1. CAP
- Viruses that cause viral pneumonia - influenza A/B, para flu, adeno, rsv
- No recent exposure to serious organisms (no hospital stay within 90 days, not living in a nursing home, doesn't go to dialysis frequently) can treat as outpatient without coverage of hardcore gram negatives
- Low suspicion of resistance: can tx with z pack or doxy, if you suspect resistance can give respiratory quinolone or z pack plus cephalosporin
2. Inherited thrombophilias
- high risk mutations/deficincies : antithrombin, protein c and s deficiency, homozygous factor v or prothrombin
- low risk: heterozygous factor v
3. Anti phospholipid syndrome
- For diagnosis need both a vascular event or pregnancy morbidity and 2 positive anti phospholipid Ab tests at least 12 weeks apart
- Can occur alone or with other autoimmune disease (lupus)
4. When to screen for inherited thrombophilias: 
- first clot at age <50 without provoking factor
- family history
- recurrent clots
- unusual sites (i.e. mesentery)
5 Don't screen for inherited thrombophilias in the following
- Clots in the context of a reason (cancer, immobility, disease process known to cause clotting)
- Arterial clots, (inherited dx tend not to cause arterial clots)
- Upper limb clots (likely catheter releated) this is controversial.
6. When to anticoagulate people with inherited thrombophilias
- Asymptomatic/never had a clot: don't anticoagulate them (evidence grade 1c, unless they are going through a hyper coagulable period (surgery, pregnancy)
- History of one clot - treat as any other first clot : If provoked, 3 mos of anticoagulation, then stop. If unprovoked, give 3 mos anticoagulation, check bleeding risk, if bleed risk not high then treat forever, if bleeding risk high then stop at 3 months.
- If they clot multiple times, they've bought themselves a lifetime of coumadin.
7. What to anticoagulate with
- lovenox not tested in thrombophilia patients
- riviaroxaban/dabigatran not tested in thrombophilias
- recommend warfarin
8. Crich: (vs trach)
- Cricoid is the only complete tracheal ring; if you push the plastic against it, it's more likely to go down towards the trachea
- Lower risk of bleed as it avoids going through thyroid tissue
- Accessible in an emergency
- Its proximity to vocal cords leads to increased risk of subglottic stenosis, fibrosis over time. Should be converted to trach within 24-48 hours.
9. Trach (vs ETT)
- Usually for people who can't be off the ventilator
- People really shouldn't be on the ETT for longer than a week or so-- any longer and they should switch to trach
-  Shorter straw, less dead space
- Allow better suctioning
- More comfortable
- Decreased risk of subglottic stensois
- Allows speaking
- More secure
- These things all increase likelihood/ease of weaning vent
- If you see someone bleeding massively after they get a trach put it, they may have a tracheal-innominate fistula. If this happens, take out the trach, put your finger through the tracheostomy, and pull forward (as the vessel is usually anterior). Then put in an ETT tube with a cuff, inflate it, and go to the OR.
10. How to wean
- Weaning ETT/trial extubation: patient requires 3 things: adequate GCS to follow commands, strong cough, ability to control secretions. Deflate the cuff, see if you can hear air leak around it. If not, keep in the tube, if so, they can probably be extubated.
- Weaning trach: downsize the trach. Cap the trach to see how they do, then take it out.