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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
Q

What is pulsus pardoxus?

A

decrease in SBP >10 with respiration

suggests tamponade, severe asthma, COPD

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26
Q

Appearance of pulsus alternans on a-line?

A

alternating strong and weak pulses
iso low cardiac output shock states

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27
Q

Appearance of pulsus bisfirens on a-line?

A

double peaked pulses
Severe AR +/- AS

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28
Q

Appearance of pulsus tardus on a-line?

A

Late peaking pulse
Seen in severe AS

29
Q

Criteria for decannulating pt with trach?

A
  • Pt not requiring suctioning more than 2 times every 8h during 24h period

Superior to using capping trial

30
Q

Management of submassive hemoptysis?

A

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
Q

Causes of rapid decreased TV in pressure targeted vent modes?

A

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
Q

Calculating stroke volume using POCUS

A

SV= cross-sectional area x velocity time integral (VTI)

SV= (LVOT/2)^2 x pi x VTI

33
Q

Assessing right atrial pressure using IVC POCUS- expected measures for high pressure

A

RAP 16-20- IVC collapses <50% on inspiration and is >2.5cm in diameter

34
Q

How to estimate RAP 5-10cm on POCUS

A

IVC collapses >50% on inspiration and is 1.5-2.5cm diameter

35
Q

How to fix diff in a line BP and cuff?

A

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
Q

Which bacteria can raise CK

A

Streptococcus (including S pneumoniae)
Staphylococcus aureus
Legionella species
Klebsiella species
Pseudomonas species
Escherichia coli.

37
Q

Which viruses can raise CK in sepsis

A

SARS-CoV-2, influenza virus, coxsackievirus, and HIV

38
Q

Symptoms of serotonin syndrome

A

mental status changes, GI disturbances (diarrhea), neuromuscular abnormalities (hyperreflexia, shivering, myoclonus, rigidity), and autonomic dysfunction (fever, shock, flushing)

<12 h after exposure

39
Q

Neuroleptic malignant syndrome (NMS) clinical presentation

A

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
Q

Treatment of amiodarone toxicity

A

Prednisone 50mg daily

41
Q

Risk factors for amiodarone pulm tox

A

dose of ≥400 mg/day and is highest in those on it for >2 months

Can occur at any dose

42
Q

Histology of amiodarone tox

A

lipid-laden foamy macrophages in alveolar spaces

43
Q

meaning of tetrahydrocannabinol and vitamin E acetate in BAL fluid

A

Likely EVALI

44
Q
A
45
Q

What causes dilution of end-expiratory CO2

A

Air leak
- cuff underinflation
- displacement of the tube high up in the trachea
- high mean airway pressure

46
Q

What does a obstruction in the airway look like on end exp CO2 capnogram?

A

less steep upstroke without an alveolar plateau (shark fin) - reflects the inhomogeneity of gas distribution and alveolar ventilation

47
Q

Treatment for myasthenia crisis

A

Plasma exchange to remove Ab (works faster than IVIG)

IVIG

48
Q
A

Coronary Sinus

49
Q

Babesia on Histology

A

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
Q

Treatment of hemothorax iso DIC

A

Likely will need surgery because embolization likely to be unsuccessful so need to find bleeding vessel

51
Q

How to fix double triggering

A

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
Q

What is this?

A

Moderator band (contains right bundle branch)

53
Q

Initial treatment of spontaneous intracerebral hemorrhage in pt on warfarin

A

Reversal of AC with 4-factor prothrombin complex (faster than FFP)

No need to control BP

54
Q

Brain death testing

A

Confirm Coma with exam

Apena test - elevation PaCO2 to 60 or 20mmHg higher than baseline
(10 min!)

2 exams 24hr apart

55
Q

Breathing pattern of during expiration, the lateral walls of the abdomen go inward, and the periumbilical region moves outward is characteristic of?

A

Abdominal rounding

Volume overload and heart failure

56
Q

What pressor to add if need second pressor in septic shock

A

Vasopressin

57
Q

What pressor to add if refractory afib on high dose norepi

A

Phenylephrine

58
Q

Pressors for cardiogenic shock

A

Dobutamine or milrinone
AND
norepi

59
Q

Pressor for anaphylaxis

A

epinephrine

60
Q

When to use dopamine

A

NEVER

More mortality
more arrhythmias

61
Q

Length of empiric abx in ICU

A

3-5d

62
Q

Duration of abx therapy in septic shock

A

7-10d

63
Q

When to prolong use of abx in septic shock in ICU

A
  • Slow clinical response
  • Undrained focus of infection
  • S aureus bacteremia
  • certain viral/fungal infections
  • severe immune impairment
64
Q

How to classify ARDS severity?

A

P/F

Severe <100
Moderate 100-200
mild 200-300

(ALI no longer a category with new criteria)

65
Q

Ventilator

What ventilator mode is this?

A

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
Q

POCUS

What pathology is seen on this POCUS M-Mode?

A

Pneumothorax with stratosphere or bar code sign.

67
Q

What are clinical clues that can indicate acquired methemoglobinemia?

A

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
Q
A

ABIM Pulmonary Boards - Jackie (11 decks)

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