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Critical Care Flashcards

1
Q

Size of ET tube for adult

A
  1. 0-8.5 mm male
  2. 5-8.0 mm female
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2
Q

Sizes of Mac + Miller blades for adults

A

Mac: #3 avg, #4 for large

Miller: #2 avg, #3 large

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3
Q

Correct placement of ETT

A

Cuff passes vocal chords

Tip of tube 2cm above carina

Base of pilot tube usually at the teeth

23 cm at teeth men, 21 cm women

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4
Q

How much air to inflate ETT tube balloon with

A

5 cc

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5
Q

Intubation dose Etomidate

Onset

Duration

Side-effects

A

Dose: 0.3 mg/kg (LBW dosing)

Onset: 15-45 s

Duration: 3-12 min

Side-effects: myoclonic jerking, seizures, vomiting

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6
Q

RSI dose Rocuronium

Onset

Duration

Side-effects

A

1 mg/kg

Onset: 60 s

Duration: 40-60 min

Side-effects: tachycardia

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7
Q

RSI dose Propofol

Onset

Duration

Side-effects

A

1.5 mg/kg

Onset 20-40s

Duration 8-15 min

Side effects: Apnea, hypotension

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8
Q

RSI Dose Ketamine

Onset

Duration

Side-effects

A

1-2 mg/kg

Onset 1 min

Duration 10-20 min

Side-effects: increased secretions, hypertension, emergence reaction, laryngospasm, not recommended in pregnancy

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9
Q

Succinylcholine RSI Dose

Onset

Duration

Complications

A

1.5 mg/kg (4 mg/kg IM)

Onset: 45-60 s

Duration: 6-10 min

Hyperkalemia: mostly from upregulation of Ach receptors, starts 5 days after insult (burn, demyelinating disorder, myopathy, stroke, crush injury, severe infection), and lasts 3-6 months and until healed. If hyperK present for other reason (e.g. CKD), may still give sux if no ECG changes (expected rise is ~0.5-1 mEq).

Malignant Hyperthermia: fevers, acidosis, rigidity.

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10
Q

How to perform nasotracheal intubation?

A

1) Lidcaine spray nostrils
2) ETT 0.5-1.0 mm smaller
3) Sitting, sniffing, bevel towards septum, advance, rotate medially ~30deg until max airflow heard then swiftly advance at initiation of respiration. Pt may cough. Any vocal sounds means failed attempt.
4) 28 cm at nares men 26 cm women

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11
Q

Mallampati Score

A


Class I: soft palate, uvula, fauces, pillars visible
Class II: no pillars
Class III: base of uvula
Class IV: only hard palate

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12
Q

ACLS Tachycardia Algorithm

A
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13
Q

ACLS Bradycardia Algorithm

A

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14
Q

ACLS Arrest Algorithm

A

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15
Q

ACLS Post-Arrest Care Checklist

A

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16
Q

LEMON - Difficult Laryngoscopy

A
  • *L**ook (gestalt)
  • *E**valuate (3-3-2 rule)
  • *M**allampati
  • *O**besity/obstruction
  • *N**eck mobility
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17
Q

MOANS - Difficult BVM

A
  • *M**ask seal/male sex/mallampati
  • *O**besity/obstruction
  • *A**ge >55
  • *N**o teeth
  • *S**tiff/snoring
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18
Q

RODS - Difficult EGD

A
  • *R**estricted mouth opening
  • *O**besity/obstruction
  • *D**isrupted/distorted anatomy
  • *S**tiff
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19
Q

SMART - Difficult Cricothyrotomy

A
  • *S**urgery
  • *M**ass
  • *A**ccess/anatomy
  • *R**adiation
  • *T**umor
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20
Q

6 P’s of RSI

A
  • *P**reparation
  • *P**retreatment
  • *P**reoxygenation (3 minutes @ 100% FiO2 or 8 vital capacity breaths @ 100% FiO2) + Nasal Cannula @ 6 LPM
  • *P**aralysis with induction
  • *P**ositioning
  • *P**lacement with proof
  • *P**ost-intubation care
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21
Q

Pretreatment Agents for RSI

A
  • Lidocaine:* 1.5 mg/kg
  • Fentanyl:* 3 mcg/kg IV over 30-60 seconds

Asthma - Lidocaine
Brain (IICP) - Lidocaine + Fentanyl
Circulation (CV patients susceptible to sympathetic surge) - Fentanyl
Consider Atropine in infants (<1 year of age)

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22
Q

ETT Size for Kids

A

4 + age/4 (uncuffed), 3.5 + age/4 (cuffed)

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23
Q

ETT insertion depth

A

Tube size X 3 (at the lips)

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24
Q

Cormack-Lehane Grading

A

Grade 1: all structures of glottis visible
Grade 2a: Only part of cords visible
Grade 2b: Only posterior structures visible
Grade 3: Only lip of epiglottis visible
Grade 4: No glottic structures visible

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25
Q

Definition of a Failed Airway

A

Definition of a Failed Airway: any of i) failure of an intubation attempt in a patient who is unable to be oxygenated with BVM (CICO), ii) 3 attempts by an experienced intubator, iii) failed intubation in the forced to act situation (although oxygenation may be possible).

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26
Q

FiO2 with different devices

A

NP @ 2-4 L: 30-35%
Mask @ 6-10L: 45-55%
NRB@ 10-15L: 70%
BVM with good seal and resevoir @ 10-15L: 100% (must have one-way exhalation valve)

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27
Q

BiPap Settings

A

Start 8/3 IPAP/EPAP, keep IPAP 5 points greater than EPAP
Keep EPAP <8-10 cm H20 in COPD

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28
Q

ETCO2 in Cardiac Arrest

A
  • Qualitative ETCO2 has 25% false negative rate
  • <10mm Hg means poor CPR
  • abrupt increase to 30 mm Hg may mean ROSC (venous bicarb may cause transient rise)
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29
Q

OPA Sizing

A

Mouth to (angle of) Mandible, 8-10 cm for most adults

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30
Q

NPA Sizing

A

Tip (of nose) to Tragus, 6-8 mm for most adults

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31
Q

Prep for flexible endoscopy (airway)

A

Glycopyrrholate 0.01 mg/kg IM or IV 10-20 minutes pre-procedure to reduce secretions and enhance effect of topical anesthesia

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32
Q

Surgical Airway In Children

A

If <10 years old, do not attempt Cric (membrane too small), use needle tracheotomy with BMV ventilation

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33
Q

Cricothyrotomy

No Drop Open Technique

A

1) Prep (#4 cuffed tube will work for most patients)
2) If awake - infiltrate 1% lidocaine and spray some in trachea to suppress cough
3) Left hand immobilize larynx
4) 2 cm vertical midline skin incision
5) Re-identify membrane
6) Insise cricothyroid membrane (horizontal incision) at lower pole
7) Insert hook above scalpel - assistant holds traction upwards
8) Remove scalpel, insert Trousseau dilator, dilate vertically
9) Insert tracheostomy tube, rotate dilator counter-clockwise to help insertion

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34
Q

Cricothyrotomy

Seldinger Technique

A

1) Prep
2) Insert needle caudally, aspirating for air
3) Insert guidewire
4) Cut skin with scalpel
5) Insert dilator and tracheostomy tube as one unit
6) Remove dilator

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35
Q

Cricothyrotomy

Bougie Technique

A

1) Scalpel, Bougie, 6-0 ETT
2) Locate Cricothyroid membrane
3) Cut (any way)
4) Bougie until stops
5) ETT until balloon past incision
6) Ventilate

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36
Q

Percutaneous Transtracheal Ventilation

A

Percutaneous Transtracheal Ventilation

Equipment:

  • 12-16g angiocath attached to 20 mL syringe, may add 15 deg bend at end
  • 3.0-3.5 ETT adapter connected to 3-4” IV tubing

Procedure:

1) Insert needle into trachea at 30 deg angle aspirating for air
2) Advance catheter over needle
3) Connect IV tubing with ETT connector and BVM

37
Q

Universal Difficult Airway Algorithm

38
Q

Emergency Medicine Difficult Airway Algorithm

39
Q

Difficult Airway Algorithm

40
Q

Failed Airway Algorithm

41
Q

Crash Airway Algorithm

42
Q

ALCAPA (anomalous left coronary artery from the pulmonary artery) syndrome

A

ALCAPA (anomalous left coronary artery from the pulmonary artery) syndrome

LCA compressed between main pulmonary artery and aorta, especially during increased venous return (e.g. exercise). Dx Cardiac MRI/CT. Tx surgical.

43
Q

Catecholaminergic Polymorphic Ventricular Tachycardia (CPVT)

A

Catecholaminergic Polymorphic Ventricular Tachycardia (CPVT)

exercise/stress related vtach, syncope. Many have sinus brady on ECG. Starts early adulthood/childhood. Tx BB, ICD if syncope.

44
Q

Cardiac output =

A

CO = HR x SV

45
Q

MAP =

A

MAP = CO x SVR

MAP = [(2 x DBP) + SBP]/3

46
Q

Shock Index

A

SI = HR/SBP

Normal is 0.5-0.7

Persistent > 1 signifies LV dysfunction and high mortality

47
Q

Intravascular Volumes

A

7% IBW

~5L blood

2L RBC

3L Plasma

48
Q

Concentration Na and Cl in normal saline and Osm

A

154 mmol/L Na+

154 mmol/L Cl-

Osm 308 mOsm/L

49
Q

Na & Cl concentrations in LR and Osm

A

130 Na+

109 Cl+

Osm 273 mOsm/L

50
Q

Glucagon Dose for Anaphylaxis

(Refractory Hypotension on BB)

A
  • Adults: 1 milligram IV every 5 min until hypotension resolves, followed by 5–15 micrograms/min infusion
  • Peds: 20-30 mcg/kg over 5 min, max 1 mg, followed by infusion of 5-15 mcg/min.
51
Q

Go to Drug for ACEI or Hereditary Angioedema

A

Icatibant 30 mg subcut x 1

52
Q

Alternative blood product for hereditary angioedema

A

FFP 2-3 units

53
Q

Glucagon Dose for bradycardia secondary to BB or CCB overdose

A
  • Glucagon 3–10 milligrams IV infused over 1–2 min, followed by an IV continuous infusion of
    • 1–5 milligrams/h
    • s/e: NxVx
54
Q

Dopamine/Epi Infusion for bradycardia

A
  • Dopamine 2-10 mcg/kg/min
  • Epi 2-10 mcg/min
55
Q

Therapeutic Hypothermia

A
  • for Vfib/Vtach arrest, but also consider for PEA/asystole
  • not for trauma/bleeding or awake/alert patients
  • anticoagulation not a contraindication
  • Procedure
    • Lower T to 32-36 deg C within 4-6 h after ROSC
    • Ice packs to axillae, neck, groin
    • Intravascular cooling
    • 30 mL/kg NS at 4 deg C over 30 min
    • Intubate and ventilate, central line, art line
    • May need paralytics to prevent shivering
    • lytes Q4h
  • maintain for 12-24 h, then rewarm slowly over 12-24 h (risk of hypotension)
56
Q

Propofol Drip

A
  • Propofol: 20-50 mcg/kg/min (1, 400 - 3, 500 mcg/min)
57
Q

Ketamine Drip

A
  • Ketamine: 0.5 mg/kg/h
58
Q

Fentanyl/Midaz Drip

A
  • Fentanyl: 0.5-1 mcg/kg/h
  • Midazolam: 0.05 mg/kg bolus IV then 0.025 mg/kg/h
59
Q

Dose of Racemic Epi/nebulized epi (asthma, croup, stridor post-extubation)

A
  • 0.25-0.75 mL (0.05 mL/kg) 2.25% racemic epi in 4 mL NS or
  • 0.5 mL/kg, max: 5 mL 1:1000 epi
60
Q

Meds that can be given through ETT

A

ETT meds

  • Lidocaine
  • Epi (1:1000, 2-2.5 mg)
  • Atropine
  • Naloxone
61
Q

MAP Goals for:

Traumatic hemorrhagic Shock

TBI

All other shock

A
  • Traumatic Hemorrhagic Shock: MAP 40 mm Hg
  • TBI: MAP 90 mm Hg
  • All other shock: MAP 65 mm Hg
62
Q

CVP

A
  • 2-8 mm Hg normal in healthy people
  • 8-12 mm Hg advocated in shock
  • 250 mL NS bolus, if CVP increases by < 2, give more, if by > 5, stop
  • measure at end-expiration
  • measure at base of c wave (right before ventricular contraction, represents preload)
63
Q

JVP

A

Distance from sternum to RA is 5 cm

Add 5 cm to measurement from manubrium to JVP at 45 deg angle

> 4.5 cm is high

64
Q

Pulse Pressure Variation & Fluid Responsiveness

A

In mechanically ventilated patients who are completely in sync with ventilator breaths and have no dysrhythmias:

  • PP increases with inspiration and decreases with expiration
  • PPV = PP (max value on insp) - PP (min value on exp) / avg of both values
    • if > 13%, may be fluid responsive, goal is < 10 %
65
Q

Passive Leg Raise & Fluid Responsiveness

A
  • 30 deg above chest for 1 min
  • equivalent to 300 mL bolus in 70 kg patient
  • as sensitive and specific as PPV
66
Q

ScvO2, SmvO2

A
  • ScvO2 = central venous oxygenation, usually measured from central line, represents upper extremity/brain venous O2
  • SmvO2 = mixed central venous oxygenation, more accurate, but measured in pulmonary artery
  • Normally ScvO2 2-3% lower than SmvO2, in shock states ScvO2 5-10% higher (as blood flow redistributed to brain)
  • Normal is ~70%
67
Q

Transvenous Pacing

A
  • preferred sites are Right IJ and Left Subclavian
68
Q

Pacemaker Nomenclature

A
  • 1st letter A/V/D indicates which chambers are paced
  • 2nd letter A/V/D indicates which chambers are sensed
  • 3rd letter I (inhibit)/T (trigger)/D (both) indicates what occurs when an event is sensed
69
Q

Push Dose Epi

A
  • 1 mL cardiac epi (1:10, 000) into 9 mL saline = 1:100, 000 epi (10 mcg/mL)
  • 0.5-2 mL (5-20 mcgs) Q 1-2 min
70
Q

Push dose phenylephrine

A
  • 1 mL 10 mg/mL phenyl into 100 mL NS bag
  • 100 mcgs/mL phenyl
  • 0.5-2 mL (50-200 mcgs) Q2-5 min
71
Q

Vtach (sustained & non-sustained)

A
  • sustained
    • HR >120/130
    • lasts >30s or HD unstable
    • shock or amio/procainamide
  • non-sustained
    • HR >120/130
    • <30 s and stable
    • don’t use antiarrhythmics
    • Mg if low
    • search for reversible causes
    • beta blockers OK
72
Q

Hydralazine Class and Dosing

A
  • arterial vasodilator
  • 10-20 mg IV Q4H PRN
  • 10 mg PO QID, increase by 10-25 mg/dose Q2-5 days to max 300 mg/day
73
Q

Duration of Propofol

A

6-10 minutes

74
Q

Dose of Propofol for conscious sedation

A

1 mg/kg (IBW) then 0.5 mg/kg Q90s as needed

75
Q

Dose of Ketamine for conscious sedation

76
Q

Dose of ketofol for conscious sedation

A

0.5 mg/kg or 1 mg/kg of each

77
Q
  1. Dose of Fentanyl for pain control
  2. Duration of action
A

1.5 mcg/kg IV then 0.75 mg/kg IV Q2-3 min until pain is controlled

Duration: 1 hour

78
Q

Concentration of

a) 1:1000 Epi
b) 1:10000 Epi

A

a) 1 mL = 1 mg
b) 1 mL = 0.1 mg

79
Q

Dose of epi for anaphylaxis

A

0.01 mg/kg IM Q5-15 min into anterolateral thigh

80
Q

Dosing and Brands of Epi-Pens

A

1) EpiPen (0.3 mg) and EpiPen Jr (0.15 mg)
2) Twinject (0.15 mg and 0.3 mg versions) - carries two doses

10 kg - 25 kg get lower dose (0.15 mg)

>25 kg get higher dose (0.3 mg)

Should administer when symptoms recurr after exposure to an allergen known to have caused anaphylaxis in the past (this means using EpiPen for isolated uritcaria after peanut if peanut caused anaphylaxis before). Also administer for CV or resp symptoms of anaphylaxis.

81
Q

Anaphylaxis cocktail (besides epi)

A

H1 blocker: Benadryl 1 mg/kg (max: 50 mg) PO/IM/IV

H2 blocker: Ranitidine 1 mg/kg (max: 50 mg) PO/IV

Prednisone 1 mg/kg PO (max 75 mg) or methylprednisolone (Solu-Medrol) 1 mg/kg IV (max 125 mg)

DC with:

Benadryl 1 mg/kg (max: 50 mg) PO Q6h X 2-3 d

Ranitidine 1.25 mg/kg (max 150 mg) PO BID X 2-3 d

82
Q

Corrected Calcium Calculation

A

Corrected Calcium = Measured Calcium + [(40-Albumin)X0.02]

83
Q

Inspiratory sound like snoring/snorting which localizes to the nose.

84
Q

Management of Acute Upper Airway Obstruction

(FB)

A
  • ~50% tracheal + bronchial FB’s are negative on plain films
    • inspiratory + expiratory films may help (hyperinflation on expiration on affected side)
      • lateral decubitus films not helpful
  • acute FB –> monitor airway, call anesthesia
    • CPR/Heimlich if complete obstruction
    • laryngoscopy with mcgill forcep removal
    • ram ETT down R mainstem if can’t remove
  • Don’t BVM if possible, as can move FB from supraglottic to subglottic position
85
Q

Mnemonic for sudden decompensation of vented patient

A
  • Dislodged tube
  • Oxygen source (off/faulty)
  • Pneumothorax
  • Equipment Failure
86
Q

Bleeding Trach

A
  • within 48h insertion
    • likely local skin bleeding from procedure, call surgeon
  • after 48h
    • concern for tracheoinnominate artery fistula
    • small/herald bleed
      • bronchoscopy + good external skin exam
      • CTA if no source identified
      • if lots of space between vessel and trach and no stranding then OK
      • otherwise OR/trach removal with bronch and exchange for ETT
    • large bleed
      • overinflate cuff
      • if not working
        • slide finger between trach and vessel and hook/compress against sternum
        • remove trach and ETT if finger doesn’t fit with trach in
        • may try Foley
87
Q

Dose of tPA for supramassive PE

A

50 mg IV alteplase (tPA) over 1 min

88
Q

Definition and Treatment of Refractory VF/Vfib

A

See Evernote “ACLS”

89
Q

Review Vent Stuff

A

Vent Stuff

EM (27 decks)

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