A&E Flashcards
3 complications with central venous catheter
infection
rupture of artery
PTX
Daily protein calorie intake
daily requirement in critical care - 1.5-2 g/kg/day
What are the typical symptoms of a patient with renal failure?
- metabolic acidosis, hyperkalemia
- pulmonary edema
- increase in BUN
- loss of consciousness
- uremic encephalopathy
When a patient has DKA when should we stop giving insulin?
when blood glucose becomes normal
When a patient has hyperkalemia, what doe we see on the ECG?
- peaked T waves on preicordial leads
- Lengthening of QRS interval
- U waves
- Widening and flattening of P wave, which eventually disappears
Lethal triad
coagulopathy
hypothermia
metabolic acidosis
What is the lethal triad?
- coagulopathy
- hypothermia
- metabolic acidosis
Treatment for hyperkalemia
- insulin glucose
- calcium-gluconate IV
- hemodialysis
- beta agonist - activates Na/K pump moving K into the cells
- if there is metabolic acidosis give sodium bicarbonate
Post-op how to decrease O2 demand to brain
cannot
- maintain BP
- control pain
- minimize sediation
Symptomatic treatment o bradycardia
- Atropine 500 mcg IV (0.5mg) for a max 3 times
- isoprenaline
- adrenaline
- glycopyrrole
- dopamine
what are 3 applications of EtCO2
- noninvasive technique which measures the partial pressure or maximal concentration of CO at the end of the exhaled breath (normal 35-45mmHg)
- can be used to detect metabolic acidosis
- used during CPR for assessment of ROSC
What is the treatment for DKA?
fluid resuscitation - isotonic saline (crystalline) soln - IV 0.9% NaCl
potassium repletion when under < 5.3 mEq/L
insulin therapy - short acting once the potassium level is >3.3 mEq/L
treat reciprocating causes
When does Low anion gap metabolic acidosis occurr?
It is very rare
eg.
- low albumin levels
- hypophosphatemia
- bromide intoxication
- high concentration of lithium
- very high concentration of positive ion
e.g. hypercalemia, hyperkalemia, hypermagnesmia, hypercholesterolemia
Name 3 antibiotics used to treat Pseudomonoas
- piperacilin-Tazobactam
- carbapenems
- fluroquinolones
5 reasons AMI can cause cardiogenic shock
wall rupture (late phase)
arrhythmia
valvular dysfn (papillary muscle necrosis)
decreased contractility
wall rupture –> tamponade
How to calculate pulmonary MAP
1/2 SBP + 2/3 DAP
4 IV anesthetics
Thiopental - barbituate 3-6mg/kg
Midazolam - benzodiazapem - 0.01 - 0.1 mg/kg
Propofol - 2-4 mg/kg
Ketamine - 1-5mg/kg
Caloric value of carbohydrates
should be 60-80% of nutrition
4.3 Kcal/g
max glucose for ICU patient is 5 mg/kg/min
How many joules do we use of the defribillator for infants/children
4 Joules/kg
Normal ABG values
pH 7.35 - 7.45
PaO2 75 - 100 mmhg
PaCO2 34 - 35 mmHg
HCO3- 22 - 28 mmol/L
BE 2 - -2 mEq/L
First line tx for PTX
respiratory support and tx dyspnea
immediate tube thoracostomy
Formula for Cardiac Output
CO = SV x HR
3 antibiotics against MRSA
vancomycin
doxycycline (skin MRSA)
linezold
trobamycin
What are the 4 T’s
tension pneumothorax
cardiac tamponade
thrombosis - coronary or pulmonary
toxins
They are reverisble
first choice treatment for bradycardia
atropine - 500 mcg
Name preemptive analgesics
opioid
NSAID
Indications to give Bicarbonate
CPR when there is severe acidosis : pH < 7.1
Strong suspicion of metabolic acidosis
correct hyperkalemia
What are 5 uses of end tidal CO2 during CPR?
PQRST
P - placement of endotracheal tube
Q - quality of compressions
R - ROSC - return of spontaneous circulation
S - situation
T - termination
Anaphylatic shock symptoms
ABCDE
A - wheezing (broncoconstriction)
B - dyspnea
C - hypotension, skin: hives, itching, urticaria, angioedema
D - dizziness, fainting
E - nausea, vomitting
Formula for Mean Arterial Pressure
SBP + 2DBP. / 3
Type 1 respiratory failure
hypoxemia without hypercapnia
Difference between CRRT and IRRT
CRRT - continuous renal replacement therapy
- over 24 hours
- slow type of dialysis
- better hemodynamic stability
IRRT - intermittant renal replacement therapy
- performed for less than 24 hours, 2-7 times per week
Antidote for opiates,
naloxone
what are the 5 P’s in the circulation part of ABCDE
pain
pallor
pulse
paresthesia
paralysis
What is the dose of epinephrine and how do you give it to a patient in the ICU?
infusion
0.01-0.03 microgram/Kg/min
formula for oxygen delivery
DO2 = [(1.34 x Hgb x SaO2) + (PaO2 x .003)] x CO
What is the EtCO2?
35-45 mmHg
3 sublingual antihypertensive drugs and their doses
nitrates, ACEi, niflodipine
- captopril - 25 mg
- nifedipine - 10 mg
- prozasin - 2 mg
What is Euglycemic Ketoacidosis?
some of the newer antidiabetic drugs such as Empagliflozin (SGLT2i) are causing it
same symptoms as DKA but normal blood sugar
Bicarbonate dosage for DKA
100 mmol/L
4 symptoms of shock
MOF
urine output <0.5 mL/kg/hr
loss of consciousness
confused
GI: absent bowel sounds
Name 3 non-invasive airway measures
Head Chin tilt
Eschmark
CPAP
BiPAP
Bg mask
Injection site for spinal anesthesia
- usually below L2 to avoid damage to spinal cord
- needle is inserted into subarachnoid space between arachnoid and pia mater
When can we determine that the patient has renal failure?
We check the urine output - if it is lower than 1/2 mL/kg/hr - that means that the GFR is taking too long
When treating for DKA when should the patient be given sugar (glucose)?
when the blood glucose level is below 15 - then continue the insulin therapy and start glucose
afterwards it should be slowed down and be stopped when blood glucose becomes normal
Tx for acute hyperkalemia
IV calcium gluconate
with more time:
- insulin + glucose
- NaHCO3-
- loop diuretics (furosemide)
What are the 3 types of renal failure?
- Prerenal failure - decrease in blood flow to kidney causing a decrease in intraglomerular pressure
- Intrarenal/Intrinsic failure - intrinsic renal damage
- Postrenal failure - obstructive causes, which lead to congestion of the filtration system leading to a shift in the filtration driving forces
What are the 5 indications for dialysis?
AEIOU
- acidosis
- electrolytes (K>7 mmol/L)
- intoxication
- overload with fluid
- uremia
Largest peripheral Needle
14 G
Describe interosseous line
used in emergencies (burns, dehydration, heart attack) needle inserted through the bone cortex into the marrow
in the anteriormedial tibia or humus or femur
Caloric value for lipids
9.1 kcal/g
lipid oxidation is limited
Formula for osmolarity
osmolarity = 2 Na + glucose + urea (mmol/L)
name 5 opiods commonly used
sufentanyl
rumifentanyl
tramadol
morphine
fentanyl
3 ways to measure cardiac output
doppler ultrasound
pulse pressure methods
impedence cardiography
MRI
transpulmonary thermodilution
calculate CO=SV x HR
4 IV anesthetics
thiopental (barbituate)
Midazolam (benzodiazepem)
Propofol
Ketamine
How do you know a patients airway is obstructed?
paradoxical movment
What is the definition of shock?
Acute hemodynamic disorder (micro and macrocirculatory) independent of the cause which leads to insufficient oxygen supply and tissue hypoxia
What is the correction for symptomatic bradycardia?
- isoprenaline 5 microg/min
- adrenaline 2-5 microg
atropine - 0.5 mg
maximum of 3mg
every bolus can only be 0.5 mg
3 symptoms of upper GI bleeding
- hematemesis
- melena
- drop of BP, lightheadedness
Caloric value of protein
4 kcal/gram
What is the 60-40-20 rule?
total body water 60% of weight in kg
intracellular fluid 40%
extracellular fluid 20%
Criteria for empty stomach before surgery
clear fluids - 2 hours
breast milk - 4 hours
nutritional drinks, solid foods - 6 hours
formula of osmolarity
Calculated osmolarity = 2 (Na+) + 2 (K+) + Glucose + Urea (all in mmol/L)
What is different about child CPR and adult CPR?
Compression rate: 100–120/minute
Compression-to-breath ratio:
Single rescuer: 30:2
Two rescuers: 15:2
Postpubertal children/ adolescents: Same CPR technique as for adults
Children ≥ 1 year of age until puberty
Chest compressions: Deliver with one hand/2 fingers for smaller children.
Compression depth: 5 cm
Infants < 1 year old
Compression depth: 4 cm
Rescue breaths: Form a seal over both the nose and mouth.
hypoxia is the main cause of cardiac arrest in children
Why is there metabolic acidosis in renal failure?
loss of bicarbonate and low filtration of acids
e.g. uric acids
Difference between dehydration and hypovolemia
Hypovolemia - intravascular fluid is lost
- a condition where the extracellular fluid volume is reduced and it sresults in decreased tissue perfusion. It can be caused by salt and water loss
Dehydration - intravascular and extravascular is lost
What are we investigating when we do an ultrasound during CPR?
1 H and 3 T’s - reversible causes
- Subxiphodial/substernal are for cardiac tamponade and Pulmonary embolism
- pleural sliding for PTX
- IVC for hypovolemia
- dilation of right side of heart for hypervolemia
What are some non-nephrological indications for hemodialysis?
- intoxication
- hypothermia
What does metabolic alkalosis cause
vomit
diarrhea
3 indications of central venous line
fluids
dialysis
long hospital stay
icu
Give 4 indications for acute renal dialysis
- hyperkalemia
- uremic encephalopathy or cardiomyopathy
- persistent metabolic acidosis
- fluid overload
Gynecological emergencies in ICU
placental abruption
miscarriage
ectopic pregnancy
acute PID
pelvic endometriosis
How do you differentiate between high and non-high metabolic acidosis?
- anion gap
- renal function – for osmolarity and for oxylate crystals - indicator for intoxication)
- hepatic function
Why do patients with DKA need lots of fluids?
due to the high glucose that goes to the kidney tubules –> there is osmotic activity and lots of water is pulled with the glucose that is being urinated
3 inotropes
Dobutamine
Milirone
Dopamine
E
NE
HCO3- dosage for DKA
100 mmol
3 indications for systemic thrombolysis
- Massive PE and acceptable risk of bleeding complications
- Ischemic Stroke
- New hemodynamic instability
- Severe right ventricular (RV) dysfunction by chest CT scan (RV:LV ratio > 0.9)
IV antihypertensives
- CCB - Nicardipine
- nitroglycerin
- direct acting vasodilator - hydralazine
- selective beta 1 blocker - esmolol
- ACE inhibitor: enalaprilat
Normal range of Lactic Acid
< 2 mmol/L
Name 3 non-invasive airway measurements
- head chin tilt
- eschmark
- bipap or cpap
- oxygen
- bag mask
What are the top nosocomial bacterias?
Pseudomonas
MRSA
Klebsiella
Acinetobacter
Antidote for Benzodiazepine
Flumazenile
NSAID Side effects
ulcer
renal function impairment
heart attack or stroke
aplastic anemia
allergy
Parameters in mechanical ventilation
FIo2 - fraction of inspired O2
PEEP - positive end expiratory Pressure - in the alveoli at end of expiration
Tidal Volume - normal breath
Mode:
- assisted control
- intermediate mandatory ventilation or pressure support
CPAP, BiPAP, FiO2, tidal volume and RR will change the alveolar ventilation and positive end expiratory pressure (PEEP)
septic shock definition
a type of septic shock caused by excessive inflammatory response to disseminated infection, which leads to etravasation from the vascular space and loss of intravascular volume
atmospheric pressure in mmHg and mmH2O
760 mmHg
10332.276 mmH2O
What are the ways to decrease intracranial pressure
head elevation - venous return (15-30 degrees)
liquor drainage (ventricular drain)
MAP elevation
Mannitol
General daily calorie intake
1600-2400 calories/day for women
2000-3000 calories/day for men
BMR men = 66 + (13.7 x weight) + (5 x height in cm) - (6.7 usage in year)
BMR women = 65.5 + (9.6 x weight in kg) + (1.7 x height) - (4.7 x age in years)
4 organ systems in septic shock
kidney
liver
heart
brain
Layers that must be penetrated for for spinal anesthesia
skin
subcutaneous fat
supraspinal ligament
intraspinal ligament
ligamentum flavum
epidural space
dura mater
arachnoid mater
subarachoid mater
Definition of Shock
acute hemodynamic disorder (micro and macrociculatory) independent of the cause which leads to insufficient oxygen supply and tissue hypoxia
What is an anion gap?
the difference between the positive ad negative ions
AG = [Na+] + [K+] - ([Cl-] + [HCO3-])
normal value is 10 - 16 mmol/L - dependent on if K is included in the calulation
helps to distinguish between High and Non-High Anion Gap Metabolic Acidosis
4 indications for Central venous Catherter
-large volume resusscitation
- poor peripheral veins
- administration of irritant meds
- long term IV therpay
Puncture in the ribs - PTX
Along upper edge of rib in the 4-5 intercostal space in the midaxillary line
OR
in in the 2nd intercostal space midclavicular line
What are the main symptoms of DKA?
- polyuria
- polydipsia
- lethargy
- anorexia
- hyperventilation (kussmal)
- ketotic breath
- dehydration
- vomitting
- abdominal pain
- flushed face
3 symptoms of hypoglycemia
- pale
- sweating
- tachycardia
- CNS
Antidote for non-depolarizing muscle relaxant
Neostigmine (cholinesterase inhibitors)
What is the Horowitz Index
ratio of partial pressure of oxygen in blood (paO2) in mmHg and the fraction of oxygen in the inhaled air (FIO2)
PaO2/FiO2
its used to assess the lung function in patients, esp those on ventilators
ASA 1- 6 charactertistics
1 - healthy
2 - mild systemic disease (HTN, DM)
3 - severe systemic disease - functional limit
IV - severe systemic - threat to life
V - unlikely to survive next 24 hours
6 - brain dead
When and how can we use epidural anaesthesia?
can be used for acute pancreatitis –> increased blood flow to pancreas for healing
no parasympathetic fibers are affected in epidural anesthesia
injection site:
- may be performed at any vertebral level
- needle is inserted into the epidural space between ligamentum flavum and dura mater
Side effects of local anesthetics
- bradycardia
- ventricular arrhythmia
- infections
- allergic reactions
- hypotension/headache
What are the 4 H’s
hypoxia
hypovolemia
hypothermia/hyperthermia
hypokalemia/hyperkalemia
They are reversible
what are the 5 P’s in the circulation part of ABCDE
pain
pallor
pulse
paresthesia
paralysis
What is type 2 Respiratory Failure
PaCO2 > 50 mmHg
or pH < 7.3
and PaO2 < 60 mmHg
Treatment for Tachycardia
- beta-blockers
- vagal maneuvers
- cardioversion - electrical or chemical
- Implantable cardioverter defibrillator
- Ablation
- Pacemaker
DX airway at risk
listen for snoring
gurgling
choking
paradoxical movement
