General Review Topics Flashcards
Names 3 Medications for Bradycardia with Doses
Atropine 0.5-1 mg
Dopamine 2-20 mcg/kg/min
Epinephrine 2-10 mcg/min
Treatment of Hypercalcemia
IVF, loop diuretics.
HD if Ca > 18, HF, severe AKI, AMS.
Bisphosphnates (zolendronic acid, pamidronate)
Steroids
Calcitonin (tachyphylaxis)
Rhabdomyolysis - treatment? electrolyte abnormalities?
IVF - typically NS (100-150 cc/hr if Ck < 10k)
IVF - typically Bicarb with goal 2-3 cc/kg UOP and UpH > 6.5
Monitor for hyperkalemia, hypocalcemia, hyperuricemia
Watch for hemolysis /DIC (late)
Treatment for AF-RVR with accessory pathway?
Ibutilide 1 mg IV over 10 minutes
Procainamide 100-200 mg
Do not use digoxin, amiodarone, CCBs.
Options for pharmacologic cardioversion of atrial fibrillation?
-Ibutelide (4% risk of Torsades, avoid with HF)
-Amio (less effective)
-Procainamide (even less effective)
EKG findings of AVRT?
Delta-wave: slurred up-slope of QRS. AVRT=WPW.
Treatment of unstable SVT?
SYNCHRONIZED cardioversion. Biphasic, 120-200J.
Tx of unstable VT w/ a pulse?
-Regular -> DCCV, 100J
-Irregular -> Defib, 200J
Leukemia associated with bleeding and thrombosis (DIC or hyperfibrinolysis)
Treatment?
Acute Promyelocytic Leukemia
Rx: all trans retinoic acid
Worry about APL differentiation syndrome (Fever, leukocytosis, pulmonary infiltrates, and effusions) Rx: steroids
Leukemia associated with lymphadenopathy, organomegaly, CNS, bone pain, and tumor lysis
ALL
Leukemia associated with hypercalcemia and bone lesions
T Cell leukemia
3 classic symptoms of hyperviscosity syndrome
Mucosal bleeding
Neurologic symptoms
Visual symptoms (retinal artery plumping)
Treatment of Hypercalcemia
IV fluids, loop diuretics
Zolendronic acid or pamidronate
Calcitonin
Steroids
Medication used in tumor lysis syndrome if renal failure has developed
Rasburicase
Electrolytes abnormalities in tumor lysis syndrome
Hyperkalemia, Hyperuricemia, Hyperphosphtemia, Hypocalcemia
Common syndrome from CAR T therapy
Treatment?
Cytokine release syndrome (CRS)
Tocilizumab, Steroids
Must exclude as cause of hypterensive urgency / emergency?
-Medication effect (e.g., steroids)
-Toxic ingestion
-Hyperaldosteronism
-Cushing’s
-Pheochromocytoma
-Renal disease
Treatment of cyanide toxicity from nitroprusside?
IV Thiosulfate
BP targets with ACS & preferred agents?
SBP < 140 in first hour. Use nitroglycerine or BBs.
BP targets in aortic dissection? Agents to use?
SBP < 120 in first hour. Use esmolol, labetalol & nitroprusside.
Use of atropine cautioned in what three conditions?
-AMI, may increase infarct size
-Heart transplant. Lack of, or paradoxical, response.
-2nd degree type 2 block, or 3rd degree block. Block is below AV node, and will not be effective.
Medication used for CCB or BB overdose?
Glucagon
Pacer codes? (5 positions)
- Pacing
- Sensing
- Response
- Programability
- Multisite pacing
Pacer code: DDD.
What is it used for?
Used for all heart blocks. Maintains AV synchrony. Most physiologic mode. Must have wires in A & V.
What does magnet mode do for a pacer?
Turns off sensing, results in asynchronous pacing at fixed rate. I.e., AOO, VOO, DOO. (Pacing/Sensing/Response).
Can be useful to stop inappropriate pacing from electrical nose such as Bovie, or to stop PPM-induced tachycardia.
EKG findings in brugada syndrome? Treatment
ST elevations in V1, V2, no reciprocal changes in opposing leads. RBBB.
Rx Quinidine or amio, then ICD and ablation
Treatment of catastrophic antiphospholipid antibody syndrome?
Anticoagulation, steroids, plasma exchange.
Sx of cyanide exposure?
Tachycardia followed by bradycardia, hypotension, cyanosis, metabolic acidosis, and seizures
Indications for CT Surgery for TV IE? (4)
-Refractory bacteremia
-Vegetations >1cm
-HF
-Fungal BCx (+).
Sx of Steven-Johnson Syndrome / Toxic Epidermic Necrolysis?
Fever, malaise, myalgia, musous membrane involvement (photophobia, orodynia, odonyphagia). Prodrome of skin pain.
What is an AIVR (Accelerated Idioventricular Rhythm)?
Seen after cardiac reperfusion, wide-complex rhythm 50-120bpm. The reperfused Purkinje fibers beat faster than the SA node. Stable, no treatment needed.
Characteristic lab finding in TTP?
ADAMST13 level <10
False positives for the beta-D-glucan test for aspergillosis (7)?
HD with cellulose filters, PJP, Pseudomonas, Candida, augmentin, albumin, IVIG.
Bacterial infections implicated in Acute Hyperammonemia status post lung transplant?
Mycoplasma Hominis.
Ureaplasma Urealyticum & Parvum
Organophosphate pesticides cause what kind of poisoning?
Rx?
Cholinergic symptoms: Parasympathetic. Salivation, Lacrimation, Urination, Diarrhea, GI distress, Emesis. Also, bradycardia, and bronchorrhea. Like sarin nerve gas.
-Diazepam to prevent seizures.
-Atropine (high doses).
-Pralidoxime (Acetylcholinesterase reactivator)
New medication used for hyperkalemia?
Sodium zirconium cyclosilicate (Lokelma) is approved by the FDA for treatment of hyperkalemia in adults. It preferentially captures potassium in exchange for hydrogen and sodium, which reduces the free potassium concentration in the lumen of the GI tract and thereby lowers the serum potassium level.
Indications for HD in hypercalcemia?
Ca < 18, severe AKI, AMS
Pathophysiology of hyperviscoscity syndrome?
Elevated IgG. Can be due to aggressive IVIG treatment.
Prophylaxis for tumor lysis syndrome?
Allopurinol. Febuxostat is 2nd line.
Treatment of acute mesenteric ischemia?
IVF, vasopressors. Abx including anaerobes. Anticoagulation. Surgery.
definition of driving pressure?
plateau - peep
keep less than 7 in ARDS
Effect of prone positioning in ARDS?
decreased mortality if used for at least 16 hours.
FENa > 1% suggests what?
Intrinsic disease such as ATN
A patient presents with UNSTABLE wide complex tachycardia. What are the appropriate steps?
ABCs, IV, O2
CARDIOVERT 120-150-200
Procainamide - 20 mg/min
Amiodarone - 150mg X 3 (Q3-5mins)
Sotolol - 100mg
When are SYNCHRONIZED shocks recommended?
- unstable SVT
- unstable atrial fibrillation
- unstable atrial flutter
- unstable regular monomorphic tachycardia with pulse
When are UNSYNCHRONIZED shocks recommended?
- pulseless V-tach or V-fib
- patient demonstrating clinical deterioration
- if you’re unsure if VT is monomorphic or polymorphic in the unstable patient
Sellar lesion differential
SATCHMOL
Sarcoid/pit adenoma
Aneurysm
Teratoma
Craniopharyngioma/RCC/Chordoma
Hamartoma
Meningioma/mets
Optic glioma
Lymphoma
Criteria for fulminant C Diff?
Hypotension, ileus or megacolon
Treatment for initial, non-severe C Diff?
2 agents
PO vanco 125 QID -or- fidaxomycin 200 mg BID for 10 days. Alternative is Flagyl.
Treatment for initial, fulminant C Diff?
IV Flagyl + PO Vanco 500 TID. If ileus, consider PR vanco too.
O2 delivery equation?
CI x 1.39HgbSaO2 + 0.003 xPaO2)
Invasive fungal disease commonly have what three immunodeficieny-related host factors?
Neutropenia >10 days, stem cell transplant, steroids
Treatment of invasive cryptococcus infection?
-Induction: Liposomal amphotericin B + flucytosine x2 weeks.
-Consolidation with high dose fluconazole x8 weeks.
-Maitenance with low-dose fluconazole for 6-12 months.
Infection risk for AIDS & CD4 count <100?
MAC, Nocardia, Aspergillus, Toxo.
-In addition to <200 (Primary TB, PJP, cryptococcus)
< 50 CMV
Treatment of disseminated CMV infection? 1st and 2nd line?
-1st: Ganciclovir. Causes BM suppression.
-2nd: Foscarnet. Causes renal failure.
Toxicity of IFN-alpha blockers?
Granulomatous infections: TB, MAC, Fungi. IRIS can occur when stopping.
Used for Interferon alfa is used in a variety of treatments, including certain forms of leukemia, malignant melanoma, non-Hodgkin’s lymphoma hepatitis B, and hepatitis C
Toxicity of calcineurin blockers?
Nephrotoxicity, neurotoxicity, microangiopathy w/ thrombosis. (Tacrolimus, Cyclosporine)
Immune checkpoint inhibitor with highest toxicity?
Ipilimumab (CTLA-4 inhibitor)
5 most common side effects from immune checkpoint inhibitor therapy for immunosuppression?
-Skin rash.
-Diarrhea / colitis.
-Hepatitis.
-Endocrine (hypothyroid, hypophysitis).
-Pneumonitis.
Dose of Octreotide for variceal bleeding
50 mcg bolus followed by 50 mcg/hr for 3-5 days after hemostasis
Tube used in severe upper GI bleeding
Blakemore or Minnesota tube
4 contraindications to TIPS procedure
CHF
Severe PHTN
Systemic infection/sepsis
Severe TR
Diagnostic and therapeutic intervention for lower GI bleeding that can’t undergo scope
Angiography (can localize and embolize)
Pancreatitis Score?
BISAP
BUN
Impaired mental status
SIRS
Age
Pleural effusion
Treatment of choice for infected necrosis in acute pancreatitis
Carbapenem
Mortality Score for GI Bleed
AIMS65
Albumin
INR
Mental status (altered)
SBP
Age (<65)
Antidote for precedex-induced bradycardia?
Glycopyrrolate
What is stiff chest syndrome, and what causes it?
skeletal (thoracic and jaw) tetany due to repeated opioid doses (e.g., conscious sedation).
3 medical conditions to void desmopresin in?
HF, psychosis, cirrhosis
EKG changes in hypokalemia?
ST depression, small T waves, U waves.
EKG changes in hyperkalemia?
Peaked T waves. Long PR. Wide QRS. Loss of P waves. Sine wave.
Symptoms of hypocalcemia?
Tetany, seizures, hypotension, QTc prolongation. Anxiety, psychosis.
EKG findings of hypercalcemia?
Short QTc, tall/broad T wave.Osbourne/J-waves look like dicrotic notches.
Main mechanism of metabolism for the 4 NOACs
Apixaban - biliary/fecal
Dabigatran/Rivaroxaban/Edoxaban - renal
How many ml in 1 unit of FFP
250 ml
Amount of FFP that will give 20-30% of factor repletion in the average patient?
10 - 15 ml/kg
Medication for diabetes that places patient at risk for euglycemic DKA
SGLT2 inhibitors
T4 treatment dose for myxedema coma
IV thyroxine 200-500 mcg loading dose
daily 50-100 mcg/day
Medication that should be given in addition to thyroid hormone in myxedema coma
Hydrocortisone 300mg/day
Steps to treating thyroid storm
- Reduce serum T4/T3 levels (PTU or MMI)
- Inhibit further hormone release (iodine or lugol’s solution)
- Reduce peripheral conversion from T4 to T3 (PTU, propranolol, glucocorticoids)
- Manage adrenergic symptoms (BB’s)
- Decrease enterohepatic recycling (cholestyramine)
10 MRSA Antibiotics
Bactrim
Clindamycin
Daptomycin
Delbavancin
Doxycycline (or minocycline)
Fosfomycin
Gentamycin
Linezolid
Oritavancin
Vancomycin
Dose for propofol for intubation induction
0.5 - 2 mg/kg
Dose for ketamine for intubation induction
2 mg/kg
Dose of sugammadex for rocuronium reversal
16 mg/kg
3 components of “lung rest” when placed on VV ecmo
Ultraprotective lung ventilation (< 4 ml/kg)
Pressure limited vent mode (PC)
RR 8-10/min with peep 10
Complication on ecmo where the wall of the vessel is sucked up against the cannula and the RPM’s will vary and the tubing will shake back and forth
Chattering
Cause: low blood volume so pump is preload dependent
4 goals for VA ecmo
- Pulse pressure > 15 (try to keep the native heart beating and not overwhelmed by ecmo pressure)
- Normal lactate
- Urine output > 0.5 ml/kg/hr
- MAP 65-80 mmHg
What is HLH?
Hemophagocytic lymphohistiocytosis (HLH) is an aggressive and life-threatening syndrome of excessive immune activation. It most frequently affects infants from birth to 18 months of age, but the disease is also observed in children and adults of all ages.
What is MAS?
Macrophage activation syndrome (MAS) refers to a form of HLH that occurs primarily in patients with juvenile idiopathic arthritis or other rheumatologic diseases. Some authors call this “reactive hemophagocytic syndrome.”
What is typical presentation of HLH?
acute or subacute febrile illness associated with multiple organ involvement. Initial signs and symptoms of HLH can mimic common infections, fever of unknown origin, hepatitis, or encephalitis.
Fever – 95 percent
●Splenomegaly – 89 percent
●Bicytopenia – 92 percent
●Hypertriglyceridemia or hypofibrinogenemia – 90 percent
●Hemophagocytosis – 82 percent
●Ferritin >500 mcg/L – 94 percent
●Low/absent NK cell activity – 71 percent
●Soluble CD25 elevation – 97 percent
Medications for Neurogenic Bladder
●Anticholinergic medications (eg, oxybutynin, tolterodine) decrease bladder tone, suppress bladder contractions, and may reduce urinary frequency and incontinence.
●Alpha adrenergic medications (ephedrine and phenylpropanolamine) can increase bladder storage in patients with pathologic relaxation of the sphincter.
●Cholinergic medications (bethanechol) may help complete bladder emptying in those with hypotonic bladders.
●Alpha-blockers (eg, prazosin, terazosin) help sphincter relaxation, lowering bladder pressures during contraction. These can be prescribed for treatment of detrusor sphincter dyssynergia but may aggravate hypotension.
