Critical Care Flashcards by AA J

Features of TCA overdose

What changes are seen on ECG?

Excessive sedation, dry mouth and dry flushed skin
Tachycardia, sweating, dilated pupils (sympathomimetic effect)
Hypotension
ECG - sinus tachycardia, prolongedQRS, QT, PR
Wide QRS, broad complex tachycardia

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Management of TCA overdose

ECG monitor
Metabolic acidosis- IV bolus NS 250ml
+ Na bicarbonate 50mmol slowly of 8.4% NaHco3 IV

Aim for pH 7.5-7.55
The bicarbonate will correct the ecg changes and cardiac rhythm

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Electrolyte imbalance in refeeding syndrome?

Hypophosphatemia

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What is refeeding syndrome?

Metabolic disturbances that occur as a result of reinstitution of nutrition in patient who have starved/severely malnourished

Starvation — low glucose, low insulin , high glucagon, increased gluconeogenesis == hypophosphatemia as a result of depletion of phosphate stores due to low glucose

Refeeding -high glucose, high insulin, increased cellular uptake of phosphate
Hypophosphatemia from starvation + phosphate demand from refeeding

== severe hypophosphatemia
- tissue hypoxia, myocardial dysfunction, diaphragm can’t contract

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Other electrolyte imbalances in refeeding syndrome

Hypophosphatemia
Hypokalemia
Hypomagnesemia

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How do you avoid refeeding syndrome?

Slow feeds

Magnesium K+ and phosphate supplement

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What drug is useful in SAH

Aspirin/ClopidogreL

Sumatriptan/ Nimodipine

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What serious complication can occur with SAH at 4-12 days

How do you manage it

Cerebral vasospasm

Diminish this by giving calcium antagonist (Nimodipine) for 5-14 days

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Most common cause of SAH

Aneurysm

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Common associated genetic conditions to SAH

Ehler-Danlos

Polycystic kidney disease (ADPKD) - HTN + repeated kidney stones = assoc. berry aneurysm = assoc SIADH = HypONa**

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Dx SAH

CT w/o contrast
If inconclusive - LP after 12 hrs on onset
= bloody CSF -> Xanthochromic (due to bilirubin)

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Splenic rupture manifestations

Left sided chest pains + abdomen * esp after RTA
Rapid fall in BP
Rise in HR

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Findings on imaging splenic rupture

What method is diagnostic?

XR - Absent left posts shadow
FAST - free peritoneal fluid
CT** DIAGNOSTIC

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If splenic rupture is confirmed what is the Tx?

Urgent surgery

*subsplenic hematoma can be treated conservatively if stab;e and kept under observation

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Coiled NGT above hemidiaphragm after RTA is a sign of?

Diaphragmatic rupture

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What is the most accurate way of assessing NGT placement

XRAY

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What is triple vessel disease?

LAD RCA Circumflex arteries are blocked with atherosclerotic plaques

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Management of ACS in pt with triple vessel disease + anemia

ECG shows ST depression ischemia in several leads

Dual anti platelets - aspirin + clopidogrel
+ SC Fondaparinux ( LMWH)
+blood transfusion

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Heart ischemia - what 2 meds should be given

What is the indication for blood transfusion

Aspirin oral
SC LMWH - Fondaparinux

Blood transfusion -
Hb < 80 g/l + sx of anaemia
Or
Hb < 70 g/l with or w/o sx of anaemia

Death certificate

What is to be written in 1a or 1b

1a - clear and specific “disease or condition directly leading to death”

1b - write the condition that has lead to 1a

When do you intubate in resp failure?

Desaturation despite HF O2 + silent chest

Medications that can cause metabolic acidosis

Paracetamol
Aspirin
Alcohol
SSRI (e.g citalopram)

Respiratory conditions that cause Respiratory acidosis

Asthma

COPD

What metabolic abnormality can be seen in pulmonary contusion

Respiratory acidosis

Fall on chest - contusion/ oedema - hypoxemia + CO2 accumulation

What metabolic abnormality is seen in PE and panic attacks

Resp alkalosis *PAO2 is NORMAL in panic attacks and LOW in PE

What is the GCS | At what GCS should you intubate?

E - 4 = spontaneous, speech, pain, no response V - 5 = oriented, sentences, words, sound, no responses M - 6 - obeys, localises pain, flex-pain, ext-pain, no response 13-15 - mild 9-12 - moderate 3-8 - severe Below 8 - intubate

What is acute chest syndrome?

a complication of sickle cell disease ``` New pulmonary infiltration on CXR + >/= 1 of : Chest pain Cough Sputum Fever Hypoxia Lung infiltrates ```

What is the most common presenting complaint of acute chest syndrome in adults

Chest pain when breathing

What is the most common presenting complaint of acute chest syndrome in children/infants

Fever cough tachypnea hypoxemia or abdominal pain

Treatment of acute chest syndrome

Adequate analgesia - morphine sulphate O2 Empiric antibiotics Blood transfusion depending on clinical investigations Careful with IV fluid as it may worsen pulmonary oedema

HTN + chest pain radiating to back + big pressure difference in rt & lt arm What do you suspect? What is your investigation of choice ?

Aortic dissection If stable - CT angio Unstable - TEE (transoesophageal echo)

What are important risk factors of aortic dissection? | What is seen on the CXR?

Marfans syndrome Ehler-Danlos CXR - wide mediastinum

What is a massive blood transfusion?

Pt receives >= 10 units of blood or 50% blood volume within 24 hours

Important complications of blood transfusion

Hypocalcemia Hypomagnesemia Hypo/Hyperkalemia Metabolic alkalosis - citrate is metabolised to bicarbonate — increased pH Hypomagnesemia/calcemia can result due to citrate toxicity - when citrate is high Ca++ and Mg++ bind to it and thus become reduced

How many grams of citrate does 1 unit of blood contain?

Red flag criteria of sepsis (10) | What happens if any of the red flag criteria are present?

``` Responds to voice/pain/unresponsive* Acute confusional state Systolic BP 40 from normal* HR >130* RR >_ 25/min* Pt requires oxygen to keep spo2 >_ 92% non blanching rash , mottled ashen or cyanotic UO _2mmol/l* Recent chemo ``` Start SEPSIS 6 - give 3 take 3 Give - high flow o2, IV fluids (500 ml bolus <15 mins), iv broad spectrum ABx Take - blood cultures, FBC U&E clotting factors, lactate Start monitoring UOP hourly Admit with in patient management

What are the signs of AKI in sepsis?

Oliguria | High serum urea and creatinine

What is septic shock?

Sepsis + BP fails to respond to fluid bolus

What is one of the most common causes of tension pneumothorax?

Mechanical ventilation | Suspect it if patient on MV and suddenly deteriorates and develops low O2 saturation and hypotension

Fat embolism vs tension pneumothorax

FE - long bone fracture , desaturation, hypotension TP - decreased air entry on one side of chest Higher pressure required to achieve tidal volume These make a dx of TP more likely

What is the appropriate fluid for dehydration caused by vomiting and diarrhoea?

NS .9% NaCl

Hemodynamics of shock

Hypovolemic shock = decreased preload CO and after load increase Cardiogenic shock - preload & after load increase; CO decreases Distributive shock - decreased preload and afterload ; CO increases Preload=PCWP Afterload = SVR

Treatment of aortic dissection

Give iv beta blockers = labetalol

How do you manage drug induced hyperthermia?

Dantrolene

MDMA/ ecstasy overdose symptoms

``` Agitation confusion*, anxiety, ataxia Tachycardia *, HTN Tachypnea* Thirst* Metabolic acidosis* - increased venous lactic acid Hyyperthermia* Spots of colours* Uncontrolled body movements, muscle rigidity *, trismus. ```

How do you manage and MDMA overdose

Supportive care - ABC + treat metabolic acidosis IV diazepam or lorazepam - for agitation Dantrolene - hyperthermia if simple measures fail