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Notes > Critical Care > Flashcards

Critical Care Flashcards

1
Q

MAP Calculation

A

[SBP + 2*DBP] / 3

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2
Q

Normal MAP

A

70 - 100mmHg

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3
Q

MAP >65 is essential for what function?

A

cerebral perfusion pressure

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4
Q

urine output indicative of hypoxia

A

UR < 0.5ml/kg/hr

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5
Q

when does lactic acid rise?

A

anaerobic metabolism
hypoperfusion - as air runs out for the organs they start to use other sources

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6
Q

normal lactic acid level

A

< 1 mmol/L

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7
Q

hemodynamics of hypovolemic shock

A

low cardiac index and wedge pressure
reduced preload (lack of volume) means less to pump
SVR reflexively increases to compensate

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8
Q

cardiogenic shock hemodynamics

A

acute HF (low cardiac index)
heart is not pumping correctly so it causes congestion (increased wedge pressure)
this in turn decreases volume in circulation leading to hypoperfusion which will reflexively increase SVR which in turn hurts the pumping of blood more (increased afterload)
causes decrease in renal excretion of sodium and water

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9
Q

Obstructive Shock Hemodynamics

A

massive PE, tamponade filling pleural space, aortic stenosis, etc
puts too much pressure on the diastolic chambers so they cannot fill well to then be pumped out, same hemodynamics as cardiac

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10
Q

distributive shock hemodynamics

A

sepsis, anaphylaxis, intoxication, pancreatitis, could even be endocrine - could be all over the map here
usually have increased cardiac index with leaky capillaries to fill with fluid and decreased BP

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11
Q

definition of septic shock (2 requirements)

A

MAP < 65 requiring vasopressors
Lactic acid >2 mmol/L

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12
Q

when to administer IVF in sepsis and what fluid volume to give?

A

30ml/kg x 1 and give if hypotension or Lactate > 4mmol/L

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13
Q

sepsis vasopressor of choice and dose

A

Levophed - typical is 0.01 - 3 mcg/kg/min (ours is a flat 8mcg/min)

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14
Q

when to add vasopressin to levophed and what dose?

A

infuse at a fixed rate of 0.03units/min usually
when flow rates are around 0.25 - 0.5mcg/kg/min

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15
Q

when to use phenylephrine as a vasopressor

A

if severe tachyarrhytmias develop w/levophed and vasopressin

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16
Q

duration of peripheral vasopressor until you NEED a central line

A

> 6 hours

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17
Q

extravasation of vasopressor treatment

A

phentolamine injected around the site
may sub w/nitroglycerin paste q6h or SC terbutaline

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18
Q

dopamine ADRs

A

arrhythmias
endocrine changes (decreased prolactin, GH, and TH)
depletes endogenous levophed (precursor to levophed)

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19
Q

when do you use antifungals in sepsis?

A

recent broad spectrum antibiotics
indwelling Central line
long-term PN
recent abdominal surgery
immunocompromised

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20
Q

when to use hydrocortisone

A

varying opinions
possible add 200mg IV daily once levophed doses > 0.25mcg/kg/min for at least 4 hours

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21
Q

Bicarb Normal Range

A

22 - 26 meq/L

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22
Q

acidosis means more or less bicarb

A

acidosis means less bicarb (bicarb is basic)

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23
Q

respiratory acidosis means higher or lower PCO2

A

acidosis is increased PCO2 and alkalosis is a decrease

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24
Q

normal range of PCO2

A

35 - 45 mmHg

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25
Q

respiratory compensation shift

A

blood that is pH < 7.35 will result in an increased respiratory rate to get rid of more CO2 and raise the pH

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26
Q

acidosis/alkalosis and the respiratory/urinary response

A

immediately -respiratory compensation occurs
acidosis results in respiratory increased breathing rate to get rid of CO2 (acid)
alkalosis results in respiratory slowing to decrease loss of CO2

kidneys take longer to compensate
bicarb excretion or retention will change the pH

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27
Q

differentiate b/w metabolic or respiratory alkalosis/acidosis

A

pH <7.35:
pCO2 elevated is respiratory, bicarb is low its metabolic

pH >7.45:
pCO2 decreased is respiratory, bicarb is high its metabolic

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28
Q

Anion Gap Calculation

A

Sodium - Chloride - Bicarb

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29
Q

Anion Gap Normal Range

A

6 - 12 meq/L

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30
Q

what causes respiratory acidosis?

A

PE
pulmonary edema
over-sedation, CNS depression
stroke
PNA
bronchospasm
spinal cord injury

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31
Q

what causes respiratory alkalosis?

A

stimulants
anxiety
pain
head injury
decreased O2 carrying in blood
reduced alveolar O2 extraction
respiratory rate
extracorporeal removal
hyperventilation

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32
Q

metabolic acidosis with anion Gap causes

A

MUDPILES

methane
uremia
DKA
propylene glycol
intoxication/infection
lactic acidosis
ethanol
salicylate

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33
Q

metabolic acidosis without anion Gap causes

A

F-USED CARS

fistula (pancreatitis)
uteroenteric conduits
saline excess
endocrine (hypo-parathyroid)
diarrhea
carbonic anhydrase inhibitors
arginine, lysine, Cl
renal tubular necrosis
spironolactone

34
Q

metabolic alkalosis causes

A

Urine Cl >25:
hyperaldosteronism
high mineralocorticoid

urine Cl <25:
vomiting
NG suction
diuretic

35
Q

treatment for respiratory acidosis

A

ventilation
correct causet

36
Q

treatment for respiratory alkalosis

A

slow breathing
sedation
ventilation
oxygen

37
Q

treatment for metabolic acidosis

A

treat cause
bicarb not as effective but is used sometimes for non-AG

38
Q

treatment for metabolic alkalosis

A

Urine Cl >25:
potassium
aldosterone antagonist
acetazolamide

Urine Cl < 25
NS
acetazolamide
HCl if severe

39
Q

normal PaCO2

A

35 to 45 mmHg

40
Q

EtCO2 level to determine if good outcomes can be hoped for after ROSC

A

EtCOS < 10 is a poor prognostic factor after intubation or 20 mins after ROSC

41
Q

longest duration for breaks in chest compressions

A

10 seconds

42
Q

drugs and doses that can be given endotracheal tube

A

NALE
naloxone
atropine
lidocaine
epinephrine

2 - 2.5x the standard dosing

43
Q

targeted temperature management goal temps

A

32 - 36 C for at least 24 hours if still unconscious after ROSC

44
Q

how to treat shivering with TTM

A

preceded, ketamine, opioids, anesthetics, bupsirone, paralytics (use last)

45
Q

effects of TTM on drug metabolism

A

CYP 3A4 and 3A5 are hindered
sites of delivery are hindered (propofol for example)
use bolus dosing in this setting
reduce doses of all sedatives for tx during this time

46
Q

heart effects with TTM

A

bradycardia

47
Q

shifts in electrolytes and glucose during TTM

A

during cooling - hyperglycemia as insulin secretion slows, K-Phos-Mag go low as they seep into the cells

during rewarming - hyperkalemia, hypoglycemia as insulin increases

replace electrolytes slowing so not to overshoot on rewarming and monitor glucose q1h

48
Q

rewarming goal rates

A

increase by 0.25 to 0.5 degrees/hr

49
Q

causes of hypoventilation

A

drug overdose
neuromuscular disease
CPR
CNS injury

50
Q

hypoxemia causes that can lead to respiratory failure

A

pulmonary injury
PNA
pulmonary edema
pulmonary embolus
ARDS

51
Q

2 bets pain scales for ICU and one patient set it is bad for

A

bad if patients have TBI

Behavioral Pain Scale
Critical-Care Pain Observation Tool

52
Q

sedation scales and goals

A

RASS goals 0 to -1
SAS goals 3 to 4

53
Q

morphine opioid highlights

A

prolonged duration of action with renal failure
active metabolites
can cause bronchospasm

54
Q

fentanyl highlights

A

no hypotension or flushing
longer you use it the longer the 1/2 life gets

55
Q

continuous sedation benzos

A

lorazepam can cause propylene glycol toxicity
measure osmolal Gap to monitor
lorazepam preferred due to no metabolites, no effects if renal/hepatic failure or CYP enzymes

midazolam - greater lipophilicity and active metabolites but rapid onset for dressing changes, etc

diazepam - accumulates, rarely used, only used for alcohol withdrawal usually

56
Q

propofol highlights

A

initial dose 5mcg/kg/min titrated by 5 q5 min
avoid >80mcg/kg/min - may develop propofol related infusion syndrome, no loading dose b/c of hypotension usually
no pain control
Monitor:
BP, Triglycerides if over 48 hours

57
Q

propofol related infusion syndrome (PRIS)

A

metabolic acidosis, cardiac failure, arrhythmias, cardiac arrest, rhabdo, hyper-Kalemia, kidney failure

58
Q

Preceded highlights

A

prolonged duration in hepatic failure
usual dose 0.2 - 0.7 mcg/kg/hr depending on intubation or light sedation

59
Q

ketamine highlights

A

has some sedation and analgesia properties
NMDA and partial MU receptors
ADR - HTN, tachy, delirium (30% of pts) treat w/benzos

60
Q

haldol for delirium

A

give 1 - 2.5mg IV in elderly, double dose every 20 minutes until it works
not proven to shorter delirium

61
Q

antipsychotics for delirium

A

measure all for QT prolongation
risperidone and olanzapine have less QTc
haloperidol and risperidone - higher EPS

62
Q

neuromuscular blockade use

A

cisatricurium 15mg x1, then 37.5mg/hr for those on analgesics and sedatives and still not recovering from intubation

can lower intracranial HTN in TBI

should use artificial tears

precedex is not deep enough sedation for nmb

63
Q

who should not receive SC insulin? IV is prefered

A

if they have significant peripheral edema
vasopressors
rapid correction of blood sugar preferred

64
Q

Behavioral Health Pain Score treat score

A

6 or higher means unacceptable pain

65
Q

CPOT score meaning

A

> 3 is unacceptable pain

66
Q

drugs that increase neuromuscular blockade

A

steroids
aminoglycosides
clinda
TCN
polymyxins
CCB
antiarrhthmics
furosemide
lithium

67
Q

drugs that decrease neuromuscular blockade

A

aminophylline
theophylline
carbamazepine
phenytoin

68
Q

electrolytes and neuromuscular blockade

A

low electrolytes increase block

high electrolytes block blockade

69
Q
A
70
Q

when is POC glucose testing least accurate?

A

hypotension
high highs or low lows
anemia
hypoperfusion

71
Q

does POC glucose testing OVER estimate or UNDER estimate levels?

A

over estimate

72
Q

any of these designate SUP by themselves

A

mechanical ventilation x 48 hours
platelets < 50, INR > 1.5 or aPTT x 2 ULN
GI bleed within last one year of admission

73
Q

any 2 of these risk factors would designate SUP

A

spinal cord injury
hypoperfusion
severe burns
organ dysfunction acutely
>250mg/day of hydrocortisone
liver failure causing coagulopathy
transplant
AKI
major surgery
multiple traumas

74
Q

sucralfate can cause what toxicity?

A

aluminum in renal failure

75
Q

H2RA’s for SUP and doses

A

famotidine 20mg IV/PO daily or BID
Nizatidine 150mg PO q12h
cimetidine 300mg q6h PO

76
Q

PPI for SUP and doses

A

omeprazole 20mg daily
esomeprazole 20-40mg PO/IV daily
lansoprazole 30mg PO/IV daily
pantoprazole 40mg PO/IV daily

77
Q

PPI Side effects

A

HA
diarrhea/constipation/ab. pain/nausea
C diff / PNA risk increased

78
Q

H2RA side effects

A

thrombocytopenia
mental status changes
renal function dose adjustments
PNA risk increased

79
Q

epidural access and LMWH

A

can place an epidural 12 hours after last LMWH dose I for VTE

can maintain a catheter with daily dosing

if BID, cannot keep an epidural in

remove catheter at least 10-12H after LMWH dose

80
Q

EN residual volume to start worrying

A

250 - 500 ml residuals

81
Q

DOC to prevent vasospasm after intracranial hemorrhage

A

nimodipine PO 60mg q4h x 21 days

Notes (12 decks)

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