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Absite Slayer > Critical Care > Flashcards

Critical Care Flashcards

1
Q

Formula for MAP

A

MAP = DBP + 1/3 x (SBP-DBP)

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2
Q

Normal range for CO

A

4-8 L/min

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3
Q

Normal range for CI

A

2.5 to 4 L/min

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4
Q

Normal range for SVR

A

800-1400 dyn s/(cm5)

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5
Q

Normal range for PCWP

A

7-15 mm Hg

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6
Q

Normal range for CVP

A

2-6 mm Hg

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7
Q

Normal range for PA pressure

A

20-30/6-15 mm Hg

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8
Q

Normal range for mixed SvO2

A

70% +/- 5

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9
Q

What is SVO2

A

Oxygen saturation of blood in RV/PA that serves as indirect measure of peripheral oxygen supply and demand

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10
Q

Factors that influence SVO2

A

Oxygen delivery

Oxygen extraction

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11
Q

Approx % of CO that goes to kidney

A

25%

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12
Q

Approx % of CO that goes to brain

A

15%

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13
Q

Approx % that goes to heart

A

5%

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14
Q

If patient receives air embolus

A

Roll patient to LEFT and place head DOWN (trendelenberg) to keep air in RA/RV. Attempt to aspirate air with central catheter/PA catheter

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15
Q

Relative contraindications for PA catheter placement

A

LBBB

Previous pneumonectomy

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16
Q

Treatment for hemoptysis after PA catheter placement

A

Imbed pull PA catheter slightly back and reinflate balloon
Increase PEEP to help tamponade
Mainstem intubate non affected side
Attempt made to place fogarty catheter down affected side; if recalcitrant, may need thoracotomy and lobectomy

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17
Q

What West zone of lung is desired location for PA catheter?

A

Zone III

Pa > Pv > PA (pressure in aa > pressure in veins > pressure in alveoli)

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18
Q

Which portion of lung has highest V/Q ratio?

A

Upper lobes

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19
Q

Which portion of lung has lowest V/Q ratio

A

Lower lobes

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20
Q

At what point in respiratory cycle is PCWP most accurate in ventilated patient

A

End expiration

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21
Q

At what point in respiratory cycle is PCWP most accurate in NON ventilated patient

A

Peak inspiration

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22
Q

What conditions make wedge pressure unreliable

A 
Aortic regurg
high PEEP
Mitral stenosis
Mitral regurg
Poor LV compliance
Pulm HTN
Pulm disease (ARDS)
Tamponade
PTX
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23
Q

PA catheters allow direct measurement of which parameters?

A 
CVP
RA pressure
PA pressure
LVEDVP
PAWP
SVO2
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24
Q

What is an IABP?

A

Mechanical device that consists of cylindrical balloon that actively deflates in systole increasing forward blood flow by reducing after load and actively inflates in diastole increasing blood flow to the coronary arteries resulting in decreased myocardial oxygen demand and increased CO

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25
Q

When does balloon from IABP inflate on ECG?

A

T wave (diastolic)

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26
Q

When does balloon from IABP deflate on EKG?

A

P wave or start of Q wave (systole)

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27
Q

Indications for IABP

A

Bridge to heart transplant for patients with LV failure
Cariogenic shock
Percutaneous coronary angioplasty
Post-CT surgery
Pre sop use for high risk patients (unstable angina with stenosis >70% main coronary artery)
Reversible intracardial mechanical defects complicating infarction
Unstable angina pectoris
Ventricular dysfunction with EF <35%

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28
Q

Absolute CI to IABP

A

Aortic regurgitation
Aortic dissection
Severe aortoiliac occlusive disease

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29
Q

Relative contraindications to IABP

A

Prosthetic vascular grafts in aorta
Aortic aneurysm
Aortofemoral grafts

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30
Q

Desired location for tip of IABP

A

1-2 cm below top of aortic arch just distal to left subclavian

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31
Q

What is preload

A

End diastolic length of cardiac myocytes which is linearly related to end diastolic volume and filling pressure

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32
Q

What 3 things determine SV?

A

LVEDV (preload)
Contractility
Afterload

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33
Q

How is EF calculated

A

Stroke volume/EDV

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34
Q

How is stroke volume calculated?

A

LVEDV - LVESV

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35
Q

Normal O2 delivery to consumption ratio

A

5 to 1

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36
Q

Primary determinants of myocardial O2 consumption

A

HR, increased ventricular wall tension

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37
Q

Normal range for alveolar:arterial gradient

A

10-15 mm Hg

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38
Q

What shifts O2-Hgb dislocation curve to LEFT

A

Decrease temperature
Decrease DPG
Decrease pCO2
Increase pH

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39
Q

What shifts O2-Hgb dissociation curve to RIGHT

A

Increase temperature
Increase DPG
Increase pCO2
Decrease pH

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40
Q

When does BP begin to decrease (what stage of shock)

A

Class III

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41
Q

When does pulse pressure begin to decrease (class of shock)

A

Class II

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42
Q

What class of shock do you start to see tachycardia

A

Class II

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43
Q

What class of shock do you see RR 30-40?

A

Class III

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44
Q

What class of shock is UOP 5-15 mL/hr

A

Class III

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45
Q

What is formula for O2 content of blood

A

[Hb + SaO2 x 1.34] + [0.003 x PaO2]

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46
Q

What is formula for O2 delivery?

A

CaO2 x CO; [(Hb x SaO2 x 1.34) + (0.003 x PaO2)] x (HR x SV)

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47
Q

What is formula for O2 consumption

A

VO2 = CO x (CaO2 - CVO2) x 10

Can be rearranged to estimate mixed venous saturation

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48
Q

How many mL O2 will gram of hemoglobin is fully saturated with oxygen?

A

1.34 mL of O2 is bound to each gram of Hgb

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49
Q

Manipulation of what factors increase O2 delivery?

A

Greatest increase of O2 delivery with increasing Hgb content and SaO2
Can also increase oxygen delivery by raising CO by increasing either HR or SV

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50
Q

Equation for oxygen extraction ratio

A

VO2/DO2

Normal is 25-30%

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51
Q

Treatment for vfib/pulseless v tach

A

1 shock monophonic 360 or biphasic 100-200 J
CPR with additional counterchecks
Epi 1 mg Iv and repeat q 3-5 min or vasopressin 40U IV
Consider amiodarone (300 mg IV), lidocaine (1-1.5 mg/kg), magnesium (1-2 gIV)

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52
Q

Treatment for asystole/PEA

A

Verify with lead rotation
Epi 1 mg IV and repeat q3-5 or vasopressin 40units IV
Consider atropine 1 mg IV q3-5 up to 3 doses

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53
Q

Treatment for UNSTABLE bradycardia

A

Transcutaneous pacing

If not immediately available, give atropine 1 mg and epi 2-10 mg/min

54
Q

In which pts with fib is anticoagulation unnecessary

A

Fib for <48 hrs

55
Q

What is tx for fib with hemodynamic INSTABILITY

A

Cardioversion and anticoagulation

56
Q

Tx of fib withOUT hemodynamic instaiblity

A

Rate control (amid, CCB, beta blockers, digoxin) and correct not underlying cause; anticoagulation

57
Q

10 for 0.08 rule of acid base balance

A

pH falls by 0.08 for every increase of PaCO2 by 10 mm Hg

58
Q

What is 35-45 rule of blood gas values

A

pH = 7.35 to 7.45 corresponds to pCO2 35-45

59
Q

Most common cause of post op renal failure

A

Hypotension

60
Q

What lab results suggest pre renal cause of ARF

A

Bun/Cr ratio >20
FENa < 1%
urine Na <20/24 hrs
urine osmolality >500 mOsm

61
Q

What is formula for FENa

A

UNa x pCr / pNa x urine Cr

62
Q

What does FeNA <1% indication

A

Pre renal due to decreased renal blood flow

63
Q

What does FENa > 3%

A

Intrinsic kidney damage (ATN, severe obstruction of both kidneys)

64
Q

What are indications for ialysis

A 
fluid overload
Metabolic acidosis
Hyperkalemia
Poisoning
Uremic coagulopathy or encephalopathy
65
Q

Advantages of intermittent hemodialysis over CRRT

A

Lower cost
Lower risk of systemic bleeding
Facilitates transport for other interventions
More suitable for severe hyperK

66
Q

Advantages of CRRT over intermittent hemodialysis

A 
Better fluid control
Better hemodynamic stability
Fewer cardiac arrhythmias
Improved nutritional support
Better pulmonary gas exchange
67
Q

Disadvantages of intermittent hemodialysis over CRRT

A

Availability of dialysis staff
Inadequate fluid control
Inadequate dialysis frequency
Inadequate nutritional support
More difficult hemodynamic control
Potential complement activation by non biocompatible membranes
Not suitable for pts with intracranial HTN

68
Q

Disadvantages of CRRT over intermittent hemodialysis

A 
Greater cost
Greater vascular access problems
Higher risk of systemic bleeding
Long term immobilization of patient
More filter problems (clotting, rupture)
69
Q

How much steroids should patient be on preoperatively to have presumed HPA axis suppression

A

20 mg prednisone or equivalent per day for 3 weeks or longer

70
Q

How much preoperative steroid supplementation should you give a patient with HPA axis suppression undergoing moderate operation (open chole, LE revascularization)

A

50-75 mg/d of hydrocortisone equivalent for 1-2 days

71
Q

How much preoperative steroid supplementation should you give a patient with HPA axis suppression undergoing a major operation (colectomy, cardiac surgery)

A

100-150 mg/d hydrocortisone equivalent for 2-3 days

72
Q

How much preoperative steroid supplementation should you give a patient iwht acute adrenal insufficiency

A

100 mg hydrocortisonne IV q6 -8 hours tapered as the patient’s condition stabilizes

73
Q

Rapid ACTH stim test: normal response

A

If baseline cortisol doubles

If baseline cortisol is >34 mg or incremental increase >9 in patients iwht baseline between 15-34

74
Q

alpha 1 receptors

A

Vascular smooth muscle constriction
Gluconeogenesis
Glycogenolysis

75
Q

Alpha 2 receptors

A

Venous smooth muscle constriction

76
Q

Beta 1 recpetors

A

Myocardial contraction and rate

77
Q

Beta 2 receptors

A

Relaxes bronchial smooth muscle
Relaxes vascular smooth muscle
Insulin secretion

78
Q

Role of dopamine receptors

A

Relaxation of renal and splanchnic smooth muscle

79
Q

Site of action of intermediate dose (4-10) dopamine

A

++beta 1
+alpha 1
Increase isotropy with some vasoconstriction

80
Q

What is site of action of high dose (>10) dopamine

A

+++ alpha 1 agonist

Marked arteriolar vasoconstriction increasing afterload

81
Q

What is site of action of epinephrine?

A

Low dose beta 1 and beta 2 (incr contractility, increase vasodilation)
High dose alpha 1 and alpha 2 (vasoconstriction)

82
Q

What is site of action of norepinephrine?

A

Low dose B1 (incr contractility)

High dose a1 and a2 (vasoconstriction)

83
Q

What is site of action of vasopressin

A

V1: vasoconstriction of vascular smooth muscle
V2: water reabsorption in collecting ducts of kidney
V3: immediate release of vWf and factor VIII

84
Q

What is site of action of phenylephrine?

A

a1 (vasoconstriction)

85
Q

What is site of action of dobutamine

A

B1 (5-15) and B2 agonist (>15)

Incr isotropy, incr chronotropy, decrease SVR

86
Q

What is site of action and effect of isoproterenol?

A

B1 and B2 agonist

Incr isotropy, incr chronotropy, incr vasodilation of skeletal and mesenteric vascular beds, extremely arrhythmogenic

87
Q

What is milrinone

A

a phosphodiesterase inhibitor that causes vasodilation, vascular smooth muscle relaxation and leads to increased cAMP –> increased calcium flux –> increased myocardial contractility

88
Q

What CV drug is arterial and venous dilator: nitride or nitroglycerin

A

Nitride is arterial and venous dilator (NTG is predominately VENOdilator)

89
Q

What is treatment for cyanide toxicity

A

Inhaled amyl nitrite then IV sodium nitrite followed by thiosulfate

90
Q

What is atrial natriuretic factor

A

Vasodilator that is released from atrial wall with atrial distention that inhibits sodium and water resorption in collecting ducts

91
Q

What is most potent stimulant for SIRS

A

Endotoxin (LPS lipid A)

92
Q

What happens to insulin and glucose with early gram negative sepsis

A

Decreased insulin
Increased glucose
Impaired utilization

93
Q

What happens to insulin and glucose with late gram negative sepsis

A

Increased insulin
Decreased glucose
Insulin resistance

94
Q

What is the early sepsis triad

A

Confusion , hyperventilation, respiratory alkalosis

95
Q

What is the diagnostic triad of ARDS

A

PCWP <18 mm Hg
Xray of chest with bilateral infiltrates
PF ratio <200

96
Q

What concentration of O2 –> O2 toxicity

A

FiO2 >60% for 48 hours

97
Q

What are main causes of CO2 retention

A

Increased dead space ventilation
Hypoventilation
Increased CO2 production

98
Q

What is total lung capacity

A

Lung volume after maximal inspiration

TLC = forced vital capacity (FVC) + residual volume (RV)

99
Q

What is FVC

A

Volume of air maximally exhaled after maximal inhalation

100
Q

What is RV

A

Lung volume after maximal exhalation

101
Q

What is tidal volume

A

Volume of air with normal inspiration and expiration

102
Q

What is function residual capacity

A

Lung volume after normal exhalation

FRC = expiratory reserve volume (ERV) + RV

103
Q

What is ERV

A

Volume of air that can be forcefully expired after normal expiration

104
Q

What is inspiratory capacity

A

The maximal amount of that that inspired from FRC

105
Q

What is FEV1

A

Forced expiratory volume after maximal inhalation in 1 second

106
Q

What are advantages of PEEP

A

Prevention of alveolar collapse/atelectasis
Decreased shunt fraction
Improved gas exchange
Increased pulmonary compliance

107
Q

What are side effects of excessive peep

A 
Decreased preload l--> decreased CO
Barotrauma
Increased intracranial pressure
Decreased compliance
Decreased gas exchange
Fluid retention
108
Q

What is dead space

A

Portion of inspired air that does not participate in gas exchange (large airways/ET tube)

109
Q

What increases dead space

A

Undwrperfusion (PE, pulmonary artery vasoconstriction, low CO)
Overventilation (excessive peep, emphysema)

110
Q

What is shut fraction

A

Portion of pulmonary venous gas that does not participate in gas exchange

111
Q

Increased airway resistance seen in

A 
Airway/ET tube obstruction
ARDS
Bronchospasm
CHF (pulm edema)
Mucus plug
112
Q

Low UOP and increased peak airway pressures

A

Abdominal compartment syndrome

Tension PTX

113
Q

How can you manipulate ventilation to decrease pCO2

A

increase minute ventilation

114
Q

How can you increase PO2 in a ventilated patient

A

Increase PEEP

Increase FIO2

115
Q

Why does increasing the FiO2 in a patient with a high shunt fraction have minimal effect on arterial PO2?

A

If >50% shunt fraction the oxygenated blood is already at maximal oxygen absorption

116
Q

What is minute ventilation

A

Total lung ventilation per minute
Tidal volume x RR
Can be measured by expired gas collection for period of 1-3 minutes

117
Q

What is the normal range of minute ventilation

A

5-10 L /min

118
Q

What is CPAP

A

Patient breathes on their own with continuous positive pressure delivered during inspiration and expiration with no volume breaths given by the ventilator

119
Q

What is pressure support ventilation

A

A mode that overcomes resistance of vent circuit to decrease work of breathing
Ventilator only delivers pressure during initiated breath

120
Q

What is IMV mode on ventilator

A

Patient can breathe on their own above the mandatory rate without assistance from vent
Otherwisise vent will deliver mandatory breath at predetermined rate

121
Q

What is SIMV

A

Delivers mandatory breath synchronously with patients initiated breath
If patient does not initiate a breath the ventilator delivers a predetermined mandatory breath

122
Q

What is AC mode

A

Ventilator assets the patient by delivering a breath when the patient imitates a breath
Otherwise the ventilator takes control if patient does not initiate a breath and delivers a breath at a predetermined rate

123
Q

What medications can be delivered through an ET tube

A 
Narcan
Atropine
Vasopressin
Epi
Lidocaine
(NAVEL)

Acetylcysteine, albuterol

124
Q

Extubation criteria –> NIF

A

NIF < -20 cm H2O

125
Q

What adjustments should you make to TPN in patient with hypercapnia, RQ > 1 and difficulty getting off the vent

A

Decrease amount of carbs in diet

Carbs have highest CO2 production

126
Q

What is most sensitive predictor for successful extubation

A

RSBI < 100

127
Q

More likely to cause increased auto-PEEP

A

Pressure controlled inverse ratio ventilation

128
Q

Lower-normal CI and high wedge pressure

A

Cariogenic shock

129
Q

High CI and lower SVR

A

Distributive shock

130
Q

Decreased CVP, PCWP and CO

A

Hypovolemic

Absite Slayer (1 decks)

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