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A ORAL BOARDS 2016 > ICU > Flashcards

Flashcards in ICU Deck (82):
1

1.5 years s/p renal transplant fever work-up

cxr
CBC
blood cx
UA
renal bx

adrenal function

tenderness over graft

2

1.5 years s/p renal transplant fever and interstital process on cxr: dx, w/u, tx

CMV
fiber optic bronch

need to rule out any bacterial causes.

CMV cultures,
and send IgO and IgM titers and would start the patient on
ganciclovir .

on broad-spectrum antibiotics, to
cover the gram-positive,
Vancomycin for gram-negative,
prophylactic antifungal ie. fluconazole; Bactrim for Pneumocystis carinii prophylaxis.

CAT scan of the chest and
abdomen.

I would continue the ganciclovir for six weeks and after that, I
will switch the patient to acyclovir.

3

Frank:
Starling curve is optimized

for fluid ressus of patient with recent MI and peritonitis from diverticulitis

shooting for a cardiac index of more than 2,

wedge pressure of 14 to 18,

SVR less than 1,000

4

V tach (or V fib) ACLS


CPR
One mg epinephrine (repeated every three minutes)

Shock 300 jewels

CPR
300 mg amiodarone

Shock 360 jewels

CPR
150 mg amiodarone

Shock 360 jewels

Also try given:

Magnesium 2 – 3 g IV
Procainamide 100 mg Q5 minutes
Bicarb 1 amp
Lidocaine 1 mg per kilogram IV

5

5 Hs and 5 Ts

these are cause of PEA and Asystole:

Hypovolemia, Hypoxia, Hydrogen ion (acidosis),

Hyper-/hypokalemia, Hypoglycemia, Hypothermia.

think cardiopulm bypass and what is associated with stopping the heart:
hyper k (cardioplegia), acidosis hypothermia, hypotension, hypoxia

The T’s include:

Toxins, Tamponade(cardiac),Tension pneumothorax, Thrombosis (coronary and pulmonary), and Trauma.

think trauma box work up:
Tenssion ptx, tamponade, trauma, thrombosis, toxins

6

ABG

pH 7.4 7.35 to 7.45
Pa02 90mmHg 80 to 100 mmHg
Sa02 93 to 100%
PaC02 40mmHg 35 to 45 mmHg
HC03 24mEq/L 22 to 26mEq/L

7

post arrest care

EKG
Echo
ABG, lytes, cbc, lactate, base def

Inotropic and vasopressor support can mitigate the myocardial dysfunction that is common during the first 24 to 48 hours after cardiac arrest [20,39].

no evidence demonstrating the superiority of any one vasopressor in the post-cardiac arrest patient. Commonly employed vasopressors include

dopamine (5 to 20 mcg/kg per minute),

norepinephrine (0.01 to 1 mcg/kg per minute; 0.5 to 70 mcg/minute),

epinephrine (0.01 to 1 mcg/kg per minute; 0.5 to 70 mcg/minute).

In cases of cardiogenic shock (eg, global

dobutamine (2 to 15 mcg/kg per minute)
or
milrinone (loading dose: 50 mcg/kg over 10 minutes, then 0.375 to 0.75 mcg/kg per minute)

Either agent may cause hypotension from vasodilation; dobutamine may cause tachyarrhythmias.

Antiarrhythmic drugs should be reserved for patients with recurrent or ongoing unstable arrhythmias.

No data support the routine or prophylactic use of antiarrhythmic drugs after the return of spontaneous circulation following cardiac arrest, even if such medications were employed during the resuscitation.

Determining and correcting the underlying cause of the arrhythmia (eg, electrolyte disturbance, acute myocardial ischemia, toxin ingestion) is the best intervention. (See 'Determining the cause and extent of injury after cardiac arrest' above.)

8

low UOP w/u

flush foley
bladder scan
(FeNa if urine)
renal US
BMP / lytes
UA - spec grav / proteinuria / casts
myglobin

CXR
EKG
(enzymes)

CVP / swan

9

Indications for renal replacement therapy

acidosis refractory
Acute severe electrolyte changes - hyper K!

Toxins: methanol/ethanol

Volume overload
Uremia:
Encephalopathy
Severe azotemia – BUN > 100
Significant bleeding
Uremic pericarditis

A – Acidosis – metabolic acidosis with a pH 6.5 mEq/L or rapidly rising potassium levels; see previous postfor a review of the causes and management of hyperkalemia

I – Intoxications – use the mnemonic SLIME to remember the drugs and toxins that can be removed with dialysis: salicylates, lithium, isopropanol, methanol, ethylene glycol

O – Overload – volume overload refractory to diuresis

U – Uremia – elevated BUN with signs or symptoms of uremia, including pericarditis, neuropathy, uremic bleeding, or an otherwise unexplained decline in mental status (uremic encephalopathy)

10

Medication associated with adrenal insufficiency

Etomidate–though, usually not one time bolus

11

SSx of adrenal insuf


Inability to wean from the ventilator

Persistent hypotension that is vasopressors dependent

Low sodium and high potassium

Unexplained fever

Weakness

vague abd pain

12

adrenal insuf test

Cortisol may be checked at any time in the critically ill
proposed as the appropriate minimum value :

18 is considered normal stress repsonse
for being in the ICU - below this is insuf
(range, 10 to 34 μg/ dL);

"18 year olds are old enough for trauma and have enough cortisol)


(ACTH) stimulation NOT USEFUL in TRAUMA / ICU

administering 250 μg of ACTH (cosyntropin) either intravenously or intramuscularly.

Cortisol levels 30 and 60 minutes

delta 9



who showed a change in baseline cortisol levels by 9 μg/ dL at 30 or 60 minutes during the ACTH stimulation test had lower mortality rates if they received corticosteroids. This test is thought to demonstrate adrenal reserve in the face of critical illness or sepsis but



low-dose version of the ACTH stimulation test

only 1 µg of cosyntropin is administered intravenously.
Due to the low dose, it is thought that it is more sensitive for partial AI.

13

best steroid replacement

The administration of hydrocortisone (150 to 200 mg daily for 5 to 7 days) has been shown to lead to a decreased vasopressor requirement as well as improved organ dysfunction, fewer ventilator days, fewer ICU days, and most importantly lower 28-day mortality.

50 mg IV q 6 hr

or

100 mg q 8 hr

14

The differential diagnosis of severe hypoxemia in this patient ICU

Aspiration pneumonia
or
pneumonitis

Pulmonary embolus

Heart failure

Pulmonary edema

Transfusion-associated acute lung injury (TRALI)

Acute respiratory distress syndrome (ARDS)

15

ARDS is a syndrome defined by

1 acute onset

2 pao2 / fio2

16

Workup The workup for ARDS includes

exclude the other potential diagnoses of the acute hypoxemic respiratory failure.

Transthoracic Echocardiography This diagnostic test is used to evaluate for cardiogenic pulmonary edema.

no evidence of right heart strain or right ventricular dysfunction that may be present in patients with pulmonary embolus.

Laboratory Tests Arterial blood gas confirms hypoxemia,
PaO2 of 85 mm Hg on FiO2 1.0, which confirms a PaO2/ FiO2 ratio ≤ 200 mm Hg.

Brain (B-type) natriuretic peptide (BNP) levels are elevated in acutely decompensated heart failure, so low levels may be indicative of a diagnosis of ARDS.

Sputum Respiratory cultures should be obtained to evaluate for possible bacterial or aspiration pneumonia as the etiology of the patient’s acute respiratory failure.

Electrocardiogram Electrocardiogram (EKG) without MI or Right heart strain

consider Duplex

consider CT chest

17

vent goals for ARDS

lung protective vol 6 cc /kg vol

permissive hypercapnea

incr PEEP

fluid conservative considered if ressuss done

good lung down

---
others:
incr PEEP
(watch ptx)

reverse I:E

prone


Airway release ventilation

or

high-frequency oscillatory ventilation

RESCUE:
Recruitment maneuvers
Prone position
Inhaled nitric oxide
Inhaled prostaglandin
ECMO


18

vent setting for ARDS


Plateau pressure goal less than 30

PH goal 7.3 point three– 7.4

19

VAP reduction

head of bed 30
Oral care

silver impreg

20

REcruitment

cont positive airway pressure:

30 cm h20 PEEP for 30 sec

risk ptx, hypoxia, hypotension

21

ECMO

veno-venus

22

VAP basic definition

Defined as a pulmonary infection that starts after 48 hours of mechanical ventilation

leading cause of death in ICU!

second most common nosocomail infection in ICU

23

Criteria to diagnose VAP

Fever
WBC
New infiltrate

--

Fever
WBC
Lung infiltrate
Nature of tracheal secretion
Oxygenation
+/- bronchoalveolar lavage gram stain finding of

neutrophils OR bacteria

NO sputum

24

Collecting source to w/u BAL

bronchoscope
or

coaxial catheter that is inserted blindly through the endotracheal tube.

The latter approach, called the mini-BAL -diagnostic yield is considered similar to conventional bronchoscopy.

Additionally, some ICUs use a protective brush inserted via a bronchoscope to obtain direct cultures from the affected area of the lung.

The brush is then retrieved and directly plated onto the culture media.

bacterial burden of more than 10 to the 4 CFU/ mL.

25

bacteria and abx VAP

early ( 4 ventilator days).

early VAP
Enterobacteriaceae
or
gram-positive organisms such as
staph

second-generation cephalosporins,
fluoroquinolones,
extended-spectrum penicillins as a single agent.

Late VAP
invariably resistant organisms

methicillin-resistant
Staphylococcus aureus (MRSA),
Pseudomonas species,
Acinetobacter species

combination therapy

vancomycin plus beta lactams

(third-generation cephalosporins, carbapenems)

or

fluoroquinolones +/ − aminoglycosides is

26


Torsadeselectrolyte disturbances

hypokalemia

and

hypomagnesemia



27

Treatment of intermittent torsades

stable patients

correcting any underlying metabolic or electrolyte abnormalities

INCRASE! the heart rate to shorten ventricular repolarization.

Intravenous magnesium sulfate is also effective in treating paroxysmal torsades.

28

early Sepsis swan findings

high output cardiac failure,

SVR is decreased due to toxins that produce vasodilation.

SvO2 should be HIGH because the tissues are unable to extract oxygen from the blood effectively.

29

what type of line has the highest DVT risk


Femoral catheters (complete contratindicaiton in peds)

30

list order of lest to greatest infection risk with lines

Sublavian (lowest infection)
IJ
Femoral (highest infection)

31

cause of hypoxemia in pulmonary embolism


Ventilation-perfusion (V/Q) mismatch


32

increase the p50 of normal hemoglobin Increased:


2,3-DPG,
temperature,
PCO2
(incr Hydrogen / decreased pH

33

Norepinephrine mech

stimulates

alpha-1,

alpha- 2,

beta-1


The effect
increased contractility

peripheral and splanchnic vasoconstriction.

34

The most important determinant of Arterial oxygen content

The most important determinant in this equation is the hemoglobin level

1.34 x Hgb


CaO2 = (1.34 x Hgb x SaO2) + (0.003 x PaO2).


The SaO2 and the PaO2 play a smaller percentage in determining the overall content.

35

A sudden drop in end tidal CO2 upon induction of pneumoperitoneum


should raise the suspicion for a CO2 embolus from the pneumoperitoneum.

Careful, this is paradoxical that endtital CO2 is low with too much CO2 collected in vascular system -> heart!

36

Managment of A sudden drop in end tidal CO2 upon induction of pneumoperitoneum


Suspect a CO2 embolus from the pneumoperitoneum

First,
the ventilator tubing should checked

discontinue the pneumoperitoneum,

place the patient in the left lateral decubitus position,

attempt to aspirate the air from a central line in the right atrium.

Hyperventilating can help to diffuse the carbon dioxide.

37

increase in end tidal CO2 is indicitive of what beside MH and what is treatment


alveolar hypoventilation

Increasing the tidal volume is the treatment for

38

This patient has SIADH as evidenced by
vol
sodium
urine osmo
urine na



normovolemic

hyponatremia (water in more than Na)

urine osmolality greater than 100 mOsm/kg

urine sodium greater than 20 mEq/L (concentrating urine)

39

current guidelines recommend a delay of how long before withdrawing DUAL antiplatelet therapy for a nonurgent operation for bare metal vs drug-eluting stent


4–6 weeks after placement of a BARE METAL stent

6–12 months! after deployment of a DRUG ELUTING
stent

The incidence of perioperative death, myocardial infarction, and stent thrombosis may be as high as 30% within the first month, regardless of the type of implanted stent.

Although this risk decreases over time, some studies have suggested that the risk remains high for up to 2–3 years for drug-eluting stents.

The original indication for stent placement—stable angina versus acute coronary syndrome—appears, however, to be a more powerful predictor of perioperative cardiac complications than the type of stent deployed.

40

The VAP bundle includes

HOB
ORAL
SED
GAST
DVT

a daily sedation holiday,

stress gastritis prophylaxis,

elevation of the head of bed,

deep vein thrombosis prophylaxis,

daily oral care.

OTHER measures that may help prevent VAP include enhanced use of noninvasive positive pressure ventilation and

continuous aspiration of subglottic secretions.

41

The treatment of hypernatremia is to replace the free water deficit.

correction of 10–12 mmol/L per day.

Severe or rapidly evolving hyponatremia from replacing toto fast can lead to seizures, coma, permanent brain damage, respiratory arrest, brain-stem herniation - CPM, and death.

The treatment of hypernatremia is to replace the free water deficit.


Free water deficit =
TBW × [(serum Na+/140) – 1]

Note. TBW = estimated total body water (normal TBW for men = 0.6 and women = 0.5 times the ideal body weight).

The current recommendations for patients with hypernatremia for longer than 24 hours is a correction of 0.5 mmol/L per hour or roughly a maximum correction of 10–12 mmol/L per day.

42


Neurogenic shock


acute transection of the spinal cord. Clinical manifestations include warm skin,

bradycardia,

and

hypotension

secondary to a loss of sympathetic tone causing subsequent vasodilatation and increased venous capacitance.

Treatment includes administration of alpha-adrenergic vasoconstrictive agents, such as phenylephrine, to re-establish peripheral vascular tone and decrease venous capacitance.

This is different the brain Cushing reflex of HYPERtension and brady!

43

proven earlier liberation from mechanical ventilation with




daily spontaneous breathing trials (SBT),

patients breathe through a T-tube

or

using a small amount of continuous positive airway pressure,


AND

sedation holiday

SBT had more ventilator-free days, fewer days in intensive care, and fewer days in the hospital.

Although these results are early, both sedation vacation and SBT are recommended standard practice and should be paired when possible.

44

SIADH

euvolemic

vasopressin secretion continues despite a low plasma tonicity/osmolality.

seen in patients with central nervous system disturbances

Plasma osmolality is less than 270 mOsm/kg,

urine sodium is more than 20 mEq/L.

The patient’s volume status is an essential differentiator between SIADH and cerebral salt wasting, because both can be seen in neu­rologically injured patients.

The treatment of SIADH is fluid restriction

and

slow sodium replacement, again often with hypertonic saline.


45

Diabetes insipidus

impaired secretion of vasopressin (opposite of SIADH)

profound diuresis

and

rapidly developing hypernatremia.

Excess free water replacement leads to a hypervolemic relative hyponatremia with high urine output.

46

Nephrotic syndrome

hypervolemic

hypoalbuminemia

lowered plasma oncotic pressure

lead to an effective volume contraction

and

low flow state

that stimulates vasopressin release

and

causes renal sodium and water retention and causes peripheral edema.

47

Surviving sepsis guidelines


One hour:
Abx in first hour if not normal (get blood cxs first)

Normals:
CVP eight – 12
MAP greater than 65
UOP greater than 0.5
SpO2 70%

Antibiotics

Three hours:
Lactate
Blood culture (pre-antibiotic)
If blood pressure is decreased and lactate is increased:
Fluids 30 mL per kilogram

Six hour:
If still decreased blood pressure - norepinephrine– Drive the MAP >65

Repeat physical exam!

CVP
SPO to
Bedside cardiac ultrasound SS food response

Possible Swan

Vasopressors:
Norepinephrine two – 20 µg per kilogram
Max this out first

Then add epinephrine
Two – 20 µg per kilogram
(dopamine alternative to epinephrine if a low risk for arrhythmia)

Then add vasopressin 0.03 µg per minute

NO phenylephrine unless epinephrine causing arrhythmia

Steroids if cannot adequately fluid resuscitate:
Hydrocortisone 200 mg per day
(taper when off of pressers)
Do not need corozal or ACTH stem test

Blood glucose goal 150

Plateau pressure ventilator in less than 30 cm of water (survival benefit!)

48

Refeeding syndrome

Insulin drives into cell:

phosphorus,
potassium,
magnesium

This causes cardiac depression

Also causes die from weakness

49

Acute liver failure lab findings


Increase Bilirubin
Increased lactate

Decreased phosphorus
Decrease sodium
Decreased potassium

Lactic acidosis
AND
respiratory alkalosis

50

Acetaminophen acute liver failure criteria

King's criteria:
PH less than 7.3
Lactate greater than three

51

SIRS



Temperature greater than 38 last 36

Pulse 90

WBC greater than 12 less than 4

Respiratory rate greater than 20

PaO2 listen 32

52

Management of unstable myocardial infarction

Entra aortic balloon pump

53

Weaning parameters

NIF less than 30

minute ventilation less than 10 meters per minute

Title volume less than five – 7 mL per kilogram





54

CAVH

continuous aterial venous hemofiltration

works by: convection

from opposite legs

RIGHT femoral ARTERY cordis

LEFT femoral vein tripple lumen

via

7.5 fr cath

preserves cardiac preload and decompression of splancnic vasculature

55

land marks for IJ placement

sternal and clavicular heads apex with clavicle as base

palpate carotid pulse
(this is medial to vein)

LATERAL vein
point to IPSILATERAL nipple

56

Markers of pulmonary embolism

Tachycardic
tachypnea
hypotensive

INCREASED pulmonary artery pressure

Increased central venous pressure

DECREASE PaO2 AND pCO2
ventilation perfusion mismatch
gas is not seeing blood

Right heart failure
Ralph
Fourth heart sound

57

mean arterial pressure

80-90

calculation map equals diastolic pressure +1/3 (systolic pressure minus diastolic pressure)

58

cardiac index


cardiac output divided by meter squared
2.5-3.5


59

systemic vascular resistance

SVR = (MAP - CVP) x 80/CO
1000-1500 dyne

60

mixed venous oxygen content


CVO2
75%
15 cc O2 in 100 cc

61

lift things that cause improvement of Frank Starling curve with ventricular dysfunction


#1 diuretics
#2 inotrope
#3 vasodilator

62

how does dopamine


compared to norepinephrine dopamine and baby nor epinephrine

63

trade name for norepinephrine

levophed

64


Immediate treatment for myocardial infarction

morphine
oxygen
angio / anticoag
nitro
ASA
Ace

65


Gen. mechanism dopamine: Heart rate,
contractility,
preload,
afterload



heart rate increased
contractility Increased
preload decreased
Increase/normal

66


Gen. mechanism dobutamine:

Heart rate,
contractility,
preload,
afterload

Heart rate INCREASE
Contractility INCREASE the
Preload decrease
Normal decrease

67


Gen. mechanism nitroprusside
Heart rate,
contractility,
preload,
afterload

heart rate no change
Contractility no change

Preload decrease

Afterload DECREASE

68

how is pediatric Parkland formula modified


Parkland PLUS maintenance
Kidsneed D5 and a little K.

(approximately 15% above Parkland)

69

Trauma definition of systolic hypotension


110

70

Classify severity of base deficit

Mild: -3 to -5
Moderate: -6 to -9
Severe: Greater than -10


Mortality and percentage the patient with a base deficit of -6 25% and trauma related

71

And INR 1.5 on arrival to ICU as what percent mortality

and what is treatment


30%
Transfuse FFP

72

This common causes of vasodilatory shock

MOST common SEPTIC

Pancreatitis

Burns

Anaphylaxis

Acute adrenal insufficiency

Hypotension: Hemorrhagic,

cardiogenic, cardiopulmonary bypass

Lactic acidosis

Carbon monoxide

73

ventilator scenarios with ABGs, PEEP, high peak airway pres- sures,
AC
/IMV/
PC/inverse ratio, swan placement etc

placement etc

74

nephrotxic drugs

NSAIDS
ACE inhibitor
Cyclosporine
Tacrolimus
Amphotericin B
Aminoglycoside
Vancomycin
NSAIDS

75

Studies to a very low urine output

Ultrasound:
post void residual study
Hydronephrosis
Stones

IVP:
Evaluate for ureteral obstruction/injury
Is Irene's kidney function

RUG:
If you suspect ureteral injury

CPP/ Swan

EKG if troponins are positive

76

Normal cardiac index

2.5 - 5 L/min

77

Wedge

11+ and -4

"low teens"

78

Examples of obstructive etiologies causing the low urine output

PE!
Cardiac tamponade
Pneumothorax

79

Indications for dialysis

Acidosis
Electrolyte abnormalities
Intoxication
overload
Uremia

80

ARDS ratio

PaO2/F I O2
Less than 200

81

How low can you go on pH with permissive hypercapnia

PH 7.2!

82

Normal swan numbers

CVP five
wedge quarter over dimes
Correct index three
Systemic vascular resistance 1000