Pages 21-30 Flashcards
Csf Findings in Bacterial meningitis?
Opening Pressure: Elevated White Blood Cell count: 1,000-10,000* Neutrophils: >80% Glucose: Reduced Protein: Elevated Gram Stain: Bacteria
Csf Findings in Viral meningitis?
Opening Pressure: Normal White Blood Cell count: Less than 300 Neutrophils: 1- 50% Glucose: Normal Protein: Normal Gram Stain: Nothing
Csf Findings in fungal meningitis?
Opening Pressure: Elevated White Blood Cell count: Less than 500 Neutrophils: 1- 50% Glucose: Normal Protein: Elevated Gram Stain: Nothing
Treatment order in meningitis patients needing CT?
Prior to CT:
- Blood cultures should be drawn
- Steroids
- Empiric antimicrobial therapy
Rx encephalitis?
Supportive Care
*HSV encephalitis: ACYCLOVIR
IV emperic meningitis rx based on age?
- Less than 1 month: Ampicillin + Cefotaxime or Gent
- 1-3 months: Ampicillin and Cefotaxime
- Children over 3 months: Dexamethasone b4 Cephalosporin + Vancomycin
- 50 years or younger: Dexamethasone b4 Cephalosporin + Vancomycin
- Over 50: Dexamethasone b4 Cephalosporin + Vancomycin AND Ampicillin
Presentation subarachnoid hemorrhage?
- Acute onset thunderclap HA
- Typically occipital or unilateral
- Significant portion also have a warning (sentinel) HA - LOC
- Vomiting
- Neck stiffness
- Seizure
RF SAH?
- FH = 3- 5 x Risk
1. Recent exertion
2. Hypertension
3. Excessive alcohol consumption
4. Sympathomimetic use
5. Cigarette smoking
Diagnosis SAH?
- CT: 7% not visualized on initial head CT
- LP:
- Absence or clearing of blood.
- Xanthochromia
How to analyze blood in LP of SAH?
- Normal CSF does not contain RBCs
- Many sources state that if # RBC decreases by 50% from tube 1 to tube 4, blood attributed to tap trauma
- However, this decrease can occur in SAH as well
- Tap should only be labeled ‘traumatic’ if 4th tube is fewer than 5 RBCs per HPF
What is xanthochromia?
Yellow or pink discoloration of supernatant once the CSF is centrifuged
- Results from breakdown of RBC
- Determined by visual inspection or spectrophotometry
- Presence of xanthochromia highly sensitive of SAH
Next step if CT or LP consistent with SAH?
Angiography is necessary
- Conventional digital subtraction angiography (DSA) is gold standard
Mgmnt SAH?
- Assess and reassess ABCD’s
- Discontinue or reverse anticoagulation
- Prevent hypotension and hypoxemia
- Control ICP
- Seizure prophylaxis
- Treat fever and infection aggressively
- Control blood glucose: target 140-185
How do you control ICP?
- Monitor/lower BP in consult w/ neurosurg
- Elevate head of the bead to 30 degrees
- Provide sedation and analgesia
- If signs of rapidly rising ICP or herniation: mannitol or mild hyperventilation: target CO2 ~ 30 mmHg
When are epileptic patients prone to seize?
- Medical noncompliance: most common cause
- Sleep deprivation
- Emotional or physical stress
Causes of secondary seizure?
- Hypoglycemia: most common cause
- Hyponatremia
- Alcohol withdrawal, drugs, toxins
- Trauma
- Tumor
- Infection
- Eclampsia
Diagnosis mimicking seizure?
- PNES
2. Syncope
Lab tests in seizure patient?
First time: 1. HcG 2. CMP 3. Head CT 4. MRI / EEG - outpatient Recurrent: (above plus) 1. Phenytoin 2. Carbamazepine 3. Phenobarbital 4. CT head only if seizure quality is different or in status epilepticus 5. Continuous EEG if status
Vitals in alcohol withdrawal?
- Tachycardia
- Hypertension
- Hyperthermia
- Tachypnea
Drugs causing seizures?
- Isoniazid: TB patients
- TCAs - widened QRS
- Prominent terminal R in AVR
Characteristics of PNES?
- Rhythmic, controlled shaking activity
- Ability to talk or follow commands during the seizure
- Recall of a seizure that involves both sides of the body
- Lack of a postictal period
What is status epilepticus?
Single unremitting seizure w/ duration longer than 5-10 min or frequent clinical seizures w/o interictal return to baseline
Rx Status epilepticus?
- First line: Benzos (usually lorazepam)
- Second: fosphenytoin/phenobarbital/VPA
- Third: versed/pentobarbital/propofol infusions
Dosing of Benzos in seizure?
2 mg of lorazepam or midazolam every 2-5 min until seizures controlled
Dosing of other meds in seizures?
Diazepam: 5 mg Pq 2-5 min (also available PR)
Phenytoin: 15-20 mg/kg PO/IV
Fosphenytoin: 15-20 phenytoin equivalents/kg IV
Phenobarbital: 20 mg/kg IV (use single dose of 60-120 mg PO for oral load)
Valproic acid: 15-45 mg/kg IV
Rx for secondary seizures?
Eclampsia - Magnesium sulfate
Hyponatremia - Hypertonic saline
Isoniazid - Pyridoxine
Hypoglycemia - Dextrose
Cholecystitis presentation?
- Biliary colic: may radiate to the back, r. flank/scapula
- RUQ or epigastric pain
- N/V may
- Pain is burning, pressure-like, or heavy
- Occur in relation to the ingestion of fatty meals
Ddx acute Cholecystitis?
- Choledocholithiasis
- Cholecystitis
- Cholangitis
What is Charcot’s triad?
- RUQ pain
- Fever
- Jaundice
- Seen in 70% cholangitis patients
What is Murphy’s sign?
Ask patient to breathe out then gently hand below costal margin at mid-clavicular line
- Patient then inspire
- If patient stops breathing in (as the gallbladder is tender and, in moving downward, comes in contact with the examiner’s fingers) and winces with a “catch” in breath, test is positive
- Good sensitivity (63-90%)
- Low specificity (45-65%)
Efficacy of US in cholecystitis?
- Sensitive: Over 95%
2. Less sensitive under 80% for choledocholithiasis
What level of dilation of bile duct are we looking for?
Greater than 6mm in adults or 8mm in elderly)
- Choledocholithiasis
- Cholangitis
What level of gallbladder wall thickening do we look for?
5mm or greater
When is ERCP needed?
To diagnose and treat diseases of the biliary and pancreatic ducts
Rx Biliary colic?
- NSAIDS and/or narcotics
- IVF
- Antiemetics
Abx Cholangitis?
Ampicillin/sulbactam
Appendicitis presentation?
- Vague epigastric or periumbilical pain followed by:
- Anorexia, n/v
- Migration of pain to RLQ
* Only 1/2 - 1/3 present in this manner
- Retrocecal appendicitis: vague and poorly localized pain - Pelvic appendicitis:midline or L.-sided pain
When is vomiting more indicative of appendicitis?
If it comes after pain
Presence of fever in appendicitis?
Fever typically absent during initial onset of pain
- Commonly develops within 24 hours
WBC useful in appendicitis?
Not really
US sensitivity in appendicitis?
- 75 to 90% sensitive
Findings suggestive of appendicitis include: noncompressible lumen, a diameter greater than 6mm, absence of gas in the lumen, appendicoliths, and a thickened wall - CT more sensitive and can rule out other causes
Presentation ruptured AAA?
- Pain
- Hypotension
- Pulsatile abdominal mass
Target BP in rupured AA?
Systolic between 90 and 100
Blood to use while waiting for crossmatch?
O-
What is pain out of proportion to exam indicative of?
Mesenteric Ischemia:
Patient may be screaming in pain, but their abdomen is soft with no guarding or rebound
Causes and Rx mesenteric ischemia?
- Embolus: thrombolytics during angiography
- Mesenteric artery thrombosis: start heparin then same as above
- Mesenteric vein thrombosis:
- Nonocclusive ischemia: treat underlying cause
Dx in mesenteric ischemia
CT angiography
- Angiography can also be used and is therapeutic
Signs of mesenteric ischemia on imaging?
Circumferential thickening of the bowel wall, bowel dilatation, bowel wall attenuation, and mesenteric edema
Meds to stop in mesenteric ischemia?
Vasoconstrictors
What is papaverine?
Can be given during angiography to increase blood flow to bowel that is not perfusing well by reducing mesenteric vasoconstriction
Most common cause SBO?
- Tumors
- Adhesions
- Hernias
- Strictures
- Intussusception
- Chrons
- Volvulus
What is inability to pass gas indicative of?
SBO
Multiple air-fluid levels are seen along with distended loops of small bowel?
Bowel obstruction
Diagnosis of orthostatics?
Systolic drop of more than 10 or a pulse increase of more than 20
What is elevated BUN indicative of?
GIB: due to degraded blood being absorbed in GI tract. A BUN/Cr ratio greater than or equal to 36 is suggestive of UGIB
Most common causes LGIB?
- Angiodysplasia
2. Diverticulosis
What does a A 99mTechnetium labeled red cell scan do ?
Looks for source of lower GI bleed
Rx varices?
- Octreotide
2. Abx in patients with known cirrhosis
