ICCM - Quiz 2

what is congestive heart failure?

a pump problem leading to fluid back-up in the legs and lungs

how do you classify heart failure?

left ventricular ejection fraction (LVEF) and symptoms

what are causes of heart failure?

chronic hypertension

diabetes

dyslipidemia

CAD

MI

valvular disease

drugs

what are the signs/symptoms of heart failure?

dyspnea, edema, weight gain, etc

what are the two types of heart failure?

reduced ejection fraction

preserved ejection fraction

what is the first medication that you need to give for a CHF exacerbation and why?

nitroglycerin

it is a vasodilator for the veins (SVC and IVC) which reduces the workload on the heart and alleviates symptoms like pulmonary edema

what is the other medication given for CHF exacerbation and why?

loop diuretic

relieves symptoms of fluid overload, such as shortness of breath and swelling, by forcing the kidneys to excrete excess salt and water

what are you going to see on physical exam for a patient with a CHF exacerbation?

signs of fluid overload

such as jugular venous distension, peripheral edema, and rales or crackles in the lungs

route and dosage options of nitroglycerin for CHF exacerbation

sublingual - 0.4 mg q 5 min as needed

IV - 5 mcg/hour

paste/lotion - 1/2 to 1 inch thick

what are side effects of nitroglycerin?

headaches, dizziness, low blood pressure, flushing

what is the mortality rate for a patient after being seen for a CHF exacerbation in the ED?

50% in 5 years

what is the mortality rate for a patient after being seen for flash pulmonary edema in the ED?

50% in 2 years

route and dosage of loop diuretics for CHF exacerbation

furosemide (Lasix) - 40 mg PO or 20 mg IV

torsemide (Demadex) - 20 mg PO or 10 mg IV

bumetanide (Bumex) - 1 mg PO or 0.5 mg IV

how would you compare the loop diuretics?

furosemide -> torsemide -> bumetanide

more potent, harder on the kidneys, and more expensive

if someone takes 80 mg PO of furosemide at home, how much torsemide IV would they need in the ED?

40 mg IV

what is the general rule for dosing loop diuretics in the ED for CHF exacerbations and why?

double the dose that they are on at home

want to give enough to alleviate the patient's symptoms, but not too much to cause dehydration

what labs and imaging should you order for a patient coming in with dyspnea?

labs - CMP, CBC, troponin, Mag, BNP

imaging - EKG and chest x-ray

what is your differential diagnosis for bilateral, symmetric leg edema?

CHF exacerbation

end-stage kidney failure

liver failure

hypothyroidism

lymphedema

what is severe hypothyroidism called and what sign is present?

myxedema coma - pretibial edema

what is cardiac tamponade?

fluid in the pericardial space

what are signs/symptoms of cardiac tamponade?

dyspnea, jugular vein distention, muffled heart sounds, hypotension

what is Beck's Triad?

jugular vein distention

muffled heart sounds

hypotension

what can cause cardiac tamponade?

acute onset - trauma, MI, aortic dissection, pericardial effusion

slow onset - autoimmune, malignancy, chronic inflammation, pericarditis, hypothyroidism, connective tissue disorders

what population do you see cardiac tamponade the most?

patients with autoimmune diseases

what do you see on EKG for cardiac tamponade?

electrical alternans - beat-to-beat alternation in the QRS

tachycardia

low QRS complex voltage

what do you see on echo for cardiac tamponade?

swinging heart in the pericardial sac

what do you see on x-ray for cardiac tamponade?

water bottle shaped heart

what do you see on ultrasound for cardiac tamponade?

pericardial Effusion

RA systolic collapse

RV diastolic collapse

plethoric IVC

what is the treatment for cardiac tamponade?

emergent pericardiocentesis

what trial supports lisinopril/lorsartan, amlodipine, and hydrochlothiazide as treatment options for hypertension?

Systolic Blood Pressure Intervention Trial (SPRINT)

what does the SPRINT study support?

which medications are best for hypertension treatment

what are the three medications used for hypertension management?

lisinopril/losartan

amlodipine (preferred)

hydrochlothiazide

more on lisinopril

ACE inhibitor

dose - 2.5 - 40 mg PO DQ

side effects - dry cough -> angioedema, hyperkalemia (AKI)

what is angioedema?

swelling of the tongue and throat

a bradykinin mechanism

when can angioedema occur when taking lisinopril or losartan?

any time

what is the treatment for angioedema?

fresh frozen plasma

more on losartan

ARB

dose - 25 - 100 mg PO QD

side effects - dry cough -> angioedema, hyperkalemia (AKI)

more on amlodipine

non-DHP calcium channel blocker

dose - 2.5 - 10 mg PO QD

side effects - edema, dizziness

more on hydrochlorothiazide

thiazide diuretic

dose - 12.5 - 25 mg PO QD

side effects - polyuruia, lightheadedness, electrolyte abnormalities (hyponatremia, hypokalemia, hypomagnesemia, hypercalcemia), hyperglycemia

what is pulmonary embolism?

blood clot in the lungs

how does a pulmonary embolism occur?

when a thrombus breaks free from elsewhere in the venous system and travels to the lungs

what is the most common cause of a PE?

DVT

where is the emboli found in a PE?

pulmonary artery

what can occur if a PE is large enough?

stop the heart

what is the location of a saddle PE?

bifurcation of the main pulmonary artery

what are the signs/symptoms of a PE?

dyspnea on exertion, hypotension, hemoptysis

other - pleuritic chest pain, dizziness, hypoxia, leg pain or swelling

what are the risk factors for a PE?

known or family history of DVT, recent surgery, cancer, coagulation disorders (factor V leiden), atrial fibrillation, immobility, pregnancy, oral contraceptives, smoking

what are the diagnostic testing options for a PE?

d-dimer - preferred for low-risk patients to help rule out PE

CT angiography - preferred for moderate- to high-risk patients

pulmonary angiography - gold standard, but not done due to invasiveness

what are some anticoagulant options?

heparin - IV

enoxaparin (lovenox), - SQ

apixaban, rivaroxaban, dabigatran, warfarin - PO

what are the treatment options for PE?

anticoagulant - heparin (IV) or enoxaparin (SQ)

thrombectomy - large clot or severe signs/symptoms

comparison of anticoagulant options for PE

heparin - preferred in surgery/thrombectomy due to being able to stop the drip during the procedure if needed whereas enoxaparin is in the system for 12 hours

enoxaparin - injection BID (easy admin for nurses)

high-dose heparin IV bolus dosage for PE

80 units/kg

max 10,000 units

high-dose heparin IV drip dosage for PE

18 units/kg

max 2,000 units/hour

enoxaparin (lovenox) SQ dosage for PE

1 mg/kg SQ BID

max 120 mg

does heparin remove the clot causing the PE?

no - it just prevents future clots

what is goal INR

2-3

how do you reverse heparin and enoxaparin?

protamine sulfate

do all patients with a PE need a thrombectomy?

no - the body will break down smaller clots and thrombectomies are needed for larger clots or patients with severe signs/symptoms

when do you do a thrombectomy?

large clots

evidence of right ventricle strain

hypotension

hypoxia

elevated BNP or troponin

what is pneumonia?

infection of the lungs with thick, fluid build up

what are the causes of pneumonia?

bacteria, viruses, fungi, aspiration

what is the most common cause of pneumonia?

viral

most common - COVID, RSV, influenza

other - adenovirus, parainfluenza, human metapneumovirus

how is bacterial pneumonia spread?

secretions

how is viral pneumonia spread?

airborne/droplets

what are the bacteria that cause typical pneumonia?

streptococcus pneumoniae

haemophilus influenzae

moraxella catarrhalis

klebsiella pneumoniae

what are the bacteria that cause atypical pneumonia?

legionella pneumophila

mycoplasma pneumoniae

chlamydia psittaci

what are risk factors for pneumonia?

elderly, COPD, asthma, cystic fibrosis, immunocompromised, smokers, history of viral respiratory infection, mechanical ventilation

what are the outpatient treatment options for pneumonia?

amoxicillin/clavulonic acid (augmentin)

doxycycline

levofloxacin (levaquin)

azithromycin (Z-Pak)

amoxicillin/clavulonic acid PO dosage for outpatient pneumonia

875 mg PO BID

7-10 days

doxycycline PO dosage for outpatient pneumonia

100 mg PO BID

7-10 days

levofloxacin PO dosage for outpatient pneumonia

750 mg PO BID

7-10 days

azithromycin PO dosage for outpatient pneumonia

day 1 - 500 mg PO QD

days 2-5 - 250 mg PO QD

what are the inpatient treatment options for pneumonia?

ceftriaxone (rocephin) and azithromycin (Z-Pak)

levofloxacin

ceftriaxone IV and azithromycin PO dosage for inpatient pneumonia

ceftriaxone 1 g IV QD

azithromycin

day 1 - 500 mg PO QD

days 2-5 - 250 mg PO QD

levofloxacin IV dosage for inpatient pneumonia

750 mg IV QD

what can cause ascending paralysis?

Guillain-Barré syndrome

tick bites - rocky mountain wood tick or american dog tick

what can cause descending paralysis?

botulism - clostridium botulinum

myasthenia gravis

gram positive bacteria list

staphylococcus

streptococcus

enterococcus

clostridium

listeria

bacillus

corynebacterium

gram negative bacteria list

escherichia

vibrio

salmonella

haemophilus

moraxella

pseudomonas

bartonella

pasturella

proteus

neisseria

klebsiella

enterobacter

helicobacter

yersinia

campylobacter

shigella

brucella

francisella

treponema

anaerobe bacteria list

bacteroides

eikenella

fusobacterium

eubacterium

atypical bacteria list

chlamydia

legionella

mycoplasma

what streptococcus species lives in the mouth?

streptococcus mutans

who gets listeria?

under 3 months and over 75 years

how can someone get listeria?

moldy bread, unpasteurized dairy products, raw or undercooked meats, raw vegetables, processed foods

who gets klebsiella?

alcoholics

will present with currant jelly sputum with bacterial pneumonia

thrombotic thrombocytopenic purpura (TTP)

reductions in ADAMTS-13 activity

signs/symptoms - hemolytic anemia, thrombocytopenia,

acute renal failure, AND fever and neurological symptoms

treat - plasma exchange (TPE)

hemolytic uremic syndrome (HUS)

cause - ingestion of undercooked ground beef contaminated with E. coli (shiga toxin-mediated)

signs/symptoms - hemolytic anemia, thrombocytopenia,

acute renal failure

how do you get salmonella?

poultry, egg shells, raw or undercooked meat, dairy products, fruits, and vegetables

what is the most common cause of duodenal ulcers?

H. pylori

what are the options to treat C. diff?

vancomycin 125 mg PO QID x 10 days

metronidazole 500 mg PO BID

fidaxomicin

what is the most common cause of bacterial meningitis?

streptococcus pneumoniae

what is a considerations for treating bacterial meningitis?

dexamethasone needs to be started prior to antibiotic treatment

what is a typical IV dose for piperacillin/tazobactam?

3375 mg IV Q6 hours

what is typical IV dose for vancomycin

patient < 75 kg - 1 g IV BID

patient > 75 kg - 1.5 g IV BID

prior to vaccination, what was haemophilus the most common cause of?

epiglotitis

what causes rice water stool?

vibrio cholerae

what are the PO options to treat MRSA?

trimethoprim-sulfamethoxazole (bactrim)

clindamycin

doxycycline

linezolid

what is the history of fluoroquinolones?

discovered in 1962

the first quinolone, nalidixic acid, is discovered as a byproduct of chloroquine synthesis

what is the mechanism of action of fluoroquinolones?

inhibit DNA gyrase and topoisomerase IV, disrupting DNA replication

what are the side effects of fluoroquinolones?

tendonitis (tendon rupture), GI upset (nausea, vomiting, diarrhea) with dairy