Critical Care Flashcards
Epistaxis - complications of cautery
- Septal perforation
- Staining of silver nitrate
- Secondary bacterial infection
Epistaxis - complications of packing (try for x8)
- Pressure necrosis
- Pain, discomfort
- Airway compromise
- Neurogenic syncope
- Septal hematoma, ulceration, perforation
- Synechiae/adhesion formation
- Rhino-sinusitis infection
- TSS
Indications to transfuse platelets?
- <100 for CNS bleed or CNS surgery
- <50 if actively bleeding or undergoing major surgery or unstable NAIT
- <10 for prophylactic treatment
Indications for pRBC transfusion?
- Acute blood loss of >15% of total blood volume
- Hb <70 with symptoms of anemia
- Significant pre-operative anemia without other corrective options available
- Hb <130 on ECLS
- Chronic transfusion program for disorders of RBC production
Decision to CT for head injury - rules to use and absolute/relative indications.
Rules: PECARN, CATCH
Absolute: focal neuro deficit, suspected or diagnosed open/depressed fracture
Relative: GCS <14 initially (or GCS <15 at 2h post), clinical worsening 4-6h, boggy/large hematoma, basal skull fracture signs, mechanism, seizures, persistent irritability, known coagulopathy
Pharmacological management of status epilepticus (include doses)
First line: midaz IN/IM (0.2 mg/kg), lorazepam IV (0.1 mg/kg)
Second line: keppra 60 mg/kg, fospheny/pheny 20 mg/kg, phenobarb 20 mg/kg (for <6 months)
Cardiac manifestations of TCA toxicity, including mechanism
Due to ability to block fast Na channels
- sinus tachycardia
- widening of QRS complex
- PVCs
- ventricular dysrhythmias
- hypotension
Rx for widened QRS secondary to TCA toxicity?
Na bicarb
Med to give in refractory VF (including dose)
Amiodarone 5 mg/kg
How to check tetany in hypocalcemia?
Chvostek - tapping face
Trousseau - BP cuff
VT with pulse - what to do with hemodynamic compromise?
Synchronized cardio version
Epi dosing for anaphylaxis and cardiac arrest
Anaphylaxis: 0.01 ml/kg of 1 mg/ml
Cardiac: 0.1 ml/kg of 0.1 mg/ml
Parkland formula
What fluid to give?
4ml x kg x %BSA = first 24 hours
Divide by 1/2 for the first 8 hours
Add maintenance if patient <30kg
Ringer’s lactate
What bacterial pneumonia is associated with RSV?
Pneumococcal pneumonia
Jimson weed - purple flower
Anti-cholinergic
Antidote for benzo overdose
Flumazenil
Iron toxic ingestion - medication, next step
Give activated charcoal?
Deferoxamine
Whole bowel irrigation
ETT x2 equations
Uncuffed: age/4 +4
Cuffed: age/4 + 3.5
Min SpO2 for bronchiolitis
90
How do you differentiate serontonin syndrome vs neuroleptic malignant syndrome?
Rigidity in NMS
Sympathemetic vs anti-cholinergic
AC - pupils slow to react, dry, bowel sounds decreased
Anticholinergic - toxins
Anti-histamines, atypical antipsychotics, Jimson weed, TCAs
What size of needle to use for pneumothorax?
18 gauge angiocath
What RSI medication is contraindicated for burn patients?
Succinylcholine
Signs of inhalation injury
Burns involving face/neck, singeing of eyebrows/nasal hairs, hoarseness/stridor, sings of parenchymal involvement
First management for CO poisoning
Initiate 100% FiO2 through NRM
Signs on examination of when to consider intubation for upper airway obstruction?
- Muffled/hot potato voice
- Inability to control secretions
- Stridor
- Dyspnea
Dx for patient with upper airway obstruction + trismus
Peritonsilar abscess
Steeple sign
Croup
Thumb printing
Epiglottitis
Brassy cough
Bacterial tracheitis
Minimal oxygen supplementation for age (L/min)
<1 yr = 2 L/min
1-5 yr = 4 L/min
5-10 yr = 6 L/min
>10 yr = 8 L/min
Most respiratory cause of ARDS and most common non-respiratory cause of ARDS
Resp = PNA Non-resp = sepsis
Why is intubation avoided in asthma patients - x2 pathophysiology reasons?
Hemodynamic instability
FB in airway can cause further bronchospasm
What is the normal range for SVO2?
70-75%
x3 signs of uncompensated shock
- Hypotension
- Altered LOC
- Oliguria
Better to push bolus through central or peripheral line
Peripheral
SIRS criteria
Require 2 of the following - with one being temperature or WBC:
- Temperature instability
- Tachycardia/bradycardia
- Tachypnea
- Leukopenia/leukocytosis
Sepsis = definition
SIRS + suspected/confirmed infection
What dosing range will you have more beta effect vs alpha effect for epi?
Beta - low dose
Alpha - high dose
What is the one VS derangement do we want to avoid the most with TBI patients?
Hypotension
What should our ICP be below in setting of TBI?
<20 cm H20
CPP targets for age to maintain ICP thresholds
Infants/toddlers = >40 Children = >50 Adolescents = >60
Steps (x3) to address increased ICP
- Hyperosmolar therapy
- Analgesia + sedation
- Neuromuscular blockade
What could you give in rhabdo with anuria?
Mannitol infusion
Difference between costochondritis vs Tietze Syndrome
Costo = multiple costochondral + costosternal junctions, no swelling typically. Tietze = more localized form with discrete area of swelling
Airway differences between children and adults
- Large occiput
- Large tongue
- Floppy epiglottis
- Anterior/cephalad larynx
- Narrow subglottic airway
Fasting guidelines
- Clear fluids 1 hour
- Human milk 4 hours
- Formula, light meal, non-human milk 6 hours
ASA - basic ideas for anesthesia
- ASA I = healthy
- ASA II = mild systemic disease
- ASA III = severe systemic disease
- ASA IV = constant threat to life
- ASA V = not expected to survive 24 hours
Emergency equipment to have at bedside for procedural sedation
SOAPME:
- Suction
- Oxygen
- Airway equipment
- Positive pressure system (BVM)
- Monitors
- Emergency cart
PECARN absolute rules for CT
<2 years = GCS<15, AMS, palpable skull fracture
>2 years = GCS<15, AMS, signs of basilar skull facture
PECARN intermediate factors for CT
<2 years = emesis, LOC >5s, irritable, severe mechanism of injury
>2 years = emesis, LOC >5s, worsening HA, severe mechanism
Causes of elevated AG metabolic acidosis
MUDPILES:
- Methanol
- Uremia
- DKA
- Paraldehyde
- IEM, iron
- Lactic acidosis
- Ethanol, ethylene glycol
- Salicylate
2 main categories + causes for primary metabolic alkalosis
- Saline responsive: pyloric stenosis, GI loss (emesis), laxative/diuretic use, CF, Cl deficient infant formula
- Saline resistant: hyper-reninemic HTN, CC’s, K deficiency, genetic block of steroid synthesis (17-OH def), renal dysfunction (Bartter, Gitelman, Liddle syndrome(
x4 side effects of ventolin
- Tachycardia
- Hyperglycemia
- Hypokalemia
- Lactic acidosis
x2 side effects of MgSO4 in asthma exacerbation
- Hypotension
- Bradycardia
Equation to calculate size of ETT for cuffed + uncuffed
- Uncuffed: age/4 + 4
- Cuffed: minus 0.5
MOA of ketamine
- NMDA receptor antagonist
- Dissociative analgesia, sedation + amnesia
- Bronchodilator
SE and contraindication for ketamine
- SE: hypotension, increased secretions, hallucinations
- Contraindication: hx of anaphylaxis, cardiac sensitivity to catecholamine surge (myocarditis)
Is PUD a common cause of abdominal pain for CF?
No
Clinical presentation of cholinergic toxidrome
=DDUMBELLS!
- Diaphoresis
- Diarrhea
- Urination
- Miosis
- Bronchorrhea
- Emesis
- Lacrimination
- Lethargy
- Salivation
x3 categories/examples of cholinergic toxins
- Organophosphates: insecticides
- Carbamates: neostigmine, pyridostigmine, pesticides
- Alzheimer’s medications
Difference in MOA between (a) organophosphates and (b) carbamates?
Both bind/inhibit acetylcholine esterase
(a) irreversibly
(b) transiently
Management of cholinergic intoxication
Supportive:
- Supplemental O2
- ETT if needed (avoid succhinycholine)
- IVF
- Benzos (for agitation/seizures)
Decontamination:
- Remove all clothes
- Irrigate skin
- Wear PPE
Treatment:
- Atropine 0.05 mg/kg IV/IM/IO bolus q5min until secretions improved
- Pralidoxime (pries pesticide off anticholinergic receptors)
- Inhaled atrovent
Clinical presentation for anti-cholinergic toxidrome
=Opposite DDUMBELLS
- Hyperthermia, flushed
- Decreased bowel sounds
- Dry skin + mouth
- Decreased urination
- Mydriasis
- Confused
If you are seeing an anti-cholinergic toxidrome, what is the most important Ix to consider?
ECG - to see if widening QRS as a clue for TCA overdose
Examples of toxins that would present with anti-cholinergic toxidrome
- Atropine, cyclopentolate
- Scopolamine, glycopurrolate
- Antihistamines
- Jimson weed
- Neuroleptics (olanzapine)
- TCA
Management of anti-cholinergic toxidrome
Supportive:
- IVF
- Cool down with H20/fans
- Benzos for agitation
Decontamination:
-Activated charcoal
Treatment:
- Physostigmine = reversible acetylcholinesterase inhibitor (do NOT give if TCA)
- Sodium bicarb = if TCA
x2 differences between anti-cholinergic and sympathomimetic toxidromes?
- Antiperspirant keeps you dry = so do anticholinergic!
- Pupils are both dilated but sympath are reactive
Clinical presentation for sympathomimetic toxidrome (minus complications)
- Mydriasis
- Diaphoresis
- Psychosis
- Severe agitation
- Tachycardia/HTN
- Hyperthermia
- Rigidity + hyperreflexia
Complications of sympathomimetic toxidrome
- Seizures (from hypoNa)
- Rhabdo/DIC (from hyperthermia)
- MI
- Hypertensive emergency (SAH, ICH)
- Hepatotoxicity
Examples of sympathomimetic toxidrome
- Cocaine
- Amphetamines/metamphetamines
- MDMD (ectasy)
- Methylxanthines
Management of sympathomimetic toxidrome
Supportive:
- Fluid restriction if hypoNa
- Keep cool
- Benzo if agitation
Decontamination:
-Activated charcoal
Treatment:
-No antidote
Serotonin syndrome - triad of symptoms
plus SSRI other symptoms
= altered mental status, autonomic instability, neuromuscular hyperactivity
-sedation, tachycardia (QTc prolongation), seizures
What is the antidote for serotonin syndrome?
-Cyproheptadine
What causes neuroleptic malignant syndrome?
-Anti-psychotic medications
Tx for neuroleptic malignant syndrome
- Supportive
- Withdrawal of agent
For (a) serotonin syndrome, (b) neuroleptic malignant syndrome, and (c) anticholinergic toxicity - what is (1) time course, (2) pupil size, (3) mucosa/skin, (4) neuro, and (5) mental status?
(a) 1. <12 hours, 2. big, 3. wet, 4. hyperreflexia/hypertonia, 5. agitation
(b) 1. 3-4 days, 2. normal, 3. wet, 4. rigid, 5. stupor
(c) 1. <12 hours, 2. big, 3. dry, 5. normal, 5. agitation
Presentation for an opioid toxidrome
- Respiratory depression
- Bradycardia
- Hypotension
- Miosis
- Coma
Antidote for opioids
Naloxone
When to NOT use activated charcoal?
PHAILS:
- Potassium
- Hydrocarbons
- Alcohols
- Iron
- Lithium
- Solvents (caustic ingestions)
Examples of hydrocarbons
- Kerosene
- Lamp oil
- Gasoline
- Camphor
- Nail polish remover
What could you give as decontamination for local anesthetics, bupropion, and amitriptyline?
Intravenous lipids
Antidote for methanol
Fomepizol
Antidote for carbon monoxide
Oxygen
Antidote for diazepam
Flumazenil
Antidote for iron
Deferoxamine
Antidote for beta blocker or CCB
Glucagon
Antidote for glyburide
Glucose
What is the complication for hydrocarbon toxicity?
Aspiration + surfactant inactivation
What is your first step in investigation and management for hydrocarbons?
- STAT CXR + repeat in 4-6 hours
- O2 + bronchodilators
What toxin do you think of if you see perihilar infiltrates + pneumatoceles on CXR?
Hydrocarbons
How does an overdose of metformin look like?
- No hypoglycemia
- Produces lactic acidosis
What stage for tylenol ingestion is there peak hepatic injury (liver failure)?
Stage 3 at 72-96 hours
What acid base disturbance occurs in tylenol toxicity?
Anion gap metabolic acidosis
What time frame should NAC be started within?
within 8 hours
Why is it important to have patients on CRM as NAC starts?
For anaphylaxis reactions
What dose of tylenol is (a) hepatoxic and (b) toxic?
(a) >90 mg/kg/day for more than 1 day
(b) >200 mg/kg/day
Presentation for salicylate overdose
- N/V, GI bleeding
- Diaphoresis, hyperthermia
- Seizures
- Tinnitus
- Tachypnea = resp alkalosis
- Metabolic acidosis
- Hypoglycemia
Hallmark features of salicylate overdose
- Resp alkalosis + metabolic acidosis
- Dehydration
- Intracellular hypoglycemia
Management of salicylate overdose
- Decontamination = AC within 6 hours
- No antidote
- Treatment = glucose bolus (even if serum is normal), alkalinize to urine pH, fluid resus, treat hypoK, hemodialysis
Iron overdose presentation - within the first 6 hours + in the 3rd/4th stages
- First 6 hours: emesis, bloody diarrhea, abdo pain
- Within 6-72 hours: met acidosis, GI hemorrhage, coagulopathy, shock, multi-organ failure (ARDS, hepatoxicity, liver failure)
Management for iron toxicity
Supportive:
-IV fluid resus = follow along UA until clear
Decontamination:
-WBI if lots of pills on XR
Treatment:
-IV deferoxamine
What is the hallmark feature of isopropyl alcohol toxicity?
Ketosis
What is the complication of methanol toxicity?
Retinal injury
What are the x2 lab findings (+associated consequences) related to ethylene glycol toxicity?
- HypoCa –> prolong QT
- Metabolic acidosis –> cardiac decompensation
The pathophysiology for TCA toxicity (including receptors/neurotransmitters involved).
- Inhibits NER + serotonin reuptake
- Block fast Na cardiac channels = wide QRS + prolonged QT
- Block alpha receptors = hypotension
- Block GABA receptors = seizure
- Block histamine receptors = sedation
- Block muscarinic receptors = weakly anticholinergic
management of TCA toxicity
- Activated charcoal
- Na bicarb if QRS >100
When to consider a XR for a toxic ingestion?
Think COINS
- Choral hydrate
- Opioids
- Iron
- Neuroleptics
- Salicylate, sustained release
What ingestion do you think about if high osmolar gap?
Toxic alcohols
What are the two phases of nicotine toxicity?
- Stimulant
2. Parasympathetic
What is the best test to do in a patient who presents reporting an ASA ingestion?
Do tylenol level (often confused)
What is the most common cause of death in (a) 1-4 year olds and (b) 5-14 year olds?
(a) trauma
(b) MVC
Complications of a submersion event?
- ARDS
- Pulmonary edema
- PNA
- Cerebral edema (then increased ICP)
- Trauma
- Hypothermia
Best prognostic factor for submersion injury plus 4 other ones
- BEST = immediate bystander CPR
- ROSC <10 minutes
- Submersion <5 minutes
- PERL at scene
- Normal sinus at scene
Definition of hypothermia
Core temp <35
At what temperature does shivering stop?
32 deg
At what temperature do ECG changes occur in hypothermia?
Below 32 deg
What are the classic ECG changes (x4) in hypothermia?
- Osborn or J waves
- Marked sinus brady
- First deg AV block
- Prolonged QT
What x6 biochemical changes are associated with hypothermia?
- Lytes = hypoK, hypoCa, hypoglycemia
- Metabolic acidosis
- Coagulopathy
- Pancreatitis
Stages of re-warming for a hypothermia injury
- Mild (32-35) = passive external rewarming
- Moderate (28-32) = ADD active external + core rewarming
- Severe (<28) = ADD additional active core rewarming + ECMO
If there is a shockable rhythm, how may defibrillations can you give in a hypothermic patient?
x3 until T >30
When can you use vasoactive drugs in a hypothermic patient?
Once core temp is >30
What renal complication is seen in 30% of patients with heat stroke?
Acute tubular necrosis
Definition of heat stroke
-Core temp >40 deg with CNS dysfunction
Three stages of heat injuries
- Heat cramps
- Heat exhaustion (T 37.7-39.4)
- Heat stroke (T >40)
x5 complications of heat injuries
- HypoNa
- Seizure
- Rhabdo
- DIC
- Multi-organ dysfunction
x4 causes of lactic acidosis in a fire
- Hypoperfusion/hypovolemia
- Cyanide poisoning
- Mathamoglobinemia
- Carbon dioxide
x4 types of burns
- Superficial
- Superficial partial thickness
- Deep partial thickness
- Full thickness
How to differentiate between (a) superficial partial thickness burn and (b) deep partial thickness burn?
(a) blisters, pain, moist
(b) dry, less pain, speckled
What rules can you use for BSA calculation for children for burn injuries
> 9 years old = rule of 9’s
<9 years old = child’s palm = 1%
x4 indications for intubation following a fire
- Carbonaceous sputum
- Singed nasal hair
- Soot in airway
- Hoarseness
x2 bugs each for early infection + late infection associated with burns
- Early = staph, GAS
- Late = pseudomonas, bacteroides
x8 indications for admission for a burn injury
- > 1% BSA to hands/feet/face/perineum
- > 2% BSA full thickness burn
- > 10% BSA partial thickness burn
- Suspected NAT
- Circumferential burn
- Inhalation injury
- Electrical injury
- Associated trauma
What Abx prophylaxis or empiric Abx should be started in a burn patient?
No role
Complications to monitor for from a high tension wire electrical injury?
- Muscle injury –> compartment syndrome, rhabdo, ARF
- VF/arrest
- CNS injury
What is the source of the electrical injury if there is (a) a feathering pattern on the skin vs (b) entrance + exit wound?
(a) Lightning
(b) High tension wire
Definition of status epilepticus?
- Continuous seizure activity for >30 minutes
- OR x2 discrete seizures with no return to baseline in-between
When do you consider status epilepticus refractory during hospital management?
Once received x2 different second-line medications and the patient continues to seize >5 minutes later.
VF with a pulse + hemodynamic compromise - next step
Synchronized cardioversion - 1J/kg then 2J/kg
VF with a pulse + stable hemodynamics - next step
- Check to make sure the rhythm is regular + QRS is monomorphic
- Then try adenosine - then synchronized cardioversion
Threshold for intervention for a pneumothorax (percentage wise in terms of size)?
> 30%
How much to give of ORT?
50-100 mL/kg over 4 hours
Do GCS scoring
Yes you got it!!
x2 equations for ETT size
Uncuffed: age/4 +4
Cuffed: age/4 + 3.5
What IV Abx is recommended to start empirically for uncomplicated PNA?
Ampicillin
Algorithm/approach for child post-swallowing a button battery?
- Urgent XR
- Determine if esophageal vs gastric
- If esophageal = urgent endoscopy
- If gastric = (a) if <5 y/o + >20mm = endoscope in 24-48 hours, (b) if >5 y/o +/or <20mm = could consider observation
x4 criteria for the apnea test
-Final PaCO2 >60
-Final PaCO2 >20 from pre-test
No spontaneous respiratory effort
-pH <7.28
pVT - CPR started, 100% sats, what next step?
Defibrillate 2J/kg
What would count as a serious iron ingestion that would cause you to consider desfuroxime?
- High iron level at 4-6 hours
- Ingestion of >60mg/kg (or lots of pills on AXR to suggest this)
- Significant AG metabolic acidosis
- Severe symptoms
Antidote for barbituates?
None
How can we manipulate - (a) oxygenation, (b) ventilation, and (c) respiratory effort?
(a) FiO2, PEEP
(b) RR, Vt, dead space
(c) increase caliber of airway, increase inspiratory pressure
Typical low to high range for flow in HFNC
1-3 L/kg/min
What is the PRAM score out of? And what are the main components?
=out of 12
- Oxygen saturation
- Suprasternal retraction
- Scalene muscle contraction
- Air entry
- Wheezing
How many breaths to compressions do you give once an advanced airway has been placed?
Breath every 2-3 seconds (approximately 30 breaths/minute)
4mo adm with bronchiolitis, acute crash, appears cyanotic/limp, sats 50% + HR 40 bpm, pulse+ = what is next step?
Bag-mask ventilate with FiO2 100%
-Given chest compressions if HR <60 after adequate oxygenation/ventilation
How must a NDD assessment be done for a (a) neonate (<30 days and >36 wk GA), (b) infant, and (c) child >1 year?
(a) Full + separate exams must be done by x2 physicians at lest 24 hours apart and >48h after birth
(b) Full + separate exams but no fixed interval
(c) Full exams but can be done concurrently
If there has been significant resuscitation, when is the earliest time that you can do a NDD assessment?
> 24 hours
x3 diagnostic criteria for DKA
- Acidosis = pH <7.3, HCO3 <15
- Ketones present
- Glucose >11
Dx if diffusely tall QRS complexes on ECG
Pompe
Antidote for methanol ingestion - what is x1 long term consequence?
Fomepizole
-Blindness
Migraine ED protocol
IV fluids
IV metoclopramide
IV ketoralac (ensure spaced out from other NSAIDs)
IV ondans
10 day old, lethargy, poor feeding. RR 56, HR 183, BP 60. No femoral pulses, hepatomegaly. (a) what kind of shock, (b) cause, (c) why now, and (d) treatment
(a) obstructive
(b) coarct
(c) PDA closing
(d) PGE infusion, intubation, cardiology
Name for nursemaid’s elbow
Radial head subluxation
What do Cullen and Grey’s sign indicate?
Intra-abdo hemorrhage
What to think of if serpiginous rash?
Serum sickness
Dx if atypical lymphocytes, epitrochlear adenopathy, and exudative tonsillitis
EBV
What to give for pertussis?
Azithro
