supermemo

surginfection ACLS ED Supermemo Step 2 ABSITE Rigler’s Triad of gallstone ileus: Pneumobilia (air in the biliary tract), low small bowel obstruction with distended small bowel loops, and an impacted gallstone in the terminal ileum.

Bacterial organisms in infants <1month: E. coli, GBS, listeria, virus 1-3mo:E. coli, H flu, listeria, N. meningitis, S. pneumo, virus 3mo-3y: H. flu, N. meningiditis, S. pneumo, virus

What is h-VISA? heteroresistant vancomycin intermediate S. aureus

What is the cutoff for S. aureus resistance to vancomycin? 2 micrograms per mililiter

What is the concentration in the epithelium of the lung compared to that of serum? 14%

Vanco is hydrophilic and bulky

What is the cost of Linezalid? $100/pill

Binds 23S rRNA of 50S ribosome subunit

halflife 4.5-5.5h

Dose 600mg IV or PO q12h No renal dosing

adverse effects: GI upset, thrombocytopenia (after first two weeks) MAO activity....can interact w/ SSRIs

Daptomycin creates pores in wall of bacteria cidal for many organisms inc s. aureus why not good for PNA? trapped in surfactant layer

Static versus enterococcus, s aureus cidal versus strep

What is the mechanism of VRSA resistance to vancomycin? Mutation of binding site from D-ala D-ala to D-ala D-lactate

How does S. aureus acquire resistance to vancomycin? Transfer of plasmid from VRE

What is the gene that produces complete resistance to vancomycin? Van-A

What is the mechanism of VISA resistance to vancomycin? High production of cell wall

Mnemonics Use the handy mnemonic "ADC VAAN DIMSL" to organize admission orders: A dmit to: Ward, service (i.e., Medicine/Surgery, etc), your name/resident's name, beeper #. (attending name but not his/her pager #) D iagnosis: Pneumonia, colon CA, R/O MI, S/P CABG. There may be more than one diagnosis. C ondition: Stable, fair, guarded. V ital Signs: Temp, pulse, RR, BP, O2sat - how often do you want them taken? A llergies: Any medication or food allergies. A ctivity: Ad lib, strict bed rest, out-of-bed (OOB) with assistance. N ursing Order: Input/Output measurement, daily weights, wound care, glucose finger sticks, Foley catheter, oxygen (flow rate and type of delivery system). D iet Order: Regular, nothing by mouth, diabetic, low sodium, full liquid. I V Fluids: Type of solution: D5, NS, D5NS (if none, write none) Rate of infusion: 50cc/hr, TKO ("to keep open" means an IV placed with the minimum running to keep the line open), hep lock. M edications: Dosage, frequency, route of administration, not to exceed dose, hold meds for (such as waiting for BP < x). S pecial Studies: EKGs, Cx-rays, CTs, MRIs. L abs: AM labs: CBC, SMAC, PT, PTT, U/A; Call HO (house officer) for: (Temp > x or < y) (Pulse > x or < y) (RR > x or < y) (SBP > x or < y) (DBP > x or < y); (O2 sat < x%) (Urine output < y cc/hour)

"PINTO SAAB VH2" is for thinking about admission and standing order medications:

P ain I ntravenous fluids N ausea T ylenol O wn meds S leep A ntibiotics A nti-coagulation B owel movement (laxatives) V itamin H2 blockers

Cystic lesions of the pancreas may be divided pathologically into retention cysts, pseudocysts, and cystic neoplasms.

Simple cysts — Simple (true or retention) cysts of the pancreas are small, developmental, fluid-containing spaces lined by normal duct and centroacinar cells.

Simple pancreatic cysts are usually incidental findings which are of no clinical significance and can be left untreated.

Pseudocysts of the pancreas develop as a result of pancreatic inflammation and necrosis

The walls of pseudocysts are formed by adjacent structures such as the stomach, transverse mesocolon, gastrocolic omentum, and pancreas.

The lining of pancreatic pseudocysts consists of fibrous and granulation tissue;

The lack of an epithelial lining distinguishes pseudocysts from true cystic lesions of the pancreas.

Cystic neoplasms — Four types of cystic neoplasms of the pancreas have been described: Mucinous cystadenoma/cystadenocarcinoma, Mucinous duct ectasia (intraductal papillary mucinous neoplasm, Serous cystadenoma, Papillary cystic neoplasm

What is the best diagnostic test for distinguishing benign versus malignant mucinous pancreatic cysts? CEA

What is the threshold level of CEA above which mucinous cysts are considered malignant? 192

Using a cutoff of 192 ng/mL, CEA levels were most accurate for differentiating mucinous versus nonmucinous cystic lesions (sensitivity 73 percent, specificity 84 percent).

2 characteristics of abscess on CT: peripheral enhancing, gas bubbles

insensible operative losses: 500cc/hour/quadrants

FeNa: <1: dehydration, >3: ATN FeUrea: <35% dehydration, >60% ATN

Who is recommended to get PO Vanco for C.diff? age>65, renal failure, WBC>20 gqastroenterology 2002 123(5) 1440 amantadine purpura fulminans

abdominal films overutilized? http://www.rcsed.ac.uk/journal/vol43_4/4340049.htm

http://www.mamc.amedd.army.mil/cardiology/book101.pdf

Why are H2 blockers preferred over PPIs for cushing ulcer prophylaxis? PPIs make susceptible to C. diff IPAA Ilioanal pouch anal anastamosis DLI diverting loop ileostomy Kock continent iliostomy Remicade for IBD

C. protein virulence factors: muocardial suppressant, stops chemotaxis c. perfringens DONE Lung Protective Ventilation Study www.ihi.org/ihi/topics/critcare/sepsis kumar et al crit care med 2006 1h delay increase mort

rivers et al NEJM fast cultures

DONE annane JAMA 2000 JAMA 2002 DONE Cochrane review 2005 low dose steroids

Sprung et all CORTICUS NEJM 2008

Van den Bergh NEJM 2001 tight glycemic control ven den berge crit care med 2003

DONE ARDS net 2000 NEJM vent w/ lower tidal vollumes

Bidani et al JAMA 1994 permissive hypercapnea

Laffey et all Am j resp crit care med 2000

PROWESS trial bernard NEJM APC

Schleroisng peritonitis Korete et al Nephro Dial Transplant 2007

MELANOMA NEJM 2004 351 998-1012 J clin onc 2001 19: 3622-3634 Cancer 2000 89 1495-50 Cancer 2003 97 1941-1946 Ann surg onc 1998 5: 322-328 Cloques node Melanoma: LDH Pediatric surg int 2002 19 99-102 J clin onc 2002 20 2045-2052