Hint Hint Flashcards
(152 cards)
1
Q
Causes of increased lactate
A
Seizures, exercise, beta agonist use, infection, shock, alcohol ingestion
Type A: supply/demand imbalance
Type B: clearance problem (e.g. liver), drug induced production (beta agonist, metformin, cyanide), problem with krebs cycle (genetic cause)
2
Q
Steps to x Ray interpretation
A
- Pt identifiers / labels
- Type of film
- Adequacy (ribs, spine, clavicles)
- Tubes and toys
- Soft tissues
- Bones
- Mediastinum
- Lungs
3
Q
MUDPILES
A
Methanol Uremia DKA Paraldehyde Iron Lactate Ethanol/ethylene glycol Salicytes
4
Q
DO2 equation
A
DO2 = CO x CaO2
5
Q
Arterial oxygen content
A
CaO2 = Hgb x 1.39 x SaO2
6
Q
Normal ScvO2
A
60-80% (distal port on CVC, SaO2 on EPOC)
7
Q
IAH
A
Intraabdominal hypertension, end-expiration foley pressure > 12
8
Q
ACS
A
Abdominal compartment syndrome, decreased organ perfusion, sustained pressure > 20 at end expiration
9
Q
Parkland formula (BCEHS/VGH specific)
A
3 mL/kg/%BSA,
Give half amount over first 8 hrs
10
Q
Trauma assessment
A
Airway Breathing Circulation (carotid, femoral, pelvic binder, FAST) Disability (pupils, GCS, collar) Exposure, environment
11
Q
Massive transfusion end points
A
Hgb > 70 Platelets > 100 INR < 1.8 Temp > 36 Fibrinogen > 1.5
12
Q
Causes of hypoxemia
A
Shunt V/Q mismatch (dead space) Hypoventilation Decreased FiO2 Diffusion restriction
13
Q
Shunt
A
Perfusion - good
Ventilation - bad
14
Q
Dead space
A
Perfusion - bad
Ventilation - good
15
Q
Restrictive lung disease
A
Problems with lung/alveolar expansion (low compliance)
16
Q
Obstructive lung disease
A
Resistance to air flow within the lungs (high resistance)
17
Q
Cranial contents
A
CSF
Parenchyma
Blood
Mass effect (tumour)
18
Q
Spinal cord injury treatment goals
A
Maintain MAP > 85
Adequate ventilation and oxygenation
Hgb > 80
PaO2 > 80
19
Q
Burn treatment goals
A
SpO2 > 91
MAP > 65
HR < 130
20
Q
Principles of damage control resuscitation
A
Damage control surgery
Balanced haemostatic resuscitation
Permissive hypotension
21
Q
What are the principles of balanced hemostatic resuscitation?
A
Minimize crystalloid use Prevent acidemia Reduce coagulopathy Keep warm Give early blood
22
Q
Indicators for massive transfusion (ABC score)
A
Penetrating trauma
SBP < 90
HR > 120
Positive FAST
Need 2
23
Q
Burn goals
A
Urine output 30-50 mL/hr MAP > 65 Lactate <4 ScvO2 > 70 Hgb > 70
24
Q
Tx of abdo compartment syndrome
A
OG/NG Ultrasound for potential drain Proper analgesia (muscle relaxation) Reverse trendelenburg Paralysis Surgical intervention
25
West lung zones
```
1 = V > Q
2 = V =Q
3 = V < Q
```
26
Increasing PIP and Plat =
Decreasing compliance
27
Increasing PIP with minimal change in plat =
Increasing resistance
28
Driving pressure
ARDS related term
Plat - PEEP
15 is a good goal
29
Reasons for dysyncrony
Trigger
Flow delivery
I:E switch over
30
What to do on a high pressure alarm
```
1 check the circuit (kinked)
2 chest motion (pneumonia, r main)
3 suction
4 D/C vent and hand bag
5 check paralysis/sedation
```
31
Useful values of VBG
pH
CO2 (-15)
HCO3
32
Berlin criteria
Bilateral infiltrates on CXR
Non-cardiogenic pulmonary edema
P:F <300
> 1 week illness
33
Proning criteria
P:F < 150
Optimally ventilated
Dx ARDS
34
Tx for asthma
```
Ventolin 5 mg
Atrovent 500 mcg
Methylprednisone 125 mg IV
Mg 2 g IV
Epi
BPAP to buy time for Rx to work
Intubation with low RR, iTime, PEEP, high flow (ketamine, propofol for RSI)
```
35
LFTs
Albumin
PT
INR
Bili
36
Liver enzymes
AST
ALT
Alk Phos
GGT
37
Serum osmolality
(2 x Na) + glucose + urea
Normal 280ish
38
Approach to hypoxemia in ARDS
```
Increase FiO2
Maximize PEEP
Increase RR
Paralyze
AC to PC mode
Recruitment maneuver
Prone
Ti inverse
ECMO
```
39
Causes of hypoxia
Anemic
Hypoxemic
Histotoxic
Stagnant
40
Most effective interventions in reducing ICP
```
Temp control (parenchyma volume and blood volume)
CO2 (blood volume)
HOB 30 degrees (blood volume)
Loosen ties (blood volume)
EVD (CSF)
```
41
Intracranial pressures (normal, abnormal, severe)
Normal = 10
Abnormal > 20
Severe > 40
42
Reasons for decreased ScvO2
```
Increased extraction
High demand/metabolism
Low O2 supply
Lung/oxygenation problem
Decreased cardiac output
```
43
Reasons for high ScvO2
Histotoxia
Ischemic tissue
Decreased metabolism
Shunt (May be high or low)
44
Venous return equation
Mean systemic filling pressure - R atrial pressure
| / SVR
45
Driving pressure
Only applicable in ARDS
PPlat- peep
Driving pressure of 15 is a good goal
If you increase PEEP and driving pressure does not increase then you have recruited more lung.
46
Treatment pathways for hypoxia
VQ - edema = PEEP
- pneumonia = position, abx
Shunt = fluid, inotropes, vasopressors
Venous admixture - CO = inotropes
- SpO2 = oxygenation
47
Causes of fever
Infection
Connective tissue diseases
Malignancy
48
Sepsis end therapy goals
ScvO2 > 70
CVP 8-12
MAP > 65
Urine output > 0.5 ml/kg/hr
49
Sepsis tx algorithm
1. Source control
2. Early antibiotics
3. Adequate perfusion
4. Adjuncts
50
adequate lactate clearance
20% over 2 hrs (lecture)
Or
(Initial lactate - 2 hr lactate) / initial lactate x 100
51
qSOFA
GCS < 15
RR > 22
BP < 100
52
SIRS criteria
Temp 36-38
HR > 90
RR > 20
WBC 4-12
53
Sepsis
2 SIRS
| + confirmed infection
54
Severe sepsis
SIRS x 2
Signs of end organ damage
BP < 90
Lactate > 4
55
Septic shock
```
Despite adequate fluid resuscitation BP < 90
2 SIRS
Confirmed infection
Signs of end organ damage
Lactate > 4
```
56
Massive PE vs submassive
SBP < 90 after fluid resuscitation = massive
57
How to prevent aspiration during intubation
```
HOB at 30
Paralytic
Topical anesthetic
Suction ready
NG to aspirate GI contents
Cricoid Pressure
Low tidal volumes with BVM
```
58
Obstructive airway diseases
Asthma
COPD
CF
59
COPD exacerbation tx
```
Oxygen for SpO2 88%
Ventolin
Atrovent q 1 hr
Prednisone 50 mg PO/IV
Arterial line
Atypical antibiotic coverage
BPAP (unless drowsy, secretions or acidosis)
```
60
Rivers EGDT in sepsis
CVP 8-12
MAP > 65
ScvO2 > 70
Urine output > 0.5 ml/kg/hr
61
Preload assessment
```
CVP (trends, < 6 = give fluid)
IVC collapsibility (RASS -5, paralyzed, in sinus rhythm)
Pulse pressure variation on art line
Passive leg raise (30-45 sec if 10 pt increase in MAP = give fluids)
ScvO2 (< 70 = give fluid)
JVP
```
62
Cardiogenic shock algorithm
1. Fix the lungs (intubate, BPAP)
2. Optimize the MAP (> 65), consider vasopressors/fluid or vasodilators
3. Consider fluid removal
4. Consider inotropes in HFrEF (dopamine, dobutamine, milrinone)
5. Treat underlying etiology (rhythm, MI)
63
Dopamine vs dobutamine vs milrinone
Dopamine (mid = inotrope, increased HR) (high = inotrope, increased afterload/SVR)
Dobutamine (inotrope, decreased SVR, increased HR)
Milrinone (inotrope, decreased SVR, no effect on HR)
64
VAP bundle
```
HOB 30 degrees
Extubation
Subglottic suctioning
Oral care (including supraglottic suctioning)
Proper nutrition
```
65
Obstructive lung diseases definition
Conditions that make it hard to exhale all the air in the lungs (high resistance, hypercapneic)
66
Restrictive lung diseases
Difficulty fully expanding the lungs with air (poor compliance)
67
Measurement of fibrinolysis effectiveness in STEMI
Reduction in STE > 25% within 60-90 mins of administration
68
Wall tension equation
(Pressure x radius) / wall thickness
69
Elastance
Pressure / volume
How much pressure to recoil
70
Compliance
Volume / pressure
Pressure to distend
71
Cardiac output equation
EF x EDV x HR
EF = (SV / EDV) x 100
72
Type I MI
Occlusive obstruction
73
Type II MI
An imbalance between oxygen supply and demand unrelated to acute atherothrombosis
74
Rescue PCI
Within 24 hrs of failed fibrinolysis (STE not < 25 % , ongoing pain, arrthymia, cardiogenic shock)
75
Aortic dissection tx plan
SBP < 140
Labetalol 20, 40, 40, 80 mg q 10 mins
Hydralazine
Nitrates
76
STEMI for PCI algorithm
ASA
Ticigrelor
Heparin
77
STEMI for fibrinolysis algorithm
```
Within 12 hrs pain onset
ASA
Clopidogrel
TNK
Heparin
```
78
NSTEMI treatment algorithm
ASA
Clopidogrel/ticagrelor
Enoxaparin (12 hrs), fondaparinox (24 hrs), UFH (if renal failure)
79
Gustilo classification
Open fracture classification
I - clean wound of < 1 cm in length with simple fracture pattern
II - wound > 1 cm without extensive soft tissue damage and simple fracture pattern
III - wound associated with expensive soft tissue damage (should be given empirical antibiotics)
80
Rules for clearing c spine
```
NEXUS
D - deficit present
T - tenderness on midline palpating
A - altered LOC
I - intoxicated
L - leg fracture (I.e. distracting injury)
```
Require above without imaging, otherwise CT and GCS 15, or ALOC and MRI.
81
Crush syndrome vs compartment syndrome
Crush syndrome: the systemic manifestations of a crushed/ischemic muscle compartment
Compartment syndrome: increased pressure within a compartment results in insufficient blood supply to tissue within the compartment space
82
Eye vital signs
```
Visual acuity
Intraoccular pressure
Pupils
Extraoccular movement
Visual fields
```
83
Venous thromboembolism (penetrating neck wound) tx
Left lateral decubitus positioning to prevent air embolism in RV preventing forward flow (RV collapse)
84
Spinal motor exam (deficit levels)
```
C4 - spontaneous breathing
C5 - shoulder shrugging
C6 - flexion of elbow
C7 - extension of elbow
C8-T1 extension of fingers
T1-12 intercoastal/abdominal muscles
L1-L2 flexion at hip
L3 - adduction (in) at hip
L4 - abduction (out) at hip
L5 - dorsiflexion (up) of foot
S1-S2 plantar (down) flexion of foot
S2-S4 rectal sphincter tone
```
85
TILE score
Pelvic fracture score
Type A - stable, posterior arch intact
Type B - partially stable, incomplete disruption of posterior arch
Type C - unstable, complete disruption of posterior arch
86
Young Burgess classification
Pelvic fracture
Lateral compression
Anterior posterior compression
Vertical shear
87
Neck zones
I - base of neck to cricoid
II - cricoid to chin-ish
III - chin to base of skull (mostly posteriorly)
88
Ludwig’s angina
Bacterial infection that occurs in the deep neck tissues
89
ET tube placement on CXR
5 cm above carina
| In between clavicles and carina
90
CXR findings in pulmonary edema
```
Curly b lines
Peribronchial cuffing
Bat wings
Hilar congestion
(Cardiogenic will be concentrated around mediastinum whereas non-cardiogenic will be more diffuse)
```
91
Rigler’s sign
In abdo X-ray
Air in bowel combined with free air surrounding bowel creates greater contrast between bowel wall making intestinal structures easier to see (sign of a possible bowel perforation)
92
Steps to assess cervical x Ray
A - alignment of 4 lines in lateral view
B - bone
C - cartilage (look for consistent disc spacing)
S - soft tissues (C4 = < 7 mm, C7 = < 21 mm)
Odontoid view = lateral masses should be aligned between C1-C2 and spaces should be equal on both sides
93
Goals in aortic dissection
HR approx 60
BP 100-120 systolic
Labetalol
Hydralazine
94
Retroperitoneal organs
```
Part of duodenum
Ascending colon
Defending colon
rectum
Part of pancreas
Kidneys
Proximal ureters
Bladder
```
95
Types of fractures
```
Transverse (straight across bone)
Oblique ( diagonal across bone)
Comminuted (shattered fragments)
Spiral (around shaft)
Sigmental (floating section of broken bone I.e 2 fractures)
```
96
CT views
Saggital (divides L and R)
Coronal (divides front and back)
Transverse/axial (slices top and bottom)
97
4 A’s of anesthesia
Amnesia
Analgesia
Areflexia
Autonomic stability
98
Indications for intubation
```
Protection
Progression
Oxygenation
Ventilation
Refractory shock
```
99
Anaesthetics and MOA
```
Propofol (GABA-A receptor agonist)
Etomidate (GABA-A)
Midazolam (GABA-A)
Ketamine (NDMA receptor blocker)
Opiates (Mu receptor agonist)
```
100
GABA-A anesthetics and MOA
Propofol
Etomidate
Benzodiazepines
Activates post-synaptic GABA-A receptor causing influx of chloride leading to hyperpolarization and reduction in nerve impulse transmission.
101
NDMA anaesthetics and MOA
Ketamine
Antagonizes post-synaptic NDMA receptor (responsible for pain and awareness) which stops influx of sodium and calcium and stops eflux of potassium. Other Na/K pumps are still working in neuron which allows the propagation of other neural impulses (I.e. they are still responsive to commands).
102
MOA of opiates
Attaches to (primarily) Mu receptor which blocks the influx of Ca in presynaptic neuron.
Also opens K channels on post-synaptic neurons causing hyperpolarization
103
MOA of succinylcholine
Binds to post-synaptic nicotinic receptor which mimics the action of ACh and depolarizes cells. Not easily broken down by ACh-esterase therefore it prevents the neuron from depolarizing again.
104
MOA of rocuronium
Blocks nicotinic ACh receptor from becoming depolarized
105
```
Propofol
RSI
Maintenance
Onset
Duration
```
RSI 1-2 mg/kg (0.5 mg/kg if in shock)
Maintenance 30-60 mcg/kg/min
Onset rapid
Duration 10 mins
106
```
Midazolam
RSI
Maintenance
Onset
Duration
```
RSI 0.15-0.3 mg/kg (0.075-0.15 mg/kg)
Maintenance 2-15 mg/hr
Onset 3-5 mins
Duration 2 hrs
107
```
Ketamine
RSI
Maintenance
Pain
Onset
Duration
```
```
RSI 1-2 mg/kg (0.5-1 mg/kg if in shock)
Maintenance 1/2 induction dose/hr
Pain 0.1 mg/kg IV
Onset 1 min
Duration 15 mins
```
108
```
Fentanyl
RSI
Maintenance
Pain
Onset
Duration
```
```
RSI 1-2 mcg/kg (0.5-1 mcg/kg if in shock)
Maintenance 25-100 mcg/hr
Pain 25-50 mcg IV
Onset faster than morphine
Duration 30-60 mins
```
109
Rocuronium
Dose
Onset
Duration
1 mg/kg
Onset 1 min
Duration 30 mins
110
Succinylcholine
Dose
Onset
Duration
1.5 mg/kg
Onset 1 min
Duration 10 mins
111
Difficult BVM
```
Bearded
Obese
Old
Toothless
Sounds
```
112
Difficult intubation
```
Look
Evaluate 3-3-2
Mouth opening mallanpati
Obese/obstruction
Neck mobility
```
113
Non-anion gap metabolic acidosis differentials
GI loss
| RTA
114
TIMI score
```
Likelihood of ischemic events or mortality with UA/NSTEMI
Age > 65
3 or more CAD risk factors
Known CAD > 50%
ASA use in past 7 days
> 2 episodes of angina in last 24 hrs
ST deviation > 0.5
Elevated trop
```
115
Killip class
I- no signs of congestion
II- s3 / rales
III- acute pulmonary edema
IV - cardiogenic shock
116
Forester class
I - warm and dry
II- warm and wet
III- cold and dry
IV - cold and wet
117
Steps to head CT interpretation
1. Pt details
2. Technique
3. Orbits and soft tissues
3. Bones
4. Brain parenchyma
5. Ventricles
6. Midline structures
118
Fisher score
Used to estimate the risk of cerebral vasospasm after SAH using CT scan
Group 1: no subarachnoid blood detected
Group 2: thin layer less than 1 mm thick
Group 3: localized clots or layer more than 1 mm thick
Group 4: diffuse or no subarachnoid blood with intracerbral or intraventricular clots
119
Steps of neuro exam
1. Mode of ventilation
2. Sedation level
3. Open eyes - is there movement? (CN III, midbrain)
4. Pupil response to light (CN II, III, midbrain)
5. Corneal reflex (V, VII, pons)
6. Gag (IX, X, medulla)
7. Cough (X, medulla)
8. Respiratory centre (medulla)
9. Motor response GCS
10. Tone (flaccid, rigid, spastic)
11. Reflexes (biceps C5, wrist C6, elbow C7, plantar)
120
TBI goals
```
CPP > 60
MAP > 80 (systolic <160)
PaO2 100
PaCO2 35-45
Hgb > 90
```
Rapid transport for surgical etiology ( epidural, subdural)
121
BP target in ischemic stroke
Thrombolytics = 180
| No thrombolytics = 220
122
BP target in ICH
<140
123
Signs to intubation in SCI
```
Nasal flaring
Shoulder shrugging
Sternocliedomastoid muscle use
High RR with normocapneia
Paradoxical breathing
(If biceps curl ability present = phrenic innervation intact)
```
124
MAP target in SCI
> 85
125
Indications for prophylactic anti convulsants
Penetrating head trauma
Depressed skull fracture
Previous seizure disorder or presentation
Temporal pathology
125
FAST exam RUQ
Hepatorenal interface
Pouch of Morrison
Caudill tip of liver
Spine sign
Fan through
126
FAST LUQ
Spleno-renal interface
Caudile tip of spleen
Diaphragm and spleen* (at least 9 o clock)
127
FAST pelvis
Lateral view of bladder
Front view of bladder
Seminal vesicles should be black
Pouch of Douglas (females)
128
eFAST lungs
```
Highest point
Lung sliding (shimmering and comet tails)
```
129
FAST heart
Subxiphoid
Look for apex of heart and fan through
130
BP goal in SAH
If controlled < 220
| If not < 140
131
ACA occlusion
Contralateral leg
132
Left MCA occlusion
Right face, arm And speech deficits
133
Right MCA occlusion
Left face and arm deficits
134
PCA occlusion
Contralateral vision problems
135
Basilar artery occlusion
Acute LOC, normal pupils, locked-in syndrome
136
Internal carotid occlusion
Face, arm and leg deficits
137
Vertebral artery occlusion
Poor gag, poor coordination, hemianopsia
138
Occlusive CVA BP goals
No thrombolytics < 220
| Thrombolytics < 180
139
Symptoms SIADH
No urinary output
Dilutionally low Serum Na
Tx free water restriction (except in SAH with hypotension)
140
Symptoms of cerebral salt wasting
High urinary output
| Low serum Na
141
Central diabetes insipidus
Polyurea
Relatively high Serum Na
Tx DDAVP (synthetic ADH)
142
ONSD measurement
3 mm down from back of eye
> 6mm = ICP > 15
143
IVC collapsibility
1 cm right to midline
Look for hepatic vein draining into vena cava
Measure caudile to hepatic vein
50% indicates fluid replete
144
Dose of NTG and hydralazine in cardiogenic shock
NTG 20 mcg/min (100 not uncommon)
Hydralazine 5-20 mg IVP
145
Cardiogenic shock inotrope doses
Dopamine mid = 5-15 mcg/kg/min (increase inotropy, increase HR)
Dopamine high = 20-50 mcg/kg/min (increase inotropy, increase SVR)
Dobutamine = 2-20 mcg/kg/min (increase inotropy, decreased SVR, increase HR)
Milrinone = 0.25-0.75 mcg/kg/min (increase inotropy, decrease SVR, no effect on HR)
146
UFH doses
Bolus 70U/kg (max 5000U)
Maintenance 12U/kg/hr to PTT 50-75
147
Clopidogrel dose
600 mg for PCI
300 mg for fibrinolysis unless > 75 then 75 mg
148
Ticigrelor dose
180 mg
149
Timeline for rebleeding in SAH
Peaks at 7 days
150
Timeline for vasospasm in SAH
3-5 days after surgery
151
Indications for mech vent in neuromuscular disease patient
FVC < 20 ml/kg
MIP less than -30 cmH2O
MEP less than 40 cmH2O
VC decreased by 30% of normal
