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Icu Flashcards

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1
Q

Indications for artificial ventilation in adult at rest

A

VC 10ml/kg
RR >35
AA gradient over 300mmhg

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2
Q

Types of ventilator associated lung injury

A 
Volutrauma 
Barotrauma 
Atelectatrauma 
Biotrauma (inflam) 
Sheer stress
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3
Q

Ventailator associated lung injury can appear like ARDS

A

True both can present bilateral infiltrates on CXR

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4
Q

How to set PEEP in VALI

A

Set PEEP at the lower inflection point (I.e the point that alveolar recruitment happens in inflation)

Note peep improves oxygenation but not mortality

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5
Q

Indications for artificial ventilation in gbs

A

VC <15ml/kg

Reducing trend

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6
Q

Clinical features of tricyclics antidepressant overdose

A 
Tachycardia 
Hypotension 
Flushed 
Raised temperature 
Dry mouth 
Dry skin 
Dilated pupils 
Seizures 
Agitation 
Reduced conscious level 
Urinary retention
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7
Q

ECG features of tricyclics antidepressants

A 
Sinus tachycardia
Short pr interval 
Wide qrs 
Long QT 
AV block
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8
Q

What is proposed mechanism for intralipid I’m drug toxicity ieLAST and TCA

A

Intralipid acts as lipid sink. Binds to free lipid soluble drug and reduces the free plasma concentration. Drug then redistributes from the tissues and is excreted as normal

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9
Q

Specific changes to ALS protocol in poisoning secondary to TCA or LAST

A

Administer hco3
Prolonged resuscitation
Use intralipid

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10
Q

Initial approach to poisoning

A 
ABCDE approach 
100% o2 
PPE 
Secure airway if GCS <8 
IV access and bloods for Fox inc paracetamol salicylate alcohol 
Toxbase 
Identify agent or toxidrome 
Specific antidote if available
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11
Q

Scoring tool by trauma audit and research network to measure overall severity of injury

A

Injury severity score
Out of 75
If any area gets a score of 6 (unsurvivable) they are automatically given score of 75
Injury severity score more than 15 is major trauma

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12
Q

3 core principles of damage control resuscitation

A 
Permissive hypotension (first clot is best) 
Haemostatic resuscitation with early use of blood 
Damage control surgery
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13
Q

Aims of damage control surgery

A 
Control haemorrhage 
Prevent triad of death 
Restore physiology 
Prevent contamination 
Return to theatre at later date to restore anatomy
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14
Q

What is triad of death in trauma

A

Coagulopathy
Hypothermia
Metabolic acidosis

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15
Q

Mechanism of action of TXA

A

Tranexamic acid is an antifibrinolytic that competitively inhibits the activation of plasminogen to plasmin

Therefore prevents plasmin induced fibrinolysis

Stabilises the clot

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16
Q

Dose of TXA

A

1 gram immediately (less than 3 hours)

1 gram over 6-8 hours

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17
Q

What evidence supports use of TXA

A

CRASH 2
Benefit if transexamic used less than one hour
Poor outcome more than 3 hours
Mortality reduced

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18
Q

Indications for tracheostomy (grouped)

A

Indications for trache grouped into

  • requirement for prolonged mechanical ventilation
  • provision of pulmonary toilet
  • protection of airway
  • management of upper airway obstruction
  • as part of a surgical procedure
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19
Q

Considerations choosing tracheostomy tube

A

Type and size (appropriate internal diameter remembering That inner tube may significantly reduce the diameter )

Subglottic suction required

Longer or extended tube size (obesity or anatomy may result in needing adjustable flange)

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20
Q

Checking position of trache on insertion

A

Capnography

Endoscope

Neutral head position

Leak test to 20-30cm h2o

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21
Q

NAP 4 most common reason for trache critical incident

A

Displaced trache

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22
Q

Project that audits and teaches re tracheostomy

A

National tracheostomy safety project

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23
Q

National tracheostomy safety project algorithm patent upper airway

A
  1. Call for help, look listen feel mouth and tracheostomy, mapleson c may help if available and capnography
  2. If breathing - high flow o2 to mouth and stoma
    (If not breathing cpr)
3. Assess tracheostomy patency 
Remove speaking valve 
Remove inner tube 
Try pass suction catheter 
If unable to pass deflate cuff 
Look listen and feel/map c/ capnography 
Is patient improving.
  1. If not improving remove trache tube
    Look listen feel/map c
  2. Is patient breathing
    No call resuscitation team, cpr if no pulse
  3. Primary emergency oxygenation
    Oral airway manoeuvres and cover stoma
    Or tracheostomy stoma ventilation

7, secondary Emergency oxygenation.
Oral intubation prepared for difficult intubation
Intubation of stoma

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24
Q

Complications of tracheostomy

A

Early
Haemorrhage
Pneumothorax
Failed

Short term 
Blockages 
Tube displacement 
Surgical emphysema 
Tracheal necrosis 
Tracheal arterial fistula

Long term
Tracheomalacua
Tracheal stenosis
Decannulation issues

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25
Bedside signs in tracheostomy
``` Size When was inserted (Tracheostomy vs laryngectomy) Why Inserted How ie surgical vs percuatneous Any sutures in place Any issues with airway and how was managed ```
26
Bedside equipment tracheostomy
Spare tube and inner cannula Suction Stitch cutters Emergency bell Fibreoptic scope nearby
27
Bleeding trache
Causes abberant vessels.... rarely Inominate artery fistula Suction External compression surgical clips or cautery Gauze soaked in adrenaline or tranexamic acid around bleeding site Consider hyperinflating cuff to tamponade Surgical exploration and repair
28
Types of RRT
Peritoneal dialysis IHD CVVHF CVVHD CVVHDF SLED (sustained low efficiency dialysis)SCUF (slow continous ultrafiltration)
29
Aims of RRT
Solute and water removal Correction electrolyte abnormalities Normalisation a die base
30
Basics how RRT works
Diffusion (hd)or convection (hf) Extracorpeal curcuit filled with blood Roller lumps control speeds of flow towards memebrane Por size of membrane effects what can pass through Middle molecules are preferentially cleared by convective measures Small molecules better cleared by diffusion
31
Describe haemofiltration in terms of CVVHF
Haemofiltration is a comvective process where a hydrostatic pressure gradient is used to filter plasma, water and solute across a membrane Solute drag where appropriately sized molecules are pulled along with mass movement of solute Convective transport is independent of solute concentration but determined by magnitude or transmembrane pressure Ie higher flow rate equals increased UF Measures that increase negative pressure across membrane including pump in effluent line can have marked effect - high volumes effluent discarded and circulating volume of patient replaced with balanced crystalloid buffer
32
Describe haemodilaysis as in CVVHD
Hamodilaysis solute clearance is achieved by diffusion across the membrane Space outside the blood containing fibres within the filter is filled with dialysate which is pumped counter current to flow. Diialysate is reconstituted to include a buffer and essential electrolytes Diffusion occurs down a concentration gradient to equilibrium - countercurrent maintains a waste solute gradient
33
Types of RRT membrane
Cellulose | Synthetic
34
Types of filter fluid in RRT
``` Lactate based (lactate accumulation in hepatic dysfunction) Hco3 based ``` Can be added before filter (reduces risk of filter clotting) or mixed with blood in venous drip chamber ( increases clearance solutes)
35
Positives of continuous RRT in icu
Enhanced haemodynamic stability Superior management of fluid balance Enhanced clearance of inflammatory mediators Better preservation cerebral perfusion No difference in survival benefit Kdigo favours CRRT for haemodynamic instability
36
Classical indications for initiating RRT
``` Refractory hyper Kalaemia over 6.5 Refractory fluid overload Refractory metabolic acidosis Certain drug and alcohol intoxication’s Signs of uraemia ie pericarditis or encephalopathy Temperature control ```
37
Risks of RRT
``` Cannula insertion Biocompatibility Fluid shifts Altered drug metabolism Nursing workload Cost ```
38
Discontinuation RRT
When kidney function improving Ie UOP Creatinine clearance
39
Dosing RRT
Continuous technieques dosing is sum of effluent in ml per kg per hour Initial high rates used but now dosing 20-25ml/kg/hr
40
Vascular access choices RRT kdigo
1) Right IJ 2) Femoral 3) Left IJ 4) Subclavian In order.
41
Anticoagulation in RRT
Systemic or regional anticoagulation Systemic heparin most common cheap but risk of haemorrhage and heparin resistance and HIT Systemic with heparnoids ie danaparoid especially if HIT Regional anticoagulation with citrate but as chelates calcium (inhibiting platelet aggregation) require calcium infusions, and potential metabolic complications (alkalosis and acidosis hypocalc and hypomagnesia) Regional prostacyclin
42
What percentage those with aki and RRT never regain full renal function
40
43
Classifications of renal failure
RIFLE (risk injury failure loss esrf) AKIN (aki network) Based in serum creatinine and urine output
44
Causes of non specific aki
``` Sepsis Critical Illness Circulatory shock Burns Trauma Cardiac surgery Nephrotixic drugs Radiocontrast agents ```
45
Susceptibilties to aki
``` Dehydration Age Female Black CKD DIABETES cancer Anaemia ```
46
Traumatic and non traumatic causes Rhabdo
Traumatic causes Crush injury Burns esp electrocution Compartment syndrome ``` Non traumatic Injection MH Serotonin syndrome Drug related Exertional Status Metabolic ie DKA ```
47
Clinical findings traumatic rhabdo
``` Signs of compartment syndrome ie Swelling tense Pallor Pain Myalgia ```
48
Tests for rhabdo
Urine for myoglobin Lactic acidosis CK over 5000
49
Principles of managing a patient with rhabdo
Aggressive fluid rehydration aiming for UOP more than 3ml/kg/hour Early surgical fixation cause Treat hyperk Alkalise urine Renal replacement therapy Early enteral nutrition MDT involvement
50
Electrolytes values for brain stem death
Na 115-160 K more than 2 Phosphate and mag 0.5-3 Glucose 3-20
51
Brain stem tests and CN
``` Pupillary light II III Corneal V and VII Ocvestibular reflex VIII and III,IV,VI Painful stimuli V VII Gag IX X Cough XX ```
52
Apnoea test
Increase fio2 to 1 ABG to calibrate ETCO2 Reduce minute volume until ETCO2 is 6 and ph 7.4 (sats 95%) Disconnect and apneoic ventilation 5 mins either with oxygen or CPAP Confirm increase paco2 more than 0.5kpa
53
Drugs used prior to organ donation
Vasopressin Methylprednisolone 15mg/kg T3
54
Absolute contraindications to donation
``` Cjd HIV disease Metastatic cancer Melanoma unless sumo,e Untreated TB Ages over 85 ```
55
Vasopressin functions physiologically
``` Reabsorb water at collecting duct (plasma osmolality) Maintains circulating volume ACTH release Thermoregulation Circadian rhythm ```
56
Vasopressin receptors
V2 kidney at CD V1 sm arteriolar (vasoconstriction) Oxytocin like receptors in myometrium (vasoconstriction) ACTH receptors pituitary (increase acth)
57
Pharm agents derived from vasopressin
Desmopressin DI VWD Terlipressin varicella bleeding Argipressin hypotensive or septic shock
58
Delirium
Delirium is acute syndrome Deficits in attention and cognitive function Hyper or hypo psychomotor activity Disordered sleep wake cycle
59
Features of hyperactive delirium
Agitation Delirium Can’t follow commands Hallucinations
60
How many types delirium
Hyper Hypo Mixed
61
Screening tools delerium
Cams ICU 4 AT Delerium detection score
62
Patient factors predisposing to delerium
``` Increased age Dementia Depression Alcohol or drug withdrawal Visual impairment ```
63
Critical illness factors predisposing to dementia
``` Acidosis Hypothermia Sepsis Anaemia Metabolic disturbances ```
64
Apart from pharmacological management what other management of delerium
``` Orientation ie clocks Sleep hygiene Maintain physiological homeostasis Management of withdrawal phenomenon Medications review ```
65
Types of critical illness weakness
Polyneurpathy Myopathy Neuromyopathy
66
Things to rule out before diagnosis of CIW
``` GBS CNS infection Anterior spinal artery stroke MG LEMS Porphyria Drug induced weakness ```
67
Patient factors contributing to CIW
``` Age Female Multiple comorbidities Infection Mof iPpv Hyperglycemia Low albumin ```
68
Pharm factors contributing to CIW
Neuromuscular blockade Long term steroids Aminoglycosides RRT
69
Motor findings in CIW
Symmetrical weakness Reduced reflexes Facial sparing Mrc scale out of 60- 48 suggests a diagnosis
70
Investigations of weakness in icu
LP for csf Nerve conduction MRI Muscle biopsy
71
Symptoms PE
Sob Cp Collapse
72
Signs of pe
Cyanosis Tachycardia Lous s2
73
Investigations in pe and what would be looking for
ECG sinus tachycardia Rv strain Echo rv dikation , tricuspid regurgitation Ctpa filling defect Vq mismatch
74
Management massive PE
``` Fluid resuscitation Consider intubation and ventilation Thrombolysis is hypotension and RVF Dobutamine MDT input ie cardiology Therapeutic anticoagulati’n Thrombectomy ```
75
Point of care ultrasound in icu
``` Airway and vascular use pre tracheostomy Diagnostic lung ultrasound Poc echo Placement of drains Oesophageal Doppler Trasncranial doppler ```
76
Indications for tracheostomy
``` Airway obstruction Airway protection Pulmonary toilet Long respiratory wean Laryngectomy ```
77
Benefits of percutaneous tracheostomy technique
Avoid transfer Reduced wound infection Reduced early complications
78
Things to check or do pre tracheostomy
``` Who checklist Check coagulation NG stopped 6 hours US neck Check airway equipment Check laryngoscopy view ```
79
Complications of tracheostomy early & management to help
Bleeding - use la with adrenaline Airway loss - 2 person procedure Pneumothorax - under direct vision Misplacement - under direct vision
80
What is nec fasc
Nec fasc is a subcutaneous infection through fasciae layers rapidly spreading leading to potential life threatening emergency
81
Risk factors nec fasc
``` Diabetes IVDU Malignancy Renal disease Obesity Peripheral vascular disease ```
82
Classification nec fasc
Anatomical Type 1 poly microbial Type 2 monomicrobial Type 3 grams negative Type 4 fungal
83
Diagnosis nec fasc
Clinical - pain more than expected, crepitus, bullae Investigations raised inflammatory markers raised CK low calcium CT air in fascia layers
84
Treatment nec fasc
Early diagnosis Broad spectrum antibiotics including clindamycin for endotoxins Debridement Hyperbaric oxygen Immunoglobulin (strep and staph) Organ support fluid resus and vasopressors
85
Benefits early nutrition
``` Reduced mortality Reduced length of stay Improved muscle function Reduced duration weaning Psychosocial Reduced wound breakdown Reduced infection ```
86
Energy requirements per kg by artificial nutrition
Energy 25kal per kg ``` Carb 2 gram per kg Protein 1 Fat 1 Sodium 1-2 mol kg day Potassium 1 mol kg day Calcium and magnesium 0.1 Phosphate 0.4 ``` Micronutrients ie zinc Immune modulators
87
Positives enteral nutrition
Cheap Reduced risk ileus Reduced risk gastric ulcers Reduced infection
88
Negatives enteral nutrition
Micro aspiration Displacement Peg if more than 4 weeks
89
Define acute liver failure
Specific liver condition that evolves rapids,h into life threatening illness Hallmarks are coagulopathy Hepatic encephalopathy
90
Hyper acute vs acute vs subacute liver failure
Hyperacute less than 7 days is rapidly evolving but also offset faster Acute 7-28 days Subacute 28 days to 12 weeks - more insidious BUT prognosis often poor by time diagnosed
91
Grades encephalopathy
Grade 1 mild Grade 2 disorientated Grade 3 incoherent, somnolence Grade 4 coma
92
Tests in acute liver failure
Intrahepatic tests ie LFTs, coagulation, ammonia Extra hepatic ie u&e, Fbc ``` For cause Viral screen Autoantibodies ie ana for aih or anti mitochorndrial psc Paracetamol levels Pregnancy test ```
93
Management ALF
Early intubation and ventilation Lung protective strategies but need to be balanced with cerebral protection Fluids and vasopressors. Avoid terlioressin in acute use norad Early renal replacement therapy if aki continous proffered Treat intracranial hypertension and seizur3s Coagulation abnormalities use TEG Sepsis most common cause death so prophylactic antibiotics especially if on urgent transplant ,list Treat hyperglycemia Early enteral feeding as protein catabolism Specific treatments Refer to specialist centre early NAC for paracetamol ( cysteine precursor of gluthione which neutralises NAPQI) Steroids for autoimmune Hep b lamivudine Wilson’s penicillamine ? Plasma exchange ? Mechanical assist Liver transplant definitive
94
Kings college criteria for paracetamol overdose liver transplant
Ph less than 7.25 Create more than 300 Inr more than 6.5 or PT more than 100 Grade 3 or 4 encephalopathy
95
Kings college non paracetamol guidelines
Inr more than 6.5 PT more than 100 Biki over 300 Jaundice to encephalopathy more than 7 days Seronegative

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