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NAPLEX 2023 > Chapter 53: Acute & Critical Care Medicine > Flashcards

Chapter 53: Acute & Critical Care Medicine Flashcards

1
Q

Which fluids are less costly and generally have fewer side adverse reactions - crystalloids or colloids

A

Crystalloids

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2
Q

Colloids are ____ molecules (typically protein or starch) dispersed in solutions that primarily remain in the ______ space and ____ oncotic pressure

A

Large molecules
intravascular space
Increase

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3
Q

Which fluid is used when water is needed intracellularly, as these products contain “free water”

A

Dextrose

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4
Q

Which fluids are the most common drugs used for volume resuscitation in shock states

A

Lactated Ringers and Normal saline

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5
Q

Which fluid is the most commonly used colloid

A

Albumin

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6
Q

When is albumin useful

A

significant edema (e.g., cirrhosis)

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7
Q

Boxed warning for hydroxyethyl starch

A

avoid use in critical illness (including sepsis) due to mortality, renal injury, and coagulopathy

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8
Q

Which common fluids are crystalloids

A

D5W
Normal saline
Lactated Ringers
Multiple electrolyte injection (i.e., Plasma-Lyte A)

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9
Q

Which common fluids are colloids

A

Albumin 5%, 25% (Albutein, AlbuRx)
Dextran
Hydroxyethyl starch

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10
Q

Hyponatremia is Na below

A

< 135 mEq/L

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11
Q

How do you treat hypotonic hypovolemic hyponatremia

A

administer sodium chloride IV solutions

stop any offending agent (diuretics)

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12
Q

How do you treat hypotonic hypervolemic hyponatremia

common causes

A

Diuresis with fluid restriction (since it is caused by fluid overload)

cirrhosis, heart failure, renal failure

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13
Q

What drugs/drug class can be used to treat SIADH and hypervolemic hyponatremia

A 
tx: diuresis, stop offending agent, fluid restriction
Arginine vasopressin (AVP) receptor antagonists
Conivaptan and tolvaptan
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14
Q

when is NaCl 3% an option

A

when Na < 120 mEq/L
or severe symptoms

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15
Q

Rate to correct hyponatremia

Correcting sodium more rapidly than ___ mEq/L over ___ hrs can cause ______ or _____, which can cause ________

A

usually 4-8 mEq/L/day
max: 12 mEq/L over 24 hrs
osmotic demyelination syndrome (ODS) or central pontine myelinolysis –> paralysis, seizures and death

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16
Q

Tolvaptan brand name

A

Samsca

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17
Q

Tolvaptan is limited to how many days and why

A

≤ 30 days due to hepatotoxicity

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18
Q

administration of tolvaptan

conivaptan?

A

tablet (PO)

IV

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19
Q

Where must tolvaptan be initiated and re-initiated

why?

A

In a hospital

close monitoring of serum Na

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20
Q

Side effects of tolvaptan

A

Thirst, nausea, dry mouth, polyuria

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21
Q

Tolvaptan monitoring

A

Rate of Na increase

risk of ODS (increase ≥ 12 mEq/L/day)

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22
Q

Hypernatremia is sodium greater than ____ mEq/L

what is it associated with?

A

145 mEq/L

water deficit and hypertonicity

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23
Q

Hypokalemia is potassium less than ___ mEq/L

A

3.5 mEq/L

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24
Q

Medications that can cause hypokalemia

A

amphotericin, insulin

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25
Q

A drop of 1 mEq/L in serum K below 3.5 mEq/L represents a total body deficit of ___-___ mEq

A

100-400 mEq

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26
Q

Through a peripheral line, IV potassium replacement includes a max infusion rate of ≤ ___ mEq/hr & a max concentration of ___ mEq/___ mL

A

10 mEq/hr
10 mEq/100 mL

> 10 requires continuous EKG monitoring

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27
Q

IV potassium can be fatal if administered in which ways

A

undiluted or IV push

never never never IV push

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28
Q

When hypokalemia is resistant to treatment, what should be checked

A

serum magnesium

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29
Q

Most likely cause of hyper-kalemia or magnesemia

A

renal dysfunction

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30
Q

When serum Mg is < __ mEq/L with life-threatening symptoms (seizures & arrhythmias), what is recommended

A

< 1 mEq/L
IV magnesium sulfate

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31
Q

Magnesium < 1 mEq/L with no symptoms tx

A

IV or IM administration

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32
Q

When serum Mg is > 1 mEq/L but < 1.5 without life-threatening symptoms, what can be used

A

oral magnesium oxide

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33
Q

When is hypophosphatemia considered severe

A

When serum phosphate is < 1 mg/dL

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34
Q

When serum PO4 is < 1 mg/dL, what is used for replacement

A

IV Phosphorus

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35
Q

What does IV immune globulin contain

A

Pooled immunoglobulin (IgG)

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36
Q

What are some off-label uses for IVIG

A

MS, myasthenia gravis, Guillain-Barre

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37
Q

IVIG brand names

A

Gammagard, Gamunex-C, Octagam, Privigen

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38
Q

IVIG can impact the response to what?

A

vaccinations

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39
Q

When should a slower infusion rate be used with IVIG

A

In renal and CV disease

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40
Q

IVIG boxed warnings

A
  • Acute renal dysfunction - rare, but fatal (more likely with products stabilized with sucrose)
  • Thrombosis (even without risk factors)
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41
Q

IVIG boxed warnings

A

infusion reaction (facial flushing, chest tightness, fever, chills, hypotension - slow/stop infusion)

a slower titration and premedication may be needed if hx

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42
Q

What is the scoring tool used to determine prognosis and estimate ICU mortality risk

A

The Acute Physiologic Assessment & Chronic Health Evaluation II (APACHE II)

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43
Q

Most vasopressors work by stimulating ____ receptors, which causes _____ & (increases/decreases) systemic vascular resistance (SVR), which increases ____

A

Alpha receptors
Vasoconstriction (think vasopressor PRESSES down on the vasculature)
Increases
BP

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44
Q

_____ is a natural precursor of NE and is recommended for use in symptomatic bradycardia

A

Dopamine

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45
Q

Low (renal) dopamine dose ?

acts on what receptors?

A

1-4 mcg/kg/min

DA-1 agonist

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46
Q

Medium dopamine dose?

acts on what receptors?

A

5-10 mcg/kg/min

beta-1 agonist

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47
Q

High dopamine dose?

acts on what receptors?

A

10-20 mcg/kg/min

alpha-1 agonist

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48
Q

Epinephrine MOA

A

Alpha-1, beta-1, beta-2 agonist

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49
Q

epinephrine brand name

A

Adrenalin, EpiPen

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50
Q

Norepinephrine brand name

A

Levophed

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51
Q

Norepinephrine MOA

A

Alpha-1 agonist > beta-1 agonist

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52
Q

Phenylephrine MOA

A

Alpha-1 agonist

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53
Q

What are the other names for vasopressin

A

ADH and arginine vasopressin (AVP)

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54
Q

All vasopressors are ____ when administered IV

A

Vesicants

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55
Q

How should vasoconstrictor extravasation be treated

A

phentolamine

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56
Q

Vasopressor side effects

A

Arrhythmias, tachycardia (esp DA, Epi, and vasopressin), necrosis (gangrene), bradycardia (phenylephrine), hyperglycemia (epi)

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57
Q

What should be monitored with all vasopressors

A

continuous BP

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58
Q

don’t use vasopressor solutions if…

A

discolored or precipitate

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59
Q

How should all vasopressors be administered

A

central IV line

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60
Q

Dose of epinephrine used for IV push

A

0.1 mg/mL (1:10,000 ratio strength)

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61
Q

Dose of epinephrine used for IM injection

A

1 mg/mL (1:1,000 ratio strength)

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62
Q

T/F: extravasation is a medical emergency with vasopressors

A

True, all vasopressors are vesicants and should be treated with phentolamine (alpha blocker)

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63
Q

Phentolamine MOA

A

alpha-1 blocker

64
Q

When is nitroglycerin often used

A

When there is severe myocardial ischemia or uncontrolled HTN

65
Q

Effectiveness of nitroglycerin may be limited after __-__ hrs due to ____

A

24-48 hrs due to tachyphylaxis (tolerance)

66
Q

Nitroglycerin MOA

A

low doses: venous vasodilator
high doses: arterial vasodilator

67
Q

Nitroprusside MOA

A

mixed (equal) arterial and venous vasodilator at all doses

68
Q

When should nitroprusside NOT be used

A

active myocardial ischemia (can cause blood to be diverted away from the diseased coronary arteries - “coronary steal”)

69
Q

Metabolism of nitroprusside results in:

A

formation of thiocyanate and cyanide (both can cause toxicity)

esp in renal or hepatic insufficiency

70
Q

What can be administered to reduce the risk of thiocyanate toxicity with use of nitroprusside

A

Hydroxycobalamin

71
Q

What can be administered to reduce the risk of cyanide toxicity with use of nitroprusside

A

Sodium thiosulfate

72
Q

nitroprusside brand name

A

Nipride

73
Q

NTG contraindications

A

SBP < 90 mmHg

Use with a PDE-5 inhibitor or riociguat

74
Q

Side effects of NTG

A

HA, tachycardia, tachyphylaxis

75
Q

What kind of container does NTG require

A

non-PVC container (e.g., glass, polyolefin)

76
Q

Nitroprusside is not for direct injection & must be diluted with

A

D5W preferred

77
Q

Nitroprusside can cause increased:

A

Intracranial pressure

78
Q

If nitroprusside turns this color, it indicates degradation to cyanide

A

Blue

79
Q

Inotropes increase:

A

contractility of the heart

80
Q

Dobutamine MOA

A

Beta-1 agonist

81
Q

Milrinone MOA

A

PDE-3 inhibitor in cardiac and vascular tissues

82
Q

Which drugs are inotropes

A

Dobutamine & milrinone

83
Q

Dobutamine may turn what color due to oxidation, but it does not indicate potency has been lost

A

Slightly pink

84
Q

How is shock characterized?
How it is defined?

A

Hypoperfusion usually in the setting of hypotension
SBP < 90 or MAP < 70

85
Q

General principles of treating shock

A
  • Optimize preload with IV crystalloid bolus (PRN)
  • Peripheral vasoconstrictor (alpha-1 agonist) to increase systemic vascular resistance (SVR)
  • Beta-1 agonist to increase myocardial contractility & CO
86
Q

First-line therapy for hypovolemic shock that is not caused by hemorrhage

A

Fluid resuscitation with Crystalloids

87
Q

If the patient does not respond to initial crystalloid therapy in hypovolemic shock, vasopressors may be indicated, but they will not be effective unless:

A

Intravascular volume is adequate

88
Q

Example of distributive shock

A

Sepsis

anaphylactic, neurogeninc

89
Q

Two common causes of ICU infections

A
  • Mechanical ventilation pushes air into the lungs for pts who cannot breathe on their own
  • Foley catheters
90
Q

Bundles to reduce mortality from sepsis and septic shock includes

A

Early administration of broad-spectrum abx & IV fluid resuscitation with IV crystalloids

91
Q

How to define septic shock

A

persistent hypotension requiring vasopressors to maintain MAP ≥ 65 mmHg

92
Q

If adequate perfusion cannot be maintained with IV crystalloids in septic shock, what is the vasopressor of choice that can be used

A

Norepinephrine

93
Q

Sudden weight gain, inability to lie flat without becoming SOB, decreasing functionality, increasing SOB and fatigue is called acute decompensated HF & when hypotension and hypoperfusion are also present it is called

without hypotension and hypoperfusion it’s called

A

Cardiogenic shock

actue decompensated heart failure

94
Q

Beta-blockers should only be stopped in an acute decompensated HF episode if:

A

hypotension or hypoperfusion is present

95
Q

What is the name of the catheter that some patients with acute decompensated HF require

A

Swan-Ganz catheter

= pulmonary artery catheter

96
Q

What does the Swan-Ganz catheter measure in acute decompensated HF?

A

pulmonary capillary wedge pressure (for congestion)

97
Q

What treatments are used for volume overload in acute decompensated HF

A

Loop diuretics

possibly IV Vasodilators can be added (NTG, nitroprusside, nesiritide)

98
Q

What treatments are used for hypoperfusion in acute decompensated HF

A

Inotropes (dobutamine, milrinone)
If the pt becomes hypotensive, consider adding a vasopressor
*avoid vasodilators since they can ↓ BP and worsen hypoperfusion

99
Q

First-line for analgesia in the ICU

A

Opioids given IV like morphine, hydromorphone and fentanyl

100
Q

____ are preferred for sedation and are associated with improved ICU outcomes

A

Non-BZDs like propofol and dexmedetomidine

101
Q

dexmedetomidine brand name

A

Precedex

102
Q

What is the only sedative approved for use in intubated and non-intubated pts

A

dexmedetomidine

103
Q

how often should sedation vacations be tried?

A

daily

104
Q

Which atypical antipsychotic may be beneficial in delerium

A

Quetiapine

105
Q

Fentanyl brand name for ICU

A

Sublimaze

106
Q

hydromorphone brand name

A

Dilaudid

107
Q

Morphine brand name

A

Duramorph, Infumorph

108
Q

dexmedetomidine MOA

A

Alpha-2 adrenergic agonist

109
Q

dexmedetomidine side effects

A

Hypo/hypertension, bradycardia

110
Q

Duration of infusion for dexmedetomidine should not exceed ____ hrs per FDA labeling

A

24 hrs

111
Q

Propofol brand name

A

Diprivan

112
Q

Propofol contraindications

A

Hypersensitivity to egg & soy

113
Q

Propofol side effects

A

Hypotension, apnea, hypertriglyceridemia, green urine/hair/nail beds, propofol-related infusion syndrome (PRIS-rare but can be fatal), pancreatitis, QT prolongation

114
Q

Propofol vial & tubing should be discarded within how many hours of use due to bacterial growth

A

12 hrs

115
Q

Propofol oil-in-water emulsion provides ___ kcal/mL

A

1.1

116
Q

Lorazepam injection can cause

A

propylene glycol toxicity (acute renal failure and metabolic acidosis)

117
Q

lorazepam brand name

A

Ativan

118
Q

Midazolam brand name

A

Versed

119
Q

Midazolam contraindications

A

Use with potent 3A4 inhibitors

120
Q

Midazolam can accumulate in

A

renal impairment (active metabolite)

121
Q

Etomidate monitoring

A

Adrenal insufficiency

122
Q

Ketamine warnings

A

Emergence reactions (vivid dreams, hallucinations, delirium)

123
Q

ketamine MOA

A

NMDA receptor antagonist

124
Q

haloperidol brand name

A

Haldol

125
Q

quetiapine brand name

A

Seroquel

126
Q

What are the recommended agents for prevention of stress ulcers

A

H2RAs and PPIs

127
Q

PPIs have been associated with an increased risk of

A

GI infections (C.diff), fractures and nosocomial pneumonia

128
Q

Which risk factors in the ICU is associated with the development of stress ulcers

A

Mechanical ventilation > 48 hrs
coagulopathy

sepsis, major burns, acute renal failure, high dose steroids, TBI

129
Q

Inhaled anesthetics can rarely cause

A

malignancy hyperthermia

130
Q

Which anesthetic commonly used in epidurals can be fatal if administered IV

A

Bupivacaine

131
Q

Local anesthetic

A

Lidocaine (Xylocaine)

132
Q

Inhaled anesthetics

A

desflurane (Suprane), sevoflurane

133
Q

Injectable anesthetics

A

Bupivacaine, ropivacaine, lidocaine

134
Q

lidocaine brand name as local anesthetic

A

Xylocaine

135
Q

Desflurane brand name

A

Suprane

136
Q

Neuromuscular blocking agents can cause

A

paralysis of the skeletal muscle

137
Q

Patients can require the use of a NMBA agent in surgery for what reasons:

A

to facilitate mechanical ventilation
to manage increased intracranial pressure
to treat muscle spasms (tetany)

138
Q

Patients should receive adequate what before starting and NMBA

A

Sedation and analgesia

139
Q

Patients must be _____ while on NMBAs since they can paralyze the diaphragm

A

mechanically ventilated

140
Q

All NMBAs must be labeled with a colored auxiliary label stating:

A

“WARNING, PARALYZING AGENT”

141
Q

What is the only available depolarizing NMBA

A

Succinylcholine

142
Q

Succinocholine is typically reserved for

A

intubation

143
Q

Special care when using NMBAs includes

A

protecting the skin, lubricating the eyes and suction the airway frequently to clear secretions

144
Q

Which anticholinergic drug can be used to reduce secretions when using NMBAs

A

Glycopyrrolate

145
Q

medications that can enhance the effect of NMBAs

A

aminoglycosides
polymyxins

others: CCBs, vanco, cyclosporine

146
Q

Which drug is a non-depolarizing NMBA

A

Cisatracurium

also atracurium, pancuronium, rocuronium, vecuronium

147
Q

Cisatracurium brand name

A

Nimbex

148
Q

Side effects for all non-depolarizing NMBAs

A

Flushing, bradycardia, hypotension, tachyphylaxis

149
Q

How is Cisatracurium metabolized

A

Hofmann elimination (independent of renal and hepatic function)

150
Q

Which non-depolarizing NMBA is long-acting

A

Pancuronium

151
Q

How do systemic hemostatic drugs work

A

They inhibit fibrinolysis or enhance coagulation

152
Q

Tranexamic acid injection brand name

A

Cyklokapron

153
Q

Tranexamic acid tablet brand name

A

Lysteda

154
Q

Recombinant Factor VIIa brand name

A

NovoSeven RT

155
Q

Lysteda (tranexamic acid tablet) is approved for

A

Heavy menstrual bleeding

NAPLEX 2023 (88 decks)

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