critical care Flashcards
What effect does amiodarone have on serum levels of T3 and T4 in euthyroid patients?
Amiodarone inhibits type 1 and type 2 deiodinase enzymes leading to decreased serum levels of T3 and increased T4, free T4, reverse T3, and TSH.
What is the best test to diagnose a patient with multiple enlarged lymph nodes and several weeks of fevers, night sweats, and weight loss?
The best test is excisional lymph node biopsy.
What are the 4 criteria used to transition to subQ insulin from an insulin drip when treating DKA?
- Anion Gap has closed
- Bicarb > 17
- Appropriate mentation
- Tolerating PO
What are the endocrine complications of immune checkpoint inhibitors?
Endocrine complications include adrenal insufficiency, thyroid disease, and hypophysitis.
What defines sepsis in terms of organ dysfunction?
Sepsis is defined by an increase of ≥2 points in total SOFA score from baseline.
What should be done for a DKA patient when the pH falls below 6.9?
A bicarb drip should be started.
What does a Wells score of <2 indicate?
<2 is low risk for PE.
What does a Wells score of 2-6 indicate?
2-6 is intermediate risk for PE.
What does a Wells score of >6 indicate?
> 6 is high risk for PE.
What is a widely noted cardiac side effect of phenylephrine?
Reflex bradycardia.
What is the initial fluid challenge for patients with sepsis-induced hypoperfusion?
The initial fluid challenge should be at ≥30 mL/kg (~2L in a 70-kg adult).
What is the most appropriate initial anticoagulation therapy for a patient with high risk for bleeding submassive PE?
Unfractionated heparin is preferred over LMWH.
What factors are involved in calculating the SOFA score?
PaO2/FiO2 ratio, platelets, bilirubin, MAP, Glasgow Coma Scale, and creatinine.
What do the 2021 Surviving Sepsis Campaign guidelines recommend regarding IV antibiotics?
Administration of effective IV antibiotics within 1 hour of recognizing sepsis or septic shock.
What should be done if a DKA patient displays hypokalemia?
Potassium must be replaced before starting insulin.
What is the next step if a patient has an intermediate Wells score?
Obtain D-dimer; if less than 0.05, no further imaging is obtained.
What are signs of acute tubular necrosis (ATN)?
Granular casts or muddy brown casts.
What is the safest way to deliver vasopressors?
Through central venous access (internal jugular, subclavian, femoral catheter, or peripherally inserted central catheter).
What is the likely diagnosis for a neutropenic patient with septic necrotic purpuric plaques?
Likely diagnosis is ecthyma gangrenosum.
What are the qSOFA criteria?
- Alteration in mental status (Glasgow Coma Score ≤13)
- Systolic blood pressure ≤100 mm Hg
- Respiratory rate ≥22/min
What is a widely noted adverse effect of norepinephrine?
Peripheral digital ischemia.
What is the mechanism of action of benzodiazepines?
Benzodiazepines stimulate the GABA A receptor.
What is the half-life of diazepam?
The half-life of diazepam is 20 to 120 hours.
What is the most likely etiology for an 81-year-old former smoker with acute on chronic cough and leg edema not responsive to furosemide?
Most likely etiology is COPD exacerbation.
What is the typical adult bolus dose and infusion rate for midazolam?
Typical adult bolus dose is 1 to 5 mg, and an infusion rate of 1 to 5 mg/hr.
What is the most useful diagnostic test to guide antibiotic treatment in a patient with pneumonia?
Lower respiratory tract culture.
What is the most appropriate treatment for asthma exacerbation?
Nebulized duoneb and IV steroids.
What do the 2021 Surviving Sepsis guidelines recommend regarding crystalloid solutions?
Choosing a balanced crystalloid solution, such as lactated Ringer’s, instead of saline.
What is the goal SAS score for mechanically ventilated patients?
The goal SAS score is 3 to 4.
What is the bicarb level threshold?
Bicarb > 17
What indicates appropriate mentation?
Appropriate mentation
What is the most appropriate treatment for asthma exacerbation?
Nebulized duoneb and IV steroids
What do the 2021 Surviving Sepsis guidelines recommend for fluid resuscitation?
Choose a balanced crystalloid solution, such as lactated Ringers, instead of saline.
What is the typical RAS scale goal for mechanically ventilated patients?
Typical goals for mechanically ventilated patients for the RAS scale is -2 to 0.
What is the range of the Richmond Agitation–Sedation Scale (RASS)?
Range of scale is -5 (cannot be aroused) to 4 (combative).
How is sepsis defined in terms of SOFA score?
Organ dysfunction as defined by an increase of ≥2 points in total SOFA score from baseline.
What are the SIRS criteria?
Diagnosed if ≥ 2 of the following 4 criteria are fulfilled:
- Temperature: > 38°C or < 36°C
- Heart rate: > 90/min
- Respiratory rate: > 20/min or PaCO2 < 32 mm Hg
- White blood cell count: > 12,000/mm3, < 4000/mm3, and/or > 10% band cells.
What is the typical bolus dose of lorazepam?
Typical bolus dose is 1 to 4 mg, with an infusion rate of 1 to 5 mg/hr.
Why is it relevant that lorazepam does not have an active metabolite?
Its offset may be more predictable than midazolam or diazepam.
What is the diagnosis for a patient with acute hypoxemic respiratory failure and multifocal pulmonary opacities?
Dx: Pneumonia
What is the first line treatment in hypotonic hypovolemic hyponatremia?
Isotonic fluids
What are the qSOFA criteria?
- Alteration in mental status (Glasgow Coma Score ≤13)
- Systolic blood pressure ≤100 mm Hg
- Respiratory rate ≥22/min.
What is the initial fluid of choice for DKA?
Isotonic saline until the patient’s intravascular volume has been restored.
What should be added to IV fluids in DKA if K is normal?
Potassium to prevent hypokalemia.
What is the recommended blood pressure for patients with diabetes mellitus?
The American Diabetes Association recommends BP < 140/90.
What is the half-life of midazolam?
Midazolam has a half-life of 3 to 11 hrs.
What receptors does norepinephrine act on?
Norepinephrine acts on α1»_space; β1 > β2 receptors.
What is the next step if the Wells score is low?
Stratify using PERC Criteria.
What is the treatment for severe hypercalcemia?
IV bisphosphonates and isotonic saline.
What predisposes a patient taking TNF inhibitors to disseminated histoplasmosis?
Living in the midwestern United States.
What should be done for DKA when blood glucose decreases to approximately 300 mg/dL?
Add dextrose to intravenous (IV) fluid to prevent hypoglycemia.
What is the effect of amiodarone in euthyroid patients?
Can inhibit type 1 and type 2 deiodinase enzymes leading to decreased serum levels of T3 and increased T4.
What is the acceptable increase in serum creatinine after initiation of an ACE-I or ARB?
An increase in serum creatinine up to 30% is acceptable.
What is the first-choice vasopressor in septic shock according to the 2021 Surviving Sepsis Campaign guideline?
Norepinephrine.
What is the treatment for acute decompensated heart failure?
Should be started on IV diuretics, particularly loop, regardless of the renal function.
What should be withheld in treating ATN?
ACE-I or ARBs drugs should be withheld as they interfere with glomerular autoregulation and can lead to hyperkalemia.
What is the typical bolus dose of diazepam?
Typical bolus dose is 1 to 5 mg.
What factors make lymphoma more likely in suspected cases?
Age >40, lymphadenopathy in more than 3 body sites, constitutional symptoms.
What is the Glasgow Coma Scale score indicating severe impairment?
A score of ≤13 indicates severe impairment.
What is the systolic blood pressure threshold for concern?
Systolic blood pressure ≤100 mm Hg.
What respiratory rate is considered a concern?
Respiratory rate ≥22/min.
What is the onset of action for Lorazepam?
Lorazepam has an onset of action of 5 to 20 minutes.
Which patients should ideally avoid bisphosphonates?
Patients with GERD should ideally avoid bisphosphonates.
Which electrolytes should be monitored and replaced if low?
Phosphate and magnesium.
What class of drug is Milrinone?
Milrinone is a phosphodiesterase inhibitor.
What condition is Milrinone typically used for?
Milrinone is typically used in cardiogenic shock.
What does Dopamine act on?
Dopamine acts on D1>B1>A1>A2.
What type of inhibitor is Ipilimumab?
Ipilimumab is a CTLA-4 inhibitor.
What type of inhibitor is Pembrolizumab?
Pembrolizumab is a PD-1 inhibitor.
What type of inhibitor is Avelumab?
Avelumab is a PD-L1 inhibitor.
What class do Pembrolizumab, Avelumab, and Ipilimumab belong to?
All are in the immune checkpoint inhibitor class of drugs.
What is SIRS?
SIRS is diagnosed if ≥ 2 of the following 4 criteria are fulfilled.
What is the temperature criterion for SIRS?
Temperature: > 38°C or < 36°C.
What is the heart rate criterion for SIRS?
Heart rate > 90/min.
What is the respiratory rate criterion for SIRS?
Respiratory rate > 20/min or PaCO2 < 32 mm Hg.
What is the white blood cell count criterion for SIRS?
White blood cell count > 12,000/mm3, < 4000/mm3, and/or > 10% band cells.
What are the criteria for transitioning to subQ insulin from an insulin drip in DKA?
- Anion Gap has closed
- Bicarb > 17
- Appropriate mentation
- Tolerating PO.
What is sepsis?
Sepsis is a severe, life-threatening condition resulting from a dysregulation of the patient’s response to an infection.
What is the GFR threshold for avoiding bisphosphonates?
Bisphosphonates are usually avoided in patients with GFR of less than 35.
