Critical Care Flashcards
Upper GI Bleeding definition, sx, dx, tx
Ligament of Treitz: separates UGIB from LGIB
*bleeding proximal 🡪 hematemesis, melena
*bleeding distal 🡪 hematochezia
Etiologies:
*PUD
*esophagitis
*portal HTN
*Mallory-Weiss tear
*angiodysplasia
sx
Hematemesis – vomiting blood, “coffee-ground”
*bloody: suggests moderate-severe bleeding
*coffee ground: suggests more limited bleeding
Melena – black, tarry stools
*hematochezia usually indicates LGIB but can occur in massive UGIB
Symptom assessment:
*PUD – upper abdominal pain
*esophageal ulcer – odynophagia, reflux, dysphagia
*mallory-weiss tear – emesis, retching, or cough prior to bleeding
*variceal hemorrhage or portal HTN gastropathy – jaundice, abdominal distention (ascites)
*malignancy – early satiety, dysphagia, weight loss, cachexia
PE to assess hemodynamic stability:
*mild-mod hypovolemia (<15% volume loss): tachycardia
*≥15% volume loss: orthostatic hypotension
*≥40% volume loss: supine hypotension
dx
PMH – previous episodes of bleeding, comorbid conditions
Medication hx
*aspirin/NSAIDs predispose to PUD
*anticoagulants/antiplatelets ↑ bleed risk
*SSRIs/CCBs/aldosterone antagonists have been associated w/ GI bleeding
Labs: CBC, CMP, electrolytes, lipids, liver enzymes, albumin, creatinine, BUN, thyroid, coagulation studies
*monitor Hgb every 2-8hrs
*typically have ↑ BUN-to-creatinine ratio
- >30:1 suggest UGIB
UPPER ENDOSCOPY (within 24hrs)
tx
Hemodynamically unstable:
*IV access
*fluids
*transfusion
Once underlying cause is identified, treat the underlying cause
PPI (esomeprazole, pantoprazole)
Octreotide for esophageal varices or cirrhosis
Lower GI Bleeding definition, sx, dx, tx
Ligament of Treitz: separates UGIB from LGIB
*bleeding proximal 🡪 hematemesis, melena
*bleeding distal 🡪 hematochezia
Etiologies:
*diverticulosis
*angiodysplasia
*colitis (infectious, ischemic, IBD)
*colon cancer
*hemorrhoids
*anal fissure, polyps
sx
Hematochezia – maroon/bright red blood, blood clots
*L colon origin: bright red
*R colon origin: dark/maroon colored
Symptom assessment:
*hemorrhoids: painless bleeding w/ wiping
*anal fissures: severe rectal pain w/ defecation
*proctitis: rectal bleeding & abdominal pain
*polyps: painless rectal bleeding, no red flag signs
*colorectal cancer: painless rectal bleeding & a change in bowel habits in a pt 50-80yrs
PE to assess hemodynamic stability:
*mild-mod hypovolemia (<15% volume loss): tachycardia
*≥15% volume loss: orthostatic hypotension
*≥40% volume loss: supine hypotension
dx
Labs: CBC, CMP, electrolytes, lipids, liver enzymes, albumin, creatinine, BUN, thyroid, coagulation studies
*typically have normal BUN-to-creatinine ratio
- <20:1
+/- upper endoscopy to r/o UGIB
COLONOSCOPY, CT angiography, radionucleotide scanning
tx
Hemodynamically unstable:
*IV access
*fluids
*transfusion
Once underlying cause is identified, treat the underlying cause
Acute Narrow Angle-Closure Glaucoma definition, sx, dx, tx
Increased intraocular pressure leading to damage of the optic nerve
Risk Factors:
*pts w/ preexisting narrow angle or large lens
*age >60yrs, far-sighted, Asians, females
PATHO:
- decreased drainage of aqueous humor via trabecular meshwork & canal of Schlemm
- precipitants: mydriasis further closes the angle (dim lights, sympathomimetics, anticholinergics)
sx
Sudden onset of severe, unilateral ocular pain
*halos around lights, loss of peripheral vision (tunnel vision)
N/V, HA
PE:
*conjunctival erythema, cloudy “steamy” cornea
*mid-dilated fixed pupil (reacts poorly to light)
*eye hard on palpation
dx
Tonometry: ↑ IOP (>21mmHg)
Fundoscopy: optic disc blurring or “cupping” of optic nerve (thinning of the outer rim of the optic nerve head)
tx
Timolol + apraclonidine + pilocarpine + PO acetazolamide
*timolol – topical BB
*apraclonidine – topical alpha-2 agonist
*pilocarpine – topical miotic/cholinergic
Definitive: iridotomy – laser preferred
Acute Respiratory Distress Syndrome definition, sx, dx, tx
Acute, diffuse inflammatory form of lung injury & respiratory failure due to a variety of causes
Risk Factors:
*gram-negative sepsis MCC
*trauma, severe pancreatitis, aspiration of gastric contents, near drowning
sx
*acute dyspnea
*hypoxemia *refractory to O2
Severe 🡪 multi-organ failure
dx
CXR: bilateral diffuse pulmonary infiltrates
-spares the costophrenic angles
PaO2/FIO2 ratio <300
PCWP <18mm *>18mm seen in cardiogenic pulm edema
tx
Noninvasive or mechanical ventilation
*CPAP w/ full face mask
*PEEP
*low tidal volume
Treat the underlying cause
Acute Hypoglycemia definition, sx, dx, tx
Blood glucose level ≤70mg/dL
A complication in the management of diabetes – usually due to too much insulin use, too little food, or excess exercise
sx
Autonomic:
*sweating, tremors, palpitations
*nervousness, tachycardia, pallor, cool clammy skin
CNS:
*HA, lightheadedness, confusion
*slurred speech, dizziness, irritability
*difficulty concentrating, blurred vision, nausea, syncope
dx
Finger stick – glucose ≤70mg/dL
Unknown cause:
*C-peptide – elevated in endogenous insulin production
*plasma insulin levels
*anti-insulin antibodies
tx
Mild-moderate:
*15-20g of fast-acting carbs, fruit juice, hard candies
*recheck in 10-15min
Severe, unconscious, ≤40mg/dL:
*IV bolus of D50 or IV glucagon
Hypovolemic Shock *circulatory shock
definition, sx, dx, tx
*loss of blood or fluid volume due to hemorrhage or fluid loss
Etiologies:
*hemorrhagic
*non-blood fluid loss: vomiting, bowel obstruction, pancreatitis, severe burns, DKA
PATHO: loss of blood or fluid volume 🡪 ↑ HR, vasoconstriction (↑ SVR), hypotension, ↓ CO
sx
*pale, cool, mottled skin
*slow capillary refill >2sec
*↓ skin turgor
*dry mucous membranes
*tachycardia, ↓ BP & CO
dx
Early: ↑ Hgb/Hct
Late: ↓ Hgb/Hct
↓ PCWP
tx
ABCDEs, insert 2 large bore IV lines or a central line
Volume resuscitation:
*crystalloids (NS, LR) 3-4L
*monitor urine output
Control source of hemorrhage
*+/- packed RBC transfusion
Cardiogenic Shock *circulatory shock definition, sx, dx, tx
Etiologies:
*MI, myocarditis
*valvular disease, cardiomyopathies
*arrhythmias
PATHO: primary myocardial abnormality 🡪 heart unable to maintain CO
sx
*severe respiratory distress
*cool clammy skin
*vasoconstriction, hypotension, ↓ CO
dx
↓ BP & CO
↑ PCWP
tx
*oxygen
*isotonic fluids (AVOID a large amount!)
Inotropic support:
*dobutamine, epinephrine
*amrinone if refractory
Treat the underlying cause
*MI: early angioplasty or thrombolytics
Obstructive Shock *circulatory shock definition, sx, dx, tx
Etiologies:
*pericardial tamponade
*massive PE
*tension pneumothorax
*aortic dissection
PATHO: extrinsic or intrinsic obstruction of heart or great vessels
sx
*severe respiratory distress
*cool clammy skin
dx
CXR
EKG
↑ PCWP
tx
Oxygen, isotonic fluids, inotropic support:
*dobutamine, epinephrine, intra-aortic balloon pump
PE: heparin, thrombolytics, +/- embolectomy
Pericardial tamponade: pericardiocentesis
Tension pneumo: needle decompression
Proximal dissection: surgical intervention
Septic Shock *distributive shock definition, sx, dx, tx
PATHO: severe host immune response
sx
Early (warm):
*↑ CO: warm, flushed extremities & skin, brisk capillary refill, bounding pulses, wide pulse pressure
Later (cool):
*cool clammy skin
dx
SIRS: at least 2 of the following 4
*temp >100.4F or <96.8F
*pulse >90bpm
*RR >20 or PaCO2 <32mmHg
*WBC >12,000, <4,000, or >10% bands
Sepsis: SIRS + focus of infection (lactate >4)
Severe Sepsis: SIRS + multi-system organ failure
Septic Shock: sepsis + refractory hypotension
tx
Broad-spectrum IV abx
*Zosyn + ceftriaxone
*MRSA – vancomycin
*Pseudomonas – gentamicin
*abdominal infxns: clindamycin, metronidazole
*asplenic pts: ceftriaxone
IV fluid resuscitation: isotonic crystalloids (NS, LR)
Vasopressors if no response to fluids
Anaphylactic Shock *distributive shock definition, sx, dx, tx
Etiologies:
*insect bites/stings, food allergies
*drug allergies, recent IV contrast
PATHO: IgE mediated systemic HSN reaction w/ histamine release 🡪 vasodilation leading to ↑ capillary permeability
sx
*pruritis, hives, +/- angioedema
*+/- throat fullness, hoarseness, wheezing
*recent hx of insect bite/sting, food, drug, or IV contrast
dx
*↓ CO
*↓ PCWP
*↓ SVR
tx
*epinephrine first line
*airway management
*antihistamines
*observe pt for 4-6hrs
Neurogenic Shock *distributive shock definition, sx, dx, tx
Etiologies: acute spine injury
PATHO: sympathetic blockade 🡪 unopposed vagal tone on vessels 🡪 vasodilation
sx
hypotension W/O tachycardia**
*+/- bradycardia
dx
*↓ CO
*↓ PCWP
*↓ SVR
tx: fluids, pressors, +/- steroids
Endocrine Shock *distributive shock definition, sx, dx, tx
Etiologies: adrenal insufficiency (Addisonian crisis)
PATHO: decreased corticosteroid & mineralocorticoid activity
sx
*low serum glucose
*hypotension refractory to fluids & pressors
dx
*↓ CO
*↓ PCWP
*↓ SVR
tx: hydrocortisone 100mg IV
