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BCPS > Critical Care > Flashcards

Critical Care Flashcards

1
Q

Hypovolemic Shock

A

GI bleed, hemorrhage

Low CI
Low PCWP
High SVR (reflex)

Treat with fluid resuscitation
Blood products if Hgb <7 or actively bleeding
Pressors if hypotension not improved after fluids

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2
Q

Cardiogenic Shock

A

Acute MI, ADHF, valvular injury

Low CI
High PCWP (impaired blood flow causes congestion)
High SVR (reflex vasoconstriction)

Treat based on acute cardiovascular diseases

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3
Q

Obstructive Shock

A

Massive PE, Tamponade

Low CI
Low PCWP, if tamponade
High PCWP, if massive PE, aortic stenosis)
High SVR

Treat obstruction to reverse shock
PE: thrombectomy or thrombolytics
Tamponade: remove fluid

Fluids & vasopressors may improve symptoms but not outcomes

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4
Q

Distributive Shock

A

Sepsis

Early:
High CI
Low PCWP
Low SVR

Late:
Low CI
High PCWP
Low SVR

Antibiotic & fluid resuscitation in first hour

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5
Q

Sepsis

A

life-threatening end organ dysfunction caused by dysregulated response to infection

Do not use qSOFA as only screening tool

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6
Q

Septic shock

A

subset of sepsis
profound circulatory, cellular, and metabolic abnormalities are associated with greater mortality risk than sepsis alone

criteria: vasopressor need for MAP >65 and lactate > 2 despite fluid resuscitation

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7
Q

Surviving Sepsis Campaign 1 hour bundle

A

1) Baseline lactate
2) Obtain blood cultures prior to antibiotics
3) Administer broad spectrum antibiotics
4) 30mL/kg crystalloid infusion (LR may be > NS)
5) Initiate vasopressors if hypotensive during or after fluids for MAP > 65
6) Reassess if persistent arterial hypotension

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8
Q

Vasopressor extravasation

A

Get central venous access ASAP but may start peripherally to not delay administration

If extravasation occurs, stop immediately and switch to another site

Inject phentolamine (alpha receptor antagonist) around site ASAP to reduce tissue necrosis

Alternatives in shortage: nitroglycerin ointment or SC terbutaline

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9
Q

Vasopressor treatment cascade

A

1) DOC: Norepinephrine
2) Vasopressin may be added if needed at 0.03 units/minute
3) Epinephrine can be added if inadequate MAP on norepi + vasopressin

Alternative: Dopamine
Phenylephrine

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10
Q

Norepinephrine vs Dopamine

A

No difference in 28-day mortality

Dopamine associated with higher risk of arrhythmia, more days on vasopressor therapy, and needed another pressor.

Norepi does not improve mortality but is safer and more effective.

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11
Q

Norepinephrine (dose, receptors, info)

A

0.01-3 mcg/kg/min

alpha&raquo_space; B1
No activity at B2 or DA

Decrease renal perfusion
Increase SVR, MAP
No change or increase CO
May cause peripheral ischemia
Can induce tachyarrhythmia & Myocardial ischemia

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12
Q

Vasopressin (dose, receptors, info)

A

0.03-0.04 unit/min - no titration

No adrenergic activity at alpha, B1, B2, or DA
V1 agonism = peripheral vasoconstriction

No adrenergic activity = effective during acidosis & hypoxia
High dose = coronary vasoconstriction, peripheral necrosis

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13
Q

Epinephrine (Dose, receptors, info)

A

0.04-1mcg/kg/min

alpha&raquo_space;>B1=B2
No activity at DA
low doses = beta adrenergic

Positive inotrope/chronotrope = tachyarrhythmia & myocardia ischemia

May increase lactate (type B lactic acidosis) and blood glucose
May reduce splanchnic circ = gut ischemia

Used in refractory hypotension

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14
Q

Phenylephrine (dose, receptors, info)

A

0.5-8 mcg/kg/min

alpha only (no B1, B2, DA) - minimal cardiac activity

Reduce renal perfusion
Increase SVR, MAP

Primarily used to raise BP. Can rapidly inc SBP, DBP which may cause bradycardia = reduction in CO.

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15
Q

Low dose dopamine (dose, receptors, info)

A

1-3 mcg/kg/min = lower inotropic dose

+/- alpha
+ B1
+/- B2
++++ DA

Causes renal, coronary, mesenteric, and cerebral arterial vasodilation & natriuretic response

Do not use for renal protection. No evidence to support

Complements vasoconstrictive effects of norepi

May induce arrhythmia. May cause endocrine changes.

Immediate precursor to norepi. Prolonged infusion can deplete norepi stores = loss of vasopressor response

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16
Q

Moderate dose dopamine (dose, receptor, info)

A

3-10 mcg/kg/min

+ alpha
++ B1
0 B2
++ DA

May increase contractility and SVR

Can induce arrhythmia. Can cause endocrine changes.

Immediate precursor to norepi. Prolonged infusion can deplete norepi stores = loss of vasopressor response

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17
Q

High dose dopamine (dose, receptors, info)

A

10-20 mcg/kg/min

alpha +++
B1 ++
B2 0
DA +

Vasodilatory effect on renal blood flow may be lost due to predominant alpha1 vasoconstrictive effects

Can induce arrhythmia. Can cause endocrine changes.

Immediate precursor to norepi. Prolonged infusion can deplete norepi stores = loss of vasopressor response

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18
Q

Dobutamine (dose, receptor, info)

A

2-20 mcg/kg/min

B1&raquo_space;> alpha = B2
0 DA

Positive inotrope = increased CO

B2 stimulation = possible hypotension

Higher doses can cause tachyarrhythmia and changes in BP which may cause myocardial ischemia

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19
Q

Milrinone (dose, receptor, info)

A

50 mcg/kg load over 10 min, then 0.375-0.75 mcg/kg/min
*Load often omitted due to increased risk of vasodilation - vasodilation can cause hypotension, arrhythmia

Nonadrenergic
PDE type 3 inhibitor

Positive inotrope = increased CO

Renally adjust

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20
Q

Angiotensin II (dose, receptor, info)

A

10-80 ng/kg/min then 1.25-40 ng/kg/min

Nonadrenergic
Causes smooth muscle contraction & vasoconstriction

Increased thrombotic risks
May cause increased HR, LA, infections, delirium

ACE-I = exaggerated response
ARB = reduced response

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21
Q

Antibiotic cascade in SSC

A

Broad spectrum abx initiated within an hour (septic shock) after 2 sets of blood cultures and other cultures obtained

Each 1 hour delay = increase risk of mortality by 7.6%

Infuse broadest antibiotic first as rapidly as possible

Limit empiric antibiotic to 3-5 days

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22
Q

SSC steroid recommendation

A

Hydrocortisone 200mg/day

Unsure if mortality benefit, but has short term benefits

Do not use corticotropic stimulation test

Initiate when norepinephrine needs of > 0.25mcg/kg/min for at least 4 hours

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23
Q

Ascorbic acid in septic shock

A

Possible anti-inflammatory, antioxidant properties

2021 guidelines recommend against use of ascorbic acid

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24
Q

Metabolic acidosis

A

pH <7.35
pHCO3 <22

Compensation: increase RR to decrease pCO2

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25
Q

Metabolic alkalosis

A

pH > 7.45
pHCO3 > 26

Compensation: decrease RR to increase pCO2

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26
Q

Respiratory acidosis

A

pH < 7.35
pCO2 > 45

Compensation: increase HCO3 (kidneys regulate this)

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27
Q

Respiratory alkalosis

A

pH > 7.45
PCO2 < 35

Compensation: decrease in HCO3 (kidneys regulate this)

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28
Q

Anion gap calculation

A

Na - [Cl + HCO3]

Normal: 6-12
>12: primary metabolic acidosis

For every 1 decrease in albumin less than 4, AG decreases by 2.5-3

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29
Q

Respiratory acidosis causes

A

Think - Decreased respirations

Bronchospasm
Cardiac arrest
CNS depression
PE
Pneumonia
Pulmonary edema
Spinal cord injury
Sedatives
Stroke

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30
Q

Respiratory acidosis treatment

A

Correct cause

Invasive/noninvasive ventilation

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31
Q

Respiratory alkalosis causes

A

Think - increased respirations

Anxiety, pain
CNS tumor
Stroke
Head injury
Hypoxia
Stimulants
Reduced oxygen-carrying capacity
Reduced alveolar oxygen extraction
RR stimulation
Extracorporeal removal

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32
Q

Respiratory alkalosis treatment

A

Correct cause

O2 supplement
Invasive/noninvasive ventilation
Hypoventilation
Sedation

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33
Q

Anion gap metabolic acidosis causes

A

MUDPILES

Methanol
Uremia
DKA
Propylene glycol
Intoxication, infection
Lactic acidosis
Ethylene glycol
Salicylate

34
Q

Non-anion gap metabolic acidosis causes

A

F-USED CARS

Fistula (pancreatic)
Uteroenteric conduits
Saline excess
Endocrine (hyperparathyroid)
Diarrhea
Carbonic anhydrase inhibitors
Arginine, lysine, chloride
Renal tubular acidosis
Spironolactone

35
Q

Metabolic acidosis treatment

A

Correct cause

Base use (sodium bicarbonate) may be considered but controversial

36
Q

Metabolic alkalosis Urine Cl > 25 causes

A

Chloride resistant

Hyperaldosteronism
Increased mineralocorticoid

37
Q

Metabolic alkalosis Urine Cl < 25 causes

A

Chloride responsive

Vomiting
NG suction
Diuretic

38
Q

Metabolic alkalosis Urine Cl > 25 treatment

A

Correct cause

Potassium
Aldosterone antagonist
Acetazolamide

39
Q

Metabolic alkalosis Urine Cl < 25 treatment

A

Correct cause

0.9% NaCl
Consider acetazolamide
Consider HCl if severe

40
Q

Vfib or pulseless Vtach in CPR

A

shock therapy

41
Q

PEA or asystole in CPR

A

epinephrine

42
Q

Med admin in CPR

A

Do not stop compressions

Central venous access preferred

IO > ET administration

Peripheral: follow with 20 ml of IV fluid

43
Q

Meds that can be administered in ET tube

A

ET “LANE” during CPR
2-2.5x IV dose, diluted in 5-10 ml sterile water

Lidocaine
Atropine
Naloxone
Epinephrine

44
Q

General post cardiac arrest care

A
  1. Sao2 >= 94%
  2. Hypotension (SBP <90) treated w/ fluid bolus, pressors
  3. Avoidance of fever
  4. TTM for first 24 hours to 32-37.5 C (0.3-0.5 C every hour)
45
Q

Complications of TTM

A
  1. Shivering
  2. Reduced drug metabolism - use lower doses
  3. Bleeding risk
  4. Dehydration thru renal loss of water
  5. Arrhythmia, hypotension
  6. Hyperglycemia during cooling, hypoglycemia in rewarming
  7. Infection
  8. Hypokalemia/magnesemia/phosphatemia during cooling
46
Q

Meds to reduce shivering

A

Sedatives (precedex, ketamine)
Anesthetics
Analgesics (meperidine, tramadol, fentanyl)
Dexamethasone
Clonidine
Buspirone
Ondansetron
Magnesium

Avoid paralytics

47
Q

Potassium in TTM

A

Decreases during cooling phase

Increases during warming phase due to electrolyte shift

Do not over-replete during cooling.

48
Q

Behavioral Pain Scale (BPS)

A

Use to monitor pain in adults in ICU
Takes into account facial expression, upper limb movements, and compliance with mechanical ventilation

> =6: significant pain

49
Q

Critical Care Pain Observation Tool (CCPOT)

A

Use to monitor pain in adults in ICU

Takes into account facial expression, body movements, muscle tension, compliance with ventilator, and vocalization (if extubated)

> =3: significant pain

50
Q

Richmond Agitation-Sedation Scale (RASS)

A

Assesses quality & depth of sedation
Individualize goal but typically 0 (alert & calm) to -2 (light sedation)

51
Q

Sedation Agitation Scale (SAS)

A

Assesses quality & depth of sedation
Individualize goal but typically 3 (sedated) - 4 (calm & cooperative)

52
Q

Propofol-related infusion syndrome

A

Rates of 80mcg/kg/min for at least 48 hours

Metabolic acidosis, cardiac failure, bradycardia, cardiac arrest, rhabdomyolysis, hyperkalemia, kidney failure

53
Q

Calories from propofol

A

1.1 kcal/mL (in 10% lipid emulsion)

54
Q

Propofol dosing, AE

A

Preferred sedative
5 mcg/kg/min, increase by 5 mcg/kg/min every 5 minutes to achieve certain RASS

Avoid bolus dosing = hypotension

Sedative only, does not provide pain relief.

AE: Respiratory depression (must be intubated), Elevated trigs (stop if 500-800), propofol-related infusion syndrome

55
Q

Dexmedetomidine dosing, AE

A

0.2-0.7 mcg/kg/hr (possible up to 1.5 mcg/kg/hr), max 24 hours

Does not cause respiratory depression (do not need to be intubated)

ADR: bradycardia, hypotension (do not bolus in ICU)

Noninferior to propofol for sedation

Can use clonidine to help wean off

56
Q

Ketamine place in therapy, AE

A

Analgesic & sedative properties
May use w/ opioid in postsurgical patients, no other routine role

hypertension, tachycardia, delirium

57
Q

Lorazepam dosing, ADR

A

1-4mg q2-6 hours

1mg/hr continuous infusion but RISK of proplyene glycol toxicity (“P” in mudpiles)

Preferred in hepatic dysfunction - lack of active metabolites

58
Q

Midazolam dosing, ADR

A

1-4mg q15min - 1 hour or 1mg/hr continuous infusion

May accumulate in renal & hepatic dysfunction, has active metabolites

Must be mechanically ventilated for continuous infusion

59
Q

IV Diazepam place in therapy

A

alcohol withdrawal - long half-life, fast onset

May cause hypotension, thrombophlebitis

60
Q

Analgesia cascade in critically ill

A

1) Opioids are first line therapy for pain
2) May add gabapentin > carbamazepine for nerve pain
3) Tylenol and ketamine can be added for multimodal pain relief, keep doses lower
4) Avoid NSAIDs (risk of bleed, kidney injury in critically ill)
5) Non-benzo > benzo sedatives

61
Q

Delirium

A

Acute change in cognitive function characterized by disorganized though, altered level of consciousness, and inattentiveness

Associated w/ increased mortality, prolonged length of stay in ICU, and cognitive impairment after ICU discharge

Nonpharm&raquo_space;> pharm treatment!

62
Q

Confusion Assessment Method for ICU (CAM-ICU)
Intensive Care Delirium Screening Checklist (ICDSC)

A

Validated delirium screen

CAM-ICU: detect delirium at time of testing
ICDSC: detect delirium during nursing shift

63
Q

Pharm treatment for delirium

A

Haloperidol
Quetiapine
Olanzapine
Ripseridone
Ziprasidone

All have QTc risk, less with olanzapine and risperidone
Atypicals besides risperidone have sedative benefit

Nonpharm preferred

64
Q

Cisatracurium dosing, place in therapy

A

0.1mg/kg load then 2-10 mcg/kg/min

May use in severe ARDS x 48 hours – persistently hypoxemic or risk for ventilator injury

MUST be completely sedated with adequate pain control
Precedex should not be used for sedative

65
Q

Neuromuscular blockade concerns

A

Masks seizure activity
Critical illness poly-neuromyopathy
Masks insufficient analgesia, sedation
Increased risk of VTE
Increased risk of skin breakdown, decubitus
Corneal abrasion due to lack of blinking

66
Q

Paralytics prolonged in renal, hepatic failure

A

Vecuronium
Rocuronium

67
Q

Electrolyte disorders on paralytics

A

Hypermagnesemia, hypocalcemia, hypokalemia: potentiate blockade

Hypercalcemia, hyperkalemia: antagonize blockade

68
Q

Meds that may potentiate blockade

A

Steroids
Antibiotic (aminoglycosides, clinda, tetracycline, polymyxins)
CCBs
Type Ia antiarrhythmics
Furosemide
Lithium

69
Q

Meds that may antagonize blockade

A

Aminophylline
Theophylline
Carbamazepine
Phenytoin

70
Q

Glucose control in ICU

A

Insulin infusion to maintain blood glucose 140-200

Avoid SC insulin if on vasopressor, significant edema, or need for rapid correction

Draw whole blood glucose instead of finger prick

71
Q

Stress ulcer prophlyaxis warranted in these pts

A

Mechanical ventilation for > 48 hours

Plt < 50,000
INR > 1.5
PTT > 2x normal

Recent GI bleed

72
Q

Risk of PPIs for stress ulcer prophylaxis

A

Ventilator-associated pneumonia
Cdiff infection

73
Q

VTE prophylaxis in critically ill

A

LMWH or LDUH better than mechanical or no ppx

Choose pharm or mechanical - not both

LMWH all therapeutically equivalent and less risk of HIT than LDUH

Rivaroxaban approved for medically ill ppx, not critically ill

74
Q

VTE ppx if CrCl < 30

A

Dose adjust LMWH. If <20, avoid

May use dalteparin if <30 due to minimal renal metabolism

Avoid fondaparinux

LDUH safe to use in reduced kidney function

75
Q

VTE ppx in major trauma

A

Enoxaparin 30mg q12h

76
Q

Caloric requirements in critically ill

A

non obese: 12-25 kcal/kg ABW
BMI >30: 11-14 kcal/kg ABW

77
Q

Protein requirements in critically ill

A

nonobese: 1.2-2 g/kg ABW
BMI >30: 2-2.5 g/kg IBW

78
Q

Glasgow Coma Scale

A

Assesses level of consciousness

Higher the score = more conscious
15 is highest score

79
Q

ICH Blood pressure control

A

If SBP 150-220, lower to 140 using nicardipine or clevidipine (or other IV titratable agent)

80
Q

Aminocaproic acid

A

Antifibrinolytic therapy recommended if delay of 72 hrs to intervention for intracranial hemorrhage

4-5g load followed by 1g/hr

Preferred over TXA

Monitor VTE

81
Q

Vasospasm prevention in aneurysmal SAH

A

Nimodipine 60mg q4H for 21 days. May cause hypotension.

82
Q

Types of intracranial hemorrhage

A

Intraparenchymal hemorrhage
Subarachnoid hemorrhage (worst headache of life)
Subdural hematoma
Epidural hematoma

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