Random Flashcards
The accepted thresholds for therapy (based on the Brain Trauma Foundation guidelines) are to prevent prolonged elevations of the ICP higher than ____ and to maintain the cerebral perfusion pressure greater than ____
Goal is: ____ but no evidence to support lowering BP to get there
Equation for CPP?
Prevent prolonged elevations of the ICP higher than 22 mm Hg and to maintain the cerebral perfusion pressure greater than 50 mm Hg.
CPP goal of 50 to 70 mm Hg.
CPP = MAP − ICP
VZV Exposure management of HCP
- Give vaccine if they don’t have it (ideally within 3-5 days post-exposure, later is ok too)
- If can’t get vax (pregnant) or at risk for severe disease: Varicella-zoster immune globulin
- Keep HCP non-vaxxed or non immune away from patients for 8 to 21 days after exposure
Hypothermia
- K
- glucose
Rewarming
- K
- glucose
K goes intracellular-> hypoK
Low metabolism so hyperBG
K comes out-> hyperK
Glucose gets used-> hypoBG
Treatment of severe V vulnificus necrotizing fasciitis
Double coverage with ceftazidime and doxycycline is recommended
No remdez if
LFTs>10x
or crcl<30
Mycobacterium marinum is an aerobic, weakly pathogenic photochromogenic nontuberculous bacteria found in marine and brackish waters worldwide.
It typically causes:
Tx:
Nonhealing granulomatous skin infections in humans by direct inoculation.
Combination clarithromycin plus trimethoprim-sulfamethoxazole is a preferred treatment.
Characteristics of pressure support include triggering of each breath by patient effort (decrease in airway pressure), consistent inspiratory pressure among breaths, and variable duration of inspiration among breaths.
Also shows ineffective trigger asynchrony.
Graphic display of pressure vs time (top), flow vs time (middle), and volume vs time (bottom) for SIMV mode with volume control breath (arrow) on right and pressure support breath on left.
Electrical activity of the diaphragm (Edi) (bottom, light green)
The yellow bars highlight the variable duration of inspiration with pressure supported spontaneous breaths. The yellow arrows identify ineffective triggering, and the green arrow identifies diaphragmatic electrical activity.
Ventilator graphics demonstrating SIMV mode with presence of double-trigger asynchrony (closely positioned breaths 2 and 3).
Double triggering is often seen when there is a prolonged inspiratory effort exerted by the patient in the setting of a relatively brief set inspiratory time
Pseudomonas aeruginosa can cause serious infection in patients with ____ or ____.
diabetes or leukemia
In patients with____ P aeruginosa most characteristically is associated either with a water-exposed wound that secondarily develops cellulitis or with an aggressive form of otitis externa (ie, malignant otitis externa) in which the organism becomes highly invasive, often eroding through skin and into bone in the external canal and infratemporal fossa.
Diabetes
In patients with ____, granulocytopenia is usually the major predisposition to bloodstream infection with P aeruginosa.
leukemia
Ecthyma gangrenosum is the classic skin lesion encountered in patients with neutropenia with sepsis due to P aeruginosa and appears as
Hemorrhagic bullae on an erythematous base
Can also happen from other types of bacteremia but 75% are from pseudomonas
CSF profile in HSV-1 typically demonstrates:
Increased WBC count and lymphocytosis but the majority of patients also have an elevated RBC count
Rickettsia rickettsii causes Rocky Mountain spotted fever (RMSF)
- when?
- initial px?
- when does the rash start?
- charateristic labs?
- CSF: wbc and protein?
Spring and early summer
Presents with fever, nausea, vomiting, and headache.
Maculopapular rash that typically starts 48 to 96 h after fever onset.
Characteristic thrombocytopenia, leukopenia, and elevated transaminase levels
CSF WBC typically <100/μL [<0.1 × 109/L] with a higher elevation of protein (100-200 mg/dL
Weakness from neuroinvasive WNV
Acute flaccid paralysis syndrome has similarities to poliomyelitis, as the virus affects the anterior horn cells of the spinal cord.
A key feature of the weakness associated with WN virus is that it is asymmetric
Indications for early surgical treatment in infective endocarditis includes
1. valve dysfunction leading to signs or sx of heart failure
2. persistent and uncontrolled infection evidenced by persistent bacteremia and/or fever after more than 5 days of appropriate antibiotics.
3. ??
Consideration if:
1. IE caused by highly resistant or fungal organisms
2. recurrent emboli or enlarging vegetations despite appropriate antibiotic therapy
3. ???
- heart block, annular or aortic abscess, or other destructive, paravalvular lesions (eg, the patient in this case)
- large (>10 mm) vegetations, especially when large vegetations are associated with valvular regurgitation.
Some organisms (“SPICE” or “ESKAPE” organisms, including E cloacae, Citrobacter freundii, Serratia marcescens, Providencia stuartii, Pseudomonas aeruginosa, Hafnia alvei, and Morganella morganii) have inducible resistance through chromosomally encoded ampC genes.
Clinically, the risk for emergent AmpC-mediated resistance is greatest for ___
Enterobacter species, which includes Klebsiella aerogenes
Treatment with cefepime, piperacillin-tazobactam, or a carbapenem is an evidence-based recommendation by the Infectious Diseases Society of America.
ARREST trial
OHCA from VF or pulseless ventricular tachycardia (VT) and no ROSC after three shocks
Required estimated transport time less than 30 min from activation of the ECMO team, patients 18-75
Result of trial?
Improved outcomes with eCPR compared with standard ACLS in patients with out-of-hospital cardiac arrest (OHCA) and VF
Survival rates of 43% vs 7% Favorable neurologic outcomes in survivors
Acute onset fever, dry cough and progressive shortness of breath in a healthy patient with association to smoke, sandstorm, dust, or burning oil exposure
Acute eosinophilic pneumonia
Diagnosis of acute eosinophilic pneumonia
IMG?
Peripheral eosinophilia?
BAL?
Diffuse, bilateral, pulmonary opacities, and sometimes small pleural effusion more easily appreciated on CT images.
Peripheral eosinophilia is absent early in disease
BAL eosinophilia (>25% and often much higher), after exclusion of infection, vasculitis, or other known inciting factors, is highly supportive of an AEP diagnosis.
Acute eosinophilic pneumonia treatment and prognosis
AEP is treatable with corticosteroids, rapid improvement over weeks is typical, and relapse is rare. Smoking cessation should be strongly encouraged.
Fulminant form of diffuse lung injury that initially presents with fever, cough and shortness of breath
Acute Interstitial Pneumonia
Clinical course of Acute Interstitial Pneumonia
Rapid onset (1-2 weeks), diffuse lung injury-> unexplained ARDS with 50% mortality
Treatment of Acute Interstitial Pneumonia
Supportive care + steroids
Cyclophosphamide is sometimes used.
Diagnosis of AIP
Clinical syndrome of idiopathic ARDS and histologic confirmation of diffuse alveolar damage
FIrst line treatment for submassive or intermediate risk PE?
Both the American College of Chest Physicians and American College of Cardiology guidelines recommend against routine use of catheter-directed thrombolysis in patients with submassive or intermediate-risk pulmonary embolism.
Just anticoagulate
Tx of PE + SBP<90 or 40mmHg drop in SBP?
Lytics
Tx of massive PE (SBP<90 or 40 drop in BP) in patients with high risk of bleeding
Catheter-directed thrombolysis can be considered
Studies evaluating intermediate-risk PE + thrombolytics
Reduced incidence of hemodynamic decompensation with lytics but increased bleeding, especially intracranial.
Overall, the mortality rate was similar between thrombolytics and systemic anticoagulation at both 7 and 30 days.
Bleeding risk was especially high in people >75
Retained hemothorax (RH)
Hemothorax that remains “retained” in the pleural space despite drainage by catheter (either pigtail or chest tube)
Risk factor for infection (empyema) and formation of fibrothorax and trapped lung.
Management of Retained hemothorax (RH)
Guidelines recommend early (within 4 days) drainage of RH via VATS-> shorter hospital stays and greater cost savings
Alternative treatment of RH includes intrapleural fibrinolytic therapy via chest tube or pigtail catheter.
Hemothorax management: Drain unless ____
Other ways to manage?
Size is quite small (<500 mL)
Pigtails have similar complication rates to chest tube but better tolerated
Consider embolization of vessel
Failure to respond to these measures is an indication for thoracotomy.
ESBL-producing bacterial bloodstream infection (ceftriaxone non-susceptible)
MERINO trial, a multicenter, open-label, noninferiority, randomized controlled trial, compared piperacillin/tazobactam with meropenem for definitive treatment of ESBL-producing E coli and ESBL-producing Klebsiella bloodstream infections
Higher mortality rate with zosyn compared to meropenem
Lung abscess management
- which abx
- duration?
- when to consider biopsy, thora, chest tube or surgery
- Prolonged antibiotics (6 weeks - 6 months), starting with IV for 1-2 weeks
- Treat with b-lactam + lactamase inhibitor, carbapenem or clindamycin
- Consider surgical resection if no response to treatment or >6cm
- High mortality c emergent surgery
- Thoracentesis, chest tubes, and transthoracic biopsies should not be attempted, as they can contaminate the pleural space and lead to empyem
OUD managed with buprenorphine or buprenorphine-naloxone as an outpatient who present with acute critical illness
Continue outpatient regimen
Maximizing nonopioid analgesia strategies and adding short-acting opioids as needed
Consider dose reduction if maintenance dose is high (eg, >16 mg total daily dose) or if pain control is still inadequate after providing adequate doses of short-acting opioids.
Consider dose reduction in severe hepatic dysfunction
No renal adjustment, no dialysis adjustment
ARDS Network low tidal volume trial
Larger tidal volumes and higher airway pressures were associated with significantly better oxygenation and mechanics but _____
Worse mortality
Recruitment Manuvers
Result in improved oxygenation and lung mechanics but significant adverse _____ during RM. Also showed increased ______ despite better P/F
Significant adverse hemodynamic effects during RM
Increased all-cause mortality
PPI for VAP?
PPI for mortality or length of ICU stay?
Positioning patients with the head of the bed elevated to 30° to 45° is recommended
Routine gastric residual monitoring, PPI and early parenteral nutrition have not been shown to be effective in preventing VAP
Several multicenter clinical studies show that PPI does not reduce the rates of nosocomial pneumonia, mortality, or ICU length of stay.
NUTRIREA-2 study
Nutrition delivered via the enteral and parenteral routes in patients who were critically ill and being treated with mechanical ventilation and vasopressors
Similar outcomes however enteral nutrition route resulted in more mesenteric ischemia and colonic pseudo-obstruction
ARDS Network EDEN study demonstrated that trophic feeding rates for the first 6 days resulted in similar clinical outcomes as advancing enteral feeds to goal rates as soon as safely possible, with lower incidence of:
Gastrointestinal complications
NUTRIREA-3 study
Compared
- Lower calorie (6 kcal/kg/day) and lower protein administration (0.2 g/kg/day)
- Advancing to goal calorie and protein rates as soon as possible
Patients who were receiving mechanical ventilation and vasopressors during first 7 days of enteral feeding
Outcome
- Similar 90-day mortality rates
- Faster time to readiness for ICU discharge in the lower calorie and protein group
- Fewer gastrointestinal complications
Serum creatinine increase of ≥0.5 mg/dL or a relative increase of ≥25% in the 48 to 72 h after the administration of contrast material when other potential causes of AKI have been excluded
CIN
Major risk factors for CIN?
- age >70
- CKD
- concomitant use of nephrotoxic drugs
- 2 other chronic conditions
- 2 acute conditions
- diabetes and CHF
- shock and hypovolemia
Association between CIN and risk of dialysis or death
Patients who received radiocontrast had a similar need for dialysis and a similar risk of death as did the patients who did not receive radiocontrast. This finding was independent both of the type of radiocontrast and of the presence of diabetes and chronic kidney disease.
IVF or hemodialysis to prevent CIN?
No significant difference in incidence of AKI between patients who received peri-CT IVF
No benefit from attempting to remove contrast with hemodialysis
Treatment of acute chest syndrome
ACS is often precipitated by infection, so empiric antimicrobial treatment for pneumonia to cover bacteria such as Streptococcus pneumoniae and Haemophilus influenzae along with atypical bacteria (such as Mycoplasma and Chlamydia) should also be started.
Esophageal tamponade
- duration?
- management during use?
- pressure target?
Temporizing measure only to stabilize the patient for further treatments as soon as possible.
Only use for 24-48 h
Deflate every 12 h
Monitor pressure every hour
Maintain at 30-45 mm Hg (high enough to tamponade venous bleed without blocking critical perfusion)
INTUBE observational study
Evaluate incidence and nature of adverse peri-intubation events in international patients undergoing tracheal intubation in ICU, ER and ICU
Cardiovascular instability occurred in 42% of patients (SBP<65 x1 or <90 x 30 minutes, or new/increased pressors or fluid bolus)
Severe hypoxemia (SpO2 <80%) in 22% -> decreased to 10% with bag-mask ventilation
Difficult intubation (>2 attempts) in 5%
Aspiration of gastric contents in 4% (not made worse using BVM)
ESCAPE trial
RCT often cited as evidence that PAC does not change outcomes in patients with heart failure
Excluded: patients with recent inotropic therapy
Severe prospective series have reported improved outcomes, including decreased in-hospital mortality, when pulmonary artery catheters are used in patients with cardiogenic shock.
Indications:
Failure to respond to empiric inotropic therapy and uncertainty about intravascular volume status-> help with titration of diuretics and vasoactive agents to maximize cardiac output while minimizing arrhythmias and myocardial oxygen consumption.
Use of PAC to obtain complete hemodynamic data before initiation of temporary mechanical circulatory support is associated with:
Decreased mortality from all-cause cardiogenic shock.
IABP for cardiogenic shock?
Compared with no mechanical circulatory support, IABP use was not associated with a reduction in mortality
Only venoarterial extracorporeal membrane oxygenation plus IABP was associated with favorable outcomes compared with no mechanical support
Ineffective Triggering
Insufficient change in airway pressure or flow to meet the ventilator’s set parameters to trigger breath
Ineffective Triggering is caused by:
Auto-PEEP
Low respiratory drive
Weak inspiratory muscles
Partial ETT obstruction
High trigger sensitivity
Double Triggering (premature cycling)
Two or more positive pressure breaths occur in short succession with an incomplete expiration between them, resulting in large tidal volumes
Double Triggering (premature cycling) occurs when:
Ventilator’s inspiratory time is set to a shorter duration than the patient’s inspiratory time
Appropriate adjustments include:
- Increasing tidal volume
- Increasing inspiratory time
- Increasing sedation
Two or more positive pressure breaths occur in short succession with an incomplete expiration between them, resulting in large tidal volumes
Double triggering (premature cycling)
AUTO-TRIGGERING (Extra triggering)
Ventilator delivers a positive-pressure breath without patient initiation or appropriate time-cycling
When does AUTO-TRIGGERING (Extra triggering) occur?
Occurs in the setting of a circuit leak, fluid in the ventilator circuit, chest tube leak, or vibrations related to ventilator tubing or cardiac oscillations
FLOW DYSSYNCHRONY (Target dyssynchrony)
Occurs when the set ventilator flow rate is lower than the patient’s desired flow rate.
The pressure-time graph shows concave inspiratory deflections because the patient produces increased negative inspiratory pressures to drive increased inspiratory flow
What dyssynchrony occurs when ventilator flow rate is lower than the patient’s desired flow rate?
Flow dyssynchrony (target dyssynchrony)
How to fix flow dyssynchrony or target dyssynchrony?
Increasing ventilator flow rates typically resolves this problem
Or change to pressure control ventilation
Cycle Dyssynchrony
Occurs when the duration of the ventilator-delivered breath does not match the patient’s desired breath duration
Cycle dyssynchrony occurs when the duration of the ventilator delivered breath does not match the patient’s desired breath duration.
If ventilator breath is shorter than the patient desires, the patient _____. The airway pressure curve will be _____ and _______ will occur after the ventilator breath terminates.
This can result in:
may exert continued inspiratory effort
pulled downward
reversal of expiratory flow
double triggering
Cycle dyssynchrony occurs when the duration of the ventilator delivered breath does not match the patient’s desired breath duration.
If ventilator breath is longer than the patient desires, the patient will begin _____ during a positive-pressure inspiration, producing ___ with increased expiratory flows
active expiration during a positive pressure inspiration
end-inspiratory peak pressure elevations with increased expiratory flows
Cycle dyssynchrony
Ventilator breath is longer than the patient desires so patient begins active expiration during a positive-pressure inspiration, producing end-inspiratory peak pressure elevations with increased expiratory flows
Antibiotic duration for inpatients with gram-negative bacteremia who were afebrile and hemodynamically stable for at least 48 h and who had adequate source control
7 days of antibiotics was non-inferior to 14 days
Oral step-down within first 5 days of bacteremia was non-inferior to full IV course
Cumulative percentage of time over a 24-hour period that free (unbound) antibiotic exceeds the minimal inhibitor concentration
- Which category
- Example?
Time-dependent killing
B-lactam antibiotics
Defined by the peak concentration in a dosing interval divided by the MIC
Concentration-dependent killing
Aminoglycosides
Daptomycin
Determined by the area under the curve (AUC) over a 24 hour period divided by the MIC
Concentration-dependent with time-dependent killing
Fluoroquinolones
Tigecycline
Linezolid
Vancomycin
Serum IgE levels may be helpful to identify patients with:
Severe, poorly controlled asthma who may benefit from the addition of targeted biologic therapy
Tryptase levels peak at:
Remain elevated for at least:
60 to 90 min after an anaphylaxis event
5 hours
Serum histamine is a more sensitive marker of anaphylaxis than ___ but ___
Tryptase
Only remains elevated for 30 to 60 min after symptom onset
Angioedema is self-limited, localized subcutaneous or submucosal swelling that can occur in isolation, with urticaria, or in association with anaphylaxis.
Initial evaluation includs:
If low:
Complement protein C4 level.
Low levels should prompt further evaluation for hereditary or acquired C1 inhibitor deficiency, including a C1 inhibitor antigen and functional levels
Drugs that interfere with poc glucose measurements?
Ascorbate (vitamin C)-> false elevated
Less predictable: mannitol, acetaminophen, icodextrin (a peritoneal dialysate), and dopamine
Flu-like illness (fever, headache, cough, sore throat, and arthralgias) that may have a erythematous face rash
Parvovirus B19
Factor VIII is ____ in DIC because of ongoing consumption
reduced
Factor VIII is ____ in liver disease because much of it is made by non-hepatic endothelial cells
normal or increased
If any A + B:
A: flu-like illness OR neuro w/u OR tox w/u or hyperlactemia w/u OR cohabitants sick together
B: winter OR using any fuel-burning device OR burn victim or methylene chloride (paint striper )
Check carboxyhemoglobin level!
Oxygen saturation gap in carbon monoxide poisoning means:
Pulse oximetry is close to 100% compared to low PaO2 on ABG
Carboxyhemoglobin in non-smokers:
Smokers:
0-3
0-10% (?15)
Treatment of carbon monoxide poisoning?
Give 100% FiO2 (HFNC> regular)
Target low-normal pCO2 (35-40)
Maintain hemodynamics
Avoid fevers
Consider regular transfusion (exchange transfusion usually not quick enough since half-life of CO is ~1 hour when giving 100% FiO2)
Hyperbaric if resources permit, especially if pregnant. More beneficial if given early (<6 hours)
Bright red venous blood (+ high central venous oxygen saturation >75%)
Consider cyanide poisoning
Smoke inhalation in an enclosed space plus
- AMS
- soot in nares/mouth
- full arrest (without full body burns incompatible with life)
Treat with hydroxycobalamin!
Venous PO2 similar to arterial PO2 with profound lactic acidosis (>8)
Consider cyanide toxicity
Fires (similar to CO toxicity)
Burning of nitrogen-containin polymers (plastic, wool, silk), pestaside creation
Chemical weapon
Peach, pear, apricot or crab apple pit
Prolonged use of Nitroprusside
Cyanide
_____ binds directly to cyanide and creates a harmless metabolite called cyanocobalamine, which is cleared by kidneys
Hydroxocobalamin (vitamin B12)
“cyanide antidoate package” which contains sodium nitrite, amyl nitrite, and sodium thiosulfate
- can cause:
methemoglobinemia
Avoid if concomitant CO toxicity
Impairs oxygen delivery to tissues and, importantly, binds to the cytochrome C oxidase site of mitochondria, which is the primary site of oxygen consumption.
This in turn impairs aerobic metabolism and decreases adenosine triphosphate production, which leads to cellular dysfunction and is ultimately fatal.
Carbon monoxide
Binds the ferric ion (Fe3+) of cytochrome oxidase a3, inhibiting its enzymatic activity in the mitochondrial cytochrome complex and uncoupling oxidative phosphorylation. The result is anaerobic metabolism to produce adenosine triphosphate and
cyanide
Oxidizing substances converts the iron in hemoglobin to _____, which is incapable of binding to oxygen. Resulting in inadequate oxygen transport.
Methemoglobinemia
Medication Triggers for Methemoglobinemia
- Topical for EGD or TEE
- IV/po/inhaled
- Antibiotics (4)
- Chemo (2)
- Benzocaine
- Nitroglycerine, iNO, nitroprusside, oral nitrate
- dapsone, rifampin, sulfonamides, anti-malarials
- Rasburicase, cyclophosphamide
Toxin/environmental triggers of Methemoglobinemia
Anti-freeze
Hydrogen peroxide
Fertilizers, weed killers, plastics, dyes, paints, rubber
Methemoglobinemia
Levels
< 2 %
3- 15%
20 - 30%
>40%
Normal
Asymptomatic
Fatigue, tachypnea, dyspnea, tachycardia, anxiety, dizziness, nausea, vomiting
Seizure, coma, arrhythmia
Cyanosis + oxygen saturation above 80%
Methemoglobinemia (usually need lower O2 for cyanosis)
ABG with high PaO2 (>100mm) despite pulse ox 80-90%
Methemoglobinemia
Indications for Methylene blue
Symptoms or level >30%
If not high enough to treat, you need to trend and be ready to treat
Contraindications to Methylene blue
- Options?
G6PD or high risk for serotonin syndrome
- Risk of giving it-> drop NADPH levels, leading to hemolysis (but methemoglobinemia by itself can cause hemolysis) and there are different types of G6PD, which determine risk for hemolysis
- Call toxicologist
- Can use IV vitamin C and Riboflavin (vitamin B2), or try methylene blue (especially if african american), or consider exchange transfusion
If no improvement within minutes after giving 2mg/kg of methylene blue?
Consider G6PD if no improvement after 2mg/kg
Rebound can occur after 4-12 hours with some agents or large volume
Osmolar gap
Calculated osmolarity= measured - calculated
2NA + glucose/18 + BUN/2.8 + etoh/4.6
(can be falsely normal)
Of the 4 toxic alcohols, which have elevated AG and which have elevated OG
All 4 will typically have elevated OG
- Methanol and ethylene glycol will have AG
- sometimes ethanol does too
2 toxic alcohols in anti-freeze
isopropyl alcohol and ethylene glycol
If garage fluids + AG + OG
Fomepizol
Hemodialysis if severe acidosis, large ingestion, severe CNS depression, AKI or any visual impairment
Drank windshield wiper fluid, now with vision impairement
- AG
- OG
- which alcohol
- tx
Methanol/moonshine (my eyes)
+AG, +OG
Fomepizole and dialysis
Drank rubbing alcohol, now has elevated ketones but no AG
- which alcohol
- tx
Isopropyl alcohol
Supportive care
Indication for Hydroxyurea in sickle cell patient?
Prophylaxis in patient’s with multiple vaso-occlusive crises/year
Decreases risk of ACS
No role in acute management
Which BBB is a risk for PA catheter insertion?
Pre-existing LBBB because when you insert, you can cause transient RBBB which can lead to complete heart block
Lab abnormalities after salicylate ingestion
- Acid base
- BMP
- detection
- which coags
Primary respiratory alkalosis (due to hyperventilation caused by the effect on the medullary respiratory center): elevated pH low pCO2
AGMA with elevated lactate (due to impaired oxidative phosphorylation resulting in an increased anaerobic metabolism)
Hypoglycemia
High salicylate level (>30 mg/dL)
Coagulopathy (impairs vitamin K+-dependent coagulation factors)
Ingestion leads to non-specific symptoms including fever, N/V, tinnitus, abdominal pain and neuro symptoms including dizziness, hallucinations or coma.
Results in hyperventilation caused by the effect on the medullary respiratory center, resulting in:
Salicylate (aspirin (150mg/kg), wintergreen oil, slicyclic acid (wart remover)).
Primary respiratory alkalosis with HAGMA
How to avoid death spiral of salicylate toxicity
One thing that can precipitate it
Watch/correct:
Intubating can precipitate because you take away their attempt to compensate
Alkalinization with bicarb to keep it in the non-toxic form that leads to absorption until salicylate level is below 40
Fluid status (usually need a good amount of resuscitation) and electrolytes (K/glucose)
Salicylate toxicity most commonly presents:
as a mimic of sepsis, meningitis or pneumonia
When to consider hemodialysis for salicylate toxicity?
Altered mental status or noncardiogenic pulmonary edema
Noncardiogenic pulmonary edema requiring supplemental oxygen
Salicylate level >100 mg/dL
80 -90 if renal dysfunction or despite fluid resuscitation
pH < 7.2 despite supportive care (e.g. bicarbonate)
Spontaneous esophageal rupture from vomiting can result in chest pain and subcutaneous emphysema. Can lead to left pneumothorax and left pleural effusion.
- Next step?
- If thoracentesis is performed, pleural fluid is exudative, with a low pH and extremely high ____ level
- Risk?
- Treatment
Assessment for possible esophageal leak by fluoroscopic study would be the next appropriate step
Exudative, with a low pH and extremely high amylase level, due to saliva spillage.
Once mediastinal and pleural infection become entrenched, which happens quickly, sepsis and high mortality characterize this process.
Definitive repair by thoracotomy in most cases, sometimes stenting via endoscopy is an option
Muscle weakness with painful spasms and rigidity that starts in the jaw and spreads downward. Associated with autonomic instability
Tetanus
Treatment of tetanus includes wound care/debridement, administration of ____ and ___.
Supportive care, which may include benzos and _____.
No benefit to giving ____
+ human tetanus immunoglobulin
+ antibiotics (high-dose penicillin G or metronidazole)
+ NMB
Tetanus toxoid in vaccine has no use in treating tetanus
Superficial infection (keratitis or onychomycosis) in immunocompetent host
Sinusitis, endophthalmitis, pneumonia, skin involvement, and fungemia in immunocompromised patients
Fusarium species mold infection
Invasive fungal infection in patient with prolonged neutropenia and widely disseminated skin lesions
Mold infection with Fusarium species
Skin lesions: reddish gray macules, some with central ulceration but others with black eschar formation, consistent with the angioinvasive property of Fusarium
Patient with malignancy, on posaconazole prophylaxis is at risk for which type of fungal infection?
Fusarium species
Similar to Aspergillosis but Fusarium typically has more skin lesions and positive blood cultures
Colorless vapor with strong odor (freshly moved hay or green corn)
Industrial accident or terrorist attack
Phosgene
Symptoms of Phosgene
- High concentration on initial exposure
- Low concentration over prolonged exposure
High concentration on initial exposure: Mucous membrane and eye irritation, cough, chest tightness-> leave area and do ok
Low concentration over prolonged exposure: Delayed cough, dyspnea, tachypnea and respiratory distress-> non-cardiogenic pulmonary edema (around 8 to 48 hours post)
Treatment of phosgene (carbonyl dichloride) exposure
Supportive
No meds have shown benefit
Exposure to green-yellow gas that smells like bleach
Chlorine gas
Symptoms of chlorine gas exposure
Immediate eye, mucus membrane and upper airway symptoms
Cholinesterase (acetylcholinesterase) inhibitor toxicity
- blocks normal breakdown of acetylcholine
Caused by organophosphates (nerve agents) or carbamates (insecticides)
Result in nicotinic _____ and muscarinic (SLUDGE) symptoms
Nicotinic: tachycardia, muscle twitching, paralysis and seizure
S: salivation
L: lacrimation
U: urination
D: diaphoresis
G: GI upset (N/V/D)
E: eyes (miosis)
Organophosphates poisoning results in ____ toxicity
Cholinesterase inhibitor toxicity (acetylcholinesterase toxicity)
Symptoms:
- muscarinic: SLUDGE
- nicotinic: twitching, seizures
Treatment of organophosphate toxicity
- Muscarinic symptoms
- Nicotinic symptoms
- seizures:
- atropine (may require high doses)
- Pralidoxime (asap!)
- benzos
Painless pustular lesions on exposed areas with central necrosis (black eschar) and regional lymphadenopathy
Bacilus anthracis
Anthrax
Mediastinal widening, pleural effusions, hemorrhagic alveolitis
Antrax/ Bacilus anthracis
Gram stain showing encapsulated gram- positive, “boxcar”- shaped bacilli
Anthrax, bacillus anthracis
First line treatment for Anthrax
- Includes antimicrobial AND **
we actually don’t know. seems like giving a bacteriasidal agent (meropenem or clidamycin) and a protein-synthesis inhibitor is reasonable (doxycycline or ciprofloxacin)
Antitoxin Therapy: Monoclonal Antibodies (Raxibacumab or Oblitoxaximab) or Anthrax Immunoglobulin
Monoclonal antibody therapies (REGN-EB3 and mAB114) for Zaire variant of ***
Ebola
Exposure to white powder results in pulmonary edema, cough and fever
Inhalation of ricin (protein toxin from castor bean)
Ingestion: vomiting and bloody diarrhea
Usually 4-6 hours after exposure
Treatment of ricin exposure
Supportive
Double vision, slurred speech with weakness that spreads down entire body
Botulism causes descending paralysis with bulbar palsies and GI symptoms
Which bioterrism agents have a specific anti-toxic or immunoglobulin
Botulism (anti-toxin)
Anthrax (monoclonal antibody or immunoglobulin)
Tetanus (immunoglobulin)
Anti-viral therapy: tecovirimat for severe disease and immunocompromised patients
Monkeypox
