Causes, Lists And Definitions 1-11 Flashcards
Outcome scores for AAA
Hardman index
Glasgow Aneuyrsm Score. (Score of 84 - 65% pred mortality)
Hardman (1 point each, >2 = 80% mortality)
Age>76 Cr>190 Hb<90 Ischaemic ECG LOC in Hospital.
Glasgow Age - year in points Shock 17 Myocardial disease 7 Cerebr0vascular 10 Renal disease 14
Complications of a AAA repair
Graft Early - Massive Transfusion Distal embolus Branch involvement - pancreatitis, AKI ENDOLEAK
Graft Late - Infection, occlusion, Aorto-enteric fistula, pseudoaneury…
Non graft early - MI, renal failure, paraplegia, HAP/VAP/ARDS, transfusion issues, ARDS, ACS, ileus
Non graft late - slow resp wean
Small bowel obstruction
DVT/PE
Hernia
When to electively operate AAA
Male >5.5cm
Fem >5cm
Growth >1cm/year
Abdominal pressures
Normal 5-7
1 - 12-15
2 - 16-20
3 21-25
4 25+
ACS - >20 with new organ dysfunction (+/- APP<60)
Risk factors for Ab Compartment
Diminished Wall Compliance —- tight closure, burns, obese
Increased abdo content - Intra and extra lum
Capillary leak - sepsis, pancreatitis, acidosis, fluid +++
Other - MV, PEEP>10, Shock, increased head of bed
Issues with an open abdomen
Nursing - skin, turning, positioning, pain
Fluid loss - ?fluid balance
Malnutrion - loss of protein/nitrogen
Infection
Ileus
Risk of entero-Cutan fistula
When to CT a stroke
Thrombolysis or anti coag decisions
Known anti-coag use
Bleeding tendency
GCS <13
Fluctuating or progressive symptoms
Papilloedema, stiff neck, fever
Head at onset
Oxford (bamford class of stroke)
TACS - MCA
PACS MCA/ACA
LACS - deep penetrating artery with subcortical
POCS Brainsetm cerebellum
Define Contrast Induced AKI
Development of AKI within 48 hours of contrast load
Mechanisms of contrast AKI
Reactive Oxygen Species are nephrotoxic
Imbalance vasoconstriction vs dilation
Increased O2 consumption
Contrast diuretics
Increased urine viscosity
KDIGO stages
1 - 1.5 to 2x increase in baseline (or 26umol) OR <0.5ml/kg 6-12hrs
2 2-3. OR 0.5ml/kg >12 hours
3 - 3x (or 354 umol) OR <0.3 for 24 or anuria for 12
Indications for RRT
Metabolic acidaemia
Hyperkalaemia
Symptomatic uraemia
Fluid overload
Overdose
Types and principles of RRT
CVVHF - CONVECTION - bulk flow down hydrostatic gradient
CVVHD - DIFFUSION - countercurrent of blood and diasylate
SCUF
CVVHDF
Things to prescribe on RRY
Intermittent or continuous
HF or HD (diffusion better for small solutes)
Dose - how much filtrate produced (25-35ml/kg/hour)
Fluid - pre or post dilution
Fluid balance target
Anticoagualtion
Flow rates
Anti coag methods in RRT
None - no bleed short filter life
UFH - Titratable, monitored, reversible. RISK OF HIT
LMWH - no titration. No reversal
Prostacyclin - Less bleeding, short filter, HYPOTENSION
Citrate - Good regional, stays in circuit.
BUT, hypocalcaemia, large sodium load. CI in liver disease. Citrate acid.
Define Acute Liver Failure and its classification
Rare life threatening illness usually with liver disease already, with acute deterioration in synthetic function
Presents as jaundice, enceph, coaguloapthy
Hyper acute < 1 week
Acute 1- 4
Sub acute 4-24 weeks
Duration from jaundice to enceph
Causes of ALF
Infection - Hep, HSV, CMV, VQV EBV
Drugs - PARACETAMOL, phenytoin, tb - isnoiazid, chemo, amphet.
Toxins - mushrooms
Malignancy
Vascular - budd chiara (vein thrombosis), ischaemia
Pregnancy, HELLP. Acute fatty liver
Wilsons
Autoimmune
King criteria - paracetamol
pH< 7.3
OR
All of
PT>100s
Cr>100
Grade 3/4 enceph
Kings - non para
PT>100
OR
3 of
Age <11 >40
Non hep a/b
Not hyper acute
PT>50s
Bilirubin >300
Encephalopathy grading
West Haven
1 lack of awards, euphoria/anxiert
2 - lethargy, apathy
3 - Somnelence, semi stupour
4 - coma
ARDS definitions - proper
Acute and diffuse
Inflammatory lung injury
Causing increased lung vascular permeability
Increased lung weight
Loss or aerated tissue with
Hypoxaemia, bilateral radio graphic opacities, increased venous admin
Increased dead space and decreased compliance
ARDS berlin
Within 1 week of acute resp insult
Bilateral opacities that are NOT effusions, collapse or nodules
Resp failure NOT explained by LVF/overload (echo)
Ventilated with PEEP>5
PF<300
Causes of ARDS
Pulmonary or Non Pulmonary
:
Pulmonary:
Pneumonia Contusion Aspiration pneumonitis Burns Vasculititis Drowning
Extra-pulmonary
Sepsis, Burns Trauma TRALI Pancreatitis Bypass (pump lung)
Pathophysiology of ARDS
Exudate, Proliferative, Fibrotic
Exudative - Leakage of fluid in alveoli, microtrombus
Proliferative - type II pneumocytes form, fibrin deposition, exudate»_space; scar
Fibrotic - fibrosis
Vent strageties for ARDS
Low Tv 5-7ml/kg IBW
Accept a higher resp rate
Aim Sats 88-95 to reduced FiO2
PEEP>5
Pplat<30
Improving vent in ARDS
Vent strategies
NMBDs
Recruitment
Prone
HFOF
ECMO
Inhaled NO
Steroids
Murray score
PF ratio
PEEP
Compliaance
CXR quadrants
0-4, average score used..
>3 refer
Contra indications to ECMO
Irreversible organ damage/MOF
Advanced malignancy
Chronic severe pulm hypertension
Indications VA ECMO
Cardiogenic shock - myocarditis, arrhythmia, PE, anaphylaxis Wean from bypass Heart transplant Chronic cardiopmyopathy - bridge to VAD ECLS
Indication VV ECMO
Potentialy reversible acute failure
ARDS with bacterial / viral pneumonia
Lung transplant - bridge / graft failure
Pulmonary haemorrage/haemoptysis
Status asthmaticus
relative CI to ECMO
Age>75 Polytrauma, multiple bleeds CPR.60 minutes MOF CNS injury
VA CIs
Severe aortic regurgitation
Aortic dissection
VV CI
Unsupportable cardiac failure
Pulm Hypertension
Cardiac arrest
Complications of ECMO
Cannulation - Pneumothorax, vascular injury, infection, emboli, bleed
Anticoag - haemorrhage
EAquipment - pump failure, oxygenation failure
Causes of adrenal insufficiency
Primary - Addisons (adrenal is destroyed)
Secondary - Insufficient production of ACTH (rare)
Tertiary/relative - Suprresion of HPA axis due to steroids
Causes of primary adrenal insufficiency
Autoimmune (common)
Infection - TB, fungal, HIV (CMV)
Cancer - mets
Drugs - etomidate, ketoconazole
Other - critical illness insufficiency
Amyloid
Causes of secondary adrenal insufficiency
Dystruction of pituitary
Sheehans
Malignancy
Bleed
Causes of tertiary adrenal
Relative
Suppression of exogenous corticosteroids
Definition of Addisons
Autoimmune disease of cortex, reduced or absent cortisol
Cortisol deficiency = rise in ACTH
MSH rises - pigmentation
ACTH and MSH come from pre-opiomeanoncortin
Diagnosing adrenal insuffiency
Cortisol and ACTH (primary C low, A high)
Sec/ter : both low
Synacthen test:
Adrenal antibodies
When might you use steroids in crit care
Treatment of disease - COPD, asthma, adrenal crisis
Organ donor - methy pred
PCP in HIV
Airway oedema
Anaphylaxis
Myxoedemia coma
S.pneumonia bacterial meningitis]
Sepsis
Pathology of amniotic fluid embolus
Initially thought emboli..tissue in the circulation.
Now - two phase immune response to tissue ANTIGENS
1 - RIGHT heart failure.
Vasoactive substances produced. Pulmonary vasospasm.
Hypotension, hypoxia. 30 minutes
2 - Right recovers, LV fails. Pulmonary oedema
Increased cap. Permeability, DIC, uterine Antony, MOH.
Triad of AFE
Hypoxia
Cardiovascular collapse
Coagulopathy
Define AFE
Rare catastrophic emergency presenting as sudden maternal collapse associated with shock, hypoxia and coagulapathy.
Happens with amniotic fluid/cells enter maternal circ
Risk factors for AFE
Advanced maternal ages Polyhydromanios Induction of labour Placenta Pravin/abruptions Multip Uterine rupture IUD Trauma
Differential of AFE
Obs and non obs
Obs - Placental abruption,
Eclampsia
Uterine rupture
PPH
Non obs - Anaphyalxis, total spinal, sepsis PE
Define anaphylaxis
A severe life threatening generalised systemic hypersentivity reaction divided in allergic and non-allergic
Allergic: Immune mediated - IgE
Histamine, cytokines, prostaglandins - vasodilation, hypotension, tachy
Non-AllergicL. Mast cell and basophils degranulation with no immune trigger
Classify hypersensitivity
I - Immune - IgE - Asthma, anaphylaxis
II - antibody mediated IgG/M. Goodpastures
III - Immune complex mediated - IgG and complement. Lupus nephritis, RA
IV - Delayed - T cells, macrophages. Contact dermatitis, coeliac. Transplant reject
V - Idiopathic
Drugs causing anaphylaxis
NMBD - roc, sux, atra
ABx - penicillins
Thio
Latex
Gelatine/starches
Chlorhex
Iodine contrast
Drugs for anaphylaxis
IM adrenaline - 1ml of 1:1000
iv 50-100mcg iv of 1:10000
Saline 500 to 1litres
Chlorphenarmine - 10mg
Hydrocortisone - 200mg
When to take bloods in anaphylaxis
At the time
1-2 hours later
24 hours
Tests for anaphylaxis
RAST - radioallergosorbant - antigen specific IgE
ImmunoCAP
Skin prick testin
Types antibiotics and examples
Bacteriostatic and bacteriocidal.
Cidal - causes cell death, hosts undamaged
Penicillins Carbapenems Aminoglyc Rifampicin Quinolone
Static - limit growth while immune system removes
Macrolides
Tetracyclines
Sulphonamide
Trimeth
Mechanisms of antibiotic activity
Inhibit cell wall synthesis
Inhibit DNA synthesis/function
Inhibit Tetrahydrate folate synthesis
Inhibit protein
Abx that inhibit cell wall synth
Penicillins
Cephalosporins
Glyco - vanc/teic
Polymixin E - Colistin
Abx that inhibit DNA
Metronidazole. Complexes DNA and strands break
Rifampicin Inhibit DNA dep. RNA polymerase
Quinolone - Cipro - inhibits DNA Tyra sent
Abx that inhibit THF
Trimethoprim
Co-trimoxazole
Dapsone
Inhibit conversion of Di to trihydrofolate
What is septrin
Co-trimoxazole
Sulfamethoxazole and trimethoprim.
Sulfa affect different step of folate metabolism
PCP, maltophilia
ABx that inhibit protein
Tetracycline
Gentamicin
Amikacin (aminoglycs)
Chloramphenicol
Macorlide - eryth/claritth (attached to ribosomal subunits)
Clindamyin. - anti exotoxins
Linezolid
Gram positive cocci
Staph
Strep - b haem - GAS - pyogenes. GBS -
Y-haem enterococcus
A haem - st.pneumonia/viridian
Gram neg cocci
Neisseria
Moraxella
Gram positive bacilli
Actinomycetes
Bacillus
Diptheria
Listeria
Mechanism of Abx resistant
Intrinsic - there’s no target, no transport mechanism, membrane is impermeable
Acquired - Drug inactivation - beta lactamases
Reduced permeability
Reflux of drugs - gram neg pump them back out, pseudomonas pumps pencilling
Altered molecule target/creation of new path
E.g MRSA makes a penicillin binding protein
VRE - new cell wall substrate
How do bacteria acquire these changes
Sporadic mutation
OR
Horizontal gene transfer
TRANSformation - Free DNA from listed bacteria
TRANSduction - Bacteriophages (virus transfer DNA from one bac to other)
TRANSposition - Transporons move between plasmids
Conjugation - Plasmids - require contact between two bacteria
SSD regime
Topical paste
Tobramycin
Polymixin E
Amphotericin B
Gastro cover
Enteral vancomycin (MRSA cover)
Systemic cefotaxime.
What is C.diff
Gram positive bacillus
Anaerobic
Spore forming
Produces two toxins
A - entero - causes fluid sequestration
B - cyto - detected in the CDT test
Tx - metro/vancomycin
