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Medicine > 2024 CCM Board Review > Flashcards

2024 CCM Board Review Flashcards

1
Q

Urinary sodium consistent with ATN

A

> 20 mEQ/L

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2
Q

AKI is associated with…

A

Decreased 10yr survival, progression to CKD, and CV disease

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3
Q

Early RRT initiation is associated with

A

… no improved outcomes

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4
Q

Late RRT (72hrs+) is associated with

A

worse outcomes

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5
Q

FENa calculation

A

[Una/Pna] / [Ucr/Pcr] x100 = [ PCr * UNa] / [Pna*Ucr] *100

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6
Q

Which ATN has worse prognosis?

A

oliguric

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7
Q

Most patients with AKI of critical illness prognosis?

A

Recover normal renal function

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8
Q

FENa in contrast-induced nephropathy

A

<1%

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9
Q

Early initiation of RRT in critically ill patients with AKI is associated with?

A

Delay of return of renal function

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10
Q

FENa in hepatorenal syndrome

A

<1%

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11
Q

Anion gap correction for Albumin

A

For every 1 below normal, add 2.5 to AG

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12
Q

Winters formula (pCO2 change for a bicarb change in acidosis)

A

expected pCO2 = 1.5*bicarb + 8 (+/-2)

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13
Q

pCO2 changes in metabolic alkalosis

A

expected pCO2 = 0.9*bicarb + 15 (+/-5)

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14
Q

Bicarb changes in respiratory acidosis (normal 24)

A

1 for every 10 pCO2 for acute
4 for every 10 in chronic

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15
Q

Bicarb changes in respiratory alkalosis (normal 24)

A

2 for every 10 pco2 in acute
5 for every 10 pco2 in chronic

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16
Q

GOLDMARK

A

Glycols
Oxoproline
L lactate
D lactate
Methanol
Aspirin
Renal Failure
Ketoacidosis

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17
Q

5-oxoproline (pyroglutamic acid) risk factors

A

women, malnourished, chronic tylenol use, kidney/liver dysfunction

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18
Q

NAGMA Causes

A

HARDUP
Hyperalimentation/infusing acid
Acetazolamide
RTA
Diarrhea
Uretero-bowel fistulas
Pancreatic fistula/post hyperventilation

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19
Q

Urine anion gap formula

A

Una + Uk - Ucl

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20
Q

UAG for a positive/abnormal result

A

> 10
(reflects abnormal NH4+ secretion)

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21
Q

Causes of low or negative anion gap

A

hyperK/Mg/Ca, lithium, paraproteins, lab error

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22
Q

Indications of CT before LP in meningitis

A

Immunocompromised
Hx CNS disease
New onset seizure within 1 week
Papilledema
Focal deficit
Abnormal consciousness

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23
Q

Asymmetric weakness with encephalopathy and fever

A

West Nile Virus

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24
Q

Ascending weakness

A

Guillain-Barre Syndrome

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25
Q

Descending paralysis

A

Botulism

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26
Q

Indications for steroids in PJP

A

HIV patients with hypoxia, has a mortality benefit. Magnified if mechanically ventilated

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27
Q

Medications risk for PRES

A

tacro, cyclosporine, sirolimus, cisplatin, interferon

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28
Q

Serum sickness symptoms

A

Fever, filling ill, other skin/joint manifestations

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29
Q

Empyema chest tube non-abx treatment

A

tPA and DNase combination improved outcomes (decreased surgery and LoS) vs placebo or monotherapy

streptokinase alone no benefit by meta-analysis or RCT

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30
Q

First line benzo for acute seizures

A

Lorazepam
potentially midazolam IM 10mg if don’t have it
Diazepam has more recurrences

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31
Q

Second line seizure medications for status epilepticus (after benzo)

A

Levetiracetam 60mg/kg (4500 max)
Valproate 40mg/kg (3000 max)
Fosphenytoin 20mg/kg (1500 max)

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32
Q

Third line therapy for status epilepticus

A

Pentobarb (?fewer breakthroughs, but more hypotension and ventilation)
Propafol
Phenobarb
Continuous benzos
Ketamine
All the second line

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33
Q

Burst suppression in seizures is associated with

A

more hypotension, delirium, and mortality
(typically only do it for 24-48hrs)

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34
Q

Indication for prophylactic anticonvulsants

A

Moderate/severe TBI and acute subdurals
(7 days)

GCS<10 or abnormal CT
(phenytoin or levetiracetam)

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35
Q

Intense BP control for intracerebral hemorrhage associated with what?

A

reduced hematoma size/growth, but no other improved outcomes

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36
Q

When to start DVT ppx after hemorrhagic stroke? approx

A

48hrs

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37
Q

Sub-arachnoid hemorrhage treatment

A

Coil or clip ASAP (maybe coil better)
vasospasm ppx: nimodipine 60 q4 x3wk (NNT 20) +/- magnesium

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38
Q

Guillain Barre treatment

A

plasma exchange or IVIG

no steroid benefit

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39
Q

Subdural surgical indications

A

> 10mm or midline shift >5mm

Follow-up CT in 36hrs, 24hr abx ppx?

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40
Q

ICP monitoring in TBI

A

abnormal CT on admission or
>40yrs and posturing

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41
Q

Mannitol treatment of elevated ICP

A

0.25-1g/kg bolus q2-4hrs

onset is 10-15min with max effect 20-60min
Target osm 320

Risk: renal failure

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42
Q

Hypertonic saline treatment of elevated ICP

A

3% at 2mg/kg

Target osm 320, Na <155

Risk: pulmonary edema, vein sclerosis, hyperchloremic acidosis

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43
Q

Craniotomy timing for elevated ICP

A

late associated with lower mortality
(RESCUEicp)

early has more unfavorable outcomes but similar mortality
(DECRA)

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44
Q

Staircase approach to elevated ICP

A
  1. intubation, normocarbia
  2. increased sedation
  3. CSF drainage (Ventricular)
  4. hypertonics/osmolars
  5. hypocapnia (but keep >30)
  6. hypothermia
  7. metabolic suppression (barbiturates)
  8. surgery
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45
Q

When is whole bowel irrigation for ingestion potentially indicated?

A

Ingestions with slow absorption/onset

essentially is giving a lot of miralax

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46
Q

When is activated charcoal indicated in ingestion?

A

within 1-2hrs of ingestion (most effective)

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47
Q

What does activated charcoal not absorb?

A

iron
lithium
alcohols
hydrocarbons
acids
alkalis

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48
Q

What ingestions should you use activated charcoal for?

A

Carbamazepine
Barbiturates
Theophylline
Dapsone
Quinine

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49
Q

When is fomepizole useful?

A

In toxic alcohol ingestions while there is still and osmolar gap (unprocessed alcohol)

Osm gap decreases while aniong gap increases (dampened by co-ingested ethanol)

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50
Q

Differentiate ethylene glycol and methanol toxicity:

A

Ethylene glycol: oxalate crystals

Methanol: optic neuropathy, ICH/infarct

51
Q

Treatment of toxic alcohol ingestion (aside from potential fomepizole)

A

Hemodialysis: if levels >25 or 50, metabolic acidosis, osm gap >25, renal failure, or visual symptoms

Folinic acid for methanol

52
Q

Cyanide poisoning symptoms

A

lactic acidosis
seizures
coma
hypotension

(oxidative phosphorylation inhibition)

setting: metal extraction, electroplating, smoke/fire, nitroprusside

53
Q

Cyanide poisoning treatment

A

sodium nitrate
sodium thiosulfate

hydroxocobalamin (b12)

54
Q

Medication treatment of beta blocker and calcium channel blocker toxicity

A

BB = glucagon (3-5mg then 2-5mg/kg infusion)

CCB = calcium (1-2g q10-20m then 0.2-0.4ml/kg/hr) - aim for iCal 2xnormal

Both potentially get high dose insulin, lipid emulsion

55
Q

High dose insulin therapy for CCB/BB toxicity

A

1u/kg bolus then 1u/kg/hr with max dose 10u/kg/hr

56
Q

Lipid emulsion for BB/CCB toxicity dosing

A

1/5ml/kg bolus then 0.5ml/kg/min for 30-60min

20% lipid emulsion solution

57
Q

Anti-depressant overdose treatment

A

Consider gastric lavage
Blood alkalization (7.45-7.55) in TCA overdose

If refractory: hypertonics and lipid emulsions
make sure to use vasopressor with alpha-agonist activity

58
Q

Serotonin syndrome treatment (drugs specific to this)

A

cyproheptadine
chlorpromazine

59
Q

Sulfonylurea overdose treatment

A

Octreotide 50-100 ug q6-8hrs SQ/IV

60
Q

Lithium toxicity treatment

A

CNS symptoms and potential arrhythmias

Optimize volume, get levels q2hrs
iHD or CRRT

61
Q

Cholinergic syndrome symptoms

A

bradycardia, tachycardia, weakness
hypersecretory

causes: organophosphates, carbamates, nerve gases

62
Q

Cholinergic syndrome treatment

A

atropine
glycopyrrolate if don’t have

pralidoxime for weakness

AVOID succ (requires same pathway to breakdown so prolonged paralysis)

63
Q

Sympathomimetic okay to be treated with anti-psychotics (and not benzos)

A

Bath salts
if prolonged delirium or psychosis
not evidence based

64
Q

Benzodiazepine antidote

A

flumazenil

contraindicated in TCAs or chronic benzo use
AE: seizures, arrythmias
Not typically recommended

65
Q

Naloxone dosing for opioid OD

A

IN 4-8mg
IV 2-10mg bolus

66
Q

ECG finding in hypothermia

A

J wave (small elevation after the R)

67
Q

Laboratory change sin hypothermia

A

Incr: Hct, glucose, BUN/Cr, Acid
Decr: Platelets

Coags may be normal because lab heats them up to run it
No need to correct ABG for temperature

68
Q

Length of pulse check in hypothermia

A

30 (to 60) seconds

69
Q

Changes to ACLS drugs in hypothermia

A

IF <30C then avoid drugs for asystole and VF

because the drugs don’t activate and then a lot will once warm

70
Q

Poor prognosis indicators in hypothermia

A

None are terribly reliable

But K >10 and persistent shock despite vasoactive drugs

71
Q

Temperature target to stop active rewarming in hypothermia

A

32C or 90F

72
Q

Perioperative hypothermia definition and risks

A

Temp <35 or 36

Increase mortality, infections, and bleeding

Tx: rewarming devices and warmed fluids

73
Q

Targeted temperature management risks/benefits

A

No long term mortality difference
Increased neurologic function at discharge

More arrythmias vs normothermia
Infection risk

74
Q

Laboratory changes in heat stroke

A

Respiratory alkalosis

Lactate, Rhabdo, AKI, thrombocytopenia, coagulopathy, inflammatory markers

75
Q

Management of heat stroke

A

Golden half hour (to get below 40C)

IVF, avoid anticholinergics, goal 37-38C
Foley, O2, airway protection

76
Q

Mortality risk factors in heat stroke

A

Older
Comorbidities
Hypotension
Lactic acidosis
Renal failure
Coma

77
Q

Triggers for malignant hypothermia

A

Halogenated anesthetics (halothane, isoflurane, sevo, desflurane)
Succinylcholine
Stress/Infection/Caffeine

78
Q

Dantrolene for malignant hypothermia dosing

A

2-3mg/kg bolus initially (max 10mg/kg)

Then cool and avoid CCBs

79
Q

Risk for neuroleptic malignant syndrome

A

lithium
anticholinergics
dehydration

more common in young men

80
Q

Treatment of NMS (aside from removing offending agent)

A

Dantrolene for rigidity (paralysis if refractory)
Antipyretics NOT effective

Bromocriptine/Amantadine/Levodopa/carbidopa

81
Q

Management of rhabdomyolysis

A

Fluid replacement +/- alkalinization of urine (goal UOP 2-3cc/kg/h)

Treat hypocalcemia only if symptomatic
RRT if necessary
Monitor for compartment syndrome

82
Q

Prognosis of post-op A-fib

A

Self-resolving in 90% by 6-8 weeks after surgery

83
Q

Typical A-flutter characteristics

A

Sawtooth pattern in inferior leads
Regular p-p intervals
Due to re-entry around TV

84
Q

Rate control of Afib/flutter in heart failure patients

A

Amiodarone

or digoxin (not typically in ICU patients)

85
Q

Chemical cardioversion agents for Afib/flutter

A

Ibutilide 4% risk of TdP, pre-treat with Mg
Amiodarone
Procainamide (less effective)

86
Q

SVT that does not respond well to cardioversion

A

Multifocal atrial tachycardia

87
Q

WPW EKG findings

A

Delta wave (slow QRS upstroke)
Short PR

88
Q

WPW with SVT Treatment

A

Procainamide + beta blocker

Or chemical cardioversion: procainamide, ibutilide
or DC cardioversion

Avoid AV nodal blockers as single agents (digoxin, CCB, Bblockers, amio)

89
Q

Features that support VT over SVT with Aberrancy

A

Fusion/capture beats (20%)
AV dissociation (<50%)
QRS > 140 msec RBBB
QRS >160 msec LBBB
Left axis deviation

Brugada Criteria:
Absence RS in precordial leads
R to S >100ms in one precordial lead
Concordance of QRS in precordial
QRS morphology favoring VT

90
Q

Features that support SVT with aberrancy

A

Terminates with vagal tone
Onset with p-wave
Long short sequence before wide complex beats
Critical rate at which QRS widens
Alternating bundle branch block

91
Q

Treatment of acute VT with pulse

A

Unstable:
Regular: synchronized DC cardioversion
Irregular: defibrillation

Stable:
If regular consider adenosine
Procainamide 20-50mg/min
Amio 150mg over 10min

92
Q

Acute management of Torsade de Pointes

A

Treat underlying (electrolytes, ischemia)
Defibrillation
Baseline prolonged QT: MgSO4, isuprel, lidocaine, atrial pacing

93
Q

Causes of sinus bradycardia

A

Sinus node dysfunction (fibrodegenerative, prior surgery, collagen vascular disease, infiltrative disease)

Vagal
Medications
Metabolic/Endocrine (hyperK/Mg, hypothyroid/thermia/glycemia/O2)

Other (athletic heart, infection, increased ICP)

94
Q

Atropine dosing

A

0.5mg every 3-5min (max of 3mg)

95
Q

Bradycardia medical treatment (after atropine)

A

Epinephrine
Dopamine
Isoproterenol
Glucagon (for BB or CCB od)

96
Q

Treatment of bradycardia after acute MI

A

[be careful as could worsen ischemia]
Indications: [1] symptomatic, [2] sinus pause >3s, [3]HR <40 w/hypotension

Atropine 0.5-1mg (may be effective in first 6hrs after inferior wall infarction as more likely due to increased vagal tone)
Temporary pacing

97
Q

Magnet effect on pacemaker/ICD

A

Asynchronous pacing
Stops ICD (but will not affect pacing mode)

Important for surgery as bovie noise interferes with sensing

97
Q

Indications for transvenous temporary pacing

A

Asystole
Alternating RBBB and LBBB
T2 second degree AV block with new bundle
or with fascicular block and RBBB
Third degree AV block

98
Q

Causes of inappropriate ICD shocks

A

Electromagnetic interference on sensing lead (eg ungrounded pool)
Lead malfunction (eg fracture)
SVT with RVR

99
Q

Causes of non-hypotonic hyponatremia (false hyponatremia)

A

hyperglycemia
hyperproteinemia (multiple myeloma)
hyperlipidemia
uremia
ethanol

100
Q

Hyponatremia with urine sodium <10 mmol/L

A

Extrarenal losses or Hypervolemic state

vomiting, diarrhea, third spacing (nephrotic, cirrhosis, CHF)
burns, pancreatitis, traumatized muscle

101
Q

Emergent treatment of hyponatremia

A

100mL of 3% over 10min (up to 3) - goal 4-6meq over hours

Less emergent can do 50mL slow bolus

Consider prophylactic desmopression (1 -2mcg q6-8hrs for 24-48hrs)

102
Q

Risk factors for osmotic demyelination syndrome

A

Na <120 (although especially important if <105)
HypoK
Alcoholism
Malnutrition
Liver disease

103
Q

Free water deficit formulat

A

%body water * kg * (Na - goal / goal)

104
Q

U wave (hump after T wave) is associated with…

A

hypokalemia

but also, hypoCa/Mg, ICP, hypothermia, LVH
Meds: dig, phenothiazines, class Ia/III antiarrhythmics (amio, sotolol, procainamide, quinidine)

105
Q

Causes of hypokalemia

A

GI/urinary loss (mineralocorticoid, DKA, RTA, amopho)
Insulin
Beta-agonists
Alkalosis
Hypokalemic periodic paralysis (calcium channel defect)
Hypothermia
Drugs

106
Q

EKG signs of hypokalemia

A

U wave
ST depression
Decreased T wave

Also bradycardia, AV block, Vtach/fib

107
Q

EKG signs of hyperkalemia

A

Peaked T
Long PR
Widened QRS -> sine wave
Loss of p waves

108
Q

Medications that can cause hyperK

A

Bblockers
Digitalis
Succinylcholine
Hypoaldosteronism (ACEi, heparin, NSAIDS, calcineurin inhibitors)
Spironolactone

109
Q

Dosing of treatments of HyperK

A

CaCl 500-1000mg over 2-3min
Insulin (10U regular) and glucose (50mL D50)

110
Q

Signs of hypocalcemia

A

Tetany
Anxiety/psychosis
Seizure
HypoT and QT prolongation

111
Q

Goal UOP in hypercalcemia

A

100-150ml/hr

112
Q

Etiologies of hypomagnesium (aside from GI/lack of intake)

A

Pancreatitis
Chronic PPI
Meds (diuretics, AG, ampho, pentamidine)
Alcohol use disorder
Hypercalcemia
Diabetes (poorly controlled)
Rare diseases

113
Q

Signs of hypomagnesemia

A

Tetany, weakness, coma
Arrythmias (AFib, TdP)
HypoK/Ca

114
Q

Electrolyte abnormalities in adrenal insufficiency

A

HypoNa, HyperK

115
Q

Hypophos symptoms

A

encephalopathy
decreased cardiac contractility
respiratory muscle weakness
dysphagia
ileus

116
Q

Berlin ARDS criteria

A

<1 week of known clinical insult
bilateral not explained by something else
not fully cardiac
hypoxemia (PF<300 and PEEP 5+ need)

117
Q

HFNC in acute hypoxemic respiratory failure

A

Similar intubations rates but more vent free days
Increased 90d survival

118
Q

Transfusion strategy in ARDS

A

Restrictive has improved survival in APACHE <20 (nearly 10% absolute difference in 30d mortality)

119
Q

Proning requirements

A

After 12-24hrs of attempted stabilization
at least 16 hours prone

120
Q

Steroid benefit in ARDS?

A

Only for underlying indication with early administration
COVID-19, severe CAP

Try to avoid in influenza and late ARDS

121
Q

Goal for STEMI revascularization

A

To cath by 2hrs of presentation (acceptable facility delay is 1 hour)

If unable, give tPA within 30min and transfer to center

122
Q

Discharge medications for acute MI

A

Aspirin + Clopidogrel
ACEi/ARB/ARNI
B-blocker
Statin
Spironolactone if EF<40%

123
Q
A

Medicine (1 decks)

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