Acute/Crit Care Medicine Flashcards
Fluids, electrolyte disorders, VTE ppx, sympathetic targeters, shock, other common ICU conditions, OR meds
FAST HUGS BID
what does the pneumonic stand for and why is it important in CC medicine?
Feeding
Analgesia
Sedation
Thromboprophylaxis
Head of Bed (VAP ppx)
Ulcer ppx
Glycemic control
Spontaneous breathing trial
Bowel regimen
Indweling catheters
De-escalation of ABX
can and should be done/assessed twice a day in CC!
examples of crystalloid fluids
LR
NS
D5W
D50
D5NS
Plasma-Lyte-A
examples of colloid fluids
albumin 5%, 25%
dextran
hydroxyethyl starch
hyponatremia is broken down into which 3 categories
hypotonic hypovolemic shock (HHS)
hypotonic isovolemic shock
hypotonic hypervolemic shock
hypotonic hypovolemic shock (HHS)
causes
treatment
diuretics, salt-wasting, adrenal insuff, blood loss, V/D
treat with 3% saline IV
hypotonic isovolemic shock
causes
treatment
SIADH (too much vasopressin causing water retention and dilution of Na)
d/c offending drug + diuresis
+/- demeclocycline
hypotonic hypervolemic shock
causes
treatment
fluid overload, cirrhosis, HF, renal failure
diuresis with fluid restriction
tolvaptan
MOA
uses
BBW
ADE
vasopressin antagonist (inc fluid excretion)
can be used in isovolemic or hypovolemic hypotonic hyponatremia, but evidence unclear
BBW: do not correct Na faster than 12mEq/L/day 2/2 ODS
ADE: thirst, N, xerostomia, polyuria, inc BG
hypernatremia is classified as a sodium >________.
how do we treat hypernatremia?
> 145mEq/L
hypovolemic (dehydration, N/V) –> fluids
isovolemic (diabetes insipidus) –> desmopressin
hypervolemic (intake of hypertonic solutions) –> diuresis (excrete Na and water)
Na should be corrected at _________ to prevent __________________________________
12mEq/L/day
osmotic demyelination syndrome
___________ should be replaced before _____________
A. potassium/magnesium
B. sodium/magnesium
C. magnesium/sodium
D. magnesium/chloride
E. magnesium/potassium
E. magnesium/potassium
what is magnesium normal range?
what is considered hypomagnesemia and what are possible causes?
how do we determine which dosage form to use for mag repletion?
normal range 1.5-2.4
hypomag = <1.3
can be due to AUD, Amph B, V/D, diuretics
if Mg <1 replace with IV mag
if Mg >1 replace with po mag
hypokamemia
treatment? what if IV? what if oral?
how many mEq will it take to raise K by 0.1
oral or IV K
if IV, must be a central line and infused at </= 10mEg/hour and a concentration of </= 10mEq/100mL
oral doses not to exceed 40mEq
10mEq oral K will raise K by 0.1mEq/L
phosphate
normal range
treatment of hypophosphatemia
normal 2.6-4.5
infuse 0.08-0.16 mmol/kg in NS or D5W over 6 hours
what is inceptive spirometry
facilitates lung expansion in hospitalized patients or those with atelectasis (dec lung volume)
IVIG can be used in what three conditions
and should be infused fast/slow?
myasthenia gravis
multiple sclerosis
Guillain Barre
slow!
DA
MOA
dosing
DA is a sympathomimetic
dosing is dependent on renal function
low/renal dosing = 1-4mcg/kg/min, DA1 ag
medium dose = 5-10mcg/kg/min, B1 ag
high dose = 10-20mcg/kg/min, a1 ag
BBW for all pressors
extravasation
pressor extravasation treatment
stop pressor, do not remove needle/cannula, do not flush line
treat with phentolamine (a1 blocker that antagonizes pressor)
NTG ointment also an option
EN MOA
a1, B1, B2 agonist
NE MOA
a1 ag >B1 ag
what score estimates ICU mortality risk
APACHE II
phenylepherine MOA
pre a1 agonism
vasopressin
MOA
ADH, vasopressin R agonist
no inotropic or chronotropic effects
warnings for all vasopressors
extravasation since all are vesicants
caution with MAO-i
all IV vai CENTRAL LINE
need continuous monitoring
concentration of EN push is__________
concentration of EN inj is______________
push is 0.1mg/mL
inj is 1mg/mL
NTG at low doses is a _________ dilator whereas it is a ________________ dilator at higher doses
A. venous/arterial
B. arterial/venous
A. venous/arterial
NTP
risks compared to NTG
MOA
not for use in _________________
purely 1:1 arterial and venous vasodilator
lowers BP more than NTG and is
metabolized into cyanide and thiocyanate –> use lowest dose for lowest duration
not for use in myocardial ischemia 2/2 shunting from heart (coronary steal)
NTG and NTP both increase __________
ICP
what can be given to reduce the risk of thiocyanate toxicity with NTP administration
hydroxocobalamin
what can be given for cyanide toxicity
sodium thiocyanate
hypovolemic shock
treatment
how will PCWP, CO, SVR and pvO2 present
fluid challenges
(replace blood with FFP or PRBC if hemorrhagic hypovolemia)
if fluid chalenges do not work, vasopressors are second option
dec PCWP dec CO inc SVR dec svO2
septic shock
septic shock is a type of ________ shock
treatment
how will PCWP, CO, SVR and pvO2 present
distributive
fluids, ABX, pressors (NE = #1), inotropes
(fill the tank, squeeze the pipe, kick the pump)
dec PCWP dec/inc CO dec SVR inc/dec svO2
cardiogenic shock
treatment
how will PCWP, CO, SVR and pvO2 present
treat underlying (MI, HF exacerbation etc.)
includes diuretics, inotropes, pressors
inc PCWP dec CO inc SVR dec svO2
what is the preferred treatment for hypoperfusion in cardiogenic shock in patients with hypotension? hypertension?
hypotension - may prefer pressors NW, EN, DA
hypertension may prefer inotrope (dobutamine)
target RASS score for most patients
0 to -2
alert and calm to light sedation
treatment options for ICU delirium
low dose quetiapine
orientation, music, noise reduction
dexmedetomidine
brand
MOA
hemodynamic effects
use
Precedex
a2 agonist
dec HR dec BP
can use as sedation in intubated or non intubated patients
what patients do we use precedex cautiously in
liver imp, DM, heart block, bradycardia, ventriculat dysfxn, hypovolemia, HTN
propofol
brand
CI
SE
Diprivan
CI egg or soy allergy
SE: dec BP, apnea/resp dep, inc TG, PRIS
does precedex cause respiratory depression
no
what is PRIS
propofol-related infusion syndrome
rare, but fatal reaction in intubated patients on propofol (Diprivan) categorized by multi-organ failure, metabolic acidosis, lactc acidosis, rhabdo, hyperkalemia
propofol is made up of _____ in _____ and provides what amount of nutritional component in TPN
oil in water
1.1 kcal/mL lipids/fat
midazolam has a BBW for
resp depression
etomodate
brand
uses
Amidate
ultra short-acting
used to induce sedation
ketamine
brand
uses
SE
Ketalar
induction for intubation
SE: resp dep, inc CSF pressure, apnea, psych
risk factors for stress ulcers while hospitalized
mechanical vent >48h
coagulopathy
sepsis
TBI
major burns
acute renal failure
high dose steroids
concerns about H2RAs for ulcer ppx
thrombocytopenia
AMS in elderly
renal impairment concerns
tachyphylaxis has been reported
concerns about PPIs for ulcer ppx
osteoporosis
c diff
fractures
nosocomial PNA
local anesthetics
lidocaine
benzocaine
liposomal bupivicaine
all inhaled anesthetics can cause
malignant hyperthermia
bupivicaine cannot be administered
A. IV
B. epidural
C. intrathecal
A. IV
anasthetic in most epidurals
bupivicaine
_________ is the only depolarizing NMBA
succinylcholine
what are intermediate-acting NMBAs
rocuronium
vecuronium
atracurium
cisatracurium
what is the only long acting NMBA
pancuronium
NMBAs must have a label that says
WARNING, PARALYZING AGENT
tranexamic acid
uses
ADE
menorrhagia, to stop bleeding in hemorrhage
ADE: vascular occlusion, thrombosis
