Critical Care

Question 1

[diagnosis]

72/M with COPD, CHF and back pain. On oxycodone and morphine treatment

unarousable, discovered multiple intake of morphine

BP 130/80, HR of 90/min, O2 sats 90% pinpoint pupils

Answer 1

Dx: Acute hyperbaric respiratory failure secondary to opiate overdoe

Initial test: ABG

Appropriate management: reverse effects of opiates, require intubations

Question 2

[Type of Respiratory Failure]

PaO2 <55-60 mmHg

alveolar flooding, intrapulmonary shunt

Answer 2

Type I (flood)

Pulmonary edema, pneumonia, alveolar hemorrhage, ARDS

Question 3

[Type of Respiratory Failure]

pCO2 >45-50mmHg

Diminished CNS drive to breathe, reduced neuromuscular strength, increased load to respiration

Answer 3

Type II (cant eliminate CO2)

Question 4

[Type of Respiratory Failure]

perioperative respiratory failure, atelectasis

Answer 4

Type III Athreelectasis

Question 5

[Type of Respiratory Failure]

hypoperfusion of respiratory muscles in shock

Answer 5

Type IV SHOCK!

Question 6

[Cause of hypoxemia]

Increased A-a gradient that is correctable with O2 can be caused by?

Answer 6

This is V/Q mismatch

1. Airway disease
2. Interstitial lung disease
3. Alveolar disease
4. Pulmonary vascular disease

Question 7

[Cause of hypoxemia]

Increased A-a gradient that is not correctable with O2 can be caused by?

Answer 7

This is a form of R-L shunt

1. Intracardiac shunt
2. Vascular shunt within lungs

Question 8

[Cause of hypoxemia]

Normal A-a gradient that has increased PaCO2

Answer 8

This is hypoventilation

1. Decreased respiratory drive
2. Neuromuscular disease

Question 9

[Cause of hypoxemia]

Normal A-a gradient that has a normal PaCO2

Answer 9

Low FiO2 (high altitude)

Question 10

What is the parameter for ventilation?

Answer 10

PaCO2

Question 11

How will you correct hypercarbia?

Answer 11

increase the minute ventilation or increase RR

Question 12

How will you correct hypoxemia?

Answer 12

increase FiO2 or increase PEEP

Question 13

[diagnose]

46M currently admitted developed progressive dyspnea and hypoxia 84%

High pitch crackles, CXR diffuse bilateral infiltrates

ABG: pH 7.3 pCO2 50, HCO3 19, PO2 60 at 10lpm

Answer 13

Dx: ARDS

Next step: Intubate

Question 14

What is the diagnostic criteria for ARDS?

Answer 14

Berlin Criteria

Question 15

In Berlin Criteria,

what is the CXR finding suggestive of ARDS?

Answer 15

Bilateral alveolar or interstitial infiltrates not fully explained by effusion, consolidation or atelectasis

Question 16

In Berlin Criteria, what is the cut-off value for left atrial hypertension?

Answer 16

PCWP <18 mmHg

Question 17

What are the PF ratio of severity in Berlin Criteria?

Answer 17

PF is:

Severe: <100
Moderate: 100-200
Mild: 200-300

Question 18

What are the components of Berlin Criteria?

Answer 18

1. Acute onset
2. Ratio of PaO2/FiO2
3. Diffuse bilateral infiltrates in CXR
   atrial hypertension
4. Swan-Ganz pressure <18 mmHg

Question 19

What is the best management MV management for ARDS?

Answer 19

1. Low tidal volume 6mL/kg of predictive body weight

Question 20

What is the MV management for ARDS?

Answer 20

1. TV 6mL/kg

2. PEEP 12-15mmHg

Question 21

Early muscular blockade using this drug is recommended in the first 48 hours?

Answer 21

Cisatracurium besylate

Question 22

What keeps the alveoli open in ARDS?

Answer 22

PEEP

Question 23

[diagnose]

57/M with CHF presents at the Er with progressive dyspnea.

PE: 68/50 140 bpm, elevated JVP, bilateral crackles, cold clammy extremities

Answer 23

Dx: Cardiogenic shock
Urgent Step: fluid resuscitation

First line vasopressor: NE
Inotrope DOC: Dobutamine

Question 24

What is the cutoff lactate value for lactate?

Answer 24

> 1.5 mmol/L

Question 25

What are the components of shock state?

Answer 25

1. Systemic arterial hypotension 2. Tissue hypoperfusion 3. Hyperlactatetemia

Question 26

[type of shock] 2DE: Normal cardiac chambers, preserve contractility

Answer 26

Distributive shock Normal or High CO

Question 27

[type of shock] 2DE: Small cardiac chambers and normal or high contractility

Answer 27

Hypovolemic shock Low CO LOW CVP

Question 28

[type of shock] 2DE: large ventricle, poor contractility

Answer 28

Cardiogenic Low CO High CVP

Question 29

In circulatory shock, what is the second line vasopressor?

Answer 29

Epinephrine First line: NE DO NOT USE DOPAMINE

Question 30

In circulatory shock, What is the fluid resuscitation of choice?

Answer 30

Crystalloid solution Infuse 300 to 500 mL in 20-30 minutes

Question 31

How will you manage acute CHF?

Answer 31

1. Diurese - furosemide 2. Morphine 3. Nitrates 4. Oxygen 5. Position, sit upright

Question 32

[How will you manage this case?] Shock, hypoperfusion, CHF acute pulmonary edema

Answer 32

1. Lasix (Furosemide) 0.5 to 1mg/kg 2. Morphine IV 2 mg 3. Oxygen 4. Nitroglycerin, NE or Dopa 5. Dobutamine 2 to 20 ug/kg

Question 33

What is the ACEi for acute pulmonary edema

Answer 33

Captopril

Question 34

[How will you manage this case?] Low CO shock, systolic BP greater than 100?

Answer 34

Give Nitroglycerin 10 to 2 ug/min IV

Question 35

[How will you manage this case?] Low CO shock, Systolic BP 70 to 100 mmHg, No signs of shock?

Answer 35

Dobutamine 2 to 20 ug/kg per minute IV

Question 36

[How will you manage this case?] Low CO shock, Systolic less than 100mmHg, with signs of shock?

Answer 36

NE 0.5 to 30ug/min IV or | Dopamine 5 to 15 ug/kg/min

Question 37

Cite the SIRS criteria?

Answer 37

SIRS ``` Temp >38, or <36 RR >20 HR >90 WBC >12 Leukopenia <4000 or 10% bands ```

Question 38

Arterial hypotension is defined as

Answer 38

SBP <90 MAP <60 Changes in SBP from baseline >40

Question 39

What is the criteria for septic shock?

Answer 39

1. Infection 2. Vasopressor needed to maintain MAP >/65 3. Serum lactate >2 despite resuscitation

Question 40

Sepsis is diagnosed when...

Answer 40

1. Suspected infection PLUS | 2. More than 2 in SOFA points

Question 41

What are the most common gram positive bacteria that cause CAP?

Answer 41

1. S. aureus | 2. S. pneumoniae

Question 42

What are the most common gram negative bacteria that cause CAP?

Answer 42

1. E. coli 2. Klebsiella 3. P. aeruginosa

Question 43

[According to Surviving Sepsis] the recommended fluid resuscitation is ___

Answer 43

30cc/kg in the first 3 hours, crystalloids

Question 44

[According to Surviving Sepsis] the recommended vasopressor is?

Answer 44

NE then Epi Then add vasopressin to taper NE AVOID DOPA

Question 45

[According to Surviving Sepsis] the recommended antibiotics?

Answer 45

vancomycin + tapimycin (avoid double coverage)

Question 46

[According to Surviving Sepsis] the only transfuse when the Hgb is ___ in the absence of acute bleeding and MI

Answer 46

Hgb <7

Question 47

[According to Surviving Sepsis] what is the recommended TV

Answer 47

6mL/kg

Question 48

[According to Surviving Sepsis] what is the recommended plateau pressure

Answer 48

30cm H20

Question 49

[According to Surviving Sepsis] what is the target MAP

Answer 49

MAP 65 mmHg