ah2 4

broad spectrum resistance to infection ; WBCs and inflammtory response

natural (innate) immunity

developed from exposure: vaccination & contracting the illness

acquired immunity

filters old RBCs

spleen

remove foreign materials from blood stream

lymph nodes

defective immune system from birth; predisposed to frequent infections, auto immunity and cancer

primary immune system disorders

what are warning signs of immune system disorders

4+ ear infections before 1, 2+ rounds of abx to clear, thrush, failure to gain weight, sepsis, skin infections, pneumonia

result of underlying disease processes (i.e HIV) or tx (i.e chemo); most prevalent cause is MALNUTRITION

secondary immune system disorders

how does histamine mediate allergies

rash, bronchoconstriction, vasodilation

how do eosinophils mediate allergies

elevated on CBC w diff

how do platelet activating factor mediate allergies

bronchoconstriction, increased vascular permeability

how do prostaglandins mediate allergic reactions

vasodilation and increased capillary permeability

what shows in histamine release

local edema or hives; pruritus; watery eyes and inflamed conjuctiva; sneezing/runny nose; abd n/v and cramping + diarrhea

what happens in anaphylaxis

IgE reacts to antigen, releases histamine

constricts bronchial smooth muscle; increases vascular permeability; vasodilates

histamine 1 release

increased gastric acid

histamine 2 release

immediate reversal of bronchoconstriction and vasodilation for anaphylaxis

epinephrine

what med for bronchodilation in anaphylaxis

duoneb

what antihistamines for anaphylaxis tx

benadryl (h2) and pepcid (h2)

tick associated, IgE mediated allergy to galactose-a 1, 3-galactose (alpha-gal)

alpha gal syndrome

what are dx for alpha gal syndrome

allergic reaction and serum alpha-gal IGE

what is first line med for alpha gal

IM epinephrine, repeat 15-15m prn

what to give for hypotension in alpha gel

iv isotonic fluids

what to avoid for alpha gal

mammalian meat, including beef, pork, lamb, vension, and rabbit

life threatening reaction w ACE inhibitors

angioedema as allergy

ACE-I inhibit their breakdown; increase vascular permeability; buildup causes a nonallergic, nonhistmine-mediated angioedema

bradykinin reaction

what is ineffective for angioedema as allergy

epi / benadryl / steroids ineffective

how to treat angioedema as allergy

bradykinin-receptor blockers: lcatibant ; ± C1 inhibitor (off label use); ± FFP - provides enzymes that degrade bradykinins

low levels of one of the c1 inhibitor proteins: autosomal dominant or gene mutation (Type III), 3 types

low levels of one of the c1 inhibitors proteins

control inflammation

c1 esterase inhibitor proteins

CM of hereditary angioedema

swelling limbs and face; abdominal swelling manifests as pain, n/v; airway swelling » SOB; < 1/3 have any rash

what are triggers of hereditary angioedem

stress, illness (cold, flu), trauma

tx for hereditary angioedema

c1 inhibitor proteins, replace dysfunctional inhibitor

examples of c1 inhibitor proteins for hereditary angioedema

Berinert (self admin), Ruconest, Haegardia

what are tx for latex allergies

remove source, antihistamines, topical corticosteroids

skin irritation; itchy dry rash; blister ooze and crust

skin irritation

Type IV delayed sensitivity; may develop after prolonged / repeated exposure

contact dermatitis

eczema where the skin flexes; dry skin leads to itching; scratching → redness so can get bacterial infections

atopic dermatitis

tx for atopic dermatitis

antihistamines; topical steroid creams; biologics - control inflammation at the source

reduce flares and itching and suppresses immun esystem

biologics

what are pt teaching for biologics

home injection / adherence for steady control; symptoms or reactions; avoid live vaccines

when an organism destroys its own health cells

autoimmunity

immune complexes build up and are deposited in synovial tissue or organs damaging them

inflammation

damage from inflammation

degeneration

affects joints, muscles, bones and tendons

rheumatic disease

examples of systemic rheumatic disease

rheumatoid arthritis, systemic lupus erythematosus

organ specific rheumatic disease

sarcoidosis, hashimotors thyroiditis, crohns disease, T1 DM

genetic autoimmune disease and chronic disease that can affect every organ

lupus

CM of lupus

butterfly rash, scarring and skin pigment changes, oral ulcers, fever, malaise, anorexia, weight loss, joint deterioration, and PAIN; cardiac, renal and neuro effects as disease progresses

what are dx and lab for lupus

hx and physical example 4 of 11 criteria; antinuclear antibody test

halts productions of antibodies in lupus

Belimumab (Benlysta)

blocks type I interferon activity that drives lupus

Alirocumab (Rituxan)

anti-malarial- manage skin manifestations

Hydroxychloroquine (Plaquenil)

pharm for lupus

biologics, corticosteroids, hydroxychloroquine

pain management for fibromyalgia in lupus

NSAIDs +/ - narcotics ; Lyrica for chronic pain

slowly progressive arterial narrowing and occlusion of lower extremities

systemic arteriosclerosis

accumulation of lipids, calcium, blood components, carbs and fibrous tissue in the intima of the artery

atherosclerosis

distal aorta, iliac arteries

inflow

femoral, popliteal, tibial arteries

outflow

what are symptomatic differences of inflow

lower back, buttocks, upper thighs

what are symptomatic differences of outflow

calves and ankles / feets and toes

what are cues for stage 1 asymptomatic of peripheral artery disease

at risk, no pain, may have bruit / aneurysm; decreased or weak pedal pulses

what are cues for stage 2 claudication of peripheral artery disease

intermittent claudication - arterial occlusion obstructs blood flow to distal extremity ; pain w exercise subsides at rest

what are most common vessels in peripheral artery disease stage 2 claudication

superficial femoral artery and popliteral artery

what are cues for stage 3 rest pain of peripheral artery disease

awakened from sleep; may have numbness, burning; dependent position relieves pain

what are cues for stage 4 necrosis of peripheral artery disease

ulcers, necrotic tissue

what are acute cues of arterial occlusion

severe acute pain, loss of pulse, cold, pallor, vein collapse, impaired sensory motor function

what are chronic cues for arterial occlusion

decreased pulses; chronic pain; thick nails; dry skin; hair loss; temp gradient'; muscle wasting; tissue impairment / gangrene

what are the s/s of painful ulcers in arterial occlusion

begin on toes, minimal exudate; pale wound bed; necrotic tissue may cover the wound; well defined wound margins

what are complications of peripheral artery disease

ulceration; gangrene; infection » sepsis; amputation

what are PAD detection

ankle brachial index; doppler studies; angiography; MRA; CT scan (measures vessel cross section)

what are labs for peripheral artery disease

coag workup - PT/ INR/ PTT/ fibrinogen level

what are genetic risk for peripheral arty disease

acute DVT / PE without normal risk factors; factor v leiden; c reactive protein

how to take action for acute occlusion

thrombolytics; endovascular stent (discrete localized lesion); emergent bypass

how to take action for chronic occlusion

endovascular stents (great for discrete localized blockages and limb salvage); vascular surgery; bypass

restores vascular bypass and restores circulation ; alternate flow route

peripheral vascular bypass

where can grafts be performed for vascular surgery

saphenous vein and synthetic grafts

what are 6ps of circulatory checks

pain, pulses, pallor, paresthesia, paralysis, poikilothermy (internal temp varies and fluctyates w temp of surrounding)

s/s of graft occlusion

usually first 24h; increasing abd pain; cool, pallor, decreased pulse

tx for graft occlusion

thrombectomy; thrombolytics or llb/ llla antiplatelet drugs into thrombus; return to OR graft revision

improve perfusion & decreases vasoconstriction

antihypertensives

how to avoid stump edema

elevate stump for first 24h and promotes venous return

what to do for surg pain in amputees

IV narcs » PO

what pharm for phantom pain

Lyrica, Gabapentin (Neurontin) also TENS, acupuncture, try repositoning

localized dilation of arterial wall that results in alteration of blood vessel size, shape, and blood flow & may be asymptomatic

aortic aneurysms

column of blood separates the vascular layers ; torn intima; blood contained between layers

aortic dissection

exsanguinate - drained of blood

aortic rupture

what is location of type II and type II thoracic aortic aneurysm

ascending aorta

what is location of type III thoracic aortic aneursym

descending aorta

often between renal arteries and bifurcation of aorta

abd aortic aneurysm

what are solutions for <4 cm aortic aneurysm

monitor BP; serial ultrasounds; weight management

what are solutions for 5+ cm aortic aneurysm

surgical intervention

CM for aortic dissection

palpable mass in abd; tearing abdominal / chest pain; syncope / altered LOC; fleeting / absent distal pulses; shock

preo op aortic dissection CV stable or hypertensive

2+ ivs; manage HTN (metoprolol or labetalol first then nitroprusside or nitroglycerine); manage pain (morphine); OR for resection and grafting

pre op aortic dissection CV unstable

permissive hypotension ; IV fluids (crystalloids, NO NS); blood (PRBCs); OR emergently

standard aneurysm repair; large abd incision; graft sewn onto aorta

open surgical repair for aneurysm

stent and graft ; XR guided; epidural anesthesia; groin incision

endovascular aneurysm repair

what is post op for aortic aneurysm

high risk AKI r/t hypovolemia and cross clamp for AAA

how to prevent post op paraplegia after thoracic aortic aneurysm

cross clamp time; BP management (>90); lumbar drains

who may need coronary artery bypass graft

L main or triple vessel disease or any disease involving the LAD; 70% occlusion in 1+ arteries; ejection fraction > 50%