Critical Care Flashcards by Paapa A-Odame

SEPSIS

What are the 4 clinical signs of SEPSIS?

(hint: use an ABC approach or think of the OBS)

O2 saturations appear low at the outset (1)
A raised respiratory rate manifests itself early in the course of the deterioration (2)
Tachycardia is normally seen prior to hypotension (3)
Hypotension is the latest of the signs (4)

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ABCDE

How much fluid should you give to patient in shock initially?

Established shock an initial 20 ml/kg is suggested

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SEPSIS

Define Sepsis

Source of infection + SIRS

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Systemic Inflammatory Response Syndrome

How would you know a patient was having a systemic inflammatory response? Give a structured answer

General OBS

Temp abnormal
RR above 20
Tachycardia

Bloods

CO2 less than 4.3
Low WCC 4 12
High immature neutrophil count 10%

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How is severe sepsis different to regular sepsis?

Severe Sepsis associated with organ dysfunction.

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Define Septic Shock

Sepsis + Hypotension

despite adequate fluid resuscitation.

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Differentials in Critical Care

What are the three classifications for clinical signs accompanying a coma?

Coma with focal neurological signs
Coma without focal neurology or meningism
Coma with meningism

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Differentials in Critical Care

What might cause a coma with focal neurological signs?

Infection

meningitis
abscess,
encephalitis

cancer
-tumour

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ABCDE

in an unconscious patient what do you need to check first

Airways

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ABCDE Assessment
AVPU / GCS

How do you distinguish between flexion and localising to pain

localising to painful stimuli = raise hands above the level of the clavicle

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Intensive Care Unit

The Acute Physiology and Chronic Health Evaluation score is used at the beginning of patient admission to ITU in order to calculate?

ICU Mortality

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Acute Emergencies in ITU

At what point in airway Mgx would you consider using positive airway pressure?

If Oxygen delivery through a mask is inadequate for patients in Respiratory Failure

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Acid Base Disorders

You are the GP

Maisy a 16 year old girl has asthma. Which acid base balance disorder would you expect in a patient with mild asthma?

Respiratory alkalosis

patients hyperventilate in response to hypoxia

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Fluids

Average volume of water in a 70kg man

42 L

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Fluids

Mr Bills is a 63 year old man who has been vomiting. What Assessment would you carry out? and What is the formula to calculate maintenance fluid requirements?

ABCDE

4 ml/kg/h for the first 10 kg
2 ml/kg/h for the next 10 kg
1 ml/kg/h for every kg over 20 kg

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Fluids

Using the maintenance fluid formula, how much fluid would a 80 kg patient require?

40 + 20 + 60 = 120 mL / hr

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Respiratory Physiology

What is a shunt?

Shunt describes areas with no ventilation but preserved blood flow

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Respiratory Physiology

Formula to calculate oxygen delivery

Oxygen delivery

Cardiac output x CaO2

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Respiratory Physiology

What is the oxygen content of the blood sensed by and where are these sensors located in the body?

The oxygen content of blood is sensed by carotid (mainly) and aortic oxygen-sensitive chemoreceptors in carotid and aortic bodies.

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Respiratory Physiology

What is hypoxic pulmonary vasoconstriction?

Pulmonary capillaries constrict in response to hypoxia

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Respiratory Physiology

Explain the Bohr effect

A description of the clever way haemoglobin releases oxygen

Represesnted by either a right or left shift in the oxygen dissociation curve

Respiratory Physiology

Describe the Haldane effect

It is the dependency of carbon dioxide carrying capacity on the oxygenation status of haemoglobin.

Deoxygenation of haemoglobin in the tissues enhances carbon dioxide carriage, by activation of proton binding and carbamino formation sites.

Oxygenation of haemoglobin causes the reverse effect of displacing hydrogen ion and carbon dioxide, thereby facilitating unloading of carbon dioxide in the lungs.

In patients at risk of hypercapnia, administration of excessive oxygen results in CO2 being displaced from haemoglobin contributing to the increase in PaCO2.

Respiratory Physiology

Hypoxia effects on the heart and kidney

Heart

Coronary vasodilatation
Decreased systemic vascular resistance
Tachycardia

Renal effects:

Activation of the renin-angiotensin system
Increased erythropoietin production

Respiratory Physiology

Hypoxia effects on the blood vessels carrying oxygen to the brain

cerebral vasodilatation

Respiratory Physiology What level of brain hypoxia will cause confusion and decreased mental function

Confusion and decreased mental functioning occurs if the PaO2 falls to 6 kPa ( ~ SaO2 80 %)

Respiratory Physiology What level of brain hypoxia will cause a loss of consciousness

Consciousness is lost at 4 kPa ( ~ SaO2 56 %)

ABCDE The BTS guidelines recommend the use of high flow oxygen delivered by a ________ in all critically ill patients Complete the sentence

Hudson non rebreathe reservoir mask at 15 L min in all critically ill patients

ABCDE The BTS guidelines recommend the use of a ______ for cardiac and respiratory arrest in order to ventilate a patient Complete the sentence

bag-valve mask with oxygen reservoir should be used

ABCDE ABG Indications

- During the initial assessment of a critically ill patient - Patients with un-explained hypoxaemia (SpO2 <94 %) - Worsening of long standing hypoxaemia - Any previously stable patient who deteriorates and requires a significantly increased FiO2 to maintain a constant oxygen saturation - Any patient with risk factors for hypercapnic respiratory failure who develops acute breathlessness, deteriorating oxygen saturation, drowsiness or other symptoms of carbon dioxide retention - Breathless patients who are thought to be at risk of metabolic conditions such as diabetic ketoacidosis or metabolic acidosis due to renal failure [Grade D] - Acutely breathless or critically ill patients with poor peripheral circulation in whom a reliable oximetry signal cannot be obtained

ABCDE OXYGEN You are the a and e doctor. The patient has COPD with low sats of 82. You put them on Oxygen via a venturi mask. What blood test do you need to do to make sure patient is accumulating CO2?

ABG For patients with a target saturation of 88-92 %, blood gas analysis done within 30-60 min of starting oxygen therapy helps to detect carbon dioxide accumulation.

ABCDE OXYGEN What is the lowest dose of oxygen for most stable convalescent patients and what do you administer with

2 L/min of oxygen with nasal cannulae or 24 % venturi mask for patients at risk of hypercapnia.

ABCDE OXYGEN For spontaneously breathing patients, oxygen therapy devices fall into two categories:

Fixed performance devices (HAFOE) Variable performance devices

ABCDE OXYGEN Variable performance devices

Nasal cannulae and catheters Medium oxygen concentration providing face masks High oxygen concentration providing face masks with reservoir bag

ABCDE OXYGEN What group of patients might need controlled oxygen therapy?

COPD CF Obese > 40BMI Chest Wall Deformity

ABCDE OXYGEN Correct oxygen therapy for Post op patient

Medium concentration oxygen delivery through nasal cannula facemask

ABCDE OXYGEN Correct oxygen therapy for critically ill patient

15L Oxygen from a non rebreathe Hudson mask with resevoir bag

ABCDE OXYGEN Correct oxygen therapy for patient at risk of hypercapnic respiratory failure

Controlled oxygen therapy with venturi mask

ACID BASE alveolar hypoventilation will cause what type of acid base disturbance

Respiratory acidosis

ACID BASE alveolar hyperventilation will cause what type of acid base disturbance

Respiratory alkalosis

ACID BASE What does the deficit refer to

the amount of acid in mmol/L that must be added or subtracted from the same blood sample with an Hb set at 5.5 g/dL to regain a normal pH at a PCO2 of 40 mmHg The more negative the SBE, the more acidotic the blood sample

TRUE or FALSE The pulmonary excretion of CO2: will raise the serum H+ concentration

False

TRUE or FALSE The pulmonary excretion of CO2:will raises the serum pH

True

TRUE or FALSE The pulmonary excretion of CO2: Decreases the renal excretion of bicarbonate

False

TRUE or FALSE The pulmonary excretion of CO2: Raises the serum concentration of bicarbonate

True

If a normal person hyperventilates for 2 hours to an arterial PCO2 of 4 kPa: The cerebral blood flow decrease

True

If a normal person hyperventilates for 2 hours to an arterial PCO2 of 4 kPa: The standard bicarbonate decreases

False

If a normal person hyperventilates for 2 hours to an arterial PCO2 of 4 kPa: The Hb-oxygen dissociation curve shifts to the left

True

If a normal person hyperventilates for 2 hours to an arterial PCO2 of 4 kPa: The ionised calcium concentration decreases

True

If a normal person hyperventilates for 2 hours to an arterial PCO2 of 4 kPa: The plasma bicarbonate increases

False

Critical Care Patient

``` Presentation of Condition needing Surgery CVS Resp Funtional Capacity Other Systems Review Drugs Allergies Peri Op Modifications Examination eg airway Igx Findings Differentials Precipitating Factor for critical care referral Initial ABCDE Initial Mgx Goals of critical care Care Bundles ``` Future Mgx