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Critical Care Flashcards

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1
Q

This syndrome is defined by end-organ hypoperfusion as a result of circulatory failure

A

Shock

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2
Q

This type of shock can be due to sepsis, anaphylaxis, spinal cord injury

A

Distributive

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3
Q

This type of shock can be due to acute MI, end-stage cardiomyopathy, severe valvular disease, myocarditis, or arrythmias

A

Cardiogenic

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4
Q

This type of shock can be due to PE, tamponade, tension pneumothorax, abdominal compartment syndrome

A

Obstructive

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5
Q

This type of shock can be due to hemorrhage or severe dehydration

A

Hypovolemic

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6
Q

What is a first-like agent for vasoactive drugs due to their rapid onset, high potency, and short half life?

A

Adrenergic agonists (NE)

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7
Q

Good and bad of use of NE for shock?

A

Stimulating B-adrenergic increases CO but also increases risk of MI

Stimulating a-adrenergic R increases vascular tone and MP but also impairs CO and flow to hepatosplanchnic region

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8
Q

What will happen if you give dobutamine when patients are not well volume resuscitated?

A

Blood pressure can decrease

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9
Q

These agents are PDE-III inhibitors, which decrease metabolism of cAMP and comines inotropic and vasodilating properties

A

Milrinone and enoximone

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10
Q

This study compared NE with NE + Vasopressin, showing no overall difference in survival between the treatment groups

A

VAAST study

 The
norepinephrine +
vasopressin group had
decreased norepinephrine
requirement. Mortality
benefit was seen in the
subgroup of patients with
less severe septic shock
receiving both
norepinephrine+
vasopressin when the
norepinephrine dose was <
15 μg/min
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11
Q

Side effects of NE?

A

Arrhythmias, bradycardia, peripheral ischemia

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12
Q

Side effects of Epi?

A

Arrythmias
Reduction in gut blood flow
Increases lactate

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13
Q

Side effects of dopamine?

A

More arrythmogenic than NE

↑ 28 day mortality with cardiogenic shock

Possible ↑ mortality in those with septic shock

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14
Q

Side effects of phenylephrine?

A

Reflex bradycardia

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15
Q

What happens if you titrate above the fixed dose of vasopressin?

A

Increased cardiac and peripheral ischemia

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16
Q

True/False: Intra-aortic balloon pump has shown a mortality benefit in cardiogenic shock

A

FALSE

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17
Q

Target Hgb for transfusion in most shock?

A

7 g/dL

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18
Q

Normal mixed venous O2 sat (Svo2)?

A

60-80%

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19
Q

Say you don’t happen to have a PA catheter to check a pure/majestic/unadulterated Svo2 and decide to check it off the central line in the right IJ instead (Scvo2). What is the normal Scvo2 compared to Svo2?

A

Scvo2 is slightly < Svo2

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20
Q

In the critically ill, what happens to Scvo2 compared to Svo2?

A

Scvo2 is often > Svo2

Giving you false hope that it isnt cardiogenic shock?

Also, there may be a benefit in targeting Scvo2 > 70% in the first 6 hours of shock.

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21
Q

Patient clinically improving overall from shock but lactates still elevated. What organ might have dysfunction?

A

Liver

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22
Q

Goal SBP in acute aortic dissection?

A

<120

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23
Q

Goal SBP in hemorrhagic CVA?

A

<140

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24
Q

Goal SBP in ischemic CVA?

A

<220

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25
Goal MAP in hypertensive encephalopathy?
Decrease MAP by 20-25%
26
Goal DBP in pre-eclampsia?
<110
27
What % of upper GI bleed are caused by PUD?
50%
28
Urea:Cr in upper GI bleed?
>100
29
How do vasoactive medications decrease bleeding in variceal hemorrhage?
They decrease portal blood flow | vasopressin, somatostatin and analogues like octreotide
30
What is the AIMS65 mnemonic for severity of upper GI bleed?
``` Albumin < 3.0 INR > 1.5 altered Mental status SBP > 90 Age > 65 ```
31
This intervention is reserved for unsuccessful endoscopic therapy for variceal bleeding
TIPS
32
True/False: prophylactic intubation before endoscopy has not shown to reduce the risk of aspiration
TRUE
33
What is the most common cause of lower GI bleed?
Diverticulosis
34
Drugs/toxins that can cause acute liver failure?
``` Acetaminophen Alcohol Amanita phalloides (mushroom) Idiosyncratic drug reactions Toxin exposure ```
35
Infections that can cause acute liver failure?
Hepatitis viruses (BCDE) CMV EBV
36
Perfusion problems that can cause acute liver failure?
``` Ischemic hepatitis Shock liver Veno-occlusive disease HELLP HLH ```
37
Genetic diseases that can cause acute liver failure?
Wilsons | AIH
38
Kings college criteria for liver transplant?
Arterial pH <7.3 | Grade III/IV encephalopathy with PT >100sec and Cr >3.4
39
Most common cause of death in acute liver failure?
Cerebral edema
40
Treatment of cerebral edema in liver failure?
Hyperosmotic agents (mannitol) Hyperventilation (PaCO2 targets 25-30) Barbiturates
41
When to use antibiotics in pancreatitis?
If there is necrotizing pancreatitis. Consider IR/surgical drainage
42
In most ICU patients, when should enteral nutrition be initiated?
Within 48hours of admission
43
When should TPN be considered?
1 week
44
Contraindications to enteral nutrition?
Hemodynamic instability in those predisposed to bowel ischemia, bowel obstruction, upper GI bleed, intractable vomiting, diarrhea
45
Contraindications to parenteral nutrition?
hyperosmolality, hypervolemia, severe hyperglycemia or electrolyte abnormalities
46
Indications for FFP administration?
Factor deficiency Reverse warfarin TTP (contains ADAMSTS13) Coagulopathy in acute bleed
47
What are the components inside cryoprecipitate?
Fibrinogen, fibronectin, vWF, factor XIII, and factor VIII
48
What can be infused for patients with hemophilia A or B with life-threatening bleeds?
Factor VII | THATS 7
49
TRALI or TACO: Fever, hypotension, pulmonary infiltrates, not likely to respond to diuretics
TRALI
50
Which type of HIT is immune mediated and takes longer to see?
Type II Type I is more mild, a direct result of heparin on platelets, and occurs within the first 2 days of heparin exposure.
51
How long is anticoagulation indicated for patient swith HIT without thrombosis?
4-6 weeks
52
How long is anticoagulation indicated for patients with HIT with thrombosis?
3 months
53
Should you use warfarin for HIT?
NO They exacerbate the prothrombotic state
54
3 different treatment options for TTP?
PLEX!!!! Steroids if no evidence for drug-induced etiology or AKI despite PLEX Rituximab with or without cyclophosphamide in refractory TTP-HUS
55
How long should PLEX be administered in TTP/HUS?
Until resolution of thrombocytopenia and hemolysis (LDH)
56
Which one of these has ↑PT/PTT, ↓platelets, ↓fibrinogen, ↑D-dimer: TTP, HUS, DIC
DIC
57
According to the Cairo-Bishop definition, how many lab abnormalities do you need to be diagnosed with TLS?
2 or more ↑BUN, ↑K, ↑PO4, ↓Ca
58
Indications for emergent dialysis in TLS?
Severe oliguria/anuria, persistent hyperkalemia, or hyperphosphatemia-induced symptomatic hypocalcemia
59
How many blasts do you need on peripheral blood smear to be deemed to be in a blast crisis?
≥20%
60
``` 47-year-old woman who worked in a textile mill with wool had malaise, fever, and myalgia 5 days ago is now presenting with severe hypoxia and delirium. Chest radiography shows widened mediastinum. What type of exposure is suggested? ```
Bacillus anthracis | inhalation
61
Initial antibiotics for suspected bacterial meningitis in those >50, immunosupressed, alcoholics, or debilitated?
Ceftriaxone + vancomycin + ampicillin
62
Initial antibiotics for suspected bacterial meningitis in those after neurosuregery or have penetrating cranial trauma?
Ceftazidime + vancomycin
63
Dexamethasone dose and timing for meningitis?
0.15mg/kg Q6 for 4 days given before or with first antibiotic dose
64
Treatment for RMSF encephalitis?
Doxycycline
65
Treatment for neurosyphilis encephalitis?
PCN G
66
Treatment for lyme encephalitis?
PCN or 3rd gen cephalosporin
67
Treatment for herpes encephalitis?
ACV
68
Treatment for VZV encephalitis?
ACV
69
Treatment for brain abscess?
Ceftriaxone + metronidazole + surgery
70
Needed Duke criteria for diagnosis of endocarditis?
2 major, or 1 major and 3 minor, or 5 minor
71
Major Duke criteria for endocarditis?
Positive blood cultures: - Typical microorganism from 2 separate blood cultures - Persistently positive blood culture - Single blood culture for Coxiella burnetii or aniphase I immunoglobulin G antibody titer > 1:800 Evidence of endocardial involvement: - Positive echo findings - New valvular regurgitation
72
Minor Duke criteria for endocarditis?
Predisposition (heart condition, IVDU) Fever Vascular phenomena (arterial emboli, septic pulmonary infarct, mycotic aneurysm, incracranial hemorrhage, conjunctival hemorrhage, Janeway lesions) Immunologic phenomena (glomerulonephritis, Osler nodes, Roth spots, RF) Positive blood cultures that do not meet major criteria
73
Duration of antibiotics for native valve endocarditis? Prosthetic valves?
Native - 4 weeks Prosthetic - 6 weeks
74
EKG abnormality that shows worsening endocarditis?
PR prolongation
75
3 major indications for surgery for endocarditis?
1. Heart failure (cardiogenic shock). 2. Uncontrolled infection (abscess, enlarging vegetation, dehisence of prosthetic valve, persistent fever/blood cultures >7 days) 3. Prevention of embolic event based on size (>15mm or > 10mm with complication).
76
Duration of antibiotics for line infection after line removal for organisms that isnt S. aureus?
5-10 days
77
Duration of antibiotics for line infection after line removal for organisms that is uncomplicated S. aureus?
14 days
78
Duration of antibiotics for line infection after line removal for candidemia?
14 days Make sure to check them eyes!
79
Indications for surgery for C. diff infections?
Toxic megacolon Perforation Necrotizing colitis Rapidly progressive or refractory disease with SIRS and multiple organ failure
80
What type of soft tissue infection is likely given the following data: Thin, dark, foul-smelling wound drainage with gas, pain, crepitus. Caused by clostridium species
Necrotizing cellulitis
81
What type of soft tissue infection is likely given the following data: Deep infection that spreads quickly, elevated CPK, crepitus, caused by mixed bacteria (type I) or group A strep (type II)
Nectrotizing fasciitis
82
What type of soft tissue infection is likely given the following data: Severe pain and induration of a muscle after skin abrasions, blunt trauma, or heavy exercise. Caused by group A strep.
Necrotizing myositis
83
What type of soft tissue infection is likely given the following data: Progression to red/yellow/green/black discoloration and bullae with crepitus. Causes acute sudden pain and swelling, sepsis, and serosanguineous drainage with sweet odor
Clostridial myonecrosis
84
``` What antibiotic is included in the empiric antibiotic treatment of severe soft tissue infection because of its antitoxin effects against streptococci and staphylococci species? ```
Clindamycin
85
Protein and BP levels for the diagnosis of preeclampsia?
Proteinuria >300 mg/d BP >140/90mmHg
86
Single most important predictor of hemorrhagic stroke in patients with preeclampsia?
SBP >160
87
Antihypertensive treatment options in those with preeclampsia?
Labetalol Nicardipine Hydralazine
88
Indications for delivery in HELLP?
``` DIC Pulmonary edema Liver hemorrhage/infarction Renal failure Placental abruption Nonreassuring fetal status ```
89
Most common cause of post-partum hemorrhage?
Uterine atony God this is like doing medical school all over again. The worst.
90
Young female patients present 3 months after delivering baby with fatigue, lethargy, secondary amenorrhea, and hyponatremia. What do you suspect?
Sheehan syndrome
91
Treatment of Sheehan syndrome?
Make em hormonal again
92
Which peripartum medications are associated with noncardiogenic pulmonary edema?
The tocolytics: Terbutaline (ß2 agonist) Ritodrine (ß2 agonist)
93
This is the development of new-onset cardiomyopathy (LVEF <45%) that develops during the last month of pregnancy or up to 5 months postpartum
Peripartum cardiomyopathy
94
Treatment for Peripartum cardiomyopathy?
Heart failure treatment guidelined except dont sue ACEi in pregnancy
95
Outcomes for Peripartum cardiomyopathy?
1/3 recover 1/3 have residual cardiac failure 1/3 need transplant
96
Preferred imaging modality for suspected PE in pregnancy?
VQ scan
97
Preferred anticoagulation in PE with pregnancy?
LMWH
98
How long to continue anticoagulation postpartum for a PE during pregnancy?
≥6 weeks (minimum 3-6 months)
99
Young woman delivers and develops abrupt shock, profound hypoxemia, DIC, pulmonary edema, and coma. Suspected Dx?
Amniotic fluid embolism
100
Treatment for Amniotic fluid embolism?
Supportive care for BP and hypoxemia, consider inhaled NO, control hemorrhage with blood products and factor VIIa
101
Treatment for air embolism in pregnancy?
Place in left lateral decubitus position (prevents air from lodging in lungs) and trendelenburg (prevents going to brain)
102
What is this clinical triad? Bradycardia Respiratory depression Hypertension
Cushings triad
103
Treatment for elevated ICP?
``` Treat cause (duh) Elevated HOB Hyperventilate (PaCO2 goal 25-30) IV mannitol or hypertonic saline Intubate using lidocaine ```
104
After all other criteria for brain death are met and pt does not have hypothermia, hypercapnia, hypotension, or hypoxemia, what is the PaCO2 rise threshold for apnea test?
>60mm Hg or 20 mmHg greater than baseline
105
Which ancillary testing is indicated for brain death when clinical criteria cannot be done?
``` Cerebral angiography Transcranial doppler Magnetic MRA CT angiography EEG ```
106
Suspected substance of overdose given the following clinical criteria? ``` Pupils ↑ Temp ↑ BP↑ HR↑ RR↑ Other: agitation, hallucinations, paranoia ```
``` Cocaine Amphetamines Pseudoephedrine Caffeine Theophylline ```
107
Suspected substance of overdose given the following clinical criteria? ``` Pupils ↑ Temp↑ BP↑ HR↑ RR↑ Other: Myoclonus, hyperreflexia, diaphoresis, flushing, tremors, trismus, rigidity, confusion, agiation ```
MAOI, SSRI, TCA, dextromethophran
108
Suspected substance of overdose given the following clinical criteria? ``` Pupils ↑ Temp↑ BP↑ HR↑ RR↑ Other: Nystagmus, perceptual distortions, hallucinations, agitation ```
Hallucinogens (LSD, ecstasy, PCP)
109
Suspected substance of overdose given the following clinical criteria? ``` Pupils ↓ Temp↓ BP↓ HR↓ RR↓ Other: CNS depression, confusion, stupor, coma, hyporeflexia ```
Sedatives (benzos, alcohol, barbituates)
110
Suspected substance of overdose given the following clinical criteria? ``` Pupils ↓ Temp↓ BP↓ HR↓ RR↓ Other: CNS depression, coma, hyporeflexia, pulmonary edema ```
Opioids
111
Suspected substance of overdose given the following clinical criteria? ``` Pupils ↓ Temp ↔ BP↑ HR↓ RR ↨ Other: Salivation, incontinence, diarrhea, emesis, diaphoresis, lacrimation ```
Cholinergic agents (organophosphate, nicotine, verve agents, physostigmine, edrophonium)
112
Suspected substance of overdose given the following clinical criteria? ``` Pupils↑ Temp↑ BP↑ HR↑ RR↑ Other: Dry/flushed skin and mucus membranes, urinary retention, myoclonus, hypervigilance, agiation, delirium ```
Anticholinergics (antihistamines, atrtopine, scopolamine, Jimson weed, TCA)
113
NMS or serotonin syndrome: Fevers, altered mental status, rigidity, hyperreflexia, myoclonus
Serotonin syndrome NMS has hyporeflexia
114
Treatment for NMS?
Dantrolene Stop the drug
115
Epinephrine dose for anaphylaxis?
0.3-0.5mg IM Can repeat every 5-15 mins
116
What are the pulmonary, neurologic, cardiovascular, and hematologic manifestations of near drowning?
Pulm- noncardiogenic pulmonary edema Neurologic - cerebral edema and ↑ ICP Cardiovascular - arrhythmias 2/2 hypothermia and hypoxemia Heme- hemolysis and coagulopathy (rare)
117
True/False: Heat stroke can be managed by cooling methods in addition to dantrolene, tylenol, and aspirin
FALSE Meds dont work
118
Drugs of choice for anthrax exposire?
Cipro or doxy
119
Berlin definition of ARDS? Onset Imaging Etiology P:F
Onset - within 1 week of clinical insult CXR- bilateral opacities Etiology- non-cardiogenic P:F - determines severity. Mild (200-300), Mod (100-200), Severe (<100).
120
``` What condition is associated with the pathologic finding of diffuse alveolar damage with no known cause? ```
Acute interstitial pneumonia (Hamman-Rich syndrome)
121
Direct lung injury causes of ARDS?
``` Pneyumonia Aspiration Neara drowning Inhalation (smoke/toxin) Pulmonary contusion Embolism Re-expansion injury Reperfusion injury (after transplant) ```
122
Indirect lung injury causes of ARDS?
``` Sepsis Shock Trauma Blood transfusions Cardiopulmonary bypass Anaphylaxis Medications (opioids, salicylates, amiodarone, tocolytics, chemotherapy) Pancreatitis ```
123
This phase of ARDS is characterized by release of inflammatory markers, leading to fluid leakage into the alveoli. Bx shows diffuse alveolar dmg.
Exudative phase
124
Timeframe for exudative phase of ARDS?
<7-10d
125
This stage of ARDS is characterized by resolution of pulmnary edema, proliferation of type II alveolar cells, squamous metaplasia, interstitial infiltration by myofibroblasts, early collagen deposition, and oblitration of pulmonary capillaries.
Proliferative stage
126
Timeframe for proliferative stage of ARDS?
7d-2wk
127
This stage of ARDS is characterized by obliteration of normal lung architecture, diffuse fibrosis, and cyst formation.
Fibrotic stage
128
Timeline of fibrotic stage of ARDS?
>2 weeks
129
ARDSnet guidelines for TV, plateau pressure, PaO2 goal, pH goals?
TV 4-6mg/kg IBW Plateau pressure < 30 PaO2 55-80 pH 7.3-7.45
130
Risks of prostacyclin or NO in ARDS?
Can worsen shunt and oxygenation
131
Patients that you want to avoid APRV due to short exhalation time?
Bronchospasm, obstructing secretions
132
Initial inspiratory flow rates on volume control ventilation?
30-80 L/min High flow rates has lower Ti but higher peak pressures
133
Calculate resistance using peak and plateau pressures
R = peak - plateau
134
Causes of large resistances on the vents (>5cmH2O)?
Increased airway resistance from bronchospasm, ET occlusion, patient biting tube
135
Causes of elevated peak pressures but small difference between peak and plateau?
Decreased compliance: ``` pulmonary edema pneumonia PTX Auto-PEEP chest wall abnormality increased abdominal pressure ```
136
Calculate static compliance on the vent
TV/(plateau-PEEP)
137
Calculate dynamic compliance on the vent
TV/(peak pressure - PEEP)
138
Normal dynamic compliance on the vent?
50-100cm/H2O
139
When paralyzed and mechanically ventilated peak airway pressure shows what?
the force required to overcome resistive and elastic recoil of the lung and chest wall
140
Things you can do to adjust for double triggering on the vent?
Usually the Ti is shorter than the actual patients inspiratory time, so you can increase TV, inspiratory time, or sedation and switching to a variable flow setting
141
Most common cause of asynchrony where inspiratory effort that doesnt trigger a breath?
Auto-PEEP Tx = increase PEEP. This reduces the amount of pressure drop needed for the patient to trigger a breath.
142
Cause of autotriggering on the vent?
Vent is reading inspiratory effort but due to circuit leak, tube condensation, or vibration of ventilation
143
Type of asynchrony where there is concave deflection on the pressure-time graphic
Inadequate flow rate Tx = increase flow rate
144
In cycling asynchrony, the duration of the breath is too short or long. What is the treatment?
Decrease Ti Increase flow
145
Cuff pressure goals to reduce the risk of tracheal stenosis or TE fistula?
18-25 mmHg
146
2 methods to reduce risk of VAP?
CHG mouth scrubs | HOB elevation to >30 degrees
147
True or False: an indication for NIPPV is fever and pulmonary infiltrates in immunocompromised host.
TRUE This population is at an increased risk for VAP and alveolar hemorrhage if intubated, so OK to use NIPPV.
148
Formula that relates CO2 production to alveolar ventilation?
PaCO2 = K (VCO2/VA) K=0.863 VCO2 = CO2 ventilation VA = alveolar ventilation
149
THis is the concentration of CO2 at the end of each breath.
ETCO2
150
Normal ETCO2?
35-45mmHg
151
ETCO2 less than what # means poor quality CPR?
<10
152
Why does ETCO2 rise when spontaneous circulation occurs during resuscitation?
Increased cardiac output
153
What is the "20-30-40 rule" when you need ventilatory support with respiratory muscle weakness?
VC < 20 ml/Kg NIF/MIP < -30 cm H2O MEP < 40
154
If a patient has unilateral diaphragmatic paralysis secondary to phrenic nerve injury, what happens to FVC and MIP on PFTs?
They decrease
155
Patient post-CABG presents with fever, leukocytosis, elevated ESR, and pleural effusion. Thora reveals exudate with high neutrophil and eosinophil count. Diagnosis?
Post-pericardiotomy syndrome This is thought to be due to an immunologic response to damaged cardiac tissue. Happens >1 wk post surgery.
156
Bronchoscopic managment of bronchopleural fistula?
Gel foam, blood patch, fibrin glue Valves Ethanol injection "laser"
157
Hct threshold on pleural fluid to be deemed hemothorax?
>50% of total body hct

Pulmonary Review (14 decks)

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