Géri/Allergie/MIGO/Préop/USI Flashcards
25F G1P0 currently at 34 weeks gestation presents to ER with sudden onset pleuritic chest pain and shortness of breath. She denies any unilateral leg, buttock, or back pain. Sinus tachycardia in 130’s and saturations are 89% on room air and 93% on 2L nasal prongs. CXR is unremarkable and labs do not show evidence of pre-eclampsia.
Which of the following is the least appropriate?
a) Start therapeutic LMWH now given high index of suspicion of PE
b) Order d-dimer and if <500 PE ruled out
c) Order CTPA
d) Order V/Q scan
e) Order bilateral leg dopplers
f) Order Troponin, BNP, COVID and flu swabs
B) D dimer helpful in ruling out VTE in low/intermediate pretest probability cases.Highest utility in the first trimester due to increase in d dimer with trimesters.
64 year old man with no past medical history. Brought in by wife as she has noticed a change in personality. He repeatedly checks that doors are locked and has made inappropriate sexual comments to a family friend. He has been missing appointments and his wife has taken over managing these. He has episodes of irritability and verbal aggression directed at his wife, and a few weeks ago he threw a phone at her. MoCA 22/30, no abnormality on physical exam. What is the most appropriate with respect to management?
A. Start Donepezil
B. Start Memantine
C. Start Trazodone
D. StartRisperidone
The correct answer is C. There is escalating aggression which poses a safety concern for patient’s
wife.Risperidone is another possible option; however there can be paradoxical worsening with anti-psychotics, SSRI or Trazodone generally first line. No role for CI or memantine in FTD
77M presents with cognitive decline. He has a history of T2DM, PVD, DLP, peripheral neuropathy, and GERD. Medications include ASA, metformin, empagliflozin, rosuvastatin, ramipril, bisoprolol. He feels that he is becoming more forgetful. His husband comments that he is slower to respond in conversation. He previously prepared all family meals but recently finds that he will forget a dish or that items are ready at different times. He gave up driving this past year due to a near miss. His husband has taken over managing finances as he had started to make mistakes. MoCA 22/30. What is the most likely diagnosis?
A. Dementia with Lewy Bodies
B. Alzheimer’s Disease
C. Vascular Dementia
D. Frontotemporaldementia
The correct answer is C. He has significant vascular risk factors
and deficits are predominantly in executive function (poor
planning) and slow processing speed. MRI brain indicated to
evaluate for microangiopathic changes and infarcts
78F with admitted to hospital after fall and hip fracture.
PMHx: MCI, HTN, insomnia
Home Meds: Amlodipine 2.5mg daily, lorazepam 1 mg po qhs for sleep, vitamin D3 1000u daily
Current Meds: Acetaminophen 1 g TID, amlodipine 2.5mg daily, lorazepam 1 mg po qhs, hydromorphone 0.5 mg PO q4h PRN, Senna 2 tabs BID, enoxaparin 40 mg SC daily, and vitamin D3 1000 IU daily.
On POD2 she becomes disoriented. On exam she is calm but not able to follow a conversation and her responses are disorganized. Physical exam otherwise unremarkable. HR 90, regular, BP 125/58, afebrile, RR 16, SpO2 94% RA. Routine labs and ECG are repeated and unchanged from previous. What is the next best step in management:
A. Discontinue Hydromorphone
B. Start Quetiapine 12.5mg po qhs
C. Insert Foley catheter for presumed urinary retention
D. Decrease lorazepam to 0.75mg po qhs
The correct answer is D. While sudden discontinuation of lorazepam could result in withdrawal and worsen delirium. It is likely contributing to current presentation and taper with close monitoring is indicated.
80M referred for cognitive assessment. He has a history of T2DM, describes a 2-3 year history of worsening forgetfulness. His partner reports he frequently repeats stories and forgets things he has been told. More recently he has developed word finding difficulty. This year his partner took over managing finances due to missed bill payments. MoCA 22/30. BP 124/68, HR 48, RR 18, SpO2 99%. Neuro exam is normal. What is the next best step in management?
A. Exercise
B. Donepezil 2.5mg daily
C. GinkoBilboa
D. Donepezil 10mg daily
The correct answer is A.
STEM describes mild AD. Patient has bradycardia which requires work-up, donepezil should not be initiated in this context.
Exercise is recommended per CCCDTD. No evidence for ginko bilboa
89F with past medical history of MCI, HTN, anxiety admitted to hospital after fall and hip fracture. Smokes 1pk/day and drinks a glass or two of wine per night.
Home Meds: Amlodipine 2.5mg daily, lorazepam 2 mg po BID, vitamin D3 1000u daily Current Meds: Acetaminophen 1 g TID, amlodipine 2.5mg daily, hydromorphone 0.5 mg
PO q4h PRN, Senna 2 tabs BID, enoxaparin 40 mg SC daily, and vitamin D3 1000 IU daily.
On POD3 she becomes disoriented, agitated yelling and tries to punch. You suspect delirium. HR 109, regular, BP 125/58, afebrile, RR 16, SpO2 94% RA. She is restless, diaphoretic, confrontational not participating in physical exam. TSH, electrolytes, B12 and ECG all normal. What is the next best step in management:
A. Increase Hydromorphone
B. Insert foley
C. Give Lorazepam
D. Give Quetiapine
The correct answer is C. This patient has a history of high dose chronic
benzodiazepine and possibly significant alcohol history. The most concerning (and
potentially life-threatening cause of delirium is benzo/alcohol withdrawal.
- Homme de 80 ans, égyptien. Présente une endocardite aiguë à SASO. Mentionne une réaction à la PNC lorsqu’il était enfant, mais ne se rappelle pas de la réaction. On veut vraiment le traiter avec la PNC. Quoi faire :
A. Testcutané
B. DosagedesIgE-PNC
C. Désensibilisation
D. TestdeRAST
A)
90 year old woman with past medical history of depression, HTN, urinary incontinence and falls. Which of the following would you recommend to prevent LTC admission.
A. HighdoseVitaminE
B. CognitiveStimulation/Reminiscenttherapy
C. Hearingassessment
D. Statin
The correct answer is B. In a recent meta-analysis cognitive stimulation/reminiscent therapy,
specialized geriatric care, and multicomponent interventions were shown to decrease LTC
admission in pooled analysis of both inpatient and outpatient studies Gaugler et al. JAGS 2023
A 22yF woman presents at 26 weeks pregnant and is keen to update her vaccines but requests advice as to what is safe in pregnancy. She reports her last vaccine was a tetanus booster 4 years ago, but otherwise no regular vaccines since age 4. You review her antenatal record and see she is HepB SAg neg, HCV neg, Rubella non-immune. What is false?
a) TdAP is indicated in all pregnant women, irrespective of last booster, ideally between 27-32 weeks
b) Inactivated Influenza and COVID19 mRNA vaccines can be co-administered at the same time in pregnancy
c) HPV and Hepatitis B Vaccine series should be offered postpartum if she was not previously immunized for same
d) MMR should be delayed until done breastfeeding
D – MMR does not need to be delayed while breastfeeding. MMR /live attenuated vaccines should not be given during pregnancy but can be given while breastfeeding. Exception is smallpox (AKA MONKEYPOX) and yellow fever vaccines should not be given while breastfeeding.
A 24y G1P1 woman experiences preeclampsia at 36 weeks and her daughter is delivered. She is seen 6 weeks postpartum. She is healthy with normal BP, BMI and has no history of diabetes. She is presently breastfeeding.
In follow-up which is false?
a) She should be counselled that breastfeeding reduces risk of future cardiovascular diseases.
b) In future pregnancies she should take ASA 162mg to prevent preeclampsia from 12-36 weeks.
c) A lipid profile should be drawn at nearest opportunity and statin therapy initiated if intermediate-high risk
d) Moderate intensity Exercise 150 min /week is recommended in pregnancy to prevent risk of preeclampsia
C – drawing lipid profile and starting statin. JAMA 2022 meta analysis of >1million parous women showed reduction in MI, Stroke, CV death in women who breastfed controlling for multivariable. Prior preeclampsia is an indication for ASA. In all women with hypertensive disorders of pregnancy CCS suggests lipid profile be drawn postpartum but frankly we aren’t given a lot of guidance as to what to do with results in a 24 year old – it’s to inform decision making. Certainly you won’t start a statin in a breastfeeding woman.
A 25F G1P0 currently 35 weeks gestation tests positive for COVID-19. She is unvaccinated and has shortness of breath at rest. She is found to be 89% on room air and CXR shows bilateral lower lobe infiltrates. She is placed on 2L NP and admitted to hospital for further management.
All of the following should be done except:
a) Start DVT prophylaxis
b) Start Dexamethasone and Remdesivir
c) Close monitoring of fetal status using NST and fetal ultrasound
d) Monitor for increased risk of pre-eclampsia and maternal respiratory compromise including need of ICU admission and mechanical ventilation
e) Recommend vaccination 3 months after COVID-19 infection
: B –Avoid Dexamethasone due to its readiness to cross the placenta and cause adverse fetal complications. Use Methylprednisolone or other steroid alternatives for COVID-19 treatment. Remdesivir is no longer recommended in pregnancy (BC Treatment Table)
A 28F G2P1 at 28 weeks of gestation is found to have severe IUGR with fetal weight of <1st percentile on ultrasound. She is admitted to antenatal floor for monitoring. You are asked to see to assess for possible pre-eclampsia. She has a history of pre-eclampsia at 33 weeks requiring C-section in her first pregnancy.
On review of labs done in first pregnancy, she had an elevated cardiolipin IgM.
Which of the following is most appropriate?
a) Initiate ASA 81-162mg QHS to prevent preeclampsia
b) Initiate enoxaparin 40 mg sc for obstetric acute phospholipid antibody syndrome
c) Initiate Nifedipine XL 30mg if her blood pressure is >140/85
d) Order uric acid as an early marker of preeclampsia
e) She should get Betamethasone IM
f) She should get Magnesium Sulfate
C – initiate Nifedipine if BP>140/85. Aspirin should be started <16 weeks. Prophylactic LMWH started at onset of pregnancy for antiphospholipid syndrome. Betamethasone given if preterm delivery anticipated within next 7 days (not enough information to initiate this). Doesn’t meet criteria for Magnesium Sulfate start.
A 29F previously healthy G2P1 had an uncomplicated vaginal delivery 30 minutes ago, but is now experiencing significant vaginal bleeding. In addition to ABCs and giving fluids and blood products as necessary, which of the following is false?
a. Assess for uterine atony and retained placental products as cause
b. Post partum hemorrhage is defined as more than 500mL of blood loss post vaginal delivery and 1000mL after C-section
c. Give misoprostol and tranexamic acid now
d. Giving tranexamic acid prophylactically immediately after delivery would have prevented post partum hemorrhage
e. Severe bleeding is treated with intra-uterine balloon or uterine artery embolization
D – prophylactic tranexamic acid. Studies show that TXA given prophylactically immediately after vaginal delivery does not reduce PPH.
A 30yoF G1P0 currently 30 weeks gestation is referred to you for palpitations. Her cardiac exam is reassuring. You do a 48 hour Holter monitor which shows 10% PVCs and no other arrhythmias.
What would you not recommend at this time?
a. Start Amiodarone for symptomatic PVCs
b. Start Metoprolol for symptomatic PVCs
c. Start Diltiazem for symptomatic PVCs
d. Monitor for symptoms of heart failure
e. Do labs for electrolytes, Calcium profile, and TSH
A – Avoid Amiodarone in pregnancy. In addition to checking metabolic labs you would also get an ECHO and refer to a cardiologist – 10% is a high burden of PVCs even if not pregnant in a young woman.
A 35F G4P3 currently at 32 weeks gestation presents to hospital with blood pressure of 200/120 and HR 88 with shortness of breath. She has jugular venous distension and bilateral crackles. She has a history of chronic hypertension on Labetalol 200mg TID and Nifedipine XL 30mg BID. She has been on Aspirin 160mg daily since 10 weeks gestation.
Basic labs show Hgb 110, WBC 13, Plt 174, ALT 56, Cr 142, urinalysis 3+ protein
Which of the following is least appropriate?
a) Give Nifedipine 10mg IR and increase Nifedipine XL to 60mg BID with repeat BP
b) Give Hydralazine 10mg IV and start Methyldopa 500mg TID
c) Betamethasone 12mg IM stat
d) MgSO4 4g IV bolus then infusion at 2g/hr
e) CXR to assess for evidence of pulmonary edema / dyspnea workup
f) OB to urgently perform fetal ultrasound for growth and placental dopplers
D)
This is too much Mg : would want to know her urine output and possibly repeat Cr before giving that bolus. High risk toxicity if already on pulm edema.
Usual Dose: 4g IV loading bolus then 1g/hr x 24h Q30min vitals; Q1h monitor: U/O, reflexes Caution if oliguric renal failure à Mg Toxicityi
A 38 week pregnant woman G1P0 presents with shortness of breath worsening for the past 2 weeks. She recently travelled from North Bay to Toronto for a “babymoon” (3.5 hour car ride). No infectious symptoms. She is scheduled for a C-section at 39 weeks for breech baby, EFW is >97%le.
BMI 43, BP 110/70, HR 110, SpO2 100% RA. ECG is normal. Pulmonary exam is normal. There are non tender varicose veins on the left calf, no leg edema or pain.
Labs: Hgb 96, Cr 42, WBC 11, Plt 382, D-Dimer 912 What is the best next test or intervention?
a) CTPAtoruleoutPE
b) Bilateral leg dopplers to rule out DVT
c) Ferrous fumarate 300 mg po daily
d) Iron Sucrose 300 mg IV
e) Urgent spirometry
D – Iron Sucrose. Using the YEARS algorithm, you have ruled out PE (0 clinical criteria and D-dimer <1000). Leg dopplers are not recommended unless there are signs of DVT. Thankfully North Bay is quite close to Toronto – just north enough to be perfect, consider relocating to practice here when done, and I have yet to have a patient develop a DVT from drivingthere;) Sheisduein1weekandhighriskofmajorhemorrhage(Csection,anemia,?macrosomicinfant)soshould have urgent IV iron replacement for symptomatic anemia.
A 40F G2P1 with BMI of 35 is currently 28 weeks gestation. Her screening 1-hour 50G OGCT is 13. Her blood pressure is 120/70 and she feels well.
Which of the following statements is not recommended in management of pregnant patients with diabetes?
a) Start measuring glucose fasting and 2 hour post meals
b) Start NPH qhs to target fasting glucose <5.3
c) Start Glyburide to target 2hr post-prandial glucose <6.7
d) Measure Fasting Glucose, A1C and lipid profile
e) Stop insulin and all oral hypoglycemics immediately postpartum
D – measure lipids. Lipid profile is generally NOT measured in pregnancy due to physiologic
increase in lipids during pregnancy makes the values meaningless in terms of treatment targets.
A 42 year old G3P3 with type 2 diabetes is planning a pregnancy. Her HbA1c is 7% on Metformin, Sitagliptin and Semaglutide. She is also on Atorvastatin and Perindopril. Her blood pressure is 125/75, Cr 85 with ACR of 35.
Which of the following statements is false?
a) Continue Metformin and discontinue Sitagliptin and Semaglutide
b) Continue Perindopril until positive pregnancy test
c) Continue Atorvastatin until positive pregnancy test
d) Target BP <130/80 during pregnancy
e) She is at increased risk of pre-eclampsia and will require ASA 162mg f) She may require insulin during pregnancy
C – continue atorvastatin until positive pregnancy test. Should stop statins 3 months pre-pregnancy or while attempting to conceive due to uncertainty regarding teratogenic effects or miscarriage risk, in this scenario for 1o prevention so can stop.
A 45F G1P0 undergoing IVF just discovered she is pregnant. She has a history of type 2 diabetes on Metformin, Sitagliptin, Gliclazide, and Semaglutide weekly injections. Her BMI is 40 and blood pressure is 132/85. Last HbA1c is 7.5%.
Which of the following statements is false in management of pregnant patients with diabetes?
a) HbA1c should ideally be 6.5% pre-conception
b) DPP-4 inhibitors, GLP-1 agonists, and SGLT-2 inhibitors are contraindicated
in pregnancy and breastfeeding
c) Metformin and Gliclazide may be continued in pregnancy
d) She will likely be started on insulin in pregnancy
e) She should be started on Aspirin 162mg daily and continued until 36 weeks
c) Gliclazide is not recommended in
pregnancy, while Glyburide may be
used as third line in pregnancy if patient
declines insulin and metformin l
A 45F G3P1A2 seen in the ER for acute shortness of breath and chest pain. CTPA confirms PE. She has a two miscarriages at 8 weeks gestation and a pregnancy delivered at 30 weeks due to pre-eclampsia.
You do antiphospholipid testing and she is positive for lupus anticoagulant and anti- cardiolipin, negative for beta-2 glycoprotein.
You recommend the following except:
a. She has antiphospholipid syndrome and should be on lifelong Warfarin
b. Her INR target should be 2.5-3.5
c. She is at increased risk of recurrent miscarriage, pre-eclampsia and thrombosis in pregnancy
d. During future pregnancies, she should be switched to therapeutic LMWH
e. For future pregnancies, she should also be on low dose ASA
C – INR 2.5-3.5. INR target for antiphospholipid syndrome is 2-3.
A 62yF is scheduled for thyroidectomy for symptomatic goitre. She reports she had a mild heart attack 3 years ago after death of her husband– had angiography and was advised angio/coronary arteries normal, no stenting required.
Meds: ASA 81mg daily, Bisoprolol 5 mg daily, Simvastatin 10 mg daily.
What do you advise with regards to her antiplatelet management prior to surgery?
a) Continue ASA perioperatively
b) Hold ASA 7 days preop, resume when surgeon says safe postop
c) Hold ASA 72h preop, resume POD #2
d) Hold ASA 72h preop, resume POD #1
Pick B - Thyroidectomy for goitre is high risk bleeding (airway compromise if patient gets postop hematoma).
Without compelling indication for ASA, although CCS says to hold ASA “at least 3 days preop” your surgeon will probably appreciate
pt being completely off ASA!
A 63yF is scheduled for an elective TKA for severe Rt knee Osteoarthritis in 6 days. She has a history of stable CAD following NSTEMI and PCI with 1 stent in 2018. She reports she is short of breath when she walks up the stairs but this has been present for over one year as she has significant weight gain due to lack of exercise with painful knee arthritis.
BP 110/68, BMI 37, HR 58. CV Exam unremarkable.
Meds: Clopidogrel 75 mg daily, Rosuvastatin 10mg daily, Bisoprolol 5mg daily, Lisinopril 10 mg daily, celecoxib 100 mg po BID, acetaminophen 1 g po TID.
ECG: Sinus Brady, old inferior Q’s.
Labs: Hgb 109, Cr 83, A1C 6.3% , NT pro BNP 120 mg/L
With regards to preventing myocardial injury after surgery, what is the best recommendation at this time?
a) Advise anesthesiologist to target MAP >80 intraoperatively
b) Advise anesthesiologist to deliver FiO2 >= 80% intraoperatively
c) Advise anesthesiologist to keep temperature 37oC intraoperatively
d) Delay surgery
e) Continue bisoprolol perioperatively
PICK D - This patient has significant symptomatic anemia and is scheduled for surgery with high risk of major bleeding (>1L average blood loss). At this time safest to delay surgery to optimize Hgb – major anemia puts pt at high risk of “type 2” supply/demand mismatch MINS or even ACS ALSO - clopidogrel on board, ideally for anesthesia to give spinal want held 7 days There are RCTs whichshow(a)and(b)andcdon’treduceMINS. Bisoprololcanbecontinuedperioperativelythough“atthistime”youdon’twantto greenlight elective surgery in a cardiac patient who is not optimized.
A 72y M is referred for preop assessment. The surgeon wonders if they can stop clopidogrel prior to upcoming elective laparoscopic cholecystectomy for symptomatic gallstones.
PMH: Lacunar stroke 2 years ago. HTN, Dyslipidemia, ex-smoker. No history of cardiac disease or Afib. Osteoarthritis. Last known LVEF 65%.
Meds: Clopidogrel 75mg daily, Indapamide 2.5mg daily, Simvastatin 40 mg daily, vitamin D, Ibuprofen PRN arthritis.
On exam: Alert, oriented. Using his iPhone he shows you his BP and HR trend for past 2 years which he tracks meticulously. BP 128/72, HR 68. Cardiac exam normal.
ECG shows normal sinus rhythm with ECG LVH.
With regards to his pre-operative management, which is the next best recommendation?
a) Measure NT-pro BNP
b) Order post-operative ECG and Troponin
c) Order exercise stress test
d) Advise to hold clopidogrel 5 days preoperatively
Advise to hold clopidogrel 5 days pre op
This is a low risk OUTPATIENT surgery so no BNP
A 76yF is seen prior to elective hip arthroplasty. She had a previous inferior STEMI w TNK and RCA stent in 2018. She is on clopidogrel, ramipril, rosuvastatin, nitro PRN. She is a non-smoker. She gets short of breath on exertion, stable for the past 1 year. She undergoes a stress test which shows 1mm ST depression in II, III, AVF. What do you recommend with regards to her perioperative management:
a) No further testing or changes
b) Rivaroxaban 2.5mg po bid for perioperative vascular optimization
c) Referral to cardiology for PCI prior to surgery
d) Start and titrate beta-blocker, proceed to OR
e) Hold clopidogrel 5 days prior to surgery
Pick D - STABLE CAD. The bigger question is why did she get a preop stress test with stable symptoms? Rivaroxaban 2.5 BID per COMPASS trial not indicated to start periop Stable CAD no role for PCI. Clopidogrel needs to be held, 7 days for spinal, change to ASA 81mg How long to wait for OR? Depends on clinical scenario. If patient is booked for surgery tomorrow you really don’t have time to start – but if OR in a couple weeks can start today eg bisoprolol 2.5 daily , reassess in a week …
A middle aged woman with history of mechanical bileaflet AVR for bicuspid aortic stenosis is scheduled for a hysterectomy for a large fibroid uterus. She presented with post menopausal bleeding. She is otherwise healthy. Wt: 60 kg eGFR 100, ECG = sinus with LVH
Meds: Warfarin, Vitamin D, Multivitamin
How do you advise her with regards to pre-operative warfarin management?
a) Stop warfarin 5 days preop, take enoxaparin 60 mg sc Days -3, -2, -1 preop. INR day - 1.
b) Stop warfarin 5 days preop, INR morning of surgery, if >1.5, vitamin k 2mg po x 1
c) Stop warfarin 5 days preop, take enoxaparin 30 mg sc Days – 3, -2, -1, INR on day of surgery
d) Stop warfarin 5 days preop, INR day before surgery, if >1.5, vitamin k 1mg po x 1
Pick D - High risk of bleeding (because she presented with bleeding) and has a bileaflet AVR but no other thrombosis risk factors so bridging is NOT recommended here. Ideally have INR check day before surgery to avoid delays day of surgery, vitamin K 1-2 mg po if over 1.5 is suggested by thrombosis Canada
A middle-aged female presents with a 6 month history of urticaria. She has never had any episodes of swelling. The urticaria resolve within 12hr, with no residual bruising or scarring. She reports that she has been eating out at restaurants more recently. She is otherwise well. Initial bloodwork is normal including a CBC, creatinine and liver profile. What is the most likely cause of this patient’s symptoms?
1. Chronic Idiopathic Urticaria
2. Food allergy
3. C1 esterase deficiency
4. Autoimmune Disease
- Chronic idiopathic urticaria
A young man presents with occasional angioedema of his lips and hands. Which of the following features make it least consistent with C1 esterase deficiency?
1. Occasional GI symptoms
2. Triggered by dental procedure
3. Presence of urticaria
4. Laryngeal involvement
Presence of urticaria
ACE inhibitors and breast feeding ?
Safe (enalapril, quinapril, captopril)
ACHEi are indicated in those dementias EXCEPT ?
- Alzheimer
- Vascular
- Dementia with Lewy bodies
- Parkinson dementia
- Gronto temporal dementia
Fronto temporal dementia no role for ChEI
Trazodone, SSRIs for behavious only
Amines qui diminue la pulmonary capillary wedge pressure ?
Epinephrine
Milrinone
Dobutamine
An 87 year old female resident in a nursing home with a diagnosis of severe dementia has been reported to yell and curse at staff around bathing. She is argumentative with other residents throughout the day. She has gone without bathing weeks at a time because staff are unwilling to approach her. When asked months of the year backwards, she consistently completes December to April then gives up. What is the best next step in her management?
a. Quetapine 12.5mg PO PRN prior to bathing b. Tylenol 1g PO TID
c. Risperidone 0.125mg PO BID
d. Routine bloodwork including CBC, lytes, creatinine, LFT, TSH, B12 and head imaging
The correct answer is B. Adequate pain control reduces BPSD. This patient’s aggression is stable, which is more suggestive of BPSD than delirium.
Beer’s criteria inappropriate medications in geratric patient ?
Warfarin, rivaroxaban, anticholinergics (amitryptiline, dimenhydrinate, hydroxyzine, paroxetine)
Drug-drug interactions : warfarin + SSRIs / Li + ARB/ACEi
Baclofen as renal clearance
ChEIs side effects?
BRADYCARDIA so avoid if conduction defects/syncope
GI intolerance
Urinary incontinence
Wild or vivid dreams
Clinical findings associated with poor neurological outcome in ACR?
Absence of pupillary reflex to light at 72h or more LR + 4
Presence of status myoclononus during first 72h LR +5
Absence of the N20 sonatosensory evoked potential cortical wave 24-72h after cardiac arrest or after rewarming LR +16.1
Also : reduced grey white matter differentiation on CT and large diffusion restriction on MRI have poor outcome
Clinical presentation of TCA overdose ?
Anticholinergic toxicity
RED as a beet
DRY as a bone : urinary retention
MAD : sedation, confusion, hallucination
BLIND : mydrasis non responsive
HOT hyperthermic
Seizures
Comment différencier intox alcool isopropylique et intox methanol/ethylene glycol ?
ABSENCE d’un ANION GAP a 4-6h post ingestion : isopropyl ROH
ROH isopropylique :
- cause PAS d’AG augmente
- Toxicite retinienne (methanol)
- IRA (ethylene flycol)
Compliance VCI et necessite de bolus ?
Intubated, fully ventilated : distenbility > 15-20% likely to fluid responsive
Spontaneoulsy breathing not intubated IVC < 2cm and respiratory variation > 50% : likely fluid responsive
COVID 19 in pregnancy management ?
- Should have 3rd trimester growth ultrasound following infection as risk of growth restriction
- Hypertensive disorders including severe preeclampsia higher following infection
IF ADMITTED
- < 22w or >34 w : methyprednisolone x 10d
- 22-34w : dexamethasone x 2d (replace betamethasone for lung maturation) then methylprednisolone x 8d
- Post partum : dex x 10d
Consnider paxlovid and tocilizumab
Criteres de dialyse pour intox lithium ?
- Arrhymias
- Seizures or severely abN mental status
- Serum lithium levels > 5
- Serum lithium levels > 4 with a Cr > 176
Criteria for ARDS ?
Hypoxemia PaO2/FiO2 < 100 if severe, 101-200 if moderate
Hypoxemia SpO2/FiO2 < 315 with SpO2 < 97%
David Homme de 25 ans en choc avec ARDS. Intubé aux USI. Sous perf de levo 0.4mcg/kg/min. TA 120/65. Hématocrite à 0,31 et Hb 95. ScvO2 à 53% et lactates 3.2. IET avec AI 12, PEEP 10, FiO2 70%, VC 450cc. Gaz pH: 7,46/30/80/25. (reponse pneumo dada)
Quoi faire?
A) Culot HB
B) Débuter perfusion dobutamine
C) Augmenter la perfusion de levophed
D) Débuter perfusion de vasopressine
B) Perf dobutamine
ScVO2 N 60-80%
Composé PaO2, Hb, débit cardiaque et ici PaO2 et Hb sont OK
Décrivent un patient avec myopathie des soins. Lequel de ces éléments n’est pas associé à ceci?
a) ventilation mécanique
b) corticothérapie
c) Usage de curare prolongée
d) Alitement prolongé
Usage de curare prolongé
ECG in TCA overose ?
- QRS > 100
- Tall R in AVR
- Deep slurred S in 1 and aVL
- R/S ratio > 0.7 AVR
- Type 1 Brugada (RBBB, downslope ST depression V1-V3)
Eclampsia : delivery safe if PLT ?
Platelet targets in ITP ?
PLT > 75
ITP : Vaginal delivery >30, C-section >50, neuraxial anesthesia >70-80
treat ITP if PLT < 30, clinically bleeding or < 50 near delivery
EKG and lithium overdose ?
T wave flattening in the precordial leads, QT prolongation, brady, unmask Brugada
F avec pneumonie LIG, sepsis avec TA 85/36. Post 4L de volume, TA toujours 90/35, mais reste avec TVC à l’angle de Louis, pas de surcharge. À l’écho, VG hyperdynamique et VD pas surchargé, pas d’ép péricardique. VCI 1cm avec variation >50% à l’inspiration. TX?
A) Pentasharp
B) Dopamine
C)Lévo
D)Soluté de LR
C)
Choc refractaire au volume meme wsi encore vide : debuter la levo precocement ameliore la mortalite
