ORALS - T+K

Question 1

ANAPHYLAXIS / ANGIOEDEMA CASE

Answer 1

1. PPE/MOVID
   BW: C1 esterase, tryptase
2. MGMT (anaphylaxis)
   Epi: 0.3-0.5mg q5-15min (0.01mg/kg of 1mmg/mL)
   O2, IVF (20cc/kg)
   Ventolin (if needed) 2.5-5mg neb
   H1 antihistamine: cetirizine 10mg IV
   Benadryl 25-50mg IV
   H2 antihistamine: famotidine 20mg IV
   Glucocorticoid: methylpred 125mg (1mg/kg) IV

Kitchen sink:
Epi infusion 0.1mcg/kg/min
vasopressors
Glucagon 1-5mg (if on BB, adults only)
USE ketamine to intubate (bronchodilation)

2. MGMT (angioedema)
   berinert (C1 inhibitor)
   icatibant (bradykinin receptor antagonist)
   FFP (blocks bradykinin production)

follow up questions
1. Definitions of anaphylaxis
=> Known exposure PLUS hypotension
=> Likely exposure PLUS (2 of): skin, resp, GI, BP
=> UNKNOWN exposure PLUS skin AND A- resp B- BP

2. Risk factors for anaphylaxis
   High SES
   summer months / falls
   hx of atopy (asthma, eczema)
   parenteral > oral
   mastocytosis + mast cells
   Physical exertion
3. indications for prolonged observation with anaphylaxis
   Hemodynamic unstable
   airway unstable
   IV epi infusion
   low outpatient support
4. How to differentiate btwn anaphylaxis and angioedema
   Anaphylaxis - elevated tryptase, normal C1 esterase inhibitor
   Angioedema, acquired - non elevated tryptase, deficient C1 esterase inhibitor
5. Types of angioedema
   Allergy - histamine mediated
   Hereditary - bradykinin (C1 inhibitor deficiency)
   Acquired - bradykinin (C1 inhibitor deficiency)
   ACEi induced - aCEi induced (ACE activates bradykinin)
   Idiopathic - bradykinin (unknown)
6. Risk factors that cause cause ACEi angioedema
   recent ACEi start
   Black
   female
   smoker
   older age
   (TPA can cause angioedema)

Question 2

PNEUMONIA

Answer 2

CURB-65

Question 3

ENDOCARDITIS CASE

Answer 3

1. PPE/MOVID
   => septic w/o: blood cultures, UA/UCX, CXR
2. MGMT
   => IVF, early pressors
   => ceftriaxone, vanco x4 weeks
3. CONSULTS
   => ICU, needs inpatient ECHO

FOLLOW UP QUESTIONS
1. Complications of endocarditis
septic emboli - mesenteric emboli, arterial emboli, retinal artery emboli, CVA
ICH
stroke

2. Common endocarditis bacteria
   => S aureus
   => S viridans
   => S bovis
   => Enterococci
   => HACEK - hemophilus, actinomycetemocomitans, cardiobacterium, eikenella, kingella
3. List the DUKE CRITERIA (BE FEVIR)
   Blood culture + (Typical bacteria)
   Echo findings (paravalvular abscess, new regurg, new dehesicnace of valve, vegetation on valve)
   Fever
   Vascular findings (janeway, infarcts, emboli)
   Immunologic findings (roth spots, osler nodes, GN)
   Evidence - single positive C+S
   Risk factors (foreign body - heart transplant, PM, ICD, degen AV/MV, prosthetic valve, rheum HD, IVDU, immunocompromised)
4. Indications for surgical management (VHBEF)
   Vegetation / peri-annular extension
   Heart failure
   Bacteremia (persistent)
   Emboli (recurrent)
   Fungal