Critical Care Flashcards
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
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
Electrolyte imbalance in refeeding syndrome?
Hypophosphatemia
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
Other electrolyte imbalances in refeeding syndrome
Hypophosphatemia
Hypokalemia
Hypomagnesemia
How do you avoid refeeding syndrome?
Slow feeds
Magnesium K+ and phosphate supplement
What drug is useful in SAH
Aspirin/ClopidogreL
Sumatriptan/ Nimodipine
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
Most common cause of SAH
Aneurysm
Common associated genetic conditions to SAH
Ehler-Danlos
Polycystic kidney disease (ADPKD) - HTN + repeated kidney stones = assoc. berry aneurysm = assoc SIADH = HypONa**
Dx SAH
CT w/o contrast
If inconclusive - LP after 12 hrs on onset
= bloody CSF -> Xanthochromic (due to bilirubin)
Splenic rupture manifestations
Left sided chest pains + abdomen * esp after RTA
Rapid fall in BP
Rise in HR
Findings on imaging splenic rupture
What method is diagnostic?
XR - Absent left posts shadow
FAST - free peritoneal fluid
CT** DIAGNOSTIC
If splenic rupture is confirmed what is the Tx?
Urgent surgery
*subsplenic hematoma can be treated conservatively if stab;e and kept under observation
Coiled NGT above hemidiaphragm after RTA is a sign of?
Diaphragmatic rupture
What is the most accurate way of assessing NGT placement
XRAY
What is triple vessel disease?
LAD RCA Circumflex arteries are blocked with atherosclerotic plaques
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
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?
3g
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
