Mmd Test 4

Front 1

Examples of Localization - can be localized to? (7)

Back 1

- brain

- spinal cord

- nerve root

- anterior horn cell

- peripheral nerve

- NMJ

- muscle

* localize based on history and neuro exam

Front 2

UMN Findings - pattern of weakness? reflexes? babinski is? also see (2)

*diseases affect?

Back 2

- spasticity

- hyperreflexia

- pyramidal pattern of weakness (extensors in lower, flexors in upper limbs)

- upgoing toes = positive Babinski

- clonus

**diseases affect CCS tract

Front 3

LMN Findings - atrophy of? tone is? muscle may? reflexes?

- diseases affect? (3)

Back 3

- muscle atrophy

- fasciculations

- flaccid tone

- hyporelfxiea

- areflexia

** diseases affect nerve roots, anterior horn cells, peripheral nerves

Front 4

Vascular vs Inflammatory Events

- vascular involve? typically?

- Inflamm in? onset? evolve over?

Back 4

V = involving the nervous system are typically abrupt onset

I = in nervous system, typically gradual onset and evolve over hours to days

Front 5

Localization in Brain - would see if right sided?

- weakness? loss of? on?

- reflexes? positive?

Back 5

- left sided weakness in pyramidal pattern

- left hemi-sensory loss

- left arm and leg hyper-reflexia

- positive left babinski

Front 6

For left lumbosacral nerve root lesion, would expect?

- lower back?

- weakness in?

- sensory loss in?

- loss of?

- muscle?

Back 6

- lower back and radiating left leg pain

- weakness in myotomal pattern

- sensory loss in dermatomal paterrn

- loss of deep tendom reflexes = L4 or S1

- uscle atrophy in left leg if chronic

Front 7

For thoracic spinal cord lesion, expect

- weakness of? sensory loss of?

- symptoms seen in?

- in legs see?

Back 7

- bilateral lower limb weakness (spared arms)

- bilateral lowrr limb sensory loss 9spared arms)

- sensory level on torso

- bowel and bladder symptoms

- UMN findings in legs

Front 8

EMG - reduced sensory amplitudes

- consistent with? can diagnose?

Back 8

- consistent with diffuse, axonal, length-dependant sensory peripheral neuropathy

- can diagnose idiopathic peripheral neuropathy

Front 9

In diffuse length-dependent sensor peripheral neuropathy, expect?

- bilateral? (2)

- reflexes?

Back 9

- bilateral distal limb weakness

- bilateral distal limb sensory loss

- reduced or absent distal reflexes

Front 10

See bilateral eyelid ptosis, bilateral weakness of eye closure, reduced reflexes and diffuse limb weakness, expect?

- think of? such as?

Back 10

- pre-synaptic NMJ transmission defect, such as botulism

Front 11

Disorders of NMJ, expect? (6) = P/D/B/Diffuse? Symptoms of? Weakness that?

Back 11

- ptosis

- diplopia

- bulbar symptoms

- diffuse limb weakness

- resp symptoms

- weakness fluctuates

Front 12

When to use electromyogrpahy and nerve conduction symptoms? (5)

Back 12

- peripheral neuropathy

- radiculopathies

- anterior horn cell disease

- myopathy

- disorders of NMJ

Front 13

All causes of left foot weakness?

- brain? could be? from? spinal cord? idiopathic? NMJ of?

Back 13

- right hemisphere lesion = Hematoma, stroke

- left L5 radiculpathy = disk herniation

- spinal cord lesion = thoracic cord compression

- peripheral neuropathy = idiopathic

- NMJ = botulism

Front 14

When to suspect increased Intracranial pressure when lesion is in the brain

- see? (5) due to?

- see focal? and related?

Back 14

- see headache, N, V, papilledema, diplopia due to 6th nerve palsies

- see focal neuro symptoms

- see related seizures

Front 15

SC Syndromes - Brown Sequard

- is a lateral?

- below level, see ipsilateral? (2)

- contralateral?

- no? **

Back 15

is a lateral hemisection syndrome, see:

= ipsilateral UMN signs below level

= ipsilateral loss of prop and vibration sense

= contraL loss of pain and temp below level of lesion

= no bladder symptoms**

Front 16

SC Syndromes - AC Syndrome

- syndrome of?

- can see changes of?

- bilateral?

- symptoms of?

- normal? **** as this is found in?

Back 16

- is a ventral cord syndrome, see:

= weakness, reflex chnages

= bilateral loss of pain and temp

= urinary incontinence

= normal tacitle, position and vibration sense (in dorsal columns)

Front 17

SC - Posterior Cord Syndrome

- is a syndrome of?

- weakness presents as? A vs C?

- loss of?

- may have both? (2)**

Back 17

- is dorsal cord syndrome, see:

= weakness, if acute (muscle flaccid, hyporeflexia), if chronic (hypertonia, hyperreflexia)

= loss of tactile, position and vibration

= +/- upgoing plantar

= +/- urinary incont

Front 18

SC CENTRAL CORD SYNDROME

- loss of? in the? at?

- presents as a? *

- normal?

- alsp normal?

- some? if?

Back 18

- loss of pain and temp in dermaotmes at site of SC lesions **suspended sensory level**

- normal pain and temp above and below

- normal vibration and proprio

- see some weakness and reflex loss with larger lesion

Front 19

DDx for Polyneuropathy - (7)

Back 19

- diabetes

- HIV infection

- Amyloidosis

- Hypothyroidism

- B12 defic

- lyme

- Malignancy

Front 20

Signs and Symptoms of brain Lesions

- signs of? pattern?

- general?

- focal? aphasia of?

- dysfunction of?

Back 20

- UMN signs, pyramidal pattern

- general = headache, seizure, nausea, vomiting,syncope

- focal = weakness, sensory loss, aphasia if dominant side (apraxia if non-dom)

- visual spatial dysfunction

Front 21

Signs of SC Lesions

- big hint is?

- signs of? weakness in?

- if localized?

Back 21

- bilateral motor and sensory signs is big hint

- UMN signs and pattern of weakness

- if localized, symptoms in muscle groups innervated below that level, normal abovw

Front 22

Cauda Equian Syndrome

- pain that is?

- weakness of?

- dysfunction of?

Back 22

- assymetric multiradicular pain, leg weakness and sensory loss, bladder dysfunction

Front 23

Segmental Transection Syndrome

- loss of all?

- weakness found?

- see dysfunction of?

Back 23

- loss of all sensory modalities, weakness below affected level, bladder dysfunction

Front 24

Nerve Root Signs and Symptoms

- signs? (3)

- weakness in? sensory loss in? (patterns)

- diff mainly by?

- damage due to?

- hallmark?

Back 24

- LMN signs and weakness with hyporeflexia, muscle atrophy, fasciculations

- weakness in myotomal pattern, sensory loss in dermatomal pattern

- diff. mainly by sensory loss symptoms

- damage often due to compression, results in hallmark symptom of pain

Front 25

LS Radiculos - S1 vs L5 vs L4 vs L3

Back 25

Front 26

Cervical Radulos - C5 vs C6 vs C7 vs C8

Back 26

Front 27

Anterior horn Cell Signs and Symptoms

- signs of? see??

- difficulty?

- no***

- vs peripheral nerve, see?

Back 27

- LMN signs, see muscle atrophy, difficulty performing or doing things do to weakness

- no sensory deficits ******

- vs peripheral nerve, see some sensory defs

Front 28

Periphral Nerve signs and symptoms

- can be either?

- sensory with?

- motor with? resulting in? likely affected?

Back 28

- can be mono or pomy neuropathy

- see sensory with burning, tingling, numbness

- motor, see weakness to muscles supplied by peripheral nerve, muscle cramps, longest nerves with largest diameter fibres more likely of disruption

Front 29

NMJ signs - P/D/B such as?

- intermittent?

- resp?

- no?

- key is**

Back 29

- ptosis

- diplopia

- bulbar symptoms = dysphagia, dysarthria

- intermittent, limb weakness,

- resp symptoms

- no sensory deficits

- key is fluctuation of symptoms **

Front 30

Lhermitte Signs

- transient? described as? after?

- seen mostly in? but also? (3)

Back 30

- transient sensory symptoms described as electric shock radiating down spine into limbs most often after flexion of the neck

- seen in MS mostly but also lesions of cervical cord, tumours, cervical disk hernaition

Front 31

Uhthoffs Phenom - worsening of?

- condition of? when body?

- result of? seen in?

- see?

Back 31

- worsening of neuro symptoms in MS

- demyelinating condition when body gets overheated from hot weather, showering, etc

- result of conduction block developing in central pathways

- see black spots when exercising, have hot shower

Front 32

GBS Lumbar Puncture

- LP reveals? elevated? normal?

- abnormal?

Back 32

- LP reeals elevated CSF protein when normal CSF WBC count

- elevated WBC count is abnormal

Front 33

NMJ - see a? fluctuating?

Back 33

- pure motor syndrome with fluctuating ptosis, diplopia, bulbar symptoms, limb weakness

Front 34

Acquired Myasthenia Gravis - is? prevalence of?

- found in all?

- onset?

- women, more common in? men?

Back 34

- AI disorder of NMJ, prevalence of 20/ 100, 000

- all age groups

- bimodal onset

= more common in women when onset <40

= more common in men when onset > 50

Front 35

Clinical Features of MG - P/O

- weakness of? (2)

- neck?

- limb?

- also see?

*mainly can tell by?

Back 35

- ptosis

- opthalmoparesis

- faical muscle weakness

- bulbar weakness

- neck flexor and extensor eakness

- limb weakness

- dyspnea

* see fluctuating and fatig. weakness, betters with rest****

Front 36

Pathophys of MG

- antibody that? at?

- results in? to?

Back 36

- Antibody destroying Acetycholine receptors of post-synaptic junction

- results in decreased ability of Ach to eleicit response

Front 37

Diagnostic Testing to make MG diagnosis -3 steps

- bedside?

- then do? which can show?

- serological then?

Back 37

1) Bedside test = tensilon test

2) Electrodiagnostic Test = Repetitive Nerve Stimulation (RNS) and Single Fiber EMG (SFEMG)

- RNs shows decrease power with repetition

3) serological tests = Acetylcholine receptor Abs

Front 38

MG Disease Management

- symptomatic? = (3)

- DMT = (3)

- surgery?

Back 38

1) Symptomatic Therapy

= Mestinon, Plasma Exchnage, IVIG

2) Disease Modifying Therapy

= Corticosteroids, Azathioprine, Cyclosporine, Myco Mofetil

3) Disease Mod Surgeyr = thymectomy?

Front 39

MG Disease Prognosis

- disease has become?

Back 39

- before modern day therapy, see 33% remission, 33% active disease and 33% died

- with today's therapy, see disease well controlled in most, mortality less than 5%

Front 40

Myopathy Signs ****

- pure? proximal? lower?

Back 40

- pure motor syndrome with proximal upper and lower extremity weakness ***

Front 41

See myopathy in? (2)

investigations should include? (5)

- should perform?

- do MRI of? for?

Back 41

- Hyperthyroidism and Graves disease

- should investigate CK levels, TSH, ESR and CRP and ANA

- should perform EMG and nerve conduction studies, MRI of proximal muscle for myositis, muscle biopsy and genetic testing

Front 42

DD of Muscle Diseases - MD/CM/ MM/ MM/ ERM/ Med induced? Inflamm?

Back 42

- muscular dystrophy

- congenital myopathy

- mitochondiral myopathy

- metabolic myopathy

- endocrine related myopathy

- medication-induced/ toxic myopathy

- inflamm myopathy

Front 43

Diffuse Motor Neuron Disorder presents as? *****

- a progressive? mixed? seen in?

Back 43

- a progressive pure motor syndrome involving mixed upper and lower motor neuron findings in bulbar and limb muscles

Front 44

Motor Neuron Disease = subtypes?

- upper and lower include?

- could also be just? or just?

- incidence of ALS is?

- peak incidence?

- mean survival after?

Back 44

- subtypes include:

= upper and lower motor neurons= ALS

= upper motor neurons

= lower motor neurons

- incidence of ALS is 1-2/ 100,000

- peak incidence is age 50-75

- mean survival after diagnosis = 3 yeras

Front 45

Amyotrophic Lateral Sclerosis (ALS)

- progressive disorder of?

- pathophys is poorly?

- pyramidal cells in?

- sparing of?

Back 45

- progressive disorder of upper and lower motor neurons:

- pyramidal cells in motor cortex = layer 5

- alpha motor neurons of brainstem and spinal cord

- sparing of oculomotor motor nuclei and nucleus of Onufrowicz

* pathophys poorly undestood

Front 46

Clinical Features of ALS

1) Spinal? %? upper vs lower?

- distal? typically? gradual?

2) Bulbar? affects? presents as? is typically?

* key feature

Back 46

1) Spinal Onset ALS = 80%

= upper limb onset > lower limb

= distal focal limb weakness and atrophy

= typically unilateral

= gradual spread to other regions

2) Bulbar Onset ALS

= cranial nerves 7,9 and 10

= dysarthria and dysphagia

= aggressive disease with typically rapid progression

* key feature is Upper and Lower motor neurons findings in involved region

Front 47

Diagnosis of ALS requires progressive?

- supportive?

- no evidence of?

Back 47

- progressive pure disorder of upper and lower motor neurons

- supportive EMG studies

- no electrophysiologic, neuroradiological or neuropathological evidence of another condition to explain findings

Front 48

Pathophys of ALS - poorly? major focus on? (2)

- additional theories include? (4)

Back 48

- poorly understood

- excitotoxicity and oxidant stress are current major areas of focus

- additional theories include = genetic predisposition, toxin exposure, mito dysfunction and viral etiology

Front 49

Natural History of ALS - relentless? results in?

- ultimately causes?

Back 49

- relentless progressive disease

- quadraplegia

- respiratory muscle involvement and ult. resp. failure

Front 50

treating ALS - primarily? Riluzole is? only gives?

Back 50

- treatment are primarily supportive

- Riluzole often prescibed but effect in minimal

- 3 month average increase in survival

Front 51

A pure motor syndrome with fluctuating ocular, bulbar and limb weakness makes you think?

Back 51

NMJ

Front 52

A pure motor syndrome with proximal upper and lower extremity weakness makes you think?

Back 52

- myopathy

Front 53

A progressive pure motor syndrome involving upper an dlower motor neuron findings in bulbar and limb muscles makes you think?

Back 53

- diffuse motor neuron disorder

Front 54

Peripheral Nervous System

- originates in? ends in?

- includes both? as well as?

Back 54

- analogous to the wiring of the NS

- originates and ends in SC and end organs

- motor and sensory systems involved in involuntary reflex arc as well as volutnary control/awareness

Front 55

General Localizations in PNS - (7)

Back 55

- myopathy

- NMJ

- mononeuropathy

- plexopathy

- radiculopthy

- motor/sensory neuronopathy

- polyneuropathy

Front 56

Components of Peripheral Neurons - Motor

- cell body in? then? then? then? at?

Back 56

- cell body located in anterior horn of SC

- nerve root

- axon/ myelin sheath

- NMJ

- muslce

Front 57

Components of Peripheral Neurons - Sensory

- sensory end organs are?

- cell body is?

- axon terminal in?

Back 57

- sensory end organs = receptors

- axon/ myelin sheath

- sensory ganglion = cell body

- nerve root

- axon terminal located in dorsal horn of SC

Front 58

Principles of Nerve Conduction

- propagation of impulses occurs?

- depol is?

- transmission depends on?

Back 58

- propagation of nerve impulses occurs analogously to transmission in CNS

- depol/ hyperpolariation dependent balance between sodium influx and K efflux from cells

- strength and speef of transmission depends on type of nerve fibre = motor, sensory, autonomic

Front 59

Saltatory Conduction

- nerves contain? acts as? prevents? enhances? via?

conduction ranges from?

- autonomic conduct? due to?

Back 59

- motor and sensory nerves contain myelin sheaths = neuronal insulation

- myelin sheath prevents currents "leak" and enhances neuronal transmission via saltatory conduction (current skipping)

- nerve conduction ranges from 40-60 meters/ second depending on location (upper and lower extremity) and modality (motor vs sensory)

- autonomic nerves conduct much slower due to lack of myelin

Front 60

Mechanisms of Nerve Injury

- disrupted? is most?

- also can be due to? (2)

- or?

Back 60

- disrupted axonal transport = most common

- nerve infarction

- nerve inflammation

- compression / direct trauma

Front 61

Axonal Transport

- see transportation along?

- anterograde used for?

- retrograde used for?

- highest chance of disruption in?

Back 61

- building blocks are transported from the cell body throughout the length of the axon

- anterograde transport is responsible for bringing essential nutrients to the neuron

- retrograde transport returns debris to cell body for recycling

- longest nerves (toes) and largest diameter fibers (sensory) have the highest chance of having disruption in this system

Front 62

Polyneuropathy - most common type of?

- has a? affects first? then reaches? then seen in?

- is dependent on?

Back 62

- most common type of peripheral neuropathy

- "length dependent" pattern:

= affects sensation in the toes first

= once symptoms reach the level of the knees, fingertips begin to be affected

** length dependent = related to deficiency in axonal transport

Front 63

Clinical Features of Polyneuropathy

- Sensory = ?

- tingling of? also see?

- motor see? (2)

Back 63

- Sensory:

= itching, burning, freezing = +, small fiber

= tingling = +, large fiber

= numbness (-)

- Motor:

= muscle cramps (+)

= weakness (-)

* leads to gait difficulties, falls, self-injury

Front 64

Polyneuropathy - Clinical Features - Autonomic - can cause? HR? increased? bowel? dysfunction of? blurring of?

Back 64

- syncope/ presyncope

- arrythmia = tachy, brady

- increased + or decrease perspiration (-)

- diarrhea + or constipation +

- bladder dysfunction

- visual blurring

- sexual dysfunction

Front 65

Etiologies of Polyneuropathy - can be either?

Back 65

- can be hereditary or acquired

Front 66

Acquired - Distal Symmetric Polyneuropathies - Main Categories

- metabolic includes?

- defic in?

- toxic?

- also caused by? (3)

Back 66

- metabolic neuropathy = endocrinopthies, organ dysfunction

- nutritional deficiencies

- toxic neuropathy = enviro, medications

- infectious causes

- cancer assoc.

- connective tissue diseases

Front 67

Acquired - Distal Symmetric Polyneuropathies = Common Specific Etiologies (10)

Back 67

- idiopathic

- diabetic neuropathy = impaired glucose tolerance

- B12 defic

- thyroid disease

- paraproteinemia = monoclonal gammopathy, malignant

- alcohol

- renal disease

- syphilis/ HIV

Front 68

Acquired - Medications Causing Neuropathy

- chemo =? anti? cardiac? also with?(4)

Back 68

= chemo = cisplatin, taxol, Vincristine

= anti-infectious = Isoniazid, metro, colchicine, Ethambutol, HIV meds

- phenytoin

- cardiac meds = amiodarone, hydralazine

- pyridoxine

- Cimetidine

- Disulfiram

- Chloroquine

Front 69

Acquired Neuropathy - developing world #1 cause? developed?

Back 69

- in developing world = #1 cause of neuropathy is leprosy

- in developed world = #1 cause is Diabetes

Front 70

Hereditary Neuropathy - ISP - often without?

- abnorms of? such as?

- usually focused?

- most common hered is? **

Back 70

1) Insidious Symmetric Progression = often without pain or positive sensory or motor symptoms, often severe weakness and sensory loss without much disability

2) Bony and Cutaneous Abnorms = pes cavus = high arched feet and hammer toes

3) Usually a focused FH

* most common type of hereditary neuro is Charcot-Marie-Tooth = CMT

Front 71

NCS/EMG uses

- evaluates the?

- able to provide info on? (4) - if and when? extent? duraiton? type?

Back 71

- test evaluating the electrophys of the peripheral nervous system

- able to provide info on:

= if and when there is signif damage

= extent of injury

= duration of dysfunction

= type of damage (axonal vs demyelinating)

** does not tell us about:

= etiology

= central or non-neuro disorders

Front 72

NCS relies on? from/ on?

- evaluates? in?

Back 72

- relies on responses obtained from recording electrodes following a delivery of current to the skin

- evaluates certain motor and sensory nerves in the distal arm and leg

Front 73

EMG uses a? inserted into?

- in order to?

- can tell us? in?

Back 73

- uses a micro-electrode inserted IN the muscle itself, in order to study the properties of the muscle and indirectly the nerve

- can tell us about the nerve and muscle lesions in any accessible muscle

Front 74

Distal Symmetric Polyneuropathy - Lab Tests

- (4)

- comprehensive? including?

Back 74

- CBC

- ESR

- comprehensive metabolic panel = blood glucose, renal function, liver function, thyroid function tests

- serum B12

- serum protein immunofixation electrophoresis

Front 75

Lab and Testing for Distal Symmetric Polyneuropathy

- screening should be considered for?

- highest yield is? with?

- perform a?

Back 75

- screening lab tests may be considered for all patients with polyneuropathy

- highest yield = serum B12 with metabolites and serum protein immunofixation electrophoresis

- 2 hour glucose tolerance test may be considered if fasting blood sugar, hemoglobin A1c normal

Front 76

Patterns of Peripheral Nerve Dysfunction

- PN/P/R/MN/ MNM

Back 76

1) Polyneuropathy

2) Plexopathy

3) Radiculopathy

4) Mononeuropathies = CTS, Ulnar Neuropathy, Peroneal Neuropathy, Cranial Neuropathy

5) Mononeuropathy Multiplex

Front 77

Atypical Features = Red Flags

early?

- involvement of?

- rapid?

- pure?

- involvement of?

- asoc of?

Back 77

= early simultaneous upper limb symptoms

= cranial nerve involvement

= rapid progression

= focality/ multifocality

= pure motor involvement

= bower or bladder involvement

= assoc symptoms = rash, weight loss, organ involvement

Front 78

Axonal, Length Dependent Polyneuropathy vs Demyelinating Neuropathy

- seen in? (2)

Back 78

- GB, CIDP

Front 79

Polyradiculopathy vs Mononeuropathy Multiplex

Back 79

Front 80

Etiologies of Atypical Neuropathy

- radiculos = C/I/I - examples

- MNM - includes (3 - V/A/M)

- demyel - can be? (3)

Back 80

1) Radiculopathy

= compressive = spinal stenosis

= inflammatory = GBS, CIDP

= infiltrative = Leukemia

2) Mononeuropathy Multiplex

= Vasculitis, Amyloidosis, Mimics (Leprosy, Diabetes)

3) Demyelinating = CMT, CIDP, GBS

Front 81

Disease Dependent treatment

- B12 - give?

- if toxic?

- if diabetes?

- if infectious?

Back 81

- B12 related = replacement

- Toxic = removal of toxic agent / drug

- Diabetes = diabetic control

- Infectious = anti-microbial treatment

Front 82

Polyneuropathy Treatment

- no general?

- treatment directed at?

- mainstay of treatment?

Back 82

- no general disease modifying treatments available for polyneuropathy

- specific treatment should be directed at underlying causes

- symptomatic treatment is mainstay of management

Front 83

Polyneuropathy Symptoms

- main symptoms of? (4)

- affects? (3)

Back 83

- main symptoms = pain, cramps, autonomic, anesthesia

- affects sleep, mood, QOL

Front 84

Neuropathic Pain Symptomatic Treatment

- Pain = N/PG/AT/D/CC/T/O

Back 84

1) Pain

- neurontin/ pregabalin

- amytriptyline

- duloxetine

- Capsaicin Cream

- tramadol

- Opioids

- non-steroidal anti-inflammatory

2) Anti-Epileptics

= dilantin

= carbemazepine

Front 85

Muscle Cramps Symptomatic Treatment

- give? tell to?

- supplement?

- give?

- also can give?

- meds for? (3) = D/C/L

Back 85

- stretching/ hydration

- Vitamin B supplementation

- Calcium channel blockers

- Quinine sulphate

- Baclofen

- Anti-epileptic meds = dilantin, Carbemazapine, Leveteracitam

Front 86

Conclusions of Peripheral Neuropathy

- most common type of periph nerve is?

- pathophys is?

- length dependent patterns affect?

Back 86

- most common type of peripheral nerve dysfunction is a distal, length dependent sensorimotor polyneuropathy

- pathophys behind polyneuropathy is disrupted axonal transport causing a length dependent pattern of injury

- length dependent patterns affects distal sensation in the legs feet initially

Front 87

Conclusion of Peripheral Neuropathy

- screening tests should include?

-non-length dependent pattern should prompt? (3)***

- treatment should include?

Back 87

- screening tests for PN include fasting blood glucose, 2-hour glucose tolerance test, Hb A1c, TSH, B12, CBC, metabolic profile, serum protein electrophoresis, ESR

- non-length dependent pattern should prompt consideration of alternate etiologies (Mononeuro Multiplex, Radiculopathy, Demyelinating Neuro)

- treatment of peripheral neuropathy should include global approach

Front 88

Headache - why care - most common?

- 1/3 of?

- most are not?

- most expensive?

Back 88

- most common medical disorder

- 1/3 of patients in doctors offices have headaches

- most headaches are not serious

- WHO deems headache the most expensive brain disorder

- 100 billion dollars lost annually due to headaches

Front 89

Primary Headaches - DD

- migraine - can include? (3) C/E/M

- TGA = includes? (3)

- Tension? Or?

Back 89

1) Migraine:

= episodic = with or without aura

= chronic

= menstrual

2) Trigeminal autonomic :

= cluster, SUNCT,Hemicranias

3) Tension type headaches

4) Other

Front 90

Headache History

- when? how? F? dur? also see?

- factors that?

- strategies that?

- history of?

- factors of?

Back 90

- when and how did a headache first present

- frequency

- duration

- pain location, quality, severity

- assoc. features

- exac. or attenuating factors = positional? triggered by exertion?

- curent and past treatment strategies, over the counter med use, alternative treatment

- history of head, neck injury or MVA

- lifestyle factors

- adverse childhood events, FH of headaches

Front 91

Classification of primary headaches

= three most useful clinical features include?

F / AFs / dur?

Back 91

= three most useful clinical features:

1) Frequency - chronic vs episodic

2) Assoc. Features - migrainous (worse with exertion), sympathetic, paraS

3) Duration - 4 hours? seconds vs minutes?

Front 92

Classification of Primary headaches - recurrent

- time? types? (3)

- of time of? types? seen with? (4)

- other includes? (2)

Back 92

1) Recurrent, >4 hours duration

= migraine, tension type, Hemicrania Continua

2) Recurrent HAs < 4 hours

= trigeminal autonomic Cephalagias (V1 pain, ipsi autonomic features, cluster)

= cough, exertion, sexual, hypnic HA

= other = trigeminal neuralgia, primary stabbing headache

Front 93

Differentiating Trigeminal Autonomic Cephalalgias (TACs)

- attack frequency/ duration/ pain quality/ pain intensity/ circadian

Back 93

Front 94

Definition of Migraine without Aura

- 5 or more?

- 2 or more - qualities include? (4) loc/puls/intens/agg?

- at least 1 of? = (4)

Back 94

- 5 or more attacks lasting 4-72 hours

- 2 or more of the following characteristics = unilateral location, pulsating quality, moderate to severe intensity, aggravation by routine

- at least 1 of the following assoc. symptoms = N/V, photophobia and phonophobia

Front 95

Prevalence of Migraines in Adolescents

- see increase in? then?

- in females, see?

Back 95

- see increase in prevalence until 11 or 12, then decline

- rise again in females at 15

Front 96

Childhood Migraine Equivalents

- cyclical? recurrent?

- in sleep? sickness of?

- abdos?

- infant?

- alternating?

Back 96

- cyclical vomiting

- recurrent abdo pain

- sleep walking

- motion sickness

- abdo migraine

- infant colic

- alternating hemiplegia of childhood

- vestibular migraine

- benign paroxysmal torticollis

Front 97

Treatment of Young Migraineurs

- mods of? including?

- acute treatment - mild? severe?

- preventative - done if?

Back 97

- behaviour and lifestyle mods = protein, hydration, sleep hygiene, exercise, supplements such as B2, Magnesium Citrate

- acute treatment = mild (NSAIDs), mod and severe (triptans)

- preventative treatments = done if HAs more frequents than 1/week

Front 98

Treatment of Young Migraineurs - Acute Treatment - NSAIDs

-superior one is?

- dose?

- can slo give?

Back 98

- NSAIDs

= ibuprofen demonstrated to be superior to placebo or acetaminophen in children and adolescents

= 7.5-10 mg/kg per dose

= +/- anti-emetics

Front 99

Treatment of Young Migraineurs - Acute Treatment - Triptans

- agonist of (2)

- in Canada, there are?

Back 99

- agonist of serotinin 1B and 1D receptors

- 7 are available in Canada = Sumatriptan, Zolmitriptan, Rizatriptan, Almotriptan, Eletriptan, Frovatriptan, Naratriptan

Front 100

Migraine with Aura - 1 and 2

- need at least 2?

- aura consists of? (3) all are? no?

Back 100

1) At least 2 attacks fulfilling criteria 2-4

2) Aura consisting of at least 1 of the following, but no motor weakness

= fully reversible visual symptoms

= fully reversible sensory symptoms

= fully reversible dysphasic speech disturbance

Front 101

Migraine with Aura - 3 and 4

- at least 2 of? VS/ SS

- >1 aura symptom of? or different?

- each symptom is?

- HA fulfilling? migraine without aura - begins? and then follows?

Back 101

3) At least 2 of the following:

= homonymous visual symptoms and or unilateral sensory symptoms

= 1> aura symptom over >5 minutes and or different aura symptoms in succession over >5 minutes

= each symptom >5 and <60 minutes

4) headache fulfilling criteria B through D for migraine without aura begins during the aura and follows aura within 60 minutes

Front 102

Clinical Features of Migraine

- attacks have a? then?

- duration of attack? in children?

- unilateral vs bilateral?

- pain can be? 50% have?

Back 102

- attacks have a gradual onset and a peak, and then subside

- the duration of an attack ranges from 4 to 72 hours in adults and 2 to 48 hours in children

- the location is unilateral in 60% of indivs and bilateral in 40% of indivs

- the pain can be moderate to severe in intensity, pulsating in 50% of individuals and feeling tight or exerting pressure in 50%

Front 103

Clinical Features of Migraines

- increased incidence of?

- exac during?

- reduced during?

- from?

- increased after?

- caused by certain?

Back 103

- increased incidence on weekends and holidays

- menstrual and ovulatory exarcerbations

- educed frequency in 1st trimester of pregnancy

- stress

- fasting, missing meals, sleep disruption

- certain foods, ex/ MSG, alcohol, cheese

- changes in weather = drops in barometric pressure

* see hormonal modulation of migraine - low estrogen, after migraine see high estrogen

* see hormone - related to pain free at 2hours and 24 hour relapse after 4 hours pain free

Front 104

Pathophys of Aura

- is a transient? which then?

- seen in?

- mechanism is?

Back 104

- transient focal visual, sensory, or motor symptoms which develop gradually

- 30% of migrainers experience aura

- mechanism is Cortical Spreading Depression:

Front 105

Cortical Spreading Depression Mechanism

- slowly prog? assoc with? massive?

- correlates with?

- vascular correlate is a?

- migrainers have?

Back 105

= slowly propagating wave of neuronal depol assoc. with cessation of spontaneous or evoked synaptic activity, massive glutamate and K release

= correlates with prop. of neurological symptoms rates of 3 mm/min

= vascular correlate is a focal wave of hyperemia followed by oligemia

= migrainers have reduced thresholds for cortical excitability

Front 106

Stroke Risk in Migrainers

- migraine without aura doesnt?

- yet in women under 45, with aura?

- MWA and hormonal creates?

- women - MWA and smoke?

Back 106

- migraine without aura does not confer increased stroke risk

- in women under 45 migraine with aura confers a 2x increased stroke risk

- migraine with aura and hormonal therapy confers a higher increased risk, further 2x increase

- risk in women with migraine with aura who smoke very high, estimate RR of 4

Front 107

Treatment of Migraine - Acute

- mild - use? short acting? long?

- severe - use? or combine?

Back 107

1) Mild to Moderate = NSAID

= short acting = Naproxen

= long acting = nabutone

2) Moderate to Severe

= Triptan

= NSAID

= Triptan + NSAID

Front 108

Proper Use of Triptans

Back 108

- take first dose as early as possible

- second dose can be taken after 2-4 hours if response is suboptimal or if headache recurs

- dose can be front loaded but should not exceed 2 in 24 hours

- consider wafers, subcut, nasal formulations in patients with very rapid onset or delayed gastric emptying

- maximum per month = my rule of thumb is NO MORE THAN 8x per month

Front 109

Selecting a Triptan - formulation? T1/2?

- adverse effects? (6)

Back 109

- adverse effects = nausea, dry mouth, paresthesia, dizziness, somnolence, pain/pressure

Front 110

Selecting a Triptan - if wakens with severe HA - use? such as?

- if ident onset, such as? use? such as? (A/E/R)

- if has N/V - use? with?

- if slow onset - use? (N/F) - same for?

Back 110

1) Wakens with severe headache

= fast acting = Sumatriptan injectable or nasal spray

2) Identifiable Onset, develops over 30-60 mins

= fast acting = Almotriptan, Eletriptan, Rizatriptan

3) Rapidly develops N/V

= nasal spray or oral triptan + anti emetic

4) Slow onset

= Naratriptan or Frovatriptan

5) Predictable Menstrual Migraine

= Naratriptan or Frovatriptan

Front 111

Cintraindications to Triptans

- if have? (4)

- type of migraine? (3)

- relative - use of? or use of?

Back 111

- ischemic heart disease, uncontrolled hypertension, PVD, stroke

- basilar, hemiplegic migraine or ophthalmoplegic migraine

- relative = use of SSRIS and SNRIs or use with MAO inhibitors

Front 112

Prevention of Migraines - Triptans

- reduces (3)

- may prevent?

- using both? to help decrease?

Back 112

- reduces frequency, severity and duration

- may prevent chronification of HA

- using both acute and preventative rx results in decline in office visits, ER visits, CT and MRI scans and acute med costs

Front 113

Preventing Migraines - behav and lifestyle

- keep? document? (7)

Back 113

= keep diary **

= sleep routine

= diet

= hydration

= walking/exercising

= stress management

= mindfulness

= psych support

= PT

Front 114

Pharm Prevention of Migraines

- Approved = T/ D/ T/ P - strong = (2)

- off label = (4)

- herbal = (3)

Back 114

1) Approved

= topiramate = strong rec for use

= Divalproex = often CI due to teratogen

= Timolol

= Propranolol =strong rec for use

2) Off label

= nadolol, metoprolol, candesartan, gabapentin all strong rec, some SSRIs

3) Herbal = Mg Citrate, Riboflvin, Butterbur, Q-10 - strong rec for use

Front 115

Prophylactic Drug Choice in Migraine Prevention

- should be based on? (3)

- most commonly used?

- if have depression? if have anxiety?

- start? then go? better?

Back 115

- should be based on efficacy, SEs, clinical features and other disorders

- most commonly used in Topiramate, if have depression use SSRIs, if anxiety use Gaba, etc

- start low, go slow = evtter efficacy at lower doses with fewer AE

Front 116

DD of Chronic Headaches

- CM

- Chronic TT = present as? intensity? not?

Back 116

1) chronic migraine

2) chronic TT headache

= bilateral, pressing, mild to mod, not agrr. by PA

Front 117

DD of Chronic Headaches

- new persistent - defined by? (3) diagnosis of?

- HC =? is seen on? often is? and lasts?

- moderate with? features such as? (3) P/L/R

Back 117

3) new persistent daily HA

= defined by new onset, persistent, diagnose of exclusion

4) hemicrania Continua

= unilateral, daily, continuous, moderate with exacerbations, has trigeminal features such as ptosis, lacrimation, rhinorrhea

Front 118

Definition of Chronic Migraine

- duration? with ? with or without?

- typical patient is? has?

- as HAs become more frequent?

Back 118

- >15 days HA per month with current or prior diagnosis of migraine with or without medication overuse

- typical patient is female, has migraines without aura

- as headaches become more frequent, migrainous features become less prominent

Front 119

Chronification of Migraine

- at first? then as prolongs? becomes?

- can lead to? (3)

Back 119

- see episodic at first, then as prolongs, HA symptoms do no return to baseline, becoming chronic

- leads to depression, anxiety, sleep disorders

Front 120

Structural Chnages in Chronic Migraine

- MRI shows? in? such as? (5)

Back 120

- MRI shows gray matter volume reductions in pain modulating structures

= bilateral insula, motor/premotor, prefrontal cingulate cortex, right posterior parietal cortex and orbitofrontal cortex

Front 121

RFs for Chronic Migraine

- freq?

- treatment?

- chronic?

- weight? low? stress?

- things like?

Back 121

- attack frequency - or 8, 10-14d

- treatment patterns - or 4-5 acute meds >10ds

- chronic back pain

- obesity

- low SES

- stressful life events = ACE/PTSD

- head injury, snoring, caffeine, psychiatric illness

- allodynia

Front 122

Medication Overuse HA (MOH) - interaction between?

- prevalence is?

- seen with? of?

- using increased? with?

- when off meds?

- incomplete?

- patients begin to fear?

Back 122

- MOH is an interaction between a therapeutic agent and susceptible patient

- prevalence = 10-20% of referrals, in US up to 80%

- seen with analgesic use > 2-3 days of a week

- escalating doses with decreased effectiveness

- withdrawal symptoms when off medication

- incomplete relief with re-dosing

- patients fear next attack = anxiety

Front 123

MOH Thresholds

- number of days/ month?

- triptans used? length?

- analgesics? opioids?

combo?

Back 123

- HA on >15 d per month and:

= triptans > 10 d per month for > 3 months

= analgesics > 15 d per month for 3 months

= opioids > 10 days/mo for 3 months

= combo of above > 10 days/ m for 3 months

Front 124

MOH Treatment

- essential is?

- led to decrease in?

Back 124

- Essential is detox from over-used medications

- see 73# decrease in HA frequency and 70% returned to episodic HAs when continued med overuse

Front 125

Adverse Childhood Events and Migraine

- dysfunctional? witnessed? death of?

- strong assoc of?

Back 125

- storng assoc with depression, anxiety, abuse, assoc of ACE, migraine and inflammatory markers

Front 126

Managing Migraine in Pregnancy

- lifestyle mods = (8)

Back 126

Front 127

Managing Migraine in Pregnancy

- acute include? (3)

- preventative include mainly? (4)

- can also try? (3)

Back 127

Front 128

Acute Stroke - sudden loss of? due to? loss of?

- 2 main types? caused by? %?

Back 128

- sudden loss of brain function

- interruption of blood flow

- loss of oxygen and glucose supply to a part of the brain

- 2 major types:

1) Ischemic stroke = lack of blood flow due to clot (85%)

2) Intracerebral hemorrhage = bleeding in brain due to vessel rupture (15%)

Front 129

Transient Ischemic Attack (TIA)

- self limited?

- temporary? not assoc with?

Back 129

= self-limited episode of neurologic dysfunction

= temporary focal cerebral ischemia not assoc. with cerebral infarction

Front 130

Impact of Stroke - for developed countries, is the?

Back 130

- for developed countries = 3rd most common cause of death, leading cause of disability

- in Canada, 1 stroke / 10 mins, costs 2.7 billion annually

Front 131

Stroke and Aging Population

- age is the? each decade see?

- M vs F?

- growth of pop vs interventons - means?

Back 131

- age is the single most important non-modifiable risk factor for stroke

- stroke rates double each decade after 55 got both men and women

- incidence is 1.25x higher in men than women

- growth of population over 65 years will continue at the same rate but impact of interventions will reach plateua

- decrease in stroke hosp. is projected to flatten out, may increase in future

Front 132

Key Stroke Points - important cause of?

- have long term?

- aging will? as ages?

Back 132

- strokes are important cause of morb affecting 1% of Canadians chronically, use 3% of health care dollars

- have long term and wide ranging impacts on people

- effect of aging on population have been countered by inteventions to prevent strokes

- as pop ages, impact of interventions expected to plateua, may see increase in stroke rates

Front 133

Arterial Territories and Stroke Localization - 4 major? each with?

Back 133

- 4 major arterial territories, each with own symptom signature

Front 134

Cerebral Vascular Anatomy - Extracranial

- aortic arch is the?

- EC circulation includes? (2)

- VAs arise from? (2)

Back 134

- aortic arch is the origin of all cerebral blood supply

- extracranial cerebral circulation includes internal carotid arteries and vertebral arteries

- vertebral arteries arise from common carotid arteries and subclavian arteries

Front 135

Cerebral Vascular Anatomy - Intracranial

- includes the? location?

- connects?

Back 135

- intracranial circulation includes circle of willis:

= circle of anastomoses at the base of the brain, connecting the right, left, anterior and posterior circulations

Front 136

Cerebral Vascular Territories - Main - Brainstem

- supplied by? (2)

Back 136

- supplied by basilar and vertebral arteries penetrating brances

Front 137

Cerebral Vascular Territories - Main - Cerebellum

- supplied by? (3) P/A/S

Back 137

- supplied by:

= PICA = posterior inferior cerebellar arteries

= AICA = anterior inferior cerebellar arteries

= SCA = superior cerebellar artery

Front 138

Cerebral Vascular Territories - Main Cerebral Arteries? (#) = A/M/P

Back 138

= ACA = anterior cerebral

= MCA = middle cerebral

= PCA = posterior cerebral arteries

Front 139

Cerebral Vascular Territories - ACA mainly?

- MCA mainly? PCA mainly?

Back 139

Front 140

Cerebral Vascular Territories - Deep Brain Structures

- includes? perfused by? (2)

- Thal - perfused by top of? and the?

Back 140

= BG = largely perfused by MCA and perforating arteries

= Thalamus = perfused by the top of the basilar and proximal perforating arteries

Front 141

ACA - Supplied and Syndrome

- supplies medial?

- ischemia leads to CL? leg vs arm and face?

Back 141

- ACA supplies the medial portion of the frontal and parietal lobes

- ACA ischemia leads to:

= contralateral hemianesthesia and hemiparesis

= leg affected more than the arm or face

Front 142

MCA Supply - supplies lateral? superior?

Back 142

- MCA supplies the lateral frontal and parietal lobes and superior temporal lobes

Front 143

MCA Syndrome - ischemia results in?

- CL? face vs leg?

- eyes?

- neglect?

- gaze deviation? due to?

Back 143

- MCA ischemia results in:

= CL hemianesthesia and hemiparesis, (face, arm > leg)

= CL homonymous hemianopsia

= CL hemineglect and ipsilateral gaze deviation (due to loss of attention-related frontal lobe functions)

Front 144

MCA Syndrome and Language

- language affected if?

- can have expressive if? lobes? as affect?

- can have receptive if? lobes? as affect?

Back 144

- language impairment occurs if the dominant hemisphere is involved

- expressive aphasia = lesions in the left posterior-inferior frontal love = Broca's area

- receptive aphasia = lesions in the left posterior-superior temporal lobe = Wernicke's area

Front 145

PCA Supplies the inferior? and the? as well as?

Back 145

- supplies the inferior temporal love and occipital lobe as well as the thalamus

Front 146

PCA ischemia - results in mainly?

Back 146

- CL homonymous hemianopsia

Front 147

Brainstem Syndromes - Basilar Artery territory

- supplies the? (2)

- brainstem contains both?

- tracts carry? side?

- nuclei supply? side?

Back 147

- supplies the pons and midbrain

- brainstem contains both tracts and nuclei

- tracts carry signal to/from CL body

- nuclei supply ipsilateral head/face structures (except for trochlear nuclei)

Front 148

Brainstem Ischemia

- lesions involving both tracts and nuclei result in? ips vs CL?

- commonly result in? (4)

Back 148

- lesions involving both tracts and nuclei result in ** crossed face-body deficits

- see ipsilateral face and contralateral body weakness and/or sensory loss

- commonly results in:

= eye movement abnormalities and nystagmus

= diplopia

= dysphagia

= N/V

Front 149

Cerebellar Syndromes

- if affects vermis? (2)

- if affect cerebellar henispheres - see ipsi? (2), also? (3)

Back 149

1) lesions to the vermis = gait ataxia and truncal instability

2) lesions to the cerebellar hemispheres:

= ipsilateral limb ataxia and nystagmus

= vertigo, N, V

Front 150

Small Penetrating Arteries

- come off of? perfuse?

- affect the? including (CR/IC/DGN)

Back 150

- small penetrating arteries of the ACA, MCA and PCA or basilar artery territories perfuse deeper structures of the brain

= white matter tracts - corona radiata and internal capsule and deep grey nuclei

Front 151

Small vessel Ischemia

- result in? causing?

- commonly results in dense? without**

Back 151

- results in small discrete lesions causing classic syndromes

- commonly results in dense deficits in one modality, **without language or visual impairment

Front 152

Lacunar Syndromes

- small infarcts in? (5)

- can result in? (3)

- ataxix? which is?

- or clumsy?

Back 152

- small infarcts in corona radiata, internal capsule, BG, thalamus or pons can result in:

= pure hemi-motor stroke

=pure hemi-sensory stroke

= hemi-sensorimotor stroe

= ataxic hemiparesis = weakness and incoord. of limbs on one side of the body

= dysarthria-clumsy hand syndrome

Front 153

Top of Basilar Perforators = Thalamic Lesions

- CL loss of? may lead to?

- Dejerine-Roussy Syndrome sees initial? then?

Back 153

= CL sensory loss is most common, may lead to chronic painful condition

= Dejerine-Roussy Syndrome = initial CL loss of sensation, weeks to months later numbness can develop into severe and chronic pain

Front 154

Key Points for Vasc Territories and Stroke Localization

- cerebral circulation includes?

- EC vessels from? are? (3)

- IC vessels forms? include (3)

- main three? ac tto?

Back 154

- cerebral circulation consists of EC vessels in neck and IC vessels

- EC vessels from aortic arch = common carotids, internal carotids, subclavian arteries

- IC vessels anastomose to form Circle of Willis = IC internal carotid arteries, vertebral arteries, basilar arteries

- ACA, MCA and PCA emerge from Circle of Willis to perfuse hemispheres

Front 155

Key Points for Vasc Territories and Stroke Localization

- vertebral and basilar role?-

- ACA role?

- MCA role?

- PCA role?

- stroke results from?

Back 155

- vertebral arteries and basilar artery perfuse brainstem and cerebellum

- ACAs perfuse medial frontal and parietal lobes

- MCAs perfuse lateral frontal, parietal, temporal lobes

- PCAs perfuse the occipital lobes and medial and inferior temporal lobes

- stroke results from loss of blood flow to an area of the brain causing a neurological lesion that is confined to a vascular territory

Front 156

Key patterns of Stroke Localization

- ACA sees combo of? seen more in?

- MCA seen combo of? side? also includes? (3) some dysfunction of? if?

- PCA - CL? no? if thalamus, get?

Back 156

1) ACA = combo of CL hemiparesis and hemianesthesia, leg> face, arm

2) MCA = combo of CL hemiparesis, hemianesthesia (face, arm> leg), CL hemianopsia and gaze deviation, CL hemineglect and language dysfuction (left hemisphere)

3) PCA strokes = CL hemianopsia without motor or sensory deficit, hemisensory loss if thalamus is involved

Front 157

Braimstem Strokes - due to? (2)

- combo of?

- CS/ eye? dys? N/V?

Back 157

- due to basilar and vertebral arteries

- combo of:

= crossed symptoms

= eye movement abnorms and nystagmus

= dysphagia

= N/V

Front 158

Cerebellar Strokes - combo of?

- G/TI/ Ipsi?

- also see? (3)

Back 158

- combo of:

= gait ataxia, truncal instability

= ipsilateral limb ataxia

= nystagmus, vertigo

= N/V

Front 159

Lacunar Strokes

- result from?

- pure HM? HS? SM?

- Ataxic? or?

Back 159

- result from small infarcts in deep brain structures

- pure hemi-motor stroke

- pure hemi-sensory stroke

- hemi-sensorimotor stroke

- ataxic hemiparesis

- dysarthria = clumsy hand

Front 160

Mechanisms of Ischemia

- common pathway is?

- main etiologies = (4)

Back 160

- common pathway = insufficient blood flow to perfuse cerebral tissue leading to irr. neuronal damage

- main etiologies:

= thrombosis

= embolism

= hemorrhage

= systemic hypoperfusion

Front 161

Thrombosis

- formation of a? in an? causing?

- triggered by?

- from? inherently?

- plaques can? or? to expose?

- leading to?

Back 161

- formation if clot or thrombus in an artery persisting long enough to cause ischemic insult to cerebral tissue it supplies

- triggered by local pathology in endothelium:

= atherosclerotic plaques - inherently pro thrombotic

= plaques can rupture or ulcerate exposing contents with highly thrombogenic properties = leads to in situ thrombosis at site of ulceration

Front 162

Internal Carotid Artery and Atherosclerosis

- ICA is a? due to buildup of? leading to?

Back 162

- ICA common sites of Athero related to strokes

- plaque buildup at common carotid junction and ICA leads to reduced blood flow to brain

Front 163

Embolism

-formation of? which then? lodging in?

- common sources (A/C)

- causes of those (1/ 3)

Back 163

- formation of clot/thrombus in an other area of circulation, which then travels to cerebral circulation lodging itself in a smaller vessel and occluding it

- common sources of embolism:

= artery to artery = from athero plaque

= cardiac to artery = atrial fibrillation, valvular disease (mech, infection, masses), poor cardiac function

Front 164

Intracerebral Hemorrhage

- common cause?

- Amylood Angiopathy is a? that? leads to?

- results in loss of?

Back 164

- hypertension is a common cause

- Amyloid Angiopathy = vasculopathy that weakens vessel walls leading to spont rupture and large lobar hemorrhages

- results in loss of perfusion of territories distal to ruptured vessel

Front 165

Systemic Hypoperfusion

- generalized? leading to?

- commonly due to?

- leads to global?

Back 165

- generalized loss of arterial pressure leads to systemic HP that includes the brain

- commonly due to cardiac arrest

- leads to global brain hypoperfusion and brain anoxia

Front 166

Key Points of Stroke Etiology

- caused by?

- related to either?

- results if? both related to?

- athero? cardiac?

- 30% are?

Back 166

- caused by blood flow interruption, leading to ischemia and brain dmamage

- related to blockage (ischemic strokes) or rupture (hemorrhage) of a vessel

- result if presence of a clot that formed locally or came from another area, both related to stroke RFs due to:

= athero changes in large and small arteries of brain

= abnormal cardiac function = Afib, abnormal valves or abnormal wall movement from MI

**30% cryptogenic strokes = no cause identified

Front 167

Ischemic stroke Etiologies

- 45% are? due to?

- 20% are? due to a?

Back 167

- 45% are atherosclerotic = small or large vessel disease, due to athero thrombotic or embolic events

- 20% due to cardiogenic = cardio-embolic event

Front 168

Stroke RFs - Modifiable = (8)

- related to both?

Back 168

- related to arteries (AS RFs) and heart (cardiac sources)

Front 169

Stroke RFs - non-mod = (4)

Back 169

Front 170

Hypertension

- is the most important?

- risk of stroke increase with?

- for each 10 mmHg reduction? until?

Back 170

- single most important modifiable risk factor for stroke

- risk of stroke increases linearly with increases in systolic or diastolic BP

- 30% reduction in stroke risk for each 10 mm Hg of sbP or 5 or dBP

- effect maintained down to BPs of 115/75

Front 171

Hypertension and Stroke

-lowering BP helps to?

- greatest drop with?

- optimal targets havent? want?

- combo = use of? (P/I_

Back 171

- lowering BP reduces stroke risk in both hypertensive and normotensive patients = PROGRESS trial - see greatest drop with combo therapy

- optimal targets have not been formally defined through RCTs, want > 140/90 or 130/80 for diabetics

- *** combo = use of Perindopril and Indapamide

Front 172

Lowering BP should be considered for? (2)

- good for both?

Back 172

- considered for patients with history of stroke or TIA, irrespective of baseline bp

- lowering BP reduces stroke risk across all ages in both hyper and normotensive patients

Front 173

Diabetes - poorly controlled leads to? such as?

- bad for?

- high risk of? both?

- tied to?

- target?

Back 173

- poorly controlled glycemia leads to microvascular and macrovascular complications as elevated blood glucose bad for vascular endothelium

- diabetics have high risk of vascular events, both cerebrovascular and cadiovascular

- risk in diabetes tied with hypertension, have strict target of <130/80

- target fir glycemic control is HbA1c < 7%

* negative effect of hypertension is compounded in diabetes

Front 174

Dyslipidemia

- strong relationship between?

- fibrates act to? yet no effect on?

- more effective? which lower?

Back 174

- strong relationship between dyslipidemia and atherosclerosis

- fibrates reduce cholesterol but have not shown a beneficial effect on stroke, pref. effect on reduction of triglycerides, do reduce CV risk

- statins most effective at reducing stroke risk, via reducing LDL

Front 175

Statin Therapy and Dyslipidemia

- statins resulted in? via?

- each 10% decrease in? saw?

Back 175

- statins results in 25% reduction in vascular events, Heart Protection Study

- each 10% reduction in LDL reduces stroke risk by 13%

- risk reduction increases with increases doses, seen via Treating New Targets Study and SPARCL study

Front 176

Targets for Stroke Prevention

- stroke prevention guided by?

- for high risk, LDL <? TC:HDL <?

- secondary, want LDL? TC:HDL? LDL reduction of?

Back 176

- primary stroke prevention guided by Framingham, for high risk LDL <2.0, TC:HDL< 4.0

- secondary stroke prevention, want LDL <2.0, TC:HDL< 4.0 and 50% LDL reduction

Front 177

Dyslipidemia Key Points

- strong relationship between?

- statins are the only? % decrease?

- most beneficial in?

- effect is?

Back 177

- strong relationship between dyslipidemia and atherosclerosis

- statins are the only lipid lowering therapy that reduces stroke risk

- statins result in reduction of 25% across all levels of risk, most beneficial in high risk patients and for secondary prevention but will also benefit lower risk patients, in primary prevention

- statins have dose dependent effect, higher doses more effective

Front 178

Lifestyle Modifications

- essential part of? often?

- includes? (5)

Back 178

- essential part of approach to lowering risk of first or recurrent stroke, often underestimated

- include:

= smoking cessation

= diet = low Na, low fats, high fiber, limit alcohol

= weight loss

= exercise

= obstructive sleep apnea assessment

Front 179

Heart - Atrial Fibrillation

- common? %? over age?

- causes? forms in?

- results in more? higher?

- most common cause of? age?

Back 179

- common arrhythmia present in 14% of patients over 75 years of age

- causes stroke via embolization of thrombus forming in left atrium

- results in more severe strokes with higher morbidity and mortality

- most common cause of stroke in population > 80 yo

Front 180

Benefits of Anticoagulation

- reduces risk in?

- superior is? yet increased risk of?

- dosing of warfairn must?

- requires? many?

Back 180

- reduces stroke risk in Afib

- warfarin superior to ASA, 68% reduction with warfarin compared to 19% of ASA, yet see increased risk of major bleeds

- dosing of warfarin adjusted to maintain an INR between 2-3

- requires regular blood tests, see many interacitons with meds and food

Front 181

Alternatives to Warfarin

- includes = D/A/R - ban

- shown to be?

- lower?

- are easier? no? less? require good?

Back 181

- include dabigatran, Apixaban, Rivaroxaban

- as effective or superior to warfarin

- lower risk of bleeding complications

- these are easier to use, no INR to monitor, standard dosing, require good renal function

Front 182

Afib key points

- major? especially in?

- assoc with?

- once diagnosed, should be?

- screening?

Back 182

- major stroke RF in elderly

- assoc. with more severe strokes and higher stroke mortality

- once diagnosed, should be treated with oral anticoags

- patients over 80 presenting with stroke should be screened for Afib

Front 183

TIA definition

- self-limited? resulting from? no?

- symptoms can be? high ris of?

- treat as strong?

Back 183

- self-limited episode of neurologic dysfunction resulting from focal temporary cerebral ischemia without infarction

- symptoms can be of variable duration, high risk for stroke within next 90 days

- treat as strong risk of stroke after TIA

Front 184

Approach to Stroke Prevention

- manage? such as?

- treat? such as?

Back 184

1) manage RFs = atherosclerotic and cardiac

2) Treat established problems = antipt medications, carotid artery disease

Front 185

Managing Modifiable RFs

- treat? start? aiming for?

- screen for? target?

- for Afib?

- discuss?

Back 185

- treat hypertension

- start a statin aiming for 50% reduction in LDL and LDL <20, TC:HDL <4.0

- screen for diabetes and treat target of HbA1c <7%

- anticoag for Afib

- discuss and encourage lifestyle modifications

Front 186

Treating Established problems

- atherosclerotic plaques have? can be a?

- Antipts are used to reduce?

- common site? can?

Back 186

- atherosclerotic plaques have thrombogenic properties and can be focal source of thrombus formation

- Antipts are used to reduce stroke risk by reducing the potential for thrombus formation on atherosclerotic plaques

- internal carotid arteries are a common site of atherosclerosis - severe narrowing assoc. with high risk of stroke, can be treated surgically

Front 187

Benefits of ASA - reduced? saw small?

- absolute benefit is? but good as? (3)

- dose should be? standard is?

Back 187

- ASA reduced risk of recurrent stroke and ICH risk only slight increased

- absolute benefit small but:

= widely available intervention

= low cost

= minimal adverse events

* at any dose over 30 mg, equally effective in preventing vascular events after stroke, lower doses have fewer bleeding events

- standard therapy is 81 mg PO daily

Front 188

Newer Antipts = Aggrenox = ?

- slighlt better than? but caused?

Back 188

= Dipyramidole + ASA

- slightly better than ASA, but more discontinuation due to HA

- ESPS and ESPRIT trials

Front 189

Newer Antipts = Plavix - also known as?

- better than? no benefit of adding?

Back 189

= Clopidogrel

- slightly better than ASA, equiv to Aggrenox

- no added benefit of adding ASA

Front 190

First Line Antipt therapy

- ASA/Plavix/ Aggrenox = at?

- generally start? in? more?

Back 190

- ASA 81 mg daily, Plavix 75 mg daily, Aggrenox 1 tab bid

- generally start ASA in antipt naive patients, most cost-effective

Front 191

Second Line Antip Therapy

- plavix ar? or?

- generally used when?

- considered a?

Back 191

- plavix 75 mg daily or Aggrenox 1 tab BID

- generally used when patients on ASA present with stroke or TIA

- considered failure of ASA, these agents slightly superior

Front 192

AntiPt Key points

- ASA at? prevents? small? but good as?

- Plavix and Aggrenox are better? but need to?

- start ASA after? in? switch once?

- not recommended to have?

Back 192

- ASA 81 mg prevents recurrent strokes, small absolute effect but widely available, low cost, minimal SEs

- plavis and Aggrenox are better than ASA but need to consider cost and SEs

- start ASA after stroke or TIA, in patients not on any antipt therapy

- switch to Plavix or Aggrenox after stroke or TIA, for paitnets who have event on ASA

* long term dual antipt therapy not recommended

Front 193

Carotid Disease Management

- can be done via? (CS/CE)

- CE reduces? yet benefir?

- should do following? goal to?

- if younger than 70?

Back 193

- via carotid endarterectomy and carotid stenting

- CE reduces risk of recurrent stroke, yet benefit of surgery decreases with time

- should do following TIA, goal should be to operate within 14 days

- up to 70, no diff between stenting and endarterectomy, over 70 slight CE benefit

Front 194

Carotid Revasc Key Points

- all patients with >50% symptomatic carotid stenosis should?

- benefit depends on?

- over 70%?

- 50-69%?

Back 194

- all patients with >50% symptomatic carotid stenosis should be considered for CE or stenting

- benefit from CE depends on degree of stenosis, delay to surgery afetr events

- patients with symptomatic stenosis over 70% benefit most from surgery, revasc and should be referred

- paitents with 50-69% stenosis should be assessed

- ideally patients treated within 2 weeks of stroke symptoms

Front 195

Key Points of Stroke, TIA management

- treat? start? revasc at? give? for?

- lower?

- add?

- screen and treat?

Back 195

- treat early

- start antipt agent

- revasc ICA stenosis of 70%

- anticoag Afib

- lower bp (<140/90)

- add a statin (50% LDL reduction)

- screen for and treat diabetes (HbA1c <7%)

Front 196

Acute Management of Major Ischemic Strokes - Thrombolysis

- most signif? had 6?

- TPA =? known as a?

- time window is?

Back 196

- most signif advance in stroke care, 6 landmark RCTS (Atlantis)

- TPA = tissue plasminogen activator = clot busting drug

- ** time window for benefit of tPa is within 4.5 hours of stroke onset

Front 197

Risks of TPA

- risk of? =? increases with?

- odds of dying werent?

- requires?

Back 197

- ICH risk of 5%, risk of ICH assoc. with increasing age

- overall odds of dying were not increased however

- requires careful selection of patients

Front 198

Key Pints for Thrombolysis

- tpA can be used within? try to?

- restoring? to improve?

- non-neg?

Back 198

- tPa can be used within 4.5 hours of stroke onset to try to reverse a clot and restore blood flow to brain

- restoring blood flow limits extent of ischemic damage to brain and improves outcomes

- non-neg risk of significant bleed

Front 199

Endovascular Therapy = ? also known as a?

- extraction of? from? with?

- need to? time from onset?

Back 199

= Embolectomy = catheter cerebral angiogram

- extraction of a clot from larger proximal vessels of anterior circulation in addition to tPa

- need to carefully select paitents, up to 6 hours from symptom onset

Front 200

Key Points for Embolectomy

- time with tpA? to?

- time without tpA?

- improves? leading to?

- requires careful?

Back 200

- used within 4.5 hours of stroke onset in combo with tpA to restore blood flow to brain

- used within 6 hours of stroke onset without tPA, extending treatment window

- improves rates of early recanalization leading to improved outcomes

- requires careful selection of patient = based on clinical and radiological criteria

Front 201

Practical Guide to CNS Tumours

- if it is CNS - ask whether it is? (3)

- if intra-axial - ask if it is?

- if within parenchyma - is it? is it even a?

Back 201

- if it is in CNS = is it intra axial? (within brain parenchyma), extra-axial? or intraventricular?

- if intra-axial - is it above the tentorium or below it?

- if within brain parenchyma - is this a primary tumor or met? is it a tumour?

Front 202

CNS Mass Lesions in Adults

- tumour =?

- vascular = (3)

- infectious = (3)

- inflammatory = (2)

Back 202

- tumour = primary, met

- vascular = AVM, cavernous malformaiton, aneurysm

- infectious = bacterial or fungal abscess, tuberculoma, parasite

- inflammatory = MS, vasculitis

Front 203

Where Can lesions Be?

- Extra axial = (3) = M/ HP/ Mets

- Intra axal = G/Me

- IntraVent = CPT / M / Me?

Back 203

1) Extra axial = Meningioma, Hemangiopericytoma, Mets

2) Intra-axial = glioma, mets

3) Intra-ventricular = choroid plexus tumour, meningioma, mets

Front 204

Posterior Fossa Tumours in Children

- Intra axial = Pil Astro? Ependy? Medullo?

- Intravent = CPP? CPC?

Back 204

1) intra axial = Pilocytic Astrocytoma, Ependymoma, Medulloblastoma

2) Intraventricular = choroid plexus papilloma, choroid plexus carcinoma

Front 205

Piloctic Astrocytoma - commonly occurs in?

- manifests as? (2)

- in children, common in? can also be in?

- Grade 1 = ?

- imaging - see? may have strong?

Back 205

- most commonly occurs in children and manifests as hydrocephalus or cerebellar dysfunction

- in children, most commonly occurs in posterior fossa, but may occur in brainstem or along optic tract/nerve

- WHO Grade 1 Astrocytoma = non-infiltrative

- Imaging = cystic lesion with mural nodule - may have strong contrast enhancement**

Front 206

Pilocytic Astrocytoma

- pathology is? with compact? fibers?

- goals of therapy?

- outcomes - 5 year?

Back 206

- pathology is biphasic appearance with compact fascicles of bipolar cells, loose mesh interspersed, Rosenthal fibers

- goals of therapy = if safe, surgery

- outcomes = 90% 5 year progression-free survival

Front 207

Glioma Grades

Back 207

Front 208

Pediatric/Posterior fossa Tumour Guidelines

- #1 = pediatric tumours occur in?

- #2 = Posterior fossa tumour present with? (2)

- #3 = WHO Grade 1 tumours are? curable via?

Back 208

#1 - Pediatric tumours occur in the posterior fossa

#2 - Posterior Fossa tumours present with cerebellar signs or hydrocephalus

#3 - WHO Grade I tumours are non-infiltrative and surgically curable

Front 209

Oligodendroglioma

- most commonly present with?

- typically arise within? opposed to?

- WHO Grade II = ? surgery isnt?

- imaging - on CT see? on T1? on T2?

Back 209

- most commonly present with seizure (50-80%)

- typically arise within the cortex as opposed to subcortical white matter

- WHO Grade II tumour = infiltrative, surgery not curative

- imaging = calcification of CT, dark on T1, bright on T2, does not enhance

Front 210

Oligodendroglioma

- pathology = appear? vasculature?

- defined by presence of? loss of?

- goals of therapy are? maintain?

- outcome of survival is? with (3)

Back 210

- pathology = fried egg appearing cells, chicken-wire vasculature

- defined by presence of IDH mutation and loss of 1p and 19q chromosomes

- goals of therapy = prolongation of disease remission and maintenance of neuro function

- outcomes = overally survival 8-16 years with surgery, radiation and chemo

** inevitably undergo malignant degen

Front 211

IDH1 Mutation - IDH1 is foind in?

- mutation seen in? mutations result in decreased ability to? loss of? leads to?

- assoc. with dysregulation of?

-thought to be?

Back 211

- IDH1 = isocitrate dehydrogenase 1, found in cytoplasm

- mutation seen in Oligoden, mutations results in:

= decreased ability to produce NAPDH, loss of substrate leads to DNA hypermethylation

*IDH mutations assoc. with dysregulation of glial differentiation and global histone methylation

*thought to be one initial hit in gliomagenesis

Front 212

Tumours Guidelines

#4 = if infiltrative, are?

#5 = low grade tumours present with? rather than?

#6 = appearance on CT? T1? T2?

#7 = low-grade tumours dont? on CT have?

Back 212

#4 = infiltrative gliomas (WHO grade II-IV) are incurable

#5 = low grade tumours present with seizure rather than neuro deficits

#6 = tumours are hypodense on CT, hypodense on T1 MRI and hyperintense on T2 MRI

#7 = low-grade tumours do not enhance and have calcification on CT

Front 213

Secondary Glioblastoma

- accounts for %?

- may present with? (4) H/ND/S/raised?

- Grade? are? not?

- imaging - present as?

Back 213

- accounts for 20-30% of all glioblastomas

- may present with HA, neuro deifcits, seizure or raised ICP

- WHO grade IV tumour - infiltrative, not curative surgery

- imaging = heterogenous enhancing mass

Front 214

Secondary Glioblastoma

- pathology - see areas of? with pockets of?

- goals of therapy are?

- outcome include survival of?

Back 214

- pathology = areas of low-grade tumours with pockets/sheets of malignant degeneration

- goals of therapy = achievement of disease control and maint neuro function

- outcomes = overall survival 12-14 months

Front 215

Glioblastoma

- by definition is?

- treatment includes? with daily (2)

Back 215

- by definition is an infiltrating cancer

- treatment - Stupp Protocol, with TMZ daily and RT

Front 216

Glioblastoma and MGMT Methylation

- MGMT is located on?

- encodes a?

- target site for?

Back 216

- MGMT = located on chromosome 10q26

- encodes a DNA-repair protein that removes alkyl group from O position of guanine = target site for chemo-induced DNA alkylation

Front 217

Tumours Guidelines

- #8 = low grade gliomas will?

- #9 = if malignant?

-#10 - rapid symptom progression assoc. with?

Back 217

#8 = low-grade gliomas will invariably progress to glioblastoma

#9 = malignant tumours enhance

#10 = rapid progression of symptoms is assoc. with increased malignancy

Front 218

Tumour Summary

Back 218

Front 219

Tumour Summary

Back 219

Front 220

Epilepsy Epi

- active prevalence is?

- active means?

- 5% of people by?

Back 220

- active prevalence is 4-7/100 (active = getting treatment or seizures within 5 years)

- 5% by age 80, increases past 60

Front 221

Epileptic Seizure is? Epilepsy is?

- ES is transient? due to abnormal?

- epilepsy is disorder of? generate?

- must have had?

Back 221

- ES is transient occurrence of signs and symptoms due to abnormal excessive synchronous neuronal brain activity

- epilepsy is a disorder of the brain with an enduring predisp, to generate epileptic seizures

- in a patient who has had at least one seizure

Front 222

Focal Seizures

- conceptualized as? limited to?

- there may be discretely? or more?

Back 222

- conceptualized as originating within networks limited to one hemisphere

- these may be discretely localized or more widely distributed

Front 223

Generalized Seizures

- originating at some point within?

- both?

- can include both? but not necc?

Back 223

- conceptualized as originating at some point within, and rapidly engaging, bilaterallly distributed networks

- can include cortical and subcortical structures, but not necessarily include the entire cortex

Front 224

Seizure Classification

- focal = (2)

- generalized means?

- unknown means?

Back 224

1) Focal = motor vs non-motor

2) Generalized = motor vs absence

3) Unknown Onset = motor vs non-motor

Front 225

Childhood Absence Epilepsy

- is known as?

- seen in? may have?

- ages? peak?

- prior hx of?

- frequent daily? usually? can be provoked by?

Back 225

- genetic generalized epilepsy

- cognitive normal children - may have ADD or learning difficulty

- ages 2-12 (peak 5-6 years)

- prior hx febrile seizures

- frequent daily absence seizures, usually brief <10 seconds, can be provoked by hyperventilation

- GTCs may occur, usually later after adolescence

- imaging = normal

Front 226

Juvenile Myoclonic Epillepsy

- onset at? occasionally evolve from?

- normal?

- 5% have?

Back 226

- onset 8-25 years of age, occasionally evolve from CAE

- normal cognition and development

- febrile seizures = 5%

Front 227

Seizures of Juvenile Myoclonic Epilepsy

- myoclonic seizures are a? often occur within?

- generalized? seen in? often preceded by?

- absence seizures seen in? time? less frequent than?

Back 227

1) Myoclonic Seizures

= mandatory feature of syndrome, often occur within 30-60 minutes of awakening

2) Generalized Convulsive Seizures

= 90% of patients, often preceded by myoclonic seizures

3) Absence Seizures

= 1/3 of patients, briefer (3s) and less frequent than in CAE or JAE

Front 228

Epilepsy with Generalized Tonic-Clonic Seizures- known as?

- genetic?

- normal?

- infrequent? at age? occur within?

- often provoked by?

- require?

Back 228

- "Grand Mal Seizures on Awakening"

- genetic generalized epilepsy

- normal cognition and development

- infrequent generalized convulsions starting 11-20 yo, predom. these occur within 1-2h of awakening

- often provoked by sleep deprivation, fatigue, alcohol

- require lifelong therapy

Front 229

DD for Spells

- S/ C/ M/ S/ Dec/ Movement/ Psych?

Back 229

- seizure

- cardiac = syncope, cardiac arrythmia, PE

- migraine

- stroke/ TIA

- decerebration

- movement disroder = paroxysmal kinesigenic/nonkin choreo

- psychogenic nonepileptic event

Front 230

Epilepsy historical Interview

- warning? any? such as? or any?

- precips = S/A/W/ chnage in? lack of?

- ask about health at?

Back 230

- Warning with seizure - presyncopal sensation? olfactory or epigastric or deja vu aura? hallucinations?

- Precipitating factors - sleep deprivation? alcohol consumption? withdrawal? positional change? dehydration? painful?

- Health at seizure onset? febrile, confused? HA?

Front 231

Patient History

- positive = S/J/S/A/ deviation of?

- any post-ictal? (3)

Back 231

- Positive Phenomenology - shaking? jerking? stiffening? flashing light auras? head deviation? automatic behaviour?

- Post-ictal confusion? tongue-biting? urination?

Front 232

Patient history - Predisp. Factors for Remote Sympt Seizures include?

- insult of? type of seizure? previous? traumatic? FH of?

Back 232

- predisp. factors for remote symptomatic seizures:

= birth insult

= febrile seizures

= meningitis/enceph

= traumatic brain injury

= FH or epilepsy

Front 233

Prior history of Seizures?

- ask about time? if any? spells where? lose? become? act as? awaken with?

- about 50% of patients with first seizure have?

Back 233

- frequency - times a month?

- experience of auras?

- spells where space out? lose awareness? become confused? are lost?

- awaken with tongue-biting? urinary incontinence? pillows on floor?

** about 50% of patients present with first seizure have evidence of having had a prior seizure that was unrecognized as such

Front 234

Potential Causes

- acute intoxication - due to? (6)

- remote symptomatic, such as?

Back 234

- Acute precipitants = drug intoxication, drug withdrawal, metabolic derangement, meningitis, brain abscess, ICH/SAH/ Venous sinus

- Remote symptomatic = sequelae of stroke, ICH, SAH, enceph, febrile seizures, tumour, focal cortical dysplasia

Front 235

Investigations for Solitary Seizure

- general?

- labwork = (8)

- EKG - look for?

- also perform?

Back 235

- general system and neuro exam

- labwork = CBC, lytes, MG, Ca, glucose, urea, Cr, tox screen, LP

- EKG = long QT syndromes, Brugada, Holter, Echo, Cardio

- EEG

- Neuroimaging

Front 236

EEG - Diagnosis- helps with?

- look for presence of? to confirm?

- type? can help?

Back 236

- helps with diagnosis:

- presence of epileptiform abnorm will confirm suspicion of epileptic events if clinically consistent with seizures

- type of epileptiform abnorms can help classify the epilepsy syndrome

Front 237

EEG - Prognostification

- if negative, 27% risk of?

- if positive, 50% risk of?

Back 237

- if negative, 27% risk of recurrent seizures in the next 5 years after a 1st isolated seizure

- if positive, 50% risk of recurrent seizures in the next 5 years after 1st isolated seizure

Front 238

Sensitivity of Interictal Epileptiform Discharges (IEDs) for Epilepsy

- Initial EEG - IED seen in?

- repeat EEG - IEDs seen in?

** negative EEG doesnt?

Back 238

- Initial EEG = IEDs seen in 29-55% of patients

- Repeat EEG = IEDs ultimately seen in 80-90% of patients

* negative EEG does not rule out epilepsy

Front 239

Neuroimaging and Epilepsy

- imaging abnorm found in?

- should get an? unless?

-do for?

Back 239

- CT/MRI signif abnorm found in about 10% of paitents

- should get MRI unless you know its primary generalized epilepsy syndrome

- do for brain tumours, vascular malforms, neurocyst, mesial temporal sclerosis

Front 240

Predictors for Recurrent Seizures

- look for epileptiform abnorms on?

- look for prior? such as?

- post-ictal?

- prior seizure risk is?

- multiple seizures in first 24 hours?

Back 240

- epileptiform abnormalities on EEG

- known etiology, remote symptomatic = prior head injury, prior stroke, mental retardation, CP, tmour

- post-ictal Todd's paresis

- prior seizure = after 2nd sz, recurrence risk is 70%

- multiple seizures in first 24 hours are not predictive of recurrence

Front 241

JME made worse by? (3)

- myoclonus can be exac by?

Back 241

- can be made worse with CBZ, OCX, GBP

- myoclonus can sometimes be exacerbated by use of LTG

Front 242

Initiation and Dosing

Back 242

Front 243

Phenytoin Dosing

- for emergencies, give? IV

- otherwise give? may need?

- pharmaco is? small dosing changes can? may need to?

Back 243

- for emergencies = 20 mg/kg load oral or IV - max of 50 mg/minute

- otherwise = 300 mg po daily, may need titrating upwards or downwards to get levels into therapeutic range

- phenytoin exhibits non-linear pharmso a certain point, small change in dosing can result in dramatic chnages in levels, may need to change doses in small increments

Front 244

Phenytoin Adverse Effects

- CNS - see N/A/D? little effect on? enceph with? can cause?

- in GI - should give?

Back 244

- CNS = nystagmus, ataxia, drowsiness, modest to little effect on cognition, encephalopathy with toxic range doses, movement disorders (dyskinesia, choreoathetosis)

- GI = helped with admin with meals

Front 245

Phenytoin Chronic Adverse Effects

- dysfunction of?

- periph?

- cosmetic? 20% of? results in?

Back 245

- cerebellar dysfunction - may be rare complication of PHT intox

- peripheral neuropathy

- cosmetic - gingival hyperplasia - 20% of pts, hirsutism, coarsening of facial features

Front 246

Phenytoin Idiosyncratic Reactions - can cause? (6)

Back 246

- rash, fever, leukopenia, lymphadenopathy, SJ syndrome, hepatitis, SLE

Front 247

Contraindications to Phenytoin

- hypersens to?

- ULD?

- acute?

- heart = (2 - SBC/AVB)

Back 247

- hypersensitivity to hydantoin drugs

- Unverricht-Lundbord Disease

- Acute intemittent porphyria

- sinus bradycardia, AV block, Stokes-Adams Syndrome

Front 248

Carbamazepine Dosing

- stating dose of? usual adult dose is?

- titration time is?

- start with? then give? then increase by? for day #?

- get to?

Back 248

- starting dose of 200 mg/day

- usual adult dose of 600-1600 mg/day

- titration time to maintenance = usually 7-14 days

- regular and CR formulations

- SO:

= start with 100 mg po bid x 3 days

= then 100 mg po tid x 3 days

= then increase by 100 mg each 3 days until

= 200 mg po tid * initial target dose

Front 249

Carbamazepine

- good efficacy against? (2) POS/GTCS

- ineffective against? (A/M)

- dont use in?

- not really useful in? like?

Back 249

- good efficacy against partial onset seizures and generalized tonic-clonic seizures

- ineffective against absence seizures and myoclonic seizures

- dont use in Juvenile Myoclonic Epilepsy

- not really useful in symptomatic generalized epilepsies like Lennox-Gastaut syndrome or West Syndrome

Front 250

Carbamazepine SEs - are often?

- GI - causes?

- neurotoxic effect is? (5) - fewer cognitive effects than?

Back 250

- dose-related SEs

= nausea, Gi discomfort

= neurotoxic effect = dizziness, diplopia/blurred vision, sedation, HA, ataxia, incoordination, fewer cognitive effects than phenobarb or phenytoin

Front 251

Carb Idiosyncratic reactions

- R/AG/H/H

Back 251

- hypersensitivity rash

- agranulocystosis/aplasitc anemia

- hepatitis

- hyponatremia

Front 252

VPA Dosing

- emergencies - can be loaded?

- usually will want to?

- start at?

- increase by? time?

- goal to reach?

Back 252

- emergencies - can be loaded IV 20 mg.kg IV or even higher

- usually will want to gradually titrate the dose upwards for tolerability

- start at 250 mg po bid

- increased by 250 mg/day each week

- goal in newly diagnosed epilepsy of 750-1500 mg/day

Front 253

VPA SEs

- hematologic = thromb? abnormal? BMF?

- bone?

- can cause?

Back 253

- haematologic = thrombocytopenia, abnormal pt function, bone marrow failure, myelodysplasia

- osteopenia, osteoporosis

- hypersens rash

- tertogenicity

Front 254

Levetiracetam

- can be started at?

- rapid? within?

- push doses to? returns?

Back 254

- can be started at an initial therapeutic dose

- 500 mg po bid

- rapid onset o faction within first 1-3 days of use

- can push doses u pto 1500 mg po bid, although diminishing returns in seizure control by this point

Front 255

Levetiracetam Adverse Effects

- somn? D?

- chanhes in? S?

- rare?

Back 255

- somnolence, dizziness

- behav/ mood disturbs = seen in 13% of patients, suicidal ideation

- hypersens/ SJ reactions rare

Front 256

Juvenile Myoclonic Epilepsy

- is a triad of? (A/GC/M)

- high rate of? on?

- commited to?

- historical drug choice is? now use?

Back 256

- triad of absence seizures, generalixed convulsions, and myoclonic seizures

- high rate of seizure freedom on AED

- committed to life long therapy

- historical drug of choice is Valproate

- Lamotrigine is the recommended alternative

Front 257

Issues in Women with Epilepsy - Teratogenicity

- major fetal malform rate is? increased with many? such as? (3)

- VPA is bery?

- also really bad to use?

- attmept to mitigate with?

Back 257

- major fetal malform rate in general pop is 2%

- increased risk of malforms 4-6% with many major anticonvulsants = Phenytoin, Carb, Pheno

- VPA very teratogenic, see 10% risk of major malforms

- polytherapy (multiple drugs) also bad 15%

- attempt to mitigate with folic acid 1-5 mg daily

Front 258

Medications with High Risk for reducing the efficacy of OCP

- P/P/P/C/X/T

Back 258

- phenobarb, primidone, phenytoin, carbamazepine, Oxcarbazepine, Topiramate

Front 259

Meds for Epilepsy for Women in OCT - can use depot? L? or copper?

- possibly can use?

- dont use combine? (3)

Back 259

- can use depot MPA, levonorgestrel, or Copper IUD

- possibly can use combined injectables, Levo/Etonogestel implants

- dont use combined OCP, Prog. only OCP or transdermal patch

Front 260

Status Epilepticus - definition includes:

= time? of?

- or 2 or more?

Back 260

- operational definition:

= 5 minutes or longer of continuous seizure

= or 2 or more discrete seizures without complete recovery of consciousness

Front 261

Classifications of SE

- generalized?

- nonconvulsie = (2)

- focal motor = EPC?

- status?

Back 261

- generalized tonic-clonic status

- nonconvulsive status = absence status, complex partial status

- focal motor status = epilepsia partialis continua

- myoclonic status

Front 262

Mortality of Status Epilepticus =?

- variable depending on?

- best predictor?

- age effect?

Back 262

- mortality for 17-23%

- variable depending on etiology, duration (best predictor of mortality), age (worse if older) and treatment adequacy

Front 263

Morbidity of Status Epilepticus

- leads to delay of?

- if febrile status, can cause?

- left with?

- changes in?

Back 263

- neurodevelopmental delay in 34% of children with prolonged status epilepticus

- speech deifcits in children with febrile status epilepticus

- 10-23% of patients with SE left with disabling neuro deficits

- hippocampal chnages seen following SE

Front 264

Difficulty of Therapy with Time

- in rats, dizaepm good for? but not?

- delays in treat make SE?

- important for?

Back 264

- rat models = easy to use diazepam to stop sz < 5 min, but not longer seizures

- delays in therapy may make status epilepticus more likely to be refracotry to treatment

- therefore early therapy important to prevent the development of refractory status epilepticus

Front 265

epilepsy Management Pathway

- manage? perform a?

- check? (2)

- meds?

- diagnose and treat?

Back 265

- Manage ABCs = O2, IV Access, EKG, labs

- check serum glucose, thiamine if admin glucose

- anticonvulsant meds

- diagnose and treat underlying cause

Front 266

Anticonvulsant Meds

- timing - once?

- at 6-10 minutes, use? (3)

- at 10-20 minutes? (2)

Back 266

- timing = once seizure has been established for 5 minutes or more

- Benzos = 6-10 minutes = Ativan, Diastat, Midazolam

- Next line = 10-20 minutes = Phenytoin, Fosphenytoin

Front 267

Next Line = ICU needed

- give continous? (3 = M/P/P)

- then IV?

Back 267

1) Contiuous IV Midazolam

2) Cont. IV Propfol

3) Continuous Phenobarb

4) IV VPA

Front 268

Establishment of Underlying cause

- determine if caused by? (M/Acute? Symptomatic)

Back 268

- medication reduction/change/ noncompliance in the context of longstanding epilepsy

- acute brain injury = trauma, hem, stroke, sinus thrombosis, mening, enceph, tumour

- symptomatic = metabolic (hypon, hypogly), anoxia, hypertensive enceph, drug, EtOH, EtOH withdrawal

Front 269

What to Do if First Drug Fails

- consider if have? titrate? try to minimize?

- goal is no? (2)

- you can either? or try to?

Back 269

- consider if have right diagnosis

- titrate upward as tolerated, minimizing or avoiding SEs

- goal is no seizures, no SEs

- you can either introduce a secoond drug as adjunct, or switch from first drug to second drug

Front 270

Refractory Epilepsy

- definition is not well controlled after? at?

- 20-40% end up?

Back 270

- epilepsy not well controlled after 2 appropr. first-line drugs at max tolerated doses

- 20-40% end up being difficult to control on meds alone

Front 271

Kwan and Brodie Take Home

- should be referred if?

- seizures will continue to be?

- most likely need?

Back 271

- patients who continue to have seizures after you have tried them on adequate doses of two approp. chosen drugs should be referred on for subspec. care

- their seizures will be difficult to control with med manip alone and their situation needs to be re-eval

- patients in this situation likely need an eval. in an Epilepsy Monitoring Unit (EMU) to confirm diagnosis and to evaluate poss. epilepsy surgery

Front 272

Epilepsy Surgery

- concept that partial epilepsies may be from?

- surgery to resect? may?

- epileptogenic zone is the minimal?

Back 272

- concept - partial epilepsies may be the rsult of specific dysfunctional regions of brain that are sites for onset of seizures

- epilepsy surgery to resect these regions of brain may potentiall cure seizures

- epileptogenic zone = minimal amount of cortex needed to be resected to effect a surgical cure of epilepsy

Front 273

Value of Epilepsy Surgery- chance of seizure freedom is?

- decreased?

- improvement in?

Back 273

- seizure freedom chance of up to 70-80%

- decreased mortality = standardized mortality is probably 2-5

- improvement in QOL = regaining driver's license and independent, employment, depression scales improve

Front 274

Getting Referred for Epilepsy Surgery

- is the? average duratino to get to?

- should be refeered to if?

Back 274

- common perception that surgery is last resort

- patients at times specific. advised against surgery and given dissuasive info aobut surgery, espec. if have serious neuro complications

- average duration of havign surgery before patients have surgery = 20 years

- should be referred to spec. centre if seizure not control not achieved within 9 months by the general neuro

Front 275

Epilepsy Take Home Points

Back 275

Front 276

New Paradigm Shift in Dementia

- new?

- pathology believed to be?

- role of?

Back 276

- new criteria

- specific distribution of pathology

- pathology present years before clinical signs

- investigation

- treatment

Front 277

Dementia Criteria

- type of symptoms? that ?

- decline? not explained by?

Back 277

- cognitive and behavioral symptoms that:

= interfere with work or usual social activities

= represent a decline from prior levels of functioning

= not explained by delirium nor major psych disorder

Front 278

Dementia Criteria

- cognitive impairment involves at least two of? (4)

Back 278

- cognitive impairment is detected and diagnosed, involves at least two:

= impaired ability to acquire and remember new info

= impaired reasoning and handling of complex tasks, poor judgement

= impaired visual spatial and abilities

= impaired language functions

= chnages in personality/ usual character

** not a diagnosis

Front 279

Dementia - seen in? (8)

Back 279

- seen in Alzheimers, Parkinsons, Frontotemporal Dementia, Primary Progressive Aphasia, Vascular disease, Lewy Body Disease, Huntingtons Disease, Creutzfeld Jacob Disease

Front 280

Primari Neurodegenrative Diseases include? (6) = A/LB/P/FTD/PS/CB

Back 280

- Alzheimers Disease

- Lewy Body Disease

- Parksinsons Disease Dementia

- Frontotemporal Dementia (bvFTD, svPPA)

- Progressive Supranuclear Palsy

- Cortciobasal Syndrome

Front 281

Alzheimer's Disease - on history, see?

- most common presentation? impairment in?

- non-amnestic means?

- AD is the?

Back 281

- cognitive deficits are evident on history and exam

1) Amnestic Presentation = most common syndromic presentation of AD dementia, see impairment in learning and recall, see cog dysfunction

2) Non-Amnestic Presentation = language, visual and executive dysfunction

** most common cause of dementia

Front 282

Lewy Body Dementia - see diffuse?

- have dementia, plis 2 of? (3)

Back 282

- see diffuse atrophy, normal hippocampi

- dementia + 2 of:

= fluctuation

= visual hallucinations

= Parkinsonism

Front 283

Parksinson's Disease Dementia

- dementia with? two parts are?

Back 283

= Parkinson's disease (tremor, rigidity) + Dementia

Front 284

Vascular Dementia - Probable VaD

- have? evidence of?

- clear relationship between?

- severity of CI related to?

Back 284

= cognitive impairment and imaging evidence of CVD

= clear temporal relationship b/w vascular events and onset of CI

= relationship b/w severity and pattern of CI and presence of diffuse, subcortical CVD

= no evidence for other neurodeg. disorder

Front 285

Vascular Dementia - Possible VaD

-have? with evidence of?

- no clear?

- insuff? as no?

- may have? however cant test?

- some evidence of?

Back 285

= cognitive impairment and imaging evidence of CVD but no clear temporal relationship b/w vascular event and onset of CI

= insuff. evidence for dx of VaD because no imaging evidence

= severe aphasia so cannot test but normal before

= evidence for other neurodeg. disorder

Front 286

Frontotemporal Lobar Degeneration - is a?

- includes? (3) = Beh? Sem? Non-fluent?

Back 286

- family of syndromes, including:

= behavioral variant FTD

= semantic variant Primary Progressive Aphasia (svPPA)

= non-fluent variant PPA

Front 287

Behavioral Variant FTD - syndrome of? see change in?

- need three of six? = BD/A/loss of? Com? changes in? also chnage in?

Back 287

= behav. syndrome, see change in personality

= possible if three of six:

= early behav. disinhibiton

= early apathy or inertia

= early loss of emotional reactivity

= perservative/stereotyped or compulsive

= Hyperorality and dietary changes

= FTD neuropsych profile = executive

Front 288

Behav Variant FTD - Probable

- on MRI, see?

- presence of?

Back 288

1) Frontal and/or anterior temporal atrophy on MRI

2) Presence of known mutation

Front 289

Behav. Variant FTD

- most common of?

- gender?

- onset?

- progress?

- high relationship to?

- assoc. with?

Back 289

- most common of 3 clinical syndromes (56% of all FTD)

- M:F = 2:1

- earliest age of onset, 58 yo

- progresses most rapidly (3-4 y)

- highest genetic susceptibility

- strongly assoc. with ALS/MND

Front 290

Primary Progressive Aphasia

- syndrome involving?

- 3 different? = ?

Back 290

- clinical syndrome that involves language impairments selectively or primarily early on

- 3 syndromes = 2 FTLD syndromes, 1 AD syndrome

Front 291

Semantic Variant PPA

- presentation determined by?

- if left sided, see? lose?

- right sided, see? altered? loss of?

Back 291

- hemisphere affected determines presentation

- left-sided atrophy = loss of meaning for words, objects and emotions

- right sided atrophy = behav. syndrome, alterations on social conduct, loss of person-based semantic knowledge, loss of empathy/ability to recognize emotions

Front 292

Semantic Variant PPA

- %?

- onset age?

- progression?

Back 292

- <20% of all FTD cases

- shares earlier age of onset with bvFTD

- slowest progression (5.2 yrs from diagnosis to death)

Front 293

Nonfluent Variant PPA

- disorder of?

- primary sign is? also see? PP/SA

- preserve?

- often develops into?

Back 293

- disorder of expressive language/speech production

- nonfluent speech + agrammatism, phonemic paraphasias and speech apraxia

- behaviour/ insight preserved early on

- often develops into PSP or CBS

Front 294

Nonfluent Variant PPA

- %?

- progression?

- intermediate rate of?

Back 294

-25% of FTD

- intermediate rate of progression (4.3 years from diagnosis)

- intermediate rate of genetic cause

Front 295

Extending Term FTLD

- originally? which includes (2)

- those added inclide? (MND, CBS, PSP)

Back 295

- originally FTD = bvFTD,svPPA and nfvPPA

- added to the fold:

= FTD-with motor neuron disease (FTD-MND)

= Corticobasal Syndrome (CBS)

= Progressive Supranuclear Palsy (PSP)

Front 296

Aiding Dementia Diagnosis

- test? looking for (2) - sens and spec? for?

- amyloid increases with?

- in AD trials, see?

Back 296

- CSF = A-beta, Tau

- Sens = 91%, Spec = 85%, accuracy 90% for neuritic plaque

- presence of amyloid increases with cognitive decline

** most clinical trials in Alzheimers disease require biomarker positivity before can enroll

Front 297

Misdiagnosis

- AD is often? yet 11%

- gender role?

Back 297

- studies showing that AD often misdiagnosed

1) 78% have correct diagnosis, 11% of patients diagnosed with AD did not have it, 11% had it and didnt get diagnosed with it

2) Men more likely to get misdiagnosed because present with behav, language or other non-memory symptoms

Front 298

Disease Onset Before Clinical Symptoms - seen in both?

Back 298

- seen in both AD and FTD

Front 299

Mild Cognitive Impairment - concern regarding?

- impairment seen in? below mean of?

- yet have preservation of?

- not?**

Back 299

1) Concern regarding a change in cognition

2) Impairment in one or more cognitive domains below the mean for their age and education matched peers on culturally approp. norm data

3) Preservation of independence in functional abilities

4) Not demented

Front 300

Top Ten DD for Cognition/Behaviour

Back 300

1) Alzheimer Disease

2) vascular Disease

3) Drugs, Depression, Delirium

4) Ethanol

5) Medical/ Metabolic

6) Endocrine

7) Neurologic

8) Tumor, Toxin, Trauma

9) Infection, Idiopathic, Immunologic

10) Amnesia, AI, Apnea

Front 301

Goals of Treatment for Cognitive Impairments

- interfere with?

- remove?

Back 301

- interfere with formation and accumulation of toxic substances

- remove toxic substances

Front 302

Pharm for Dementia

- no meds to? but meds for?

- make sure to treat, such as?

- review all?

Back 302

- no meds available to cure or delay signif progression of any dementia, but meds available for symptomatic relief

- treat concomitant medical conditions including infections, parkinsonian symptoms, seizures, pain and improve nut status

- review all meds = incl. alternative

Front 303

Pharms for Alzheimers Disease

- first give? main one? (A/E)

- then can give antag of? E?

- antideps?

- low doses of?

Back 303

1. Acetylcholinesterase Inhibitors (AChEIs) = Aricept, Exelon

2. NMDA-receptor antag = Ebixa

3. SSRIs = antideps = Citalopram, Effexor

4. Atypical Antipsychotics =low doses of atypical antipsychotics such as quetiapine, olanzepine or risperidone for agitation, aggression

5. Others = Trazadone, VPA

* many anti-amyloid treatments in clinical trials for Abx and Ace-inhibs

Front 304

Frontotemporal Dementia

- no? can try to give? or low dose?

- in future?

Back 304

- no treatments available

- antidepressants

- low dose antipsychotics

- future = protein specific treatments for Tau, Progranulin, and FUS

Front 305

Parkinson's Disease Dementia and Lewy Body Disease

- give a? such a?

- can also try (ACEI)? (ex/) or?

Back 305

- dopamine agent, ex/ Sinemet

- anticholinesterase inhibitor, ex/ Aricept, Exelon

- Antidepressant

Front 306

Vascular Dementia - must control?

- ex/ (3)

- tell to?

- may use?

Back 306

- control vascular RFs

- ex/ BP, sugars, lipids

- exercise

- +/- Aricept

Front 307

Dementia Risk is Reducible

- S/ D/ HTN/ edi/ D/ O/ decreased by?

- lots of evidence that?

Back 307

- diabetes heightened risk by 50%

- smoking heightened risk by 50%

- HTN in midlife increased risk of vascular dementia by 60%

- education lowered risk by 40%

- depression and obesity also increased risk

- PA and cognitive stimulation decreased it

*lots of evidence that dementia risk is reducible

Front 308

Role of Lifestyle in Dementia

- moderate? assoc with?

- independent of? (6)

Back 308

- moderate PA, ie more strenuous than walking, assoc. with better cognition in a 25 year follow up

- assoc. with better cognition in old age

- independent of midlife hypertension, smoking, education level, sex, obesity, binge drinking

Front 309

Dementia and Cognitive Reserve

- role of occupation?

- growing evidence that?

Back 309

- people who had more complex jobs, remained socially active and avoided depression were also more resilient to Alzheimers

* growing evidence that incidence of dementia has decreased

Front 310

Diagnosis of Dementia

- begins during?

- patient's?

- informants?

Back 310

- exam begins during history

- patient's CC, education, work history - attention, speech and language, orientation and insight

- informant's chief complaint and social interaction

Front 311

1st Symptoms in Dementia

- first symptoms include?

- required for? which is then ndded for?

- important to elicit?

Back 311

- first symptoms - clue to anatomy and neurophysiology

- anatomy and neurophys clue to diagnosis

- diagnosis required for treatment and prognosis

- eliciting detailed and accurate history is paramount for adequate exam

Front 312

AD 1st Symptom - is?

- seen with? (4)

Back 312

- 1st symptom is memory

- missing appointments, losing keys, repeating stories, asking repetitive questions, getting lost

Front 313

Frontotemporal Dementia - begins in? (3) = AC,I, VPC

- 1st symptom is?

- chnage in? lack of?

- loss of?

Back 313

- FTD begins in anterior cingulate, insular and ventral prefrontal cortex

- 1sy symptoms in FTD are:

= disinhibition, personality chnage, lack of concern for others, apathy, overeating, executive difficulty- cannot plan/organize, poor judgment

Front 314

Dementia with Lewy Bodies

- progressive? changes in?

- also see? (VH/P)

- fluctuation?

- affects?

Back 314

- progressive dementia = Attention, V-S

- visual hallucinations

- parkinsonism

- day to day fluctuation

- REM sleep behav. disorder

- neuroleptic sensitivity

Front 315

1st Symptoms

- AD =?

- FTD = ?

- DLB =? visual? fluctuations of?

Back 315

AD - memory, language, executive, spatial

FTD - behavioural

DLB - movement, visual hallucinations, fluctuations, REM motor behaviour

Front 316

How to Assess Dementia - global? M/L/VS/ EF/ M

Back 316

- global cognition

- memory

- language

- visual-spatial function

- executive function

- mood/personality

Front 317

Summary of Dementia

- first symptoms provide?

- pattern of? assoc with?

- need for?

Back 317

- first symptoms provide clues to underlying neuropathology

- pattern of cognitive deficits are assoc. with specific anatomy and neurodegen. diseases

- accurate diagnosis required for treatment

Front 318

Approach to CBC - review? (4)

- also look at?

- think about? whether it is?

Back 318

- review Hb, mcv, WBC coutn and differential

- review pt count

- bone marrow problem?

- production vs destruction? decide?

Front 319

CBC Abnormalities

- if multiple cell lines affected? such as?

- if single line affected, think? such as?

Back 319

- if multiple cell lines affected, thick about bone marrow problem, ex/ chemotherapy

- if single cell line affected, think about missing building block or something causing a peripheral destruction of that cell line ex/ iron deficiency

Front 320

Signs and Symptoms of Anemia

- F/H/L/N/CP/S/T/HF/H

Back 320

- fatigue

- HA

- lightheadedness

- nausea

- chest pain = ischemia

- SOB

- tachycardia = fast heart rate

- heart failure

- hypotension

- death

* rate of development very important

Front 321

Approach to Anemia - 2 Key Pieces of Info

- size of? helps to?

- count of? if low? if high?

Back 321

1) Red cell size = MCV = helps narrow diff.

2) Reticulocyte Count - underproduction (low retics) vs destruction/loss (high retics)

Front 322

Role of Retics

- retics are? if able to make?

- on blood film, retics present as? (3)

- still contain?

Back 322

- retics are brand new RBCs

- if able to make retics, means production is okay

- retics on a blood film have increased colour, decreased central pallor and larger size

- retics still contain RNA so we can stain for this to help us count them = Retic count

Front 323

Exam of CBC = MCV < 80 - means?

- often related to? measure? (2)

- if low? suspect?

- if normal?

- if high ferritin, suspect?

Back 323

- microcytic anemia, often related to iron, measure ferritin and serum iron

- if low ferritin (<15), low serum iron and high TIBC, suspect iron defic.

- if normal = thalassemia

- if high ferritin (>100), low serum iron and low TIBC, suspect anemia of chronic disease

Front 324

If MCV 80-100? - called? look at?

- if <2%, may mean? seen in? (2) L/AA

- if >2%? due to? (2)

Back 324

- normocytic anemia, look at reticulocyte count

- if <2% = hypoproliferative = leukemia, aplastic anemia, pure red cell aplasia

- if >2% = hyperprolif = hemorrhage, hemolytic anemia

Front 325

Causes of Microcytic Anemia = TAILS = means?

Back 325

= thalassemia

= anemia of chronic disease = anemia of inflammation

= iron defic - most common cause worldwide

= lead poisoning = rare

= sideroblastic anemia = rare

Front 326

Iron Indices - ferritin is? reflects?

- Tf is synth in? acts as? known as?

- uptake from? via?

- TIBC is then? used to?

Back 326

- ferritin is primary iron storage protein and reflects total body iron stores

- transferrin (Tf) is synth in liver, acts as iron transporter = TIBC

- uptake from transferrin is via transferrin receptors

- serum iron/transferrin (or TIBC) = % transferrin saturation used to assess iron overload

Front 327

Diagnosis of Iron Defic.

- low ferritin diagnostic of? start with?

- decreased MCV usually is?

- would then find decreased? (2)

- increased?

Back 327

- low ferritin is diagnostic of iron defic = start with ferritin if low, no further testing needed

- decreased MCV usually - MCV falls before Hb but sometimes will fall together, ex/ pregnancy

- dont need to measure but would find decreased retics, decreased serum iron and increased serum transferrin (TIBC)

Front 328

Diagnosing Iron Defic.

- iron defic warrants?

- ask about? (3)

- ferritin of less than 50 with normal Hb assoc with?

- always treat? even if?

- iron nec. for?

Back 328

- in males and non-menstruating females, iron defic. always warrants search for blood loss from GI tract

- ask about diet, GI bleeding and GU bleeding

- although most labs report 20-200 normal, ferritin of less than 50 with normal Hb assoc. with fatigue

- treat iron defic. even if not anemic esp. in women of child bearing age

- iron is nec. for normal fetal development

Front 329

Iron Defic.

- WHO defines iron defc as?

- most common?

- found in?

- result of increased? or?

Back 329

- WHO defines iron defic. as ferritin < 15 in adults and <12 in children younger than 5 years

- is the most common and widespread nutritional disorder in the world

- 20-25% of humans are iron defic.

- result of increased demand, limited supply and increased blood loss

- disease of women and children

Front 330

Presentation of iron Defic

- increased? decreased? (2)

- changes in?

- in women of childbearing?

Back 330

- increased fatigue (ferritin <50)

- decreased physical performace

- decreased cognitive abilities

- irritability and mood chnages

- 40% women of childbearing age have iron defic. (ferritin <30) and 4% IDA

Front 331

How Does Iron Defic. Affect the Brain?

- decreased, leading to less?

- altered? important in?

- glucose utilization is?

- decreased functioning of?

Back 331

- decreased arborization of dendrites, decreases interneuronal connections

- altered neurochem and monoaminergic pathway, important in motor control, sleep cycles, learning and memory

- altered bioenergetics - glucose utilization in the brain is highly iron dependent

- decreased functioning of oligos and decreased myelin - effect is not reversible

Front 332

Treatment of Iron Defic.

- can be given?

- start with? go? try to minimize by?

- if not tolerating?

- IV is?

Back 332

- iron supplementation can be given po or IV

- start with oral iron, go slow, take iron at bed to try and minimize symptoms and take with source of vitamin C to increase absorption

- try different preparations if trouble tolerating - N/bloating, const. common

- IV iron well tolerated offer to patients if urgent treatment needed or can not tolerate oral iron

Front 333

Transfuse RBC rule?

- do not? for? without?

- IV or oral iron for?

Back 333

- dont transfuse RBCs for iron defic. without hemodynamic instability

- preop and patients with chronic iron defic. without hemodynamic instability should be given oral or IV iron

Front 334

Microcytic Anemia - Anemia of Chronic Disease

- is anemia secondary to?

- most commonly due to? (5)

- can be either?

- caused by? increased? leading to reduced?

Back 334

- anemia secondary to acute or chronic inflammatory state

- most commonly = chronic infections, IBD, rheum disorders, malignancy, renal disease

- can be microcytic or normocytic

- caused by cytokines that increase hepcidin leading to:

= reduced RBC survival, reduced response to EPO, reduced iron utilization

Front 335

Anemia of Inflammation Investigations

- if see increased ferritin?

- may also see decreased? (3)

- reduced?

Back 335

- see increased ferritin = retics will be inapprop. low for the anemia

- decreased serum iron, decreased TIBC, and decreased % transferrin saturation

- soluble transferrin receptor - normal in anemia of inflammation but increased in IDA

- inapprop. reduced EPO level

Front 336

Treatment of Anemia of Inflammation

- treat the?

- give EPO at?

- may need?

often difficult?

Back 336

- treat underlying disorder

- EPO = 150-200 IU/kg 3x week, or 40,000 once/week

- may need po/ IV iron also

- often difficult to treat

- Hepcidin inhibitors in development

Front 337

Thalassemia is abnormal?

Back 337

- abnormal production of Hemoglobin

Front 338

Macrocytic Anemia Approach - MCV is?

- check to see if? (2) on?

- if present? means? either?

- if not present? (4) - A/MDS/LV/CBM

Back 338

- MCV < 100

- check to see megalocytes and segmented neutrophils on peripheral smears

- if present = megaloblastic = Vit. B12, folate defic or drug-induced

- if absent = alcohol abuse, myelodysplastic syndrome, liver disease, congenital bone marrow failure

Front 339

Macrocytic - Check to see if?

- looking for?

- if nonmegalo, see?

Back 339

- check to see if megaloblastic blood film - look for oval macrocytes and hypersegmented neutrophils

- nonmegalo blood film= round or oval macrocytes

Front 340

Megaloblastic Anemia

- characteristic?

- cells cannot? due to?

- cause mainly by? (2)

Back 340

- characteristic bone marrow morphology of open chromatin

- cells can not mature due to defective purine and pyrimidine production

- caused by B12 defic, folate defic, cytotoxic drugs, rare genetic disorders

Front 341

B12 (Cobalamin) Defic

- B12 found in? absorbed by?

-body stores?

- assoc with abnorms of? (3)

- see? (MA/P)

- on blood film?

Back 341

- found in animal products, also synth by microorgs

- absorbed via intrinsic factor

- body stores last for 3-4 years

- assoc. with psychiatric, neuro and hematologic abnorms = macrocytic anemia and panctyopenia

- oval macrocytosis and hypersegmented neutrophils on blood film

Front 342

Causes of B12 defic

- strict?

- unable to? seen in?

- no? called? or have had?

- infections of?

Back 342

- strict vegan

- unable to absorb = terminal ileum disease

- no IF - pernicious anemia or gastric surgery

- GI infections - tapeworm, bacterial overgrowth

Front 343

Pernicious Anemia

- lack of? due to?

- not? classicaly described as?

- measure?(2)

- before a?

- treat with?

- may see no improvement of?

Back 343

- lack of intrinsic factor due to autoantibodies

- uncommon

- classically described as lemon yellow

- measure B12 (10% falsely normal) and IF antibodies

- OGD and biopsy

- trat with high dose IM or po B12

- psychiatric symptoms may not improve

Front 344

Non-Megaloblastic Causes of Macroytic Anemia

- other (4)

Back 344

- myelodysplastic syndrome

- possibly retics = bleeding or hemolysis

- liver disease

- hypothyroidism - uncommon

Front 345

Destruction of RBCs - if destroyed too soon?

- if enough retics made, see? therefore can be?

Back 345

- destroyed to soon = hemolysis

- if enough retics made, can see increased MCV - can be macrocytic or normocytic

Front 346

Approach to Normocytic Anemia - Need?

- if low, cant? =? such as?

- or secondary =?

- make diagnosis with?

Back 346

- need retics

- if low retics = cant make new RBC effic.

= primary bone marrow failure = aplastic anemia

= secondary bone marrow failure = HIV infection

*diagnosis made via bone marrow aspriate and biopsy

Front 347

If have low retics, may have low? secondary to?

- need to determine?

Back 347

- may also have low EPO secondary to renal failure

- diagnosis = need EPO levels

Front 348

Hemolysis - Extra vs Intra

- extravascular means? destoryed by?

- intravascular means?

- when hemolysis occurs?

Back 348

- Extravascular = RBCs dont make it to 120 days, destoryed by reticuloendothelial system

- Intravascular = abnormal process leading to red cells being destroyed within Bvs

*when hemolysis occurs, red cell contents spill out

Front 349

Investigations for hemolysis

- destruction of RBCs leads to increase? (3)

- decreased?

Back 349

- destruction of RBCs leads to:

= increeased retics, increased bilirubin, increased LDH and decreased haptoglobin (protein that binds free Hb)

Front 350

To determine EV vs IV

- perform a? EV if see? IV if see?

- also can perform? looking for?

Back 350

1) Blood film - Sperocytes (EV) vs Schistocytes (IV)

2) DAT direct Antiglobulin test - look for complement and Ab on RBC surface

Front 351

What Causes Red Cell Hemolysis - Internal

-Hb? enzymes? cyto?

Back 351

- intrinsic red cell problems:

1) Hb = Sickle Cell

2) RBC enzymes = G6PG defic.

3) RBC cytoskeleton = hered. spherocytosis

Front 352

What Causes Red Cell Hemolysis - External

- D/I/ Abs/ struct/ dissem/ MAHA - decreased?

Back 352

- drugs

- infections

- Abs against red cell antigens - ABO incompatible

- Struc. problems - defective valves

- disseminated intravasc. coagulation

- Microangiopathic Hemolytic Anemia (MAHA) or MA = decresed Hb and pts

Front 353

Internal IV Hemolysis Investigation - see free? fragments of?

Back 353

= free Hgb, schist fragments

Front 354

Extravasc. Hemoylsis = Investigations - see? +? iron is?

Back 354

- spherocytes

- DAT +

- iron recycled

Front 355

Investigation of Erythrocytosis - look for increased? decreased?

- relative erythro = decrease? due to?

Back 355

- increased red cell mass vs decreased plasma volume

- relative erythrocytosis = decreased plasma volume, often due to reduction in plasma volume (diuretics, smokers)

Front 356

Investigation of Erythrocytosis - Increased red cell mass

- meassure? if low, means? if high?

- EPO released due to?

Back 356

- measure EPO level

- low EPO means red cell production independent of EPO

- high EPO means inapprop EPO driving red cell production

*hypoxia = causes Epo secretion

Front 357

Primary Erythrocytosis

- increased RBC mass with low EPO caused by?

- is a? due to?

- mutation in?

Back 357

- increased RBC mass but low EPO caused by:

= polycythemia vera (PV) which is a bone marrow myeloprolif disorder = JAK-2 tyrosine kinase mutation

= mutation of EPO receptor gene

Front 358

Secondary Erythrocytosis - increased? driven by?

- main cause is? from? (3)

- EPO can also be increased by? (5)

Back 358

- increased red cell mass driven by high EPO

1) Hypoxia = heart/lung disease, high altitude living, abnormal Hbs

2) Increased EPO = cancer, uterine fibroids, renal cysts, renal artery stenosis, EPO doping

Front 359

Increased Red Cell Mass Symptoms

- (5)

Back 359

- symptoms include HA, plethora, shortness of breath, numbness and tingling in hands and feets, blood cots

Front 360

Treatment of Increased Red Cell Mass - Polycyhtemia Vera

-is a? increased progression to?

- key issues are?

- perform?

- can give? to prevent?

Back 360

= this is a pyeloprolif disorder increased risk of progression to leukemia

- key issues are preventing thrombosis and managing symptoms

- phlebotomy or chemo to keep hematocrit below 0.45 for men and 0.42 for women

- give Anticoags to prevent thrombosis

- use JAK2 inhibitors

Front 361

Treatment of Increased Red Cell Mass - EPO Mutation? Secondary Erythrocytosis

- mutation in? maintain? via?

- or manage the?

Back 361

1) EPO Mutation = maintain hematocrit with plhebotomy

2) Secondary Erythrocytosis = manage underlying cause

Front 362

WBC Terminology

- too few WBCs? too many? too few Ns? too many? too few lymphs? too many?

Back 362

- leukopenia = too few WBCs

- leukocytosis = too many WBCs

- neutropenia = too few neutrophils

- neutrophilia = too many neutrophils

- lymphopenia = too few lymphocytes

- lymphocytosis = too many lymphocytes

Front 363

Leukopenia - Ethnic Variations - normal depends on?

- CBC only assess?

- lower normals in?

- need diff to?

Back 363

- normal depends on controls

- CBC only assesses the circulating WBC pool

- lower normal range in South African blacks, Arab Jordanians, Yemenite Jews

- normal response to infection - need differential to see which WBCs are low

Front 364

Causes of Neutropenia

- decreased? seen with? (4)

- increases? due to?

- may be? seen with?

* can lead to?

Back 364

1) decreased production = drugs (chemo), bone marrow disorders, benign cyclic neutropenia, congen. neutropenia syndromes

2) increased destruction = AI or alloimmune

3) dilution/sequestration = Felty's syndrome

* can lead to fatal bacterial infection if ANC < 0.5

Front 365

Febrile Neutropenia

- seen in? if ANC?

- must monitor for?

- if develop? must?

- Neuopgen is? sometimes used to?

Back 365

- patients receiving chemotherapy at risk if ANC <0.5

- patients must monitor for signs of infection

- if develop temp >38.3, must use broad spectrum Abx immed.

- G-CSF (Neupogen) sometimes used to stimulate granulocyte prolif, accelerate recovery

Front 366

Causes of Neutrophilia

- demarg means? dues to?

- reactive sees? often due to?

- or due to a?

Back 366

1) Demargination = from endothelium into circ. blood = exercise, pain, infection, steroids

2) Reactive = left shift, immature WBCs move out of marrow, due to infection or inflammation

3) Bone Marrow Malignancy

Front 367

Causes of Lymphopenia

- I/D/CID/ mild?

Back 367

1) Infection = bacterial, viral, parasitic, fungal

2) Chemotherapy/Drugs

3) Congenital Immunodefic. disorders

4) Mild lymphopenia on very CBC common

Front 368

Causes of Lymphocytosis

- reactive = such as? also due to? (2)

- malig?

Back 368

1) Reactive = viral infections (infectious mono), stress (MI), smoking

2) Lymphoid Malignancy

Front 369

Approach to Lymphocytosis

- need to? to?

- also determine if it is? via?

Back 369

- cant guess if reactive or malignant need to investigate further if not clear

- is it polyclonal or monoclonal = morphology, immunophenotype, molecular studies

Front 370

Eosinophilia - seen with? (A/P/M)

Back 370

- allergic reactions = enviro, medication

- parasitic infections = strongyloides, schistosomiasis

- malignancy

Front 371

Monocytosis - seen with chronic? such as?

- also diseases like? (2)

Back 371

- chronic infections - TB, syphilis

- Chronic Inflamm Diseases = IBD, RA

- malignancy = Acute and chronic leukemias

Front 372

Platelet Conditions - too few? too many?

Back 372

- too few = thrombocytopenia

- too many = thrombocytosis

Front 373

Approach to Thrombocytopenia - is it true? take?

- is it? or are other?

Back 373

- is it true thrombocytopenia = take a bleeding hisotory, review blood film

- is it isolated TC or are other cell lines affected = review blood film

Front 374

Pseudothrombocytopenia - due to? pts get?

- machine cant?

Back 374

- due to platelet clumping, pts get activated during collection

- machine cant count them, lab should report pt clumping on blood flilm

- platelet satellitism = in vitro phenomena

Front 375

Thrombocytopenia

- disorder of? often presents as?

- no smyptoms until?

- presence of? which are?

- worry when?

Back 375

- disorder of primary hemostasis, see mucous membrane bleeding

- usually no symptoms until pts <30

- presence of petechiae - non blanching non-palpable or mucosal bleeding - pts below 10 = worry

Front 376

Approach to Thrombocytopenia

- decreased? inceased? or stuck?

Back 376

- decreased platelet production

- increased platelt destruction

- sequestration = pts suck in spleen/liver

Front 377

Thrombocytopenia - History and PE

- bleeding? recent? B? ask aobut? such as? past?

- history of?

- bruising of?

- exams?

Back 377

- bleeding hisotry

- recent infection - HIV and Hepatitis

- systemic symptoms = fever, night sweats, weight loss

- AI disease = thyroid disease

- past medical, surgical transfusion history

- Meds, FH, alcohol and smoking history

- petechiae bruising - look inside mouth

- exam = LNs, hepatosplenomegaly

Front 378

Bleeding and Thrombocytopenia

- if < 10? need?

- 10-30, are? will then?

- 30-50 - mild? dont?

- higher than 50?

Back 378

- pts < 10 = risk of spont bleeding = need treatment

- pts 10-30 = symptomatic, usually treat (chidlren <50)

- pts 30-50 = mild or no symptoms, dont need treatment unless surgery or pregnant

- pts >50= do not need treatment

Front 379

Thrombocytopenia and Decreased production

- often due to a? such as? (5)

- toxin of? from?

- infection such as?

- or defic of?

- iron defic will?

Back 379

- primary bone marrow disorder = aplastic anemia, leukemia, myelodysplastic syndrome, congenital thromboytopenia

- marrow toxin = alcoho, drugs

- infection - viral, bacterial, malaria

- B12 or folate defic = not iron defic as it usually increases pts

Front 380

Thrombocytopenia and Increased Destruction - Immune Causes

- Primary =? is a?

- Secondary includes? (4) post? use of?

Back 380

Primary - Immune Thrombocytopenia = ITP = diagnosis of exclusion

Secondary = viral, collagen vasc disease (SLE), lymphoprolif disorder, drugs (esp. heparin), post-transfusion

Front 381

Immune Thrombocytopenia ITP

- in children, most are? then?

- in adults are? onset?

- no standard? always are?

- must rule out? important to?

Back 381

- in children, >80% cases are acute, follow viral illness and resolve spontaneously

- in adults, usually chronic, insidious onset

- no gold standard test for ITP, always looking for other causes

- must rule out HIV, hep B and C- important to investigate in women on childbearing age as Ab can cross to baby = cause neonatal thrombocyto

Front 382

Primary ITP - is immune mediated? live less than?

- inapprop repsonse of?

- treat includes? imm. vs longterm?

- TPO increase cia?

Back 382

- immune mediated early destruction, live less than 7 days

- inapprop. TPO response = like anemia of chronic disease for pts

- treatment = steroids immediate, longterm do splenectomy or immune suppression

- can also increase TP = receptor agonist

Front 383

Heparin Induced Thrombocytopenia

- should ask if?

- usually occurs after?

- patient will? dont?

Back 383

- should ask in any patient on heparin and see sudden fall in pts

- much more common with UFH and usually occurs 5-10 days after starting heparin

- patients clot, dont bleed

Front 384

HIT

- caused by? which causes?

- patient develops? leads to? not?

- patients die of? need to stop? and start?

Back 384

- caused by an antibody to heparin and PF4

- antibody activates pts

- patients develop low pts but lead to thrombosis not bleeding

- patients die of thrombosis if heparin not stopped and another non-heparin anticoag is not started

Front 385

treatment of HIT

- stop all? must use? no?

- so use?

- warfarin may?

Back 385

- stop all hepatin

- must use alternative non-heparin and non-warfarin anticoag even if no thrombosis

- use Fondaparinux or Argatroban

- warfarin may cause massive thrombosis

Front 386

Thrombocytopenia and Increased Destruction - Non Immune Causes

- D/D/S/M/PE

- MAHA - see low? due to?

- worry if on film?

Back 386

- drugs, DIC/sepsis/ mech destruction, TTP/HUS or pre-eclampsia

- MAHA - see low pts and red cell fragments due to fibrin activation causes RBC frag

** if see thrombocytopenia and red cell fragments on film, worry!

Front 387

Thrombotic Thrombocytopenic Purpura TTP - caused by lack of? which can be?

- many symptoms = (2)

- also see? (3)

Back 387

- caused by lack of ADAMTS13, which can be congenital (very rare) or autoimmune

- symptoms = anemia (schists), low pts

- also see fever, renal failure, neuro symptoms

Front 388

TTP - Thrombotic Thrombocytopenic Purpura

- untreated mortality?

- fibrin? leads to? pts are?

- patients both?

- treatment is urgent? to replace?

Back 388

- untreated mortality is >80%

- fibrin clots in small blood vessels from uncontrolled VWF, leads to red cell fragents, pts activation, fever, renal failure, neuro symptoms

- patients bleed and clot

- treamtent is urgent infusion of plasma (to replace VWF) followed by plasmapheresis

Front 389

In TTP, see uncontrolled? plus uncontrolled? due to?

Back 389

- uncontrolled vWF release + uncontrolled plt activation due to loss of ADAMTS13

Front 390

Thrombocytosis

- reactive = I/I/B/ Defic of/ or?

- bone marrow? known as?

- redis = ?

Back 390

1) Reactive = infection, inflamm, bleeding, iron defic, cancer, bone marrow infiltration

2) Bone marrow premalig or malig = myeloprolif disorders = essential thrombocytosis

3) Redistributive = post splenectomy

Front 391

Categories of Bone Marrow Disorders

- failure = not enough? seen in (2)

- myeloprolif =? seen with? (3)

Back 391

1) Bone Marrow Failure = not enough blood = aplastic anemia, myelodysplastic syndrome

2) Myeloprolif Neoplasms = too much blood = polycythemia vera, essential thrombocythemia, primary myelofibrosis

Front 392

Aplastic Anemia - destruction of?

- have empty? leads to severe?

- if untreated?

Back 392

- destruction of HSCs

- empty bone marrow = bone marrow failure

- severe pancytopenia

- untreated, severe aplastic anemia leads to rapidly to death

Front 393

Presentation and Diagnosis of Aplastic Anemia

- presents over? F/I/ B/B - from?

- diagnose using? (2)

Back 393

P = pancytopenia, progressive over weeks-months, anemia (fatigue), leukopenia (recurrent infection), thrombocytopenia (bruising, bleeding)

D = bone marrow aspiration and biopsy

Front 394

Treatment of Aplastic Anaemia

- regen - via?

- best in patients that are?

- remission?

Back 394

1) Regenerate Stem Cells

= immunosuppressive therapy = ATG

= best for patients > 40 years

= long term remission in 60%

Front 395

Treatment of Aplastic Anaemia

- replace - via?

- best for patients that are?

- cure rate?

Back 395

2) Replace Stem Cells

= allogeneic stem cell transplantation

= best for patients <40 years

= cure in >80%

Front 396

Myelodysplastic Syndrome (MDS)

- disorder of?

- affected stem cell then?

- progeny are? with?

- leads to?

Back 396

- clonal stem cell disorder

- affected stem cell takes over the marrow

- progeny of affected stem cell are defective = abnormal morphology, function, apoptosis

- cytopenias

Front 397

Presentation and Diagnosis of MDS

- progresses over? seen? most commonly see?

- diagnose using? can also perform? look at (3)

Back 397

P = cytopenias, slowly progressing over months-years, most commonly anemia

D = blood film, bone marrow aspirate and biopsy (blast count, cytogenetics, iron stains)

Front 398

MDS Treatment - Must first?

- as some become? others?

Back 398

- risk stratification = heterogenous disease, some transform rapidly to AML, some are stable and chronic

Front 399

MDS Treatment

- lower risk - fix? to help? give (E/L/A)

- if high risk, want to delay? to extend? - perform? or give?

Back 399

- lower risk = fix cytopenias to ameliorate symptoms = ESAs, Lenalidomide, ATG

- higher risk = delay or prevent AML to extend lifespan = Azacytidine or Allogeneic stem cell transplantation

Front 400

Aplastic Anemia Summary

- very? seen in? BM is? due to either?

causes? two treatments?

Back 400

- very rare

- younger patients

- bone marrow empty

- AI or toxic

- pancytopenia

- immunosuppressive treatment or BMT

Front 401

MDS Summary

- patients are? bone marrow is? disorder of? cells are? leads to? treatment based on?

Back 401

- older patients

- bone marrow full

- clonal disorder

- dysplastic cells

- cytopenias

- variety of treatment according to risk stratification

Front 402

Myeloproliferative Neoplasms

- disroder of?

- see overproduction of?

- may eventually enter?

- can transform to?

- 97% have a?

Back 402

- clonal stem cell disorders

- overproduction of one or more cell lineage

- may eventually enter a fibrotic phase

- can transform to acute leukemia (rarely)

- in 97%, activating mutation of JAK2 or MPL or CALR

Front 403

Three Types of MPN - PV/ ET/ PMF

Back 403

1) Polycythemia Vera

2) Essential Thrombocythemia

3) Primary myelofibrosis

Front 404

Polycythemia Vera - overproduction of? blood is? leads to symptoms like? (5)

- red seen with?

- develop?

- risk of?

Back 404

- overproduction of RBC

- thick blood leads to symptoms = HA, visual distrbs, bleeding, pruritis

- red = plethora, bloodshot eyes, erythromelalgia

- splenomegaly

- thrombosis**

Front 405

EPO and JAK2 V617F

- present in %? activates? which then?

- EPO is?

Back 405

- JAK2 V617F present in 97% of PV, activates JAK-STAT which activates EPO receptor, allows EPO receptor to fire without EPO, EPO is unrestrained

Front 406

Diagnosis of Polycythemia Vera

- D must exclude? such as? (2)

- other features include?

Back 406

D = exclude other causes = Spurious polycythemia (dehydration), secondary polycythemia (hypoxia, EPO)

- other features of MPN (splenomegaly), JAK2 mutation (97%)

Front 407

Treatment of Polycythemia Vera

- reduce? via? or oral?

- ASA to reduce? inhibitors of?

- is a? AML? LE is?

Back 407

- reduce RBCs = phlebotomy, oral chemo (hydroxyurea)

- ASA = reduce thrombosis

- JAK2 inhibitors = Ruxolitinib

* chronic disease, AML develops in <5%, life expectancy = decades

Front 408

Essential Thrombocythemia

- overproduction of?

- usually/

- sometimes causes?

- develop? risk of?

Back 408

- overproduction of pts

- usually asymptomatic

- sometimes bleeding

- splenomegaly

- thrombosis

Front 409

Mutations seen in ET - 65% have? 15% have? 5% have?

Back 409

1) JAK2 = 65%

2) MPL = 5%

3) CALR = 15%

Front 410

Essential Thrombocythemia Diagnosis

- must exclude? check for? (4)

- check for?

- disease is? AML?

- LE?

Back 410

- exclude reactive thrombocytosis - infection, inflammation, malignancy, iron deficiency

- JAK2 mutation (in 65%)

- chronic disease, AML in <1%

- life expectancy same as healthy person

Front 411

Treatment of Essential Thrombocythemia

- if asymptomatic? even if?

- if thrombosis? give? (2)

- if bleeding?

Back 411

- if asymptomatic = observation = even if pt count is very high

- if thrombosis = ASA, hydroxyurea

- if bleeding = hydroxyurea

Front 412

Primary Myelofibrosis

- marrow replaced by? see abnormal? that then?

- leads to? blood made in? so they are?

- early see increased? then later?

Back 412

- marrow is replaced by fibrosis, see abnormal megakaryocytes that stimulate collagen deposition

- leads to extramedullary haematopoiesis, as blood is produced in liver and spleen, which are hugely enlarged

- early = see increased blood counts

- later = counts fall

Front 413

Diagnosis and Life of Primary Myelofibrosis

- beware? look at both?

- mutations?

- AML in? chronic? with?

- survival?

- dependent?

- see symptoms of? (2)

Back 413

- marrow and blood = beware "dry tap"

- JAK2 mutation in 70%

- CALR mutation in 25%

- AML in 8-23%

- chronic disease with steady deterioration

- survival is 2-15 years

- transfusion dependency

- see const symptoms and symptoms from splenomegaly

Front 414

Treatment of Primary Myelofibrosis

- mainly do? risky to perform?

- can transplant?

- inhibitors of?

Back 414

- transfusions

- splenectomy = very risky

- stem cell transplantation can be curative - very risky

- JAK2 inhibitors (ruxolitinib) can be used

Front 415

Summary of Myeloproliferative Neoplasms

- overproduction of?

- in 97%, see?

- for PV and ET, LE is? main issue is?

- for PMF, see? problems with? LE?

Back 415

- overproduction of one or more lineages

- in 97%, JAK2 or MPL or CALR activated by mutation

- PV and ET:

= life expectancy is long, thrombosis is most signif issue, has complex pathogenesis

- PMF: progressive course, problems from splenomegaly, cytopenias, LE shorter

Front 416

Defenses Against Bleeding

- primary hemostasis is? with? (2)

- secondary is the? phases of? pathways? end result?

Back 416

1) Primary Hemostasis = cellular defense = pts and VWF

2) Secondary Hemostasis = coagulation cascade = new initiation and propagation phases, old extrinsic and intrinsic pathway, end result of thrombin and fibrin clot

Front 417

Defenses Against Bleeding

- clot stab via? and?

- last step is? includes activation of?

Back 417

3) Clot stabilization = Factor 13 and Thrombn Activatable Fibrinolysis Inhibitor (TAFI)

4) Healing = delayed activation of fibrinolytic cascade (starts with coagulation)

Front 418

Common Pathway - starts with? activated by? which then activates? known as?

- this activates? known as? which forms?

- prothrombinase complex is?

Back 418

- factor 10, activated by 5, activates factor 2 (Prothrombin)

- Thrombin activates Factor 1, Fibrinogen, which forms insoluble fibrin clot

* Prothrombinase Complex = 10 + 5

Front 419

Extrinsic Pathway of Coagulation

- Factor? activated by? which is activated by?

Back 419

- Factor 7, activated by TF, which is activated by vascular injury

Front 420

Intrinsic Pathway - starts with? then? then? with faxtor 8, activates?

- starts overall with (2) = H//PK

Back 420

- HMWK and Prekallikrein, activates Factor 12, which activates Factor 11, which activates Factor 9

- Factor 9, with Factor 8, activates Factor 10

Front 421

Contact factors

- PK =? HMWK =? lead to?

- generally not needed to?

Back 421

- Prekallikrein (PK)

- High molecular weight kininogen (HMWK)

- Factor 12

* PK and HMWK help activate Factor 12

* not needed to control bleeding

Front 422

Coagulation Cascade

Back 422

Front 423

Natural Anticoagulants

- proteins? (2) act to degrade?

- the rest inhibited by? which acts on?

Back 423

1) Protein C and S = proteolytically degrade Factors 5 and 8

2) Anti-thrombin inhibits the rest, mostly 2a and 10a

Front 424

Basic Clot based tests

- PT =? use?

- or use? means?

- end result?

Back 424

1) Prothrombin = PT, use INR = International Normalized Ratio

2) Activated Partial Thromboplastin Time (PTT)

*end result = clot formation

Front 425

INR = equation? ^?

ISI is the? indicates? assessed by?

Back 425

= (PT in seconds / Geometric mean of normal range) ^ ISI

* ISI = International Sens. Index = indicates reagent sensitivity to vitamin K dependent factors assessed by PT

- designed for Warfarin

Front 426

Coagulation Factors

- no-enzymatic? (3)

- zymogens are mostly? include (4) - undergo?

Back 426

1) Non-Enzymatic Cofactors = F-V, F-VIII and TF

2) Zymogens = mostly serine proteases = F2, 7, 9 and 10 undergo vitamin K dependent gamma carboxylation (charged groups allow these factors to bind membranes via calcium bridge)

Front 427

Vitamin K Dependent Factors - include? (4)

- are?

Back 427

= enzymes and substrates of Xase and Prothrombinase

Front 428

Coag. Cascade

Back 428

Front 429

Where are Coagulation Proteins Made

- all made in? except (3)?

Back 429

- all are made in the liver, except:

1) tPA = activator of fibrinolysis

2) VMF

3) Thrombomodulin = important endothelial substance that triggers activation of the natural anticoagulants

*Factor 8 is also made by the endothelium

Front 430

Half Lives of Coagulation
- shortest? and?

Back 430

- shortest = Factor 7 and Factors 5 + 8

Front 431

Common Disorders of Hemostasis - Primary Hemostasis

- inherited =?

- acquired = (3)

Back 431

1) Inherited = VWD

2) Acquired = drugs, thrombocytopenia, uremia

Front 432

Common Disorders of Hemostasis - Secondary Hemostasis

- inherited =? defic in? or defic in?

- acquired = ? (4)

Back 432

1) Inherited = Hemophilia (Factor VIII or IX defic), Factor XI defic.

2) Acquired = drugs, liver disease, DIC, Vitamin K defic.

Front 433

Standardized Bleeding Assessment

- most important predictor is? BATs are?

- improves?

- informs? allows?

Back 433

- bleeding history is the most important predictor of the presence of a bleeding disorder

- validated bleeding Assessment Tools = BAT's

- improves post test probability of lab tests, facilitates exploration of variability in bleeding severity

- informs treatment decisions

- allows effective communication

Front 434

vin Willebrand Factor

- made by? (2)

- stored in? (2)

- role in (2)

- chaperones? t 1/2 with and without VWF?

Back 434

- synthesized by endothelial cells and megakaryocytes

- stored in Weibel-Palade bodies (endothelial cells) and alpha granules (pts)

- role in platelet adhesion and aggregation

- chaperones = F - VIII

* t1/2 = 12h with VWF

* t1/2 = 2h without VWF

Front 435

von Willebrand Disease - published prev? symptomatic?

- inheritance? gender?

Back 435

- published prevalence in 1 in 100, symptomatic prevalence is 1 in 1000

- autosomal inheritance = M=F

- females diagnosed 2-3:1

Front 436

Diagnosis of VW Disease - 3 Clinical Components (3)

Back 436

1) Bleeding Symptoms

2) FH

3) Laboratory results

Front 437

Bleeding Symptoms - MC vs MSK

- in MC, see? excessive? from minor? in the? (2) also after?

- MSK, such as?

Back 437

1) Mucocutaneous = menorrhagia, epistaxis, bruising, excessive bleeding from minor wounds, GI bleeding, oral cavity, post-op, post-partum

2) Muskuloskeletal = hemarthrosis, soft tissue, muscle hematomas

Front 438

Family History - look for? as it is?

- asking more about? pre test?

Back 438

- positive FH helpful

- autosomal inheritance

- low VWF > bleeding

- pre-test probability 50%

Front 439

ISTH VWD Classification

- Type 1 means? %?

- Type 2 means? %?

- dominant are? (3) recessive?

- Type 3 =? 1 per?

Back 439

- Type 1 = mild/ mod quant. trait = 80%

- Type 2 = qualitative trait = 20%

= 2A, 2B, 2M = dominant

= 2N = recessive

-Type 3 = severe quantitative trait = 1 per million

Front 440

VW Disease Lab Tests

- normal are? (3)

- decreased? (3)

Back 440

- CBC, INR, PTT often normal

- VWF Antigen = decreased

- VWF Ristocetin Cofactor Activity = decreased

- Factor VIII activity = decreased

Front 441

Treatment of VW Disease - Medical

- can give?

- transfusion based?

- women to use?

- agent of?

Back 441

- DDAVP/Desmopressin

- Transfusion based - VWF:FV-III concentrate

- Combined OCP

- topical agents

- Anti-fibrinolytic agents

Front 442

Treatment of VW Disease - Gynecology

- give? ablation of? or perform?

Back 442

- hormonally coated IUD = Mirena

- endometrial ablation

- hysterectomy

Front 443

Hemophilias - X linked

- intrinsic complex =?

- Hem B is? seen in?

- Hem A is? seen in?

- FH in?

Back 443

- factor 9 and factor 8 = intrinsic complex

- Hem B = Factor 9 defic = 1 in 30,000 males

- Hem A = Factor 8 defic = 1 in 5,000 males

* 3200 in Canada, no FH in 30% of cases

Front 444

Clinical Manifestations of Hemophilia - Bleeding Severity a Factor Levels

- mild sees > then? %? present as?

- moderate is? %? provoked by?

- severe is? %? often see?

Back 444

1) Mild > 0.05 U/mL = 5%

- mild symptoms, can be asymptomatic aside from trauma or surgery

2) Moderate 0.01-0.05 U/mL = 1-5%

- provoked by minor trauma, serious with trauma or surgery

3) Severe < 0.01 U/mL = <1%

- frequent, spontaneous, life-threatening with trauma or surgery

Front 445

Clinical Manifestations

- MSK? (3)

- mouth?

- brain?

- bleeding with?

- women may have? may mean?

Back 445

- MSK bleeding = hemathrosis, intra-muscular hematoma

- mouth bleeding, epistaxis

- intracranial bleeding

- bleeding with trauma, procedures, surgery

- menorrhagia = symptomatic carriers

Front 446

Principle of Bleed Management ****

Back 446

- treat first, investigate later

Front 447

Categories of treatment Products

- specific? such as? role of DDAVP?

- topical agents to promote?

- stabilize clot with?

- ancillary?

Back 447

- specific replacement of FV III or F IX = concentrate (F VIII or F IX) or DDAVP (recruitment of endogenous F VIII)

- topical agents to promote fibrin clot formation

- stabilization of clot with anti-fibrinolytic agents

- ancillary strategies = rest, cold, anti-inflamms

Front 448

Factor XI Defic = Hemophilia C

- transmission? seen is?

- very important to determine?

- PTT vs PT? diagnostic assay?

- bleeding pheno is?

- no correlation of?

- treatment = (4)

Back 448

- autosomal recessive

- gene freq - 4.3% in Ash Jews

- patient and FH of bleeding very important

- PTT very long, PT (INR) normal, Factor XI assay diagnostic

- bleeding phenotype is variable

- degree of factor defic. does not correlate with bleeding severity

- may bleed with trauma and surgery

- treatment = DDAVP, anti-fibrinolytics, frozen plasma, Factor XI concentrates

Front 449

Liver Disease and Hemostasis

- liver disease can cause? such as? (3)

- bleeding with?

- less common to see?

- risk of both?

Back 449

- patients with severe liver disease can suffer life-threatening bleeding problems - see esoph and GI varices, gastritis, ulcers

- bleeding can occur with trauma, biopsies, surgery

- mucosal and soft tissue bleeding - less common

- coagulopathy is complex because of multiple hemostatic problems - risk of bleeding and thrombosis

Front 450

Liver Disease and Hemostasis

Back 450

Front 451

Liver Disease and Hemostasis

Back 451

Front 452

Liver Disease - Common Lab Findings

- prolonged?

- decreased?

- decreased?

- evidence of?

Back 452

- thrombocytopenia

- prolonged PT/INR, APTT

- decreased factors except Factor VIII

- fibrinogen assay = decreased

- evidence of DIC = increased FDPs, D-dimers

Front 453

Treating Liver Disease and Hemostasis

- first treat?

- Vit K not?

- if bleeding, consider? (3)

Back 453

- treat liver disease if able to at this stage

- Vit K usually not effective

- bleeding or major surgery consider = DDAVP, anti-fibrinolytic agents, replacement therapy

Front 454

Dissem. Intravascular Coagulation (DIC)

- acquired? with?

- overwhelms?

- may result in? or? depending on?

Back 454

- an acquired syndrome wit widespread systemic activation of coagulation

- overwhelms to natural antithrombotic control mechanisms

- may result in systemic bleeding and/or clotting depending on the balance of prothrombotic and antithrombotic forces

Front 455

Pathophys of DIC - activation of? uncontrolled generation of?

- leads to:

- formation of? consumption of? concomitant activation of? generation of?

Back 455

- activation of the coagulation system results in the ongoing uncontrolled generation of both** thrombin and plasmin

- leads to:

= intravasc. formation of fibrin

= consumption of all hemostasis components

= concomitant activation of fibrinolysis

= gen. of coagulation by products = FDPs, D-dimers

Front 456

Clinical Conditions Assoc. with DIC

- all assoc with release of?

- S/T/C/O/VD/ID/ T

Back 456

- all assoc. with excessive TF release

= sepsis

= trauma

= cancer

= obstetrical

= vasc. disorders

= immunological disorders

= toxins drugs

= liver disease

Front 457

Diagnosis of DIC - no single?

- combo of?

- tests need to? to?

- most helpful to watch?

Back 457

- no single test will acc. diagnose DIC

- diagnosis of DIC made by combination of:

= clinical disorder assoc. with DIC
= abnormal hemostatic screening tests

- tests need to be repeated to monitor progress and severity of DIC

- monitoring fibrinogen levels often most helpful

Front 458

Screening Tests for DIC

- blood = (3)

- pts?

- prolonged? due to?

Back 458

- blood fil - frag RBCs, low pts, MAHA

- pt count - pt consumption is low

- prolonged PT/INR - consumption of multiple factors

Front 459

Screening Tests for DIC

- prolonged? due to?

- decrease? due to?

- increased? (2) due to?

Back 459

- prolonged APTT = consumption of multiple factors (incl. 8)

- decreased fibrinogen = consumption of fibrinogen

- increased FDPs, D-dimers = formation and lysis of fibrin

*indicative of thrombin and plasmin action

Front 460

Treatment of DIC

- treat the underlyic?

- early - use? (2)

Back 460

- treat underlying cause = protein C and antithrombin concentrates have been shown to help if used early in overhwhelming DIC

Front 461

Vit K Deficiency

- VK facilitates? dependent factors include (4), anticoags (2)

- defic results in? if level below?

Back 461

- Vitamin K facilitates carboxylation of 6 coagulation factors, coverts them to functional forms

- Vitamin K dependent factors = procoagulants (factors 2,7,9,10), anticoagulants (protein C, protein S)

- Vitamin K defic. will result in signif bleeding if factor level activity falls below 10-15%

Front 462

causes of Vitamin K Defic.

- warfarin is an?

- poor?

- some?

- GI?

- newborn?

Back 462

- Vit. K Antags = Warfarin

- Nutritional deficiency / poor oral intake

- antibiotics

- biliary obstruction/ malabsoprtion

- hemorrhagic disease of the newborn

Front 463

Vit K Defic Labs and Treatment

- see prolonged (2)

- reduced?

- treat via?

Back 463

- labs:

= prolonged PT/INR

= prolonged APTT in more severe cases

= reduced factors 2,7,9,10

- treatment:

= oral or IV vitamin K

Front 464

Differential Diagnosis: Isolated Prolonged APTT (normal PT)

- defic of a? likely?

- if factor 12? if HMWk or PK?

- uncommon is?

- acquired includes (3) inhibit? or specific?

Back 464

1) Single Factor defic = inherited

- defic of factors 8,9, or 11

- defic of 12 = no bleeding history

- defic. of HMWK or Prekallikrein = no bleeding history

2) VW disease = uncommon, inherited

3) Inhibitors = acquired

- drugs = heparin, direct thrombin inhibitors

- non-spec = antiphospholipid antibody

- specific = factor inhibitor (most comm. to factor 8)

Front 465

Differential Diagnosis: Isolated Prolonged PT/INR (and normal APTT)

- inherited?

- acquired? seen with (4)

Back 465

1) Inherited Factor 7 defic.

2) Acquired Factor 7 defic

= Vitamin K Antagonist

= Vitamin K defic

= early liver disease

= specific inhibitors to factor 7 (rare)

Front 466

DD of Prolonged APTT and PT/INR - Inherited

- inherited defic of? such as? (4)

- abnormal?

Back 466

- inherited defic. of common pathway factors = 10,5,2, fibrinogen

- inherited dysfibrinogenemia = abnormal fibrinogen

Front 467

DD of Prolonged APTT and PT/INR - Acquired

- non specific inhibitors of? such as?

- specific inhibitors of?

- severe?

- severe?

-seen in?

- massive?

- dilution?

Back 467

- non-specific inhibitors = drugs, heparin, direct thrombin inhibitors, direct Xa inhibitors, antiphospholipid antibodies

- specific inhibitors to common pathway fator

- severe vitamin K defic.

- supratherapeutic warfarin

- severe liver disease

- DIC

- isolated factor X defic. associated with amyloidosis

- severe depletion of fibrinogen - massive hemorrhage or fibrinolysis

- hemodilution - post-op sample, massive transfusion

Front 468

Most Common Bleeding Disorders

#1? then? then? finally defic of?

Back 468

1) VW DIsease

2) Platelet Function Disroder

3) Hemophilia A and B

4) Factor XI Defic.

Front 469

aPTT =?

Back 469

- activated partial thromboplastin time

Front 470

Platelet-Fibrin Thrombus is mix of? leads to?

- RBCs are trapped in?

Back 470

- mix of fibrin, platelets and RBCs in BV, leading to a thrombus

- see RBCs trapped in a fibrin mesh

Front 471

Venous Thromboembolism = VTE = types? (2)

Back 471

1) Deep Vein Thrombosis = DVT

2) Pulmonar Embolism = PE

Front 472

Deep Vein Thrombosis - thrombus in?

- legs vs arm?

- other sites?

Back 472

- thrombus in one or more deep veins

- legs >>> arms

- other sites include abdo, cerebral,etc

Front 473

Proximal DVT

- likely in? then? then?

- behind?

- leads to 90% of?

Back 473

- popliteal -> femoral -> iliac veins -> IVC

- behind the knee, up to the heart

- leads to >90% of PE

Front 474

Distal or Calf DVT

- are found distal to?

- most calf are?

- rarely lead to?

Back 474

- distal to the popliteal vein, below knee

- most calf DVT asymptomatic

- rarely lead to PE

Front 475

Superficial Thrombosis

- not? doesnt lead to?

Back 475

- not DVT, doesnt lead to PE

Front 476

Potentiation of Calf DVT

- 90% of calf? 10-20% become?

- >50% of proximal lead to? can caus?

- calf rarely?

Back 476

- 80-90% of Calf DVT resolves spontaneously

- 10-20% becomes proximal DVT

- >50% proximal DVT leads to PE, possibly death

*rare that Calf DVT causes death

Front 477

How Common is VTE?

- occurs in? 2- vs 80?

- is commonly a? yet causes?

Back 477

- VTE occurs in 1 per 1000 pop/year

- age <20 = 1/10,000

- age >80 = 1/100

- VTE is a common preventable cause of hospital death (5-10% of in-hospital deaths)

Front 478

Risk Factors for VTE - Virchows Triad =?

** all contribute?

Back 478

- Virchow's Triad:

1) Activation of coagulation

2) venous stasis

3) Injury to the BV wall

* all contribute to thrombosis

Front 479

RFs for VTE - major? T?C?Imm? acute? inflamm? use of?

Back 479

Front 480

RFs for VTE - previous? FH? inherited? age? body weight?

Back 480

Front 481

Important RFs for VTE - increases with?

- largely acquired in?

- high risk for? (4)

- mod risk for (3)

- risk if no? risk duration?

Back 481

- increases with age

- largely hospital-acquired (60% of all VTE in the pop)

- 5,000 hospital-acquire VTE in Ontario every year

- different risk:

= high risk = SC injury, major trauma, THR, TKR

= mod risk = gen surg, gyne/urol, neurosurg

*no prophylaxis + routine screening for asympt DVT

* risk of VTE after surgery is prolonged

Front 482

VTE is common in Cancer - RR?

- 20% will?

- is occasionally the?

Back 482

- VTE is 25x more common in cancer patients than people without cancer

- 20% of cancer patients will develop VTE

- VTE is occasionally the 1st manifestation of cancer

Front 483

VTE Risk Factors in Cancer patients - Related To

- type? patients? treatment?

Back 483

1) Cancer = specific type, advanced stage, location

2) Patient = increased age, previous VTE, immobility

3) Treatment = surgery, radiotherapy, hosp, chemotherapy, hormonal therapy, central venous lines

Front 484

Estrogen, Pregnancy and VTE

- OCT causes?

- risk depends on?

- HRT also?

- pregnancy risk? PP period?

Back 484

- OCT (combined estrogen-prog) causes 4x increased risk of VT

- risk depends on dose of estrogen, specific progestogen, patient age and other RFs (smoking, obesity)

- HRT also increases risk 4x

- pregnancy carries 4x risk, postpartum period has 8x increased risk

Front 485

Thrombophilia

- deficiency of?

- % in population? in VTE is?

Back 485

- see factor V Leiden, Prothrombin, deficiency of AT, PRc and PRs and Antiphos. Ab

- thrombophilia in general pop is 10%, in unprovoked VTE is 30%

- only test if results will affect management = almost never do

Front 486

Multifactorial VTE - based on? (3)

- consider? (6)

Back 486

- genetic

- acquired

- provoking and triggering factors

*consider, age, tamoxifen use, FH, coag abnorms, triggering surgery

Front 487

Deep Vein Thrombosis Signs

- (4)

- yet many are?

Back 487

- leg swelling

- leg pain

- warmth

- purple-blue colour

- many are asymptomatic

Front 488

PE Signs - (7) **

Back 488

- SOB

- chest pain - pleuritic

- desaturation

- tachycardia

- unexplained fever

- blood in sputum

- feeling faint, collapse

- cardiac arrest

- many are asymptomatic

Front 489

Investigating Suspected VTE

- assess? (3) - forms?

- look at?

- if suspect DVT perform?

- if suspect PE perform?

Back 489

- risk factors + PE + history = pretest probability

- D- dimer

- if suspect DVT = Doppler US

- if suspect PE = CT pulmonary angiogram

Front 490

D-Dimer - formed by effect of? increased in? as plasmin causes?

- also increased after? there normal?

- if positive?

- never done on? as?

Back 490

- is formed by effect of plasmin on fibrin

- increased in acute VTE as plasmin causes more FDPs made

- also increased after surgery, trauma, cance, infection, liver disease, pregnancy, elderly

- normal D-dimer rules out acute VTE

- positive D-dimer not helpful, may mislead

*never done on inpatients or patients at high risk of having a positive result

Front 491

Doppler US

- very accurate for? do over? looking for?

Back 491

- very accurate for proximal DVT, do over femoral vein in which dont see compression, still has large gap

Front 492

Diagnostic Tests for PE - CTPA is the?

- sometimes look for?

- VQ - can rule out? most are?

- only VQ if? with normal?

Back 492

1) CT Pulmonary Angiography (CTPA) = test of choice for most patients

2) Sometimes look for DVT = DUS

3) Vent/Perfusion Scan = rules out PE if perfusion scan normal, but 60% are non-diagnostic

*only use VQ if young patient with normal CXR, renal failure, and allergic to contrast

Front 493

CTPA - very accurate for?

- if normal, no?

- may be too?

- requires? therefore must consider? alot of?

Back 493

- very accurate for PE (normal = no PE)

- too sensitive? (uncertain about small defects)

- requires contrast dye = think kidneys

- alot of radiation

Front 494

Treatment of VTE - IV heparin

- advantage is good? rapidly?

-DAs = need? frequent? can lead to?

Back 494

Advans = good control of cascade, rapidly reversed when discontinued

Disads = IV, frequent lab tests (aPTT), heparin-induced thrombocytopenia (HIT)

Front 495

Treatment of VTE - SC Low Molecular Weight Heparin

- examples = (D/E)

- As = given? can be? effect is? better for?

- DAs - need? if renal failure? more?

Back 495

- LMWH = Dalteparin, Enoxaparin

- Advans = SC (outpateint, predictable effect, no lab, safe in preg, best cancer option)

- Disads = SC needles, accumulates in renal failure, most costly

Front 496

Treatment of VTE - Oral Warfarin -

- As - no renal? able to? $?

- DAs - effect may be? see variation in? regular? affected by?

Back 496

- Advats = >6% experience, no renal elim, antidotes (vit. K), cheap

- Disads = unpredictable effect, 50x varition in dose, affected by foods, meds, regular lab monitoring (INR)

Front 497

Treatment of VTE - Direct Oral Anticoaga (DOACs)

- Ads = effect is? few? fixed? dont need any?

- DAs = may acc in? cant use with? problem of?

Back 497

- Ads = predictable, few interactions, fixed dose, no lab monitoring

- Disads = accumulates in renal dysfunction, not with mech. heart valves, cost

Front 498

Treatment of VTE Mechs - 4 anticoagulants

- Hep acts on? (4)

- LMWH - acts on (2)

- Warfarn - acts on (4)

- DOACS on? (2)

Back 498

1) IV Hep = Factors 12, 11, 9, 10 and 2

2) LMWH = Factors 10 and 2

3) Warfarin = 7,9, 10 and 2

4) DOACS = Oral Xa inhbis and Oral IIa inhibs

Front 499

Treatment of VTE - immediate? stop? if doesnt? then?

Back 499

- immediate anticoagulation

- stops the acute thrombotoc process

- does not dissolve the thrombus = 3 options

Front 500

3 Options for Treating DVT/PE

- use? for? with? maintain?

- for 28 days give? done for? high risk of?

- DOACs? - three ones are?

Back 500

1) LMWH injections once a day for 7 days with warfarin = INR of 2.0-3.0

2) LMWH injections for 28 days = pregnancy = ost VTE assoc. with cancer, high bleeding risk

3) DOAC use = rivaroxaban, apixaban, dabigatran

Front 501

Length of VTE Treatment - if provoked? for? means?

- if unprovoked - means? length is?

- if continued risk, then?

Back 501

- if provoked = surgery, trauma, pregnancy, acute illness = transient, reversed risk = anticoagulation done for 3 months

- if unprovoked = active cancer, ongoing RF, high risk thrombophilia, male, residual DVT = indefinite length

- if continued risk = unresolved cancer = indefinite

Front 502

For most patients with unprovoked CTE

- risks of bleeding are?

- therefore should continue? msut?

Back 502

- risks of bleeding (<1%/year), lifestyle impact, costs, labs are outweighed by risks of recurrence (5-10%/year) and security of being protected

- therefore continue with anticoagulation

* must reassess with new RFs, new knowledge and patient preference

Front 503

Natural History of VTE/ PE

- most improve with? however can lead to?

- PEs over time?

- yet is? see? 50% develop? 3% develop?

Back 503

- most improve over time, like iceberg melting

- however can lead to chronic venous insufficiency with recanalization

- most PEs also resolve over time

-is a chronic disease however, with recurrent VTE (30% over 5 years), post-thrombotic syndrome (50% 5 YEARS) and chronic TE pulmonary hypertension (3% PE patients)

Front 504

Prevention of VTE = Thromboprophylaxis

- 60% VTE is? most are? therefore need?

Back 504

- 60% of all VTE in population is hospital-acquired

- most are preventable - TP is standard of care for most hosp. patients

Front 505

Thromboprophylaxis Summary

Back 505

Front 506

VTE Summary - common are? Rfs are? investigate with?

- treat with? then? then?

- duration is? indef for?

- TP is mostly?

Back 506

- DVT and PE are common, often multi-causal

- RFs = genetic, acquired, triggering

- Investigate via Doopler US and CTPA

- treat with DOAC, LMWH then warfarin then LMWH alone (preg,cancer)

- Duration is 3 months (provoked), indef (unprovoked)

- TP is LMWH for most in patients

Front 507

Multiple Myeloma Diagnostic Pitfalls

- can present with? main two are? (2)

- myeloma can present without?

- disease is?

- median age? more common in?

Back 507

- can present with non-specific symptoms = low back pain, anemia

- myeloma can present without symptoms = 30-35% present with lab abnorms

- disease is rare = <1% of malignancies

*median age in 65, most common in black than white males

Front 508

Multiple Myeloma pathophys

- cancer that forms in?

- plasma cell helps by?

- MM causes? crowd out?

- can lead to (3) **

Back 508

- a cancer that forms in plasma cell

- Plasma cells help you fight infections by making antibodies that recognize and attack germs

- Multiple myeloma causes cancer cells to accumulate in the bone marrow, where they crowd out healthy blood cells

- can lead to neuropathy, infections and renal failure

Front 509

Renal Failure in MM

- due to? called?

- also deposition of? causes?

- pre-renal failure see?

- production of?

- also see ? (A)

Back 509

- tubular deposition = cast nephropathy

- light chain deposition disease

- volume depletion

- hypercalcemia = pre-renal failure

- nephrotoxins = NSAIDs for bone pain

- Amyloidosis

Front 510

Myeloma Features - CRAB ***

Back 510

- Calcium elevation

- renal disease

- anemia

- bone disease

* CRAB

Front 511

Presenting Symptoms of Myeloma - most common is? then F/A/RI/C/S/F/NP

Back 511

- Back pain/ bone pain - most common

- fatigue

- anorexia

- recurrent infection

- constipation

- somulence

- fracture

- neuropathy

Front 512

Presenting Signs of Myeloma

- also can have? hyper? renal? lytic?

Back 512

- anemia/pancytopenia

- hypercalcemia

- renal infsuff

- lytic lesions/ osteoporosis

- monoclonal proteins

- organomegaly

- hypogammaglobulinemia

Front 513

Initial Diagnostic MM Workup

- main symptoms suggesting MM = (6)

- investigations include? (8)

Back 513

- symptoms suggesting MM = fatigue, back pain, anemia, renal failure, infections, periph neuropathy

= CRB, Creat/Lytes, Calcium, Albumin, SPEP, immunofix, immunoglob quant, urine bence jones

Front 514

SPEP = Serum protein electrophoresis

- investigate?

- in normal, see?

- in MM, see? (2)

Back 514

- investigate globulins

- in normal, see polyclonal smeart

- however in M, see high Albumin peak and high M-spike

( in immunofix, see IgA kappa)

Front 515

Bence Jones Testing = 24 hr hour

- 20% myelomas assoc with? only see?

- light chains wil then? when? called?

Back 515

- 20% myelona assoc. with light chain production = only kappa or lambda

- light chains precip when urine is heated to 40C, unlike albumin = BJ testing

Front 516

Full Diag. Workup for MM - many things include?

- also do biopsy of? looking for?

Back 516

- do BM biopsy, look for clonal plasma cells

Front 517

MM Features - have? M protein? clonal plasma cells?

- is smoldering MM if?

Back 517

- CRAB +

1) M-protein = often > 30g/l in serum

2) Clonal plasma cells = often >10% in BM

** smoldering MM if have two features but no CRAB features

Front 518

MGUS = Monoclonal Gammopathy of Undetermined Signficance

- prevalence increases as? at 70 yo?

- 1% risk of?

Back 518

- prevalence increase with age, 5% at 70 yo

- on average, 1% risk per year of progression to MM or Lymphoma

Front 519

MGUS Diagnostic Criteria

- serum M protein is?

- marrow plasma cells are? no?

- later becomes? with? no? then symptomatic with?

Back 519

- serum M-protein <3.0 g/L

- marrow plasma cells <10%

- no related organ damage

* later becomes asymptomatic MM (has lab targets but no organ involvement) and then symptomatic (lab values + CRAB or events)

Front 520

Summary of Myeloma

- can present with? or no?

- problem as delay?

- consider workup in? (5)

- prognosis is?

Back 520

- can present with non-specific symptoms or no symptoms at all

- delays in diagnosis can be devastating

- consider workup in anemia, renal failure, bone pain, fatigue and infections

- prognosis is improving

Front 521

Lympadenopathy Epi

- defied as nodes that are?

- occurs in? % malignant?

Back 521

- seen when nodes are greater than 1 cm in size

- 0.6% annual incidence of unexplained adenopathy in general population = 10% referred, 3.2% had biopsy, 1.1% malignant

Front 522

When to Worry about Lymphadenopathy

- A/ chars/ loc / clinical?

Back 522

1) Age

2) Node characteristics

3) Location of node

4) Clinical setting assoc.

Front 523

Age and Lymphadenopathy

- in children, more likely to?

- patients <30 - %?

- >50, %?

Back 523

- children/young adults - more likely to respond to minor stimuli with lymphoid hyperplasia

- LNs in patients <30 are clinically benign in 80% of cases

- whereas in patients >50, only 40% are benign

Front 524

Characteristics/ Locations of LA

- look at? duration? location?

- common is? size? often?

- if supraclav? older than 40?

- other locations? (2)

Back 524

- consistency, <2 weeks, cervical nodes (50% young adults have)

- inguinal is common - 1-2cm in size, often benign reactive

- supraclav = high risk of malig - 90% in patients older than 40

- paraumbilical

- epithrochlear

Front 525

LA History

- cause of? symptoms that suggest?

- sites = (4)

- symptoms of?

- clues related to?

- meds?

Back 525

- identifying cause = localizing symptoms or signs to suggest infection/neoplasm at particular site = sinusitis, pharyngitis, periodontal disease, conjuct insect bites

- const symptoms

- epi clues = occupation, animal, travel, high-risk behav.

- medications - serum-sickness syndrome

Front 526

PE of LA

- full? consider?

- size of?

- localized?

Back 526

Front 527

Causes of Generalzied LA

- M/I/ AI/ D/ rare?

Back 527

1) Malignancy = lymph, leuk,mets

2) Infections

3) AI - Seropositive Spondyl

4) Drugs

5) Rare = sarcoid, amyloid, lipid, hyperthyroid, Kawasakis, Rosai

Front 528

Treatment of LA - wait? then?

-no indication for?

- glucos can be? may?

Back 528

- wait 4 weeks and re-examine

- no indication for empiric Abx

- glucos can be harmful, can delay diagnosis

Front 529

Options for LNs

- FNA - 1/3 will? other need?

- perform a? as sees?

- gold standard?

Back 529

1) FNA = 1/3 complete diagnoses, 2/3 require addit. biopsy

2) Core needle biopsy - see arch

3) Excisional LN biopsy = gold standard

Front 530

Lymphoma - cancer of?

- fifth most?

- lifetime prob of leukemia?

- in young adults?

- many?

Back 530

- cancer of IS cells

- lymphoma is fifth most common cancer in NA

- 3.8% lifeitme prob. of developing leukemia or lymphoma

- 2nd leading cause of cancer death in young adults

- many years lost

Front 531

Classifying Lymphomas

- main WHO classes are? (F/D/C)

- more reasonable classes = A/I/H/Z - %?

Back 531

- main WHO ones = follicular, Diffuse large B cell, Composite, etc

- more reasonable = Aggressive (46%), Indolent (38%), Hodgkins (10%) and Zebras (6%)

Front 532

Aggressive vs Indolent Non-Hodgkins Lymphoma

- growth? symptoms? survival? cure? often classified as?

Back 532

1)Aggressive = rapid growth, symptomatic, fatal in months if untreated, potential for cure, * diffuse Large B cell lymphma

2) Indolent = slow growth, asymptomatic, fatal in years, incurable, ** follicular lymphoma

Front 533

Hodgkin Lymphoma - look for?

Back 533

- see Reed-Sternberg Cells

Front 534

Symptoms of Lymphoma - enlarged? low?

- general? (5)

- less than 20% have?

Back 534

- enlarged LNs

- low blood cell counts

- general = weight loss, fever, night sweats, fatigue, itching

- less than 20% of patients have general symptoms at onset

Front 535

Staging of Lymphoma

- Stage I at? II at? III both? no? IV - involvement of?

- A - means absence of?

- B - see? (3)

Back 535

A = absence of B symptoms

B = fever, night sweats, weight loss

III = above and below diaphragm, no liver

Front 536

Diagnosis and Staging of Lymphoma

- perform? (2)

- labs = (3)

- then finally?

Back 536

1) Biopsy = LN biopsy, bone marrow

2) labs = CBC, LDH, viral serologies (HIV, hep B, C)

3) imaging = CT

Front 537

Treating Lymphoma - can do?

- CD20 is a? as expressed on? not?

- use? which is?

Back 537

- can do chemo and radiation

- CD20 is a good target, as expressed on ?90% of B cells NHL, not shed or internalized = use of Rituximab = anti-CD20

Front 538

Leukaemia - arises in?

- takes over? prevents?

Back 538

- clonal disease arising in a single haematopoitic cell

- takes over the bone marrow, prevents normal blood cell production

Front 539

Acute Leuks

- AML = ? blasts have chars of? reminiscent of?

- ALL = ? blasts have chars of? reminiscent of?

- without? will be?

Back 539

1) AML = myelogenous - blasts have residual characteristics of myeloid cells, reminiscent of neutrophils or monocytes

2) ALL = lymphoblastic = blasts have residual chars of lymphoid cells, reminiscent of B cells or T cells

* without treatment, fatal in weeks

Front 540

Haem Stem Cell vs Leuk Stem Cell

- in leuk, gets? no?

Back 540

- in leuk, get formation of blasts, no blood

Front 541

Why Leuk Makes you sick

- start with?

- as LSC, get decreased? and appears?

- by end, have?

- hard to tell**

Back 541

- start with nice, blood cell forming bone marrow

- as get LSC, see blood cell production decrease and leukaemia appears clinically

- by end, have useless, leuk filled bone marrow

*hard to tell AML and ALL blasts apart

Front 542

Acute Leuk Epi

- AML is mostly? vs ALL?

Back 542

- AML is mostly a disease of older adults

- ALL is mostly a disease of young children

Front 543

Presentation of Acute Leuk (AML or ALL)

- developed over? see manifestations of?

- A =?

- L = ?

- thrombo = ?

- LA = ?

Back 543

- develop over a period of weeks, see manifestations of bone marrow failure:

= anemia = pallor, breathlessness, chest pain

= leukopenia = infection

= thrombocytopenia = bruises, bleeding

= lymphadenopathy = mostly ALL

Front 544

Treatment of Acute Leuk

- still the same?

- Phase 1 is the? via? not a?

- Phase 2 -post?

- in ALL - do? below?

Back 544

- standard of care for ALL, AML same as 1979

- Phase 1 = Induction of remission via chemotherapy after Leuk appers ***not cure, can relapse

- Pase 2 = Post-remission therapy chemo = cure

* in ALL = do intrathecal chemo, below L3

Front 545

Tissue Infiltration in AML

- favourite spot? known as?

- seen in? with?

Back 545

- the gums are a favourite spot = gingival infiltration

- especi. with AML with monocytic characteristics

Front 546

Leukostasis

- develop? known as? occurs when?

- blasts then? can lead to? (3)

Back 546

- myeloid leukaemias = sticky blasts

- occurs when blast count > 100

- blasts sludge the microvasculature, can lead to retinal hemorrhage, stroke, resp. failure

Front 547

Acute Promyelocytic Leukemia

- abnormal? called?

- characterized by? involving?

- known for its? give? (2)

- CR rate is? 2 year?

Back 547

- APL, there is an abnormal accumulation of immature granulocytes called promyelocytes. The disease is characterized by a chromosomal translocation involving the retinoic acid receptor alpha

- known for its responsiveness to all-trans retinoic acid = ATRA + arsenic

- CR rate 100%, 2 year DFS 97%

Front 548

Chronic Leukaemias

- CML =? prolif of? (3) and?

- CLL =? just prolif?

- mostly affect?

- more common is? CLL starts?

Back 548

1) CML = myeloid = see prolif of granulocytes (Ns/Es/Bs) and precursors

2) CLL - lymphocytic = see prolif of B cells

* CML and CLL mostly affect older adults, CLL is much more common than CML and CLL starts much further down Haem Line

Front 549

CML Presentation

- incidental findings on? such as? also see? (2)

- usually?

- may have?

Back 549

- incidental finding on routine CBC = leukocytosis, extended left shift, basophilia, thrombocytosis

- usually asymptomatic

- splenomegaly - may be massive

Front 550

CLL Presentation - finding on CBC is?

- on slide see?

- usually is?

- later in disease, see?

Back 550

- incidental finding on CBC = lymphocytosis

- see smudge cells

- usually asymptomatic

- nodes and spleen come later in disease

Front 551

CML Natural History - starts with? then? crisis of?

- median survival?

Back 551

Front 552

CLL Natural history?

- starts with?

- develop? then?

- then on CBC get?

- median survival? many never?

Back 552

Front 553

CML treatment

- treatment starts?

- use? such as? (5)

- block function of?

- STKIs do no? but help to?

Back 553

- STKIs do not cure CML, keep in remission

Front 554

CLL Treatment

- treatment started only?

- use? such as? (F/CPP)

- give?

- or Bruton's kinase inhibitor =?

- need successive?

- over time see?

Back 554

- successive rounds of treatment provide control

- chemo has diminishing returns with time

Front 555

AML Summary

- treatment is? presentation is?

- alot of? many?

- treatment?

Back 555

Front 556

ALL Summary

- treatment is? presentation is?

- so many? many? including?

- treatment?

Back 556

Front 557

CML Summary

- is only? presentation? spleen in?

- blasts are?

- genetics?

Back 557

Front 558

CLL Summary

- urgency? idea that?

- no? look for?

- treatment is?

Back 558

Front 559

Child Presenting with lower back pain, pallor and fatigue - DD?

- ortho =? (2)

- rheum =?

- infectious = ? (2)

- malig = ? (3)

Back 559

1) ortho = trauma, spondylolysis

2) Rheum = arthritis

3) infectious = viral, discitis

4) Malignant = bone tumour, tumour on cord, leukemia/lymphoma

Front 560

Most Common Childhood Maligs

- most common at 0-14?

- most common at 15-19?

Back 560

Front 561

Childhood Cancer

- % total cancer? third largest?

- most childhood cancers are?

- 2/3 survivors are? 1/3 have?

- are relatively? must be?

Back 561

-1-2% of total cancers, the leading cause of disease-related death among children beyond infancy

- third largest contributor to PYLL/G after breast and lung cancer

- see 1500 children with new cancer diagnosis per year in Canada, most ALL, 90% survival

- 2/3 survivors have one more more chronic condition, 1/3 have severe complication

- relat rare, diagnoses and outcomes differ, must be suspicious

Front 562

Leukemia

- is clonal? from both?

- myelos? lymphos?

- acute leukemias %? ALL vs AML %?

- chronic leuks only?

Back 562

- a clonal proliferation of blood cell precursors, from myeloid stem cells and lymphoid stem cells

- myeloblast = granulocytes

- lymphoblasts = NK, T and B cells

- acute leukemias = 95% of childhood, ALL is approx 80%, AML is approx 15%

- chronic leuks = 5% in childhood

Front 563

ALL - most common?

- %?

- gender? race?

- peak age?

- 5 year survival?

Back 563

- most common paeds malignancy

- 25-30% of paeds cancer

- M > F, white > black

- peak age = 2-5 years

- 90% 5 year survival

Front 564

Making ALL Diagnosis

- look at both? (2)

- perform a? with?

- do a?

- also perform a?

**diagnose leukemia if?

Back 564

- blood counts and periph smears

- BM aspirat and +/- biopsy

- lumbar puncture for CSF exam

- testicular exam

* leuk diagnosed if there are >25% blasts in BM

Front 565

ALL Peripheral Blood Caveat

- WBCs may be?

- HbG or plts may be?

- 20% of ALL pts will not?

Back 565

- white cell counts may be low, normal or high

- HgB or pts may be low or normal

- 20% of ALL patients will not have circulating blasts at diagnosis

Front 566

Bone Marrow/Periph Blood testing

- morphology - AML - see?

- imm - look for?

- cytogens - use? identify?

- molecular - look at?

Back 566

- morphology - Auer rods only in AML

- immunophen = use antigen to distinguish

- cytochem - less specific

- cytogenetics - FISh and kary to identify known and unknown leuk clone

- molecular - PCR to look for transcripts

Front 567

RFs for Childhood Cancer

- genetic? enviro? infection?

- in most?

Back 567

1) Genetic - in utero, polymorphs, genetic conditions such as T21, fragility syndromes, cancer predisp syndromes

2) Enviro - radiation, in utero, chemical? dietary?

3) infection - rare immune response to common virus

* most- dont know why develops, complex, always take FH, address guilt up front

Front 568

Children with Down Syndrome and Cancer

- x risk?

- lower risk to develop?

- inferior? as more?

- better outcomes with?

Back 568

- 10-20x increase risk of leuemia

- lower risk to develop solid tumours

- inferior outcomes for ALL due to more severe toxicities

- better outcomes for AML with less therapy

Front 569

Clinical Presentation of Childhood Cancers

- often have non? yet need to maintain?

- lack normal?

- presence of?

- often related to? main ones** (2)

Back 569

- non spec signs and symptoms, maintain high suspicion, consider:

- lack of normal BM output

- presence of leukemic blasts

- related to extramed disease = CNS disease, testicular disease, other

Front 570

Lack of Normal BM Output preseents as - Hb/ WBC/pt

Back 570

1) Hb = pallor, fatigue, irritability

2) WBCs = fever, sepsis

3) pts = bruising, bleeding, petechiae

Front 571

Leukemic Blasts Symptoms

- bone? organs? LA? presentation of? sludging due to?

Back 571

1) Bone pain = Xray changes, path features

2) Hepatosplenomegaly

3) Lymphadenopathy

4) Lymphomatous Presentation

5) Hyperleukocytosis = WBC >50-100 = can cause sludging

Front 572

Extramedullary Disease - affects? % in?

- most are? yet some present with? such as? if paenchymal involvement?

- in testicular - see? %?

Back 572

1) CNS = 1.5-1% at diagnosis

- most asymptomatic, may present with increased ICP symptoms such as HA, V, CN VI palsy

- may show parenchymal involvement = seizure, CN palsies

2) Testicular = 2% at diagnosis = painless enlargment

Front 573

First 24 Hours - What can Harm patient

- HL =?

- lysis?

- mass? or? (2)

Back 573

- hypeleukocytosis = sludging

- tumour lysis syndrome

- mediastinal mass

- infection

- bleeding

Front 574

Further Lab Work for Children - chemistries?

- perform a?

- if fever?

- also improtant to do?

- check?

Back 574

- chemistries = K, CA, PO4, uric acid, LDH

- CXR

- blood cultures if fever, start Abx

- type and screen

- varicella serology

- INR/PTT

Front 575

Tumour Lysis Syndrome (TLS)

- occurs at? or soon after?

- cell lysis when? leads to? (3) K/Ur/Ph = cause ???

Back 575

- at presentation or after tratment initiation

- metabolic derangement resulting from cell lysis with tumour kills, leads to:

1) increased K = arrhythmias

2) increased urate = renal failure

3) Increased phos/decrease calcium = tetany/seizure

Front 576

Approach to TLS - frequent? no IV? for?

- forced?

- medical?

- give allupurinol to?

- worst case?

Back 576

- frequent bloodwork

- hyperhydration - no IV additives

- forced diuresis

- medical man. of electrolytes

- allupurinol or rasburicase to prevent, manage hyperuricemia

- worst case = dialysis

Front 577

Reason for CXR?

- check for? risk of?

- think about? (3)

Back 577

- mediastinal mass

- anaesthesia risk

- think about:

= SVC compression, airway compression, cardiac tamponade, right ventricular outflow tract obstruction

Front 578

Other Issues after Diagnosis - infection

- due to? counts dont?

- start? if fever?

Back 578

- Infection due to dysregulated immune status, WBC and neuts counts dont matter

- start Abx and do blood culture stat if fever or unwell

Front 579

Other Issues after Diagnosis - Transfusions

- pt transfusuons for? for coag, use?

- RBC transfusion will increase? only do if? use?

Back 579

1) pts transfusions = for bleeding and procedures, use frozen plasma for coag

2) RBC transfusion = will increase viscosity, only transfuse if symptomatic, use small aliquots due to hyperleukocytosis

Front 580

Treatment for ALL - chemo phases = (4)

- duration?

- intensity based on?

- includes ?

Back 580

- chemo phases = induction, consolidation, re-intensification, maintenance

- is a 2-3 year duration

- intensity based on risk group

- includes CNS prophylaxis/treatment

Front 581

Prognostic Factors for Risk Assessment

- age at? initial?

- presence of?

- immuno?

- response to?

- best indicator?

Back 581

- age at diagnosis

- initial WBC at diagnosis

- CNS or testicular disease

- immunophenoytpe = B vs T

- cytogenetics

- initial response to therapy*** - best

- pharmacogenetics

Front 582

Response to Initial Therapy is the most?

- measured by?

- performed following?

- remission defined by?

- MRD able to?

Back 582

- most important prognostic variable

- measured b minimal residual disease = MRD

- performed following 1st phase = induction

- bone marrow morphology defines remission if blast count <5%'

- but MRD can identify even less cells

Front 583

Chemo in ALL - use combo of? at?

- now using? such as? (3)

Back 583

- use combo of non-cross resistant chemo agents at maximum dose intesnity

- designer approach to Therapy, now use targeted therapies such as Ritizumab, Car T-cells or Blinatumomab

Front 584

Late Effects of Therapy

- depends on?

- can lead to? (6)

- most common cause of death?

Back 584

- depend on therapy recieved and complications arising during therapy

- obesity, bone health, endocrine dysregulation, neurotox, cardiotox, secondary neoplasms, psychosocial effects

* most common cause of death is relapse

Front 585

Whole Blood Collection

- plasma contains? (3)

- buffy coat =?

- then finally?

Back 585

1) plasma = cryosupernatant, crytoprecipitate and fractionated products (PCCs, Albumin, IVIG)

2) Buffy coat = WBCs and Pts

3) RBCs

Front 586

Old Female - Anemic- Why? (3)

- consider?

Back 586

- menorrhagia

- blood loss

- iron defic anemia

* consider iron supps

Front 587

Manifestations of Anemia - RBCS needed to?

- no accurate way to determine? surrogate marker is?

- symptoms = (4)

Back 587

- RBCs are transfused to increase oxygen delivery to tissues

- no accurate way to determine if oxygen deliv. in inadequate so use symptoms of anemia (non-spec) and Hb level as surrogate markers

- symptoms = fatigue, chest pain, SOB, lightheadedness

Front 588

Whats in a unit of RBC?

- volume? RBC/ plasma/ anticoag/ and finally?

- one unit raises Hb by? pt isnt?

Back 588

- volume of RBC unit = 280 ml = 160 ml RBCs, 20 ml plasma, 100 ml of anticoagulant (citrate) and SAG-M additive (sodium, chloride, adenine, dextrose, mannitol)

- one RBC unit raises Hb by 10 g/ L in non-bleeding patient

Front 589

When Should we Transfuse RBcs

- HB > 90? 70-90 - do if? <70? if younger?

Back 589

1) Hb > 90g/L = likely inappropriate

2) Hb 70-90 = depends on patient = in CAD, elderly, closer to 80 g/L

3) Hb < 70 = likely approp, younger patients may tolerate Hb <60

Front 590

TRICC Trail - transfused 1 unit as? mortality higher in?

Back 590

- transfused 1 unit at restrictive Hb <70 or liberal Hb <100

- mortality higher in liberal group

*similar to FOCUS trial

Front 591

Acute UGI Bleeding

- higher survival in?

- note increase?

Back 591

- transfused 1 unit at restrictive Hb <70 or liberal Hb <100

- higher survival in restrictive group, saw more adverse events and bleeding in liberal group

*noted increased portal pressure gradient in liberal group

Front 592

Acute Coronary Syndrome and HB

- rule to? re-assess as?

- consider closer?

Back 592

- RCTs - conflicting as CRIT found restrictive did better and MINT, liberal did better

- transfuse a unit at a time and re-assess clinically

**remember CAD, consider transfusion closer to 80 g/l

Front 593

How to transfuse RBCs

- transfuse one unit over? not more than?

- consider slower rate? if? also consider?

- outcome is? check before?

Back 593

- transfuse one unit at a time over 2 hours, not more than 4 hours

- consider slower rate and furosemide for patients with suspected impaired cardiac function

- assess the outcome = clinical Hb level, before transfusing further

Front 594

Writing a RBC Transfusion Order

- order? then?

- max time? longer if?

- always include

Back 594

1) Order one unit at a time - then reassess patient and HgB between

2) Max is 3.5 hours per unit, longer if at risk for cardiac overload

3) Always include indication for transfusion

Front 595

Why My Patient be thrombocytopenic

- likely? on film? suggests?

Back 595

- likely bone marrow failure because there are blasts on blood film, suggests leukemia

Front 596

Caution when ordering Pt transfusion in? as may? these include (3)

- if immune thrombocytopenia, more effective to?

Back 596

- thrombotic thrombocytopenic syndromes as may add fuel to the fire:

= TTP, HIT, APLA syndrome

- immune thrombocytopenias, as other therapies such as prednisone more effective

Front 597

Manifestation of Low Pts

- plts mediate? therefore symptoms include?

- in mouth?

- GU? GI?

- plt transfusion used to?

Back 597

-pts mediate primary hemostasis, bleedign due to low pts typically seen as:

= petechiae, ecchymoses

= mucosal bleeding = epistaxis, gum bleeding, blood blisters in mouth, GU (hematuria, menorrhagia) and GI (melena, hematochexia)

- pt transfusion used to prevent or treat bleeding

Front 598

What's in a dose ot Pts?

- 1 adult dose contrain 1 pool of? made from?

- volume? increases count by?

Back 598

- 1 adult dose of pts:

= 1 buddy coat pool of pts (made from 4 whole blood donations

= 1 apheresis pt = volume 250-300 ml, will increase pt count by 15-50 x 10^9

Front 599

When Should We transfuse Pts

- when plts less than? treating? prevent?

- when pts less than? to prevent?

Back 599

- when pts < 50 x 10^9, to treat major bleeding and to prevent bleeding with major procedures

- when Pts < 10 x 10^9, to prevent spontaneous bleeding (except ITP)

Front 600

When Should We Transfuse Pts

- at any pt count when? such as?

- pts <100 - to treat? prevent?

Back 600

- Any pt count = to treat severe bleeding in setting of pt dysfunction = antipt agents, post CPB)

- pts < 100 X 10^9 = to treat bleeding in sancutary sites (CNS, eyes), to prevent bleeding in sanc sites

Front 601

Therefore transfuse for major bleeding if? for minor bleeding

Back 601

- major bleeding = pts 50-75

- minor bleeding and minor procedures - pts between 50 and 10

Front 602

How to Transfuse Pts

- transfuse over? max?

- slower rate if? also can give?

- assess outcome via? before?

Back 602

- transfuse each dose over 1-2 hours (max 4 hours)

- consider slower rate and furosemide for patients with suspected impaired cardiac function

- assess outcome = clinical, pt count, before transfusing further

Front 603

How to Write a Pt Transfusion Order

- transfuse at? max?

- always include?

Back 603

-transfuse at 1 hour, longer if at risk for cardiac overload, max is 3.5 hours per unit

- always include indication for transfusion

Front 604

Manifestations of Elevated INR

- plasma contains? for?

- bleeding due to? results in? (3) E/H/GI

- need plasma to?

- hemostasis needs?

Back 604

- plasma contains all clotting factors required in secondary hemostasis

- bleeding due to clotting factor deficiency = Echhymoses, hematoma (intramuscular, intra-articular), GI bleeding

- plasma transfusion used to treat bleeding

- require levels of 30-50% for hemostasis

Front 605

What is in a unit of Frozen Plasma- volume?

- contains all?

- t1/2 is? in?

- dose =? increases?

Back 605

- volume of 1 unit of FP is 250 ml

- contains all nec. clotting factors for hemostasis = T1/2 is 6-8 hours in non-bleeding patient

- dose = 15 mL/kg (3-4 units) which increases clotting factors by 20%

Front 606

When Should We Transfuse Plasma - when need?

- for major? when INR is? not really for?

- cant wait for labs for? (2)

Back 606

** multiple clotting factor defics where a more specific concentrate is not available, and :

1) Major bleeding, procedure with INR >1.5 (most minor procedures such as line placement, paracentesis done safely any INR)

2) Microvasc bleeding, massive transfusion and cannot wait for labs

Front 607

Frozen Plasma Practical Info

- needs to be?

- must be?

- universal plasma is?

Back 607

- FP needs to be thawed for 30 minutes

- must be ABO compatible

- universal plasma is AB plasma

Front 608

How to Write Plasma Transfusion order

- max time? longer if?

- always indicate? have high?

Back 608

- max is 3.5 hours/unit, longer if cardiac overload risk

- always include indication for transfusion - high INR and why?

Front 609

Warfarin and Increased INR

- causes defic. in?

- these include? (6) pro/anti

Back 609

- warfarin causes defic. if Vit. K dependent factors = ,9,10, 7, and 2 and Protein C and S which stop cascade

Front 610

Prothrombin Complex Concentrates

- contains the? = ?

- are? and made sure to be?

- used for emergent? (2)

- typical dose?

- effect only lasts?

Back 610

= contains Vit K dependent factors = II, VII, IX, X and Protein C and S

- pooled, virally inactivated products, indicated for urgent or emergent reversal of warfarin or Vit K defic

- typical dose in 1000 units (40 mL) but depends on INR elevation

- effect lasts only 6 hours

Front 611

PCC Practical Info - infuse volume? over?

- form? therefore is?

- for prolonged reversal, need?

- for emerg bleeding - give? works in?

- for nonemerg bleeding - give?

Back 611

- infuse 100 units PCC IV over 15 minutes - in powder form so quickly available

- Vit K required for prolonged reversal:

- Therapeutic INR and emergency bleeding/procedure = vitamin K 10 mg IV (works in 6 hours)

- Supratherapuetic INR and not bleeding = may require small dose vit K PO alone (works in 24 hours)

Front 612

Low fibrinogen - seen in?

- assoc with? can complicate?

Back 612

- seen in obstetrical hemorrhage

- assoc. with microvascular bleeding and can complicate massive hemorhhage

Front 613

What is in a Unit of Cryoprecipitate

- 1 unit volume? contains? also (4)

- typical dose units?

- increases fibrinogen by? per?

Back 613

- volume of 1 unit = 15 ml

- contains fibrinogen = also factor VII, VWF, XIII,fibronectin

- typical dose = 10 units

- increases fibrinogen by 0.5 g/L per 10 units

Front 614

When Should you Order Cryoppt?

- if fibrinogen <1.5 ? <1?

Back 614

- fibrinogen <1.5-2 - to treat life-threatening hemorrhage

- fibrinogen < 1g/L - to treat microvasc. bleeding

Front 615

Summary - Approach to prescribing blood transfusion

- must consider? as well as the?

Back 615

- what is mech of abnormality

- potential manifestations

- management of the problem

Front 616

Informed Consent for Blood Transfusion

- obtained by? always is? except?

- must discuss? and then?

- afterwards?

Back 616

- obtained by treating physician

- mandatory except if patient's life at immediate risk and neither patient nor SDM able to conset

- benefits, risks, alternatives discussed

- discussion documented in chart

- afterwards, advise patient of what was recieved

Front 617

Risks of Transfusion - from RBCs (2)? from pts? from volume? or?

- viral infection is?

Back 617

- main ones:

= red cell sensitization and hemoltyic transfusion reaction

= febrile reaction from pts

= circulatory overload

= minor allergic reaction

*viral infection = less than one in a million

Front 618

Risks fo Transfusion - most common? (3)

- serious = (4)

Back 618

- common things = fever, hives, Taco

- serious = TRALI, sepsis, anaphylaxis, wrong blood

Front 619

Acute Transfusion reactions - occur?

= (4) F/U/D/H

Back 619

- symptoms occurring during or shortly after transfusion:

= fever

= urticaria

= dyspnea

= hypotension

Front 620

fever def and DD - defined as? up to? may present with?

- DD = (4) A/B/F/U

Back 620

- >1C rise in temp and temp >38C during or up to 4 hour post-transfusion, may present with chills/rigors

- DDx:

= acute hemolytic transfusion reaction = AHTR

= bacterial contamination = BaCon

= febrile non hemolytic transfusion reaction = FNHTR

= fever due to underlying illness

Front 621

Acute Hemolytic Transfusion Reaction = AHTR

- mech is due to? less common due to?

- manifests as? (6) F/C/H/P/H/N/V/D

Back 621

- mechanism: due to ABO incompatibility, less common due to other minor blood group

- manifests as fever, chiils, hemoglobinuria, pain, hypotension, N, V, dyspnea, renal failure, DIC

Front 622

Managing AHTR - stop? check for? compare?

- notify? send?

- send samples to?

- send labs to look for?

- give?

Back 622

- stop transfusion

- check for clerical error = amr band vs blood label

- notify blood bank, send bag bank

- send samples to recheck ABO group

- send labs to look of rhemolysis - CBC, LDH, bili, haptoglobin, creatinine, INR, PTT, fibrinogen

- support care

Front 623

BACTERIAL CONTAMINATION (BaCon)

- blood components can be? from? (3)

- most often occur in? due to?

Back 623

- blood components can be contam by normal skin flora from donor, bacteremia in donor, contam in handling (rare)

- most often occur with pts due to room temp storage

Front 624

BaCon Manifestation and Management

- manifests as? (6)

- manage by stopping? notfiy? quarantine? culture? start?

Back 624

- Manifests = fever, rigors, tachy, hypotension, N, V, dyspnea, DIC

- Management = stop transfusion, notify blood bank and quarantine other blood components from same donor, culture patient and start broad-spectrum Abx immed.

Front 625

Febrile Non-Hemo Transfusion Reaction (FNHTR)

- mech = in product there are? such as?

- leads to?

- diagnosis of?

Back 625

- Mech = cytokines in transfused product, recipient Abs (to WBCs or pts) in transfused product

- Manifests as fever, chills, rigors, N,V, hypotension

- is a diagnosis of exclusion

Front 626

FNHTR Management - pause? give? if fever resolves?

Back 626

- pause transfusion

- give acetaminophen

- if fever resolves and no serious symptoms, then restart transfusion

Front 627

Managing fever Patient during Transfusion

Back 627

Front 628

If Have Fever and Serious Symptoms

Back 628

Front 629

Urticaria Def and DD

- defined as? assoc with? may present with? FE/AE/D/W/HT

- DD = major? minor? cause?

Back 629

- urticaria = hives = assoc with allergic reaction, may present with facial edema, airway edema, dyspnea, wheezing, hypotension, or shock

- Ddx:

= anaphylaxis/ major allergic reaction

= urticaria / minor allergic reaction

= urticaria from another cause = drug/food

Front 630

Anaphylaxis Mechs - mostly?

- recip has?

- transfusion of?

- passive?

Back 630

- most unexplained, potential mechs:

= recip has IgG against missing protein

= transfusion of allergen to sens patient

= passive transfer of IgE from donor

Front 631

Anaphylaxis Manifestation and Management

- main manifestation is? (3), some resp as?

- CV as?

- management to? give?

- if anaphylaxis, give? then? then? (2 - E/C/V)

Back 631

- Manifests as cutaneous reaction such as rash, pruritus, angioedema, some resp such as wheezing, stridor, dyspnea and some CV such as hypotension, chest pain and tachy

- Management = stop transfusion, admin diphenhydramine

- if anaphylaxis, give DPH then epinephrine, corticos and vasopressors

Front 632

Urticaria and minor Allergic Reaction

- very? mech is something?

- manifests with no?

- management is to? give? then restart if?

Back 632

- very common (1 in 100)

- mechanism - something in plasma

- manifests with no serious symptoms

- management = pause transfusion, give DPH 25-50 mg po/iv and restart if urticaria < 2/3 of body and no serious symptoms

Front 633

Managing Hives

Back 633

Front 634

Hives and Serious Symptoms

Back 634

Front 635

Dyspnea Def and DD = ? assoc with?

- TACO =?

= TRALI =?

- major? or not?

Back 635

- dyspnea = SOB, may be assoc. with drop in O2 sat

- DDx:

= transfusion assoc. circulatory overload = TACO
= transfusion related acute lung injury = TRALI

= major allergic transfusion reaction

= dyspnea not related to transfusion

Front 636

TACO - mechanism is?

- RFs = (3)

- manifests as? O/C/TC/HT/ increased?

- CXR can fine?

Back 636

- mech = volume overload

- RFs = CHF, elderly, renal dysfunction

- manifests as orthopnea, cyanosis, increased HR, increased BP*** and increased JVP

- CXR finds volume overload

- NT-proBNP from normal to elevated after transfusion

Front 637

Taco Mangement

- stop? CXR to? support via?

- key is?

Back 637

- stop transfusion

- CX to discern other causes

- support = oxygen and diuretics

* prevention is key

Front 638

TACO Prevention - transfuse one?

- do over? for?

- consider use of? particularly for pts with? age?

Back 638

- transfuse one unit at a time for prophylactic transfusion

- transfuse slowly over 3.5 hours for prophylactic transfusion

- consider use of furosemide in patients >60 years or hx of CHF

Front 639

TRALI - also known as?

- defined by onset of?

- see new? on CXR see?

- no evidence of? no pre-existing?

Back 639

- non-cardiogenic pulmonary edema

- definition = onset during or within 6 hours of transfusion

- see new acute lung injury, bilateral infiltrates on CXR

- no evidence of circulatory overload and no pre-existing acute lung injury

Front 640

TRALI Mechanism- Ab hypothesis includes? sbstances then cause?

- two event hypothesis has underlying? then see?

Back 640

1) Ab Hypothesis

- donor Abs lead to release of substances that cause pulmonary endothelial damage and cap leak

2) Two Event Hypothesis

= underlying condition = 1st event

= transfusion of BRM or Abs = 2nd event

Front 641

TRALI - Manifests and Management

- manifests as? (4) D/H/F/HT

- manage by stopping? assess? quarantine?

- do a?

- provide?

Back 641

- Manifestations = dyspnea, hypoxia, fever, hypotension

- Management - stop transfusion and assess patient, inform transfusion lab and quarantine other products with dangerous Abs, CXR and supportive care = oxygen, fluids, mech vent in 75%

Front 642

Managing Patient with Dyspnea During Transfusion

Back 642

Front 643

Hypotension Def and DDx

- >? in?

- csn be due to? (6)

Back 643

- >30 mmHg drop in SBP or DBP

- DDx:

= AHTR

= BaCon

= TRALI

= Anaphylaxis

= Severe FNHTR

= Bradykinin Mediated Hypotension

Front 644

Mech and Manifestation of Hypotension

- mediated by? often occurs with? also often involves?

- manifests as? (4)

Back 644

Mech = Bradkinin-mediated, often occurs with pt transfusion and often involves ACE inhibitors

Manifestation = assoc. with dyspnea, urticaria, nausea, vomiting

Front 645

Management of Hypotension - stop? provide? rule out other? such as?

- check?

- culture?

- look for symptoms of?

- look for signs of?

Back 645

-stop transfusion

- supportive care = fluids

- rule out other transfusion reactions such as:

= AHTR = check bag for clerical errors

= BaCOn = culture bag and patient

= Look for symptoms of dyspnea and CXR = TRALI

- look for skin and allergic symptoms = Anaphylaxis

Front 646

Delayed Reactions in Transfusions = (4)

Back 646

= DHTR
= TTI

= PTP

= TaGVHD

Front 647

Delayed Hemolytic Transfusion Reaction - results from formation of? in response to?

- occurs after?

- leads to? decreased? increased? (3)

- need to identify? give?

- notify?

Back 647

- results from formation of Abs in recipient to transfused RBC that was not initially detected

- occurs 3 days-2 weeks after transfusion

- see hemolysis = decreased Hb, increased retics, increased bili, increased LDH, decreased hapto and + DAT

- need to identify Ab and give Ag neg. blood for future transusion

- notify patient that they have Abs

Front 648

Transfusion Transmitted Infections = TTIs

- use questionnare to? these include?

- test all? for? (6)

- risk is?

- may be? that?

Back 648

- all volunteer donors

- donor screening questionnaire to screen for diseases not captured = malaria, CJD

- donor testing = HIV, Hep C,B, HTLV, West Nile, Syphilis, Chagas

- risk is negligible but not zero

- potential pathogens we dont yet know about

Front 649

Function of Skeleton - (4)

Back 649

- locomotion and function

- protection of soft tissue and viscera

- environment for marrow

- mineral depot

Front 650

Long Bone Anatomy - at end? between that and middle?

- metaphyses is where?

Back 650

- epiphysis at end of bone, metaphysis between epiphysis and diaphysis (middle of bone)

- metaphysis is where bone flares

Front 651

Bone Organic vs Inorganic - %?

- organic includes? has both? contains? minerals are laid down on?

- inorganic has deposition of? is seen on?

Back 651

1) organic = 30%

- collagen type I scaffold "osteod", osteoblasts, osteoclasts, periosteam, BVs and nerves

- minerals laid down on collagen scaffold

2) Inorganic = 70%

- calcium phosphate salt deposition, hydroxylapatite, seen on xray

Front 652

Bone Types - L vs W?

- majority of bone is? tubes arranged?

- woven bone seen in? seen in? is more?

- cortical more on?

- both cortical and cancellous are?

Back 652

- lamellar bone and woven bone - majority of bone in body is lamellar bone, tubes arranged parallel to lines of stress

- woven bone seen in immature bones - in kids and at fracture sites, more flexible

- cortical bone and cancellous bone - both have lamellar bone

- cortical makes up wall of diaphysis, cortical more on edges

Front 653

Bone Mechanics - mineral component for?

- stiff so? strong so? brittleness so?

- organic component for? is?

Back 653

1) compression load = mineral component

- stiff = deforms very little under laod

- strong = high load before failure

- brittleness = breaks with veyr little deformation

- collagen component makes it flexible

2) Tension sheer load = organic component

- elastic

Front 654

Fracture - is an?

- trauma increase? stress decreases? pathology decreases?

Back 654

- interruption in the continuity of bone

- trauma = increased force against normal bone

- stress = low force that is repeated, overwhelms normal bone and healing response

- pathologic = less force against abnormal bone

Front 655

Stress Fractures

- due to? happens in? as? transfer?

- see acute chnages in?

- risks? (4)

Back 655

- do to overuse/fatigue, happens in areas not used to seeing force, muscles are overwhelmed and transfer abnormal force to the bone

- see acute change in amount/intensity of activity

- risks:

= lower extremity

= tennis/ track/ distance/ basketball

= female

= delayed Xray, CT, MRI

Front 656

Pathological Fracture

- bone is?

- two most common causes?

- can be due to?

- seen in?

- most common at?

- on xray see?

Back 656

- bone and its biomechanical properties are weakneded

- two most common causes are metastatic disease and hematologic malignancies such as multiple myeloma

- can be due to metastatic tumour

- seen in older age group (>50)

- also seen in breast,lung,renal, prostate, thyroid, hema MM - mets often comes from paired structures

- axial sites are most common

- xray - see osteolysis

- see osteoclast activation via RANK

Front 657

Pathological Fractures - osteomalacia vs osteoporosis - decreases?

Back 657

1) Osteomalacia = less organic matrix = then less decreased inorganic

2) Osteoporosis = decreased inorganic

- see fragility fractures

Front 658

Pathological Fracture - Biphosphate Paradox

- biphos can cause? that?

- bone is? but also is? not good for?

- increased risk of?

Back 658

- biphos can cause paadoxial chnages in bone, can predispose to fractures as alter mineralization

- bone is stronger but more rigid, not good against shearing or bending forces

- see reduced incidence of fragility fractures

- see increased risk of femur fractures

Front 659

Traumatic Fracture Appearance

- detemrined by?

- cimminuted?

- displacement determined by? (3)

Back 659

- pattern determined by mechanism of injury and direction of force

- ex/ simple vs comminuted = comminuted = multiple fragments**

- displacement determined by:

= integrity of perisoteum

= direction of force

= pull of unopposed attachments

*displacement described according to position of distal component relative to proximal

Front 660

Communication Traumatic Pattern

- closed reduction is reversing?

Back 660

- closed reduction = reverse the deformity by reversing mechanism and displacement

Front 661

Tensile or Distracting Force - Trauma Pattern

- type of fracture?

- fracture line is?

- often from?

Back 661

- see transverse fractures

- fracture line perpendicular to long axis (+/- 30 degrees)

- often high energy

Front 662

Compressive Force - Trauma Patterns

- type of fracture?

- fracture line is?

- from?

Back 662

- oblique fractures

- fracture line 30-60 degrees greater than perpendicular to long axis

- high energy

Front 663

Spiral Fractures - Trauma Patterns

- fracture line is?

- energy? type of froce?

Back 663

- fracture line greater than 60 degrees to perpendicular to long axis of bone

- low energy

- rotational force

Front 664

fracture Displacement - consider (7)

- fractures most oftne lead to?

Back 664

- translational

- direction = AP, Med, Lat

- quantity % of diameter

- length

- impaction/shortening

- distraction/ lengthening

- quantify

- fratures most often lead to shortening, may get lengthening if soft tissue is interposed

Front 665

Fracture Displacement - angle described as?

- angle described by direction?

Back 665

- angle described by direction of displaced distal fragment

- angle described by direction of apex of created angle: varus vs valgus

Front 666

Valgus vs Varus - apex is?

Back 666

- Valgus = apex medial

- Varus = apex lateral, distal medial

Front 667

Xray interpretation Checklist - intro? pattern? location? displacmernt? exceptions?

Back 667

- introduction = views, site, patient

- pattern = simple vs comminuted, transverse, oblique, spira

- location = name bone, rule of 1/3s, epiphysis, metaphysis, diaphysis, intra-articular

- displacement = translation, length, angle, rotation, distal relative to proximal

- exceptions - fractures of humeral head and femoral head and neck

Front 668

Pediatric Fractures - Salter-Harris Classification - S/A/B/T/C

- have thicker? fractures less likely to?

- msot bone is? more?

- most fractures occur at?

Back 668

= Straight

= Above

= Below

= Through

= Crushed

*have thicker periosteum, makes fractures less likely to displae

- most bone is woven, more elastic and not rigid = angulated breaks, less likely to be complete with rotation or angulation componenet

- most fractures occur at growth plates where there is more woven immature bone

Front 669

Pediatric Fractures - Type 1 through 5

type 2 invovles? 3 goes through?

- 4 - from? into?

5 - is a full?

Back 669

-Type I: transverse across growth plate

-Type II: across growth plate and involvesproximal metaphysis

-Type III: across growth plate and goesthrough physis

-Type IV: goes from metaphysis into the physis

- Type V: compression fracture of growthplate

Front 670

Healing Response

- three phases?

- overlap of? process take around?

- fracture does not?

Back 670

= inflammation phase, reparative phase, remodelling phase

= overlap of phases, process takes months or years

- fracture does not regain full strength untul about 2 years

Front 671

Hematoma Phase (inflammation phase)

- sourrounding fracture is?

- have assoc.

- see necrosis of?

- time course?

Back 671

- hematoma surrounds fracture

- assoc. intramedullary hemorrhage

- necrosis of bone ends

- inflamm. mediators

- time course is days or weeks

Front 672

Proliferative Phase (Reparative phase)

- new? such as?

- response from?

- time course?

Back 672

- new bone forms:

= periosteum, endosteum, cortex, pluripotential mesenchymal cells

= response primarily from periosteum

- time course = weeks and months

Front 673

Remodelling Phase

- first bone is? process is?

- bone hypertrophies accoridng to?

- signal for maturation is?

Back 673

- initial bone is "woven"

- remodelling an ongoing process

- bone hypertrophies according to Wolf's law

- trabecular formation and realignment

- signal for maturation is application of stress

Front 674

Timing of Healing and Strength

- Hema? inflamm? soft callus? hard callus? remod takes?

- beginnign of woven bone is?

Back 674

- hematoma and inflammation one pahse

- soft callus os beginning of org of woven bone, hard callus when well established

Front 675

Fracture Healing - Timing

- on palpation feel?

- pain on?

- xray not normal for?

Back 675

- tenderness on palpation

- pain on fracture stress = angulation, weight bearing

- xray not normal for months - can see fracture lines

- think of activity type

Front 676

History of Fractures - ask about?

- events? function? assess?

Back 676

- allergies

- meds

- PMH

- last meal

- events = mechanism, energy high vs low

- function = occupation, handedness, ADL independent, sports/interests

- assessment = multifocal MSK, head, thorax, abdo, spine, neurovasc

Front 677

Fracture Examination

- around? also check?

- look for? E/S/T - ROM NV? screen?

Back 677

- skin/wounds around wound/trauma, also check remainder of limb

- deforms, position of limb

- ecchymosis

- swelling

- tenderness

- ROM = pain, decreased, crepitus

- neurovasc status

- MSK screen

- most common assoc. injury is neurovascular, need to do distal vascular exam

Front 678

Radiograph Rules

- rue of 2s = (3)

Back 678

- rules of 2s

= 2 orthogonal views

= 2 joints above and below

= 2 sides PRN = pediatric

Front 679

Goals of Fracture Treatment - save? (3)

- restore? while?

Back 679

- saves lives, save limbs, save joints

- restore function, prevent complications

Front 680

Main Three Principles of Fracture care - R/I/R

Back 680

1) Reduction

2) Immobilization

3) Rehabilitation

Front 681

Reduction and Immob. Immediate

- gross? not triyng? simply?

- prevent? minimize? relief?

Back 681

- gross realignment - not trying to get displacement perfect, simply re-align limb grossly

- prevent further injury

- minimize blood loss

- pain relief

- transport

- temporize for consultation

Front 682

Closed Reduction Definitive - Correction of Deformity

- no reduction needed if? or if?

Back 682

- no reduction needed if initial position acceptable

- no reduction if displacement is zero or acceptable, can move onto immobilization

Front 683

Closed vs Open Reduction

- closed is no? indirect? non?

- open means? direct?

Back 683

Closed = no visualization, indirect manipulation, non-operative

Open = means surgical, direct visualization, direct manipulation, operative

Front 684

Reduction means? to?

- must be? to?

Back 684

- surgical procedure to restore a fracture or dislocation to the correct alignment

- For the fractured bone to heal without any deformity the bony fragments must be re-aligned to their normal anatomical position

Front 685

Closed vs Open Reduction

Back 685

- Open reduction is where the fracture fragments are exposed surgically by dissecting the tissue

- Closed reduction is the manipulation of the bone fragments without surgical exposure of the fragments

Front 686

Closed Reduction Step 1 - Analgesia - for? helps to?

- muscles are in? need to?

Back 686

- comfort

- relaxes voluntary and involuntary displacing forces

- muscles are in spasm and are contracting, need to neutralize this

Front 687

Closed Reduction Steps

- then provide? which? heps to?

- finally? by applying? using?

Back 687

Step 2 = traction - try to tire out muscle, may end up reducing displacement as well

Step 3 = Reverse deformity - apply forces opposite to displacing force as splint or cast must maintain reduction forces

Front 688

Closed - Post Reduction must?

- can do?

- ensure?

Back 688

- must re-examine neurovascular exam/status

- xray - acceptable

- need to ensure new position is accetable

Front 689

Casting Immobilization

- see adequate?

- during acute injury crescendo - use? as?

- plateua - use? as?

- want frequent?

- need to account for?

Back 689

- see adequate padding = Gypsum plaster and molding

- acute injury swelling crescendo = non circumferential split - therefore start with

- subacute injury swelling plateau = circumferential cast to increase stability

- maintenance of reduction reliability = frequent Xray followup

- need to account for continued swelling

- can apply circumferential cast for definitive mgmt after swelling has subsided

Front 690

What's an Acceptable Reduction - Fracture Factors

- avoidance of? return? avoid?

Back 690

- evidence based criteria range

- union rate

- avoidance of deformity

- return to function

- avoidance of complications

*criteria different for each bone

Front 691

What's an Acceptable Reduction - Patient Factors - consider? (3)

- crtieria is?

- if not satisfactory?

Back 691

- age

- functional demand/goals

- comorbidity

*criteria different for each patient, functional demands of patient have impact on displacement management

- if unsatisifactory reduction radius, try closed reduction again or proceed t open reduction

Front 692

Open Reduction Advantages - more?

- early?

- aovids?

- implant will?

Back 692

- accurate reduction

- reliable maintenance of reduction

- early mobilization - patient, limb

- avoids prolonged time in external immobilizers (internal fixation)

- implant will hold fracture in desired position

Front 693

Open Reduction Indications

- inability to?

Back 693

- inability to obtain or maintain an acceptable reduction by closed mean

Front 694

Open Reduction Special Scenarios

- strict? as need to?

- when there is? such as? (3)

- or if there are? as may develop?

Back 694

- strict acceptable criteria - need to preserve blood flow

= high risk of AVN
= femoral neck

= talus neck

= scaphoid waist

= intra-articular fractures = may go on to develop OA with articular damage, want no displacement in this case

= Salter Harris III or IV

Front 695

Open Reduction Indications - compromise of? (2)

- pathology of? as it prevents?

- if cannot?

- for both (2)

-

Back 695

- vascular compromise

- neurological compromise

- metastic pathological features as tumour prevents bone from healing (even if no displacement)

- do if closed reduction unacceptable

- for hip and femoral shaft fractures

* need to document neurovasc status

Front 696

Open Reduction Risks

- do for? or for?

- complications from? - (4)

Back 696

- use OR if result from closed reduction is unacceptable for type of fracture = hip, femur, polytrauma, even undisplaced,

- complications from long term immobilization:

- DVT/PE

- pressure ulcers

- pneumonia

- pain

- nursing care

Front 697

Open Reduction - Open Fracture

- infection due to? can lead to?

- problem as?

- deformiton may?

Back 697

- infection due Staph, Strep, Clostridium, life-threatening sepsis, limb threatening amputation

- due to communication with external enviro

- deformation may push bone outside muscular envelop, open would chnages management

Front 698

Open Fracture IV Antibiotics

- risk of amputaiton when wound < 1cm? when > 10cm?

- increase amputation risk with? (4) - treatment time? defect in? injury to?

- strong bearing on?

Back 698

- high risk = level 3 = risk of amputation is 25%

- has strong bearing on prognosis

Front 699

Open Fracture Approach - must consider (6)

- compromise prognosis when?

Back 699

- tetanus status

- emergent OR - 6 hours

- when/where, ABCs

- wound size

- contamination

- soft tissue defect

* prognosis compormised when outside 6 window, open fractures always high energy, ATLS is trauma protocol

Front 700

Open Fracture treatment - give IV? also give?

- then steps = (4)

- need to?

- most limb threatening infection?

- do? to reduce?

Back 700

- IV antibiotics

- tetanus

- irrigation and debridement, ORIF, wound cover

* need to close wound so fracture no longer exposed

* Clostridium tetani is most limb threatening infection

- see irrigation, debridement, stabilization with hardware to reduce risk of infection and amputation then close wound

Front 701

Open Fracture IV Antibiotics

- start with? such as?

- if wound > 10 cm?

- if soft tissue defect or gross contam?

Back 701

- start with Gram + = Ancef

- then move to Gram - if the wound >10cm = Gentamycin

- if soft tissue defect or gross contamination = anaerobes = Flagyl

Front 702

Complications Approach Fractures - Early

- local (3)

- systemic? **

Back 702

local = infection, neurovascular, compartment sx

systemic = fat embolism syndrome

Front 703

Complications Approach Fractures - Late (5) early? systemic?

Back 703

local - stiffness, malunion, nonunion, AVN, osteoarthritis

- systemic - none

Front 704

Early Local Vascular Injury

- is a? essential to get?

- can be both?

- always assess? and make sure to?

Back 704

- surgical emergency

- early diagnosis and treatment essential

- limb and life threatening

- assoc. with displaced and/or open fractures

- always assess and record vascular status, even in closed fractures

Front 705

Early Local Neuro Injury

- always assess? assoc with? assess?

- laceraiton assoc with?

- explore?

- closed injuries - observe for? even if?

- nerve may be? is the most?

Back 705

- always assess and record distal function

- assoc. with specific fractures

- assess both pattern and severity of loss

- laceration assoc. with open injuries

- explore open injuries

- observe closed injuries for 3 months

- explore closed injuries at three months if recovery has not occurred

- nerve may be overstretched, causing dysfunction - most common cause of injury is overstretching

Front 706

Early Local Compartment Syndrome

- compartments defined by? with?

- pressure normally is? yet in CS?

- signs when? in the?

- >6 hours?

Back 706

- compartments defined by fascial envelop, muscles, nerves BV in compartment

- pressure in normally higher in vascular bed then tissues around it, see reversal in CS where pressure in interstitium is higher

- see signs and symptoms caused when the intracompartmental pressure exceeds perfusion pressure in an anatomic compartment

- see irreversible muscle necrosis at >6 hours contracture

Front 707

Causes of Early Local Compartment Syndrome

- intracompartmental = (5)

- extra = ***** - may get?

Back 707

- Intra compartmental = fracture, crush injury, coagulopathy, vascular reperfusion, pus/tumour

- extra compartmental = cast, cast, cast, cast, burn eschar

- may get edema and compartment syndrome after reperfusion

Front 708

Clinical Diagnosis of ELCS

- presents as? with? seen as?

- discuss?

- determine via?

- RF is?

Back 708

- ++++ pain, pain with passive stretch, tense comp = pain out of proportion

- discuss pain scale, pain evolution, pain setting, use of analgesics over time

- determine via pressure measurement

- RF for CS in high energy injury

Front 709

Unreliable Pain Perception in?

(7)

Back 709

- paediatric

- elderly

- head injury

- intoxication

- intubated

- nerve injury spine/peripheal

- distracting injru

Front 710

Early Local Compartment Syndrome treatment

- release? then? re-eval every?

- no role for?

- need urgert? to release?

- will then need?

Back 710

- release circumferential constraints

- elevate limb

- re-eval every 15 minutes

- no role for pressure measurements

- need urgent fasciotomy within 6 hours, release fascia longitudinally along length of whole compartment

- will need skin graphs after compartment pressure is released

Front 711

Early Systemic Fat Embolism Syndrome

marrow contents? common after?

- blood clots will not?

- deposition of lipids in skin?

- see? (4)

- mortality?

Back 711

- marrow contents spill into venous system, most common after long bone fracture

- blood clots will not cross from R to L side, fat/oil in this case can pass to L side

- deposition of lipids in skin give petechial rash pattern

- see hypoxia, pulmonary edema, petechial rash, CNS depression

- mortality at 15%

- need early ventilatory support, early fracture stabilization

Front 712

Late Local Complication - Stiffness - most?

- due to? (5)

- most chnages are?

Back 712

- stiffness is most common complication

chnages:

= inflammatory infiltrate

= fibrotic reaction

= prolonged cast immbolization

= callus adhesions

= inadequate rehab

- most changes that occur are reversible with physiotherapy

Front 713

Late Local Complications - Stiffness

- can see? (HO) formation of?

- can cause? needs to be?

Back 713

- can see heterotopic ossification, which is formation of bone outside of the skeleton and soft tissues

- see overexuberant bone formation

- this can cause stiffness, needs to be excised

Front 714

Late Local Complications - Malunion healed frature is?

- not obtained? not?

- need to have?

Back 714

- healed fracture position outside of acceptable range

- not obtained = missed fracture

- not maintained = follow up/compliance

- have osteotomy/ open reduction/ internal fixation

- may have cosmetic or functional deficits

Front 715

Late Local Complications - Nonunion - Hypertrophic

- adequate? inadequate?

- often due to?

- can occur when?

- need to have?

- can have? yet still see?

- hypertrphic nonunion occurs when?

Back 715

- adequate biology, inadequate stability

- poor casting

- non compliance

- return to activity too soon

- have open reduction and internal fixation

- can have abundant callous but patient still has pain

- hyertrophic nonunion - fracture environment not stable enough for hematoma to progress to woven then lameller bone

Front 716

Late Local Complications - Nonunion - Atrophic

- suboptimal?

- location often (2)

- can be due to? (7)

- no evidence of?

- cant give? as they?

Back 716

- suboptimal biology/ vascularity

- location = tibia, femoral neck

- fracture personality

- smoking, meds, NSAIDs, malnutrition, diabetes, open fractures and infection

- no evidence of formation of fracture callous

- no anti-inflamm can be given as they block inflammatory healing phase

Front 717

Late local Complications - OA, AVN - can happen with?

- AVN often occurs at? (3) FN/TN,SW

- can islands of? develop?

- also may lead to?

Back 717

- can happen with intraarticular fractures

- AVN = femoral neck, talus neck, scaphoid waist - get weakened bone as have islands of subchondrial bone and no support, can develop osteochondral flaps on femur head

- AVN may also cause compression fractures, abnormal mechanics leading to OA

Front 718

Non-Accidental Trauma

- unroecgnized %? abuse is?

Back 718

- unrecognized = 25% risk of serious injury, 5% risk of death within one year

- abuse is second leading cause of mortality in infants and children

- 1-1.5% incidence

Front 719

RFs for Non-Accidental Trauma

- young? infant age? the first? if child is? parents are?

- fmailes that are?

Back 719

Front 720

Red Flags to Watch for in Non-Accidental Trauma

- history of? different? multiple?

- different? delay in?

Back 720

- history of multiple fractures

- different stages of healing for fractures

- multiple hospital visits

- multiple care givers

- different stories given from different caregivers

- delay in seeking medical attention

- mechanism of injury does not fit fracture/injury pattern

Front 721

Non-Accidental Trauma - Full Physical Exam

- child must be?

- signs = (4)

- head - look for?

- also look at? (3)

Back 721

* child must be fully undressed and examined

- sign = bruises, abrasions, burns, cigarettes

- head = examine for skulltrauma, palpate fontanelles if open, optho exam

- trunk = palpate rib cage, abdo

- extremities = palpate every bone

- genitalia

Front 722

Suspicious Fractures

- MCF? <1 yo? <3 yo? sternal? posterior?

Back 722

- metaphyseal corner fracture

- femur fracture < 1 yo

- humeral shaft < 3 yo

- sternal fractures

- posterior rib fractures

- spinous process fractures

Front 723

Suspicious Fracture Workup

- consult?

- make sure to?**

- eplain?

Back 723

Front 724

Developmental Hp Dysplasia (DDH)

- is abnormal?

- subluxatable? dislocatable? subluxated? dislocated? or finally?

- more likely to occur in?

Back 724

- hip dysplasia = abnormal developmental of femoral head and/or acetabulum

- spectrum of instability:

= subluxatable = partial displacement, lies in socket at rest

= dislocatable = can be moved completely out of socket

= subluxated = reducible, outside of socket at rest but can be put back in

= dislocated = reducible

= irreducible

- teratologic hip dislocation = syndromes = Arthrogryposis

- first child more likely to have hip dysplasia

Front 725

Epi and Etiology of DDH

- incidence is? true incidence

- RFs = (4)

- - uterius problems such as?

- also seen more in?

Back 725

- incidence of hip instability at birth is 1/100

- true incidence of DDH = 1/1000

- RFs

= breech

= positive FH = 7x increase

= female = 80% cases

= 1st born = primigravida uterus = prolonged periods of abnormal positioning, limited hip motion, tight package, left side more commonly adducted against sacrum

= cultures where babies are swaddled

Front 726

DDH RFs - Absolute Risk gender? positive? presentation? if held?

Back 726

1) all newborns = 11.5/1000 = girls = 19/1000, boys = 4.1/1000

2) positive FH = girls 32/1000, boys = 6.4/1000

3) Breech Presentation = 133/1000, boys = 29/1000

4) Swaddling = high risk when hips are held adducted and extended

Front 727

Natural History of DDH - first seen with?

- can have? get ipsilateral? leads to?

- pain in? then degen?

Back 727

- leg length inequality - if unilateral

- scoliosis

- ipsilateral knee pain and deformity

- gait abnormality

- low back pain due to hyperlordosis (if bilateral)

- disabling degen. arthritis

- degen. arthritis related to severity of dysplasia

Front 728

DDH Clinical Screening

1 - look for assymetric?

2 - barlow = perform - move hips? see hips? is a?

Back 728

1) Asymmetric Abduction of hips

2) Barlow's Sign = Clunk of Dislocation

= hip is in at rest, hip slips out when adducted and a posterior force applied, provocative test

Front 729

DDH Clinical Screening

- Ortolani sign is?

- Galeazzis sign is?

Back 729

3) Ortolani Sign = Clunk of Reduction = hip is out at rest, reduces with a clunk when hip is abducted and an upward force applied

4) Galeazzi Sign = shorter thigh segment

Front 730

DDH Clinical Findings in Older Child (> 3 months)

- absent?

- limited? seen with?

- discrep?

=- painless?

- can do? before 6m? after?

Back 730

- signs of instability are absent (usually)

- limited ROM = asymmetric abduction

- leg length discrepancy

- painless limp = Trendelenberg gait

- imaging studies = US up to 6 months, radiographs after 6 months of age

Front 731

Imaging Studies

- do a? on?

- indications? (2)

- radiographs after?

Back 731

- dynamic US

- coronal and transverse plane

- indications = high risk baby, equivocal PE

- radiographs after 6 months of age, when ossific nucleus has developed

Front 732

AAP Clinical Practice Guidelines

- do for all?

- check with?

- if positive Barlow or Ortolani?

- imaging?

Back 732

Front 733

DDH Management - Pavlik Harness - is the? used for?

- age? length of time?

- use US to?

- abandon if? used during?

- complications (2)

- effective in?

Back 733

- initial management - Pavlik Harness = guided reduction

- up to 6m old

- full time use for 6 weeks

- U/S to confirm reduction

- abandon if not reduced within 3 weeks

- night time for 6 weeks

- complications = AVN, femoral nerve palsy

- effective in majority of cases (>85%)

- double/triple diapers are ineffective

Front 734

DDH Management - Closed reduction with spica cast

- done after? age?

- usually done by?

- use imaging to?

- use for?

Back 734

- done with failure of Pavlik harness

- older than 6 months

- usually accomp. by adductor tenotomy

- CT or MRI scan to confirm reduction in the cast

- Spica cast for 6 to 12 weeks followed by abduction brace

Front 735

DDH Surgical Management - is a?

- after 18 months, add?

- older child add?

- main risk?

Back 735

- open reduction and capsulorraphy

- add inominate (pelvic) osteotomy after 18 months

- add femoral shortening osteotomy in older child

- risk of AVN

Front 736

Clubfoot - Congenital Talipes Equino Varus

- is? seen in? gender? often?

- prenatal diagnosis?

- FH?

- see variability in?

Back 736

- congenital, 1 in 1000 birth, M:F = 2:1, 50% bilateral

- pre-natal diagnosis by US

- FH = 2nd child has 2-5% chance (20 to 30x baseline rate)

- see variable severity and stiffness

Front 737

Congenital Talipes Equino Varus Idiopathic Etiology

- mech? neuromusc? arrested? inherited?

Back 737

= mech factors = unlikely in isolation

= neuromusc defect = subclinical

= arrested fetal development

= inherited (polygenic multifact. trait)

Front 738

Congenital Talipes Equino Varus Syndromic and Neuromusc. Causes

- seen in? (4)

Back 738

- spina bifida

- Arthrogryposis

- Cerebral palsy

- Polio

Front 739

Talipes Equino (Cavo) Varus - known as?

- see deep?

- empty?

- hindfoot varus is? midfoot cavus is?

- see? lateral border?

Back 739

- hindfoot equinus = hell looks rounded and soft

- deep posterior crease

- empty (soft) heel

- hindfoot varus = apex lateral

- midfoot cavus = deep medial crease

- see forefoot adducted, lateral border is convex

Front 740

Calcaneovalgus Foot - not? is a? corrects?

Back 740

- not clubfoot

- is a positional deformity

- correct spontaneously

Front 741

Treatment Goals - be?

- no? normal? close to?

Back 741

- plantigrade = flat on ground

- flexible

- painless

- normal shoe wear

- functional

- close to normal appearance

Front 742

Standard Treatment of Clubfoot - early?

- 80% require? in?

- release of?

- AFO to?

- recurrence?

- long term? (3)

Back 742

- early serial casting

- 80% required surgery = 3 to 9 months

- postero-medial or complete subtalar release

- AFO to maintain correction

- 20% recurrence rate = reoperation

- long term = stiff feet, weak, painful

Front 743

Clubfoot Ponseti treatment

- manip?

- serial casting means? average?

- CAVE correction?

Back 743

- manipulation prior to each casting

- serial casting = weekly changes, above knee onset, average 6 sets

- sequential correction = CAVE = Cavus, Adductus, Varus, Equinus

Front 744

Clubfoot Ponseti Treatment

- residual? percutaneus?

- cast for?

- full time for?

- until age 4?

Back 744

- residual equinus = percutaneus tenotomy of achilles tendon

- cast for additional 3 weeks

- foot abduction Orthosis (Boots + Denis-Browne Bar) to maintain

= full time for 3 months

= night and nap times until age 4

Front 745

Update on Clubfeet

- clubfoot surgery has been?

- use? is easy?

- start?

- essential treatment?

Back 745

- Ponseti method of casting has virtually eliminated clubfoot surgery

- Ponseti method is easy to learn and implement

- start casting early = 1st month

- night time foot abduction orthosis (DBB) is essential part of treatment package

Front 746

Ponseti Method Recurrences

- reported up to? poor?

- repeat?

- resume?

Back 746

- reported up to 20%, assoc. with poor compliance with food abduction orthosis wear

- repeat serial casting, repeat tenotomy as needed

- resume bracing

Front 747

Ponseti Method Late Recurrence

- foot see? weight bearing?

- perform a?

Back 747

= supinated foot, weight bearing on outer border of foot

= tibialis anterior tendon transfer to 3rd cuneiform + Tendo Achilles lengthening if equinus present

= posterior release as needed

Front 748

Surgical Management - Posteromedial Release - Inidcations

- limited?

- failed? late?

- recurrent?

Back 748

- limited indications:

= failed non-operative management, late referrals (neglected or older clubfoot), recurrent clubfeet (post-surgical), revision surgery

Front 749

Surgical Management - Posteromedial Release - contains? pinning to? Brace for?

Back 749

- posteromedial/circumferential release:

= tendons, joint capsule, ligaments

= pinning to maintain position

= Brace for 1 or 2 years

Front 750

Malalignment - Bowed Legs - Consequences

- problem as?

- disturbance of?

- joint?

- abnormal?

- see? (3)

Back 750

- cosmetic

- growth disturbance

- joint laxity

- joint instability = patellofemoral, knee

- abnormal gait

- OA

- pain

- functional problems

Front 751

Bow Leg Deformities - DD (8)

- metabolic =?

- skeletal?

Back 751

- physiologic Genu varum

- Blount's disease

- Metabolic bone disease = Rickets, Renal disease, X-linked hypophosphatemia

- Skeletal dysplasias = Achondroplasia, MED

- post-traumatic

- post-infectious

- tumour = multiple hereditary exostoses

Front 752

History of Bowed Leg

- ask about?

- history of?

- also?

Back 752

- history - when noticed, progression, any symptoms

- pregnancy and birth history = gestation, presentation, mode of delivery, complications

- developmental history

- nutritional history

- history of immunization

- PMH - infection, trauma

- ROS

- FH

Front 753

Alignment in Frontal Plane

- all babies have?

- neural at? by 7, are?

- at birth, normal to?

Back 753

- 15 degree varus at birth = all babies have bowed legs at birth

- neutral at 18 months

- 10-12 valgus = 3 to 4 years

- 5-7 valgus by 7 years

- bowed legs are normal from birth to walking age

Front 754

PE of Bowed Legs

- cna be due to? general?

- assess via satic? dynamic?

- supine? prone?

- main RFs? (20

Back 754

- body habitus = height, weight

- general = dysmorphic features

- static assessment = standing alignment, frontal/sagittal/transverse

- dynamic assessment = walking: look for varus thrust, foot progression angle, knee progression angle

- supine: ROM and joint stability

- prone = torsional profile

- RFs - heavy, early walking

Front 755

Physiologic Genu Varum

- seen in? if have?

- often is?

- have bowed?

- no joint?

- MD angle of?

- resolves by?

Back 755

- early walker

- FH
- bilateral

- femur and tibia bowed

- no joint laxity

- normal physes

- MD angle < 11 angle

- resolves by 2-3 years

Front 756

Infantile Blount's Disease

- onset?

- is the abnormal?

- decrease?

- leads to deform of?

- inceases?

- causes?

Back 756

- early onset as a toddlet - is the abnormal or asymmetric growth in proximal tibia

- decreased medial physeal growth

- deformity of proximal tibia

- increasing genu varum

- internal tibial torsion = in-toeing

- varus thrust

Front 757

Infantile Blount's Disease

- is comon to have?

- gender?

- assoc with?

- more common in?

Back 757

- commonly bilateral > 50%

- females > males

- assoc. with obesity

- more common in blacks

- in children <2 years, difficult to distinguish from physiologic genu varum

Front 758

Infantile Blount's Disease - Management Strategies

- if not improving?

- done before?

- role for?

- little evidence to support?

Back 758

- early osteotomy if the bowing is not improving spontaneously

- ideally before 4 years

- over correct

- role for guided growth (temporary hemiepiphyseodesis)

- very little evidence to support bracing

Front 759

Late Onset Blount's Disease

- ages? common cause?

- different as common to only?

- have assoc.?

-assess?

Back 759

- juvenile = 5 to 10 years

- adolescent = 11 years and older

- obesity common

- commonly unilateral tibia vara

- often multiplanar deformity

- assoc. knee pain

- assess femoral alignment = Valgus (1/3), Varus (1/3), normal alignment (1/3)

Front 760

Late Onset Blount's Disease - Management

- restore? via?

- guided grwoth via? (HE)

- want to minimize? via early? over?

Back 760

- restore mechanical axis

= acute correction

= gradual correction with external fixator (monolateral, circular)

= hemiepiphyseodesis = guided growth, staple, screw

* want to minimize risk of recurrence = early intervention, overcorrection, complete epiphyseodesis

*consider limb lengths

Front 761

Features of Rickets

- impaired? failure of?

- impact on growth?

- often are?

- have iregular?

- looser's lines =?

- bowed?

Back 761

- impaired mineralization

- failure of osteoid to calcify

- growth retardation

- skeletal deformity

- osteopenia = thin cortices, small trabeculae

- irregular widened physes

- flared, cupping metaphysis

- Looser's lines = milkman's pseudofractures

- Bowed diaphyses

Front 762

Rickets/Metabolic DIsease - ask about? (3)

- perform? give?

- surgical treatment?

Back 762

- nutritional history

- prolonged breast feeding without supplementation

- limited exposure to sunlight = North

- skeletal survey

- lab tests

- Med treatment = Vit. D

- surgical treatment = residual deformity

Front 763

Summary = Age consider? Etiology consider?

Back 763

Front 764

Peds Orthopedics - Spectrum of Disorders

Back 764

Front 765

Clinical Features of Bone Tumours

- 4 ways of presentation (4)

Back 765

- typically present in one of 4 ways:

= pain

= mass/swelling

= pathological fracture

= incidental finding on xray

Front 766

Pain Features of Bone Tumours

- most malignant have?

- get pain when? usually from?

- pain at?

Back 766

- Where:

= location, most malignant tumours are painful and have pain related to lesion

- When:

= with activity/weight-bearing - usually destructive lesion and bone is mech compromised

= night pain = typical of malignant tumors

Front 767

Pain Features of Bone Tumours

- quantity - malig vs benign

- quality - malig is usually? burning if?

Back 767

- Quantity:

= severity, pain from malignancy usually severe, requiring narcotics whereas benign not severe

- Quality:

= nature of pain, pain due to malignancy is usually constant, deep seated ache

- may be burning pain if adjacent to nerve

Front 768

Pain Features of Bone Tumours

- allev by? or by?

- aggrav by?

Back 768

- Alleviating Factors

= typically analgesics, sitting down or taking weight off leg

- Aggravating Factors

= typically weight bearing

Front 769

Soft Tissue Mass

- impotant to determine whether? if it is?

-most benign?

- soft tissue tumours usually?

Back 769

- important to ascertain whether the mass is fixed to bone, then it is likely a primary bone malignancy

- most benign bone tumours do not have soft tissue masses

- soft tissue tumors are usually mobile over bone

Front 770

Other features of Malignancy on Clinical Assessment

- const symptoms? history of cancer? history of radiation or pagets?

Back 770

- may have const. symptoms = Ewing's Sarcoma

- may have history of cancer elsewhere = bone mets

- may have history of radiation or Paget's disease = Osteosarcoma

Front 771

Clinical presentation of Bone Tumours - (4)

Back 771

= pain

= mass

= pathologic fracture

= incidental finding on xray

Front 772

Radiographic Features of Bone Tumors - (4)

Back 772

= bone destruction

= periosteal reaction

= soft tissue mass

= matrix

Front 773

Bone Destruction on Xray - bone appears?

- due to?

Back 773

- aka lysis

- bone appears darker on xray

- tumour cells activate osteoclasts in the bone that stimulate resorption

- feature of benign aggressive or malignant lesion

Front 774

Periosteal Reaction on Xray

- reaciton of? as it is?

- hallmarks of?

- malignant appears? have?

- if benign, has?

Back 774

- reaction of periosteum as it is lifted off the bone by growing tumour

- some are hallmarks of malignant lesions, others of benign

- malignant - onion-skinning, sunburst, Codman's traingle

- Benign - Periosteal neocortex

Front 775

Osteosarcoma and Periosteal Reaction = Sunburst

- also known as?

- see spicules?

Back 775

- "sunburst" or "hair on end " typical features

- spicules of bone emanating at right angles to the bone

Front 776

Periosteal Reaction - Codman's Triangle

- angle of new bone that? as?

- is a?

Back 776

- an angle of new bone that is formed along the cortex as the periosteum is lifted up by the tumor

- feature of malignant tumors

Front 777

Periosteal Reaction - Ewing Sarcoma

- see multiple? as?

- feature

Back 777

- see multiple lamellae of new bone laid down as tumor elevates the periosteum

- feature of malignancy and Ewing Sarcoma

Front 778

Periosteal Reaction - Periosteal Neocortex

- thin? made by? after?

- feature of?

Back 778

- thin "eggshell" of new bone formed by periosteum after the cortex is destroyed by tumor

- features of benign aggressive tumors

Front 779

Periosteal Reaction - in benign tumors see?

Back 779

- well-ordered new bone without onion-skinning, sunburst or Codman's triangle

Front 780

Soft Tissue Mass - Xray - typically seen with?

- mass grown through? presents with?

Back 780

- typically a feature of primary malignant bone tumours

- mass growth through Haversian BV system, presenting with mass outside bone with bone intact

Front 781

Tissue in MSK Tumours

- MSK tumours can make?

- if bone? if cartilage? if fibrous tissue?

Back 781

- 3 types of tissue typically manufactured by MSK tumours

= bone = osteoid = Osteosarcoma

= cartilage = chondroid = Chondrosarcoma

= fibrous tissue = fibrous dysplasia

Front 782

Osteioid Matrix - looks like? in? called?

Back 782

- looks like clouds of bone that have been formed in medullary canal or soft tissue

- Osteosarcoma

Front 783

Chondroid Matrix - called?

feature of? (2) B vs M

Back 783

- cause "punctate" or "popcorn" calcification

- can be feature of benign (enchondroma) or malignant (chondrosarcoma) tumours

Front 784

Fibrous Matrix - also called?

- loss of? but not? appears?

- found in?

Back 784

- AKA = ground glass

- loss of normal bone trabeculae but not completely lytic, there is a hazy matrix present

- found in benign lesions = ex/ fibrous dysplasia, non-ossifying fibroma

Front 785

Summary of Radiographic Features - Malignant

- often?

- periosteal reaction includes? (3)

- mass?

- make?

Back 785

- often destroy bone

- periosteal reaction including onion-skinning, sunburst or Codman's triangle

- soft tissue mass

- produce matrix

Front 786

Summary of Radiographic Features - Benign

- don? periosteal? no? may or may not?

Back 786

- usually don't destroy bone = exception is giant cell tumour

-periosteal neocortex

- no soft tissue mass

- may or may not have matrix

Front 787

Enchondroma - benign? also called?

Back 787

- definition = benign hyaline cartilage neoplasm of medullary bone

- synonyms = central chondroma

Front 788

Enchondroma - Epi % of benign?

- age? seen in? failure of?

- can be present in?

% malignant?

Back 788

- Solitary

= 10-25% of benign bone tumours

= all age groups, predominate in 2nd-4th decades

- Enchondromatosis

= Ollier's disease and Maffucci's syndrome = developmental disorder caused by failure of enchondral ossification

= present in first two decades if life

= malignant transformation in 25%

Front 789

Enchondroma

- sites of involvement? small? long?

- see tenderness over? no? normal?

- gross - size? appears? frequently?

Back 789

- Sites of Involvement:

= small bones of hands, feer = 50%

= long tubular bones (proximal humerus, femur)

= enchondromatosis = any part of skeleton

- see tenderness over proximal humerus, normal ROM, no soft tissue mass

Gross:

= small, often <3cm, white-grey, translucent, gritty

= frequently multi-nodular

Front 790

Enchondroma - Microscopic - closely rsembles?

- lacks? dont see?

- on xray, see? erosion of? no?

Back 790

- hypocellular tumiur closely resembling normal hyaline cartilage

- lacks invasion of surrounding tissues

- dont see multiple nuclei

- radiographic = lesions similar in hand and shoulder, erosion of cortex, punctate calcification (suggests cartilage), no soft tissue mass or periosteal reaction

Front 791

Enchondroma - Pathogenesis - poorly?

- gene affected?

- abnorms?

Back 791

- poorly understood

- diploid or near-diploid with simple structural abnormalities, particularly involving chromosomes 6 and 12

- HMGA2 gene frequently rearranged

- A mutant PTHR1 has been ident in subset if patients with enchondromatosis

Front 792

Chondrosarcoma - defined as?

- synonyms?

Back 792

- definiton= malignant neoplasm composed of hyaline cartilage

- synonyms = NA

Front 793

Chondrosarcoma - Epidemiology

- accounts for?

- age? gender?

Back 793

- accounts for 20% of malignant bone tumours

- adults and elderly

0 M > F (slight)

Front 794

Chondrosarcoma - Sites of Involvement, Gross

- sites mainly? (2)

- gross appears as? size? is?

Back 794

- Sites:

= pelvis (partic. iliac)

= long tubular bones (proximal femur and humerus(, ribs

- Gross:

= large, blue-grey, translucent, gritty, soupy

= destructive

Front 795

Chondrosarcoma - Microscopic - invades?

- see?

Back 795

- hypercellular tumour that invades bone trabeculae and surrounding tissue

- pleomoprhism, mitotic activity

Front 796

Chondrosarcoma - Genetics - poorly?

- most have?

Back 796

- poorly understood

- complex and hetero structural abnorms, particularly involving many

- most have isocitrate dehydrogenase mutations

Front 797

Management of Enchondroma - are? typically do not?

- assoc with? espec in?

- treat with?

- if repeated fractures? then?

Back 797

- benign and non-progressive, do not typically require treatment

- can be assoc. with pathologic fracture, esp. in hands and feet

- treat with cast and fracture will heal

- with repeated fractures, scrape tumour out of bone (curettage) and fill with bone graft, cement or synthetic bone substitute

Front 798

Management of Chondrosarcoma - image? to?

- often not?

- standard is?

- resection is?

- then? via?

Back 798

- staging= CT of chest and bone scan

- not responsive to chemotherapy or radiation therapy

- surgical management is standard

- wide resection - removal of tumour with a margin of normal tissue around it

- reconstruction of defect - prosthesis or bone graft

Front 799

Ewing Family Tumours

- defined as? origin? one of?

- % of bone tuours?

- age? gender? more in?

Back 799

- definition = primitive small cell neoplasm, with neuroectodermal differentiation, one of small round blue cell tumours

- synonyms = Ewing Sarcoma, Askin tumour, Primitive Neuroectodermal tumour

- epi = 6-8% of primary malignant bone tumours, second most common sarcoma of bone and soft tissue in children, majority < 20 years, M>F, more common in Caucasians

Front 800

Ewing Family Tumours - Sites of Involvement - Osseous

- main site is? of?

- common at?

- rarely in? (5)

Back 800

= mainly diaphysis or metaphyseal-diaphyseal portion of long bones

= pelvis and ribs = common locations

= rarely skull, vertebra, scapula, hands and feet

-

Front 801

Ewing Family Tumours - Extra- Osseous - ST/M/V

Back 801

- soft tissue

- mucosa

- viscera

Front 802

Ewing Family Tumours - Gross -texture? colour? often are?

Back 802

- soft and/or friable

- tan-grey

- necrotic and/or hemorrhagic

Front 803

Ewing Family Tumours - Microscopic - cell is? arranged in? cytoplasm?

Back 803

- small round cell tumour

- cells arranged in sheets, occasionally rosettes

- cytoplasm contains abundant glycogen

Front 804

Ewing Family Tumours - Immunohistochemical Stains - stain for?

Back 804

- + CD00, FLI-1

- (+/-) Neuron Specific Enolase, Synaptophysin

Front 805

Ewing Family Tumours - Pathogenesis

- origin is? may be?

- translocaton of?

- common to do?

Back 805

- cell of origin remains unknown, may be mesenchymal stem cell

- characteristic translocation partners EWS with an ETS transcription factor family (FLI-1, ERG)

- karyotype showing the most common rearrangement

- arrowheads indicate breakpoint

Front 806

Management of Ewing Sarcoma

- first do? to? apsirate?

- responsive to?

- surgery to?

- sometimes need?

Back 806

- staging = CT of chest, bone, bone marrow aspirate

- very responsive to chemo = referral to medical oncologist

- surgical removal of tumour and reconstruction using prosthesis or bone graft

- sometimes needs radiation if response to chemotherapy is poor or if margins are close

Front 807

Giant Cell Tumour of Bone

- defined as? but is locally? componsed of?

- also known as?

- 20% of all?

- age? gender?

Back 807

- definition = benign, locally aggressive neoplasm composed of sheets of neoplastic mononuclear cells interspersed with reactive osteoclast-type giant cells

- synonyms = Osteoclastoma

- epi = 20% of all benign bone tumous, peak between 20-45 years (rarely in immature skeleton)

- F > M

Front 808

Giant Cell Tumour of Bone - Sites of Involvement

- often at the? of? espec is? (4)

- occassionly seen in?

- xray will shown? cortex is? margin?

- is? so see?

Back 808

- metaphysis of long bones = esp. distal femur, proximal tibia, distal radius, proximal humerus

- occasionally flat bones and spine

-radiographic = location at end of done, cortex eroded, geographic margin (easy to tell where stops/starts), has neocortex with thin new bone around lesion

- is hemorrhagic, see large cavities

Front 809

Giant Cell Tumour of Bone - Gross - texture? colour? may have?

Back 809

- friable, hemorrhagic, red-brown

- may have cortical destruction and extension into soft tissue

Front 810

Giant Cell Tumour of Bone- Microscopic

- sheets of? nuclei? cells?

Back 810

- sheets of polygonal mononuclear cells

- osteoclast-type giant cells = 50-100 nuclei

- multinulceat giant cells

Front 811

Giant Cell Tumour of Bone - Pathogenesis

- poorly? may be from?

- cells express? which increases?

Back 811

- poorly understood

- cells of origin unknown, possibly derived from osteoblasts

- mononuclear tumour cells express RANKL, which stimulate formation and maturation of osteoclasts from monocyte precursors

- cytogenetically contain telomeric associations representing end-to-end fusions of chromosomes

Front 812

Giant Cell Tumour of Bone - Management

- mainly? includes? and then?

- high?

- may want to?

Back 812

- surgical resection - scraping tumour out of bone and filling defect with bone graft or bone cement

- may require use of adjuvant such as liquid nitrogen or phenol as the recurrence rate of the tumour is very high (approx 15%)

- if bone is expendable, it can be resected (proximal fibula, distal ulna)

Front 813

Osteosarcoma

- defined as? cells make?

- many different?

Back 813

- definition = conventional osteosarcoma is an intermed. high grade malignant tumour in which neoplastic cells produce osteoid

- other variants = telangiectatic, small cell, low grade central, parosteal, periodteal, high grade surface

Front 814

Epi of Osteosarcoma - is the most common?

- is? age?

- gender?

- predisposing = (3)

Back 814

- most common non-haem malingant tumour of bone

- bimodal; 60% < 25 years of age

- M > F = 3:2

- predisposing conditions = Paget disease, prior radiation, genetics

Front 815

Osteosarcoma Sites of Involvement

- long bones of? (3) site?

- on xray, is? see extensive? immature?

- cortex is?

- MRIs show?

Back 815

- long bones of distal femur, proximal tibia, proximal humerus

- metaphysis

- radiographic = poorly defined, dense bone formation, extensive soft tissue mass, periosteal reacton with immature new bone formation (sunburn appearance), cortex is intact

- MRI shows tumour inside and outside bone

Front 816

Osteosarcoma - Gross - size? texture? colour? appears?

- produces a? as it?

- on xray is poorly? no?

Back 816

- large, fleshy or hard

- gray-white, necrotic

- granular or densely sclerotic (depending on amount of mineralization)

- frequently transgresses cortex, producing a soft tissue mass

- radiographic = lytic lesion, poorly defined, erosion of cortex, no signfic soft tissue mass, no periosteal reaction

Front 817

Osteosarcoma - Microscopic

- sheets of? that? osteoid is?

- osteoblastics vs condroblastic vs fibroblastic

Back 817

- sheets of pleomorphic cells producing osteoid

- osteoid is dense, pink, extracellular material

- conventional OS has several subtypes based on extracellular matrix

= osteoblastic = 50% = osteoid matrix

= chondroblastic = 25% = osteoid and chondroid matrix

= fibroblastic = 25% = spindle cells with minimal matrix

Front 818

Osteosarcoma - Pathogenesis - poorly?

see genetic?

- RB is resp for? if hered, see increase in?

- p53 causes?

Back 818

- poorly understood

- aneuploidy and complex chromosomal aberrations

- genetic susceptibility:

1) RB = 30-40% of sporadic cases, hered RB causes 1000x risk of osteosarcoma

2) P53 - 35% of cases, increased in Li-Fraumeni syndrome

Front 819

Management of Osteosarcoma

- historically?

Back 819

- historically extremity was amputated

- 95% of patients had amputation

- 90% of patients died from mets

Front 820

Current Management of Osteosarcoma

- staging bia?

- referred to?-

- resections of? with?

** no role for?

- currently?

Back 820

-

Front 821

Mets- Definition and Epi

- defined as? is the third?

- age?

- often deposits from?

Back 821

- Defs = neoplasm, usually malignant, originating at another site to involve bone

- Epi = third most common site (after lung, liver)

= majority 40-60 years

= breast, lung, prostate, kidney and thyroid represent over 90% of deposits

Front 822

Mets - Gross and Microscopic

- appears as? feels?

- tumours attempt to appear like?

Back 822

Gross:

= occassionaly sclerotic

= friable, tan-haemorrhagic

Microscopic:

= tumours attempt to recapitulate primary

= may not be able to identify by morphology or immunohistochemistry

Front 823

Mets - Pathogenesis - usually result of? rarely via?

Back 823

- usually result of haeomatologic spread

- rarely via direct tumour extension

Front 824

Investigation of Met Carcinoma

- search for? likeky sites? (5)

- do CT of?

- manage?

-treat?

Back 824

- search for primary - lung, kidney, breast, thyroid and prostate most likely sites

- CT scan of chest/abdo, mammogram, thyroid US, prostate exam

- management of metabolic abnorms esp. hyperclacemia

- treatment of primary with chemotherapy

Front 825

Investigation of Met arcinoma

- first treatment?

- surgery for?

- treatment almsot always?

Back 825

- radiotherapy usually first treatment for bone mets

- surgery for mechanically compromised bone to prevent fracture - scrape tumour out of bone, fill with cement, plate, nail or prosthesis

- treatment is almost always palliative

Front 826

Summary of Investigations for Patient with Bone Tumours

- if malignant features on clinical exam - do? (4)

Back 826

- if there are malignant features on clinical exam and xray:

= MRI, bone scan, CT chest, biopsy - can be done by radiologist (needle biopsy) or ortho onco (surgical biopsy)

Front 827

ACL Anatomy

- maintains?

- runs from?

- blood supply?

- AM tight in? PM tight in?

- also has?

Back 827

- anatomy and function still debated, maintains stability of the kee

- runs from femur to tibia

- patellar fat pad provides blood supply from front

- anteromedial (AM) and posterolateral (PL)

- bundles:

= AM = tight in flexion, an anterior restraint

= PL = tight in extension, rotatory restraint

- blood: middle geniculate artery and trough patella fat pad

- has mechanoreceptor fibres = proprio

Front 828

ACL Injuries

- more in? due to? resulting from?

- when have injury, see? hear?

- associated? acute vs medial?

Back 828

- more in females = smaller notch and ligaments, more laxity, different landing biomechanics (greater total valgus knee loading)

-result from noncontact pivoting injuries

- audile pop and immediate hemarthrosis

- assoc. meniscal injuries

- more lateral meniscus tear with acute ACL tear

- more medial meniscal tear with chronic ACL tear

- usually not an isolated injury

Front 829

ACL: Exam

- Lachman test is? Anterior Drawer? Pivot shift?

Back 829

- Lachman = pull tibia forward at 30 degress flexion

- Anterior Drawer = pull tibia forward at 90 degree flexion

- Pivot Shift = thigh internal rotation + knee valgus, bring knee from extension to flexion (sudden anterior tibial thrust)

Front 830

ACL: Imaging - XR generally?

- do a? to confirm need a?

- Segon sign is?

Back 830

- XR will generally be normal, may see Segon sign

- lack of ACL on Sagittal T2 confirms injury

- Lateral capsule (Segond) sign: small lateral tibial avlsion

- MRI : to confirm diagnosis - Sagittal T2

- can scope as remnant stays with tibia

*lateral bone bruise (trab microfracture) in >50% in acute injury

Front 831

Treatment Options for ACL

- (3)

Back 831

1) physiotherapy

2) Custom ACL brace

3) Reconstruction

Front 832

ACL Treatment

Back 832

- Factors = activity level, instablity, assoc. injuries and medical condition

- Initial treatment = physiotherapy and mobilization (avoid immob.)

- Isolated ACL tear and competitive sport = reconstruction

* dont treat based on age

Front 833

ACL Treatment - reconstruct if? may be non-op if?

- in elderly or arthritis?

Back 833

- Isolated ACL and strenuous activity = reconstruction

- Isolated ACL and recreational and light activity = recon or non-operative

- ACL tear in elderly or arthritis = non-operative

Front 834

ACL Reconstruction

- not recommended to do?

- instead do a? often from?

Back 834

- primary repair not recommended = myofibroblasts "coat" at stump end

- graft selection:

1) Bone Tendon Bone = faster healing, earlier return to sport, higher rate of anterior knee pain and arthritis

2) Hamstring Tendon Autograft

3) Single bundle ACL vs double bundle ACL - no signif clinical difference

* use hamstring for most cases

- others = quadriceps tendon, allograft

Front 835

Reconstruction Options

- options?

- no?

Back 835

- Bone tendon bone

- single vs double bundle

*no clinically significant difference between single and double bundle repair

Front 836

ACL Surgical Complications

- suboptimal? causes limited?

- stiff knee known as? seen in?

- BTB = leads to?

Back 836

1) Suboptimal tunnel placement = too anterior femoral tunnel causes limited flexion, vertical graft causes rotational instability

2) Arthrofibrosis (stiff knee) = occurs in acute reconstruction

3) BTB: anterior knee pain, kneeing discomfoty, extension loss, poor Q-ceps recovery

Front 837

ACL Surgical Complications

- higher rates of?

- use allograft if?

- main two also?

Back 837

4) Hamstring = knee flexion and internal rotation weakness, saphenous nerve injury

5) Allograft = higher re-tear in active patients, higher infection (clostridium, HIV), generally used for revision surgery

6) Infection

7) DVT

Front 838

ACL Post-Op Protocol

- early? (2)

- want some?

- for 6 weeks avoid?

- generally dont need?

Back 838

- early motion (extension) and early weight bearing

- closed-chain and compressive loading (co-contraction of muscles)

- open-chain extension should be avoided for 6 weeks

- generally dont need a brace post-op

Front 839

ACL Post-Op Protocol

- no diff. between?

- post op brace proved?

- want early?

Back 839

- no diff. between accelerated vs non-accelerated rehab

- post op brace proved to be beneficial only in downhill skier

- early progressive eccentric exercise improve quadriceps and gluteal bulk and function

Front 840

Meniscus: Anatomy - shape? medial vs lateral?

- only 30% is? to?

- stability via?

- not completely?

Back 840

- crescent-shaped, triangular in cross section

- medial = C shape, lateral = O shape

- fibrocartilage, type I collagen

- only 30% of peripheral are vascularized = genicular arteries

- stability = deepen tibial plateau

- not completely fixed, only part of periphery has blood supply

Front 841

Meniscus Role - acts as? role in?

- can move?

- lateral is more?

- problematic if?

Back 841

- shock absorber, role in joint nutrition

- move anteriorly with extension and posteriorly with flexion

- lateral meniscus more mobile (x2) than medial meniscus

- longitudinal tears very problematic

Front 842

Meniscus tear Classification based on? (4)

Back 842

- blood supply

- position

- appearance

- orientation

Front 843

Meniscal Tear

- MM tear is more?

- lateral more with?

- high rate of OA with?

Back 843

= MM tear = more common = 3x

= LM tear = more common with ACL tear

= high rate of OA after both meniscal tear and meniscectomy

Front 844

Types of Meniscal Tears

- traumatic - to? often are?

- degen - with? onset?

- periph - has highest?

Back 844

1) Traumatic tears = young patient, sport related - get surggical repair

2) Degen. tear = older patient with insidious onset - do not do surgical repair

3) Peripheral third tear = highest potential for healing

Front 845

Meniscal Tear Exam

- Apley?

- McMurray?

- tests?

- can image using? see?

Back 845

- Apley = prone-flexion compression

- McMurray = IR and ER of tibia from deep flexion to extension - best test

- tests = squat test, McMurray test (ER and IR of knee)

* can see tear on MRI - see white ligaments indicating tear or inflammation

Front 846

Treatment of Meniscus Tear = Conservative

- no? such as?

- tear is?

- partial?

Back 846

- no mechanical symptoms = swelling, catching, locking, giving way

- tear is degenerative type

- partial-thickness teat = <5-10mm in length, <1-2 mm displacement

Front 847

Treatment of Meniscus Tear = Operative - seen in? symptoms of? cant?

Back 847

- younger patient with acute tear

- mechanical symptoms

- failure of conservative managment

Front 848

Partial Meniscectomy

- most tears not?

- higher risk of? with?

Back 848

- most tears not amenable to repair: complex, central, radial, degenerative, unstable flip

- arthroscopic minimal resection to stable rim

- higher risk of arthritis with a more severe meniscal injury

Front 849

Meniscal Repair - done in? such as?

- able to?

Back 849

- in peripheral tears = especially in young and in conjunction with ACL tear

- can repair if tear is peripheral

Front 850

Meniscal Repair Results

- depends on? in acute perihperal? if ACL intact? ACL defic knee?

Back 850

- depends on location, type of tear, chronicity

- 90% success in acute peripheral tear in young with concurrent ACL recon.

- 60% success rate when ACL is intact

- 30% success rate in ACL defic. knee

Front 851

Meniscal Cyst

- seen with?

- treated with? (2)

Back 851

- with lateral meniscal horizontal cleavage tear

- Rx = partial meniscectomy and decompression through it

- Popliteal(Baker) cyst = related to meniscal pathology

Front 852

Discoid Menisci - can be?

- may develop? hear?

- can be?

Back 852

- can be complete or partial

- may develop mech symptoms or popping with extension

- can be a congenital deformity

Front 853

Discoid Menisci - Xray see? widening?

- treat with? if no tear?

Back 853

- Xray = squaring of lateral femoral condyle, cupping of lateral tibial plateau, widening of joint space

- Rx = partial menisectomy for tear, simple observation if no tear

Front 854

Rotator Cuff Tear/Impingement Pathology

- acts as a? from? to?

- in athletes, often to?

Back 854

- a continuum = mild impairment, partial tear, full tear, massive and irreparable tear to cuff tear arthropathy

- tear in chronic management impingment: bursal surface or within tendon substance

- tear in young athlete = articular surface

- deltoid not able to perform its functions without these muscles

*likelihood of full tear increases with age

Front 855

Rotator Cuff tear - History

- pain? ask about? partial tear can be?

- onset?

Back 855

- pain = activity related vs rest/night pain

- weakness

- partial tear can be asymptomatic and age related

- gradual onset, or sudden pain after a traumatic event

- acute on chronic tear

- diff. from neck referring pain

Front 856

Sizes of Rotator Cuff Tears

- small? medium? large? massive?

Back 856

- small < 1cm

- medium = 1-3 cm

- large = 3-5 cm

- massive > 5cm (>one tendon)

Front 857

Rotator Cuff Tests

- impngement?

- SS - able to? test?

- IS amd TM - do?

- ER - asssess?

- Xxray see? US? mri?

Back 857

- impingement tests = Hawkins, Neer

- SS = empty can test, drop arm test

- IS and TM = external rotation tests

- subscapularis = liftoff test, belly press test

- external rotation test assesses infraspinatus and teres minor

- Xray = usually no findings, appears normal

- US - normal

- MRI - white tendon indicates tear or inflammation

Front 858

Muscles to consider in Rotator Cuff tear - four muscles (4)

- tear - can see? do ?

Back 858

- SS = supraspinatus

- IS = infraspinatus

- SP = subscapularis

- TM = teres minor

- Tear Arthroplasty - see with proximal humral head migration = indicates loss of SS and IS with proximal humeral head

Front 859

Rotator Cuff Tear Treatment

- conservative managemen tfor? (5)

- Arthroplasty fr?

Back 859

- conservative management for:

= impingement syndrome or partial tear

= small full thickness tear

= chronic cuff tear

= noncompliant patient

= medical contraindications

= RC arthropathy = massive irreparable tear with joint arthritic chnages

Front 860

Conservative Management for RCT

- modify? best exercise?

- PT via?

- meds?

- try conservative for?

Back 860

- activity modification, best exercise is external rotation

- physiotherapy = RC strengthening, scapular stabilization exercises

- NSAIDs, modalities, steroid or PRP injection

- want to try conservative for 4-6 months

Front 861

Surgery for RCT

- done if?

- Rx is?

Back 861

- in chronic impingement non-response to 6 months of conservative manageent

- Rx = Arthroscopic subacromial decompression = bursectomy and acromioplasty

Front 862

RC Repair - done for? (2)

- can be? (3)

- healing time?

Back 862

- done for non-responders and large tears

- can be open, mini-open and all arthroscopic

- biologic healing time = minimum 8-12 weeks

Front 863

RC Repair - Acute full thickness tear for?

Back 863

- for acute thickness tear = early repair (rapid progress)

- partial tear = debridement vs repair

Front 864

Large and Massive Cuff tear

- higher? tissue?

- infiltration of?

- treatment? (3)

Back 864

= higher failure rate = tissue fails

= fatty atrophy and fatty infiltration

= treatment = graft augmentation, tendon transfer, arthroplasty

Front 865

Signif if Hip Fractures

- incidence? ris doubles?

- large?

Back 865

- 2.5x incidence in women, see incidence increasing in future

- risk doubles/ 10 years > 50

- 20% require LTC admission

- 50% independent ambulation

- 25% mortality within 1 year

- big burden

Front 866

Anatomy of Hip - Intracapsular Zone

- is insie? have a?

- therefore is a? risk of? damage to?

Back 866

- is inside hip capsule, have ring of vessels that come off of femoral artery, travel upwards

- femoral neck base = head

- vulnerable blood supply

- femoral head AVN risk is proportional to displacement of head fragment

- fracture sees damage to periosteum, compromising blood supply to femoral head

- dispalcement surrogate for AVN risk

Front 867

Anatomy of Hip - Extracapsular Zone

- includes? no risk of? as?

Back 867

- intertrochanteric and subtrochanteric zones

- no risk of AVN

- multiple blood source

Front 868

Normal Pelvis Xray

- three? large vs small?

- most common spot of fracture? look for?

- Shenton's line is? want to see?

Back 868

- three bony rings:

= large = levic brim

= small = obturator rings

-pelvic fracture needs to be on Ddx, most common place for these is in rami, want to make sure intact

- Shenton's line = line along the inner margin of the femoral neck and extending the superior margin of the obturator foramin, want to see smooth continuous arc

- Neck Shaft Angle = 130

- with reduced neck shaft angle, see apex more aaway from midline

Front 869

Types of Hip Fracture

- intracasp disrupts? closer to? increasing?

- or can be? (2)

Back 869

- Intracapsular fractures - see disrupted Shenton's line (not smooth, cont), see closer to 90 degrees = increased varus

- Intertrochanteric fractures

- Subtrochanteric fractures

Front 870

Hip Fracture RFs - big 4? often with?

Back 870

- age, osteoporosis, female, falls

*often seen with polypharmacy and comorbidities

Front 871

Hip Fracture Presentation - leg is? (4)

- do a?

- shortens due to?

Back 871

- shortened

- externally rotated

- unable to weight bear

- guarding/ minimal ROM

- MSK fragility screen

- in intracapsular = abductors and ERs will pull leg out, iliopsoas accounts for shortening

Front 872

Treatment Plan- Surgery

- unacceptable to?

- always do for?

- risks like? (3)

Back 872

- closed reduction and immobilization unacceptable

- do if hip and femoral shaft fractures, polytrauma - unacceptable

- unacceptable if mortality near 100%

- see risks like DVT/PE, pressure ulcers and pneumonia

- consider pain, nursing care

Front 873

Preop Phase - consider? (4)

- proph of? (2), give?

- time to OR is?

Back 873

- admit to hospital, preop investigations, anesth and med optimize comorbs and stratify risk

- DVT proph, Abx proph preop, analgesics, operative plan, consent

- time to OR < 48 hour

Front 874

Operative Plan - if Extracapsular Zone - no? perform? with?

Back 874

- intertroch/ subtroch

- no risk of AVN

*perform open reduction internal fixation

Front 875

Operative Plan - INTRACAPSULAR Zone - seen in? risk of?

- choice between? (2)

Back 875

- seen in femoral neck fracture

- risk of AVN

- choice of:

1) open reduction internal fixation

2) hemiarthroplasty prosthetic replacement

*risk of AVN related to displacement at fracture site

Front 876

AVN Risk - if undisplaced? includes?

- garden 1 - see? garden 2 - is?

- if displaced? includes?

- G3 has increase?

- G4 is a?

Back 876

1) Undisplaced = low risk of AVN = 10-30%

= Garden 1 (increased valgus, increased angle)

= Garden 2 = still 130 degrees, undisplaced

2) Displaced = high risk of AVN = 50%+

= Garden 3 = increased varus

= Garden 4 = complete, angle close to 90%

Front 877

Operative Plan - Intracapsular - Non-definitive = Open Reduction Internal Fixation (ORIF)

- risk of? (2)

- may require?

- long term? spare?

- great?

Back 877

- risk of AVN, non union

- may require revision surgery

- long term definitive

- femoral head spared

- revision surgery unlikely

- great definitive outlook with ORID if short term risks avoided

Front 878

Operative Plan - Intracapsular - Definitive - Hemiarthroplasty Prostethic Replacement

- no risk of? unlikely to need?

- long term? as?

Back 878

- no risk of AVN, nonunion

- revision surgery unlikely

- long term nondefinitive

- prosthesis life span 8-10 years

- revision surgery depends

Front 879

Operative Plan - Old, low AVN risk - do? as unlikely to?

Back 879

- do hemiarthroplasty, unlikely to wear out joint

Front 880

Operative Plan - Young, displaced - opt for? likely to? chance of getting?

- want to aovid?

Back 880

- opt for ORIF, reason is because they are likely to burn through the prosthesis, also chnace they may not get AVN, better outcomes if ORIF is replaced with THR layer

- avoid years of wear on prosthesis if ORIF is done

Front 881

Operative Plan

Back 881

Front 882

Operative Plan - high AVN risk, displaced and old - can do?

Back 882

- ORIF or total hip

Front 883

Complications of Hip Fracture Surgery - Early

Back 883

Local = infection, neurovascular

Systemic = mortality, transfusion, cardiac, medical, DVT/PE, pneumonia, pressure sores

*early = same risks for ORIF and hemiathroplasty

Front 884

Complications of Hip Fracture Surgery - Late

- local? systemic?

- in ORIF?

- in HA?

Back 884

Local = revision surgery, AVN/ nonunion, osteoarthritis, prosthesis failure

Systemic = N/A

ORIF - late = AVN, nonunion, OA, need for revision surgery

- HA - late = prosthetic failure, need for revision surgery

Front 885

Post Operative Hip Fracture Surgery

- goal is for?

- critical factor?

- MDs invovled?

Back 885

- goal = immediate mobilization and weight bearing, time to get into OR critical factor in mortality

- MD care = nursing, diet, hospitalist, neuropsych, endocrine, PT, occ. therapy, social work, discharge planner, CCAC

Front 886

Post Operative QBP Bench Marks

- inpatient for?

- inpatient rehab for?

-

Back 886

- mean acute inpatient LOS of 7 days

- 90% of all hip fracture patients discharged from acute care within 7 days of admission

- mean inpatient rehab LOS of 28 days

- 90% of all hip fracture patients discharged from inpatient rehab within 28 days of admission

- dont need to know

Front 887

Post Operative QBP

- 25%?

Back 887

- 25% mortality within 1 year

- 12.5% mortality in ON

- 2.5x incidence in women

- risk doubles/ 10 years women > 50

- 20% require LTC admission

- 50% indep. ambulation

Front 888

Trauma Overview

- deaths worldwide?

- more affects?

- gender?

- from 10-24, accounts for?

Back 888

- worldwide, >5 million deaths/year

- 14,000 injuries/day, every six seconds

- low and middle income countries affected even more

- males > females

- trauma is a disease of the young, leading cause of death in Western world between ages 1 and 44

- >50% death in males 10-24

- fourth leading cause of death in all age groups, 2/3 unintentional

Front 889

Trauma Oeverview

- is a major?

- third most commn?

- many are?

- important factor?

Back 889

- major cause of morbidity, with third most common cause of years lived with disability, large $ burden

- many are preventable, alcohol and drugs are major players

- speed is an important factor

Front 890

Mechanisms of Trauma - Blunt vs Penetrating

- blunt seen in?

- penetrating with?

Back 890

- Blunt = MVCs, pedestrians hit, falls, assaults

- Penetrating = firearms, knives, variety of sharp objects

Front 891

Mechanisms of Trauma - also can consider? especially for?

Back 891

- high vs low energy

- seen especially for firearms

Front 892

Injury Severity - AIS - is an? based on?

- each region gets? 1 = ? 6 =?

Back 892

= Abbreviated Injury Score = AIS = an anatomic scoring system that divided body into six regions

= each region gets a score from 1-6, with:

=1= mild injury

= 6 = nonsurvivable injury

Front 893

Injury Severity Score = SS - is the sum of?

Back 893

= the sum of the squares of the 3 (of the 6) body regions with the highest AIS

Front 894

AIS

Back 894

Front 895

Injury Severity Score -

Back 895

Front 896

Injury Severity - ISS correlates with?

- minor trauma defined as? major? severe?

Back 896

- ISS correlates with length of hospital stay, morbidity and mortality

- minor injury defined as ISS < 9

- major trauma defined as ISS > 15

- severe trauma defined as ISS > 25

Front 897

Deaths from Trauma - Time Distribution

- if seconds to minutes - must?

- golden hour is? need?

- if days, consider?

Back 897

1) Seconds to Minutes = prevention key = trauma

2) Golden hour = minutes to hours = appropriate and timely care is key

3) Days - Weeks = sepsis, MOSF

Front 898

Early Deaths - often due to massive? from?

- or injury of? affecting? (3)

Back 898

1) Massive Hemorrhage = large vessel injury

2) Catastrophic Neurologic Injury = high spinal cord, brainstem, brain

Front 899

Advanced Trauma Life Support (ATLS)

- organized? focus on? and determine?

- TEAM = ? for?

Back 899

- organized approach to trauma pt, focus on initial assessment and management and determination of need for transfer for definitive treatment

- PHTLS = Pre-hospital

- ATCH = Advanced Trauma Care for Nurses

- TEAM = Trauma Eval and mangement = for med students

Front 900

Approach to Any** Acutely Ill Patient

- need rapid? consider? (5)

Back 900

- rapid, simultaneous assessment and management of life-threatening conditions

= A = airway

= B = breathing

= C = circulation

= D = disability

= E = exposure

Front 901

ABCDE - airway is it? protect from?

- breathing consider?

- circulation consider? (3)

- disability - look at? such as?

- E - means? prevent?

Back 901

A = airway = patency? protection for aspiration

B = breathing = oxygenation, ventilation (CO2)

C = circulation = shock - BP, HR, C.O.

D = disability = neurologic assessment = GCS/pupils

= E = exposure - undress but prevent hypothermia

Front 902

History of Trauma - AMPLE - ?

Back 902

- A = allergies

- M = meds

- P = PMH

- L = last meal

- E = events leading to trauma

Front 903

Approach to Trauma Patient - ATLS - Primary Survey

- airway also includes? B? C? and? D? E?

- deal with each? do not need a?

Back 903

= A = airway (and C spine protection)

= B = breathing

= C = circulation (and hemorrhage control)

= D = disability

= E = exposure (and enviro control)

* deal with each category before moving on to the next

* do not nec. nee a defintiive diagnosis before going to the OR

Front 904

Approach to Trauma Patient - ATLS - Secondary Survery

- goal of 2 survey is to detect? perform? start?

- do not go to until? discuss?

Back 904

- goal of 2 survey is to:

= detect non-life threatening injuies

= head to toe assessment

= radiologic investigations = XRays, CTs

*do not go to 2 survey untilfinished 1 survey

* discuss definitive care = OR, ICU, specialized centre, etc

Front 905

ATLS Full Approach

Back 905

Front 906

Field Traige - Where to Take patient

Back 906

Front 907

Field Traige - Where to Take patient

Back 907

Front 908

Trauma Management in Toronto - Team - usually has a? with?

- also need?

- non MDs?

Back 908

- Team = MDs

=Trauma Team Leader (surgery, emerg, Anesthesia, occasionally ortho),

= Anesthesia, gen surg and orthopedic residents,others as needed

= non - MDs = RNs, RTs, Xray techs, USWs, etc

Front 909

Summary of Trauma

- can become?

- need a?

- not always crucial to?

- key to get?

Back 909

Front 910

Best Way to Elicit ABCs? - ask patient?

- if give approp response? from?

- failure to respond/

Back 910

- ask patient for their name and what happened

- appropriate response suggests no major airway complications (able to speak clearly), breathing not severely compromised (ability to generate air movement to permit speech) and there is no major decrease in consciousness (alert enough to describe)

**failure to respond suggests A,B, or C abnormality

Front 911

Airway Maintenance - have to protect? make sure dont?

Back 911

**protect and immobilize neck and spinal cord

* make sure dont rotate head when assessing airway

Front 912

Breathing Assessment

- expose? assess?

- listen for?

- inspection of? identify?

Back 912

Front 913

Circulation Assessment

- predom cause? eliminate?

- consider?

- look at? (3)

Back 913

Front 914

Disability and Neuro Assessment

- rapid? includes? (50

- perform the?

Back 914

Front 915

Enviro Control and Exposure

- patent should be? remove? make sure doesnt?

Back 915

Front 916

Priorities in Trauma Patient - 1 and 2 Survey

- 1 = assess and manage?

- 2 - perform a? search for?

Back 916

1 = assessment and management of life-threatening injuries, prioritize

2 = head to toe examination, search for non life-threatening injuries

Front 917

A and B in 1 Survey

- top priority are? as patient must have?

- no point in having normal?

Back 917

- A and B = top priority, as patient must have patent airway and adequate ventilation

- no point in having a normal BP if not getting any oxygen in

Front 918

Airway Management Questions

- is the airway? if not?

- in trauma, first goal is to?

Back 918

- is the airway patent? - if no, must establish patency

- in trauma patient, first goal*** of A is to ensure C-spine maintained in neutral position

Front 919

Normal Airway - look at? (4)

Back 919

= mouth/nose

= orophharynx/ nasopharynx

= larynx/glottis = vocal cords

= trachea

Front 920

Normal Patient Airway - see intact?

- normal?

- tissues arent?

- in airway, no? (4)

Back 920

- intact anatomy = bones and cartilage

- normal airway muscle tone

- no swelling of tissues

- no foreign bodies, blood, vomit, teeth in airway

Front 921

3 possibilities of airway patency?

Back 921

1 = unobstructed

2 - partial

3 = complete

Front 922

Recnognizing Airway Obstruction

- if talking? if noisy breathing? no breathing? could be due to?

Back 922

1 = Talking = normal, patent for now

2 = noisy breathing = snoring/gurglng = partial

3 = no breathing = not breathing due to drugs, secondary injury or complete obsutction

Front 923

Airway Obstruction - Hoarseness

- means that? likely a?

- these injuries often? have to be aware that?

Back 923

- means vocal cords affected, likely laryngeal injury or burn

- these injuries can worsen rapdily so beware, airway may be patent now but mat be completely obstructed a short time later due to swelling and//or bleeding

Front 924

Recognizing Airway Obstruction

- look for? (5)

- listen for? (2)

- feel for? (3)

Back 924

1) Look - respiratory effort, chest rising, indrawing (trachea, intercostals), paradoxical breathing (chest/abdo) for FBs, vomit, secretions in mouth

2) Listen - noisy breathing, voice (hoarseness)

3) Feel - air via mouth/nose, face, neck (for trachea, subcut emphysema)

Front 925

Establishing Airway Patency

- remove? via?

- perform the? which then?

- Oro airway? LMA?

Back 925

1) Suction = remove debris = blood/vomit/secretions

2) Jaw Thrust/Chin Lift = pulls mandible and tongue forward

3) Oroph/Nasoph Airway = pushes and keeps tongue forward

4) Layngeal mask airway

Front 926

Laryngeal Mask Airway - do if?

- often provides?

- does not however? not a?

- yet can be used as?

Back 926

- do if other maneuvers dont work

- often provide patnet airway when other maneuvers fail

- does not protect from aspiration = not a definitive airway

- lifesaving piece of equipment

Front 927

Once Youve Established Airway Patency

- 1st goal to? must also ensure?

- need to be?

- definitive means?

Back 927

- 1st goal is to establish patency, but: not enough just to establish

- must also ensure airway is protected from aspiration

- needs a definitive airway for this

** definitive airway = tube with a cuff in trachea = with cuff inflated

Front 928

ETT - means? goes through?

Back 928

= endotracheal tube, goes through mouth and oropharynx into trachea

Front 929

Definitive Airway provides? (3) **

Back 929

= patent airway

= protection from aspiration = vomit, blood

= able to deliver gas by pressure to the lungs

Front 930

Choosing a Definitive Airway - can be inserted?

- from above? = ?

- from below? through? = (2) C/T

Back 930

1) From above vocal cords = mouth/nose = endotracheal intubation (oral/nasal)

2) Below vocal cords = go through neck:

= cricothroidotomy = via crico membrane

= tracheostomy = via trachea

Front 931

Indications for Definitive Airway

- P/P/O/V/P

- almost always give?

Back 931

1) Patency

2) Protection from aspiration

3) Oxygenation (improves p02/o2)

4) Ventilation (improve pCO2)

5) Pulmonary (suctioning of secretions, rarely sole indication)

*almost always an oral ETT

Front 932

Indications for Definitive Airway - often oral ETT - 4 Ps**

- patients often have?

Back 932

= patency

= protection

= positive pressure ventilation**

= pulmonary toilet

*patients often have several of these issues

Front 933

Airway Management in Elective Surgical Patients

- anatomy often? stomach is? normal? no (2) **

Back 933

- normal anatomy

- fasted = empty stomach

- normal BP/BV

- no head injury

- no limitation of C-spine mobility

Front 934

Airway Management in Elective Surgical Patients

- put in? apply? get it? have?

- meds for? ventilate via?

- confirm?

Back 934

- put in an IV

- appliy monitors

- sniffing position = C spine flexion, head extension

- 100 O2

- anaesthetic meds = hypnosis, paralysis

- ventilate = jaw thrust, oral a/w if required

- intubate

- confirm correct placement of ETT in trachea

Front 935

Confirming Definitive Airway is in the Trachea

- visualize? exhaling? is the***

- look for?

- equal?

- on tube, see?

- cna perform?

Back 935

- visualizing tube going in

- exhaled CO2 = gold standard, should be sustained

- chest rising

- equal A/E - listen in axillae

- condensation on tube

- bronchoscopy = look thorugh tube with scope to see if tube is in trachea

Front 936

Confirming Definitive Airway is in the Trachea

- perform a? does not confirm? as could be in?

- also useful to look at?

Back 936

- Chest Xray = single view AP CXR

- does not confirm ETT is in trachea, could be in esophagus

- CXR useful for seeing the position of the ETT in the trachea once you have confirmed it is actually in trachea

- also useful for looking at thorax, lungs and rubs

Front 937

Airway in Trauma Patient

- is? altered? often?

- risk of?

- possible ?

- other injuries of?

- decrease?

- laso (2)

Back 937

- is emergent and urgent

- altered LOC or uncooperative = HI/intoxicated

- full stomach = vomiting/aspiration

- possible C-spine injury***

- facial #s, neck hematoma, airway injury

- hypovolemic, decreased BP

- hypoxemic

Front 938

Managing the Airway in Trauma

- presume a? therefore need to?

- importance of putting into? while?

- as it helps to?

Back 938

- presume C-spine injury**

- C spine immobilization needed = keep in neutral position at all times

- importane of putting into sniffing position while intubating, can do without but does make it more difficult and increases the chances you wont get a good view of the cords so have to be prepared

*sniffing position increases good view of the cords

Front 939

Breathing - patent airway doesnt always mean?

- patient may be? (3)

Back 939

- patent airway does not mean adequate ventilation/breathing

- patent may be:

= breathing adeqautely, not breathing at all, breathing but not adequantely (taking small tidal volume breaths or breathing just injuries are decreases O2 and increasing CO2)

Front 940

Assessing Breathing -2 aspects

- act of? including getting?

- then the? into?

Back 940

1) Act/Mechanics of breathing = taking normal VT breath, getting O2 into alveoli

2) Diffusion of O2 from alveoli into pulmonary capillaries (and CO2 from capps to alveoli)

Front 941

Assessing Breathing

- look for? (3)

- feel? assess for? (3)

- listen for (3)

Back 941

1) Look = resp rate/ distess, adequate TV, chest rising symmetrically

2) Feel =chest wall = tenderness, rib #s, subcutaneous emphysema)

3) Listen = to patient = speaking, pain, SOB, to lungs

Front 942

Assessment Breathing - Measure (if inad ventilation)

- (2)

- perform a? to look for?

- also do (2)

Back 942

- oxygen saturation

- ABG

- CXR = PTX, HTX, aspirations, rib numbers

- CT scan of chest

- ultrasounds

Front 943

Management of Breathing - if breathing adequately

- apply? start with?

- also apply?

*** to all trauma patients?

Back 943

- apply oxygen mask = start with 100% O2

- apply an oxygen saturation monitor

- monitor for deterioration

*note: apply oxygen to all trauma patient on arrival

Front 944

Management of Breathing - If not breathing at all (apnea)

- ensure? then? with?

- determine?

Back 944

- ensure airway is actually patent

- ventilate patient - can be with rescuscitation bag or a ventilator

- determine etiology of apnea

Front 945

Management of Breathing - If not breathing Adequately

- ventilate? intubate if?

- then?

Back 945

- ventilate patient if inadequate VTs

- intubate patient if inadequate O2 sat/pO2 despite high FI02

- determine etiology of inad. ventilation

Front 946

Inadequate Ventilation

- think about?

- affected could be? (4)

- look for?

- poor ventilation could be due to?

Back 946

- think about neuro control and mechanics of normal breathing and diffusion

- brainstem, SC, phrenic nerve and intercostal nerves, respiratory muscles (diaphragm, intercostal muscles), a breath, O2 into lungs, blood stream, exhale, CO2 eliminated

** injury anywhere can lead to poor ventilation

Front 947

Brainstem to Lungs

- brainstem affected by? (3)

- spinal cord?

- check wall mainly?

- pleural space? (2)

- lungs (2)

Back 947

1)Brainstem = injury, drugs, meds

2) Spinal cord = injury

3) Chest wall = chest wall injury = ribs = can affect resp mechanics and cause pain

4) pleural space = PTX, HTX
5) lungs = contusions, aspirations

Front 948

Airway and Breathing Summary

- must ensure? must have?

-patent airway doesnt?

- lack of breathing due to?

- must consider?

- use adjuncts to? =?

Back 948

- ensure adequate delivery of oxygenated blood, must have patent airway and adequate breathing

- patent airway doesnt ensure ventilation

- lack of breathing could be due to either airway or breathing

- must take into accoutn trauma issues = CSI, aspiration risk, airway anatomy

- use adjuncts to supplement = ETCO2, oxygen sat, CXR

Front 949

Common Thoracic Injuries

- (6)

Back 949

- rib fractures

- flail chest

- pulmonary contusions

- PTX, HTX

- pericardial tamponade

- traumatic aortic injury

Front 950

Assessing Ventilation - look for? (6)

- auscultate for?

- palpate for (2)

- ancillar =? (5)

Back 950

1) Look = resp distress, resp rate, TV, chest rising symmetrically, chest wall bruising/open wounds, cyanosis

2) Auscultaiton = ait entry

3) Palpation = chest well = rib fractures, subcut, emphysema

4) Ancillary = Oxygen saturation, ABG, CXR, CT scan, US

Front 951

Rib Fractures - are the most important due to? (2)

- markers of? as need?

Back 951

- most important because ofL

1) Assoc. injuries = pulmonary contusion, PTX, HTX

2) Pain - pain management

*rib fractures are markers of more severe concomitant injuries, as signif force required to fracture a rib

Front 952

Rib Fractures

- 1st and 2nd ribs need?

- with lower ribs, see?

- fractures increase? each rib sees?

Back 952

- especially large amount of force required to fracture 1st and 2nd rubs

- spleen and liver injuries with lower ribs = 9th to 12

- rib fractures increase morbid,mortal, especially in elderly (each rib increases 20%, 27% increase in pneumonia)

Front 953

Flail Chest - defined as? fractures in?

- leads to??

- problems related to? (3)

Back 953

- defined as 3 consecutive ribs, each fractures in 2 places

- leads to free-floating segments

- causes problems related to:

= pain

= paradoxical movement

= injury to underlying lung = pulmonary contusion

Front 954

Treating Flail Chest

- manage?

- give?

- can?

- surgery to?

Back 954

= pain management = oral and/or IV, or epidural

= oxygen

= intubation and mechanical ventilation prn

= surgical stabilization of rib fractures

Front 955

Pulmonary Contusions - defined as? due to?

- may only be seen on?

- over time?

- worsen with?

- usually peak by? resolve within?

Back 955

- bruising of lungs = microhemorrhages and alveolar hemorrhages

- may only be seen on CT scan initially

- evolve over time***

- worsen with + fluids

- usually peak by 72 hours

- resolve with 5-7 days

Front 956

Pulmonary Contusions

- may develop?

usually occur with?

- Rx =? give if?

Back 956

- may develop ARDS if severe

- usually also have rib fractures but can occur without, esp. in children

- Rx = analgesia, PPV (NIPPV or intubation) as needed for hypoxemia and/or hypercarbia

Front 957

Pneumothorax - air between?

- can be get in from?

- types = 5?

Back 957

- air between visceral and parietal pleura

- air can get in from outside or from lungs

- types:

= closed vs open

= simple, tension, occult

Front 958

Closed vs Open PTX - gets into pleural space from? air in due to?

Back 958

- closed = no connection to outside, air gets into pleural space from inside (alveoli, bronchi)

- open = hole in chest wall and parietal pleura, air gets sucked into pleual space from outside on inspiration due to negative intra-thoracic pressure

Front 959

Open PTX - air then unable to? leads to? forcing?

Back 959

- if these is a ball-valve effect, air can be sucked into pleural space and unable to escape, can lead to tension PTX if enough air trapped, forces lung to shrink

Front 960

Simple vs tension PTX

- defined by?

- simple has no affect on? no shift in?

- tension has? leads to shift in? increasing? leading to?

Back 960

= defined by affect on BP

= simple = no affect on BP or shift of mediastinum

= tension = air in pleural space, leads to shift of mediastinum, increase in intrathoracic pressure, decrease in venous return, leading to decreased BP

Front 961

Clinical Signs of Tension Pneumothorax

- signs of? plus?

- on side of TPTHX, see? (2)

- trachea? JVP?

Back 961

- all of the signs of resp distress discussed, plus:

= hypotension

= decreased air entry on side of TPTX

= hyperresonance on side of TPTX

= deviation of trachea to opposite side

= elevated JVP if pt not hypovolemic

Front 962

Note for PTX - simple PTC can be from? same with?

- air can access?

Back 962

- a simple PTX can result from either a closed or open PTX mechanism

- same for tension PTX

*air can access pleural space from either the inside (lung/bronchus) or outside

Front 963

Occult PTX

- not visible on? only?

- some will?

- treatment?

Back 963

- not visible on CXRm only on CT scan

- some (25%) will progress to tension PTX

- treatment = observation vs chest tube

Front 964

Treatment of Pneumothorax

- provide?

- drain?

- in simple use?

- in tension need? given at?

- follow needle with?

Back 964

1) oxygen

2) drain air from pleural space:

= simple PTX = chest tube

= tension = needle decompensation (2nd ICS MidClav line - above rib) *always follow needle with chest tube

Front 965

Hemothorax - blood is in?

- bleeding may be? (6)

Back 965

- is blood in the pleural space

- bleeding may be from:

= lung parenchyma = low pressure

= pulm vessels = low pressure

= intercostal artery = arterial pressure

= internal mammary artery = arterial pressure

= aorta (traumatic aortic injury) = L HTX

= abdo = rare

*detected by CXR, US, CT

Front 966

Hemothorax

- Rx with? size?

- occasionally use?

- indications for thoracotomy include? (2) >*

- most important factor?

- also indicated if it is?

Back 966

- most rxd with chest tube - large = 32F, 36F, 40F

- occassionaly require thoracotomy, indications:

= 1 = > 1500 cc initial drainage

= 2 = > 250 cc/hr x 4 hours

* clinical status is most important factor

= 3 = retained hemothorax, can lead to empyema fibrothorax - consider thorascopy vs thoracotomy

Front 967

Pericardial Tamponade

- blood is in the?

- pericardium has limited?

- accumualtes slow vs fast?

Back 967

- blood in the pericardial space

- pericardium has limited ability to stretch, if accumulates slowly it can accomodate but if rapidly, cannot

- restricts filling of the heart, decreasing BP

Front 968

Pericardial Tamponade

- need pressure gradient of?

- tamponade sees? leads to ? that then?

Back 968

- need pressure gradient from SVC/IVC to right atrium to fill RA

- tamponade = increase pressure in all 4 chambers of heart

= increased RA pressure decreases venous return to RA, decreases BP

Front 969

Pericardial Tamponade Diagnosis

- Beck's Triad = (3)

- may see?

Back 969

= Beck's Traid:

= hypotension

= muffled heart sounds

= elevated JVP

* may see pulsus paradoxus (accentuated drop in SBP on inspiration)

* look at US

Front 970

Treatment of Pericardial Tamponade

- if time to go to OR, do?

- if emergent? seen by? perform?

Back 970

- if time to get to OR = surgery = sternotomy

- if emergent = severe decreased BP = emergent thoracotomy and pericadiocentesis (only if no other option)

Front 971

Traumatic Aortic Injuries (TAI)

- blunt injury to? classic location?

- varies in?

- 85%?

Back 971

- blunt injury to thoracic aorta

- classic location of injury is descending aorta at level of aortic isthmus (ligamentum arteriosum)

- severity of injury varies from intimal flap to complete transection

- 85% die at scene (transection), 5% make it to hospital hemod unstable (MR > 90%)

Front 972

TAI Mechanism of Injury - classic is? means shearing of? immobile?

- also due to? (3)

Back 972

- classic = decelaration injury = shearing of mobile heart and proximal aorta vs immobile descending aorta (junction at ligamentum arteriosum)

- also due to lateral impact, thoracic compression and abrupt increased BP

Front 973

Diagnosis of TAI - problematic as not?

- suspect in any?

- on CXR, see? such as?

- yet can see with?

- 10%

Back 973

- problematic because no classic physical findings

- suspect in any patient with high energy trauma

- CXR = numerous signs, none specific

- wide mediastium = 2' to mediastinal hematoma

- however any condition with mediastinal hematoma can cause a wide mediastinum

*** 10% TAI pts do not have wide mediastinum

Front 974

TIA Dx - other CXR findings

- loss of? deviations of?

- depression of?

- left?

- fractures of?

Back 974

- loss of aortic knob

- NG deviation to R

- tracheal deviation to R

- depression of L mainstem bronchus

- opacification of aorto-pulmonary window

- apical cap

- L HTX

- 1st and 2nd rib fractures

- sternal fracture, T spine fracture

Front 975

TAI - Other Dx modalities

- A = is the prveious?

- currently use? as very? can diagnose also?

- TEE = ? for those? yet can miss?

Back 975

1) Aortography - previous gold standard, sensitive and specific, only 10% pts with wide mediastinum will have aortic injury

2) CT = current, very sens and specific, can diagnoise other thoracic injuries,

3) Transesoph Echocardiography = TEE = for patients too unstable for CT, can miss injuries in aortic arch

Front 976

TAI Treamtent - BP control is?

- control the? *** chnage?

-want BP to be?

Back 976

- BP control is crucial while awaiting defin treatment

- control shear stress*** against aorta - change in pressue vs time

- exact level of BP unclear but as low as possible while still having adequate perfusion to major organs = SBP of 100

Front 977

TAI Treatment - traditionally was? yet had?

- therefore now? until?

- use now?

Back 977

- traditionally was surgery but high morbidity

- therefore delayed surgery advised until stable, esp resp, CV, coagulation, neuro

- endovascular therapy (stents) now replaced open surgery

Front 978

Thoracic Trauma Summary - high? accounts for?

- most trated with? yet can?

- can be?

Back 978

- high morbidity, accounts for 25% of all trauma deaths

- most treated without surgery

- can lead to problems with oxygenation and/or ventilation

-can be life--threatening, must be recognized and dealt with emergently

Front 979

Definitions - Hypotension vs Shock

- hypotensuon is? doesnt use?

- shock means? not?

- hypoxemia vs hypoxia?

Back 979

1) hypotension = low blood pressure, dont use a specific number

2) Shock = inadequate oxygen delivery to tissues = cant meet metabolic demands

3) Hypoxemia = decreased oxygen in blood

4) Hypoxia = decreased oxygen in tissues

Front 980

Physiologic Concepts of BP

- flow = ?

- pressure?

- BP = ?

- CO = ?

- SV considers?

- CO of 70/minute =?

Back 980

-flow = pressure / R

- pressure = R x flow

- BP = CO x MAP

- CO = HR x SV

- SV = preload, contractility, afterload

- CO = 70/minute = 70 xx = 5000 cc/min

Front 981

Assessment of Circulation - BP - use?

- can also feel? carotid vs femoral vs radial?

- pulse pressure =?

Back 981

- BP - use cuff, can also estimate SBP by feeling pulses

- if only carotid pulse present - SBP = 60

- if femoral also present = SBP = 70

- if radial pulse also present = SBP > 80

*pulse pressure = SBP-DBP

Front 982

Assessment of Circulation - also loo at? its?

- assess? via? (3)

Back 982

2) pulse - rate, strength (gives assessment of BP)

3) Organ perfusion:

= skin = colour (pale), temp (cool), sweaty

= other organs = mental status, urine output

Front 983

Classes of Shock

- Class II HR?

- CLASS II BP sees?

- Class IV sees?

(loss, HR, BP, PP)

Back 983

Front 984

Approach to Trauma Patent with Hypotension

- must do both? look at?

- determine then?

- could be?

- A/R/C

Back 984

- assessment and management must occur simultaneously

- A, B, C, D, and E

- determines causes of low BP and correct them = hemorrhagic, non-hem

- assess severity of blood loss

- resuscitate

- constant assessment of resuc efforts

Front 985

Assessing Trauma Patient with Low BP

- determine? assess?

Back 985

= determine causes of decreased BP

- assessment of severity of blood loss

Front 986

Management of Trauma Patient with Low BP

- correct? determine if?

- then?

- then?

Back 986

= correct causes of low BP = non hem vs hemm (source control)

= resuscitate (volume)

= assess response to resusc efforts

Front 987

Causes of Decreased BP (Physio Approach)

- H/ O/ D/ C - do to?

* in trauma, decreased BP is? until

Back 987

- hypovolemic

- obstructive = obstruction of VR to RA

- distributive = vasodilation

- cardiogenic

* in trauma, decreased BP is due to hypovolemia until proven otherwise

Front 988

Causes of Decreased BP in Trauma

- HV from? Obstructive seen in? (2)

- dis seen with? (3)

- CARDIO FROM?

Back 988

1) Hypovolemic = blood loss

2) Obstructive = TPTX, pericardial tamponade

3) Distributive = vasodilation (spinal cord, sepsis, anaphylaxis)

4) Cardiogenic = cardiac causes (rare in trama)

Front 989

Causes of Decreased BP in Trauma - SHOCK stands for?

Back 989

S - spinal cord, sepsis

H - hemorrhage

O - obstructive - TPTX/HPTX, tamponade

C - cardiogenic - pericardial, myocaridal, endocardial

K - anaphylaksis

Front 990

DDx of Hemorhhage/ Decreased BP in Trauma

- E/C/A/P/LBs

- dont need?

Back 990

1 = External

2 = Chest

3 = Abdo = Peritoneum, Retroperit

4 = Pelvis

5 = Long bones = femurs

*dont need defin diagnosis to go to OR for surgry

Front 991

Clinical Approach of Decreased BP in Trauma Patient

- for spinal cord, do?

- consider?

- for obstructive, look for? (2) perform?

- if tamponade, look for? = (3)

Back 991

1) Spinal cord = PE, radiology

2) Hemorrhage

3) Obstructive:

= TPTHX/HPTX = exam = decreased A/E, increased JVP, CXR

= Tamponade = exam = Beck's triad = decreaed BP, increased JVP, muffled heart sounds

4) Cardio = exam, US, echo

*dont see increased JVP if pt is hypovolemic

Front 992

Hemorrhage Clinical Approach in Trauma Patient-

- external? chest? abdo? pelvis? long bones?

*assoc with?

Back 992

1) External = hx, PE

2) Chest = PE, CXR, CT scan

3) Abdo = PE, US, CT

4) Pelvis = exam, XR, CT, angio

5) Long bones = exam, xray

*hem assoc with low JVP

Front 993

Treatment of Trauma Patient with low bp depends on?

- determine if? then do?

Back 993

- non hem. causes

- hemorrhagic causes = source control

Front 994

Treatment of Reversible Non-Hem Causes in Decreased BP Trauma

- for TPTX? for tamponade?

Back 994

- needle and/or chest tube for TPTX

- surgery/EC thoractomy, pericardiocentesis for PC tamponade

Front 995

Treatment of Hemorrhage in Decreased BP Trauma Patient

- stop? usually via? then do?

- prevent? ** - must stop? (2) as they?

Back 995

1) Stop the bleeding - usually surgery, occas/ inteventional radiology

2) Volume resusciatation

*prevent coagulopathy/hypothermia/acidosis (latter two wrosen the first)

Front 996

Volume Resuscitation - use?

- need 2? size? to?

- usually done it? such as the?

- best if IVs have? are?

- want? for btter?

Back 996

- IV access:

= Need 2 large IVs (14g, 16g) to give fluids rapidly

= usually in upper extremities - antecubital fossae usually

= peripheral IVs best = large, short cannulae

*flow = P/R = want large diamter and short length IV cannulae

Front 997

Intraosseus Access - is an alternative when?

- as BM is?

- vasc is?

- highly vasc BM is? need to infuse under?

Back 997

- an alternative when IV access unsuccessful

- bone marrow is highly vascular

- vasculature is non-collapsable even when hypovolemic

- highly vasc. bone marrow connected to central vascular system via nutrient and emissary veins

- need to infuse under pressure = use pressure bags

Front 998

Volume Resucs - Traditional Approach

- start with? make sure they are?

- 3:1 rule?

- after 3L cryst? or if?

- in severely injured patients?

Back 998

- start with crystalloid (ringers or saline), **warm fluids

- 3:1 rule = need to give 3-4 mls/1ml blood loss

- switch to blood after 3L crystalloid (40 cc per kg) or earlier if severely decreased BP

- in severely injured patients - approach assoc. with worse coagulopathy and outcome

Front 999

Damage Control Resucs (DCR)

- an approach to? consists of? rapidly? and then?

- goal to? stop? (2)

- main aspect is? with? rather than?

Back 999

- an approach to resuscs, consisting of a number of aspects/goals with aims to rapidly stop bleeding and prevent further bleeding until bleeding is stopped

- goal to correctminimize coagulopathy, hypothermia and acidosis

- main aspect is early and aggressive resusc with blood products (RBCs, coag products) rather than crystalloids to prevent worsening coag.

Front 1000

Damage Control Resuscitation Steps

- identify? perimissive? minimize? early? use of? (3), give? minimize? (2)

Back 1000

1) Identify and stop bleeding

2) permissive hypotension

3) Minimize crystalloids

4) Early PRBCs

5) Early and aggressive use of coagulation products = FFP, pts, fibrinogen

6) Tranexamic Acid

7) Minimize Hypothermia and Acidosis

Front 1001

Hypotensive Resuscitation (permissive Hypotension)

- aggressive resusc with? could dislodge? lead to? increase?

- suggested to only? until?

- mostly for? to? not for?

Back 1001

- aggressive resusc. with normalizaiton of BP could dislodge clots and dilute coagulation factors, leading to increased bleeding

- suggested to resusc. only to SBP 80-90 (or less) until definitive surgical control of bleeding

- mostly for stab wounds to trunk (chest and abdo), not for pts with head injuries

Front 1002

Damage Control Resuscitation

- start with?

- aggressive use of?

- provide? (3)

- pharm agents =? attenuates?

Back 1002

- start with RBCs rather than crystalloids

- aggressive use of coagulation products

= plasma (FFP), fibrinogen (cryoprecipiate) and pts

- pharmacologic agents:

= antifibrinolytics (TXA) = attenuates hyperfibrinolysis assoc. with severe trauma

Front 1003

Role of Transexamic Acid

- used largely in?

- dose?

- decreases?

- no decrease in

Back 1003

- largely in developing country

- 1g/10 mins then 1gm/8 hours vs placebo

- decreased all-cause mortality (if given within 3 hours of injury)

- decreased deaths due to bleeding

- no decrease in blood transfer between groups

Front 1004

RBCs in Volume Resusciation

- fully? need type?

- uncrossmatched use? in females of childbearing age?

- temp?

- also give? to prvent?

Back 1004

- fully crossmatched (Xm) blood

- type-specific blood

- uncrossmatched blood = O+ in most, O- in females of childbearing age

- give warm blood to avoid hypothermia

- give plasma, pts, cryprecipirate to prevent coagulopathy

Front 1005

Blood in Volume Resuscitation (Fully Xm blood)

- identify?

- screen for?

- ensure?

- time?

Back 1005

- identify pts blood type (ABO and Rh)

- screen for any Abs in pats serum

- ensure donor blood fully* compatible with pts (no antigens in donor blood that pt has antibodies to)

- takes about 45 minutes

Front 1006

Blood in Volume Resuscitation - Type-Specific

- identify?

- release? that is? hasnt been?

- lab will continue to?

- time?

Back 1006

- identify pts ABO and Rh blood type

- release donor blood that is compatible with pts ABO/Rh blood type

- but: hasnt been tested to see if fully compatible

- lab will continue to do full crossmatch

- takes about 10 minutes

Front 1007

Blood in Volume Resuscitation - Uncrossmatched Blood

- need? give? as it is?

- therefore give?

- O- for? O+ for?

Back 1007

- need blood imeediately

- type O blood is universal donor

- therefore give type O blood

- O- for women of child-bearing age

- O+ for everyone else

Front 1008

Response of Blood Pressure to Fluids

- normalized?

- transient?

- no/min reponse? leads to?

Back 1008

1) normalized = volume loss replaced, no ongoing bleeding

2) transient = volume loss replaced, ongoing bleeding, need to stop bleeding

3)No/min response = volume loss not replaced and ongoing bleeding; impending death if not treated

* Need definitive treatment to stop bleeding*

Front 1009

Trauma Induced Coagulopathy (TIC)

- traditional causes are? (6 = B/C/D/H/A/H)

Back 1009

- traditional causes of coagulopathy have been:

= bleeding (loss of blood - RBC, plasma, pts)

= consumption

= dilution

= hypothermia

= acidosis

= hypocalcemia

Front 1010

The Lethal Triad/ Vicious Cycle - bleeding leads to? which further?

Back 1010

- bleeding leads to acidosis and hypothermia, all three contribute further to coagulopathy

Front 1011

Trauma Induced Coagulopathy (TIC)

- now known that?

- 1/3 patients are? with increased?

Back 1011

- now known that there is an endogenous coagulopathy that occurs in some trauma patients (acute coagulopathy of Trauma)

- recent evidence has shown that 1/4-1/3 of trauma pts are coagulopathic (increased INR) at time of presentation/scene

*occurring long before traditional causes of TIC have had time to occur

Front 1012

Acute Coagulopathy of Trauma (ACT)

- requires both? not just?

- seen in ISS of?

Back 1012

- severe tissue trauma** and hypoperfusion** (shock) BOTH appear to be required for development of ACT

- not either alone

- in study of ACT, the worst coagulopathies were seen in pts with ISS > 35 and** base deficit less than -12 mEq/L

Front 1013

Clinical Importance of ACT

- see increased? (4)

Back 1013

in ACT, we see:

= increased transfusion requirements

= increased mortality

= increased morbidity in survivors

= increased multi-organ failure, infection, time on mechanical ventilation, hospital LOS

Front 1014

ACT Mechanisms - normally, see?

- coagulation includes? (3)

- anticoag includes? (2)

Back 1014

- normal hemostasis is a balance between coagulation and anticoagulation

- coagulation:

= endothelium, platelets, coagulation factors

- anticoagulation:

= anticoagulant factors (Protein C,S), fibrinolysis

Front 1015

ACT Mechanisms - The Procoagulant Side

- vascular?

-plts are? dont usually?

- see low?

Back 1015

1) Vascular Endothelium = glycocalyx disrupted

2) Platelets = plts counts are mildly reduced in trauma, dont usually decline to levels expected to contribute significantly to coagulopathy, probable that functional impairment occurs

3) Factors = fibrinogen levels low in many ACT patients, factor 5 levels low in ACT

Front 1016

ACT Mechanisms - Anticoagulant Side

- Fibrin? Protein C is? leads to?

- PAI-1 leads to?

Back 1016

1) Fibrinolysis = Hyperfibrinolysis when it occurs, high mortality

2) Protein C = gets activated by trauma and shock, leads to inhibition of thrombin, inactivation of F5 and F8, consumes PAI-1

*PAI-1 leads to release of tPA and causes hyperfibrinolysis

Front 1017

Assessing and Managing Patient

- A?B?C?

- assess? such as?

- manage via?

Back 1017

A = ensure ETT in good position

B = ensure chest clear and good A/E

C = assess and manage simultaneously

- assess = BP, pulse, skin, urine output, cause of decreased BP: shock pneumonic, clinical exam and xrays

- manage = treat non-hem causes, 2 large bore IVs and fluid warmer, fluids (blood, RBCs, plasma, FBG), transexamic acid, hem. control

Front 1018

Abdominal Trauma

- if patient has? goal to?

- perform laparotomy if? (2)

- do CT scan if? but no?

Back 1018

- if patient has decreased BP, goal to determine cause

- if decreased blood pressure + intra-abdominal bleeding = laparotomy (dont need to determine exact organ injured)

- if intra-abdominal bleeding + no decreased BP = further investigations (usually CT scan)

Front 1019

Abdominal Trauma - Diagnostic Options

- exam of? is?

- need further?

Back 1019

- clinical exam of abdomen in trauma is notoriously inaccurate

- false + and false -s

- need further investigations

Front 1020

Abdominal Trauma - Investigations

- FAST is? also can do? (4) C/L/A/WE

Back 1020

- US = FAST = focused assessment with Sonograph in Trauma

- CT scan

- Laparoscopy

- Angiography

- Wound Exploration = stab wounds

Front 1021

US (FAST) - assess for?

- not for? 4 regions include?

- E-FAST for?

Back 1021

- assesses for free fluid (blood)

- not for organ injury

- 4 regions:

= RUQ (liver/kidney/Morrison's pouch)

= LUQ (spleen/kidney)

= Bladder (cul-de-sac)

= Pericardium

- E-FAST = Extended = also looks for PTX

Front 1022

US (FAST) + means? appears? needs to be?

- indications are?

- advantages (4) - highly?

Back 1022

- FAST +ve means (blood = black), need 400 cc to be positive

- indications are decreased BP

- advantages = noninvasive, portable, can repeat, high spec (95+)

Front 1023

CT Scan - only for? need?

- good for? and entire? such as?

- may also see? indicates? called?

Back 1023

- only for stable patients, need IV contrast

- good for: Dx for solid organ injury (liver, spleen) and entire abdomen (including retroperitoneum)

- may also see extravasation of contrast (indicates active bleeding) = is called "blush"

Front 1024

Disads of CT SCAN - misses? also misses?

Back 1024

= misses hollow organ injuries (bowel)

= misses diaphragm injuries

Front 1025

Disads of US (FAST) - not useful in? cant be used in?

- does not?

Back 1025

= early

= subsequent emphysema, obese

= insensitive (80%)

= does not assess retroperitoneum

Front 1026

Indications for Laparotomy in Blunt Abdo Trauma

- HI? with either (2)

- P?

- DI?

Back 1026

1) Hemodynamic Instability

= with intra-abdo blood (on FAST)

= with intra-abdo injury

2) Peritonitis

3) Diaphragmatic Injury

Front 1027

Abdo Trauma - Nonoperative Management of Solid Organ Injuries

- solid? must be?

- go to OR if?

Back 1027

= solid organ injuries (spleen, liver)

= must be hemodynamically stable

= if develop decreased BP or require blood, go to OR

Front 1028

Abdo Trauma - Management is?

- if stable, can?

- if unstable?

- unstable means? (4)

Back 1028

- is surgery

- if patient is hemod. stable, can take time in the OR to perform definitive surgery

- if unstable, must be quick

*unstable = hemodynamically, coagulopathic, acidotic, hypothermic

Front 1029

Damage Control Surgery - prevent? (4)

- deal with? pack to?

- go to ICU to? return to? to?

- very beneficial in reducing? yet new problem of?

Back 1029

- prevent/minimize: hypothermia/coagulopathy/ acidosis, death

- deal with life-threatening problems only (Hem, Bowel perfusions) in most expeditious way, packs to tamponade bleeding

- go to ICU to resuscitate, return to OR in 24-48h to remove packs and definitive surgery

*very beneficial in reducing lethal triad and acute mortality, yet new problem of Abdo. Compartment Syndrome (ACS)

Front 1030

Intraabdo Pressure and Intraabdo Hypertension

- normal IAP?

- elevated if?

Back 1030

- normal IAP = 0 to 5 mmHg

- IAH = elevation of IAP above "normal" defined > 12 mmHg

Front 1031

Abdominal Compartment Syndrome (ACS)

- abdo cavity can only?

- if over certain point?

- seen in? (5)

- anything that decreases? will also?

Back 1031

- abdo cavity can only hold so much volume

- if volume increases over certain point, pressure inside abdo increases

- blood, ascites, bowel edema, ileus, and packing all increase intra-abdominal volume

- anything that decreases compliance of abdo wall will also increase IAP (edema, burns)

*increased IAP can cause adverse physiologic effects

Front 1032

ACS - increased? + end organ?

- in CV, see decreased? (2)

- in resp, see decreased? (3)

- renal, see?

- neuro - see?

Back 1032

- ACS = increased IAP (>20) + end-organ dysfunction

- CV = decreased venous return, increased afterload, decreased BP and C.O.

- Resp = decreased compliance, decreased FCR, atelectasis/collapse, decreased O2

- Renal = low urine output; acute renal failure

- Neuro = increased intracranial pressure

Front 1033

3 Parts of ACS **

- improvement with?

- organ systems?

Back 1033

1) Organ dysfunction

2) Resulting from elevated IAP

3) Improvement with abdo decompression

- organ systems = splanchnic, CVS, pulm, renal, CNS (intracranial)

Front 1034

IAH and ACS acts as?

- acts as a? IAH is a? can lead to?

- key to monitor?

Back 1034

- acts on a continuum

- IAH is an earlier phenom that when uncorrected leads to ACS

- key to monitor and Tx of IAH to prevent ACS

Front 1035

Diagnosis of ACS - measurement of?

- direct?

- indirect? **

Back 1035

- involves measurement of IAP

- direct = intraperitoneal

- indirect = gastric, IVC, bladder**

Front 1036

Measurement of IAP = Bladder Pressure - is the? correlation with? acts as a?

- use a? inset? see change with?

- can use?

Back 1036

- is the gold standard, high correlation with IAP

- bladder acts as a passive conduit

- use foley catheter, insert 25 cc (max) NS into bladder, connect to transducer and see respiratory variation

- can use intermittent or continuous monitoring

Front 1037

ACS Treatment

- only defin treatment is?

- must open?

- temporizing measure include? (2)

- have temp?

Back 1037

- only definitive Tx is to open the abdomen

- must open fascia and skin

- temporizing measures = paralyze patient, paracentesis (drainage of any fluid, ie ascites, collections)

- have temp closure = protective covering over top with room to expand*

Front 1038

Pelvic Fractures

- can lead to?

- patients often are?

- PF must be in DD of?

- require? so often?

- need to determine if?

Back 1038

- can lead to massive bleeding

- patients with hemodynamic instability from pelvic fractures have high MR

- must be in the DD of hypotensive trauma pt

- requires a lot of force, have other injuries

- high incidence of concomitant intra-abdo injury

- need to determine if decreased BP is from pelvis/abdo/both

Front 1039

Diagnosis of Pelvic Fractures

- clinical exam is?

- CT scan for?

Back 1039

- clinical exam = pain, mechanical instability

-plain X rays

- CT scan (if stable) = can see fractures and contrast blush

Front 1040

Pelvic Fractures and Bleeding

- bleeding from?

- major vessels run along?

- see colalterals between?

- bleeding is mostly from?

Back 1040

- bleeding occurs from bones, veins (90%), arteries (10%)

- major vessels in pelvis run along posterior aspect of pelvis

- ++ collaterals between R and L sides

- arterial bleeding is mostly from internal iliac artery or branches of it

Front 1041

Management of Pelvic Fractures

- must?

-options include? wrap?

- perform? give?

- or do a? with?

Back 1041

- must stop the bleeding, options include:

= stabilize pelvis = wrap with sheet, pelvic binder, external fixator

= surgery = pre-peritoneal packing

= angiography + embolization

Front 1042

Surgery - Pre-Peritoneal Packing - Packing ExtraPerit. Space

- incision? location?

- open? not? called?

Back 1042

- midline incision 8 cm in length just above the pubis extending toward the umbilicus

- skin and subcut. tissue is opened in the midline, as is the fascia (not peritoneum) = Space of Retzius

Front 1043

Surgery - Pre-Peritoneal Packing - Packing Retroperit. Space

- bladder is then? use? and place?

- then? time?

Back 1043

- bladder retracted away from the fracture, blunt dissection with hands and three laparotomy pads placed in the RP space on each side toward the iliac vessels

- fascia and skin are closed

- takes about 20 minutes

Front 1044

Pelvic Fractures - Angiography and Embolization

- indicated in?** especially if?

- use in patients with? (2) after trying?

- do ahead of packing if?

Back 1044

- indicated in pts with contrast blush on CT, esp. if decreased BP

- pts with pelvic fractures and decreased BP (no other cause) despite above measures (binder, preperitoneal packing)

- can also be used ahead of packing if angio suite and personnel immed. available

Front 1045

Definitive Pelvic Fracture Treatment

- (2)

Back 1045

- external fixator

- open reduction internal fixation (ORIF)

Front 1046

Approach to Pt with Pelvic Fracture and Decreased BP

- rule out? such as?

- in trauma room?

- if FAST +?

- last option is?

Back 1046

- rule out/ in additional sources of decreased BP and Tx accordingly, esp. intra-abdo bleeding

- pelvic binder (or sheet) in Trauma room

- if FAST + = OR for laparotomy and preperit. packing for pelvis

- if still decreased BP from pelvis after this, do angio

Front 1047

Approach to Pt with Pelvic Fracture and Decreased BP - If FAST negative

- apply?

Back 1047

- pelvic binder applied

Front 1048

Approach to Pt with Pelvic Fracture and Decreased BP - If BP improves with + resusc.

- to? if contrast blush? if external fixator?

Back 1048

- to CT

- to angio if contrast blush seen on CT

- to OR for external fixator

Front 1049

Approach to Pt with Pelvic Fracture and Decreased BP - If BP doesnt improve?

- give? or go to?

Back 1049

- pre-perit. packing or angio suite

- if BP still doesnt improve: Angio suite or pre-perit packing

Front 1050

Summary of Abdo Trauma

- exam is? need?

- never go to CT with?

- surgery for?

- need to determine?

- key to good outcome is?

Back 1050

- abdo exam unreliable in diagnosing intra-abdo trauma

- need imaging = US, CT

- never go to CT scan with decreased BP patient

- decreased BP + Intra-Abdo blood = surgery

- pelvic fractures bleed like crazy ,need to determine whether from pelvis or other sites as well (abdo)

- rapid management is key to good outcome in pts with pelvic fractures (dx and tx of bleeding + resuc)

Front 1051

Before Sending Patient to Radiology Department, need?

- patient needs to be?

- stab. devices include? (2)

- deadly if?

Back 1051

- patient needs to be hemo stable

- stabilising devices = neck brace (C-spine), spinal board (lumbar spine)

- facial and C-spine fractures can be deadly if neck flxed during CT scan

Front 1052

Trauma Imaging

Back 1052

Front 1053

Types of Imaging

- plain films for?

- US for?

- CT for?

- Angio for?

- MRI for?

Back 1053

- Plain films = CXR, fractures, long bones

- US = abdo injury, fluid (assessing hemoperitoneum)

- CT = organ injury

- Angio = bleeding requiring embolization

- MRI = neuroassessment, espec. SC

Front 1054

CT Scan for Fractures

- important for? such as?

- better at? shows?

- can do?

Back 1054

- important for complex fractures:

= facial, spinal, pelvic fractures

= defines fractures better

= shows assoc. complication

= useful for surgeon

* can do 3D reconstruction of CT images - can be used to plan type of surgery

Front 1055

MRI used for?

- to assess?

- done in? assess for?

Back 1055

- used mostly for CNS trauma, to assess cord and brain injury, surgery planning, assess prognosis

- done in hemodynamically stable patient

- can assess for cervical spine fractures

Front 1056

Two Types of Angiography

- conventional is? punctures? after do?

- CT is? only? after?

Back 1056

1) Conventional

= invasive, artery punctures, can embolize sites of bleeding, do xray after

2) CT Angiography

- not invasive, only antecubital vein punctures, CT scan done after

Front 1057

Types of Trauma - either?

- types of injury include?

Back 1057

1) Organ Specific

= multiple organ involvement = MHC, etc

= localized organ invovlement = abdo, chest, head injury

2) Type of Injury

= penetrating

= blunt trauma

Front 1058

Multi Organ Trauma - requires? best if CT is?

- look for lacerations of? appear?

- shock bowel appears as?

Back 1058

- requires aggressive imaging

- best if CT located in emergency room

- head,chest and Abdo CTs can be done quickly

* look for liver or renal laceration ( more hypodense due to blood)

* shock bowel = hyper enhancing bowel wall, adrenal gland can look bright

Front 1059

Single Organ Trauma

- careful? need more?

- can become? look for?

- may need?

Back 1059

- careful clinical analysis before imaging as usually stable

- more selectively imaging

- can become unstable quickly, ex/ delayed rupture of organs (ex/spleen), look for splenic hematoma

- may need spec. care = complex pelvic, C-spine fractures

Front 1060

Type of Injury - Penetrating

- can be? if penetrating?

- imaging? do not perform**?

Back 1060

- can be life threatening, instrument best left in patient

- imaging:

= plain film, CT scan to assess internal organ damage

= MRI cannot be performed

Front 1061

Fall From height - type of injury?

- see fractures of? (3)

- must see?

Back 1061

** type of injury determines tests

- see fractures of:

= Calcaneus

= Pelvis

= Lumbar spine, see compression fractures

* must xray many areas

Front 1062

Lateral Cervical Spine X-ray - ABCs

- A/B/C and then?

- alignment - should see?

- bones - look for?

- also want?

Back 1062

= Alignment - 4 lines - should be straight (\), last should be curved

= Bones = Vertebral Bodies = 7

= Cartilage (Disc)

= Soft Tissue

*also want open mouth (odontoid) view

Front 1063

Adequacy of Cervical Spine X-Ray

- must visualize? from? to?

- C1 is? see separate?

- C2 is? up to?

- inadequate film if?

Back 1063

- must visualize the entire cervical spine, from skull base to the cervico-thoracid junction

- C1 is small, separate between spinous process and vertebral body

- C2 is large, up to C7

- film that does not show the upper border of T1 is inadequate**

Front 1064

Cartilage and Soft Tissue

- cartilage should be?

- soft tissue, look for?

- at #4 size? #6 size?

Back 1064

- cartilage - should be symmetrical between vertebral bodies

- soft tissue: look for misalignmentt

= 4-7 mm = 1/2 vertebral body at #4

= 16-20 mm = full vertebral body at #6

Front 1065

Spinous Process Fracture of C7 called?

Back 1065

- Clay-Shoveler Fracture

Front 1066

Open Mouth (Odontoid) View

- C1 appear? look at? should be?

- can assess? when not?

Back 1066

- see C1 on each side of C2

- look at open mouth view, should be symmetrical

- can assess for fracture of C1 when not aligned on sides of mouth

Front 1067

Hangman Fracture - fracture of? seen in?

Back 1067

- fracture of C2 posterior element

- seen in those trying to hang themself

Front 1068

Heads - Types of Bleeds - 4 types?

Back 1068

= epidural hem

= subdural hem

= subarachnoid hem

= intracerebral hem

Front 1069

Epidural Hemorrhage - occurs between?

- dura is? adherent to?

- hemorrhages appear? seen more commonly in? with?

Back 1069

- occur between the dura and bone = dura in thick, dense and closely adherent to inner surface of bone

- are lenticular and biconvex**, more commonly seen in young patients (with trauma, assoc. bleeding)

Front 1070

Epidural hemm looks like?

Back 1070

Front 1071

Subdural Hemm - occurs between?

- appears? shape?

- seen in more? due to movement of?

- if hypodense? hyperdense? also see?

Back 1071

- occurs between dura and arachnoid

- appears crestentic, concave inner margin

- seen in older patients, due to movement of smaller, atrophic brain leading to bleeds in bridging veins

- if hypodense - chronic

- if hyperdense - more acute

** also see midline shifts

Front 1072

Subarachnoid Hemm - appear? are both inter? bright in?

Back 1072

- subtle, diffuse, inter-hemispheric, inter-ventricular

- bright in sub-arachnoid spaces

Front 1073

Intra-cerebral Hemorrhage - appear?

- can be either?

- also can see?

Back 1073

- hyperdense areas inside parenchyma

- can be hemorrhagic or non-hemorhhagic

- can see intra-ventricular extensions

Front 1074

Chest - Consider? (4) A/F/L/PI

- lung injury includes? pleural injury includes?

Back 1074

- aortic injuries

- fractures

- lung injury = contusions, lacerations

- pleural injury = PTX, HTX

Front 1075

Imaging Assessment in Trauma

- CXR is usually? CT then for? Angio is becoming?

Back 1075

1) CXR = usual method of inital screening in trauma

2) CT = often needs CT for assessment of other regions (abdo, head)

3) Angiography = becoming uncommonly used for aortic injury (CT is most common)

Front 1076

Life Threatening Events of Chest (4) T/F/HT/AD

Back 1076

= TPTH

= flail chest

= large hemothorax

- aortic dissection/ rupture

Front 1077

CXR Findings in Aortic Injury - is? but not?

- should first do?

- signs of hematoma? (5) *** M/I/A/D/ increased?

Back 1077

- CXR sensitive but not specific for aortic injury

- normal CXR should preclude further assessment for aortic injury

- CXR findings = signs of Hematoma

= Mediastinal widening

= Indistinct aorta

= Apical cap (darkening at lung top)

= Displacement of NG tube

= Increased density behind heart

Front 1078

CT Findings in Aortic Injury

- indirect =?

- direct = signs of? such as? look for?

Back 1078

1) Indirect Signs

= mediastinal hematoma

2) Direct Signs

= sign of aortic injury = pseudoaneurysm = hyperdense, circular inside organ

*look for trachea movement to side

Front 1079

In hemothorax, see complete? shift of?

- CT, see? can also see?

Back 1079

- complete opacification of right hemi thorax

- shift of mediastinum, trachea to one side

- CT see completely dense area

- can also see rib fractures

Front 1080

Flail Chest- definition? ribs then? leads to?

Back 1080

- see three continuous ribs, breaks in two more spots

- ribs completely independent of rib cage, area will be inefficient in breathing

Front 1081

Diaphragmatic Rupture - rise of? displaced? ***

- PTX appears as?

Back 1081

- diaphragm rises

- see displaced NG tube

- see distended stomach in chest***

**PTX appears as dark top of lung

Front 1082

Multiple Trauma Patient - Organ Specific Injuries - often to (4)

- injury appears are? fat? blood?

Back 1082

- liver

- spleen

- kidneys

- bladder

*hypodense in organs likely from injury, fat appears dark, lighter for blood

Front 1083

Traumatic Solid Organ Injury - Clinical Findings - commonly seen in?

- clinical findings = (3) ** signs of?

Back 1083

- commonly injured in blunt trauma

- clinical findings

= often non-specific

= peritoneal irritation

= signs/symptoms of acute hemorrhage

Front 1084

Solid Organ Injury Imaging - do not use?

- US for? modality of choice is?

- angio for?

Back 1084

- plain film not useful

- US = hemoperitoneum

= contrast- enhanced CT is modality of choice

- angio = therapeutic embolization

Front 1085

Types of Solid organ injuries - (3)

Back 1085

= hematomas

= lacerations

= infarctions

Front 1086

For hematomas, do?

- high density shows?

- with IV - no?

- with time? can become?

Back 1086

- CT is best imaging

- on plain CT = high density shows blood

- with IV = no enhancement

- density of hematoma decreases with time, can become hypodense

Front 1087

Laceration and CT - spleen? kidney?

- defects are often?

- if hyperdense?

- if hypodense?

Back 1087

- can see peri spleen, kidney fluid

- low density linear defects within the organs (usually from lateral border towards hilium)

- if hyperdense, may be pseudoaneurysm

- hypodense shows lacerations

Front 1088

Lacerations

- mechanism is often? torn by?

- clinically see? (3)

- can affect? and the?

- imaging to use? delayed images to diff between?

Back 1088

- Mech = blunt trauma, laceration by lower ribs, torn by rapid accel/decel

- clinically see back pain, hematuria, hemo unstable

- can affect renal parnechyma, vessels, collecting system

- US is limited

- CT is study of choice - important of delayed images to diff. between hematoma (hypodense) and leakage from collecting system (appear hyperdense)

Front 1089

Lacerations Transecting Collecting System - best?

- absence of? due to?

- around kidney see?

- abrupt?

Back 1089

- CT is best, see:

= absence of contrast enhancement due to no flow

= hematoma around kidney

= abrupt cut off of contrast filled renal artery

Front 1090

Pelvic Fractures with Active Bleeding - do? see?

- to stop bleeding?

Back 1090

- do contrast extravasation to see active bleeding, fracture locations, can use catheter and coil or gelfoam to stop bleeding

Front 1091

Traumatic Brain Injuries Epi

- one of the leading?

- importance of? assesses? (2)

Back 1091

- one of leading causes of trauma-related deaths, huge amount of disability and cost to society

- importance of D = GCS, pupils (size, response to light)

Front 1092

Glasgow Coma Scale - Eyes - out of? scoring?

Back 1092

Front 1093

Glasgow Coma Scale - Verbal - out of? scoring?

Back 1093

Front 1094

Glasgow Coma Scale - Motor Response - out of? scoring?

Back 1094

Front 1095

GCS - devised for assessing? in?

- useful to follow? for?

- categories? min? max?

Back 1095

- devised for assessing LOC in pts with TBI

- useful for following pts progress and for communication with MDs

- 3 categories = eyes, verbal, motor

- min score = 3

- max score 15

Front 1096

Classification of TBI

- mild? moderate? severe?

Back 1096

= Mild Head Injury = GCS 13-15

= Moderate Head Injury = 9-12

= Severe Head Injury = GCS < 8

Front 1097

Classification of TBI - CT Scan Findings in TBI

- look for? (4)

- may be?

Back 1097

- normal

- epidural hematoma

- subdural hematoma

- intracerebral contusions

- diffuse axonal injury

*may be more than one of these on CT

Front 1098

Subdural Hematoma - see shift in? compressed?

Back 1098

- see shift in midline

- compressed lateral ventricles

Front 1099

Intracerebral Contusions - see? usually?

Back 1099

- see contusions inside parenchyma

- usually >1cm in diameter

Front 1100

Diffuse Axonal Injury - see? in?

Back 1100

- see blood in lateral ventricles, basal cistern, petechial hemorrhages

Front 1101

Assessment and Management of TBI - Mild Head Injury

- defined as? with? GCS?

- CT?

- discharged if? must have?

- generally admit if?

Back 1101

= defined as witness LOC, amnesia, witnessed disoreintation with GCS of 13-15

= usually normal CT

= discharged home if GCS = 15 = must not be intoxicated and must have a reliable caregiver, be able to return

= generally admit for observation if 13 or 14

Front 1102

Canadian CT Head Rule - High Risk

- only required for?

Back 1102

= only required for patients with minor head injuries with any one of following:

Front 1103

Canadian CT Head Rule - Medium Risk

Back 1103

Front 1104

Moderate Head Injury - GCS of?

- do? and then?

- intervention as?

- if deteriorates?

Back 1104

- GCS of 9-12

- do CT head and admit for observation

- intervention as appropriate based on CT and clinical status

- if deteriorates: repeat CT head and treat as appropriate

Front 1105

Severe TBIs are?

Back 1105

- GCS equal to or less than 8

Front 1106

Severe TBI - Management - crucial? look for?

Back 1106

- A, B, Cs are crucial

- TBI + Hypoxemia +/or Hypotension increase mortality

Front 1107

Severe TBI - Goal is to? maintain? equation?

- maintained mainly by?

- ** goal to prevent? (3)

Back 1107

- prevent secondary injury

- maintain cerebral perfusion pressure (CPP)

- CPP = MAP - ICP, primarily by reducing intracranial pressure (ICP)

- prevent/treat hyperthermia

- prevent/treat seizures

- prevent/treat hyperglycemia

Front 1108

Severe TBI - ICP Management - doctrine?

- skull is?

- able to? compensatory as?

- after limits?

Back 1108

= Monroe-Kellie Doctrine:

- skull is rigid, contains brain (cells + ISF), blood, CSF

- can accommodate some increase in volume

- compensation occurs by displacing CSF/venous blood

- after limits of compensations, ICP will increase ++

Front 1109

ICP Increase - in compensated? see decrease in? (2) as?

- inuncomp, ICP is? see very little?

- after decomp?

Back 1109

- in compensated state, ICP is normal, see decrease in venous volume and CSF as mass increase

- in uncompensated state, ICP elevated as mass increases more, see very little venous volume and CSF

- after point of decompensation, see ICP increase steeply until herniation

Front 1110

Upon high ICP, look for? occurs as?

Back 1110

-fixed, dilated pupils can be sign of very high ICP and hernation as 3rd cranial nerve gets compressed

Front 1111

ICP Management - increased ICP leads to? leads to?

- assoc. with? treatment towards?

Back 1111

- increased ICP leads to compression of small arteries, leading to brain ischemia

- increased ICP assoc. with worse outcomes

- therefore, treatment targeted towards reduced ICP

Front 1112

Monitoring ICP- normal ICP at? to measure?

- monitor ICP if? look for?

- EVD is?

Back 1112

- normal ICP at 10 mmHg, various devices to measure ICP are invasive

- monitor ICP if GCS <8 and abnormal CT scan

- monitor via External Ventricular Device (EVD), can use intraparenchymal probe and epidural transducer

Front 1113

Goal of CPP - want to maintain? to prevent? (3)

- CPP is?

- number?

Back 1113

- want to maintain CPP to prevent hyperthermia, seizures and hyperglycemia

- CPP = MAP - ICP

* want to maintain ICP < 20-25 so CPP > 60

Front 1114

ICP Management - 1st Line Options/Measures - Hematoma and CSF - do?

Back 1114

- think of contents of skull:

= hematoma = evacuate = craniotomy

= CSF = drain (if ventricular drain in place)

Front 1115

ICP Management - 1st Line Options/Measures - ICF/ISF and Blood

- for ICF- use? these include (2) - act to?

- for blood, venous want to? by?

- if arterial? which decreases? then?

Back 1115

= ICF/ISF:

= hyperosmotic agents = mannitol, hypertonic saline, pull water out of ISF and ICF spaces

= blood:

= venous = encourage venous drainage from brain (elevate head)

= arterial = hyperventilation (mild) - decreases paCO2 leads to cerebral v/c leading to decreased CBF and CBV

Front 1116

paCO2 and Cerebral Blood Flow - as increase paC02? causes?

Back 1116

- as increase PaCO2, see MAP increase and CBF increases

- high enough PaCO2 eventually causes CBF to plateua

Front 1117

ICP Management - 2nd/3rd Line Options

- propofol to? decreases?

- temp? to decrease?

- or can perform? to?

Back 1117

= barbiturates or Propofol = lower cerebral metabolism = decreases CBV to decrease ICP

= hypothermia = decreases CBV by lowering metabolism

= decompressive craniectomy = removal of skulls to allow brain to swell to reduce ICP

Front 1118

CPP Management - want to keep CPP at?

- done via?

- if CPP < 60 and? use? such as?

Back 1118

- want to keep CPP 50-70 mmHg

- generally accomplished with ICP management

- if CPP < 60 with maximal ICP control, use meds to raise MAP = Norepinephrine

Front 1119

Severe TBI - Other NB issues- things that increase? act to? and therefore?

- prevent? (3)

Back 1119

- things that increase cerebral metab = fever, seizures = increase CBF and CBV to increase ICP

- therefore prevent:

= hyperthermia**

= seizures = look for non-convulsive seizures on EEG

= hyperglycemia = worse outcomes

Front 1120

Severe TBI and Sodium

- NA affects?

- HyperNa causes?

- HypoNa causes?

Back 1120

Front 1121

Summary of Brain Injuries

- cant chnage? focus on?

- act to? understand?

Back 1121

- cant change primary injury, focus on preventing 2nd injury

- optimize ABCs, understand determinants of ICP and CPP and management

Front 1122

C-Spine Injuries - Incidence

- in blunta trauma? most common level of injury?

- 2nd most common?

- not uncommon to have?

Back 1122

- in blunt trauma - 2-3%, 1% in low energy and 10% high energy

- C2 most common level of injury (25% of all fractures)

- C6 and C7 2nd most common = 40%

- not uncommon to have more than one fracture, can also have ligament disruption

Front 1123

CSI and head Injuries - with GCS <8, see?

- 7% have? therefore increased incidence of?

- often have?

Back 1123

- % CSIs increasing with GCS <8, accounts for most, 10% of CSIs

- 6-7% CSI have facial injuries

- therefore injuries above clavicles have increased incidence of CSI

- often have other injuries = 25-50% of patients with CSI have head injury (HI)

Front 1124

Missed CSIs and Deterioration - Causes for Missing CSIs

- injuries? (3) need for?

- poor? miss?

Back 1124

- head injury

- intoxication

- distracting injuries

- need for urgent ETT

- poor quality of imaging/missed on imaging

- neurol symptoms missed or attributed to other causes (periph injuries/anxiety)

Front 1125

if Missed CSIs - often leads to? more likely to?

- include?

- can occur with?

Back 1125

- often leads to failure to immobilize, more likely to suffer primary or secondary spinal cord injury

- include of neurologic deterioration (after reaching hospital) = 2-10%

- can occur with airway management/ halo application/ surgery/ sepsis, still can occur with appropriate mgmt

Front 1126

C Spine Immbilization

- must assume?

- always remember to?

- immobilize with?

Back 1126

- must assume every blunt trauma patient has a C-spine injury until proven otherwise**

- remember = A = airway + C spine protection

- immobilize = hard collar + sandbards + tape log roll when turning patient

-

Front 1127

C- Spine Immobilizaiton - must keep? until?

- make sure to? if?

Back 1127

- must keep spine imm. at all times until injury ruled out

- in-line immob./stab/ whenever performing maneuvers that could cause neck movement (airway maneuvers, etc)

Front 1128

Clearing the C-Spine - ruling out? must also rule out?

- can clear?

- can not?

- often need?

Back 1128

- ruling out a significant injury in the vertebral column (bones and/or ligaments)

- must R/O bony and ligamentous injury

- can clear clinically without xrays

- can not clear with xray without clinical exam

- often need neurosurgical or orthopedic opinion

Front 1129

Clearing C Spine - ClinicalClearance

- no (4)??

- painless?

Back 1129

1) No sensorium = no alcohol, drugs, TBI

2) No midline spine pain/tenderness

3) No neuro signs/ symptoms

4) No distracting injuries

5) Painless ROM of C-spine (after above 4 criteria are met)

Front 1130

Clearing C Spine - Must perform radiologic evaluation, if?

- if do not meet? do ?

Back 1130

- if any of these 4 not met:

1) No sensorium

2) no midline spine pain/tenderness

3) no neurologic signs/ symptoms

4) no distracting injuries

* do CT scan with 3-d reconstructions

Front 1131

Ruling Out Clinically - can not? without?

- must still?

- after CT, still make sure? (3)

- if not?

Back 1131

- can not clear with xrays, without clinical exam

- must still clear clinically as well (still possibility of ligament injury), therefore after a normal CT, must make sure:

= No pain/ tenderness

= No neurologic symptoms/ signs

= able to move head/neck without pain

*if not, keep immobilized and get NSx/Ortho consult

Front 1132

Clearing C-Spine - Severely Head Injured Patient Special Situation

- may not? for?

- options - leave?

- take off?

- MRI isnt?

Back 1132

- may not be able to clear clinically for days/wks/ever

- options:

= leave collar on until wakes up (sometimes done)

= take collar off and re-apply if wakes up with pain or symptoms (most common approach)

= dynamic flex/ext views - not done

= MRI = not routine, done at some centres

Front 1133

Spinal Cord Injuries - Complete vs Incomplete SCI

- motor and sensory?

- reflexes?

- incomplete if?

Back 1133

1) Complete = no* motor or sensory function below level of injury, reflexes often hyperactive

(motor function will not improve with time)

2) Incomplete = some* motor and/or sensory function below lesion (may improve with time)

- any preserved motor or sensation (may only be sacral sparing/perianal sensation) makes the SCI incomplete

Front 1134

Spinal Cord Injuries - Spinal vs Neurogenic Shock

- spinal shock sees? patient will have? lasts?

- nero sees? loss of? at?

Back 1134

1) Spinal Shock = complete loss of all spinal cord function below level of injury

- Pts will have no motor, sensory or reflxes below

- lasts days-weeks

2) Neurogenic Shock = decreased BP occurring secondary to SCI, occurs secondary to loss of sympathetic innervation (T1-L2)

- higher lesions = most sympathetics lost

Front 1135

SCI Goals - prevent? (2)

Back 1135

- prevent secondary injury

- prevent/ treat complications

Front 1136

SCI and Preventing Secondary Injury - cant? focus on?

- even 1?

Back 1136

- cant affect injury thats already occured, focus to prevent worsening

- even 1 level worsening could be signif

= ex/ C6 to C5 level

Front 1137

Ways to Prevent Secondary Injury - imm? maintain? via? avoid? (2)

Back 1137

- immobilization

- maintain Spinal Cord Perfusion Pressure

= MAP - CSF pressure

- avoid hyperglycemia and hyperthermia

- early surgical intervention?

Front 1138

SCI - Complications - RESP - remember**

- loss of?

- decreased?

- look for?

- think about? (2)

Back 1138

= C345, keeps diaphragm alive

= loss of intercostals, abdo muscles

= decreased FEV, FVC, cough

= atelectasis/collapse

= pneumonia

= prolonged ventilation

= tracheostomy = secondary to prolonged ventilation

Front 1139

SCI - Complications - CVS - decreased? worsens with?

- cant? see?

- problem of? due to?

- increased BP due to?

Back 1139

= decreased BP = worsens with decreased VR (such as PPV)

= hypothermia = cant vasoconstrict

= DVT = from immob and hypercoag

= Autonomic dysreflexia = increased BP with certain stim. below SCI level

Front 1140

Other Spinal Cord Injuries - GI? skin?

Back 1140

- GI = gastric atony/ileus, Gi ulcers

- Skin = decubitus ulcers

Front 1141

Myotomes - Assessing Motor Level

- C5 to L5?

Back 1141

- C5 = deltoid

- C6 = elbow flexion

- C7 = elbow extension

- C8 = finger flexor

- T1 = small finger abductors

- L2 - hip flexor

- L3 = knee extension

- L4 = ankle dorsiflexor

- L5 = 1st toe extensor

- S1 = plantar flexor

Front 1142

Grading Motor Power - scale? may add?

Back 1142

Front 1143

Fluids - Dont give PO (by mouth) and use IV route if? - need to give?

- cant tolerate? due to?

Back 1143

- need to give large volume or complex solution

- patient cant tolerate p.o. due to GI problem or depressed level of consciousness

Front 1144

Goals of Fluid Therapy - rapidly? restores? avoid? especially?

Back 1144

- rapidly expand intravascular volume to restore blood pressure and therefore perfusion of vital organs

- avoid change in cell size, especially of brain cells

Front 1145

Choice of Fluids = Normal Saline (NS) - is?

- NaCl is?

- % means?

- 154 is? close to?

- giving NS means?

Back 1145

- normal saline = 0.9%

- NaCl = 154 mmol/ L NaCl

- % means g solute / 100 cc of water

- 154 pretty close to 140, very close to plasma water Na of 151

- giving NS means plasma Na will change only a little as direct effect of giving the fluid

Front 1146

Body Fluid Compartments

- ICF is? ECF is? separated by? - sizes

Back 1146

- ICF = 2/3 = small amount is water in RBCs

- ECF = 1/3

= 3/4 ISF, 1/4 plasma

Front 1147

What is Tonicity - this is?

- an effective osmole is one that?

-not effective osmoles? (2)

Back 1147

- this is effective osmoles

- an effective osmoles is one which when added to the ECF stays there (does not enter cells); eg Na

- urea and ethanol are not effective osmoles, since they enter cells and achieve the same concentration in ICF and ECF

Front 1148

Where Does the Water Not go

- if ICF tonicity < ECF?

- if ECF < ICF?

- if NS doesnt chnage? then?

Back 1148

- water crosses into the cell if the tonicity of the ICF exceeds that of the ECF

- water comes out of the cell if the tonicity of the ECF exceeds that of the ICF

- if the NS does not change the [Na] and therefore doesnt change the tonicity, then the cell size does not change

Front 1149

What fraction of admin NS stays in circulation?

- as add water with NaCl? force for?

- majority of NS? only?

Back 1149

- as add water with NaCl, the capillary hydrostatic pressure rises and the capillary albumin concentration falls, leading to a force for water to exit capillaries

- majority (2/3-3/4) of admin NS enters interstitial space, so only 1/3-1/4 stays in plasma

Front 1150

How Much NS to Give- standard bolus? over?

- may give?

- often follow this with? about?

- maintenance rule?

Back 1150

- standard bolus is 10-20 cc/kg over 30-60 minutes, may give faster or slower depending on severity of clinical situation

- often follow this with an infusion of fluid, about 50 ml/h above maintenance

- maintenance from 4-2-1 rule

Front 1151

4-2-1 Rule - is?

Back 1151

- first 10 kg = need 4 cc/kg/h

- next 10 kg = need 2 cc/kg/h

- remaining kgs = 1 cc/kg/h

Front 1152

60 kg patient gets?

Back 1152

- (4x10) + (2x10) + (60-20)x10

= 40 + 20 + 40 = 100 cc/h

Front 1153

Problems with NS - if give too much NS? can lead to?

- give a large volume of? can lead to?

Back 1153

- give too much NS with too little clinical monitoring, espc. with an older patient and/or one with heart disease = CHF

- give a large volume of NS leading to dilution of HCO3 = dilutional acidosis

Front 1154

Ringers - Lactate - nearly? contains? regens?

Back 1154

= nearly isotonic alternative to NS

= contains lactate as it is metabolized in the liver and regenerates HCO3

Front 1155

Fluids - What are We not Using - C? shown to?

Back 1155

- colloids

- eg/ Albumin, Pentaspan

- dont work, except with advanced liver disease

Front 1156

Route of Admin for Fluids (6)

Back 1156

- peripheral IV line

- central IV line

- intra-osseous

- subcutaneous

- oral

- G tube or NG tube

Front 1157

What is Free Water - water without?

- consider a litre of? which is equivalent to?

Back 1157

- water without isotonic Na

- consider a litre of "half-normal" (0.45%) NaCL iv fluid

- equivalent to:

= 0.5 L of NS

= 0.5 L of just water = free water

Front 1158

Patient - Why Hypernatremic - received? losing? that is?

- defic of? leads to? often during?

- leads to failure to?

Back 1158

- received isotonic fluid

- losing large volumes if dilute urine full of free water

- free water urine loss often due to acute deficity of ADH = due to hypothalamic injury peri-op

- leads to failure to reabsorb free water from renal tubule

Front 1159

If hypernatreamic, need ? Na?

- options include? (3) **

Back 1159

- need an IV fluid that has free water in it = [Na] < 140

- options:

= 5% dextrose = D5W = glucose - H20

= 0.45% NaCl = 1/2 normal saline

= 3.3% dextrose and 0.3% NaCl = 2/3 and 1/3

Front 1160

Why Cant We Give IV Water - at end of cannula, see? as?

- need a? that?

Back 1160

- hemolysis at the end of the IV cannula because the RBCs are suddenly bathed in hypotonic fluid, they osmotically suck up the water and they burst

- need a particle that stays in plasma (glucose, NaCl) to prevent the administered water entering RBC

Front 1161

Where in Body Does Administered Free Water Go?

- initially added?

- 2-3 goes into? like?

- added? to? meaning?

- 2/3 of added free water goes?

Back 1161

- initially added free water is in plasma

- 2-3 of it goes into ISF, just like NS

- added free water reduces the tonicity of ECF fluid below tonicity of ICF, meaning a proportion of added water will enter cells

- recall: 2/3 of TBW is inside cells as thats where 2/3 particles are, therefore 2/3 of added free water enters cells ***

Front 1162

How Much Free Water to Give?

- calculate with?

- TBW x current plasma = ?

- 70 kg man TBW is?

Back 1162

- calculate free water deficit using C1V1 = C2V2

- TBW (now) x current plasma [Na] = TBW (normal) x 140

- recall TBW man = 60% of body weight

- patient is 70 kg, so TBW = 42 L

Front 1163

How Much Free Water to Give?

- 42 x 155 =?

- deficit = ?

Back 1163

- 42 L x 155 = TBW (normal) x 140

- TBW (normal) = 42 L x 155 / 140 = 46.5 L

- deficit = TBW (normal) - TBW (now)

- deficit = 46.5 - 42 = 4.5 L

Front 1164

How Quickly Should We Give this?

- if chronic hypernatremia? avoid?

- safe limit? correct over?

- free water? or?

Back 1164

- chronic hypernatremia should be corrected slowly to avoid causing cerebral edema

- safe limit = 8 mmol/L/day, so with a patient whose plasma [Na] = 155, correct here over 2 days

- 4.5 L of free water / 48 h = 100 cc/h of free water

= 5% dextrose at 100 cc/hour

= 0.45% NaCl at 200 cc/hour

Front 1165

If have acute hypernatremia - can be corrected?

Back 1165

- can be corrected more quickly

Front 1166

Ongoing Losses - need to remember there will be? must either?

Back 1166

- need to remember there will be ongoing losses

- must either correct the cause of the losses (here, give exogenous ADH = DDAVP) and/or keep up with ongoing losses

Front 1167

Considerations for IV fluid - losses during? =?

= stress of surgery causes? so if give free water? leads to? risk of?

Back 1167

- losses of fluid during surgery = blood, isotonic fluid into surgical field (third-spacing)

- release of ADH by stress of surgery = if give her free water, she will retain it and she will develop hyponatremia and risk of brain cell swelling

Front 1168

Types of Deficits - deficit in? indicated by?

(3)

- free water deficit indicated by?

Back 1168

- isotonic fluid deficit, as indicated by physical exam = flat JVP, dry mouth, low level of consciousness

- free water deficit as indicated by hypernatremia (Plasma Na of 155)

- K+ Deficit as indicated by hypokalemia

Front 1169

If need isotonic fluid and free water and have K+ deficit?

- can give? to?

- can start? to?

- add? to?

- or give?

Back 1169

1)

= can give NS bolus to raise BP

= can start infusion of D5W to correct hypernatremia

= add KCl (10-20 mmol/L) to D5W

2)

= 0.45% NaCl plus KCl

Front 1170

Why Hyponatremic?

- diuretic can lead to? resulting in?

- causes include increases? or release?

Back 1170

- ECF volume depletion from diuretic can result in hyponatremia

- causes:

= thirst with increased fluid intake = add free water

= volume-mediated ADH release = fail to excrete free water

Front 1171

Why Hyponatremia - free water? tends to?

- over time?

Back 1171

- free water gain dilutes plasma [Na], tending to cause brain cell swelling

- over time, brain adapts by exporting particles

Front 1172

What if Hyponatremic and give lots of NS?

- sudden? drop in? increase in?

- rise in? shrinkage of? can cause?

Back 1172

- sudden correction of ECF volume depletion

- sudden drop in ADH levels

- sudden increase in urinary excretion of free water

- sudden rise in plasma [Na]

- sudden shrinkage of brain cells with risk of devastating demyelination

Front 1173

Take Home Points

- if hyovolemic and hypotensive?

- if hypernatermic? also should?

- post op patients release? if give free water?

Back 1173

1) Hypovolemic, hypotensive patients should get NS or Ringer's lactate

2) Hypernatremic patients need free water (D5W 2/3 & 1/3, 0.45% NaCl) but also treat underlying cause of free water deficit

3) Post-op patients release ADH and will get hyponatremic if given free water, so use NS

Front 1174

Take Home Points

- NaCl is used for?

- if hyponatremic, dont give? as can?

- IV fluids require?

Back 1174

4. 0.45% NaCl is useful fluid for hypernatremic, volume-depleted patients

5. Dont give large volumes of NS to hyponatremic patients due to risk of overly-rapid correction with devastating CNS outcomes

6. IV fluids require careful reassessment to avoid complications

Front 1175

Percentages of Body Weight that is Water

- 2/3 is? 1/3? plasma vs ISF?

- newborns have higher? elders have?

Back 1175

ICF = 2/3

ECF = 1/3 = 25% plasma, ISF 75%

- newborns have higher fraction, elderly have lower fraction, obese is lower

Front 1176

Movement of Water

Back 1176

Front 1177

Calculate Effective osmolarity - calculated as?

- if add Kcl to body?

Back 1177

= 2 x ( Na + K )

* if add Kcl to body, plasma Na > 140, cell size < normal

Front 1178

Effects of Hypotonic, Isotonic and Hypetonic Solutions on Cell Size

- if gain fluid? if lose fluid?

Back 1178

- free water refers to waterin a solution in addition to isotonic protein

Front 1179

Sites of Blood Loss = (5)

- causes reduction in? leads to?

Back 1179

- GI bleeding, uterine bleeding, urinary bleeding, trauma and surgery bleeding

- causes reduction in intravascular volume and leads to translocation of ISF into bloodstream

Front 1180

Isotonic Fluid Losses - from (4)

- causes loss of? % - from? no change in?

- third space losses assoc. with? (5)

Back 1180

- from skin, urine, gut, or third space losses

- cause loss of ECF volume = 25% of loss from plasma, 75% from ISF, see no change in ICF volume

- third space losses = pancreatitis, peritonitis, crush injury or major fracture, DVT, post-op fluid losses

Front 1181

Loss of Fluid from Plasma

Back 1181

Front 1182

If have 12 litres, with 3 L in plasma and 9 L in ISF and lose 4 litres, end up with?

- from plasma lose? ISF?

Back 1182

- lose 1L from plasma and 3 from ISF

- results in 2 L in plasma, 6L in ISF, end with 8 litres

Front 1183

Pure of Free Water Loss - happensvia?

- lost from? form ICF? from ECF?

- therefore if lose 3L from ECF? see?

- overall then?

Back 1183

- happens via skin or occasionally in the urine

- lost from TBW = 2/3 from ICF and 1/3 from ECF

- of ECF loss, 1/4 from plasma and three quarters from ISF space

- therefore if lose 3 L from ECF, 2 litres of water moves from ICF to ECF

- overall lose 2L from ICF and 1 litre from ECF

**free water loss always 2/3 from ICF and 1/3 from ECF

Front 1184

Introduction to Burns

- high?

- centers have improved?

- survival now? depends on?

Back 1184

- approx 500,000 burns per year in US, approx 10% require transfer to birn centre

- high morbidity and LOS

- burn centres have improved morbid/mortal

- survival from burns now >94%, but depends on availability of expertise, resources

- see mortality at extreme ages

Front 1185

Etiology of Burns - occur from contact with?

- majority from?

- degree of injury determined by (2) also?

Back 1185

- burns occur from contact with heat, chemical agents, radiation

- will be focusing on thermal burns

- majority of burns are from fire, scalds, and contact with hot objects

- degree of injury determined primarily by temp, duration of contact, also by thickness of skin

Front 1186

Classification of Burns - Etiology

- flame from? scald from? contact from? chem? electricity?

- most common?

Back 1186

- flame = damage from superheated oxidized air

- scald = damage from contact with hot liquids

- contact = damage from contact with hot solidmaterials

- chemicals = contact with noxious chemicals

- electricity = conduction of electrical current through tissues

*flame and scalds are most common causes

Front 1187

Classification of Burns - Depth

- 1st degree? 2nd degree? through?

- supericial 2nd - to?

- deep 2nd - into?

Back 1187

- 1st degree = injury localized to the epidermis

- 2nd degree = partial thickness = thru epidermis and into dermis

= Superficial 2nd = injury to epidermis and supericial dermis

= Deep 2nd = injury through epidermis and into deep dermis

Front 1188

Classification of Burns - Depth

- 3rd degree =? through? into?

- 4th degree - through? into?

Back 1188

-3rd degree = full thickness = injury through the epidermis and entire dermis and into subcut. fat

-4th degree = injury through skin and subcut. fat into underlying muscle or bone

Front 1189

Degrees of Burns

Back 1189

Front 1190

Classification of Burns - Depth

Back 1190

- most burns are not uniform and have areas of varying depth

- depth often continues to evolve after presentation

Front 1191

Thermal Injury Zones - 1) Zone of coagulation

- necrosis of? irreversible?

Back 1191

= necrosis of epidermis and underlying tissue, area of necrosis and irreversible damage

Front 1192

Thermal Injury Zones - 2) Zone of stasis/ ischemia

- immed?

- assoc with? decreased?

- area can? go on to?

Back 1192

- immed. surrounding the zone of coagulation

- assoc. with vascular damage, decreased tissue perfusion (also vessel leakage)

- this area can survive or go on to coagulative necrosis

Front 1193

Thermal Injury Zones - 3) Zone of Hyperemia

- VD from? tissue is? not at risk for?

Back 1193

- VD from inflammation

- tissue is viable and not at risk for further necrosis, often includes dermis

Front 1194

1st Degree and 2nd Degree Burns

Back 1194

Front 1195

3rd and 4th degree burns

Back 1195

Front 1196

Assessment of Burn Size: Percentage of Body Surface Area - must assess? with?

- rule?

-- 1% BSA is?

Back 1196

- must assess % BSA with 2nd and 3rd degree burns

- rules of nines

- palm of patient's hand and fingers = 1% BSA

Front 1197

Rule of Nines - front of trunk? back? legs? arms? head? perineum?

Back 1197

- front of trunk = 18% = thorax 9%, abdo 9%

- back of trunk = 18% (^^)

- legs = 18% each (front 9%, back 9%)

- arms = 9% each (front 4.5%, back 4.5%)

- head = 9%

- perineum = 1%

Front 1198

Rule of Nines

Back 1198

Front 1199

Classification of Burn Severity in Adults

- mild? moderate? severe?

Back 1199

- mild: <10% BSA

- moderate: 10-20% BSA

-severe: >20% BSA

*also considered severe: >5% full thickness burns, signif burns to eyes, face, ears, genitals or joints, assoc. trauma and high voltage injury

- pts with severe injuries should be transferred to burn centre

Front 1200

Criteria for Transfer to Burn Centre

- BSA? burns on?

- >5%? burns injury of? burns from?

- complicating factors?

Back 1200

- >20% TBSA

- burns on face, hands, feet, perineum, joints

- >5% full thickness burns

- electrical, chemical burns

- inhalation injury

- complicating factors = patient with special medical needs

Front 1201

Inhalation Injuries - inhalation of?

- causes injury to?

- causes edema of?

- can lead to?

- also a concern of?

Back 1201

- inhalation of steam (heat) or toxic compounds from burning can cause injury to upper and lower airways

- cause edema of upper airway (lips, vocal cords), can occur rapidly

- edema and inflammation of lower airways and parenchyma leads to pulmonary infiltrates

- CO toxicity also a concern

Front 1202

Management of Pt with Thermal Injuries - 4 Phases

Back 1202

1) Initial evaluation and resuscitation

2) Initial Wound Management

3) Definitive Wound Closue

4) Rehab

Front 1203

Thermal Injuries Management Overview

- remove?

- then?

- remember?

- may need? due to?

- first? next most important?

- pts wil be?

Back 1203

- remove pt from source and stop burning process

- A,B,C,D,E

- remember poss. of traumatic injuries

- may need early defin. airway due to rapid upper airway edema

- after stabilization of A and B, volume resuc. is most important

- patients with signif burns will be suffic. volume depleted

Front 1204

Thermal Burns - Airway Special Aspects of management

- early? esp. if?

- can progress to?

- injury of? to?

- compounded by? (2)

Back 1204

- early airway management is essential esp if signs of airway obstruction (stridor/hoarseness)

- can progress to airway obstruction rapidly

- inhalation injury can lead to signif upper airway edema

- this is compounded by generalized vascular permeability and massive fluid resusc.

Front 1205

Airway Management

- if have facial burn? also if fire in?

- also possibly?

- ideally?

Back 1205

- suspect airway injury in pts with facial burns or carb. sputum; fire within a closed space; also possibly if singed nasal hairs or tachypneic

- however these are not sens or specific; therefore, ideally fiberoptic laryngoscopy recommended (if not, use above signs)

Front 1206

Thermal - Airway Management

- all inhalation injury pts?

- those who should be intubated? (3)

Back 1206

- intubate pts with inhalation injury early (progression)

- also intubate early:

= pts with burns > 40% TBSA

= resp. distress

= usual criteria for intubation

Front 1207

Thermal - Special Aspects of Breathing Management

- hypoxemia, hypercarbia may occur due to? (5)

Back 1207

- hypoxemia and/or hypercarbia may occur b/o:

= airway obstruction

= thoracic trauma

= eschars and edema of chest and/or abdo wall

= CO poisoning

= abdo compartment syndrome (ACS) - can also occur with massive fluid resusc

Front 1208

Thermal - Special Aspects of Circulation Management

- pts will be? mainly from?

- could also be?

- in first few days?

- can also develop? with?

Back 1208

- pts with signif burns will ultimately be hypotensive

- mainly because of volume loss from vascular perm (so will be very edematous)

- could also be hypotensive from trauma

- also can get myocardial depression for first few days

- can also develop ACS with large amounts of fluid (>250 mls/kg fluid)

- may need to insert IVs through burnt tissue

Front 1209

Thermal - Special Aspects of Fluid Resuscitation = Parkland Formula

- amount? type of burn?

- in first 8 hours, give? then?

- use? monitor?

Back 1209

= 4 mls/kg/% BSA burned = 2nd and 3rd degree

- give 1/2 over first 8 hours (from time of burn) and give 1/2 over next 16 hours

- use Ringers

- monitor organ perfusion, U.O and adjust fluids

Front 1210

70 kg pt with 35% BSA burns need?

Back 1210

= 4 mls x 70 xs 35 = 9800 mls = 9.8 L

Front 1211

Thermal - Special Aspects of D and E

- all usual?

- think about?

- loss of skin could cause?

Back 1211

- all usual causes of altered level of consciousness, but:

- also could be from CO poisoning

- loss of skin = loss of heat = hypothermia

Front 1212

Inhalation Injury - Three Processes

- upper? subglottic? chemical? from?

Back 1212

1) Upper airway injury = lips to larynx

2) Subglottic Injury (subglottic airway and pulm parenchyma)

3) Chemical Asphyxia (CO)

Front 1213

Inhalation Injury Mechanisms

- in upper airway?

- inhale also? leads to injury of? causing?

- CO causes?

Back 1213

1. Inhlalation of hot gases leads to edema of upper airway

2. Inhalation of toxic gases and particulate matter, leads to injury to airways and pulmonary parenchyma, small airway obstruction and pulmonary inflammation and edema, leading to bronchospasm and airspace disease

3. Inhalation of CO = chemical asphyxia

Front 1214

Carbon Monoxide

- produced by? have in body from?

- binds to? forms?

- CO vs O2 affinity?

- COHb means?

Back 1214

- CO = produced by oxidation of carbon, have CO in body from breakdown of heme

- CO binds to Hb, forms COHb

- CO's affinity for Hb = 240x > 02

- COHb means less O2Hb = results in tissue hypoxia

Front 1215

Role of Carbon Monoxide

- leads to loading? doesnt?

- O2 decreases?

- without vs with O2? yet with hyperbaric?

Back 1215

- COHb also leads to loading (left) shift of 02 Hb curve

- doesnt affect pO2

- O2 decreases half life of CO:

= 4-6 hrs without O2 (room air)

= 1 hour with 100% O2

= 20 mins with hyperbaric O2

Front 1216

Diagnosis of CO Poisoning - diagnosed? via? (3)

- no single?

Back 1216

- diagnosed clinically via:

= Hx of suspected/exposure to CO

= Symptoms of CO poisoning

= Increased COHb level in blood

* note = no single symptom is either sens or spec for dx

Front 1217

CO Symptoms - (8)

- symptoms do not?

- main problem is?

- most common symptom?

Back 1217

- headache, confusion, dizziness, LOC, N, V, SOB, chest pain

- symptoms do not correlate with COHb levels

- main problem form CO is long term cognitive sequelae

*HA most common symptoms

Front 1218

CO Hb levels for Diagnosis

- smoker baseline? abnormal? non vs smokes

- levels must be measured by?

Back 1218

- smokers have baseline 3-5%. abnormal is >3% in non smoers, 10% in smokers

- levels must be measured by co-oximetry, will get falsely elevated O2Hb on pulse oximetry

- COHb is misread on SaO2 probe as O2Hb

Front 1219

COHb levels for CO Diagnosis - CPHb only used to? dont necc? dont predict?

- major outcome?

Back 1219

Front 1220

CO Poisoning Treatment

- goal to prevent? treatment is? competes for?

- accelerates?

- give? to decrease?

- therefore should?

Back 1220

- goal to prevent long term deficits

- treatment is O2, competes for Hb binding

- accelerates elimination of CO

- half life of COHb decreased with 100% O2

- therefore give 100% for anyone with suspected CO poisoning

Front 1221

CO Poisoning Treatment

- recommended to? requires?

- evidence showed?

Back 1221

- hyperbaric oxygen (HbO2) therapy recommended for CO poisoning

- HbO2 therapy requires trasnfer to proper facilities

- evidence showed pts with 3x HBO2 treatment within 24 hours had half rate of cognitive problems at 6 weeks, 6 months, etc

Front 1222

Suggested Indications for HBO2 - (3)

- signic? COHb?

Back 1222

- LOC, neuro deficits, ischemic cardiac chnages

- signif metabolic acidosis

- COHb level >25%

Front 1223

Burn Summary - burns have?

- all but mild burns are?

- hypothermia is?

- most burns from?

- must assess?

- early?

- if severly burned, then?

- need aggressive?

- consider?

- major concern?

Back 1223

- hypothermia is major concern, keep warm

- consider CO poisoning so admin 100% O2 to everyone

Front 1224

Vaccines and GBS

- believed that?

- vaccine effect?

- imms shown to?

Back 1224

- believed that immune stimulation plays a role in pathogenesis of BGS

- vaccines have effect on IS

- immunizations such as H1N1 or meningococcal have been shown to increase risk of contracting GBS

Front 1225

GBS is a?

- presents as? provoked by?

- immune response? because of?

Back 1225

- acute immune-mediated polyneuropathy, presenting as acute paralyzing illness provoked by preceding infection

- immune response cross-reacts with peripheral nerve components because of molecular mimicry and attacks myelin or axons

Front 1226

Clinical features of GBS

- progressive? absent?

- weakness starts in? can?

- weakness in?

- pain in?

- also see?

Back 1226

- progressive, fairly symmetric uscle weakness with absent or depressed deep tendon reflxes

- weakness usually starts in legs, can lead to respiratory weakness

- see facial, oropharyngeal and oculomotor weakness

- pain typically in back and extremities

- dysautonoia

Front 1227

Diagnosis of GBS

- LP reveals? seen in?

- use? believed to?

Back 1227

- LP often reveals elevated CSP protein with normal CSF

- seen in >75 patients after third week

- use IMIG, believed to create anti-idiotypic Abs that interfere with complement and cytokine production

Front 1228

Dementia DDX (10)

Back 1228

- Alzheimers

- Mild cognitive impairment

- vascular dementia

- mixed dementia

- dementia with lewy body

- Parksinsons disease

- frontotemporal dementia = FTD

- CJD

- normal pressure hydrocephalus

- huntingtons

- Wernice- Korsakoff Syndrome

Front 1229

Complications of Hip Fractures - seen more in?

- (5)

Back 1229

- seen more in femoral neck fractures

- infection

- thromboembolism

- AVN, nonunion

- chronic pain

- dislocation

Front 1230

5 Is of Falls = ?

Back 1230

- intellectual impairment

- instability

- immobility

- incontinence

- iatrogenic = polypharm

Front 1231

Why is leg shortened and externally rotated - due to? with some?

- axis of?

- iliopsoas causes?

Back 1231

- due to irritation and spasming of the iliopsoas muscle, with some contribution from lateral rotators of the hip

- axis of femoral head is altered

- when liopsoas contracts, leads to shortening as well as external rotation

Front 1232

Garden 1 - is a? not? typically? orientation?

Back 1232

= impaction fracture, is undisplaced and typically impacted with a valgus and retroverted orientation

Front 1233

Garden 2 - is? but is also? less? no shift in?

Back 1233

= undisplaced, complete fracture. Less common, have break in trabeculations but no shift in bone alignment

Front 1234

Garden 3 - involves? is? not completely?

Back 1234

= Involves varus displacement of the femoral head, shaft however is not completely displaced

Front 1235

Graden 4 - complete loss? between? shaft often?

Back 1235

involves comples loss of continuity between fragments, shaft translates proximally

Front 1236

Long bone fractures - more likely to see?

Back 1236

- higher rate of fat embolization

Front 1237

NPO Guideleines - goal to minimize?

- at 8 hours? 6 hours? 4 hours? 2 hours?

Back 1237

- goal to minimize gastric volume at time of surgery to prevent pulmonary aspiration

- 8 hours - stop fried or fatty food, or meat

- 6 hours - stop nonhuman milk, formula, light meal

- 4 hours - stop breast milk

- 2 hours - clear liquids, chewing gum (if not swallowed)

Front 1238

3 Antipt meds - A/ C/ Di / Ti - MOA?

Back 1238

- Aspirin = inhibits COX to decrease T-A2 production

- Clopidogrel = inhibits ADP-dependent plt aggregation

- Dipyridamole = inhibits AD and phospho, accumulates cyclic AMP to inhibit plt aggregation

- Ticlopidine = MOA similar to Clopidogrel

**these stop primary hemostasis

Front 1239

3 Anticoag meds - D/R/A - inhibitor of? prevents?

- all affect?

Back 1239

- Dabigatran = direct thrombin inibitor, prevent it from cleaving fibrinogen to fibrin

- Rivaroxaban = direct factor Xa inhibitor, prevent cleaving prothrombin to thrombin

- Apixaban = direct factor Xa inhibitor, prevent it from cleaving prothrombin to thrombin

* affect secondary hemostais

* still not as good as warfarin as reversible

Front 1240

Advantages of LMWH over heparin - greater? longer? better? lower risk of?

Back 1240

- greater BA

- longer duration of anticoag effect

- better correlation between dose and response

- lower risk of HIP

- lower risk of osteoporosis

Front 1241

Disads of LMWH - delayed? less easily? prolonged?

Back 1241

- delayed onset of action

- less easily inactivated

- prolonged half life in renal failure patients

Front 1242

Open Reduction Internal Fixation

- open eduction means?

- internal fixation refers to? used to?

Back 1242

- open reduction = surgery needed to realign bone fracture to normal position

- internal fixation = refers to steel rods, screwes, plates used to stabilize fracture to heal right way

Front 1243

Joint Resurfacing - preserves? uses?

- metal? usused to?

- now has?

Back 1243

- preserves femoral enck and uses metal prosthesis to replace femoral head

- metal acetabular component used to create a metal on metal bearing surface

- fallen out of faven

Front 1244

Hemiarthroplasty - replacing? leaves?

Back 1244

= replacing femoral head and neck while leaving acetabulum intact

Front 1245

Total Hip Athrplasty - used in those? signif?

- most common?

- some more?

Back 1245

- used in those who have failed to responed to nonpharm and pharm management, significant decrease in QOL

- most common defin surgical procedure for OA

- some more serious adverse events

Front 1246

Cough

- is a common? may be?

- different types?

Back 1246

- is a common presenting symptom, may be very distressing symptom for the patient

- acute < 3 weeks

- subacute = 3-8 weeks

- chronic > 8 weeks

Front 1247

Function of Cough

- clear? inhaled?

- protect?

Back 1247

- clear mucuous and inhaled substances

- protect airway from inhalation of foreign substances

Front 1248

Cough Receptors

- 5 locations?

- all act on? via? also receives?

Back 1248

- larynx and supralaryngeal area

- trachea and bronchi

- ear canal and eardrums

- pleura, pericardium and diaphargm

- esophagus and stomach

** all act via vagus to cough centre (medulla, mucleus tractus and solitarus)

** also recieves from CNS cortical modulation

Front 1249

Cough Centre Acts on? (3) which include? (SM/P/V)

Back 1249

- spinal motor = expiratory muscles, pelvic sphincters

- phrenic = diaphargm

- vagus = larynx, trachea, bronchi

Front 1250

Physiology of Cough

- Inspiratory? Compressive? Expuls?

Back 1250

1) Inspiratory phase = wide open larynx, diaphragm contracts for rapid, deep inspriation

2) Compressuve phase = larynx closes and expiratory muscles contract, generating positive intrathoracic pressure

3) Expulsive phase = larynx open widely, with sudden outflow of air

Front 1251

Causes of Chronic Cough

- if healthy, then? which?

Back 1251

- generally healthy person - if have chronic cough

- the big 3 = accounts for 90%

Front 1252

Big 3 of Chronic Cough **

Back 1252

1) Upper Airway Cough Syndrome = Post Nasal Drip

2) Asthma

3) GERD

Front 1253

Upper Airway Cough Syndrome

- secretions in?

- symptoms ? (ND/T/S)

- causes? (3)

- sometimes can be?

Back 1253

- secretions in the upper airway stimulate cough receptors in the laryngeal mucosa

- symptoms = nasal discharge, throat clearing, sensation of dripping in back of throat

- causes - allergic rhinitis, vasomotor rhinitis, sinusitis

- sometime difficult to diagnose = empiric therapy may be best test

Front 1254

Treatment - Upper Airway Cough Syndrome

- may respond to? but dont want to?

- may also use? or?

Back 1254

- may respond to antihistamines and decongestants (pseudoephedrine), but may not want to use these longer term

- may also use topical nasal steroids (esp. if allergic component) or ipatropium bromide (if vasomotor rhinitis)

Front 1255

Asthma - Symptoms - main four? (4)

- cough may only be?

Back 1255

- cough, wheezing, chest tightness and dyspnea

- cough may be only manifestation of asthma

Front 1256

Asthma - Diagnosis and History

- often history of?

- diagnosis may be? or do a?

- cough usually responds to?

Back 1256

- often a history of atopy or a FM of asthma

- diagnosis may be confirmed on spirometry or bronchoprovocation (methacholine challenge) testing

- cough usually responds to treatment of asthma (inhaled steroids, bronchodilators)

Front 1257

GERD

- acid from? that then?

- may have? such as?

- cough may ?

Back 1257

- acid from stomach acting on esophagus, laryngopharyx, stimulating cough receptors

- may have symptoms of heartburn = burning retrosternal chest discomfort, worse after meals and lying down, acid taste in mouth

- cough may be only manifestation

Front 1258

GERD - Diagnosis and treatment

- done with?

- often give? such as? (2)

Back 1258

- diagnoses made on 24 hour esophageal pH monitoring, empiric therapy is often instituted instead

- can be treated with H2 antags, PPIs

Front 1259

The others

- responsible for?

- include? (70

Back 1259

- responsible for 10% of chronic cough

- Resp tract infection

- ACE inhibitors

- chronic bronchitis

- bronchiectasis

- lung cancer

- intersttial lung disease

- recurrent aspiration

Front 1260

Resp Tract Infection

- caused by? may lead to?

- may have history of? see?

- other elements?

Back 1260

- viral URTI may lead to prolonged cough

- may have had a history of other URTIs ymptoms at onset of cough =runny nose, sore throat, fever and myalgias

- etiolgoy of cough has some element of upper airway cough syndrome from nsasal secretions, airway inflammation from infection, airway hyperresponsiveness from underlying asthma

Front 1261

RTI - mostly caused by?

- most do not?

- post viral cough often?

- consider?

Back 1261

- chronic cough is mostly caused by viral infections

- most do not benefit from Abx therapy

- post viral cough may respond to inhaled ipatropium bromide

- consider specific infections in certain cases = Bordatella pertussi, Myco tb

Front 1262

Bordatella pertussis Infection

- sometimes referred to as?

- can also be seen in?

- is highly? but usually?

- caused by?

Back 1262

- sometimes referred to as whooping cough

- commonly regardas as childhood illness, can be seen in adults

- highly contagious but vaccination usually effective at preventing severe cases in childhood

- caused by gram neg coccobacillus

Front 1263

Bordatella Pertusiss - Whooping Cough

- see? following?

- % present?

- mean cough duration? referred to as??

Back 1263

- inspiratory, stridorous sound following paroxysms of coughing

- only 20 to 40% of adults present with whooping

- may have post-tussive vomiting

- mean duration of cough in adults is 36 to 48 days but sometimes referred to as "100 day cough"

Front 1264

Diagnosis of Bordatella

- can be a? made with? or by?

- highest sens in?

- if presenting after 4 weeks?

Back 1264

- can be a tricky diagnosis

- can be made with nasopharyngeal swab, by PCR or by culture

- highest sensitivity within first few weeks of symptoms

- if presenting after 4 weeks, can consider doing serology for IgG titres if not vaccinated within 2 years

Front 1265

Treatment of Bordatella Pertussis

- treatment may reduce?

- many patients do no?

- treat if?

- treat with either?

Back 1265

- treatment may reduce the severity of illness and reduce inectivity if admin early

- many patients do no present early enough

- treat if within 3 to 4 weeks of symptoms

- consider treatment if persistent symptoms after 4 weeks

- macrolide Ab = Azithro at 500 mg x 1 day, then 250 mg for 4 days or Clarith 500 mg 7 days

Front 1266

Mycobacterium Tb

- consider if? such as?

- present with (3)

Back 1266

- consider TB especially if patient is from a higher risk group = immigrant from endemic region, first nations, immunocomp

- may present with hemoptysis, weight loss and night swetas

Front 1267

ACE Inhibitors

- commonly used to?

- % that develop?

- thought to be due to? which?

Back 1267

- commonly used to treat hypertension and heart disease

- up to 15% of patients devleop cough

- thought to be due to accumulation of bradykinins, which stimulate cough receptors

Front 1268

ACE Inhibitor Cough

- usually occurs? but can?

- may have?

- improves with?

- usually recurs with?

Back 1268

- usually occurs within 1 week of initiation, but can present after even 6 months

- may have itchy or scratchy sensation in throat

- improves with stopping therapy but may take up to 4 weeks

- usually recurs with re-challenge

Front 1269

Chronic bronchitis

- major RF?

- diagnosis confirmed?

- cough may improve with?

Back 1269

- majorRF is smoking

- diagnosis confirmed by pulmonary function testing

- cough may improved with inhaled bronchodilators and steroids, smoking cessation

Front 1270

Bronchiectasis

- inflammation that?

- leads to? poor? and then?

Back 1270

- inflammation causes small airway damage

- leads to airway dilatation and scarring, poor secretion clearance, and chronic recurrent infection

Front 1271

Some Causes of Bronchiectases (7)

Back 1271

- postinfectious

- primary immune disorders

- CF

- alpha-1-antitrypsin disease

- inflammatory disorders and connective tissue diseases

- airway obstruction

- allergic bronchopulmonary aspergillosis

Front 1272

Imaging of bronchiectasis - on CXR, look for?

Back 1272

- features can be noted on chest xray but best seen on high-resolution CT scan

- dilated, thickened airways

Front 1273

Treatment of Bronchiectasis

- exacs treated with? to?

- base Abx choice on?

- candidates for? think about?

- enhance sputum clearance with?

- surgery may be?

Back 1273

- treat exacerbations of bronchiectasis with Abx to prevent worsening of bronciectasis

- may base antibiotic choice on sputum culture

- patents (esp CF) may be candidates for chronic inhaled Abx, chest physiotherapy and inhaled agents (mucolytics) to enhance sputum clearance

- surgery is occasionally considered for very localized bronchiectasis or for recurrent hemoptysis

Front 1274

Lung Cancer

- may present with? (3)

- key is?

Back 1274

- may present with chronic cough, hemoptysis, weight loss

- imaging is key to the diagnosis

Front 1275

Interstitial Lung Disease

- cough is? (2)

Back 1275

- cough from ILD is usually persistent and non-productive

Front 1276

Recurrent Aspiration

- seen in?

- RFs = (4)

- ask whether?

Back 1276

- patients with swallowing difficulty (dysphagia) may be prone to recurrent episodes of aspiration

- RFs = neurologic dysfunction, esophageal disease, NG feeding tubes, prolonged recumbency

- ask whether coughing is often temporally related to eating or drinking

Front 1277

Cough Algorithm - do? consider? tihnk of?

Back 1277

Front 1278

Big Three - Investigation? Treatment?

Back 1278

Front 1279

After the Big Three - do? imaging of?

- also perform? (3)

Back 1279

Front 1280

Resp General Principles

- goal should be? and then?

- monitor?

- often multiple?

Back 1280

- goal should be to elucidate the causes of the cough and use directed therapy

- monitor response to therapy and compliance

- there are often multiple causes of cough, mainly partially effective treatments

Front 1281

Cough - If All else falls

- consider? can use?

- non opioids?

- or use?

Back 1281

- consdier central acting anti-tussive agents

- opioids such as codeine

- non-opioids such as dextromethorphan

- Gabapentin

Front 1282

Asthma Definition

- is a? char. by?

- defined by? (3) vary over?

- has variable?

Back 1282

- heterogenous disease, usually characterized by chronic airway inflammation

- defined by history of respiratory symptoms such as wheeze, SOB, chest tightness and cough that vary over time and in intensity

- has variable expiratory airflow limitation

Front 1283

Symptoms of Asthma

- vary over? usuallt?

- wheeze is a? seen on?

Back 1283

- vary over time and severity, usually multiple:

= SO, wheeze, coughing, chest tightness

- wheeze = a continuous whistling sound associated most commonly with expiration due to collapse of intrathoracic airways

Front 1284

Symptoms of Asthma

- worsen ? provoked?

- seen with? worse with?

Back 1284

- occur or worsen at night

- provoked by exposures, either specific allergens or nonspecific irritants

- recurrent or prolonged chest infections (>2 weeks), actually asthma exacerbations

Front 1285

Epidemiology of Asthma

- high? prev? 15%

- most?

Back 1285

- high burden of disease around the world

- 10% prevalence of asthma

- 15% if children have had asthmatic symptoms

- most cases allergic/atopy related

- occupational exposures

Front 1286

Causes of Wheeze

(9)

Back 1286

- allergic rhinosinusitis

- post-infectious cough

- GERD

-COPD

- acute bronchitis

- heart failure

- foreign body

- obstructing lesion

- vocal cord dysfunction

Front 1287

Diagnosis of Asthma - demonstration of?

- increased? after?

- variability in? (2)

- response to?

- positive?

Back 1287

- demonstration of reversible airflow obstruction is key

- increased FEV1 > 12% and >200 cc after bronchodilator (+/- norm. of FEV1/FVC)

- variability in FEV1 over time

- variability in Peak Flow over time

- response to trial of therapy

- positive challenge test (Methacholine, Exercise) with fall in FEV1 by >20%

Front 1288

Spirometry in Asthma

- pattern = (2)

- see positive

Back 1288

- the pattern of asthma on spirometry is:

= reduced FEV1/ FVC ratio

= positive bronchodilator response

* see positive methacholine challenge

Front 1289

Pathophys of Asthma

- inducers? (3)

- inflammation leads to?

- triggers = (4)

- symptoms (4)

Back 1289

- inducers = allergens, chemical sensitizers, air pollutants, virus infections

- inflammation leads to airway hyperresponsiveness and airflow limitation

- triggers = allergens, exercise, cold air, particulates

- symptoms = cough, wheeze, ches ttightness, dyspnea

Front 1290

Therapies for Asthma

- avoid?

- bronchodilation via? (2)

- anti-inflamm? (2)

Back 1290

- allergen/ trigger avoidance

- bronchodilation = B2 agonists, anticholinergics

- anti-inflammation = stewards, leukotriene, receptor antagonists

Front 1291

Therapy and Allergen Avoidance

- avoid? often is?

- crucial to?

- 25% is?

Back 1291

- avoidance of identified triggers in allergic asthma is beneficial but often difficult

- occupational allergens are crucial to identify and avoid

- up to 25% of asthma is work related with up to 10-15% of cases caused by occuptational allergen

Front 1292

Therapy - Bronchodilation - generally used for?

- good for?

- B2 agonists - reduced? target?

- dont use antichols when?

- comes as either?

Back 1292

- BDs are generally relievers or rescue medications

- have immediate effect with relief of symptoms**

- B2 agonists = B2 vs B1 = reduced cardiac SEs, target smooth muscle cells

- anticholinergic drugs exist, but not used as commonly for asthma when stable

- comes as short acting or long acting

Front 1293

Short Acting Bronchodilators

- colour? types? S/T

Back 1293

- Salbutamol

- Terbutaline

= "blue" puffer

Front 1294

Long Acting B2 Agonists

- better for? then?

- dont use as?

- types = S/F

Back 1294

- provide improved and prolonged bronchodilation compared to short-acting drugs

- but when used as monotherapy, resulted in increased mortality

= Salmeterol and Formoterol

Front 1295

Therapy - Corticosteroids

- need to treat? which is?

- used as both?

- see improvement over?

- delivered by? prefer? oral when?

Back 1295

- treat the underlying pathophys of asthma - inflammation

- mainstay treatment of asthma = maintenance or preventer

- improvements over days

- can be delivers by inhaled route = much preferred, action at target organ with reduced SEs

- oral route is systemic, see large inflammation reduction, use during severe exacerbations but has alot of SEs

Front 1296

Inhaled Corticos - Safety

- local = 2 - C/D 0 are?

- systemic are? including (4)

Back 1296

- local = risk modifiable = candidiasis, dysphonia

- systemic, rare, risk modifiable:

= adrenal suppresion (very rare)

= growth inhibition in children (1 cm)

= osteoporosis

= cataracts, glaucoma

Front 1297

Inhaled Coticos - colour? examples (3 - T/M/B)

Back 1297

= orange/red/brown puffer

= Takeda, Mometasone, Budesonide

Front 1298

Asthma Combination Therapy - better to?

- reduced? (2) better (3)

Back 1298

- LABA combined with ICS was better than doubling the dose of ICS

- reduced symptoms

- better nocturnal control

- better QOL
- better lung function

- reduced exacerbations

Front 1299

Combination Therapy - such as? (2)

- S/FP

- B/F

Back 1299

=Salmeterol/ Fluticasone Propionate

= Budesonide/ Formoterol

- many others

Front 1300

Asthma Therapy - Leukotriene Receptor Antags

- leukotrienes are made by?

- promote? increase? cause?

- LTRAs block?

Back 1300

- leukotrienes produced by the action of the arachidonate 5-lipoxygenase enzyme

- promote bronchoconstriction, increase mucous secretion and cause inflammation

- LTRAs block action of leukotrienes on target cells such as bronchial smooth muscle cells

Front 1301

Leukotriene Receptor Antagonist

- med used for?

- is good for?

- used largely in?

- inferior to?

- only avail?

Back 1301

- a maintenance/preventer medication

- non steroidal, oral medication

- used largely in children

- inferior to ICS in adults as controlling medication

- Singulair = only one available in Canada

Front 1302

Escalation Therapy of Asthma

Back 1302

- maintenance = ICS

Front 1303

Managing Asthma - Control means? daytime? night time? during PA? exacs? absence? need for?

Back 1303

- uncontrolled if any char. is out of range

Front 1304

Asthma Control - if not controlled, means?

- good control means?

- see athletes?

Back 1304

- patients who are not controlled have decreased QOL, increased risk of exacerbations

- good control = means essentially normal activity with no symptoms

- 5-10% of Olympic athletes have asthma

Front 1305

Acute Exac of Asthma

- acute loss of control assoc. with? (3)

- admission based on?

- useful to get?

Back 1305

- acute loss of control is often assoc. with triggers = infection, enviro, allergen

- admission to hospital can be predicted based on response to bronchodilator and ER therapies

- serial peak flow of FEV1 is useful,quant measure of response to therapy

Front 1306

Acute Exacerbations of Asthma - Acute Treatment

- BD = (2)

- oral - such as?

- monitor?

- Abx?

Back 1306

- bronchodilators = B agonists and anticholiners = lots

- oral steroids = 4o to 60 mg of prednisone

- monitor peak flow/ spirometry

- Abx not usually indicated

Front 1307

Acute Exacerbations of Asthma - Ward - (3)

- monitor? training? role in?

Back 1307

- asthma education

- inhaler technique training

- monitor peak flow/ spirometry

Front 1308

Testing to investigate asthma symptoms

- in office, can? start on? give?

Back 1308

- spirometry can be done in office

- start on low dose inhaled ICS (Budesonide) and reassess symptoms

- give rescue med = Salbutamol inhaler

Front 1309

Adjusting Meds in Uncontrolled Asthma Patient

- increase to? review?

Back 1309

- increase to combination inhaler (Salmeterol/Fluticasone) and review inhaler technique

Front 1310

Definition COPD

- slowly? involving?

- characterized by?

- caused mainly through?

Back 1310

- slowly progressive disease involving the airways or pulmonary parenchyma (or both) that is characterized by persistent airflow limitation

- caused mainly through exposure to tobacoo smoke, but can also be attrib. to other inhaled irritants like biomass fuels and occupational exposures

Front 1311

Chronic Bronchitis

- known as?

- see? (6) no? frequent? excess?

Back 1311

- known as blue bloater

= chronic cough

= wheeze

= excess mucus from goblet cells in airway

= frequent bronchitis

= no air hunger

= hypercapnic, hypoxic

Front 1312

Emphysema - known as?

- are? see? abnormal? destruction of?

- blood is?

Back 1312

- known as pink puffer

= breathless

= wheeze

= abnormal enlargement of alveolar spaces

= destruction of the alveolar walls and diffusing membranes

= normocapnic, mildly hypoxic

Front 1313

Most COPD is a bit of both?

Back 1313

- a bit of both emphysema and chronic bronchitis

Front 1314

DD - Breathlessness - main one? airways vs parenchymal (1) vs vessels (2) vs muscles (1)

- also from? (3) CD/A/D

Back 1314

1) Pulmonary Disease

= airways = asthma, bronchiectasis

= parenchyma = ILDs

= vessels = PH, PE

= muscles = neuromusc. disease

2) Cardiac disease

3) Anemia

4) Deconditioning / Obesity

Front 1315

DD - Chronic Cough

- main one? airways (2) vs parenchyma? (2)

- also consider? (3) S/R/M

Back 1315

1) Pulmonary DIsease

= airways = asthma, bronchoiectasis

= parenchyma = ILDs, infection

2) Sinus disease

3) Reflux

4) Medication = ACEi

Front 1316

Epi of Cough - is the 4th leading?

- only cause of death that?

- prevalence?

Back 1316

= 4th leading cause of death

= only major cause of death that has increased in recent years

= prevalence = 5% of Canadians >35 yo, % of women and 4% of men

Front 1317

Causes of COPD

- most prev?

- occupational?

- biomass?

- defic?

- long standing?

Back 1317

- smoking = most prevalent, easily rec. "noxious" fume

- occupational = organic, inorganic dust exposures

- biomass fuels = wood, animal dung, coal, crop residues, women who cook in developing nations

- a1 - antitrypsin deficiency

- long standing/ untreated asthma

- air pollution

Front 1318

Smoking and COPD

- rates in smokers? continuous smoker risk?

- see contnued?

- cessation therapy is?

Back 1318

- rates of COPD in smokers varies considerably in studies, but it is not 100%

- continuous smokers have an estimated lifetime risk of COPD of 25-50%

- see continued effect of smoking, leading to disability and death

- smoking cessation is 1 of only 2 therapies that reduces mortality

Front 1319

Diagnosis of COPD

- clinical suspicion when? (4), with?

- key to diagnosis?

- do not accept?

Back 1319

- clinical suspicion in patients with dyspnea, wheeze, chronic cough and/or sputum production with an exposure history (most commonly smoking)

- spirometric confirmation is key to the diagnosis**

- do not accept a clinical diagnosis unless the patient is unable to perform spirometry

Front 1320

COPD Pulmonary Function tests

- obstruction defined by?

- reduced? shows?

- elevated? shows?

- emphysema sees low?

Back 1320

- obstruction defined by low FEV1/FVC

- reduced FEV1 shows severity of airflow obstruction

- elevated TLC shows hyperinflation

- low diffusion capacity consistent with emphysema

Front 1321

Spirometry - FEV1/FVC Ratio of COPD

- hard cutoff at? overdiagnosis of? underdiagnosis of?

Back 1321

- hard cutoff of <0.70

- overdiagnosis of the elderly where the FEV1/ FVC naturally falls bellow 0.070

- underdiagnosis of the young where the FEV1/FVC naturally falls above 0.070

Front 1322

Pathophys of COPD

- inflammation plays? pattern is?

- amplifie? resulting in?

Back 1322

- inflammation plays central role in development of COPD, but the pattern is different from asthma

- amplified response to noxious stimuli resulting in inflammatory mediators, oxidative stress, protease-antiprotease imbalance

Front 1323

Pathophys of COPD

- increase? leading to?

- decreased? leads to?

- gas exchange?

Back 1323

1 = Mucus hypersecretion = increased cough

2 = Airflow limitation from decreased airway luminal diameter = results in dypsnea

3 = gas exchange abnorms from destruction of alveoli = hypoxia, hypercapnia and dyspnea

Front 1324

COPD - Hyperinflation

- limitation of? trouble with?

- less air is? leading to?

- with high RV, see? makes? gives?

- leads to?

Back 1324

- airflow limitation = >> trouble with exhalation

- with each breath, less air is expelled versus amount inhaled = "Breath Stacking"

- with high RV, the lung is now at a mechanical disadvantage, making respiratory efforts inefficient = sensation of dyspnea

- high RV due to obstruction, build up gas in lung

Front 1325

Therapies fo COPD

- broncho - use?

- give? for?

- rehab for?

- try both? (2)

Back 1325

- bronchodilation = B2 agonists, anticholinergics

- anti-inflammation = steroids

- physical conditioning and education = pulmonary rehab

- oxygen

- vaccinations

Front 1326

Therapy for COPD = Bronchodilation

- lack of?

- reduces? (2)

- can use?

- or use?

Back 1326

- although lack of bronchodilator response on spirometry, clinical response recognized

- reduces dynamic hyperinflation

- may reduces exacerbations

- can use anticholinergics = short and long acting

- B2 agonists = short and long acting

Front 1327

Therapy - Anticholinergics

- prefer? in?

- better? reduced?

- examples = (3)

Back 1327

- prefer long-acting agents in patients with persistent symptoms

- better bronchodilation

- reduced exacerbations

= Tiotropium, Umeclidinium, Aclidinium

Front 1328

Therapy - Long Acting B2 Agonists

- can use? unlike in?

- use? (3) = S/F/I

Back 1328

- unlike asthma, monotherapy with LABA is acceptable

= use Salmeterol, Formoterol, Indacaterol

Front 1329

COPD Combination Therapy

- now have a? in COPD use?

- such as?

Back 1329

- cones in a now wide assortment

- dual bronchodilators indicator in COPD only

- Umeclidinium/ Vilanterol, Aclidinium/Formoterol, etc

Front 1330

Therapy - Inhaled Corticos

- unlike asthma as use? as?

- decreases? improves?

- cant use a? must?

Back 1330

- unlike in asthma, where corticos are the mainstay, in COPD, ICS is an adjunct therapy

- decreases frequency of exacerbations, improved QOL< indicated in more severe disease for symptoms of breathlessness

- not a monotherapy option in COPD = always with long acting bronchodilators

Front 1331

COPD Therapy - Pulmonary Rehab

- focused?

- reduces? increases? improved?

Back 1331

- focused exercise and educational program geared to patients with a chronic resp. illness

= reduces dyspnea

= increased exercise capacity

=improved QOL

= reduced risk of exacerbations and mortality after exacerbations

Front 1332

COPD Therapy - Oxygen

- one therapy that?

- titrate to?

- excessive?

Back 1332

- one of the few therapies in COPD that actually reduces mortality from the disease

- titrate to target SpO2 = 88-92%

- excessive oxygen (often during acute exacerbation) can be detrimental

Front 1333

Problem of Excessive Oxygen

- careful in? increased?

- loss of? worsening? change in?

Back 1333

- in patients who are CO2 retainers, excessive O2 will result in increased hypercapnia which may be fatal

- loss of hypoxic drive to breathe, worsening V/Q mismatch, chnage in carrying capacity of HgB for CO2

Front 1334

COPD Therapy - Imms

- weak evidence for? but minimal?

- annual?

- should also get?

Back 1334

- weak evidence for benefit in preventing exacerbations, but minimal harm/risk

- influenza annually

- pneumococcal variation:

= Prevnar 13 x 1

= Pneumovas x1 with 1 repeat booster after 10 years

Front 1335

COPD Escalation Therapy

Back 1335

Front 1336

COPD Acute Exacerbations

- worsening of? often?

- see? (3)

- as progresses?

- will likely?

Back 1336

- worsening of resp. symptoms beyond day to day variation, often triggered by infections

- see dyspnea, cough and sputum chnage

- as COPD progresses, exacerbations become more frequent

- an exacerbator will likely continue to have frequent exacerbations

Front 1337

AE COPD Impacts - more rapid?

- reduced?

- loss of?

Back 1337

- more rapid decline of lung function = FEV1

- reduced QOL

- reduced exercise tolerance

- loss of income/ health care expenditure

- increased mortality

Front 1338

AE COPD Management

- use?

- give? at?

- oxygen with?

- consider?

Back 1338

- bronchodialtors = alot and often

- systemic steroids = 40 mg prednisone x 5

- oxygen with careful titration

- Abx

- ICU care if needed

Front 1339

AE COPD and Abx

- 50% caused by? may relate to?

Back 1339

- bact. infections cause 50% of exacs

- may relate to increased bacterial burden when chronically colonized

- strongest evidence for use in purulent exacerbations, mod to severe COPD and AE needing ICU

- reduces treatment failure, mortality and symptoms

Front 1340

Diagnosis of COPD

- use? then?

Back 1340

- pulmonary funtion test and Xray to loo for hyperinflation

Front 1341

Approp Therapy for COPD

- stop?

- give? as needed?

- also give?

Back 1341

- smoking cessation

- long acting anticholinergic = Tiotropium

- use as needed = Salbutamol inhaler

- have inhaler teaching

Front 1342

AE COPD Therapy

- oral?

- if purulent?

- then give?

- consider?

Back 1342

- oral steroids = prednisone

- purulent = Abx

- Salbutamol and Ipratropium every 2 to 4 hours

* consider hypercapnia due to retaining oxygen

Front 1343

Breathing Discomfort caused by? (4)

- inability to?

- heavy?

Back 1343

- air hunger

- chest tightness

- heavy breathing effort

- inability to get a deep breath

Front 1344

Mechanisms of Dyspnea

- increased? decreased? also?

- increased? leads to?

- heavy? from? that then?

Back 1344

- increased PCO2, decreased PO2 and acidosis leads to air hunger

- increased J receptors and airway irritant receptors leads to bronchoconstriction and chest tightness

- brain causing heavy breathing = increases work of breathing

Front 1345

Approach to Dyspnea - Mechanisms

- CHF leads to? that then?

- increased? then causes?

- anemia then? leads to?

Back 1345

= CHF leads to increased interstitial fluid = increases J receptor stimulation

= Poor fitness increases anaerobic metabolism = acidosis

= Anemia decreases oxygen delivery = leads to acidosis

Front 1346

Approach to Dyspnea - Acute Causes - (5)

Back 1346

- upper airway

- pulmonary

- cardiac

- toxic/metabolic

- misc

Front 1347

Pulmonary Causes of Dyspnea - causes (6)

Back 1347

- PE

- COPD/asthma

- pneumothorax

- chest trauma

- infection

- pulm hemorrhage

Front 1348

Approach to Acute Dyspnea - establish? provide? assess?

- screening for? (4)

- initial treatment = (3) D/B/VS

Back 1348

1) Establish stability of the patient = provide O2, assess vitals, IV access, monitoring, airway assessment

2) Screening exam = pneumothorax, tamponade, foreign body, bronchospasm

3) Initial treatment = decompression, bronchodilator, ventilatory support

Front 1349

Approach to Acute Dyspnea

- initial?

- then do?

- treatment? (4)

- further investigations =? (5)

Back 1349

- initial investigations = Xray, ECG, bloodwork

- history and physical

- further treatment - steroids, bronchodilators, Abx, diuretics for CHF

- further investigations = CT chest, spiromtery, echo, ABG, BNP level

Front 1350

Dyspnea Signs of Severe Resp. Distresss

- (6)

Back 1350

- tachypnea

- indrawing and accessory muscle use

- inability to lie down

- inability to speak in sentences

- agitation

- cyanosis, diaphoresis

Front 1351

Signs of Impending Resp. Failure - reduced? inability to? rising?

Back 1351

- reduced level of consicousness

-inability to maintain resp. efforts

- rising PCO2 and acidosis

Front 1352

Pulmonary Causes of Chronic Dyspnea

- (5) A/R/PV/P/P

Back 1352

- airway disease

- restrictive disease

- pulmonary vascular disease

- parenchymal disease

- pleural disease

Front 1353

Approach to Dyspnea - Chronic - History - ask about? (6)

Back 1353

- onset and duration

- quantify severity

- exacerbating/ alleviating factors

- associated symptoms

- general medical and FH

- social history

Front 1354

Dyspnea - Medical Research Council Dyspnea Scale

- Grade 1? 2? 3? 4? 5?

Back 1354

- Grade 1 = breathless with strenous exercise

- Grade 2 = SOB when hurrying on the level or walking up hill

- Grade 3 = walks slower than people of same age

- Grade 4 = stops for breath after waling 100 years

- Grade 5 = too breathless to leave the house or breathless when dressing

Front 1355

Dyspnea - Chronic - PE - perform?

- look for? (3)

Back 1355

- respiratory

- CV

- general = thyroid disease, anemia, clubbing

Front 1356

Dyspnea - Chronic Tests - (7) Investigations

Back 1356

- chest Xray

- blood tests

- PFTs

- CT scan

- ABG

- echo

- exercise testing

Front 1357

Dyspnea Test - Chest Xray

- may show? or other?

- may not show? (2)

Back 1357

- may show interstitial disease, other parenchymal disease, pleural disease

- may not show airways disease, pulmonary vascular disease

Front 1358

Dyspnea test - Blood Tests - main two? (2)

- look at? for?

Back 1358

- Hemoglobin may show anemia or polycythemia (2 to chronic hypoxemia)

- TSH may show evidence of thyroid disease

Front 1359

Dyspnea - PFTs - obstructive causes (2)

- restrictive = (3)

- low diffusion = see? (4)

Back 1359

- obstructive = asthma, COPD

- restrictive = ILD, chest wall, neuromuscular

- low diffusion = anemia, ILD, emphysema, pulmonary vascular

Front 1360

Approach to Dyspnea ask? yes?

- if no - it is?

- if yes - ask? yes or no?

Back 1360

- Is FEV1/ FVC low? (<70%)

- Yes = is FVC low (<80% pred):

= if no = obstructive

= if yes = is TLC low? (

= if no = obstructive

= if yes = mixed

Front 1361

Approach to Dyspnea - ask?

- if no - ask?

- no?

- yes - ask? yes?

Back 1361

- Is FEV1/ FVC low? (<70%)

- No = is FVC low? (<80%)

= No = normal

= Yes = Is TLC low (<80%) = yes = restriction

Front 1362

PFT Algorithm

- first check? then ask? then ask?

Back 1362

Front 1363

PFT Causes and Diagnosis - Obstructive

- if normal DLCO? low?

- asthma if post bronchodilator?

Back 1363

- obstructive + normal DLCO = asthma or chronic bronchitis

- obstructive + low DLCO = emphysema

* increase in FEV1 of >12% and >200 cc post bronchodilator = asthma

Front 1364

PFT Causes and Diagnosis - Restrictive

- normal DLCO? (2) low?

Back 1364

- restrictive + normal DLCO = chest wall, neuro-muscular

- restrictive + low DLCO = ILD

Front 1365

PFT - If normal and low DLCO? (2)

Back 1365

- anemia

- pulm. vascular

Front 1366

Tests of Chronic Dyspnea - CT and ABG

- CT - better for? see?

- ABG - look at? if? from (2)

Back 1366

- CT = better definition of parenchymal interstital disease, pleural disease, contrast evaluation for thromboembolism

- ABG = PCO2 if suspect hypoventilation (chest wall, neuromuscular)

Front 1367

tests of Chronic Dyspnea - Echo, Exercise Testing

- echo to assess? (3)

- exercse - evaluate?

Back 1367

- Echo = cardiac function, valvular disease, shunt, pulmonary hypertension

- Exercise = evaluate functional capacity, prognosticate and evaluate response to therapy, diff. causes of exervise

Front 1368

Asthma when? triggers?

- have?

- CXR?

- on PFT?

Back 1368

- episodic dyspnea, triggered by cold air, viral infections

- wheezing

- normal CXR

- obstruction on PFT when bronchodilator response

Front 1369

- Interstitial Lung Disease when? on?

- hear?

- on CXR? on PFT?

- do? (2)

Back 1369

- slowly progressive dyspnea on exertion, cough

- crackles, clubbing

- increased interstitial markings on CXR

- restriction with low DLCO on PFT

* do CT chest = 6MWT

* do echo to assess cardiac function and pulm.pressures

Front 1370

- consider COPD or CHF, when? (4)

- do? to then?

Back 1370

- history of CHF, smoker, dyspnea

- elevated JVP

- hyperinflation on CXR

- moderate obstruction on PFT

* do cardiopulmonary exercise test to distinguish cause of exercise limitation

Front 1371

Dyspnea when?

Back 1371

Front 1372

Restrictive Lung Disease Definition

- disease that? defined as?

- main three causes? (3) - PR/CW/NM ***

Back 1372

- disease that reduces the size of the lungs (TLC)

- defined as TLC <80% predicted

- several possible causes:

= interstitial lung disease = parenchymal restriction

= chest wall restriction

= neuromuscular disease

Front 1373

ILD - Parenchymal Restriction

- diseases that?

- thickened alveolar membrane causes? (2) increased/decreased? leading to?

Back 1373

- diseases which increase the thickness of the alveolar membrane

- thickened alveolar membrane causes:

= increased stiffness of the lungs (less compliance, more work to inflate lungs)

= reduced diffusion across the alveolar membrane, leads to hypoxemia

Front 1374

Making ILD Diagnosis - CXR for? PFT for?

- retics seen as? nodes as?

Back 1374

- CXR will show interstitial changes

- PFT will show parenchymal restriction

* reticulation shown as lines

* nodularity shown as dots

Front 1375

ILD and Parenchymal Restriction on PFT

- restrictive causes? also see?

- causes prop?

- therefore both?

- normal?

Back 1375

- restrictive = TLC goes down

- Measures like FVC go down with TLC

- cause a proportional reduction in FEV1 and FVC

- both FEV1 and FVC are reduced by similar amount

- see normal FEV1/FVC ratio = >0.7

Front 1376

Spirometry of Normal vs Obstructed vs Restricted

Back 1376

Front 1377

Fick-s Law - Diffusion of gas influenced by? (5)

- in ILD, see?

Back 1377

- SA for diffusion

- gradient across the membrane

- solubility of the gas diffusing

- thickness of the membrane the gas must cross**** ILD = more thick

- molecular weight of the gas

Front 1378

ILD Causes

- on CXR? seen as?

- reduced?

- reduction in? ratio?

- low?

- spiro shows?

Back 1378

- an interstitial pattern on CXR = lines, dots or both

- reduced lung volumes = low TLC

- proportional reduction in FEV1 and FVC (ratio > 0.7)

- low diffusing capacity and hypoxemia

- spirometry shows upward loop

Front 1379

Diagnostic Approach to Restrictive Lung Disease

- restrictive, see?

- parenchymal restriction shown by?

- results in?

- if normal DLCO?

Back 1379

- low TLC = restrictive lung disease

- low DLCO = parenchymal restriction

* creates ILD

- if normal DLCO = extra-parenchymal restriction

Front 1380

Chest wall restriction due to?

- low TLC due to?

- possible causes? (3)

Back 1380

- low TLC due to squeezing from the outside

- possible causes include obesity, bony abnorms, pleural disease

Front 1381

Bony Abnorms - Chest Wall Restriction - (3)

Back 1381

- pectus excavatum

- pectus carinatum

- Ankylosing Spondylitis

Front 1382

Cobb Angle - used to measure

- lung restriction at?

- if >100? due to?

Back 1382

- Kyphoscoliosis severity is measured using Cobb angle

- Cobb angle > 60 degree assoc. with lung restriction

- Angle >100 can lead to hypercapneic resp. failure due to diaphragm dysfunction

Front 1383

Chest Wall Restriction - Pleural Disease - look at?

- see? also see?

Back 1383

- look at ray, see large pleural effusion, calcified pleural plaques secondary to asbestos exposure

Front 1384

Chest Wall Restriction - PFT Summary

- shown? means that?

- reduction in?

- prop.?

- diffusion is? no?

Back 1384

- PFTs show extra-parenchymal restriction = caused by something outside the lung = extra-parenchymal

- reduction in TLC < 80%

- proportional reduction in FEV1 / FVC

- diffusion capacity is normal because gas exchange at the level of the alveolus is normal (**no thickening of the membrane like in ILD)

Front 1385

ILD - Neuromuscular Disease - results in? problems in?

- due to?

Back 1385

- results in muscle weakness, causing problems with active expansion of the lung

- due to problems along the path from brain to diaphargm

Front 1386

Neuromuscular Disease causes - C ? causes

- P = (3)

Back 1386

1) C Spine = C3,C4,C5

= mechanical, ischemic, inflammatory

2) Phrenic nerve

= mechanical, ischemic, idiopathic

Front 1387

Neuromuscular Disease causes

- N? pre vs post?

- D? from? (2_

Back 1387

3) Neuromuscular Junction

= pre-synaptic (Lambert Eaton), post-synaptic (MG)

4) Diaphargmatic Muscle Disease

= muscular dystrophies, inflammatory myositis

Front 1388

Making NM Disease Diagnosis - History

- common? episodes of?

- may have? previous? FH?

Back 1388

- dyspnea and orthopnea are common

- episodes of hypercapneic resp. failure

- may have weakness in other groups

- previous trauma or thoracic surgery

- FH of myopathy

Front 1389

Making NM Disease Diagnosis - Physical Exam

- use of?

- in neck? decreased? abdo? means?

Back 1389

- use of accessory muscles on quite respiration

- hypertrophy of access muscles in neck

- decreased diaphragmatic excursion (percussion)

- abdo paradox(moves inward) on inspiration

Front 1390

Neuromuscular Disease (Muscle Weakness) - PFT show? similar to?

- low? prop. reduciton in?

- diffusion?

- to diff from chest wall problems?

Back 1390

- PFTs show extra-parenchymal restriction

= similar to PFTs in mech chest wall disease

= low TLC, proportional reduction in FEV1/ FVC

= diffusion capacity is normal

* diff muscle problems from chest wall problems with tests assessing muscle strength

Front 1391

Tests of Resp. Muscle Strength - MIPs/ MEPs - stand for? muscle weakness when?

Back 1391

- maximum inspiratory and expiratory pressures

- MIPs or MEPS < 50% of predicted suggests muscle weakness

Front 1392

Tests of Resp. Muscle Strength - Positional Forced Vital Capacity

- when lie supine, see?

- therefore takes?

- if have muscle weakness? defined as?

Back 1392

- when lie supine, gravity pushes abdo contents into chest

- so it takes more diaphragmatic strength to take a breath when supine

- patients with muscle weakness have a smaller FVC when supine

- drop in FVC of >20% from sitting to supine = muscle weakness

Front 1393

Diagnostic Approach to Restrictive Lung Disease

- extra-parenchymal if?

- if normal muscle strength - DDx?

-NMD if?

Back 1393

- low TLC and normal DLCO = extra-parenchymal

- normal muscle strength = DDx of chest wall and pleural disease

- abnormal MIPS/MEPS or positional VC = DDx of neuromusc. disease

Front 1394

Diagnostic Approach to Restrictive Lung Disease

- parenchymal restriction - see?

- ILD can be either?

Back 1394

- low TLC and low DLCO = parenchymal restriction

- ILD = upper lobe disease or lower lobe disease

Front 1395

Diagnostic Approach to Restrictive Lung Disease

Back 1395

Front 1396

Upper Lobe Interstitial Disease = FASST

- stand for?

Back 1396

= Farmer's Lung = Hypersens. Peumonitis

= Akylosing Spondilitis

= Silicosis

= Sardoidosis

= TB

Front 1397

Pathogenesis of Hypersens. Pneumonitis

- repeated? can cause?

- debated mech?

- onset can be?

Back 1397

- repeated inhalational exposure to some antigens can cause pulmonary sensitization

- debated mech = Type 3 or 4 hypersens reaction

- latency of onset = sens. can be weeks or years after exposure, requires ongoing exposure to cause symptoms

Front 1398

Causes of Hypersens Pneumonitis

- organisms include? (3)

Back 1398

- Microbial organisms:

= Farmers lung = Thermophillic actinomyces in hay

= Tobaccos long = Asperigullus

= Hot tub lung = Mycobact in water

Front 1399

Causes of Hypersens Pneumonitis - Other Causes

- (3)

Back 1399

- animal proteins -bird feathers, feathers of pillows or duvets

- low mol. weight chemicals - isocyantes

- meds

Front 1400

Clinical Presentation of Hypersens Pneum - can be? should have?

- resp see? also see? (5)

Back 1400

- can be non-specific = should have temporal relationship to exposure

- resp. symptoms are variable = cough, sputum, dyspnea, wheeze

- const symptoms = fevers, chills, sweats, weight loss

Front 1401

Hypersens Pneum - Variable Latency

- acute? subacute? chronic?

Back 1401

= acute HP = symptoms 4-6 hours after exposure

= subacute HP = intermittent exposure and fluc Sx

= chronic HP = long term exposure with progressive lung fibrosis

Front 1402

Diagnosis of Hypersens Pneum

- determine?

- ask about? worsening?

- PFT?

Back 1402

- determine exposure to HP antigen = history, serology

- clinical syndrome and HP = resp and const. symptoms, worsening symptoms when exposred to Ag

- PFT abnorms = obstruction, restriction or combo of both with low DLCO

Front 1403

Diagnosis of Hypersens Pneum

- radiographic? see? (2)

- cytology?

Back 1403

- radiographic abnorms = upper lobe nodules, reticulation, fibrosis

- supportive cytology/pathology = lymphocytosis on BALF (>20% lymphocytes), poorly-formed non-nec. granulomatous inflammation on lung biopsy

Front 1404

Treatment of Hypersens Pneum

- avoid?

- can give? that then?

Back 1404

- Antigen avoidance

= remove, prevent leaks, workplace design (ventilation, moisture)

- Immunosuppression

= accelerates recovery, reserved for more severe cases, prednisone 1.0 mg/kg over weeks,

Front 1405

Upper Lobe Interstitial Disease - Silicosis

- almost always?

- symptoms are?

Back 1405

- almost always occupational exposure = mining, quarrying, etc

- symptoms variable = may be asymptomatic with CXR, PFT abnorms, may have severe resp. symptoms with progressive massive fibrosis

- PFT - parenchymal restriction with low DLCO

Front 1406

Silicosis

- imaging - see? (3) of?

- develop a?

- treatment involves?

Back 1406

- imaging = upper lobe nodules and fibrosis, calcified LNs

- inflammatory reaction to inhaled silica particles, pathology shows silicotic (dust) nodules within lung tissue

- treatment involves reducing exposure to solica dust

Front 1407

Sarcoidosis

- is a? of non?

- cause is?

- inflamm can be?

- occurs more often in?

- lungs often?

Back 1407

- inflammatory reaction of non-caseating granulomatous inflammation

- cause unknown = probably due to an undetermined exposure

- inflammation can occur anywhere in body

- occurs more often in people <50 and of African descent

- lungs are invovled in 90% of cases, often other organs involved

Front 1408

Sarcoidosis Different presentations - Stage?

- incidental? resp? Loffgrens? may have?

Back 1408

- incidental finding = Stage 1 / 2

- resp. symptoms = Stage 2, 3, 4

- Loffgren's Syndrome = Subgroup of Stage 1

- extra-pulm symptoms

Front 1409

Stage 1 and 2 Sarcoidosis

- Stage 1 finding? is?

- 2 = combo of? may have some?

Back 1409

-Stage 1:

= incidental finding of bilateral hilar adenopathy, asymptomatic

= asymptomatic

- Stage 2:

= combination of hilar adenopathy and upper lobe ILD (nodules)

= may have some resp. symptoms

Front 1410

stage 3 and 4 Sarcoidosis

- Stage 3 = fibrosis of? common to have?

- Stage 4 = end? signfic?

Back 1410

- Stage 3

= upper lobe ILD with fibrosis (no adenopahy)

= resp. symptoms are common

- Stage 4

= end stage fibrosis of the upper lobes

= signif resp. symptoms

Front 1411

Sarcoidosis Chances of Spont. Remisson in 2-3 years

- each stage?

Back 1411

- Stage I = 70-90%

- Stage II = 50-70%

- Stage III = 10-30%

- Stage IV = 0%

Front 1412

Upper Lobe Interstital Disease = Sarcoidosis - Loffgren's Syndrome

- subgroup of? on CXR see? also have?

- pathology of?

- commonly with? use? to?

Back 1412

- subgroup of Stage 1 sarcoidosis with:

= bilateral hilar adenopathy on CXR

= fever

= migratory polyarthralgias / arthritis

= Erythema nodosum = Leukcytoclastic vasc. on pathology - non-spec

- common presentation - resolves spont, use NSAIDs to help with skin and joints

Front 1413

Sarcoidosis Extrapulm Disease

- often have? can be?

- ocular?

- calcium is then? due to? leads to symptoms of?

- also have?

Back 1413

- skin lesions common (up to 20%), rash to disfiguring lupus pernio

- ocular symptoms - Uveitis is most common ocular Sx

- Calcium met due to activated Vitamin D, increases calcium absorption

- symptoms of hypercalcemia and kidney stones can result

- cardiac involvement- granulomas = arrhythmias, sudden death

Front 1414

Making Sarcoidosis Diagnosis

- CXR shows? patients may? either?

- PFTs may be?

- pathology?

Back 1414

- CXR shows different abnorms = usually 1st symptoms (Stage 1-4)

- patients may or may not have symptoms = pulm or extra-pulm

- PFTs - may be normal or have obstruction or restriction with low DLCO

- pathology - non-nec. granulomatous inflammation without identified cause

Front 1415

Sarcoidosis treatment - many pts dont?

- Stage 1 and 2 often?

- Stage 3 and 4 use?

- extra-pulm?

Back 1415

- many patients do not require treatment

- Stage 1 and 2 = often resolves spontaneously without treatment

- Stage 3 and 4 = treat with prednisone if severe/progression

- Extra-pulomary disease = immunosupp therapy differs by organ, treat if severe/progressive

Front 1416

Lower Lobe interstitial Disease = RAAIDS

Back 1416

= rheumatoid arthritis

= Asbestosis

= Aspiration = recurrent

= idiopathic Pulmonary Fibrosis

= Drugs = Amiodarone, Nitrofurantoin, others

= Scleroderma

Front 1417

Lower Love Interstiital Disease - Connective Tissue Disease = CTD-ILD

- common for? is the?

- in RA? in Sclero?

- lung symptoms can? should screen?

Back 1417

- most rheum conditions can cause ILD, leading cause of death if present in CTD

- RA common CTD-ILD = uncommon manifestations of common disease

- Scleroderma is common CTD-ILD = common manifestation of rare disease

- lung symptoms can come before or after joints - must screen all ILD patients for occult CTD

Front 1418

Connective TIssue Disease - ILD

- if have ILD, need?

- look for? (5)

- investigations?

- treated with?

Back 1418

- patients with ILD need careful history, PE

= joint pains, Raynauds, skin rashes, examine for active joints, nail and skin changes

- basic serology should be done = ANA, RF, anti CCP, ENA

- progressive CTD-ILD can be treated with immunosupp. therapy

Front 1419

Asbestosis

- is a? used for? now is?

- significant exposure defined by?

Back 1419

- naturally occurring fiber, primarily excavated in Russia, China, Canada

- many desirable properties for use in insulation, now mostly banned yet still see disease

- significant exposure - working with, not just living in space

Front 1420

Manifestations of Asbestosis

- lower? appearance of? can also cause? (3)

Back 1420

- lower lobe ILD

- pleural plaques = often calcified

- pleural effusions

- lung cancer

- mesothelioma = pleural malignancy

Front 1421

Diagnosis and Treatment of Asbestosis

- diagnosis based on? with?

- treatment?

Back 1421

- diagnosis based on history with compatible disease, +/- fibers seen on pathology

- treatment = no specific except avoidance, patient report to WSIB

Front 1422

Idiopathic Pulm Fibrosis (IPF) - most common?

- cause? must?

- pathogenesis is? without?

- survival?

Back 1422

- IPF is most common ILD in patients aged >50

- idiopathic = due to unknown cause, must rule out other ILD causes, importance of PE and history

- pathogenesis appears wound healing and fibrogenesis without signif inflammation (others ILDs due to inflammation)

- mean survival is 3-5 years after diagnosis

Front 1423

IPF

- prognosis is?

- disease is?

- patients may?

- most patients die from?

Back 1423

- prognosis is worse than all cancerrs except lung, pancreatic

- disease course in unpredictable

- patients may progress slwoly, step-wise or wuickly

- most patients die from hypoxic resp. failure`

Front 1424

Making IPF Diagnosis

- need to rule out? do?

- CT for? (4) ** signs

Back 1424

- rule out all other causes of ILD via history and PE, do blood work for CTD serology

- CT scan shows usual interstitlal pneumonia pattern:

= reticulation (lines) as predom abnormality

= subpleural and basal predom. distribution

= honeycombing cysts with/wo traction bronchiectasis

= absence of features that are inconsistent with UIP

Front 1425

IPF Lung Biopsy

- pathology shows?

- distribution is? see some areas?

- should be little?

Back 1425

- pathology shows fibrosis with fibroblastic foci

- distribution is heterogenous with areas of relatively normal lung and areas of severe fibrosis

- there should be minmal active inflammation (not inflamm disease)

Front 1426

Treatment of IPF

- do not treat with?

- very different?

- consider using? caused?

Back 1426

- treatmen with prednisone, immunosupps shown to increase mortality

- very different than other forms of ILD

- new class of drugs = anti-fibrotics = slow fibrosis

= Pirfenidone in Canada, Nintedanib

Front 1427

Diagnostic Approach to Restrictive Lung Disease

Back 1427

Front 1428

ILD History

- resp symptoms = (3)

- CTD - consider? (4)

- also consider?

Back 1428

- respiratory symptoms - cough, sputum, wheezing

- connective tissue diseases - GERD, dysphagia, aspriation, Raynauds

- toxins, exposures, RFs (smoking, FH)

Front 1429

ILD Physical Exam

- resp = look for? (5)

- CV = (3)

- rheum - look for?

Back 1429

- resp = cyanosis, muscle use, clubbing, muscle weakness, fine crackles

- cardiac = pulm hypetension, right sided heart failure, cor pulmonale

- rheum = active joints, skin rashes, findings in fingers and nails

Front 1430

ILD Investigations

- PFTs - do? NMD for?

- CXR - look for? (3)

- CT - look for?

- if suspect sarcoidosis?

Back 1430

- PFTs = MIPS/MEPS, positions VC for NMD

- CXR = nodules, reticulation, distribution

- CT = UIP pattern

- Bllod work, serology, ANA, Abx for hypersens, calcium and ECG if susepct saroidosisI

Front 1431

ILD - Treatment

- diseases by? then?

- systemic = (3) - treat?

- immunosupp is?

- consider?

Back 1431

- diseases by agents = Hypersens, silicosis, asbestos = avoid

- diseases with systemic component = Sarcoid, RA, Slceroderma = treat extra-pulm manifestations

- immunosuppression - helpful in many, **harmful in IPF

- consider new anti-fibrotics = IPF

Front 1432

What is Pulmonary Hypertension (PH)?

- elevation of?

- mPAP sees?

- caused by?

Back 1432

- elevation of mean pulmonary artery pressure (mPAP)

- right heart catheterization showing mPAP > 25 mmHg

- caused by problems anywhere in pulmonary circulation

Front 1433

What is Pulmonary Arterial Hypertension (PAH)

- narrowing of?

- leads to? causing?

- right side vs left side?

Back 1433

- narrowing of the small pulmonary arteries and arterioles

- leads to progressively increasing vascular resistance = causes right heart failure and death

- right heart catheterization shows mPAP > 25 mmHg and normal left sided heart pressures (wedge pressure < 15 mmHg)

Front 1434

Mean PAP (mPAP) - measured at?

Back 1434

- measured at the pulmonary artery

Front 1435

Causes of Pulm. Hypertension

- at pulm artery? at pulmonary arteriole? at capillary? (2)

Back 1435

1) Pulmonary Artery = acute and chronic pulmonary embolism

2) Pulmonary arteriole = PAH

3) Pulm Capillary

= chronic lung disease (destruction of capillary bed)

= hypoxic lung disease = vasoconstriction of capillary bed

Front 1436

Causes of Pulm. Hypertension - at PV? at left heart?

Back 1436

4) Pulmonary veins = veno-occlusive disease (PVOD)

5) Left heart = backflow from problems in left heart

Front 1437

Pulmonary Hypertension Nice Classification

- Group 1 through 5?

Back 1437

- Group 1 = PAH and PVOD

- Group 2 = left heart disease

- Group 3 = respiratory diseases

- Group 4 = Pulmonary Artery

- Group 5 - Miscellanous

Front 1438

Causes of Group 1 (PAH) - is? genetic? (2)

- acts as a?

- can be induced by?

- associated with? (5)

Back 1438

- idiopathic

- genetic = BMPR2, ALK-1

- veno-occlusive disease

- drug and toxin induced = Fenfluramine, Amphetamine, SSRIs

- associated with underlying:

= CTD, HIV, portal hypertension, congenital heart disease, Schistosomiasis

Front 1439

causes of Group 2, 3 PH

- Group 2 from?due to? (2)

- Group 3 is from? due to? seen in those with?

Back 1439

- Group 2 = Left heart Disease

= LV dysfunction, Valvular (MR, MS, AI, AS)

- Group 3 = Resp. Disease

= destruction of lung (COPD, IPF, bronchiectasis)

= chronic hypoxia = hypovent, OSA

Front 1440

Causes of Group 4, Group 5

- 4 from? 5 is ? includes (2)

Back 1440

- Group 4 = Pulmonary Artery

= chronic thromboembolic disease

- Group 5 = misc

= sarcoidosis, hemolytic anemia

Front 1441

Group 1 = PAH

- is a? cases? less common than?

- gender?

- age of diagnosis?

- usually have symptoms for? if untreated?

Back 1441

- rare disease = 1-2 cases per million = PAH is much less common than group 2 disease (left-sided heart disease)

- F:M

- generally diagnosed in 4th decade of life

- time from symptoms to diagnosis = 2.5 years

- survival 2.5 years from diagnosis if untreated

Front 1442

Pulmonary Hypertension - History and PE

- see?

- RFs? (6)

- group 2 through 5?

Back 1442

- resp and cardiac symptoms = dyspnea, chest pain, syncope, leg swelling

- RFs for PAH = group 1 = FH, toxic drugs, CTD, HIV, liver disease, travel history

- RFs:

= Group 2 = extensive cardiac history

= Group 3 = extensive resp. history

= Group 4 = thrombosis history

= Group 5 = hemoglobin, other diseases

Front 1443

PE of PH

- heave? loud?

- extra?

- increased?

- positive? liver is? also see? (2)

Back 1443

- parasternal heave

- loud S2

- right sided S3/S4

- elevated JVP

- positive abdo jugular reflex

- pulsatile liver

- ascites, edema

Front 1444

PH investigations

- look for? by doing? (4)

- also look for?

- perform? (2)

- measures?

Back 1444

- look for resp disease = PFT, CXR, ABG, sleep study

- look for underlying conditions that predispose PAH = lab testing, HIV, liver enzymes

- look for cardiac disease (ECG), thromboembolic disease (CT, V/Q scan)

- measures pulmonary pressures = echo, right heart catheterization

Front 1445

Pulmonary Hypertension Treatment

- treat the?

- give? for?

- oxygen for?

- in select cases?

Back 1445

- treat underlying disease = cardiac, respiratory

- diuretics for right sided CHF

- oxygen for hypoxemia

- lung or heart transplantation in selected cases

Front 1446

Pulmonary Hypertension - Specific Vasodilatory Therapy

- entags of? include? (3)

- inhibitors of? fils? (2)

- cyclins?

Back 1446

= endothelin antags = Bosentan, Ambrisentan, Macisentan

= Phos 5 inhibitors = Sildenafil, Tadalafil

= Prostacyclines = Epoprostonol

Front 1447

Groups of PH - 1 through 5?

Back 1447

Front 1448

Lung Cancer Epi

- 2nd highest?

- gender? increased chance of?

- trends?

Back 1448

- 2nd highest incidence in males and females

- more common in males, higher chance of developing lung cancer and dying from lung cancer in men than women

- decreasing in males, increasing in females

Front 1449

Smoking and Lung Cancer

- leading cause?

- change in RR?

Back 1449

- cigarette smoking is the leading cause of lung cancer

- 90% of lung cancer cases are caused by cigarette smoking

- compared to never-smokers, current smokers have 20x increase in lung cancer risk

Front 1450

Risk of Lung Cancer and smoking

- risk increases with? decreases with? use of?

- also assoc with?

Back 1450

- risk of lung cancer increases with number of cigarettes smoked per day and duration of smoking

- risk of lung cancer decreases with time since quitting smoking, use of filtered cigarettes and lower tar yield

- cigar and pipe smoking are also assoc. with increased lung cancer risk, not as high as cigarettes

Front 1451

Second Hand Smoke

- spouses of? have a?

- up to 35% of LC in never smokers is?

Back 1451

- non-smoking spouses of smokers have an approx 30 increased risk of developing lung cancer

- about 15 to 35% of lung cancer cases in never smokers have been attrib to second hand smoke exposure

Front 1452

Other Environmental Risks

- (4)

Back 1452

-tar and soot = benzopyrene

- metals = arsenic, chromium, nickel

- asbestos

- radiation = radion, radiation

Front 1453

Classification of Lung Cancer

- primary? (6)

= SCC/SCC/AC/LCC/CT/ carc of?

Back 1453

- primary malignant epithelial tumours of lung:

= squamous cell carcinoma

= small cell carcinoma

= Adenocarcinoma = Bronchioalveolar carcinoma

= large cell carcinoma

= carcinoid tumour = typical, atypical

= carcinomas of salivary gland type

Front 1454

Practical Classification of Lung Tumours - mainly?

Back 1454

- non small cell lung cancer

- small cell lung cancer

Front 1455

Why the Practical Classification - two groups separated based on? (3)

- greater need to?

Back 1455

- two groups are separated based on:

= clinical behaviour, likelihood of mets, molecular genetics, response to currently available therapies

- with increasing awareness of molecular genetics, greater need to properly subclassify non-small cell carcinomas

Front 1456

Primary vs Secondary Lung Cancers

- primary has? must rule out? as this?

- if multiple lesions?

Back 1456

- lung is the site of numerous met lesions that must be ruled out

- changes tumour behaviour, prognosis and therapy

- multiple lesions, especially bilateral, favour mets over primary lung cancer

Front 1457

Incidence of Different Histologic Types of Lung Cancer

- men highest? then?

- women highest? then?

Back 1457

Front 1458

Squamous Cell Carcicoma

- tumur of? showing? may have?

- usually have? with possible? (2 - C/BO)

Back 1458

- malignant epithelial tumour of squamous cells, showing kerat and/or intercellular bridges

- usually have central (hilar) lesions with

- +/- cavitation

- +/- bronchial obstruction

Front 1459

Precursor to SCC

- see? dyspslasia of?

Back 1459

- squamous metaplasia and dysplasia of bronchial epithelium

Front 1460

Adenocarcinoma of Lung

- malignant? with diff of?

- usually is?

- not as strong assoc. with?

Back 1460

- malignant epithelial tumour with glandular diff. +/- mucin

- usually peripheral lesion

- not as strongly assoc. with smoking as squamous or small cell carcinoma (75% of lung adenocarcinomas occur in smokers vs 98%)

Front 1461

Incidence of AC of Lung

- incidence is? yet?

Back 1461

- incidence has increased significantly in last two decades

- rise in incidence is unclear

Front 1462

Precursor Lesions to AC of Lung

- atypical? also?

Back 1462

- atypical adenomatous hyperplasia

- bronchioalveolar carcinoma

Front 1463

Bronchioloalveolar Carcinoma

- specific? that may?

- tumour cells grow along?

- is at first? but then may?

- no present?

Back 1463

- specific in-situ form of adenocarcinoma which may precede development of invasion

- tumor cells grow along intact alveolar architecture

- non-invasive but may spread aerogenousl throughout lungs

** no destructive tissue invasion present

Front 1464

Small Cell Carcinoma of Lung

- origin?

- composed of? cytoplasm? cell borders? nucleus? (3)

- mitoses are?

- behaviour?

Back 1464

- malignant tumor of neuroendocrine origin

- composed of small cells with scant cytoplasm, ill-defined cell borders, round to oval nuclei with nuclear molding and inconspicious nucleoli

- mitoses are numerous and necrosis common

- extremely aggressive behaviour

Front 1465

Small Cell Carcinoma of Lung

- arise from? along?

- NE markers = (S/C)

- central vs periph?

- ability to? leads to?

Back 1465

- arise from neuroendocrine cells present along bronchial epithelium

= Neuroendocrine markers = synaptophysin, chromogranin

- typically central lesion

- ability to secrete polypeptide hormones = paraneoplastic syndromes

Front 1466

Small Cell - cells appear? (4)

- see areas of?

Back 1466

- small cells with scant cytoplasm, irregular nuclei, nulcear molding and frequent mitoses

- see areas of necrosis

Front 1467

Large Cell Carcinoma of Lung

- an undiff? lacks features of?

- cytoplasm?

- may represent? that?

- small subset show?

Back 1467

- an undiff malignant epithelial tumour that lack squamous and glandular features and the cytologic appearance of small cell carcinoma

- may represent squamous cell carcinomas or ACs that are too poorly diff to recognize

- subset of large cell carcinomas show neuro-endocrine differentiation

Front 1468

Carcinoid Tumours of Lung - type of tumours?

- T vs AT vs LC vs SC?

Back 1468

- neuroendocrine tumours of lung:

= typical carcinoid tumour

= atypical carcinoid tumour

= large cell neuroendocrine carcinoma

= small cell carcinoma

Front 1469

Carcinoid Tumours of Lung - % of tumours?

- low grade are either?

- typical patient? gender?

- located in either?

Back 1469

- represent 1-5% of lung tumours

- low-grade malignant neuroendocrine tumours = typical vs atypical

- usually occur in patients <40 yo (M=F)

- may be located centrally or in the periphery of the lung

Front 1470

Carcinoid Tumours of Lung - Typical

- composed of? with?

- mitotic count? no?

Back 1470

- typical carcinoids are composed of nests of uniform, regular cells with round nuclei

- mitotic count < 2 mitoses/10 HPF

- no necrosis

Front 1471

Carcinoid Tumours - Atypical

- mitotic count? or see?

- often see?

Back 1471

- mitotic count 2-10 mitoses/ 10 HPR or focal necrosis

- often show increased cellular atypia

Front 1472

Small Cell Carcinoma - Molecular Genetics

- mutated genes include? (4) M/R/p/B

- see overexpression of?

- see increased?

Back 1472

- dominant genes mutated include Myc, Rb, p53, and BCL-2

- overexpression of c-kit

- increased expression of telomerase

Front 1473

Non-Small Cell Molecular Genetics

- mutated genes include? (4) p/p/E/K

- AC - primarily see? (2)

- squamous and AC - see?

- increased?

Back 1473

- dominant genes mutated include EGFR, K-ras, p53 and p16

- EGFR and K-ras occur primarily in AC
- p53, p16 mutations have same frequency in squamous and AC

- see increased expression of telomerase

Front 1474

Targeting Genetic Therapies

- if EGFR mutations, see? therapy?

- K-ras - see?

- K-ras causes?

Back 1474

- patients with EGFR mutations have improved survival with upfront EGFR inhibitor therapy = gefitinib

- mutations in K-ras correlate with worse outcome and resistance to EGFR inhibition

- constitutive activation of K-ras bypasses EGFR, leads to downstream activation

Front 1475

Grading of Lung Cancer

- if non-small cell?

- high grade when?

Back 1475

- non-small cell carcinomas should be graded according to histo features

- small cell carcinoma and large cell carcinoma = high grade

Front 1476

Clinical Manifestations of Lung Cancer

- (8)

Back 1476

- cough, hemoptysis

- dysphagia, chest pain, dyspnea

- hoarseness, Horner's, SVC obstrcution

Front 1477

Hoarseness - is a disruption of? often from? (2)

- results in?

Back 1477

- disruption of recurrent laryngeal nerve (esp. left) from tumour or mediastinal adenpathy

- results in unilateral vocal cord paralysis

Front 1478

Horner's Syndrome

- weakness of? PD/LP = (2) called? (M/P)

- lack of? called?

- apical tumour can?

Back 1478

- weakness of pupillary dilators = miosis

- weakness of levator palpebrae = ptosis

- lack of sweating = anhydrosis

- apical tumour invades superior sulcus, impinging on sympathetic chain

Front 1479

Climical Symptoms of Mets

- liver? bone? adrenal? brain? (6)

Back 1479

- liver = asmpt or increased liver enzymes

- bone = pain, increased alk phos, increased calcium

- adrenal = suaully asymptomatic

- brain = HA, vomiting, visual changes, focal weakness, CN deficits, seizures

Front 1480

Paraneoplastic Syndromes with Lung Cancer - results in/

- HC/ S/ H/ HO/ DM/ CS/ N

Back 1480

- hypercalcemia

- SIADH secretion

- hematologic

- hypertrophic osteoarthropathy

- dermamyositis

- Cushing's syndrome

- neurologic

Front 1481

Hypertrophic Osteoathroplasty

- also known as?

- may be? symptom?

- may invovles? (4)

- new? in?

- assoc with?

Back 1481

- clubbing

- may have symmetrical, painful polyarhtopathy involving ankles, kness, wrists, elbows

- periosteal new bone formation in long bones

- most commonly with AC

Front 1482

Diagnosis of LC - CXR

- see increased? do? looking for?

Back 1482

- see increased opacity

- can do CT to look for nodules

Front 1483

Diagnosis of LC - Percutaneous Transthoracic Lung Biopsy

- performed by?

- best for?

- localized using? (2)

- insertion of? to?

- done under?

Back 1483

- performed by interventional radiologist

- best for peripheral lung lesions

- localized using US, CT

- insertion of needle into lesion with aspiration or core biopsy

- done under local anesthetic

Front 1484

Percut. TT Lung Biopsy

- sens and spec?

- complications? (4) - main one?

Back 1484

- sens and spec both around 90%

- complications include:

= pneumothorax = 20%

= pneumothorax requiring chest drain = 3%

= hemothorax = 1.5%

= hemoptysis = 5%

Front 1485

SVC Obstruction

- means that?

- venous drainage from upper body is? leads to?

- over time, see? appears as?

Back 1485

- SVC becomes occluded by the tumour/clot

- venous drainage fro the upper body is impaired, leading to upper extremity and facial edema

- over time, collaterals form, see dilated veins over chest

Front 1486

Bronchoscopy

- best for lesions with?

- perfomed by?

- to oropharynx, apply? also to? reducing?

Back 1486

- best for lesions with endobronchial component

- performed by respirologist or thoracic surgeon

- conscious sedation

- local anesthetic applied to oropharynx, also injected through the scope onto vocal cords and airways, to reduce coughing

Front 1487

Samples via Bronchoscopy

- use forceps to?

- cytology brush to?

- to aspirate cells, use?

Back 1487

- biopsy forceps to take chunks of tissue

- cytology brush to scrape cells onto a slide

- transbronchial needle to aspirate cells onto a slide, may be done with endobronchial US

- saline lavage to wash cells off and spin down

Front 1488

DD for Solitary Pulmonary Nodule - Malignant

- (3)

Back 1488

- lung cancer

- metastatic cancer

- carcinoid

Front 1489

DD for Solitary Pulmonary Nodule - Benign

- infection =? (2)

- benign?

- vascular?

- congen?

- inflamm? (3)

Back 1489

- infectious granuloma = TB, fungal infection

- other infections

- benign neoplasms = hematoma, lipoma

- vascular malformations

- congenital abnorms = bronchogenic cyst

- inflammatory = Wegeners, granulo, rheumatoid

Front 1490

Probability of malignancy based?

- age? Rfs? (3)

Back 1490

- patient factors

= age - older = more likely

= RFs = smoking, occupation, FH

Front 1491

Borders

- benign if? (2)

- malignant if?

Back 1491

- if smooth or lobulated = suggest benign

- if irregular or spiculated = suggest malignants

Front 1492

Role of Size - more likely to be malignant if?

Back 1492

- larger lesions more likely to be malignant

Front 1493

Calcification and Malignancy

- benign suggested by? (4) C/D/P/L

- malig suggested by? (2) S/E

Back 1493

- if diffuse, central, popcorn shaped or laminated, suggests benign

- if stippled or eccentric, suggests malignancy

Front 1494

Growth and Malignancy

- if doubles in volume, results in?

- malignancy considered if?

- if less than? or greater than? means that benign nodule likely?

Back 1494

- doubling in volume, results in about a 26% increase in diameter

- doubling time between 20 and 400 days is consistent with malignancy

- a nodule that grows very rapidly or very slowly is more likely to be benign

Front 1495

Making Lung Cancer Diagnosis - after Solitary Nodule Algorithm

Back 1495

Front 1496

FDG - Positron Emission Tomography (PET) Scan

- measures?

- patient is administered? that is tagged with?

- taken up by?

- very? but not? as other lesions may?

Back 1496

- measures the metabolic activity of lesion

- patient is administered glucose tagged with positron emitting isotope of fluorine = FDG

- metabolically active cells such as malignant cells take up FDG more avidly

- very sensitive but not very specific (infectious and inflammatory lesions may also be positve)

Front 1497

Staging - Non-Small Cell

- depends on? presence or absence of? distant?

Back 1497

- staging depends on cell type of cancer (non-small cell versus small cell)

- depends on the size and location of tumour, presence or absence of involved LNs, and distant metastases

Front 1498

Determining LN Involvement

- radiographic staging using?

- bronchoscopic staging using? (TBNA) with?

- surgical staging with?

Back 1498

- radiographic staging using CT and PET scanning

- bronchoscopic staging using transbronchial needle aspiration with endobronchial US

- surgical staging with mediastinography

Front 1499

Simplified Staging of Non-Small Cell Lung Cancer - TNM

- stage 1 and 2 - size? no?

- stage 3 - size? or involvement or? (3)

- stage 4 = any? (2)

Back 1499

- Stage 1, 2 Cancers

= tumour size < 7cm and no mediastinal or contralateral nodes

- Stage 3 Cancer

= tumour size >7cm or invading important structures and/or mediasitnal or contralateral nodes

- Stage 4 Cancer

= any pleural involvement or distant metastases

Front 1500

Treatment of Non-Small Cell Lung Cancer

- treatment of stage 1 and 2?

- generally involves? either by?

- proximal tumours require?

Back 1500

- treatment of choice for Stage I and II tumours is surgical resection

- this generally involves performing a lobectomy, either using VATS or open thoracotomy

- more proximal tumours may require pneumonectomy

Front 1501

Treatment of Non-Small Cell Lung Cancer

- patients with lung cancer often have?

- for resection, must? to help predict?

- to tolerate surgery, must have post-op est?

- may also need?

Back 1501

- patients with lung cancer frequently have comorbs including underlying lung disease such as COPD and cardiac disease

- suitability for resection must first be determined by evaluating pulmonary function to predict remaining function after surgery

- post-op estimated FEV1 and DLCO must be at least 40% of predicted to tolerate surgery

- patients may also require cardiac evaluation

Front 1502

Treatment of Non-Small Cell lung Cancer

- if cannot tolerate surgery?

- Stage II also get?

Back 1502

- patients with Stage I and II tumours who cannot tolerate surgery may be given radiation

- adjuvant chemotherapy (after surgery) may be given in patients with Stage II disease

Front 1503

Treatment of Non-Small Cell Lung Cancer

- Stage III treated with? (3)

- Stage IV not? given? (2)

Back 1503

- patients with Stage III tumours are often treated with a multi-modality approach, involving chemotherapy, radiation therapy, and sometimes surgical resection

- Stage IV tumours are not surgically resectable and are generally managed with chemotherapy and sometimes radiation therapy

Front 1504

Small Cell Lung Cancer

- if limited, means that it is? treated with?

- if extensive, means? outside? treated with?

- not an option?

- small cell is sens to? yet able to?

Back 1504

- limited = confined to ipsilateral hemithorax and 1 radiation port (30 to 40%), usually treated with chemotherapy and sometimes radiation therapy

- extensive = metastatic disease outside the ipsilateral hemithorax (60 to 70%), usually treated with chemotherapy alone

- surgery not an option

- small cell lung cancer is very sensitive to chemo and radiation therapy but the cancer recurs quickly

Front 1505

Prognosis of Small Cell Lung Cancer - median survival and 5 year survival rate - limited stage vs extensive stage

Back 1505

Front 1506

Pleural Effusion - Normal Anatomy and Fluid

- visceral pleura has? drain into? pushes into?

- parietal pleura has? drain into? pushes into?

Back 1506

- visceral pleura has bronchial lymphatics, bronchial microvessels that drain into pulmonary veins, pushes into lungs

- parietal pleura has intercostal microvessels that drain into systemic circulation and lymphatic lacunae that pushes into chest wall

Front 1507

Pleural Effusion and Abnormal Fluid Accumulation

- steady state means?

- fluid accumulation when? (2)

- see decreased absorption if? can also lead to?

- seen in?

Back 1507

- fluid absorption = fluid formation = steady state

- if have decreased absoprtion or increased formation, see fluid accumulation

- decreased absoprtion due to lymphatic drainage

- also see pleural membrane disruption and increased micro vessel pressure

- ex/ see in CHF

Front 1508

CHF = Transudate

- seen during? PVH

- fluid pushed from/to?

- systemic venous hypertension sees fluid pushed from?

Back 1508

- see pulmonary venous hypertension push fluid from visceral pleura into pleural space, from higher to lower pressure

- see systemic venous hypertension push fluid from parietal pleura to pleural space, from higher to lower pressure

Front 1509

Inflammation = Exudate

- occurs when inflammation? fluid moves from? also causes fluid from?

Back 1509

- inflammation disrupts pleural membrane, see movement of fluid from visceral pleura to pleural space

- inflammation also causes movement of fluid into pleural space from parietal pleura

Front 1510

Malignancy = Exudate

- decreased? disrupting? increased?

- fluid then? yet protein?

Back 1510

- decreases lymphatic drainage, disrupts pleural membrane and increases microvessel pressure

- cytokines from malignancy, causes movement of fluid into pleural space, protein out of lymphatic lacuna into parietal pleura

Front 1511

Causes of Transudate Pleural Effusions (3)****** C/H/N

Back 1511

- CHF

- Hepatic hydrothorax

- Nephrotic syndrome

Front 1512

Causes of Exudate Pleural Effusions

- infection -? (4)

- malignancy? (4)

- inflamm?(5)

- other? (2)

Back 1512

- infection = bacterial, TB, viral, fungal

- malignancy = carcinoma, lymphoma, mesothelioma, chylothorax, myeloma

- inflammatory = connective tissue disease, pancreaittis, benign asbestos, ARDS, post cardiac injury

- other- drug induced, hypothyroidism

Front 1513

Chest Xray and Pleural Effusion - AP Xray

- see blunting of?

- increased?

- silhouetting of? diaphragm?

Back 1513

- see blunting of costophrenic angles

- increased opacity at base

- so silhouetting of heart border

- can see hemidiaphragm

Front 1514

Lateral Chest Xray

- look for? (2)

- look in the? as can see?

Back 1514

= look for pleural effusions and hemidiaphragm

= look in lateral decubitus, can see pleural fluid

Front 1515

Thoracentesis

- is a sampling of?

- use of? fluid level is localized by?

- can be done under?

- needle inserted above? to?

- complications (3)

Back 1515

- is a sampling of pleural fluid

- use local anesthetic, fluid level localized by percussion/aucultation

- can also be done with US guidance

- needle inserted above the rib to avoid neurovasc bundle

- complications = infection, bleeding, pneumothorax

Front 1516

Light's Criteria

- fluid is an exudate if?

1) pleural fluid protein: serum?

2) P and serum LDH?

3) pleural fluid LDH? upper limit is?

Back 1516

- fluid is an exudate if any one of the following is present:

= pleural fluid protein : serum protein > 0.5

= pleural fluid LDH = serum LDH > 0.6

= pleural fluid LDH > 2/3 upper limit of normal for serum LDH (about 200 IU/L)

Front 1517

Pleural Fluid Analysis

- LDH - high in? (3)

- protein - high in? (2)

- pH - normally about? low in? (5)

- glucose - low in? (5)

Back 1517

1) LDH = high in emphysema, rheumatoid, malignancy

2) Protein = high in TB, myeloma

3) pH = normally about 7.6, very low in emphysema, TB, rheumatoid, malignancy, esophageal rupture

4) Glucose = low (fluid to serum ratio <0.5) in emphysema, TB, rheumatoid, malignancy, esophageal rupture

Front 1518

Pleural Fluid Analysis

- cell count - see high neuts in? lymphs in (2)? eosino in? (3)

- cytology to see?

- stains - such as?

Back 1518

5) Cell Count and Diff = neutrophil's predominant: bacterial infections, lymphocyte predom in malignancy and TB, eosinophilia in pneumothorax, hemothorax, parasites

6) Cytology = may show malignant cells

7) Stains and Cultures = gran stain and bacterial culture, AFB stain and mycobacterial culture

Front 1519

Video Assisted Thoracoscopy

- can be used to identify? then used to?

Back 1519

- thoracentesis can sometimes identify an exudate

- VATS can be used to remove fluid and biopsy abnormal areas of pleura

Front 1520

Chest Xray of Pleural effusion

- see?

Back 1520

- see bilateral ppleural effusions

Front 1521

Transudative Effusion

- most likely diagnosis?

- if new onset pleural effusions, should?

- transudates more likely to be?

Back 1521

- most likely diagnosis = CHF

- most new-onset pleural effusions require thoracentesis for diagnosis but this is one situation in which one might not perform thoracentesis unless effusions fail to resolve with therapy for heart failure

- in general, transudates are more likely to be bilateral than exudates

Front 1522

Management of Transudate

- if CHF, treat with? manage?

- in general, primary treatment is to?

Back 1522

- treat for congestive heart failure with diuretics and afterload reduction, management of angina

- in general, primary treatment of transudative effusions is to treat the underlying condition

Front 1523

Exudative Effusion

- may be due to? also due to?

- first? then due?

- most likely?

Back 1523

- may be due to underlying primary lung carcinoma but metastatic disease to pleura from an extrapulmonary site is also possible

- after drainage of effusion, repeat imaging showed an underlying lung mass, likely AC of lung with mets to pleura

Front 1524

Management of Malignant Effusion - Repeated Thoracentesis

- is done for? requires?

Back 1524

- for slowly re-accumulating effusions in patients with shift life expectancy

- requires repeated instrumentation

Front 1525

Management of Malignant Effusion - Pigtail Catheter Insertion

- more complete?

- not meant for?

- effusion likely?

Back 1525

- more complete drainage of effusion

- not meant for long term fluid management

- effusion likely to recur after removal

Front 1526

Management of Malignant Effusion - Pleurodesis

- is a more?

- requires? with a?

- success rate?

- dine via?

Back 1526

- more definitive management

- requires hosp, chest tube, complete fluid removal and sclerosing agent (talc, doxycycline)

- success rate 80-90%

- can be done surgically using VATS

Front 1527

Management of Malignant Effusion - Indwelling Pleural Catheter

- tunneled under?

- can be done?

- patient able to?

Back 1527

- tunneled under skin to prevent accidental removal and reduce risk of infection

- outpatient insertion

- patient can intermittently connect self to drainage system

Front 1528

Purulent Fluid likely?

- high? low? (2)

- is most likely? from?

Back 1528

- exudate with very high LDH, low glucose and low pH

- aspiration consistent with empyema probably secondary to bacterial pneumonia

Front 1529

Uncompliated Effusion - see decreased? increased?

Complicated effusion means?

Can lead to?

Back 1529

- uncomplicated can lead to bacterial invasion = decreased pH, increased LDH

- complicated effuision means pH < 7.20

- can lead to empyema = pus or bacterial growth

Front 1530

Management of Empyema in Pleural Effusion

- commonly has?

- pH <7.20 means?

- give? with?

- if chest tube fails?

Back 1530

- bacteria common in empyema as there may be anaerobes

- pH < 7.20 predicts poor response to Abx

- in addition to broad spectrum Abx, requires chest tube drainage of fluid

- if chest tube fails to clear fluid, surgery may be required = VATS or open thoracotomy

Front 1531

Pneumothorax and Tension Pneumothorax

- PTX leads to?

- decreases? (2)

- leads to?

Back 1531

- PTX leads to mediastinal shift

- decreases venous return

- decreases BP

- leads to tension pneumothorax

Front 1532

Pathophys of PTH

- in traumatic PTX, communication with either? or?

- in spont PTX, see comm. with?

- results in the? and subsequent?

- if one way valve mech, leads to? (4)

Back 1532

- communication with pleural space can develop on chest wall side, alveolar side, or both in traumatic pneumothorax

- communication is on the alveolar side in spont. PTX

- results in accumulation of air within the pleural space and collapse of the lung

- if there is one way valve mechanism, this can lead to progressive ipsilateral hyperinflation, mediastinal shift, hemodynamic compromise and death

Front 1533

Causes of Primary Spont PTX

- no?

- see in? (4)

Back 1533

- no lung disease

- see smoker, male, FH, Marfan's

Front 1534

Causes of Secondary Spont PTX

- have?

- see in? (4)

Back 1534

- have lung disease

- COPD, CF, pneuocystis jiroveci infection, TB

Front 1535

PTX Clinical Presentation - History

- sudden onset? (2)

- onset usually at? or after?

- may have underlying?

Back 1535

- sudden onset dyspnea and pleuritic chest pain

- onset usually while at rest (spontaneous) or history of chest trauma

- may have history of underlying lung disease (secondary)

Front 1536

PTX PE Findings

- see? (3)

- on affected side, reduced?

- percussion?

- trachea?

- if tension PTX - see?

Back 1536

- respiratory distess, tachypnea, tachycardia

- reduced chest excursion on affected side

- reduced breath sounds on affected side

- hyper-resonance on percussion of affected side

- tracheal shfit away from PTX

- subcut. emphysema

- if tension = hypotension

Front 1537

Management of Primary Spont PTX - Stable Patient

- look first at?

- then if?

- if minimal symptoms? if symptomatic? unsuccessful?

Back 1537

- if unsuccesful, chest tube

Front 1538

Management of Primary Spont PTX - Unstable

- put in a? if successful? unsuccessful?

Back 1538

Front 1539

Management of Secondary Spont PTX - Stable

- first look at?

- symptoms vs no symptoms?

Back 1539

Front 1540

Management of Secodnary Spont PTX - Unstable

- first do? if unsuccessful?

Back 1540

Front 1541

Microbio of TB

- belongs to? caused by?

- have a special? resistant to? leading to?

Back 1541

- belongs to genus Mycobact which includes the NTM such as MAC

- TB caused by members of M.tuberculosis complex

- special cell envelope around mycobact is resistant to destaining by acid alcohol leading to the term acid fast bacillus (AFB)

Front 1542

Microbio of TB

- to detect, use?

- growth is? to culture, can take?

- treatment minimum of?

- see red?

Back 1542

- use Zhiel-Neelsen or Kinyoun stain to detect them

- M. tuberculosis is very slow growing, it can take up to 7 weeks to culture and treatment takes a minimum of 6 months or more

- see red TB bacillus on ZN stain

Front 1543

Transmission

- appear as?

- people then? get to?

- no infection occurs if?

Back 1543

- patients with pulmonary or laryngeal TB aerosolize the TB bacilli in droplet nuclei

- contact person inhales the TB bacilli which they may get to the alveoli

- if the local defenses can destroy the TB bacilli, no infection occurs

Front 1544

Transmission TB

- if TB bacilli gets to alveoli? get encased in?

- then considered?

- about 10% of people will? time?

Back 1544

- if TB bacilli gets to alveoli in large numbers in normal immunity, cell mediated immunity eventually responds in several weeks to encase the TB in granuloma

- then considered latent TB infection

- about 10% of people with latent TB infection will develop active TB in their lifetime, half of those cases will occur within the first 2 years after infection

Front 1545

Active and latent TB

- if primary infection is unchecked?

- within 2 years, see?

- majority of active TB is?

Back 1545

- if the primary infection is unchecked, progressive primary TB disease can occur

- see active disease development within 2 years of initial infection

- majority of active TB in the world is usually reactivation TB from latent TB infection

Front 1546

Latent vs Active TB

- 1/3 of worlds population is?

Back 1546

- 1/3 of the worlds population is infected with M TB

Front 1547

Diagnosis of TB Infection - Latent - perform a? also do a?

Back 1547

- tuberculin skin test

- interferon gamma release assays (IGRAS)

Front 1548

Diagnosis of Active TB Disease

- perform a?

- pathology - look for? presence? positive?

- also have?

Back 1548

- acid fast bacilli (AFB) and TB cultures from a particular site (sputum, LN, etc)

- patohology consistent with necrotizing granulomas and presence of AFB and positive TB cultures

- clinical presentation

Front 1549

TST Tuberculin Skin Test

- is a? from?

- patients infected with MTB - see delayed?

- give? to the?

- read at?

- measure the?

Back 1549

- glycerol extract of tubercle bacillus

- in patients infected with MTB causes a delayed hypersens type of reaction

- 5 tuberculin units of purified protein derivative (PPD-S) given intradermally on the volar aspect of the arm

- read at 48 to 72 hours later

- ** measure only the transverse diameter of induration - record in mm

Front 1550

LTBI = latent TB infection

- goal is to identify?

- two accepted tests? (2)

- IGRA measures? as WBC from infected patient will?

Back 1550

- goal is to identify indivs at increased risk for development of active TB

- two accepted tests for identification of LTBI = the TST and the interferon gamma release assay (IGRA)

- IGRA measures person's immune reactivity to M. tuberculosis, as WBCs from infected patient will release IFN-g, when mixed with antigens derived from M. tuberculosis

Front 1551

LTBI vs IGRA

- IGRAs are more specific than?

- both IGRA or TST cant separate?

Back 1551

- IGRAs are more specific than TST if previous vaccination with Bacille Calmette-Guerin (BCG), especially if BCG is given after infancy or multiple times

- neither can separate LTBI from TB disease and therefore have no value for active TB detection

- IGRAs also more specific for M.TB infection vs non-tuberculous mycobact

Front 1552

Interpretation of TST

- considered according to? (3)

Back 1552

- TST should be considered according to three dimensions:

1. size of induration

2. positive predictive value

3. risk of disease if the person is truly infected

Front 1553

TST Size

- negative? positive? >10 mm when?

Back 1553

- less than 4 mm = negative

- greater than 5 mm = positive

- certain conditions, greater than >10 mm

Front 1554

TST PPV

- probability that?

- dependent on?

- confounded by? (2)

Back 1554

- probability that a positive TST represent true presence of TB infection

- dependent on age, incidence of TB in the population and is confounded by:

= previous BCG vaccination

= previous NTM exposure

Front 1555

PPV and BCG Effect

if received BCG <1 yo, then 1% haad?

- if BCG from 1-5 yo, then positive TST is?

- BCG after 6?

Back 1555

- BCG received <1 years old, 1% had a TST result of >10 mm if tested > 10 years later

- BCG received between ages of 1 to 5 years old = positive TST seen in 10-15% up to 25 years later

- BCG recieved >6: 40% had persistent positive reactions

Front 1556

PPV and BCG

- therefore if BCG receieved after 1?

- espec if person is?

Back 1556

- therefore if BCG was received after age 1, it can cause false - positive TSTs, espec. if the population from which the person is from has a low prevalence of LTBI

Front 1557

Non-tuberculous Mycobacterium

- found in? people may be?

- in Canada, doesnt normally?

- this is why?

Back 1557

- found in soil and water in warm, temperate climates so people may be exposed and sensitized

- in Canada, sens is less common and does not usually cause a TST reaction greater than 10 mm

- this is why 10 mm remains the standard cut-point to determine whether TB infection is present

Front 1558

TB - Risk of Development of Active TB - high risk (8)

Back 1558

Front 1559

TB - Risk of Development - Increased Risk and Low risk

Back 1559

Front 1560

Interpretation of Positive TST

- calc risk based on?

Back 1560

- by utilizing the info from TST size, PPV of a positive TST (espec. if the person had a BCG) and risk of development of active TB, one can calculate risk of developing active TB

Front 1561

Positive TB Skin test - what to do - first rule out?

- perform a?

- sputum if?

Back 1561

- rule out active TB:

= history and PE

= CXR to rule abnorms

= Sputum if symptoms or abnormal CXR + referral to a TB clinic

= if CXR normal and no symptoms

Front 1562

Who should get treatment of latent TB Infection

- all convertors have? then rest of lives?

- offer to? of those who?

- also to those that are?

- and those with increased? (3)

Back 1562

- all convertors = 5% chnace of reactivating in first 2 years after conversion and then 5% for rest of their lives

- offer to new immigrants, less than 5 years in Canada

- offer to HIV+ and immunosuppressed

- offer to those with increased risk of reaactivation = renal failure, diabetes, abnormal CXR

Front 1563

LTBI Treatment - given in?

- for 9 months? 4 months?

Back 1563

- in immunocompetent or immunocompromised:

1) INH 9 months

2) Rifampin 4 months

Front 1564

What are the Major SEs of Isoniazid

- max dose?

- <1% chance of?

- SEs?

- treat for? also give?

Back 1564

- 5 mg/g to max 300 mg/day

- <1% chance of hepatotoxicity if excluding alcoholics and those with chronic active hepatitis

- see rash, GI upset

- treat for 9 months, give vitamin B6 25 mg per day to decrease neuropathies

Front 1565

Repeating TST

- in someone who is already positive, repetitive TB skin tests?

- once positive? do not?

Back 1565

- repetitive TB skin tests in someone who is already positive will continue to increase the size of reaction (Booster effect)

- once positive will always be positive, even after treatment, do not repeat TST if already positive once

Front 1566

When Do I Suspect Active TB - common symptoms of active pulm TB

- prolonged?

- other symptoms (5)

Back 1566

= prolonged cough (>3 weeks) and sputum

- fevers, chills, night sweats

- weight loss

- fatigue, loss of appetite

- hemoptysis

- other = LN swelling

Front 1567

RFs for Active TB

(4)

- consider immunosuppression in? (5)

Back 1567

- Aboriginal population

- previous history of TB or contact with active TB

- marginalized population

- immunosuppresion = HIV transplants, chronic steroid use, cancer, renal failure, diabetes

Front 1568

What Do I DO if I think someone has active TB?

- first do? investigation?

- analysis of? via? (3)

- TBST - still see? do not use?

Back 1568

- isolation precautions

- CXR

- respiratory secretion analysis:

= spont. early morning sputum x 3

= induced sputum

= bronchoscopy samples

* TBST = 20-30% false negative in active TB, therefore do not use TST if suspect active disease

Front 1569

Active TB

- most active cases are missed as?

- high resistance due to? therefore use? different from latent as?

- must consider?

Back 1569

- most active TB cases are missed because diagnosis is not considered ***

- since number if organisms are much higher, chance of resistance to a single treatment agent is high, therfore multi-drug regimen is needed for treatment in contrast to latent TB where only one agent is effective

- must consider resp. isolation and testing and treating the contact cases as well***

Front 1570

Extrapulm Disease (8)

Back 1570

- LN TB

- pleural TB

- CNS = mening, tuberculoma

- pericardial TB

- MSK TB

- peritoneal

- genitourinary

- dissem TB

Front 1571

Suspected Active TB Patient Algorithm

Back 1571

Front 1572

Pulmonary vs Extrapulm Source - Flow

Back 1572

Front 1573

If Positive for Active TB?

- give? discuss? then start?

Back 1573

- give education in patients own language

- transmission, med SEs, action plan for SEs, role of public health

- then start therapy

Front 1574

Active TB - steps

- monthly? await? adjust?

- follow up for?

Back 1574

- monthly clinical follow up and drug supply

- await final sensitivities, adjust meds as needed

- follow for sputum conversion

Front 1575

DOT therapy?

- stands for?

- do if TB is?

- or if? (5)

Back 1575

- if TB drug-resistant, language barrier, prolonged positive sputum, non-compliant, homeless, Hx of substance abuse, consider:

= Direct Observed Therapy = Public Health = DOT

Front 1576

Managing Active TB

Back 1576

- always start 4 drugs until sensitivities are known (>4% 1 drug resistance)

= INH = isoniazide = 5 mg/kg

= RIF = rifampin = 10 mg/kg

- PZA = pyrazinamide = 20-25 mg/kg

- EMB = ethambutol = 15-20 mg/kg

- Vit B6

Front 1577

Effect of Drugs on Various Bacillary Populations

- INH kills? acts?

- RMP kills? is the?

- PZA used to? therefore?

Back 1577

- INH kills dividing bacteria = first exponential

- RMP kills bacterial with spurts of metabolism = second exponential

= PZA kills dormant organisms = second exponential

Front 1578

Differential Diagnosis of Wheezing

- 9

Back 1578

- asthma

- congenital anomalies with airway impingement = vascular rings, tracheobronchial obstruction, mediastinal mass

- bronchopulmonary dysplasia

- cystic fiboris

- GERD
- aspiration

- FB aspiration

- heart failure

- sinusitis and allergic rhinitis

- bronchiolitis

- pertusiss

- TB

- immune system disorders

Front 1579

Potential RFs for wheezing - Host

- G/A/AH/G/R

Back 1579

- genetics

- atopy

- airway hyperresponsivenes

- gender

- race/ethnicity

Front 1580

Potential RFs for Wheezing - Environ

- (10)

Back 1580

- indoor allergens, outdoor allegens, occupational sensitizer

- tobacoo smoke, air pollution, resp infections, SE status, family size, diet and drugs, obesity

Front 1581

Operations Diagnostic Criteria for Asthma in Children One to Five years of Age

- documented?

- see? improves with?

- no?

Back 1581

1) Documentation of airflow obstruction - documented wheezing

2) Documentation of reversibility of airflow obstruction - improvement with SABA, oral corts

3) No clinical evidence of an alternative diagnosis

Front 1582

Diagnosis of Asthma - Pulm Function Criteria

- reduced? increase in? after?

- is less than the?

- after BD challenge?

Back 1582

- reduced FEV1/FVC and increase in FEV1 after bronchodilator or therapy

- less than lower limit based on age, etc reduced FEV1/FVC

- >12% increase after bronchodilator challenege

Front 1583

Asthma Management - start with? mainstay? if worse?

Back 1583

Front 1584

Asthma Control Chractarized as?

- daytime? nighttime? PA? exacs? need for?

Back 1584

- see much more not controlled than thought

Front 1585

Key Diffs between Peds and Adult Asthma Management - Meds

- most children controlled on? if 6 to 11?

- if 12 and over - add? in form of?

- high doses ICS assoc with?

- less than 12 - dont use?

Back 1585

- most children control on low dose ICS

- if not adeaquate:

- children 6 to 11 = increase ICS to moderate dose

- 12 and over = add LABA to low dose ICS in form of combination inhlaer

- high doses ICS assoc with many SEs

- use of single inhaler therapy combo of budesonide and formoterol not approved in children less than 12 years old

- most children 6 years and over should be able to use a holding chamber with mouthpiece

Front 1586

Key Diffs between Peds and Adult Asthma Management - Monitoring

- start with? given to?

- in children, monitor?

- see increase in exacs in?

- lower dose in?

Back 1586

- education given to parent - child triad for young children, shift to child as age

- carefullly monitor growth (H/W) in childen each visit, fall needs to be prompt referral

- see increase in exacs in Sept/OCt yea rround

- lower dose - see better growth velocity

Front 1587

ICS vs Anti-Leuks

- moe effective? at?

Back 1587

-ICS more effective at decreasing asthma exacs than anti-leuks agents

Front 1588

Cystic Fibrosis

- is a? caused by?

- see abnormal? median survival?

Back 1588

- AR genetic disease affecting more than 70,000 people worldwide

- caused by CFTR mutation

- see abnormal transport of chloride and sodium across the epithelium leading to thick secretions

- median survival is 51.8 years

Front 1589

of 2000 CFTR Mutations

- CF disease caused by? classified into?

- all rest mutations cause? classified into?

Back 1589

- 242 become CF disease, classified ito pancreatic insufficient or pancreatic sufficient

- all the rest are benign polymorphs or CFTR related disorders

- mutation classified from 1 through 6

Front 1590

CFTR Mutation Classes

- Class I - see?

- Class III - see?

- Class 6?

Back 1590

- Class I = no functional protein due to absent functional CFTR

- Class 3 = Defective channel regulation

- Class 6 = decreased CFTR stability

Front 1591

Pan Insuff vs Pan suff

- 85% are? 15% are?

- change due to? (3)

Back 1591

- idea of genotypoe vs phenotype

- 85% are pancreatic insufficient, 15% are pancreatic sufficient

- change due to genetic modification, environment and passage of time

Front 1592

CF Related Lung Disease ad Damage

- abnormal CFTR leads to? impaired? cycle of?

- in turn leads to? (4)

= SD/B/PI/RF

Back 1592

- abnormal CFTR leads to reduced airway surface liquid and impaired mucociliary clearance

- leads to cycle of infection and inflammation

- in turn leads to:

= structural damage

= bronchiectasis

= pulmonary insufficiency

= respiratory failure

Front 1593

Prevalence of Resp Infections

- up to 25, most common?

- above 25?

Back 1593

- in younger patients, up to 25, S. aureus is the most common

- above 25, P aeruginosa is most common cause of infection

Front 1594

Sinopulmonary Manifestations

- 90% of?

- B/A/C/S/NP/P/H/A

Back 1594

= 90% of the M % M

= bronchiectasis

= asthma like phenotype

= clubbing

= sinusitis

= nasal polyps

= pneumothorx

= hemoptysis

= ABPA

Front 1595

In Pulmonary Disease, - during exacerbations - see?

- increased? (3)

- decreased?

- loss of? missed? PE? decreased? new?

Back 1595

- increased cough

= increased sputum production

= decreased exercise tolerane

= increased dyspnea

= weight loss

= missed school

= PE findings = crackles

= decreased FEV1 10%

= new CXR findings

Front 1596

In Pulmonary Disease - Pulm Function - see?

- decline starts?

- increased? due to?

- worsening?

- decreased?

Back 1596

= decline starts early in life

- air trapping = increased RV/TLV

= worsening airway obstruction:

= decreased FEV1, FVC, FEF 25-75

= FEV1 drops once signif disease

Front 1597

Primary CFTR Dysfunction

- see? (10) P/MI/D/C/NC/S/C/I/H

Back 1597

= pancreatic insufficiency

= CFRD

= pancreatitis

= meconium ileus

= DIOS
= constipation

= neonatal cholestasis

= steatosis

= cirrhosis

= infertility

= heat protration

Front 1598

Secondary CFTR Dysfunction

= G/O/ rectal? defic in?

Back 1598

= GERD

= OP

= rectal prolapse

= vitamin ADEK deficiency

= zinc defic

= FTT

Front 1599

Lab Evidence of CFTR Dysfunction

- positive? (2)

- want to see two?

Back 1599

- positive sweat test

- positive nasal PD

- two disease-causing mutations in CFTR

Front 1600

Clinical Features Compatible with CF

- sinopulm? abnorms in? snndromes related to ?

- relative?

Back 1600

- sinopulm disease

- GI and nutritonal abnorms

- salt loss syndromes

- obstructive azoospermia

- or CF history in sibling or positive newborn screening

Front 1601

Newborn Screening for CF

- started in? checking?

- if? then do? looking for?

- perform sweat chloride if? or if?

Back 1601

- stated in 2008, checks immunoreactive trypsinogen (IRT) on bloodspot

- if elevated (top 4%) DNA testing performed for top 35 mutations

- sweat chloride is performed if 1 or 2 mutations are found or if IRT is top 99th percentile

Front 1602

Sweat Test

- developed in? give? to?

- in CF. see increased? due to?

- positive? intemediate?

- lower sweats in? (2)

- if less than 3 months, positive in?

- if intermediate?

Back 1602

- developed in 1959, stimulate sweating with pilocarpine

- in CF, see increased Cl in sweat due to obstructed CFTR

- sweat Cl > 60 mmol/L is positive

- sweat Cl 40-60 mmol/L is intermediate

- pancreatic sufficient have lower mean sweats

- infants how lower sweats

** <3 months of age = positive is > 30 mmol/L

* cant exclude diagnosis of CF if intermediate if clinical symptoms

Front 1603

Algorithm to CF

- first have?

- three options of mutations =?

= 2? 1? O?

Back 1603

Front 1604

CF Algorithm

- first have?

- if 2 mutations? follow in?

- if 1 mutation do? check if?

- if 0 mutations? then?

Back 1604

- see increased immunoreactive trypsinogen, then do DNA analysis:

= 2 mutations = CF diagnosis = follow in CF clinic

= 1 mutations = sweat test = if above >60mmol/L, CF

= 0 mutation = do IRT again = if still increased, do sweat test and if not, discharge

Front 1605

Nasal Potential Difference Measurement

- assesses?

- in CF airway, see? leads to?

Back 1605

- assessment of CFTR function in nasal mucosa using NPD

- in CF airway epithelium, see water can only go into epithelium and not out, leading to decreased potential

Front 1606

Treatment of CF - Pulmonary Manifestations

- give a chest?

- mucolytics?

- Abx?

- anti?

- give supplemental?

Back 1606

- chest PT

- mucolytics = dornase alfa, hypertonic saline

- Abx = inhaled, oral, IV

- bronchodilators

- anti-inflamms = inhaled, oral

- supplemental oxygen

- BiPAP

- lung transplant

Front 1607

Treatment of Cystic Fibrosis - Extrapulmom Manifefestations

- replace? also give?

- diet?

- consider transplants of?

- ursodiol if? insulin if?

Back 1607

- enzyme replacement

- ADEK vitamins

- high calorie,high fat diet

- Ursodiol if CFLD

- Insulin if CFRD

- liver transplant

- pancreas transplant

Front 1608

CFTR Modulators - Potentiators

are?

- increase? name?

Back 1608

- orally bioavailable drugs

- potentiator = Ivacaftor = increases opening of CFTR channel

Front 1609

CFTR Modulators - Correctors

- are? increase? name?

Back 1609

- BA drugs

= Lumicaftor = increase number and function of CFTR channels at the cell surface

Front 1610

Primary Ciliary Dyskinesia

- is a? prevalence?

- often is a?

- abnormal?

- impaired?

Back 1610

- AR recessive disease

- prevalence is 1 in 10-40 000

- late diagnosis

- abnormal ciliary structure and function

- impaired mucociliary clearance

Front 1611

Signs of PCD

- recurrent?

- neonatal?

- serous?

- loss of?

- in males?

- also see?

Back 1611

- recurrent pulmonary infections

- neonatal respiratory distress

- sinusitis

- serous otitis media

- hearing loss

- bronchiectasis

- male infertility

- laterality disorders in 50%

Front 1612

Diagnosis of PCD - Screening

- no? **

- look at? NO produced throughout?

- level in PCD? however not?

Back 1612

*** no perfect test

= Nasal Nitric Oxide

- NO produced throughout airways but more abundant in paranasal sinuses

- low in PCD patients

- but not diagnostic because reported to be normal in subset of PCD patients

Front 1613

Diagnosis of PCD - Diagnostic

- try?

- EM for? yet is?

- genetics as?

Back 1613

- high speed video microscopy

- electron microscopy = normal in 20% PCD

- immunofluorescence

- genetics = >30 genes and identify 60% of cases

Front 1614

CF vs PCD - CF

- no? (2)

- FTT if?

- male?

- low?

- on PFT?

Back 1614

- no neonatal resp distress

- no increased incidence of ear infections

- FTT if pancreatic insufficient CFRD

- male infertility

- airway obstruction on PFTs

- low NO

Front 1615

CF vs PCD - PCD

- see? prominent feature?

- no assoc?

- on PFT?

- low?

- not all wheeze is?

Back 1615

- neonatal resp distress

- prominent feature is recurrent otitis media

- no assoc GI disease

- male infertility

- airway obstruction of PFTs

- low NO

*no all wheeze is athma

Front 1616

If obstructive pulm. graph and normal DLCO? Asthma if?

- can be either?

- asthma if?

Back 1616

- can be chronic bronchitis or asthma

- if increase in FEV1 is >12% and >200 cc post bronchodilator, is asthma

- sub-optimal control if have persistent symptoms

Front 1617

Asthma Treatment

- patient needs? (3)

- 1st line?

- 2nd line is? should not?

Back 1617

- patient needs:

= environmental control, rescue bronchodilator, controller medication

= 1st line = inhaled steroid

= 2nd line is long acting beta agonist = should not be sed as controller monotherapy

Front 1618

Algorithm of Chronic Cough

- if have cause? then? if inadequate?

- if smoking? then if inadequate?

Back 1618

Front 1619

Red flags of cough **

Back 1619

- hemoptysis

- weight loss

- abnormal CXR

Front 1620

Big Three Causes of Cough and Treatment

# 1 is? give? (3)

# 2 is? do? give? then?

# 3 is? give or do?

Back 1620

1) Upper Airway Cough Syndrome = antihistamines, decongestants, nasal steroids

2) Asthma - do spirometry with methacholine challenge = inhaled steroids then bronchodilators

3) GERD = PPI, lifestyle mods

Front 1621

COPD treatment ladder

- start with?

- then give? then? if that doesnt work?

Back 1621

Front 1622

COPD - Mild vs Mod vs Severe Treatment

- always do?

- always start with? then?

- last resort?

- to reduce exacs

Back 1622

- theophylinne last resort

- smoking cessation no brainer

- SA and LA BDs are approp. with pulm rehab to reduce exacs

Front 1623

COPD Treatments

- ICS used to?

- theophyilline only used if?

Back 1623

- inhaled cortcs (ICS) reduce frequency of exacerbations but shouldnt be used as monotherapy

- theophylline may be used if having persistent symptoms despite all other treatments

Front 1624

Acute Exacs of COPD

- systemic steroids to?

- Abx used in?

- oxygen for?

- SABDs vs LABDs?

Back 1624

- systemic steroids can reduce duration of hospitalizations and increase time to next exacerbation

- Abx are indicated in exacerbations with sputum purulence

- oxygen is indicated if patient is hypoxemic

- SABDs are appropriate, LABDs can be continued but likely not helpful for acute relief

Front 1625

If restrictive and low DLCO - think of?

- hallmarks are? (3)

= low? (2)

= normal?

Back 1625

- think of ILD

- hallmarks of restriction on pulmonary function testing are:

= low FVC

= normal FEV1/FVC

= low TLC

Front 1626

ILD and Idiopathic Pulmonary Fibrosis

- on PE, see?

- on walk test? on CT chest?

- patients with ILD do not?

Back 1626

- crackles and clubbing consistent with IPF

- see desaturation on walk test and honeycombing pattern on CT chest

- patients with ILD do not usully have hemoptysis, unless other problem also **

Front 1627

Most likely etiology of hoarseness when have lung cancer?

- recurrent?

Back 1627

- recurrent laryngeal nerve involvement of lung tumour

Front 1628

Hoarseness caused by disruption of? from? (2)

- see unilateral?

Back 1628

- disruption of recurrent laryngeal nerve (esp. left) from tumour or mediastinal adenopathy

- unilateral vocal cord paralysis

Front 1629

Most likely cell type in lung cancer of non-smoker?

- smoking history in AC or other cell types?

Back 1629

- adenocarcinoma

- smoking history in 75% of ACs vs 98% of other cell types

Front 1630

Nodules and Risk of malignancy

- age?

- popcorn means? stippled or eccentric?

- smooth or lobulated borders? irregular or spiculated borders?

- diameter?

- nodule growth?

Back 1630

- older patients have higher risk of malig

- popcorn calcification suggests benign etiology

- most patterns of calc suggest benign except stippled or eccentric

- smooth or lobulated borders suggests benign

- irregular or spiculated suggest malignant

- diameter > 1cm (large lesions) increases risk of malignancy

- nodule that grows very quickly and have doubling <20 days, or very slowly (> 400 days) are more likely to be beinign

Front 1631

Light's Criteria - fluid is an exudate if?

- protein?

- LDH?

- pleural fluid LDH > then? usually?

Back 1631

- if any one of the following present:

= pleural fluid protein: serum protein > 0.5

= pleural fluid LDH: serum LDH > 0.6

= pleural fluid LDH > 2/3 upper limit of normal for serum LDH (200 IU/L)

Front 1632

Pleural Effusions - Causes - Transduate - main causes? (3)

Back 1632

- CHF

- hepatic hydrothorax

- nephrotic syndrome

Front 1633

Pleural Effusions - Causes - Exudate

- I/ M/ I/ other

Back 1633

- Infection = bacteria, TB, viral, fungal, parasitic

- Malignancy = Carc, Lymphoma, Meso, Chylo, Myeloma

- Inflammatory - CTD, pancreatitis, asbestos, PE, ARDS

- Other = iatrogenic, drug-induced, hypothyroid

Front 1634

Types of Pain

- nociceptive can be? neuropathic can be?

Back 1634

- nociceptive = somatic vs visceral = more dull

- neuropathic = central vs peripheral = more burning

- mixed

Front 1635

Pain Vs Suffering

- nociception is the?

- pain is the?

- suffering is the?

Back 1635

- nociception = is the physiologic formation of pain signal

- pain = perception or feeling or sensation

- suffering = reception or response to feeling

Front 1636

Pain Mechanisms

- gate theory sees ascending? before? used in?

- biomech theory - response affected by

- pro noci signals = (3)

- anti noci signals are? (3)

Back 1636

1) gate Theory = ascending pain signals blocked at spinal cord, before thalamus, theory behind TENS

2) Biomechanical Theory = response to pain stimulus affected by intra-neuronal neurotransmitters

- pro-nociceptive = glutamate, aspartate, substance P

- anti-nociceptive = GABA, serotonin, ACh

3) Chronic Pain Theory

Front 1637

Pain and Signal Processing

- transduction? transmission? modulation? perception?

Back 1637

1) Transduction = receptor activation = energy converted into nerve impulses

2) Transmission = information is transferred from primary afferent fibres to SC dorsal horn and onto brain stem

3) Modulation

4) Perception = begins with activation of sensory cortex

Front 1638

Nociceptive Pain

- fibers that respond to damaged tissue?

- goes through? then? then?

Back 1638

- primary afferent fibers = A-delta, C = respond to damaged tissue

- cell bodies = DRG or cranial nerve ganglia

- spinal columns

- brain

Front 1639

- Pain Subtypes - Nociceptive, Somatic

- quality?

- location is?

- ex/? (2)

Back 1639

- quality = sharp, stabbing, throbbing

- well localized

- ex/ meniscal tear, laceration

Front 1640

- Pain Subtypes - Nociceptive, Visceral

- quality?

- location is?

- seen in? (2)

Back 1640

- quality = deep, dull, cramping

- poorly localized

- cholecystitis, endometriosis

Front 1641

- Pain Subtypes - Neuropathic

- quality?

- location?

- seen in? (2)

Back 1641

- quality = burning, tingling, numb

- localized or generalized

- radiculopathy, polyneuropathy

Front 1642

Acute Pain

- usually a response to? stimulus can be?

- causes? time?

- treatment aimed at?

- seen in?

Back 1642

- usually a response to noxious = mechanical, thermal, chemical stimulus

- causes depolarization of nociceptors

- time-limited

- treatment aimed at removing underlying pathologic process

- ex/ wrist fracture

Front 1643

Chronic Pain

- may not be assoc. with?

- have a? that correlates less with?

- additional?

- sleep? function?

- seen in?

- higher costs than?

- seen more in? (3)

Back 1643

- may not be associated with noxious event/ pathologic process

- underlying pathology correlates less with reported level of pain

- additional psychologic and behavioural mechs

- often poor sleep and decrease in function

- 2-55%, 70% in primary disability

- higher costs than cancer, depression, hypertension

- seen in elderly, disabled, terminal conditions

Front 1644

Complications of Chronic Pain

- physical?

- psychological?

- societal?

Back 1644

1) Physical = decreased ROM, myofascial pain, muscle weakness, tolerane, substance use disorder, drug dependency

2) Psychological = depression, spouse distress, family distress, insomnia

3) Societal = lost wages, social support systems

Front 1645

Chronic Pain Mood Symptoms

- depression leads to higher? greater? life interference related to?

- pain related? leading to higher? more? behaviours?

Back 1645

1) Depression in Chronic Pain = higher lvels of pain, less active, report greater disability and life interference related to pain

2) Pain related Anxiety = higher severity, great disability, pain behaviours (fear avoiding)

Front 1646

Assessing Chronic Pain

- perception?

- cognition?

- attention?

- emotion?

- learning and memory?

- motivation?

Back 1646

- perception - altered perception

- cognition - deficits in performance

- attention - hypervigilance

- emotion - depression, anxiety, suicide

- learning and memory - deficits, fear learning

- motivation - decreased, centered value

Front 1647

Chronic Pain Biopsychosocial Assessment

- history to characterize? via?

- investigations if?

- assessment of? (4) - good for?

Back 1647

1) Pain history = OPQRST = characterize as somatic, visceral, neuropathic to guide mngmt

2) Red flag symptoms = warrant investigations

3) Functional Assessment = IADLS, BADLs, Vocational, PA = context pain, goal-setting

Front 1648

Chronic Pain Biopsychosocial Assessment

- screening for? if untreated can?

- ask about? feeling?

- if untreated, can?

Back 1648

4) Mood Screening = depression, anxiety = untreated can amplify pain

5) Sleep screening = OSA, non-restor sleep = untreated, amplifies pain, with opioids can increase risk of overdose

6) PE

*pain is subjective, acknowledge pain

Front 1649

Normal Sensation after damage?

- nociception leads to?

- low-threshold mechs lead to?

Back 1649

- is pain from nociception

- low-threshold mechanoceptors lead to touch

Front 1650

If have central sensitization

- nociception can lead to?

- low threshold mechs lead to?

Back 1650

- can lead to hyperalgesia from nociception

- low-threshold mechanoceptors leads to allodynia

Front 1651

Chronic Pain - Brain Morph Chnages

- see decreased?

- in CBP - affects? PFC/T

- IBS? I and CG

- fibromyalgia? N

- tension HAs? N

- treatment able to? normalizes?

Back 1651

- see decreased gray matter

1) Chronic Back Pain = prefrontal cortex, thalamus

2) IBS = insulate and cingulate gyrus

3) Fibromyalgia = numerous

4) Tension Headaches = numerous

*see treatment can reverse abnormal brain anatomy and function, normalizes brain activity

Front 1652

Chronic Pain - Variability in Perception

see different? in? (CG/I)

Back 1652

- variable correlation between stimulus and ratings for the 16 subjects

- activity in cingulate gyrus and insula statistically different between stimulus and perception

Front 1653

Addiction vs Dependence vs Tolerance - Addiction

- considered impaired? use is? continued despite?

Back 1653

- Addiction = impaired control over drug use, compulsive use, continued use despite harm and craving

Front 1654

Addiction vs Dependence vs Tolerance - Dependence

- pattern marked by?

- see? made by? or decreased?

Back 1654

- Dependence = maladaptive pattern of drug use marked by tolerance and a drug class-specific withdrawal syndrome that can be produced by abrupt cessation, rapid dose reduction, decreased blood levels of drug or admin of an antag

Front 1655

Addiction vs Dependence vs Tolerance - Tolerance

- state of? drug induces changes that?

Back 1655

- state of adaptation in which exposure to a drug induces changes that result in diminution of one or more of the drug's effects over time

Front 1656

Chronic Pain Management and Assessment

- pain best managed using?

- assess (4) = P/M/FI/C - via?

Back 1656

- pain is best managed using biopsych assessment and approach

- assess via:

= pain = OPQRST

= mood = anxiety, depression, anger = DSM-5

= functional interference = vocational, IADLs, BADLs

= coping and beliefs

Front 1657

Chronic Pain Management - six parts

- AM/ RP/ PM/ IP/ PI/ S

- forms a?

Back 1657

= activity modification

= rehabilitation program

= pharmacological management

= interventional procedures

= psychiatric interventions

= surgery

*forms comprehensive pain program

Front 1658

Chronic Pain Non-Pharm Management (8)

Back 1658

- MCEs

- taichi

- yoga

- progressive relxation

- EMG

- CBT

- mutlidisc rehab

- acupuncture

- etc

Front 1659

Chronic Pain Pharm Management (10)

Back 1659

- acetaminophen

- NSAIDs

- gabapentinoids

- Tricyclic Antidepressants

- Opiods

- SNRIs

- SSRIS

- ketamine

- lidocaine

- cannabinoids

Front 1660

Chronic Pain - Pharm Management Peripherally, Centrally

- peripherally at receptor - use? (4)

- peripherally along nerve? (2)

- centrally =? use (4)

Back 1660

1) Peripherally at nociceptor = cannabinoids, NSAIDs, opioids, tramadol

2) Peripherally = along nociceptive nerve = local anesthetics, anticonvulsants

3) Centrally = various parts of the brain = acetaminophen, anticonvulsants, tramadol, opioids

Front 1661

Chronic Pain - Pharm Management - Descending Inhibitory Pathway, Dorsal Horn

- DIP = (4)

- Horn = (5)

Back 1661

4) Desc Inhibitory Pathway in SC = cannabinoids, opiods, TCA, SNRIs

5) Dorsal horn of SC = anticonvulsants, cannabinoids, gabapentin, NMDA antags, opioids

Front 1662

Interventional Pain Management

-blocks? (2)

- injections (2)

- soft tissue?

- RF ablations to? (2)

Back 1662

1)Diagnostic nerve blocks = medial branch, lateral femoral cutaneous

2) Intra-articular injections = glenohumeral, sacroiliac

3) Soft tissue injections - bursas, trigger points

4) Radiofreq ablations - suprascapular, medial branch

Front 1663

Chronic pain Management - 6 parts **

- also want to normalize?

Back 1663

- CBT, relaxation strategies, mindfulness based stress reduction

- TFESI to decrease pain

- want to normalize sleep

Front 1664

Pain Clinical Points

- always examine? make sure to?

- pain wont? is a?

- do not? especially? unless?

Back 1664

- always examine patient

- always acknowledge the patient's suffering from pain

- pain does not show up on imaging, subjective experience

- do not order imaging, especially MRIs, unless it will def chnage management

Front 1665

Allodynia? Hyperalgesia?

- A = stimulus?

- HA - increased?

Back 1665

- pain caused by stimulus that does not normally provoke pain

- HA = increased response to a stimulus that is normally painful

Front 1666

Nociception vs Pain

Back 1666

Front 1667

Why Treat Pain with Medication?

- patients want? doctors want?

- expect?

- practice?

- non-drug?

- anecdotes?

- goal is not only?

Back 1667

- patient want relief, doctors want to help

- societal expectation

- practice models/ insurance coverage

- non-drug measures are hard

- anecdotes of success

- goal is not simply pain relief but to afford benefit > harm

Front 1668

Acetaminophen

- #1?

- major uses? mechanism?

- adult dose? peds dose?

- dont give reflexively for?

Back 1668

- #1 analgesic worldwide

- major uses for pain, fever

- mechanism is decreased prostaglandin synthesis in CNS

- adults dose is 1000 mg 3-4x/day

- peds dose is 10-15/kg 3-4 times/day

- dont not give reflexively for fever

- better for acute pain ? chronic

Front 1669

Acetaminophen for Back Pain and OA

-shown to be?

Back 1669

- ineffective, minimal short term benefit for people with OA

Front 1670

Acetaminophen Toxicity

- produces? which is?

- dose dependent?

- therefore if go over? see increase in?

Back 1670

- produces NAPQI, which is toxic to the liver

- hepatotoxicity is dose-dependent

- therefore if go over regular amount use, see increase in liver enzymes due to damage as NAC enzyme cannot handle

Front 1671

APAP-Warfarin Interaction

- warfarin blocks? therefore warfarin reduces?

- NAPQI acts to?

- together put?

Back 1671

- warfarin blocks enzyme that recycles vitamin K

- therefore patients on warfarin have depleted Factors 2,7,9 and 10

- NAPQI = acetmainophen metabolite, also decrease y-carboxylase activity

- two put patient into grossly anticoagulated state

Front 1672

Role of NSAIDs

- inhibit?

- COX1 has? inhibited by? (2)

- COX2 has? inhibited by? (3)

Back 1672

- inhibit COX

- COX-1 has cytoprotective PGS = inhibited by NSAIDs and Aspriin

- COX-2 has inflammatory PGs = inhibited by COX-2 inhibs, NSAIDs, Aspirin`

Front 1673

Different Role of Different NSAIDs

- ASA is? acts to? isnt?

- Nonselective means? include? (4)

- COX-2 inhib =?

Back 1673

1) ASA = Aspirin = platelet inhibition = irreversible

2) Nonselective (COX-1, COX-2) = ibuprofen, naproxen, indomethacin, ketorolac

3) COX-2 Inhibitor = celecoxib

Front 1674

NSAID Gastropathy

- prevent by?

- injury at?

- consider?

- consider use of? in those? (5)

Back 1674

- prevention via limiting dose and durarion

- injury to GI tract happens at 7-14 days

- consider H.pylori eradicaiton

- use PPi in high risk:

= age > 60, steroids, dyspepsia, concurrent ASA, previous ulcers

Front 1675

NSAIDs and Kidney - act to? therefore reduce?

Back 1675

- NSAIDs constrict afferent arteriole, also reduce glomerular perfusion

Front 1676

Different Opioids (7)

Back 1676

- heroin, morphine, hydromorphine, oxycodone, fentanyl, methadone, tramadol

Front 1677

Mechanism of Opioids

- stimulate?

- presynaptic binding acts to?

Back 1677

- stimulate opioid receptors in PNS/ CNS = mu, kappa, delta

- presynaptic mu binding decrease release of other NTs

Front 1678

Evolution of Opioids

- 70s, 80s - limited?

- but in 90s, see? due to?

- in 2002, see?

Back 1678

- 70s, 80s - limited prescribed just for acute and cancer pain

- 90s - see better treatment for all pain, due to toxicities and limited effectiveness of other drugs

- 2002- WHO Analgesic Ladder - still a problem as oxycodone shouldnt be considered a weak opioid = industry influence

Front 1679

WHO Analgesic Ladder

- 1 = known as (3)

- 2 = known as (3)

- 3 = known as(6)

** problem as?

Back 1679

Front 1680

Role of Oxycodone

- see prescribing?

- problem with codeine?

- after 2000, sales?

Back 1680

- bought into use of oxycodone, see prescribing of oxycodone increase after induction of long-acting oxycodone

- codeine becomes unknown amount of morphine, do not give as dont know how much is being converted

- see sales of oxycodone significantly increase after 2000, differs based on region, highest in ontario

Front 1681

Evidence for Opioids

- is? no studies that?

- typical RCTs (3) - easy to show?

Back 1681

- terrible - no study of opioid therapy versus no therapy evaluated >1 year outcomes elated to pain, QOL, function

- typical RCTs are 12 weeks long, exclude high risk patients, measure pain scores compared to placebo, easy to show it doesnt hurt in small time

Front 1682

Problems in Over prescribing

- large? see rapid increase in?

- also increase in?

Back 1682

- large harm, see rapid increase in commonly prescribed opioids and synthetic opioids and has been steadily increasing since 2001

Front 1683

Side Effects of Opioids

- C/D/F/SA/ decreaed/ OIH/ PD/D/S

Back 1683

- constipation

- delirium

- falls and consequences

- sleep apnea, altered sleep architecture

- reduced testosterone

- hyperalgesia (OIH)

- physical dependence

- depression

- suicide

- see increase risk of road trauma

Front 1684

Important of First Prescription

- if first round supply is less days? if more?

Back 1684

- if supplied less days in first supply of first opioid prescription, see less likely to continue use

- if have increased days in first opioid prescription, more likely to continue use

Front 1685

Physical Dependence

- response that is? not?

- defined by? under?

- results in? (5)

- dependence within?

Back 1685

- expected, adaptive response = not addiction

- defined by withdrawal under sudden decrease in dose

- results in symptoms = fatigue, headaches, nightmares, numbess, anxiety, etc

- dependence happens within 24 hours

Front 1686

Opioid Induced Hyperalgesia

- features increased? known as?

- pain often? and is?

- mechanism is?

Back 1686

- features:

= increase sensitivity to noxious stimuli, allodynia, pain often generalized and ill-defined

- mechanism:

= excessive activation of NMDA receptors

Front 1687

What to Do about OIH

- recognize?

- can give? such as? (3)

- must do?

Back 1687

- recognize +/- opioid rotation

- NMDA antagonist = Ketamine/ DM/ methadone

- slow taper

Front 1688

Patients not Addicts

- patients using?

- genuine? less likely as ?

- illusory?

Back 1688

- patients using opioids daily to control pain

- genuine benefit >harm = less likely as daily dose increase

- illusory benefit = physical dependence/ withdrawal

Front 1689

Key Points of Opioids Prescribing

- used as? start with?

- keep dose less than? can accept?

- encourage?

- avoid in? (2)

Back 1689

- opioids effectively last resort for chronic pain, sensible to start with morphine

- keep dose <50 mg morphine or equivalent, 90 for patients willing to accept increased risk

- encourage slow taper for legacy patients

- avoid in patients with active SUD

- avoid co-prescribing with Benzos

Front 1690

Problems of Opioids

- deaths at?

- increased risk of? in?

- twin crises of?

Back 1690

- see deaths at higher doses

- see increase risk of overdose in those with concurrent use of BZDs

- twin crises of addiction and of flawed pain management

Front 1691

Cervical Axial Pain Epi

- prevalence?

- chronic pain in? severe in?

- workers under? over 45?

Back 1691

- prevalence = 9-18%

- traumatic pain = chronic in 40%, severe in 8-10%

- workers under 30 - 30%

- workers 45+ = 50%

Front 1692

Radicular Pain Epi

- under 30? 45+

- history of? or preceding?

Back 1692

- annual incidence is 83/ 100 000

- under 30 = 5-10%

- 45+ = 25-40%

- history of trauma or preceding physical exertion in only 15%

Front 1693

Cervical Spine Anatomy

- vertebrae? roots?

- most axial rotation? most flexion? most lateral flexion?

Back 1693

- 7 vertebrae and 8 roots

- most axial rotation at C1-C2

- most flexion at C4/5 and C5/6

- most lateral flexion = C3/C4 an C4/C5

Front 1694

Cervical Spine Anatomy - ZPP facet joints for? connect?

- Luschka joints =? prevent?

- Intervertebral discs are found between? act to?

Back 1694

- Zygapophyseal Facte joints allow motion within C-spine and connect vertebral segments

- Uncovertebral Joints = Luschka = C3-C7 = prevent lateral translation

- Intervertebral Discs = between bodies f C2-C7 and dissipate axial forces

Front 1695

Cervical Intervertebral Disc

- inner = is? %? throughout life?

- outer = ? are? withstand?

- main function?

- axial load pushes on? acts to?

- if AF break?

Back 1695

- inner nucleus Pulposus = gelatinous, 90% water at birth, dessicates throughout life

- Outer Annulus Fibrosis = concentric fibrous layers to help withstand strains

- main function is shock absoprtion

- Axial load pushes on nucleus and stretch annulus fibers

- If annulus fibers break, have herniated NP

Front 1696

Mechanical Axial Pain

- cervical? (2)

- herniated?

- FJMP?

- cervical?

Back 1696

- cervical sprain

- cervical strain

- herniated Nucleus Pulposus

- Facet Joint-Mediated Pain

- Cervical Stenosis/ Myelopathy

Front 1697

Axial Pain Rheumatologic (8)

Back 1697

- Ankylosing Spondylitis

- Reiter Syndrome

- Psoriatic Arthritis

- Enteropathic Arthritis

- Rheumatoid Arthritis

- Diffuse Idiopathic Skeletal Hyperostosis

- PMR

- Fibromyalgia

Front 1698

Other Causes of Axial Pain - Endo = (5)

- also consider? (2)

Back 1698

- Endocrinologic

= Osteoporosis = compression fracture

= Osteomalacia

= Parathyroid Disease

= Paget Disease

= Pituatary Disease

- Infections

- Tumours

Front 1699

Cervical Sprains and Strains

- sprain means? from?

- strain is a?

- account for?

- mechanism = M/W/A

Back 1699

- ptrain = MSKtendinous injury produced from overload

- Strain = ligamentous overstretching or tearing

- account for 85% neck pain

- mechanisms:

= MVA = accel/decel

= Workplace = postural (thoracic kyphosis)

= Athletes = trauma, repetition

Front 1700

Symptoms and Signs of Cerivcal Sprain and Strains

- symptoms = (4)

- aggravated by?

- signs = decreased? palp of? normal?

- no painless?

Back 1700

- Symptoms: neck pain, stiffness, fatigue, HAs, aggravated by passive or active neck motion

- Signs: decreased cervical ROM, palpation of area uncomfortable or mod painful (upper trap, SMC), normal neuro exam and motor exam shows no painless weakness

Front 1701

Investigations of Cervical S/S

- indicated for?

- do?

- most common cause = ? from?

Back 1701

- indictaed for neurologic or motor abnorms

- do flexion/extension Xrays

- most common = straightening of lordosis from muscle spamsTrea

Front 1702

Treatment of Cervical S/S

- control? to allow?

- meds (2)

- modalities? (4)

- gradual return to?

- exercise program with?

Back 1702

- control pain and inflammation to facilitate active rehab

- meds = NSAID, acetaminophen

- modalities = massage, heat, TENS, soft cervical collar

- gradual return to activities 2-4 weeks post injury

- exercise program = incorporate proprioceptive retraining, balance, postural conditioning

Front 1703

Herniated Nucleus Pulposus

- NP migrates through? release of?

- most common at?

- often at? then? then?

Back 1703

- NP migrates through annular fibers, see release of inflamm mediators

- most common at 30-40 years of age

- L4/5-L5/S1 > C5/C6

Front 1704

Etiolgy of Hrniated NP

- (4)

Back 1704

= spontaneous

= lifting activities

= coughing/ sneezing

= bending / twisting

Front 1705

Symptoms of Herniated Nucleus Pulposus

- acute? interscap?

- if no nerve root impingement?

- if NR impingement?

- or can be?

- aggrav by?

- allev by?

Back 1705

- acute cervical or back pain, interscapular pain

- may cause:

= axial pain if no nerve root impingement (radiculo)

= radiating pain down the arm or leg if NR impingement

= both

- aggrav. by coughing, lifting

- allev by lying supine with head support

Front 1706

Signs of Herniated Np

- must exclude?

- restrictions?

- tender to? over?

Back 1706

- must exclude myelopathy and radiculopathy

- suble range of motion restrictions

- tender to palpation over the cervical spinous processes

Front 1707

Imaging of Herniated NP

- MRI isnt useful?

- look for?

Back 1707

- MRI not useful in detecting symptomatic cervical disks

- look for red flags

- cervical provocation discography

Front 1708

Treating Herniated NP

- control?

- modalities?

- meds? (2) sparingly?

- staiblize?

- interventional?-

- surgery?

Back 1708

- control pain and inflammation

- modalities = heat, traction (CI in myelopathy), TENS, cervical collar (<72 hours)

- Meds = NSAIDs, TCAs, sparingly opiates

- Cervical Spine Stabilization

- Interventional = Epidural Steroid Injections

- Surgery = Fusion

Front 1709

Cervical Radiculopathy - Common Causes

- #1 is? due to? #2 is cervical? or? due to?

Back 1709

#1 = cervical herniated NP = structural compression and peri-neural inflammation

#2 = cervical spondylosis (Osteoarthritis) = zygophophyseal hypertrophy or uncovertebral hypertropy

Front 1710

Symptoms of Cervical Radiculopathy

- axial? followed by?

- gradual? that is?

- deep?

- aggrav by?

- allev by? as relieves?

Back 1710

- axial cervical pain followed by explosive onset of upper limb pain

- spondylotic, gradual onset of pain

- deep,dull ache or sharp/ lancinating

- aggravating by coughing, sneezing

- allev by elevating humerus = abduction relief manuever

Front 1711

Signs of Cervical Radiculopathy

- (4)

- no?

Back 1711

- muscle wasting/ atrophy

- motor weakness

- decreased or absent reflex in affected myotome

- decrease sensation (light tough, pinprick, vibration) in affected dermatome

- no UMN signs = Hoffmans, Babinksi

Front 1712

Cervical Radiculpathy - C5 through T1 - nerve and Muscle ??

- nerve is? muscle?

- C5/6 is? 7/8? C8/T1 is?

Back 1712

C5/6 - biceps, BR

C7/8 - triceps

C8/T1 - finger flexors

Front 1713

UMN Syndrome

not?

- hyper?

- gait?

- also see?

Back 1713

- not radiculopathy

- positive Hoffmans

- hyperreflexia

- gait ataxia

- spasticity

- clonus

Front 1714

Investigations of Cervical Radiculopathy

- mRI to see if?

- NCS to test? assess?

- Nerve root block has?

Back 1714

1) MRI to see structual compression at nerve root

2) Nerve Conduction, EMG - test 6 peripheral nerves and parapsinal, assess for other neuropathies such as CTS - high detection for CRs

3) Fluroscopically Selective Nerve Root Block - high spec

Front 1715

Treatment of Cervical Radiculopathy

- patient?

- modification of? avoid?

- pain relief via?

- stab via?

- interventional? surgery?

Back 1715

- patient educaiton

- activity modification - avoid heavy lifting, repetitive C-spine extension/rotiation

- pain relief via nonpharm (TENS) and pharm (NSAIDs, TCA, MRelx, Opiates in acute)

- Stabilization via posture, strengthing

- Interventional = neve root injectiosn

- Surgical Discectomy

Front 1716

Facet Joint- Mediated Pain - Cervical

- mostly seen at?

- prevalence is?

- at same level?

Back 1716

- C2/3 > C5/6 > C6/7

- chronic, traumatic cervical facet pain prev is 64%

- usually have symptomatic disc at same level

- 53# patients after whiplash injury

Front 1717

Symptoms of Facet Joint- Mediated Pain

- no? to?

- more likely facet pain if source is?

Back 1717

- no pathognomonic findings to distinguish form other sources of axial neck pain

- unilateral paramidline more likely facet than disc

Front 1718

Signs of Facet Joint-Mediated Pain - Cervical

- neuro exam?

- tenderness? low?

- imaging role?

Back 1718

- neuro exam normal

- may have focal tenderness to palpation over facet joint

- low spec

* image via Xray/Ct/MRI - hard to discriminate

Front 1719

Treatment of Facet Joint-Mediated Pain - Cervical

- analgesia via?

- therapy to? strengthen?

- interventional is?

Back 1719

1) Analgesia = ice, mobilization, massage colage <72 hours, NSAIDs, opiates

2) Therapy = normalize ROM, soft tissue length, strengthen spine, proprioception

3) Intervention = MBB, RFA, Intra-articular

Front 1720

Diagnostic Zygaphophyseal Joint Blocks for FJMP

- block of ? as it?

- if positive?

Back 1720

- is a medial branch block with local anesthetic to medial branches that supply facet joint

- if positive, then candidate for long-term radiofrequency denervation (median 9 months relief)

Front 1721

Cervical Stenosis/ Myelopathy

- injury to?

- age of onset?

- caused by? (6)

Back 1721

- injury to cervical spina cord

- average age of onset = 50

- caused by OA, motor neuron disease, MS, nasculitis, syringomyelia, spinal tumours

Front 1722

Symptoms of Cervical Stenosis - gait? changes in? overall? dysfunction of?

Back 1722

- gait ataxia

- weakness

- sensory changes

- bowel dysfunction

- bladder dysfunction

Front 1723

Signs of Cervical Stenosis/ Myelopathy

- hyper?

- also see? (2)

- positive signs? are? (3)

Back 1723

- hyperreflexia

- clonus

- spasticity

- L'Hermittes Sign

- Hoffmans Sign - flick patients extended middle finger and monitor for twitching of thumb

- Babinski sign

Front 1724

PE for Myelopathy vs Radiculopathy

Back 1724

Front 1725

Red Flags and Condition

- gait ataxia =?

- bladder dysfunction = ?

- night pain?

- fevers?

Back 1725

1) Gait Ataxia/ UMN changes = myelopathy

2) Bowel/bladder/Sexua dysfunction = Cauda Equina Syndrome

3) Night pain/ weight loss = tumour

4) Fevers/ chills = infection

Front 1726

Masqueraders of Cervical Radiculopathy

- majority of patients have?

- most common MSK?

Back 1726

- 69% of patients referred for radiculo with normal studies had MSK disorder

- 29% of patients with NCS/EMG confirmed radiculo had an MSK disorder

- most common MSK disorder = myofasical pain syndrome

Front 1727

Causes of Upper Extremity "radicular pain"

- true = (2)

- also see? (6)

Back 1727

- true radiculopathy - herniated NP, lateral stenosis

- tendinopaties = RC, etc

- OA, Inflamm Arthritis

- muscle pain syndromes

- ligament injuries - MCL

- neurologic - CTS, ulnar neuropathy

- vascular

Front 1728

Regional Pain Syndromes - Myofasical Pain Syndrome

- characterized by? caused by?

- MtrPs are? with? taut band of? compression causes?

Back 1728

- a regional pain syndrome characterized by muscle pain caused by myofascial trigger points (MTrPs)

- MtrPs are:

= circumscribed split in muscle with pain or tenderness

= taut band of skeletal muscle fibres

= compression can cause referred pain

Front 1729

Myofasical Pain Syndromes - muscles affected? (4) I/T/S/B

Back 1729

- see:

= infraspinatus

= trapezius

= scalenes

= brachialis

Front 1730

Etiology of Myofascial Pain Syndrome

- usually secondary to? (4)

= muscular? chronic? Poor? systemic?

Back 1730

- usually secondary to:

= NMDs = strains, sprains, arthritis

= chronic repetitive minor muscle strains

= poor posture

= systemic disease

Front 1731

Symptoms and Signs of Myofascial Pain Syndrome

- main symptom is? can be?

- sign is tender? referral?

Back 1731

- symptoms = pain = can be nociceptive, neuropathic, axial or appendicular

- signs = tender taut band, possible referral of pain with palpation of taut band

Front 1732

Imaging of Myofascial Pain Syndrome

- EM see? LM see? US see? MR see?

- not seen on?

Back 1732

- EM = taut bands and contraction knots

- LM = contracrtion knots

- US = hypoechoic

- MR elastography

* not seen on routine imaging

Front 1733

Microdialysis Needle

- used to measure?

- looking for? (5)

- bchs assoc. with?

Back 1733

- use to measure biochem responses of soft tissue to pain

- look for CRGP, bradykinin, TNFa, IL-6 and IL-8

- biochemicals assoc. with pain eleveated in soft tissue near TPI

Front 1734

Myofascial Pain Syndrome Treatment

- treat the underlying?

- PT for?

- home exercise with?

- focus on the? to suppress? with?

Back 1734

- treat underlying lesions (tear)

- PT = stretching, manual release, modalities

- home exercise program = stretching, focal massage, heating

- trigger point injections = suppression of local nociceptors with needle in trigger point

Front 1735

Fibromyalgia Pathophys

- lower? due to dysfunction of?

- all nociceptors are? seen in?

- muscles only vs widespread called?

Back 1735

- lower pain threshold related to dysfunction of descending anti-nociceptive system

- all nociceptors in the body are hyperirritable

- muscles, tendons, ligaments, fat (myofasical = muscles only)

- widespread/ whole body pain (myofascial = regional)

Front 1736

Triggers of Fibromyalgia - PA/PI/ sleep? or?

Back 1736

- physical activity

- physical inactivity

- sleep disturbance

- emotional stress

Front 1737

Symptoms and Diagnosis of Fibromyalgia main three are? (3)

- all rated from?

Back 1737

- fatigue

- waking unrefreshed

- cognitive symptoms

* all rated from 0 to 3

- many other symptoms

Front 1738

Unique Approach to Fibromyalgia

- accurate? accept? role of?

- encourage patient to?

- importance of?

Back 1738

- accurate diagnosis based on Am. Coll. of Rheum

- accept diagnosis = both patient and physician

- patent and family education

- encourage patient to take an acitve role in self-care

- psychologic and psychiatric counselling

- rehab programs (PT, OT)

Front 1739

Management of Fibromyalgia Syndrome inAdults (11)

Back 1739

- self-management strategies

- psychological interventions

- exercise

- complementary and alternative medications

- tylenol

- NSAIDs

- Opioids

- Cannabinoids

- Antidepressants

- Anticonvulsants

Front 1740

Shoulder Pathology

- always examine? these incloude?

- muscle? bursa? referred?

Back 1740

- always examine the joint above and below for referred patterns of pain

- joints = glenohumeral, Acromioclavicular, Sternoclavicular

- Muscle = rotator cuff strain, bicipital tenosynovitis

- Bursa = subacromial subdeltoid bursitis

- Referred = neck, elbow, myofascial pain syndrome

Front 1741

Glenohumeral Osteoarthritis

- OA leads to? in the?

- symptoms mainly? relieved by? may be at?

- signs = limitation in? **

also tenderness to?

Back 1741

- OA leads to destruction of the articular cartilage of the joint space

- symptoms = pain with activity, may be nocturnal, may be relieved by rest

- signs = **limitation in AROM and PROM****, tenderness to palpation of the anterior and posterior shoulder

Front 1742

Imaging for Glenohumeral Osteoarthritis

- xrays see (6)

- irreg? narrow? sclerosis? OP? flattened?

Back 1742

- xrays see:

= irregular joint surfaces

= joint space narrowing

= subacromial sclerosis

= osteophytosis

= flattened glenoid

= cystic changes of humeral head

Front 1743

Treatment of Glenohumeral Osteoarthritis

- goal is to decrease? start? modify?

- rehab can include? (2)

- meds?

- interventional?

- surgical?

Back 1743

- goal is to decrease pain and inflammation, start rehab program

- activity modification

- rehab = ROM, rotator cuff strengthening

- medications = Tylenol, NSAID

- interventional = US or Fluroscopic-guided injections

- Surgical = total shoulder arthroplasty, Arthrodesis

Front 1744

Rotator Cuff Syndromes - Tendinopathy

- tendons become more? leads to? (2)

- symptoms? (2)

- signs include? positive (2)

- investigate with?

- treatment starts with? then? then do? with?

Back 1744

- tendons become swollen and hypercellular, collagen disorganization, weakness in tendon, can become calcified

- symptoms = pain with overhead activity, night pain

- signs = tenderness to supraspinatus tendon, painful arc, positive Neers and hawkins

- investigation with US, RI

- Treatment starts with activity modification, NSAID, US, then do rehab, GH stability, muscular strengthening

Front 1745

Rotator Cuff Tear

- any? most commonly?

- see pain with resisted? signs and symptoms?

- investigations?

- tratment starts with? then? then do with?

Back 1745

- any rotator cuff muscle, most commonly Supraspinatus

- see pain with resisted testing of other muscles, same signs and symptoms as tendinopathy

- investigations = US, MRI

- treatment same as tendinopathy, consider surgery for full tear

Front 1746

Subacromial Subdeltoid Bursitis

Back 1746

Front 1747

Rotator Cuff Impingement

Back 1747

Front 1748

Lumbar Axial Pain

- pain between?

- 10% develop from?

Back 1748

- pain between costal margins and gluteal folds

- lifetime prevalence up to 84%

- 80-90% of health care and social costs of back pain are for the 10% who develop from acute to chronic

Front 1749

Lumbar Anatomy

- 2 roles of spine?

- 3 joint complex with?

- 5?

Back 1749

- dichotomous role of spine = support and protection, flexibility as allows limbs to move

- 3 joint complex = intervetebral disc with vertebral endplates, 2 zygapophyseal (facet joints)

- 5 lumbar vertebrae (rarely 6)

Front 1750

Lumbar IV Disc

- inner is? 90%? throughout life? outer is? withstands?

- main function?

- axial load pushes one? stretches?

Back 1750

- inner NP = gelatinous, 90% water at birth, desiccates throughout life

- outer annulus fibrosis = concentric fibrous layers to help withstand strains

- main function = shock absoprtion

- axial load pushes on nucleus and stretches annulus fibers, if AF break, see herniated NP

Front 1751

Main Common Causes of Axial Lumbar Pain

- herniated? pathology at? (2)

- MFPS?

Back 1751

- herniated NP

- Zygophophyseal Joint Parhology

- Sacroiliac Joint Pathology

- Myofasical Pain Syndrome = Paraspina/ Gluteal Muscles

Front 1752

Less Common and not to be missed causes of axial lumbar pain

Back 1752

Front 1753

Approach to Mechanical Lumbar Axial Pain

- pattern guides? anatomic guides?

Back 1753

1) Pattern Bases Approach

= guides initial management

2) Anatomic Apporach

= guides late stage management

Front 1754

Pattern based Approach to Lumbar Back Pain

- evidence with?

- tools for?

- supporting?

Back 1754

- evidence review with expert opinion for areas with lack of evidence

- 2 page tool = history, physical, initial management, referrals

- supporting amterial of opioid risk tool, StarT back screening

- endorsed by Spine Society, Fam Phys of Canada

Front 1755

Classifying Mech LBP

- four different?

- 1 and 2 are? 3 and 4 are?

Back 1755

- four different patterns of mech LBP with anatomical correlates

- patterns 1,2 = back dominant symptoms

- pattens 3,4 = leg dominant symptoms

Front 1756

Patterns 1-4 - ask if? rule out? what increases typical pain? **

Back 1756

Front 1757

Red Flags of Back Pain - prform?

- neuro?

- infection?

- fracture?

- tumour?

- inflammation?

Back 1757

1) Neuro = motor or sensory loss, neuro deficits, CE syndrome = urgent MRI

2) Infection = fever, IV drug use, immune supprssed = XR and MRI

3) Fracture = trauma, OP, frgility fracture = Xray and CT

4) Tumour = hx of cancer, severe fatigue, weight loss = Xray and MRI

5) Inflammation = chronic pain, <45 yo, morning stiffness, better with exercise = rheum

Front 1758

Yellow Flags - are? questions include? (4)

Back 1758

- are psychosocial RFs for developing chronicity

Front 1759

Why Assess yellow Flags - 30-40% also develop?

- persistent pain causes? higher risk of?

- LBP x3 more likely?

- see beliefs of? relucatance to?

Back 1759

- 30-40% of patients with chronic back pain also hae depression

- persistent pain leads to depression, and those have a higher risk of developing neck and back pain

- LBP patients 3x more likely to have low physical and emotional function

- see fear avoidance beliefs = relucatance to engage in active rehab, must treat fear avoidance to reduce disability

Front 1760

Inflammatory BLP

- age? onset? pain when? improves with? morning stiffness? elevated?

Back 1760

- <40 year old

- insidious onset, 3 months +

- back pain in 2nd half of night

- improves with exercise

- moderate morning stiffness, 30-45 mins

- elevated inflamm markers

Front 1761

Mech LBP

- any? variable?

- with rest? morning sitffness? markers?

Back 1761

- any age, variable onset and features

- improves with rest

- short-lived morning stiffness

- normal inflamm markers

Front 1762

Ankylosing Spondylitis

- chronic? of the? affects?

- onset? gender? race?

- onset? lngth?

- AM see? improves with?

- 16+?

Back 1762

- chronic inflammation disorder of axial skeleton affecting spine and SI joint

- onset in late adolescence, early adulthood, M>F, more in whites

- symptoms:

= insidious onset of back pain at SI joint for 3x mnths

= AM stiffness, improves with exercise

= cervical ankylosis in those with AS for 16+ years

Front 1763

Ankylosing Spondylitis

- manifests as? (6)

- decreased? +

- serology?

- tests? (4)

Back 1763

- Manifestations = fatigue, weight loss, fever, iritis, aortitis, pulm fibrosis, CE syndrome

- Signs = + Schober's test, decreased chest expansion

- Serolgy = HLAB27 +, increased ESR, CRP, RF + , ANA negative

Front 1764

Ankylosing Spondylitis Imaging and Management

- imaging do? see? (6) bone? spine look?

- management - refer? give? (2)

Back 1764

I = Xrays = SI pseudowidening, scleorsis, bone resoprtion, bamboo spine, syndesmophytes, osteopenia

M = refer to rheum = education, PT, NSADIS, DMADS, ICS

Front 1765

Painful Spinal Structures = innervated structures

- bone? joints? disk? ligs? all?

- means they cause?

Back 1765

= bone = vertebrae

= joints = ZPP

= disk = only external annulus

- ligaments = ALL, PLL, interspinous

- muscles and fascia

- nerve root

**cause pain, can be targeted

Front 1766

Noninnervated Structures of Spine - Do not cause pain

- LF? IA? of disk?

Back 1766

- ligamentum flavum

- internal annulus

- disk = nucleus pulposus

Front 1767

Mechanical Lumbar Pain Syndromes

Back 1767

Front 1768

Herniated Nucleus Pulposus

- similar assess and management as? therapy is based on?

- if no nerve root? if NR impingement?

Back 1768

- similar A/M as cervical - usually extension based therapy program

- axial pain if no nerve root impingement

radicular and leg pain if NR impingement

Front 1769

Anatomical Diff between C and L Spine

- C - disk and nerve#? if hits C6/7

- L - hits nerve that is? if hits L4/5

Back 1769

- C = disc # = nerve # = ex/ C6/7 disc hits C6

- L usually hits nerve below disc level = ex/ L4/5 disc hits L5 traversing nerve root, not exiting L4

Front 1770

Diagnostic Testing for LBP - frequrntly?

- lab testing for?

- imaging based on?

Back 1770

- frequently unnecessary

- lab testing = as indictaed for infections, malignancies, other testable conditions

- imaging = based on disease, modality, availability, recomms

Front 1771

Indications for Imaging - Xryas

- done for ages? Hx (2)

- recent?

- progressive? prolonged?

Back 1771

- age <15 or >50 yo

- Hx of malignancy or unexplained weight loss

- Hx of fever, IC state of IVDU

- recent trauma (aside from low energy lifiting)

- progressive neurologic deficitis

- prologne durations of S/S

Front 1772

Indiciations for Imaging - CT, MRI

- for vertebral fractures, superior? all other soft tissue?

- LBP almost never see? as in MRIs?

Back 1772

- CT superior to MRI for vertebral fracture

- MRI superior for all other soft tissue pathologies

* 90% of MRIs for LBP are abnorma and only <2% of CTs for HA are abnormal making value of a negative test is nearly non-existent for LBP

Front 1773

MRI and Lumbar Spine

- is the?

- yet common to find? espec in?

- poor correlation with?

- hard to determine?

Back 1773

- modality of choice in evaluation of most spinal disorders

- incidental abnormal findings common within asymptomatic individuals (57-80% abnorms for those over 60 yo)

- poor correlation with symptoms, therapeutics, patient outcome

- hard to determine candidacy for spinal surgery

Front 1774

Imaging Recomms

- uncomplicated LMP?

- low velocity trauma, osteopor?

- cancer, IS =?

- radiculo = ?

- past lumbar surgery?

- CE syndrome?

Back 1774

- uncomplicated LBP = any

- low velocity trauma, OP = MRI without constrast

- Cancer, ImmunoSupp = MRI without contrast

- Radiculopathy = MRI without contrast

- Past Lumbar Surgery = MRI +/- contrast

- CE Syndrome = MRI without contrast

Front 1775

Lumbar Root Lesions - Root - Muscle - Reflex

- L2? L3? see? L4? see? L5? S1 is? see?

Back 1775

Front 1776

Role of EMG

Back 1776

- Nerve Conduction Studies = motor, sensory

- Electromyography

- H and F

- Structure vs Function

Front 1777

Herniated Nucleus Pulposis Treatment

- control?

- modalities? dont use in?

- rehab for? via? (3)

- meds (3)

intervention is for? give? or perform?

Back 1777

- control pain and inflammation

- modalities = heat, traction (CI in myelopathy), TENS

- rehab for spine stab = education, stretching, core strength (extension)

- Meds = NSAIDs, TCAs, Opiates

- Interventions = Steroid injections for leg dominant pain, decompression surgery

Front 1778

Etiology of Facet Joint- Meidated Pain

- O/ C/ Im/ Sp?

Back 1778

- overload

- capsular tears/ injury

- Synovial impingement

- Spondylosis

Front 1779

Symptoms and Signs of Facet Joint- Meidated Pain

- pain exac by? or by?

- signs is localized? no?

- pain can be?

Back 1779

- Symptoms = pain exacerbated by lumbar extension, rotation

- Signs = localized tenderness over facet joints, no neuro deficits

* pain can be referred in non-dermatomal distribution

Front 1780

Imaging and Treatment of Facet Joint- Meidated Pain

- imaging via?

- treatment = (3)

rehab with? interventions with? (2)

Back 1780

- Imaging = XR, bone scan, CT, MRI

- Treatment:

= acitivity mod

= pain management

= rehab program - flexion based exercises

= interventions = medial branch block = RF ablation

Front 1781

Spondylolysthesis is slippage of? relaitve to?

- spondylosis is?

- spondylolysis is?

-

Back 1781

- Spondylosis = OA of spine (facet)

- Spondylolysis = fracture of pars intercularis

- Spondylolisthesis = slippage of vertebral body relative to vertebral body below it

Front 1782

Spondylolysthesis Etiologies D/I/D/T/P/P

Back 1782

- dysplastic

- isthmic

- degenerative

- traumatic

- pathological

- post-surgical

Front 1783

Spondylolysthesis Symptoms and Imaging

- main symptom is? with?

- imaging (4)

- non-operative for?

- surgery for?

Back 1783

- Symptoms = low back pain +/- radicular pain

- Imaging = Xrays, bone scan, CT, MRI

- Tx - non-operative Grades 1-2, asymptomatic grade 3

- Tx - surgery for Grades 4,5, symptomatic Grade 3

Front 1784

Spinal Stenosis - Central - narrow? due to?

- hypertrophic? leads to?

- can affect? cause?

Back 1784

- narrowed vertebral canal

- because of facet arthritis, hypertrophied ligamentum flavum, disc encroachment, SL

- can affect spinal cord (possible neural ischemia)

Front 1785

Spinal Stenosis - Lateral

- narrowed? away from?

- can affect? via? (2)

Back 1785

- narrowed lateral elements (away from SC)

- can affect nerve roots (structural impingement, inflammation)

Front 1786

CSS and LSS Symptoms

- CSS symptoms is? can have?

- LSS syptom is? with possible?

Back 1786

- CSS Symptoms = Back Pain +/- neurogenic claudication

- LSS Symptoms = Back pain +/- radiculopathy

Front 1787

Neurogenic Claudication

- pain in? (3)

- relieved with? sign of?

Back 1787

- pain in buttock, thigh or calf

- relieved with sitting or leaning forward = shopping cart sign

Front 1788

Neurogenic Claudication vs Vascular - pain/location, exac riding bike? downhill? walking uphill? remission? assoc factors?

Back 1788

Front 1789

Vascular Claudication

Back 1789

- pain, location, exac, riding bike, downhill walking, uphill, remission, assoc. factors

Front 1790

Scoliosis - curvature of? symptoms? imaging? obtain?

Back 1790

- lateral and/or rotatory curvature of anywhere in C/T/L spine

- symptoms = back pain

- imaging - Xrays to obtain Cobb Angle

Front 1791

Causes of Scoliosis

- idiopathic?

- congenital? due to?

- neuromusc?

Back 1791

1) Idiopathic = most common = infantile, juvenile, adolescent

2) Congenital = due to embryologic deficit = myelomeningocoele

3) Neurmusc = DMD, assoc pulmonary, SC complications

Front 1792

Treatment of Scoliosis

- need to decide? depends on? (3)

- assessed by?

Back 1792

- surgical vs non-surgical

- depends on Cobb Angle, etiology, rate of progression

- shpuld be assessed by spine specialist

Front 1793

Cauda Euqina Syndrome Anatomy and Pathophys

- SC ends at? becomes? that still?

- pathophys is injury to?

Back 1793

- A = SC ends at L1-L2, becomes a horse tail below this level that still innervates lumbar and sacral segments

- Pathophys = injury of nerve roots forming the Cauda Equina

Front 1794

Etiology of CES

- (4)

Back 1794

- lumbar + sacral fractures

- pelvic ring fracture

- spondylosis

- large disc herniation

Front 1795

Symptoms of CES

- flaccid? sensory loss in?

- pain in? (3)

- dysfunction of? (3)

- saddle?

Back 1795

- flaccid paralysis in affected nerves

- dermatomal sensory loss

- pain = lumbar, buttock, perianal

- Bowel and Bladder dysfunction - retention, freq, incontinence ***

- sexual dysfunction

- saddle anesthesia

Front 1796

Signs of Cauda Equina Syndrome

- LMN? high post void?

- hypo? absent?

- emergency as need to?

Back 1796

- LMN weakness

- high post-void residual = urinary retention

- hyporelfexia

- absent bulbocavernosis reflex

** Manage by ER for surgical decompression

Front 1797

Vertebral Body Compression fracture Etiology (5)

Back 1797

- trauma

- OP, OM

- medicated related = coticos

- neoplasms

Front 1798

Vertebral Body Compression Fractures Symptoms

- have sudden?

- exacerbated by? (4)

- imaging?

Back 1798

- have sudden onset thoracolumbar pain

- exacerbated by Valsalva, turning in bed, coughing, incidental trauma (step oof curb)

- imaging = xrays, bone scan, CT, MRI

Front 1799

Vertebral Body Compression Fracture Treatment - restrict? manage? rehab for? consider?

- surgery sees? can lead to?

Back 1799

- acitvity restriction

- pain management

- rehab program - hyperextension

- bracing

- vertebroplasty in some acute

- surgery = 50% loss of vertebral height, instability, neurologic compromise

Front 1800

Sacroiliac Joint Pain Etiology

- (4)

Back 1800

- hyper or hypomotility

- repetive overload

- trauma

- capsular tears

Front 1801

SI Joint Pain Symptoms

- pain can be either? in (4)

- referred to?

- signs include? no?

- imaging?

Back 1801

- acute or gradual back, buttock, leg or joint pain

- painc an be referred in non-dermatomal distribution

- signs = localized tenderness over SI joint, no neuro signs, SI joint special tests

- imaging = xrays, bone scan, CT, mri

Front 1802

Treatment of SI Joint Pain

- mod of? manage? rehab on?

- interventional include (3)

- surgery for?

Back 1802

-activity mod

- pain management

- rehab program - core and hip girlde strengthening

- Intervention = articular injections, branch block, RF denervation

- surgical fusion

Front 1803

Causes of Lower Extremity Radicular Pain - True Radiculo

- main two?

- central vs lateral - see?

Back 1803

- disc herniation

- spinal stenosis:

= central = neurogenic claud

= lateral = radiculopathy

Front 1804

Masqueraders of Lower Extremity Radicular Pain (7)

Back 1804

Front 1805

Hip Pain - must consider?

- OA seen with? rathe than?

- always assess if? for? in (3)

- AN - most commonly from?

Back 1805

1) OA = most often groin rather than lateral thigh or buttock pain

2) Hip fractures = always assess if trauma, OP or elderly

3) Avasc Nec = most common from steroid use or alcohol use

Front 1806

Greater Trochanteric Pain Syndromes Symptoms and Signs

- pain of? (2) aggrav by? (2)

- signs = pain with? (2) positive?

- investigate with? MRI for? (2)

Back 1806

- Symptoms = nociceptive lateal thigh or psoterior gluteal pain, aggrav by activity, lying on affected side

- Signs = pain with restricted hip abductor testing, pain with palpation of peritrochanteric tissues (GT, abductor insertions, bursas, tenor fascia), positive FABER test

- investigate with US, MRI for tendinosis or tendinitis

Front 1807

Treatment of Greater Trochanteric Pain Syndromes

- Stage 1 = (4)

- Stage 2 = eccentric? focus on?

- interventional uses? for?

Back 1807

- Stage 1 = activity modification, NSAIDS, US, glycerul trin

- Stage 2 - rehab,, hip girdle stability, eccentric strengthening, lumbopelvic biomech

- Interventional = US guided injections for trohcnateric bursitis or intralesional injections

Front 1808

Take Home Points

- always screen for?

- most conditions treated with? (3) not?

- myofascial pain syndrome is a? cannot be??

Back 1808

- always screen for non mech sources of axial/lumbar pain

- most conditions treated with activity modificaiton, pain management and an active rather than passive rehab program

- myofascial pain syndrome is commin masquerader of radiculopathy and cannot be diagnosied on routine imaging

Front 1809

Take Home Points

- look for? as the can?

- red flags must be?

- always examine**

Back 1809

- lumbar pain yellow flags can identify patients who may have poorer outcomes for same condition

- lumbar pain red flags must be considered on every assessment

- alwaus****** examine patient with axial pain

Front 1810

Epidemiology of Immobility - hours sedentary - men? women? boy? girl? 4 of 5 Canadians dont?

Back 1810

- Men = 9.6 hours/day sedentary

- Women = 9.8 hours/ day sedentary

- boy = 8.5 hours

- girls = 8.7 hours

*4/5 Canadians do not meet the Canadian Physical Activity Guidelines

Front 1811

PA is bodily movement made by?

- measured in?

- exercise is a? has a?

Back 1811

- bodily movement produced by the contraction of skeletal muscle that increases energy expenditure above the basal level

- measured in metabolic equivalents (METs) = metabolic activity

- exercise = a form of PA that is planned, structured, repetitive, and purposeful with a main objective of improvement or maintenance of one or more components of physical fitness

Front 1812

Difference in Mets

Back 1812

Front 1813

Exercise Physiology

- focuses on?

- at rest? with exercise - burn?

- need?

Back 1813

- Energy Expenditure of a human

= @ rest = 1.2 kcal/ min

= intense exercise = 18-30 kcal/min = 15-25x

- ADP to ATP to allow exercise to continue

Front 1814

3 Pathways to Produce ATP

- for quick energy? for minutes? are?

- aerobic limited by?

Back 1814

1) Creatine Phosphate = 25-30 seconds (anaerobic) = spirting

2) Rapid glycolysis = 0.5-2 minutes (anaerobic) = weightlifting

3) Aerobic Oxidation = limited only by fuel (carbs, fat, protein) and oxygen (aerobic)

Front 1815

Muscle Physiology - Type 1

- speed? high in? innerv. by?

- rich? for low/long? slower?

Back 1815

= Slow Twitch

- high in oxidative enzymes

- innervated by slow motor units

- rich capillary supply

- for low intensity, long-duration exercise

- slower peak tension and relaxation

Front 1816

Muscle Physiology - Type 2 - speed?

- large? innerv by?

- for more? rapid?

Back 1816

= fast twitch

- large fiber diameter

- innervated by large, fast motor neurons

- for high intensity, short-duration exercise

- rapid peak tension and relaxation

Front 1817

Cardioresp. Physiology

- HR? SV? CO - change with exercise?

Back 1817

1) Heart Rate = resting (60-80 bpm), increases with relative workload, max HR decreases with age

2) Stroke Volume = reaches max at 50% of aerobic capacity then plateaus, higher in supine/ prone position, decreased in upright position

3) Cardiac Output = resting = 4-5 L/min, 20L with exercise

Front 1818

Cardioresp Phys - blood flow/ venous return/ BP / pulm vent - with exercise?

Back 1818

4) Blood flow = rest is 20% of CO, exercise is 90%

5) VR = contracting skeletal muscle as pump, diaphragm contraction lowers intra-thoracic pressure

6) BP = SBP increases with work intensity, can monitor inotropy of heart

7) Pulm Ventiliation = 15-25x in exercise > rest, increase in tidal volume then resp. rate

Front 1819

Benefits of Exercise - Physiological

- decreases? increases?

- increases in muscle?

- hypertrophy of? improved?

Back 1819

- reduction of BP in hypertensive patients

- increase in HDL, decrease in LDL, decrease in TG

- decrease in TBW

- increase in muscle glycogen

- hypertrophy of fast and slow twitch fibers

- improved capacity of ATP-Creatine phosphate system

- improved VO max

Front 1820

Benefits of Exercise - Specific Populations

- for renal? for schiz? for pain? for breast cancer? for anxiety?

Back 1820

1) Renal failure = lowers BP

2) Schizo = cognitive enhancement

3) Chronic pain = improves pain severity, QOL

4) Breast cancer = alleviates radiation fatigue

5) Anxiety = decreases anxiety

*at least 30 chronic diseases

Front 1821

Definitions - Forms of Activity

- PA is? sedentary is? moderate is? vigorous is?

- CSEP guidelines want?

Back 1821

PA = movement increasing heart rate and breathing

Sedentary = postures or activities that require very little movement

Moderate = 5-6/10 on personal capacity scale, can talk but not sing during activity

Vigorous = 7-8/10 on personal capacity scale, cant say more than a few words

- CSEP guideline - aim for moderate to vigorous acitvity = MVPA

Front 1822

CSEP Activity - want for toddlers? children? youth? adults?

Back 1822

- toddlers and preschoolers should get 180 minutes

- children 5-11 should get 60 minutes

- youth aged 12-17 should get 60 minutes

- adults should get 150 minutes

Front 1823

Canadian Association of Sport and Exercise Med Statement

- benefits of exercise are?

- NNT is? vs smoking cessation?

Back 1823

- beenfits of exercise = reduced BP, glycosylated hemoglobin, reduced risk of depression, improved cognition with dementia

- NNT = 12 to meet rec. guidelines, 4x lower than smoking cessation

- exercise prescription could save 2.1 billion $/year if adopted at population

Front 1824

CASEM Position Statement

- can be given like a?

- good for?

- tools?

- need to try to avoid?

Back 1824

- if healthy, progression to MVPA is safe and can be self-admin, like an OTC medication

- stable asymptomatic CV, metabolic, renal disease

- tools = step counts, texts, exergames

- exercise profs = avoid barriers to integration of daily PA, MDs should feel enabled to prescribe PA

Front 1825

Par-Q Pre-Participation Screen

Back 1825

Front 1826

Major Symptoms suggestive of Cardiopulm Disease

Back 1826

Front 1827

Exercise Prescription - FITT (P) - ASS

- FITT stands for?

Back 1827

1) Frequency = # of exercise session per day/week

2) Intensity = physiologic difficulty of exercise

3) Timing = length of exercise session

4) type = particular form of exercise

5) progression = increase in activity over time

Front 1828

FITT(P) - ASS Types of Exercise - ASS = types?

Back 1828

- aerobic

- strengthening

- stretching = flexibility

Front 1829

Exercise Prescription Aerobic ACSM

- FITT?

Back 1829

- frequency = 3-5x / week

- intensity = perceived exertion 13-16 "somewhat hard to hard"

- timing = 1 or more sessions of 10+ minutes, at least 150min/ week or 30 min/day

- type = large muscle groups engaged in rhythmic aerobic activity = walking, jogging, cycling, rowing, stair climbing, water exercise

Front 1830

Exercise Prescription - Strength ACSM - FITT?

Back 1830

- frequency = at least 2 days per week

- intensity = one set of 8-12 repetitions resulting in volitional fatigue for each exercise

- timing = the entire program should last no more than 1 hour (grater than 1 hr have higher dropout rate)

- type = perform a minimum of 8-10 exercises that train the major muscle groyps

Front 1831

Exercise Prescription - Stretching ACSM - FITT?

Back 1831

- frequency = at least 2-3 days per week

- intensity = mild degree of tightness without discomfort

- timing - stretches held for 15-60 seconds

- type = static, dynamic and PNF stretching of major muscle groups including the low back and posterior thigh

Front 1832

PARmed-X for Pregnancy - benefits include improved? promotion of? facilitaiton of? may prevent?

- want? attempt? no?

Back 1832

- benefits:

= improved aerobic and muscular fitness

= promotion of appropriate weight gain

= facilitation of labour

= may prevent glucose intolerance

= may prevent pregnancy-induced hypertension

* 3 times/week, attempt 15 minutes, not weight-bearing

Front 1833

Exercise SMART Goals - stand for?

-ex/

Back 1833

- specific, measurable, achievable, relevant, timed

ex/ I am going to be walking on the treadmill 3x a week for 40 minutes at a hard intensity by our follow up in 4 weeks

Front 1834

Summary of CSEP, CASEM and ACSM - Aerobic, Resistance and Stretching of F/I/T/T

Back 1834

- individualize via SMART goals

Front 1835

Extreme Conditioning Programs (ECP) - includes?

- no high quality?

- benefits?

- case reports see?

- need further?

Back 1835

- crossfit, insanity, Gym Jones, P90x

- no high quality lit comparing to traditional

- benefits = muscle strength, endurance, aerobic fitness

- case reports see rhabdomyolysis and carotid artery dissection

- further high-quality studies needed

Front 1836

Immbolity - Muscle

- by day, decreases? by 9 days?

- plateua at?

- decrease endurance by decreasing? and?

Back 1836

- decreases strength by 1.0-1.5%/day

- as much as 30% with 9 days of bedrest

- plateau at 25-40% of original strength

- decreases muscular endurance by decreasing Type 1 fiber diameter and oxidative enzymes

Front 1837

Immobility on Bone and Joints

- OP due to? HC due to?

- decreased? from?

ligaments have less? increased?

Back 1837

- Osteopenia = lack of stress and tension on bone

- Hypercalcemia = excreted in urine = atrophy, fractures

- Decreased joint extensibility = cartilage deterioration from less nutrition

- Ligaments = decreased strength, increased compliance, increased collagen degradation

Front 1838

Immobility on Cardiac Function

- reduction in? postural?

- increased? decreased CV?

- increased risk of? from? (2)

Back 1838

- reduction in blood and plasma volumes

- postural hypotension = venous blood pooling

- increased resting HR, decreased SV = decreased CV efficiency, HR up by 0.5 beats/min/day, immob. tachy, see SV down

- increased risk of thromboembolism = decreased BV, increased coag.

Front 1839

Immobility on Other Organ Systems

- pulmonary? GI? GU?

- also see? (2)

Back 1839

- Pulmonary = decreased CE, diaphragmatic movement, reduced cough, bronchial ciliary activity, reduction in TV

- GI = constipation and loss of appetite

- GU = urinary stasis, increased risk of urolithiasis

- Integumentary = skin atrophy, pressure ulcers

Front 1840

Take Home Points of Exercise and Immobility

- exercise is? good for?

- can use tools for?

- importance of?

Back 1840

- exercise is medicine for everyone

- exercise is beneficial and encouraged in pregnancy with approp precuaitons

- pre-participation screening should be performed with approp. tools

- individualize patient's exercise program

- immob. negatively affects multiple systems

Front 1841

Physiatry is?

- focus shifts from?

- not just a?

- time limited?

Back 1841

- inpatient rehab here focus shifts from acute care to getting back to life

- not just a discharge destination

- time limited therapy with specific goals (like a Rx)

- not approp. for eveyone

Front 1842

Good Candidate fo SCI/ABI inpatient rehab?

- new loss of? patient is? also is?

- demonstrates ability to?

- requires at least?

- want to have?

Back 1842

- new loss of functional chnage

- motivated/interested in participating

- medically stable

- demonstrates ability to learn and retain skills

- requires at least two allied health services

- functional goals can be sustained in community

Front 1843

Elements of a Rehab Prescription

- physical = treating? used in?

- cognitive used in? includes?

Back 1843

1) Physical = TBI and SCI

= treating spasticity, mobility, pain, pressure ulcers, bowel/bladder function

2) Cognitive = TBI

= cognitive retraining, adaptation, aids

Front 1844

Elements of a Rehab Prescription

- behav- used in? uses? (3)

- functioning - used in? includes ideas like?

Back 1844

3) Behav/ Psychiatric (TBI and SCI)

= counselling, Mx, behavioural strategies, supports

4) Functioning/Community/Social Integration (TBI and SCI)

= transition from patient to person, redefining self, redefining roles, involving family, learning self-advocacy

Front 1845

SCI and TBI means?

Back 1845

SCI = spina cord injury

TBI = traumatic brain injury

Front 1846

Rehab Focus on? relearning? directing?

- examples? (5)

Back 1846

- functional goals as an inpatient and outpatient

- relearning ADL/IADLS or directing your care

- examples = self-feeding, walking, accessible enviro, accessible transporation, attendant care services, vocational, avocational goals, parenting, injury preventon, sexuality

Front 1847

Why is SCI and TBI rehab important - can affect?

- common causes? (4)

- are potentially?

Back 1847

- these injuries can affect anyone

- common causes of a SCI or TBI include:

= MVA

= falls

= medical

= violence

- potentially preventable

- annual cost = 3.6 billoon

Front 1848

SCI - causes of death? TBI is more common than?

Back 1848

- pressure ulcer cause of death in SCI

- TBI more common than AD and MS combined

Front 1849

Tetraplegia - impairment or loss of? in the?

- affects?

Back 1849

- impairment or loss of motor and/or sensory function in the cervical segments of the SC

- arms, trunk, legs and pelvic organs affected

Front 1850

Paraplegia - impairment or loss of? in the? (3)

- spared?

- affected? includes?

Back 1850

- impairment or loss of motor and/or sensory function in the thoracic, lumbar or sacral segments of SC

- arms spared

- trunk, legs, pelvic organs may be affected

- includes conus medullaris and cauda equina injuries

Front 1851

Skeletal Level vs Neurologic Level - Skeletal

- on xray can see? yet on neuro exam?

- skeletel level is level at which

Back 1851

- can see C5 burst fracture n Xray and C6 appearance on neuro exam

- skeletal level = level at which, by radiographic exam, the greatest vertebral damage is found

Front 1852

Skeletal vs Neuro - Neuro Level

- the most? with? on both?

Back 1852

- the most caudal segment of the SC with normal sensory and motor function on both sides of the body

- 4 segments identified

Front 1853

Importance of knowing the Neuro Level Post SCI - if C5 neuro level, cant? if C6 neuro level, cant?

Back 1853

Front 1854

Importance of Knowing Neuro Level Post SCI - ADLs - C5 vs C6 neuro level

Back 1854

Front 1855

Common Complications in SCI Rehab

- physical - main one? seen if SCI is?

- neurogenc? (2)

- PUs? pain that is? also see dysfunction of? bones?

Back 1855

1) Physical

= autonomic dysreflexia (SCI T6 or above)

= neurogenic bowel

= neurogenic bladder

= pressure ulcer

= neuropathic and nociceptive pain

= spasticity

= osteopenia/ osteoporosis

= sexual dysfunction

2) Psych/Psych = life adjustment, depression

Front 1856

TBI definitions - head injury may or may not?

- mild vs mod vs severe TBI = GCS of? can have? LOC?

Back 1856

= traumatic brain injury - head injury may or may not have brain injury

= mild TBI = concussion, GCS 13-15, LOC < 15 min

= mod TBI = GCS 9-12, LOC 15 min-6 hours

= severe TBI = incl. coma, GCS <9, LOC > 6 hours

Front 1857

Common Complication in TBI Rehab

- physical = (5)

- cognitive - main ones? (2)

Back 1857

1) Physical

= seizures, hemiplegia/spasticity, diplopia, hormonal complications, vertigo, fatigue, sleep distubs, HA/pain

2) Cognitive

= impaired arousal and attention**, learning and memory**, language and communication, executive function

Front 1858

Common Complication in TBI Rehab

- psych - main ones? (2)

- behav = (4)

Back 1858

3) Psych/Psychiatric

= depression**, anxiety, delirium**, psychosis, life adjustment

4) Behav

= apathy, agitation, disorganization, sexual dysfunction

Front 1859

- Unique concern in SCI

- is? is a? unique to? if it is at?

- risk of? (3)

Back 1859

- autonomic dysreflexia = is a medical emergency

- unique to SCI if it is at T6 or above

- risk of cardiac arrest, stroke, death

Front 1860

Autonomic Dysreflexia Symptoms

- occurs at?

- two main symptoms?

- PSNS symptoms seen? include? (4)

- SNS seen? include? (2)

Back 1860

- occurs at SCI at or above T6

- two main symptoms = 20-30 mmHg rise in SBP and pounding headache**

- see PSNS symptoms above SCI level = nasal congestion, sweating, chest tightness, flushing

- see SNS symptoms below SCI level = cold/clammy skin and goosebumps

Front 1861

Triggers of Autonomic Dysreflexia

- any potential?

- most common? then? other? (3)

Back 1861

- any potentially painful stimulus below SCI level

- bladder distention = 75-85%

- bowel distention = 13-19%

- other = DVT, menstrual period, cholelithiasis

Front 1862

Pathophys of Autonomic Dysreflexia

- potent? response? caused? increases? reduced - due to? get descending? that are only?

Back 1862

1) Potent painful stimulus below SCI

2) Sympathetic response

3) Generalized VC including splanchnic vasculature bed which is located below T6 = SNS

4) Increased BP = SNS

5) Carotid Baros reduce HR = PSNS

6) Get descending PSNS inhibitory signal that are only effective above SCI level

Front 1863

Treatment of Autonomic Dysreflexia

- sit? remove? monitor? every?

- BP >150 - give? such as?

- dont use? if?

Back 1863

- sit patient up as blood pools in legs

- remove the cause = bladder/bowel distention

- monitor BP every 2-5 minutes until symptms resolve

- if systolic BP > 150, give fasting acting antihypertensive (Nitropaste, Captopril) to reduce SBP <150

- * do not use nitrates if PDT-5 inhibis (slidenafil) used within 24 hours or vice versa

Front 1864

SCI - Neurogenic Bowel Routine

- diet? give? digital?

Back 1864

- diet = fibre and fluids

- laxatives and suppositories

- digital stimulation

Front 1865

SCI - Neurogenic Bladder Routine

- have intermittent? or use a?

Back 1865

- intermittent catheterization (every 4 hours or based on fluid intake)

- condom catheter

Front 1866

SCI and Pressure Ulcers

- need a? shift every/when? turn every/when?

Back 1866

- need skin pressure relieving routine:

= shift every 15 minutes when seated

= turn every 2 hours when lying in bed

Front 1867

Common Causes for Cognitive Decline post TBI

- main there = C/D/M - due to?

- must then?

Back 1867

= cerebral complication = seizures, hydrocephalus

= delirium = new enviro factors, new medications (sleep,pain) , new medical condition (UTI, hyponatremia)

= mood disorder

* do H/PE/rule out medical illness via lab and talk to family (see if fluct.)

Front 1868

Common Cognitive Impairments post TBI

- impairments in? (4)

Back 1868

- impairments in:

= arousal and attention

= learning and memory

= language and communication

= executive function

Front 1869

Dealing with Changes in Cognitive Function

- Remediation includes?

- compensation includes?

Back 1869

1) Remediation = manageable sub-tasks, cueing and redirection, overlearning

2) Compensation = electronic reminder system, work modification, pacing, safety dogs, engagement of family

Front 1870

Common Behavioural Impairments due to TBI - A/A/D/MI

- often are mislabelled as?

Back 1870

- apathy

- agitation

- disinhibition

- mental inflexibility/preservation

- often mislabelled as lazy, rude, stubborn, argumentative

Front 1871

Behavioural Strategies for Behavioural Impairments from TBI

- use simple? avoid? repeat? redirect?

- avoid (2)

Back 1871

- use simple directions

- avoid scolding

- repeat instruction

- redirect attention

- avoid environmental overstimulation

- avoid restraints = consider sitters, bed alarms, transponders (wrist alarm), locked units

Front 1872

Post-TBI Depression

- seen in about? RF for?

- may be confused with?

- predisposed by? such as? (3)

Back 1872

- depression = 25-60% in 8 years

- RF for poor recovery

- may be confused with cognitive deficits

- premorbid conditions may predispose = poor supports, coping strategies, PMHx

Front 1873

Causes of Post-TBI Depression

- chnages in? reduction in?

- see chnages in?

- increased TB severity doesnt?

Back 1873

- neurochemical/structural changes = see reduction in serotonin over time

- see changes in life situation

- *** Increased severity of TBI does not increase risk of depression

Front 1874

Time Course of Cognitive and Depressive Complaints Post TBI

- as time from TBI goes on, decrease in? increase in?

Back 1874

- as time goes on from TBI:

= see decrease in cognitive impairments from TBI

= see increase in depression causing cognitive complaints

Front 1875

SC and TBI Take Home Points

- after SCI - rehab based on? not?

- AD is a? also is?

- cognitive impairment post TBI can be?

- depression is?

Back 1875

1) After an SCI, rehab goals are based on the neurological level, not the skeletal level

2) Autonomic Dysreflexia is a potentially life threatening but treatable condition post SCI

3) Numerous factors can worsen cognitive impairment post TBI

4) Depression is common post TBI

Front 1876

What is Arthroplasty?

- refers to?

- in total? see that pelvic and femoral?

Back 1876

- refers to replacement of a joint with a prosthetic implant

- total joint arthroplasty = entire joint replaced

- sometimes interested in replacing bone leading up to the joint

- in total, pelvic and femoral sides not linked

Front 1877

What is Hemiarthroplasty

- only replacing? capped with? no?

Back 1877

- only replacing one side of the joint

- capped with a second larger head, need to add this second head to size mathc with the acetabulum

- no pelvic component

Front 1878

Total hip vs total knee replacement

- TH - dont need to? forces are?

- TK - need? to?

Back 1878

- TH = dont need cement or grout becuase the forces are mostly compression so they promote fusion

- TK = shear component on the parts, need cement as well to lock everything in

Front 1879

Athroplasty Technique Template

- done to detemine? first step is?

- match?

Back 1879

- done to determine the size of femoral and tibial prosthesis to optomize fit and fill on AP and Lay

- first phase is preoperative phase

- match the best components to each patient, use software to help with this but dont make custom components

Front 1880

Arthrplasty Surgical Technique

- need to? cut through?

- shape?

- have trial?

Back 1880

- need to expose knee joint, need to cut through quadriceps tendon

- shape distal femur to match back of femoral component

- have trial components during surgery

Front 1881

Conditions for Arthroplasty - (8) - #1?

Back 1881

- osteoarthritis = #1

- rheumatoid arthritis

- psoriatic arthritis

- AVN = hip, shoulder, knee

- post-trauamtic arthritis

- fractures

- bone tumours

- paget's disease

Front 1882

OA - most common? most disalbing? 95% of?

Back 1882

- most common arthritis with 3/4 of people with arthritis have OA

- 1 in 3 by 2040

- knee OA most disabling

- most joint replacements for OA = 95%

Front 1883

OA Indications for Athroplasty

- pain for? do?

- have to make sure?

Back 1883

- pain arising from OA

- history, PE, history

- need to make sure pain is in fact from OA

- may have psitive Xray findings but no symptoms

Front 1884

Knee OA history - pain is? may?

- agrav by? relieved by? no? onset?

Back 1884

- pain localized over knee

- may radiate to hip or shin

- aggrav. by prolonged activity

- relieaved by rest

- limitation of activity

- no neuro sympotms

- often insidious in onsent

- can cause radicular pain - vague pain radiating down leg

Front 1885

Hip OA History

- pain in? that may?

- aggrav by? releive by? no? onset?

Back 1885

- groin pain that may radiate to buttock, thigh, knee

- aggravated by prolonged activity

- relieved by rest

- limitation of activity

- no neuro symptoms

- often insidious onset

- pain radiating below knee may be due to neuro cause

Front 1886

PE in Knee OA

- look for? (6)

- reduced?

- typically dont see?

Back 1886

-mal-alignment

- varus/valgus

- antalgic gait

- joint line tenderness

- bony enlargement

- crepitus

- reduced ROM = extension

flexion contracture

- inflammation typically not present = no redness, swelling

Front 1887

PE in Hip OA - gait? lean to?

- legs? first lose? limited?

Back 1887

- tredelenberg gait - lean to affected side

- leg length discrepancy

- contracture

- first lose internatal rotation

- able to ext rotate, flex, abduct

- limited ROM

Front 1888

Diagnosis OA on Xray

- (4)

Back 1888

- see joint space narrowing

- see marginal osteophytes

- see subchondral scleorsis = response to arthritic friction

- may also see subchondral cysts

Front 1889

Varus vs Valgus - if lateral affected, alignment is? medial?

Back 1889

- if lateral component affected, get valgus malalignment

- if medial, get varus

Front 1890

OA Indications - if it is? effect on? night? failure of?

Back 1890

- if it is significant and disabling pain

- negative effect on QOL

- affecting sleep

- pain at rest and activity

- failure of med management

Front 1891

Nonop OA Mngmt - non pharm = (3), pharm = (5)

Back 1891

- non pharm = weight loss, activity modification, cane, physio

- pharm = acetaminophen, NSIADs, narcotics, topical, CS injections

Front 1892

OA Indiciations - Function - ask how? need to? dificulty in?

Back 1892

- walking distance = aks how far they can walk

- need for cane/crutch

- difficulty climbing stairs

- difficulty with shoes/ socks

- difficult foot hygiene

- work, hobbies, sport

Front 1893

OA Contraindications - ongoing? as can? is an?

- too?

poor?

- relative include?

- not candidate if?

Back 1893

- ongoing infections = absolute - infeciton elsewhere can seed prosthesis

- too young and active

- poor skin coverage around hip, knee

- paralyzed qaudriceps or abductor msucles

- NMD = relative

- severe mental dysfunction = relative

- serious physical disease

- extreme obesity, cardiopulm disease

- not candidate if they cannot do physio

Front 1894

OA Indications (4)

Back 1894

- patient choice

- subjective pain

- magnitude of quality of life compromise

- balance of benefit and risk

Front 1895

Athroplasty Benefits

- success rate of hip vs knee?

- benefit defined as?

Back 1895

- hip athroplasty = 95% success rate

- knee arthroplasty = 80% success rate

*benefit defined as a pain improvement after surgery to the extent that the patient says they would go through the same operation again

Front 1896

Complications/Risks of Arthroplasty - Early

- local (3) systemic (5)

Back 1896

- local = infection, neruvasc, hip dislocation

- systemic - mortality, transfusion, cardiac, stroke, DVT, pneumonia

Front 1897

Complications of Arthroplasty - Late - mainly?

Back 1897

- local = prothesis failure, revision surgery

Front 1898

Infeciton - occurs in? give?

- if infeciton, need to do a?

Back 1898

- approx 1% incidence of deep infection in primary THA and TKA

- approx 4% in revision TJA

- proph Abx have been critical to infection reduction

- see two stage revision - put in spacer filled with Abx, close wound, put on IV Abx for 6 weeks then need to be readmitted and have another knee replacement

Front 1899

Neurovasc Injuries

- injury to? most improve by?

Back 1899

- nerve injury

- primary 1-2%, revision 3-4%

- neuropaxia = 90% improve by 12 weeks

- vascular injury = 0.003%

Front 1900

Complications - Dislocation

- incidene related to?

- prine because of?

- also prone due to?

Back 1900

- incidence inversely prop. to surgical experience

- shallow cup for femoral head with an arthroplasty is prone to dislocation

- soft tissue (capsule, ligaments) restrains also removed during operation, also makes it prone to dislocation

- >50 THA / yr = 1.5% at 90 days

- <5 THA/yr = 4.2% at 90 days

Front 1901

Complications - Lossening and Wear

- life spaan of hip? knee? therefore if 50 years old?

- wear from?

Back 1901

- hip arthroplasty life span is about 15 years

- knee arthroplasty life span is 20 years

- 50 year old = 75% lifetime risk of revision

- 75 year old = 25% lifetime risk of revision

* excessive use can cause loosening, wear, as do more revision, see complications go up and success rate lowers