final cram Flashcards
(91 cards)
1
Q
significant levels of troponin
A
I - 0.35
T - 0.2
2
Q
cardiac tamponade
A
muffled heart sounds
↑ CVP
paradoxical pulse (gt 10mm)
- abnormally large decrease in SBP during inspiration
3
Q
CURB-65
A
PNEUMONIA!
Confusion B*U*N gt 7 Respiratory rate g/e 30 BP - SBP gt/eq 90 or DBP lt/eq 60) 65
Scoring:
0-1: outpatient treatment
2: hospital admission
3-5: ICU consideration
4
Q
SIRS Criteria
A
2+ of…
HR gt 90 RR lt 20 - 32 gt T lt 36 - 38 gt - 96.8 - 100.4F WBC lt 4k - 12k gt - immature neuts gt 10
5
Q
sepsis
A
SIRS likely s/t infection; positive cultures add to validity but not required
PROBABLE OR CONFIRMED INFECTION!!!
clinical s/s: tachycardic, tachypnic, hypotensive, hypoxic, confused/lethargic/agitated, hyperthermic → Hypothermic
6
Q
severe sepsis
A
sepsis + at least 1 sign of hypoperfusion or organ dysfunction (new, not explained by other etiology)
7
Q
septic shock
A
severe sepsis associated with
- refractory hypotension (BP lt 90/60) despite adequate fluid resus
- and/or serum lactate gt 4.0
occurs with evidence of perfusion abnormalities: lactic acidosis, oliguria, AMS
- not perfusing brain, kidneys, lungs can’t compensate, other organ dysfunctions
8
Q
shock: management & hemodynamics goals
A
supportive therapy while finding/managing/tx shock source
- MAP gt 60
- CVP 8-12
- CI gt 2.1
- UOP gt 0.5 mg/kg/hr
- SaO2 gt 92%
- SVO2 gt 70
remember: septic has its own criteria
9
Q
ARDS: definition
A
acute lung injury manifested by non-cardiogenic pulmonary edema
result of inflammatory lung injury
10
Q
2 things present in all shock
A
- inadequate tissue perfusion
- cellular hypoxia (leads to dysfunction
11
Q
s/s hypovolemic shock apparent when
A
gt 15% volume lost
12
Q
vasopressors + hypovolemic shock
A
CAUTION. fill before you squeeze!
13
Q
main causes of obstructive shock x3
A
THINK FILLING & EMPTYING
decreased ventricular fill:
- cardiac tamponade
- tension pneumothorax
decreased ventricular emptying
- main PA or saddle PE
14
Q
volume/vasopressor + obstructive shock
A
gentle - it’s temporizing
15
Q
shock + vasopressin
A
adjunct if not getting a good response from patient
16
Q
1 cause of cardiogenic shock
A
MI
17
Q
neurogenic shock classic triad
A
bradycardia
massive vasodilation
hypothermia
d/t parasympathetic overstimulation
18
Q
neurogenic shock: avoid what drug and why?
A
phenylephrine - unopposed A1 activity could potentially worsen the shock
bradycardia d/t reflex vagus nerve - it’s a CNS effect esp at high doses
19
Q
anaphylactic shock meds list
A
EPINEPHRINE !!! - CV collapse without
- vasopressor & mast cell stabilizer (prevent histamine release)
IM 1:1,000 → Dose 0.1-0.5mg q10-15 min
IV 1: 10,000 → Dose 0.1 – 0.25mg q 5-15min
H1 blocker: Benadryl (only block receptor)
H2 blocker: Famotidine (Pepcid)
Respiratory: Albuterol
Corticosteroid: methylprednisolone
20
Q
epinephrine + anaphylactic shock
A
- CV collapse without
- vasopressor & mast cell stabilizer (prevent histamine release)
IM 1:1,000 → Dose 0.1-0.5mg q10-15 min
IV 1: 10,000 → Dose 0.1 – 0.25mg q 5-15min
21
Q
late phase anaphylactic reactions
A
- 6-12 hrs after initial rxn
- typically follow favorable response to treatment
- treated the same way
implications:
- airway mgmt: keep pts intubated 14-16 hours
- line maintenance: leave big IVs in
- ICU care: code cart & epi nearby
22
Q
anaphylactic shock + airway management important implication
A
keep intubated 14-16 hours after event - concern for late anaphylactic reaction
23
Q
sepsis: hemodynamic goals
A
within 6 hours of presentation/symptoms
CVP g/e 8-12mmHg MAP g/e 65mmHg UOP g/e 0.5ml/kg/hr SVO2 g/e 70% Lactate lt 2mmol
24
Q
surviving sepsis: goal directed treatment within 3 hours
A
Within 3 hours presentation of SIRS + strong indication organ failing
- Measure lactate level
- Obtain cultures before abx:
– 2 blood cultures
– +/- Urine culture - broad spectrum antibiotics
- 30ml/kg crystalloid “fluid challenge” for:
–hypotension
OR
– lactate g/e 4mmol/L
25
surviving sepsis: goal directed treatment within 6 hours
Within 6 hours presentation of SIRS + strong indication organ failing
- vasopressors (for hypotension that doesn't respond to initial fluid resuscitation)
- - GOAL: MAP g/e 65mmHg
- - NE first, then dopamine, then vasopressin
- if persistent hypotension after initial fluid administration (MAP lt 65mmHg)
OR
initial lactate was g/e 4mmol/L, re-assess volume status + tissue perfusion
-re-measure lactate if initial elevated
26
septic shock treatment considerations
- Fluids (crystalloids; albumin if needed)
- Vasopressors (NE, epi, vasopressin)
- Inotropes if cardiac dysfxn (Dobutamine, esp. w/ HF)
- Corticosteroids (only if unable to meet hemodynamic goal)
- Blood product administration (Goal Hgb 7-9g/dL)
- Sedation if intubated (Propofol, not benzos: ICU delirium risk)
- BG monitoring q2h/insulin use (goal BG 110-180 mg/dL)
- Renal replacement therapy in ARF
- Early but slow enteral feeding (GI perf/peritonitis – be cautious)
- DVT/GI prophylaxis (Lovenox, heparin, PPI/H2 antagonist)
27
septic shock
- Fluids (crystalloids; albumin if needed)
28
septic shock - Vasopressors
NE, epi, vasopressin
29
septic shock inotropes
- if cardiac dysfxn (Dobutamine, esp. w/ HF)
30
septic shock - corticosteroids
only if unable to meet hemodynamic goal
31
septic shock - goal hgb
Goal Hgb 7-9g/dL
with blood product admin
32
septic shock - Sedation if intubated
Propofol, not benzos: ICU delirium risk
33
septic shock - BG monitoring
q2h/insulin use (goal BG 110-180 mg/dL)
34
septic shock + ARF?
renal replacement therapy
35
septic shock - early but slow enteral feeding
GI perf/peritonitis – be cautious
36
septic shock - DVT/GI prophylaxis
Lovenox, heparin, PPI/H2
37
documentation/evaluation of volume resuscitation in septic shock x2
EITHER repeat focused exam (after initial fluid resuscitation) -- VS, CV, cap refill, pulse, skin findings
```
OR 2+ →
CVP
ScvO2
Bedside CV US
dynamic assessment of fluid responsiveness with passive leg raise or fluid challenge
```
38
how do we know a shock patient is better?
- stable VS with ↓ pharm/non-pharm support: HR 60-90, MAP gt 65, CVP 8-12
- adequate UOP: 0.5 - 1.0 ml/kg/hr
- evidence of adequate O2 delivery/utilization: SVO2 65 - 75
- lactate levels normalized
- improvements in PE
39
SIRS: hypotension refractory to fluid replacement consideration
(a) hang 1000mL NS/LR, 200mL stays in vascular bed
- - LR requires functional liver to create buffer
(b) hang 1000mL D5W bag, 800mL stays in vascular bed
guidelines: LR or NS
40
ARDS: first major change
Inability to oxygenate
Further destruction of alveoli
- shunting (blood passing by non-vent alveoli & bypassing ventilated)
refractory to O2 increase: junk in alveoli = UP THE PEEP
41
ARDS: second major change
Narrowing of small airways
Damage to lung microvasculature
- V/Q imbalance d/t alveolar dead space (alveoli full of junk) = no gas exchange
42
ARDS: third major change
Elevated pulmonary artery pressure (vasoconstriction d/t hypoxia)
Increased PVR
*Not an increase in wedge!*
43
ARDS: first phase
| definition + s/s
exudative - first 72 hours
- angry neuts increase lung injury & cap permeability
- - increased alveolar edema
- - macrophages + mediators = pulmonary bed vasoconstriction = V/Q mismatch (blood bypass ventilated alveoli) = pulm htn
```
clinical s/s: may only see tachypnea & dyspnea
• Coarse crackles
• Cyanosis
• Tachycardia
• Lungs less compliant
• Dec ventilation of alveoli
• Hypercapnia
```
44
ARDS: second phase
| definition + s/s
proliferative - 4 to 21 days
- resolution of pulmonary edema
- type II pneumocytes hyperplasia
- proliferation fibroblasts
- hemorrhagic exudate → granulation tissue (hyaline membrane)
s/s: PROGRESSIVE HYPOXEMIA
45
ARDS: third phase
| definition + s/s
remodeling & fibrosis - 14 to 21 days
- alveoli + bronchioles obliterated
- decreased FRC
- more V/Q mismatch/shunting
clinical s/s
initial: restlessness, respiratory alkalosis s/t hyperventilation (↑ pH, ↓ paCO2, HCO2 normal) + non-specific complaints
rapid progression to: respiratory distress, non-compliant lungs (more P to get same TV), crackles everywhere, elevated pulmonary airway pressure (PIIP), REFRACTORY HYPOXEMIA
P/F lt 200
46
P/F definition for ARDS
lt 200
47
normal PF
gt 286
| lt 200 represents significant shunt gt 20% - ARDS
48
a/A + PaO2/PAO2
a/A - what's available in blood vs what's available in alveoli
P/P - % O2 diffusing across alveoli into blood
normal: gt 45% or 0.75
49
diagnostic criteria for ARDS
* Bilateral pulmonary infiltrates (whiting out on CXR)
* PCWP lt 18mmHg (no LVHF - normal 5-12)
* Severe hypoxemia
* PaO2/FiO2 lt 200
50
Berlin Criteria Definition of ARDS
mild: P/F 201-300
moderate: P/F 101 - 200
severe: P/F lt 100
51
ARDS management goals
maximize pulmonary gas exchange
optimize O2 delivery to tissues
prevent further organ injury
52
septic shock: evidence of perfusion abnormalities
occurs with evidence of perfusion abnormalities (lactic acidosis, oliguria, mental status changes, other organ dysfunctions)
53
EF + sepsis
low d/t myocardial depressant factor
54
sepsis causes
bacteria 85% of time
- gram neg (like e coli) release endotoxins - inflammatory cascade
- gram pos
55
surviving sepsis: fluid resuscitation
crystalloids - begin in ED
- 1st 30 min bolus 500-1000cc (cryst)
- 30 ml/kg/hr for hypotension or lactate gt 4
GOAL: CVP g/e 8 or CVP on vent g/e 12
goals not met? consider PBRC (goal hct g/e 30%)
56
surviving sepsis: blood products considerations
consider PRBC if hgb lt 7
- goal hct g/e 30%
platelets
- plt lt 5000
- plt 5-30k + high risk for bleeding
57
surviving sepsis: mechanical ventilation considertions
- target TV 6ml/kg (low)
- PEEP (beware tension pneumo)
- permissive hypercapnia
- sedation: intermittent bolus OR continuous with daily interruption/lighting to produce awakening
58
MODS
begins with SIRS = subtle changes = dysfunction/ progressive failure 2+ organ systems d/t circulating mediators + clinical conditions
59
SIRS to MODS transition
a) Failure to control source of inflammation/infection
b) Persistent perfusion deficit
c) Flow-dependent O2 consumption (abnormal DO2 & VO2)
d) Necrotic tissue
60
SIRS/MODS patho summary
a) Maldistribution of vol → vasodilated + third spacing
b) Imbalance O2 supply/ demand (abnormal DO2 and VO2)
c) Hypermetabolic
if A + C can't be fixed MODS OCCURS
the problem: inflammatory/immune response is over-activated, the body
can’t clear the mediators and toxic metabolites fast enough and a self-perpetuating cycle exists
61
when does MODS occur?
after SIRS when vasodilation, third spacing, and hypermetabolic state can't be fixed
62
MODS: hyperdynamic CV response
INITIAL RESPONSE
↑ CO, HR, DO2, VO2
↓ PAWP, CVP, SVR
63
MODS: hypodynamic CV response
many mediators = myocardial depressants; their continued influence = ↓ myocardial contractility/function
↓ CO, DO2, VO2
↑ CVP
Tachycardia, dysrhythmias, weak pulses
64
why does MODS hypodynamic CV response happen?
many mediators = myocardial depressants; their continued influence = ↓ myocardial contractility/function
65
cranial nerve III vs IV, VI
CN III is PERRLA
CN III, IV, VI is EOM intact - each is responsible for 2 movements
66
stage 1 hypertension + drugs
140-159/90-99
| Thiazide OR consider ACEi, ARB, CCB, BB (no comorbs)
67
stage 2 hypertension + drugs
≥ 160/100
| 2 drugs - Thiazide + ACEi, ARB, CCB, BB (no comorbs)
68
Target Organ Damage (MI, HF, CVA, DM, CKD) + htn drugs
- combo diuretic, ACEi, ARB, CCB, BB, Aldactone
- lifestyle modification & pharm
- if BP > 20/10 above goal → thiazide + other.
69
use diaphragm
Diaphragm: medium-high sounds,S1, S2
70
use bell
Bell: low pitched sounds
| mitral stenosis, diastolic murmurs, S3, S4
71
S3
indicates difficulty w/ passive filling LA to LV (mitral valve is open & blood is flowing in)
```
VENTRICULAR gallop – “Kentucky”
PASSIVE FILLING into noncompliant LV
early diastolic, bell, mitral area
Left lateral position may increase the sound
Associate with HF (chronic or AMI)
```
72
S4
“atrial kick" - difficulty with active filling, LA actively contracting (typically, compensate↑ CO by ~25% but if bad contraction—heart will lose atrial kick = s4)
- ventricle can no longer take any more
ATRIAL gallop – “Tennessee”
Blood entering noncompliant ventricle during ATRIAL CONTRACTION
late diastolic, bell, mitral area
Left lateral position may increase the sound
Associated with CHF, MI, AoS, HTN, and CAD
A-fib will NOT have an S4 (no atrial kick)
73
you will not hear this heart sound with afib
S4 because a fib has no atrial kick
74
summation gallop
S3 and S4
Implies significant HF
75
S1
Best heard with the diaphragm
Loudest at the apex
Mitral and tricuspid valves close
76
S2
Best heard with the diaphragm
Loudest at the base
Aortic and pulmonic valves close
77
heart failure - decrease in CO leads to?
RAAS activation:
sodium retention secondary to ALDOSTERONE
fluid retention ADH
vasoconstriction increases afterload - ANGIOTENSIN II
78
neurohormonal model
accounts for the effects of
- prolonged sympathetic stimulation (first)
- prolonged angiotensin release (kidneys need more volume)
- prolonged aldosterone release
serves as the basis for the treatment of heart failure
79
systolic heart failure: loop diuretics
do not impact neurohormonal model!
80
heart failure: beta blockers positive benefits
reduce sympathetic nervous system response by decreasing circulating catecholamines
reduce overstimulation of renin angiotensin system
81
most common reason for diastolic heart failure
chronic hypertension
82
acetaminophen consideration
Interferes with warfarin to prolong PT/INR
| Steven Johnson Syndrome
83
Tetraology of Fallot
Pulmonary stenosis, VSD, and R to L Shunt (cyanotic)
84
alpha nerve fibers release
NE - eye dilation, clammy, hypo bowel
| PERIPHERAL vasoconstriction, ↓ UOP, cool skin, gas exchange, bowel sounds
85
beta nerve fibers release
Epi - ↑ BG, heart & lung vasodilation, blood flow=O2 delivery
NE - ↑ free fatty, tissue perfusion, myocardial O2 needs
86
prolonged stress response is what?
medulla secreting more catecholamines
87
BP goal for young, healthy (less than 60)
lt 140/90
88
BP goal for older adult (60+)
lt 150/90
89
Max. Target HR
220 – Age
90
ideal body weight
Women: 100 lb + 5 lb for every inch over 5 feet
Men: 106 lb + 6 lb for every inch over 5 feet
91
caloric need
IBW x 10 = basal caloric needs
• Basal caloric needs + [IBW x activity level]= total cals needed
Activity level
• 3= Sedentary
• 5= Moderate
• 10= Strenuous
