July MICU Deck

Question 1

Purpose of repleting K to 5 in COPD patient getting diuresis

Answer 1

COPD pts retain pCO2, want to prevent acidosis

Lasix dumps Cl (inhibits NKCC), causing kidneys to hold onto another anion, bicarb. Holding onto bicarb which neutralizes the CO2 being held onto => normalizes pH and reduces respirtory drive in COPDers

By repleting K you’re giving KCl…therefore getting rid of Na (and water) w/o losing Cl => w/o retaining bicarb

Question 2

Diuretic that works synergistically w/ lasix

Answer 2

Metolazone = Diuril- inhibits NaCl transporter in the DCT

Question 3

Mechanism of metolazone

Answer 3

Metolazone inhibits NaCl transporter in DCT

Question 4

Explain physiology of why a hemothorax can cause lung collapse

Answer 4

Hemothorax (or really anything) makes the pressure in the pleural space more positive => less negative pressure of the chest wall holding the lung open = lung collapse

B/c at baseline negative pressure of chest wall vs. smaller positive pressure of lung elasticity keeps lung open

Question 5

Mechanism of hyperventilation to decrease ICP

Answer 5

Hyperventilation => decreased CO2/alkalemia => cerebral vasoconstriction

Question 6

Name the three chambers of a chest tube

Answer 6

1. Drainage- collects fluid from patient
2. Water seal- prevents backflow, also where you see air leak. Air from inside pt comes here and bubbles out => can’t go back into pt during expiration
3. Suction chamber- open to air (so can’t exceed 20mmHg) and can connect to wall suction

Question 7

Function of water chamber in chest tube

Answer 7

Water chamber

1. prevents backflow of air back into chest: air can only move from high to low pressure => can only move out into water (that has suction on it) than back into chest wall
2. lets you see if there is still air in the chest! (where you visualize air bubbles

Question 8

Function of suction chamber in chest tube

Answer 8

Suction chamber open to both (1) air- sets a max suction at atmospheric -20 (2) external source = wall suction to provide the pressure to pull stuff out of the chest

-external source provides the amount of pressure actively suctioning the entire system

Question 9

Explain the respiratory variation you’d expect to see in chest tube tubing

Answer 9

Expect to see fluid go slightly back into (towards) pt w/ inspiration b/c of negative inspiratory pressure

Question 10

Explain how to chase lasix w/ metolazone

Answer 10

Metolazone (diuril) first to inhibit the NaCl transporters in the DCT, causing upregulation of the NKCC in the loop

Then 30-60 mins later give lasix- to bind to the more available NKCC channels and further have potent diuresis effect

Question 11

Differentiate aspergilloma from invasive aspergillosis

Answer 11

Spectrum of disease ranging from just a fungus ball (aspergilloma) that doesn’t invade tissues to

invasive aspergillosis = see filamentous stuff in the actual tissue, typically seen in immunocompromised (leukemia)

Question 12

Name a drug that can cause false-positive galactomannan

Answer 12

Galactomannan = beta-D glucan = serum marker for invasive aspergillosis, can be false positive in pts on PCN abx such as Pip-tazo

Question 13

4 main adverse reactions to voriconazole

Answer 13

Voriconazole = antifungal (first line for aspergillus)

1. visual disturbance/changes in 30%
2. skin changes/dermatologic rash
3. hepatitis (monitor LFTs)
4. Drug-drug interactions: tons, prolongs QTc (watch w/ antipsychotics), can raise serum atorvastatin

Question 14

Unexplained MAC in infertile M

Answer 14

Think CF (cystic fibrosis)
-MAC usually needs some other pulmonary disease as substrate

Question 15

Broad ACS algorithm for bradycardia

Answer 15

Get on monitor and pacers (quickly if unstable) , get 12-lead, atropine 0.5mg q3minutes then pace at 70 bpm, can start at 100 mA and decrease until find minimum voltage to capture

Question 16

1st line medication for symptomatic bradycardia

Answer 16

Symptomatic brady (AMS, light-headed etc): atropine

Atropine 0.5mg IV q3 mins

Get EKG: atropine is an AV nodal blocker (anticholinergic) => works best on sinus brady, first degree AV block, maybbbe second degree type 1

But second degree type II and complete heart block definitely just need pacing

Question 17

How to sedate someone before pacing for symptomatic/unstable bradycardia

Answer 17

Fentanyl 25 mcg + Versed (midazolam) 1 mg

Question 18

Reversal agent for beta-blockers

Answer 18

Reverse beta-blocker (ex: symptomatic bradycardia): give 1 g IV glucagon

Question 19

Reversal agent for calcium channel blockers

Answer 19

CCB reversal (ex: symptomatic bradycardia): can try first w/ 2g calcium
-then escalate to high dose (like 1U/kg) insulin ggt w/ dextrose (of course uptriage to MICU)

Question 20

Pharmacologic agents besides atropine to use in symptomatic bradycardia

Answer 20

Between atropine and pacing can potentially try some pressors, especially one w/ beta-chronotropic (increase HR) effect:

Epinephrine and dopamine (ggts)

Question 21

30 yo w/ headache and unilateral vision loss

Answer 21

Central retinal artery occlusion, retinal detachment

But what to NOT consider = GCA, basically a non-started (incredibly rare) in pts under 50 yoa

Question 22

First line tx for GCA

Answer 22

1g solumedrol (crazy high dose)

Question 23

Criteria for ASCVD calculator

Answer 23

ASCVD calculator: ages 40-79, LDL 70-189, to determine 10-year risk of cardiovascular event

If gt 7.5% indication enough to start statin therapy

Question 24

ACS algorithm for treatment of NSTEMI

Answer 24

NSTEMI = positive trop w/o EKG changes

1. Aspirin load = 4 baby aspirin (324mg) then daily ASA 81
2. Plavix load w/ plavix 300mg then daily clopidogrel 75mg
3. Consider starting heparin ggt: can bolus then titrate to goal PTT 50-75 on q6 PTTs

Question 25

Adenosine vs. atropine

Answer 25

Adenosine = AV nodal blocking agent to use in supraventricular tachycardias to unmask underlying rhythm

Atropine = anticholinergic to use for symptomatic bradycardia, best in sinus but also beneficial in first degree block

Question 26

How to differentiate SVTs?

Answer 26

Adenosine (AV nodal blocking agent): push 6mg, AFib or AFlutter will come back after adenosine wears off (super short half life)

While AVNRT will revert to NSR bc blocking the SA node will block the reentrant pathway

Question 27

Main electrolyte abnormality in refeeding syndrome

Answer 27

Hypophosphatemia

B/c you suddenly start eating so need tons of ATP for digestion => you replete your phos stores quickly

Question 28

Main criteria/guidelines for cooling s/p arrest

Answer 28

• Out of hospital arrest for a shockable rhythm (VF, VT)
• ROSC w/in 60 minutes, now not following commands/non-verbal
• w/in 6 hrs of collapse
• no coagulopathy (normal INR)

Question 29

Distinguish ICD for primary vs. secondary prevention

Answer 29

ICD

Primary prevention = prevent a first attack from occuring
-main indication is MI w/ EF under 35%, but MI more than 40 days in the past

Secondary prevention = prevent a second/future attack
-h/o VT/VF and hemodynamic instability w/o reversible cause

Question 30

Main indications for ICD for primary prevention

Answer 30

ICD for primary prevention = to prevent a first attack from occurring

1. MI more than 40 days ago with EF under 35%
2. Known structural heart disease w/ inducible VT
3. HF not improved on max medical management for at least 3 months
4. Congenital prolonged QTC syndrome: Brugada, HOCM

Question 31

NYHA classes of HF

Answer 31

NYHA = NY heart failure association classes are based on symptoms/exercise tolerance limitations

class I: physical disease w/o activity limitation

class II: physical disease w/ DOE on hard to moderate activity

class III: physical disease w/ marked DOE, pain/SOB/symptoms on 2-5 METS (walking at 2.5mph)

class IV: symptoms at even lower METS

Question 32

Beta-blocker(s) w/ mortality benefit in HF

Answer 32

in HF use: metoprolol succinate (the long acting) or carvedilol (coreg)

Question 33

Why may carvedilol be better than metoprolol in HF

Answer 33

Metoprolol is a beta-1 specific beta-blocker, while coreg (carvedilol) blocks beta1, beta2, and alpha1

alpha1 blockade may help reduction in afterload

Question 34

Anesthesia asks you to stop chest compresisons so they can intubate…

Answer 34

NOO!!! Chest compressions are keeping them perfused

Either tell them to figure it out or ask for an LMA

Question 35

Why do you want intubation so badly in a code situation?

Answer 35

Of course to secure airway and get O2 to the lungs, but that’ll passively kind of happen anyway…

You want end tidal CO2 so you can gauge adequacy of chest compressions

Question 36

What to use for urgent needle decompression in tension pneumothorax

Answer 36

Ideal would be a 16-18 guage angiocath

Angiocath and not needle b/c then you can remove needle (so person doing compressions doesn’t get stuck) but pleural space stays open to air

But if leaving in angiocath you’ll want a waterseal on it (to prevent air blackflow in pleural space on inspiration)