrome)" Fever (>40 C or 104F), lasting at least five days in addition to 4 of the following 5 symptoms (CRASH)
Conjunctivitis (bilateral, non-exudative, painless)
Rash on the trunk
Adenopathy of the cervical lymph nodes
Strawberry tongue and diffuse erythema of mucous membranes
Hands and feet have edema with induration, erythema, or desquamation
Coronary artery aneurysms can occur within weeks of the illness but are not included in the diagnostic criteria (these can rupture and extend within the aneurysm leading to MI). Since they don’t show up for weeks, you don’t need to them to make the diagnosis
Treatment: IVIG (ideally within the first 10 days of illness)
High- dose aspirin, continued until 49 hours after fever resolution, followed by low- dose aspirin until inflammatory markers (platelets, ESR) return to normal (usually 6 weeks)
Steroids are not indicated and are of no proven benefit
Echocardiogram in the acute phase and 6-8 weeks later
20 year-old Asian female
Takayasu arteritis
2 year-old Asian female
Kawasaki disease
Associated with asthma
Eosinophilic granulomatosis with polyangiitis
young male smoker
Thromboangiitis obliterans
associated with PMR
Temporal arteritis
Associated with IgA nephropathy
Henoch Schonlein purpura
Associated with hepatitis B
polyarteritis nodosa
elderly woman with jaw claudication and vision loss
temporal arteritis
strawberry tongue
Kawasaki disease
desquamation on hands/feet
Kawasaki disease
Poor pulses in the arms
Takayasu
Palpable purpura on the legs
HSP
vasculitis of the kidney and GI tract, spares the lungs
PAN
Vasculitis of the kidney, upper airway, and lungs
GPA
necrotizing immune complex inflammation of visceral and renal vessels
PAN
infants and young children: involves coronary arteries
Kawasaki disease
most common vasculitis
temporal arteritis
Cushing’s triad and other signs of increased intracranial pressure
hypertension
bradycardia
bradypnea
papilledema
altered mental status
pupil asymmetry
classic findings in a basilar skull fracture
bruising around the eyes (raccon eyes)
bruising over the mastoid process (Battle sign)
Blood behind the tympanic membrane
CSF rhinorrhea or otorrhea
Next step: possible fracture and +DPL
emergent laparotomy
pelvis fracture + DPL shows urine in the pelvis
urgent, non-emergent laparotomy
pelvis fracture + nothing on DPL + pelvic instability
angiography with possible embolization (you suspect a retroperitoneal hemorrhage)
Blunt abdominal trauma + unstable vital signs + FAST positive
exploratory laparotomy, emergent
blunt abdominal trauma + unstable vital signs + FAST shows no fluid in pelvis
angiography with possible embolization
blunt abdominal trauma +unstable vital signs + FAST inconclusive
DPL
Blunt abdominal trauma + stable vital signs
CT abd/pelvis
abdominal stab wound + hypotensive or signs of peritonitis
emergent laparotomy
Antibiotic prophylaxis for a rape victim:
Gonorrhea
Chlamydia
Trichomoniasis
HepB if not yet vaccinated or if perpetrator is known carrier
HIV
Pregnancy
Ceftriaxone 125 mg IM (gonorrhea)
Azithromycin 1g PO or doxycycline 100mg PO BID for 7 days (chlamydia)
Metronidazole 2g PO (trichomoniasis)
Hepatitis B !1 of 3 if not yet vaccinated +/- hepatitis B immune globulin (not standard of care)
HIV prophylaxis for 3-7 days with follow-up for further counseling
Other prophylaxis:
Antiemetic (promethazine) for nausea caused by HIV meds and pregnancy prophylaxis
Levanorgestrel (Plan B) 0.75 mg PO- repeat dose in 12 hours (alternatively, both doses can be taken at once for improved compliance). Other options exist
How do we evaluate for extremity trauma?
sensory, motor, vascular exam in addition to `imaging
What antidepressants are associated with hypertensive crisis?
MAOIs, exacerbated by tyramine
When is post-op MI most likely
within the first 48 hours after surgery
Telemetry in the postop period helps check for this
What are signs of hepatic disease in a pre-operative workup
increased PT/PTT
low platelets
increased bilirubin
decreased albumin
what interventions help optimize lung function in a patient with pre-existing pulmonary disease
incentive spirometry pain control deep breathing physical therapy bronchodilators inhaled steroids
What do you order in your evaluation of post-op fever?
CXR urinalysis with urine culture blood culture sputum culture examine surgical wound wound culture
What are 2 indicators of how severe hypotension is in a shock patient?
urine output
mental status
Hyperacute transplant rejection
Seen within initial 24 hours after transplantation
Cause: anti-donor antibodies in recipient
Treatment: untreatable, avoided by proper crossmatching
Acute rejection
seen 6 days to 1 year later
Cause- anti-donor T-cell proliferation in recipient
Treatment: immunosuppressive agents (reversible)
chronic rejection
seen >1 year after transplant
Treatment- untreatable, but immunosuppressants can delay onset
which cytokine is most important for T cell differentiation
IL2
Adverse effects of cyclosporine
nephrotoxic, mannitol can help prevent nephrotoxicity
Azathioprine adverse effects
bone marrow suppression, leukopenia
metabolized by xanthine oxidase (don’t combine with allopurinol)
Tacrolimus adverse effects
nephrotoxicity
corticosteroids adverse effects
Cushingoid features
osteoporosis
diabetes
Muromonab side effects
leukopenia
Rapamycin side effects
thrombocytopenia, hyperlipidemia
Mycophenolate adverse effects
This drug is often used to treat lupus
leukopenia
lymphoma
teratogenic
Anti-thymocyte glubulin side effecs
depletes T cells
Hydroxychloroquine adverse effects
lupus, transplant, RA
visual disturbances
Thalidomide adverse effects
phocomelia
Graft versus host disease
grafted bone marrow is now attacking the patient’s entire body
H&P: maculopapular rash, abdominal pain, n/v, diarrhea, recurrent bleeding, easy bleeding
Labs: elevated LFT, decreased immunoglobulin levels, decreased platelets
Biopsy of the skin and liver will detect inflammatory reaction with significant cell death
Treatment: steroids, tacrolimus, mycophenolate
AXR findings consistent with ruptured viscus
free aid under the diaphragm
Labs to get in a patient presenting with generalized abdominal pain
CBC with differential, basic metabolic profile, LFTs, beta hCG, stool guaiac, amylase and lipase, EKG and cardiac enzymes if >45yo especially if women, diabetics, elderly
