Critical Care Flashcards
1
Q
what does FAST stand for in FASTHUGSBID
A
feeding
analgesia
sedation
thromboembolism prophy
2
Q
what does HUGS stand for in FASTHUGSBID
A
head of bed
ulcer prophy
glycemic control
spontaneous breathing trial
3
Q
what does BID stand for in FASTHUGSBID
A
bowel regimen
indwelling catheters
de-escalate abx
4
Q
which analgesics are commonly used in the icu
A
fentanyl, hydromorphone, morphine, oxycodone
5
Q
which 2 agents are preferred for sedation in the icu
A
propofol
dexmedetomidine
6
Q
how many times is FASTHUGS applied
A
twice daily
7
Q
when should thromboembolism prophy be given in the ICU? preferred agents?
A
ALL PATIENTS
enoxaparin, unfractionated heparin (if renal dysfunction)
8
Q
what is head of bed for? what is maintained?
A
maintain head of bed at 30-45 degrees for VAP prophy
9
Q
major risk factors for ulcers in the icu
A
mech vent >48 hours
or based on coagulopathy
10
Q
minor risk factors for ulcer in icu
A
drugs, shock/sepsis/hypotension, hepatic/renal failure, multiple trauma, burns, organ transplant, history of upper GI bleed or PUD
11
Q
which agents are used for ulcer prophy in icu?
A
ppis or h2ras
12
Q
where should blood glucose be maintained in icu
A
140-180 mg/dl
13
Q
what is spontaneous breathing trial
A
daily to assess readiness to extubate
14
Q
typical diagnosing factors for DKA
A
gluc >300
bhb>3 mmol/L or ketone 2+
ph <7.3 or bicarb <18 mmol/L
15
Q
typical diagnosing factors for HHS
A
glucose >600
osmolality >300 mosm/kg
NO KETONES OR ACIDOSIS
16
Q
which hyperglycemic crisis has NV and abdominal pain?
neurologic manifestations?
A
nv, abd —- DKA
neuro —- HHS
17
Q
what is BG in euglycemic DKA? common cause?
A
BG <200, SGLT2 use
18
Q
initial fluid management for hyperglycemic crisis
A
500-1000 mL/hr for 2-4 hours
19
Q
when do you switch to D5W or D10W for hyperglycemia fluids?
what about euglycemic dka?
A
when BG reaches 250 mg/dL
euglycemic- start dext w/ crystalloid when starting insulin
20
Q
initial insulin dose for mild DKA
A
0.1 U/kg rapid act SQ bolus
then
0.1 U/kg QH or 0.1U/kg Q2H
21
Q
initial insulin dose for mod/sev DKA
A
0.1U/kg short act IV bolus
then
0.1 U/kg/hr IV infusion
22
Q
initial insulin dose for HHS
A
0.05 U/kg/hr short act IV infusion
23
Q
goal BG for DKA on insulin
A
150-200 mg/dL until parameters normal
24
Q
goal BG for HHS on insulin
A
200-250 mg/dl until parameters normal
25
when should the insulin infusion be decreased for dka/hhs
when bg <200 DKA and <250 HHS
26
what should insulin infusion be decreased to when goal BG is reached
0.05 u/kg/hr
27
weight based estimate of SQ insulin when switching from IV
0.5-0.6 U/kg/day TDD
28
treatment in hyperglycemia when K<3.5
hold insulin
replete K at 10-20 meq/hr until k>3.5
29
treatment in hyperglycemia when K 3.5-5
10-20 meq K given with every L of fluid
30
treatment of hyperglycemia when k>5
do not give K until falls below ULN
31
when is bicarb indicated for hyperglycemia
ph <7
32
when is phosphate indicated in hyperglycemia
cardiac dysfunction, respiratory depression, phos <1 mg/dl
33
what are the 2 SHOCKABLE rhythms
pulseless ventricular tachycardia
ventricular fibrillation
34
what are the 2 NON-SHOCKABLE rhythms
asystole
pulseless electrical activity
35
general algorithm for shockable ACLS
2 shocks -- epi - shock - ami
following 2 min CPR cycles
epi every 3-5
36
general algorithm for nonshockable acls
epi immediately then every 3-5 mins
following 2 min CPR cycles
37
5 meds that can be given via endotracheal tube
naloxone
atropine
vasopressin
epinephrine
lidocaine
38
3 antiarrhythmics for acls
which is 1st line
amiodarone****
lidocaine
magnesium
39
dose of amiodarone in acls
300 mg IV bolus
redose at 150 mg
40
AEs of amiodarone
hypotension, bradycardia
41
when can lidocaine be considered in acls
2nd line
consider if torsades due to minimal QTC prolonging risk
42
dose of lidocaine in acls
1-1.5 mg/kg IV/IO
redose at 0.5-0.75 mg/kg every 5-10 mins
43
when is magnesium used in ACLS
VF/pVT associated with torsades
44
H's of cardiac arrest (5)
hypovolemia
hypoxia
hydrogen ions
hyperkalemia
hypothermia
45
how to treat hypovolemia causing ACLS
isotonic fluids
46
2 options for hyperkalemia in ACLS
calcium chloride
sodium bicarbonate
47
5 Ts of cardiac arrest
toxins
cardiac tamponade
tension pneumothorax
coronary thrombosis
pulmonary thrombosis
48
5 major parameters of hemodynamics
BP
cardiac output
stroke volume
systemic vascular resistance
MAP
49
MAP =
1/3 SBP + 2/3 DBP
50
shock is characterized by SBP
<90 mmhg
50
treatment goals for shock
MAP >65 mmHg
lactate < 2 mmol/L
UOP >0.5 ml/kg/hr
improved mental
SVO2 >65%
SCVO2>70%
51
3 invasive monitoring types for shock
central venous catheter
pulmonary artery catheter
arterial line
52
what does CVC measure for shock?
SCVO2
53
what does PAC measure in shock
PCWP, cardiac output, SCO2, SVR
54
what does arterial line measure in shock
MAP, SBP/DBP, arterial blood gas
55
shock state
inappropriately low and sudden loss of intravascular volume
hypovolemic
56
what is happening in circulatory system during HYPOVOLEMIC SHOCK
dec preload -> dec CO -> compensate inc SVR
57
management of hypovolemic shock
replace source of loss
58
Shock state
failure of the LV to deliver blood due to impaired stroke volume or HR
cardiogenic
59
what is happening in circulatory system during CARDIOGENIC shock
fail to empty LV -> dec CO and inc preload -> compensate inc SVR
60
primary cause of cardiogenic shock
acute MI
61
shock state
pronounced vasodilation
distributive shock
62
what is happening in circulatory system during DISTRIBUTIVE SHOCK
vasodilation reduces SVR -> reduced volume back to heart -> dec preload -> compensate inc HR to maintain CO
63
main cause of distributive shock
septic shock
64
shock state
result of critical decrease in LV stroke volume or increase in LV outflow obstruction
obstructive shock
65
what is happening in circulatory system during OBSTRUCTIVE SHOCK
dec LV stroke volume -> dec CO and tissue perfusion -> inc afterload in attempt to compensate
66
main cause of obstructive shock
pulmonary embolism
67
fluids used for shock
crystalloids 30 ml/kg over 15-30 mins then 10 ml/kg boluses
68
when are vasoactive agents initiated for shock?
when MAP is still <65 mmHg despite fluids
69
MOA of norepinephrine
alpha agonist, increases MAP via peripheral vasoconstriction
70
1st line vasopressor for shock
norepinephrine
71
MOA of epinephrine
alpha & beta agonist, increase stroke volume and HR
72
when is epinephrine used for shock
secondary choice
good for anaphylactic shock
73
how could using epinephrine for shock alter monitoring of treatment
increase aerobic lactate production
cannot use lactate to monitor therapy
74
dopamine's action as a vasopressor is what?
dose dependent
75
when is dopamine used as a vasopressor
last line
most effective in hypotensive patients with depressed cardiac function
76
MOA of phenylephrine?
what is a potential effect?
alpha 1 agonist- potential reflex bradycardia
77
when is phenylephrine used as a vasopressor
not recommended for septic shock
unless tachyarrhythmias from NE, CARDIAC OUTPUT IS HIGH & BP IS PERSISTENTLY LOW, or as salvage therapy
78
when is vasopressin used for shock
to reduce concurrent vasopressor doses, never alone
79
MOA of dobutamine
inotrope, acts at B1
80
risk associated with use of angiotensin II (Giapreza)
thromboembolism
80
when is dobutamine added for shock
when CO or SCO2/SCVO2 goals have not been met with vasopressor therapy
81
2 scales used to identify sepsis
qSOFA bedside score
SIRS criteria
82
sepsis according to qSOFA is 2 of the following
SBP <100 mmhg
RR >22 breaths/min
altered mentation
83
sepsis according to SIRS criteria is at least 2 of the following
temp >38 or <36
HR >90 bpm
RR >20 breaths/min
WBC >12 x10^9/L or <4x10^9/L
84
if shock is present with sepsis, when should antibiotics be given
within 1 hour
85
risk factors indicating need for MRSA coverage in sepsis
hx of mrsa infection, recent iv abx, hx of recurrent skin infections, invasive devices, hemodialysis, recent hosp admiss, severity of illness
86
risk factors indicating 2 agents for MDR gram neg organisms in sepsis
proven colonization with resistant organisms in last year, broad spect IV abx last 90 days, travel to endemic country last 90 days, local prevalence, hospital acquired infection
87
2 trials showing no difference between albumin and crystalloid for sepsis
SAFE trial
ALBIOS trial
88
1st line vasopressor for shock?
added next?
1 norepinephrine
2 vasopressin
89
what can be added for sepsis after poor response to fluids and vasopressors
hydrocortisone +/- fludrocortisone
90
3 opioids used for analgesia
morphine
fentanyl
hydromorphone
91
onset & duration
morphine
on 5-10 min
dur 3-6 hr
92
onset & duration
fentanyl
on seconds
dur 1-2hr
93
onset & duration
hydromorphone
on 5 mins
dur 2-4 hrs
94
when might morphine accumulate
renal impairment, has active metabolite
95
possible AEs associated with histamine release with morphine
hypotension, bronchospasm, urticaria
96
how is fentanyl metabolized
hepatic
97
con of using fentanyl
tachyphylaxis
98
3 pros of hydromorphone
good if renal imp
option if fentanyl tolerance
available as PCA
99
target RASS for light sedation?
deep sedation for paralytics?
0 to -2 light
-3 to -5 deep
100
4 sedative options for ICU
propofol
dexmedetomidine
benzos
ketamine
101
does propofol provide analgesia
no
102
onset & duration
propofol
on <1 min
dur 10-15 min
103
onset & duration
midazolam
on 2-5 min
dur 1-2 hr
104
onset & duration
lorazepam
on 5-20 min
dur 2-6 hr
105
onset & duration
diazepam
on 5-10 min
dur t1/2 of 44-100 hrs
106
3 benzo options for sedation
midazolam, lorazepam, diazepam
107
which sedative is good for EtOH withdrawal and provides 1.1 kcal/ml of nutrition
propofol
108
AEs of propofol
resp depression, hypotension, bradycardia, decreased CO
109
2 monitoring parameters for propofol
TGs
PRIS
110
AEs of dexmedetomidine
bradycardia, hypotension, drug induced fevers
111
which sedative has no resp depression, effects like natural sleep, is opioid sparing, and titratable
dexmedetomidine
112
does dexmedetomidine provide analgesia
yes
113
which sedative CANNOT achieve RASS < -3
dexmedetomidine
114
possible cons for using dexmedetomidine for extended time
withdrawal, drug tolerance, tachyphylaxis
115
which BZD is lipophilic with active metabolites that can accumulate in renal impairment
midazolam
116
which BZD can be used in renal/hep failure, but may cause propylene glycol acidosis
lorazepam
117
can continuous drips of BZDs be used for sedation?
NO
reserved 1st line for status epilepticus, extreme alcohol withdrawal, severe ARDs
118
does ketamine provide analgesia
yes dose dependent
pain ---> anesthesia
119
AEs of ketamine
emergence rxn, oral secretions, tachycardia, HTN
120
3 pros of using ketamine
favorable hemodynamics
bronchodilator
opioid sparing
121
modifiable risk factors for delirium
benzo use, blood transfusions
122
major con of NMBs and point to be aware of
pt CANNOT COMMUNICATE!!!
deep sedation needed
123
monitoring for NMB use
train of 4 --> 2 twitches goal
124
which 3 options best for deep sedation (-4 to -5)
propofol, ketamine, benzo drip
125
3 non-depolarizing NMBs
can be used as drip
cisatracurium
rocuronium
vecuronium
126
onset & duration
cisatracurium
on 2-5 min
dur 30-90 min
127
onset & duration
rocuronium
on 1-2 min
dur 3-60 min
128
onset & duration
vecuronium
on 3-5
dur 45-60 min
129
depolarizing NMB
not used as drip
succinylcholine
130
onset & duration
succinylcholine
on 30-60 sec
dur 5-10 min
131
precautions for succinylcholine use
malignant hyperthermia
hyperkalemia
132
3 agents for rapid sequence intubation PRETREATMENT
lidocaine, fentanyl, midazolam
133
4 agents for rapid sequence intubation INDUCTION
midazolam, etomidate, ketamine, propofol
134
3 agents for rapid sequence intubation PARALYSIS
rocuronium, vecuronium, succinylcholine
135
onset & duration
etomidate
on 30-60 sec
dur 2-5 min
136
pro of etomidate
hemodynamic stability
137
cons of etomidate
pain with injection, relative adrenal insufficiency
138
what is a key thing to remember if using etomidate to intubate
ADD A SEDATIVE AFTER INTUBATION!!!
139
2 benzos used for alcohol withdrawal? other option?
lorazepam, diazepam, phenobarbital
140
what is general treatment for stroke WITHIN 4.5 HOURS of onset
fibrinolytics +/- thrombectomy
141
permissive HTN allowed if excluded from fibrinolytics up to what BP?
what anti-HTN agents are used?
220/110
1- labetalol, nicardipine
2- hydralazine, enalaprilat, clevidipine
142
BP requirements for bolus fibrinolytics
<185/110
143
BP requirements for infusion fibrinolytics
<180/105 mmHg
144
2 complications of fibrinolytic therapy
symptomatic intracranial hemorrhage
angioedema
145
contraindications to fibrinolytic (so many)
<18 yo, ischemic stoke w/in 3 mos, intracranial/spinal surgery in 3 mos, GI malignancy/bleed last 21 days, LMWH last 24 hrs, infective endocarditis, unclear onset time, onset >4.5 hr, current intracranial hemorrhage, severe head trauma last 3 mos, subarachnoid hemorrhage, platelet <100,000, INT >1.7, aPTT >40s, DOAC last 48 hrs, aortic arch dissection
146
how is alteplase admin
bolus 10% over 1 min then infusion 90% over 60 min
147
admin of tenecteplase
iv push over 5-10 sec
148
main meds used post-stroke
HD statin, ASA (possible DAPT), DVT prophylaxis, anticoagulation if cardioembolic
149
potential risks that provoke seizure (7)
intoxication, withdrawal, trauma, meningitis, psychiatric, metabolic derangements, non-compliance
150
1st line used in first 0-5 mins of a seizure
lorazepam or diazepam IV
alt- midazolam IM or diazepam PR
151
what is given in the 5-30 min window of seizing?
initial ASM- levetiracetam, phenytoin, valproic acid, lacosamide, phenobarbital
152
target phenytoin levels
10-20 mcg/dl, 15-25 ok if seizing
153
key PK points about phenytoin
michaelis menten
highly protein bound
154
what is done in 30-60 min window of a seizing if RESPONSIVE? UNRESPONSIVE?
responsive --> 2nd ASM
unresponsive --> propofol, midazolam, ketamine
155
what is done if a seizure is refractory
rebolus or add ASM, add phenobarb or ketamine, add additional anesthetic, boost current anesthetic
156
goal of treating status epilepticus
burst suppression on the LTM for 24-48 hours then titrate off IV infusions
