Final Flashcards
What are s/s of sympathomimetic toxidrome poisoning?
Hyperthermia Tachycardia Hypertension Warm/moist skin Agitated delirium
What are some examples of sympathomimetic toxins?
No antidote?? Supportive care??
Cocaine
Amphetamine/meth
Phencyclidine (PCP)
Withdrawal
What are s/s of cholinergic toxidrome poisoning?
Muscarinic: DUMBELS (diarrhea/diaphoresis, urination, miosis, bradycardia, emesis, lacrimation, salivation) or SLUDGE
Nicotinic (opposite of muscarinic) & CNS receptor effects
What are some examples of cholinergic toxins?
Antidote?
Pesticides, nerve agents
Antidote: Atropine, 2-pralidoxime
What are s/s of anticholinergic toxidrome poisoning?
Hyperthermia (HOT) Tachycardia/HTN Red, hot, dry skin (DRY, RED) Mydriasis (BLIND) Absent bowel sounds Urinary retention Confusion/hallucinations (MAD)
What are some examples of anticholinergic toxins?
Antidote?
Antihistamines Antipsychotics Atropine/scopolamine Tricyclic antidepressants Skeletal muscle relaxants
Antidote: Physostigmine
What are s/s of opioid toxidrome poisoning?
Miosis, CNS depression, respiratory depression
What are some examples of opioid toxins?
Antidote?
Opiates (morphine, codeine), Opioids
Antidote: Naloxone
How does serotonin syndrome present?
Antidote?
Agitation, autonomic (VS) instability, NMJ effects (tremor, hyperreflexia)
Antidote: Cyproheptadine
What poison is glucagon used as an antidote?
Insulin?
Beta blocker
Calcium channel blocker
What is the antidote for iron poisoning?
Supportive care, deferoxamine chelation
What is the antidote for benzodiazepines?
Flumazenil
What are 4 causes of respiratory failure?
Mechanical dysfunction of the lung
Loss of respiratory control d/t impaired central respiratory drive
Upper/lower airway obstruction
Multisystem organ failure, cardiac arrest
What ventilator changes can you make when the problem is oxygenation (low O2)?
Increase mean airway pressure (MAP) by increasing PIP, PEEP, or I-time
Increase FiO2
What ventilator changes can you make when the problem is ventilation (high CO2)?
Increase alveolar ventilation by increasing tidal volume or rate
What are some examples of restrictive lung disease?
What vent mode and settings do you want?
ARDS, aspiration pneumonia
Mode: AC
Settings: high PEEP, low tidal volume
What are some examples of obstructive airway disease?
What vent mode and settings do you want?
COPD, asthma
Mode: AC (volume > pressure) or SIMV+ PS
Settings: low rate, short I-time
What is part of the respiratory exam for a patient on mechanical ventilation?
WOB (retractions, belly-breathing, nasal flaring, head bobbing), breath sounds, waveforms on vent, patient-ventilator “synchrony”
What are 4 causes/troubleshooting for a distressed vent patient or decompensation on mechanical vent?
D - displacement of tube
O - obstruction
P - pneumothorax
E - equipment failure
Capnography - decreasing EtCO2
Causes?
ETT cuff leak
ETT in hypopharynx
partial obstruction
Capnography - sudden increase in EtCO2
Causes?
ROSC
Capnography - bronchospasm (shark fin appearance)
Causes?
Asthma
COPD
Capnography - decreased EtCO2 (variable changes)
Causes?
Apnea
Sedation
Vent adjustments for dynamic hyperinflation. and evidence of auto-PEEP?
decrease rate, I-time
What are some examples of severe metabolic acidosis?
What vent mode do you want?
Salicylate poisoning, septic shock, toxic exposures, DKA
Mode: PS
What are the diagnostic criteria for AIDS?
HIV positive
CD4 T-cell count < 200 cell/min or the development of an opportunistic infection
What is the hospital plan management for a newborn of HIV+ mom?
- Zidovudine 4mg/kg BID in first 12hrs of life
- Labs: HIV qual RNA PCR, CBC w diff (do NOT send HIV antibody)
- Consult peds ID for 2wk f/u
What are the metabolic anomalies associated w/ tumor lysis syndrome?
Hyperuricemia (uric acid > 8)
Hyperkalemia (K > 6)
Hyperphosphatemia (PO4 > 6.5)
Hypocalcemia (Ca < 7)
What is tx for (or prevention of) tumor lysis syndrome?
IV fluids, no K
allopurinol/rasburicase - to dec uric acid
sevelamer - to dec phos
What are 4 complications of hyperleukocytosis (WBC > 100k)?
tumor lysis syndrome, hemorrhage/intracranial bleed, pulmonary leukostasis, sudden death
What is tx for mediastinal mass?
empiric therapy, corticosteroids, radiation therapy
avoid intubation if possible d/t difficult airway
What is tx for increased ICP?
elevate HOB, dexamethasone, mannitol and/or 3% saline, intubate and hyperventilate
WBC 1,200 Neutrophils 57% Lymphocytes 32% Monocytes 8% Eosinophils 2% Basophils 1%
What is ANC?
ANC = WBC x [(%segs + %bands) / 100]
ANC = 1,200 x (57% / 100) = 684
What abx do you choose for hem-onc patient presenting with fever & neutropenia (ANC < 500)?
Cefepime
+/- vanco (for sepsis s/s)
+/- flagyl (metronidazole) or zosyn (for GI s/s)
What are the 3 criteria for engraftment after a patient receives stem cell infusion?
- ANC > 500 x3 consecutive days
- Plts > 20k x1 week (w/o transfusions)
- Hct > 25% x20 days (w/o transfusion)
What are 3 main organs involved in aGVHD?
skin, liver, GI tract (intestine)
What are diagnostic clinical features of aGVHD?
maculopapular rash, increasing bilirubin levels, diarrhea (w/wo hematochezia)
What are the stages and grade of the following presentations of skin, liver, intestine in aGVHD?
rash >50% of BSA
bilirubin 3-6 mg/dL
diarrhea 1000-1500 mL/day
skin 3
liver 2
intestine 2
aGVHD grade: III
rash <25, 25-50, >50, generalized
liver 2-3, 3-6, 6-15, >15
diarrhea 0.5-1k, 1-1.5k, >1.5k, gross blood
0: none I: skin 1-2 II: skin 3, liver/GI 1 III: skin 3, liver/GI 2-3 IV: 4 of any
How do you manage GVHD?
- steroids (first line)
- cyclosporine
- methotrexate
- tacrolimus
What immunizations should you NOT give during chemotherapy?
Live vaccines (oral polio, rotavirus, nasal flu, varicella, MMR)
What EKG rhythm(s) would you consider using atropine?
slow HR rhythms (sinus brady, Mobitz II 2nd degree HB, complete HB)
What med class would you consider using for high HR arrhythmias?
Beta blocker
How would you treat unstable vs stable SVT?
Unstable - synch cardiovert
Stable - vagal maneuvers, adenosine
What do these represent:
P wave
QRS complex
T wave
P - atrial depol
QRS - vent depol
T - vent repol
What are causes of ST segment elevation? ST segment depression?
Elevation - acute MI, pericarditis, ventricular hypertrophy
Depression - myocardial ischemia
What may you see on the EKG when a patient has hyperkalemia? hypokalemia?
Hyperkalemia - peaked T waves
Hypokalemia - U waves
What is the tx for DKA?
Fluid bolus
Insulin gtt 0.05-1 U/kg/hr
2 bag system 1.5-2x mIVF NS & D10NS + 20 KCl
What is the most worrisome complication of DKA?
How would it present?
How would you tx it?
Cerebral edema
Headache, slowing HR, rising BP, change in neuro status
Tx - 3% saline 3-5mL/kg fast push or mannitol
How would DKA present?
Dehydration, Kussmaul respirations (deep, sighing), n/v, abdominal pain, confusion, drowsiness
What would you expect to see on labs for DKA?
BG > 250 pH < 7.3 bicarb < 18 anion gap > 10 elevated serum/urine ketones
How would define polydipsia? Polyuria?
Polydip - inc thirst (>2L/m2 daily)
Polyur - inc urine output (>2L/m2 daily)
What condition results from not enough ADH?
What happens to Na levels and urine?
diabetes insipidus
Na high (>150) UOP high (>3) dilute, spec grav < 1.005
What condition results from too much ADH?
What happens to Na levels and urine?
SIADH
Na low (<130) UOP low (<1) concentrated, spec grav > 1.020
Labs: serum Na < 130 urine Na > 60 serum Osm < 275 urine Osm > 500 spec grav > 1.020 UOP < 1
What condition is this?
SIADH
Labs: serum Na > 150 urine Na < 40 serum Osm > 305 urine Osm < 250 spec grav < 1.005 UOP > 3
What condition is this?
DI
Labs: serum Na < 130 urine Na > 150 serum Osm < 275 urine Osm > 300 spec grav > 1.010 UOP > 3
What condition is this?
cerebral salt wasting
SIADH tx?
fluid restrict (1/4 - 1/2 mIVF)
salt
NaCl 1g 3-4x/day
3% saline
How would differentiate between central DI and nephrogenic DI during a water deprivation study?
Give DDAVP if urine osm < 600 any time during or at the end of the study
If:
urine osm 2x over next hr -> cDI
urine osm no response -> nDI
How would you r/o or dx DI during a water deprivation study?
If urine osm > 600 during the test, okay to r/o
urine osm < 600 = inability to concentrate urine -> DI
What are the 3 stages of triphasic response?
- transient DI
- hyponatremia/SIADH
- permanent DI
Tx for DI?
cDI vs nDI?
correct Na slowly (dec shouldn’t be faster than 12mEq/L every 24 hours)
Low salt, low protein diet
cDI - DDAVP
nDI - thiazide diuretics (hydrochlorothiazide)
What are spirometry values in obstructive lung dz? -FVC -FEV1 -FEF 25-75% FEV1/FVC
-flow shape
FVC > 80%
FEV1 < 80%
FEF 25-75% < 55%
FEV1/FVC < 70-80%
-caved in, left shift
What are spirometry values in restrictive lung dz? -FVC -FEV1 -FEF 25-75% FEV1/FVC
-flow shape
FVC < 80%
FEV1 < 80%
FEF 25-75% > 55%
FEV1/FVC > 70-80%
-circular (d/t dec volume), right shift
What are 4 things you need to know to perform spirometry?
Height
Gender
Smoker status
Ethnicity
How would you differentiate between restrictive vs obstructive lung dz with PFTs?
Obstructive - dec FEV1/FVC
-Asthma dx if FEV1 or FVC inc >12% post bronchodilator tx
Restrictive - dec FVC, inc FEV1/FVC
What sxs would be in each of the 4 stages of asthma severity?
- stage 1 intermittent
- stage 2 mild persistent
- stage 3 mod persistent
- stage 4 severe persistent
1: sxs < 1x/wk, night <2x/month, FEV1/PEFR >80% predicted
2: sxs > 1x/wk (not daily), night > 2x/month, FEV1/PEFR > 80% predicted w 20-30% variability
3: sxs daily, night > 1x/wk, FEV1/PEFR 60-80% predicted w >30% variability
4: sxs continuous, night frequent, FEV1/PEFR < 60% w >30% variability
How well controlled (well, not well, very poor) is this patient’s asthma?
>2 days/wk sxs
>2 nighttime awakenings/month
>2 days/wk albuterol use
What would recommend as a tx?
not well controlled
Start long term controller therapy (inhaled, systemic corticosteroid)
Where is the ideal position for PICCs and CVCs on CXRs?
Superior to cavoatrial junction in the superior vena cava (SVC-RA junction); 2 vertebral body heights below carina
Where is the ideal position of an ETT on CXR?
2-4cm above carina (T2-T4)
-carina located ~T6 (T5-T6)
On a CXR, you see air in the pleural space (no lung markings past a sharp line). What do you suspect?
Pneumothorax
No lung markers w sharp line = suspect collapsed lung
Steeple sign on CXR implies what dx?
Croup
Deviated trachea on CXR implies what dx?
Mediastinal mass
What does increased lung translucency imply?
Air trapping (asthma, bronchiolitis, COPD, CF), upper airway (tracheal) obstruction
What is the order (pneumonic) of reviewing CXR?
A - airway B - bones C - cardiac D - diaphragms E - everything else
What makes kids’ bones different?
- More flexible
- Growth plates (cartilage) at the end of bones
- Bones heal faster. Periosteum is thicker and stronger
What is the SALTER-harris classification?
S - separate/straight through physis A - above physis L - lower/below physis T - through metaphysis & epiphysis R - cRush/erasure of growth plate
What is the most common fracture site in pediatrics?
What is the mechanism of this fracture?
Wrist, distal radius via FOOSH
How would a child present that makes you suspect a nursemaid’s elbow?
How would you tx?
Sxs: refuse to bend or rotate elbow or use arm
Tx: reduce via supination and elbow flexion or hyperpronation
What are the ottawa ankle rules?
Get an xray for:
- tenderness over lateral malleolus
- inability to bear weight for 4 steps
- tenderness over medial malleolus
What is the most common adolescent hip disorder?
How does it present?
Tx?
Slipped capital femoral epiphysis
sxs: pain in groin, thigh, or knee; pain w hip motion; obligate ER w hip flexion
tx: in situ screw fixation
What are 5 causes of traumatic knee effusion?
Occult fracture Patella dislocation Cruciate ACL/PCL injury Collateral MCL/LCL injury Meniscus injury
What should you suspect if there is tenderness over a physis?
Fracture, until proven otherwise
What are the 4 indications for ETT intubation?
- inadequate oxygenation/ventilation
- inability to maintain/protect airway
- potential for clinical deterioration
- prolonged diagnostic studies or patient support
What are indications for an LP?
diagnostic (suspect CNS infection, subarachnoid hemorrhage)
therapeutic (drug delivery, contrast media, relief of pseudotumor cerebri)
What is the target location for an LP?
What position should the patient be in?
L4-L5 or L5-S1
Lateral decubitus or sitting
What are the normal events of healing?
Injury, hematoma, inflammation and activation of factors to heal wound
What are the weakest part of the suture?
Knots
What is the difference between square knot and surgeon’s knot?
Square knot: once round around needle for each throw
Surgeon’s knot: twice round for first throw and once round for subsequent throws
What is the pneumonic for acid base gases?
ROME
respiratory opposite
metabolic equal
What are some causes of metabolic acidosis?
DKA, severe diarrhea, renal failure, shock
What are some causes of respiratory alkalosis?
Hyperventilation (from fear, anxiety, PE), mechanical ventilation
What are some causes of metabolic alkalosis?
Severe vomiting, excessive GI suctioning, diuretics, excessive NaHCO3
What are some causes of respiratory acidosis?
Anesthesia, drug overdose, pneumonia
What causes L shifts to the O2 Hgb dissociation curve?
Inc affinity, more O2 in blood, dec temp, dec pCO2, inc pH, respiratory alkalosis
What causes R shifts to the O2 Hgb dissociation curve?
dec affinity, less O2 in blood, inc temp, inc pCO2, dec pH, respiratory acidosis
What are disadvantages and advantages of subclavian cannulation vs IJ?
+ lower incidence of infections and thrombosis
- higher incidence of mechanical complications
- “pinch off” syndrome
Why are children more prone to respiratory distress?
-5 reasons
- Higher O2 metabolism
- Lower functional residual capacity
- More prone to fatigue of respiratory muscles
- Smaller tidal volumes
- Higher tendency to be agitated
What is tx for croup?
Racemic epi
Dexamethasone
PPV measures (bagging)
What is the difference between bronchiolitis and asthma?
Acute inflammation of bronchioles vs chronic inflammation
What is tx for bronchiolitis?
Positioning (towel under shoulders), O2 if sats < 90%
What is tx for acute asthma exacerbation?
- O2 + positioning
- bronchodilators + anticholinergics (albuterol/ipratropium)
- steroids (dex)
- sq vs IM epi
- hydration if needed
AVOID intubation if possible
What breath sounds may help you distinguish between 4 types of respiratory types?
Upper airway obstruction - stridor (usually insp), barking cough, hoarseness
Lower airway obstruction - wheezing (usually exp), prolonged exp phase
Lung tissue dz - grunting, crackles, dec breath sounds
Disordered control of breathing - normal
When should mothers get screening for syphilis in high prevalence settings?
- First presentation to care (prenatal)
- early 3rd trimester (24-48 wks)
- at delivery
What is the reverse algorithm for syphilis testing?
Trep –> nontrep RPR if positive
What could this mean?
first +trep
second -nontrep
third +trep
Possible past, successfully treated syphilis
What could this mean?
first +trep
second -nontrep
third -trep
likely false positive screening test
What could this mean?
first +trep
second +nontrep
likely untreated or recently treated syphilis
What is the recommended tx for primary, secondary, and early non-prim non-sec syphilis?
single dose BPG (pen G) 2.4 million units
What is the tx for neurosyphilis?
aqueous crystalline penG 19-24 million units per day administered as 3-4 million units IV q3-4h or continuous infusion for 10-14 days
What are clinical manifestations of congenital syphilis if newborn is symptomatic?
S/s manifests years after birth?
FTT, restlessness, fever, rhinorrhea, maculopapular rash, hepatosplenomegaly
Hutchinson triad - interstitial keratitis, CN 8 deafness, Hutchinson teeth (triangular)
What tests does a newborn need if mom is seropositive?
serologic test nontrep RPR –> CSF studies
What might you see on a CSF study if infant is seropositive?
high protein, low glucose +/- high WBC
high WBC –> neurosyphilis
Tx for syphilis seropositive newborn?
crystalline penG 100,000-150,000 units/kg/day x10 days
F/u plan for seropositive newborn treated in hospital before discharge?
Repeat nontrep titers at 3, 6, 12 months to document falling titers
Neurosyphilis must follow w/ serologic tests and CSF determination every 6 months for at least 3 years or until CSF findings normal
How do you calculate hourly fluid needs? daily?
Hourly: 4-2-1
Daily: 100-50-20
What are the 3 types of donor choices for cancer patients?
What has the lowest risk of GVHD? Highest risk?
Autologous - patient’s own stem cells (no GVHD risk)
Syngeneic - identical twin (no signifiant GVHD risk)
Allogeneic - donated stem cell (highest risk)
What are the 3 sources of allogeneic (donated stem cells)?
related HLA match (sibling) unrelated HLA match (donor registry) haploidentical match (parent)
What are 4 things you would prefer to have in an unrelated donor selection?
- CMV negative
- If female, preferably nulliparous
- Younger
- Similar ethnic background
Hem-onc patient presents with decreased oral intake, pain, ulcers, mucosal bleeding, n/v. What is this complication? What’s the biggest worry? How would you manage?
Mucositis
Risk of airway compromise
Tx: TPN, pain management (PCA), tranfusions, mouth/perineal care
Hem-onc patient presents with weight gain, ascites, painful hepatomegaly, increasing bilirubin. What is this complication? How would you manage this?
Veno-occlusive disease
Tx: Fluids, diuretics, CVVH (continuous veno-venous hemofiltration), defribotide
How would a hem-onc patient with pulmonary toxicity present? How would you treat?
Crackles, hypoxia, respiratory distress
Tx: intubate, mechanical ventilation
How would a hem-onc patient with transplant associated microangiopathy (TA-TMA) present? How would you treat?
microangiopathic hemolytic anemia, renal dysfunction +/- neuro abnormalities
Tx: hydrate, transfuse, withdraw immunosuppression when possible, treat BK viruria/viremia, eculizumab
How would you define these 3 types of asthma control: well controlled, not well controlled, very poorly controlled?
well controlled: <2 days/wk, <1 night/month, <2 days/wk bronchodilator
not well controlled: >2 days/wk, >2 nights/month, > 2 days/wk bronchodilator
very poorly controlled: daily sxs and multiple doses of albuterol per day
What would you recommend for managing exercise-induced bronchospasm?
Warm up and cool down
Take SABA 15-20 mins and LABAs 30 mins prior to exercise
How would you do a hand neuro exam on a toddler?
Rock = median nerve Paper = radial nerve Scissors = ulnar nerve
What are the 3 fractures you cannot, should not miss?
- Monteggia fracture-dislocation: ulna fx with dislocated radial head
- Medial epicondyle fracture (or entrapped medial epicondyle) - associated w elbow dislocation
- SCFE
What does the PR interval represent?
Time between depol of SA node to onset of vent depol
What does QRS duration represent?
Time for vent depol (normal 0.06-0.10 secs)
What does QT interval represent?
The time it takes for ventricles to depol to beginning of repol
What does ST segment represent?
The time between ventricles finishing depol and beginning repol
What are flattened or small T waves associated with?
Resolving pericarditis, digoxin, myocarditis
Anion gap calc?
Na + K - Cl
