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Flashcards in ER/ICU/Critical Care Deck (101):
1

antidote for arsenic

dimercaprol, succimer, or penicillamine

2

antidote for methanol, ethylene glycol (antifreeze)

fomepizole, ethanol

3

vasopressors

phenylephrine
NE
EPI
Dobutamine
Dopamine
Isoproterenol

4

Phenylephrine

alpha 1 agonist
use in septic shock

5

Epinephrine

A1, A2, B1, B2 agonist that vasoconstricts at high doses
use:anaphylaxis, septic shock

6

dopamine

b1 agonist at low doses, a1 agonist at high doses
use: cardiogenic shock, not renal -protective

7

dobutamine

beta-1 agonist
use in cardiogenic shock

8

isoproterenol

beta 1 agonist, beta 2 agonist
use in cardiac arrest

9

Packed RBCs

RBCs that have been separated from other blood components

this is suitable for a patient who has lost a lot of blood (trauma, surgery, etc)

10

vasopressin

ADH analog with weak pressor effect
uses: resistant septic shock

ACLS: VF, PEA

11

Platelets

active bleeding due to thrombocytopenia

12

Fresh frozen plasma

plasma from which cellular components have been removed

Use in warfarin overdose, clotting factor deficiency, DIC, TTP

13

Cryoprecipitate

precipitate rich in clotting factors and von Willebrand factor, collected while FFP is thawing

smaller volume than FFP

14

Specific clotting factors

pooled from multiple donors

15

Albumin

given after large- volume paracentesis (>5L of ascites from abd)
to prevent hypotension and maximize colloid pressure

given in cases of hypoalbuminemia

16

Transfusion reactions

nonhemolytic febrile reaction caused by cytokines generated by cells in the blood while in the blood is in storage

onset 1-6 hours after transfusion
fever, chills, malaise
no hemolysis

treat with acetaminophen

17

acute hemolytic reaction

1/250,000 transfusions
Due to ABO incompatibility
main reason is clerical error

onset during transfusion
antibody- mediated hemolysis
fever, chills, nausea, flushing, tachycardia, tachypnea, hypotension

18

AB+

universal recipients

19

O-

universal donors, but can only receive blood from other O-

20

delayed hemolytic reaction

caused by antibodies to Kidd of Rh (D) antigens
Occurs 2-10 days after transfusion
slight fever, less- severe hemolysis, mild increase in unconjugated bilirubin

21

anaphylactic reaction

1/150,000 transfusions
shock
hypotension
angioedema
respiratory distress

maybe 2/2 anti IgA IgG as that IgA- deficient patients have but maybe don't know about

Treatment iV fluids, airway maintenance

for these patients, provide extra-washed RBCs when possible

22

Minor allergic reactions

caused by plasma present in donor blood, leads to urticaria
treat with diphenhydramine

23

Post- transfusion purpura

thrombocytopenia developing 5-10 days after transfusion, primarily in women who are sensitized by pregnancy

24

how to treat severe anemia due to autoimmune hemolytic anemia

pRBC

25

treat hemophilia

give specific clotting factor (8 or 9)

26

treat DIC

FFP, platelets

27

treat shock due to trauma or postpartum hemorrhage

pRBCs, IV fluids

28

to maintain blood pressure during large volume paracentesis

albumin

29

for hemorrhage due to warfarin overdose

FFP

30

need for vWF-rich blood product

cryoprecipitate

31

give for thrombocytopenia

platelets

32

high doses optimize the alpha-1 vasoconstriction

epinephrine

33

ADH analog

vasopressin

34

best choice for anaphylactic shock

epinephrine

35

best choice for septic shock

NE

36

best choice for cardiogenic shock

dobutamine

37

causes vasoconstriction but with bradycardia

phenylephrine

38

What physiologic pressure does PCWP approximate

LAP

39

What are the preferred vessels to target in the placement of a Swan- Ganz catheter

R. IJ
L. subclavian

40

what 2 cardiovascular diseases are the biggest risk factors for CHF

hypertension and ischemic heart disease

41

Polyarteritis nodosa

necrotizing inflammation of small or medium arteries, leading to ischemia of the affected tissue

PAN can affect any tissue, but it often affects the kidneys, heart, GI tract, muscles, nerves, and joints


SPARES THE LUNGS

Risk factors: Hepatitis B, hepatitis C

Labs: increased WBC, increase ESR

proteinuria, hematuria if there is kidney disease

negative for ANCA

Renal angiography may show aneurysms

42

Temporal (giant cell) arteritis

subacute granulomatous inflammation of external carotid and vertebral arteries

granulomas where macrophages cluster around

more common in older women
associated with polymyalgia rheumatica

unilateral or bilateral headache,
scalp pain, temple tenderness, jaw claudication, and transient or permanent blindness in one eye

Labs: ESR, if elevated get a temporal artery biopsy
multinucleated biopsy

Start treatment- prednisone, continue until biopsy results are available,
If positive, keep going on high-dose prednisone, then taper off

Aspirin
calcium, vitamin D to prevent osteoporosis 2/2 steroids (this goes for anyone on steroids for more than 3 months)

43

Takayasu arteritis

arteritis in one of the 3 main branches of the aorta

inflammation of the arch of the aorta
Cerebrovascular ischemia
Myocardial ischemia


Asian heritage, women ages 10-40 (young)

Can cause vertigo, syncope, fever, decreased pulses in the limbs ("pulseless disease:)

If you find poor pulses in the upper extremities think about takayasu arteritis

CTA to look for stenosis and defects in vascular walls

Treat with steroids, immunosuppressive agents,
or surgically bypass obstructed

44

Eosinophilic granulomatosis with polyangiitis (Churg- Strauss)

inflammation of small and medium arteries

associated with asthma, nasal polyps, sinusoidal obstruction

H and P: fatigue, malaise, mono or polyneuropathy, tender skin nodules, palpable purpura, papular rash

labs: eosinophilia, p-ANCA

45

Eosinophilia DDx (CANADA-P)

Collagen vascular disease (PAN, dermatomyositis)

Atopic diseases (allergies, asthma, Churg-Strauss, allergic bronchopulmonary aspergillosis)

Neoplasm

Adrenal insufficiency (Addison disease)

Drugs (NSAIDs, penicillins, cephalosporins)

Acute interstitial nephritis

Parasites (strongyloides, ascaris > Loffler eosinophilic pneumonitis)

Other causes: HIV, hyper-IgE syndrome, coccidiomycosis, etc).

Tx: steroids and immunosuppressive agents

46

Henoch- Schonlein Purpura

IgA immune complex- mediated vasculitis, affecting arterioles, venules, and capillaries

CHildren> adults

recent URI
LE palpable purpura
arthritis
arthralgias
abdominal pain
renal disease from IgA deposition in the kidney

often self- limited but we can use steroids in patients who have GI symptoms

47

Granulomatosis with polyangiitis (Wegener's)

focal necrotizing vasculitis
granulomas in the lung and upper airway
glomerulonephritis

c-ANCA positive

48

Thromboangiitis obliterans (Buerger disease)

vasculitis of small and medium- sized peripheral arteries and veins

affects young male smokers (30s-40s)

Clinical presentation:
intermittent claudication
superficial nodular phlebitis
Raynaud phenomenon
Gangrene, auto-amputation of the digits

Treatment: stop smoking and it will go away

49

Kawasaki disease

necrotizing vasculitis
infants and young children
Asian descent

diagnostic criteria (mucocutaneous lymph node syndrome)"
Fever (>40 C or 104F), lasting at least five days in addition to 4 of the following 5 symptoms (CRASH)

Conjunctivitis (bilateral, non-exudative, painless)
Rash on the trunk
Adenopathy of the cervical lymph nodes
Strawberry tongue and diffuse erythema of mucous membranes
Hands and feet have edema with induration, erythema, or desquamation

Coronary artery aneurysms can occur within weeks of the illness but are not included in the diagnostic criteria (these can rupture and extend within the aneurysm leading to MI). Since they don't show up for weeks, you don't need to them to make the diagnosis

Treatment: IVIG (ideally within the first 10 days of illness)

High- dose aspirin, continued until 49 hours after fever resolution, followed by low- dose aspirin until inflammatory markers (platelets, ESR) return to normal (usually 6 weeks)

Steroids are not indicated and are of no proven benefit

Echocardiogram in the acute phase and 6-8 weeks later

50

20 year-old Asian female

Takayasu arteritis

51

2 year-old Asian female

Kawasaki disease

52

Associated with asthma

Eosinophilic granulomatosis with polyangiitis

53

young male smoker

Thromboangiitis obliterans

54

associated with PMR

Temporal arteritis

55

Associated with IgA nephropathy

Henoch Schonlein purpura

56

Associated with hepatitis B

polyarteritis nodosa

57

elderly woman with jaw claudication and vision loss

temporal arteritis

58

strawberry tongue

Kawasaki disease

59

desquamation on hands/feet

Kawasaki disease

60

Poor pulses in the arms

Takayasu

61

Palpable purpura on the legs

HSP

62

vasculitis of the kidney and GI tract, spares the lungs

PAN

63

Vasculitis of the kidney, upper airway, and lungs

GPA

64

necrotizing immune complex inflammation of visceral and renal vessels

PAN

65

infants and young children: involves coronary arteries

Kawasaki disease

66

most common vasculitis

temporal arteritis

67

Cushing's triad and other signs of increased intracranial pressure

hypertension
bradycardia
bradypnea


papilledema
altered mental status
pupil asymmetry

68

classic findings in a basilar skull fracture

bruising around the eyes (raccon eyes)
bruising over the mastoid process (Battle sign)

Blood behind the tympanic membrane

CSF rhinorrhea or otorrhea

69

Next step: possible fracture and +DPL

emergent laparotomy

70

pelvis fracture + DPL shows urine in the pelvis

urgent, non-emergent laparotomy

71

pelvis fracture + nothing on DPL + pelvic instability

angiography with possible embolization (you suspect a retroperitoneal hemorrhage)

72

Blunt abdominal trauma + unstable vital signs + FAST positive

exploratory laparotomy, emergent

73

blunt abdominal trauma + unstable vital signs + FAST shows no fluid in pelvis

angiography with possible embolization

74

blunt abdominal trauma +unstable vital signs + FAST inconclusive

DPL

75

Blunt abdominal trauma + stable vital signs

CT abd/pelvis

76

abdominal stab wound + hypotensive or signs of peritonitis

emergent laparotomy

77

Antibiotic prophylaxis for a rape victim:
Gonorrhea
Chlamydia
Trichomoniasis
HepB if not yet vaccinated or if perpetrator is known carrier
HIV
Pregnancy

Ceftriaxone 125 mg IM (gonorrhea)

Azithromycin 1g PO or doxycycline 100mg PO BID for 7 days (chlamydia)

Metronidazole 2g PO (trichomoniasis)

Hepatitis B !1 of 3 if not yet vaccinated +/- hepatitis B immune globulin (not standard of care)

HIV prophylaxis for 3-7 days with follow-up for further counseling

Other prophylaxis:
Antiemetic (promethazine) for nausea caused by HIV meds and pregnancy prophylaxis

Levanorgestrel (Plan B) 0.75 mg PO- repeat dose in 12 hours (alternatively, both doses can be taken at once for improved compliance). Other options exist

78

How do we evaluate for extremity trauma?

sensory, motor, vascular exam in addition to `imaging

79

What antidepressants are associated with hypertensive crisis?

MAOIs, exacerbated by tyramine

80

When is post-op MI most likely

within the first 48 hours after surgery
Telemetry in the postop period helps check for this

81

What are signs of hepatic disease in a pre-operative workup

increased PT/PTT
low platelets
increased bilirubin
decreased albumin

82

what interventions help optimize lung function in a patient with pre-existing pulmonary disease

incentive spirometry
pain control
deep breathing
physical therapy
bronchodilators
inhaled steroids

83

What do you order in your evaluation of post-op fever?

CXR
urinalysis with urine culture
blood culture
sputum culture
examine surgical wound
wound culture

84

What are 2 indicators of how severe hypotension is in a shock patient?

urine output
mental status

85

Hyperacute transplant rejection

Seen within initial 24 hours after transplantation
Cause: anti-donor antibodies in recipient
Treatment: untreatable, avoided by proper crossmatching

86

Acute rejection

seen 6 days to 1 year later
Cause- anti-donor T-cell proliferation in recipient
Treatment: immunosuppressive agents (reversible)

87

chronic rejection

seen >1 year after transplant
Treatment- untreatable, but immunosuppressants can delay onset

88

which cytokine is most important for T cell differentiation

IL2

89

Adverse effects of cyclosporine

nephrotoxic, mannitol can help prevent nephrotoxicity

90

Azathioprine adverse effects

bone marrow suppression, leukopenia

metabolized by xanthine oxidase (don't combine with allopurinol)

91

Tacrolimus adverse effects

nephrotoxicity

92

corticosteroids adverse effects

Cushingoid features
osteoporosis
diabetes

93

Muromonab side effects

leukopenia

94

Rapamycin side effects

thrombocytopenia, hyperlipidemia

95

Mycophenolate adverse effects

This drug is often used to treat lupus

leukopenia
lymphoma
teratogenic

96

Anti-thymocyte glubulin side effecs

depletes T cells

97

Hydroxychloroquine adverse effects

lupus, transplant, RA

visual disturbances

98

Thalidomide adverse effects

phocomelia

99

Graft versus host disease

grafted bone marrow is now attacking the patient's entire body

H&P: maculopapular rash, abdominal pain, n/v, diarrhea, recurrent bleeding, easy bleeding

Labs: elevated LFT, decreased immunoglobulin levels, decreased platelets

Biopsy of the skin and liver will detect inflammatory reaction with significant cell death

Treatment: steroids, tacrolimus, mycophenolate

100

AXR findings consistent with ruptured viscus

free aid under the diaphragm

101

Labs to get in a patient presenting with generalized abdominal pain

CBC with differential, basic metabolic profile, LFTs, beta hCG, stool guaiac, amylase and lipase, EKG and cardiac enzymes if >45yo especially if women, diabetics, elderly