SEEK Flashcards
(117 cards)
1
Q
Poor prognostic factors of HPS
A
lymphoma, age >30, higher ferritin elevation, marked thrombocytopenia, male sex, and low albumin
2
Q
2ndary HLH causes
A
HIV
lymphoma
EBV
aka macrophage activation syndrome with JIA, SLE, adult Still’s dz
3
Q
HLH diagnostic criteria
A
4
Q
Testing for HLH includes
A
functional NKcell receptor activity
soluble CD25 testing
Ferritin
5
Q
Treatment options for HLH
A
- Dex + Etop +/- cyclosporine A, doxorubicin, IVIG, ruxolitinib, anakinra, and allogeneic stem cell transplant.
- Cyclophosphamide, adriamycin, vincristine, prednisone (CHOP) and rituximab – in lymphoma and EBV
- PLEX
- Splenectomy (relapse)
6
Q
A
Bradypnea
7
Q
A
airway obstruction, COPD
“shark-fin” gradual rise in exhaled CO
8
Q
A
vent dyssynchrony/double trigger
9
Q
A
Inverse ratio I:E
10
Q
- end inspiration with no CO2
- fast rise, mix of gas, emptying of alveoli
- Inspiration
A
11
Q
Preferred therapy for WPW
A
Ibutilide
- Class III (K+) antiarrhythmic drug that prolongs refractoriness of both the AV node and accessory pathway and acutely terminates atrial fibrillation or flutter
Procainamide
- Class Ia (Na+) antiarrhythmic that increases refractoriness of atrial and ventricular myocardium without any AV nodal-blocking effect
12
Q
3 Characteristics concerning for preexcitation (WPW) for afib w/ accessory pathway
A
wide complex tachyarrhythmia
irregularly irregular rhythm
varying widths of the QRS complexes
13
Q
Why no Dig or Adenosine in WPW/pre-excitation rhythm
A
May precipitate ventricular arrhythmia (AV-node blockers)
*verapamil lengthens AV refractoriness without effect on accessory pathway
14
Q
When/who to feed in the ICU
A
less than 60% protein intake by day 7-10
15
Q
TTP - define, 2 types, and treatment
A
- reduced von Willebrand factor-cleaving protease ADAMTS13
- autoimmune (Ab) vs genetic mutation
- platelet-rich thrombi, thrombocytopenia (<30K), microangiopathic hemolytic anemia (<10), and organ damage (ARF, AMS, seizure)
- PLEX, glucocorticoids, and rituximab
16
Q
Monoclonal Ab for refractory TTP
A
Caplacizumab, binds to von Willebrand factor & blocks its interaction with platelet glycoprotein 1b-IX-V
- HERCULES and TITAN studies demonstrated that the addition of caplacizumab to immunosuppression and plasma exchange in severe immune-mediated TTP led to fewer deaths, faster normalization of platelet count, fewer exacerbations, and shorter hospital stays
17
Q
TXA mechanism
A
reversible and competitive manner on plasminogen, reducing the affinity of plasminogen to fibrin and resulting in reduced conversion of plasminogen to plasmin – prevent DIC
CRASH-2: 9% reduction in relative risk of mortality when tranexamic acid was administered within 3 h to patients with a systolic BP <75 mm Hg and significant hemorrhage or a risk of significant hemorrhage
MATTERs - good when used early, but no difference in 24-h mortality and higher rates of venous thrombotic events
18
Q
Lung compliance
A
C = ΔV/ΔP
normal would be 70-100
19
Q
Treatment of bacterial meningitis
A
vanco
ceftriaxone
amp if >50 yo or RF
- given dex 0.15mg/kg q6 hrs early, dc by day 4 if neg workup
causes N menin, S pneumo, L monocytoges
20
Q
Check point inhibitor (anti-PD1, CTLA-4)
Presentation/side effects and treatment
A
- rash, colitis, pneumonitis, myocarditis, encephelitis, etc
Presentation: confusion, weakness, rotatory nystagmus, peripheral neuropathy - paraneoplastic syndrome, likely caused by anti-Ma2 antibodies against both central and peripheral neurons and associated with renal cell carcinoma
TX: steroids, PLEX
21
Q
How does Dantrolene treat MH?
A
MOA: binds to ryanodine receptor type 1 (RYR-1) and inhibiting calcium ion release from the sarcoplasmic reticulum.
2.5 mg/kg, repeated every 5 min until reversal of the reaction or a total dose of 10 mg/kg is reached
22
Q
Volume control
- trigger, target, cycle
A
trigger time
target flow
cycle volume
23
Q
Pressure control
- trigger, target, cycle
A
trigger time
target insp pressure
cycle insp time
24
Q
Clinical signs of botulism
A
GI: vomiting
Neuro: descending neuropathy/weakness
- CN III, CN IV (accommodative paresis, ptosis, ophthalmoparesis, and dilated pupils)
- bulbar CN 9-12 (dysarthria, dysphagia, and dysphonia)
- bilateral presentation
25
Vent pattern:
PC - slow prolonged expiration, loss of flow and TV, pressure remains same
Airway obstruction (e.g ETT pulled)
26
What's qSOFA
1. SBP <100
2. RR >22
3. AMS
27
Clostridium myonecrosis causes
trauma or hematogenous from malignancy (colorectal cancer commonly)
28
v vulnificans
wound infections; shellfish
- doxy/cipro tx
- associated with DM and CKD
29
Physiologic implications of VAE
cause pulmonary vasoconstriction, increased pulmonary artery pressure, elevated resistance to right ventricular outflow, and right ventricular failure. These physiological changes can also cause shifting of the interventricular septum, leading to decreased left ventricular filling, decreased cardiac output, and shock. Neutrophil activation in the pulmonary capillary bed can cause thromboxane- and leukotriene-mediated increases in airway resistance and pulmonary capillary permeability, resulting in pulmonary edema
30
Treatment for venous vs arterial air embolis
venous: left lateral decub
arterial: hyperbaric O2
31
32
RV infarct -> wall, 2ndary sequelae and mgmt
inferior wall (II, III, aVF, recuprocal ST dep aVL, can be preceded by hyperacute T waves)
- cardiogenic shock, 2nd/3rd heart block
- inotropic or mechanical support if right side pressures high (avoid/judicious fluid)
- avoid nitrates
33
calicum/phos product indication for RRT
>80
34
rasbuicase vs allopurinol MOA
enzyme to break down and clear uric acid
vs
stop the conversion into uric acid
35
What cut off of end tidal CO2 rise indicates possible fluid responsiveness? How much CO can be augmented?
When the end-tidal CO2 value rises >5% (2 mm Hg when the end-tidal CO2 is 40 mm Hg), a fluid bolus will augment cardiac output by >15% (specificity 100%)
36
Eosinophil cut off in BAL for acute pulmonary eosinophilia/ARDS
25%
37
ABPA diagnostic requirements
38
Eosinophilic granulomatosis with polyangiitis (Churg-Strauss disease) criteria
asthma
P-ANCA
MPO-ANCA
w/ skin, neuro, renal lesions
- increased airway resistance and a discordance between the peak airway pressure on the ventilator and the inspiratory pause pressure
39
This abx can cross react with glacatomannan/beta D glucan assay for false positive
Zosyn
test has low sensitivity/specificity
40
Which antifungal would you want to avoid in liver injury/coagulopathy?
azoles
41
staph hemolyticus and epidermidis w/ line - treatment?
remove line, 5-7 days abx
42
work up staph lugdenesis for what sequelae
IE
43
how long is heparin continued after MI
24 hours
44
Accelerated idioventricular rhythm after MI management
observation, is a sign of reperfusion to purkinje fibers, transient, can evolved to VT, but no associated with worse outcomes
45
Arrhythmias are mediated by 3 mechanisms
1. automatcity
- can increased in response to sympathetic activation
2. afterdepolarization
- triggered by electrical current/electrolytes, meds, QT (Early more Na/some Ca), eg TdP
- late is more Ca channel
3. reentry - depending on speed and timing (SVT, WPW, VT)
46
Mechanism of opioid induced pulmonary edema
- stress capillary failure
- negative intrathoracic pressure from inspiring against a closed glottis
- gastric aspiration
CT chest: central airspace disease with peripheral sparing
47
West Nile encephelopathy
stroke like symptoms
meningitis
48
Rabies presentation
1. autonomic dysfunction
- temperature up/down
- hypersalivation
2. peripheral nerve myelopathy - ascends spinal cord to brain
49
This part of the aorta is more prone to blunt force injury
50
In a VSD, why is loud holosystolic murmur normal?
Blood from LV -> RV recirculates to LA->LV, so high pressure on left side is normal. As RV afterload increased, murmur will decreased in sound as less LV -> RV flow.
51
Risk factors/underlying conditions associated with strep pneumo
asplenia
HIV
lymphoma
MM
alcoholism
52
Austrian triad
steph PNA
meningitis
endocarditis
associated with AoV rupture
53
reverse triggering
patient initiates an inspiratory effort during the delivery of a controlled breath.
54
double trigger
patient inspiration is so prolonged, it triggers additional breath
55
5 commercially available NOACs
apixaban
dabigatran
endoxaban
rivaroxaban
betrixaban
56
NOACs with higher risk GI bleed vs VKA
dabigatran, edoxaban, and rivaroxaban
57
NOACs with high menstrual bleeding vs VKA
apixaban and rivaroxaban
58
Dabigatran will prolong these coagulation factors
PT/PTT
Mostly NOACs affect PT * rivaroxaban having the most and apixaban the least impact
59
Idarucizumab vs adenxanet
human monoclonal antibody Fab fragment that binds dabigatran with significantly greater avidity than thrombin, and offers rapid and sustained reversal of this agent
vs.
recombinant inactive variant of human factor Xa, and can bind both oral factor Xa inhibitors and reverse low molecular weight and unfractionated heparin
60
Normal TV inflow velocity with inspiration
with inspiration -> increased venous return -> high TV velocity, less left sided pressure
61
Normal Thrombin time is a good surroage for which anticoagulation use
dabigatran
62
Drugs that mess with POC glucose
Vit C, acetaminophen, mannitol, icodextran, dopamine
63
Long QT syndrome - types, gene, channel, mutation
Type 1 - triggered by activity, loss of fx K , KCNQ1 - respond to bblocker
Type 2 - trigger exercise, KCNQ2, most meds act on this gene - bbocker, aldo-ant
Type 3 - gain of fx, Na, SNC5A - mexilitine
- delayed repol,
64
Pattern of botulism
descending flaccid paralysis characterized by ptosis, diplopia, dysphagia, dilated nonreactive pupils, and respiratory distress
65
Drugs that prolong QT
procainamide,
quinidine,
sotalol,
amiodarone,
haloperidol,
methadone,
erythromycin,
levofloxacin,
trimethoprim-sulfamethoxazole,
azole antifungals,
vasopressin,
and tacrolimus
66
Most reliable method for RV evaluation
apical 4-chamber
nl: RV <2/3 LV size
67
Holiday heart pathophys
68
SS vs NMS vs anticholinergic
69
Albumin for SBP
within first 6h - 1.5mg/kg
days 3 give 1mg/kg
esp if Cr >1, bili >4, BUN > 30
70
two enzymes to be checked in anaphylaxis
histamine (gone in 60 min)
tryptase (up to 5 hours)
Anaphylaxis/Angioedema - Initial evaluation includes a complement protein C4 level. Low levels should prompt further evaluation for hereditary or acquired C1 inhibitor deficiency, including a C1 inhibitor antigen and functional levels
71
Encephelitis
- usually altered
- seizures
- CN palsy or focal neuro deficit
- usually viral, can be bacterial/fungal
- CSF: lymphocyte predominant pleocytosis, <250, high protein, nl gluc
- if blood - think HSV
-WNV, WEE, and EEE (arbovirus seen in summer) are notable for patches of inflammation in the basal ganglia, thalamus, and cortex
72
HIT type 1
development of platelet-activating IgG antibodies directed against the multimolecular PF4/heparin complex
73
IV direct thrombin inhibitors
Bival and argatroban
- Argatroban is FDA approved for HIT (caution in patients with congestive heart failure, liver disease, severe anasarca, or after cardiac surgery)
Bival more used in CV surgery but watch for renal/liver issues
74
Indirect factor Xa inhibitors
danaparoid and fondaparinux
- Fonda good for HIT but watch in bleeding risk, elderly, renal issues
75
Management of SCAD (coronary dissection)
ASA, no evidence on DAPT
- bblocker and nitro
76
Sepsis/shock Echo findings
Dynamic obstruction is usually localized to the left ventricular outflow tract (LVOT) and due to systolic anterior motion of the mitral valve as flow acceleration tends to draw the anterior leaflet into the LVOT (Bernoulli effect)
77
EVALI characteristics
use of e-cigarettes within 90 days (or less) of symptom onset,
ground-glass opacities on imaging,
and the absence of infection or other alternative etiologies
- lipid laden macrophages
78
Foamy macrophages on BAL ddx
interstitial lung disease,
organizing pneumonia,
bronchiolitis and
amiodarone exposure
79
Hemosiderin macrophage on BAL
DAH
80
On esophageal manometry
When PL is negative at the end of expiration (when Paw = PEEPtotal), this represents a condition in which the pressure outside the system (Ppl) is greater than the pressure inside the system (Paw). This results in atelectasis in the area of the lung for which the PL is negative and also may predispose the patient to ventilator-induced lung injury through atelectrauma, or cyclic atelectasis. Thus, one goal of using Pes to guide mechanical ventilation is to minimize dependent atelectasis and atelectrauma by achieving a positive PL (PL > 0 cm H2O) at end expiration by increasing applied PEEP. Keep Pl <20-25
81
Can consider resection for abscess in lung greater than
>/= to 6cm
82
Lung primary graft dysfx - assoc. w/
preoperative sarcoidosis or pulmonary arterial hypertension,
obese recipient body habitus (BMI >30 kg/m2),
use of cardiopulmonary bypass,
and donor with a smoking history
83
84
Effects of proning
homogeneous distribution of ventilation,
improved oxygenation,
higher respiratory system compliance,
reduction in ventilator-induced lung injury,
and right ventricular (RV) unloading
85
Exposure to this material can precipitate thyroid storm in those with subclinical hyperthyroidism
Iodine contrast (avoid amio for AF d/t the iodine)
86
First (E) wave is passive, related to mitral valve opening, and generally is the larger of the two peaks.
The second corresponds to atrial systole (A wave) and is generally the smaller of the two. The relationship between early- and late-diastolic filling conveys information about diastolic function.
87
TB CSF analysis
high WBC
mostly lymph (can be neuts if early)
high protein
very low glucose
88
bacterial CSF
very high WBC
mostly neutro
high protein
low gluc
89
viral CSF
high WBC
mostly lymph
nl protein
nl gluc
90
listerial CSF
high WBC
mostly lympho
low to nl glyc
slighty high protein
91
CMV effects
CD4 <50 (also Rf for MAC)
- GI involvement - refractory candida, ulcers, diarrhea
- polyradiculopathy, neurologic issues
- adrenal insufficiency (myco TB, histo)
92
Treatment for CCB overdose
IV calcium,
high-dose insulin,
and lipid emulsion therapy
93
Talaromyces marneffei
in HIV patients
- fever, weight loss, nonproductive cough, skin lesions, hepatosplenomegaly, and lymphadenopathy
94
Fusarium fungal infection
- more like a mold
- neutropenia or severe T-cell immunodeficiency
- can be multidrug resistant, but not usually blood stream infection
95
Conditions that affect common pathway/PTT/PT/INR
disseminated intravascular coagulation (DIC),
supratherapeutic heparin,
direct thrombin inhibitors,
warfarin,
vitamin K deficiency,
and hepatic insufficiency
96
Cortisol cut offs for CIRCI
baseline serum cortisol level <10 µg/dL (276 nmol/L)
or
an increase in serum cortisol <9 µg/dL (248 nmol/L) 30 to 60 min after a 250 µg dose of ACTH
vs <18 for outpatient AI dx with endocrine
97
Mackler's triad
vomiting, chest pain, SQ emphysema
98
Brugada
STE in V1-V2
- loss of function of cardiac sodium channels
- genes SCN5A and SCN10A
- reduce inward sodium currents, thereby reducing the duration of normal action potentials, so some cells have shorter refractory period and so recover excitability before the surrounding cells. Creates re-entry excitability.
99
PJP PNA is associated with which malignancy
CNS malignancy - steroid use, tapering high risk
- also tx with Temozolomide is RF
- Elevated serum lactate dehydrogenase and β-D-glucan levels
100
Indications for consideration for CTS eval in right sided endocarditis
failure of medical therapy (persistent bacteremia or enlarging vegetation),
large vegetations (>1 cm),
fungal endocarditis,
and heart failure due to tricuspid regurgitation
101
Enlarged coronary sinus on echo
think left sided SVC
- elevated right atrial pressures, partial anomalous pulmonary venous return to the CS, and coronary arteriovenous fistula or when it abnormally receives a hepatic vein
102
PPV
(maximum PP − minimum PP)/average of maximum and minimum PP
103
Acute kidney injury with potassium and phosphate wasting due to renal tubular toxicity from acetaminophen can also occur in low ATP states and is further exacerbated by futile ATP-depleting 5-oxoproline metabolism.
104
This drug/antiepileptic had 0 order kinetics... this neuro-sequelae seen when [drug]>20
nystagmus
phenytoin
Peas and WHEATS.
warfarin, heparin, ethanol, acetaminophen and aspirin, theophylline, and salicylates (WHEATS)
105
drugs with first order kinetics
azathioprine, cefazolin, and sildenafil
106
4 Ts of PPH
tone (uterine atony), trauma (lacerations and rupture), tissue (retained placenta or clots), and thrombin (clotting disorders)
107
VITT
vaccine (adenovirus) induced thrombotic thrombocytopenia
- 5-30 days
- give IVIG to combat Abs
- like HIT
- direct thrombin inhibitor tx for clots
108
Fusarium fungus
immunocompetant - keratitis or onychomycosis
immunocompromised - sinusitis, endophthalmitis, pneumonia, skin involvement, and fungemia
lack of predictable response to antifungal agents like echinocandins or voriconazole (treat with Ampho, high MIC)
109
Tx for aspergillus vs candida
azole
-cofungins
110
Organs involved in aspergillus
lung, sinuses, skin, and CNS. rarely blood culture +
skin lesions are usually singular
111
Scedosporium
immunocompetent -near-drowning events in water polluted with fungal organisms.
immunocompromised - heme malignancies
sinuses, lungs, and CNS, not in blood
112
Hantavirus cardiopulmonary syndrome
Hemorrhagic PNA, incubation 1-2 weeks, onset 2-4 weeks, ARDS
- Rhinorrhea and pharyngitis are uncommon. Conjunctivitis is sometimes seen, as are petechiae on the soft palate, chest, neck, and/or axillary folds
- capillary leak: hemoconcentration and thrombocytopenia. Elevated liver transaminase, serum lactate dehydrogenase, and serum lactate levels
113
Blastomycosis
thick-walled, round to oval fungal yeast forms, approximately 8 to 15 µm in diameter
- broad-based budding yeast
114
Aspergillus
thin, septate, acute-angle branching hyphae
- Tx IV -azole
115
This paralytic undergoes Hoffman elimination and doesn't depend on liver/kidney metabolism
Cisatracurium
- NMBAs pancuronium, vecuronium, and rocuronium undergo hepatic metabolism
116
JC virus
- subacute deficits that include altered mental status, ataxia, and visual disturbances (hemianopia and diplopia)
- subcortical white matter with T2-weighted (T2W) images demonstrating fluid-attenuated inversion recovery
117
