Week 15: Impaired Immunity Flashcards

Question

Distributive/Septic shock, clinical manifestations

Answer 1

- Sepsis: systemic inflammatory response to documented or suspected infection - Severe sepsis = Sepsis + Organ dysfunction * Presence of sepsis with hypotension despite fluid resuscitation * Presence of tissue perfusion abnormalities Clinical manifestations * ↑ coagulation and inflammation * ↓ fibrinolysis * Formation of microthrombi * Obstruction of microvasculature * Hyperdynamic state: increased CO and decreased SVR * Tachypnea/hyperventilation * Temperature dysregulation * ↓ urine output * Altered neurologic status * GI dysfunction * Respiratory failure common.

Answer 2

(pulmonary embolis) Develops when physical obstruction to blood flow occurs with decreased CO * From restriction to diastolic filling of right ventricle due to compression * Abdominal compartment syndrome Patient experience * Dec CO * Increased afterload * Variable left ventricular filling pressures Rapid assessment and immediate treatment important

Answer 3

* Usually not clinically apparent * Usually considered reversible * Metabolism changes from aerobic to anaerobic. * Lactic acid accumulates -must be removed by blood and broken down by liver. * Process requires unavailable O2. * Clinically apparent –Neural, Hormonal &Biochemical compensatory mechanisms * **Attempts aimed to overcome consequences of anaerobic metabolism and maintaining homeostasis.**

Answer 4

* Baroreceptors in carotid and aortic bodies activate SNS in response to ↓ BP. * Vasoconstriction while blood to vital organs maintained- * ↓ blood to kidneys \> activates renin– angiotensin system ↑ venous return to heart, CO, BP * Impaired GI motility- Risk for paralytic ileus * Cool, clammy skin from blood * Except septic patient who is warm and flushed

Answer 5

* Shunting blood from lungs increases physiologic dead space. * ↓ arterial O2 levels * Increase in rate/depth of respirations * V/Q mismatch * SNS stimulation increases myocardial O2 demands. * If perfusion deficit corrected, patient recovers with no residual sequelae * If deficit not corrected, patient enters progressive stage

Answer 6

* Begins when compensatory mechanisms fail * Aggressive interventions to prevent multiple organ dysfunction syndrome (MODS) * Hallmarks -↓ cellular perfusion & altered capillary permeability * Leakage of protein into interstitial space * ↑ systemic interstitial edema Anasarca * Fluid leakage affects solid organs and peripheral tissues. * ↓ blood flow to pulmonary capillaries Movement of fluid from pulmonary vasculature to interstitium * Pulmonary edema * Bronchoconstriction * ↓ residual capacity Fluid moves into alveoli * Edema-Dec surfactant * Worsening V/Q mismatch * Tachypnea, Crackles * Inc work of breathing CO begins to fall * Dec peripheral perfusion * Hypotension * Weak peripheral pulses * Ischemia of distal extremities Myocardial dysfunction results in * Dysrhythmias * Ischemia; Myocardial infarction * End result: complete deterioration of cardiovascular system Liver fails to metabolize drugs and waste. * Jaundice; Elevated enzymes * Loss of immune function * Risk for DIC and significant bleeding Mucosal barrier of GI system becomes ischemic * Ulcers * Bleeding * Risk of translocation of bacteria * Dec ability to absorb nutrients

Answer 7

* Exacerbation of anaerobic metabolism * Accumulation of lactic acid * ↑ capillary permeability * Profound hypotension and hypoxemia * Tachycardia worsens. * Failure of one organ system affects others. * **Recovery unlikely**

Answer 8

* Thorough history and physical examination * No single study to determine shock * Blood studies * Elevation of lactate * Base deficit * 12-lead ECG * Chest x-ray * Hemodynamic monitoring

Answer 9

* Identification of patients at risk for shock * Integration of patient’s history, physical examination, and clinical findings to establish diagnosis * Interventions to control or eliminate cause of dec perfusion * Protection of target and distal organs from dysfunction * Provision of multisystem supportive care

Answer 10

* General management strategies * Ensure patent airway. * Maximize oxygen delivery (sat above 90%) * **Cornerstone of therapy for septic, hypovolemic, and anaphylactic shock = Volume expansion** * Isotonic crystalloids (e.g., normal saline) for initial resuscitation of shock * 2-3 liters fluid, then give a blood produc * Volume expansion * If patient does not respond to 2 to 3 L of crystalloids, blood administration & central venous monitoring may be instituted. * **_Complications of fluid resuscitation_: Hypothermia & Coagulopathy**

Answer 11

Primary goal of drug therapy = Correction of decreased tissue perfusion * Vasopressor drugs (e.g., norepinephrine) * Achieve/maintain MAP \>60 to 65 mm Hg. * Reserved for patients unresponsive to fluid resuscitation * Vasodilator therapy (e.g., nitroglycerin, nitroprusside) * Achieve/maintain MAP \>65 mm Hg.

Answer 12

Nutrition is vital to decreasing morbidity from shock. * Initiate enteral nutrition within the first 24 hours. * Initiate parenteral nutrition if enteral feedings contraindicated or fail to meet at least 80% of caloric requirements * Monitor protein, nitrogen balance, BUN, glucose, electrolytes * Need high calories/protein

Answer 13

* Restore blood flow to myocardium by restoring balance between O2 supply and demand. * Thrombolytic therapy * Angioplasty with stenting * Emergency revascularization * Valve replacement * Hemodynamic monitoring * Drug therapy (e.g., diuretics to reduce preload) * Circulatory assist devices (e.g., intraaortic balloon pump, ventricular assist device) * to decrease contractility: beta blockers

Answer 14

* Management focuses on stopping loss of fluid and restoring circulating volume. * Fluid replacement is calculated using a **3:1 rule** (3 mL of isotonic crystalloid for every 1 mL of estimated blood loss). * may need a vasopressor if this isn't working

Answer 15

* Fluid replacement to restore perfusion * Hemodynamic monitoring * Vasopressor drug therapy * Vasopressin for patients refractory to vasopressor therapy * IV corticosteroids for patients who require vasopressor therapy, despite fluid resuscitation, to maintain adequate BP * Antibiotics after cultures obtained (e.g., blood, wound exudate, urine, stool, sputum) * Drotrecogin alfa (Xigris)-Major side effect: bleeding * Glucose levels \<150 mg/dL (combination of tpn and nutrition) * Stress ulcer prophylaxis with histamine (H2)-receptor blockers * Deep vein thrombosis prophylaxis with low-dose unfractionated heparin or low-molecular-weight heparin

Answer 16

In spinal cord injury: spinal stability * Treatment of hypotension and bradycardia with vasopressors and atropine * \***Fluids used cautiously as hypotension generally is not related to fluid loss** * Monitor for hypothermia (warming blankets)

Answer 17

* Epinephrine, diphenhydramine * Maintaining patent airway * Nebulized bronchodilators * Endotracheal intubation or cricothyroidotomy may be necessary. * Aggressive fluid replacement * Intravenous corticosteroids if significant hypotension persists after 1 to 2 hours of aggressive

Answer 18

* Early recognition and treatment is primary strategy. * Mechanical decompression * Radiation or removal of mass * Decompressive laparotomy

Answer 19

* ABCs: airway, breathing, and circulation * Focused assessment of tissue perfusion * Vital signs * Peripheral pulses * Level of consciousness * Capillary refill * Skin (e.g., temperature, color, moisture) * Urine output * Brief history * Events leading to shock * Onset and duration of symptoms * Details of care received before hospitalization * Allergies * Vaccinations

Answer 20

* Ineffective tissue perfusion: renal, cerebral, cardiopulmonary, GI, hepatic, and peripheral * Fear * Potential complication: organ ischemia/dysfunction Planning Goals for patient * Assurance of adequate tissue perfusion * Restoration of normal or baseline BP * Return/recovery of organ function * Avoidance of complications from prolonged states of hypo-perfusion

Answer 21

Health promotion * Identify patients at risk. * Elderly patients * Those with debilitating illness * Those who are immunocompromised * Surgical or accidental trauma patients * Planning to prevent shock * Monitoring fluid balance to prevent hypovolemic shock * Maintenance of hand washing to prevent spread of infection Acute interventions * Monitor the patient’s ongoing physical and emotional status to detect subtle changes in the patient’s condition. * Plan and implement nursing interventions and therapy. * Evaluate the patient’s response to therapy. * Provide emotional support to patient and family. * Collaborate with other members of health team when warranted. Neurologic status: orientation and level of consciousness Cardiac status * Continuous ECG * VS, capillary refill * Hemodynamic parameters: central venous pressure, PA pressures, CO, PAWP * Heart sounds: murmurs, S3, S4 * Respiratory status Respiratory rate and rhythm * Breath sounds * Continuous pulse oximetry * Arterial blood gases * Most patients will be intubated and mechanically ventilated. - Urine output - Tympanic or pulmonary arterial temperature - Skin: temperature, pallor, flushing, cyanosis, diaphoresis, piloerection - Bowel sounds - Nasogastric drainage/stools for occult blood - I&O, fluid and electrolyte balance - Oral care/hygiene based on O2 requirements - Passive/active range of motion Assess level of anxiety and fear. * Medication PRN * Talk to patient * Visit from clergy * Family involvement * Comfort measures * Privacy * Call light within reach

Answer 22

* Normal or baseline, ECG, BP, CVP, and PAWP * Normal temperature * Warm, dry skin * Urinary output \>0.5 mL/kg/hr * Normal RR and SaO2 ≥90% * Verbalization of fears, anxiety

Answer 23

4. Variations in cardiac output and decreased systemic vascular resistance in septic shock.

Answer 24

3. Increased serum potassium levels.

Answer 25

1. hypovolemic shock 2. Administer LR, PRBCS, NS 3. Give levofed 4. Monitor LOC, Cardiac Monitor/tele

Answer 26

* High rate of illness among those exposed * High attack rate * High rate of death among those who get ill * High case fatality rate * Short time between onset of illness and death * Small window to start treatment * Low level of immunity in the population * No effective or available treatment * Can be transmitted person to person * Easy to produce and disseminate * Difficult to diagnosis either clinically or diagnostically (i.e. laboratory identification)

Answer 27

Bacterial * **Anthrax** * **Plague** * Tularemia * Brucellosis * Q fever * Other * food borne pathogens * waterborne pathogens Viral * **Smallpox** * **Viral Hemorrhagic Fevers** * Viral Encephalitis Toxins * **Botulism** * Staph Enterotoxin B * Ricin toxin * Tricothecene mycotoxins

Answer 28

* **Gram positive** spore forming bacterium **Bacillus anthracis** * Primarily disease of herbivores which are infected by ingesting spores in soil * Natural transmission to humans by contact with infected animals or contaminated animal products * “Woolsorter’s disease” * Three forms of disease * Cutaneous * Inhalational * Gastrointestinal (GI)

Answer 29

direct contact, ingestion (lesion), and inhalation

Answer 30

* Accounts for 80% of naturally occurring Anthrax cases * Enters through openings in skin from abrasions, lacerations * 20% progress to systemic form if untreated * Most cases recover

Answer 31

* Inhalation of spores * **Incubation, 2-3 days (range up to 60 days)** * Spores engulfed by macrophages and transported to mediastinal and peribronchial lymph nodes * Insidious onset: malaise, low grade fever, nonproductive cough * Abrupt development of respiratory distress * Hemorrhagic mediastinitis * Hematogenous spread * Meningitis in 50%, usually fatal

Answer 32

**Ciprofloxacin** * 400 mg intravenous every 12 hours for adults * 10 -15 mg/kg intravenous every 12 hours for children **Doxycycline** * 100 mg intravenous every 12 hours for adults and children \> 8 yr and \> 45 kg * 2.2mg/kg every 12 hours for children * \< 8 yr (up to 200 mg/day) **\*IDEALLY USE BOTH** PLUS * One or two additional anti-microbial agents effective against anthrax (e.g. imipenem, clindamycin, rifampin, macrolides) Additional issues * **Penicillin should never be used as a monotherapy** * If meningitis is suspected, an antibiotic with good CSF penetration should also be administered (e.g. rifampin or chloramphenicol) * Supportive therapy for shock, fluid volume deficit and airway management may be needed. * Drainage of pleural effusions may improve clinical outcome Anthrax Immune Globulin (AIG) can be used to neutralize anthrax toxin.

Answer 33

Start 60 days of oral antibiotics ASAP after exposure * Ciprofloxacin or Levofloxacin OR * Doxycycline OR * Amoxicillin or Penicillin (if known PCN sensitive) Vaccine: Can be given post-exposure in conjunction with antibiotics

Answer 34

* Variola virus, two forms of the disease: minor and major * Spread via respiratory droplets or aerosols expelled from the oropharynx * May also spread via direct contact * Patients are most contagious during the time at which the skin rash is present * Approx. 30% of patients exposed go on to develop the disease * Approx. 30% mortality with ordinary smallpox

Answer 35

* **Febrile Syndrome** – occurring 1-4 days prior to rash. * **Classic Smallpox lesion** – deep-seated, firm/hard, round, well-circumscribed; lesion may become umbilicated or confluent. * Can be mistaken chicken-pox * **Febrile Syndrome** – occurring 1-4 days prior to rash. * **Lesion in Same Stage of Development** – Evolve from macules → papules → pustules at the same time. * **Centrifugal distribution** – First lesion on oral mucosa, face, or forearms. * lesions on palms and soles

Answer 36

Spares the trunk: Smallpox Primarily the trunk: chickenpox

Answer 37

* exposure * incubation period: 12 days (range 7-19 days)NOT Infectious * Prodrome phase (2 - 4 days): Abrupt onset of fever \>38.3°C, Malaise/myalgia, Headache, Nausea/vomiting, Backache, Usually NOT Infectious * Early Rash Phase: Mucous membrane lesions. Small red spots on the tongue and throat. Lesions enlarge, ulcerate, then shed virus. Infectious 24 hours before visible skin rash * Rash Phase: (21 days) macules, papules, vesicles, pustules, scabs, Infectious until all scabs fall off

Answer 38

* Strict respiratory/contact isolation of patient * Patient infectious until all scabs have separated * Treatment is supportive care only * Antivirals are under evaluation * Cidofovir * ST246

Answer 39

* Immediate vaccination of ALL close contacts (\< 6 ft) and ALL contacts of patients contacts (Ring vaccination) * Vaccination within 4 days of exposure may prevent or lessen disease * Mass vaccination may be necessary and/or everyone may want to be vaccinated

Answer 40

* Live vaccinia virus * Because it is a live virus, there can be adverse events from vaccination * Occurs mostly in immunologically suppressed persons * Immunity is not life-long, but having been vaccinated in the past may reduce morbidity and mortality

Answer 41

* Plague is a severe bacterial disease of humans and animals produced by the gram negative nonsporulating bacillus **Yersinia pestis** * Bite of a rodent flea that is carrying the plague bacterium, or by handling an infected animal * Hundreds of millions of people died * when human dwellings were inhabited * by flea-infested rats * Modern antibiotics are effective, but without prompt treatment the disease can likely cause illness or death Types: * Bubonic * Septicemic * Pneumonic

Answer 42

Routes of Plague Transmission ## Footnote Animal Resovior A = Bite of Flea B = Contact with animal or carcass C = Inhalation of respiratory droplets D = Contact with sputum or fluid

Answer 43

\*exposure \*IncubationPeriod: 1-6 days \*_Early Presentation_: Abrupt onset of fever, malaise, headache, myalgia, Chest pain and dyspnea, Tachypnea (particularly in young children), Productive cough (sputum may be purulent or watery, frothy, blood-tinged), Hemoptysis \*Antibiotic therapy in the first 24 hours can prevent septicemia, cardio-respiratory failure, shock, and death \*Late Presentation * Rapid progression to pulmonary disease/ARDS * Pulmonary edema, dyspnea, cyanosis * Meningitis may be a complication * Hypotension, DIC, septicemia, and death * Lab findings -- bacterial infection and sepsis * Organism usually seen on sputum gram stain * Mortality approaches 100% if untreated in 24 hours

Answer 44

**Early antibiotic treatment\* is paramount to patient survival** **Adults**: * **Streptomycin 1 gm IM b.i.d. for 10 days (DRUG OF CHOICE);** * Chloramphenicol 25 mg/kg IM or IV 4 times daily for 10 days * Gentamicin 5 mg/kg IM or IV once daily for 10 days; * Doxycycline 100 mg IV b.i.d. or 200 mg IV once daily for 10 days; * Ciprofloxacin 400 mg IV b.i.d. for 10 days; Children: * Streptomycin 15 mg/kg IM twice daily for 10 days (max 2 gm/day); * Chloramphenicol 25 mg/kg IV 4 times daily for 10 days (max 4 gm/day) * Gentamicin 2.5 mg/kg IM or IV 3 times daily for 10 days; * Doxycycline 2.2 mg/kg IV twice daily for 10 days (max dose 200mg/day); * Ciprofloxacin 15 mg/kg IV twice daily for 10 days (max 1 gm/day) \*CDC recommends initiating treatment with _two_ drugs believed effective against Y. pestis until antimicrobial susceptibility data is available on isolates.

Answer 45

* Pneumonic plague contacts (transmitted via droplets) * Oral Doxycycline or Ciprofloxacin * For 7 days after last exposure * Vaccine no longer manufactured

Answer 46

Caused by toxin from Clostridium botulinum * Colorless, odorless and tasteless * Lethal dose for 70kg human is 1ng/kg * Botulinum toxin is the most lethal neurotoxin known to man * Dispersal of aerosolized toxin, 1 gm of aerosolized toxin could kill up to 1.5 million people

Answer 47

* C. botulinum in the soil, flora and fauna (in honey and botox) * Toxin production in foods prepared or stored at ambient temperature * Colonization and toxin production in an open wound * Intestinal colonization and toxin production in susceptible infants and adults * _Botulism_:Acute, symmetric, descending flaccid paralysis with bulbar palsies

Answer 48

_exposure_ I_ncubation Period_: * _Inhalational_: 24-72 hours * _Foodborne_: 18-36 hours (range 2 hours to 8 days) Dependent on toxin dose _Cranial Nerve Palsies: Cranial Nerves III, IV, VI, VII, IX_ * Blurry vision * Diplopia * Ptosis * Expressionless Facies * Regurgitation * Dysarthria/Dysphagia _Descending Flaccid Paralysis: Symmetric Paralysis Voluntary Muscles_ 1. Neck 2. Shoulders 3. Upper extremities 4. Lower extremities \*BP often normal; Mental status normal

Answer 49

* Early administration of antitoxin: within 24 hours, 1 vial per person, acts by binding to free toxins in the system * Supportive care * Monitoring respiratory function * Providing mechanical ventilation * May be needed for weeks or months

Answer 50

_Hemorrhagic fever viruses (RNA) belong to four taxonomic families_: * **Filoviridae (Ebola/Marburg)** * Arenaviridae (Bolivian HF)) * Bunyaviridae (Congo-Crimean HF) * Flaviviridae (Dengue) _Natural vectors – virus dependent_ * Rodents, mosquitoes, ticks _No natural occurrences in U.S._

Answer 51

These viruses are considered suitable weapons because: * they have a low infectious dose * they cause high morbidity and mortality * they cause fear and panic in the general public * effective vaccines are either not available, or supplies are limited

Answer 52

exposure incubation period: * 2-21 days (depending on the virus) Early Manifestations * High fever * Headache * Myalgia * Arthralgia * Anorexia * Varying degrees of nausea, vomiting and diarrhea Later Manifestations * External and internal hemmorage * Ecchymosis * Petechiae * Bleeding from puncture site * Bleeding from nose and gums * Hemorrhagic conjunctivitis * Gastrointestinal bleeding * Severe vaginal bleeding * Pleural effusion * Renal Failure * Shock * Laboratory Findings * Leukopenia or leukocytosis * Thrombocytopenia * Elevated Liver Function Tests * Anemia or Hemoconcentration * Prolonged PT, PTT

Answer 53

* Aggressive supportive care with intravenous fluids, colloids, blood products as needed * Specific therapy (ribavirin) may be helpful in bunyaviruses and arenaviruses * Avoid IM injections or invasive procedures (due to bleeding) * Strict aerosol precautions (i.e. respiratory isolation)

Week 15: Impaired Immunity Flashcards

(77 cards)