Group Learning

Heart Failure

200

What are the four causes of an elevated troponin in Acute Heart Failure

• Type 1 MI – acute thrombosis
• Type II MI – supply and demand mismatch of myocardial oxygenation
• Acute myocardial injury – stretch-related injury
• Chronic myocardial injury – Structural heart disease, CKD

400

Describe the pathophysiology behind SCAPE

Sympathetic activation which causes vasoconstriction resulting in increased afterload (worsens heart failure) and fluid redistribution into the lungs causing pulmonary edema.

600

What is approximate goal urine output after giving IV diuretic in AHF?

150 ml/hour.

800

List three causes (each) for a falsely low and falsely high BNP

Low:

• Patient obesity
• Flash pulmonary edema (too early to detect significant BNP elevation)
• Constrictive pericarditis or restrictive cardiomyopathy

High:

• Renal dysfunction
• Older age
• Female
• Pregnancy
• Atrial fibrillation
• Inflammatory conditions

1000

List 4 risk factors for loop diuretic resistance

• CKD
• Hypoalbuminemia
• Past history of loop diuretic resistance
• Extremely low cardiac output
• More severe AHF presentation
• High home dose of loop diuretic
• Urine output 1 hr after loop diuretic < 480 ml
• Total urine sodium in 1st hour after loop diuretic < 35.4 mmol
• Diuretic efficiency at 3 hours < 3.5ml urine/mg IV furosemide

Peds Lung Disorders

200

80% of children with Cystic Fibrosis will be permanently colonized with this pathogen by the age of 18

Pseudomonas aeruginosa

400

Risk factors (3 each) for S. pneumonia vs S. aureus pneumonias in children 

S. pneumonia

• Immunodeficiency
• Chronic renal disease
• Functional/anatomical asplenia
• Children of Indigenous descent

S. aureus 

• Foreign body aspiration
• Immunosuppression
• Concomitant skin infection

600

Mycoplasma pneumonia can cause some uncommon, though serious, side effects. Please list 3.

Hemolytic anemia 

HUS

Myopericarditis

Neuro Dx (GBS, meningoencephalitis, transverse myelitis, cranial neuropathy)

Rhabdomyolysis 

Arthritis 

SJS

800

Please list and describe the three clinical stages of Pertussis

Catarrhal Phase - 1 to 2 weeks. Mild URT symptoms and cough

Paroxysmal Phase - 2 to 4 weeks. Disease progresses to staccato cough followed by posttussive emesis. May have episodes of cyanosis and apnea in infants < 6 months. Fever generally absent. 

Convalescent Phase - 6 to 10 weeks. Symptoms gradually wane.

1000

Pneumonias caused by this pathogen are preceded by conjunctivitis in ~50% of cases

Chlamydia trachomatis

Drowning

200

Contact with water that is more than 5 degrees Celsius below body temperature causing syncope from cardiac dysrhythmias is defined as ___________. 

Immersion Syndrome 

400

The largest risk factor for drowning

Alcohol

600

The length of time of observation for a patient with submersion with normal room air oxygen saturation and a normal chest x-ray

8 Hours

800

A specific risk to consider when applying positive pressure ventilation in patient’s who has drown?

Gastric dilation and aspiration of fluid that was swallowed during drowning

1000

The amount of fresh or salt water needed to aspirate to cause loss of surfactant

1 – 3 ml/kg

ASA and NSAIDs

200

Household products that contain salicylates (at least 3)

aspirin, bismuth subsalicylate (pepto-bismol), oil of wintergreen, topical salicylates, analgesic balms, Alka Seltzer

400

You are managing a patient following an acute ASA ingestion. While they were initially asymptomatic, on reassessment you find them to be lethargic. Explain the pathophysiology of their altered mental status, and how you would manage it.

Salicylates interfere with mitochondrial oxidative phosphorylation, causing anaerobic metabolism. As more glucose is consumed, the risk of central hypoglycemia can develop. In all altered patients in the setting of salicylate overdose, give 0.5-1g/kg of IV dextrose, REGARDLESS of their serum glucose level.

600

Outline the 3 stages of salicylate toxicity, and the acid-base disorders associated with each stage

• Early (0-4hrs) [1.1-3.3 mmol/L]: Respiratory alkalosis, due to the salicylates effect on the medullary respiratory center, causing hyperventilation.
• Moderate (2-12hrs) [2.7-5 mmol/L]: Respiratory alkalosis with a metabolic acidosis. However, pH is neutral/alkalemic at this stage. Salicylates interfere with aerobic metabolism by uncoupling mitochondrial oxidative phosphorylation. The hyperventilation effects from stage 1 are now compensatory for this concomitant metabolic acidosis.
• Severe (6-12hrs) [>4.4 mmol/L]: Respiratory alkalosis or acidosis and metabolic acidosis. Now acidemia should be present on blood gas. As acidemia develops, more salicylate becomes un-ionized, and is able to pass through the blood brain barrier

800

Indications for hemodialysis in the setting of acute salicylate poisoning (at least 5)

• Altered mental status, coma, seizure
• Renal failure
• Hepatic failure
• Pulmonary edema or resp failure
• Acidemia (pH < 7.1 to 7.2)
• Deterioration in condition
• Need for intubation
• Rapidly rising salicylate level
• Acute ingestion with a serum level > 5.6 mmol/L
• Chronic ingestion with a serum level > 2.2 mmol/L

1000

Despite your best resuscitation efforts your massive ASA overdose patient continues to decompensate, and the decision is made to intubate. What specific concerns would you worry about, and how would you address them.

Very PHYSIOLOGICALLY difficult airway. As the patient’s respiratory alkalosis and hyperventilation is compensating for their metabolic acidosis, removing the patient’s respiratory drive can cause rapidly worsening acidemia.

• Apneic period: Premedication with 1-2 amps of NaHCO3 to temporarily compensate for the lack of respiratory drive on induction. This should be done regardless of pH to account for the lack of respiratory compensation.
• Matching their minute ventilation: In the setting of overdose, these patients have a very high respiratory drive, and compensation is likely not going to be achievable with a ventilator. Attempt to hyperventilate them as much as possible, but ultimately hemodialysis will be needed to prevent acidemia.

Ultrasound

200

Assuming appropriate anatomical positioning/location, we can confirm an IUP from this scan because of these three features:

Decidual Reaction

Gestational Sac

Yolk Sac +/- Fetal Pole 

400

M Mode images of the lung

Seashore sign - normal lung

Barcode sign - pneumothorax

600

Posterior Vitreous Detachment

800

Describe the phenomenon occurring in this scan and why it occurs

Lung hepatization 

As the lung accumulates fluid with consolidation, it can appear echogenic and "live-like" 

1000

Approximately how much fluid is required for a positive upper quadrant fast scan?

600 mL