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Surgery > critical care > Flashcards

critical care Flashcards

1
Q

glucose

A

-<180
-granulites -> WBC issues
-if higher -> start insulin drip
-look at the last three blood pricks

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2
Q

ABG

A

-positive allen test is a good thing
-ulnar artery is the primary blood supply to the hand
-must document
-occlude both arteries, pt open and closes hands, release ulnar side -> color returns -> positive

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3
Q

temperature

A

-two temps are taken
-spike temp at 24 hrs
-Tmax and T??
-cortisol drops in the evening -> temp is higher at night

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4
Q

ideal body weight / ventilator

A

MALES
-50kg for first 5 ft
-heigh in INCHES x number of inches above 5 ft

-(ht in inches -60) 2.3 + 50 = MALE
-(ht in inches - 60) 2.3 + 45.5 = FEMALE

-divide cm by 2.54 = inch

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5
Q

tidal volume

A

-6-8cc per kilo
-80kilos -> tidal volume should be 480-640
-dont want to over distend the alveoli

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6
Q

ventilator

A
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7
Q

ICU

A

-vitals every hour
-neuro exam daily

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8
Q

sedation

A

-depression of a pts perception of environment and repsonse to environmental stimulus
-assoc with shorter periods of ventilation and ICU stay
-diprivan (propofol)
-dexmedetomidine hydrochloride (precedex)
-sublimaze (fentanyl)
-midazolam (versed)

-benzo OD- give Flumazenil

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9
Q

richmond agitation sedation score (RAAS)

A

-0 to -2 is good

+4 combative
+3 very agitated
+2 agitated
+1 Restless

0 Alert and calm
-1 Drowsy
-2 light sedation

-3 moderate sedation
-4 deep sedation
-5 unrousable

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10
Q

propofol related infusion syndrome (PRIS)

A

-Diminished cardiovascular contractility.
-Metabolic acidosis.
-Lactic acidosis.
-Rhabdomyolysis.
-Hyperkalemia.
-Lipidemia.
-Hepatomegaly.
-Acute renal failure.
-Mortality
-The main presenting signs of PRIS include high anion gap metabolic acidosis

-dx- triglycerides every three days

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11
Q

propofol related infusion syndrome (PRIS) risk factors

A

-Critical illnesses.
-Increased serum catecholamines.
-Steroid therapy -> upregulates alpha receptors -> metabolic demand
-Obesity- stored in fat
-Young age (significantly below three years).
-Depleted carbohydrate stores in the body -> body relies on fatty acid metabolism which is impaired in PRIS
-Increased serum lipids.
-Heavy or extended dosage of propofol,*** >48hrs

-pt has high dose or long term therapy

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12
Q

key monitoring PRIS

A

-Must observe :
-The patient’s electrocardiogram (ECG).
-Serum creatine kinase.
-Lipase, amylase.
-Lactate.
-Liver enzymes.
-Myoglobin levels in urine.
-Length of propofol sedation
-functions as hypnotic sedative inhibiting GABA

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13
Q

tx of PRIS

A

-RRT- renal replacement therapy for AKI
-oliguric renal failure- furosemide challenge -> you always want urine being made
-if that doesnt work -> dialysis cath -> continuous veno-venous hemofiltration (CVVH)
-bicarbonate
-switch to benzo or dexmedetomidine
-give fluids for the BP
-vasopressors

-bumix and furosemide -> dont give it to pts with sulfa allergy -> ethacrynic acid!!!

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14
Q

paroxysmal sympathetic hyperactivity (PSH)

A

-TBI
-affect cortical communication
-imbalance between sympathetic nervous and parasympathetic
-excess catecholamine production, neuron firing, distress
-pt could be asleep and this is happening in their brain
-PSH storming: A stress response seen in severe TBIs:
-Agitation.
-Hypertension (>160 mmHg).
-Tachycardia (> 120/min).
-Tachypnea (20/min).
-Hyperthermia (temp > 38.5C),
-Diaphoresis.
-Extreme posturing- extensor (decerebrate) or flexure (decorberate)
-Dystonia.
-Pupillary dilatation.
-LOC
-unexplainable fluid loss - hypovolemia

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15
Q

PSH etiology

A

-Disassociation from SNS and PNS.
-Onset within the first 24 hours and persist for months.
-Triggering Events:
-Non-noxious stimuli.
-Pain.
-Environmental stimuli.
-Suctioning.
-Hyperthermia.

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16
Q

PSH storming Tx

A

-Opioids:
-Morphine- better than fentanyl!
-Fentanyl

-Beta-blockers:
-Propranolol!!- best
-Metoprolol
-Labetalol

-Alpha agonists:
-Dexmedetomidine- good for pts coming on ventilator
-Clonidine- maintenance after

-Benzodiazepines:
-Diazepam
-Lorazepam
-Midazolam

-Neuromodulators: last choice
-Bromocriptine
-Gabapentin

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17
Q

PSH sequelae

A

-Cardiac injury.
-Skeletal muscle injury.
-Increase in metabolic rate by 100 – 200 %. -> increase caloric requirement
-Increased cerebral hemorrhage (bc of HTN)
-control BP <140 - IV diltiazem

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18
Q

delirium

A

-impairment in attention and awareness that develops over a relatively short time interval that is associated with additional cognitive deficits.
-Change is in attention and awareness.
-Types of Delirium:
-Hyperactive (Most commonly seen type out of ICU)
-Hypoactive
-Mixed

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19
Q

hyperactive delirium

A

-Agitation.
-Restlessness
-Emotional lability.

-Psychotic features:
-Hallucinations
-Illusions that often interfere with the delivery of care.
-New-onset psychotic symptoms in older adult patients are unlikely to be a primary mental illness.***

-can be missed easily

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20
Q

hypoactive delirium

A

-higher morbidity and mortality than the others 6 months out
-Confusion.
-Sedation.
-Apathy.
-Decreased responsiveness.
-Slowed motor function
-Withdrawn attitude.
-Lethargy.
-Drowsiness.

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21
Q

mixed delirium

A

-Most frequent type of delirium.
-Has characteristics of the two previous forms.

22
Q

delirium etiologies

A

-Infectious.
-Alcohol/substance intoxication or withdrawal.
-Wernicke’s disease.
-Metabolic.
-Hypoglycemia.
-Medications.
-Trauma.
-Neurocognitive.
-Seizures.
-Vascular.
-Hypoxia.
-Vitamin deficiencies.
-Endocrinopathies.
-Toxin or heavy metal ingestion.

23
Q

delirium who is at risk

A

-Older age.
-Cognitive impairment.
-Visual impairment.
-Alcohol abuse.
-Respiratory disorder.
-Illness severity.
-Terminal illnesses.
-Comorbidity.
-Infection.
-Majorsurgery (e.g., complex abdominal, hip fracture, and cardiac surgery)..

24
Q

non hemorrhagic ischemic strokes BP requirement

A

> 160 BP
-pressors

25
Q

specific ICU risks: delirium

A

-Pre-existing dementia.
-Mechanical ventilation.
-Sepsis.
-History of hypertension.
-High severity of illness on admission.
-Pain.
-Stroke.
-Psychiatric disorders.
-Depression.
-Traumatic head injury.
-Myocardial infarction.
-COPD.
-Steroids.
-Hypertension.
-Psychoactive medications including narcotics.
-Deep levels of sedation.
-Environmental factors such as the absence of visible sunlight.
-Immobility and physical restraints.
-Poor sleep quality.
-Social factors like alcohol abuse and smoking.
-Lack of visitors.

26
Q

delirium severity scale

A
27
Q

delirium tx

A

-Tx of the underlying cause.
-Correction of potential electrolyte disturbances.
-Removal of offending pharmacologicalagents.
-Maintain proper sleep/wake cycles.
-Manage pain.
-Address sensory impairments (hearing, vision).
-Encourage family visits and frequent reorientation.
-Early mobilization!!!

28
Q

medical tx of delirium

A

-Antipsychotics:
-Haldol
-Risperidone
-Quetiapine

-Dexmedetomidine.

-Short Acting Benzodiazepine:
DO NOT USE BENZOS IF YOU DONT NEED TO ESPEICALLY IN ELDERLY !!!!!
-Midazolam.
-Lorazepam.

29
Q

ABCDEF Mneumonic

A

A=Assess, prevent and manage pain
B=Both Spontaneous Breathing Trials (SBT) and Spontaneous Awakening Trials - breaths are initiated by the pt and the ventilator can provide positive pressure -> can try to take them off ventilator
C=Choice of sedation and analgesia.
D=Delirium: assess, prevent, and manage.
E=Early mobility and exercise- intubated pt with ventilator walks with support
F=Family engagement and empowerment

30
Q
A

-infarct
-MCA stroke
-huge
-midline shift
-GCS =3
-intubate
-ABCDE
-2 large bore 18g
-put in a bolt to assess ICP
-CCP = MAP - ICP
-hypertonic solution (mannitol causes rebound ICP)
-raise head of the bed
-hyperventilate
-norepinephrine
-fentanyl propofol for ICP
-EVD- take out CSF
-antiepileptic - keppra
- ET tube - feed- metabolic requirement
->5 mm shift -> drain

31
Q

acute HF

A

-MC manifestation of CV pathologies in the ICU.
-CHAMPS Mnemonic:
-Coronary Syndrome.
-Hypertensive Emergency.
-Arrhythmia.
-Mechanical Etiology.
-Pulmonary Embolism
-Systemic or Other Causes:
-Infection (e.g., sepsis, endocarditis)
-Thyrotoxicosis
-Anemia
-Drugs: Non-compliance with HF meds or use of negative inotropes (e.g., beta-blockers in high doses).
-Fluid overload

32
Q

acute HF dx and tx

A

-BNP > 400
-ECG
-X-ray- cephalization, Kerley B lines, edema, cardiomegaly, effusions
-TTE, Echo
-systolic HF- low LVEF; diastolic HF- LVEF preserved

-LMNOP
-Loop diuretics (furosemide)
-Modify medications- SGLT2 inhibitors -flozin
-Nitrates- vasodilate
-Oxygen if hypoxic
-Position (with elevated upper body)
-do NOT give morphine

-if unstable/hypotensive - dobutamine

33
Q

primary concern: acute cardiac decompensation

A

-Airway and Respiratory Management.
-Circulatory Management.

-Vasoactive Drugs:
-Dobutamine or milrinone with mild hypotension.
-Norepinephrine.
-Vasopressin.
-Epinephrine.

-Interventional Devices.
-Pulmonary Vasodilators.

-Rhythm Management:
-Atrial.
-Pacing.
-Beta agonists.

-Cardiac Tamponade.
-Sedation.
-AKI with Renal Support.
-Palliative Care/Goals of Care. Primary Concern: Acute Cardiac Decompensation

34
Q

ECG changes during myocardial infarction

A
35
Q
A
36
Q
A
37
Q
A

Pulmonary embolism

38
Q

shock

A

-Hypovolemic

-Cardiogenic
-arrhythmia, MI, congenital, valvular
-high preload, high after load
-do not give too much fluids!!!!!!!

-Distributive:
-Septic
-Anaphylactic

-Neurogenic- phenylephrine (usually use norepinephrine for other shock)
-warm and bradycardia

-Obstructive:
-Tension Pneumothorax
-Pulmonary Embolism- virchow triad - hypercoagulability, venous stasis, endothelial injury
-Cardiac Tamponade- narrow pulse pressure, tachy -> GIVE VOLUME

-ALWAYS GET BLOOD CULTURES BEFORE ANTIBIOTICS -> START EMPIRIC -> THEN NARROW IT DOWN

39
Q

right ventricular infarct

A

-milrinone
-right ventricular infarct
-can be worse than left
-without right there is no left
-cor pulmone can cause

40
Q

sequelae of portal hypertension

A

-reversal of flow -> into spleen, coronary veins, lower esophageal sphincter
-varices
-hemorrhoids
-caput medusa
-ammonia builds up -> encephalopathy
-ammonia most accurate in the morning

-dx-
-thrombyocytopenia, hyperbilirubinemia
-Transient elastography- US stiffness
-doppler
-Hepatic venous pressure gradient (HVPG) measurement- gold standard

-tx-
-non-selective BB- carvedilol
-TIPS

41
Q

45-year-old man comes to the emergency department with a history ofchronic alcohol use disorder (drinks 6 – 10 beers daily) for the past 20-years), presents withhematemesis andmelena for the past 12 hours. He reports that the episode began after several hours ofsevere retchingand vomiting, which occurred after a drinking binge. He had consumed8-10 beers in the afternoon and continued drinking heavily in the evening. He describes the vomitus asbright red bloodand mentions aburning sensation in the chestprior to vomiting.
His symptoms began around midnight, and he initially attempted to manage by drinking water, but the blood continued. He had two large episodes of vomiting blood before he sought medical attention. He has a history of similar episodes ofretchingbut without significant blood loss in the past.

A

-pale conjunctiva - hct is less than 21
-CBC, LFT, electrolytes, pending blood cultures
-CTA (if stable)
-EGD

-IV fluids
-Blood transfusion- 2U PRBC
-octreotide- reduce portal pressure and control bleeding
-PPI- reduce gastric bleeding and promote healing
-FFP- if INR remains elevated
-Sengstaken-Blakemore tube (SBT)- must R/O mallory weiss tear first bc balloon with cause complete tear

-endoscopic variceal band ligation- stop active bleeding

-detox
-thiamine to prevent wernicke-korsakoff
-BB if HTN and to decrease portal pressure to prevent variceal bleeding

-follow up with hepatologist

42
Q

portal vein stent- TIPS

A

-portal vein and hepatic vein stent
-indication = recurring or treatment-resistant upper GI bleed
-perforate hepatic vein -> slide in a stent -> mix portal and systemic to decrease pressure
-bypass deamination of blood
-ammonia is put into the systemic
-all these pts will be become encephalopathic - lactulose
-buys you time

43
Q

anticoagulants

A

-never for surgery or CNS injury
-not even for PE
-give a filter

44
Q

distributive shock

A

-blood pools in periphery
-vasodilation
-decrease BP
-less blood to organs -> brain, heart, kidneys
-demand ischemia -> troponins -> MI
-AKI- rise in BUN/Cr

45
Q

obstructive shock

A

-tension
-tamponade
-PE
-prevents blood return to RV

46
Q

ventilatory support

A

-Apnea and Impending Respiratory Arrest.
-Exacerbation of Chronic Obstructive -Pulmonary Disease,
-Acute Severe Asthma.
-Neuromuscular Disease.
-Acute Hypoxemic Respiratory Failure
-Heart Failure and Cardiogenic Shock.
-Acute Brain Injury

47
Q

types of respiratory failure

A

-know this

Type 1 (hypoxemic)
Also known as “oxygen failure”, this type occurs when the body doesn’t get enough oxygen into the blood. It’s usually caused by uneven airflow in and out of the lungs compared to blood flow

Type 2 (hypercapnic)
Also known as “ventilatory failure”, this type occurs when the body can’t remove enough carbon dioxide from the blood

Type 3 (perioperative)
This type is related to surgery and can occur when patients develop atelectasis from pain or sedatives

Type 4 (shock)
This type is secondary to cardiovascular instability and can be caused by sepsis or fever.- decrease perfusion

48
Q

indications for intubation

A

4 P’s:
Protect
Preserve
Pulmonary Toileting
Pulmonary Failure

-GCS < 8

49
Q

types of ventilatory support

A

-know how to read ABG
-Assist Control (AC)- not really ever used
-Controlled Mechanical ventilation (CMV)!!!
-Intermittent Mandatory Ventilation (IMV).
-Synchronized Mandatory Ventilation (SIMV).
-Pressure Support (PS).
-Continuous Positive Airway Pressure (CPAP).
-BiLevel Positive Airway Pressure (BiPAP).
-Airway Pressure Release Ventilation (APRV).

50
Q

MI

A

-sx + ECG = MI -> enzymes after
-MONAB
-morphine
-oxygen
-nitroglycerin
-aspirin, cloprigel
-beta blocker

-PCI within 90 mins with DES and DAPT for 12mo
-thrombolysis (TPA)

Surgery (23 decks)

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