Special Populations Flashcards
This deck covers Chapters 183-189 in Rosens, compromising geriatrics, transplant & immunocompromised patients, and combative patients.
Which patients (7) with febrile neutropenia are high risk (require inpatient management)?
BOUNCE HI
- Blood cancer
- Organ failure
- Uncontrolled cancer
- Neutropenia expected >10d
- Comorbid
- Evidence of infection (CAP, SSTI, Altered, Abdo pain, line)
- Hemodynamically unstable
- Inpatient when febrile neutropenia begins
Why (4) do elderly patients with abdominal pain have more vague physical exams and more serious complications?
- Decreased musculature
* Can’t manifest guarding/rebound - Omentum shrinks
* Can’t wall off infection/abscess - Atherosclerosis with decreased GI blood flow
* Increased perforation rates - Increased SVR
* More vascular causes of abdo pain (AAA, ischemia)
List 10 complications of IVDU
- Job loss
- Social isolation
- Incarceration
- Psychosis
- Suicide
- Homicide
- CVA
- MI
- SS
- Botulism
- Tetanus
- Endocarditis
- Bacteremia
- Sepsis
- HIV
- Hep B
- Hep C
- Abscess
- Cellulitis
- Death
List 5 drugs that interact with alcohol and the consequences
- NSAIDs (increased gastritis)
- Benzos (increased sedation)
- GHB (increased sedation)
- Cocaine (cocaethylene = longer effects)
- Tylenol (increased hepatotoxicity)
- Methanol/EG (decreased toxicity)
Name 2 ways the body metabolisms alcohol. Describe the pharmacokinetics of alcohol elimination. What is the mechanism of action of alcohol?
Metabolism
- ADH pathway
- MEOS
Pharmacokinetics
- Zero-order elimination
Mechanism
- GABA agonist
- Antagonism of NMDA
List 10 complications of steroids
- Cushing’s
- HTN
- Poor skin healing
- Easy bruising
- Infection
- AVN
- Cataracts
- Glaucoma
- Hyperglycemia
- Osteoporosis
- Pancreatitis
- DKA
- HONK
- Myopathy
- Psychosis
- Insomnia
What is the legal limit for EtOH while driving? What rate is EtOH removed from the body?
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
List 6 indications to start vancomycin in a patient with febrile neutropenia.
- Septic shock
- Lines insitu
- Colonized with MRSA
- High rates of MRSA at the institution
- Gram + BCx (not speciated)
- Severe mucositis
- Fluoroquinolone prophylaxis
List 5 organisms likely to causes infection in a patient with asplenia
Encapsulated bugs
- S. pneumoniae
- N. meningitidis
- H. influenzae
- B. holmesii
- Capnocytophagia
List 12 physiologic changes with aging
CNS
- Decreased BBB efficiency
- Decreased response to temperature change
- Alterations in neurotransmitter levels
- Altered autonomic nervous system
Cardiovascular
- Decreased inotropy
- Decreased chronotropy
- Decreased ventricular filling
- Increased SVR
Respiratory
- Decreased vital capacity
- Decreased lung compliance
- Decreased ventilatory drive
- Decreased diffusion capacity
- Decreased chemoreceptor response
GI
- Decreased gastric mucosa
- Decreased blood to GI system
- Decreased hepatic cell mass
- Decreased hepatic blood flow
- Altered hepatic microsomal enzyme activity
Renal
- Decreased renal cell mass
- Decreased total body water
- Decreased thirst response
Skin
- Atrophy of all layers
- Decreased sweat gland number/activity
MSK
- Decreased bone mass
- Decreased muscle mass
- Increased adipose tissue
Give 5 DDx for Alcohol-related seizure
- Withdrawal seizure
- Co-ingestion
- Toxic alcohol
- Intracranial bleed
- Epilepsy
- Metabolic seizure (hypoglycemia, hypoNa)
- Sleep deprivation
- Non-compliance with anticonvulsants
- CVA
- Infectious
What is the mechanism of action of cyclosporine? List 5 adverse effects.
Calcineurin inhibitor
- Hepatotoxic
- Nephrotoxic
- Hyperkalemia
- HTN
- Gout
- DLD
- Gingival hyperplasia
- Tremor
List 5 general strategies for dealing with difficult patients
- Be supportive
- Structure the interview
- Set limits
- Point out impasses
- Share your reactions
- Redirect the interview
- Take time out
- Use teamwork
- Understand the patient’s agenda
List 5 drugs that produce a disulfiram-like reaction with EtOH.
- Disulfiram
- Metronidazole
- Sulfa drugs
- Sulfonylureas
- Macrobid
What is the most important pathogen causing infection in transplant patients 1-6 months post-transplant?
CMV
Pneumonitis is common
Active CMV can trigger rejection
Explain the pathophysiology of autonomic dysreflexia.
Name 4 symptoms. Name 4 triggers. How is it managed?
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)
What are the 3 phases of transplant rejection?
Hyperacute
- Immediate
- ABO incompatibility
Acute
- First months
- Shows signs of organ failure
Chronic
- Years
- Gradual failure
Describe the pathophysiology, sign/symptoms, and management of Wernicke-Korsakoff syndrome
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)
How do you manage trach associated resp distress?
- Oxygen
- Suction
- Change trach
- Ventilate stoma
What is the time of onset/duration of these medications:
- Haloperidol
- Lorazepam
- Midazolam
- Olanzapine
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
What are the 5 basic steps in crisis intervention?
- Recognize the crisis
- Gather information
- Understand the development of the crisis
- Reproducing the peak tension of the crisis
- Finding the solution
List 8 complications of CSF shunts
- Dislodged
- Blocked
- Disconnected
- Underdrainage
- Overdrainage
- Infection
- Hydrothorax
- Intussusception
- Hiccups
- Volvulus
How would you differentiate Miller-Fisher GBS and Wernicke’s encephalopathy?
- GBS
- No reflexes
- Wernicke’s
- Memory impairment
Both have ataxia, eye findings
List 6 factors which affect absorption, distribution, and clearance of drugs in the elderly
Absorption
- Altered GI motility
- Altered GI blood flow
Distribution
- Decreased lean muscle mass
- Increased adipose tissue
Clearance
- Decreased hepatic blood flow
- Decreased renal function
List 7 complications of G-tubes
- Leakage of gastric contents
- Peritonitis
- Obstruction
- Fistula
- Falls out
- Wound infection
- Mucosal injury
How do patients present with AKA? What is the pathophysiology? Management?
Presentation
- Patient stops drinking abruptly
- Presents N/V
Pathophysiology
- Lack of glucose
- Use FFAs as fuel (ketones)
Management
- Glucose + IVF (D5NS)
- Electrolyte replacement
What blood tests can serve as markers of alcoholism?
- AST/ALT >2
- GGT
- Low platelets
- Macrocytic anemia
- Ethanol level
List 6 conditions that result in FUNCTIONAL asplenia
- SLE
- RA
- Sarcoidosis
- Amyloidosis
- IBD
- Sickle cell disease
- Celiac disease
What are the elements of the CAGE questionnaire? Name 2 other screening questionnaires.
CAGE - positive if 2+
- Cutdown
- Annoyed
- Guilty
- Eye-opener
AUDIT-C
FAST
List 5 complications of central lines
- Infection
- Bleeding
- Clot
- Arterial placement
- Obstruction
- Air embolism