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Royal college IM > Critical Care > Flashcards

Critical Care Flashcards

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Royal College: Emergency Medicine flashcards
1
Q

4 stages of anesthesia

A
  1. Induction
  2. Excitement or delirium
  3. surgical anesthesia
  4. Overdose
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2
Q

Indications for intubation

A

respiratory failure
Apnea
GCS<8
airway injury
Impeding compromise to airway
Trauma
electively
self extubation

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3
Q

Contraindications to intubation

A

severe airway trauma or obstruction

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4
Q

4 principles of airway management

A
  1. is the airway patent
  2. is an advanced airway indicated
  3. is proper placement of advanced airway confirmed
  4. is tube secure and placement confirmed frequently
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5
Q

narrowest area of adult airway

A

glottis

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6
Q

4 D’s of a difficult airway

A

distortion
disproportion
dysmobility
dentition

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7
Q

how much oxygen is needed for pre oxygenation in controlled intubation

A

end tidal oxygen should be 80% if possible
100%FiO2

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8
Q

confirming tube placement

A

return of end tidal CO2 for minimum of 4 breath cycles
equal chest rise
misting of tube
equal AE on Auscultation

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9
Q

Equipment/ set up required for intubation

A

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

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10
Q

Meds For induction

A

Sedative: propofol, etomidate,
paretic: ROC, Sux
analgesia fentanyl etc.

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11
Q

checking tube placement on CXR

A

2CM above carina

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12
Q

Indications for RSI

A

emergency/ urgent need to intubate
Assumed full stomach
Risk of Aspiration e.g. UGIB

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13
Q

positive pressure breath test

A

in controlled intubations BVM breath given before paralytic to ensure patient can be ventilated prior to paralytic.

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14
Q

differences between RSI and controlled induction

A

no positive pressure breath test (increased risk of aspiration)
Drugs usually pushed one after another
Cric pressure required

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15
Q

difficult airway guideline

A

BURP
Bouje
Blade

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16
Q

etomidate

A

0.3-0.4mg/kg

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17
Q

fentanyl

A

2-10mcg/kg

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18
Q

propofol

A

1-2.5mg/kg

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19
Q

midazolam

A

0.1-0.3mg/kg

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20
Q

ketamine

A
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21
Q

Rocuronium

A

0.6-1.2mg/kg

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22
Q

Succinylcholine

A

1-2mg/kg
DOA 5-7 mins
Deplorarising NMBA
wait for muscle fasciculations to stop

CI: Burns, spinal cord injuries, hyperkalemia, neurological injuries.

23
Q

complications of intubation

A

Right mainstream intubation
oesophageal intubation
injury to airway
pneumothorax
air leak from bronchial injury

24
Q

indications for surgery in cerebral hemispheric hematoma

A

> 50ml volume
frontal or temporal hemorrhage >20ml with midline shift>5mm and/ or cistern compression with decreased GCS

25
Q

indications for surgery with posterior fossa hematoma

A

brainstem compression
distortion of the 4th ventricle
effacement of basal cisterns
obstructive hydrocephalus

26
Q

diabetes insipidus DDAVP dose

A

2 mcg

27
Q

indications for surgery epidural hematoma

A

> 30ml Volume
thickness>15mm
midline >5mm
Acute with impaired consciousness focal neurology.

28
Q

parameters for TBI patients

A

normal oxygenation 60-80
Normocapnia 30-35
MAP 70-90
Na 140-145
Normal ICP of approx. 10

29
Q

initial TBI management

A

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

30
Q

drugs to avoid in TBI

A

steroids
Should initially avoid Lasix, and antihypertensives.

31
Q

Norepinephrine

A

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

32
Q

Vasopressin

A

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

33
Q

Epinephrine

A
  • 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
34
Q

Phenylephrine

A

Pure alpha 1 agonism
* Add if significant tachyarrhythmias
* Caution if concern of increasing afterload
dec. HR, CO
Inc SVR, PCWP

35
Q

Dobutamine

A

Inc HR, CO
Decrease SVR, PCWP

36
Q

dopamine

A

Inc. HR, SVR, CO, PCWP

37
Q

milrinone

A

inc HR, CO
Dec. SVR, PCWP

38
Q

contraindication to NIPPV

A
  • 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)
39
Q

how to decrease PaCO2 on a vent

A
  • Increase RR
  • Increase tidal volume
    (minute ventilation = RR * Vt)
40
Q

how to increase O2 on vent

A

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)

41
Q

Benefits of Invasive mechanical ventilation

A

Improved VQ mismatching
Reduced shunt physiology
Improved oxygen delivery

42
Q

Risks of Invasive mechanical ventilation

A

Ventilator induced lung injury
Ventilator associated pneumonia
Organ failure
Neuromuscular weakness
Ventilator dependence

43
Q

symptoms of early salicylate toxicity

A

Tinnitus
Nausea and vomiting
hyperventilation
Fever

44
Q

late symptoms of salicylate toxicity

A

pulmonary oedema (non-cariogenic)
coma/ seizures
arrhythmia
thrombocytopenia
AKI

45
Q

causes of high anion gap

A

ketones
Tylenol
Salicylates
Lactate

46
Q

treating salicylate poisoning

A

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!

47
Q

indications to use digibind

A
  1. acute ingestion of 10mg or more
  2. K>5
  3. hypo perfusion
  4. life threatening arrhythmia
48
Q

ECG changes with toxic levels of digoxin

A

first degree heart block
paroxysmal atrial tachycardia
regularized atrial fibrilation
univocal or multifocal PVC’s
ventricular bigeminy
Bidirectional VT

49
Q

ECG changes with therapeutic levels of digoxin

A

sagging of ST segments
flattened T waves
U waves
Shortened QT

50
Q

medications that increase digoxin levels

A

medications that inhibit p-glycoprotein
- amiodarone
- carvedilol
- ranolazine
- ticagrelor
- verapamil
- tacrolimus
- cyclosporin
- azithromycin, erythromycin, clarithromycin
- azole antifungals

51
Q

medications that decrease digoxin levels

A

p- glycoprotein agonists
- Carbamazepine, fosphenytoin, phenobarbital
- rifampin

52
Q

how to treat gas trapping on vent

A

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.

53
Q

symptoms of serotonin syndrome

A

autonomic
neuromuscular hyperactivity
change in mental status

54
Q

symptoms of neuroleptic malignant syndrome

A

Fever
Autonomic
Rigidity
HYPOREFLEXIVE
Change in mental status

Royal college IM (18 decks)

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