Brucellosis

Fungi Fungi
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FUNGI
Like warmth and moisture
(skin folds, groin, axilla, vagina)
Like to eat sugar- in diabetics
To prevent fungal infections, keep cool
and dry
Have a unique lipid in their
membrane called ergesterol
Antifungals
Bind to ergestrol
Amphotericin B- IV for systemic fungal infections
Gets confused with cholesterol
Pokes holes in your cells- releasing K+
Nystatin
Mycostatin
Miconazole
Clotrimazole
Tolnaftate
Terbenafine
Flucytosine (5FC) inhibits mitosis
(acts like pyramadine)
Antifungals
Inhibits ergesterol synthesis
Fluconazole- best CNS penetration
Itraconazole
Ketoconazole- inhibits P450s, blocks 5
reduct se
Inhibits microtubules
- Griseofulvin
Superfici l Fungi
Piedre bl ck b lls on the h ir
sh ft
Tx: cut h ir
Microsporum Beigeii- white
b lls on h ir sh ft
Tx: cut h ir
Cut neous Fungi
Gener l (4 cl sses):

 Derm tophyton skin

Trichophyton- h ir follicle
Epiderm phyton- epidermis
Microsporum- (Wood l mp +)
Cut neous Fungi
Tine
C pitus -sc lp
Versicolor- v on b ck
Corporus- body ring worm
M nis betweeneen fingers M nis betw fingers
Nigr p lms life lines get d rk
Intertrigo-skin to skin
Cruris- jock itch - groin
Pedis between the toes
Unguum under n il beds (one n il
ffected)
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Deep Fungi
Onychomycosis- fungus of n ils
C ndidi sisi sis most common C ndid most common
c use of v ginitis
V ginitis
C ndid : curdy white disch rge; pruritic
C ndid p rt of norm l flor nd l ctob cili keep
it in check ( ntibiotics will destroy l ctob cilli)
Tx: Flucon zle
G rdnerell d ll fishy h dor; lue lls G : fi od cl cell
Tx: Metronid zole

Trich mon s : frothy green disch rge

Protozo : fl gell
Tx: Metronid zole nd remember to tre t
rtner (STD)

Systemic Fungi
Histopl smosis (Midwest) pigions, b ts
Bl stomycosis (North e st) pigon,
bro d b se budding
Coccidiomycosis ( South west) Bro d
b se budding
P r coccidiomycosis (South Americ )
shipwheel

Systemic Fungi
Sporothrix- rose g rdner, skin-pot ssium
iodine; Amph B nd Flucon zole if systemic
Cryptococcus- AIDS p tient with
meningitis, indi n ink st in meningitis indi n ink st in
Aspergillus-Moldy h y or moldy
b sement (mimics sthm )
Rhizor/ Mucor nose of di betic
p tients
Symptoms from the
Southwest
Coccidiomycosis- fungus
H nt virus-virus t i i (hemorrh gic) h i ) H (h
Yersini

Pestis-b cteri

P ulmon ry I nfiltr te with

E osinophili
Allergic Bronchopulmon ry Dyspl si
Loefflers Syndrome
N ec tor Americ nus
A nclystom Duoden le
S trongyloides
S histosomi sis
A sc ri Lumbricoides
Churg-Str uss
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PARASITES PARASITES
FARTENPOOPIN FARTENPOOPIN
PARASITES
C use g stroenteritis
T-cells, M croph ges, Eosinophils
LOW VOLUME STATE
Chronic infections le d to iron
deficiency nemi
Liver Flukes
Schistosomi sis : w lking b refoot thru
sw mp
S m nsoni: liver c ncer

 S. hem tobium: c uses squ mous cell c rcinom

of the bl dder (chronic irrit tion)
Ecchnococcus : messing with sheep; r w
l mb; dog food
C uses solit ry ( hyd tid) cyst of the liver
Liver Flukes
Tox c r : c t or dog poop
C rti- c t l rv e
C ni- dog l rv e
Cut neus l rv migr ns- burrowing under
skin
Liver Flukes
Clinorchis ( or opthorchis)
Sinensis: seen in Chinese; likes the
bili ryy tr ct (Alk line Phosph t se)p ( )
TX for ll liver flukes:
P rziqu ntel
Hookworms
Hooks into the intestin l/bowel w ll
Severe cr mps nd di rrhe

NEATNEAT AS AS
Nec tor meric nus
Enterobius Vermiculris-pin worm
Pruritis ni (eggs)
Scotch t pe test- fem le comes out
Worm lives in the cecum

t night

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Hookworms
NEAT AS
Anclystom Duoden le
Duoden l obstruction
Trichuris Trichurium- Whip worm Trichuris Trichurium Whip worm
Anchors into rectum
Rect l prol pse
Asc ris lumbricoides
Strongyloides
Hookworms
Tre tment:
Mobend zole- p r lyzes microtubules
(c nt hook on to tissue)
Pyr ntel p m o te- specific tre tment
for pin worm
Thiobend zole- tx for Strongyloides

NASSA
NASSA- p r sites ssoci ted with
loffler syndrome (endoc rditis
nd pneumonitis)

N
A
S
S
A

ec tor meric nus

nclystom duoden le
chistosomi sis
trongyloides
sc ris lumbricoides

Fl t Worms
Will curl round the intestine:
D. L tum- like to e t B12
T ne S gin tum- r w beef
T ne Solium- r w pork, swims in
queousq humor of the eyey
Trichinell Spir lis- r w be r me t,
tunnel under skin c using myoisitis
Tx: Hyclos mine
Niclos mine
Inhibit oxid tive phosphoryl tion decre sing ATP
Protozo Protozo
Protozo
Br in:
N egl ri Fowleri
Swimming through sw mp- cribiform pl te
Fulmin nt meningo enceph litis

Toxopl smosis Toxopl smosis

C t litter (feces)
P riet l lobe ring enh nced lesion
Tx: Pyremeth mine/ Sulf di zine

Tryp nosom Rhodienses

C rried by Tsetse fly
Afric n sleeping dise se
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Protozo
Corne :
Ac nthomoeb
Cont ct lenses
Will e t through corne
Protozo
Erlichiosis
Dog licking f ce (in s liv )
Penetr tes side of eye
Protozo

He rt
Tryp n som Cruzi
Ch g s dise se
E ts g ngli g nd c uses he rt block g
South Americ
Reduuvid bug
Protozo
Lung:
Pneumocystic Corinii
Silver st in ( lso Legionell )
CD4 count < 200
Tx: B ctrim (SMX-TMP)
Protozo
GI
Gi rdi - g stroenteritis
Loves fresh w ter/well w ter
Hiking in the mount ins
Tx:: IV Metronid zole Tx IV Metronid zole
E. histolyticum
Multiple liver bscesses
(never do surgery)
Tx: Metronid zole (8 weeks)
Protozo
GI
Microsporidium
MCC of di rrhe in AIDS p tients

Cryptosporidium
W tery di rrhe
P rti lly cid f st
Tx: Ciproflox cin

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Protozo
GU
Trichimon s
3rd MCC of V ginitis
Tx: Metronid zole 2gmg x 1
Also tre t p rtner
Protozo
Skin
Leschm ni sis (RASH)
Gulf W r syndrome
S nd fly
Leschm ni Donivini (f ce e ten
Att cks skin nd nostrils

w y)

 Leschm ni Rhodiensis (org n)

Systemic ( tt cks org ns)-K l Az r
Tx: Stiboglucon te
Protozo
Lymph tics
Wucheri B crofti
Eleph ntitis
No tre tment
Protozo
Blood
B besiosis
E stt co stst E s co
Looks different on
sme r
Tx: nti-m l ri l
Ixodes tick
(s me for Lyme dise se)
Protozo
Blood
Pl smodium M l ri
- MC str in world wide (fever every 3rd
d y)
F lcip rum- most f t lt l (hemolize F lcip rum most f (hemolize
RBCs)
Bl ck w ter fever- urine turn bl ck
Viv x- go to the liver (chronic m l ri )
Likes reticulocytes (young RBCs)
Ov le- go to the liver (chronic m l ri )
Likes m ture RBCs
Protozo
Blood- Pl smodium
Symptoms
M l ri - fever every 3rd d y
F lcip rum, viv x, ov le- fever every 2
d ys
Tre tment:
Quinine
Chlor quine- mostly RBCs
Mefloquine- good liver penetr tion
Prim quine- best liver penetr tion
(viv x nd ov le)
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Mycob cterium,
Spirochetes ,
Rickettsi
Mycob cterium,
Spirochetes ,
Rickettsi

Mycob cterium
NOT true b cterium
H s b cterium in its n me bec use
it h s peptidoglyc n w ll
Atypic l due to MYCOLIC ACID in Atypic l due to MYCOLIC ACID in
its membr ne
Cell medi ted infl mm tion
If you destroy mycolic cid, you
destroy mycob cterium
Mycolic Acid
A speci l lipid found in the w ll of
mycob cterium
INH works by inhibiting mycolic cid INH works by inhibiting mycolic cid
synthesis
Isoni zid ( INH)
Inhibits the synthesis of mycolic cid
F t soluble
Pulls vit min B6 out of the system
Must give vit min B6 with this drug to Must give vit min B6 with this drug to
prevent neurop thy
Side effects: myositis; hep titis;
hep tic necrosis ( especi lly fter
ge 35 ye rs); neurop thy;
oxidizes RBCs: blocks P450
Prim ry response to
Mycob cterium
Asymptom tic
Ghon focus: n ked tubercle on
respir tory epithelium
Virulence l f ctor: CHORD FACTOR Vi f CHORD FACTOR
Ghon complex: tubercle ingested by
m croph ges nd t ken to the
lymph nodes
Gr nulom : m croph ges now
surrounded by T cells
Prim ry Tuberculosis
Usu lly l nds in the RLL in termin l
bronchioles
Once GRANULOMA is formed:
Interferon
Tumor Necrosis F ctor
1 hydroxyl se
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32
Inflixim b

 An ntibody g inst TNF

Useful in p tients with RA
Decre ses joint destruction
As long s your T cells
m croph ges st y he lthy

nd

You h ve nothing to worryy g

bout.
.
But if cell medi ted immunity is
ever imp ired
Mycob cterium is still live within
m croph ges
Mycob cterium explodes out of the
h ges d into t the iirw ys m croph nd i th
Hemoptisis occurs
Mycob cterium works its w y to
the upper lobe nd sets up
c vit ry lesion
P tient now very symptom tic
Second ry Tuberculosis
Fever, night swe ts, weight loss,
nd hemoptysis
RLD profile
C vit ry lesion visible in upper C vit ry lesion visible in upper
lobes on the Xr y
Tx: first isol te p tient when
TB is suspected; get sputum
s mple for culture
After TB replic tes inside of the c vity,
it then dissemin tes
Mycob cterium now h s full
to the entire body.

ccess Mycob cterium now h s full

Dissemin ted Tuberculosis

In GI: c uses ileum obstruction
Bone: Potts Dise se
Lymph Nodes: diffuse lymph denop thy
Skin: Erythem Nodosum
Along Pso s Muscle: cold bscess
CNS: posterior foss
Neurop thies
Hydroceph lus
Meningitis
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Dissemin ted Tuberculosis

ccess

 Ren l: sterile pyuri

Adren l gl nd: insufficiency
In pregn nt wom n: tre t s in
nyone else nyone else
Most people dont know they
h ve ever come in cont ct
with TB unless
TB Tre tment
Four drugs for 4 months for everyone
If str in of TB is sensitive to both INH
nd RIFAMPIN, then finish 8 more
months with just these two drugs
If str in of TB is NOT sensitive to both
of these drugs, complete 8 more
months with four drugs
Substitute other drugs if ny b d
side effects
TB Tre tment
At the end of twelve months of tre tment, then
culture the sputum g in
Sputum cultures re repe ted monthly
Stop tre tment when there re three
consecutive neg tive sputum s mples
P tient m y t ke drugs every d y; or he
m y opt to t ke it every other d y but
witnessed by
he lthc re profession l
TB Prophyl xis
INH plus vit min B6 for 9 to 12
months
In pregn nt women, you must still
ive hyl xis l i gi proph
In p tients with history of BCG
v ccine, ignore the history, nd
merely follow the lgorhythm
Mycob cterium F mily
M. TB
M. Lepr e ( H nsons Dise se)
M. Avium Intr cellul re
flul ceum M. Scrof
M. M rinum
M. Ulcer ns
M. K ns sii
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34
D psone
Indic ted for the tre tment of derm titis
herpetiformis, Pneumocystis c rinii in HIV
p tients, nd for leprosy
For leprosy: use with clof zimine
rif mpinp for 6 to 24 months
Mimics PABA like sulf

nd

drugs

Side effects: meg lobl stic nemi ;

oxidizes RBCs; coombs positive hemolytic
nemi ; inhibits P450 system
Spirochetes
So n med due to their spir l sh pe
H ve xi l fil ments
ends ends
Use

t their two

l ter l tumbling motion

Cell medi ted response

Treponem P llidum
C uses syphilis
The most common c use of p inless
genit l ulcer
Prim ryry syphilis-- non tender ch ncrencre Prim syphilis non tender ch
( cont gious )
Second ry syphilis- 1 to 3 mo
( r sh P & S )
Terti ry syphilis *
Terti ry Syphilis
T bes Dors les
Shooting, l ncin ting, st bbing neurop thy
Syphilitic ortitis
Argyle Robertson pupil
Syphilis loves to tt ck bones
( s ber shins)
TORCH infections
They tt ck in the first trimester
( except herpes)
They c use severe neurologic l
d m ge d m ge
All c use IUGR, microceph ly,
hypotoni nd development l
imp irment

 How do you sep r te them ?

Toxopl smosis
Multiple ring enh ncing lesions in the p riet l
lobes
C used by c t urine
Asymptom tic in he lthy people (w lled off
in gr nulom )
Symptom tic t ti in tt due to S i pregn n women d t
suppressed immune system
Pregn nt women should NOT ch nge litter
box
Tre t with pyremeth mine/sulf di zine
combo
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Syphilis
Loves to tt ck bones
Fl t forehe d
S ddle nose
Sniffles
Microgn thi
Rh g des
Hutchinsons teeth
S bre shins
Rubell
Blueberry muffin r sh
C t r cts
PDA
loss He ring l
Autism
Autism
Four fe tures:
In bility to bond
Imp ired l ngu ge development
Autom tism- no control of there ctions
Overre cts to sm ll disturb nces
Br in is found on utopsy to be
rrested in development
MMR controversy
Autistic
AUTISM- below norm l intelligence, difficulty
forming rel tionships
Asperger syndrome: milder form, norm l
intelligenceence nd l ckck soci ll skills intellig
Perv sive development l disorder of childhood

nd l soci

skills

 Retts syndrome- girls only, st rts by

ge 4, h nd wringing
Cytomeg lovirus
Loves to tt ck the retin
Mcc of Congenit l blindness
C uses centr l c lcific tions
Att cks the midline
Herpesvirus
Att cks newborn on the w y through the
v gin
Loves to tt ck the tempor l lobe, c using
tempor l lobe hemorrh gic enceph litis
If pregn nt mother h s n outbre k of
lesions within two weeks of delivery, do
C-section
Give pregn nt mother cyclovir in l st
month to prevent outbre ks
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36
Syphilis
Tre tment:
Prim ry syphilis: 1.2 million units of long
cting penicillin (Proc ine or Benz thine)
Second ry syphilis: 2.4 million units, h lf in
hbuttock tt k e ch b
Terti ry syphilis: 2.4 million units once
weekly for 3 weeks
Neon t l syphilis: 50,000 units per
Kg per d y in divided doses
Treponem F mily
Treponem P llidum
Treponem P llidum v ri nt: Bijel
Treponem Pertenue: Y wstropic l form
Treponem C r teum: Pint
Borelli Borgdorferi
Lyme Dise se
Prim ry st ge- bulls eye r sh (resolve
in 1 month)
Second ry st ge-g flu like symptomsyp ,, y
org n involvement
Terti ry st ge- rthritis

 Dx: history of Erythem Chronicum

Migr ns;
Do IgM nd IgG titers
Borelli Borgdorferi
Tre tment:
Penicillin
Doxycycline
If pregn nt wom n is bitten by
tre t with IV ceftri xone

tick,

Any p tient with he rt block,

hospit lize nd tre t with
IV ceftri xone
Borelli Recurrentis
C uses Rel psing Fever
Fever occurs once weekly
Org nism hides in lymph nodes nd
mut tes slightly e ch week
Tre t with penicillin or doxicycline
Leptospir Interrog ns
C uses leptospirosis
Seen prim rily in sew ge workers
Tr nsmitted by r t urine
Weils Dise se: tt cks the liver
(hep titis) nd the kidney (nephritis)
C uses Fort Br ggs Fever
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37
Rickettsi
Rickettsi

Rickettsi : RMSF: tick borne

Rickettsi Typhi: endemic typhus: fle borne

Rickettsi
borne

Prowzekii: epidemic typhus: louse

Rickettsi Ak ri: rickettsi l pox: mite borne

Rickettsi
chiggers
Rickettsi

Tsutsug mushi- scrub typhus;

 Tre tment: Doxicycline or

Chlor mphenicol
We both wish you the best
of luck on your ex m !!!!
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1
And NOWThe fin l topic!
VIRUSES
Wh t ll viruses do

Inv sion
Adhesion
Penetr tion
Unco ting
Replic tion
Assembly
Lysogeny

To prevent unco ting

Am ntidine
Rim ntidine
To prevent replic tion

Acyclovir
Pencyclovir
Demcyclovir
V lcyclovir
F mcyclovir
G ncyclovir
Rib v rin

Detectives
Southern blot
Northern blot
Western blot
Southwestern blot
ELIZA
PCR
The 90%
DNA Viruses
Double str nded ( ex
p rvovirus nd
hep dnovirus
Replic te in nucleus ( ex
RNA Viruses
Single str nded ( ex
orthomyxovirus nd
renovirus

 Replic tep in cytopl smy p (

poxvirus)
Assemble on nucle r
membr ne
N ked ( ex herpesvirus)
p
(ex retrovirus)
Assemble on cell
membr ne
Enveloped (ex
cocks ckievirus)
+-str nd vs -str nd
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2
Most Common c uses of
vir l infections vir l infections
From he d to toe
Enceph litis
Presents with he d che nd t xi
C uses:
Arbovirus
Herpesvirus
Meningitis
AKA septic meningitis
Present tion: mild he d che; photophobi ;
Kernigs nd Brudzinskis signs
CSF llts CS resu
C uses: enteroviruses
Common Cold
Rhinovirus
Coron virus vs Adenovirus
Herpesvirus
Influenz virus
P r influenz virus
Common Childhood infections

Mumps
Rubeol
Rubell
V ricell

H nd-Foot-Mouth
dise se
K w s ki dise se
Molluscum
iosum
V ricell -Zoster
Fifths dise se
Roseol

 Pityri sis Rose

Ros ce
cont gi
Childhood R shes
Seborrheic derm titis di per derm titis
Erythem toxicum Pediculosis pubis
Mili
Mongoli n spots
Nevus Flemmeus
C f u l it spots
Port wine st in
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3
The four itchiest r shes
Urtic ri
Sc bies
Derm titis herpetiformis
Lichen pl nus
Croup
Stridor nd b rking cough
Steeple sign on neck film
C use:
P r influenz virus 80% mild
RSV 15% severe
Adenovirus
Influenz virus
Bronchiolitis
All the signs nd symptoms of
Under 2 ye rs of ge
C ueses:
P r influenz virus 80% mild
RSV 15% severe
Adenovirus
Influenz virus

sthm

Myoc rditis
Le ds to loss of contr ctility
Diffuse ST w ve depression on EKG
C use:
Cocks ckie B Virus
Peric rditis
C uses friction or tri-ph sic rub
M y le d to t mpon de
Diffuse ST w ve elev tion
C use:
Cocks ckie B Virus
G stroenteritis
In dults: Adenovirus
In children: Rot virus

 Tr vel: Norw lk gent

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4
Cystitis
Urgency nd frequency
C use: Adenovirus
Hep titis
Hep titis Chronic Active Hep titis
Active infl mm tion on biopsy
Fibrosis present
M y progress to liver c ncer
Will le d to cirrhosis
Due to Hep titis B: Tx with interferon nd
l muvidine
Due to hep titis C: Tx with interferon nd
rib v rin
Chronic Persistent Hep titis
Elev ted liver enzymes or persistent
symptoms fter 6 months
No ctive infl mm tion or fibrosis on liver
biopsysy biop
Chronic C rrier
Still h s positive HbS g fter 6 months
No ctive infl mm tion or fibrosis on biopsy
Still pose
thre t to others
C n NOT be blood donors or org n donors
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5
TH EE ND
412
448 413
449 414
450 415
451 416
452 417
453 418
454 419

455 420
456 421
457 422
458 423
459 424
460 425
461 426
462 427
463 428
464 429
465 430
466 431
467 432
468 433
469 434
470 435
471 436
472 437
473 438
474 439
475 440
476 441
477 442
478 443
479 444
480 445
481 446
482 447
483 448
484 449

485 450
486 451
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1
Obstetrics nd
Gynecology
G5 P4 Ab1
G: Gr vit : number of
pregn ncies
P:P r :: > 20 Weeks P: P r

> 20 Weeks

Ab: Abortive: bortions

G6 P0 Ab5
Pren t l
Di gnostic g
Testing
Ultr sound (Utz.)
Non-inv sive im ging
No dverse effects on the fetus
18-20 weeks of gest tion l
n tomic l nom lies
Accur cy for gest tion l ge:
At 12 weeks +/- 5 d ys
At 18 weeks +/- 7 d ys
Nuc l Tr nslucency
10- 14 weeks vi Utz.
Thick re you should think of
cystic hydrom Downs Syndrome
Chorionic Villous S mpling
(CVS)
Aspir tion of pl cent
tissue (9-12 wks)
Sono guided
K ryotyping
Pregn ncy loss r te 0.7%
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4/29/2008
2
Amniocentesis
Tr ns bdomin l needle to withdr w
mniotic fluid under sono (15-20 wks)
Looking t DNA from fet l cells
Not enough fluiduid prioror to 15 weeks Not enough fl pri to 15 weeks
Pregn ncy loss r te (0.5%)
24 weeks- Rh isoimmuniz tion
(bilirubin levels)
34 weeks- Lecithin-sphingomyelin
Percut neous Umbilic l Blood
S mpling (PUBS)
Fet l blood from umbilic l vein
(> 20 weeks)
Fet l k ryotyping
IgM ntibody
Blood typing
Intr uterine Blood Tr nsfusion
Pregn ncy loss r te 1-2%
Fetoscopy
Experiment l (18-20 weeks)
Fet l tissue biopsy
Ichthyosisy
Genetic skin condition
(fish sc les)
Co gul tion in twin-twin
tr nsfusion
Fet l Development
1 week for Impl nt tion
Folic cid
1mg
4mg
Week 2-3 post conception
Bil min r germ disk:
- Epibl st
- Hypobl st

Cytotrophobl st
Synchotrophobl st
Primitive stre k
Weeks 4-8 Post Conception
M jor org ns forming
Ter togenic risk
- Ectoderm
- Mesoderm
- Endoderm
Must h ve ll 3 in order to
ter togen to c use problems
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3
Fem le vs M le cells
Thec
Gr nulos
Leydig di L
Sertoli
5 lph reduct se DHT (extern l
genit li )
Ter togenesis St ges
Conception to end of first week
Weeks 3-8
Post week 9
Ter togens
Ionizing r di tion
Chemother py
Tbob cco T
ETOH
Coc ine
Ter togenic Syndromes
Alcohol: fet l lcohol syndrome
Long philtrum

Midf ci l hypopl si
Short p lpebr l fissure
Ter togenic Syndromes
Diethylstilbestrol (DES)
T-sh ped uterus
V gin l denosis- cle r cell V gin l denosis cle r cell
c rcinom
Incompetent cervix
Ter togenic Syndromes
Isotretinoin (Accut ne)
Congenit l de fness
Congenit l he rt defects
iPLEDGE
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4
Ter togenic Syndromes
Lithium:
Ebstein nom ly (R he rt defect)
Tricuspid lower
Very l rge right trium
Ter togenic Syndromes
Streptomycin
CN 8 d m ge- he ring
Ter togenic Syndromes
Tetr cycline
Competes with C 2+
Teeth discolor tion

fter 4 months

Ter togenic Syndromes

Th lidomide: drug for N/V
Phocomeli (d ys 42-48)

Pyloric nd duoden l stenosis

Ter togenic Syndromes
V lproic cid (Dep kote)
Neur l tube defect
Mgt: Migr ns nd Bipol r Mgt: Migr ns
Ter togenic Syndromes
W rf rin (Coum din)
Chondrodyspl si : stippled
epiphysis
456
4/29/2008
5
Pregn ncy
Hormones Hormones
Hum n Chorionic Gon dotropin
Syncytrophobl st
In blood by d y 10
Alph subunit
Bet subunit (specific)
High levels of hCG
Twins
Hyd tiform moles
Chorioc rcinom
LOW levels:
Ectopic
Thre tened bortion
Missed bortion
Hum n Pl cent l L ctogen
(HPL)
Incre sed through pregn ncy
Ant gonizest go insulinsu es
Org n
system
ch nges in ch nges in
pregn ncy
Skin

nd Bipol r

Line nigr
Chlo sm
Ch dwick sign
Stri gr vid rum
Spider

ngiom t /p lmer erythem

457
4/29/2008
6
He rt
Blood pressure
Pl sm volume
Femor l venous pressure
CO
Peripher l v scul r resist nce (PVR)
Murmurs
Systolic murmur:
Di stolic murmur:
Blood
RBCs
Pl sm volume
WBCs
Pl telets
Co gul tion
GI
Stom ch:
L rge bowel L rge bowel
Pulmon ry
Tid l Volume
Minute volume
Respir tory volume
Blood g ses

Ren l
Incre se in size:
Glucosuri : i Gl
Proteinuri :
458
4/29/2008
7
Endocrine
Pituit ry
Thyroid
Fet l Circul tion
3 in utero shunts:
Ductus venosus
For men ov le
Ductus rteriosus
Fet l
Testing Testing
Fet l H rt Tone (FHT)
Doppler stethoscope: 10-12 wks
Auscult tion 18-20 wks
Quickening: 16-18 weeks
(primigr vid 18-20)
Ultr sound D ting
1st trimester:
2nd trimester nd 3rd
Bip riet l di meter
He d circumference
Abd. Circumference
Femur length
Pregn ncy 1st trimester
< 13 weeks
N/V
Spotting/ tti / bleeding di S bl
Wt g in 5-8 lbs

Complic tion: spont neous

bortion
459
4/29/2008
8
Pregn ncy 2nd trimester
13 26 weeks
Round lig ment p in
Br xton-Hicks-Hicks contr ctions Br xton contr ctions
Quickening
Wt g in 1 lb/wk
Complic tion: incompetent cervix
Pregn ncy 3rd Trimester
Decre sed libido, b ck p in, urin ry
frequency
Lightening
Bloody show
Wt g in 1 lb/week
Complic tion: PROM
Pren t l
L b L b
Test
Me n Corpuscul r Volume
Hb/Hct- low due to dilution
MCV most reli ble MCV most reli ble
< 80
> 100
Rubell IgG ntibody
Antibodies present
Absence puts p tient t risk
Immuniz tion:
Hep titis B Virus
HBV surf ce
v ccin tion

ntibody: successful

HBV surf ce

ntigen:

E ntigen:
460
4/29/2008
9
STD screening
Cervic l cultures:
Syphilis:
VDRL
RPR
MHA-TP
FTA
Mgt. Penicillin
Urine Screening
Urin lysis:
Proteinuri
Ketones
Glucose
B cteri
Culture:
(ASB)

symptom tic b cteruri

Tuberculosis Screening
PPD or Tine test:
Positive skin test
CXR neg tive CXR neg tive
CXT positive
HIV screening
Recommended for ll pregn nt
women
Opt out: informed refus l
Opt in: informed consent
Elis test
Detect ble HIV ntibodies
B bies born to n HIV + mothers
Western Blot
Zidovudine
Alph Fet l Protein

True c uses of incre sed AFP:

MCC- dti ting MCC d errors
461
4/29/2008
10
Triple M rker Screening
MS-AFP
hCG
Estriol
Accur te d ting is import nt Accur te d ting is import nt
Triple m rker screening
Trisomy 21 Trisomy 18
Downs Edw rds
MS-AFP-AFP MS
hCG
Estriol
Do k ryotype for both
Third Trimester L b Test
Di betic Test:
1hr (50 gm) or l glucose
3hr (100 gm) or l glucose
Norm l: FBS: < 95, 1hr <180, 2hr < 155,
3hr < 140
Anten t l
Fet l Fet l
Testing
Nonstress Test (NST)
Check frequency of fet l movement
Extern l fet l HR monitor
Acceler tions
<32 wks: >10 or more BPM, < 32 wks: > 10 or more BPM,
l sting >10 sec
> 32 wks: > 15 or more BPM,
l sting > 15 sec
Fet l Monitor Tr cing
B se line FHR: 110-160
< 110 Br dyc rdi

Meds: bet drenergic blockers, nesthetics

Fet l l rrhythmi rrhythmi - congenit lnit l he rtt blockock (lupus)lupus) Fet
conge he r bl (
>160 T chyc rdi
Meds: be t drenergic gonist (terbut line,
ritodrine)
Fever
Fet l repetive movements
462
4/29/2008
11
E rly Deceler tion:
he d compression
V ri ble Deceler tioncord compression
L te Deceler tions- uteropl cent l
insufficiency ( fet l cidosis)
Biophysic l profile (BPP)
5 components of fet l well
being:
1. NST: scores 0-2 for e ch
2. Amniotic fluid volume
3. Fet l gross bodyy movement g
4. Fet l extremity tone
5. Fet l bre thing movements
2-5 ssessed through Utz.
BPP scoring
8-10 = re ssuring (weekly BPP)
4-6 = worrisome
> 36 wks- deliver
<36 ks- BPP 12-24 24 hours < 36 wk BPP every 12 h
0-2 = fet l hypoxi (deliver ASAP)
Contr ction stress test (CTS)
Testing fetus response to toler te
tr nsitory decre ses in blood flow
Presence or bsence of l te
deceler tion
Induce with IV oxytocin
Neg tive test is good- no l te Dcells
463
4/29/2008

12
Umbilic l Artery Doppler
Me sures r tio of Systolic nd
Di stolic blood flow in umbilic l
rtery
Incre sed throughout pregn ncy,p g g y,
since di stolic pressure f lls more
Infections
Group B bet hemolytic Strep
Norm l GI tr ct flor
30% of women

re symptom tic c rriers

Vertic l tr nsmission
E rly onset
L te onset
Mgt: IV penicillin: if
nd Erythromycin

llergic- Clind mycin

Tre t for Group B Strep if

Positive urine culture GBBS
Previous b by h d GBBS
Screening by v gin l cultures:
3rd trimester
If + then prophyl xis IV PCN
Preterm or Membr ne rupture > 18hrs,
or m tern l fever Mgt.
Prophyl xis IV PCN
Toxopl sm Gondii
P r site ssoci ted with c t feces
R w go t milk
Under cooked infected me t
Vertic l tr nsmission Vertic l tr nsmission
Leth l if first trimester
Third trimester- symptom tic
Intr cr ni l c lcific tion
Mgt: Pyrimeth mine Sulf di zine
V ricell
Chicken Pox
Herpes Zoster
Spre d vi respir tory droplets
ZIG ZAG skin lesion
M tern l v ricell pneumoni M tern l v ricell pneumoni

Mgt: dminister VZIG to suspected

gr vid within 96 hrs of exposure
464
4/29/2008
13
Rubell
RNA virus spre d through
respir tory droplets
Tr nsmission only if prim ry
infection
Fetus= VSD
Neon te= congenit l de fness Neon te= congenit l de fness
Prevention: rubell IgG ntibody
screening
Live ttenu ted virus- void
pregn ncy for 1 month fter
immuniz tion
Cytomeg lovirus (CMV)
Spre d vi body secretions
Life long l tency, so fetus c n get
it on re ctiv tion
Periventricul r c lcific tion
MCC of congenit l de fness
Mgt: G nciclovir
Herpes Simplex Virus (HSV)
Multinucle ted Gi nt Cells
M tern l genit l lesion is MC route
for fet l infection
Dx: + culture from ruptured vesicle
Prevention: C-section section Prevention: C
If membr ne lre dy ruptured nd it
h s been >8-12 hours- too l te to
do C-section
Mgt: Acyclovir
Hum n Immunodeficiency Virus
HIV + mothers t ke zidovudine
st rting t 14 wks until delivery
C-section for delivery
Bre st feeding contr indic ted
Neon te gets AZT for 6 wks, then

check g in
M tern l Syphilis infection
Prim ry- p inless ulcer with rolled up
edges (ch ncre)- gone in 2-3 wks
Second ry- 2-3 months fter cont ct,
m culop pul r skin r sh nd
condylom om l t t condyl l
Terti ry- org ns ffected
He rt- ortitis
Dors l column- t bes dors lis
CSF +
Mgt: V gin l delivery: Benz thine PCN nd if llergic
desensitiz tion to PCN
Bleeding
during l te g
pregn ncy
465
4/29/2008
14
Bleeding
Initi l ev lu tion:
M tern l : check vit ls
Fetus: FHT
Mgt: l rge bore IV NS
Foley- monitor output
If fet l jeop rdy is present or +/- 36
wks- deliver
Abruptio Pl cent
P inful bleeding
Overt (extern l) Conce led (intern l)
Types of Abruption
Mild- no fet l bnorm lity
Moder te- 25 50% surf ce
sep r tion
Monitoroto foro l te te D-cellsce s
Severe- brupt, knife like uterine
p in
> 50% pl cent l sep r tion
DIC m y occur
Severe l te D-cells
Mgt. of Abruptio

Emergency Ces re n if mother or

fet l jeop rdy
V gin l delivery if bleeding is V gin l delivery if bleeding is
controlled or > 36 wks
Conserv
St ble
Confirm
Repl ce

tive (in hospit l)

nd remote from term
pl cent l loc tion on sono
fluids

Pl cent Previ
P inless bleeding
Pl cent is impl nted in lower
uterine segment
Common e rly in pregn ncy
(migr tion)
3 types:
Tot l, complete or centr l- covers os
P rti l- p rti l cover of os
M rgin l, low lying- ne r os
Mgt. for Pl cent Previ
Emergency Ces re n if mother or
fet l jeop rdy
V gin l delivery- lower pl cent l
edge must be > 2cm of os
Scheduled C-section
Fet l lung m turity by mniocentesis
Conserv tive (in hospit l)
Bed rest, preterm, confirm pl cent l
loc tion
466
4/29/2008
15
Complic tions of Pl cent Previ
Villi m y inv de uterine tissue
Endometrium
Pl cent cent Pl
ccret 75%
Pl cent Incret
20%
Pl cent
percret

5%

Bl dder
Myometrium
Seros
V s Previ
Fet l vessels tr nsverse the intern l OS
Bleeding from fetopl cent l circul tion
R pid fet l exs nguin tion
Due to

mniotomy (AROM)

Tri d:
ROM
P inless v gin l bleeding
Fet l br dyc rdi
Mgt: immedi te C-section
Uterine Rupture
Tri d:
P inful bleed
Loss of FHT
He d flo ting
MCC- cl ssic l ssic l incisionncision MCC cl i
Myomectomy
Excessive oxytocin
Mgt: surgic l
Obstetric l
Complic tionsp
Abortion vs fet l demise
Fet l de th prior to 20 weeks:
Abortion
- Missed
- Thre tened
- Inevit ble
- Incomplete
- Complete
After 20 weeks: fet l demise
Must report to the st te
Fet l demise (>20 wks)
Most serious consequence
DIC (dissemin ted intr v scul r
co gul tion)
Usu lly t kes 3-4 wks to occur

Rele se of thrombopl stin from

deterior ting fet l org ns
Do not deliver until mom is re dy
long s there is no DIC

467
4/29/2008
16
Twin Delivery
V gin l C-section ?
B
B
B
Both
Ceph lic
A- breech
B- ceph lic
A- ceph lic
B- breech
A
B
A
A
B
Rho GAM
Pooled nti-D IgG
P ssive ntibodies (IM)
IGgG tibditibodies tt ch h to the I n tt t th
foreign RBC nd lysis occurs
before mom c n produce n
immune response
RhoGAM given

Give to Rh(D) neg tive mothers t

28 weeks
Within 72 hours of
Chorionichorionic villuss s mplingmpling C villu s
Amniocentesis
Rh+ delivery
D & C
Give 300 microgr ms (1 vi l)
Kleih uer Betke Test

Qu ntit tes fet l RBCs in moms

blood
Looks t

peripher l sme r

Will ccess if more th n one vi l is

needed
Prem ture Rupture of Membr ne
(PROM)
Risk of scending infection
History of sudden gush of copious
v gin l fluids
Oligohydr mnios on Utz.
Di gnosis PROM
Sterile speculum
Pooling cle r fluid in posterior
v gin l fornix
Nitr zine positive (turns p perp blue)) p ( p
Fern test- on microslide
Chorio mnionitis:
M tern l fever
Uterine tenderness
Confirmed PROM
468
4/29/2008
17
M n gement PROM
Uterine contr ctions present
(dont use tocolysis)
Chorio mnionitis- IV ntibiotics, Chorio mnionitis IV
delivery
No infection
< 24 wks- dism l outcome
>24- bed rest, IM bet meth sone, 7 d y
prophyl xis of mpicillin nd
erythromycin
Preterm L bor
3 criteri :
Between 20 nd 37 weeks
Uterine contr ctions (3 in 30 min.)
Cervic l ch nges

ntibiotics,

(dil tion ch nges > 2cm)

Tocolytic Agents
Prolong pregn ncy for up to 72 hrs
IM bet meth sone to work
Tr nsport mother/fetus to neon t l Tr nsport mother/fetus to neon t l
intensive c re
Given p renter l
Types of Tocolytics
MgSO4- blocks C 2+
Monitor: DTR
Antidote: IV c lcium glucon te
Contr indic tions: ren l insufficiency, MG
Bet drenergic gonist- terbut line,
ritodrine
C 2+ blockers- Nifedipine, Proc rdi
PG inhibitors- Indometh cin
Post D te Pregn ncy
Worried bout pl cent l bre kdown
Fetus not getting the O2 it needs
Meconium risk
42 wks m ximum time in uterus
Shoulder dystoci
HTN during
pregn ncyg p y
469
4/29/2008
18
Preecl mpsi :
Mild Severe
B/P
Proteinuri
Gest tion
Mgt.
Ecl mpsi

Unexpl ined gr nd m l seizures

with
HTN
Proteinuri
> 20 wks gest tion
Severe diffuse cerebr l
v sosp sms
Mgt. of Ecl mpsi
First protect the mothers irw y
IV MgSO4, with IV bolus of 5g to stop
seizure seizure
M inten nce dose 2g/hr
Deliver t ny gest tion l ge
Lower di stolic B/P to 90-100mmHg
HELLP Syndrome
5-10% of preecl mptic p tients
H- hemolysis
EL- elev ted liver enzymes
LP- low pl telets
Mgt. prompt delivery

t ny ge

Fet l Present tion

Ceph lic- he d presents first
Breech- feet or buttock first
Fr nk (v gin l delivery)- sucking on
toes
Complete
Footling
Compound- more th n one body p rt
present
St tion in delivery
470
4/29/2008
19
Overview of L bor
Uterine ch nges:
Contr ction of upper uterine segment
Exerting expelling forces
Cervic l eff cement:
Thinning due to oxytocin nd PGE2
bre king disulfide bonds in coll gen

fibers
Norm l cervix: 2cm long/ 2cm wide
C rdin l Movement in L bor
Eng gement
Descent
Flexion
Intern l rot tion
Extension
Extern l rot tion
Expulsion
St ges of L bor
St ge 1: onset of uterine contr ction
nd ends with complete dil tion
L tent- cervic l dil tion up to 20 hrs (3-4 cm)
Active r pid cervic l dil tion (1.2 cm/hr)
St ge 2: complete cervic l dil tion to
deliveryivery (2 hrs) del (2 hrs)
St ge 3: delivery to pl cent l expulsion
(30 min)
St ge 4: observ tion of mother for
preecl mpsi nd post p rtum
hemorrh ge
Abnorm l
Lb bor L
Prolonged L tent Ph se
Cervic l dil tion <3cm for
> 20hrs primip r
> 14 hrs multip r
MCC ijdiinjudicious lgesi

i MCC i n l

Mgt. Ther peutic rest

Prolonged Active Ph se or Arrest
Cervic l dil tion > 3cm
Prolonged dil tion < 1.2 cm for > 2h
P ssenger problem: size or
orient tion
Power problem: in dequ te uterine
contr ction
Hypotonic muscle- IV oxytocin
Contr ction norm l- go to C-section
471

4/29/2008
20
Prolonged 3rd st ge
Pl cent h s not delivered within 30
min
If it does not remove with IV
oxytocin,y then think ccret (etc.)) , (
Mgt. m nu l remov l or
Hysterectomy
Prol psed Umbilic l Cord
Obstetric emergency
Cord gets compressed ffecting
fet l oxygen tion
Occult- he d nd uterine w ll
P rti l- he d nd cervic l os
Complete- protruding into v gin
Mgt. Knee-chest position
Elev te presenting p rt
Immedi te C-section
Shoulder Dystoci
Delivery of fet l shoulder is
del yed fter delivery of he d
Imp cted of pubic symphysis
Mgt. supr pubic pressure
McRoberts m neuver- thigh flexed
Woods corkscrew- intern l rot tion
M nu l delivery of posterior rm
Ces re n Section
M tern l mort lity nd morbidity is
higher th n v gin l delivery
Hemorrh ge : > 1000 ml
Infection
Viscer l injury: bowel, bl dder
Thrombosis- DVT
Uterine Incisions
Lower segment tr nsverse
(pull bl dder down)
Fetus must be in longitudin l lie Fetus must be in longitudin l lie
Cut non-contr ctile portion of uterus

C n still h ve VBAC
(v gin l birth fter c-section)
Cervic l Ceret ge
Pts with incompetent cervix
Shirodk r- bene th cervic l
mucos - left in pl ce with deliver
of C-section
McDon ld- removed by 36 wks for
v gin l delivery
Pl ced t 14 wks, before cervic l
dil tion nd eff cement occur
472
4/29/2008
21
Post P rtum Fever
PP d y 0: Atelect sis
PP d y 1-2: UTI
PP d y 2-3: Endometritis
PP d y 4-5: Wound infection
( ntibiotics nd dr in) ( ntibiotics
PP d y 5-6: Septic thrombophlebitis
(IV hep rin 7-10 d ys)
PP d y 7-21: Infectious m stitis
(or l clox cillin nd continue
bre st feeding)
Gynecologic
Neopl si
nd C ncer
Hum n P pillom Virus (HPV)
16, 18, 31, 33
Prem lign nt
C ncerous
611,11 6
Benign condylom

nd 35

cumin t

PAP test
Screening for prem lign nt lesions
Tr nsform tion zone (T-zone)
squ mous/column r
3 ye rs fter onset of sexu l
ctivityty or 21 y/o/o ct o y
Discontinued >70 with 3 neg tive
p ps

nd dr in)

< 30 y/o nnu lly (2 yrs liquid b sed)

> 30 every 2-3 yrs fter 3 (-) p ps
Bethesd System
Neg tive- no m lign ncy
ASC- typic l squ mous cells
LSIL- loww gr de squ mous intr epitheli lntr epitheli l LSIL lo gr de squ mous i
lesion (HPV or CIN I)
HSIL high gr de squ mous intr epitheli l
lesion ( CIN 2,3, moder te dyspl si )
C ncer- inv sive
Di gnostic Appro ch
Acceler ted repe t PAP: ASC-US
HPV-DNA testing: ASC-US
Colposcopy-olposcopy bnorm l p p C bnorm l p p
( cetic cid)
Endocervic l curett ge (ECC)- r/o
endocervic l lesion [not in pregn ncy]
Cone biopsy- PAP worse th n histologic l
473
4/29/2008
22
Mgt. ccording to histology
Observ tion: CIN I, repe t p p 6-12
months
Abl tive: CIN 1, 2, 3: Cryother py
Excision l: CIN 1, 2, 3: LEEP (loop
electrosurgic l excision), cold
knife
Hysterectomy- recurrent CIN 1,2,3
Inv sive Cervic l CA
Penetr ted through b sement
membr ne
Postcoit l v gin l bleeding
Dx. Cervic l biopsy- sq. cell CA
Mgt. Hysterectomy

Cervic l Neopl si in
Pregn ncy
Pregn ncy does not ch nge
progression
Test fem le s me s non-pregn ntp g
Skip ECC- cervix more v scul r
Inv sive CA:
<24 wks: hysterectomy
> 24 wks: w it until 32-33 wks, then
C-section nd hysterectomy
Post Menop us l Bleeding
Menop use- fter 3mo or cess tion
of menses
Endometri l c rcinom (MCC)
Unopposed estrogen
Dx: Endometri l s mpling
Mgt: Positive histology: TAH & BSO
Enl rged Uterus
Leiomyom :
Benign smooth muscle of the
myometrium
More common in bl ck fem les
Mgt. Observ tion
Presurgic l shrink ge 3-6 mo GnRH n log
Myomectomy
Emboliz tion
Hysterectomy
Enl rged Uterus
Adenomyosis:
Ectopic endometri l gl nds nd strom
loc ted within the myometrium of the
uterine w ll
Tender uterus in bsence of pregn ncyg p y
Dx. Utz or MRI
Mgt. Levonorgestrel intr uterine system
Definitive : Hysterectomy
474
4/29/2008
23

Ov ri n
Neopl si Neopl si
Premenop us l Adnex l M ss
Simple Cyst- lute l or follicul r
Complex cyst- dermoid (germ l yers)
Dx. hCG levels to rule out pregn ncy:
Sonogr m
Mgt.
Simple cyst- observ tion, OCPs,
(>7cm l p roscopic)
Complex cyst- surgic l remov l
Adnex l M ss With P in
Sudden onset of severe lower
bdomin l p in in presence of
dnex l m ss. Ov ri n torsion
Mgt. untwist Mgt. untwist
Observ tion to ssure revit liz tion
Routine ex m nnu lly
Prepubert l Adnex l M ss
Function l ov ri n cyst not
possible bec use ov ri n
follicles re not functioning
Suspiciousp of neopl smp
Dx. Tumor m rkers
LDH- dysgerminom
Bet HCG- Chorioc rcinom
Alph fet l protein- endoderm l sinus
tumor
Postmenop us l Adnex l M ss
Ov ries should be trophic
Any enl rgement, should dr w
suspicion of ov ri n c ncer
BRCA-1
Cl ssific tions
Epitheli l tumor (80%)- post menop us l
MC serous
Germ Cell tumor (15%)- teen gers
MC dysgerminom
Strom l tumor (5%)
Gr nulos cell tumor- incre sed estrogen

Met st tic tumor- Krukenberg

stom ch to ov ry
475
4/29/2008
24
Vulv r Neopl si
Vulv r lesion with pruritus
Vulv r itching
Squ mous hyperpl si
(whitish foc l re )) (
Mgt. corticosteroids
Lichen Sclerosis
(bluish-white p pule)
P rchment like
Mgt. testosterone cre m
Vulv r Intr epitheli l Neopl si
(VIN)
Squ mous dyspl si
Mgt. surgic l excision
The
End
476
10/13/2008
1
Tr um " refers to serious
or critic l bodily injury,
wound, or shock, s from
violence or ccident.
Immedi tely
thre tening
Potenti lly
thre tening

lifeinjuries
lifeinjuries

Airw y obstruction
Simple
pneumo/h emothor x
Tension pneumothor x Aortic rupture
Open pneumothor x Blunt c rdi c injury
M ssive h emothor x Pulmon ry contusion
Fl il chest Tr cheobronchi l rupture
C rdi c t mpon de Di phr gm tic rupture
477

10/13/2008
2
SIGNS & SYMPTOMS: (Your CLUES)
1. No, we k, noisy, l bored or gurgled respir tion
2. P le, cool, cl mmy skin; del yed c pill ry refill
3. Irregul r/unst ble vit l signs
4. Contusion, br sion, l cer tion, hem tom
5. P in, tenderness, gu rding, numbness/tingling
6. Bruising, swelling, deformity, f lse/limited motion
7. Muscle we kness/p r lysis, loss of sens tion
8. Altered ment l st tus
9. Asymmetric pupils, JVD, incontinence
OBTAIN HISTORY OF:
1. PMH/Meds/Allergies
2. Mech nism of injury/we pon description
3. Use of protective devices: helmets, se tbelts,
irb gs, p dding
4. Subst nce buse
5. Estim ted blood loss t scene
6. Time of injury
7. Loss of consciousness
STABLE or UNSTABLE UNSTABLE
The F mous A B Cs
- Airw y
- Bre thing
- Circul tion
The F mous A B Cs
In the vignette:
- GET RID OF DISTRACTORS!
- Look for Pt. St bility nd
decide:
478
10/13/2008
3
The F mous A B Cs
In the vignette:
- GET RID OF DISTRACTORS!
- Look for Pt. St bility nd
decide:
C se:
25 y/o m n f lls from tree. At the moment
he is unconscious. His bre thing is difficult
nd his mouth is full of blood. His rm h s n
unusu l ngle nd theres l cer tion in his

forehe d nd chest. Wh t is the best next

step?
C se:
25 y/o m n f lls from tree. At the moment
he is unconscious. His bre thing is difficult
nd his mouth is full of blood. His rm h s n
unusu l ngle nd theres l cer tion in his
forehe d nd chest. Wh t is the best next
step?
A IRWAY:
Wh t to check?
-No, we k, noisy, l bored or gurgled respir tion
-Abnorm l, silent or low voice or uncompleted
sentences while t lking
- Unconsciousness
A IRWAY:
Then: Administer

ir ANYHOW!

- M sk w/ 100% O2
- Orotr che l intub tion
- Cricothyroidotomy
A IRWAY:
Then: Administer

ir ANYHOW!

- M sk w/ 100% O2
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10/13/2008
4
A IRWAY:
Then: Administer

ir ANYHOW!

- Orotr che l intub tion

A IRWAY:
Then: Administer

ir ANYHOW!

- Cricothyroidotomy
A IRWAY:
Then: Administer ir ANYHOW!
How to choose?
Rules:
1.-Use less inv sive first
2.-Follow the order if the p tient
h s been st rted but
oxygen tion didnt succeed

(Check PULSE OX. <90)

A IRWAY:
Possible c uses: (If di gnose is sked)
- Foreign object
- Body fluids (blood, vomit)
- Swelling of tr che , epiglottis,
tongue, uvul , etc
- Disruption of irw y (direct tr um )
- Anesthesi , drugs
- He d tr um
C se:
25 y/o m n f lls from tree. At the moment
he is unconscious. His bre thing is difficult
nd his mouth is full of blood. His rm h s n
unusu l ngle nd theres l cer tion in his
forehe d nd chest. In the mbul nce the
p tient is intub ted successfully. Physic l
Ex min tion: Loud blow sound in the left
when mbu is compressed. Wh t is the best
next step?
C se:
25 y/o m n f lls from tree. At the moment
he is unconscious. His bre thing is difficult
nd his mouth is full of blood. His rm h s n
unusu l ngle nd theres l cer tion in his
forehe d nd chest. In the mbul nce the
p tient is intub ted successfully. Physic l
Ex min tion: Loud blow sound in the left
when mbu is compressed. Wh t is the best
next step?
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5
B REATHING:
Wh t to check?
-Symmetry of ir flow
-Is ir going to lungs ctu lly?
-Bre th utom tism
-OVERVENTILATION
-Crepitus in peri respir tory system
B REATHING:
Then: CORRECT (Depends in vignette)
- One side irflow - Re-direct tube
- Crepitus peri resp. - Other w y of ventil t.
- Pulse Ox. Low - Other w y of ventil t.
- Air outside lungs - Re-di gnose
B REATHING:
Possible c uses:
- B d technique

- Fl il chest
- C rdi c t mpon de
- Rupture of irw y, thor x,
di phr gm or rthery (hemo,
pneumo thor x)
- Under ventil tion
C se:
19 y/o unm rried, t term pregn nt wom n
h s MVA 30 minutes go. She is ble to
nswer the n mnesis nd is lucid. At the
moment she is crying, nd seeks for
comp nion, she is very worried bout the
b by bec use she doesnt feel movements
nymore nd sk for the mother to be c lled.
Temper ture is 37C, Pulse 102m, BP 60 over
40. Fet l signs neg tive.