Resp. CIS Flashcards
common cause of wheezing in kids
Viral infections
What time of day is more suggestive of asthma?
coughin that’s worse in the middle of the night (midnight to 3 AM)
What are some risks for developing asthma?
- RSV infection prior to 6 months of age
- patient hx or family hx of any atopy(allergic rhinitis or eczema)
What are some example of common triggers for asthma?
virus allergies exercise cold air cigarette smoke exposure
What are common findings on a CXR in a child with asthma or reactive airway disease (RAD)
Atelectasis
Hyperinflation of both lungs
Perihilar thickening
What is capillary refill like in a child
if at 2 sec… concerning
- > 2 sec is terrible
- healthy kids’ cap refill nearly instantaneously!
What is the best way to obtain blood gases in a peds patient and what are the caveats of ordering blood gases in a peds patient?
- use capillary blood gases in children
- quicker and less distressing than arterial gas
- can’t use PaO2 from them
- ONLY USEFUL FOR pH and CO2
Where should a pediatric patient with asthma exacerbation be admitted?
needs to go to PICU due to significant risk for decompensation
Options for mainanence IVF in children?
1/2 NS in >1yo or 1/4 NS in <1 yo
- NS is reserved for bolusing
- in peds usually potassium is added to IVF
When is it approptiate to intubate an asthmatic patient and what are potential treatments to add prior to intubation
- “EVERY ATTEMPT SHOULD BE MADE TO MAINTAIN THE KID’S RESPIRATORY STATUS IN THE PICU
- ADD terbutalin drip, Mg, Theophylline, subcu epinephrine, heliox, IN ORDER TO NOT INTUBATE AN ASTHMATIC
- You intubate them, they get worse and then they die
- The time to intubate an asthmatic kid is somewhere between irritable and obtunded (them, not you)
Why do you no want to intubate asthmatics?
“they can’t exhale, so you force breaths in with the vent, they get fuller and fuller until they either get bilateral pneumothorax or acute right heart collapse and die”
Which population of asthmatics has the highest mortality?
Adolescents- because they don’t carry their rescue inhaler with them
What are some signs of respiratory distress in a respiratory patient?
- inspiratory and expiratory wheezing
- nasal flaring and tachypnea
- subcostal, intercostal, and suprasternal retractions
- stridor
- sniffing or tripod positioning
- decreased air movement
What are some treatment considerations for peds asthma?
-Albuterol nebulizer or inhaler
-inhaled corticosteroids
-oral corticosteroid
oxygen (put this on first if hypoxic)
CF shoud be in the idfferential, what would indicate concern for it and how would you test for it?
- poor height and weight
- clubbing
- foul-smelling stools (evidence of malabsorption)
- recurrent pneumonia
- edema
- failure to thrive
- test with SWEAT CHLORIDE TEST*
SUDDEN stridor in a child makes you think of what?
foreign body aspiration
O2 options to consider
NC up to 5 L, simple face mask at 5-6 L, NRB at 10-15 L/min, bag valve mask, Bipap, intubation
What is GTPAL in regards to obstetrical hx taking?
Gravidity= number of total preggos Term births= devlieries 38wks or more Preterm births= <38 weeks Abortions=... abortions Living children
What is a “total hysterectomy”?
take uterus and ovaries, usually but not always they take the cervix too
What can causes be of S2 splitting during cardiac exam?
- physiologic on inspiration
- persistent spliting dureing inspirationa nd expiration can be sensitive and specific screening for : heart disease in adults, the most likely cause being RBBB, and RV pressure overload situations such as acute massive PE is also a cause
What can be heard on pulmonary exam of a patient with a PE, 53% of the time?
rales
What is an invasive but highly accurate way of measuring blood pressure constantly?
arterial line (excellent in pts with any type of shock)
What labs should we consider checking for inherited thrombophilia?
Activated ptnC/ Factor V leiden, homocysteine level, functional assays of antithrombin III/ ptn C/ Ptn S, antiphospholipid antibodies
What is the most ocmmon findings on an EKG in a patient with a PE?
nonspecific ST-T wave abnormalities and sinus tachycardia
What is the gold standard imaging choice for PE?
CT angiogram (CTA) of the chest (PE Protocol) -need to consider the stability of your patient before taking them to radiology
What acan be seen on EKG that is indicative of PE?
S1 Q3 T3
-S in lead 1
Q in lead 3
-and an inverted T wav in lead 3
What is tPA
recombinant rissue type pasminogen activator… “clot buster
- binds to fibrin, which increases its affinitiy for plasminogen and enhances plasminogenactivation
- systemic thrombolysis preferred as more widespread availability and can give it rapidly as compared to taking to cath lab for angiogram and direct injection to clot itself
Are hormones pro-thrombotic?
yes
-Her hormone replacement therapy of Premarin is pro-thrombotic and a risk factor
What is Factor V Leiden (FVL)?
mutant form of coagulation factor V
- renders factor V insensitive to the actions of activated Ptn C, a natural anticoagulant
- increased risk of venous thromboembolism
- extrememly common
What is Virchow’s triad?
- a major theory delineating the pathogenesis of VTE
- alterations in blood flow
- vascular endothelial injury
- Alterations in the constituents of the blood
What are some risk factors for VTE?
- FVL
- Ptn S or C deficiency
- malignancy
- pregnancy or oral contraceptives
- paroxysmal nocturnal hemoglobinuria
What is Wells Criteria?
- clinical assessment for pulmonary embolism
- you get points for stuff
- gives you probability for PE
- > 6 is bad, between 6 and 2 is aight, 2 is golden
In the modified wells criteria, what is the magic number for if we are going to have a PE or not?
4
What are some absolute contraindications to fibrinolytic therapy?
- prior intracranial hemorrahe
- active bleeding
- pretty much anything up in the brain
- suspected aortic dissection
- trauma
- ischemic stroke within 3 months
What are some relative contraindications for fibrinolytic therapy?
hx of chronic, severe, poorly controlled htn
- pregnancy
- active peptic ulcer
- diabetic retinopathy
What are the types of shock?
Hypovolemic= high systemic vascular resistance
- Cardiogenic= high preload, low pump funciton, high afterload, <65% tissue perfusion
- Distributive= low afterload, >65% tissue perfusion
- Pericardial tamponade= high pre and afterload bc low pump function, <65% tissue perfusion
- Tension pneumothorax= high afterload, >65% tissue perfusion
What is MAP?
Mean arterial pressure
- diastolic BP+ (systolic-diastolic/3)
- > 65= good perfusion to all organs
- <65= hypotension/hypoperfusion
How do you Dx Nontuberculosis Mycobacterial infection- NTM (Kansaii)
sputum Cx and molecular diagnostics
Dx TB fungal infection
Cx results, regional exposure
Lung cancer dx:
histopathology
Lymphoma dx:
histopathology
> 5 mm induration on PPD
-What makes this result considered positive?
- HIV
- Close contact with actively infected person
- CXR with fibrotic changes consistent with TB
- Immunosuppression
> 10 mm induration on PPD
-What makes this result considered positive?
- silicosis, DM, CRF w/ dialysis, malignancies….anything that would increase risk of reactivation
- children <4
- from country with high prevalence
- Residents/employees in high risk setting: jail, healthcare facilities, mycobacterium labs, homeless shelters
> 15 mm induration on PPD
-what makes this result considered positive?
Healthy individual >4 with low likelihood of true TB infecion
Anergy, nothing on PPD
-what does this mean?
no rxn secondary to immune unresponsiveness
What are some signs and symptoms that are associated with active pulmonary TB?
-fever
-night sweat
-cough
weight loss
lymphadenopathy
What do we do for the workup and dx of TB?
Sputum culture (SCx)
Sputum staining: RA initially then Zeihl neelsen to confirm
-PPD skin test (mantoux)
-IFN gamma release assay: used for dx of LATENT TB… indicates there has been a cellular response to TB
-CXR: CAVITARY LESIONS IN APICES OF LUNGS
-NAAT: nucleic acid amplification test
What is the indication for IGRA?
individuals who have recieved a BCG vaccination and those witha positive PPD in whom latent TB is suspected
What is the 4 drug standard therapy for TB?
- isoniazid (INH)
- Rifampin
- Pyazinamide
- Ethambutol
Side effect of INH
Hepatitis, N/V, peripheral neuropathy (give pt. Vitamin B6), rash
Side effect of Rifampin
-Red/orange body fluids, N/V, rash, hepatitis, Steven-Johnson’s syndrome
Side effect of Pyrazinamide
Urticaria, hyperuricemia/gout, hepatitis, joint aches
side effect of ethambutol
optic neuritis, color-blindness
Clinical diagnosis of active TB
- clinical symptoms (bloody cough… etc.)
- assess risk factors (close contact, immigrants, IV drugs… etc)
- order radiography
- Sputum culture
Do you delay treatment if clinical diagnosis and awaiting culture?
no
-For active TB, start the four drug therapy (INH, rifampin, pyrazinamide, ethambutol)
Latent TB considerations
- clinically silent but can become active
- Get screening PPD
if there’s no history of BCG vaccination, what do you do along with the PPD?
Check CXR to make sure there is no Active TB
-if negative, treat as latent TB with 9 months of INH
If there is a hx of BCG vaccine, what do you do along with PPD skin testing?
- Check CXR and IGRA
- if CXR is negative and IGRA positive, treat as latent TB with 9 months of INH
- if they are both negative, there is no active or latent TB, positive PPD was from BCG vaccine and there is NO TREATMENT NEEDED!
