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RESIDENCY BOOT CAMP (UMMC)
Terms in this set (139)
IV or IM
PCN G formulation
aorta - away
mitral - look slike mirror
helpful hints for determing which valve has been replced
low dose - increases renal perfusiion
medium dose - b1 receptor, icnrease CO
high dose - increases Alpha 1, vasopressor
dopamine dose and receptors?
In appropriate bradycardia; normally we see increase in HR in shock, tachycardia, but they have inappropriate bradycardia; however, lots of patients get tachycatdia and lots get atrial fibrillation with RVR; arrthymogenic; we tend to avoid this drug
When do we use dopamine as a pressor?
0.3 mg epinephrine IM
tx for anaphylaxis
30 cc/kg, not NS, use LR or PLf
bolus for septic shock suspect
continuous albuterol, liver disease (cannot clear lactate)
who's a patient w/ high lactate w/o hypoperfussion?
sirs - need to make this note card; on sepsis sketchy
sirs + source = sepsis
severe sepsis - organ hypoperfusion manifested in a few ways, like thromobycopenia, dic, decrease cap refill, low UOP, Lactate > 2
septic shock - BP < 80 systolic or MAP < 65 (see skethcy) or refractory to fluids and needing pressors
What is SIRS, severe sepsis, septic shock and refractory septic shock
all 4 types of shock. discuss them, their dx and what you don't wanna miss w/ them!
when you are approaching a new patient in ED or cross coverage or over night, and pt has unstable vitals. What is a great paradigm to look at when you are asking for vitals and reviewing the chart?
PO but poor bioavailability, 4-6x/day!
PCN VK formulation
IV ampicillin can be stepped down to?
IV nafcillin or IV oxacillin
MSSA bacteremia drugs of choice
•No efficacy against MRSA and Enterococci
speak to carbapenems & their coverage of enterococci & MRSA
all except for ceftriaxone & anti-staphylococcal PCNs must be adusted for kidney function
speak to beta-lactam and kidney adjustment?
about 1-2% of PCN allergic pts will be cephalsporin allergic
about 3-5% allergic PCN pt will be also allergic to carbapenems
so, go to cephalosporins, not carbapenems first!
Speak specifically to PCN allergic patient and allergies to cephalsporins & carbapenems
aztreonam - no crossover allergy to betalactams except for ceftazidime, covers pseudomonas and most other G-s
for absolutely true PCN allergy, what gram negative covering antibiotic do we use?
amingoglycosides -- but at hight doses, they are particularly ototoxic and nephrotoxic!
these are among the most rapidly bactericidal antibiotics if given at high enough concentrations
IV = PO for flagyl
IV to PO conversion for metronidazole
•HORRIFIC side effects, including QTc prolongation, hypo- and hyperglycemia, AAA rupture, tendon rupture, delirium in the elderly, and high C diff infection rates
electorlyte abnormality seen sometimes with trim-sulfa
macrolides (clarithryomycin, azythromycin, etc.) and clindamycin
works at the same ribosomal site as clindamycin so you cannot co-prescribe these together
thrombocytopenia -- it occurs; Dr. Palmer said it causes "bone marrow suppresssion)
Per Dr. Weaver (ID, UMMC) if you are on linezolid, you will develop this eventually; he has not seen it used w/o this occuring
what type of patients typically have chronically elevated lactate?
There are a few
For Staph aureas, we presume MRSA infection. What are the antibiotics we use that cover MRSA for severe infections?
For staph aureus, we assume MRSA. For minor infections, what will cover it?
Pearl: TMP/SMX has NO activity against strep pyogenes. Therefore, if there is NO purulence, you probably shouldn't use this. But if there is purulence, then it likely is staph aureus, and it is a good option.
Strep pyogenes & TMP/SMX
It's pan sensitive for the most part. PCN and first generation cephalosporins (cefazolin, cephalexin), vancomycin, clindamycin, FQs and NOT TMP-SMX
What are some good medicines that will cover strep pyogenes infections?
Ampicillin (E. faecalis)
VAncomycin (E. faecalis)
Daptomycin, Linezolid for VRI and ampR strains
Enterococcus antibiotics (E. Faecalis and VRE)
- Ampcillin/sulbactam (unasyn)
- Pipercillin/Tazobactam (zosyn)
- ciprofloxacin (think diverticulitis)
- carbapenems for ESBL strains
You are dealing with gran negative enteric bacterial infection (GNR enterics). What antibiotics cover these?
clindamycin above the diaphgram (specifically for oral strep sp) and metronidazole below the diaphgram. Remember that carbapenems are awesome at anerobes and metro is awesome for anything except oral anerobes, so just use clinda for that one.
General rule for antibiotics for anerobes?
ANY glucose > 140 mg/dlwith or without diabetes
What is the definition of inpatient hyperglycemia?
Diabetic pt is on metformin and now has symptoms of neuropathy. What's a good lab to check just in case?
stopped at CAP
so true! like if aki gets better, may need to get increase insulijn
t/f: you need to pay attention to insulin and renal funciton. E.g., AKI and insulin needs to be lowered.
cefrtriaxone + azithromycin; IF concerned for MRSA, add vancomycin, furhter, aspiration concerns no longer recommend anerobic coverage unless empyema or lung abcess
Inpatient CAP tx
outpatient purulent skin infection tx
cipro + metronidazole
for GNR enterics and GI anaerobes for an intraabdominal infection, we often will go to unasyn or zosyn; however, what if you cannot use this in your patient. What's a good alternative?
Review IV abx that approx equal PO therapy bioavailability abx
There are several:
then these randos: •Quinupristin-dalfopristin, Oritavancin, Dalbavancin, Telavancin, Delafloxacin
What are the drugs that cover MRSA?
- ciprofloxacin, levofloxacin
- carbapenems (All except ertapenem)
- aminoglycosides (amikacin, gentamicin, tobramycin)
- ceftolozoane-tazobactam (only get w/ ID on board)
- polyxin B & E (only get w/ ID on board)
Which drugs cover Psudomonas aeriuginosa?
You can comfortably give them 1-2 L of isotonic NS over 1-2 hours to get to normal intravascular volume; now, this is when Na gets improtant is IVFs; NS has 154 mEq so you arent gonna bring them down below that with this treatment! I asked this in small group, and I got an affirmative from the 3rd year resident who is about to graduate; he recommended this
You are in the ER admitting a patient for hypernatremia. You note skin tenting, tachycardia, dry mucous membranes. They have low effective intravascular volume and are also dehydrated. Their sodium is 160 or so. What can you do to fluid-resuscitate them?
can cause skin necrosis; avoid it, use CaGluconate
Why do we note use CaCl during HyperK?
After HyperK is reported, order ECG, see patient, wouldn't hurt to get a redraw as well, but you need to make a decison so order the following
- CaGluconate (not CaCl!), 10 U R-insulin (if ESRD used 2-5 U R Insule b/c cleared by kidneys!), 1 Amp D50 (yes, must be D50) and +/- 1 amp Na HCO3
- then move on to lasix to get rid of K and lokelma
remember that most K is excreted renally
HyperK patient with ECG changes. You must make a decision. What do you do?
What patient do we particularly NOT give Mg to?
NS, note that if they start getting pain in back, order CT non-con to see if they have a kidney stone
if Albumin is wnl (3-4) then Ca is what it says it is!
Also, always remember to check Mg with Calcium if it is low
speak to ward rules with albumin and Ca
What other electrolyte should you check for hypocalcemia?
periorla parthesia (tingle lips) and first SIGN is trauseua sign (tetany w/ BP cuff)
What is the first symptom of hypocalcemia?
How do we, in general, replace Ca in hypocalcemia?
HF pt and kidney dz pt
What 2 pt populations do we especially need to make sure Mg and K are wnl for?
you see tongue fasciculations on a patinet (w/o ALS!) what electrolyte is likely derranged?
(1) think it's dehydration (2) give IVF
You see hyperphosphatemia, what do you need to (1) think and (2) do?
- the tube must be stright
- go below the diaphgram
- should not cross the spine to the R into duodena past pylorus
radiopedia has good examples; pretty easy;
You are called to confirm the placement of an NG tube via CXR. What are you steps?
- pH = 5.5
- Na = 154
- Cl = 154
What are the following in normal saline?
- pH = 6.5
- Na = 130
- K = 4
- Cl = 109
- Ca = 1.5 - 3.0
- Lactate = 28 (Sodium lacate; will NOT raise serume lactate in lactic acidosis)
What are the following for Lactated ringers?
- pH = 4.5 - 5
- 253 - 255
What are the following for D5W?
never bolus it
What is the BIG important thing to know about D5W?
- pH = 7.4
- Na = 140
- K = 5
- Cl 98
- NO CALCIUM; Ca is in LR!
- Mg = 3
- acetate & gluconate are the buffers
What are the following values for plasmalyte?
- what is the buffer(s)
Give them LR. Remember that NS will lead to hyperchloremic non-anion gap metabolic acidosis. Acidosis leads to exacerbation of hyperkalemia. So we avoid NS in hyperkalemia. LR has a K of 4 (PL has K of 5) and offers a more physiologic K gradient.
if a patient with hyperkalemia or ESRD needs fluids, what's the fluid you need to give them?
amio! if lose pulse or become unstable synchronize cardioversion!
tx for V tach w/ pulse
acceleratd idoventricular rhythm AKA "slow v tach" - normal around 24 hours s/p reperfusion
dx and tx
NS, LR, PL
IF a paitent if fluid down, and they need a bolus (do not just increase their mIVFs to change BP, etc.). What are your good options?
1/5 NS D5W (Good for diabetic) but LR and PL are also really good ones, but will need to be run slower
Good MF for adult?
Free water flushes through the gut. It will NEVER fail you. Start off like 200 cc q2h via NGT
for Hypernatremia, how do we prefer to treat it?
Used to calculate maintenance IVFs.
- 4 ml/hr for first 10 kg
- 2 ml/hr for 2nd 10 kg
- 1 ml/hr for each kg over
NB: This is effective up to about 60-80 kg, this is about where we'll stop, not higher than this
What's the 4-2-1 rule?
- UOP & Urine Na
- 5% depleted - skin tenting occurs
- 10% depleted - tachycardia
- 15% depleted - orthostatic
- 20% depleted - hypotensive (this is a lot of fluid to lose before you have hypotension!!)
note that kids become HoTN even later and elders become HoTN sooner.
For intravascular deficit, you best assess these by _____ and ______. Traditionally, the order of physical exam finds are what?
staph aurues, likely
candida can, though candidemia is not common, it is a fungi that can stain gram positive!
what non-bacterial organism can stain G+?
candida can actually grow in routine blood culture, and it is by FAR the most common fungal bactermic culpritl others will grow on fungal media
will candida spp grow in routine blood culture or fungal blood culture?
take out foley, then replace and get new sample OR take out foley and get midstream catch, IF they can do it themself. BUt the big thing is you cannot take initialy foley sample!
pt has foley, you suspect a UTI, how do you get a sample?
no you dont they are sujcitpible to like everyting, pan sesntive, not needed at all
you cx strep pyogens, do you need to order suscpetibility?
pRBC volume transfusion
plate vol transfusion
b12, folate, thiamine
3 most common nutritional deficiencies, esp ones that can cause encepholapthy
look everywehre, mouth, rectum, under arms, legs, etc. Do not forget to be focused; you will be surprised w/ things you can miss that can be infectious source/infectious causing the problem
pt p/w leukocytosis, e-lyte derrangmenets that all point to toxic encapholopathy. WHat's a good thing to do b/c you cannot find where they are infected?
with encepholapthy, review who needs to get head CT ; just b/c soemone fell out of bed at 2am and you're an intern, doesn't mean they need a head CT!
Inattention (The hallmark, what tells you it's not dementia, they can't carry on a conversation; start answering question, start answering something else, or stop answering thing)
ask pt to count backwards, say days of week in reverse order; they won't be able to do it
THIS IS INSANELY PREVALENT, LOOK AT THOSE STATS!!!
hospital delirum = acute encapholpathy 2/2 blank
What's the hallmark of delirium? What's a good quick way to see if you're dealing w/ it?
1. distressing delusions,
2. harm to self to others, includes just keeping getting out of bed, hurting others, etc. keep taking out NG tube
when do we use medicines in a delirious patient? Review medicines
Review haldol for delirium
good for prolonged QTc, can use IM, SL; stack it rapidly in 15 min if they aren't doing better, otehrs wait longer
review azyprexa for delirium and why zyprexa is great
risk of hypotension, most sedation, so best for evening symptoms
REview seroquel for delirium
CKD/ESRD pt p/w and CO2 (bicarb) is < 15, even while we are waiting for their dialysis, what do we need to do to help acidosis?
good for 3 days as inpt
type - a , b , o types
screen - looking ofr non abo abs, duffy, kell, kidd, lewis, RH, etc. This part takes time
emergency we will release O- unit
How often do you need to type and screen for pt?
O - (We use O+ in males for trauma b/c no worry w/ developing them in older types_
over 3 hours, it MUSt be transfused if it as room temp; it can only be kept at room temp for 30 min, if its not being transufesd, send it back!
how long can you hang a unit of blood/?
staph and yersinia enterocolitica (
Grows well in cold
what bacteria is commonly seen in septic transfusion reaction?
TACO -- premptively give lasix, give very slowly to avoid that deadly cardiogenic pulmonary edema; TRALI used to be number 1 but TACO has no become number 1.
what is actually the most common cause of transfusion associated mortality?
10,000; 1 unit may only raise it by 30,000 to 60,000 IF YOU ARE LUCKY
central line 20,000
LP 50,000, bleeding
CABG, neurosx 100,000
thresholds to transfusion platelets?
WE DO NOT GIVE PLASMA FOR WARFARIN REVERSAL (WE USE PCC OR VIT. K)
when do we give plasma for warfarin reversal?
low fibrinogen (<100-150) or dysifrinogenemia, relaly only this!
When do we give cryo?
think of pertussis, ask about mom getting vaccines during vaccine; look for a CBC w/ lymphocytosis!!!! fremember the picmonic!!!
young baby presents with apnea that is pretty profound, what do you think is going on?
infant w/ fever < 60 days
when you pull out med calc and use rochester criteria?
birth - 2 wks -> dissiminated; in NICU, often die
after, we capture these w/ r/o sepsis often wk 2-3, often have skin leisons, sizures, CSF abnormal, fever, vesicular rash
skin-eye-mouth: 40% mouth, birth and couple weeks, sometimes later, do full w/u, tx and tap them still!
acyclovir - concerned w/ kidney damage
discuss some things you may see in a young child w/ herpes infection (HSV)
amp-caftazidime (Frotaz) +/- acyclovir
vanc/ceftriaxone (meningitc dosing)
after 28/30 day for baby empriic coverage for meningits/sepsis? <28days?
Sine waves -- hyper-K, no no no good!!!!
hold pre-prandial, keep the sliding scale, but it may need to be down graded, and keep the basal insulin
For an NPO T2D pt who is in-patient, what do you in general do to their insulin regimen
T2d estimated tdd = 0.4 u/kg/day
estimated tdd elderly, renal insufficiency, t1d = 0.3 u/kg/day
1/2 goes to basal (glargine, leterminer) and 1/2 divided into 3 equal doses (w/ perhaps a small dose reduction for erring on side of caution to avoid hypoglycemia)
inpatient TDD for diabetes
we never put an arterial line in the brachial artery - any damage risk of losing the limb!
rando: remember to get a CXR to confirm proper placement of the PICC line.
what artery do we never put an arterial line in?
up to 1 year!!
PIC good for 3-5 days
Midline up to 28 days
PICC up to a year; long term use, single, double, triple luman
weekly dressing changes on ALL IV lines and PICC requires caps to be changesd weekly too
technically, how long can a PICC line last and stay in and be used for?
Furthermore, discuss the time frame for your different type of access lines for antimicrobial management and even chemotherapy.
The higher the number, the small the seize. A 14G is way bigger than a 22G.
Look at the gauges of catheters/needles -- discuss how the number correlates to caliber/size.
</= 7.5% - monotherapy, metformin
7.6-10% metformin + another
> 10% insulin +/- another agent
speak to A1c at diagnosis & then recommended management.
if they day w/in 24 hours of admission to hospital or during surgery; like if they presented and died 2 hours later, it's a medical examiner/corner case, not hospital
speak to when a patient presents to a hospital and when the corner/medical-lega autospy is done rather than a hospital autopsy?
see th eimage
appreciate how intersting the R lower lobe is so this is important when intereting pneumonias and lung pathologies - you gotta have that lateral view!
hypoalbuminemia -- if albumin is low, then it will hid it, so always look at that albumin, especially in the appropriate patient
norm AG = 12
12 - [(2,5 x norm albumin - pts albumin)]
What can hid a metabolic acidosis in a patient that you must be aware of?
Oxoproline is a metabolite from APAP
causes of AGMA
electrical alternans - pericardial alternans
vagal then 6mg -> 6mg -> 12 mg but always have pads on patient b/c could stop heart!
CXR, EKG, ABG & start O2
DYSPNEA work up as intern
T/F: for WPW syndrome - if adenosinse given, see delta waves, then go ahead and shocke them - straight from Dr. Lowe! IF no base line ECG
0.5 mg atropine q 3-5 min until reaching 3 mg thne you can transcutaneous pace OR dopamine but call cardiology
symptomatic bradycardia ? (hyotn, ams, hf, cp)
Pull up MD calc -> padua prediction score and this tells you if you need to anticoagulate a new inpatient
3 bucket classification is really helpful too
You're admitting a new patient and are unsure if they need VTE ppx. What do you use to help discern the path forward?
all IBD pt who are admitted need to be given heparin; pt w/ IBD have a very high risk of clotting as long as they are HDS
speak to anticoagulation and UC patients who are admitted
remember VTE sketchy! --> kideny disease patients! give them taht heparine with the 3 shots a day!
what patient do we not give lovenox to?
hip, knee arthroplasty need to be anticoagulated with LMWH for how long?
PIP/TAZO + VANC or Cefepeme + Metro but if h/o ESBL use Meropene over Pip/Tazo
Blood stream infection or SEPSIS
→ ceftriaxone + Ciprofloxacin
UTI with systemic symptoms
→ Ceftriaxone + Azithromycin but can go with Levofloxacin (if they cannot tolerate azithromycin)
→ Pip/Tazo + Vanco OR Meropenem + Vancomycin
Hospital/Ventilator Acquired Pneumonia
→ Vancomycin + Ceftriaxone or Vancomycin + Cefepime
Meningitis in the ED
→ Meropenem + Vancomycin
New meningitis in the hospital
I and AVF + is normal
= these are all you need to really look at for your axis!
for acls, gotta know them
hydrogen excess (Acidosis)
5Hs & 5Ts - know immediately
stopped at slide 14 =henson slide
make sure it all NCs above are completed!!
PNA, PE, PTX
rhemiatic (MS --> Afib now)
Thyrotoxicosis / Toxins, especially stimulant medications, caffeine, tobacco or alcoholElectrolytes (mg, ca, k)/EndocarditisSepsis (infection) / Sick sinus syndrome.
new onset Atrial fibrillation causes?
docusate + senna
use this for opiate induced constipation ppx
when nothing else will work for nausea (ondansetron, metoclopramide, promethazine) what can we go to?
- tramadol 50 q8h (opiate agonist)
- valium 5 q8h (distress)
- bentyl q12h (cramps)
- imodium 2 prn (diarrhea)
- clonidine 0.1 q12h (autonomic instability)
opiod withdrawl treatment
vancomycin AND pip/tazo (zosyn)
diabetic foot abx tx
cipro + metro (all comers)
OR pip/tazo (esp if critical conditon)
cholangitis tx abx
1. Where is the pain (going for substernal)?
2. Is it worsened by exertion and relieved with rest?
3. Is it improved with nitroglycerin?
4. Associated symptoms: presyncompe, dysnpnea, diaphoresis
5. Risk factors for ACS/CAD: Diabetes, HTN, DLD, Obesity, Smoker
6. How far can you walk without stopping? What stops you?
7. Is it the pain pleuritic (worse with inspiration)?
8. Is the pain tender?
9. Is the pain positional?
10. What's the blood pressure on both arms? Is it the same?
You are admitting a patient for chest pain. What MUST you ask every patient, every time? It is 10 questions. This will be SO COMMON it will blow your mind and you must have these mastered.
- serum osmlarity
- urine osmolarity, urine Urea, urine creatinine, IF NO DIURETICS also order urine sodium and Cr. Get a TSH too at admit.
Then go down UpToDate algorithm. OR pocket medicine (it's a little easier to follow actually)
Hyponatremia admit immediately labs you need to get?
IVC with US (sundaiaphram view). IVC >1.7 normal with good respiration variation. It'll be plump.
What's a good way to assess the fluid status when admitting a patient in the ED especially if they have hyponatremia?
What do NSAIDS, ACEI do to the glomerulus? Review dx of AKI.
- DABT (ASA + P2Y12 inhbiitor like clipidogrel, prasugrel, ticagrelor)
- anticoagulatnt therapy (unfractunated heparin -- usually heparin infusion -- , LMWH, fondaprinux)
then we will get to..
- Beta blocker
remember for STEMI we tx w/ cardiac catherization and revascularization w/in 90 minutes of first medical contact
Patients with Acute coronary syndromeb (ACS) should be treated with guide line directed medical therapy to reduce the risk of recurrent nonfatal myocardial infarction and cardiovascular death when they present what should they receive?
ddx: panic attack vs PE vs ACS
CXR, BMP, d-dimer, troponin x 3, alprazolam or clonazepam, start SSRI and f/u outpatient and d/c bzd if still using and allows
Young female presents with chest pain acutely in ED. She has no PMH and has had transient dyspnea, nausea, and dizziness. Her chest pain is 5/10 and is associated with tremors. What is your ddx and what should you order and do?
BMP + LFTs (not CMP) b/c this differentiates bilirubin
specific lab you need to order for abdominal pain
ekg, cxr, abg
Acute or worsening DYSPNEA in patient and you don't know what's going on. What do you do in the hospital?
good place to start with diffuse abdominal pain in ED or on the floor
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