syncope, PE, AMS Flashcards
medications that can prolong the QT interval
erythromycin, clarithromycin, haloperidol, amiodarone, droperidol, and others
in the evaluation of syncope, ?are the only level A recommendations from the American College of Emergency Physicians (ACEP)
a good thorough history, a physical examination, and ECG
The San Francisco Syncope rule uses five criteria to predict who requires hospitalization
history of CHF, abnormal ECG, hematocrit less than 30, shortness of breath, and/or systolic BP of less than 90 mm Hg at triage
The OESIL score is based upon
abnormal ECG, history of cardiac disease, age less than 65, and syncope without prodrome
The ROSE predictors are:
BNP +300, positive fecal occult blood, hemoglobin less than 9.0, oxygen saturation less than 94%, and Q waves present on ECG
V/Q scans to dx PEs are used in ?
renal failure and pregnant pts (actually Q without the P in preggos)
gold standard of PE dx
CTPA: CT pulmonary angiography
even better: MDCTA (high resolution)
used to be pulmonary angiography, but more invasive and higher M/M
The Prospective Investigation of Pulmonary Embolism Diagnosis II (PIOPED II) study
if low pretest probability of DVT
get US
if normal, DVT r/o
if abnormal, tx DVT
if medium pretest probability of DVT
get US
if abnormal, tx DVT
if normal, get D dimer
if D dimer is negative, DVT r/o
if D dimer positive, tx DVT
if no D dimer available, US in 1 week
if high pretest probability of DVT
get US if abnormal, tx DVT if normal, get venography if abnormal, tx DVT if normal, DVT r/o
“gold standard” for DVT dx
Venography
However, due to its invasiveness, risk of reaction to contrast dye, and the advent of newer technologies that are just as accurate, venography is rarely used in clinical practice
All patients diagnosed with a DVT where? should be treated with anticoagulation
which anticoagulants for DVT/PE?
at or above the popliteal level
UFH
LMWH: enoxaparin (Lovenox), dalteparin, fondaparinux
long term: warfarin
PE s/s
sudden onset cough (3%-55%) blood-streaked sputum (3%-40%) sudden onset of dyspnea at rest or with exertion (75%) splinting of ribs with breathing chest pain (50%-85%) diaphoresis (25%-40%) Nonspecific signs of PE include *tachypnea (50%-60%) tachycardia (25%-70%) rales/crackles (50%) low-grade fever (7%-50%)
Unusual clinical presentations of PE
seizure, syncope, abdominal pain, high fever, productive cough, adult-onset asthma, new-onset supraventricular arrhythmias, or hiccups
Wells Criteria for pretest probability of PE
Suspected DVT- 3
An alternate diagnosis is less likely than PE- 3
HR +100 bpm- 1.5
Immobilization or surgery in the previous 4 weeks- 1.5
Previous DVT/PE- 1.5
Hemoptysis- 1
Malignancy (being treated currently or in the last 6 months)- 1
Scoring of Wells Criteria
0-2: 4% LOW
3-6: 21% MODERATE
6+: 67% HIGH RISK
PERC Rule Criteria
if 8 present, very low likely PE (used if low PTP)
Age less than 50 years Pulse less than 100 bpm SaO2 +94% No unilateral leg swelling No hemoptysis No recent trauma or surgery No prior PE or DVT No hormone use
initial CXR in PE
abnormal in 76% to 90% of patients no diagnostic findings, few rare classic signs: Westermark sign (peripheral lung vasoconstriction) and Hampton hump (pleural wedge-shaped density associated with pulmonary infarction)
CXR progression in PE
suggestive of atelectasis, pleural effusion, and elevated hemidiaphragm. After 2 to 3 days, the CXR in one-third of patients with PE demonstrates focal infiltrates mimicking pneumonia
but VARIABLE, so limited use
4 groups of V/Q scan
normal, low probability, indeterminant, and high probability
ABGs are commonly done in suspected PE but limited how?
normal PaO2, normal PCO2, and normal A-a oxygen gradient does not exclude the diagnosis of PE
Thrombolytic therapy in PE?
advocated for those individuals with a massive PE, such as those with hypotension for whom mortality is as high as 20% to 30%.
There are no conclusive studies that prove a survival advantage for thrombolytic therapy in PE
80% of PEs develop from DVTs involving what veins?
the iliac, femoral, or popliteal veins
Healthy patients without any use of antimicrobials in the past 3 months with presumed CAP are best treated with ?
a macrolide (azithromycin)
pneumonia pts with comorbid diseases or recent antimicrobial use should receive ?
a respiratory fluoroquinolone (levofloxacin) or a β-lactam (cefpodoxime) plus a macrolide as a reasonable alternative
abx for pneumonia pts admitted to the ICU
β-lactam (ceftazidime) plus either azithromycin or a fluoroquinolone
Patients with concern for HAP or HCAP who are at a risk for multidrug-resistant pathogens should receive a 3-drug combination therapy:
(1) antipseudomonal cephalosporin (cefepime, ceftazidime), antipseudomonal carbapenem (imipenem or meropenem), or pip-tazo (zosyn); (2) antipseudomonal FQ(ciprofloxacin or levofloxacin); and (3) anti-MRSA coverage (linezolid or vancomycin)
HCAP/HAP pts without risk factors for multi-drug-resistant (MDR) organisms may be treated with a single agent:
ceftriaxone, ampicillin/sulbactam (unasyn), ciprofloxacin, moxifloxacin, levofloxacin, or ertapenem
ddx AMS in elderly
underlying infection (eg, sepsis, meningitis, UTI), electrolyte and metabolic abnormalities (eg, hypo- or hyperglycemia, hyponatremia), delirium, and hypoxia
What is physiologically responsible for our level of arousal?
The reticular activating system (RAS)
Signals from the RAS run through the pons in the brainstem, through the thalami, then project to both cerebral hemispheres
AEIOU TIPS for treatable causes of AMS
http://casefiles.mhmedical.com/ViewLarge.aspx?figid=141654008&gbosContainerID=70&gbosid=218369
GCS
EYES (4)
WORDS (5)
MUSCLE (6)
EYES: spontaneous verbal painful no response WORDS: oriented disoriented inappropriate words incomprehensible sounds no response MUSCLE: obeys commands localizes to pain withdraws to pain abnormal flexion abnormal extension no response
AMS causes
infectious (meningitis, UTI, pna)
metabolic (hypoglycemia, hypo/hypernatremia, hypo/hypercalcemia)
consider meningitis if any combo of these 4 symptoms
fever, AMS, headache, nuchal rigidity
The classic triad of fever, neck stiffness, and a change in mental status is present in less than 50% of patients with bacterial meningitis
other symptoms to consider in meningitis
others: seizures (S. pneumo), focal neurologic deficits (Listeria), rash (meningococcal), septic arthritis (meningococcal), papilledema and photophobia
Who does not require neuroimaging prior to LP?
Younger patients that are otherwise healthy if they have a normal neurologic examination including mental status
Initial meningitis antimicrobial therapy in adults
third-generation cephalosporin (Ceftriaxone or cefotaxime 2g) and vancomycin to cover drug-resistant S pneumoniae
Who should have should have ampicillin added to the empiric antimicrobial therapy to cover L monocytogenes
Patients older than 50 years, alcoholics, and immunocompromised patients
(at higher risk for additional organisms including Listeria, H.flu, and aerobic gram-negative bacilli)
steroids in meningitis?
Dexamethasone 0.15mg/kg IV every 6h) prior to or with the 1st dose of abx has been shown to decrease neurologic sequelae as well as M/M
meningitis leads to significant M/M as a result of the inflammatory response in the CSF
This response can be heightened when antimicrobials are administered, which will lead to bacterial lysis and release of additional inflammatory mediators
timeline in meningitis diagnosis/treatment
When it is expected that there will be a significant delay in obtaining the LP (i.e. to get CT), it is recommended to obtain blood cultures and then initiate treatment with antibiotics with or without dexamethasone, prior to obtaining the CSF
when to get CT prior to LP
altered consciousness, AMS, focal neuro deficit, immunocompromised, hx of CNS disease, new-onset seizure, papilledema, hx/evidence of head trauma
also to identify those patients that may be at risk of brain herniation during the LP
CSF values indicative of bacterial meningitis
elevated protein +220 mg/dL indicative of bacterial/fungal (normal: 14-45 mg/dL)
low glucose less than 40 mg/dL(normal 50-80 mg/dL) or CSF/serum glucose less than 0.4
elevated CSF lactate (normal less than 35 mg/dL)
cryptococcal meningitis diagnosis
India ink only positive 33% of the time
Cryptococcal Ag has 90% accuracy
opening pressure will be elevated (normal is less than 200 mm H20)
meningitis in kid younger than 1 month, consider what organisms? how to treat?
Streptococcus agalactiae, Escherichia coli, Listeria monocytogenes, Klebsiella species
Ampicillin plus cefotaxime OR ampicillin plus an aminoglycoside
what meningitis organisms to consider in 1-23 month olds? how to tx
Streptococcus pneumoniae, Neisseria meningitidis, S agalactiae, Haemophilus influenzae, E coli
Vancomycin plus a third-generation cephalosporin
what meningitis organisms to consider in 2-50 yo?
how to tx?
N meningitidis, S pneumoniae
Vancomycin plus a third-generation cephalosporin
what meningitis organisms to consider in +50 yo?
how to tx?
S pneumoniae, N meningitidis, L monocytogenes, aerobic gram-negative bacilli
Vancomycin plus a third-generation cephalosporina plus ampicillin
meningitis ppx for close contacts?
rifampin or FQ for close contacts of pt with Neisseria meningitides
not recommended for Hib meningitis contacts due to vaccination
vaccination against N meningitidis is recommended for who?
freshmen college students who live in dormitories, as they are at moderately increased risk of contracting this disease
