Critical Care Flashcards
When does increased intracranial pressure become a neurologic emergency?
When it leads to herniation of cerebral contents
What is an important signs associated with increased intracranial pressure and coma?
Hyperventilation (Have to differentiate from compensatory tachypnea- underlying heart failure, toxic ingestion, ect.)
What is the best way to distinguish tachypnea from central hyperventilation?
Presence of nonreactive pupils in central hyperventilation
What is treatment for increased ICP?
Osmotic agents: Mannitol, hypertonic solutions
NEUROSURGERY
What is characterized by unilateral pupil dilation?
Uncal herniation
What causes unilateral pupil dilation seen in uncal herniation?
Compression of the oculomotor nerve
What is malignant hyperthermia?
A hypermetabolic state that follows the administration of general anesthesia
Name 9 things that result from malignant hyperthermia
- Metabolic acidosis
- Hyperthermia
- Cardiac arrhythmia
- Elevated CK (markedly)
- Myoglobinuria
- Tachypnea
- Muscle rigidity
- Increased CO2 production
- Fever
Name 3 things to treat malignant hyperthermia
- Hyperventilation
- Oxygen
- Dantrolene
Name 7 things (insults) that ARDS can occur with
- Sepsis
- Pneumonia
- Aspiration
- Lung contusion (secondary to trauma)
- Smoke inhalation
- Blood transfusion reaction
- Near-drowning
The prognosis of ARDS is better if it occurs in what context?
Trauma
What are 3 features in the initial presentation of ARDS?
- Hypoxemia
- Atelectasis
- Pulmonary edema
What causes pulmonary edema seen in ARDS?
Increased permeability of the alveolar capillary membranes
What are 2 things ARDS can progress to?
- Decreased lung compliance (development of pneumothorax)
2. Multiorgan failure
True or False: It can take several days for the symptoms of ARDS to present
True
*Don’t be fooled by patient who is asymptomatic following initial triggering insult
What are the initial XR findings in ARDS?
Fine reticular infiltrate- Then things get worse
True or False: Steroids are indicated for acute near-drowning episodes
False
If you are presented with a patient with ARDS who isn’t improving on supportive measures, what is indicated?
Steroids
What is the key element of ventilatory support in ARDS?
Peep (because of pulmonary edema
What causes death in ARDS?
Multi-organ involvement - not respiratory failure
liver, kidney, brain, bone marrow, and lungs
When can a near drowning patient be observed at home?
If they were submerged for <1 minute with no LOC and required no resuscitation in the field
True or False: Kids rescued from near-drowning episodes can be stable upon arrival to ED and go downhill quickly requiring advanced life support
True
What is the key to prognosis in near-drowning?
Duration of asphyxia
What determines the extent of the damage in near drowning?
Duration from time of submersion to restoration of adequate respiration
Name 3 things which predict risk for future deterioration (warranting continued medical supervision) in near drowning
- History of apnea and CPR in the field
- Neurological signs (seizure/disorientation) or respiratory failure (from aspiration)
- Arterial desaturation and/or tachypnea
What can tachypnea in a near drowning victim be a warning sign of?
Aspiration pneumonia or ARDS
Name 3 things which are unfavorable signs that may worsen prognosis in near drowning
- Submersion >25 minutes
- Apnea or coma at admission
- Initial arterial pH of < 7.0
In a near drowning victim, under how many minutes of CPR has a good change they will survive with no neurologic impariment?
<10 minutes CPR
What is the most important procedure to perform initially to determine management of a child who has respiratory symptoms following blunt trauma to the chest?
Physical exam of the chest
*Once stable airway and breathing have been confirmed)
What is important to do in a child who has had blunt trauma to the chest?
Physical exam of the chest
*Even if there are no signs of respiratory distress and tachycardia
Why is a PE of the chest so important in blunt trauma to the chest?
Evaluate for flail chest
What is flail chest?
2 or more rib fractures in 2 or more locations
What results form flail chest?
Paradoxic chest wall movement- Underlying lung is pulled into the chest cavity during chest expansion and pushed out during chest wall relaxation
Patient with history of flail chest with respiratory distress and tachypnea- what is the most appropriate next step?
Placement of a chest tube (decompress hemothorax and/or pneumothorax
What should you consider with blunt abdominal trauma?
Splenic rupture
In splenic rupture, what is the most important first step?
ABCs
What is a safe and effective diagnostic tool for splenic rupture?
Abdominal CT with contrast (v. peritoneal lavage)
True or False: CBC is a reliable diagnostic measure for splenic rupture
False- baseline is useful, but no diagnostic
When is surgery indicated for splenic rupture?
When there is hemodynamic instability
What are 2 things that are often indicated for splenic rupture?
- IVFs
2. Blood products
Infant with poor weight gain, tachycardia, tachypnea, CXR has cardiomegaly…?
Acute heart failure
What EF is consistent with acute heart failure?
<25%
What valve abnormalities may be described with acute heart failure?
Tricuspid or mitral regurgitation
What is a normal EF?
> 55%
What is the best initial IV therapy for a child in heart failure?
Furosemide- Acts within minutes and may yield rapid clinical improvement
*Things like ACEi or Digoxin can be helpful, but have slower onset and are for long-term management
What medication can be helpful for acute heart failure due to myocarditis?
Steroids
When is epinephrine helpful for acute heart failure?
It isn’t- it increases cardiac afterload by increasing peripheral vascular resistance
How does chronic heart failure present in infants?
- Tire easily with feedings
2. FTT
How does chronic heart failure present in older children?
- Fatigue
2. Other nonspecific symptoms
How do infants and children in cardiogenic shock present?
- Poor perfusion
- Tachycardia
- Diminished pulses
- Gallop rhythm
- Enlarged liver (if there is right-sided heart failure)
True or False: BP is a very poor indicator of circulatory status in children
True- May not even be adversely affected by shock
What are good indicators for shock in children?
- Cap refill
- Urine output
- Mental status
What is prolonged capillary refill a good early sign for?
Shock (this is not a good predictor of dehydration)
What is important to consider when evaluating delayed capillary refill?
Environmental factors- Must be done at room temperature, with no external factors influencing the reading
How is diagnosis of cardiogenic shock made?
EKG and ECHO
What is initial treatment for cardiogenic shock?
Dobutamine (problem is the pump)
What happens if you give fluid boluses to a child in cardiogenic shock?
Makes the shock worse (not better)
What is brain death?
Irreversible end of brain activity (including absence of cardiorespiratory function)
What is required in order for someone to be declared brain dead?
No other disorders which could obscure neurological functioning (ie- hypothermia)
What are two studies which can be used to document brain death?
- Radionucleotide scan
2. Angiography
True or False: The absence of vertebral and carotid artery blood flow is consistent with brain death
True
What is the order for CPR?
C-A-B
How long do you take to check for a pulse?
5-10 seconds
What do you do if you cannot find a pulse after 5-10 seconds of checking?
Start compressions
How deep should chest compressions be?
At least 1/3-1/2 of the AP depth of the chest or approximately 2in (5cm)
What is the rate for chest compressions?
At least 100/minute (allow for complete chest recoil between compressions)
What is the ratio for one-rescuer CPR?
30:2 (start with compressions)
How many cycles of CPR should be done in single-rescuer CPR prior to activating EMS and getting an AED?
5
What is the ratio for 2-rescuer CPR?
15:2
How many cycles of CPR should pass before switching roles in 2-rescuer CPR?
5
What is the depth of chest compressions for an infant?
1 1/2in (4cm)
What technique is preferred for chest compressions in 2-rescuer CPR on an infant?
Two-thumb encircling hands (over 2 fingers on sternum)
Where do you check for a pulse in an infant?
Brachial
Where do you check for a pulse in a child?
Carotid or femoral
What is the ratio for CPR in adults and adolescents?
30:2 (regardless of # of rescuers)
What is the compression depth for CPR in adults and adolescents?
At least 2 inches (5cm)
What is the ventilation rate if an airway has been established during CPR?
1 breath every 6-8 seconds (or 8-10 breaths per minute)
How are breaths given if there is an established airway during CPR?
Independent of compressions
*Compressions are given at 100/min without pausing
If a child needs rescue breaths without compressions, what is the rate?
Breath every 3-5 seconds (about 12-20 breaths per minute)
When can chest compressions generally be discontinued during CPR?
Once spontaneous HR reaches 60
*Not absolute- if evidence of poor perfusion (delayed capillary refill, weak pulses, cool extremities) continue chest compressions
In what age group can AEDs be used?
Kids older than 1
When is AED use indicated?
After 5 cycles of CPR or as soon as available for sudden witnessed collapse
What should be done during a resuscitation after each shock?
Immediately resume CPR, beginning with compressions
When is an IO indicated?
To obtain emergency access in children during life-threatening situations (cardiac arrest, shock, burns, status epilepticus)
What can IOs be used to infuse?
Medications, blood products, fluids
When should an IO be removed?
When another method of vascular access if achieved
What is the preferred site for an IO in children?
Anteriomedial surface of the proximal tibia
