Critical Care Flashcards
(89 cards)
1
Q
Size of ET tube for adult
A
- 0-8.5 mm male
- 5-8.0 mm female
2
Q
Sizes of Mac + Miller blades for adults
A
Mac: #3 avg, #4 for large
Miller: #2 avg, #3 large
3
Q
Correct placement of ETT
A
Cuff passes vocal chords
Tip of tube 2cm above carina
Base of pilot tube usually at the teeth
23 cm at teeth men, 21 cm women
4
Q
How much air to inflate ETT tube balloon with
A
5 cc
5
Q
Intubation dose Etomidate
Onset
Duration
Side-effects
A
Dose: 0.3 mg/kg (LBW dosing)
Onset: 15-45 s
Duration: 3-12 min
Side-effects: myoclonic jerking, seizures, vomiting
6
Q
RSI dose Rocuronium
Onset
Duration
Side-effects
A
1 mg/kg
Onset: 60 s
Duration: 40-60 min
Side-effects: tachycardia
7
Q
RSI dose Propofol
Onset
Duration
Side-effects
A
1.5 mg/kg
Onset 20-40s
Duration 8-15 min
Side effects: Apnea, hypotension
8
Q
RSI Dose Ketamine
Onset
Duration
Side-effects
A
1-2 mg/kg
Onset 1 min
Duration 10-20 min
Side-effects: increased secretions, hypertension, emergence reaction, laryngospasm, not recommended in pregnancy
9
Q
Succinylcholine RSI Dose
Onset
Duration
Complications
A
1.5 mg/kg (4 mg/kg IM)
Onset: 45-60 s
Duration: 6-10 min
Hyperkalemia: mostly from upregulation of Ach receptors, starts 5 days after insult (burn, demyelinating disorder, myopathy, stroke, crush injury, severe infection), and lasts 3-6 months and until healed. If hyperK present for other reason (e.g. CKD), may still give sux if no ECG changes (expected rise is ~0.5-1 mEq).
Malignant Hyperthermia: fevers, acidosis, rigidity.
10
Q
How to perform nasotracheal intubation?
A
1) Lidcaine spray nostrils
2) ETT 0.5-1.0 mm smaller
3) Sitting, sniffing, bevel towards septum, advance, rotate medially ~30deg until max airflow heard then swiftly advance at initiation of respiration. Pt may cough. Any vocal sounds means failed attempt.
4) 28 cm at nares men 26 cm women
11
Q
Mallampati Score
12
Q
ACLS Tachycardia Algorithm
A
16
Q
LEMON - Difficult Laryngoscopy
A
- *L**ook (gestalt)
- *E**valuate (3-3-2 rule)
- *M**allampati
- *O**besity/obstruction
- *N**eck mobility
17
Q
MOANS - Difficult BVM
A
- *M**ask seal/male sex/mallampati
- *O**besity/obstruction
- *A**ge >55
- *N**o teeth
- *S**tiff/snoring
18
Q
RODS - Difficult EGD
A
- *R**estricted mouth opening
- *O**besity/obstruction
- *D**isrupted/distorted anatomy
- *S**tiff
19
Q
SMART - Difficult Cricothyrotomy
A
- *S**urgery
- *M**ass
- *A**ccess/anatomy
- *R**adiation
- *T**umor
20
Q
6 P’s of RSI
A
- *P**reparation
- *P**retreatment
- *P**reoxygenation (3 minutes @ 100% FiO2 or 8 vital capacity breaths @ 100% FiO2) + Nasal Cannula @ 6 LPM
- *P**aralysis with induction
- *P**ositioning
- *P**lacement with proof
- *P**ost-intubation care
21
Q
Pretreatment Agents for RSI
A
- Lidocaine:* 1.5 mg/kg
- Fentanyl:* 3 mcg/kg IV over 30-60 seconds
Asthma - Lidocaine
Brain (IICP) - Lidocaine + Fentanyl
Circulation (CV patients susceptible to sympathetic surge) - Fentanyl
Consider Atropine in infants (<1 year of age)
22
Q
ETT Size for Kids
A
4 + age/4 (uncuffed), 3.5 + age/4 (cuffed)
23
Q
ETT insertion depth
A
Tube size X 3 (at the lips)
24
Q
Cormack-Lehane Grading
25
Definition of a Failed Airway
**Definition of a Failed Airway:** any of i) failure of an intubation attempt in a patient who is unable to be oxygenated with BVM (CICO), ii) 3 attempts by an experienced intubator, iii) failed intubation in the forced to act situation (although oxygenation may be possible).
26
FiO2 with different devices
NP @ 2-4 L: 30-35%
Mask @ 6-10L: 45-55%
NRB@ 10-15L: 70%
BVM with good seal and resevoir @ 10-15L: 100% (must have one-way exhalation valve)
27
BiPap Settings
Start 8/3 IPAP/EPAP, keep IPAP 5 points greater than EPAP
Keep EPAP \<8-10 cm H20 in COPD
28
ETCO2 in Cardiac Arrest
* Qualitative ETCO2 has 25% false negative rate
* \<10mm Hg means poor CPR
* abrupt increase to 30 mm Hg may mean ROSC (venous bicarb may cause transient rise)
29
OPA Sizing
Mouth to (angle of) Mandible, 8-10 cm for most adults
30
NPA Sizing
Tip (of nose) to Tragus, 6-8 mm for most adults
31
Prep for flexible endoscopy (airway)
Glycopyrrholate 0.01 mg/kg IM or IV 10-20 minutes pre-procedure to reduce secretions and enhance effect of topical anesthesia
32
Surgical Airway In Children
If \<10 years old, do not attempt Cric (membrane too small), use needle tracheotomy with BMV ventilation
33
Cricothyrotomy
No Drop Open Technique
1) Prep (#4 cuffed tube will work for most patients)
2) If awake - infiltrate 1% lidocaine and spray some in trachea to suppress cough
3) Left hand immobilize larynx
4) 2 cm vertical midline skin incision
5) Re-identify membrane
6) Insise cricothyroid membrane (horizontal incision) at lower pole
7) Insert hook above scalpel - assistant holds traction upwards
8) Remove scalpel, insert Trousseau dilator, dilate vertically
9) Insert tracheostomy tube, rotate dilator counter-clockwise to help insertion
34
Cricothyrotomy
Seldinger Technique
1) Prep
2) Insert needle caudally, aspirating for air
3) Insert guidewire
4) Cut skin with scalpel
5) Insert dilator and tracheostomy tube as one unit
6) Remove dilator
35
Cricothyrotomy
Bougie Technique
1) Scalpel, Bougie, 6-0 ETT
2) Locate Cricothyroid membrane
3) Cut (any way)
4) Bougie until stops
5) ETT until balloon past incision
6) Ventilate
36
Percutaneous Transtracheal Ventilation
**Percutaneous Transtracheal Ventilation**
**Equipment:**
- 12-16g angiocath attached to 20 mL syringe, may add 15 deg bend at end
- 3.0-3.5 ETT adapter connected to 3-4" IV tubing
**Procedure:**
1) Insert needle into trachea at 30 deg angle aspirating for air
2) Advance catheter over needle
3) Connect IV tubing with ETT connector and BVM
37
Universal Difficult Airway Algorithm
[![]()](http://s6.postimg.org/samrzuk0x/Universal_Difficult_Airway_Algorithm.jpg)
38
Emergency Medicine Difficult Airway Algorithm
[![]()](http://s6.postimg.org/j44hckesh/Main_Emergency_Management_Airway_Algorithm.jpg)
39
Difficult Airway Algorithm
[![]()](http://s6.postimg.org/3k1ozru1t/Difficult_Airway_Algorithm.jpg)
40
Failed Airway Algorithm
[![]()](http://s6.postimg.org/hezzi8ogx/Failed_Airway_Algorithm.jpg)
41
Crash Airway Algorithm
[![]()](http://s6.postimg.org/6tg468i5d/Crash_Airway_Algorithm.jpg)
42
ALCAPA (anomalous left coronary artery from the pulmonary artery) syndrome
***ALCAPA (anomalous left coronary artery from the pulmonary artery) syndrome***
LCA compressed between main pulmonary artery and aorta, especially during increased venous return (e.g. exercise). Dx Cardiac MRI/CT. Tx surgical.
43
Catecholaminergic Polymorphic Ventricular Tachycardia (CPVT)
***Catecholaminergic Polymorphic Ventricular Tachycardia (CPVT)***
exercise/stress related vtach, syncope. Many have sinus brady on ECG. Starts early adulthood/childhood. Tx BB, ICD if syncope.
44
Cardiac output =
CO = HR x SV
45
MAP =
MAP = CO x SVR
MAP = [(2 x DBP) + SBP]/3
46
Shock Index
SI = HR/SBP
Normal is 0.5-0.7
Persistent \> 1 signifies LV dysfunction and high mortality
47
Intravascular Volumes
7% IBW
~5L blood
2L RBC
3L Plasma
48
Concentration Na and Cl in normal saline and Osm
154 mmol/L Na+
154 mmol/L Cl-
Osm 308 mOsm/L
49
Na & Cl concentrations in LR and Osm
130 Na+
109 Cl+
Osm 273 mOsm/L
50
Glucagon Dose for Anaphylaxis
| (Refractory Hypotension on BB)
* ***Adults:*** 1 milligram IV every 5 min until hypotension resolves, followed by 5–15 micrograms/min infusion
* ***Peds:*** 20-30 mcg/kg over 5 min, max 1 mg, followed by infusion of 5-15 mcg/min.
51
Go to Drug for ACEI or Hereditary Angioedema
Icatibant 30 mg subcut x 1
52
Alternative blood product for hereditary angioedema
FFP 2-3 units
53
Glucagon Dose for bradycardia secondary to BB or CCB overdose
* Glucagon 3–10 milligrams IV infused over 1–2 min, followed by an IV continuous infusion of
* 1–5 milligrams/h
* s/e: NxVx
54
Dopamine/Epi Infusion for bradycardia
* Dopamine 2-10 mcg/kg/min
* Epi 2-10 mcg/min
55
Therapeutic Hypothermia
* for Vfib/Vtach arrest, but also consider for PEA/asystole
* not for trauma/bleeding or awake/alert patients
* anticoagulation not a contraindication
* Procedure
* Lower T to 32-36 deg C within 4-6 h after ROSC
* Ice packs to axillae, neck, groin
* Intravascular cooling
* 30 mL/kg NS at 4 deg C over 30 min
* Intubate and ventilate, central line, art line
* May need paralytics to prevent shivering
* lytes Q4h
* maintain for 12-24 h, then rewarm slowly over 12-24 h (risk of hypotension)
56
Propofol Drip
* Propofol: 20-50 mcg/kg/min (1, 400 - 3, 500 mcg/min)
57
Ketamine Drip
* Ketamine: 0.5 mg/kg/h
58
Fentanyl/Midaz Drip
* Fentanyl: 0.5-1 mcg/kg/h
* Midazolam: 0.05 mg/kg bolus IV then 0.025 mg/kg/h
59
Dose of Racemic Epi/nebulized epi (asthma, croup, stridor post-extubation)
* 0.25-0.75 mL (0.05 mL/kg) 2.25% racemic epi in 4 mL NS or
* 0.5 mL/kg, max: 5 mL 1:1000 epi
60
Meds that can be given through ETT
**ETT meds**
* **L**idocaine
* **E**pi (1:1000, 2-2.5 mg)
* **A**tropine
* **N**aloxone
61
MAP Goals for:
Traumatic hemorrhagic Shock
TBI
All other shock
* Traumatic Hemorrhagic Shock: MAP 40 mm Hg
* TBI: MAP 90 mm Hg
* All other shock: MAP 65 mm Hg
62
CVP
* 2-8 mm Hg normal in healthy people
* 8-12 mm Hg advocated in shock
* 250 mL NS bolus, if CVP increases by \< 2, give more, if by \> 5, stop
* measure at end-expiration
* measure at base of c wave (right before ventricular contraction, represents preload)
63
JVP
Distance from sternum to RA is 5 cm
Add 5 cm to measurement from manubrium to JVP at 45 deg angle
\> 4.5 cm is high
64
Pulse Pressure Variation & Fluid Responsiveness
In mechanically ventilated patients who are completely in sync with ventilator breaths and have no dysrhythmias:
* PP increases with inspiration and decreases with expiration
* PPV = PP (max value on insp) - PP (min value on exp) / avg of both values
* if \> 13%, may be fluid responsive, goal is \< 10 %
65
Passive Leg Raise & Fluid Responsiveness
* 30 deg above chest for 1 min
* equivalent to 300 mL bolus in 70 kg patient
* as sensitive and specific as PPV
66
ScvO2, SmvO2
* ScvO2 = central venous oxygenation, usually measured from central line, represents upper extremity/brain venous O2
* SmvO2 = mixed central venous oxygenation, more accurate, but measured in pulmonary artery
* Normally ScvO2 2-3% lower than SmvO2, in shock states ScvO2 5-10% higher (as blood flow redistributed to brain)
* Normal is ~70%
67
Transvenous Pacing
* preferred sites are **Right IJ** and **Left Subclavian**
68
Pacemaker Nomenclature
* 1st letter A/V/D indicates which chambers are paced
* 2nd letter A/V/D indicates which chambers are sensed
* 3rd letter I (inhibit)/T (trigger)/D (both) indicates what occurs when an event is sensed
69
Push Dose Epi
* 1 mL cardiac epi (1:10, 000) into 9 mL saline = 1:100, 000 epi (10 mcg/mL)
* 0.5-2 mL (5-20 mcgs) Q 1-2 min
70
Push dose phenylephrine
* 1 mL 10 mg/mL phenyl into 100 mL NS bag
* 100 mcgs/mL phenyl
* 0.5-2 mL (50-200 mcgs) Q2-5 min
71
Vtach (sustained & non-sustained)
* **sustained**
* HR \>120/130
* lasts \>30s or HD unstable
* shock or amio/procainamide
* **non-sustained**
* HR \>120/130
* \<30 s and stable
* don't use antiarrhythmics
* Mg if low
* search for reversible causes
* beta blockers OK
72
Hydralazine Class and Dosing
* arterial vasodilator
* 10-20 mg IV Q4H PRN
* 10 mg PO QID, increase by 10-25 mg/dose Q2-5 days to max 300 mg/day
73
Duration of Propofol
6-10 minutes
74
Dose of Propofol for conscious sedation
1 mg/kg (IBW) then 0.5 mg/kg Q90s as needed
75
Dose of Ketamine for conscious sedation
1 mg/kg
76
Dose of ketofol for conscious sedation
0.5 mg/kg or 1 mg/kg of each
77
1. Dose of Fentanyl for pain control
2. Duration of action
1.5 mcg/kg IV then 0.75 mg/kg IV Q2-3 min until pain is controlled
Duration: 1 hour
78
Concentration of
a) 1:1000 Epi
b) 1:10000 Epi
a) 1 mL = 1 mg
b) 1 mL = 0.1 mg
79
Dose of epi for anaphylaxis
0.01 mg/kg IM Q5-15 min into anterolateral thigh
80
Dosing and Brands of Epi-Pens
1) EpiPen (0.3 mg) and EpiPen Jr (0.15 mg)
2) Twinject (0.15 mg and 0.3 mg versions) - carries two doses
10 kg - 25 kg get lower dose (0.15 mg)
\>25 kg get higher dose (0.3 mg)
Should administer when symptoms recurr after exposure to an allergen known to have caused anaphylaxis in the past (this means using EpiPen for isolated uritcaria after peanut if peanut caused anaphylaxis before). Also administer for CV or resp symptoms of anaphylaxis.
81
Anaphylaxis cocktail (besides epi)
H1 blocker: Benadryl 1 mg/kg (max: 50 mg) PO/IM/IV
H2 blocker: Ranitidine 1 mg/kg (max: 50 mg) PO/IV
Prednisone 1 mg/kg PO (max 75 mg) or methylprednisolone (Solu-Medrol) 1 mg/kg IV (max 125 mg)
DC with:
Benadryl 1 mg/kg (max: 50 mg) PO Q6h X 2-3 d
Ranitidine 1.25 mg/kg (max 150 mg) PO BID X 2-3 d
82
Corrected Calcium Calculation
Corrected Calcium = Measured Calcium + [(40-Albumin)X0.02]
83
Inspiratory sound like snoring/snorting which localizes to the nose.
* stertor
84
Management of Acute Upper Airway Obstruction
(FB)
* ~50% tracheal + bronchial FB's are negative on plain films
* inspiratory + expiratory films may help (hyperinflation on expiration on affected side)
* lateral decubitus films not helpful
* acute FB --\> monitor airway, call anesthesia
* CPR/Heimlich if complete obstruction
* laryngoscopy with mcgill forcep removal
* ram ETT down R mainstem if can't remove
* Don't BVM if possible, as can move FB from supraglottic to subglottic position
85
Mnemonic for sudden decompensation of vented patient
* **D**islodged tube
* **O**xygen source (off/faulty)
* **P**neumothorax
* **E**quipment Failure
86
Bleeding Trach
* **within 48h insertion**
* likely local skin bleeding from procedure, call surgeon
* **after 48h**
* concern for tracheoinnominate artery fistula
* ***small/herald bleed***
* bronchoscopy + good external skin exam
* CTA if no source identified
* if lots of space between vessel and trach and no stranding then OK
* otherwise OR/trach removal with bronch and exchange for ETT
* ***large bleed***
* overinflate cuff
* if not working
* slide finger between trach and vessel and hook/compress against sternum
* remove trach and ETT if finger doesn't fit with trach in
* may try Foley
87
Dose of tPA for supramassive PE
50 mg IV alteplase (tPA) over 1 min
88
Definition and Treatment of Refractory VF/Vfib
See Evernote "ACLS"
89
Review Vent Stuff
Vent Stuff
