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critical care > week 2 status epi, acute stroke, ACLS, Sepsis, pain/agitation/sedation/delirium > Flashcards

week 2 status epi, acute stroke, ACLS, Sepsis, pain/agitation/sedation/delirium Flashcards

1
Q

step plan for analgesia

A
  • give boluses or infusion of opioids
  • prn opioids (PCA)
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2
Q

step pain for sedation

A
  • when agitation not controlled by opioids
  • propofol, presadex, ketamine
  • prn boluses of benzos
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3
Q

step by plan for delirium

A
  • screen + identify early
  • non-pharm interventions
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4
Q

scales for analgesia

A

CPOT goal <2
BPS goal <5

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5
Q

opioid options for analgesia and clinical pearls , ae

A

1st line - fentanyl; hepatic metabolism, CYP3A4, tachyphylaxis (tolerance), avoid continous drip
2nd line - hydromorphone; good for renal impair, option for fentanyl tolerance, PCA available
3rd line- morphine; accumulates in renal impair, se- hypotension, bronchospasm, urticaria
Hyperanalgesia: pain threshold is decreased, nerve dysfunction

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6
Q

non-opioid options for analgesia; clinical pearls

A
  • APAP ( avoid in liver failure)
  • NSAIDS (avoid in kidney injury, risk of GI bleeds)
  • Methadone; slow titrate to avoid QT prolongation
  • Gabapentin; takes days to show effect
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7
Q

Modifiable risk factors for delirium

A
  • benzo use
  • blood transfusions - only when hgb <7
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8
Q

Non-Modifiable risk factors for delirium

A
  • age, dementia, prior coma, pre-icu emergency surgery/trauma
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9
Q

scale for delirium

A

ICDSC score<4

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10
Q

Non-pharm interventions for delirium

A

re-orient pt
use hearing aids/glasses
limit noise and light at bedtime
encourage norm sleep wake cycle
early mobilization
family presence
music therapy
limit use of benzo & anticholingerics

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11
Q

Agents for delirium

A

*only treatment not prevention
- 1st line: presadex
-opioids
- melantoin
- antipsych

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12
Q

sedation scales

A

RASS -2 light sedation
SAS 3-4

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13
Q

sedation agents- propofol

A

NO analgesic properties
fast on fast off
highly lipid soluble cautious in obese pts
ae: resp depression**intubation, hypotension, bradycardia, PRIS (propofol related inf syndrome)
lipid soluble, nutritional value
egg, sulfites and soybean allergies
first line w/ severe alcohol w.drawal and SE

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14
Q

sedation agents- Precedex

A

a2 adregenic agonist
do not use >24hrs
sedative AND analgesia effects
ae- bradycardia + hypotension
no resp depression, similar to natural sleep, opioid sparing, adj for severe EtOH w/drawal
not for sleep depression
risk of w/drawal add clonidine

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15
Q

sedation agents- benzos

A

great short term, prolonged use inc AE
- Midazolam (shortest duration), accumulates, lipophilic, 1st primary SE
- Lorazepam AE: propylene glycol acidosis (high anion gap), can use renal/hepatic failure
- Diazepam longggg half life 2-3.5 days
- risk of delirium, inc time on vent, inc length of ICU stay

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16
Q

sedation agents- ketamine

A

Multi-Moa for aggitation, pain, antidep, bronchodilator
fast on fast off
no resp dep
ae: emergence rxn (elderly w/ dementia and schizo *pretreat), oral secretion, tachycardia, HTN

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17
Q

neuromuscular blockers monitoring

A

2 twitches is goal, >2 means not enough sedation, <2 means too much

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18
Q

NMB indications

A

facilitate mech vent
dec o2 consumption (resp distress)
inc muscle activity
inc intracranial or abdominal pressure
surgical procedures
rapid sequence tubation

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19
Q

NMB drugs and pros/cons

A

Ciatracurium, Rocuronium, Vecurium, Succinylcholine
- Pros: dec diaphragm activity, dec chest wall rigidity, eliminates work of breathing
- Cons: pt cant communicate, no analgesic or sedative properties, risk of DVT and skin breakdown, corneal abrasion risk, critical illness polyneuropathy

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20
Q

identifying sepsis 2 criterias

A

-qsofa at least 2: sbp<100, rr>22, ams
SIRS at least 2: temp >38 or <36, HR>90, RR>20, WBC >12E9 or <4E9

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21
Q

sepsis 1st hr Bundle

A
  • measure lactate
  • obtain blood culture
  • admin broad spectrum abx
  • rapid admin of crystalloids 30 ml/kg ( for hypotension or lactate >=4
  • admin vasopressors a/f fluids to maintain map >65
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22
Q

abx timing for sepsis

A

if shock and/or sepsis is present, give abx immediately within first hour,
if shock is absent and sepsis is possible give abx within 3 hour

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23
Q

when to give MRSA coverage

A

hx of MRSA
recent IV abx
hx of reoccurring skin inf/wounds
presence of invasive devices
recent hosp admin
severity of illness

24
Q

when to give multi-drug resistant coverage and regimen

A

proven inf w/ resistant org w/in 1 yr
recent broad spec IV abx w/in 90 dys
travel to endemic country in 90days
local resistant org
hospital acquired inf
- 2 gram ned emperic coverage agents

25
what is refractory shock and how to treat
poor response to fluids + vasopressors - high dose corticosteroids or NE +/- vasopressin
26
which cardiac rhythms are shockable vs non-shockable
shock: VF, pVT non-shockable: PEA, Asystole
27
what drugs can be admin endotrachaeal route and conversion
2-2.5: 1 IV/IO NAVEL drugs; naloxone, atropine, vasopressin, epinephrine, lidocane dilute w/ 5-10 ml sterile H2O or NS
28
role of epi in ACLS and when to use, dose
- inc organ perfusion by inc coronary and cerebral pressure - admin ASAP in PEA/Asystole , admin after 2 shocks in VF/pVT - 1mg IV/IO q3-5 mins
29
Antiarrhytmics AC;S
- admin after 3 shocks in VF, pVT - lidocaine (do not use with norm QT interval) - amiodarone (bradycardia, hypotension, qt prolongation)
30
6Hs (reversible causes) of ACLS and treatment)
Hypovolemia (fluids) Hypoxia (100% o2 mask) Hydrogen ion acidosis (bicarb) Hyperkalemia (Bicarb, insulin, dextrose, diuresis, dialysis) Hypothermia Hypoglycemia
31
5Ts (reversible causes) of ACLS and treatment)
Tension pheumothorax (needle decompress) Tamponade (needle to drain) Toxins (naloxone-opioids, lipid emulsion-anesthesia, bicarb-antidepress) Thrombosis ( pulmonary-alteplase, coronary- tenecteplase & PCI)
32
provoked causes for seizures
intoxification w/drawal trauma meningitis psychiatric metabolic derangements
33
first line agent to stop active seizures
benzos; lorazepam 4mg> diazepam 5-20mg, midazolam max 10mg - impaired consciousness, resp depression, hypotension - give during first 10 mins
34
agents to prevent seizures
antiepileptics- phenytoin, leviteracetam, valporic acid, lacosamide
35
how to treat super refractory status epi
ketamine inf load 1.5-3 mg/kg iv once MainD 0.1-4 mg/kg/hr max 15mg/kg/hr
36
how to treat refractory status epi
High dose benzos -Midazolam bolus/inf - Propofol IV inf (only use if pt intubated) - Phenobarb or pentobarb (only use if pt intubated)
37
goal of therapy for status epi and monitoring
burst suppression for 24-48 hrs slow titration while monitoring LTM Midazolam should be titrated off early because it accumulates in fatty tissue
38
post intubation treatment (seizures)
paralytic for intubation iv inf of antiepi (propofol or midazolam) long term EEG monitoring 2-3 IV antiepi + 1 continous IV inf
39
what is refractory SE
no response to anticonvulsants; seizures lasting >2 hr OR recurring 2 or more episodes per hour w/o recovery to baseline despite treatment
40
phenyotin conct calculations
norm= (cp obs)/(.275x albumin) +0.1 poor renal norm= (cp obs)/(.1x albumin) +0.1
41
Phenytoin AEs
p450 interactions Hirsutism/hypertrichosis Enlarged hums Nystagmus Yellow-browning skin (hepatitis) Teratogenicity Osteomalacia (Vit D deficiency) Interference w/ folate metabolism (anemia) Neuropathies (vertigo, ataxia, headache) SJS, Rash fever, neutropenia, thrombocytopenia
42
phenytoin dose, metabolism and risk
- LD 20mg/kg IV, MD 4-6mg/kg/day - highly protein bound - CV: hypotension, bradycardia, QT prolongation **slow titration to mitigate
43
phenytoin monitoring
10-20 for total phenytoin correct low albumin (if albumin <3.5 more free drug available, leads to toxicity) adj for kidney function (crcl <30)
44
Leviteracetam dose, AE
LD 60mg/kg max 4500 mg, MD 1000 mg IV BID AE- agitation and drowsiness
45
Valporic Acid dose, monitor, AE
LD 40mg/kg max 3000, MD 5mg/kg IV Q8H - goal level 50-100 - AE: thrombocytopenia, Hyperammonemia > pancreatitis (peds), HA, drowsiness
46
Lacosamide dose, pearls
100-200 mg IV BID well tolerated avoid in bradyarrthymia
47
what is ischemic stroke and scales used
brain injury due to blood loss to an area of the brain time of onset critical NIHSScale mild-4 severe>20
48
how to assess ischemic stroke
neuro-imaging -non contrast CT to rule out hemorrhage (fluid area) -MRS detect early ischemic changes (dark area)
49
treatment plans for ischemic stroke
- w/in 4.5 hrs of onset (fibrolytics +/- thromboectomy) - 4.5-24 hrs sine symptom onset large vessel occulsion (thromboectomy) small vessel occulsion (heparin inf)
50
fibrolytics agents and AEs
- Alteplase (risk of hemorrhage, stop inf give cryoprecipitate) - Tenecteplase rare but fatal risk of angiedema (give methylpre, diphenhydramine, ranitide/famotidine, epi)
51
fibrolytics adjunctive therapy options
BP control 1st- labetalol, nicardipine hypertension can cause hemorrhage hypotension can worsen ischemia
52
contraindications for fibrolytics
<18 yo ischemic stroke w/in 3 months GI malignacy or GIB w/in 21 days LMWH w/in 24hrs unclear time of onset or >4.5 hours severe head trauma w/in 3 months DOAC w/in 48hrs
53
BP requirements for thrombolytics
bolus <185/110 INF <180/105 goal SBP 160-180
54
endovascular intervention options
thromboectomy (only for large vessel occulsions) +/- inter-arterial theombolytics
55
2nd stroke prevention
lifestyle/nutrition smoking cessation limit ETOH counsel on substance abuse HTN Dyslipidemia Diabetes
56
post fibrolytic care
- monitor neurologic and bp for 24 hrs - high dose stain and aspirin for all pts - dual antiplatelet for low NIH stroke x 21 days or those w/ intracerebral stent placement - DVT prophylaxis for 24 hrs post alteplase - anticoag if cardioembolic stroke or hx of afib (small occulsion 3-5 days, large 7-14 days)

critical care (2 decks)

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