ANE topic Q's Flashcards
what determines distribution of water between IC and EC?
And what distributes the water between IC and EC?
Osmotic equilibrium and onconit pressure desides
Na+ K+ Cl- distributes
hormone increasing water reabsorption in kidneys?
ADH
normal plasma osmolarity?
280mOsm/L
daily requirements of Na
1,5-2,5 mmol/kg
max Na C kidney can handle
> 1500 mOSm/kg in healthy
600-800 mOsm/kg in ICU patients
what happens to renal perfusion pressure in ICU patiens?
In healthy individuals without systemic hypertension, intrarenal blood flow is auto-regulated at renal perfusion pressures between 60 and 100 mmHg. During critical illness, these processes may be compromised.
How does pressure affect filtration rate i the kidneys?
The glomerular filtration rate is directly proportional to the pressure gradient in the glomerulus, so changes in pressure will change GFR. GFR is also an indicator of urine production, increased GFR will increase urine production, and vice versa
mechanical ventilation effect on kidneys?
increase renal perfusion pressure by increasing preload on the heart
what effect does hyperthermia have on fluid loss`
increases insensible fluid loss with 2,5 L/day
what effect does hyperventilation have on fluid loss`
increase insensible fluid loss by 0,5-2 L/day
what effect does tracheotomy have on fluid loss?
increase insensible fluid loss by 0,7 L/day
hypovolemia can cause
*Decreased tissue perfusion
*Tissue hypoxia
*Anaerob metabolism
*Inflammatory cascade↑
*Neutrophil oxidative killing↓
*Wound healing disorder
*Organ dysfunction
hypervolemia can cause
*Oedema
*Anastomosis insufficiency
*Bowel dysfunction, PONV
*Coagulation disorder
*Renal insufficiency
*Cardiopulm. complications
*Organ dysfunction
fluid compartments in the body
─ Intracellular fluid (ICF): 40% of body weight
─ Extracellular fluid (ECF): 20% of body weight
─ Interstitial fluid: 15% of body weight
─ Intravascular fluid: 5% of body weight
how can you increase Preload?
Colloid and Crystaloid solutions
how can you decrease Preload?
diuretics
How to measure CVP?
in SVC and tells us what the preload is
3 methods of measuring SV
PICCO
Swan-Gaz catheter
Echochardiography
best way to measure fluid responsivness?
measuring SV and change in the stroke volume
Normal value of IVC diameter?
1,5-2,5 cm
what can IVC tell us about volume status?
IVC < 1,5cm => volume depletion
IVC > 2,5cm => volume overload
what is the problem with using the gold standars SV to assess fluid response?
What is another option to increase fluids with 300ml withoud actullay giving fluids?
If the patient is already in a good fluid state giving 300ml crystalloid can cause edema
The led raise test because lower extremity containe about 300-400ml fluids
does the acute management of hyperkalemia solve the problem?
No, we need to do hemodialysis to actually remove the K+ from the body
what is the dose of IV K?
what can you do if you want to give a higher dose?
MAX 2g/h!!!! - IV 2g/500ml in a PVK
if you want to give a higher dose use CVK
what is the exception to giving max 2g/h of K+?
Ketoacidosis
how to find the albumin corrected Ca2+ concentration
measured Ca2+ + 0,02 x (40- Se Albumin)
what should you NOT give as a diuretic in hypercalcemia?
Thiazide
can you give calcitonin alone?
No, always with bisphosphonates
what is the absolute limit of giving Na? and why must it not exceed this level?
0.5 mmol/h
can cause pontine myelolysis
management of hyponatremia below 115 mmol/L1
First give 3% NaCl then give 0.9% NaCl
what is the first step of evaluating metabolic acidosis?
calculate anion gap
what is the reference range of anion gap?
6-10 is normal
calculating anion gap?
Na - (Cl+HCO3)
what does it tell you if the anion gap is normal in a metabolic acidosis?
its due to primary loss of HCO3 with a Cl- compensation
drugs causing resp acidosis?
due to CNS depression
Benzos
Opiates
Barbiturates
acute lung diseases causing resp acidosis?
pneumonia
pulmonary edema
acute exacerbation of COPD or asthma
which part of our circulation is the main thing in shock?
microcirculation due to shunting and skipping this part causing hypoxia
what are the hypodynamic shocks?
what do they all have in common)
cardiogenic
hypovolemic
obstructive
all: cold and clammy
what are the hyperdynamic shocks?
what do they have in common?
The three distributiv shocks
All: flushed, warm
what is the supportive care in shock?
Recognizing homeostasis
Removing metabolic acidosis
Securing oxygen
what affects oxygen delivery?
Hb
SaO2
CO
why do we do mechanical ventilation in shock?
To decrease WOB
Drug of choice in anaphylaxis/CPR resuscitation
Epinephrine/Adrenalin
Drug of choice in Septic shock?
Norepinephrine
Drug used in Cardiogenic shock?
Dobutamine
what to give if refractory to NE of in severe pulmonary hypertension?
Argipressin
Hemodynamic parameters you look at in shock?
CVP
CO
PCWP
SVR
HR
SVO2
Why is temperature important in bleeding?
Temperature affects coagulation
Hypothermia decreases coagulation!!!!
what is the deal with distributive shock?
there is a loss of vasoconstriction and blood is going “everywhere” and not to the tissue really needing it
what does CVP tell you about fluid status when giving fluids?
Rapid increase means normal volume
Slow increase means hypovolemia
3 Parameters telling us about fluid status?
- urin output
- Urin Na concentration
- Hct if normal value is known (high in hypovolemia) ( low in hypervolemia)
hemodynamic monitors for fluid status?
- PICCO - looking at pulse pressure, SV,
- US
- passive leg raise test
how to think when giving fluids
- which compartment do I have to replace
- what type of fluid am I replacing
- what lead to the fluid loss
- How much is lost/must be replaced
Mechanical circulatory support?
Aortic balloon pump
ECCMO
Isotonic crystalloids?
0.9% saline solution
Lactate ringer
Isolyte
characteristics of Colloid fluids?
- contains large proteins
- cause 1:1 ration of volume increase
- increase IV oncotic pressure
- risk of fluid overload
hypertonic crystalloids?
3% NaCl
5% NaCl
hypotonic crystalloid
Saline solution (0.45% and 0,22%)
Dextrose Solution (5% and 10%)
things about 9% NaCl solution?
Isotonic
Acidic
Resuscitation fluid
2 things about 0.45% NaCl fluid
Hypotonic
Used in hypernatremia
3 things about Dextrose 5%
Hypotonic
Suger water
Used in hypernatremia
3 things about Lactate ringer?
Isotonic
Used in surgery
Resuscitation fluid
Fluids in hypovolemic patient?
Isotonic fluid
Normal Saline
Switch to plasmalyte or LR if high volume
Fluids in hyponatremia
Hypertonic saline solution (3%)
Normal Saline
type 1 resp failure?
hypoxemia Pa02 < 60 mmhg
type 2 resp failure
hypercapnia PaCO2 > 50 mmhg
4 main causes of respiratory failure?
- impaired ventilation
- impaired gas exchange
- airway obstruction
- V/Q missmatch
define dead space in the lungs?
good ventilation but no perfusion
define cause of shunting in the lung
good perfusion but bad ventilation
what does the V/Q stand for?
V for ventilation of alveoli
Q for perfusion of the capillaries
type of resp failure in AECOPD?
type 2
type of rest failure in Acute exas asthma?
type 1
treatment of AECOPD?
Bronchodilators: Inhaled SABA: albuterol/SAMA: ipratropium bromide
Corticosteroids: prednisolone, methylprednisolone
Antibiotics: must cover gra+ and gram - (Quinolones: levofloxin)
target oxygen therapy in AECOPD?
Target SpO2 88–92%
Indication of switching to BiPAP?
RR > 25
Resp Acidosis
Hypercapnea
despite giving oxygen
what is PEFR and when is it used?
used in Asthma to assess severity of exacerbation
Peak Expiratory Flow Rate
PEFR in astma tells us (peak expiratory flow rate)
> 70% Mild asthma exacerbation
40-69% Moderate asthma exacerbation
< 40% Severe asthma exacerbation
< 25% Life threatening asthma exacerbation with respiratory failure
what is status asthmatics?
Patient not responding to standard medications
what scoring system is used for pneumonia assessment of in or out patient?
CURB-65 score and PSI
BUT clinical picture and your judgment is the most important
what is CURB-65 score?
used to decide of pneumonia is ICU or not
Confusion
Serum urea > 7 mmol/L
Respiratory rate > 30/min
Blood pressure < 90 mmHg
Age > 65
More than 2 - inpatient
Pneumonia treatment if outpatient + comorbidities?
Combined therapy
B-lactam: Cefuroxime PO
Macrolide: Azithromycin PO
Pneumonia treatment if outpatient with no comorbidities
Monotherapy of one of these:
Amoxicillin PO
Doxycycline PO
Pneumonia treatment if Inpatient
Combined:
B-Lactam: Ceftriaxone/Ampicillin IV
Azithromycin/Clarithromycin/Doxycycline PO
what decides if a pneumonia patient is ICU or non-ICU
Hypotension needing vasopressors
Respiratory failure requiring mechanical ventilation
Pneumonia treatment if Inpatient with suspicion of pseudomonas
Antipseudomonal: Piperacillin-tazobactam/Cefepime/Ceftazidime IV
PLUSS ONE OF THESE PO:
A macrolide: Azithromycin/Clarithromycin
OR Doxycycline
OR A respiratory fluoroquinolone: Moxifloxacin/Levofloxacin
4 clinical feauters of ARDS
Acute dyspnea
Tachypnea
Cyanosis
Diffused crackles
what is the most common cause of ARDS
Sepsis
Define ARDS
Acute diffuse alveolar inflammation leading to tissue damage
what is the acute timeframe of ARDS?
In this case acute is within 7 days of known suspected trigger
what are the 3 stages of ARDS pathophysiology
- Exudate phase
- Hyalin membrane phase
- Reorganizing phase
what is the Berlin criteria?
Diagnosis of ARDS
- Acute onset
- Bilateral pulmonary infiltrates on imaging
- PaO2/FIO2 ratio > 300 mmHg
- Resp failure is not due to HF or fluid overload
What acid base state is an ARDS patient in?
Alkalosis due to Tachypnea in early phase
Late phase type 2 resp failure and acidosis
what are the 5 managment strategies in ARDS?
- Fluids
- Steroids
- Ventilation
- Lung protective ventilation
- Paralysis
- Inhaled vasodilators
- ECMO
- Nutrition
Goal spO2 in ARDS?
88%
lung protective ventilation volume in ARDS?
6ml/kg of IDEAL bodyweight
remember that it is the ideal body weight not the actual bodyweight of the patient!!!!!
goal pH in ARDS
7,25 so we allow hypercapnea and acidosis
causes of PO resp failure?
- decreased respiration due to sedation and CNS suppression
- decreased respiration due to prolonged muscle relaxants
- Inhaled anesthetics causing accumulatio of secretion - atelectasis
- PO pain failure to cough our secretions
clinical presentation casing resp failure PO?
Atelectasis or pneumonia
what is the frequecy of giving epinephrin in ALS?
every 3-5 min
what are the three endpoints of BLS
- Patient shows clear signs of life
- Rescuers are to fatigue to continue
- ACLS trained providers arrive
how long do you do the first round of CPR in ALS before rhythm analysing?
2 min
do you continue checking rhythms in a non-shockable state?
yes, every 2 min
Post resuscitation 4 things to do?
- airway
- Resp parameters
- Hemodynamic parameters
- ECG
what are the 4 interventions that should be done post resuscitation?
- Coronary angiography
- EEG for diagnosing seizures
- Temperature management (TTM) (32-36)
- Neuroprotective measures
Post resuscitation Neuroprotective measures?
- EEG
- Neurological examination
- Brain death assessment after 72h
Classification of malnutrition?
In the last 6 months:
Mild: 10% loss of TBW
Moderate: 10-19% loss of TBW
Severe > 20% loss of TBW
what laboratory parameters are we looking at to assess malnutrition?
Serum albumin
Serum transferrin
Serum Prealbumin
what’s the ideal fraction of the different diet components in an ICU patient?
Carbohydrates 60-80%
Lipids 10-40%
Protein 1,5-2g/kg
Max glucose doese of an ICU patient?
5mg/kg/min
daily minimum of glucose for an ICU patient?
150g
first choice of feedin for ICU patients?
Enteral, also known as tube feeding: delivering nutrition directly to stomach or small intestine.
what is parenteral feeding and when to use it?
Parenteral nutrition is the feeding of nutritional products to a person intravenously, bypassing the usual process of eating and digestion. The products are made by pharmaceutical compounding
complications of ENTERAL feeding?
Gastric residual volume
Gastric bacterial colonization
Aspiration pneumonia
Enteral ischemia
complications of PARENTERAL feeding
Bowl mucosal atrophy
overfeeding
hyperglycemia
infection risk
permanent line is needed
more expensive
tube feeding problems?
Vomiting: to fast, too large, position
Diarrhea: too fast, intolerance, too high osmo,
Constipation: Lack of fiber, fluid and activity
Inoconstrictor drugs
NE
Epi
Dopamin
Inoconstrictor mechanism of action
Vasoconstriction - increased SVR and BP
Inotropy: increased cardiac contractility and CO
Inodilators
Milrinone: positive inotropic and vasodilatory effects
Dobutamine
pure vasoconstrictors
vasopressin
Phenylephrine
Inodilators mechanism of action
increased cardiac contractility and CO
Peripheral vasodilation and decreased SVR, afterload and improved BF and perfusion
Stages of renal failure: risk
creatinine x 1.5 BL
UO < 0.5 ml/kg for 6h
GFR loss 25%
Stages of renal failure: injury
creatinine x 2 BL
UO < 0.5 ml/kg for 12h
GFR loss 50%
Stages of renal failure: failure
creatinine x 3 BL
UO < 0.3 ml/kg 24H and Anuria 12h
GFR loss 75%
Prerenal causes of AKI
dehydration
hypovolemia
HF
Sepsis
vascular occluson
Intrarenal causes of AKI
drugs
toxins
prolonged hypotension
ATN
GN
small vessel vasculitis
post renal causes of AKI
benign prostate hyperplasia
cervical neoplasm
stenosis
retroperitoneal fibrosis
urinary stones
criteria used to classify stage of AKI
RIFLE criteria
drugs causing AKI
NSAIDS
Cyclosporins
Tacrolimus
ACEI
2 indications of dialysis?
K+ > 5
Diuresis < 5 ml/kg/t
what metabolic state is AKI patient normally in?
Hyperkalemia
Acidosis
when can you not use LR solution in pancreatitis?
if the cause is hypercalcemia because the solution contains Ca
use saline solution
when to use Ab in pancreatitis?
Acute necrotic collection or walled off necrosis
Diagnostic criteria for pancreatitis?
2/3 following:
1. Pain
2. Enzymes x3 BL
3. CT
Atlanta scores of severity in pancreatitis?
mild: no organ failure
moderate: organ failure less then 48h
Severe: persistent organ failure for ore then 48h
infusion rates in pancreatitis?
mild to moderate: 5-10ml/kg/h
severe: 500-1000 ml IV over 10-30 min
when do we do ERCP in pancreatitis?
Biliary pancreatitis
when does pancreatitis become an ICU case?
- Organ dysfunction
- SIRS
- significant need of fluids
- old age and comorbidities
what type of acidosis is DKA?
high aniongap metabolic acidosis because HCO3 is consumed as a buffer
what is the K+ state in DKA?
hypokalemia but may be masked as elevated or normal because it is the IC that is depleted
what fluids to use in rehydration in a DKA
if Na > 135 mmol/L use 0.45 NaCl
if Na < 135 mmol/L use 0.9 NaCl
symptoms of DKA vs HHS
DKA
- Dehydration
- Delirium
- Kussmals breathing
- Abdominal pain
- Nausea/vomiting
- Aceton breath
HHS
- Severe dehydration
- Polyuria
- Polydipsia
- lethargy
- Neurological deficits
- Seizures
blood used in acute hemorrhage
O Rh negative and switch to the right one ASAP
what should be in the transfusion package of a massive hemorrhage?
ratio 1:1:1 of
RBC
Platelets
FFP
Classification of hemorrhagic shock based on % blood loss?
I. <15% 750ml
II. 15-30% 750-1500ml
III. 30-40% 1500-2000ml
IV. > 40% > 2000ml
4 jobs of the liver and its complication in failure
Ammonia - urea (brain)
Stores glycogen (hypoglycemia)
Immune Kuffer cells (increased infection)
CF and Anti Coagulants (increased bleeding and coagulation
hepatotoxic medication
acetaminophen
Antimicrobials
Anticonvulsants
Chemo
infections causing hepatic failure
CMV
HSV
EBV
Toxoplasmosis
Hepatitis ABE
vascular diseases causing hepatic failure
Budd chiari syndrom
Ischemia
different classifications of hepatic failure?
Hyperacute within 0-1w
Acute within 1-3w
subacute within 3-26w
symptoms of liver failure
encephalopathy
cerebral edema
nausea/vomiting/anorexia/fatigue/malaise/lethargy
Jaundice
Pruritis
RUQ pain
management of hepatic failure
- fluids for volume status
- vasopressors if fluid non-responsive
- hydrocortisone if persistent Hypotension
- hemodynamic monitoring
- consider early intubation
- ABG
causes of HF
Myocarditis
Drug induced
Peripartum cardiomyopathy
Thyroid storm
Tachycardia induced
Valvular insufficiency
Bacterial endocarditis
Thrombotic endocarditis
Pulmonary embolism
Tamponade
Aortic dissection
drugs with negative inoropic properties
Non-dihydropyridines CCB
etiology of AHF
(CHAMPS)
Coronary syndrom
Hypertensive crisis
Arrhythmia
Mechanical cause
PE
presence of congestion/perfusion state in AHF clinical assessment?
Congestion:
Wet - yes
Dry - no
Next sted is to determine perfusion
yes - warm
no - cold
loop diuretics in HF?
Furosemide
If resistant edema combine Furosemide with thiazide or spironolactone
when can we not give vasodilators if AHF
if systolic BP is < 90 mmHg
vasodilators in HF
nitroglycerin, nitroprusside, and nesiritide.
when to give inotropic agents in HF
when systolic BP is < 90 mmHg and hypoperfusion despite fluid
Adenosin
Dopamin
Levosimendan
Phosphodiesterase III inhibitor
what is the antidote to B-blockers if that is suspected to be the cause of HF
Iv infusion of levosimendan and PDE III inhibitor
What is the most common cause of early mortality (<48h) after severe injury?
Severe cerebral/brain stem injury
what can cause a dysregulated high amplitude immune response in trauma?
tissue injuries like surgeries, second trauma, long duration shock
what is damage control surgery?
minimal invasive surgery to stabilize the patient (like external fixation)
is normovolemia or normotension the goal in fluid therapy in trauma?
Normovolemia
In trauma fluid therapy is crystalloid enough?
No, because it cannot transport oxygen and doesn’t help hemostasis, blood and blood products must also be given
How to assess bleeding risk and blood transfusion in a trauma patient?
TASH scoring system
What do you check in the TASH scoring system?
Hb
BP
BE
HR
Major bleeding sources
In traumatic coagulopathy what is most commonly seen?
Hypofibrinemia - give fibrin substitution
Hyperfibrinolysis - give tranexamic acid
normal value of ICP?
goal for trauma patients?
< 10 mmHg
< 20 mmHg
Cerebral perfusion pressure?
60-80 mmHg
Platelet activation inhibitors
Clopidogrel
Ticagrelor
Vorapaxar
Abciximab
COX1 inhibitor NSAID
is there a drug activting platelets?
No
What activates platelets?
vWF
Collagen
Thrombin
Fibrinogen
TXA2
what should you give to substitute fibrinogen in low levels?
Use fibrinogen concentrate instead of FFP (FFP has very low levels of Fi)
first thing to do if suspected PE with hemodynamic instability?
Bedside transthoracic echocardiography - if RV dysfunction do a CTPA (CT pulmonary angiogram), if positive treat as high-risk PE thrombolysis
What parameters are looked at in PE risk stratification?
- Hemodynamic instability
- PESI score
- RV dysfunction
- Elevated cardiac troponin levels
3 definitions of polutrauma?
Anatomical
Pathophysiological
Combined
what is the 2 main problems in polytrauma?
Bleeding
Hyperinflammation
what is important to consider in regards to inflammation in trauma?
the amplitude and length of the inflammation, if dysregulated higher chance of complications
what 5 things decreases O2 delivery?
hypovolemia
bleeding
anemia
hypoxia
cases of increased O2 demand in trauma?
Pain
Stress/Panick
Agitation
Hypothermia
4 states causing instability?
- Organ dysfunction
- Severe resp insufficiency
- Major bleeding/shock
- Bleeding/coagulation disorders
what is DIC (definition)
Acquired syndrom with IV activation of coagulation and loss of localization produce organ dysfunction and microvascular damage
causes of DIC
Sepsis - monocyte TF presentation
Polytrauma
Obstetric catastrophe
Massiv tissue necrosis
Hepatic failure
Allergic reaction
4 lab parameters required for diagnosis of DIC
- Pro coagulation (increased Fibrinopeptide A, B)
- Fibrinolytic activation (DD and FDP)
- Inhibitory consumption (AT III)
- End organ damage (LDH, Crt, pH, pO2)
what is the main problem with DIC and what do we solve?
Main problem is the bleeding and coagulation happening simultaneously and our goal is always to threat CAUSE
Order of EOF in DIC
Kidney
Lung
Brain
Heart
Liver
Spleen
is there always bleeding in DIC?
Not all diseases bleed
No bleeding: sepsis cancer
Bleeding: Aortic aneurism, Abruption, APL, prostate cancer
ECG signs of PE
S1Q3T3
RBBB
P-pulmonale
Normal levels of fibrinogen?
Critical low levels?
2-4 g/L
< 2 g/L
2 ICU states activating endothelia surface for coagulation?
Sepsis
Inflammation
why is there an increase of coagulopathy in anemia?
Not enough RBC to push platelets to the sides of the vessels, so no contact with endothelial surface for activation
what is TIA
Transient ischemic attack is a temporary focal cerebral ischemia with stroke like symptoms (lasts less then 24h)
Imaging in hemorrhagic shock?
Non-contrast CT
Imaging in Ischemic stroke
Diffusion weighted MRI because it shows ischemic damage after 3-30 min (CT shows after 6-24h)
Etiology of ischemic stroke?
embolic stroke
Thrombotic stroke
Global cerebral ischemia
reperfusion therapy in ischemic stroke?
IV Tissue plasminogen activator - ALTEPLASE
subtypes of hemorrhagic stroke?
Intracerebral
Subarachnoid
Intraventricular
BP in hemorrhagic stroke?
if > 220 mmHg promptly lower to 140-180 mmHg (LABETALOL)
what do to with anticoagulants if hemorrhagic stroke?
STOPP all anticoagulant therapies and if INR > 1.4 give reversible treatment
ICP and perfusion pressure in hemorrhagic shock?
ICP: < 20 mmHg
CPP: 60-70 mmHg
What is Gullian-Barre syndrom? (GBS)
Postinfectious polyneuropathy with symmetrical ascending flaccid paralysis du to cross reaction Ab attacking the host axonal antigens
GBS treatment?
IV immunoglobulins
Plasmapheresis
Frequency is US?
High:
High resolution
Low depth
Better for superficial tissue
Low:
Low resolution
High depth
Better for deep tissue
3 things to check in the RUSH protocol
Pump - heart
Tank - lungs, IVC, Abdomen
Pipes - aorta, deep veins
what to check on US: heart
EF
Pericardial effusion
RV strain
Wall motion
CO
what to check on US: IVC
Collapsable / non-collapsible
what to check on US: Aorta
Dissection / Aneurysm
what to check on US: lungs
B lines
A lines
Tension pneumothorax
Definition of chronic pain
Pain lasting longer then tissue healing time (6 months)
types of pain?
Nociceptive
Somatic
Visceral
Neuropathic
Central
Peripheral
Sympathetic
Sensitization of pain (types)
Hyperalgesia (Increased neuronal sensitivity)
Allodynia (decreased neuronal threshold)
steps of pain management?
- non-opioids (NAIDS)
- Weak opioids
- Strong opioids
- Interventional treatment
Name 6 NSAIDS
Aspirin
Ibuprofen
Diclofenac
Naproxen
Indomethacin
Meloxicam
Name 3 opioids
Oxycodone
Hydromorphone
Tramadol
morphine
fentanyl
Buprenorphine
name 3 anticonvulsants
Gabapentin
Pregabalin
Carbamazepine
Name 3 muscle relaxants
Cyclobenzaprine
Methocarbamol
Baclofen
Anesthesia (5)
Thiopental
Midazolam
Propofol
Ketamine
Etomidate
Inhaled anesthetics
Isoflurane
Desflurane
Sevoflurane
Onset of inhaled ANE
Blood soluble - Slow onset
Lipid soluble - Fast onset
goal MAP in sepsis?
> 65 mmHg
SIRS criteris?
Temp < 33 or > 38
Tachynea > 22 pCO2 < 36
HR > 90
WBC 12x109 or 4 X109
Quick SOFA
Altered mental status
SBP < 90 mmHg
RF > 22
SOFA
Resp PaO2/FiO2
CV MAP
Liver (bilirubin)
Kidney (crt)
Coagulation (platelets)
Neurologic GCS score
1st line vasoconstrictors in septic shock?
NE then try Vasopressin then try Epi
give in bradycardia sepsis?
Dobutamine
fluid in sepsis?
30 ml/kg crystalloid
oxygen level goal in sepsis?
> 90 %
cause of type II resp failure?
Impaired ventilation (so movement of air in and our)
causes of rest failure I
Impaired fass exchnage (O2 not crossing over)
What is mechanical ventilation
Mechanical ventilation is a form of life support. A mechanical ventilator is a machine that takes over the work of breathing when a person is not able to breathe enough on their own. The mechanical ventilator is also called a ventilator, respirator, or breathing machine.
On mechanical ventilator how do we increase ventilation?
increase RF
increase Tidal volume
On mechanical ventilator how do we increase oxygenation?
Increase FiO2 and or PEEP (positive end expiratory pressure)
Diagnosis of rest failure?
ABG
CXR
Echo
ECG
Microculture
CBC
Bronchoscopy
two aspects of COPD?
Chronic bronchitis and emphysema
two aspects of COPD?
Chronic bronchitis and emphysema
define chronic bronchitis
Productive cough for 3 months for at least 2 years
define Emphysemia
Alveolar wall and capillary destruction causing permanent dilation of air spaces
how to know if emphysema or chronic bronchitis is the problem in COPD?
Pink puffers have emphysema
Blue bloaters have chronic bronchitis
3 classifications of AECOPD
Mild: no hospitalization and standard dose bronchodilators
Moderate: No Hospitalization, bronchodilators + CS + AB
Severe: Hospitalization, high dose of all three + Resp failure
what does crackles on auscultation during an acute ex of asthma mean?
etiology is due to viral or bacterial trigger
acute ex of asthma treatment? (4)
- Inhaled SABA (albuterol) or LABA (ipratropium)
- IV CS Methylprednisolone
- IV Mg+ if severe
- Oxygen with goal of 92%
when to give Mg2+ on acute ex asthma?
IF respiratory arrest with persistent hypoxia after treatment
Adults with FEV < 25-30
Children with FEV < 60% after 1h of treatment
when to intubate in ex asthma?
If no response to treatment and resp arrest
mild ex asthma treatment?
only SABA and O2 if needed
Pneumonia monotherapy if no co-morbidities
Amoxicillin PO
Doxycycline PO
outpatient Pneumonia monotherapy if co-morbidities
Ampicillin + macrolide OR mono therapy with a fluoroquinolone
when id pneumonia an inpatient case?
CURB-65 > 2
PSI > 90
how to keep alveoli open and not collaps in ARDS?
high PEEP
respiratory failure in ARDS?
Type 1
causes of ARDS?
Sepsis
Trauma
Shock
Acute pancreatitis
Pneumonia
Aspiration
Inhaled toxins
short pathophysiology of ARDS?
tissue damage in or outside lung causing inflammation resulting in diffuse alveolar damage
leading complications of ANE causing postop resp failure
Atelectasis (due to using 100% O2)
Pneumonia
what is atelectasis
It occurs when the tiny air sacs (alveoli) within the lung become deflated or possibly filled with alveolar fluid. Atelectasis is one of the most common breathing (respiratory) complications after surgery
post resuscitation hemodynamic parameters
MAP < 65 mmHg
SBP < 90 mmHg
which patients are sendt to coronary angiography post resuscitation?
if ST elevation on ECG
what are the post resuscitation ABC?
ABG
BP
CXR
ICU caloric requirement?
25Kcal/kg
how to calculate ICU nutrition need?
REE = BEE x Stress factor
*REE: (Resting energy expenditure) the amount of energy expended by a resting individual
*BEE: (Basal Energy Expenditure the minimum amount of energy expended compatible with life.
Fluid therapy goals in pancreatitis
HR > 120
MAP 65-85
Urine > 0.5 -1 ml/kg/h
Hct 35-45%
CVP 8-12 mmHg
antiemetics in pancreatitis?
Ondansetron
Metoclopramide
what does HHS stand for?
hyperosmotic hyperglycemic state
DKA complications
Cerebral edema
Heart failure
Arrythmias
Mucormycosis
Symtomes of encephalopathy
altered mental status
asterixs
what to give in hyperammonemia (hepatic encephalopathy)
Lactulose
HFrEF
HFpEF
*HFpEF is defined as heart failure with a left ventricular ejection fraction, or LVEF, of 50% or greater.
*HFrEF, or heart failure with a reduced ejection fraction, is heart failure with an LVEF of less than 40%.
what causes release of BNP from the heart and what does it do?
Increased preload causes BNP release which causes vasodilation and no Na and H2O retention
what mechanism causes increased afterload?
vasoconstriction
lab studies in AHF?
NT-ProBNP
< 300 HF unlikely
> 1000 likely
2 Q’s to ask if suspected AHF?
Is the patient in cardiogenic shock
Does the patient have resp failure
if yes - ICU for treatment
what to ask if known AHF
Is the patient wet/dry (congested/not-congested)
Is he patient hot or cold (perfused/non-perfused
Three options of immediate treatment of periarrest arrhythmias
- anti-arrhythmic drugs
- Attempted electrical cardioversion
- Cardiac pacing
adverse sings in peri-arrest arrhythmias
- HF (pulmonary edema or jugular distension)
- Chest pain
- Excessive tachycardia (>140)
- Excessive bradycardia (< 40)
- Clinical signs of low CO
Cardioversion drug?
Amiodorane 300 mg IV over 10-20 min
Adult tachycardia treatment algorithm?
- Unstable/Stable
- QRS narrow/wide
- QRS irregular/regular
adult bradycardia algorithm?
- ABCDE
- Life threatening yes/no
- Risk of asystole yes/no
Evidence of life threatening bradycardia?
- shock
- syncope
- myocardial ischemia
- HF
Risk of asystole?
- Previous asystole
- Mobitz II
- Total heart block + wide QRS
- Ventricular pause > 3s
life-threatening bradycardia treatment
Atropin 500ug IV (max out to 3g if no effect)
Isoprenaline
Adrenalin
non-life threatening brady treatment
*If risk of asystole:
Aminophylline
Dopamin
Glucagon
*IF no risk of asystole just observe
Treatment of tachycardia broad regular
amiodarone 300mg
Treatment of tachycardia broad irregular
B-blocker + anticoagulants
if TdP Mg 2mg/10 min
Treatment of tachycardia narrow regular
Vagal manuver
Then Adenosine
Then Verapamil
Treatment of tachycardia narrow irregular
B-blocker + anticoagulants
IF HF give digoxin or amiodarone
DD concentration in DVT?
> 500 mg/ml positive
< 500 ng/ml negative
DVT Wells criteria (risk)
- Clinical symptoms - 3p
- PE most likely diagnosis 3p
- Tachycardia 1.5p
- immobilization 1.5p
- prior DVT 1.5p
- Hemoptysis 1p
- Malignancy 1p
DVT treatment
- parenteral LMWH for the firt 5-10 days
- long term direct oral anticoagulants 3-6 months
- Individualized decisions to continue anticoagulants for extended period
Vasodilators
Hydralazine
Minoxidil
Diazoxide
Nitro
