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ITE ReviewMust Know PulmAngela Pugliese MDDepartment of Emergency MedicineHenry Ford Hospital
Resources
HFH outlines
Rosh Review• First quiz assigned• in tutor mode, complete by end of month
• Quizzes to be given prior to each topic• will be in test mode• attempt completion prior to topic
• Mock ITE assigned beginning of January• replaces In-class exam
Study Plans
• We’re here to help
• <90% of passing ABEM board will meet with Pugliese or Slezak to create personalized study plan
• All others welcomed to meetings, contact via email
Overview• Pneumonia• Legionnare’s/PCP• Tuberculosis• Effusions• Other infections• Hemoptysis• Pneumothorax• Asthma/COPD• Drowning• ARDS
Pneumonia
Pneumonia• Most common cause of pneumonia is children??
• Strep pneumo• Viral• Staph• Hemophilus• Mycoplasma
Pneumonia• Pneumococcal pneumonia
• Most common cause of CAP• Still most common cause of pneumonia in HIV
• Gram positive lancet-shape• Most common cause of lobar pneumonia• Tx –
• Still sensitive to PCN and drug of choice• Mcrolides or doxy• Ceftriaxone (90% sensitivity) tx for inpatient
Pneumonia
• Hemophilus
• Gram negative pleomorphic rod (encapsulated and unencapsulated)• 2nd most common cause of CAP• Classic patient is elderly and debilitated• Tx- zithromax, augmentin, ceftriaxone
Pneumonia
• Klebsiella
• Plump encapsulated gram negative bacilli in pairs• THINK ETOH• Current jelly sputum• Upper lobe bulging fissure or abscess• Tx – IV cephalosporin + aminoglycoside
Pneumonia• Staph
• Gram positive cocci in pairs or clusters• THINK IVDA, SNF, INFLUENZA• Empyema common• Tx – nafcillin or vanc
Atypical Pneumonia
• Mycoplasma• Most common atypical, ‘walking pneumonia’• Cold agglutinin titers elevated 60%• tx - erythromycin
• Chlamydial• Staccato cough• Tx – 3 week doxy or erythromycin
• Psittacosis• PET BIRD or PET SHOP• Hyperexia, hemoptysis• Tx – 3 week tetracycline
Pneumonia
• The Viruses
• RSV – most common etiology in children <6, winter• Parainfluenza – 2nd most common in kids (causes croup
too)• Varicella-Zoster- bad in pregnancy, IV acyclovir and
admit• Influenza – most common etiology in adults, Nov-April,
tamiflu• CMV – transplant and AIDS, ganciclovir• Hantavirus – RODENT, southwest US, severe
respiratory distress, IV ribavirin
Legionnaire’s Disease
• Gram negative facultative intracellular bacillus• WATER SYSTEMS• Inhalation of contaminated aqueous aerosols• GI SYMPTOMS – watery diarrhea• Hyponatremia• Dx – urinary antigen test• Tx – macrolides, cipro for transplant pts
PCP
• Unicellular fungi, opportunistic• Most common opportunistic infection in HIV and leading
cause of death• CD4 < 200• CXR – normal, bilateral diffuse infiltrate ‘bat wing’• LDH increased• Tx – Bactrim and pentamidine• Alternative clindamycin and primaquine• Steroids paO2 < 70
Tuberculosis
• Think SNF, HIV, prisons, shelters and immigration
• AIDS defining illness
• Weakly gram positive obligate aerobe = acid fast
• Aerosolized droplet transmission
TB• Clinical presentation• Inactive pulmonary – 90% asymptomatic, + PPD• Reactivation – most common clinical form• Fever, night sweats, malaise, weight loss, productive cough• 80 % pulmonary involvement, apical lungs
• Active pulmonary foci – insidious• Chronic cough with hemoptysis
• Extrapulmonary - any organ• Disseminated ( miliary)• Meningitis – CSF increased protein• Pleural – effusion is exudative• GU - hematuria
TB• Diagnostic Studies• TB skin test – detects infection no active disease
• Don’t forget some people are anergic (HIV/AIDS)
• CXR –• Primary : Ghon complex, hilar adenopathy hallmark for kids• Reactivation : upper lobes• Miliary : small nodules scattered throughout both lung fields
• Micro –• Sputum test for AFB : ziehl-neelson or fluorescent, spec 98%• Confirm with culture which is gold standard
TB• Treatment• ISOLATE – mask on patient, put in negative pressure
• 4 drugs – Isoniazid, rifampin, pyrazinamide and streptomycin or ethambutol
• Side effects –• INH : hepatitis, peripheral neuropathy, intractable sz• Pyridoxine (vitamin B6)
• Rifampin : orange color secretions• Pyrazinamide :hyperuricemia, arthralgias• Ethambutol : optic neuritis• Streptomycin : nephrotoxicity
Effusions
Transudative
• CHF, nephrotic, cirrhosis• CHF most common cause
of effusions overall• Little protein
Exudative• Infection, CA, PE• Lots of protein• Pleural/serum protein >
0.5• Pleural LDH > 200• pH < 7.3 think infection• < 7 think empyema
Other Infections
Aspiration Pneumonia• Severity from specific substance • pH and volume are the big factors
• Risk factors – depressed cough or gag• FB aspiration – incomplete obstruction = cough, wheeze• CXR hyperinflation of affect side• Think new wheeze in kid
• Treatment• Supportive (ie intubate if hypoxic/airway concern)• Bronch to remove FB• Signs of infection or elderly/chronically ill
• Antibiotics, remember cover anaerobes
Lung Abscess
• Polymicrobial• Complication of aspiration• Halitosis, poor dentitia• CXR – cavitation with air fluid level, most
common RUL• Tx – clindamycin 6-8 week course
Empyema
• TB, staph, pseudomonas
• Treatment –• Must drain, ie chest tube required• Consult CT surgery• High dose broad spectrum antibiotics
SARS• Highly infectious coronavirus, transmitted in resp. droplets
• Presentation• 2-10 day incubation then…• Fever with cough and hypoxia• URI symptoms uncommon
• Thrombocytopenia and lymphocytopenia
• Treatment - supportive
Hemoptysis
Hemoptysis• Massive – single expectoration of > 50 mL• Or 600 mL in 24 hrs
• Etiology : infection• Massive - Bronchiectasis, TB, abscess or neoplasm
• Treatment• Trendelenburg with affected lung down• Consult pulmonary and CT surgery
Pneumothorax• Primary (idiopathic)• Young healthy smoker (skinny male)
• CXR confirms diagnosis (don’t forget US)
• Treatment – • O2 for all patients• Observation vs. CASP vs. Chest Tube
• Tension – needle, NO XRAY
Asthma/COPD
Asthma• Chronic, non progressive with reversible airway obstruction
• Etiology – triggers URI/virus, NSAID, ASA, beta-blocker
• Diagnostic testing – peak flow, ABG• Treatment – beta agonists, anticholinergic agents, steroids• Mag, hydration, heliox, BIPAP, epi• Intubation increases morbidity/mortality
• Pregnant patients• Incidence rises in pregnancy• Treatment same, terb over epi
COPD
• Most important risk factor smoking
• Progressive – • Can lead to right heart strain and even cor pulmonale
• Treatment – • O2 most important• Don’t forget about hypoxic drive
Drowning• 3rd most common cause of accidental death• Immersion syndrome• Sudden death with submersion in very cold water• Vagally mediated asystole or vfib
• Near drowning• Think metabolic acidosis from hypoxemia• Cerebral edema
• Treatment• Resuscitate• Don’t forget c-spine• rewarm
• Dispo – home if asymptomatic for 6 hours, O2 normal, CXR normal
ARDS• Mortality 40-70 %, sepsis most common cause• Etiology – GRAM NEG bacteremia, acute neuro crisis, tox• Pathophysiology• Permeability pulm edema, severe hypoxemia unresponsive to O2• Ireversable if inciting event not controlled
• Diagnosis• Decreased PaO2 (PaO2:FiO2 < 200)• High airway resistance• CXR – pulmonary edema with small heart
• Treatment• Fix inciting event• Oxygenate = PEEP
THE END
Announcements• Up Next Renal/GU
• ROSH!! Don’t forget Peer VIII• All outlines via email today, use for quick review