Critical Care Flashcards
4 stages of anesthesia
- Induction
- Excitement or delirium
- surgical anesthesia
- Overdose
Indications for intubation
respiratory failure
Apnea
GCS<8
airway injury
Impeding compromise to airway
Trauma
electively
self extubation
Contraindications to intubation
severe airway trauma or obstruction
4 principles of airway management
- is the airway patent
- is an advanced airway indicated
- is proper placement of advanced airway confirmed
- is tube secure and placement confirmed frequently
narrowest area of adult airway
glottis
4 D’s of a difficult airway
distortion
disproportion
dysmobility
dentition
how much oxygen is needed for pre oxygenation in controlled intubation
end tidal oxygen should be 80% if possible
100%FiO2
confirming tube placement
return of end tidal CO2 for minimum of 4 breath cycles
equal chest rise
misting of tube
equal AE on Auscultation
Equipment/ set up required for intubation
Airway cart
Bag Valve Mask
Crash Cart
Difficult Airway cart
Equipment for monitoring
Suction
Ventilator
IV Pump
Meds
Good IV access
aspirate the stomach
have fluids ready
Vasopressor
Meds For induction
Sedative: propofol, etomidate,
paretic: ROC, Sux
analgesia fentanyl etc.
checking tube placement on CXR
2CM above carina
Indications for RSI
emergency/ urgent need to intubate
Assumed full stomach
Risk of Aspiration e.g. UGIB
positive pressure breath test
in controlled intubations BVM breath given before paralytic to ensure patient can be ventilated prior to paralytic.
differences between RSI and controlled induction
no positive pressure breath test (increased risk of aspiration)
Drugs usually pushed one after another
Cric pressure required
difficult airway guideline
BURP
Bouje
Blade
etomidate
0.3-0.4mg/kg
fentanyl
2-10mcg/kg
propofol
1-2.5mg/kg
midazolam
0.1-0.3mg/kg
ketamine
Rocuronium
0.6-1.2mg/kg
Succinylcholine
1-2mg/kg
DOA 5-7 mins
Deplorarising NMBA
wait for muscle fasciculations to stop
CI: Burns, spinal cord injuries, hyperkalemia, neurological injuries.
complications of intubation
Right mainstream intubation
oesophageal intubation
injury to airway
pneumothorax
air leak from bronchial injury
indications for surgery in cerebral hemispheric hematoma
> 50ml volume
frontal or temporal hemorrhage >20ml with midline shift>5mm and/ or cistern compression with decreased GCS
indications for surgery with posterior fossa hematoma
brainstem compression
distortion of the 4th ventricle
effacement of basal cisterns
obstructive hydrocephalus
diabetes insipidus DDAVP dose
2 mcg
indications for surgery epidural hematoma
> 30ml Volume
thickness>15mm
midline >5mm
Acute with impaired consciousness focal neurology.
parameters for TBI patients
normal oxygenation 60-80
Normocapnia 30-35
MAP 70-90
Na 140-145
Normal ICP of approx. 10
initial TBI management
Basic labs inc. electrolytes, coags, VBG
Optimize coagulation inc. tranexamic acid
CT head +/- vascular imaging
Optimize BP MAP 70-90 use Norepi
imperic hypertonic saline
seizure prophylaxis
Aggresive fever management
avoid hyponatremia
drugs to avoid in TBI
steroids
Should initially avoid Lasix, and antihypertensives.
Norepinephrine
1st line pressor in Sepsis
Dose 0.03 – 0.35 ug/kg/min
* Alpha 1 > beta activity 1
peripheral vasoconstriction with smaller
amount of cardiac inotropy
Inc HR, SVR, CO, PCWP
Vasopressin
Dose is often non-titratable à 0.03 U/min (2.4 U/hr)
* Add when Norepinephrine is at 0.1-0.2 ug/kg/min
* Often second line in septic shock
dec. HR CO
Inc. SVR, PCWP
Epinephrine
- Consider if inotropy needed (ie. Concurrent cardiomyopathy) or brady
- Increases lactate, so cannot use as a resuscitation measure
- May precipitate arrhythmias (Both alpha 1 and beta 1 activity)
Dec. PCWP
Inc. HR, SVR, CO
Phenylephrine
Pure alpha 1 agonism
* Add if significant tachyarrhythmias
* Caution if concern of increasing afterload
dec. HR, CO
Inc SVR, PCWP
Dobutamine
Inc HR, CO
Decrease SVR, PCWP
dopamine
Inc. HR, SVR, CO, PCWP
milrinone
inc HR, CO
Dec. SVR, PCWP
contraindication to NIPPV
- Facial surgery, facial trauma, airway obstruction
- Decreased LOC (*relative)
- Inability to clear secretions
- Respiratory arrest
- Hemodynamic instability (reduces preload)
- Indication for intubation (e.g. airway protection)
how to decrease PaCO2 on a vent
- Increase RR
- Increase tidal volume
(minute ventilation = RR * Vt)
how to increase O2 on vent
Increase FiO2
- Increase PEEP
- Extend inspiratory time
Affect O2 delivery: é cardiac output, é Hb
ê O2 consumption: treat fever, agitation
Remove pulm vasodilators (eg nitroprusside)
Benefits of Invasive mechanical ventilation
Improved VQ mismatching
Reduced shunt physiology
Improved oxygen delivery
Risks of Invasive mechanical ventilation
Ventilator induced lung injury
Ventilator associated pneumonia
Organ failure
Neuromuscular weakness
Ventilator dependence
symptoms of early salicylate toxicity
Tinnitus
Nausea and vomiting
hyperventilation
Fever
late symptoms of salicylate toxicity
pulmonary oedema (non-cariogenic)
coma/ seizures
arrhythmia
thrombocytopenia
AKI
causes of high anion gap
ketones
Tylenol
Salicylates
Lactate
treating salicylate poisoning
sodium bicarb aiming for alkalosis around 7.5-7.59
fluid resuscitation
glucose (brain depleted of glucose even if serum is normal)
intubation is dangerous as will require high minute volumes to maintain alkalosis
Nephro consult for dialysis CRRT is NOT adequate!
indications to use digibind
- acute ingestion of 10mg or more
- K>5
- hypo perfusion
- life threatening arrhythmia
ECG changes with toxic levels of digoxin
first degree heart block
paroxysmal atrial tachycardia
regularized atrial fibrilation
univocal or multifocal PVC’s
ventricular bigeminy
Bidirectional VT
ECG changes with therapeutic levels of digoxin
sagging of ST segments
flattened T waves
U waves
Shortened QT
medications that increase digoxin levels
medications that inhibit p-glycoprotein
- amiodarone
- carvedilol
- ranolazine
- ticagrelor
- verapamil
- tacrolimus
- cyclosporin
- azithromycin, erythromycin, clarithromycin
- azole antifungals
medications that decrease digoxin levels
p- glycoprotein agonists
- Carbamazepine, fosphenytoin, phenobarbital
- rifampin
how to treat gas trapping on vent
treat anything reversible e.g. bronchodilators, suctioning, steroids
change I:E ratio to 1:4 or 1:5
lower the respiratory rate
decrease Vt
increase PEEP to counter the increased work of breathing
last line: disconnect vent and press on chest, Heliox, ECCOR2, high frequency oscillation.
symptoms of serotonin syndrome
autonomic
neuromuscular hyperactivity
change in mental status
symptoms of neuroleptic malignant syndrome
Fever
Autonomic
Rigidity
HYPOREFLEXIVE
Change in mental status
