Joy NP 4

Hodgkin’s lymphoma

 

• Hodgkins disease
• Cause is unknown
• More common in males; avg age is 32 yrs
• Usually presents with cervical adenopathy and spreads in a predicatable fashion along lymph node groups
• Characteristic Reed-Sternberg cells differentiate form non-hodgkin’s disease

• PLT (150-400K) give PLT
• Clotting factors give FFP,(Factors V, VIII, PT: INR)
• Fibrinogen (if <170 mg/dL) give Cryoprecipitate

Stage II – same side of diaphragm.

Lack of factor VIII

 

Give DDAVP preoperatively

• Olfactory= smell
• Optic= vision
• Oculomotor= most EOMs opening eyelids, pupillary constriction
• Trochlear= down and inward eye movement
• Trigeminal= Muscles of mastication, sensation of face, scalp, cornea, mucus, membranes and nose
• Abducens= lateral eye movement
• Facial= move face, close mouth and eyes, taste, saliva and tear secretion
• Acoustic= hearing and equilibrium
• Glossopharyngeal= speech sounds, gag reflex, carotid reflex, swallowing, taste
• Vagus= talking, swallowing, general sensation from the carotid body, carotid reflex
• Spinalaccessory= movement of trapezius, and sternomastoid muscles
• Hypoglossal= moves the tongue

Type- Some, say, marry, money, but, my, brother, says, big, bras, matter, most

• Appearance
• Behavior
• Cognition
• Thought processes

• TIA-period of acute cerebral insufficiency lasting less than 24hrs without residual deficits
• Signs and symptoms
• Altered vision, altered speech, motor impairment, sensory deficits, cognitive and behavioral abnormalities
• Lab/diagnostics
• CT is best in distinguishing btw ischemia, hemorrhage and tumor
• MRI is superior to CT in detecting ischemic infarcts
• Echocardiogram, Carotid Doppler and ultrasonography
• Cerebral angiography

• Vertebrobasilar- as a result of inadequate blood flow from vertebral arteries
• Presentations include: vertigo, ataxia, dizziness, visual field deficits, weakness, confusion
• Carotid- Due to carotid stenosis
• Presentations include: Aphasia, dysarthria (slurred speech), altered LOC, weakness, numbness

• Aspirin
• Plavix 75mg/day by mouth
• Ticlopidine: associated with agranulocytosis, thrombotic thrombocytopenia purpura and GI intolerance
• Assess for HTN
• Carotid endarterectomy decreases the risk of stroke and death in pts with recent TIA

• CVA infarct
• Changes in LOC, Motor weakness or paralysis
• Visual alterations, changes in vital signs
• Hemorrhagic CVA
• Signs seen on the opposite side of infarct or hemorrhage involvement
• Increase ICP, altered mentation, HA, vomiting

• Left (dominant) hemisphere involvement
• See right hemiparesis, aphasia, dysarthria, difficulty reading and writing
• Right (non-dominant) hemisphere involvement
• See left hemiparesis, right visual field changes, spatial disorientation

• Head CT
• Cerebral angiography – images of blood vessels in brain
• Lumbar puncture for grade 1 and 2 aneurysm to detect blood in CSF
•     LP contraindicated with large bleeds due to brain stem herniation

• For thrombolytic strokes
•     Fibrinolytic therapy is indicated less than 3-4.5 hrs of symptoms
• Surgical evacuation of bleeding
• Systemic BP stability – avoid hypotension, may exacerbate ischemic deficits
• Maintain Map 110-130 to treat cerebral vasospasm
• Nimotop- calcium channel antagonist, helps to counter vasospasm by preventing calcium from entering smooth muscle cells and causing contraction
• ICP goal <20

• Simple partial – common with cerebral lesions
• No loss of consciousness
• Motor symptoms often start in single muscle group and spread to entire side of body
• Paresthesia, flashing lights, vocalizations, hallucinations
• Complex partial
• Any simple partial followed by impaired level of consciousness
• May have aura, starring, or automatisms such as lip smacking and picking at clothing

• Absence- sudden arrest of motor activity with blank stare
• Common discovered in children/adolescents; begin and end suddenly
• Tonic-clonic
• May have aura
• Begins with tonic contraction (repetitive muscle contraction) loss of consciousness, then clonic contraction (maintained contraction of muscle)
• Last 2-5mins, followed by postictal period

• Series of grand mal seizures of >10 min duration
• Medical emergency
• May occur when patient is awake or asleep
• Pt never gains consciousness between attacks
• Life threatening

• Parenteral anticonvulcents are used to stop convulsive seizures rapidly
• benzodiazepines: Diazepam (valium) 5-10mg IV
• Lorazepam (Ativan) 2-4mg IV at 1-2 mg/min
• Phenytoin (Dilantin): loading dose 20 mg/kg @ 50mg/min continuous infusion
• Fosphenytoin (Cerebyx): prodrug of Dilantin
• Phenobarbital (luminal): administered if Dilantin is unresponsive
• Barbiturate coma or general anesthesia with neuromuscular blockade

• Decrease in acetylcholine receptor sites
• Ptosis, diplopia, dysarthria (slurred speech) dysphagia, fatigue, extreme weakness, resp difficulty- think visual changes, extreme weakness, and resp issue
•     Sensory modalities and DTRs are normal
• Antibodies to acetylcholine AchR-ab are found in 80%
•     Edrophonium (tensilon) test used to differentiate myasthenic vs cholinergic crisis
• No specific protocol- consult neurology
•     Anticholinesterase drugs block the hydrolosis of acetylcjoline and are used for symptomatic improvement (pyridostigmine bromide)
•     Immunosuppressive, plasmapheresis
•     Vent support during crisis

• The body’s immune attacks myelin- key substance that serves as a nerve insulator and helps transmission of nerve signals
• Weakness, numbness, tingling, or unsteadiness in a limb, may progress to all limbs- think neurosensory
• Definitive diagnosis can never be based solely on labs
• No tx to prevent progression of the disease- neurology consult
•     Recovery from relapse with steroid use
•     Antispasmodics, interferon therapy
•     Immunosuppressive, plasmapheresis

• The syndrome is usually preceded by suspected viral infection accompanied by fever 1 to 3 weeks before onset of bilateral muscle weakness in lower extremities
• Presentation- rapid progressive increase in paralysis
• CSF protein is elevated, CBC-early leukocytosis with left shift
•     LP, MRI, CT are sometimes used in aiding diagnosis
• Tx-neuro consult- txis supportive while myelin is regenerated
•     Symptoms begin to recede within 2 weeks with recovery in 2 yrs

• General concept
• Meningitis should be considered in any pt with fever and neurologic symptoms especial with hx of infection
• Acute bacterial meningitis is a medical emergency
• Symptoms
• Fever 101-103, severe HA, NV
• Nuchal rigidity (stiff neck), photophobia
• Positive kernig’s sign
•     Pain and spasms of the hamstring muscles
• Positive Brudzinski’s sign
•     Legs flex at both the hips and knees in response to flexion of the head and neck to the chest

• Lab/diagnostic
• LP-CSF will be cloudy or yellow in color with
•    Increase pressure and protein
•    Decreased glucose with presence of WBCs
• CT of head indicated

• Control symptoms and maintain electrolyte balance
• High does parenteral antibiotic therapy
•     PCN G, Vanco with a 3rd gen cephalosporin (ceftriaxone, ceftaxime, ceftazidime) until C&S is available, or fluoroquinolones

• Decompensating patient may show signs of Cushing’s triad
•     Widening pulse pressure
•     Decreased RR and HR
•       Battle signs: bruising behind ear at mastoid process
•       Raccoon eyes Otorrhea or rhinorrhea
• Diagnostics
•     Cervical spine films should be obtained for all pts
•     Skull films and head CT

C4 or above= quadriplegia; may require mechanical ventilation

C4-C5= quadriplegia; control of head, neck, shoulders, trapezius and elbow flexion

C5-C6= quad; some extension of wrist, index finger and thumb

C6-C7= elbow extension, capable of feeding, dressing

C7-T1= hand movement

T1-T2= paraplegia; upper extremity control but no trunk control

T3-T8= no trunk control

T9-T10= bowel and bladder reflex, moves trunk and upper thigh

T11-L1= most leg and some foot movement; ambulation poss

L1-L2= lower legs, feet and perineum; control bowel, bladder and sexual dysfunction if S2 to S4 spinal nerves are involved

• Methylprednisolone 30 mg/kg IV bolus, followed by infusion of 5.4mg/kg/hr for 23 hrs
•     Must be administered within 8hrs of injury
• Consult neurology/neurosurgery

• C4 injury or above: respiratory compromise
• T4-T6: may lead to autonomic dyserflexia- emergency
•     Caused by exaggerated autonomic response to a stimulus- symptoms include
•       Diaphoresis and flushing above injury
•       Chills and severe vasoconstriction below injury
•       HTN, Bradycardia, HA, Nausea
•       Tx- antihypertensive and stimulus removal
• T6 or above –neurogenic shock- massive vasodilation

• Delirium: sudden, transient onset
•     Causes- toxins, alcohol, trauma, impactions in the elderly, poor nutrition, electrolyte imbalances, anesthesia
• Dementia: gradual memory loss- neurocognitive disorder
•     Cause- Atherosclerosis, neurotransmitter deficits, cortical atrophy, ventricular dilation, loss of brain cells, viral, Alzheimer’s disease

D= drug reaction/interaction

E= emotional disorder

M= metabolic/endocrine disorder

E= eye and ear disorders

N= nutritional problems

T= tumors

I= infection

A = arteriosclerosis

Is a visual field loss on the left or right side of the vertical midline.

 

It can affect one eye but usually affect both eyes

CN- I (Olfactory), II (Optic), VIII (Acoustic)

 

Remember:

Some, Say, Marry, Money, But, My, Brother, Says, Big, Bras, Matter, Most

CN: I,   II,     III,        IV,           V,    VI,   VII,          VIII,   IX,    X,      XI,          XII

 

On Old Olympus Towering Tops A Fin And German Viewed Some Hops

CN-V (trigeminal), VII (facial), IX (Glossopharyngeal), X (Vagus)

 

Remember:

Some, Say, Marry, Money, But, My, Brother, Says, Big, Bras, Matter, Most

CN: I,   II,     III,        IV,           V,    VI,   VII,          VIII,   IX,    X,      XI,          XII

 

On Old Olympus Towering Tops A Fin And German Viewed Some Hops

• Is a surgical emergency due to compression of spinal cord root-18 nerve roots of the cauda equine at base of spine.
• S/S : Pain, numbness, tingling & low back pain radiating into leg(s),
• S1-S2: weak plantar flexion w/loss of ankle jerks, foot drop. S3-S5: Loss of bowel/bladder. Muscle weakness, sensory loss in the dermatomal distribution of the affected nerve roots.

3) Cause: tumor, spinal stenosis, herniated disc, CA, infxn, inflammation.

Valium 5-10 mg IV

Parenteral anticonvulcents are used to stop convulsive seizures rapidly benzodiazepines: Diazepam (valium) 5-10mg IV

Lorazepam (Ativan) 2-4mg IV at 1-2 mg/min

Phenytoin (Dilantin): loading dose 20 mg/kg @ 50mg/min continuous infusion

Fosphenytoin (Cerebyx): prodrug of Dilantin

Phenobarbital (luminal): administered if Dilantin is unresponsive

Barbiturate coma or general anesthesia with neuromuscular blockade

↑ opening pressure, ↑ protein, WBC, ↓ glucose

• Widespread narrowing of the airways
• Signs and symptoms
•     Resp distress at rest, difficulty speaking, RR>28, Pulse>110, cough, chest tightness
• Bad signs include-
•     fatigue, absent breath sounds, paradoxical chest/abd movement, inability to maintain recumbency, cyanosis

• Slight WBC elevation with eosinophilia
• PFT reveal obstructive dysfunction
• Hospitalization for
•     FEV1<30% that does not increase to 40% after 1hr of therapy
•     Peak flow <60L/min or does not improve >50% after 1 hr of tx
• ABG= resp alkalosis with mild hypoxemia
•     Hypercapnia is a bad finding
•     pCO2 >45 indicates emergency
•     Normal pCO2 indicates a very sick patient

• Short acting B adrenergic agonist for symptom relief
•     Albuterol
• Daily inhaled corticosteroids
•     Budesonide (Pulmicort)
• Long acting B adrenergic agonist for persistent sympt
•     Salmeterol (serevent); theophylline
• Inhaled anticholinergics may be added if necessary
•     Ipratropium bromide (atrovent)
• Antilerkotriences useful in the maintenance of chronic
•     Montelukast (singler)

• Supplemental O2
• ABG for severe attacks
• Adequate hydration
• Inhaled sympathomimetics (adrenaline effects)
•     Alupent 2.2ml q30-60mins, Proventil 3ml q30-60min
• Corticosteroids in pts who do not respond to sympathomim
•     Methylprednisolone 60-125mg IV X1 then 20mg IV q4-6hrs until attack broken
• Parenteral sympathomimetics in pts unable to cooperate
•     Aqueous epinephrine 1:1000 SQ q30-60min may repeat X4
• Anticholinergic (Atrovent) MDI 2-6puffs q4-6hrs

• Oxygen
• IV D5 ½ NS
• Inhalation and parenteral sympathomimetics
• Methylprednisolone 60-125mg or hydrocortisone 300mg IV immediately
• Consider atrovent
• Monitor ABG q10-20min
• Intubate

• Low flattened diaphragm by CXR
•     Low FEV1
•     Increased TLC, FRC, RV, paCO2, HCO3
• Outpatient
•     Inhaled ipratropium bromide or sympathomimetics mainstay of therapy
• Inpatient
•     Supplemental O2
•     Clients with purulent sputum should receive antimicrobials for 7-10 days
• Ampicillin or amoxicillin 500mg 4X daily
• Doxycycline 100mg BID
• Bactrim DS 1 tablet BID

• Chronic Bronchitis- excessive secretion + productive cough for 3months in at least 2 consecutive yrs
•     Copious sputum (purulent), stocky, obese
•      Bulla, blebs, hyperinflation on CXR,
•      hypercapnia, hypoxemia on ABG
• Emphysema= abnormal, permanent enlargement of the alveoli
•     Progressive, constant dyspnea, sputum clear
•     Thin wasted body, TLC increased

• Notify local health department
• Med regimen
•     Isoniazid 300mg, Rifampin 600mg, Pyrazinamide 1.5-2.0gm, Ethambutol 15mg/kg, or streptomycin 15mg/kg IM daily
•     Continue the first 3 drugs daily for 2 months, then 4 months of INH and RIF daily
•       Persons with HIV should be treated for nine months

• Healthy patients <60 with no comorbidities and no recent abx therapy
•     Macrolide- azithromycin, clarithromycin, erythromycin, or doxycycline
• Patients with health problems- COPD, DM, HF, Cancer, or >60 and no recent abx therapy
•     Fluoroquinolone- levofloxacin, gemifloxacin, moxifloxacin

• Supplemental O2
• Beta lactam (rocephin; Unasyn) + azithromycin or fluoroquinolone
• For pseudomonas infection
•     Piperacillin-tazobactam (Zosyn), Cefepime or menopenem + Cipro or levofloxacin or beta lactam + aminoglycoside and fluoroquinolone
• For MRSA staph aureus infection
•     Add vanco or linezolid

• Pneumonia that occurs 48hrs or more after admission
•     Staph aureus, strep pneumoniae, and haemophilus influenza most common causative organisms
• Pneumonia that arises 48-72 after intubation     
•     Pseudomonas most common causative organism

• Chest tube is first – 4th or 5th ICS, MAL
• Emergency
•     Needle thoracotomy- 2nd ICS, MCL

• Lab/diagnostic
• VQ scan for clinically stable patients
• ABG- hypoxemia (saO2<90%, paCO2 <80), hypocapnia
• Spiral CT/D-dimer
• Management
• O2, fluids for hypotension and reduced CO
• Intubation for worsening hypercapnia
• Heparin and fibrinolytic therapy