Crit care

Question 1

What is seen on UA in a pt w/ ethylene glycol poisoning? What are other s/s?

Answer 1

-oxalate crystals
-AMS, abdominal pain/cramping, metabolic acidosis, diarrhea, tachypnea, tachycardia

Question 2

What is the treatment for ethylene glycol poisoning?

Answer 2

fomepizole IV

Question 3

What is the treatment for methemoglobinemia? What if the pt has G6PD deficiency?

Answer 3

-methylene blue
-vit C (ascorbic acid)

Question 4

What are some medications that can cause methemoglobinemia?

Answer 4

-benzocaine (hurricane spray)
-prilocaine
-metoclopramide
-nitrates
-dapsone
-sulfonamides
-aniline dyes

Question 5

What is the pathogenesis of hepatorenal syndrome?

Answer 5

systemic hypotension –> renal vasoconstriction leading to underfilling. Splanchnic vasodilation in cirrhosis leads to decreased effective blood flow to the kidneys –> activation of RAAS system –> retention of Na and H2O and renal vascular constriction but globally there is vasodilation so –> renal hypoperfusion

Question 6

What are s/s of a cholinergic crisis?

Answer 6

-bradycardia
-wheezing
-salivation

-if d/t orangophosphate poisoning remember that all clothes should be removed and pt decontaminated to remve offending substance and protect EMS

Question 7

What level of radiation exposure causes cerebrovascular syndrome and what is the significance of this?

Answer 7

> 30Gu
-this syndrome is universally fatal
-at levels of > 100Gy death results within a matter of hours

Question 8

What EtCO2 is indicitive of good qulaity CPR?

Answer 8

10mmHg at a minimum

Question 9

What EtCO2 is suggestive of ROSC during CPR?

Answer 9

-30+ mmHg
-sudden (< 5s) increase in ETCO2 of >2x previous ETCO2 level

Question 10

What blood gas/lab value is most sensitive in diagnosing cyanide poisoning?

Answer 10

Lactate > 8
-cyanide blocks aerobic metabolism increasing anaerobic and lactate
-sens 94% specificity 70%

Question 11

How do you calculate plasma osmolality?

Answer 11

287(2Na+(BUN/2.8)+(glucose/18)+(blood ethanol/4.6))

Question 12

How do you calculate osmolar gap?

Answer 12

osmolar gap (measured osmolality-calculated osmolality=osmolar gap)
-should be <10
-higher gap is due to low molecular weight molecules: ethylene glycol, methanol, acetone, and ketones

Question 13

What LFT results are suggestive of alcoholic liver disease/alcohol abuse?

Answer 13

AST:ALT 2:1

Question 14

At what level do the common iliac veins join the IVC?

Answer 14

L5

Question 15

At what level do the renal veins join the IVC?

Answer 15

L1 - L2

Question 16

What are the most common congenital anomalies of the IVC?

Answer 16

-duplicated vena cava
-L sided vena cava
-circumaortic L renal vein

Question 17

Greater than what diameter constitutes megacava?

Answer 17

28 - 32mm

Question 18

Where should the tip of the IVC filter be placed?

Answer 18

confluence of renal veins

Question 19

What is the pathophys of diabetes insipidus?

Answer 19

-clinical syndrome characterized by inadequate or absent effect of ADH
-no ADH = closed aquaporins
-closed aquaporins = impaired water reabsorption in nephrons
-end result is excessive water excretion but not Na

Question 20

What are the symptoms of DI?

Answer 20

-polyuria w/ dilute urine
-hypernatremia
-hypovolemia

Question 21

What does stroke volume depend on?

Answer 21

-preload (physiologic parameter = EDV)
-afterload (parameter = SVR)
-contractility (parameter = peak systolic pressure/end systolic pressure)

Question 22

What is the Frank-Starling mechanism?

Answer 22

ability of the heart to change its force of contraction and therefore stroke volume in response to changes in venous return
-this is independent of neural and humoral influences

Question 23

What is seen on Swan-Ganz reading for hypovolemic shock?

Answer 23

-decreased PCWP
-decreased CO
-increased SVR
-decreased MVO2

Question 24

What is seen on Swan-Ganz reading for cardiogenic shock?

Answer 24

-increased PCWP
-decreased CO
-increased SVR
-decreased MVO2

Question 25

What is seen on Swan-Ganz reading for distributive shock?

Answer 25

-normal PCWP -increased CO -decreased SVR -increased MVO2

Question 26

What is the initial treatment of acute right heart failure following a MI?

Answer 26

fluid resuscitation until PCWP > 15mmHg

Question 27

How does a LVAD work?

Answer 27

axial pump that allows blood to be aspirated from the LV and pumped above the aortic valve into the ascending aorta works to unload LV reducing LV end diastolic pressure and wall tension

Question 28

What are the physiologic effects of LVAD?

Answer 28

-decreases LV end diastolic pressure -decreases LV wall tension -decreases oxygen demand -increases MAP -increases diastolic pressure -increases CO -improves both systemic and coronary blood flow -decreases PCWP and RV afterload

Question 29

What happens to the CVP, PAWP, CI, SVR, and mixed venous SvO2 during hypovolemic shock?

Answer 29

-CVP decreases -PAWP decreases -CI decreases -SVR increases -SvO2 decreases

Question 30

What happens to the CVP, PAWP, CI, SVR, and mixed venous SvO2 during distributive shock?

Answer 30

-CVP decreases/normal -PAWP decreases/normal -CI increases -SVR decreases -SvO2 increases

Question 31

What happens to the CVP, PAWP, CI, SVR, and mixed venous SvO2 during cardiogenic shock?

Answer 31

-CVP increases/normal -PAWP increases -CI decreases -SVR increases -SvO2 decreases

Question 32

What happens to the CVP, PAWP, CI, SVR, and mixed venous SvO2 during obstructive (tamponade) shock?

Answer 32

-CVP increases -PAWP increases/normal -CI decreases -SVR increases -SvO2 decreases

Question 33

What are things that can increase your SVO2 (mixed venous oxygen saturation)?

Answer 33

-increased in oxygen delivery (DO2): incr. CO, Hgb, SaO2 -decrease in consumption (VO2): hypothermia, sedation, mechanical ventilation, sepsis, A-V shunting

Question 34

What are things that can decrease your SVO2 (mixed venous oxygen saturation)?

Answer 34

-decrease in delivery (DO2): decr. CO, Hgb, SaO2 -increase in consumption (VO2): hypermetabolic sepsis, "fighting the vent"

Question 35

How does phenylephrine help improve cardiac output in a shock state and therefore oxygen delivery?

Answer 35

-rapidly treats sudden cardiovascular collapse -increases MAP in shock patients w/ aortic stenosis -treats sildenafil and nitrate induced hypotension

Question 36

How does phosphodiesterase inhibitors help improve cardiac output in a shock state and therefore oxygen delivery?

Answer 36

-milrinone -prevent breakdown of cAMP in myocardial and vascular smooth muscle --> enhances ventricular contraction and vasodilation

Question 37

How does vasopressin help improve cardiac output in a shock state and therefore oxygen delivery?

Answer 37

-acts on V1 receptors in vascular smooth muscle -acts on V2 receptors in nephron -has no effect on cardiac output

Question 38

What is the effect of dobutamine on CO? On SVR? what receptors does it act on?

Answer 38

-CO = big increase -SVR = decrease (d/t vasodilation) -beta 1 > beta 2

Question 39

What is the effect of milrinone on CO? On SVR? what receptors does it act on?

Answer 39

-CO = increase -SVR = decrease -PD inhibitor --> prevents cAMP breakdown

Question 40

What is the effect of dopamine on CO? On SVR? what receptors does it act on?

Answer 40

-CO = increase -SVR = increase -D2, mild beta 1, alpha 1

Question 41

What is the effect of norepinephrine on CO? On SVR? what receptors does it act on?

Answer 41

-CO = big increase -SVR = increase -alpha 1 > alpha 2

Question 42

What is the effect of epinephrine on CO? On SVR? what receptors does it act on?

Answer 42

-CO = big increase -SVR = increase -beta 1, alpha 1

Question 43

What is the effect of phenylephrine on CO? On SVR? what receptors does it act on?

Answer 43

-CO = almost no effect -SVR = big increase -alpha

Question 44

Which qSOFA criteria are predictive of a prolonged ICU stay or in hospital mortality?

Answer 44

-hypotension (< 100) -AMS (GCS < 15) -tachypnea (> 22)