Critical Care / Medicine

Question 1

How do you estimate blood volume?

Answer 1

60cc / kg
Blood volume is approximately half of body weight in a normal adult

Question 2

Classification for blood loss

Answer 2

Class I - EBL <750, BP and P and UOP nl
Class II - EBL 750-1500, UOP decreased, HR elevated, BP nl
Class III - EBL >1500, BP dropping, oliguria
Class IV - loss of vital signs, no urine output

Question 3

Types of shock

Answer 3

Hemorrhagic
Septic/Distributive
Obstructive
Cardiogenic

Question 4

Septic shock

Answer 4

Low systemic vascular resistance
High cardiac output
Low wedge pressure

Question 5

Hemorrhagic shock

Answer 5

High systemic vascular resistance
Normal cardiac output
Low wedge pressure

Question 6

Cardiogenic shock

Answer 6

High systemic vascular volume
Low cardiac output
High wedge pressure

Question 7

What clotting factors are in FFP?

Answer 7

FFP provides factors II, V, VIII, IX, X, XI, and antithrombin III and fibrinogen (lower concentration than cryo)

Question 8

What clotting factors are in cryoprecipitate?

Answer 8

fibrinogen (higher concentration), von Willebrand factor, factor VIII, factor XIII

Question 9

What is the massive transfusion protocol in OB?

Answer 9

1:1:6 - pRBC : plasma : platelets
(different in every hospital, may be 1:1:1 or 1:1:2)

Question 10

What is the goal level for fibrinogen in a hemorrhage?

Answer 10

> 100 or >150

Question 11

What electrolyte abnormalities can occur with massive transfusions?

Answer 11

HypoCa
Hyper K
Due to citrate in pRBC

Question 12

When to transfuse platelets?

Answer 12

<50 in massive bleeding
<10 for prophylaxis
<20 for procedures

Question 13

What is the definition of massive transfusion?

Answer 13

> 6u within 2 hours
replacement of >50% of blood volumes
10U within 24h

Question 14

what are adverse effects of massive transfusions?

Answer 14

Volume overload
HypoCa
HyperK
HypoMag
Hypothermia
Metabolic alkalosis (citrate)
DIC

Question 15

What is the fluid resuscitation for septic shock?

Answer 15

30 cc/kg/hr

Question 16

What is the goal for antibiotics administration in septic shock?

Answer 16

Broad spectrum antibiotics in <1hr
Blood cultures prior to antibiotics

Question 17

Virchow triad

Answer 17

Venous stasis
Endothelial injury
Hypercoagulability

Risk factors for PE

Question 18

What most affects nutritional status?

Answer 18

Weight > age > height

Question 19

Definition of malnutrition

Answer 19

albumin <3.4
loss of 15% of usual body weight

Question 20

What is the threshold for increased risk of low albumin?

Answer 20

Albumin <3
Associated with poor surgical outcomes, operative complications

Question 21

What is the mean survival after diagnosis after malignant bowel obstruction?

Answer 21

With TPN = 72days
Without TPN = 41days

TPN may buy about a month of time. No meaningful survival benefit.

Question 22

TPN complications

Answer 22

Infection
Cholestasis
Refeeding Syndrome
Overfeeding
Electrolyte abnormalities
Pneumothorax (with placement of line)

Question 23

Short bowel syndrome

Answer 23

<100-150cm of functional small bowel
Assoc with malabsorption, diarrhea, metabolic abnormalities, B12/fat soluble vitamin deficiencies
Caused by surgical resection AND radiation bowel injury

Question 24

Refeeding syndrome

Answer 24

Features:
- HypoPhos
- HypoK
- congestive heart failure
- peripheral edema
- hemolysis
- seizures

Due to aggressive nutrition replacement leading to fluid shifts/electrolyte imbalance

Question 25

Features of pre-renal etiology

Answer 25

FENA <1% Ur/Pr Creat >20:1 BUN/Cr >20:1 UNa <10 Uosm >500

Question 26

Causes of Afib

Answer 26

Hypoxia PE Volume overload Volume depletion

Question 27

A-fib with RVR treatment

Answer 27

Beta-blocker (first line) Diltiazem/amiodarone (second line, call cards)

Question 28

Hypertensive urgency

Answer 28

Systolic >160 Diastolic >100 Asymptomatic

Question 29

Hypertensive emergency

Answer 29

Systolic >180 Diastolic >120 + active endo-organ damage (encephalopathy, pulmonary edema, aortic dissection) Need IV tx (nitroprusside, nitroglycerin; also nicardipine, labetalol, esmolol, hydralazine) At risk for rebound hypoperfusion leading to stroke, MI, and blindness

Question 30

What antibiotics most commonly contribute to C diff?

Answer 30

Cipro PCN Cephalosporin

Question 31

Neutropenic Fever

Answer 31

T>38.3 x1 T >38.0 sustained over one hour May be limited by chronic steroid use, elderly age (may be hypothermic) ANC <1500

Question 32

Risks of neutropenia

Answer 32

ANC < 1500 = moderate risk ANC < 500 = severe infection risk ANC < 100 x3 weeks = 100% infection risk

Question 33

Tx of neutropenic fever inpatient

Answer 33

Zosyn or Cefepime

Question 34

Tx of neutropenic fever outpatient

Answer 34

Augmentin + Cipro

Question 35

What are the advantages of LMWH (lovenox) over unfractionated heparin?

Answer 35

More predictable therapeutic response Longer half life Lower risk of HIT Less bone mineral density loss

Question 36

What's the increase in cardiac output in pregnancy?

Answer 36

45%

Question 37

What's the cardiac output changes postpartum?

Answer 37

60-80% increase immediately postpartum then rapid decrease

Question 38

What is the change in HR in pregnancy?

Answer 38

20% increase