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ABIM Pulmonary Boards - Jackie > Critical Care > Flashcards

Critical Care Flashcards

1
Q

Mathematical formula and how to calculate driving pressure.

A

VT/C : Tidal volume/compliance

DP= Plateau pressure - Total PEEP

Goal <15

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2
Q

Name methods to reduce driving pressure

A

1. Decrease tidal volume (given VT/compliance)
2. Increase PEEP, which can be measured by stress index (slope of the airway pressure tracing should be linear)

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3
Q

POCUS

What is the ddx for:
1) Absent lung slide
2) B line profile

A

ARDS or pneumonia

Pneumothorax always has A-line profile from reflected pleural line

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4
Q

POCUS findings of pneumothorax

A

Absent lung slide
A lines
NO b lines
Lung point to confirm

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5
Q

What is set on APRV

A

Glorified CPAP with quick breaks to release CO2

  • P high - 30-35
  • P low (PEEP) - 0-5
  • T high (inspiratory time) - usually 4- 8 sec
  • T low (exp time) - usually 0.3-0.8sec
  • FiO2

RR= # releases (ie 60sec/Thigh - Tlow)

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6
Q

What do you adjust on VV ECMO to change CO2 clearance

A

Sweep gas flow

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7
Q

What do you adjust on VV ECMO to change Oxygenation

A

oxygenator blood flow

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8
Q

Overall goal with vent when pt on VV ECMO?

A

Reduce FiO2 and vent pressures to achieve the most protective vent settings

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9
Q

Causes of low compliance on vent (ie increased PIP and plateau pressure)

A

Pulmonary:
- atelectasis
- Pulm edema
- Pneumothorax
- Hyperinflation
- Pulmonary fibrosis

Extra pulm:
- Abdominal distention
- Chest wall rigidity
- Main stem ETT

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10
Q

What causes high lung resistance on vent?

A

Increased PIP with normal Pplat

-Secretions
-Bronchospasm (asthma, COPD)
-Trouble with tube (biting, kinked, too small)
-Circuit filled with water

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11
Q

calculating Compliance

A

Compliance = TV/ (plateau pressure - PEEP)

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12
Q

How to assess for abdominal compartment syndrome

A

Bladder pressure

> 12 abnormal
Severe is >25

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13
Q

How to fix delayed cycle termination dyssynchrony?

A

Problem with pt exhaling while machine still giving insp support

Fix: Shorten set I time on vent
or switch to PS
or adjust sedation

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14
Q

What causes double triggering?

A

pt insp time > vent insp time
2 breath given w/o expiration b/c pt still inhaling and vent changes to exhalation

Leads to large TV (although might not appear so on monitor)

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15
Q

How to fix double triggering?

A

Fix with increasing I time or decreasing flow

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16
Q

What causes flow asynchronies?

A

Flow startvation
Pt trying to start another breath during vent supported inspiration because pt trying to get more flow

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17
Q

How to improve flow asynchronies?

A

increase flow
Switch to PS

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18
Q

What causes missed trigger asynchrony?

A

pt tries to take breath but effort does not trigger mechanical breath.

Causes:
- air trapping / intrinsic PEEP
- Triggering threshold too high
- Weak resp muscles

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19
Q

How to fix missed triggering asynchrony?

A

Increase sedation
Address autopeep
Decrease TV
decrease triggering threshold
change insp pressure/flow and cycling criteria

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20
Q

How to fix auto PEEP?

A

increase expiratory time (decrease rr, increase flow)
bronchodilators
increase intrinsic PEEP

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21
Q

What causes auto trigger asynchrony?

A

Air leak

breath initiated from external trigger before vol returns to zero
air leak –> decrease exhalation pressure

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22
Q

How to fix auto trigger asynchrony?

A

Fix leak
If cant (ie bronchopleural fistula) reduce the PEEP to zero so you dont get the auto trigger

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23
Q

How to use pulse pressure variation to assess volume responsiveness?

A

PPV proportional to stroke volume. greater variability in SV (increased PPV) more likely to be fluid responsive.

PPV>12% means if give fluids likely will have increased SV

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24
Q

3 conditions for using pulse pressure variation as assessment for volume responsiveness?

A
  1. Pt in sinus rhythm
  2. on MV w/o spontaneous resp and TV=8cc/kg
  3. NO open chest

also abd pressure <12
HR/RR ratio >3.6

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25
What is pulsus pardoxus?
decrease in SBP >10 with respiration suggests tamponade, severe asthma, COPD
26
Appearance of pulsus alternans on a-line?
alternating strong and weak pulses iso low cardiac output shock states
27
Appearance of pulsus bisfirens on a-line?
double peaked pulses Severe AR +/- AS
28
Appearance of pulsus tardus on a-line?
Late peaking pulse Seen in severe AS
29
Criteria for decannulating pt with trach?
- Pt not requiring suctioning more than 2 times every 8h during 24h period Superior to using capping trial
30
Management of submassive hemoptysis?
Observation CXR labs for coagulation etc CT with contrast Consider inhaled TXA 3 times daily for up to 5 days (Study: reduced expectorated blood and increase chance resolution, decrease need for invasive tests, reduced recurrent bleed at 1 yr)
31
Causes of rapid decreased TV in pressure targeted vent modes?
obstructive changes (mucous plugging, tube kink, foreign body, blood clot, bronchospasm) -- will see reduced inspiratory flow and prolonged expiratory time Compliance reduction (flash edema, pneumothorax, pleural bleeding, mainstem ett) -- reduced insp flow, exp and insp times short
32
Calculating stroke volume using POCUS
SV= cross-sectional area x velocity time integral (VTI) SV= (LVOT/2)^2 x pi x VTI
33
Assessing right atrial pressure using IVC POCUS- expected measures for high pressure
RAP 16-20- IVC collapses <50% on inspiration and is >2.5cm in diameter
34
How to estimate RAP 5-10cm on POCUS
IVC collapses >50% on inspiration and is 1.5-2.5cm diameter
35
How to fix diff in a line BP and cuff?
Pressure transducer should be at level of heart If higher than heart then BP will be lower 10cm water height = 7.4 mmHg bp Changing height of arm does not matter as long as transducer is level with heart
36
Which bacteria can raise CK
Streptococcus (including S pneumoniae) Staphylococcus aureus Legionella species Klebsiella species Pseudomonas species Escherichia coli.
37
Which viruses can raise CK in sepsis
SARS-CoV-2, influenza virus, coxsackievirus, and HIV
38
Symptoms of serotonin syndrome
mental status changes, GI disturbances (diarrhea), neuromuscular abnormalities (hyperreflexia, shivering, myoclonus, rigidity), and autonomic dysfunction (fever, shock, flushing) <12 h after exposure
39
Neuroleptic malignant syndrome (NMS) clinical presentation
changes in mental status (mainly delirium) generalized rigidity (Parkinson-like) hyperpyrexia abnormal metabolic changes (elevation of CK levels) autonomic nervous system imbalance (HTN) 14-72 h after exposure
40
Treatment of amiodarone toxicity
Prednisone 50mg daily
41
Risk factors for amiodarone pulm tox
dose of ≥400 mg/day and is highest in those on it for >2 months Can occur at any dose
42
Histology of amiodarone tox
lipid-laden foamy macrophages in alveolar spaces
43
meaning of tetrahydrocannabinol and vitamin E acetate in BAL fluid
Likely EVALI
44
45
What causes dilution of end-expiratory CO2
Air leak - cuff underinflation - displacement of the tube high up in the trachea - high mean airway pressure
46
What does a obstruction in the airway look like on end exp CO2 capnogram?
less steep upstroke without an alveolar plateau (shark fin) - reflects the inhomogeneity of gas distribution and alveolar ventilation
47
Treatment for myasthenia crisis
Plasma exchange to remove Ab (works faster than IVIG) IVIG
48
Coronary Sinus
49
Babesia on Histology
trophozoites- pleomorphic ring forms and have been known to cluster as Maltese crosses ring-like parasites inside erythrocytes on Giemsa- or Wright-stained blood smears
50
Treatment of hemothorax iso DIC
Likely will need surgery because embolization likely to be unsuccessful so need to find bleeding vessel
51
How to fix double triggering
Extend inspiratory time If severe lung injury and need to add 1 second inspiratory pause so pt cant initiate another breath. Change to PS
52
What is this?
Moderator band (contains right bundle branch)
53
Initial treatment of spontaneous intracerebral hemorrhage in pt on warfarin
Reversal of AC with 4-factor prothrombin complex (faster than FFP) No need to control BP
54
Brain death testing
Confirm Coma with exam Apena test - elevation PaCO2 to 60 or 20mmHg higher than baseline (10 min!) 2 exams 24hr apart
55
Breathing pattern of during expiration, the lateral walls of the abdomen go inward, and the periumbilical region moves outward is characteristic of?
Abdominal rounding Volume overload and heart failure
56
What pressor to add if need second pressor in septic shock
Vasopressin
57
What pressor to add if refractory afib on high dose norepi
Phenylephrine
58
Pressors for cardiogenic shock
Dobutamine or milrinone AND norepi
59
Pressor for anaphylaxis
epinephrine
60
When to use dopamine
NEVER More mortality more arrhythmias
61
Length of empiric abx in ICU
3-5d
62
Duration of abx therapy in septic shock
7-10d
63
When to prolong use of abx in septic shock in ICU
- Slow clinical response - Undrained focus of infection - S aureus bacteremia - certain viral/fungal infections - severe immune impairment
64
How to classify ARDS severity?
P/F Severe <100 Moderate 100-200 mild 200-300 (ALI no longer a category with new criteria)
65
# Ventilator What ventilator mode is this?
**APRV** - airway pressure release ventilation Has a set Phigh and Plow pressure, and the patient breathes spontaneously as the ventilator cycles between the two pressures. Benefit: shorter sedation, paralysis time
66
# POCUS What pathology is seen on this POCUS M-Mode?
**Pneumothorax** with stratosphere or bar code sign.
67
What are clinical clues that can indicate acquired methemoglobinemia?
**1. SpO2 reading 85%**: High concentrations (>35%) of methemoglobinemia will read 85% on pulse ox regardless of true O2 content **2. Failure of SpO2 to correct** with supplemental O2 **3. Receipt of causative agent** dapsone, chloroquine, lidocaine, metoclopramide, nitrates, rasburicase, quinones, sulfonamides.
68
Criteria for tamponade diagnosis on cardiac ultrasound.
- Exaggerated variability in early diastolic flow into the ventricles: tricuspid inflow/tricuspid E velocity variability >40% on the right or mitral E wave velocity >25% on the left. - Right ventricle chamber collapse during diastole.

ABIM Pulmonary Boards - Jackie (11 decks)

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