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Professional Development > Part 21 > Flashcards

Part 21 Flashcards

1
Q

Most common type of distributive shock

A

-Sepsis (sepsis is the next step of SIRS -systemic inflammatory response phenomenon)

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2
Q

Nonhemorrhagic hypovolemic shock is most often due to ___ losses

A

Gastrointestinal

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3
Q

Third space losses

A

A type of nonhemorrhagic hypovolemic shock where fluid in a potential space sees filling due to capillary leakage (think peritoneum or pleura) and this depletes intravascular volume overall

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4
Q

Massive transfusion protocol

A

1:1:1 of packed RBC (first choice O neg, Op pos and type specific are alternatives), plasma, and platelets

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5
Q

Neurogenic shock pathophysiology

A

Dilation of the arterial and some degree of the venous side of the systemic circulation

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6
Q

Examples of obstructive shock (5)

A

(this is the least common type)

  • PE
  • tension pneumothorax
  • pericardial tamponade
  • constrictive pericarditis
  • abdominal compartment syndrome
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7
Q

Swan ganz catheterization of the right heart to obtain pulmonary capillary wedge pressure gives a measure of ___

A

left atrium

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8
Q

Cardiogenic shock diagnosis (2)

A
  • pumonary artery catheterization
  • echocardiogram of left ventricle
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9
Q

SIRS criteria (4)

A
  • temp >38 or <36C
  • HR >90bpm
  • RR >20 or PaCO2 <32 (respiratory alkalosis)
  • WBC count >12000 or <4000 or >10% immature bands
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10
Q

qSOFA criteria for sepsis (3)

A
  • RR >22
  • SBP <100
  • altered mental status (due to suspected infection)
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11
Q

Sepsis treatment options (3)

A
  • administer broad spectrum antibiotics piperacillin, ampicillin
  • steroids that mute the immune response (leukotriene storm)
  • initiate pressors as needed (norepi)
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12
Q

Goal directed therapy for sepsis (4)

A

Meet the following criteria:

  • Central venous o2 sat of > or =70
  • central venous pressure > or =8-12
  • mean arterial pressure > or = 65
  • urine output > or = .5cc/kg/hr
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13
Q

Neurogenic shock etiologies (4)

A
  • spinal anesthesia
  • vagal stimulation
  • cord transection
  • NOT head trauma
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14
Q

Why don’t you use antihistamines for anaphylaxis?

A

Because most mast cells have already degranulated at the point of anaphylaxis presence

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15
Q

Conduction requires ___ while convection is dependent on ___

A

physical contact, wind velocity air and water vapor molecules moving around the body

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16
Q

Thermoregulation mechanism of action

A
  • increased body temp
  • thermostat in hypothalamus activated by temp receptors
  • skin blood vessels dilate so warm blood allows heat to radiate from the skin surface
  • sweat glands activated increasing evaporative cooling
  • when body temp decreases
  • thermostat in hypothalamus activated by temp receptors
  • skeletal muscle activated to begin shivering to generate heat
  • skin blood vessels constrict diverting blood from skin to deeper tissues reducing heat loss from skin surface
  • body temp increases
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17
Q

Heat rash (prickly heat) definition and treatment

A

Skin irritation due to blocked sweat ducts trapping sweat beneath the skin, typically found on the neck, chest, groin, in skin folds, might be papular, pustular, or vesicular, may sting or be pruritic but typically self limiting and not a problem, can be prevented by wearing loose fitting clothing, avoiding extreme heat, etc

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18
Q

Heat edema definition and treatment

A

Dependent edema from vasodilatory pooling, too much sodium can aggravate fluid retention, greater risk in rapid transiton from cold to warm climate, treatment is NOT diuretics but rather just elevate extremities and put in a cool environment

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19
Q

Heat exhaustion signs and symptoms (4)

A
  • early identification critical to prevent progression to heat stroke
  • fatigue/malaise/weakness
  • N/V/D
  • in tact mental status
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20
Q

Heat exhaustion treatment options (3)

A
  • move to cool area, ice packs, remove excess clothing, spray with lukewarm water, trendelenberg, etc
  • gradual rehydration oral and or IV
  • monitor for progression to heat stroke (patients should respond if all they have is indeed heat exhaustion)
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21
Q

Heat stroke signs and symptoms (4)

A
  • Elevated core temp >40.5C
  • Hot dry skin
  • CNS symptoms and lack of intact mental status
  • NVD
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22
Q

Heat stroke complications (2)

A
  • high core body temp leads to multisystem damage (DIC, hepatocellular necrosis, acute kidney injury)
  • cerebral hypoperfusion leads to mental status changes and can cause cereberal ischemia
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23
Q

Heat stroke diagnostic studies (5)

A
  • CT of head to rule out edema
  • CXR
  • CBC, CMP, PT/PTT
  • EKG
  • urinalysis (rhabdo concerns)
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24
Q

Heat stroke treatment options (5)

A
  • Rapid cooling measures within 30 min
  • ice water immersion most effective
  • antipyretics ineffective and may be harmful
  • IV hydration
  • admit to hospital
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25
Q

2 types of cold injuries

A
  • Freezing (frostbite)
  • nonfreezing (chilbain or trench foot)
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26
Q

Frostnip definition and treatment

A

Mildest form of peripheral cold injury, superficial nonfreezing cold injury secondary to vasoconstriction, sees pale skin with associated numbness and paresthesias but skin is still pliable***, occurs in the apical structures (ears, nose, hands, feet), treated by simple warming techniques

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27
Q

Chilblains (pernio) definition and treatment

A

More severe than frostnip caused by exposure to nonfreezing temps and damp air, onset 1-5 hours of cold exposures but can be longer, develops over hours and subsides slowly over weeks, develop red to violet raised lesions (papules and nodules) most often on unprotected extremities such as fingers and toes, seen most often in middle aged women or those with chronic conditions such as raynauds, treated with local heat, gentle massage, nifedipine, corticosteroids, minimize cold exposure to prevent recurrent lesions or secondary infection

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28
Q

Immersion (trench) foot definition and treatment

A

Occurs when feet are wet but not freezing for prolonged periods of time, most common in homeless and military starting with numbness and tingling pain with pruritis progressing to leg cramps and complete numbness, managed with gentle rewarming, careful washing and air drying, slight limb elevation, possible bed rest, prevented by keeping feet dry at least 8 hours a day

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29
Q

Frostbite definition and its 4 degrees of severity

A

Skin and deeper structure freeze resulting in tissue injuries, water crystals disrupt cell membranes and tissue structures resulting in ischemia and death of cells, has 4 degrees of severity (hyperemia and edema, accompanied by blisters, has hemorrhagic fluid in the blisters, and comprete necrosis with gangrene)

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30
Q

Frostbite management (4)

A
  • do NOT start if still risk of re-freezing as this has worse outcomes
  • restore core body temp first
  • RAPID rewarming in a water bath until extremity has flushed appearance, once rewarming started, avoid weight bearing, very painful process
  • tetanus prophylaxis
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31
Q

Frostbite complications (4)

A
  • compartment syndrome
  • limb/digits amputaitons
  • digital shortening if growth plate injured in children
  • susceptible to reinjury
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32
Q

Hypothermia definition

A

Body’s mech for temp regulation is overwhelmed in face of cold stressor, core temp <95 F or 35C, classified as accidental (unanticipated exposure in unprepared person), intentional (therapeutic post cardiac arrest), primary (environmental exposure) or secodnary (underlying medical issue)

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33
Q

Hunter’s response

A

Paradoxical and cyclical vasodilation following initial vasoconstriction that occurs in response to cold often the fingers, toes, and face

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34
Q

Hypothermia signs and symptoms (7)

A
  • altered mental status, mood changes
  • shivering
  • flushing
  • tachycardia then bradycardia
  • facial edema
  • hypotension
  • paradoxical undressing
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35
Q

“They’re not dead till they’re warm and dead” meaning

A

Refers to how it is required to warm body before declaring death as hypothermia can often present with v-fib, dilated pupils, lack of responsiveness, etc

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36
Q

Hypothermia management (4)

A
  • passive external rewarming
  • minimally invasive active rewarming (IV fluids warmed)
  • invasive active rewarming (bladder lavage, thoracic lavage)
  • ECMO
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37
Q

If a patient is stable and can stand, what type of CXR do they get? What if they cannot get out of bed?

A
  • PA and lateral chest
  • AP x ray portable
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38
Q

FAST exam

A

Focused assessment with sonography for trauma, looking for air or fluid in the body usually due to trauma to chest or abdomen, no specific contraindications but should not interfere with resuscitation, looks at pericardium for cardiac tamponade, peritoneal spaces including perihepatic (morrisons pouch), perisplenic, and pelvic, also form called eFAST which includes the looking for pneumothoraces or hemothoraces

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39
Q

Most common pathogens involved in human bites from the oral flora (2) and the patient’s skin (2)

A
  • Eikenlla
  • Group A strep
  • staph
  • strep
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40
Q

Clenched fist bites

A

Injuries that most often occur as lacerations in the 3rd or 4th MCPs or PIPs of dominant hand and highly prone to infection because often ignored, occur most often when clenched fist of person strikes teeth of another

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41
Q

Occlusal bites

A

Semicircular or oval, skin may or may not be intact, more common on fingers, hands, or arms

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42
Q

Infections are more common with what type of animal bite?

A

Cat bites

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43
Q

Treatment for bite wound (4)

A
  • cleansing, irrigation, dressing, daily eval for infection, foreign body removal
  • most bites should be left to heal by secondary intention (left open) due to high risk of infection
  • augmentin prophylaxis (almost everyone)
  • IV if signs of systemic illness
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44
Q

Rabies post exposure prophylaxis

A

If high risk wild animal then need it, if stray dog will need it, if low risk animal or vaccination status of animal is known then do not, can monitor animal status to see if they die within 10-14 days, if patient never had exposure before need immunoglobin and vaccine (0, 3, 7, 14, and 28 if immunocompromised), if patient has then need vaccine only on day 0 and 3

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45
Q

Toxidromes

A

Signs and symptoms associated with a specific class of poisoning in a patient (anticholinergic, cholinergic, sympathomimeetic, sedative, serotonergic)

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46
Q

Coma coctail (3 parts)

A

Used for patient with altered consciousness and includes

  • dextrose (hypoglycemia)
  • thiamine
  • naloxone
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47
Q

Toxidrome approach (7)

A
  • pupil size
  • temp
  • bowel sounds
  • heart rate
  • blood pressure
  • respiratory rate
  • skin findings
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48
Q

Common anticholinergic toxidromes (5)

A
  • antihistamines (diphenyhdramine, hydroxyzine)
  • antispasmotics (dicyclomine, oxybutynin)
  • atropine
  • TCAs (amitriptyline)
  • Jimson weed
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49
Q

Anticholinergic toxidrome findings

A
  • hyperthermic, tachycardia, hypertensive
  • CNS agitation and delirium
  • mydriasis**
  • skin dry, warm flushed**
  • diminished bowel sounds, urinary retention
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50
Q

Common cholinergic toxidromes (3)

A
  • organophosphates and insectisides
  • cholinesterase inhibitors
  • nerve agents
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51
Q

Cholinergic toxidrome findings

A
  • bradycardia, high or low BP, high or low breathing
  • CNS agitation and confusion
  • pinpoint pupils, lacrimation
  • diaphoresis***
  • salivation, vomiting, diarrhea, incontinence***
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52
Q

Common sympathomimetic toxidromes (5)

A
  • cocaine
  • PCP
  • amphetamines
  • LSD
  • bath salts
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53
Q

Sympathomimetic toxidrome findings

A
  • Hyperthermia, tachycardia, hypertension
  • CNS enhanced alertness, delirium, seizure, coma
  • Mydriatic pupils
  • diaphoretic, hot skin
  • normal or active bowel sounds
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54
Q

Common opioid toxidromes (6)

A
  • opium
  • morphine
  • heroin
  • hydrocodone (vicodin)
  • oxycodone
  • fentanyl
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55
Q

Opioid toxidrome findings

A
  • hypothermia, bradycardia, normal or low BP, bradypnea
  • CNS lethargy and coma
  • pupil miosis
  • skin cool, pale, moist, evidence of needle injections
  • hypoactive bowel sounds, constipation***
  • hyporeflexia on neurologic exam
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56
Q

Common sedative hypnotic toxidromes (4)

A
  • alcohol
  • benzos
  • barbituates
  • sleeping aids
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57
Q

Sedative hypnotic toxidromes findings

A
  • hypothermia, normal or bradycardia
  • CNS drowsy, lethargy, coma
  • pupils miotic
  • decreased or no bowel sounds
  • dry
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58
Q

Sympatholytic toxidrome findings

A
  • bradycardia, hypotension, bradypnea
  • CNS normal to lethargic
  • pupils mid size
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59
Q

Common serotonin syndrome toxidromes (3)

A
  • MAOIs
  • SSRIs
  • NSRIs
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60
Q

Serotonin syndrome toxidrome findings

A
  • hyperthermia, tachycardia, hypertension
  • CNS confusion, agitation, lethargy
  • pupils mydriatic
  • diaphoretic flushed skin
  • hyperreflexia, tremors, clonus
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61
Q

Common sympatholytic toxidromes (3)

A
  • B blockers
  • a blockers
  • a2 adrenergic agonists
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62
Q

Acetaminophen toxicity antidote

A

N acetylcysteine

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63
Q

Anticholinergic agents toxicity antidote

A

Physostigmine

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64
Q

Benzodiazepine toxicity antidote

A

Flumazenil

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65
Q

Carbon monoxide toxicity antidote

A

Oxygen

66
Q

B or Ca2+ channel blockers toxicity antidote

A

IV fluids, calcium, glucagon, insulin

67
Q

Cocaine or other sympathomimetics toxicity antidotes

A

Benzodiazepines

68
Q

Acetone in ethanol, alcohol, chloroform, and salicyates have a characteristic ___ odor.
Cyanide has a characteristics ___ odor.
Arsenic, organophosphates, phosophorus have a ___ odor.
Organophoshates have a ___ odor.
Hydrogen sulfide has a ___ odor.
Methyl salicylate has a ___ odor.
Phosgene has a ___ odor

A 
Fruity
Bitter almonds
Garlic
kerosene
Rotten eggs
Wintergreen
Freshly mown hay
69
Q

Opioid toxicity antidote

A

Naloxone

70
Q

Salicylates toxicity antidote

A

Alkalinization, hemodialysis

71
Q

Warfarin toxiticy antidote

A

Fresh plasma, vit K

72
Q

Max dose of acetaminophen in adults and children, when do peak serum levels occur?

A
  • 4g/day or 3g/day if daily alcohol
  • 80mg/kg/day

-4 hours after overdose (get a 4 hour acetaminophen level!)

73
Q

Carbon monoxide poisoning symptoms (4)

A
  • nonspecific
  • vague, flu like symptoms without fever or lymphadenopathy, cherry red coloration
  • multiple patients from the same household
  • source presence such as smoke, car exhaust, malfunctioning in heating symptoms
74
Q

Oral vs IV contrast

A

Oral such as barium is used for bowel opacification and not nephrotoxic, IV is iodine based for vascular structures or solid abdominal and pelvic regions

75
Q

Endoscopic retrograde ccholangiopancreatography (ERCP) technique, uses, risks

A

Invasive procedure that uses endoscopy to directly visualize bile duct, most effective for choledocholithiasis and used as diagnoistic and treatment of stones, tumors, bile duct strictures, stent placement, risks include pancreatitis, bleeding, perforation

76
Q

Hepatobiliary iminodiacetic acid scan (HIDA)

A

Nuclear medicine scan where a radiotracer is injected IV for imaging of gallbladder and biliary tree, most useful for acute cholecystitis

77
Q

“Stack of coins” sign

A

X ray visual where small bowel folds are smoothly and uniformly thickened caused by intramural bleeding

78
Q

“Free air under the diaphragm”

A

A finding on a chest x ray where there is separation of the diaphragm above the bowel contents indicative of bowel perforation causing peritonitis allowing for bacteria to potentially cause sepsis

79
Q

Bird beak sign

A

A finding on a barium swallow where the lower esophageal spincer fails to open due to a variety of obstructive reasons

80
Q

Zollinger ellison

A

A tumor secreting gastrin from pancreas into the stomach that can cause hyper acidity in patients that causes erosion of the walls and rugae thickening

81
Q

Pyloric stenosis and “olive sign”

A

Common pediatric disease in newborns 3 weeks where they consistently throw up due to occlusion of the pylorus visible on a barium contrast study as “olive sign”

82
Q

Magnetic resonance cholangiopancreatography (MRCP)

A

Test of choice to examine diseases of liver, gallbladder, bile ducts, pancreas, and pancreatic duct to evaluate tumors, stones, inflammation or infection, is non invasive and has high sensitivity with highly detailed images but should not be used in patients with decreased renal function

83
Q

Sentinal loop

A

Short segment of adynamic ileus close to intra-abdominal inflammatory process in cases such as pancreatitis or appendacitis visualized on x ray in a patient with abdominal pain

84
Q

Intussusception places a person at significant risk for…

A

….bowel ischemia and necrosis

85
Q

Sausage sign or target sign

A

Visualizations on a ultrasound or CT respectively that are indicative of intussusception of the bowel

86
Q

Fecolith seen on imaging study, when associated with abdominal pain, has a 90% probability of being…

A

…acute appendicitis

87
Q

Apple core lesion

A

A visualization on a CT study in the large bowel indicative of a colon cancer presence

88
Q

Cobblestoning and skip lesions and string sign

A

Visualizations on a contrast imaging study that are indicative of crohns caused by inflammation and swelling of the bowel wall

89
Q

Thumbprint sign (GI)

A

A radiographic sign of the large bowel wall thickening usually caused by mucosal edema from an infective or inflammatory process

90
Q

No liver # on an LFT is a true reflection of…

A

….liver function

91
Q

ALT/AST measures

A

Slight elevations indicate low grade inflammation, high elevations indicate acute liver injury/necrosis, but normal does not mean no inflammation

92
Q

Alkaline phosphatase measures

A

Indicator of bile duct inflammation (obstruction, autoimmune, infection, etc.), can be elevated secondarily in pregnancy

93
Q

Bilirubin/alk phos measures

A

Prehpatic jaundice is due to elevated unconjugated bilirubin, hepatic is both conjugaed and unconjugated elevated, post hepatic is elevated conjugated bilirubin in serum

94
Q

Albumin measures

A

Non specific, somewhat related to liver function but also related to nutritional status, can lead astray (usually suggests chronic disease such as cancer or cirrhosis)

95
Q

ALT/AST elevated out of proportion to alk phos think ___, vise versa think ___

A

liver inflammation, obstruction (cholestatic pattern)

96
Q

Isolated hyperbilirubinemia should indicate the first test to order to be…

A

….fractionate it to determine amount of conjugated vs unconjugated

97
Q

Isolated hyperbilirubinemia primarily conjugated think ____ or ____. Unconjugated think ____ or ____

A

Dubin Johnson, Rotor syndrome

Gilbert’s syndrome, Crigler Najjar syndrome

98
Q

Most important test to evaluate liver function

A

INR (coumadin will mess it up) (INR that does not correct with parenteral vit K is suspicious for severe hepatocellular injury)

99
Q

____ may be the first sign of liver disease even years before liver disease is diagnosed

A

Low platelet count

100
Q

Extraneous labs to order in initial lab eval (acute) of liver patient (3)

A
  • tox screen
  • tylenol level
  • acute viral hep panel
101
Q

Acute liver failure definition

A

Acute hepatocellular injury, hepatic encephalopathy (confusion), and prolonged PT (elevated INR), LFT’s typically >10x upper limits of normal, may need transplant if INR continues to rise

102
Q

Initial first line imaging study for suspected liver disease

A

Right upper quadrant ultrasound (can do with doppler)

103
Q

General liver disease advice (5)

A
  • no alcohol
  • vaccinate hepA/B
  • limit acetaminophen no more than 2 grams a day
  • avoid raw seafood
  • control weight, cholesterol, diabetes
104
Q

Hepatitis A

A

Single stranded RNA virus, almost exclusively spread fecal oral route most often person to person, incubation 2-6 weeks, increasing age increases symptoms as newborns are usually asymptomatic and anicteric, boiling water/iodine/chlorine are effective for destroying virus, risk highest in developing countries, usually self limiting, prognosis generally excellent without lasting sequelae

105
Q

2 phases of Hep A infection

A

Prodrome - mild flu like symptoms
Icteric - develop dark urine then pale stools, jaundice

106
Q

If you order a patient a total Hep A antibody panel (IgM + IgG) and they have only IgG, then…

A

….patient either previously had disease or was vaccinated

107
Q

Hep A treatment

A
  • supportive
  • sugarcane in developing countries
  • locate primary source to prevent further outbreaks
  • post exposure prophylaxis with gammaguard within 2 weeks of exposure for non immunized close contacts
108
Q

Hepatitis B

A

DNA virus, estimated 1/3 of global population has been infeected, incubation period 1-6 months, transmitted via body fluids (blood/semen/vaginal secretions) including sexual/parenteral/perinatal, anicteric hepatitis has greater tendency to develop chronic hep

109
Q

2 phases of hep B infection

A
  • Acute phase - majority asymptomatic
    • Viral prodrome with icteric hepatitis (arthralgias, skin rash, low grade fever, jaundice for 1-3 months)
110
Q

Hepatitis Ig labs

A
  • core IgM indicates acute infection
  • core IgG indicates past infection (not from vaccination)
  • surface antigen indicates acute or chronic infection
  • surface antibody indicates had virus (if core antibody positive) or vaccine (if only positive value then vaccinated)
  • E antigen indicates active viral replication and highly contagious
  • E antibody indicates a carrier
111
Q

Any patient with chronic hep B requires….

A

….screening regimen for hepatocellular carcinoma (HCC), which is an ultrasound every 6-12 months

112
Q

Hep B 3 treatments

A
  • pegylated interferon alpha
  • entecavir
  • tenofovir disoproxil fumarate
113
Q

Hepatits C

A

Single stranded RNA virus, most frequent cause for liver transplant in US, most frequently occurring nonA nonB hepatitis worldwide, 80% will remain viremic and 20% of that will develop cirrhosis, transmitted primarily via iv drug use, transfusion prior to 1990, needle stick, increased risk of transmission if co infection with HIV, incidence rising due to opioid epidemic, good prognosis if treated acutely

114
Q

Who should be screened for hep C (4)

A
  • evidence of liver diz
  • HIV infected individuals
  • incarcerated
  • needle stick injury
115
Q

Hep C treatment (acute (1)and chronic (2))

A
  • acute, monitor for spontaneous clearing for 6 months
    • chronic sofosbuvir (sovaldi) or simeprevir (olysio)
116
Q

Hepatitis D

A

RNA virus transmitted same modes of hep B, only seen in patients with hep B, uncommon in west, chronic hep B with D progresses more rapidly to cirrhosis, 90% asymptomatic, treated same way as hep B (and vaccine against B is effective against D as well)

117
Q

Fatty liver disease

A

Accumulation of triglycerides and other fats in liver cells, may have associated hepatic inflammation and liver cell death, need to distinguish nonalcoholic vs alcoholic etiology (alcoholic is reversible, metabolic syndrome is commonly associated with nonalcoholic fatty liver)

118
Q

Ligament of treitz divides these 2 conditions

A

Upper GI vs lower GI bleed

119
Q

HemOCCULT testing

A

Taking a sample of stool, placing it on a card that then undergoes reagant droplet testing, with blue color meaning that it contains blood

120
Q

Mallory weiss tear

A

Uncommon cause of upper GI bleed, longitudinal mucosal laceration at the gastroesophageal junction or the gastric cardia caused by forceful retching or vomiting, often associated with alcohol use, overt bleeding is minor and bleeding ceases spontaneously unless severe then need intervention

121
Q

Bleeding varices

A

An uncommon cause of upper GI bleed due to friable weak tissue that usually resultes in sudden overt major bleeding, can be fatal

122
Q

AIMS65 score

A

Predictor of in hospital mortality due to upper GI bleed based on risk factors
Albumin <3g/dL (produced by liver and keeps fluid in circulation)
INR greater than 1.5 (can’t spontaneously clot)
-Mental status <14 of glascow coma score
Systolic BP <90
Age greater than 65

123
Q

Diverticular bleed #1 site

A

Ascending colon

124
Q

Diverticular bleed does not necessarily mean a patient has…

A

…diverticulitis (this one is more common on the sigmoid colon on the left and is infectious while diverticular bleed is ascending colon most of time, and typically painless and stop spontaneously)

125
Q

Lower GI sources of blood loss (5)

A
  • diverticular bleed
  • polyp/cancer
  • angiodysplasia
  • IBD
  • hemorrhoid or fissure
126
Q

Postural hypotension

A

Supine to upright fall in systolic BP of >10mmHg or increase in heart rate of >20 bpm indicating a moderate blood loss (up to 20% of circulatory volume)

127
Q

If a patient is in a deep GI bleed, we want to do what?

A

Give O neg blood cells until blood type identified, lacted ringer’s solution, no vasopressors (it will just cause them to squirt)

128
Q

Intrahepatic portosystemic shunt

A

Used in upper GI bleed secondary to esophageal varicies to treat portal hypertension by percutaneously creating a connection within the liver between portal and systemic circulations (diverting portal blood flow)

129
Q

Sphincter of oddi

A

The hepatopancreatic spincter that joins together the common bile duct and the pancreatic duct

130
Q

Acute pancreatitis presentation and repeating of episodes

A

Inflammatory process of the pancreas associated with abdominal pain (a boring pain drilling thru the gut) sometimes radiating to back only slightly relieved bending forward, shortness of breath, febrile, elevated pancreatic enzymes, and variable involvement of other regional tissue, repeated bouts may eventuate into chronic pancreatitis due to permanent alterations in function and morphology

131
Q

Common causes of acute pancreatitis (6)

A
  • biliary tract stones**
  • endoscopic retrograde cholangiopancreatography
  • alcohol abuse***
  • scorpion sting
  • coxsackievirus/mumps
  • trauma
132
Q

Common causes of chronic pancreatitis (3)

A
  • alcohol abuse***
  • autoimmune
  • hereditary
133
Q

The 3 F’s of cholellithiasis development

A
  • fat (obese)
  • fertile (child bearing age)
  • forty
134
Q

Common duct theory

A

The idea that because a gallstone lodges in the duct that is common between the pancreas and the gallbladder, the pancreas becomes inflamed as a result and can cause acute pancreatitis

135
Q

Drugs that are known to cause acute pancreatitis (3)

A
  • estrogens
  • nitrofurantoin
  • sulfonamides
136
Q

Pancreatitis lab studies (6) and the expected results of them

A
  • Serum amylase (can be elevated, not specific)
  • ***serum lipase (specific for pancreatic disease) –> hospitalization
  • serum electrolytes (many get hypocalcemic)
  • Lipids (elevated)
  • blood sugar (hyperglycemia)
  • LFT’s (prognostic indicators)
137
Q

Acute pancreatitis imaging studies (3)

A
  • abdominal ultrasound (1st line)
  • Confirmatory CT
  • ERCP can be 3rd line in urgent intervention
138
Q

Treatment for acute pancreatits (6)

A
  • maintain NPO
  • IV fluids
  • pain control (meperidine or dilaudid)
  • IV antiemetic
  • determine cause and treat
  • surgical management in severe necrotic situations
139
Q

Ranson’s prognostic signs/APACHE

A

An assessment of factors to determine point values that when added up assess risk of mortality of patient with acute pancreatitis clinical course, <2 mortality is 0% and >7 is up to 95%

140
Q

Chronic pancreatitis treatment (6)

A
  • supplemental pancreatic enzymes
  • fat restriction on diet
  • stop alcohol
  • pain control
  • surgery
  • whipple procedure (intense surgery cutting out damaged area of pancreas and readjoin vasculature)
141
Q

Pancreatic cancer has a very poor 5 year survival rate because of…
What is the most common type?

A

…lack of detection until late stage metastasis

…adenocarcinoma (ductal epithelium)

142
Q

Suspected pancreatic cancer signs*** and best way to diagnose

A

Weight loss (>5lbs per month), hypercoaguable state, biliary duct blockage (painless jaundice) and constantly present burning pain, diagnosis by helical CT is best***

143
Q

Painless jaundice is..

A

…pancreatic cancer until proven otherwise

144
Q

Courvoisier’s sign

A

Palpable non tender gallbladder often associated with jaundice in cachectic patients highly suspect of pancreatic cancer

145
Q

Acute pancreatitis requires***… (also what 6 things are monitored in this case)

A

…hospitalization, and monitoring during that everyday of serum lipase, ca2+ levels, blood glucose, CBC, LFT’s, and lipid panel

146
Q

Regions of the stomach

A

Cardia (first part contains cardiac sphincter)
Fundus rounded dome left of cardia and below diaphragm
body - largest main part
antrum - lower part of stomach that holds food ready for small bowel
Pylorus (part of stomach that connects to the duodenum including pyloric sphincter)

147
Q

Peptic ulcer disease definition

A

Break in lining of esophagus, stomach, or duodenum caused by corrosion due to acid* and pepsin**, most common in stomach and proximal duodenum, less common sites associated with zolinger ellison syndrome, hiatal hernieas, or ectopic gastric mucosa

148
Q

Zollinger ellison syndrome

A

rare disorder with increased production of gastrin causing unopposed acid secretion typically due to pancreatic/duodenal gastrin secreting tumor, may be associated with multiple endocrine neoplasia type 1, presents with abdominal pain, diarrhea, heartburn

149
Q

Peptic ulcer vs erosion

A

Ulcer is deeper, incites local inflammatory reaction and extends thru the muscularis mucosa while erosion is just partial

150
Q

Excluding patients who use NSAIDS, __% of gastric and duodenal ulcers are associated with…

A

90%….H pylori infection

151
Q

Peptic ulcer risk factors (5)

A
  • NSAIDS
  • H pylori infection
  • severe physiologic stress
  • hypersecretory states
  • local radiation
152
Q

H Pylori infection mech of action

A

Gram - spirochete that produces urease to alkanize microenvironment to survive the acidity oft he stomach and colonizes the gastri mucosa, this impairs duodenal bicarb secretion and increases levels of gastrin and pepsinogen which promotes gastric metaplasia in the duodenum increasing susceptibility to acid injury

153
Q

NSAID gastric ulceration mech of action

A

Inhibition of cyclooxygenase decreasing prostaglandins resulting in decreased mucus and bicarb secretion, decreased epithelial cell proliferation, and decreased blood flow

154
Q

Peptic ulcer disease clinical presentation (6) between gastric and duodenal ulcers

A
  • burning epigastric pain typically after eating (gastric) with little relief with antacids
  • nocturnal pain waking them up more characteristic of duodenal ulcer, which eating diminishes pain and is relieved with antacids
  • dyspepsia
  • heartburn
  • anemia
  • hematemesis or melena or hematochezia
155
Q

Sudden onset of sharp pain often exacerbated by movement in peptic ulcer disease should raise concern for…

A

….perforation

156
Q

Diagnostic study for peptic ulcer disease (2)

A
  • EGD (can tell benign smooth regular ulcers and malignant irregular shaped ones)
  • upper GI x ray series (back up if high risk for sedation)
157
Q

H pylori infection testing

A
  • Serum ELISA (useful only for first infection)
  • urea breath test (highly accurate but expensive)
  • stool antigen test
  • endoscopic biopsy
158
Q

How to screen for zollinger ellison syndrome (or a patient with multiple ulcers or strong family history)

A

-fasting serum gastrin level

159
Q

A nonhealing gastric ulcer is…

A

…cancer until proven otherwise

160
Q

Gastric cancer

A

3rd most common cause of cancer related death in the world, 5th most common globally, most often adenocarcinoma, early stages lacks symptoms while late stage sees sister mary joseph node and virchows node as well as N/V

Professional Development (24 decks)

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