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Royal College: Emergency Medicine > Special Populations > Flashcards

Special Populations Flashcards

This deck covers Chapters 183-189 in Rosens, compromising geriatrics, transplant & immunocompromised patients, and combative patients.

1
Q

Which patients (7) with febrile neutropenia are high risk (require inpatient management)?

A

BOUNCE HI

  1. Blood cancer
  2. Organ failure
  3. Uncontrolled cancer
  4. Neutropenia expected >10d
  5. Comorbid
  6. Evidence of infection (CAP, SSTI, Altered, Abdo pain, line)
  7. Hemodynamically unstable
  8. Inpatient when febrile neutropenia begins
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2
Q

Why (4) do elderly patients with abdominal pain have more vague physical exams and more serious complications?

A
  1. Decreased musculature
    * Can’t manifest guarding/rebound
  2. Omentum shrinks
    * Can’t wall off infection/abscess
  3. Atherosclerosis with decreased GI blood flow
    * Increased perforation rates
  4. Increased SVR
    * More vascular causes of abdo pain (AAA, ischemia)
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3
Q

List 10 complications of IVDU

A
  1. Job loss
  2. Social isolation
  3. Incarceration
  4. Psychosis
  5. Suicide
  6. Homicide
  7. CVA
  8. MI
  9. SS
  10. Botulism
  11. Tetanus
  12. Endocarditis
  13. Bacteremia
  14. Sepsis
  15. HIV
  16. Hep B
  17. Hep C
  18. Abscess
  19. Cellulitis
  20. Death
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4
Q

List 5 drugs that interact with alcohol and the consequences

A
  1. NSAIDs (increased gastritis)
  2. Benzos (increased sedation)
  3. GHB (increased sedation)
  4. Cocaine (cocaethylene = longer effects)
  5. Tylenol (increased hepatotoxicity)
  6. Methanol/EG (decreased toxicity)
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5
Q

Name 2 ways the body metabolisms alcohol. Describe the pharmacokinetics of alcohol elimination. What is the mechanism of action of alcohol?

A

Metabolism

  1. ADH pathway
  2. MEOS

Pharmacokinetics

  • Zero-order elimination

Mechanism

  • GABA agonist
  • Antagonism of NMDA
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6
Q

List 10 complications of steroids

A
  1. Cushing’s
  2. HTN
  3. Poor skin healing
  4. Easy bruising
  5. Infection
  6. AVN
  7. Cataracts
  8. Glaucoma
  9. Hyperglycemia
  10. Osteoporosis
  11. Pancreatitis
  12. DKA
  13. HONK
  14. Myopathy
  15. Psychosis
  16. Insomnia
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7
Q

What is the legal limit for EtOH while driving? What rate is EtOH removed from the body?

A

BAC = 0.08 (Ontario wants <0.05)

Legal limit = 17.4 mmol/L

  • Removed at 5-7 mmol/L per hour in acute intoxication
  • Removed at 10 mmol/L per hour in chronic alcoholism
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8
Q

List 6 indications to start vancomycin in a patient with febrile neutropenia.

A
  1. Septic shock
  2. Lines insitu
  3. Colonized with MRSA
  4. High rates of MRSA at the institution
  5. Gram + BCx (not speciated)
  6. Severe mucositis
  7. Fluoroquinolone prophylaxis
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9
Q

List 5 organisms likely to causes infection in a patient with asplenia

A

Encapsulated bugs

  1. S. pneumoniae
  2. N. meningitidis
  3. H. influenzae
  4. B. holmesii
  5. Capnocytophagia
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10
Q

List 12 physiologic changes with aging

A

CNS

  1. Decreased BBB efficiency
  2. Decreased response to temperature change
  3. Alterations in neurotransmitter levels
  4. Altered autonomic nervous system

Cardiovascular

  1. Decreased inotropy
  2. Decreased chronotropy
  3. Decreased ventricular filling
  4. Increased SVR

Respiratory

  1. Decreased vital capacity
  2. Decreased lung compliance
  3. Decreased ventilatory drive
  4. Decreased diffusion capacity
  5. Decreased chemoreceptor response

GI

  1. Decreased gastric mucosa
  2. Decreased blood to GI system
  3. Decreased hepatic cell mass
  4. Decreased hepatic blood flow
  5. Altered hepatic microsomal enzyme activity

Renal

  1. Decreased renal cell mass
  2. Decreased total body water
  3. Decreased thirst response

Skin

  1. Atrophy of all layers
  2. Decreased sweat gland number/activity

MSK

  1. Decreased bone mass
  2. Decreased muscle mass
  3. Increased adipose tissue
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11
Q

Give 5 DDx for Alcohol-related seizure

A
  1. Withdrawal seizure
  2. Co-ingestion
  3. Toxic alcohol
  4. Intracranial bleed
  5. Epilepsy
  6. Metabolic seizure (hypoglycemia, hypoNa)
  7. Sleep deprivation
  8. Non-compliance with anticonvulsants
  9. CVA
  10. Infectious
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12
Q

What is the mechanism of action of cyclosporine? List 5 adverse effects.

A

Calcineurin inhibitor

  1. Hepatotoxic
  2. Nephrotoxic
  3. Hyperkalemia
  4. HTN
  5. Gout
  6. DLD
  7. Gingival hyperplasia
  8. Tremor
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13
Q

List 5 general strategies for dealing with difficult patients

A
  1. Be supportive
  2. Structure the interview
  3. Set limits
  4. Point out impasses
  5. Share your reactions
  6. Redirect the interview
  7. Take time out
  8. Use teamwork
  9. Understand the patient’s agenda
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14
Q

List 5 drugs that produce a disulfiram-like reaction with EtOH.

A
  1. Disulfiram
  2. Metronidazole
  3. Sulfa drugs
  4. Sulfonylureas
  5. Macrobid
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15
Q

What is the most important pathogen causing infection in transplant patients 1-6 months post-transplant?

A

CMV

Pneumonitis is common

Active CMV can trigger rejection

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16
Q

Explain the pathophysiology of autonomic dysreflexia.

Name 4 symptoms. Name 4 triggers. How is it managed?

A

Pathophysiology

  • SCI above T6 with noxious stimulus below level
  • Parasympathetic counter-response unable to travel from brain down to level

Symptoms

  • HTN, H/A, Sweating, Flushing above lesion
  • Anxiety, SOB, Palpitations

Triggers

  • Bladder distension (MCC)
  • UTI, Renal colic
  • SBO
  • Pregnancy
  • DVT
  • Orthopedic injury

Treatment

  • Remove constricting items
  • Drain bladder and send for U/A
  • Treat underlying cause
  • Treat HTN (sBP <150 mmHg)
17
Q

What are the 3 phases of transplant rejection?

A

Hyperacute

  • Immediate
  • ABO incompatibility

Acute

  • First months
  • Shows signs of organ failure

Chronic

  • Years
  • Gradual failure
18
Q

Describe the pathophysiology, sign/symptoms, and management of Wernicke-Korsakoff syndrome

A

Pathophysiology

  • Transketolase deficiency

Signs/Symptoms

  • Wernicke’s Encephalopathy
  • Cerebellum
    * Ataxia
  • Eye
    * Ophthalmoplegia
    * Nystagmus
  • Brain
    * Altered
    * Memory issues
  • Korsakoff’s Psychosis
  • Alcohol-induced anterograde amnesia
  • Confabulation

Management

  • Thiamine 500 mg IV
  • Magnesium (cofactor for enzyme)
19
Q

How do you manage trach associated resp distress?

A
  • Oxygen
  • Suction
  • Change trach
  • Ventilate stoma
20
Q

What is the time of onset/duration of these medications:

  • Haloperidol
  • Lorazepam
  • Midazolam
  • Olanzapine
A

Haloperidol

  • Onset: 30 min
  • Duration: 4h - 24h

Lorazepam

  • Onset: 1-3 min IV / 15-30 min IM / 120 min PO
  • Duration: 8h - 10h

Midazolam

  • Onset: 3 min IV / 5 min IM
  • Duration: 30 min - 120 min

Olanzapine

  • Onset: 15-30 min
  • Duration: 2h - 24h
21
Q

What are the 5 basic steps in crisis intervention?

A
  1. Recognize the crisis
  2. Gather information
  3. Understand the development of the crisis
  4. Reproducing the peak tension of the crisis
  5. Finding the solution
22
Q

List 8 complications of CSF shunts

A
  1. Dislodged
  2. Blocked
  3. Disconnected
  4. Underdrainage
  5. Overdrainage
  6. Infection
  7. Hydrothorax
  8. Intussusception
  9. Hiccups
  10. Volvulus
23
Q

How would you differentiate Miller-Fisher GBS and Wernicke’s encephalopathy?

A
  • GBS
  • No reflexes
  • Wernicke’s
  • Memory impairment

Both have ataxia, eye findings

24
Q

List 6 factors which affect absorption, distribution, and clearance of drugs in the elderly

A

Absorption

  1. Altered GI motility
  2. Altered GI blood flow

Distribution

  1. Decreased lean muscle mass
  2. Increased adipose tissue

Clearance

  1. Decreased hepatic blood flow
  2. Decreased renal function
25
Q

List 7 complications of G-tubes

A
  1. Leakage of gastric contents
  2. Peritonitis
  3. Obstruction
  4. Fistula
  5. Falls out
  6. Wound infection
  7. Mucosal injury
26
Q

How do patients present with AKA? What is the pathophysiology? Management?

A

Presentation

  • Patient stops drinking abruptly
  • Presents N/V

Pathophysiology

  • Lack of glucose
  • Use FFAs as fuel (ketones)

Management

  • Glucose + IVF (D5NS)
  • Electrolyte replacement
27
Q

What blood tests can serve as markers of alcoholism?

A
  • AST/ALT >2
  • GGT
  • Low platelets
  • Macrocytic anemia
  • Ethanol level
28
Q

List 6 conditions that result in FUNCTIONAL asplenia

A
  1. SLE
  2. RA
  3. Sarcoidosis
  4. Amyloidosis
  5. IBD
  6. Sickle cell disease
  7. Celiac disease
29
Q

What are the elements of the CAGE questionnaire? Name 2 other screening questionnaires.

A

CAGE - positive if 2+

  • Cutdown
  • Annoyed
  • Guilty
  • Eye-opener

AUDIT-C

FAST

30
Q

List 5 complications of central lines

A
  1. Infection
  2. Bleeding
  3. Clot
  4. Arterial placement
  5. Obstruction
  6. Air embolism

Royal College: Emergency Medicine (25 decks)

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