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PGY4 - MISC Flashcards

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1
Q

Post Resus Care

A
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2
Q

Indications for Post-Resus Cooling

A

Adult with ROSC

From VF or VTach Arrest

Hemodynamically Stable

Comatose or not obeying commands

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3
Q

Temperature Goal for ROSC

A

TTM Trial - 36C

Various 32-36

x 24 hours

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4
Q

Post Resus Goal

  • Spo2
  • SBP
  • MAP
A

92-98%

SBP >90

MAP>65

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5
Q

Post Resus Cooling Contraindications

A

“HOLD”

Hemorrhage

OB (Preg)

Ill (Terminally)

DNR or ICU inappropriate

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6
Q

ITP

  • Presentation
  • Labs
  • Tx
A
  • Presentation:
    • Easy Bleeding + Thrombocytopenia
    • Kids:
      • 2-6 yo
      • Prior viral prodrome
      • Self-limited with in few weeks to months
    • Adults :
      • Usually present with platelets < 10,000
  • Txreatment​:
    • Supportive care - usually self resolving
    • Platelet Transfusion Indications:
      • Severe bleeding (platelets < 50,000)
      • Platelet < 20,000
    • RBCs PRN for resuscitation and anemia
    • Corticoteroids
    • IVIG (1 gm/kg): <5,000 platelets and completed steroid course
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7
Q

HIT

Pres

Labs

Treatment

A
  • Presentation
    • Thrombocytopenia + Thrombosis
    • Necrotic skin lesions
  • Labs
    • Platelets either <150 or more than 50% decrease
  • Usually 5-10 days after heparin
  • Treatment;
    • Stop heparin
    • Start alternative
      • Argatroban or Pradaxa
    • Avoid warfarin and platelet transfusion
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8
Q

TTP

  • Presentation
  • Labs
  • Treatment
A
  • Female 10-40yo
  • Classic Pentad
    • Fever
    • Thrombocytopenia
    • Renal Failure
    • Neuro Findings
    • Anemia
      • Hemolytic (schistocytes, frag RBCs)
      • Microangiopathic
  • Management
    • Treat prior to definitive diagnosis
    • Plasmaphoresis
    • Hematology Consult
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9
Q

Platelet Disorders

  • List
  • General Presentation
A

HIT

ITP

TTP

HUS

Epistaxis, menorrhagia, GIB, mucosal petechiae, easy bruising

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10
Q

HUS

Pres

Treatment

A
  • ​​ Presentation
    • Child w E Coli 0157:H7); age 6 mo-4yo
    • Triad
      • Microangiopathic Hemolytic Anemia
      • Renal Insufficiency
      • Thrombocytopenia
  • Treatment:​
    • Supportive care and admit
    • Plasma exchange
    • Abx may worsen
    • Dialysis if renal failure
    • Avoid plts
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11
Q

Coagulation Treatment Disorders

List

Presentation

A

Hemophelia, Coumadin, NOACs, DIC, VWB

Bleed into deep mm/joints, hematuria, intracranial bleed

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12
Q

Causes of Increased PT

A

Coumadin

Liver Failure

Vit K Def

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13
Q

Causes of Increased PTT

A

Heparin

DIC

Hemophilia

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14
Q

Hemophilia A

  • Factor
  • Labs
  • Treatment
A
  • ↓VIII, prolong PTT
  • Tx​:
    • Factor VIII:
      • Mild bleeding - 12.5 units/kg (replace to 50%)
        • Hematuria, early hemarthrosis, laceration
      • Moderate Bleeding - 25 units/kg (replace to 50%)
        • Oral lacerations, dental, late hemarthrosis
      • Severe Bleeding - 50 units/kg (replace to 100%)
        • CCNS, GI, major trauma/surgery
      • Each unit/kg increases plasma factor VIII level by 2%
  • Cryo if no recombinant VIII
  • DDAVP for acute bleeding or prophylaxis (0.3mcg/kg/dose IV)
  • Ice, compression, and splinting
  • Consult Heme
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15
Q

Von Willenbrand Disease

  • Factor
  • Labs
  • Treat
A

Most Common Hereditary Bleeding Disorder

  • Factor:
    • ↓VIII:vwf (
  • Labs
    • ↓VIII)
    • Normal PT/PTT
    • Bleeding time increased
  • Tx​:
    • DDAVP 0.3mcg/kg
    • Humate P- factor VIII conc
  • -Cryo- 10 units/kg
  • -FFP- limited use due to volume overload
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16
Q

Hemophilia B

  • Factor
  • Labs
  • Treatment
A
  • ↓IX,
  • Labs
    • Inc PTT
    • Normal PT
  • Tx:​
    • Recomb IX or IX conc :
      • Minor 25 units/kg
      • Moderate 50 units/kg,
      • Severe 100 units/kg.
      • Increases activity by 1%
    • FFP if no recomb IX
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17
Q

DIC

  • Labs
  • Treatment
A
  • Lab findings:
    • Thrombocytopenia (Most common)
    • Prolonged PT
    • Low fibrinogen
    • Increased Fibrin Split Products
  • Treatment:
    • Treat underlying cause (infx, obstetric pathology, trauma, malignancy, drugs, transfusion) and predominant sx
    • Platelets for Plt <50K AND active bleed
    • FFP for increased PT or low fibrinogen
    • Vit K for long PT
    • LMWH if thrombosis
    • TXA for trauma-related DIC
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18
Q

Supratherapeutic INR Tx

A
  • OPtions
    • Hold Dose
    • Vit K
      • PO or IV for all bleeding
      • Watch for anyphylaxis
    • FFP
    • PCC4
  • INR <5, No bleed
    • Lower or omit dose
  • INR 5-10, No bleed
    • Omit doses
    • +/- Vitamin K
  • INR > 10, No bleed
    • Hold dose
    • Vitamin K at high dose (2.5-5 mg PO)
  • Any INR, Serious Bleed
    • Hold Dose
    • Vit K 10mg IV
  • Life-Threatening Bleed
    • Hold Dose
    • Vit K 10 mg IV
    • FFP or PCCC
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19
Q

Heparin Reversal

A

Protamine Sulfate - 1mg/100u of heparin

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20
Q

NOAC Reversal

A

Idaricuzimab for Pradaza (Dabigatran)

Endexanet alfa for Apixaban (Eliquis) and Rivaroxaban (Xarelto)

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21
Q

Clopidogrel Reversal

A

Platelets

DDAVP

rIIIa

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22
Q

Thyroid Storm Presentation

A
  • Palpitations/afib
  • N/V/D
  • Agitated/Anxious/Psychosis/Delerium
  • AMS
  • Cardiovascular collapse,
  • Goiter
  • Proptosis,
  • Tachycardia
  • Diaphoresis
  • Tremor
  • CNS depression (late)
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23
Q

Hyperthyroidism Treatment

A
  • General
    • Supportive IVF (use D5NS)
    • Cool
    • Treat dysrhythmias
    • Replace lytes PRN
    • Treat fever w/ APAP (no ASA!/NSAIDs)
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24
Q

Thyroid Storm Specific Treatment

A
  • Supportive - Cooling, IVF, etx
  • Treat Cause
    • Infection, Infarction (PE/MI/CVA), Insulin lack (DKA), IUP, Iodine therapy/dye/amiodarone, Injury/surgery
  • Block peripheral effects:
    • Propranolol 1 mg IV q 15 m up to 10 mg-
    • OR Esmolol 500 mcg/kg, then 20-50 mcg/kg/min - used when concerns over B blockers
      • Majority of CHF in storm is high output- will respond to B blockers (fluid down)
  • Inhibit thyroid hormone synthesis:
    • PTU 600-1000 mg PO
    • OR Methimazole 90-120 mg PO
  • Inhibit thyroid hormone release: ​1 hr after PTU
    • SSKI (Potassium iodide) 5 drops PO
    • OR Lugol’s sol (K iodide) 20 drops PO
  • Steroid
    • Decadron 2mg q6h
    • OR Hydrocortisone 300mg load
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25
Unknown Wide Complex Tachycardia Differential
QRS\>120, HR\>100 * Ventricular tachycardia * SVT with aberrancy (BBB, WPW) Paced rhythms * A fib with WPW * Torsade de pointes * Drug overdose * Na channel blockers Hyperkalemia * Post-resuscitation * Artifact
26
Painful Vision Loss DDx
1. Trauma 1. Hyphema 2. Open Globe 3. Iritis 2. Optic Neuritis 3. Acute Closed Angle Glaucoma
27
Painless Vision Loss DDx
* CRAO * CRVO * Temporal Arteritis * Retinal Detachment * Vitreous Hem
28
Optic Neuritis - Pres - Treatment
1. Hx 1. Women \> Men 2. Unilateral 3. Loss of Central Vision 4. Rapid Progression 2. Exam 1. Normal Slit Lamp 3. Tx 1. Solumedrol 2. Ophtho consult
29
Closed Angle Glaucoma - Pres
* Pres * Decreased VA * Redness * Fixed, mid-dilated pupil * IOP \> 40 * Firm Globe
30
Acute Closed Angle Glaucoma Treatment
* Pilocarpine * 1 gtt q15 min until pupil constricts * One drop in C/L eye (ppx) * Timolol * 1 drop q 30 min * Acetazolamide * 500 mg IV/IM/PO * Mannitol * 1 g/kg IV * Stat ophtho consult
31
Central Retinal Artery Occlusion - Presentation - Exam - Tx
* Presentation * Sudden * Monocular * Exam * Afferent pupillary defect * Cherry red spot at fovea * Tx * Ocular massage - 5 sec on, 5 sec off * Decrease IOP * Hyperbaric Oxygen Therapy * Stat Ophtho Consult
32
Afferent Pupillary Defect
Normal pupillary constriction when light shined in unaffected eye No constriction when light shined in affected eye
33
Central Retinal Vein Occlusion - Pres - Exam - Treatment
* Pres * Monocular * Exam * Blood and Thunder Retina * Treatment * Call ophtho
34
Temporal Arteritis - Pres - Tx
* Pres * HA * Age \>50 * Assoc with Polymyalgia Rheumatica * Increased ESR * Tx * Prednisone 1mg/kg PO * NSAIDs * Call ophtho
35
Retinal Detachment - Pres - Tx
* Pres * Flashing lights * Floaters * Cloudy/Curtain-Like vision loss * Look with US * Tx = Call ophtho
36
Vitreous Hemorrhage - Pres - Tx
* Pres * Floaters or webs * Monocular * Exam * Decreased red reflex * Tx * Elevate head of bed * No anti-caog/reverse * Call ophtho
37
Pre-E/Ecclampsia Presentation Labs
* Pres * HA, vision changes, abd pain, edema, pulm edema, * HTN systolic \>140 or diastolic \>90, * hyperreflexia, tachycardia, clonus * Labs: CBC, BUN/Cr, lytes, gluc, Ca/Mg/Phos, LFTs, UA, coags, D-dimer, fibrinogen, uric acid
38
Pre-E/Ecclampsia DDX and Criteria
* Starts at 20 weeks * Pre-E * HTN * \> 140 sys or \>90 dia twice (sep by 4 hrs) * \> 160 sys or \> 110 dia once * Proteinuria * Severe preeclampsia: * ≥ 160 systolic or ≥ 110 diastolic + * End Organ Dysfunction * Thrombocytopenia, renal insufficiency, impaired liver function, pulmonary edema, cerebral or visual disturbances * Ecclampsia * Pre-E + Seizure * HELLP * Hemolysis * Elevated Liver Enzymes * Low Platelets
39
Pre-E/Ecclampsia Tx
* IVF * Decrease BP if \> 160/105 * Hydralazine 5mg IV q20 * Labetalol 0.25 mg/kg double q 10 min (300mg max) * Severe Pre-E * Mg 4-6 gm IV over 30 min (sz ppx) * Ecclampsia * Mg as above * Benzos * Delivery
40
Considerations when giving Mag for Pre-E/Ecclampsia
* Hold for: * Bradycardia * Loss of DTRs * Resp depression * Antidote for Mg toxicity is Ca
41
PE Types
* Non massive: * No signs of clinical instability, hemodynamic compromise or RV strain * Submassive PE: * Acute PE without hypotension but with any of the following: * RV dysfunction or RV dilation on POCUS, * Elevated BNP * Elevated troponin * New ECG changes (RBBB, ST changes, anterolateral T wave inversions) * Massive PE: * Sustained hypotension * Pulselessness * Persistent bradycardia * Signs of shock
42
PE Treatment - Massive
* Massive * Thrombolytics * rt-PA 10mg then 90mg over 2 hours * 50mg bolus for code dose * Must code for 45 minutes * Surgery second line
43
PE Treatment - Submassive
* Thrombolytics remain contreversial * Full Dose vs. Half Dose vs. Cath Directed * Anticoagulation * Heparin 80 u/kg then 18 u/kg/hr * OR Lovenox 1mg/kg SQ
44
PE Treatment - Non-Massive
PO: Xarelto or Elliquis
45
PE Dispo
Calculate PESI Score
46
DVT Treatment
* Lovenox 1 mg/kg SC BID * OR NOACs * Xarelto * Elliquis
47
Cardiogenic Shock DDx
* RV infarct * LV infarct * Acute valvular insufficiency * Wall Rupture * Papillary Rupture * Tamponade * Thoracic Aortic Dissection
48
Cardiogenic Shock Treatment
* Treat underlying causes (bradycardia, tachycardia, ischemic, valve problem, ect) * If suspecting i​nfarct​... * Stat Cards consult for cath/​IABP/ECMO * ASA and Heparin after CXR reviewed. Do not give BB * If no cath lab or contraindications consider thrombolytics * If ​TAD.​ .. stat CT surgery consult * Oxygenation/pulm edema: * Can trial BIPAP but may not tolerate well * Early intubation * Challenging due to hypotension, hypoxia and acidosis. * Maximize pre-intubation hemodynamics (small bolus, push dose pressors, preoxygenation, oxygenation during intubation. * Etomidate may be best choice for induction * If ↓BP / shock...​ * 250-500ml IVF bolus: eval response (need to be cautious). * Especially if dehydrated or RV infarction * BP \>90 * Consider dobutamine or milrinone (if patient on BB) * Dobutamine will need vasopressor (NE) * BP \< 90 * Consider NE. Can add on dobutamine * Optimize electrolytes (especially Ca) * Optimize H/H (higher threshold for transfusion, 10)
49
ANC - Nadir after chemo - How to calculate - Neutropenia definition - Neutropenic Fever Definition
* Nadir Time * 10-14 d s/p chemo * ANC Calc * = WBC X ((PMN/100) +(Bands/100)) * Neutropenia * ANC \< 1500 * \< 500 = Severe * Neutropenic Fever * Temp \> 38.3 single or \>38 x 1 hr * + ANC \< 1500
50
Cancer Patient DDx
* Tumor Lysis Syndrome * PE * Neutropenic Fever * Spinal Cord Compression * Hyperviscosity Syndrome * SVC Syndrome * Pericardial Disease * SIADH * Hypercalcemia
51
Neutropenic Fever - High Risk - Features - Tx
* High Risk Definition: * Shock * ANC \< 500, * ANC levels low for \> 7 days * Other organ dysfunction * MASCC Score \< 20 * Treatment * Empiric * One of: * Zosyn 4.5 gm IV * or Cefepime 2 gm IV * or Ticar/Clv or Imipenem/Cilastin * +/- Vanc 1gm IV * +/- Acyclovir 10 mg/kg IV
52
Neutropenic Fever - Low Risk - Features - Tx
* Low Risk Definition: * No hypotension * No COPD * Age \< 60 * No dehydration * Solid tumor or hematologic malignancy * Minimal symptoms * MASCC \> 21 low risk * Empiric Treatment * Cipro 500mg q8 * + Augmentin 500mg q8 x7. * Talk with Onc - May d/c.
53
SIADH Pres Treatment
HypoNA with Euvolemia Water Restriction
54
Tumor Lysis Syndrome Timing Labs Complications
* Timing * 2-3 d post chemo; * Labs * Increased * K * Phos * Uric Acid * Decreased * Calcium * Complicatons * ARF (from uric acid and calcium phos crystals), * Dysrhythmias * Neuromuscular problems
55
TLS Treatment
1. IVFs 2. Correct electrolytes 3. +/- Dialysis 4. Allopurinol- decrease uric acid production 5. Rasburicase- decrease uric acid levels (conversion to allantoin) 1. C/I in G6PD deficiency
56
Tx of acute spinal cord compression in cx
* Steroids * Decadron 25mg * NS consult * Stat MRI
57
Hypercalcemia Treatment
* Mild (\<12, no sx) * PO fluids * Mild (12-14, no sx) * IVF * Find Cause * Severe (\>14, severe sx) * IVF 200-300 mL/hr * Calcitonin 4 units/kg * Bisphosphonates after hydration * Dialysis * +/- Steroids * If due to calcitriol overproduction * Loop diuretics not recommended * Unless renal or heart failure,
58
Hyperviscosity Snydrome Presentation Tx
* Sludging from ↑ proteins --\> * Fatigue * Neuro * HA, Sz, AMS, * Cardiac * MI, CHF. * Tx: * IVF, * Phlebotomy w/ PRBC replacement.
59
SVC Syndrome Cause Pres Work Up Tx
* Obstruction of blood through SVC due to internal intravascular invasion or external compression. * Lung cancer MCC. * Pres * Neck veins distended * SOB * ↑RR * Facial swelling * Work Up: CT chest w/ IV contrast * Tx: * Solu Medrol 250 mg IV * +/- Lasix 40 mg * If respiratory compromise, * most literature does not support * IV anticoagulation if due to thrombus * Definitive: * Chemo * Possible stent placement
60
CD4 Count = AIDS
\<200
61
Absolute Lymphocyte Count
WBC x Lymph% \<1000 --\> 91% probability CD4 \< 200
62
HIV Encephalopathy
Dx of Exclusion CD4 ~200
63
Cryptococcus Neoformans
* CD4 \<100 * CSF: * Inc opening pressure * Inc mono * +Crypto Ag
64
T. Gondii
Ring enhancing lesions (with contrast)
65
HIV Pulm Infection
* Local --\> Likely bacterial * Diffuse interstitial/granular --\> Likely PCP * Hilar --\> Crypto, histo, mycobac * Upper Lobe with Cavitation --\> TB
66
PCP PNA - Pres - Tx
Pres - Unexplained Hypoxia - Inc LDH Tx - Steroids if PaO2 \< 70, A-a Grad \> 35
67
AIDS Fungal Infec
* Histo - Central/East US * Blasto - Central US * SW - Coccidio
68
AIDS GI Issues
* Candidadal Esophagitis - White plaque, scrapes away * Hairy Leukoplasia - White, corrugated lesions on edge of tongue * Diarrheal Infec * Salmonella - Recurrent bacteremia * C Dif * MAC/Cryptosporidium/Isospora
69
AIDS Skin Issues
* Kaposis Sarcoma * HHV 8 * Pink/Purple papules/nodules
70
Sickle Cell Complications
* Vaso Occlusive Crises * Pain Crisis * Consider cause - cold, trauma, dehydration * Dactylitis - painful swelling hands/feet * Stroke * Consider exchange transfusion * Priaprism * IVF, transfusion, drainage * Acute Chest * #1 Killer * Pulm Sx + New Infiltrate on CXR * Gets ABx * Hematologic Crisis * Splenic Sequestration * Enlarged spleen + decreased Hgb * Aplastic Crisis * Rapid decrease in Hgb and Retic * Causes - Folate def, infec * Transfuse * Infectious Issues * Functionally asplenic by 5 yo * Encapsulated org * S Pneumo, N Mening, Kleb, H Flu, Salmonella, Crypto, Pseudomonas * Osteomyelitis * Staph, Salmonella, E Coli
71
Encapsulated Bacteria
Some Nasty Killers Have Serious Capsule Protection * S Pneumo * Neisseria Menin * Klebsiella * H. Flu * Salmonella * Cryptococcus * Pseudomonas
72
Sick Newborn DDx
THE MISFITS * Trauma (NAT), Tumor, Thermal * Heart/Lung: Bronchiolitis, pertussis, congenital heart * Endocrine: CAH, DM, Thyroid * Met Acidosis * Inborn Errors of Metabolism * Seizures * Feeding Abnormalities * Intestinal Disorders * Sepsis
73
Neonatal Seizure Treatment
* ​If ↓ glucose​... D10 5 ml/kg IV/IO * ​If ↓ calcium​... Ca Gluconate 100 mg/kg (up to 1 gm) IV over 10 min​ * If still seizing. * Phenobarbital 20 mg/kg IV (drug of choice in neonates - intubate!) * and/or Ativan 0.1mg/kg IV (may repeat in 10 min w 1/2 dose) * If still seizing​... pyridoxine 100 mg q 5-15 min (max 500 mg) * If hyponatremic.​ ..4-6m L/kg 3%NacL
74
Neonatal Tx of Intracranial Infection
* Ampicillin 100 mg/kg IV * Cefotaxime 100 mg/kg IV or gentamycin 2.5 mg/kg IV * Acyclovir 10 mg/kg IV
75
Neonatal Shock Treatment
* 20 ml/kg IVF * Pressors * Cold Shock - Dopamine or Epi * Warm Shock - Levo * Shock not improving - Hydrocortisone
76
Neonatal Cardiovascular Distress
* Likely respiratory etiology if... * Better w/ crying * No murmur * Normal EKG * ↑ O2 sat w O2. * Likely cardiac etiology if... * Worse w/ crying * Pos murmur * Abnormal EKG * No change in O2 sat w O2. * Tx for CHF/cyanosis * If hypercyanotic/Tet spell... * Calm child * Knee to chest position * Phenylephrine * Morphine 0.1 mg/kg IV or Ketamine * ± Propranolol 0.01-0.1 mg/kg IV
77
Gray Baby in Resp Arrest at less than 2 weeks
* C/f ductal dependent lesion * Consider PGE1 0.01-0.1 mcg/kg/min IV * Intubate. * Side effects-hypoTN, apnea, hyperpyrexia) * Use Atropine prior to intubation * Pressors * Non-cyanotic = Milrinone * Cyanotic = Levophed * Oxygen for most (except hypoplastic heart)
78
BURN Thickness
* Superficial - Epidermis * Superficial Partial - Dermis (Blisters) * Superficial Deep - White * Full - Underlying structures, no pain
79
Rule of 9s
18% - Front, Back, Legs 9% - Arms, Head 1% - Genitals Peds: Head is also 18%, legs are 14%
80
Parkland Formula
LR 2-4 ml x kg x % BSA (1/2 in First 8h, rest in 16hr)
81
Indication for Fluid Resus in Burns
15% in kids 20% in adults
82
Goal UOP in Burns
30-50cc/hr Kids 1cc/kg/hr
83
Escharotomy Sites
84
Burn Center Criteria:
* \>20% adults, \>10% kids/elderly * \>5% full thickness * Face/eyes/hand/feet/genital/perineum burns * Electrical (incl lightning) * Chemical burns * Inhalation injury * Circumferential Full thickness to chest or extremity * Concern for pt with preexist dz * No hospital capability for child burn
85
Rule of 10s
LR %TBSA x 10 - Initial wt in mL/hr (for 40-80Kg) For every 10kg over 80, increase rate by 100
86
Cyanotic Heart Lesions
5 Ts ## Footnote Tetralogy of Fallot Truncus Arteriosus Transposition of the Great Vessels Tricuspid Atresia TAPVR4-7
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