PGY2 Flashcards
indications for escharotomy
circumferential chest or neck burns with increased airway pressures, hypoxemia, difficulty with ventilation, or circumferential extremity burns with decreased doppler signal, pulse oximetry < 90% distally in limb, pain/loss of sensation/delayed cap refill
MGMT of airway/mechanical ventilation in burn patients
RSI unless suspicion of airway obstruction (if signs of obstruction, awake intubation), succ is contraindicated if burn is > 5 days post-burn, avoid barotrauma: limit plateau pressure to 35 mmHg, PEEP can be helpful,
MGMT of cyanide poisoning
hydroxocobalamin 5 g IV in 250 cc NS or 70 mg/kg in pediatrics
mechanism of cyanide poisoning
binds to iron on cytochrome complex in mitochondria, the last step of oxidative phosphorylation, effectively shutting down mitochondria and ATP production resulting in tissue hypoperfusion
lab findings in cyanide poisoning
metabolic acidosis, lactate > 10
carbon monoxide poisnoning sx
headache, flu, coma, death
lab findings in CO poisoning
metabolic acidosis,
10 DDx for pancreatitis
biliary colic, cholangitis, cholecystitis, hepatitis, PNA, pericarditis, MI, PUD, pericarditis, bowel obstruction, mesenteric ischemia, AAA, ectopic
10 causes of pancreatitis
gallstones, alcohol, autoimmune, idioapthic, drugs, trauma, ERCP, viral infections (mumps, EBV), congenital - “IGETSMASHED” - idiopathic, gallstones, ethanol, trauma, steroids, mumps/viruses, autoimmune, scorpion stings, hypercalcemia/lipidemia/hypothermia/hypotnesion, ERCP/emboli, drugs (azathoprine, NSAIDs, diuretics)
MGMT of acute pancreatitis
volume resusication with RL, analgesia, electrolyte correction, correct glucose, treat nausea, early feeding, U/S for ERCP/MRCP, antibiotics if septic or infection
acute complications of pancreatitis
acute hemorrhage (GI bleeding), ileus (bowel obstruction), peripancreatic fluid collection, acute necrotic collection, SIRS/sepsis, atelectasis, renal failure, multisystem failure/shock/dic, bowel necrosis, pancreatic pseudocyst, hyperglycemia/hypocalcemia, plerual effusion, glucose intolerance
revised atlanta classification of acute pancreatitis
mild: no organ failure or complications, moderate: transient organ failure or local/systemic complications, severe: persistent organ failure
causes of chronic pancreatitis
toxic-metabolic: ETOH, obstructive, genetic, autoimmune, post-necrotis acute pancreatitis
causes of false positive amylase elevation
parotitis, malignancy, trauma, burns, liver disease, cholecysitis, renal failure, HIV, pregnancy
infectious causes of pancreatitis
mumps, coxsackie, HIV, CMV, EBV, varicella, TB, salmonella, campylobacter, legionella, mycoplasma, ascaris
encapsulated bacteria (risk if no spleen)
streptococcus pneumoniae, H.flu, neisseria meningitidis, E.coli, klebsiella, salmonella typhi
causes for elevated d-dimer
malignancy, trauma, smoking, infection, sepsis, trauma, vascular (AAA rupture/AD), elderly age, ACS, DVT, DIC, AFib, pre-eclampsia, stroke
2 types of venom in rattelsnakes
necrotoxic vs. neurotoxic
MGMT of rattlesnake bites
move away from snake, call 911, removing constricted item and immobilizing limb, DO NOT USE TOURNIQUET AND SUCK OUT VENOM,
physical features of crotalidae (venomous pit-vipers)
elliptical pupil, tail structure of single rows, triangle head and presence of fants
definition of priapism
ischemic penis; treat within 4-6 hours tp prevent impotence and ischemia
2 types of priapism
low flow: ischemic (venous obstruction - true emergency), high flow (non-iscehmic: arterial inflow)
causes of priapism
intra-cavernosal injection (triple mix), PDE5 inhibitors, antihypertensives, neuroleptics, cocaine
AAP diagnostic criteria for AOM
acute onset, inflammation of middle ear, effusion of middle ear (dull, bulging, air fluid)
definition of recurrent otitis media
3+ episodes/6 months or 4+ episodes/12 months
causes of acute otitis media
viral vs. bacterial: viral - RSV, influenza, rhinovirus, adenovirus, bacterial: pneumo, h/flu, moraxella catarrhalis, GAS, chlamydia in < 6 months
criteria to treat AOM
under 6 months, perforated TM, severe illness (39+, irritable, severe symptoms), symptoms > 48 hours
criteria for watchful waiting in AOM
follow-up visit in 24-48 hours, everyone else > 6 months old
MGMT of AOM in peds
amoxicillin 75 - 90 mg/kg/day BID, if PCN allergy, consider cefuroxime 30 mg/kg/day BID for 5 days if 2+ years old of uncomplicated disease vs. 10 days if < 2 years old, recurrent AOM or perforated TM
complications of AOM
intratemporal vs. intracranial: intratemporal - hearing loss, cholesteatoma, TM perforation, labryinthiitis, facial nerve paralysis; intracranial: meningitis, brain abscess, extradural abscess, subdural empyema, latera venous sinus thrombosis
MGMT of otitis externa
debride with curette or suction, ciprodex drops 3 BID x 5 days
MGMT of otitis externa malignant
ciproflox 750 mg PO BID x 6 weeks, ENT referral
5 causes of sudden hearing loss
infectious (meningitis/encephalitis), acoustic neruoma, hypercoaguloability, DM, pregnancy, ASA, AG, curmen, AOM, FB, barotrauma
MGMT of SNHL
prednisone 60 mg daily x 10-14 days, ENT referral, MRI to r/o acoustic neuroma
CENTOR criteria
must be older than 3 years old, no cough, exudative tonsills, nodes, temp > 38, often young < 15 and rarely old > 45 yo; if 2-3: rapid strep test and culture; if 4+: antibiotics
lemierre’s syndrome definition
oropharyngel infection followed by anaerobic sepsis with fusobacterium necrophorum resulting in thrombus of internal jugular vein
epiglottitis exam finding most sensitive and specific
tenderness on palpation of hyoid bone
ludwig’s angina definition
deep space neck infection of sublingual, submental and submandibular spaces
acute necrotixing ulcerative gingivitis definition
“trench mouth”: bacterial infection of the gingiva, ulceration with grey pseudomembranes and easy bleeding due to fusobacterium
serious complication from acute necrotizing ulcerative gingivitis
necrotizing stomatitis
true or false: streaking lymphangitis favours nec fasciitis vs. cellulitis
false: it favours cellulitis
8 clues to suggest early nec fasciitis
pain out of proportion (la belle indifference though where they have little pain), eccymoses or skin necrosis, tense edema (skin feeling hard or wooden), bullae/blister, palpable crepitus, localized skin hypoesthesia (nerve destruction), rapidly spreading rash, SIRS
MGMT Abx for nec fasciitis
pip-tazo + vancomycin
soft signs of penetrating neck trauma
minor hemoptysis, hematemesis, dysphagia/dysphonia, subcut air, non-expanding hematoma, proximity wound, oropharngeal bleed
hard signs of penetrating neck trauma
rapidly expanding and pulsatile hematoma, massive hemopytisis, air bubbling from wound, severe hemorrhage, shock not responding to fluids, decreased or absent radial pulses, vascular bruit or thrill, airway compromise/stridor, massive subcut emphysema
button battery ingestion in child MGMT
do not induce vomiting, administer honey if > 1 year old
ABx MGMT for H. Pylori
bismuth pepto bismol, metronidazole, tetracycline, PPI
lipase cut off in pancreatitis
more sensitive than amylase, 3x of upper limit is abrnomal
dx of acute pancreatitis
- abdo pain; 2. lipase 3x upper limit, 3. imaging/CT findings consistent
definition of severity in pancreatitis
mild: no organ failure, moderate: organ failure < 48 hours, severe: organ failure > 48 hours
2 types of acute pancreatitis
edematous (acute peripancreatic collection –> pseudocyst after 4 weeks) vs. necrotizing (acute necrotic collection, walled off necrosis)
encapsulated bacteria (for asplenia/SCD) pts
SHiNE KISS - strep pneumo, H.flu, N.meningiditis, Klebsiella, salmonella, e.coli, groupB strep
Name of pseudoaneurysm formation from pulmonary artery erosion of TB lesion
Rasmussen’s aneurysm
complications of pulmonary TB
hemoptysis, PTX, pleural effusion, empyema, airway TB, pericarditis, superinfection with fungal
DDx for pulmonary TB
bacterial PNA, fungal (histoplasmosis, MAC, mycobacerium kansaii, , PJP, nocardia and rhodococcus in HIV patients
DDX for cavitary lesions other than TB
klebsiella PNA, staph pyogenes, aspiration, MAC, wegener’s granulomatosis, upper lobe bullous disease due to emphysema or neurofibromatosis
extrapulmonary TB
lymphatics (most common), bone/joint, pleura, meninges, peritoneum
Term for lymphadenitis tuberculous
scrofula - seen often in children; painless, red ,firm mass in lymph node
term for spinal TB disease
Pott’s disease - loss of white striples of vertebral endplates due to destruction of subchondral bone; paraspinal cold abscesses forming in 50+% of cases spreading up and down spine: complication - SCC
classic finding of urine in renal TB infections
sterile pyuria , can be acidic
genital TB
prostatitis/epididymitis/orchiitis can be seen in renal TB patients in men or infection sprading to endometrium, oaries and cervix in women
Acute disseminated TB definition
active hematogenous spread of MTB to several organs
miliary TB definition
occurs when host is unable to contain recently acquired or dormant TB infection - seen often in children after primary infection or older adults/HIV patients
other lab findings associated with acute dissemianted TB or miliary TB
SIADH –> hyponatremia, meningitis
CNS TB affected individuals
only 6% of all cases of extrapulmonary TB invovles CNS, seen in newborns - 4 yo children often
GI involvement onf TB
ileocecal area is most common site, can have obstruction, hemorrhage, palpable mass, fissures, fistulae, peri-rectal abscess
primary TB CXR findings
similar to other typical bacterial PNA - lobar infiltrate, however can have lymphadenopathy (hallmark of TB)
lymphadenopathy on CXR in primary TB
often seen in children, less common in adults, it is usually unilateral and associated with parenchymal infiltrate
calcified scars on CXR for TB name
Ghon focuse
reactivated/postprimary TB CXR findings
upper lung infiltrate or consolidation +/- cavitation; rare to have bilateral involvement
Testing for TB
sputum studies - can use nebulized sputum induction for samples, fiberoptic bronchoscopy with bronchial washings for AFB
Other tests for TB
other than AFB (not very sensitive), can consider nucleic acid amplication tests, cultures, TB skin test
definition of massive hemoptysis
600 cc/24 hours
MGMT of massive hemoptysis in TB
death usually due to asphyxiation from aspirated blood not exsanguination - thus secure airway with large-diameter 8 mm ETT
MGMT of TB infection
1st line antibiotics: rifampin, isoniazid, pyrazinamide, ethambutol
MGMT of TB pericardial or CNS infections
corticosteroids - usually 20 - 60 mg/day
Definition of drug-resistant TB
multitdrug resistant TB: mycobacteria is resistant to 2+ first line TB ABx; extensively drug resistant TB: resistance to first line and 3+ second line drugs
RF for drug resistant TB infections (Box 127.2)
previous unsuccessful TB treatment, failure to respond or adhere to good treatment regimen, HIV, IVDU, close contact with source cases, recent immigration from area with high prevalence of drug resistance, cavitary lung disease, homelessness, imprisonment, drug malabsorption due to gastrectomy/ileal bypass surgery
Admission requirements for TB patients
active or suspected MDR_TB, acutely ill or older patients, requiring IV antibiotics, HIV coinfection, social issues (homelessness etc.)
Other investigations for TB
IGRA blood testing within days if potential concern for TB ezposure
common pathogens involved in meningitis
strep pneumo, neisseria meningitidis, listeria, H.flu
5 major serogroups of meningococcal disease
A, B, C, Y, W-135
post-op meningitis pathogens
s.pneumo, staph aureus, pseudomonas, coliform
example of tropism in HSV CNS infection
temporal lobes resulting in development of temporal lobe seizures and behavioural changes
complications of viral meningitis
orchitis, parotitis, pancreatitis, arious dermatoses
pathogens for viral encephalitis
HSV, japanese encephalitis virus, eastern equine virus, st. louis encephalitis virus, west nile, western equine virus, california encephalitis, tickborne encephalitis,
pathogens for post-infectious encepahlomyelitis
measles virus most commonly, enterovirus D68 (flaccid paralysis) seen in children
constellation of symptoms seen in CNS infections
fever, HA, photophobia, nuchal rigidity, lethargy, malaise, altered sensorium, seizures, vomiting, chills
3 sx that can exclude meningitis in immunocompetent patient
fever, stiff neck, mental status change
clinical sx associated with bacterial meningitis vs. febrile seizures in children
bulging fontanel, neck stiffness, seizures outside of typical age
definition of Kernig’s sign
inability to straighten leg when patient is supine with hip flexed to a right angle
Brudzinski sign definition
attempt to flex neck passively are accompanied by flexion of the hip
Other clinical signs for meningitis
deep tendon reflexes increased (hyperreflexia), opthalmoplegia, papilledema
associated infections/source of infection for meningitis
sinusitis, OM, mastoiditis, PNA, UTI, endocarditis, arthritis
name for syndrome of bilateral adrenal hemorrhage in meningitis
Waterhouse-Friderichsen syndrome
host factors predisposing to meningitis (Box 99.1)
age <5, age> 60, male, low SES, crowding, splenectomy, sickle cell disease, african-american race, alcoholism and cirrhosis, diabetes, immunologic defects, recent colonization, dural defect, continuous infection (sinusitis), household contact with meningitis patient, thalassemia major, IVDU, bacterial endocarditis, malignancy, ventriculoperitoneal shunt
Complications of bacterial meningitis - immediate (Box 99.2)
coma, loss of airway reflexes, seizures, cerebral edema, vasomotor collapse, DIC, respiratory arrest, dehydration, pericardial effusion, death
Complications of bacterial meningitis delayed (Box 99.2)
seizure disorder, focal paralysis, subdural effusion, hydrocephalus, intellectual deficits, sensorineural hearing loss, ataxia, blindness, bilateral adrenal hemorrhage, death, CV thrombosis
timeframe for acute meningitis
< 24 hours
timeframe for subacute meningitis
1 - 7 days
serum marker associated with serious bacterial infections, like meningitis vs. viral meningitis
procalcitonin
Causes of aseptic meningitis (Box 99.3) for viruses
enterovirus, polio, coxsackie, echovirus, herpes, CMV, EBV, respiratory viruses, mumps, arbovirus, HIV, lymphocytic choriomeningitis
Causes of aseptic meningitis (Box 99.3) for bacterial
partially treated meningits, parameningeal infection, endocarditis, mycoplasma pneumonia, TB, ehrlichiosis, borrelia burgdorferi, treponema pllidum, brucella, elptospirosis
Causes of aseptic meningitis (Box 99.3) for fungi
cryptococcus neoformans, histplasma, candida, blastomyces
Causes of aseptic meningitis (Box 99.3) for parasites
toxoplasmosis, condii, neurocysticercosis, bartonella, ricekktsiae (rocky mountain spotted fever, typhus)
Causes of aseptic meningitis (Box 99.3) for post-infectious/vaccine
rubella, varicella, variola, rabies, pertussis, influenza, yellow fever
Causes of aseptic meningitis (Box 99.3) for drugs
NSAIDs, TMP-SMX, amox, azathioprine, IVIG, isoniazid, methotrexate intrathecal, allopurinol, carbamazepine
Causes of aseptic meningitis (Box 99.3) for systemic disease
SLE, wegener’s, CNS vasculitis, RA, kawasaki, sarcoidosis, leptomeningeal cancer, post-transplantation lymphoproliferative disorder, Behcet’s disease, Vogt-Koyanagi syndrome
Causes of aseptic meningitis (Box 99.3) for neoplastic disorders
leukemia, carcinomatous meningitis
contraindications to LP for suspected meningitis
infection in skin or soft tissue at puncture site or likelihood of brain herniation - i.e., if no focal neuro findings including altered mental status, safe to perform LP without neuroimaging
Sx seen to avoid LP prior to imaging for risk of brain herniation
focal neuro signs, papilledema, seizures, depressed mental status
normal opening CSF pressure
5 - 20 in lateral position
what to test in 4 tubes
tubes 1 and 3 = cell count to differentiate true CSF pleocytosis from contamination by traumatic LP
xanthocrhomia definition
yellowish discoloration from supernatant of centrifuged CSF specimen due t breakdown of RBC relasing pigments oxyhemoglobin, bilirubin, methemoglobin into CSF- occurs within 2 hours and lasts up to 30 days
definition of membrane potential
different concentration between Na and K (inside), normal -90
definition of depolarization
cell becomes more positive (less negative), when potential reacehs -70mV, specialized Na 2+ cells open up, fast acting channels which decrease the membrane potential further, then activates calcium channles (calcium influx), which further makes it more positive
key difference between pacemaker cells and non-pacemaker cells re: depolarization
pacemaker calles can spontaneously depolarize via slow Na influx, does not have the prolonged refractory period
location of SA node
RA junction of RA and SVC
blood supply of SA node
Right coronary artery in 55%, LCA in 45%
AV node intrinsic impusle HR
45 - 60 beats/min
infranodal within His or purkinje system HR
30 - 45 beats/min
AV node location
posterior-inferior region of interatrial septum; blood supply is RCA in most (90%, LCA in 10%
PR interval relation to the heart
time it takes for atrial impulses to conduct to the ventricles
bundles in the budle system
RBB, LAFB, LPIB
blood supply to the RBB and LAFB
LAD
blood supply to left posterior bundle
RCA or LCA
QT interval relation to the heart
total time of ventricular depolarization and repolarization
Torsades de point
ventricular dysrhythmia which arises from prolonged QT interval and metabolicdrug trigger
number of classes of antidysrhythmic drugs
4 classes; class I: major effects on fast Na channels, II: beta-adrenergic antagonists (depress SA node), III: prolong repolarization and refractory period duration (acts on K+ channels), IV: calcium channel blockers
Examples of Class IA agents: slow conduction through atria, AV node and HP system, suppress conduction in accesorry pathways
procainamide: ventricular dysrhythias and Supraventricualr dysrhythmias,
Example of class IB agents: slow conduction and depolarization by shortening repolarization , little effect on accessory pathway conduction
lidocaine: suppress dysrhythmias from enhanced automaticity such as VT, and suppress SA/AV node
example of class IC agents: profoundly slow depolarization and conduction, associated with prodysrhythmias, creation of new ventricular dysrhythmias, only seen in the US
flecainide, propafenone,
Example of Class II agent: beta adrenergic blockers - suppress SA node and slow conduction through AV node; B1 > B2 is more cardioselective
esmolol (500 mcg/kg), metoprolol 5 mg IV q10-15mins)
Example of class III agent:anti-firbillatory agent, prolong action potential duration and refractory period
amiodaroe, bertylium, sotalol
class IV medications: associated with peripheral vasodilation
CCB - diltiazem, verapamil
amiodarone half -life
25 hours after single dose!!
acute SE of amiodarone
hypotension, bradycardia, heart failure
long-term effects of amiodarone
corneal deposits, photosensitivity, gastrointestinal intolerance
digoxin MOA
inhibits Na-K exchange pump –> increases Na in the cell, resulting in increased intracellular Ca –> +inotropic effects, prodysrhythmic effects , slows AV node via lengthening of refractory period
SE of digoxin
GI, fatigue, drowsiness, visual color disturbances (van gogh), headache, depression, apathy; psychosis, HB, increased ectopy, vTach, MAT, junctional rhythm
TTP sx (mnemonic)
“FAT RN” - fever, anemia, thrombocytopenia, renal, neuro symptoms
DDX to consider with ?TTP
HUS (hemolytic uremic syndrome), ITP, DIC
difference between HUS and TTP
TTP has more CNS involvement, HUS has renal involvement, HUS has often diarrhea
ITP vs. TTP
ITP pts are not very sick and have normal CBC; TTP are very sick with SCHISTOCYTES
DIC vs TTP
DIC - multiple sites of bleeding, elevated INR, PTT and d-dimer vs. TTP don’t have overt bleeding, and mildly elevated INR, PTT and D-dimer
MGMT of TTP
plasma exchange indicated in MAHA (schistocytes, elevated LDH, elevated indirect bili)
Pathophysiology of TTP
endothelial injury with platelet rich thrombi causing MAHA and thrombocytopenia; vWF made in endothelial cells and assembled in large multimers which are cut by ADAM TS13 into smaller unit; ADAMS13 does not function correctly and these vWF multilers collect and accumulate, which results in platelet aggregation forming clots, and also theres multimers cleave RBCs intravascularly
triggers of TTP (inherited or acquired)
HIV, malignancy, pregnancy, medication, organ transplant, chemotherapy, pancreatitis, autoimmune disease, idiopathic
neurologic symptoms of TTP
seizures, coma, often transient
Plt cut off for TTP
< 25
Sx for MAHA
non-immune hemolysis with schistcytes from RBC fragmentation, elevated LDH, low haptoglobin, high indirect bilirubin, LDH elevated
Other key sx for TTP
fever, renal disease (UA with mild protein, hematuria), GI symptoms, splenomegaly and jaundince, cardiac sx (MI, arrhythmia, shock, heart failure)
RF for TTP
obesity, african-american, female, patients age 30 - 50, HIV/AIDS, rheumatologic/autoimmune, clpidogrel
ADAMTS13 activity cut off for TTP
< 10% is supportive of TTP; TTP is a clinical diagnosis
MGMT for TTP
avoid platelet transfusion, consult heme, plasma exchange, transfuse FFP, steroids, IVIG, splenectomy
Reversal agents for warfarin
Vitamin K (10 mg IV over 30 mins), Plasma (FFP) - 4 - 6 units, Prothrombin Complex Concentrate (octaplex - 10,9,2,7) - works immediately, factor 7 has short halfllife, must be given with vitamin K
Contraindications for PCC
HIT, liver disease, recent thrombosis, MI, ischemic stroke, DIC
SIRS Criteria
2 of the following: fever (38.3+), HR > 90, RR > 20, WBC >
Order of ossification centres in elbow for children
“CRITOE” - capitellum, radial head, internal/medial epicondyle, trochlea, olecranon, external/lateral epicondyle
2 Lines on elbow xray
anterior humeral line (transect 1/2 to 1/3 of capitellum; if not, consider supracondylar fracture), radiocapitellar line transects middle of capitellum; if not, radial head dislocation)
posterior fat pad in elbow
occult radial head fracture
Monteggia fracture
proximal ulna fracture with radial head dislocation
Galeazzi fracture
distal radius fracture with dislocation of ulna
