HCP 6: Paul Isaac Pulmonary Embolism Flashcards
Describe the Anatomy of the Lungs
Right Lung = 3 lobes, oblique & horizontal fissure
Left Lung = 2 lobes, oblique fissure
Parietal/Visceral pleura
If PO2 drops below 60 mm Hg, how does our body compensate?
Peripheral chemoreceptors (on aortic/carotid bodies) detect decreased O2
Afferent signal via CN IX & X
Respiratory center (DRG) in medulla
Phrenic nerve
Diaphragm
Increase respiration in order to get more O2
What do central chemoreceptors detect? How do they work?
They detect H+ (Indirectly detect CO2)
In blood H+ converted to CO2 (via CA)
CO2 crosses BBB & Brain-CSF barrier
Converted to H+ in CSF
Chemoreceptors detect increased H+ (which suggests hypercapnia)
Signal respiratory center (DRG) in medulla
Phrenic nerve
Diaphragm
Increase respiration in order to blow off CO2
What other receptors/centers besides the central and peripheral chemoreceptors aid in respiratory regulation?
Lung stretch receptors (increased stretch, decrease breathing rate)
Muscle & joint receptors (increased stretch, increased breathing rate)
Apneustic Center triggers increased resp.
Pneumotaxic Center decreases respiration
What is generalized anxiety disorder?
When does it initially appear?
What are some signs/symptoms?
Persistent, excessive, unrealistic worry that is NOT focused on a specific object/situation
Initially appears 20-35 y.o.
S/Sx: disturbed sleep, trembling, difficulty concentrating, irritability, diaphoresis, palpitations
What is a panic attack?
Abrupt onset of intense fear/discomfort that reaches peak within minutes
S/Sx: sweating, tachycardia, “going crazy”
What are some cognitive/behavioral therapies that can be used for anxiety?
Goal: Equip patients with effective coping strategies
Discuss probabilities, dangers, consequences, possibilities of anxiety states
Relaxation therapy: progressive muscle relax.
Mindful meditation: increase awareness of present situation & acceptance
Sleep hygiene
What are some ways we can talk to anxious patients?
Acknowledge awareness of anxiety Encourage them to talk about their feelings Reassure that they are safe Maintain calm manner Establish working relationship & trust Orient patient to environment & new experiences Use simple language/brief statements Reduce sensory stimuli
A patient seems to have anxiety. What medications could you possibly give? What are the classifications of each?
Sertraline (Zoloft) - SSRI or Lorazepam - Benzodiazepine
You would use Lorazepam if you needed immediate results
What is the mechanism of Lorazepam?
Binds to benzodiazepine binding site on GABA-A receptor on post-synaptic neuron in CNS
Increase affinity of GABA for GABA binding site
Trigger opening of Cl- channels
Cl- influx
Hyper polarization of neuron
Decreased excitability of neuron
Decreased transmission to ascending reticular activating system
Decrease cortical/limbic arousal
What is zinc used for?
Improve immune function (used for cold prophylaxis, but rated B)
Better used for diarrhea & gastric ulcers
What is Ginkgo Biloba used for?
When does it need to be used cautiously?
Active ingredient?
Enhance cognitive performance & memory (C)
May also decrease lipid peroxidation & oxidation of mtDNA
Caution in coagulopathy
Flavanoids & terpenoids
Why would someone with PE have a sternal lift?
PE in pulmonary vasculature Increase resistance Pulmonary HTN Increase after load of RV RV strain & needs to pump harder
Why would we need to do a guaiac stool test?
Before giving heparin (anti-coagulant), we need to ensure that there isn’t a GI bleed. If there was and we gave heparin, it could worsen the bleed & cause them to bleed out.
When is a D-dimer test useful?
Ruling out PE. (High sensitivity, low specificity)
It is a fibrin degradation product.
If someone who isn’t at “risk” for other things but they have +D dimer, likely have PE.
However, it’s not useful for those who are pregnant, cancer, trauma, stroke.
ABG Interpretation
See Dr. Sakai’s Lecture
What are typical EKG findings in PE?
Sinus tachycardia
*S1Q3T3 = S wave in lead I, Q wave in lead III, inverted T wave in lead III
T wave inversion in V1-V4
What is a SPECT V/Q used for?
What are its advantages over CT pulmonagraphy?
Inhale radioactive gas & IV radioactive material, then visualize lungs. Determine if V/Q mismatch.
3D images, higher sensitivity & less radioactive tracer
V/Q Ratio & Mismatches
Ventilation/Perfusion (Ideally >0.8)
PaO2=100; PaCo2=40
At Apex=3 (highest ventilation); base=0.6 (highest perfusion)
Dead Space: V/Q approaches infinity; Q=0 (PE)
High V/Q (high PO2, low PCo2)
Low V/Q (low Po2, high PCo2)
Shunt: V/Q=0 (airway obstruction)
What is a CT Pulmonary Angiogram?
IV contrast dye
+:More specific, more available
-:More expensive; More over diagnosis & over treatment
What is the treatment for DVT?
Primary: clot dissolution (thrombolysis)
Secondary: anti-coagulation therapy (heparin/warfarin), IVC filter
What are some causes of hyper coagulable states?
Acquired: Long flights (>4 hr), heparin induced thrombocytopenia (increased viscosity), pregnancy (decreased protein S, increased fibrinogen, factor VIII, vWF), smoking (activates coagulation, increases fibrinogen), obesity
Inherited: Decreased coagulation inhibitors (AT III, protein C/S), increased coagulation (Factor V Leiden, sickle cell, prothrombin mutation), hyperhomocysteinemia
MOA of oxycodone
Opiate agonist (synthetic derivative of morphine) & analgesic
Binds to u-opiate receptors
ON PRESYNAPTIC NEURON, deactivate AC, decrease cAMP, decrease Ca2+ influx, decrease release of excitatory neurotransmitters
ON POST-SYNAPTIC NEURON, increase K+ efflux, hyperpolarization, decrease response of post-synaptic neuron to neurotransmitters
BOTH, decrease transmission signal of pain
Analgesia
What is the MOA of Sertraline?
SSRI
Allosterically & selectively inhibits serotonin reuptake via SERT
Increased Serotonin in synaptic cleft
Increased activation of post-synaptic neuron
Decrease Anxiety/Depression
BLACK BOXIncreased risk for suicide
