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IM RCPSC 2024 > ICU + Toxicology > Flashcards

ICU + Toxicology Flashcards

1
Q

Causes of distributive shock

A

Sepsis
SIRS
Anaphylaxis
Mitochondrial dysfunction (cyanide)
Endocrine crisis (thyroid, adrenal)
HLH
Post cardiac surgery vasoplegia
Liver failure

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2
Q

Causes of cardiogenic shock

A

ACS
Arrhythmia
Acute valvulopathy
Right or left sided heart failure

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3
Q

causes of obstructive shock

A

PE
Tamponade
Tension pneumothorax

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4
Q

causes of hypovolemic shock

A

Trauma
Hemorrhage
Burns
Operative losses
GI Losses
Renal Losses
Third spacing (pancreatitis)

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5
Q

Definition of sepsis as per SCCM 2021

A

“Life threatening organ dysfunction secondary to dysregulated host response to infection”

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6
Q

Criteria for septic shock (SCCM 2021)

A

Septic Shock = Sepsis +
Despite adequate volume resuscitation, Persistent ↓BP requiring vasopressors to keep MAP ≥ 65
lactate > 2 mmol/L
(need both)

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7
Q

ScvO2 criteria for differentiating between cardiogenic and other forms of shock.

A

Drawn from IJ central line
Contains blood from SVC
Normal O2 level is 60-65%
>80% indicates a high flow rate such as sepsis
<65% indicates low flow rate such as cardiogenic or hypovolemic shock.
(numbers are as per IMR slides, different thresholds in different literature)

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8
Q

Immediate resuscitation guideline for Sepsis as per surviving sepsis 2021

A

30ml/kg of crystalloid in first 3 hours
Norepinephrine first line pressor for MAP<65 and no longer fluid responsive
Broad spectrum antibiotics within first hour
DO NOT MEASURE PROCALCITONIN TO HELP DECIDE WHETHER TO INITIATE ANTIBIOTICS

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9
Q

SEPSIS antibiotic recommendation as per IMR slides

A

PIPTAZO follow by individual risk for:
MRSA (dialysis, known MRSA colonized, recurrent skin/soft tissue infection, Person Who Injects Drugs, central lines,)
- VANCO
MultiDrug resistant Organism (previous abx within 3 months, known MDR colonization, local prevalence, travel to endemic
country or hospitalization abroad):
- 2x ABx coverage (weak recommendation, low quality evidence)
Fungal (neutropenia, immunocompromised, TPN, dialysis, chronic lines, PWID, HIV, Heme or solid organ
transplant, emergency GI surgery or anastomotic leak)
-

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10
Q

Dynamic variables for guiding fluid resuscitation in Sepsis
(surviving sepsis guideline 2021)

A
  1. Response to fluid bolus
  2. Passive leg raise (45% for 30-90 secs) inc. 15% in stroke volume = still fluid responsive.
  3. Pulse pressor variation > 10%
  4. ECHO
    - Stroke volume / variation
    - IVC
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11
Q

IVC Interpretation on ECHO for fluid responsiveness

A

–Intubated, fully ventilated-Distensibility Index >15-20% likely to be fluid responsive
Intubated breathing spontaneously, cannot use
– Spontaneously breathing not intubated IVC <2cm and respiratory variation>50%, likely fluid responsive

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12
Q

IMR recommended dosing for Norepinephrine infusion

A

Norepinephrine
0.05-0.5mcg/kg/min

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13
Q

IMR Recommended dosing for Epinephrine infusion

A

Epinephrine
0.05-0.5mcg/kg/min

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14
Q

IMR recommended dosing for Vasopressin infusion

A

Vasopressin 2.4 units/hr

Add vasopressin when
Norepinephrine approx 0.25 –0.5 mcg/kg/min

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15
Q

IMR recommended dosing for Dobutamine infusion

A

Dobutamine 2.5-10 mcg/kg/min

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16
Q

IMR recommended dosing for milrinone infusion

A
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17
Q

Physiological response to phenylephrine

A

HR: Dec.
SVR: Inc
CO: dec.
PcWP: Inc

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18
Q

Physiological response to Norepinephrine

A

HR: Inc.
SVR: Inc
CO: Inc/neut
PcWP: Inc

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19
Q

Physiological response to Epinephrine

A

HR: Inc
SVR: Inc
CO: Inc
PcWP: Dec.

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20
Q

Physiological response to Vasopressin

A

HR: Dec/ Neut
SVR: Inc
CO: Dec/ neut
PcWP: Inc

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21
Q

Physiological response to Dobutamine

A

HR: Inc
SVR: Dec
CO: Inc
PcWP: Dec

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22
Q

Physiological response to milrinone

A

HR: Inc/ Neut
SVR: Dec
CO: Inc
PcWP: Dec

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23
Q

Physiological response to dopamine

A

HR: inc
SVR: inc
CO: inc
PcWP: Inc

Doesn’t cross BB barrier

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24
Q

When to consider Steroids in Sepsis

A

Theory: may help immune dysregulation, relative adrenal insufficiency. “pressor sparing agent”
- Consider when Norepinephrine at 0.25 >4hours

Hydrocortisone 200mg/d (50mg IV q6H

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25
Q

Indications for high flow nasal canula

A

Hypoxemic respiratory failure
Patients taking NIV breaks
Post-op patients

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26
Q

When should High Flow Nasal Canula NOT be used

A

Post extubation if high risk of failure (NIV preferred)
Acute hypercapnic respiratory failure

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27
Q

Physiological benefits of CPAP

A

reduced respiratory muscle oxygen consumption
recruitment of alveoli
improved V/Q matching
Reduced LV afterload
Reduced preload

28
Q

Physiological benefits of BiPAP

A

reduced respiratory muscle oxygen consumption
recruitment of alveoli
improved V/Q matching
Reduced LV afterload
Reduced preload
Increased Alveolar ventilation

29
Q

indications for NIV

A

BiPAP mild-severe acidosis (rr >20-24, pH<7.35, PaCO2>45)
Cardiogenic pulmonary edema

30
Q

When should NIV NOT be used

A

treatment of post-extubation resp failure
Hypercapnic with NO acidosis
No recommendations for: Asthma Resp Failure NYD, Acute resp failure secondary to viral illness.

31
Q

Contraindications to NIV

A

Facial surgery, trauma, airway obstruction
Decreased LOC (includes worsening agitation when starting BiPAP)
Inability to clear secretions
Respiratory arrest
Hemodynamic instability (reduces preload)
Strong indications for intubation.

32
Q

how to decrease PaCO2 on a ventilator

A

increase RR
Increase Tidal volume
(minute ventilation = RR*Tidal volume)

33
Q

How to Increase SpO2 (PaO2) on a ventilator

A

increase FiO2
increase PEEP
Increase Inspiratory time
Affect O2 Delivery: Inc. CO, Inc Hb
Dec. O2 consumption: treat fever, agitation stop pulmonary vasodilators (nitroprusside)

34
Q

what is the Peak inspiratory pressure

A

reflects airway resistance + Lung compliance
Target <35cm H2O

35
Q

what is Plateau Pressure

A

The pressure in the lungs when no air is moving, reflects lung compliance
This is the pressure that the alveoli are seeing
target <30cm H20
May be confounded by chest wall restriction (IE Obesity)

36
Q

What is Positive End Expiratory Pressure

A

Pressure at the end of the respiratory cycle
Increases solubility of gas
Splits airways, decreases work of breathing.

37
Q

What is the driving Pressure

A

Pplat - PEEP (Target <15)
OR
Tidal Volume/ Static compliance

38
Q

Sepsis treatment options specifically mentioned to NOT GIVE

A

IVIG
Vitamin C
Polymyxin
Angiotensin II infusion
Levosimendan
Activated Protein C
Liberal oxygen (target 94-96%, a sat >96% increases mortality in critically ill)

39
Q

Criteria for Mild ARDS
(2023 update)

A

Timing: within 1 week of known insult
Pulmonary edema that is not attributable to Cardiogenic or fluid overload
Bilateral infiltrates on CXR, CT or Ultrasound (by a trained professional)

*P:F 201-300 with NIV/CPAP PEEP ≧ 5 or HFNC >30l/min
SpO2:FiO2 <315 with SpO2 <97%

40
Q

Criteria for moderate ARDS
(2023 update)

A

Timing: within 1 week of known insult
Pulmonary edema that is not attributable to Cardiogenic or fluid overload
Bilateral infiltrates on CXR, CT or Ultrasound (by a trained professional)

*P:F 101-200 with NIV/CPAP PEEP ≧ 5 or HFNC >30l/min
SpO2:FiO2 <315 with SpO2 <97%

41
Q

Criteria for severe ARDS
(2023 update)

A

Timing: within 1 week of known insult
Pulmonary edema that is not attributable to Cardiogenic or fluid overload
Bilateral infiltrates on CXR, CT or Ultrasound (by a trained professional)

*P:F <100 with NIV/CPAP PEEP ≧ 5 or HFNC >30l/min
SpO2:FiO2 <315 with SpO2 <97%

42
Q

Treatment for ARDS

A
  1. ventilation strategies
  2. Prone position
  3. Neuromuscular blockade
  4. ECLS/ECMO
  5. Corticosteroids
  6. Inhaled pulmonary vasodilator
43
Q

Pathophysiology of ARDS

A
  • Proteinaceous fluid fills alveoli
  • Neutrophils flood alveolar space
  • Hyaline membranes form on epithelial basement membrane
  • Microthrombi form
  • Fibrosis develops (late stage)
44
Q

Causes of ARDS

A

Direct Lung Injury
* Pneumonia
* Aspiration pneumonitis
* Drowning
* Thoracic trauma/pulmonary contusion
* Smoke or toxic inhalation
* Fat emboli
* Reperfusion injury (post lung transplant)
Systemic inflammation
* Severe sepsis
* Transfusion reaction (TRALI)
* Shock
* Pancreatitis

45
Q

Vent settings for ARDS

A

Mode: Volume Control
Tidal volume (Vt): Initial Vt at 6ml/kg PBW à target 4-8 ml/kg PBW
Plateau pressure: ≤ 30 cm H2O, Driving pressure (Pplat - PEEP) target < 15 cm H2O
PEEP: target higher PEEP in mod/severe ARDS, based on FiO2-PEEP Tables SpO2:

target 88-93% or PaO2 55 - 80 mmHg (avoid hyperoxia – ↑s harm)

CO2: permissive hypercapnia allowed, target pH > 7.25
* Deep sedation to achieve the above parameters
* Lung Recruitment Maneuvers: Don’t use routinely (evidence of ↑ mortality). Can be
considered.
* High frequency oscillation: Do not use

46
Q

ARDS patients who should be Considered for ECMO

A
  • Severe ARDS
  • Hypercapneic respiratory failure
  • Bridge to lung transplantation
  • Primary graft dysfunction after lung transplantation
  • Status asthmaticus
47
Q

ARDs patients who should NOT be considered for ECMO

A

Absolute
* Disseminated malignancy
* Known severe brain injury
* Prolonged CPR without adequate tissue perfusion
* Severe chronic organ dysfunction
* Severe chronic pulmonary hypertension
* Non-recoverable advanced comorbidity (ie. CNS
damage or terminal malignancy)

48
Q

Criteria to consult for ECMO:

A

Call for ECMO referral if:
* P/F < 80 mmHg for > 6 hours OR P/F < 50 mmHg for > 3 hours
* PaCO2 > 60 mmHg for > 6 hours (despite optimization of vent)
* Mechanically ventilated < 7 days
* BMI < 40 or weight < 125 kg
* Age 18 - 65

49
Q

COVID Tx

A
50
Q

SBT

A

Should occur daily

51
Q
A

Assess readiness for weaning from ventilator
1. Reversal of underlying reason for intubation
and ventilation
2. Improvement of oxygenation
(PaO2 > 60 mmHg, FiO2 < 40%, PEEP < 8)
3.Ability to perform work of breathing
(Normal/compensated Co2, pH, adequate
cardiac function, adequate diaphragm
function)

52
Q
A

Assess readiness for extubation
1. Adequate cough
2. Minimal secretions, ability to manage secretions
3. Awake/Alert, following commands, no sedation
4. No increased risk of airway obstruction – post-op
swelling resolved, ETT cuff leak present

53
Q

Dexmetatomidine

A
  • Alpha-2 agonist – acts on CNS receptors
  • Recent meta-analysis compared to Propofol and Benzodiazepines:
    – ↓risk of delirium (RR 0.67, 95% CI 0.55 to 0.81; moderate certainty)
    – ↓ duration of mechanical ventilation (MD - 1.8 h, 95% CI - 2.89 to - 0.71;
    low certainty)
    – ↓ ICU length of stay (MD - 0.32 days, 95% CI - 0.42 to - 0.22; low certainty)
    – Increased risk of bradycardia (RR 2.39, 95% CI 1.82 to 3.13; moderate
    certainty) and hypotension (RR 1.32, 95% CI 1.07 to 1.63; low certainty)
54
Q
A

Haloperidol and Queiapine first line for delirium when at risk of hurting someone

55
Q
A

Multimodal approach to pain management
* Opioids are mainstay, especially post-op, but associated with side
effects (respiratory depression, delirium, dependence)
* Adjuncts should be used to reduce opioid requirements
– Acetaminophen, NSAIDS (where appropriate)
– Low dose ketamine (0.5 mg mg/kg bolus then 1-2 mcg/kg/min infusion) in
post-operative patients
– Gabapentin, pregabalin, carbamazepine for neuropathic pain
– Do not routinely use lidocaine, local anesthetics or inhaled volatiles for pain
adjuncts (may be effective for special circumstances – postoperative, trauma)
* Others recommended: cold therapy, relaxation techniques, music,
massage

56
Q
A

neuroprognostication should wait at least 24 hours

57
Q
A

3 pre-requisites before conducting DNC assessment
1. Mechanism causing devastating brain injury leading to death
2. Neuroimaging to support cause
3. Absence of confounders
– Temperature: core ≥ 36 celsius (rectal, esophageal, bladder, arterial, bladder, central venous)
– Time: wait ≥ 48hrs after arrest (unless imaging shows devastating injury)
– Drugs: Wait 5 half lives if drug is known (e.g. sedatives, neuromuscular blockers,
– Shock: Must be resuscitated appropriately (i.e. not un-resuscitated)
– Metabolic disorders*: Na 125-159, PO4 >0.4, Glucose 3-30, pH 7.28-7.5, PaCO2 < 60, Urea
< 40 (if available), Cr < 400, bilirubin < 100
“If these derangements cannot be corrected and are judged to be potentially contributing to the loss of
brain function, ancillary investigation should be considered. ”
– Severe weakness: myasthenia, ALS, spinal cord injury
– Decompressive craniectomy

58
Q
A

High lactate can be misinterpreted and ethylene glycol so if you see a very high lactate be suspicious of a toxic alcohol

59
Q

Aspirin overdose antidote

A

Sodium bicarbonate

60
Q

BB / CCB overdose antidote

A

High-Dose Euglycemic Insulin, glucagon, calcium, intralipid

61
Q

Benzo Overdose Antidote

A

Flumazenil

[caution – lasts up to an hour and if multiple drug ingestions or
withdrawal seizure will make managing seizures a challenge!]

62
Q

Cyanide poisoning antidote

A

Hydroxycobalamin, sodium thiosulfate,

63
Q

Iron overdose antidote

A

Deferoxamine

64
Q

Isoniazide toxicity antidote

A

Pyridoxine

65
Q

Digoxin toxicity antidote

A

Digibind
An IgG Anti digoxin antibody. These fragments bind free digoxin, thereby forming digoxin-immune fragment complexes. As the level of free digoxin in plasma falls, the resulting concentration gradient facilitates dissociation of digoxin from the sodium-potassium ATPase. Fab fragment complexes are renally excreted.

IM RCPSC 2024 (9 decks)

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