Exam 1 Flashcards
What are the coma cocktails of overdosed alcoholics, opioids?
alcohol: Thiamine
opioid: Narcan (Naloxone)
When should you not give activated charcoal in overdose situations?
When the pt is lethargic or not awake
What is the difference bw a CMP and a BMP?
BMP = Ca + Na (electrolytes) CMP = BMP + liver function tests
What INR level would you see with Tylenol poisoning?
Increased INR (thinner blood)
If you are ODing on tricyclic antidepressants, what curves in the EKG would you look at?
QT and QRS interval
Where is Tylenol metabolized?
95% liver -mainly glucoronidation
<5% CYTP450 !!!!!
Describe the formula for Tyelonal breakdown
Tylenol + CP450 –> NAPQI
NAPQI + glutathione –> renal
With which metabolite deficiency do you see Tylenol poisoning? What causes cell damage and death?
When glutathione stores <30%
NAPQI and proteins cause death
Which types of patients are generally glutathione deficient?
Alcoholics
AIDS
What are the levels of toxicity (liver failure) for Tylenol poisoning?
140 mg/Kg for single ingestion
7.5 g/24 hours
How do you use the Rumack Matthew Nomogram?
If Tylenol level is above the treatment line, then they need to be treated (liver transplant maybe)
- 4 hours Tylenol level is important
When can you not use the Rumack Matthew Nomogram?
multiple ingestion OD
extended release OD
What is a potential mechanism of Mucomyst?
Glutathione precursor or reverses damaging NAPQI but no one actually knows
What is the dosage of Mucomyst?
140 mg/kg PO then
70 mg/kg PO every four hours after
What part of Tylenol is toxic?
It’s metabolites !
Not Tylenol itself
What are some products that contain aspirin?
Pepto Bismol
Oil of Wintergreen
Linemints
Vaporization solutions
Under which hours interval is Mucomyst nearly always effective?
< 8 hours it is always effective
You should still give it - better late than enver
Describe how different aspirin dosages can cause different clinical presentations
< 150 mg/kg = gastric upset
150-300 mg/kg =acid/base effect
300+ mg/kg = severe/lethal
What type of acid/base state does ASA cause? Why?
metabolic acidosis (but respiratory alkylosis occurs first) -Uncoupling of oxidative phosphorylation and Krebs
How does aspirin also cause respiratory alkalosis?
Direct effect on brain to increase RR
How can aspirin cause respiratory acidosis?
After getting respiratory alkalosis, the pt tires out and RR drops –> resp. acidosis
What effect does aspirin have on the lung?
Increases pulmonary vascular permeability –> non cardiogenic pulmonary edema
(cardiac function remains unaffected)
What are acute adult aspirin OD findings?
tinnitus sweating hyperventilating resp. alkalosis metabolic acidosis
What is the key feature of chronic aspirin overdose?
neuro/behavior findings
aspirin levels may seem normal
What do you observe on an EKG with a cocaine overdose?
QRS widening
Prolonged QT interval
What is cocaine washout?
Essentially a cocaine hangover - lethargy
What is abruptio placenta?
3rd tri bleeding from cocaine or trauma
Painful
What is placenta previa?
3rd tri bleeding not from cocaine
PAINLESS
What is the treatment of Cocaine OD?
Benzodiazepines:
Valium and Adavan
Why do you not give Haldol to cocaine OD patients?
It lowers the seizure threshold so its more likely to lead to seizures
Do you give beta blockers to Cocaine OD pts? Why?
No - it lowers BP and HR
but it can lead to tachydysrhythmias with cocaine OD
How do you treat QT prolongations or complex tachycardias in cocaine OD?
alkalization on blood pH
7.45-7.5
How does demerol work?
It works at psych receptors - not pain receptors
What are the clinical features of an opioid overdose?
Pinpoint pupils (miosis) Resp depression Coma (Histamine release) (Decreased GI)
What is the effect of Narcan on opioids?
It reverses the effect of opioids
What is a potential finding in the lung from opioid OD?
non cardiogenic pulomnary edema can occur up to 24 hours after
What drugs or conditions can exhibit similar symptoms to opioid OD?
Clonidine
CO
post ictal state
pontine hemorrhage
How long after EtOH ingestion, does it reach peak blood levels?
1 hour
Which organs are involved in the metabolism of EtOH?
Liver (90%)
Lungs
Skin
Kidney
How do you treat EtOH withdrawal?
Benzodiazepines
also Thiamine, fluids…
What is the Wernicke encephalopathy triad?
ataxia
ophthalmoplegia
encephalopathy
How do you get Wernicke encephalopathy?
Low thiamine
EtOH abuse
How do you get Korsakoff amnesia and what are the presentations?
Low Thiamine and long term EtOH abuse
anterograde and/or retrograde amnesia
How do you treat warfarin overdose?
Vitamin K
Fresh Frozen Plasma
How much tighter does CO bind to Hb than O2?
250 X
How do you diagnose CO poisoning?
arterial blood gas
not pulseOx
What percentage of brain neurons are present at burth?
100%
What is the HEADSS questionairre? When is it used?
Home and Environment Education and employment Activity Drugs Sexuality Suicide/Depression
What is the mini-cog exam?
Recall 3 words (1 pt each)
Clock drawing test (2 pts)
2 points and below is impaired cognitive
What is apraxia? What does it indicate?
inability to translate an intention into an action (not paralysis)
Indicates cerebral disorder
What memory patterns do you see with dementia?
Loss of recent memory but retention of remote memory
What is dysphonia and what does it indicate?
Disorder of voice volume or pitch
Indicates disease of larynx or laryngeal nn
What is dysarthria?
Motor speech disorder (movement)
What are tactile hallucinations most commonly associated with?
EtOH withdrawal
geriatric Depression scale - what is depression?
Score greater than 5
What is thec clinical tetrad of Parkinsonism?
Tremor
Rigidity
Bradykinesia
Postural Instability
When is Reglan used?
Used to reverse parkonsonism.
Also used in pregnancy and diabetic neuropathies
What is a pseudobulbar effect? When is it seen?
Inverse emotionally
Seen in Progressive Supranuclear Palsy (Parkinson variant)
What is the main treatment for Parkinson Disease early on?
Amantadine
Also Anticholinergenics
What does Levadopa do and what are some of the drawback of it?
Reverses all symptoms of PD
Does not slow down progression
On/Off waxing and waning
Contraindication in Schizo and glaucoma
How do COMT inhibitors work in the treatment of PD?
Stops metabolism of L-dopa to methyl dopa -> sustained plasma levels
What is genetic defect in Huntington;s disease?
CAG repeats/ anticipation
More repeats–> onset is eralier
Where in the brain would you see atrophy of a Huntingtons patient?
Cerebral and caudate nucleus
What is a potential treatment option for Huntingtons?
ACh/GABA decrease
relative dopamine increase
What are genes linked to focal torsion dystonia?
DTY6
DTY7
What are some various etiologies of restless leg syndrome?
Idiopathic vs PD
Preganancy
Fe deficiency
Neuropathy
Describe Tourette’s
Facial motor tics mostly
Assd w OCD
Chromosome 15
Treat with CBT
What is maladaptive behavior in resopnse to a stress?
Adaptive disorder
W symptom specified
What is the PANICS in panic disorder?
Palpitations Paresthesias Abdominal Distress Nausea Intense Fear of Dying Chest Pain Chills Choking Sweating Shaking SOB
What is Dissociative Identity disorder?
2 or more distinct personality states
Describe the rule of 9/s for 2nd and 3rd degree burns
9% upper chest 9% abdominal 4.5 % front arm 9% front leg 4.5% face...
Describe what 2nd and 3rd degree burns are
2: blistered, partial thickness, blanchable
3: loss of adnexal structures, hair loss, gray…
What is the prognostic burn index?
PBI = TBSA + age (+20% inhal)
What is an associated injury you can develop with a burn + inhalation injury?
ARDS
Describe the protocol for tetanus vacc. administration
- Always give tetanus toxoid
2. Tetanus Ig if uknown or they dont have booster. (diff. than toxoid site)
What kind of antibiotics do you give for burn patients?
Topical Abx
NOT systemic
When do 1st and 2nd degree burns spontaneously re-epithelize?
7-10 days
How many calories do you give to a burn pt?
25 kcal/kg + 40 kcal/%TBSA
What is a common pathogen involved in burn injuries?
Pseudomonas aeruginosa
What is the most common type of pneumonia in HIV patient?
pneumococcus
What imaging modality do you use to test for a pulmonray embolism?
CT w contrast
What is a clinical presentation of a pneumothorax?
tall and skinny kid
Blebs - nonfunctioning lung space
What will you see for a tension pneumothorax? And where would you start your treatment?
Hypotension and trachea deviated away from side
Needle Decompression bw 2nd and 3rd rib
What can cause a pneumomediastinum?
Vasalva maneuver
Cocaine or MaryJ use
-The air dissects down
How do you diagnose pericarditis? And what Ejection fraction wiill you see?
Diagnose w ECHO
Normal EF of 60%
What would you see in an MCA stroke?
Contralateral paralysis - upper limb and face
contralateral loss of sensation
Possible aphasia
What would you see in an ACA stroke?
Contralateral paralysis - LOWER limb
contralateral loss of sensation - lower limb
Difference bw cluster, tension, and migraines?
Cluster and Migraine: Unilateral
Cluster: lacrimal, rhinorrhea
Migraine: POUND
Horner’s Syndrome
Ptosis
Anhidrosis - no sweating
Miosis
What is anterior cord syndrome?
Loss of motor, pain, T distal to lesion
CST and spinothalamic tract damage
-ASA or spinal contusion
What is central cord syndrome?
CST and spinothlamic damag
Greater impairment in UE than LE
What is Brown Sequard Syndrome?
aka hemisection from stab or gun
Ipsilateral loss of DC-ML
Contralateral loss of pain and T
Describe the Glascow Coma Scale
4 Eyes, Jackson 5, 6 cylinder engine
Eyes - spontaeous movement
Speech
What does decorticate mean?
you flexed to your core
What are the main mechanisms of brain injury?
- Contusion
- Increased ICP
- Diffuse Axonal Injury
What is the only way out of the intracrainla vault?
foramen magnum
What is the most life threatening hernitaion of the brain?
brainstem herniation through foramen magnum
Where do most diffuse axonal injuries in the brain occur?
Where gray and white matter meet.
What is SCIWORA?
Spinal Cord Injury without radiological
What is the goal of Rapid Sequence Intubation in a traumatic brain injury?
blunt rise in ICP
maintain MAP
Specificaly, what is the most common basilar fracture?
petrous portion of temporal bone
EAC and TM
What are some signs of a basilar fracture?
battle sign (mastoid) Racoon sign (eyes) 7th nerve palsy
What aa and bone are assoicated with an epidural hematoma?
Middle Meningeal a
Tempral bone fracture
Lucid Interval
CN 3 palsy
What is a subdural hemorrhage?
Rupture of bridging veins
Crescent shaped
What usualy causes a subarachnoid hemorrhage?
aneurysm (Berry)
secondary to hypertension
What is the first refelx to return after spinal shock?
bulbocavernosus
Which 3 systems work together to prevent vertigo?
Visual
Vestibular
Propioceptive
Describe central vestibular disease
Gradual Onset
Severe
variable Nystagmus
Worsened w rapid movement
What diseases are associated with peripheral vestibular diseases?
Menier’s disease
Vestibular Neuritis
benign paroxysmal positional vertigo
What diseases are associated with central vestibular diseases?
MS
Neoplasm
Vertebral a dissection
cerebellar infarct
What are pain insensitive structure of the head?
Choroid plexuses
Brain parenchyma
Ventricles
How do you treat migraines and tension headaches?
Acetomenaphin, aspirin, NSAIDs
How do you treat Cluster headaahces?
O2
What are signs and symptoms of a headache indicating a pathology?
Fever Nuchal Rigidity Reflex asymmetry AMS Papilledema
What is Wallenberg Syndrome?
Lateral Medullary syndrome
Stroke of PICA possible
Loss of pain and T contralateral body and ipsilateral face
In what type of pt will you see a central venous thrombosis in a sagittal sinus?
pregnant pt
When do you give tpa?
Less that 3 hours - need consent
bp must be below 180
How can you tell the difference bw Bell’s Palsy and stroke?
Bells: effects forehead - droopy
stroke: does not effect forehead
What is autoregulation in terms of a stroke?
brain maintains constant CBF despite verying cerebral perfusion pressures
Describe autoregulation in terms of HTN and stroke
the lower/upper levels of autoregulation are reset higher.
This allows tolerance.
BUT more intolerance of lower BPs
Prolonged ischemia of the brain results in what?
infarction
What is the penumbra?
Tissue around the stroke that is ischemic and still viable
What is amaurosis fugax?
sudden vision loss in one eye - transient
Which way is the gaze preference in an MCA stroke?
Away from side of weakness
towards side of brain stroke
What do you see in MCA stroke in non-dominant hemisphere?
anosognosia - unawareness
When would you see ‘locked in syndrome’ ?
Basilar stroke
can only communicate w vertical eye movemnts
What is a central venous thrombosis?
occlusion of saggital sinus
Pregnancy, hypercoaguable state
do CT w IV contrast
What is Todds paralsysi?
unilateral weakness after a seizure
What should ALL patients having acute ischemic CVA receive?
Antiplatelet therapy
Aspirin or plavix
What are some exclusion to use tpa?
BP > 185
Seizures at onset
Sure about time of onset
……
How would you prevent vasospasms following 2-3 days after subarrachnoid hemorrhage?
Nicardipine
What is intraparenchymal hemorrhage most often caused by?
HTN
How Many points is the Mini mental status out of?
30
less than 10 is severe
What is Dissociative Fugue?
Sudden travel away from home wo recalling recent past
SIGECAPS
Sleep disturbance Interest loss Guilt Energy Loss Concentration Problem Psychomotor retardation Suicide
What is the most common subtype of depression? Who would it be?
Atypical depression
‘moody teenager’
What are the treatments for Schizo?
"Old Closet Whisper Quitely" Olanzapine Clozapine Risperidone Quetiapine
What is the exact definition of meningitis?
inflammation of arachnoid and pia mater and CSF
How can you tell bacterial meningitis?
> 1000 leuko
Low glucose
Elevated CSF Protein
PMNs
Describe the morphology of bacteria assd w miningitis?
Gram neg. cocci: Meningococci
Gram neg rod: Hem. influenzae
Gram pos rod: Lysteria
Gram pos cocci: pneumococcus
What conditions predispose pts to meningococal meningitis?
C5-9 def.
asplenia
What doses drugs do you give to meningitis pts?
Ceftriaxone
Vancomycin
What is the most common bacterial agent of bacterial meningitis in adults?
pneumococcal meningitis
How do you treat listeria meningitis?
ampicilin
meropenem
What is cryptococcal meningitis?
pidgeon droppings
construction
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