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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
respiratory compensation shift
blood that is pH < 7.35 will result in an increased respiratory rate to get rid of more CO2 and raise the pH
26
acidosis/alkalosis and the respiratory/urinary response
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
27
differentiate b/w metabolic or respiratory alkalosis/acidosis
pH <7.35: pCO2 elevated is respiratory, bicarb is low its metabolic pH >7.45: pCO2 decreased is respiratory, bicarb is high its metabolic
28
Anion Gap Calculation
Sodium - Chloride - Bicarb
29
Anion Gap Normal Range
6 - 12 meq/L
30
what causes respiratory acidosis?
PE pulmonary edema over-sedation, CNS depression stroke PNA bronchospasm spinal cord injury
31
what causes respiratory alkalosis?
stimulants anxiety pain head injury decreased O2 carrying in blood reduced alveolar O2 extraction respiratory rate extracorporeal removal hyperventilation
32
metabolic acidosis with anion Gap causes
MUDPILES methane uremia DKA propylene glycol intoxication/infection lactic acidosis ethanol salicylate
33
metabolic acidosis without anion Gap causes
F-USED CARS fistula (pancreatitis) uteroenteric conduits saline excess endocrine (hypo-parathyroid) diarrhea carbonic anhydrase inhibitors arginine, lysine, Cl renal tubular necrosis spironolactone
34
metabolic alkalosis causes
Urine Cl >25: hyperaldosteronism high mineralocorticoid urine Cl <25: vomiting NG suction diuretic
35
treatment for respiratory acidosis
ventilation correct causet
36
treatment for respiratory alkalosis
slow breathing sedation ventilation oxygen
37
treatment for metabolic acidosis
treat cause bicarb not as effective but is used sometimes for non-AG
38
treatment for metabolic alkalosis
Urine Cl >25: potassium aldosterone antagonist acetazolamide Urine Cl < 25 NS acetazolamide HCl if severe
39
normal PaCO2
35 to 45 mmHg
40
EtCO2 level to determine if good outcomes can be hoped for after ROSC
EtCOS < 10 is a poor prognostic factor after intubation or 20 mins after ROSC
41
longest duration for breaks in chest compressions
10 seconds
42
drugs and doses that can be given endotracheal tube
NALE naloxone atropine lidocaine epinephrine 2 - 2.5x the standard dosing
43
targeted temperature management goal temps
32 - 36 C for at least 24 hours if still unconscious after ROSC
44
how to treat shivering with TTM
preceded, ketamine, opioids, anesthetics, bupsirone, paralytics (use last)
45
effects of TTM on drug metabolism
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
heart effects with TTM
bradycardia
47
shifts in electrolytes and glucose during TTM
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
rewarming goal rates
increase by 0.25 to 0.5 degrees/hr
49
causes of hypoventilation
drug overdose neuromuscular disease CPR CNS injury
50
hypoxemia causes that can lead to respiratory failure
pulmonary injury PNA pulmonary edema pulmonary embolus ARDS
51
2 bets pain scales for ICU and one patient set it is bad for
bad if patients have TBI Behavioral Pain Scale Critical-Care Pain Observation Tool
52
sedation scales and goals
RASS goals 0 to -1 SAS goals 3 to 4
53
morphine opioid highlights
prolonged duration of action with renal failure active metabolites can cause bronchospasm
54
fentanyl highlights
no hypotension or flushing longer you use it the longer the 1/2 life gets
55
continuous sedation benzos
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
propofol highlights
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
propofol related infusion syndrome (PRIS)
metabolic acidosis, cardiac failure, arrhythmias, cardiac arrest, rhabdo, hyper-Kalemia, kidney failure
58
Preceded highlights
prolonged duration in hepatic failure usual dose 0.2 - 0.7 mcg/kg/hr depending on intubation or light sedation
59
ketamine highlights
has some sedation and analgesia properties NMDA and partial MU receptors ADR - HTN, tachy, delirium (30% of pts) treat w/benzos
60
haldol for delirium
give 1 - 2.5mg IV in elderly, double dose every 20 minutes until it works not proven to shorter delirium
61
antipsychotics for delirium
measure all for QT prolongation risperidone and olanzapine have less QTc haloperidol and risperidone - higher EPS
62
neuromuscular blockade use
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
who should not receive SC insulin? IV is prefered
if they have significant peripheral edema vasopressors rapid correction of blood sugar preferred
64
Behavioral Health Pain Score treat score
6 or higher means unacceptable pain
65
CPOT score meaning
>3 is unacceptable pain
66
drugs that increase neuromuscular blockade
steroids aminoglycosides clinda TCN polymyxins CCB antiarrhthmics furosemide lithium
67
drugs that decrease neuromuscular blockade
aminophylline theophylline carbamazepine phenytoin
68
electrolytes and neuromuscular blockade
low electrolytes increase block high electrolytes block blockade
69
risk factors for SUP in ICU patients
1 of the following: intubated Plt <50, INR >1.5 Head/spinal injury low gastric pH GI bleed history major surgery (>4 hours) 2 of the following: ICU > 7 days sepsis occult bleeding high dose steroids hepatic failure renal insufficiency hypotension anticoagulation
70
when is POC glucose testing least accurate?
hypotension high highs or low lows anemia hypoperfusion
71
does POC glucose testing OVER estimate or UNDER estimate levels?
over estimate
72
any of these designate SUP by themselves
mechanical ventilation x 48 hours platelets < 50, INR > 1.5 or aPTT x 2 ULN GI bleed within last one year of admission
73
any 2 of these risk factors would designate SUP
spinal cord injury hypoperfusion severe burns organ dysfunction acutely >250mg/day of hydrocortisone liver failure causing coagulopathy transplant AKI major surgery multiple traumas
74
sucralfate can cause what toxicity?
aluminum in renal failure
75
H2RA's for SUP and doses
famotidine 20mg IV/PO daily or BID Nizatidine 150mg PO q12h cimetidine 300mg q6h PO
76
PPI for SUP and doses
omeprazole 20mg daily esomeprazole 20-40mg PO/IV daily lansoprazole 30mg PO/IV daily pantoprazole 40mg PO/IV daily
77
PPI Side effects
HA diarrhea/constipation/ab. pain/nausea C diff / PNA risk increased
78
H2RA side effects
thrombocytopenia mental status changes renal function dose adjustments PNA risk increased
79
epidural access and LMWH
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
EN residual volume to start worrying
250 - 500 ml residuals
81
DOC to prevent vasospasm after intracranial hemorrhage
nimodipine PO 60mg q4h x 21 days

Notes (14 decks)

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