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PSBIM Harrison 21st Edition > Approach to Critical Illness > Flashcards

Approach to Critical Illness Flashcards

1
Q

Organ systems assessed in Sequential Organ Failure Assessment (SOFA) scoring

A

6 (six)
Respiration
Coagulation
Liver
Cardiovascular
Central Nervous System
Renal

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2
Q

SOFA scoring diagnostic of SEPSIS

A

Increase of atleast 2 points in SOFA scoring from baseline, in the setting of suspected or documented infection

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3
Q

qSOFA parameters

A

RR >/= 22 bpm
Altered mental status
SBP = 100 mmHg

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4
Q

Most commonly used SOI scoring system in North America

A

THE APACHE II scoring system

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5
Q

What is shock?

A

Presence of multisystem end-organ hypoperfusion

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6
Q

Clinical indicators of Shock

A

Reduced MAP
Tachycardia
Tachypnea
Cool skin and extremities
Acute altered mental status
Oliguria

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7
Q

End result of multiorgan hypoperfusion

A

Tissue hypoxia, often accompanied by lactic acidosis

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8
Q

Mean Arterial Pressure

A

Cardiac Output x Systemic Vascular Resistance

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9
Q

Components of APACHE II scoring system

A

Rectal temperature
Mean blood pressure
Heart rate
Respiratory rate
Arterial pH
Oxygenation
Serum Sodium
Serum Potassium
Serum Creatinine
Hematocrit
WBC count
Glasgow Coma Score
Ag
Chronic Health Conditions

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10
Q

Clinical evidence of diminished cardiac output

A

Narrow Pulse Pressure
Cool extremities with delayed capillary refill

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11
Q

Signs of increased cardiac output

A

Widened pulse pressure ( ⬇️ diastolic pressure)
Warm extremities with bounding pulses
Rapid capillary refill

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12
Q

In hypotensive patients, with clinical signs of increased cardiac output, reduced BP is due to ___

A

Decreased Systemic vascular resistance

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13
Q

Better predictor of fluid responsiveness in hypotensive patients with reduced cardiac output

A

Change in right atrial pressure as a function of spontaneous respiration

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14
Q

Most common cause of High Cardiac Output Shock

A

Sepsis

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15
Q

Causes of Acute Hypoxemic Respiratory Failure

A

-Cardiogenic Shock
-Pulmonary Edema
-Septic shock with pneumonia
-ARDS

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16
Q

Causes of Ventilatory Failure

A

Increased load on the respiratory system
-Acute Metabolic (Lactic) Acidosis

Decreased Lung compliance
-Pulmonary Edema

Inadequate perfusion to respiratory muscles in the setting of shock

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17
Q

Predictor of fluid-responsiveness in spontaneously breathing patient

A

Inferior vena cava collapse seen on ultrasound

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18
Q

Signs of Respiratory Distress

A

-Inability to speak full sentences
-Accessory use of respiratory muscles
-Paradoxical abdominal muscle activity
-Extreme tachypnea (>40 bpm)
-Decreasing RR despite increasing drive to breathe

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19
Q

Goals in Mechanical Ventilation (2)

A
  1. Initially assume all or the majority of the work of breathing
  2. Facilitate a state of minimal respiratory muscle work
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20
Q

Decline in MAP seen during Mechanical Ventilation is caused by:

A
  1. Impeded venous return from positive-pressure ventilation
  2. Reduced endogenous catecholamine secretion once the stress associated with respiratory failure abates
  3. Actions of drugs used to facilitate endotracheal intubation
  4. Increase in RV afterload from positive-pressure ventilation in patients with Right Heart Dysfunction and Preexisting Pulmonary Hypertension
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21
Q

How to prevent decrease in MAP during intubation?

A
  1. IV volume administration
  2. Vasopressor support pre-intubation
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22
Q

This type of respiratory failure occurs with alveolar flooding and subsequent ventilation-perfusion mismatch and intrapulmonary shunt physiology

A

Type 1: Acute Hypoxemic Respiratory Failure

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23
Q

Categories of Pulmonary Edema

A
  1. Elevated Pulmonary Microvascular Pressures
    A. Heart Failure
    B. Intravascular Volume Overload
  2. Low pressure Pulmonary Edema
    A. Acute Respiratory Distress Syndrome
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24
Q

The pressure-volume relationship of the lung in ARDS in ______

A

Not linear

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25
Q

Principles in management of ARDS

A
  1. Low tidal volume 6mL/kg of IBW and High PEEP
  2. Prone positioning** improve survival
  3. Neuromuscular blockade
  4. Fluid-Conservative management strategy
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26
Q

This type of respiratory failure is a consequence of alveolar hypoventilation resulting from the inability to eliminate CO2 effectively

A

Type II: Hypercapneic Respiratory Failure

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27
Q

Mechanisms of Type II Respiratory Failure

A
  1. Impaired CNS drive to breathe
    A. Drug Overdose
    B. Brainstem Injury
    C. Sleep-disordered breathing
    D. Severe hypothyroidism
  2. Impaired strength
    A. Impaired neuromuscular transmission
    -Myasthenia Gravis
    -GBS
    -Amyotrophic lateral sclerosis
    B. Respiratory Muscle Weakness
    -Myopathy
    -Electrolyte derangements
    -Fatigue
  3. Increased load on the respiratory system
    A. Resistive Loads
    - Bronchospasms
    B. Reduced Lung Compliance
    - Alveolar edema
    -Atelectasis
    -Intrinsic PEEP (Auto-PEEP)
    C. Reduced chest wall compliance
    -Pneumothorax
    -Pleural Effusion
    -Abdominal Distention
    D. Increased Minute Ventilation
    -Pulmonary Embolism
    -Increased dead-space fraction
    -Sepsis
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28
Q

Treatment of Hypercapnic Respiratory Failure

A

Non-invasive positive-pressure ventilation with tight-fitting facial or nasal mask with avoidance of endotracheal intubation

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29
Q

This form of respiratory failure results from lung atelectasis

A

Type III: aka Perioperative Respiratory Failure

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30
Q

Pathophysiology of Lung atelectasis in Perioperative period

A

General anesthesia causes decrease in FRC –> Collapse of dependent lung units

31
Q

Management of Type 3 Respiratory Failure

A
  1. Frequent changes in position
  2. Chest physiotherapy
  3. Upright positioning
  4. Control of incisional/abdominal pain
  5. Non-invasive Positive-pressure ventilation (Regional Atelectasis)
32
Q

This form of respiratory failure results from hypoperfusion of respiratory muscles in patients with shock

A

Type IV Respiratory Failure

33
Q

Management of Type IV Respiratory Failure

A

Intubation and Mechanical Ventilation
** This can allow redistribution of the cardiac output away from the respiratory muscles and back to vital organs while shock is being treated

34
Q

Mainstay of therapy for analgesia in Mechanical Ventilation

A

Opiates

35
Q

Indication for sedation in mechanically ventilated patients

A
  1. Adequate pain control
  2. Anxiolysis
  3. Treatment of subjective dyspnea
  4. Reduction of autonomic hyperactivity
36
Q

Sedative associated with increased delirium and worse patient outcomes

A

Benzodiazepines

37
Q

Neuromuscular blocking agent like CISATRACURIUM, occasionally used in patients with profound ventilator dyssynchrony despite optimal sedation, may result in prolonged weakness– a myopathy known as ___

A

Postparalytic syndrome

38
Q

Neuromuscular blocking agent like CISATRACURIUM, occasionally used in patients with profound ventilator dyssynchrony despite optimal sedation, may result in prolonged weakness– a myopathy known as ___

A

Postparalytic syndrome

39
Q

Amnesia can be best achieved by which drugs?

A

Propofol
Benzodiazepines (Lorazepam, Midazolam)

40
Q

Parameters of Daily Screening of Respiratory Function

A
  1. If oxygenation is stable
    -PFR >200
    -PEEP = 5
  2. Cough and Airway reflexes are intact
  3. No vasopressor/sedatives
41
Q

Spontaneous Breathing Trial

A

30-120 min of either:
1. CPAP 5 cm H20 with/out low level pressure support
2. Open T-piece system

42
Q

Spontaneous Breathing Trial is declared a failure and stopped if any of the following occur:

A
  1. RR>35 bpm >5 min
  2. O2 sat <90%
  3. HR>140 bpm or a 20% increase or decrease from baseline
  4. SBP <90 mmHg or >180 mmHg
  5. Increased anxiety or diaphoresis
43
Q

Percentage of patients who develop respiratory distress after extubation

A

10%

44
Q

Simultaneous presence of physiologic dysfunction and/or failure of two or more organs

A

Multiorgan system failure

45
Q

Gold standard for evaluation of respiratory gas exchange in critical illness

A

Arterial Blood Gas

46
Q

Most commonly utilized non-invasive technique for monitoring respiratory function

A

Pulse oximetry

47
Q

Variables to measure PEAK AIRWAY PRESSURE

A
  1. Airway Resistance
  2. Respiratory System Compliance
48
Q

End respiratory pause

A

Plateau Pressure

49
Q

Quantitative Measure of Airway Resistance

A

Peak Airway Pressure -Plateau Pressure

Normal: >10-15 mmHg

50
Q

Definition of Respiratory System Compliance

A

The change in volume of the respiratory system per unit change in pressure

51
Q

Normal respiratory system compliance

A

~100 mL/cm H20

52
Q

Causes of decreased chest wall compliance

A

Pleural Effusion
Pneumothorax
Increased abdominal girth

53
Q

Decreased lung compliance

A

Pneumonia
Pulmonary edema
Alveolar hemorrhage
Interstitial lung disease
Auto-PEEP

54
Q

What is auto-PEEP?

A

Occurs when there is insufficient time for emptying of alveoli before the next inspiratory cycle

55
Q

Common cause of Auto-PEEP

A

Obstructed DISTAL airways
1. Asthma
2. COPD

56
Q

Leading cause of death in non-Coronary ICUs in the USA

A

Sepsis

57
Q

Life threatening organ dysfunction caused by dysregulated response to infection

A

Sepsis

58
Q

More effective for DVT prophylaxis in high risk patients, with lower incidence of heparin-induced thrombocytopenia

A

Low molecular weight heparin
e.g. Enoxaparin

59
Q

Possible complications of PPI use

A

Increased risk of Pneumonia
Increased risk of Clostridium difficile colitis

60
Q

Glucose goal in Critically ill patients

A

= 180 mg/dL

61
Q

Complications of TPN

A

Hyperglycemia
Fatty liver
Cholestasis
Sepsis

62
Q

ICU-acquired weakness most commonly occur ____

A

~ 1 week in the ICU

63
Q

___ may reduce polyneuropathy in critical illness

A

Intensive Insulin Therapy

64
Q

Causes of Anemia in the ICU

A

Chronic Inflammation
Phlebotomy

65
Q

Most common underlying etiology of AKI in critically ill patients

A

Acute Tubular Necrosis

66
Q

Definition of Delirium

A
  1. Acute onset of changes or fluctuations on mental status
  2. Inattention
  3. Disorganized thinking
  4. Altered level of consciousness
67
Q

Sedative that has been less strongly associated with ICU delirium

A

Dexmedetomidine

68
Q

Surgical procedure that relieves increased intracranial pressure in the setting of space-occupying lesions or brain swelling from stroke

A

Decompressive Craniectomy

69
Q

Treatment for Cerebral Vasospasm in SAH

A
  1. CCB (Nimodipine)
  2. Aggressive IV fluid hydration
  3. Vasoactive drugs (Phenylephrine)
70
Q

Hydrocephalus is typically heralded by _____.

A

Decreased level of consciousness

71
Q

Most effective Benzodiazepine for treating status epilepticus

A

Lorazepam

72
Q

Treatment of choice for controlling seizures acutely

A

Lorazepam

73
Q

Diagnosis of Brain death requires:

A
  1. Absence of Cerebral Function
    -No response to External Stimulus
  2. No brainstem function
    -Unreactive Pupils
    -Lack of ocular movement in response to head turning or ice water irrigation of ear canals
    -Positive apnea test
74
Q

Reversible Causes of Coma

A
  1. Sedative effect
  2. Hypothermia
  3. Hypoxemia
  4. Neuromuscular paralysis
  5. Severe hypotension

PSBIM Harrison 21st Edition (15 decks)

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