HPM Random Facts Review Flashcards
What should you always consider for first line pharmacotherapy of delirium?
Consider antipsychotic Haloperidol
For delirium should meds be routine or prn?
PRN!
What other drugs do we consider for escalating delirium, not responding to antipsychotics in patients who are a risk to themselves or others?
Rescue doses of midazolam or lorazepam in addition to antipsychotic
What med do you use in Lewy Body Dementia and Delirium ?
Quetiapine, low dose prn q4hrs
what are imaging signs of pneumonitis?
similar to pna, new focal airspace opacities
how can pneumonitis present clinically?
dry cough, SOB, likely afebrile
If pneumonitis is suspected, what is the work up or plan of care?
work up should be bronchoscopy with bronchoalveolar lavage to rule out infection, then treat with steroids
what symptoms of SVC are emergent requiring immediate surgical/XRT intervention for stent placement or radiation therapy?
AMS from cerebral edema, and stridor from central airway obstruction.
When do you consider a catheter for malignant pleural effusion?
Rapid filling in < 1 week
When are recurrent thoracentesis okay?
Slow fill > 1 month
Life span < 3 months
Low Performance Status
What do you use for relief of dyspnea in patients with advanced terminal disease?
Systemic opioids - optimally long acting with any break through controlled with short acting narcotics
what are risks for aspiration pneumonia
dysphagia, choking, coughing, excessive sedation, OSA with obesity compromising glottis closure or cough reflex during sleep
How does Heliox work?
Decrease turbulent air flow, therefore decreases airway resistance, and makes less work of breath!
Remember it’s temporary!
Name 4 steps to approaching hemoptysis management
- Locate the bleed
- Reverse any coagulopathy
- Bronchoscopy with interventions (ice saline, balloon tamponade, topical vasoconstrictor such as epi)
- if bronch fails, IR embolization/surgery
when can you not use Non invasive positive pressure ventilation?
if the patient is confused or obtunded
When should you use direct thrombolysis for a PE?
If patient is unstable, or has right heart strain
Which anticoagulation is perferred for active cancer and thromboembolism?
LMWH preferred over coumadin
in constipation in the cancer patient with bone mets what is the first step?
look for underlying cause, RULE OUT hypercalcemia prior to assuming OIC or treating.
When do you avoid bulk fiber?
If poor oral intake and or history/risk of fecal impaction
When is methylnaltrexone contraindicated?
If obstruction suspected, or for patients with any compromise of bowel integrity such as prior bowel obx.
what is a bad side effect of methylnaltrexone?
bowel perforation
what is the mechanism of methylnaltrexone?
Opioid antagonist that targets the mu receptors of the GI tract without crossing blood brain barrier or impairing analgesia by opioids.
What type of agents are the following:
- Psyllium
- senna and bisacodyl
- docusate sodium
- Bulk forming agents
- increase intestinal peristalsis and secretions
- soften stool by increasing water penetration
What is the best treatment for hypercalcemia
>14?
- IVF with (0.9% NaCl)
- Calcitonin
- Zoledronic acid
how much IVF with (0.9% NaCl) do you use for hypercalcemia?
use 2-4L/day for 2-3 days
How much calcitonin do you use for hypercalcemia?
4-8u/kg subQ every 6-12hours for 2-3 days
which bisphosphonate is best for renal insufficiency?
zoledronic acid is better than pamidronate
when someone has hemorrhage/hemoptysis how do you lay the patient?
Good side up!
lateral decubitus position with the affected lung in the dependent position
When should you do surgery in metastatic bone disease?
If life expectancy >1mo
What areas of fracture should you consider surgical repair if life expectancy is >1mo?
Tibia, Femur, Pelvis.
Spinal instability.
what is used to treat hypercalcemia due to lymphoma, sarcoid, or other granulmoatous diseases?
glucocorticoids
What can make SVC worse?
IVF
When do you need seizure prophylaxis in primary or secondary brain mets?
If post op from resection, up to 3 months
OR
If the patient has had a seizure
what is pharm agent contraindicated if suspected bowel obstruction?
metoclopramide - it is a prokinetic and may increase severity of symptoms.
Use bowel rest! IVF, Steroids, Hyoscine, NG, venting peg or surgery
when do you use O2 in patients?
When they are HYPOXIC
The vomiting center sits in the ____.
Medulla
What is the receiving part of the vomiting center called?
The NTS
Nucleus Tractus Solitarius
Where is the emitogenic signal coming from for nausea/emesis?
the DMV
Dorsal Motor Nucleus of Vagus
Name 4 parts of the body go to the NTS (receiving center)?
- Higher cortical centers - increase ICP (anticipatory nausea)
- Chemoreceptor Trigger Zone (in medulla outside of BBB) - Uremia, toxins, hypercalcemia
- GI tract (obx, stasis, mets, chemo agents/radiation)
- Vestibular Apparatus (motion, opioids)
What peripheral area of nausea goes to the CTZ or to the NTS directly?
the GI tract
What is the most common cause of death in pts with ALS ?
Respiratory failure
What is a predictor of sudden death in patients with ALS?
decreased heart rate variability
When should you consider a PEG in pts with ALS?
If VC is >50%
early in the course can stabilize weight and BMI and prolong survival if early.
Anticholinergic does what to the pupils?
Mydriasis - Dilates
what are the main presentations in Serotonin syndrome (4) ?
Hyper reflexia
Hyper tonia (myoclonus)
Hyper thermia
Midriasis!
What neurotransmitter is affected in NMS?
Dopamine (dopamine becomes LOW)
What medications cause NMS?
Anti-psychotics like olanzapine and chlorpromazine
What are the main presentations in NMS?
BRADY kinesia
Brady reflexia
Muscle rigidity
tachycardia and fever (HTN or variable)
