Acute & Critical Care Medicine

Question 1

What is the cause of

hypervolemic hyponatremia

Answer 1

Fluid overload

e.g., cirrhosis, heart failure, renal failure

Question 2

What is the cause of

hypervolemic hypernatremia

Answer 2

Intake of hypertonic fluids

Question 3

What is the cause of

isovolemic hypernatremia

Answer 3

Diabetes insipidus

Question 4

What is the treatment for

isovolemic hypernatremia

Answer 4

Desmopressin

Question 5

What is the treatment for

hypervolemic hypernatremia

Answer 5

Diuresis

Question 6

What is the cause of

hypovolemic hypernatremia

Answer 6

• Dehydration
• Vomiting
• Diarrhea

Question 7

What is the treatment for

hypovolemic hypernatremia

Answer 7

Fluids

Question 8

What is the treatment for

hypervolemic hyponatremia

Answer 8

• Diuresis with fluid restriction
• AVP receptor antagonists

AVP receptor antagonists: conivaptan, tolvaptan

Question 9

What is the treatment for

isovolemic hyponatremia

Answer 9

• Stopping drugs that can induce SIADH
• Demeclocycline (SIADH)
• Diuresis
• Restricting fluids
• AVP receptor antagonists

Question 10

What is the treatment for

hypovolemic hyponatremia

Answer 10

• Hypertonic (3%) sodium chloride IV for severe symptoms and/or Na < 120

Severe symptoms = seizures, coma, respiratory arrest

Question 11

What is the cause of

isovolemic hyponatremia

Answer 11

SIADH

Question 12

What is the cause of

hypovolemic hyponatremia

Answer 12

• Diuretics
• Salt-wasting syndromes
• Adrenal insufficiency
• Blood loss
• Vomiting
• Diarrhea

Question 13

What can happen if sodium is being corrected faster than 12 mEq/L/24 hours?

Answer 13

Can cause osmotic demyelination syndrome (ODS) or central pontine myelinolysis, which can cause paralysis, seizures and death.

Question 14

Tolvaptan (Samsca)

Answer 14

• PO
• Arginine vasopressin receptor antagonist; selective AVP antagonist [vasopressin 2 (V2) only]
• Should be initiate and re-initiated in a hospital with close monitoring of serum Na
• Overly rapid correction of hyponatremia (> 12 mEq/L/24 hrs) is associated with ODS
• Use is limited to ≤ 30 days due to hepatotoxicity
• SEs: thirst, nausea, dry mouth, polyuria

Question 15

Which electrolyte must be corrected before correcting potassium?

Answer 15

Magnesium

Question 16

What is the maximum IV KCl infusion rate and concentration for treating hypokalemia through a peripheral line?

Answer 16

• Max infusion rate: ≤ 10 mEq/hr
• Max concentration: 10 mEq/100mL

Never administer undiluted IV potassium or via IV push

Question 17

Which route of administration is preferred for KCl?

Answer 17

PO

Question 18

What is the preferred treatment when serum Mg is < 1 mEq/L w/ life-threatening symptoms (e.g., seizures, arrhythmias)?

Answer 18

IV magnesium sulfate

Question 19

Vasopressor MOA

Answer 19

Stimulating alpha receptors → peripheral vasoconstriction and ↑ systemic vascular resistance (SVR)

Question 20

Vasopressors

Answer 20

• Dopamine: dose-dependent receptor effects (D1 → beta-1 → alpha-1)
• Epinephrine: alpha-1, beta-1, beta-2
• Norepinephrine: alpha-1 > beta-1
• Phenylephrine: alpha-1
• Vasopression: vasopression agonnist
• Angiotensin II: vasoconstriction, aldosterone release

Question 21

What is the boxed warning for all IV vasopressors?

Answer 21

All vasopressors are vesicants when administered IV

Treat extravasation with phentolamine (an alpha-1 blocker)

Question 22

Vasopressor SEs

Answer 22

• Arrythmias
• Tachycardia (esp. dopamine, epinephrine)
• Necrosis (gangrene)
• Bradycardia (phenylephrine)
• Hyperglycemia (epinephrine)

Question 23

What is the concentration of epinephrine used for IV push?

Answer 23

0.1 mg/mL

Question 24

What is the concentration of epinephrine used for IM injection or compounding IV products?

Answer 24

1 mg/mL

Question 25

What lab needs to be frequentlt/continuously monitored when giving continuous IV vasodilators?

Answer 25

Blood pressure

Question 26

Low dose nitroglycerin MOA

Answer 26

Venous vasodilator | Preload

Question 27

High dose nitroglycerin MOA

Answer 27

Arterial vasodilator | Afterload

Question 28

Nitroprusside MOA

Answer 28

Mixed (equal) arterial and venous vasodilator

Question 29

What are the metabolites of nitroprusside?

Answer 29

* Thiocyanate * Cyanide ## Footnote Hydroxocobalamin → reduce the risk of thiocyanate toxicity or to treat cyanide toxicity Sodium thiosulfate + sodium nitrite → cyanide toxicity

Question 30

Which vasodilator requires a non-PVC container? | Non-PVC container: glass, polyolefin

Answer 30

Nitroglycerin

Question 31

Which vasodilator requires light protection during administration?

Answer 31

Nitroprusside

Question 32

What color of nitroprusside solution would indicate that it has been degradated to cyanide?

Answer 32

Blue

Question 33

Inotrope MOA

Answer 33

Increase the contractility of the heart * Dobutamine – beta-1 agonist * Milrinone – phosphodiesterase-3 inhibitor; also a vasodilator

Question 34

What is the characteristic of a shock?

Answer 34

* Hypoperfusion * Hypotension (SBP < 90 or MAP < 70)

Question 35

What are the general principles for treating septic shock?

Answer 35

* MAP goal: ≥ 65 * Fill the tank: optimize preload with IV crystalloids (balanced fluids such as Lactated Ringer's preferred) * Squeeze the pipe: alpha-1 agonist activity (peripheral vasoconstriction) to ↑ SVR * Kick the pump: beta-1 agnost activity to ↑ myocardial contractility and CO

Question 36

What is the vasopressor of choice in septic shock?

Answer 36

Norepinephrine

Question 37

What are the first-line analgesia in ICU?

Answer 37

IV opioids

Question 38

What treatments are used to manage agitation in ICU?

Answer 38

* Benzodiazepines (lorazepma, midazolam) * Non-benzo hypnotics (propofol, dexmedetomidine)

Question 39

Which sedative can be used in both intubated and non-intubaed patients?

Answer 39

Dexmedetomideine (Precedex)

Question 40

What can be used for delirium in ICU?

Answer 40

* Quetiapine * Haloperidol

Question 41

Propofol is contraindicated in patients with

Answer 41

egg or soy allergies

Question 42

Dexmedetomideine MOA

Answer 42

Alpha-2 adrenergic agonist

Question 43

List the risk factor for developing stress ulcers in ICU

Answer 43

* **Mechanical ventilation > 48 hrs** * **Coagulopathy** * Sepsis * Traumatic brain injury * Major burns * Acute renal failure * High dose systemic steroids

Question 44

What prophylaxis are recommended to prevent stress-related mucosal damage in pts with risk factors for stress ulcer?

Answer 44

* H2RAs (can cause thrombocytopenia and mental status changes in the elderly or those with renal impairement) * PPIs (associated with an increased risk of GI infections, fractures and nosocominal penumonia)

Question 45

# 1. Bupivacaine can be fatal if administered

Answer 45

intravenously

Question 46

What is the purpose of epinepherine in the lidocaine/epinephrine combination product?

Answer 46

Epinephrine is added for vasoconstration, which keeps the lidocaine localized to the area where the numbing is needed.

Question 47

List the commonly used anesthetics

Answer 47

* Lidocaine * Desflurane, sevoflurane * Bupivacaine, ropivacaine

Question 48

Cisatracurium (Nimbex) MOA

Answer 48

Non-depolarizing NMBA: block acetylcholine from binding to the receptor

Question 49

Succinylcholine

Answer 49

Depolarizing NMBA: activate the acetylcholine receptors and desensitizes them

Question 50

Neuromuscular blocking agents

Answer 50

* Not routinely used * Cause skeletal muscle paralysis * Patients must be mechanically ventilated * NMBAs do not provide sedation or analgesia, patients should receive adequate sedation and analgesia prior to starting an NMBA * All agents should be labeled with a colored auxiliary label stating “Warning: Paralyzing Agent causes respiratory arrest”

Question 51

What are hemostatic agents used for?

Answer 51

Stop the bleeding

Question 52

Systemic hemostatic agents MOA

Answer 52

Inhibiting fibrinolysis or enhancing coagulation * Tranexamic acid * Recombinant Factor VIIa (NovoSeven RT)