Critical care

Question 1

Admission criteria for ICU (2)

Answer 1

1) Reversible condition

2) Good functional capacity

Question 2

Scoring systems in ICU (3)

Answer 2

1) APACHE
2) SAPS
3) Mortality prediction model

Question 3

Levels of care in ICU (0-3)

Answer 3

0 - pt needs met on normal ward
1 - risk of deterioration, support of critical care team
2 - HDU (high dependency unit) - single failing organ support, post-op care
3 - ICU, resp support, support of at least 2 organs

Question 4

7 indications for sedation

Answer 4

1) Analgesia
2) Anxiety
3) Dyspnoea
4) Mechanical ventilation
5) Facilitate nursing care
6) Decrease oxygen consumption
7) Delirium

Question 5

5 main drugs used for sedation (& examples of each)

Answer 5

1) Opioids - morphine, fentanyl, femifentanil, alfentanil
2) Benzos - midazolam, lorazepam, diazepam
3) Propofol
4) Haloperidol (dopamine antagonist)
5) Alpha 2 agonists - clonidine, dexmedetomidine

Question 6

Amnesic & analgesic properties of sedatives

Answer 6

Opioids - analgesic but not amnesic 
Benzos - amnesic 
Proprofol - amnesic but not analgesic 
Haloperidol - amnesic 
Alpha 2 agonists - amnesic + analgesic

Question 7

Propofol
Mechanism of action
Effect on resp system
Effect on cardio system

Answer 7

Facilitate GABA transmission
RESP:
1) Resp depression - reduced tidal volume + increased RR
2) CO2 curve to right
CARDIO:
1) Hypotension due to vasodilation, bradycardia, reduced contractility

Question 8

What is ARDS?
Severity scale
4 Causes

Answer 8

Non-cardiogenic pulmonary oedema - damaged alveoli = leakage of fluid across alveolar capillary membrane
Severity by PaO2/FiO2 ratio (arterial O2 is less than inhaled = failure of lung to transport into blood):
Mild <300
Moderate <200
Severe <100

Causes:

1) Sepsis
2) Pneumonia
3) Trauma
4) Iatrogenic - transfusion, marrow transplant

Question 9

ARDS

• Sx 5
• diagnostic criteria 3

Answer 9

1) Cyanosis
2) Tachypnoea
3) Tachycardia
4) Peripheral vasodilation
5) Bilateral fine inspiratory crackles

1) acute
2) cxr = bilateral oedema
3) ABG = reduced PaO2/FiO2

Question 10

ARDS

- management

Answer 10

1) Mechanical ventilation
2) Avoid fluid overload
3) Severe - prone, neuromuscular blockade

Question 11

What is colonisation?

Answer 11

presence of bacteria without causing infection

Question 12

What colour do gram-positive & gram-negative bacteria stain?

Answer 12

POSITIVE = PURPLE 
NEGATIVE = PINK

Question 13

MRSA is sensitive to (5)

Answer 13

1) Vancomycin
2) Telcoplanin
3) Linezolid
4) Co-trimoxazole
5) Ciprofloxacin

Question 14

How to remember gram-positive cocci

How to remember gram-positive bacilli

Answer 14

+ COCCI:
strep, staph, Lactococci, Viridans, Enterococci = LOVE

+ BACILLI:
Actinomyces, Bacillus, Clostridium, Connybacterium, Listeria (ABC - cl)

Question 15

How to remember gram negative cocci

How to remember gram negative bacilli

Answer 15

• COCCI
  Neisseria (ne = neg), moraxella
• BACILLI
  most end in ella (shigella, klebsiella, legionella)
  Flew helicopter over camp, got water-borne diarrhoea, went to hospital = helicobacter, campylobacter, e.coli, vibrio, haemophilus, pseudomonas

Question 16

Abx treatment for c diff

Answer 16

Metronidazole/vancomycin

Question 17

What 3 main issues occur in post-critical care syndrome?

Answer 17

1) ICU-acquired weakness - breathing, muscle wasting, joint stiffness
2) Brain dysfunction - memory, attention, problem solving
3) Mental health problems - PTSD, insomnia, depression

Question 18

Mental capacity act
2 stage test
4 ways to confirm capacity
5 principles of MCA

Answer 18

1) Impairment of mind/brain?
2) Does it affect ability to make specific decision?

1) understand
2) retain
3) weigh up
4) communicate decision

1) presume capacity
2) support decision making
3) not lack capacity just because decision unwise
4) best interests
5) least restrictive option

Question 19

Is an advance statement/advance decision legally binding?

Answer 19

Advance statement - NO

Advance decision - YES, must be in writing, signed & witnessed

Question 20

What are 5 different reasons for futility & withdrawing treatment?

Answer 20

1) Physiological eg. giving adrenaline to hypotensive patient & no response
2) Benefit-centred
- quantitative: failed in last x times
- qual: QoL below threshold
3) Cost-based
4) Imminent demise - treatment won’t change fact that they will die
5) Lethal condition - won’t be affected by treatment & will die

Question 21

What 4 drugs are given at end of life

Answer 21

1) Morphine
2) Anti-emetic
3) Hyoscine Butylbromide
4) Midazolam

Question 22

What is the definition of death?

Answer 22

Irreversible loss of consciousness + irreversible loss of capacity to breathe

Question 23

How do you diagnose neuro death? (3)

Answer 23

1) Fulfilment of preconditions
- unconscious + apnoeic + mechanical ventilation
- irreversible brain damage of known aetiology
2) Exclusion of reversible contributions to state of apnoeic coma eg. drugs, cord injury, neuromuscular weakness
- nerve stimulator
- period of observation to allow drug elimination
- antagonist administration
- plasma analysis
- cerebral angiography
3) TWICE demonstrate coma, apnoea, absence of brainstem reflex activity
- pupillary constriction (CN 2 & 3)
- blinking (CN 5 & 7)
- eye movement (CN 3,4,6,8)
- response to painful stimuli (CN 5 & 7)
- gag reflex (9 & 10)
- cough reflex (10)
- apnoea test

Question 24

How do you diagnose cardiac death? (4)

Answer 24

After 5 mins asystole

1) loss of circulation - absence of pulsatile flow on arterial line/echo
2) absence of pupillary reaction
3) motor response to corneal stimulation
4) supra-orbital pressure

Question 25

What are the 2 types of organ donation & how do their processes differ? Liver & kidneys have a higher rate of non-function in... Warm ischaemic time for: liver kidney & pancreas lung

Answer 25

1) After brain stem death - diagnosis --> optimise --> mobilise team --> retrieval 2) After cardiac death - mobilise team --> wait for death --> diagnose --> retrieval Organ donation from circulatory death <30mins <60min <90min

Question 26

Absolute & relative CI for organ donation

Answer 26

ABSOLUTE 1) not on ventilator 2) >85 3) primary intra-cerebral lymphoma 4) secondary intra-cerebral tumours 5) Active cancer with spread 6) melanoma 7) TB 8) HIV RELATIVE 1) systemic sepsis 2) hep b/c 3) trauma to organ

Question 27

What is DIC and why is it a bad sign in shock?

Answer 27

When the body goes into shock the inflammatory markers will often also activate the CLOTTING CASCADE leading to SYSTEMIC PLATELET AGGREGATION and widespread microvascular thrombosis In DIC all of the products for coagulation are used up in the clots in the microvasculature and this means that there are no more platelets etc. for clotting elsewhere - it therefore presents with microvascular bruising or bleeding and extensive bleeding from surgical sites and wounds - microvascular HAEMOLYTIC ANAEMIA

Question 28

4 types of shock & examples

Answer 28

1) Hypovolaemic 2) Cardiogenic - MI, arrhythmia 3) Distributive - anaphylaxis, sepsis, neurogenic 4) Obstructive - secondary pump failure due to: impaired ventricular emptying: PE impaired ventricular filling: tension pneumothorax

Question 29

8 Signs of hypovolaemic shock impact on CO & SVR treatment (1)

Answer 29

1) pale, cool, clammy 2) syncope 3) weak 4) confused 5) Tachycardia 6) Tachypnoea 7) Low BP 8) Low urine output 9) signs of cause - tender epigastrium, grey turners/cullens. malaena Low CO Low SVR FLUIDS/blood transfusion

Question 30

10 Signs of cardiogenic shock Impact on CO & SVR Treatment (1)

Answer 30

1) pale, cool, clammy 2) chest discomfort 3) syncope 4) JVP 5) pulmonary oedema 6) orthopnoea 7) tachycardia 8) tachypnoea 9) low BP 10) low urine output Low CO Increased SVR Inotrope - Dobutamine

Question 31

7 Signs of anaphylactic shock Impact on CO & SVR Treatment (4)

Answer 31

1) flushed, swollen, itchy 2) low urine output 3) urticaria 4) LOC 5) bronchoconstriction 6) tachycardia 7) low BP Increase CO Decrease SVR 500mg adrenaline fluid challenge 10mg chlorphenamine 200mg hydrocortisone

Question 32

2 definition of septic shock 8 Signs of septic shock Impact on CO & SVR Treatment (1)

Answer 32

1) sepsis + lactate >2 2) sepsis + needing vasopressor to maintain MAP >65 1) pyrexia and rigors (rarely hypothermia) 2) nausea and vomiting 3) rash and menigism 4) warm peripheries, fast cap refill 5) bounding pulse 6) jaundice 7) bleeding dt coagulopathy (eg from vascular puncture sites) 8) confusion and reduced consciousness Increase CO Decrease SVR Vasopressor - Noradrenaline

Question 33

``` sepsis criteria temp HR BP RR WBC Mental state glucose urine output o2 sats creatinine bilirubin platelets ```

Answer 33

``` >38.3 or <36 >130bpm <90 >24 <4 or >12 altered mental state hyperglycaemia nil for 18h/<0.5 with catheter <91% creatinine >177 bilirubin >34 platelets <100 ```

Question 34

Signs of obstructive shock

Answer 34

1) Muffled heart signs 2) LOC 3) JVP 4) signs of poor perfusion

Question 35

NEWS measures 6 things

Answer 35

1) HR 2) BP 3) Temp 4) O2 sats 5) RR 6) ACVPU

Question 36

2 types of intra-vascular monitoring on ICU

Answer 36

- arterial line (measures BP and can get repeat ABGs from) | - central venous catheter (basically invasive measuring of JVP, can also give drugs like noradrenaline through)

Question 37

Define + causes Type 1 resp failure Type 2 resp failure

Answer 37

Hypoxia (perfusion problem - failure of oxygen exchange) PaO2 <8 PaCO2 normal/<6 1) cardiogenic pulm oedema 2) pneumonia 3) ARDS 4) asthma 5) lung fibrosis 6) septic shock 7) pneumothorax 8) PE Hypercarbia - ventilation problem, can't remove CO2 PaO2 normal/<8 PaCO2 >6 1) COPD 2) chest wall deformities 3) resp muscle weakness eg. gullain barre 4) resp depression from drugs

Question 38

6 Signs of respiratory distress

Answer 38

1) cyanosis 2) tripod 3) pursed lip breathing 4) accessory muscles 5) unable to speak complete sentences 6) confusion

Question 39

inspiratory:expiratory ratio what happens in obstrucive disease

Answer 39

1: 2 1: 3, 1:4 etc, trouble expelling air

Question 40

when listening to lungs where must you NOT forget to listen to?

Answer 40

AXILLA

Question 41

How to treat: type 1 resp failure type 2 resp failure

Answer 41

TYPE 1 Nasal cannula 2-6L/min or face mask 5-10L/min TYPE 2 aim 88-92% Venturi 24% or 28% or Nasal cannula 1-2L/min

Question 42

``` What are the patterns of: - FEV1 - FVC - FEV1/FVC ratio in: - normal lungs? - obstructive disease? - restrictive disease? ``` incl numbers if poss (% predicted and ratio as a decimal)

Answer 42

NORMAL - FEV1 >80% predicted - FVC >80% predicted - FEV1/FVC ratio >0.7 OBSTRUCTIVE - increased airway resistance eg. asthma, COPD - FEV1 <80% predicted (reduced) - FVC >80% predicted (may be slightly reduced) - FEV1/FVC ratio <0.7 (reduced) RESTRICTIVE - difficulty expanding eg. fibrosis, chest wall disease - FEV1 <80% predicted (reduced) - FVC <80% predicted (reduced) - FEV1/FVC ratio >0.7 (normal)

Question 43

What are the 5 different types of blood products? what are each used for?

Answer 43

WHOLE BLOOD - everything, incl clotting factors and plasma EXCEPT platelets - rarely used but good for acute large volume bleed PACKED RED CELLS - blood without the plasma - treating symptomatic anaemic and major acute blood loss (if give >4 units, give platelets too to ensure stability) PLATELET CONCENTRATES - just platelets - used to correct a low platelet count or before a procedure if bleeding is a big risk FRESH FROZEN PLASMA (FFP) - plasma, incl clotting factors - used for : - -- emergency reversal of warfarin - -- massive haemmorhage - -- intracranial bleed - -- DIC (to replace consumed clotting factors) - -- liver failure with bleeding CRYPRECIPITATE - specific clotting factors are centrifuged out of FFP - used to treat specific deficit conditions - haemophilia, vWD, low fibrinogen levels, DIC

Question 44

How much is 1 unit of blood?

Answer 44

around 500ml

Question 45

Complications of blood transfusion: - immediate? 4 - delayed? 5

Answer 45

IMMEDIATE: 1) Urticaria 2) Febrile non-haemolytic reaction - Sometimes there is an acute rise in body temperature when the blood is first run through 3) Dilution coagulopathy - After giving too much packed red cells you can dilute the clotting factors to the point where the person is at a bleeding risk (This is why you give FFP after 4 units of packed red cells) 4) Hyperkalaemia - Potassium is released during haemolysis and there will be some degree of breaking down of red blood cells in the bag and this will leak into the patient leading to elevated levels of potassium 5) Hypocalcaemia DELAYED: 1) Delayed haemolytic transfusion reaction 2) Graft versus host disease 3) Immunosuppression 4) Viral infection 5) Iron overload = hemochromatosis