Internal Medicine CRITICAL CARE Flashcards
CRITICAL CARE (139 cards)
0
Q
What is the secondary cause of adrenal insufficiency?
A
Decrease release of the pituitary ACTH
1
Q
What is the main cause of adrenal insufficiency?
A
Due to autoimmune adrenal cortical destruction (Addison’s Disease)
2
Q
Study Diagram
A
.
3
Q
How does a pt present with adrenal insufficiency?
A
Weak, Fatigue, weight loss
4
Q
What does a diagnostic test show for adrenal insufficiency?
A
Decrease cortisol, Decrease sodium, Increase Potassium, Eosinophilia
5
Q
What is the tx for adrenal insufficiency?
A
Glucocorticoid
6
Q
Hyperthyroidism is also known as
A
Thyroid Storm
7
Q
What is the etiology of of hyperthyroidism?
A
Grave’s disease, Toxic adenoma, thyroiditis
8
Q
What is the history of hyperthyroidism?
A
Weight loss, heat intolerance, anxiety, Increase bowel movement, palpitations, tachycardia or atrial fibrillation, tremor, lid lag, Exophthalmos, agitation or psychosis, confusion, and GI symptoms (e.g., nausea, vomiting, diarrhea).
9
Q
How do you diagnosis hyperthyroidism?
A
1st TSH 2nd T4 levels. T3 only with TSH and T3 is down.
10
Q
Tx for hyperthyroidism
A
- Beta blocker (Propranolol) -block target organ site
- Steroids
11
Q
Thyroid storm present with
A
fever, atrial fibrillation, delirium
12
Q
Study Diagram
A
.
13
Q
Primary hyperthyroidism
A
Decrease TSH, Increase T4
14
Q
Secondary hyperthyroidism
A
increase TSH, increase T4
15
Q
Diabetic ketoacidosis (DKA)
A
TYPE 1 NO INSULIN IS PRODUCED THEREFORE FAT IS USED FOR ENERGY, TYPE 2 VERY RARELY GETS KETOACIDOSIS
16
Q
How do you treat DKA?
A
Insulin, fluids, and electrolyte repletion
17
Q
How do Diabetic ketoacidosis present?
A
- Hyperventilation
- Altered mental status
- Metabolic acidosis with an increased anion gap
- Hyperkalemia in the blood, but decreased total body potassium because of urinary spillage
- Increased anion gap for ketones
- Nonspecific abdominal pain
- Acetone odor on breath
18
Q
What is the best measure of the severity of DKA?
A
Serum bicarbonate. If the serum bicarbonate is very low , the pt is at risk of death.
19
Q
What is Pulmonary Embolism (PE)?
A
Blockage of the pulmonary artery by foreign matter or by a blood clot
20
Q
PE 95% of the time originate from
A
DVT
21
Q
PE can lead to…
A
Right side heart failure, hypoxemia, and pulmonary infarction
22
Q
What factors contribute to PE?
A
Virchow’s Triad: Vascular trauma, Increase coagulability, Reduced blood flow
23
Q
Physical exam for PE may show the following…
A
Pleurisy, dyspnea, CP, low grade fever, increase respiration rate
24
How would you diagnosis PE?
ABG, CXR {Hampton's hump, or Westermark's sign}, ECG, CT w/ contrast, ventilation/perfusion (V/Q) scan. *Pulmonary angiogram is the gold standard*
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How would you tx PE?
Anticoagulation, IVC (inferior vena cava) filter, thrombolysis, DVT prophylaxis, Heparin
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Pneumothorax Etiology
Air in the pleural space. Spontaneous occur in tall thin males.
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Pneumothorax sign and symptoms
chest pain, hyperresonance, and decreased breaths sounds. Tracheal deviation = tension pneumothorax
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Pneumothorax Dx test
chest x-ray
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Pneumothorax tx
chest tube placement
| Tension pneumothorax req needle decompression
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P-THORAX
```
Pleuritic pain
Tracheal Deviation
Hyperresonance
Onset sudden
Reduced breath sounds
X-ray shows collapse
```
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Study Picture
.
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Acute Respiratory Distress Syndrome (ARDS)
respiratory failure with refractory hypoxemia, Decrease lung compliance, and non-cardiogenic pulmonary edema with a PaCo2/FiO2 ration less than 200.
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What can trigger ARDS?
sepsis, pneumonia, aspiration, multiple blood transfusion, inhaled toxins, trauma, near drowning, pancreatitis
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What is the diagnosis of ARDS?
```
It's not (h)ARDS to diagnosis ARDS.
-Acute onset
-Ratio PaCo2/FiO2 ration less than 200.
-Diffuse infiltration (Bilateral infiltrates which are are when both lungs fill up with fluid.(Pix)
-Swan-Gans wedge pressure <18
mmHg
```
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Treatment of ARDS:
- Mechanical Ventilation
- Treat the underlying disease
- Use PEEP to recruit collapse lungs
- Oxygenation
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What is PEEP?
PEEP is to increase the volume of gas remaining in the lungs at the end of expiration in order to decrease the shunting of blood through the lungs and improve gas exchange.
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Study Open Angle Glaucoma
.
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Study Close Angle Glaucoma
.
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Open angle glaucoma
Aqueous humor through the trabecular meshwork is limited, increase IOP.
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What are the risk factor for Open angle glaucoma?
>40 years, African Americans, diabetics and myopia.
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What are the Hx/ PE for open angle glaucoma?
- Cup to disc increases.
- Pt often have HA, visual disturbance, and impaired adaptation to darkness.
- Usually asymptomatic
- Gradual loss of peripheral vision.
42
Tx for open angle glaucoma
Beta-blockers lower the pressure inside the eye by reducing how much fluid (aqueous humor) is produced in the eye.
- Carbonic anhydrase inhibitors may also be used.
- if meds fail then use laser trabeculoplasty.
43
Dx for open angle glaucoma
Tonometry, ophthalmoscopic visualization of the optic nerve, and visual field testing is most important.
44
What are some presentation of DM?
Polyuria, polyphagia, and polydipsia
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Diagnostic Test of DM
- Two fasting blood glucose measurement greater than 125mg/dL
- Single glucose level (random plasma glucose/ 2-hour postprandial glucose level) about 200mg/dL with symptoms
- Increased glucose level on oral glucose tolerance
- Hemoglobin A1C > 6.5%
46
What is the best initial drug therapy for for DM?
Metformin. This works by blocking gluconeogenesis.
47
Gluconeogenesis
Converts amino acids or fatty acids to glucose and that is performed mainly by liver cells. Glucocorticoids act in several ways to increase gluconeogenesis. They promote the breakdown of tissue proteins to amino acids, especially in muscle cells. Amino acids thus formed move out of the tissue cells into blood and circulate to the liver. Liver cells then change them to glucose by the process of gluconeogenesis
48
When is metformin a contraindication
Those with renal dysfunction because it can accumulate and cause metabolic lactic acidosis
49
DM-2 usually occur in what type of pt?
older adult with obesity and has a strong genetic predisposition; disgnosed increasingly in obese children.
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Complication of Diabetes: Cardiovascular complication
Increased risk of MI, stroke, CHF from premature atherosclerotic disease.
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Complication of Diabetes: Diabetic Nephropathy
Diabetes leads to microalbuminuria early in the disease.
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Diabetic Nephropathy
A microvascular complication associated with damage to the small blood vessels that supply the glomeruli of the kidneys
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Microalbuminuria
Increase in urinary albumin is an early sign of renal neuropathy (complication of diabetes mellitus). Annual assessment of kidney function by determination of this urinary protein is recommended. Defined as persistant albuminuria in range of 30-299mg/24 hour or albumin:creatinine ratio of 30-300 ug/mg
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Complication od Diabetes: Gastroparesis
DM decrease the ability of the gut to sense to stretch of the walls of the bowel. Gastroparesis is an immobility of the bowels that leads to bloating, constipation, early satiety, vomiting, and abdominal discomfort.
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Complication of Diabetes: Retinopathy
DM's effect on microvasculature is especially apparent in the eye. This can cause ppl to go blind.
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Microvasculature
blood vessels with greater than 0.1 mm, namely arterioles, capillaries, venules
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Complication of Diabetes: Neuropathy
Damage to the microvasculature damages the vasonervorum that surrounds large peripheral nerves. This leads to decreased sensation in the feet- the main cause of skin ulcers of the feet which lead to osteomyelitis.
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Hypertensive crisis
Spectrum of clinical presentations in which elevated BPs lead to end-organ damage. Present with end-organ damage revealed by *renal disease, chest pain (ischemia or MI), back pain or change in mental status (hypertensive encephalopathy)*
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Hypertensive Crisis define
is not defined as a specific level of blood pressure. It is associated with end-organ damage.
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Hypertensive crisis is associated
Confusion, Blurry vision, Dyspnea, chest pain.
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Warning!!
Do not lower BP in hypertensive crisis to normal, or you may provoke a stroke.
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What is the best initial therapy for hypertensive crisis?
labetolol or nitroprusside. The goal is to lower mean arterial pressure by no more than 25% over the first 2hrs. to prevent cerebral hypofusion or coronary insufficiency.
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Gastrointestinal bleed
-Bleeding from the GI tract may present as hematemesis, hematochezia and/or melen
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What is the most common cause of upper GI bleeding?
Ulcer disease. But can also be caused by gastritis, esohagitis, duodenitis, cancer, and varices.
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What is the most common cause of lower GI bleeding?
Diverticulosis. But can also be caused by angiodysplasia, polyps or cancer, Inflammatory bowel disease, hemorrhoids, High volume of upper GI bleed.
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Assessing blood pressure is the most important initial management for GI bleeding
...
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Upper GI tract bleeding is defined as bleeding from lesion proximal to the ligament of Treitz
(the anatomic boundary between the duodenum and jejunum)
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Hematochezia
Blood in the stool
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History Upper GI bleed
Hematemesis, melena > hematochezia, hypovolemia (Tachycardia, lightheadness, hypotension)
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Lavage
Irrigating or washing out of an organ, stomach, bladder, bowel, or body cavity with a stream of water or other fluid
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Diagnosis Upper GI bleed
NG tube and lavage; if stable, endoscopy
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Etiology of Upper GI bleed
PUD, esophagitis/gastric, Mallory-Weiss tear, esophageal varices
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Mallory-Weiss tear
tear that occurs in the esophageal mucosa at the junction of the esophagus and stomach caused by severe retching and vomiting and results in severe bleeding.
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Initial management of Upper GI bleed
Protect the air (intubation may be needed). Stabilize the pt with IV fluids and packed RBCs
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Long term management Upper GI bleed
Endoscopy followed by therapy directed at the underlying cause
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History of Lower GI bleeding
Hematochezia > melena, but can be either.
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Diagnosis of the Lower GI bleeding
Rule out upper GI bleed with NG lavage if brisk. Anoscopy / sigmoidoscopy for pt < 45yo of age with small-volume bleeding.
-Colonoscopy if stable; arteriography or exploratory laparotomy if unstable.
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Etiologies of the Lower GI bleeding
Diverticulosis (60%), angiodysplasia, IBD, hemorrhoids/fissures, neoplasm, AVM (Arterial Venous Malformation)
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Diverticulosis
.
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Angiodysplasia
.
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hemorrhoids/fissures
.
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Initial management of Lower GI bleed
Protect the air (intubation may be needed). Stabilize the pt with IV fluids and packed RBCs
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Long term management Lower GI bleed
Depends on the underlying etiology. Endoscopic therapy (eg, epinephine injection, intra-arterial vasopressin infusion or embolization, or surgery for diverticular disease or angiodysplasia.
84
What is Acute abdomen?
Abdominal pain. May require medical or surgical intervention.
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How do you determine if the pt has parietal (peritoneal) etiology with acute abdomen?
Sharp, focal pain with tenderness and guarding. Pt prefer immobility.
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How do you determine if the pt has visceral (organ) etiology with acute abdomen?
Dull, crampy, achy, and midline or diffuse pain. Pt are unable to lie still.
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Abdominal: Causes of Pain location > Right upper quadrant
Cholecystitis
Biliary colic
Cholangitis
Perforated duodenal ulcer
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Abdominal: Causes of Pain location > Left upper quadrant
Splenic rupture
| IBS-Splenic flexure syndrome
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Abdominal: Causes of Pain location > Right lower quadrant
Appendicitis
Ovarian Torsion
Ectopic pregnancy
Cecal diverticulitis
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Abdominal: Causes of Pain location > Left lower quadrant
Sigmoid volvulus
Sigmoid Diverticulitis
Ectopic pregnancy
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Abdominal: Causes of Pain location > epigastric
acute pancreatitis
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What should be consider with acute abdomen in a female pt?
Gynecologic history (including last menstrual period, pregnancy , and any STD symptoms)
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What is the history/PE of pt with acute abdomen?
Perforation, obstruction, inflammation, associated symptoms (N/V, anorexia, changes in bowel habits, hematochezia and melena suggest GI etiologies.
94
If a pt has a positive beta-HCG in the setting of shock, what can this possibly be?
Ruptured ectopic pregnancy until proven otherwise.
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If a pt has abdominal pain plus syncope or shock in an older patient, what can this possibly be?
Abdominal aortic aneurysm (AAA) until proven otherwise
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If meals are associated with acute abdomen, what should be considered?
mesenteric ischemia, peptic ulcer disease, biliary disease, pancreatitis, or bowel pathology
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How do you diagnosis acute abdomen?
Rectal exam, pelvic exam.
| Obtain labs: Electrolytes, LFTs, lipase, urine or serum B-HCG, UA, and a CBC with differential.
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If you suspect perforation or pulmonary pathology, what should you consider?
CXR.
| AXR may be useful for obstruction or perforation
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What diagnostic test is used to diagnose appendicitis, diverticulitis, abscess, renal stones, AAA, obstruction?
CT
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What diagnostic test is used to diagnose cholecystitis, gynecologic pathology and can diagnose hemoperitoneum and AAA in unstable pt?
US
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Treatment for Acute abdomen
-Unstable pt: Surgical management
-Stable pt: Manage may include NPO status, NG tube placement (for decompression of bowel in the setting of obstruction or acute pancreatitis, IV fluids, placement of a Foley catheter (to monitor urine output and fluid status), and vital sign monitoring with serial abdominal examination and serial labs.
-Board Spectrum Antibiotic with all pt with perforation and sepsis.
Type and cross all unstable pts as well as those in whom you suspect potential hemorrhage.
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Seizure
Determine whether the pt has a history of epilepsy. Determine the underlying medical condition and treat.
103
Define paroxysmal
sudden awakening from sleeping with shortness of breath
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Define Postictal
after a seizure
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Elevated serum prolactin levels are consistent with an epileptic seizure in the immediate postictal period.
...
106
What are some non-neurologic etiologies of seizures?
Hypoglycemia, hyponatremia, hypocalcemia, hyperosmolar states, hepatic encephalopathy, drug overdose, drug withdrawl, hypoxia, hypernatremia, uremia (elevated creatinine), eclampsia, hyperthermia, head trauma
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All of the metabolic, toxic, and CNS anatomic problems previously listed can cause
Confusion or difficulty with arousal described as delirium, stupor, obtundation, or coma.
Confusion=coma + seizure
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hepatic encephalopathy
central nervous system dysfunction resulting from liver disease; frequently associated with elevated ammonia levels that produce changes in mental status, altered level of consciousness, and coma
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Seizures with a focal onset suggest focal CNS pathology
May be the presenting sign of a tumor, stroke, AVM, infection, hemorrhage, or developmental abnormality.
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Partial Seizure
Focal to one part of the body. Eg. limited to just an arm or leg. May have simple (intact consciousness or complex (loss of consciousness: Lip smacking, chewing)
Focal seizure implies a focal brain lesion.
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What is the diagnostic tests for seizures?
Electroencephalogram (EEG). Determine underlying conditions first before EEG. Rule out systemic causes with CBC, electrolyte, calcium, fasting glucose, LFTs, renal panel, RPR, ESR, and toxicology screen.
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What is the best initial therapy for a persistent seizure?
- IV Benzodiazepine such as lorazepam or diazepam and phenytoin.
- 2nd degree seizures, treat the underlying cause.
- Recurrent partial seizure: Phenytoin
- In children, phenobarbital
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Tonic-clonic (grand mal) seizure History/PE
Loss of consciousness with tonic extension of the back and extremities for about 1-2min. Marked by tongue biting and incontinence.
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Tonic-clonic (grand mal) seizure diagnosis
EEG (shows 10Hz during the tonic phase and slow waves during the clonic phase)
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Tonic-clonic (grand mal) seizure Tx
- Protect the airway
- Treat the underlying cause if known
- 1st degree: Phenytoin
- 2nd degree: tx same as partial seizure
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Absence Seizure
Begin in children; subside in adulthood. Last 5-10sec impaired consciousness. Appear daydreaming or staring. Eye fluttering or lip smacking is common.
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DX and treatment for absence seizure
Dx: EEG
Tx: Ethosuximide 1st and Valproic 2nd
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Seizure
.
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Med for seizures
.
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What is shock?
```
Occurs when the tissue in the body do not receive enough oxygen and nutrients to allow the cells to function.
Brain: confusion
Kidney: Increased BUN/creatinine ratio
Liver: Elevated AST and ALT
Heart: chest pain and shortness
```
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Type of shock
.
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Coma
A state of unconsciousness marked by a profound suppression of responses to external and internal stimuli
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Coma is due to
catastrophic structural CNS injury or diffuse metabolic dysfunction.
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Causes of coma
Diffuse hypoxic/ischemic encephalopathy (e.g., postcardiac arrest).
■ Diffuse axonal injury from high-acceleration trauma (e.g., MVA).
■ Brain herniation (e.g., cerebral mass lesion, SAH with obstructive hydrocephalus).
■ Widespread infection (e.g., viral encephalitis or advanced bacterial meningitis).
■ Massive brain stem hemorrhage or infarction (e.g., pontine myelinolysis).
■ Electrolyte disturbances (e.g., hypoglycemia).
■ Exogenous toxins (e.g., opiates, benzodiazepines, EtOH, other drugs).
■ Generalized seizure activity or postictal states.
■ Endocrine (e.g., severe hypothyroidism) or metabolic dysfunction (e.g.,
thiamine defi ciency).
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Coma Diagnosis
.
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Come Diagnosis cont..
.
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Tx for coma
Initial treatment should consist of the following measures:
■ Stabilize the patient: Attend to ABCs (Airway, Breathing and Circulation).
■ Reverse the reversible: Administer DONT—Dextrose, Oxygen, Naloxone,
and Thiamine.
■ Identify and treat the underlying cause and associated complications.
■ Prevent further damage.
128
What is Cardiac Tamponade?
Excess fluid in the pericardial sac, leading to compromised ventricular filling and ↓ cardiac output.
129
Risk factor cardiac tamponade
Risk factors include pericarditis,
| malignancy, SLE, TB, and trauma (commonly stab wounds medial to the left nipple).
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History/ PE of cardiac tamponade
-Presents with fatigue, dyspnea, anxiety, tachycardia, and tachypnea that can rapidly progress to shock and death.
-Examination of a patient with acute tamponade may reveal Beck's triad (hypotension, distant heart sounds, and JVD), a narrow pulse pressure,
pulsus paradoxus, and Kussmaul's sign (JVD on inspiration).
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JVD
Jugular Vein Distension
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Diagnosis of Cardiac Tamponade
Echocardiogram shows right atrial and right ventricular diastolic collapse.
CXR shows an enlarged, globular heart.
■ If present on ECG, electrical alternans is diagnostic.
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Tx of Cardiac Tamponade
Aggressive volume expansion with IV fluids.
■ Urgent pericardiocentesis (aspirate will be nonclotting blood).
■ Decompensation may warrant balloon pericardiotomy and pericardial window.
134
Kussmaul's sign
increased jugular venous distention during inspiration, secondary to negative pressure during inspiration being transferred to the venous outflow tract,
135
What is Status Epilepticus?
A medical emergency consisting of prolonged (> 10-minute) or repetitive
seizures that occur without a return to baseline consciousness.
■ Common causes include anticonvulsant withdrawal/noncompliance, anoxic
brain injury, EtOH/sedative withdrawal or other drug intoxication, metabolic disturbances (e.g., hyponatremia), head trauma, and infection.
■ Death usually results from the underlying medical condition
136
Diagnosis of Status Epilepticus
Determine the underlying cause with pulse oximetry, CBC, electrolytes,
calcium, glucose, ABGs, LFTs, BUN/creatinine, ESR, antiepileptic drug
levels, and a toxicology screen.
■ *Obtain an EEG and brain imaging, but defer testing until the patient is
stabilized.*
■ *Obtain a stat head CT* to evaluate for intracranial hemorrhage.
■ Obtain an LP in the setting of fever or meningeal signs, but only after having
done a CT scan to assess the safety of the LP.
137
Treatment for Status Epilepticus
Maintain *ABCs*; consider rapid intubation for airway protection.
■ Administer *thiamine, glucose, and naloxone to presumptively treat potential
etiologies.*
■ Give *IV benzodiazepine* (lorazepam or diazepam) plus a loading dose of
fosphenytoin.
■ If seizures continue, intubate and load with *phenobarbital*. Consider an
IV sedative (midazolam or pentobarbital) and initiate continuous EEG
monitoring.
■ Initiate a meticulous search for the underlying cause.
138
Prolonged blood sugar extremes — blood sugar that's either too high or too low for too long — may cause various conditions, all of which can lead to a diabetic coma.
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