2024 CCM Board Review Flashcards
(124 cards)
1
Q
Urinary sodium consistent with ATN
A
> 20 mEQ/L
2
Q
AKI is associated with…
A
Decreased 10yr survival, progression to CKD, and CV disease
3
Q
Early RRT initiation is associated with
A
… no improved outcomes
4
Q
Late RRT (72hrs+) is associated with
A
worse outcomes
5
Q
FENa calculation
A
[Una/Pna] / [Ucr/Pcr] x100 = [ PCr * UNa] / [Pna*Ucr] *100
6
Q
Which ATN has worse prognosis?
A
oliguric
7
Q
Most patients with AKI of critical illness prognosis?
A
Recover normal renal function
8
Q
FENa in contrast-induced nephropathy
A
<1%
9
Q
Early initiation of RRT in critically ill patients with AKI is associated with?
A
Delay of return of renal function
10
Q
FENa in hepatorenal syndrome
A
<1%
11
Q
Anion gap correction for Albumin
A
For every 1 below normal, add 2.5 to AG
12
Q
Winters formula (pCO2 change for a bicarb change in acidosis)
A
expected pCO2 = 1.5*bicarb + 8 (+/-2)
13
Q
pCO2 changes in metabolic alkalosis
A
expected pCO2 = 0.9*bicarb + 15 (+/-5)
14
Q
Bicarb changes in respiratory acidosis (normal 24)
A
1 for every 10 pCO2 for acute
4 for every 10 in chronic
15
Q
Bicarb changes in respiratory alkalosis (normal 24)
A
2 for every 10 pco2 in acute
5 for every 10 pco2 in chronic
16
Q
GOLDMARK
A
Glycols
Oxoproline
L lactate
D lactate
Methanol
Aspirin
Renal Failure
Ketoacidosis
17
Q
5-oxoproline (pyroglutamic acid) risk factors
A
women, malnourished, chronic tylenol use, kidney/liver dysfunction
18
Q
NAGMA Causes
A
HARDUP
Hyperalimentation/infusing acid
Acetazolamide
RTA
Diarrhea
Uretero-bowel fistulas
Pancreatic fistula/post hyperventilation
19
Q
Urine anion gap formula
A
Una + Uk - Ucl
20
Q
UAG for a positive/abnormal result
A
> 10
(reflects abnormal NH4+ secretion)
21
Q
Causes of low or negative anion gap
A
hyperK/Mg/Ca, lithium, paraproteins, lab error
22
Q
Indications of CT before LP in meningitis
A
Immunocompromised
Hx CNS disease
New onset seizure within 1 week
Papilledema
Focal deficit
Abnormal consciousness
23
Q
Asymmetric weakness with encephalopathy and fever
A
West Nile Virus
24
Q
Ascending weakness
A
Guillain-Barre Syndrome
25
Descending paralysis
Botulism
26
Indications for steroids in PJP
HIV patients with hypoxia, has a mortality benefit. Magnified if mechanically ventilated
27
Medications risk for PRES
tacro, cyclosporine, sirolimus, cisplatin, interferon
28
Serum sickness symptoms
Fever, filling ill, other skin/joint manifestations
29
Empyema chest tube non-abx treatment
tPA and DNase combination improved outcomes (decreased surgery and LoS) vs placebo or monotherapy
streptokinase alone no benefit by meta-analysis or RCT
30
First line benzo for acute seizures
Lorazepam
potentially midazolam IM 10mg if don't have it
Diazepam has more recurrences
31
Second line seizure medications for status epilepticus (after benzo)
Levetiracetam 60mg/kg (4500 max)
Valproate 40mg/kg (3000 max)
Fosphenytoin 20mg/kg (1500 max)
32
Third line therapy for status epilepticus
Pentobarb (?fewer breakthroughs, but more hypotension and ventilation)
Propafol
Phenobarb
Continuous benzos
Ketamine
All the second line
33
Burst suppression in seizures is associated with
more hypotension, delirium, and mortality
(typically only do it for 24-48hrs)
34
Indication for prophylactic anticonvulsants
Moderate/severe TBI and acute subdurals
(7 days)
GCS<10 or abnormal CT
(phenytoin or levetiracetam)
35
Intense BP control for intracerebral hemorrhage associated with what?
reduced hematoma size/growth, but no other improved outcomes
36
When to start DVT ppx after hemorrhagic stroke? approx
48hrs
37
Sub-arachnoid hemorrhage treatment
Coil or clip ASAP (maybe coil better)
vasospasm ppx: nimodipine 60 q4 x3wk (NNT 20) +/- magnesium
38
Guillain Barre treatment
plasma exchange or IVIG
no steroid benefit
39
Subdural surgical indications
>10mm or midline shift >5mm
Follow-up CT in 36hrs, 24hr abx ppx?
40
ICP monitoring in TBI
abnormal CT on admission or
>40yrs and posturing
41
Mannitol treatment of elevated ICP
0.25-1g/kg bolus q2-4hrs
onset is 10-15min with max effect 20-60min
Target osm 320
Risk: renal failure
42
Hypertonic saline treatment of elevated ICP
3% at 2mg/kg
Target osm 320, Na <155
Risk: pulmonary edema, vein sclerosis, hyperchloremic acidosis
43
Craniotomy timing for elevated ICP
late associated with lower mortality
(RESCUEicp)
early has more unfavorable outcomes but similar mortality
(DECRA)
44
Staircase approach to elevated ICP
1. intubation, normocarbia
2. increased sedation
3. CSF drainage (Ventricular)
4. hypertonics/osmolars
5. hypocapnia (but keep >30)
6. hypothermia
7. metabolic suppression (barbiturates)
8. surgery
45
When is whole bowel irrigation for ingestion potentially indicated?
Ingestions with slow absorption/onset
essentially is giving a lot of miralax
46
When is activated charcoal indicated in ingestion?
within 1-2hrs of ingestion (most effective)
47
What does activated charcoal not absorb?
iron
lithium
alcohols
hydrocarbons
acids
alkalis
48
What ingestions should you use activated charcoal for?
Carbamazepine
Barbiturates
Theophylline
Dapsone
Quinine
49
When is fomepizole useful?
In toxic alcohol ingestions while there is still and osmolar gap (unprocessed alcohol)
Osm gap decreases while aniong gap increases (dampened by co-ingested ethanol)
50
Differentiate ethylene glycol and methanol toxicity:
Ethylene glycol: oxalate crystals
Methanol: optic neuropathy, ICH/infarct
51
Treatment of toxic alcohol ingestion (aside from potential fomepizole)
Hemodialysis: if levels >25 or 50, metabolic acidosis, osm gap >25, renal failure, or visual symptoms
Folinic acid for methanol
52
Cyanide poisoning symptoms
lactic acidosis
seizures
coma
hypotension
(oxidative phosphorylation inhibition)
setting: metal extraction, electroplating, smoke/fire, nitroprusside
53
Cyanide poisoning treatment
sodium nitrate
sodium thiosulfate
hydroxocobalamin (b12)
54
Medication treatment of beta blocker and calcium channel blocker toxicity
BB = glucagon (3-5mg then 2-5mg/kg infusion)
CCB = calcium (1-2g q10-20m then 0.2-0.4ml/kg/hr) - aim for iCal 2xnormal
Both potentially get high dose insulin, lipid emulsion
55
High dose insulin therapy for CCB/BB toxicity
1u/kg bolus then 1u/kg/hr with max dose 10u/kg/hr
56
Lipid emulsion for BB/CCB toxicity dosing
1/5ml/kg bolus then 0.5ml/kg/min for 30-60min
20% lipid emulsion solution
57
Anti-depressant overdose treatment
Consider gastric lavage
Blood alkalization (7.45-7.55) in TCA overdose
If refractory: hypertonics and lipid emulsions
make sure to use vasopressor with alpha-agonist activity
58
Serotonin syndrome treatment (drugs specific to this)
cyproheptadine
chlorpromazine
59
Sulfonylurea overdose treatment
Octreotide 50-100 ug q6-8hrs SQ/IV
60
Lithium toxicity treatment
CNS symptoms and potential arrhythmias
Optimize volume, get levels q2hrs
iHD or CRRT
61
Cholinergic syndrome symptoms
bradycardia, tachycardia, weakness
hypersecretory
causes: organophosphates, carbamates, nerve gases
62
Cholinergic syndrome treatment
atropine
glycopyrrolate if don't have
pralidoxime for weakness
AVOID succ (requires same pathway to breakdown so prolonged paralysis)
63
Sympathomimetic okay to be treated with anti-psychotics (and not benzos)
Bath salts
if prolonged delirium or psychosis
not evidence based
64
Benzodiazepine antidote
flumazenil
contraindicated in TCAs or chronic benzo use
AE: seizures, arrythmias
Not typically recommended
65
Naloxone dosing for opioid OD
IN 4-8mg
IV 2-10mg bolus
66
ECG finding in hypothermia
J wave (small elevation after the R)
67
Laboratory change sin hypothermia
Incr: Hct, glucose, BUN/Cr, Acid
Decr: Platelets
Coags may be normal because lab heats them up to run it
No need to correct ABG for temperature
68
Length of pulse check in hypothermia
30 (to 60) seconds
69
Changes to ACLS drugs in hypothermia
IF <30C then avoid drugs for asystole and VF
because the drugs don't activate and then a lot will once warm
70
Poor prognosis indicators in hypothermia
None are terribly reliable
But K >10 and persistent shock despite vasoactive drugs
71
Temperature target to stop active rewarming in hypothermia
32C or 90F
72
Perioperative hypothermia definition and risks
Temp <35 or 36
Increase mortality, infections, and bleeding
Tx: rewarming devices and warmed fluids
73
Targeted temperature management risks/benefits
No long term mortality difference
Increased neurologic function at discharge
More arrythmias vs normothermia
Infection risk
74
Laboratory changes in heat stroke
Respiratory alkalosis
Lactate, Rhabdo, AKI, thrombocytopenia, coagulopathy, inflammatory markers
75
Management of heat stroke
Golden half hour (to get below 40C)
IVF, avoid anticholinergics, goal 37-38C
Foley, O2, airway protection
76
Mortality risk factors in heat stroke
Older
Comorbidities
Hypotension
Lactic acidosis
Renal failure
Coma
77
Triggers for malignant hypothermia
Halogenated anesthetics (halothane, isoflurane, sevo, desflurane)
Succinylcholine
Stress/Infection/Caffeine
78
Dantrolene for malignant hypothermia dosing
2-3mg/kg bolus initially (max 10mg/kg)
Then cool and avoid CCBs
79
Risk for neuroleptic malignant syndrome
lithium
anticholinergics
dehydration
more common in young men
80
Treatment of NMS (aside from removing offending agent)
Dantrolene for rigidity (paralysis if refractory)
Antipyretics NOT effective
Bromocriptine/Amantadine/Levodopa/carbidopa
81
Management of rhabdomyolysis
Fluid replacement +/- alkalinization of urine (goal UOP 2-3cc/kg/h)
Treat hypocalcemia only if symptomatic
RRT if necessary
Monitor for compartment syndrome
82
Prognosis of post-op A-fib
Self-resolving in 90% by 6-8 weeks after surgery
83
Typical A-flutter characteristics
Sawtooth pattern in inferior leads
Regular p-p intervals
Due to re-entry around TV
84
Rate control of Afib/flutter in heart failure patients
Amiodarone
or digoxin (not typically in ICU patients)
85
Chemical cardioversion agents for Afib/flutter
Ibutilide 4% risk of TdP, pre-treat with Mg
Amiodarone
Procainamide (less effective)
86
SVT that does not respond well to cardioversion
Multifocal atrial tachycardia
87
WPW EKG findings
Delta wave (slow QRS upstroke)
Short PR
88
WPW with SVT Treatment
Procainamide + beta blocker
Or chemical cardioversion: procainamide, ibutilide
or DC cardioversion
Avoid AV nodal blockers as single agents (digoxin, CCB, Bblockers, amio)
89
Features that support VT over SVT with Aberrancy
Fusion/capture beats (20%)
AV dissociation (<50%)
QRS > 140 msec RBBB
QRS >160 msec LBBB
Left axis deviation
Brugada Criteria:
Absence RS in precordial leads
R to S >100ms in one precordial lead
Concordance of QRS in precordial
QRS morphology favoring VT
90
Features that support SVT with aberrancy
Terminates with vagal tone
Onset with p-wave
Long short sequence before wide complex beats
Critical rate at which QRS widens
Alternating bundle branch block
91
Treatment of acute VT with pulse
Unstable:
Regular: synchronized DC cardioversion
Irregular: defibrillation
Stable:
If regular consider adenosine
Procainamide 20-50mg/min
Amio 150mg over 10min
92
Acute management of Torsade de Pointes
Treat underlying (electrolytes, ischemia)
Defibrillation
Baseline prolonged QT: MgSO4, isuprel, lidocaine, atrial pacing
93
Causes of sinus bradycardia
Sinus node dysfunction (fibrodegenerative, prior surgery, collagen vascular disease, infiltrative disease)
Vagal
Medications
Metabolic/Endocrine (hyperK/Mg, hypothyroid/thermia/glycemia/O2)
Other (athletic heart, infection, increased ICP)
94
Atropine dosing
0.5mg every 3-5min (max of 3mg)
95
Bradycardia medical treatment (after atropine)
Epinephrine
Dopamine
Isoproterenol
Glucagon (for BB or CCB od)
96
Treatment of bradycardia after acute MI
[be careful as could worsen ischemia]
Indications: [1] symptomatic, [2] sinus pause >3s, [3]HR <40 w/hypotension
Atropine 0.5-1mg (may be effective in first 6hrs after inferior wall infarction as more likely due to increased vagal tone)
Temporary pacing
97
Magnet effect on pacemaker/ICD
Asynchronous pacing
Stops ICD (but will not affect pacing mode)
Important for surgery as bovie noise interferes with sensing
97
Indications for transvenous temporary pacing
Asystole
Alternating RBBB and LBBB
T2 second degree AV block with new bundle
or with fascicular block and RBBB
Third degree AV block
98
Causes of inappropriate ICD shocks
Electromagnetic interference on sensing lead (eg ungrounded pool)
Lead malfunction (eg fracture)
SVT with RVR
99
Causes of non-hypotonic hyponatremia (false hyponatremia)
hyperglycemia
hyperproteinemia (multiple myeloma)
hyperlipidemia
uremia
ethanol
100
Hyponatremia with urine sodium <10 mmol/L
Extrarenal losses or Hypervolemic state
vomiting, diarrhea, third spacing (nephrotic, cirrhosis, CHF)
burns, pancreatitis, traumatized muscle
101
Emergent treatment of hyponatremia
100mL of 3% over 10min (up to 3) - goal 4-6meq over hours
Less emergent can do 50mL slow bolus
Consider prophylactic desmopression (1 -2mcg q6-8hrs for 24-48hrs)
102
Risk factors for osmotic demyelination syndrome
Na <120 (although especially important if <105)
HypoK
Alcoholism
Malnutrition
Liver disease
103
Free water deficit formulat
%body water * kg * (Na - goal / goal)
104
U wave (hump after T wave) is associated with...
hypokalemia
but also, hypoCa/Mg, ICP, hypothermia, LVH
Meds: dig, phenothiazines, class Ia/III antiarrhythmics (amio, sotolol, procainamide, quinidine)
105
Causes of hypokalemia
GI/urinary loss (mineralocorticoid, DKA, RTA, amopho)
Insulin
Beta-agonists
Alkalosis
Hypokalemic periodic paralysis (calcium channel defect)
Hypothermia
Drugs
106
EKG signs of hypokalemia
U wave
ST depression
Decreased T wave
Also bradycardia, AV block, Vtach/fib
107
EKG signs of hyperkalemia
Peaked T
Long PR
Widened QRS -> sine wave
Loss of p waves
108
Medications that can cause hyperK
Bblockers
Digitalis
Succinylcholine
Hypoaldosteronism (ACEi, heparin, NSAIDS, calcineurin inhibitors)
Spironolactone
109
Dosing of treatments of HyperK
CaCl 500-1000mg over 2-3min
Insulin (10U regular) and glucose (50mL D50)
110
Signs of hypocalcemia
Tetany
Anxiety/psychosis
Seizure
HypoT and QT prolongation
111
Goal UOP in hypercalcemia
100-150ml/hr
112
Etiologies of hypomagnesium (aside from GI/lack of intake)
Pancreatitis
Chronic PPI
Meds (diuretics, AG, ampho, pentamidine)
Alcohol use disorder
Hypercalcemia
Diabetes (poorly controlled)
Rare diseases
113
Signs of hypomagnesemia
Tetany, weakness, coma
Arrythmias (AFib, TdP)
HypoK/Ca
114
Electrolyte abnormalities in adrenal insufficiency
HypoNa, HyperK
115
Hypophos symptoms
encephalopathy
decreased cardiac contractility
respiratory muscle weakness
dysphagia
ileus
116
Berlin ARDS criteria
<1 week of known clinical insult
bilateral not explained by something else
not fully cardiac
hypoxemia (PF<300 and PEEP 5+ need)
117
HFNC in acute hypoxemic respiratory failure
Similar intubations rates but more vent free days
Increased 90d survival
118
Transfusion strategy in ARDS
Restrictive has improved survival in APACHE <20 (nearly 10% absolute difference in 30d mortality)
119
Proning requirements
After 12-24hrs of attempted stabilization
at least 16 hours prone
120
Steroid benefit in ARDS?
Only for underlying indication with early administration
COVID-19, severe CAP
Try to avoid in influenza and late ARDS
121
Goal for STEMI revascularization
To cath by 2hrs of presentation (acceptable facility delay is 1 hour)
If unable, give tPA within 30min and transfer to center
122
Discharge medications for acute MI
Aspirin + Clopidogrel
ACEi/ARB/ARNI
B-blocker
Statin
Spironolactone if EF<40%
123
