drk1980
Forum Guru
Topics: 147
Posts: 1,038
|
A 45 year old hispanic woman develops low-grade fever and foul-smelling productive cough 2 weeks following an episode of new onset idiopathic seizures. Her vital signs are BP: 120/80, PR: 110, RR: 20 and T: 40C. You suspect a post aspiration lung abscess in this patient. What would be the most likely location of lung abscess in this patient?
A. Right lung apices
B. Left lung apices
C. Basal segment of the right lower lobe
D. Posterior segment of right upper lobe
E. Posterior segment of left upper lobe
Those who already know the answer from UW......Can u explain the clash btwn Goljan's step1 notes and this expln? Tx
|
| mesh
Forum Guru
Topics: 77
Posts: 401
|
D. Posterior segment of right upper lobe ?
|
| AAAAA
Forum Fanatic
Topics: 156
Posts: 1,991
|
The right middle and/or lower lobe are the most common sites of infiltration. However, left and bilobar processes are possible, depending on the amount of aspirate and the body position during aspiration.
Empyema should be ruled out in the presence of pleural effusion.
Procedures:
Protected brush or protected bronchial sample - Used to guide initial antibiotic therapy in nosocomial aspiration pneumonia, but not necessary in community-acquired pneumonia
Bronchoscopy
Thoracentesis
TREATMENT Section 6 of 11
Author Information Introduction Clinical Differentials Workup Treatment Medication Follow-up Miscellaneous Pictures Bibliography
Prehospital Care:
Oxygen supplementation as needed
Continuous pulse oximetry
Cardiac monitoring
Intravenous catheterization
Tracheal intubation may be necessary in patients with a poor gag reflex, altered mental status, or persistent hypoxia.
Emergency Department Care:
Continued oxygen supplementation as needed
Cardiac monitoring
Intravenous catheterization
Endotracheal intubation is indicated for patients with a poor gag reflex, altered mental status, or persistent hypoxia despite noninvasive measures (including high-flow oxygen, continuous positive airway pressure ventilation). Positive end expiratory pressure may be used in cases of bronchoconstriction and refractory hypoxemia.
Consider tracheobronchial suction or tracheobronchoscopy to remove particulates or plugs.
Use empiric antimicrobial therapy with coverage adequate for the given clinical scenario (eg, community-acquired or nosocomial infection).
Administer intravenous hydration with electrolyte supplementation as needed.
Consultations:
Consult a pulmonary and/or critical care specialist in severe cases of respiratory failure that require ventilatory support.
Consult an infectious disease specialist for advice about proper antibiotic therapy when the patient is at risk for nosocomial, highly resistant microbial infections.
MEDICATION Section 7 of 11
Author Information Introduction Clinical Differentials Workup Treatment Medication Follow-up Miscellaneous Pictures Bibliography
In the case of community-acquired aspiration pneumonia, empiric therapy must cover anaerobic and streptococcal species. Patients at risk for nosocomial pneumonia must be covered for anaerobic species, gram-negative bacilli (eg, Pseudomonas aeruginosa), and methicillin-resistant S aureus until sputum culture results are available to guide therapy. Corticosteroids are not indicated but may be considered for use in adjunctive therapy for coincident reactive airways or bronchoconstriction.
Drug Category: Antibiotics -- Empiric antimicrobial therapy must be comprehensive and should cover all likely pathogens in the context of the clinical setting.Drug Name
Amoxicillin and clavulanate (Augmentin) -- Drug combination that extends the antibiotic spectrum of this penicillin to include bacteria normally resistant to beta-lactam antibiotics; indicated for skin and skin structure infections caused by beta-lactamase-producing strains of S aureus.
Adult Dose 1 g IV q8h
Pediatric Dose 50-80 mg/kg/d in 3 IV injections
Contraindications Documented hypersensitivity
Interactions Coadministration with warfarin or heparin increases risk of bleeding
Pregnancy B - Usually safe but benefits must outweigh the risks.
Precautions Give for a minimum of 10 d to eliminate organism and prevent sequelae (eg, endocarditis, rheumatic fever); after treatment, obtain cultures to confirm eradication of streptococci
Drug Name
Clindamycin (Cleocin) -- Lincosamide for treatment of serious skin and soft tissue staphylococcal infections. Also effective against aerobic and anaerobic streptococci (except enterococci). Inhibits bacterial growth, possibly by blocking dissociation of peptidyl t-RNA from ribosomes and causing RNA-dependent protein synthesis to arrest.
Adult Dose 600 mg IV q6-8h; dilute 300 mg in 50 mL of saline; duration of perfusion must be >10 min
Pediatric Dose 15-40 mg/kg in 3-4 IV perfusions
Contraindications Documented hypersensitivity; regional enteritis; ulcerative colitis; hepatic impairment; antibiotic-associated colitis
Interactions Increases duration of neuromuscular blockade, induced by tubocurarine and pancuronium; erythromycin may antagonize effects; antidiarrheals may delay absorption
Pregnancy B - Usually safe but benefits must outweigh the risks.
Precautions Adjust dose in severe hepatic dysfunction; no adjustment necessary in renal insufficiency; associated with severe and possibly fatal colitis
Drug Name
Ceftazidime (Fortaz, Ceptaz) -- Third-generation cephalosporin with broad-spectrum gram-negative activity; lower efficacy against gram-positive organisms; higher efficacy against resistant organisms; arrests bacterial growth by binding to 1 or more penicillin-binding proteins.
Adult Dose 500 mg to 2 g IV/IM q8-12h
Pediatric Dose 1-4 weeks: 30 mg/kg IV/IM q12h
1 month to 12 years: 30-50 mg/kg/dose IV/IM q8h; not to exceed 6 g/d
Contraindications Documented hypersensitivity
Interactions Nephrotoxicity may increase with aminoglycosides, furosemide, and ethacrynic acid; probenecid may increase ceftazidime levels
Pregnancy B - Usually safe but benefits must outweigh the risks.
Precautions Adjust dose in renal impairment
Drug Name
Amikacin (Amikin) -- For gram-negative bacterial coverage of infections resistant to gentamicin and tobramycin; effective against Pseudomonas aeruginosa. Irreversibly binds to 30S subunit of bacterial ribosomes and blocks recognition step in protein synthesis.
Adult Dose 15 mg/kg/d in 2 IV perfusions of 30-min duration; use the patient's IBW for dose calculation
Pediatric Dose Administer as in adults
Contraindications Documented hypersensitivity
Interactions Coadministration with other aminoglycosides, penicillins, cephalosporins, and amphotericin B increases nephrotoxicity; enhances effects of neuromuscular blocking agents; causes respiratory depression; irreversible hearing loss may occur with coadministration of loop diuretics
Pregnancy C - Safety for use during pregnancy has not been established.
Precautions Not intended for long-term therapy; caution in renal failure (not receiving dialysis), hypocalcemia, myasthenia gravis, and conditions that depress neuromuscular transmission
Drug Name
Vancomycin (Vancocin) -- Potent antibiotic against gram-positive organisms and active against Enterococcus species. Useful in the treatment of septicemia and skin structure infections. Indicated for use in patients who cannot receive or who have infections that fail to respond to penicillins and cephalosporins or infections with resistant staphylococci. For abdominal penetrating injuries, it is combined with an agent active against enteric flora and/or anaerobes. Used with gentamicin for prophylaxis in penicillin allergic patients who are allergic to penicillin and undergoing GI or genitourinary procedures.
To avoid toxicity, assay vancomycin trough levels after third dose drawn 0.5 h prior to next dose; use CrCl value to adjust dose in patients with renal impairment.
Adult Dose 500 mg to 2 g/d IV divided tid/qid for 7-10 d
Pediatric Dose 40 mg/kg/d IV divided tid/qid for 7-10 d
Contraindications Documented hypersensitivity
Interactions Erythema, histaminelike flushing and anaphylactic reactions may occur when administered with anesthetic agents; taken concurrently with aminoglycosides, risk of nephrotoxicity may increase above that with aminoglycoside monotherapy; effects in neuromuscular blockade may be enhanced with coadministration of nondepolarizing muscle relaxants
Pregnancy C - Safety for use during pregnancy has not been established.
Precautions Caution in renal failure, neutropenia; red man syndrome is caused by too-rapid IV infusion (dose given over a few minutes) but is rare when dose is given over 2 hours, PO, or IP; red man syndrome is not an allergic reaction
FOLLOW-UP Section 8 of 11
Author Information Introduction Clinical Differentials Workup Treatment Medication Follow-up Miscellaneous Pictures Bibliography
Further Inpatient Care:
Admit patients with severe hemodynamic compromise and/or persistent respiratory distress to the ICU.
Admit the patient to a general-care floor if the patient's respiratory status is stabilized.
Transfer:
Intubated and ventilated patients must be transferred to a hospital with an ICU.
Deterrence/Prevention:
Keep the head of the bed at a 30° angle. Patients with dysphagia and/or a poor gag reflex should not be fed orally; feeding through a nasogastric or gastric tube may be required.
Complications:
Acute respiratory failure
Acute respiratory distress syndrome
Empyema
Pulmonary abscess
Superinfection
Prognosis:
The mortality rate of massive aspiration and/or Mendelson syndrome approaches 70%.
The mortality rate for aspiration pneumonitis complicated by empyema is approximately 20%.
The mortality for uncomplicated pneumonitis is approximately 5%.
Patient Education:
For excellent patient education resources, visit eMedicine's Pneumonia Center. Also, see eMedicine's patient education article Chemical Pneumonia.
MISCELLANEOUS Section 9 of 11
Author Information Introduction Clinical Differentials Workup Treatment Medication Follow-up Miscellaneous Pictures Bibliography
Medical/Legal Pitfalls:
The airway must always be stabilized in patients with an abnormal gag reflex or altered mental status.
PICTURES Section 10 of 11
Author Information Introduction Clinical Differentials Workup Treatment Medication Follow-up Miscellaneous Pictures Bibliography
Caption: Picture 1. Chest radiograph of a patient with aspiration pneumonia of the left lung after a benzodiazepine overdose - The patient was probably positioned to the left at the moment of aspiration.
View Full Size Image
eMedicine Zoom View (Interactive!)
Picture Type: X-RAY
Caption: Picture 2. Chest radiograph of a patient with massive aspiration pneumonia of the right lung
View Full Size Image
eMedicine Zoom View (Interactive!)
Picture Type: X-RAY
BIBLIOGRAPHY Section 11 of 11
Author Information Introduction Clinical Differentials Workup Treatment Medication Follow-up Miscellaneous Pictures Bibliography
Lumpkin JR, Westfall MD: Aspiration pneumonia. In: Emergency Medicine: Concepts and Clinical Practice. 1992: 1112-20.
Marom EM, McAdams HP, Erasmus JJ: The many faces of pulmonary aspiration. AJR Am J Roentgenol 1999 Jan; 172(1): 121-8[Medline].
Mier L, Dreyfuss D, Darchy B: Is penicillin G an adequate initial treatment for aspiration pneumonia? A prospective evaluation using a protected specimen brush and quantitative cultures. Intensive Care Med 1993; 19(5): 279-84[Medline].
Moll J, Kerns W 2nd, Tomaszewski C: Incidence of aspiration pneumonia in intubated patients receiving activated charcoal. J Emerg Med 1999 Mar-Apr; 17(2): 279-83[Medline].
Pennza PT: Aspiration pneumonia, necrotizing pneumonia, and lung abscess. Emerg Med Clin North Am 1989 May; 7(2): 279-307[Medline].
Preston AJ, Gosney MA, Noon S: Oral flora of elderly patients following acute medical admission. Gerontology 1999 Jan-Feb; 45(1): 49-52[Medline].
Sasaki H, Sekizawa K, Yanai M: New strategies for aspiration pneumonia. Intern Med 1997 Dec; 36(12): 851-5[Medline].
NOTE:
Medicine is a constantly changing science and not all therapies are clearly established. New research changes drug and treatment therapies daily. The authors, editors, and publisher of this journal have used their best efforts to provide information that is up-to-date and accurate and is generally accepted within medical standards at the time of publication. However, as medical science is constantly changing and human error is always possible, the authors, editors, and publisher or any other party involved with the publication of this article do not warrant the information in this article is accurate or complete, nor are they responsible for omissions or errors in the article or for the results of using this information. The reader should confirm the information in this article from other sources prior to use. In particular, all drug doses, indications, and contraindications should be confirmed in the package insert. FULL DISCLAIMER
Pneumonia, Aspiration excerpt
___________________
seeking study partner in USMLE, Canadian MCC OSCE examination
|
| drk1980
Forum Guru
Topics: 147
Posts: 1,038
|
Ans is D.
Step1 prep had led me to blv otherwise....thot it was C.
|
| AAAAA
Forum Fanatic
Topics: 156
Posts: 1,991
|
D
___________________
seeking study partner in USMLE, Canadian MCC OSCE examination
|
| zeloc
Forum Junior
Topics: 11
Posts: 53
|
I was wondering about this too. According to Goljan's book the most common location is the superior segment of the right lower lobe, and C is the only answer with the right lower lobe. Any other opinions?
|
| GOGETA
I'm Dr. GOGETA
Topics: 323
Posts: 2,730
|
I was between C and D
___________________
As a general rule, the better it felt when you said it, the more trouble it's going to get you into.
|
| elitoki
Forum Guru
Topics: 54
Posts: 508
|
this patient aspiration has occured during seizure.
The position was lie-down, so the most common area is posterior -right lung.
|
| Justice
Forum Fanatic
Topics: 113
Posts: 2,222
|
Here is what eMedicine says:
+ The right middle and lower lung lobes are the most common sites of infiltrate formation due to the larger caliber and more vertical orientation of the right main stem bronchus.
+ Patients who aspirate while standing can have bilateral lower lung lobe infiltrates.
+ Patients lying in the left lateral decubitus position are more likely to have left-sided infiltrates.
+ The right upper lobe is a common area of consolidation in alcoholics who aspirate in the prone position.
I would go with D... A does not fit the definition...
___________________
Don't live in a town where there are no doctors
|
| zeloc
Forum Junior
Topics: 11
Posts: 53
|
How do you decide between C and D? The emedicine article seems to suggest it would be the right middle or right lower lobe, unless you group alcoholics and seizure patients together for the right upper lobe?
|
| dr in trouble
Forum Guru
Topics: 62
Posts: 601
|
D
___________________
If u want to do something, do it today as there is no tomorrow.
|
|
| |
| | | | | | | | | | | |
