Internal Med - Critical Care

Question 1

Hyperthyroid state + acute event

Answer 1

Thyroid storm

Question 2

Sx of thyroid storm

Answer 2

Heat intolerance, palpitations, weight loss tachycardia, anxiety, jaundice

Jaundice = hepatic tissue hypoxia due to increased peripheral consumption of oxygen

Clinical → tachycardia HR >140, heart failure, hypotension, dysrhythmia (afib), hyperpyrexia (104F-106F), agitation, psychosis, coma; hyperreflexia, goiter, exophthalmos, pretibial edema

Question 3

Dx and tx of thyroid storm

Answer 3

Dx = free t4/t3, TSH → low TSH and high free T4

Tx =beta-blocker, thionamides, iodine, hydrocortisone, bile acid sequestrants

• Propylthiouracil – inhibits the conversion of thyroxine to triiodothyronine
• Methimazole or PTU (PTU if pregnant)

Question 4

A single epileptic seizure lasting more than five minutes or two or more seizures within a five-minute period without the person returning to normal between them

Answer 4

Status Epilepticus

Question 5

Tx of status epilepticus

Answer 5

• Place in left lateral decubitus position (suppressed gag reflex ⇒ prone to aspiration of gastric contents)
• Benzodiazepines (lorazepam) are the preferred initial treatment after which typically phenytoin is given

Question 6

Difference in primary vs secondary pneumothorax

Answer 6

Can be spontaneous or traumatic

• Primary: occurs in absence of underlying disease (tall, thin males age 10-30 at greatest risk)
• Secondary: in presence of underlying disease (COPD, asthma, cystic fibrosis, interstitial lung disease)

Question 7

Tx of pneumothorax

Answer 7

*Depends on size

<15% diameter → Resolves spontaneously without chest tube

Large >15% → Chest tube placement

*Serial CXR every 24hrs until resolved

Question 8

Tension pneumo = Emergency, what is the tx

Answer 8

Large bore needles to allow air out of the chest; chest tube for decompression

Question 9

Excess fluid between the heart and pericardium

Answer 9

Pericardial Effusion

Question 10

How does a pericardial effusion happen?

Answer 10

• Abnormal accumulation of inflammatory fluid, immune cells → diffuse into interstitium → fluid pools in pericardial space → pericardial dilation → pressure on heart, vena cava → decreased cardiac filling → cardiac tamponade → decreased cardiac output

Question 11

Common causes of pericardial effusion

Answer 11

Aortic dissection, heart failure, hypoalbuminemia, lymphatic obstruction, malignancy, radiation, renal failure, trauma, autoimmune disease, acute pericarditis (viral, bacterial, tuberculous, idiopathic in origin), myxedema, some drugs, iatrogenic, idiopathic

Question 12

Sx of pericardial effusion

Answer 12

Same symptoms as acute pericarditis except patient will now have signs of fluid buildup around the heart which include low voltage QRS complexes, electrical alternans, distant heart sounds and an echocardiogram showing a collection of pericardial fluid

Question 13

Dx findings of Pericardial effusion

Answer 13

• EKG showing low voltage QRS along with electrical alternans
• Echocardiogram with increased pericardial fluid
• Radiograph: Water bottle heart

Question 14

Absolute contraindictions for fibrinolytic use in STEMI

Answer 14

• Prior intracranial hemorrhage (ICH)
• Known structural cerebral vascular lesion.
• Known malignant intracranial neoplasm.
• Ischemic stroke within 3 months.
• Suspected aortic dissection.
  
  • Active bleeding or bleeding diathesis (excluding menses)

Question 15

Tx of STEMI

Answer 15

Beta Blockers + NTG + aspirin and clopidogrel + heparin + ACEI + statins + reperfusion

• Aspirin and Clopidogrel are given at once
• Very time sensitive - Immediate (within 90 minutes) coronary angiography and primary PCI
• Thrombolytic therapy within the first 3 hours if PCI not available

Question 16

Dx labs associated with DKA

Answer 16

Lab values seen in DKA include blood sugars above 250 mg/dL and anion gap metabolic acidosis with pH below 7.3 and bicarbonate below 18.

• Patients will also show present plasma ketones
• Due to an extracellular shift, patients may be hyperkalemic

Question 17

3 D’s in Cardiac tamponade

Answer 17

The 3 D’s: D istant heart sounds, D istended jugular veins, and D ecreased arterial pressure = Beck’s triad

Question 18

What is Beck’s triad

Answer 18

1. Hypotension
2. muffled heart sound
3. elevated neck veins (JVD)

Question 19

What are the heart signs associated with cardiac failure?

Answer 19

• S4 = diastolic HF (ejection fraction is usually normal)
• S3 = Systolic HF (reduced EF) with volume overload - tachycardia, tachypnea. (Rapid ventricular filling during early diastole is the mechanism responsible for the S3)

Question 20

Where would you see a left vs right bundle branch block?

Answer 20

Bundle branch block

• Left: R and R’ (upward bunny ears) in V4-V6
• Right: R and R’ (upward bunny ears) in V1-V3

Question 21

What type of rhythm causes 75% of cardiac arrest?

Answer 21

V-tach or V-fib causes 75% of episodes of cardiac arrest

Question 22

What are the main RF in Prinzmetals angina?

Answer 22

• Look for a history of smoking (#1 risk factor) or cocaine abuse
• EKG may show inverted U waves, ST-segment or T-wave abnormalities
• Preservation of exercise capacity

Question 23

Increased IOP with optic nerve damage; an impediment to the flow of aqueous humor through trabecular meshwork; canal of Schlemm’s with increasing pressure in the anterior chamber

Answer 23

Acute angle glaucoma

• Open-angle = more common ⇒ > 40 yo, African Americans + family history

⇒ Acute angle-closure glaucoma ⇒ ophthalmic emergency - complete closure of the angle

Question 24

Sx of acute angle glaucoma

Answer 24

• Classic triad: injected conjunctiva, steamy cornea, and fixed dilated pupil
  
  • Painful eye/loss of vision, tearing, nausea, vomiting, diaphoresis
• IOP acutely elevated

Question 25

Tx of acute angle glaucoma

Answer 25

TX: **Immediately refer to ophthalmology** – start **IV carbonic anhydrase inhibitor (acetazolamide)**, topical b-blocker (timolol), osmotic diuresis; laser/surgical iridotomy * Mydriatics (to dilate pupils) should NOT BE ADMINISTERED!