immunologic + shock + etc Flashcards
(313 cards)
1
Q
receptor and reservoir for HIV
A
T4 (CD4) cells
2
Q
HIV modes of transmission x4
A
- blood
- semen
- vaginal secretions
- breast milk
3
Q
HIV sero conversion: defn, s/s, & time frame
A
- conversion HIV - to +
- flu-like sx (early: fever, night sweats, weight loss)
- 3 wk to 6 mo
4
Q
AIDS defn
A
CD4
5
Q
HIV: initial screening tool
A
ELISA (sens > 99.9%)
6
Q
HIV: confirmatory test
A
Western Blot
7
Q
absolute CD4 lymphocyte count: normal
A
> 800 cells/uL
8
Q
high risk of progression to AIDS @ ? CD4 lymphocyte %
A
20%
9
Q
HIV: viral load what + how
A
- correlates closely with progression of HIV (ideally undetectable)
- PCR
10
Q
pneumocystis jirovecii (opportunistic infection) prophylactic tx in HIV+
A
bactrim
11
Q
AART - what + when
A
active antiretroviral therapy
- controversial: some experts = start @ time of dx / CDC rec = all pts on AART by CD4 = 350/uL
12
Q
osteoarthritis is…
A
degenerative joint disease
- slow destruction of articular cartilage
13
Q
OA: damage type
A
articular cartilage destruction
14
Q
rheumatoid arthritis is…
A
systemic autoimmune disease
- inflammation of connective tissue
15
Q
RA: damage type
A
inflammation of connective tissue
16
Q
inflammation OA vs RA
A
OA: asymmetrical
RA: symmetrical
17
Q
OA vs RA gender impacted
A
OA: equal
RA: women 3:1
18
Q
OA: joints involved
A
- weight-bearing (knees/hips) + fingers, hands, wrists
- heberden’s & bouchard’s nodes
19
Q
RA: joints involved
A
proximal interphalangeal joints (PIPs) metacarpophalangeal joints (MCPs) wrists
20
Q
OA: joint sx
A
swelling, edema W/O erythema/heat
21
Q
RA: joint sx
A
swelling, edema, erythema, “heat”
22
Q
heberden’s nodes
A
OA: distal interphalangeal joints (DIPs)
23
Q
bouchard’s nodes
A
OA: proximal interphalangeal joints (DIPs)
24
Q
metacarpophalangeal joints are
A
knuckles
25
OA: pain progression
AM: better - worsens as day progresses
| - aggravated by activity & relieved by rest
26
RA: pain progression
AM: worse - improves as day progresses
27
OA or RA: aggravated by activity / relieved by rest
OA
28
OA or RA: angular deformities of affected joints
OA
29
OA or RA: autoimmune w multifactorial etiology
RA
30
OA or RA: fatigue, weakness, malaise, anorexia, wt loss
RA
31
OA or RA: obesity as exacerbating factor
OA
32
OA or RA: limited ROM
OA
33
OA + RA diagnostics
OA: synovial aspirate normal (clear/yellow)
RA: synovial aspirate = inflammatory changes, WBCs
34
OA: XRay findings x4
- narrowing of joint space
- osteophytes
- juxta-articular sclerosis
- subchondral bone
35
osteophyte is...
bony outgrowth assoc with degeneration of joint cartilage
| - OA
36
juxta-articular sclerosis is...
increased density of bone directly adjacent to joint
| - OA
37
OA or RA: joint swelling
RA
38
OA or RA: joint space narrowing
both!
39
OA or RA: osteophytes
OA
40
OA or RA: osteopenia
RA
41
bone cortex is
outer "shell" of bone
42
OA or RA: progressive cortical thinning
RA
43
OA or RA: involvement of subchondral bone
OA
44
osteopenia is...
decreased bone mass (normal 833 mg/cm^2, osteopenia 833-648)
45
osteopenia vs osteoporosis
- penia: decreased bone mass
- porosis: porous bone; bone tissue normally mineralized but bone density is decreased resulting in impaired structural integrity of trabecular bone
46
OA or RA: juxta-articular sclerosis
OA
47
RA: XRay findings x4
- joint swelling
- progressive cortical thinning
- osteopenia
- joint space narrowing
48
OA: mgmt x4
- ASA
- APAP
- NSAIDs (ibuprofen, naproxen)
- COX-2 inhibitors (celecoxib/Celebrex)
49
RA: mgmt x4
- DMARDS ***
- - corticosteroids, methotrexate, antimalarials (hydrochloroquine), gold salts injections
- high-dose salicylates
- NSAIDs
50
methotrexate: important monitoring consideration
monitor LFTs + CBCs (monthly)
- dose-related hepatotoxicity
- bone marrow suppression
51
OA or RA: methotrexate
RA (DMARD!)
52
OA or RA: celecoxib/Celebrex
OA (COX-2 inhibitor!)
53
OA: supportive care x6
- wt loss
- cane use opposite side
- ice (improves ROM)
- moist heat ( ↓ muscle spasms, relieves stiffness)
- PT
- refer: joint replacement
54
RA: supportive care x4
- early rheumatology referral
- rest
- PT
- surgery
55
OA: typical age range
53 - 64 years (85%)
56
RA: typical age range
35 - 50 years (80%)
57
closed fracture is...
broken/crushed bone evident on x-ray where skin is NOT broken
58
open fracture is...
broken/crushed bone evident on x-ray where skin IS broken + underlying tissue = open to air
59
avulsion is...
fracture; bone fragments pulled off by attached ligaments/tendons
60
dislocation is...
disruption between normal relationships of joint surfaces
| - X-Ray confirms dx
61
subluxation is...
incomplete dislocation
62
what confirms a dislocated bone?
X-Ray
63
fractures & dislocations: tx x4
- ortho consult
- splinting, traction if appropriate
- IV analgesia
- if open fracture: IV abx, sterile dressing, tetanus prophylaxis, surgical debridement
64
open fracture specific tx x4
- IV abx
- sterile dressing
- tetanus prophylaxis
- surgical debridement
65
compartment syndrome is...
↑ interstitial pressure w/in closed fascial compartment
| - r/t: hemorrhage, edema, sustained external pressure on limb, constrictive casts/dressings
66
compartment syndrome causes x4
hemorrhage
edema
sustained external pressure on limb
constrictive casts/dressings
67
? should be suspected in unconscious pt with a swollen limb
compartment syndrome
68
compartment syndrome s/s x6
- severe ischemic pain
- tensely swollen
- skin perfusion & art pulses normal
- paresthesia
- passive muscle stretch painful
- progressive loss sensory & motor fxn
69
exam considerations re: compartment syndrome development
repeat examinations required!
70
compartment syndrome mgmt x2
- release constricting appliances
| - fasciotomy (only effective w/in a few hours)
71
fasciotomy considerations re: compartment syndrome
only effective if performed within a few hours
72
systemic lupus erythematosus (SLE) is...
multi-system, inflammatory autoimmune disorder
| - primarily impacts women of childbearing age
73
SLE primarily impacts who?
women of childbearing age
74
SLE s/s x18
- butterfly rash (
75
periungual erythema is
nailfold (cuticle) redness
76
splinter hemorrhage is
small streaks of bleeding areas under finger/toe nails
77
SLE: labs/diagnostics x3
ANA+ (95%)
anti-phospholipid abx
anemia, leukopenia, thrombocytopenia (often)
78
SLE: mgmt
- mild sx: bedrest, midafternoon nap, avoid fatigue
- sun protection
- topical glucocorticoid (isolated skin lesions)
- NSAIDs, hydroxychloroquine, glucocorticoids, etc
79
top 5 drugs implicated in lupus-like syndrome (per Barkley)
- amiodarone (Cordarone)
- atenolol (Tenormin)
- lovastatin (Mevacor)
- oral contraceptives
- simvastatin (Zocor)
see pg 136 for full list - there are 30
80
definite causative drugs implicated in lupus-like syndrome (per UpToDate)
```
procainamide
hydralazine
penicilliamine
diltiazem
isoniazid
quinidine
minocycline
methyldopa
chlorpromazine
practolol
```
81
giant cell arteritis is...
- aka temporal arteritis
- inflammatory condition
- typically 50+
- can lead to permanent blindness
- 15% of all FUO in 65+
82
giant cell arteritis s/s x7
```
temporal artery: nodular, enlarged/tender
HA, scalp tenderness, jaw claudication
jaw claudication
visual complaints
fever (as high as 104F)
chills/rigors
```
83
giant cell arteritis labs/diagnostics
ESR: very high
WBC: normal
temporal artery bx: + in 85-95%
84
giant cell arteritis mgmt x2
predisone & referral
85
optic disc description x3
donut-shaped
orange/pink neuroretinal rim - surrounds:
central white depression (physiologic cup)
86
neuroretinal rim is...
part of the optic disc of the eye
carries retinal ganglion cells
surrounds physiologic cup (central white depression)
87
cup/disc (optic disc) ratio
cup should not be > 1/2 size of disc diameter
| - larger: consider glaucoma
88
artery:vein ratio in eye
2:3 or 4:5
89
macula (of the retina) is
oval-shaped pigmented area near center of retina
- contains structures involved in high-acuity vision
- ~2 to 2.5 disc diameters temporal side of the optic disc
avascular
90
fovea centralis is...
one of several portions of the retinal macula
- slightly darker
- lies in center of macular region
91
what should you do if patient's macula is difficult to visualize?
ask patient to look directly into light
92
earliest detectable sign of diabetic retinopathy
microaneurysms
| per AAO, also cotton wool spots
93
what can result from rupture of microaneurysms (r/t diabetic retinopathy?)
retinal hemorrhages
- superficial (flame-shaped)
OR
- in deeper retinal layers (blot and dot hemorrhages)
94
cotton wool spots are associated with what common eye problem?
diabetic retinopathy
95
what are cotton wool spots?
infarction of the nerve fiber layer of retina; tends to result from the resolution of fluid deposition in the macula. (PATHOPHYS: microaneurysm = compromised vasculature = fluid seeping = fluid pooling = resolution leaves behind sediment = eventual vascular obstruction = infarction)
96
what are cotton wool spots?
infarction of the nerve fiber layer of retina; tends to result from the resolution of fluid deposition in the macula. (PATHOPHYS: microaneurysm = compromised vasculature = fluid seeping = fluid pooling = resolution leaves behind sediment = eventual vascular obstruction = infarction)
associated with diabetic retinopathy
97
what is AV nicking?
arteriovenous nicking - sign of *chronic hypertension*
- d/t continued htn, arterial walls thicken; at areas where arteries cross over veins, veins are compressed and a tapering of the vein on either side of the artery can be seen)
98
arcus senilis is...
cloudy appearance of cornea + gray/white arc/circle around limbus
- d/t deposition of lipid material (*high cholesterol*)
- no effect on vision
99
most common eye disorder
conjunctivitis
100
conjunctivitis is...
inflammation/infection of conjunctiva d/t allergies, bacteria, viruses, or STIs
- aka pink-eye
101
conjunctivitis s/s x7
```
itching/burning
redness
increased tears
blurred vision
sensation of foreign body
eyelid swelling
eyelid crust (sticky, mucopurulent discharge)
```
102
conjunctivitis mgmt: bacterial
| discharge + tx
discharge: purulent
tx: self-limiting, use abx drops (fluoroquinolones & aminoglycosides)
- levofloxacin, cirprofloxacin, ofloxacin
- tobramycin, gentamycin
103
conjunctivitis mgmt: allergic
| discharge + tx
discharge: stringy, increased tearing
tx: PO antihistamines
104
conjunctivitis mgmt: gonococcal/chlamydial
| discharge + tx
discharge: copiously purulent
tx:
G: ceftriaxone 250mg IM
C:
- erythromycin (ophalmic ointment) or
- PO route: tetracycline, doxycycline, clarithromycin (less used: erythromycin, azithromycin)
105
conjunctivitis mgmt: viral
| discharge + tx
discharge: watery
tx: symptomatic care
106
corneal abrasion is...
trauma to eye resulting in interruption of epithelial surface
107
corneal abrasion s/s x3
- intense pain in affected eye that worsens
- tearing
- redness
108
corneal abrasion labs/diagnostics x2
- recent hx trauma to eye
| - sodium fluorescein stain (detects abrasion)
109
corneal abrasion mgmt x5
- anaesthetize eye for thorough exam (ensure no foreign body)
- topical abx or sulfonamide drops
- pressure patch (24 hours)
- CONTRAINDICATED steroid drops, also anaesthetic drops after initial exam
- if not healed in 24 hours, refer
110
glaucoma is...
- increased IOP
- open-angle: chronic
- closed-angle: acute
111
which type of glaucoma is acute?
closed-angle
112
cataract is...
clouding/opacification of normally clear lens
113
major cause of treatable blindness
cataract
114
most common surgical procedure in 65+
senile cataracts
115
open-angle glaucoma: s/s x4
asymptomatic
elevated IOP
cupping of disc (looks like ice-cream scoop)
constriction of visual fields
116
closed-angle glaucoma: s/s x4
extreme pain
blurred vision
halos around lights
pupil dilated or fixed
117
which type of glaucoma can be asymptomatic?
open-angle (the chronic one)
118
which type of glaucoma typically involves extreme pain?
closed-angle (the acute one)
119
causes of cataracts x7
```
aging, heredity, congenital
trauma
possibly toxins/drugs/tobacco/alcohol
diabetes
AV sunlight exposure
```
120
cataracts: s/s
CLASSIC SX: painless, diplopia in one eye, halos around lights
also: clouded/blurred/dim vision, difficulty with night vision, sensitivity to light/glare, fading/yellowing of colors, need brighter light for reading/activities, no red reflex, lens opacity
121
glaucoma vs cataract: which is painless?
cataracts
| - closed-angle glaucoma is extremely painful
122
patient presentation: diplopia in one eye, halos around lights, no pain
- this is classic for ?
cataracts
123
glaucoma: labs/diagnostics
tonometry: IOP screening
| recommended by age 40
124
tonometry: normal values for IOP
10 - 20
125
cataracts: labs/diagnostics
none!
126
open-angle glaucoma: mgmt x2
- alpha-2 adrenergic agonists (brimonidine, alphagan)
| - beta-adrenergic blockers (timolol)
127
closed-angle glaucoma: mgmt x3
- carbonic anhydrase inhibitors (acetazolamide/Diamox)
- osmotic diuretics (mannitol)
- surgery
128
open or closed-angle glaucoma: surgery may be needed
closed
129
open or closed-angle glaucoma: timolol used
open
130
open or closed-angle glaucoma: acetazolamide (Diamox) used
closed
131
cataracts: mgmt x2
- change glasses as cataracts develop
| - ophthalmology referral for surgery (do promptly)
132
most common musculoskeletal change found in older adults
sarcopenia (decreased muscle ma
133
what is sarcopenia?
decreased muscle mass/strength
| - most common musculoskeletal change found in older adults
134
what changes in lean body mass & fat in older adults?
| x4
loss of lean body mass, which is replaced by fat
fat redistribution
increased adipose tissue %age UNTIL 60, then decreases
135
skeletal changes in older adults?
| x5
```
low bone mass
intervertebral disc degeneration
stature changes w/ kyphosis, height reduction
cartilaginous tissue degeneration
fibrosis (decreased joint elasticity)
```
136
total body water in older adults?
decreases
137
sarcopenia in older adults: findings
increased risk: disability, falls, unstable gait
138
typical musculoskeletal findings in older adults x7
```
sarcopenia
increased body fat %age
height reduction d/t intervertebral disc degeneration
osteoporosis
osteroarthritis
limited ROM
joint instability
```
139
immunosenescence is...
diminished fxn of immune system with age, leads to declined infection response
140
changes in innate immunity in older adults? x3
macrophages, natural killer cells, neutrophils decline
141
changes in adaptive immunity in older adults?
diminished response
142
change in thymic hormone in older adults?
decreased production leading to decreased # fxning T-cells
143
changes in antibodies & antigen response in older adults?
decreased ab production/response
| diminished antigen response
144
typical immune findings in older adults x4
increased infection susceptibility
poor wound healing
exacerbation of chronic disease
waning vaccine-induced antibody reponse
145
What are the modes of transmission of HIV/AIDS?
Blood
Semen
Vaginal secretions
Breast milk
146
What are the early s/s of HIV/AIDS?
Flu-like symptoms - think seroconversion.
Fever
night sweats
weight loss
147
What is the definition of AIDS?
T4 (CD4) count
148
What is the initial screening diagnostic for HIV/AIDS?
ELISA test
149
What is the confirmatory diagnostic for HIV/AIDS?
Western Blot
150
What is the therapy for opportunistic infections in patients with HIV/AIDS?
Bactrim for Pneumocystis jirovecii PNA ppx
151
What is the CDC recommendation for starting HAART combination tx in patients with HIV/AIDS?
When the T4/CD4 count is
152
What is the leading cause of death in AIDS patients?
Pneumocystis jirovecii PNA
153
Explain the pathology of osteoarthritis.
Degenerative joint disease with slow destruction of the articular cartilage
154
What is the characteristic of inflammation in osteoarthritis?
Asymmetrical inflammation with no redness or heat.
Pain is worse as the day goes on and increase with activity
decrease with rest
155
What joints are most affected in osteoarthritis?
Weight-bearing joints (knees/ hips) + fingers/hands/ wrists
156
What are Heberden's nodes and which disease are the associated with?
Distal interphalangeal joints (DIPs) and osteoarthritis
157
Explain Bouchard's Nodes and what disease they are associated with.
Proximal interphalangeal joints (PIPs) and OA
158
What is the diagnostic for osteoarthritis?
Synovial aspirate. Clear + yellow + normal.
159
What do you expect to find on xray in patient with suspected osteoarthritis?
Narrowing of joint space
Osteophytes
Articular sclerosis
Subchondral bone
160
What is the pharmacological management for osteoarthritis?
ASA
Acetaminophen
NSAIDS
COX-2 Inhibitors - celecoxib (Celebrex)
161
What are the supportive care measures for osteoarthritis?
Cane - opposite side
Ice
Moist heat
Joint replacement
162
Explain the pathology of rheumatoid arthritis.
Systemic autoimmune disease
| Inflammation of CONNECTIVE tissue
163
What is the characteristic inflammation of RA?
Symmetrical edema with heat and redness that is worse in the morning
DIPs
Metainterphalangeal joints (MCPs)
Wrists
164
What are the diagnostics of RA?
Synovial aspirate - elevated WBCs
Elevated ESR
ANA positive
165
What are the characteristic xray findings in RA?
Osteopenia
Joint swelling
Cortical thinning
Narrowing of joint space
166
What is the pharmacological management of RA?
High-dose salicylates
NSAIDS
DMARDS
167
What is the most cost-effective medication for RA?
DMARDs - methotrexate
168
When do you administer antibiotics to a patient presenting with a fracture?
OPEN fracture - skin is broken and underlying tissues are open to the air
169
What is the management of an open fracture?
```
IV abx
IV analgesia
Sterile dressing
Tetanus ppx
Surgical debridement
```
170
Define avulsion.
Bone fragments pulled off by attached ligaments and tendons
171
Define subluxation.
Incomplete dislocation. (disruption between normal relationship of joint surfaces)
172
Explain the patho of Compartment Syndrome.
Increased interstitial pressure within a closed FASCIAL compartment.
Hemorrhage; edema; constriction of cast; dressings.
173
What are the main signs and symptoms of compartment syndrome?
Pain disproportional to injury
Tensely swollen
Skin perfusion/arterial pulses = NORMAL
Loss of sensory/motor control
174
Explain the management of compartment syndrome.
Remove restricting appliances (cast, dressing).
| Fasciotomy: Only effective if performed within a few hours.
175
Explain the pathology of systemic lupus erythematosus (SLE).
Multisystem inflammatory autoimmune disorder. F of child bearing age.
176
What are the cardinal signs and symptoms of SLE?
Butterfly rash
Photosensitivity
Flu-like symptoms
177
What is the diagnostic for SLE?
ANA+
178
What is the management for mild SLE?
```
Bed rest
Avoidance of fatigue
Sun protection
Topical glucocorticoids - skin lesions
NSAIDS
Enteral glucocorticoids
```
179
55 yo. M presents to ED with complaints of fever for past 3 weeks; headache; scalp tenderness; and jaw claudication. Most likely diagnosis?
Giant Cell Arteritis
180
What is the pathology of Giant Cell Arteritis?
Inflammation that can lead to permanent blindess related to occlusion of opthalmic artery.
181
Explain the cardinal signs and symptoms of Giant Cell Arteritis.
```
Scalp tenderness
FUO
Headache
Jaw claudication
Temporal artery - enlarged
```
182
What is the confirmatory diagnostic for Giant Cell Arteritis?
Temporal biopsy - positive in 85-95% of cases
183
What is the management of Giant Cell Arteritis?
Prednisone taper for antiinflammatory
184
What is a sign of chronic uncontrolled hypertension?
AV nicking
185
What is the earliest detectable sign of diabetic retinopathy?
Microaneurysms.
186
27 yo. F presents to clinic with complaints of itchy red watery right eye with a thick crust of mucopurulent discharge. She denies any pain. What is most likely diagnosis?
Conjunctivitis. Pink Eye
187
Patient diagnosed with conjunctivitis and has purulent discharge. What etiology is suspected? What is the appropriate treatment?
Bacterial conjunctivitis.
| Antibiotic drops - levofloxacin, ciprofloxacin
188
32 yo. F status post surgery POD 2 now presents with new complaints of red intense progressing painful left eye and leaving contact in since before surgery. What is most likely diagnosis?
Corneal abrasion.
189
What is the management of a corneal abrasion?
Topical abx - sulfonamide eye drops
24 hr. pressure patch on affected eye
Refer if not healed
190
Explain pathology of glaucoma.
Increased intraocular pressure that results in loss of vision due to pressure and damage of ocular nerve
191
Which type of glaucoma is a medical emergency?
Acute closed-angle glaucoma.
192
What is normal intraocular pressure and how is it measured?
10-20 mmHg.
| Tonometry.
193
What are the signs and symptoms of open angle glaucoma?
Chronic onset
Cupping of the eye disc
Constriction of visual fields - center stays clear, outside is blurry.
194
What are the signs and symptoms of closed angle glaucoma?
Extreme pain
Dilated or fixed pupil
Nausea, vomiting
Halos around lights
195
What is the management of open angle glaucoma?
Alpha-2 adrenergic agonists
- Brimonidine
Beta Blockers - Timolol
Miotic agents - PILOCARPINE
196
What is the management of acute closed angle glaucoma?
Carbonic anyhdrase inhibitors - Acetaxolamide (Diamox)
Mannitol
Surgery
197
Explain the pathology of cataracts.
Clouding or opacification of the clear lens of the eye.
198
What are the classic symptoms of cataracts?
Diplopia (double vision) in one eye.
No red reflex
Opacity of the lens
199
Define sarcopenia.
Decreased muscle mass and strength. Normal physiological finding in the older adult.
200
30 yo. F recently diagnosed with SLE and started on Coumadin. Patient fears she will not be able to complain with anticoagulant therapy. What should the ACNP do?
Set up coumadin clinic visits and PCP visits for the patient.
201
If a patient with AIDS has a decreasing CD4 count and an increasing viral load count what does this indicate?
meds are not working
202
What is the most common reason why HIV/AIDS patients are non-compliant?
access to care
203
Top differentials for pain inside the eye
retinal detachment
| corneal abrasion
204
What is the major difference between glaucoma and cataracts?
glaucoma is painful and cataracts are not painful
205
Why do vaccines not work as well in the elderly patient?
decreased antibody production
| decreased response to antigens
206
How do veins present on a fundascopic exam?
veins are bigger than arteries
207
AV nicking is a sign of what
chronic HTN not DM
208
True or False: Abdominal pain is a sign of AIDS.
false
209
When is seroconversion in a patient with HIV?
3 weeks - 6 months
210
Where are Bouchard's nodes found?
PIP proximal
211
How often should a 55 yo. F with Type II DM be screened for glaucoma?
annually
212
MOA of acetazolamide (Diamox) and indication
acute closed-angle glaucoma
| decrease the production of aqueous humor and lower intraocular pressure
213
Bony enlargement in the proximal interphalangeal joints is called
bouchards nodes
214
75 yo. F is suspected of having osteoarthritis of the hip. Which radiographic finding supports this diagnosis?
a. compression fx of femoral head
b. joint space narrowing at the hip
c. subluxation of the vertebral body
d. increased bone density
joint narrowing at the hip
215
What is the earliest sign of compartment syndrome?,pain
The most frequent symptom in women with early HIV infection is:
a. candidal vaginitis
b. dysphagia
c. weight loss
d. anorexia
candidal vaginitis
| metrondiazole (Flagyl) is most effective against,anaerobic bacteria
216
Strep pneumo: 5 major associated diseases
```
meningitis
sinusitis (also common, H flu)
otitis media
bronchitis
CAP
```
217
sinusitis: 2 common causative agents
Strep pneumo
| H flu
218
central venous pressure
measure of the pressure exerted by fluid in RIGHT ATRIUM
indicative of RIGHT HEART FXN
normal: 0 - 6 mmHg
219
CVP: normal
0 - 6 mmHg
220
What hemodynamic measurement is indicative of right-sided heart function?
central venous pressure (CVP)
221
what happens to CVP in cardiogenic shock?
↑
222
what happens to CVP in fluid overload?
↑
223
what happens to CVP in distributive shock?
↓
224
what happens to CVP in severe dehydration?
↓
225
mean arterial pressure: definition and equation
indicates avg driving force in arterial system throughout cardiac cycle
SBP + 2/3DBP
226
pulmonary artery pressure
a measure of systolic and diastolic pressures in the pulmonary artery
normal: 15 - 25 / 5 - 15
227
pulmonary artery pressure: normal
15 - 25 / 5 - 15
228
what happens to pulmonary artery pressure in pulmonary hypertension?
↑
229
what happens to pulmonary artery pressure in fluid overload?
↑
230
what happens to pulmonary artery pressure in untreated diabetes insipidus?
↓
231
pulmonary capillary wedge pressure is also known as these 2 terms
pulmonary artery wedge pressure
| pulmonary artery occlusion pressure
232
pulmonary capillary wedge pressure
measure of the pressure in the LEFT VENTRICLE at END-DIASTOLE (ie, maximal stretch)
indicative of LEFT HEART FXN
also a reflection of tendency to develop PULMONARY EDEMA
normal: 6 - 12 mmHg
233
pulmonary capillary wedge pressure: normal
6 - 12 mmHg
234
what happens to pulmonary capillary wedge pressure in hypervolemia?
↑
235
what happens to pulmonary capillary wedge pressure in left ventricular hypertrophy?
↑
236
what happens to pulmonary capillary wedge pressure in severe dehydration?
↓
237
what hemodynamic measure is important in optimizing cardiac performance and minimizing tendency for pulmonary edema? what should you do with it?
pulmonary capillary wedge pressure
keep it at the lowest point at which cardiac performance is acceptable
238
cardiac output: definition and equation
amount of fluid in L/min that the heart pumps into systemic circulation
SV x HR = CO
normal: 4 - 8 L/min
239
cardiac output: normal
4 - 8 L/min
240
what happens to cardiac output after administration of inotropic agents?
inotropic agent causes ↑ HR, ∴ ↑ CO
| HR x SV = CO
241
what happens to cardiac output in SIADH?
SIADH = body retains water = excess fluid for heart to pump = ↑ SV ∴ ↑ CO
HR x SV = CO
242
what happens to cardiac output in hypovolemia?
↓
243
cardiac index: definition and equation
CO adjusted for body surface area; it is more accurate because it takes BSA into account
normal: 2.5 - 4 L/min
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cardiac index: normal
2.5 - 4 L/min
245
systemic vascular resistance: definition and equation
resistance provided by the systemic circulation AGAINST which the LEFT VENTRICLE must pump blood
( MAP - RAP / CO ) x 80
normal: 800 - 1200 (but remember Joan's tip: 1000)
psst RAP = CVP
246
CVP is essentially a measure of what?
right atrial pressure (RAP)
247
systemic vascular resistance: normal
800 - 1200, but remember Joan's tip: 1000
248
mixed venous O2 saturation
used to assess effectiveness of peripheral O2 delivery (it is measured in the venous blood that returns to the heart)
continuously displayed by pulmonary artery catheter
normal: 60 - 80%
249
what hemodynamic line can display SVO2?
pulmonary artery catheter
250
mixed venous O2 saturation
60 - 80%
251
how do you interpret an SVO2 of less than 60%?
your toes ate more O2 than normal (body tapped into venous reserve of O2)
causes typically ↓ O2 supply + ↑ O2 demand
252
what are 2 causes of SVO2 less than 60%?
↓ O2 supply
| ↑ O2 demand
253
what abnormal value of SVO2 might you expect to see in anemia?
anemia ↓ O2 supply so SVO2 could drop below 60% (toes are eating from a supply that is already low)
254
what abnormal value of SVO2 might you expect to see in malignant hyperthermia?
hyperthermia is essentially a hypermetabolic state with ↑ O2 demand so SVO2 could drop below 60%
255
what abnormal value of SVO2 might you expect to see in administration of FiO2 exceeding the patient's needs?
an SVO2 over 80% - the body has much more O2 than it really needs
256
what abnormal value of SVO2 might you expect to see in hypothermia?
an SVO2 over 80% - the body is in a hypometabolic state and is conserving energy and therefore not using all of the O2 it has available to it
257
how do you interpret an SVO2 of over 80%?
this is a high return of O2 indicating decreased tissue extraction of O2 (your toes didn't eat very much)
- often early indicator of patient status change
- causes often ↑ O2 supply + ↓ O2 demand
258
what abnormal value of SVO2 might you expect to see in septic shock?
an SVO2 over 80% - the body's cells are stressed and cells are having difficulty with O2 uptake;
additionally, O2 delivery is less effective because the body is in shock and less blood volume is circulating
259
what is shock?
clinical syndrome of systemic hypotension, acidemia, and impairment of vital organ function resulting from tissue hypoperfusion
260
why does shock result in organ dysfunction?
tissue hypoperfusion
261
CO/CI in hypovolemic shock?
↓
262
CVP in hypovolemic shock?
↓
263
PCWP in hypovolemic shock?
↓
264
SVR in hypovolemic shock?
↑
265
SVO2 in hypovolemic shock?
↓
266
CO/CI in cardiogenic shock?
↓
267
CVP in cardiogenic shock?
↑
268
PCWP in cardiogenic shock?
↑
269
SVR in cardiogenic shock?
↑
270
SVO2 in cardiogenic shock?
↓
271
CO/CI in septic shock?
↑ then ↓
272
CVP in septic shock?
↓ then ↑
273
PCWP in septic shock?
↓ then ↑
274
SVR in septic shock?
↓
275
SVO2 in septic shock?
↓ then ↑
276
CO/CI in anaphylactic shock?
↓
277
CVP in anaphylactic shock?
↓
278
PCWP in anaphylactic shock?
↓
279
SVR in anaphylactic shock?
↓
280
SVO2 in anaphylactic shock?
↓
281
CO/CI in neurogenic shock?
↓
282
CVP in neurogenic shock?
↓
283
PCWP in neurogenic shock?
↓
284
SVR in neurogenic shock?
↓
285
SVO2 in neurogenic shock?
↓
286
CO/CI in obstructive shock?
↓
287
CVP in obstructive shock?
↑
288
PCWP in obstructive shock?
↓
289
SVR in obstructive shock?
↑
290
SVO2 in obstructive shock?
↓
291
what is the difference between PAP and PAWP?
pulmonary artery pressure is essentially the "blood pressure" in the pulm art
pulmonary artery wedge pressure is a measurement using a swan ganz catheter and the inflation of a balloon in the pulm art to measure the pressure in front of it - a proxy for left ventricular pressure (and therefore function)
292
How soon should you order antibiotics in newly diagnosed septic shock?
Within 1 hour of diagnosis
293
SVR is high for which shocks and low for which shocks?
high for cardiogenic, hypovolemic, and obstructive
low for the distributives (septic, anaphylactic, neurogenic)
294
what is hypovolemic shock?
results from a loss of greater than 20% circulating blood volume
d/t ex: internal/external bleeding, burns, DKA/HHNK, severe dehydration
295
what are 5 potential causes of hypovolemic shock?
internal/external bleeding, burns, DKA/HHNK, severe dehydration
296
hypovolemic shock: mgmt
- fluid resuscitation - MAINSTAY! I mean, duh
| - PRBCs when indicated by hgb/hct
297
what is the mainstay of treatment for hypovolemic shock?
fluid resuscitation duh
298
what is cardiogenic shock?
a loss of effective contractile function resulting in impaired CO, impaired O2 delivery, and reduced tissue perfusion
d/t ex: MI (most common), dysrhythmia, pericardial tamponade, pulmonary edema, acute valvular regurg
299
what are 5 potential causes of cardiogenic shock?
MI (most common), dysrhythmia, pericardial tamponade, pulmonary edema, acute valvular regurg
300
what is the most common cause of cardiogenic shock?
acute MI
301
cardiogenic shock: mgmt
- initial, careful admin of IVF
- vasopressor support
- nitroglycerin IV PRN ischemia
302
what is distributive shock?
3 types - all characterized by vasodilation, decreased intravascular volume, reduced peripheral vascular resistance, and loss of capillary integrity
septic, anaphylactic, neurogenic
303
what is septic shock?
distributive shock caused by infective organisms which invade the bloodstream and alter vascular tone
hypovolemia develops as a result of blood pooling in the microcirculation
304
what is an important diagnostic to order for septic shock in addition to hemodynamic monitoring?
BLOOD CULTURES!!!
305
septic shock: mgmt
- crystalloid fluid resus (mainstay)
- vasopressors
- upon diagnosis of sepsis, abx WITHIN 1 HOUR !!
306
what is the mainstay of treatment for septic shock?
crystalloid fluid resuscitation
307
what is anaphylactic shock?
IgE mediated reaction that occurs shortly after exposure to an allergen
308
anaphylactic shock: mgmt
- maintain airway
- diphenhydramine 25 - 75 mg IV or IM (depends on severity)
- epinephrine 0.3 - 0.5 mg (1:1000 sol) SQ or IM for respiratory distress, stridor, wheezing, etc.
- crystalloid IVF
- IV glucocorticosteroids
- consider H2 antagonist (ranitidine/Zantac)
- inhaled beta agonist for bronchospasm
309
what is the indication for epinephrine in anaphylactic shock management?
respiratory distress, stridor, wheezing, etc
310
what is obstructive shock?
inadequate CO d/t impaired ventricular filling
causes ex: massive PE (most common), tension pneumothorax, cardiac tamponade, obstructive valve disease
311
what are 4 causes of obstructive shock?
massive PE (most common), tension pneumothorax, cardiac tamponade, obstructive valve disease
312
what is the most common cause of obstructive shock?
massive PE
313
obstructive shock: mgmt
- maintain BP while initiating tx of underlying cause
| - fluid admin + vasopressors
